CHAPTER 27 Primary and Secondary Mastopexy-Augmentation

Summary/Key Points

1. Primary mastopexy-augmentation is a difficult procedure that combines complications of both a breast augmentation and a mastopexy. It should only be performed after careful consideration of alternate options including breast augmentation only, mastopexy only or a two stage procedure.

2. When performing a primary mastopexy-augmentation, insert the implant first and then tailor the skin around the implant. This ordered approach will help to avoid excessive tension on the skin closure, minimize complications and improve the quality of scars.

3. Use extreme caution when performing mastopexy-augmentation in smokers, diabetics, patients with previous breast scars or history of radiation therapy. This operation is already difficult enough.

4. Consider performing a mastopexy-augmentation in two stages when there are risk factors for impaired cutaneous blood flow or when it is uncertain that the patient will require both procedures. In many circumstances, a lift or implant as a first stage will meet most of the patient’s goals.

5. Selection of the mastopexy pattern is based upon the amount of redundant skin, degree of ptosis, size of implant and shape of the breast. Avoid the temptation to use fewer scars if it will be at the expense of a pleasing breast shape.

Introduction

The idea of treating hypoplastic and ptotic breasts with a combined implant and lift was first described in the 1960s by Gonzalez-Ulloa and Regnault.¹^,² Since then, there has been much written on the subject, both in support of the procedure and in cautioning about the potential risks and possible adverse outcomes.

A combined mastopexy-augmentation provides the surgeon with all of the tools necessary to manage the aesthetic issues of a woman’s breast in a single operation; size, shape, symmetry, areola size and nipple position. Unfortunately, this procedure also combines the use of a device that is designed to expand and add volume to the breast with an operation that is structured to lift and tighten tissue. These opposing forces may result in difficulty obtaining the desired breast shape, achieving adequate skin tension and increase the incidence of complications including; wide or hypertrophic scars, delayed healing, infection, capsular contracture and implant exposure.

Cardenas-Camarena published his experience with 384 patients undergoing one stage mastopexy-augmentation.³ His complication rate of 18%, all described as minor, was very favorable. His approach was to first insert the implant and then plan the skin excision around the newly implanted breast. He provided guidelines for the pattern of skin excision based primarily on the degree of ptosis of the nipple–areola complex (NAC) and on the distance from the NAC to the inframammary fold (IMF).

In 2007 Stevens reported on 321 consecutive one stage mastopexy-augmentations.⁴ Approximately two-thirds of these were primary procedures and one-third were in patients with previous breast augmentation or previous breast lifts. Complications over an average 40 month follow up were rare and included saline implant deflation, poor scarring, recurrent ptosis and areola asymmetry. The total revision rate was 14.6% with three-quarters of these being implant related and one-quarter being tissue related. He compared these results favorably to a 13% revision rate in his breast implant only patients and an 8.6% revision rate in his mastopexy only patients. Stevens noted that revision was most common in smokers, those undergoing a circumareolar lift and patients having augmentation with saline implants. He concluded with the statement that ‘although a revision rate of 14.6% is significant, it is far from the 100% reoperation rate required for a staged procedure.’⁴

Spear has written about his experience with combined breast augmentation and breast lift and cautions about the increased risks and revisions associated with this approach.⁵ He noted a 10-fold increase in complications when comparing primary augmentation mastopexy with primary augmentation only. As a guideline, he recommended that women undergoing breast augmentation could avoid a simultaneous mastopexy if the nipple sits at or above the IMF, if the nipple and areola are visible on the front of the breast with some inferior non-areola skin being visible, if the breast overhangs the IMF by no more than 2 cm and if the nipple to IMF distance is less than or equal to 8 cm under maximum stretch.

It is important to differentiate between primary one stage augmentation mastopexy and secondary procedures that are performed following a previous implant or lift. Handel’s paper titled ‘Secondary mastopexy in the augmented patient: a recipe for disaster’,⁶ highlights some of the key issues that must be considered in this complex patient population. Over time, augmented breasts, especially those placed in a subglandular plane, become ptotic and develop thinning of the overlying breast tissue. The majority of these soft tissue effects are seen in the lower pole of the breast. Often, there are associated contractures of the surrounding capsules. Correction of this deformity may require explantation only, mastopexy with explantation or mastopexy with or without implant exchange or pocket change⁷ (Figs 27.1 and 27.2).

Fig. 27.1 AP and oblique views of patient following explantation only.

Fig. 27.2 A Preoperative view of patient with high riding implants and B 6 month postoperative view following explantation and mastopexy.

Handel makes several recommendations for dealing with these patients. Preoperative deflation of a saline implant allows the patient to see the breast in a deflated state and allows the surgeon to better assess the quality and quantity of remaining breast tissue. This simple step will provide valuable information that may affect the choice of operation selected by the patient. If a mastopexy is required, undermining should be minimized and capsulectomy should only be performed when necessary. It is important to make note of previous breast scars, especially as they relate to the vascular supply of the NAC. Since inferior pole tissues are often attenuated, use caution in selecting an inferior based pedicle. It may often be best to excise the thin lower pole tissues and select a superiorly based pedicle, where tissues are of better quality. Finally, in circumareolar incisions, especially with a subglandular implant, it is important to bevel the plane of dissection acutely due to the thin nature of the tissue between the skin and the underlying implant. Failure to recognize this may lead to vascular compromise of the nipple (Fig. 27.3).

Fig. 27.3 Minimal tissue thickness between the skin and the breast implant capsule dictate the need for acute beveling of periareolar incisions in order to maintain adequate vascular supply to the nipple.

This chapter will focus primarily on one-stage mastopexy-augmentation including key aspects of patient selection, preoperative planning and marking, operative technique, postoperative care and recommendations for avoiding complications. When appropriate, discussion of secondary, two-stage procedures will be included.

Patient Selection

In primary mastopexy-augmentation surgery, factors that affect the outcome can be classified into technical, choice of procedure and perhaps most important, patient selection. Women who are considered for this procedure either have some form of congenital abnormal breast development such as a tuberous or constricted breast, or have developed ptosis and hypoplasia secondary to pregnancy and lactation, weight loss or gravitational change.

The fundamental decision that must be made between patient and surgeon is what is the best operation to most closely meet the patient’s goals and objectives of surgery. This may be a mastopexy, an augmentation or a combination of both. Although some patients can only be adequately treated with a combined procedure, every consideration should be made to addressing the patient’s concerns with a single procedure, if possible (Figs 27.4 and 27.5). Initially, the patient’s goals must be clearly reviewed. Are the concerns related to size, shape, symmetry, NAC position, areola size, stretch marks or some combination? Which of these is most important to correct and what is the patient prepared to trade off in order to obtain this correction? Essentially, a risk benefit analysis must be applied after a thorough discussion about options and complications. If a mastopexy and augmentation are to be performed together, a further decision of whether or not to perform the surgery in one stage or two stages is necessary. A one-stage approach should be reserved for healthy patients, non-smokers with few risk factors for impaired healing. These patients should be certain that they desire both a lift and an implant, otherwise the issue most important to the patient is treated first. Once healed, the patient can determine if they require the second procedure to satisfy their goals. A decision tree can be helpful in performing this analysis (Fig. 27.6).

Fig. 27.4 A, B Preoperative views of patient with grade 2 ptosis. C, D 1 year postoperative views following subpectoral augmentation with full height, extra projection 360 g implant. No breast lift was performed.

Fig. 27.5 A, B Preoperative views of patient with ptosis and good breast volume. C, D Six week postoperative views following vertical scar mastopexy using an inferior flap secured under a pectoralis sling.⁹

Fig. 27.6 Decision tree for mastopexy-augmentation.

A focused history is taken and includes general health, previous surgery especially related to the breast, history of radiation therapy, family history of breast cancer and date of most recent mammogram. Patients over the age of 40 are recommended to have a mammogram prior to elective breast surgery if not done within the previous year. Smoking history is reviewed as patients undergoing a combined augmentation and lift must not be active smokers. Patients are asked about their plans for future breastfeeding. If this issue is of significant importance to the patient, they are recommended to delay any elective breast surgery until they are finished having children.

Physical examination focuses on overall body proportions and the relationship of breast size to the rest of the body. Breasts are examined for size, shape, symmetry, nipple position and stretch marks. Ptosis is assessed as defined by Regnault.⁸ It is important to assess the quality of the breast tissue and skin in all zones of the breast. This information is helpful in deciding whether tissue should be excised and if so, then from which zone. Standard measurements of sternal notch to nipple, nipple to IMF, breast width and nipple to midline are documented. Finally, a breast examination is performed for abnormal masses.