When all breast procedures are accounted for, they form a major piece of the pie of all aesthetic plastic procedures performed worldwide. Why? Because breasts are what differentiate males from females.
Throughout art history, we see how important it is for artists to represent the female breast and because plastic surgery is unique among other specialties, regarding the artistic view, this is why for the practice of a plastic surgeon, breast surgery is so important. Although we plastic surgeons are artists of the human body, we surely have important differences from a true artist. An artist is free to make their piece of art; the limit is their imagination. For us plastic surgeons, we definitely have more limitations. We work on human bodies and our starting point is not ideal; this is the magic, we need to make something that is aesthetically consonant, aesthetically balanced. Today, enhancing a person’s natural beauty is a must in plastic surgery. The times when plastic surgery was here to show that a procedure was done is in the past, because good plastic surgery today is that which is considered so natural that nobody notices it.
This is why it is becoming more popular to replace large breast implants or even take them out without replacing them, and this is frequently requested in the plastic surgeon’s practice today.
As a woman I am more prone to listen to my patients and understand them when they tell me: “Doctor, I wished I had never had the procedure” when referring to their breast augmentation procedure. Cleavage is important not only to reassure our femininity, but also because clothes look better when we have breasts, and here I am not talking about big breasts with deep cleavages.
Once I listen to the patient and understand that she does not wants her implants any more but is afraid of having them removed, I take my time to allow her to understand that doing a mastopexy and not replacing the implants is a good option. However, I tell them I cannot assure a beautiful outcome in the end, as it is not until the implant is out that we as surgeons will see what is truly left of the breast tissue and how much excess skin is present, and can determine how much we can lift the breast and how we can better re-create the upper middle pole, which is what gives the breast cleavage that we like.
By setting the right expectations for the patient, we can proceed in planning to take away the implants without replacing them and to accompany the surgery with a mastopexy.
Why It Is Important as Doctors to Offer These Types of Treatments?
As plastic surgeons, we need to listen and understand what our patients want and design a surgery plan that serves them better.
When taking into consideration taking out or replacing breast implants, many times as surgeons, we believe the patient will end up happier if we leave implants because we will have a better contour, plus the procedure will be easier to perform. However, with years and years of performing these procedures, many times, it can be even easier to take the implants and reconstruct the breast than to reduce the implant or correct malposition of previous breast implants.
Approaches to the area
Whether to remove or replace the breast implants will depend on how and what the patient wants and feels. If the patient tells me, “I am tired of my breast implants,” or, “I enjoyed my breast implants, but now they are no longer my priority,” I will propose to perform a mastopexy, remove the implants, and not replace them.
If the patient says, “For me, it is very important to keep my cleavage. I will not feel good if I lose it,” or, “I do not want to lose breast volume; I like my breast size,” I will propose to replace the implants and do a mastopexy.
Mastopexy Technique When Taking Away Breast Implants and Not Replacing Them
Here I want to share with you my preferred mastopexy technique when taking away breast implants and not replacing them.
During the appointment, show Pitanguy’s point A to the patient to have an idea of how high the nipple areola complex can move upwards and by doing so, have more realistic patient expectations after the procedure. I always tell the patient, “Please do not forget when you look at yourself in the mirror after the procedure and you think ‘I wish they would be higher.’” Remember, as plastic surgeons. We have limitations, and this point A measurement gives us a good idea of how far up the nipple/areola complex can move.
The day of the surgery, mark the patient standing up starting with Pitanguy’s point A, and also mark the submammary fold.
Start the surgery by marking on the operation table a periareolar incision with its upper limit being the previously marked point A. Medial limit of the periareolar incision is no less than 10 cm from the midline and the lateral limit is the lateral aspect of the areola. The lower limit of the periareolar incision is marked under the lower aspect of the areola and can go until 1 cm below, depending on each individual case.
Then, two downward vertical lines are drawn, one on each skin mark made with the pinching maneuver. These two vertical lines will be the limits of the skin resection. This skin resection can be widened once the implants are taken out.
The vertical lines are measured. They should be between 5 and 7 cm, nearer 5 cm if there is little breast tissue. Basal compensating triangles are marked to match the submammary fold, as seen in Figure 3.5 .
We proceed by making a horizontal incision at the submammary fold for extracting the implant. The incision goes through skin, subcutaneous tissue, muscle, and capsule. The implant is taken out through this incision.
Preferably, no drains are left; drains increase risk of future skin depression.
Now let us hear our expert and his recommendations on what to do for a mastopexy when a patient wants to have her breast implants taken out or replaced.
Expert Approach: Mastopexy After Taking Out or Substituting Breast Implants
Why did you decide to do this technique?
I decided to do my technique many years ago when I realized that the traditional approach for mastopexy after implant removal or substitution was not appropriate for all cases, and in some circumstances even led to poor results in terms of shape of the breast and reduction of the scar length.
When did you learn it? if it is your own, how did you end up doing it?
Many years ago, I had the privilege to spend some time with Dr. Claude Lassus from Nice, France, one of the masters in breast surgery. He taught me the basic principles of his mastopexy using the superior pedicle and vertical scar. I was impressed by the simplicity and safety of his technique and I started to use it successfully in my cases of primary breast ptosis and ptosis after implant removal or substitution. In this secondary group, I soon realized that any preoperative marking was difficult or even misleading, as the ideal position of the nipple/areola complex and the distance between areola and inframammary fold ( length of the vertical scar ) were significantly modified after the removal of the breast implant or its substitution. Keeping in mind the principles of Dr. Lassus’s technique, I decided to evolve toward a “ free-hand technique ” where the breast mound is created (mastopexy), simulating it with staples or stitches on both sides without removing any piece of skin.
Can this technique be compared to others and why?
My technique belongs to the big family of the superior pedicle breast lifts that have the extraordinary advantage of providing a greater fullness of the upper pole and to prevent a bottoming- out deformity in the long term. It is not an original technique, but rather a mix of these procedures, adopting what I consider the best tips from each of them.
What do you consider to be important landmarks and anatomy to be able to better perform this technique?
Some landmarks are important for the correlations of the breast and the thorax, whereas others define the ideal relationships between the different parts of the breast. The former are, for example, the anterior axillary line, the breast meridian, and the midline. The position of the breast on the thoracic cage is also important, as it can occur naturally very low and laterally or medially displaced as in pigeon thorax or in pectus excavatum respectively. The proper breast landmarks are the new position of the nipple/areola complex, the position of the new inframammary fold, and the distance between this fold and the lower border of the areola. Unfortunately, all these references cannot be defined preoperatively with the patient standing because they are conditioned by the presence of the breast implant, and can be decided only after the removal/substitution of the prostheses when the patient is lying on the operating table. Indeed, you could select the ideal position of the nipple preoperatively but once the implant is removed/substituted, this location could be incorrect. This situation makes, in my opinion, the mastopexy after breast removal or substitution one of the most difficult surgical challenges in aesthetic surgery. Ideally, at the end of the operation, the nipple/areola complex should be a little lower than the apex of the breast mound as some inferior dislocation of the breast parenchyma and/or breast implant should be previewed. The distance of the nipple from the sternal notch varies according to the height of the patient and vertical dimension of the rib cage ranging from 17 to 21 cm. One to 1.5 cm above the midline between the humerus and the elbow is another good method to determine where to place the new position of the nipple. What is really important is to not locate the upper border of the areola too high such that it can be seen when a bra or bathing suit is worn. Consider also that too low a nipple areola complex can be easily lifted on a future secondary procedure under local anesthesia after 3–6 months of the primary procedure, whereas an areola that is too high is much more difficult to correct. The position of the inframammary fold is always changed with the mastopexy and can be lowered as in the case of substitution with a large implant or raised as more often happens when the implant is removed or substituted with a smaller one. The ideal distance between the lower border of the areola and the inframammary fold is not fixed as sometimes reported in the literature, but varies according to the final size of the breast, ranging from 5 cm for very small breasts to 8 cm for larger ones.
A sound knowledge of the blood supply of the breast is fundamental, especially in secondary or tertiary cases where a mastopexy has already been performed and vascularization of the areola can be jeopardized by extensive undermining and skin incisions. In primary mastopexy, after implant removal or substitution, the superior pedicle is very safe, even in severe ptosis, providing that the areola is easily inserted in the new keyhole and any tension or compression is avoided. Vascular problems in these cases are always because of a difficulty in the venous drainage rather than reduced arterial perfusion. An accurate preservation of the subdermal plexus can be very useful and helps to prevent superficial slough of the areola in the early postoperative period. In secondary or tertiary mastopexy, undermining is very limited and sometime in case of doubt, a superior and inferior bipedicle can be used for extreme security.
Can you explain to us how do you do the assessment on a patient asking for this procedure? can you give us some guidelines for constructing an assessment chart?
In case of implant removal and mastopexy , the most important point to be clarified with the patient is if the remaining tissue, sometimes very little, is enough to give her a satisfying volume once the breast is lifted and reshaped. The patient requiring this procedure is often a woman around 50 years old who wants her breast prostheses to be removed because they are old and at risk of rupture, or have already ruptured, and who also desires smaller and more discreet breasts. The use of a fat graft can be taken into consideration when the patient wants a fuller upper pole and a minimal volume increase but refuses a new silicone prosthesis. Of course, the limits of this solution should be highlighted, mainly the resorption of the fat and the necessity of a sufficient donor site. In selected cases, when more projection and volume is needed, an inferior-based ﬂap of de-epithelialized subcutaneous and breast tissue inserted beneath a superior pedicle (auto augmentation mastopexy) can also be successfully used.
In pure post augmentation cases, a clear description of the location and length of the remaining scars is critical to avoid unhappy patients.
In the case of implant substitution and mastopexy , the most critical decision is whether the new prosthesis should be placed in a new implant pocket. Parameters to be considered are the pinch test in superior-medial quadrants (if the thickness of the soft tissue is less than 2 cm a subpectoral placement should be preferred) and the type of result desired by the patient in long-term follow-up. The risk of a waterfall deformity in case of a subpectoral new implant with a significant amount of breast tissue has to be considered and use compared with a prepectoral placement leading to a possible bottoming out, especially if large implants are used. The new shape and volume of the breast should also be discussed with the patient with the help of some postoperative results pictures. A switch from a subglandular to a subpectoral placement of the implant improves the fullness of the upper pole and provides a better coverage of the prosthesis, but at the same time, can make the breasts less mobile and the breast mounds more distant from the midline.
In secondary cases where a mastopexy has already been performed, the increased risk for the vascular supply of the areola should be mentioned to the patient, along with the other typical complications of an augmentation mastopexy.
Can you describe your technique?
As previously mentioned, the presence of an implant alters significantly any preoperative marking and drawings, making them inappropriate after the removal of the prosthesis or its substitution, especially if the plane of the pocket is also changed. For this reason, the only references that I mark before the operation are the midline, the breast meridian, and the existing inframammary fold. The procedure starts with a vertical skin incision from the lower border of the areola to a point 2 cm above the submammary fold. The soft tissues are dissected up to the periprosthetic capsule and all efforts are made to avoid penetrating it. Breast implants are removed or substituted usually after many years and the risk of dealing with a ruptured prosthesis is very high. The implant therefore is removed together with the intact capsule (total capsulectomy), thus avoiding any dispersion of the silicone gel in to the pocket.