The Myth of Breast Autoaugmentation

(1)

Swanson Center, Leawood, KS, USA

Abstract

Over 100 publications claim to increase upper pole fullness or breast projection without a breast implant. However, there is no objective evidence that these efforts are effective. A recurring concept is “autoaugmentation,” a technique of repositioning a glandular pedicle in an attempt to restore fullness to the upper pole of the breast. In one technique, a parenchymal flap is tunneled through a loop of pectoralis muscle. The authors claim that this method simulates the effect of a 100–200 cc implant. However, comparison of standardized photographs reveals no benefit in upper pole projection or breast projection. Measurements show that techniques using fascial sutures to suspend the breast are also ineffective. Claims of greater breast projection and avoidance of postoperative ptosis using implantable mesh, sometimes called an internal bra, are not supported by measurements on matched photographs. Today this old concept is being repopularized by plastic surgeons with financial ties to the mesh manufacturer.

Despite long-standing recognition of its importance, photographic standardization is ignored. Typically, the after photographs are magnified or tilted in such a way as to suggest a treatment benefit that does not exist.

Negative measurement findings should not come as a surprise. No manipulation of breast tissue can create a net gain in breast volume. Only a vertical mammaplasty can reliably increase breast projection and upper pole projection, and then only modestly (1 cm), by trading width for projection. A Wise pattern does the opposite. A breast implant is needed to substantially boost upper pole projection. Implants can be inserted safely at the time of a mastopexy if a vertical method is used. Implants hold their shape more reliably than natural breast tissue. There is no need to resort to ineffective breast autoaugmentation.

Keywords

AutoaugmentationFascial suturesInternal braPectoralis muscle slingMeshPhotographic standardizationMythUpper pole projectionBreast projection

Introduction

Numerous techniques have been published that claim to preserve or improve breast projection and upper pole fullness after mastopexy or breast reduction [1]. However, there is no objective evidence that these efforts are effective. A recurring concept is “autoaugmentation ,” a technique of repositioning an inferiorly based (or sometimes superiorly based) glandular pedicle in an attempt to restore fullness to the upper pole of the breast.

The concept of autoaugmentation has a long pedigree, dating to Ribeiro’s 1975 description [2] of an inferiorly based parenchymal flap transposed to the upper pole in an effort to simulate a breast implant. Subsequently, over 100 articles have claimed to increase upper pole fullness or breast projection without an implant. In 2011, I published a retrospective study [1] evaluating 82 published mastopexy and reduction techniques that contained suitable photographs for comparison. The measurement system featured an unchanging landmark, the sternal notch, and a consistent horizontal reference – the plane of maximum postoperative projection (see Chap. 2) [3].

In 1976, McKissock [4] commented prophetically (in that dozens of such papers have been published since and this is a perpetual topic of discussion at meetings today) on “an awesome bibliography without a justifying sense of progress,” and concluded: “We are still awaiting the paper entitled “Finesse in Mammaplasty” and are still getting the papers entitled “A New Approach to Mammaplasty.” He called attempts at autoaugmentation “cabinetmaking fantasies” [5]. McKissock [6] considered the idea of suturing the inferior pedicle to the chest wall to suspend the breast for a prolonged period of time “naïve” and an idea that has “lured generations of surgeons as intelligent as ours into a period of trial and acceptance that will take another generation to undo.” He also considered the possibility that “perhaps its intrinsic seductiveness is so great that plastic surgery is doomed forever to repeat cycles of this idea” [6]. McKissock made these observations in 1980.

Graf et al. [7] and Graf and Biggs [8] published a method tunneling a parenchymal flap through a loop of pectoralis muscle , claiming that this method simulated the effect of a 100–200 cc implant (Fig. 5.1).

Fig. 5.1

Schematic view of thoracic wall flap technique . The authors claim the size of this flap is similar to a 100–200 cc implant, boosting the volume of the upper breast pole (Reprinted from Graf et al. [7]. With permission from Springer Verlag)

Graf et al. [9] recently published their 10-year follow-up study, concluding that their method provides “comparable breast shape and upper-pole projection to an implantable prosthesis with less comorbidity to the patient.” However, once the authors’ photographs were corrected for differences in tilt and magnification, there was no evidence of a change in upper pole projection and a slight decrease in breast projection for both treated and control patients (Figs. 5.2 and 5.3). A comparison of convexity (upper pole projection/breast projection) favored the patient that was not treated with the muscle loop. A muscle loop may compress the parenchymal flap against the chest wall, accounting for concavity of the upper pole – the opposite of the desired effect [10].

Fig. 5.2

This 46-year-old woman depicted by the authors in their Figure 3 is shown before (left) and 10 years after surgery (right) using the pectoralis muscle loop. A 21% magnification of the postoperative photograph and a 4° tilt have been corrected using the Canfield 7.4.1 Mirror Imaging software (Fairfield, NJ). There is no change in upper pole projection and a very slight decrease in breast projection. Her convexity (upper pole projection/breast projection ) is 52%. The breast contour is slightly concave after surgery. Measurements were calibrated using a length of approximately 30 cm for the upper arm. MPost plane of maximum postoperative breast projection, BPR breast parenchymal ratio, BME breast mound elevation (Reprinted from Swanson [10]. With permission from Oxford University Press)

Fig. 5.3

This 42-year-old woman depicted by the authors in their Figure 4 is shown before (left) and 10 years after surgery (right) without using the pectoralis muscle loop. A 10% magnification of the postoperative photograph and a 5.5° tilt have been corrected using the Canfield 7.4.1 Mirror Imaging software (Fairfield, NJ). There is essentially no change in upper pole projection and a slight decrease in breast projection. Her convexity (upper pole projection/breast projection ) is 65%. The breast contour is slightly convex after surgery. Measurements were calibrated using a length of approximately 30 cm for the upper arm. MPost plane of maximum postoperative breast projection, BPR breast parenchymal ratio, BME breast mound elevation (Reprinted from Swanson [10]. With permission from Oxford University Press)

Artist illustrations typically depict a substantial increase in breast projection and upper pole fullness (Fig. 5.4) [11]. These drawings more accurately depict the changes expected when a mastopexy is performed simultaneously with a breast implant [12].

Fig. 5.4

The authors’ illustration shows a boost in upper pole projection and breast projection (right). The increase in upper pole projection , approximately 1.6 cm, exceeds the change produced by the authors’ method, but is matched by vertical augmentation/mastopexy (Swanson [12]). A 15-cm distance from the sternal notch plane to the plane of maximum postoperative breast projection (MPost) was used for standardization (Reprinted from Swanson [11]. With permission from Wolters Kluwer Health)

Photographic Integrity

Despite long-standing recognition of the importance of photographic standardization [13, 14], investigators continue to present nonstandardized photographs in an effort to prove that their method effectively restores upper pole volume [15–21]. Common photographic inconsistencies include different focal distances [9, 15, 16, 18, 20, 21], tilt of the torso [9, 15, 16, 18–21], and arm positions [ 9, 15, 18–21]. In 2010, Riml et al. [22] documented a widespread disregard for photographic standards in articles published in the top plastic surgery journals.

Fortunately, the Canfield Mirror imaging software (Canfield Scientific, Fairfield, NJ) makes it easy to correct many of these orientation and magnification differences. When analyzing published results, the photographs do not include a ruler. In the author’s study of 82 published reports [1], the photographs were calibrated using a standard upper arm length of 32.5 cm. The average female upper arm length is 32.45 cm ± 2.06 (1 S.D.) [23]. The use of such a reference length is justified because it is the difference between pre- and postoperative values that is being studied. As long as the same calibration is used for both before and after images, the fact that an individual patient is slightly artificially enlarged or reduced does not affect the statistical significance of differences and ratios. Figures 5.5 and 5.6 compare published photographs [19] before and after image standardization [24].

Fig. 5.5

These photographs depict a woman who has had a previous reduction mammaplasty before (above) and 6 months after (below) revision using the method popularized by Graf (below) (Reprinted from Neto et al. [19]. With permission from Wolters Kluwer Health)

Fig. 5.6

Photographs of the patient in Fig. 5.5 have now been matched for orientation and size. An 8° tilt is corrected, as revealed by the black margins (right). There is essentially no change in breast projection or upper pole projection . The nipple is slightly overelevated (Reprinted from Swanson [24]. With permission from Wolters Kluwer Health)

Bonomi et al. [18] combine an inferiorly based parenchymal flap with a superiorly based pedicle to the nipple, claiming long-lasting upper pole fullness and increased projection of the nipple–areola complex. Measurements reveal that the postoperative lateral photographs of the two patients presented by the authors are enlarged 80% and 125% respectively. Both patients are tilted forward approximately 5° preoperatively. These factors contribute to the illusion of increased upper pole fullness and breast projection after surgery (Fig. 5.7), an effect that disappears after correction for size and orientation (Fig. 5.8) [25].

Fig. 5.7

This 24-year-old is shown before (left) and 1 year after (right) a breast reduction using an inferior dermoglandular flap and a superior pedicle. The after image is magnified 80% and tilted back 5^° compared to the preoperative photograph (Reprinted from Bonomi et al. [18]. With permission from Wolters Kluwer Health)

Fig. 5.8

Lateral photographs of the authors’ patient, corrected for size and orientation. Measurements reveal a slight loss of upper pole projection and breast projection. For calibration, an arbitrary value of 30 cm was assigned to upper arm length. MPost maximum postoperative breast projection , MPre maximum preoperative breast projection, UPA upper pole area, LPA lower pole area, TBA total breast area, BPR breast parenchymal ratio, BME breast mound elevation (Reprinted from Swanson [25]. With permission from Wolters Kluwer Health)

Breast Projection and Upper Pole Projection

Breast projection was not increased significantly by published mastopexy/reduction methods evaluated in the author’s study [1]. With the exception of the vertical procedure, all mastopexy/reduction procedures reduced breast projection, although this difference reached significance (p <0.01) only for the combined group, not individually. The mean change in breast projection for all procedures was a 0.65 cm decrease [1].

No mastopexy/reduction technique significantly increased upper pole projection. The mean change in upper pole projection for all techniques was a loss of 0.17 cm (not significant). The inverted-T, superior or medial pedicle, group showed a significant loss of upper pole projection, 0.83 cm (p <0.01) [1].

Published photographs are likely to represent the authors’ best-case results, so that the findings may be more favorable than the average results; this fact strengthens the findings of no significant change in several key breast shape parameters.

The author also studied his own patients treated with vertical mammaplasties [12]. The mean increase in breast projection after vertical mastopexy was 1.19 cm on the right side and 1.28 cm on the left side. Upper pole projection increased 0.48 cm on the right side and 0.60 cm on the left side. The increment in breast projection after vertical reduction was more modest – 0.63 cm on the right side and 0.61 cm on the left side (not significant). Upper pole projection increased 0.91 cm on the right side and 0.72 cm on the left side after vertical reduction. Not surprisingly, when an implant was added, the increases in breast projection and upper pole projection were greater.

In comparing a retrospective group of inverted-T inferior pedicle mastopexies and breast reductions with a prospective group of patients treated exclusively with the vertical method, the findings were favorable for the vertical group [26]. Vertical mastopexy, but not inverted-T mastopexy increased breast projection and upper pole projection. Vertical breast reduction better preserved breast projection than the inverted-T method. Vertical reduction significantly increased upper pole projection ; the inverted-T reduction did not.

Only gold members can continue reading. Log In or Register to continue