Prospective Comparative Clinical Evaluation of 784 Consecutive Cases of Breast Augmentation and Vertical Mammaplasty, Performed Individually and in Combination



Prospective Comparative Clinical Evaluation of 784 Consecutive Cases of Breast Augmentation and Vertical Mammaplasty, Performed Individually and in Combination


Eric Swanson, M.D.



Leawood, Kans.

From the Swanson Center.

Received for publication December 11, 2012; accepted January 31, 2013.

Copyright © 2013 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3182910b2e



Breast augmentation, mastopexy, augmentation/mastopexy, and reduction are all cosmetic procedures,1 notwithstanding the physical benefits of breast reduction and mastopexy.2 Mastopexy and augmentation/mastopexy merit close evaluation because these procedures have been a source of patient and physician dissatisfaction.35 Despite the growing popularity of breast-lift surgery,6 a large prospective study of mastopexy patients has not been published. This clinical
study is part of a comprehensive evaluation of cosmetic breast surgery that also includes a prospective measurement study7 and outcome analysis.2,8


Patients and Methods

From January of 2002 to January of 2012, 759 women underwent 784 consecutive cosmetic breast procedures (Fig. 1 and Table 1). Breast reconstruction patients were excluded.


Surgery

All procedures were bilateral. In all cases, breast implants were placed submuscularly, using predominantly the inframammary approach (95.0 percent) and saline-filled implants (94.6 percent). Resections of 300 g or more from at least one breast were categorized as breast reductions. Eleven reduction patients were simultaneously treated with implants (Fig. 2). All mammaplasties were performed by the author using the vertical technique and medially based pedicle as described by Hall-Findlay,9 but without a mosque-dome pattern; the nipple position was determined intraoperatively (Figs. 3 and 4). Sequential compression devices were used. No patient received enoxaparin.


Statistical Analysis

Statistical analyses were performed using IBM SPSS for Windows version 20.0 (IBM Corp., Armonk, N.Y.). An independent t test was used to compare means of continuous variables for two groups of patients. A one-way analysis of variance was used for more than two groups. Scheffé post hoc tests were used. The Pearson chi-square test of independence was used to compare categorical variables. The “reduction plus implants” group was not included in group comparisons because of its small sample size (n = 11). Correlations were tested using Pearson correlations. A value of p < 0.01 was considered significant. An a priori power analysis was performed for the one-way analysis of variance. To achieve 80 percent power, with an alpha level of 0.01, sufficient to detect a medium-sized treatment effect (f = 0.25)10 comparing across four groups, 256 total subjects would be needed.11






Fig. 1. Cosmetic breast surgery patients, by procedure.




Discussion


Study Design

Although breast augmentation and reduction have traditionally been considered individually, interprocedural comparisons can be useful.12 Today, we recognize an overlap in indications for these procedures and even in physical benefits.2 When a vertical technique is used, the mammaplasties are essentially the same, differentiated only by the resection weight.7

There are no published prospective clinical or outcome studies of mastopexy or augmentation/mastopexy. This deficiency is remarkable considering the popularity
of breast-lift surgery, which witnessed a 72 percent surge from 2000 to 2011,6 and by the increasing popularity of augmentation/mastopexy, an operation that is now performed more commonly than mastopexy alone in many practices.7,13 Existing studies of mastopexy14 and augmentation/mastopexy13,1522 are all retrospective and often include multiple techniques13,15,17,18,22 and multiple surgeons.18,22 Prospective studies of consecutive patients are preferred, to avoid selection bias and confounding factors.23 A power analysis is recommended to determine the adequacy of sample sizes, to avoid type II statistical errors.24 A rigorous 0.01 alpha value reduces the risk of type I errors.






Fig. 3. Intraoperative photographs of vertical augmentation/mastopexy. (Left) Before and (right) after elliptical skin resection. With side-to-side tissue approximation, the vertical length increases from 10.00 cm to 15.33 cm. If the vertical and horizontal dimensions of the resection are the same (i.e., roughly a circle), an increase in vertical length to π/2 (+57 percent) is expected.






Fig. 4. Intraoperative photographs of augmentation/mastopexy. (Above, left) After the superior dog-ear is oversewn, a 39-mm areola marking ring is used to mark the circular resection at the new site for the nipple-areola. (Above, right) The left augmentation/mastopexy is complete. (Below, left) Preoperative and (below, right) immediate postoperative views show the increased breast projection provided by the implant and the position of the nipple-areola, slightly below the level of maximum breast projection. The implant takes up much of the slack in the lower pole, minimizing the need for skin gathering and keeping the vertical incision from extending onto the abdominal skin.


All-Seasons Mammaplasty

A growing number of plastic surgeons have adopted the vertical technique as their procedure of choice for mastopexy and reduction.25 At a recent meeting of the American Society of Plastic Surgeons, 47 percent of audience members responding to a poll reported using the vertical technique for their augmentation/mastopexies, versus 38 percent who still favored the inverted-T design, and 10 percent who preferred a periareolar resection.26 Persistent ptosis is a frequent problem after a periareolar mastopexy.5,16,27 The shape deficiencies of the inverted-T, inferior pedicle technique have been recognized for decades.27 Although the idea of an “all-seasons” mammaplasty has been dismissed in the past,28 an increasing number of plastic surgeons use the vertical technique exclusively,7,2934 including the author. Its versatility is demonstrated in Figures 5 through 8, which depict not typical cases but more challenging ones (i.e., very large breasts, tuberous breasts, asymmetrical breasts, and secondary surgery).

Commonly, a periareolar mastopexy is recommended for patients with minimal degrees of ptosis, a vertical technique for more moderate cases, and the inverted-T technique for cases of moderate or severe ptosis.35,36
However, a vertical technique is particularly advantageous in large resections because a long pedicle is unnecessary,7 improving safety for the nipple and areola,3134 and avoiding the need for nipple grafting. The anatomical and geometrical advantages of the vertical technique27 do not change with breast size (Fig. 5). Elegant in its simplicity, this technique may be used for all cosmetic mammaplasties, with the only variables being implant size (if used) and the resection weight, making it truly an all-seasons mastopexy. Even small, ptotic breasts and
tuberous breasts, traditionally considered the domain of the periareolar technique,15 respond well to vertical mastopexy (Fig. 6).








Table 2. Complications*

















































































































































































  Augmentation (%) Mastopexy (%) Augmentation/Mastopexy (%) Reduction (%) Reduction plus Implants (%) All Procedures (%) p
No. 522 57 146 48 11 784  
Complications
   No 430 (82.4) 38 (66.7) 93 (63.7) 23 (47.9) 4 (36.3) 588 (75.0) <0.001
   Yes 92 (17.6) 19 (33.3) 53 (36.3) 25 (52.1) 7 (63.6) 196 (25.0)  
Capsular contracture 31 (5.9) 9 (6.2) 0 40  
Size asymmetry 20 (3.8) 3 (5.3) 5 (3.4) 3 (6.3) 2 (18.2) 33 (4.2)  
Scar deformity 7 (1.3) 6 (10.5) 11 (7.5) 5 (10.4) 2 (18.2) 31 (4.0)  
Delayed wound healing 2 (0.4) 2 (3.5) 14 (9.6) 9 (18.8) 3 (27.3) 30 (3.8)  
Persistent ptosis 7 (12.3) 13 (8.9) 3 (6.3) 2 (18.2) 25  
Hematoma 17 (3.3) 0 1 (0.7) 2 (4.2) 0 20 (2.6)  
Cellulitis/infection 2 0 9 5 1 17  
Implant rippling 9 0 0 9  
Seroma 3 1 0 1 0 5  
Allergic reaction 1 0 2 1 0 4  
Implant deflation 4 0 0 4  
Symmastia 1 0 0 1  
Numbness 0 1 0 0 0 1  
Hyperpigmentation 1 0 0 0 0 1  
Total 98 20 64 29 10 221  
*Twenty-five patients had two complications. Therefore, the total number of complications exceeds the number of patients who had complications.
Breast augmentation patients experienced fewer complications than mastopexy and augmentation/mastopexy patients (p < 0.001). The difference in complication rates between mastopexy and augmentation/mastopexy was not significant. Pearson χ2 tests for independence were used to compare the complication rate across procedure groups. Adjusted standardized residuals with an absolute value greater than 3 were used to indicate when a group’s percentage was higher or lower than for all procedures. The reduction plus implants group was excluded from group comparisons because of its small sample size.

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Jan 30, 2021 | Posted by in General Surgery | Comments Off on Prospective Comparative Clinical Evaluation of 784 Consecutive Cases of Breast Augmentation and Vertical Mammaplasty, Performed Individually and in Combination

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