Commentary on: Liposuction-Augmentation Mammaplasty

Commentary on: Liposuction-Augmentation Mammaplasty The authors’ describe a novel technique of combining liposuction with breast augmentation to achieve lifting of the nipple-areola complex (NAC) and/or volume equalization prior to implant-based breast augmentation with same sized silicone implants.1 They compared their results with two other techniques, mastopexy-augmentation mammoplasty (MAM) and reduction-augmentation mammoplasty (RAM). The authors’ series on liposuction-augmentation mammaplasty (LAM) consisted of 125 patients (198 breasts). The authors’ LAM technique began with a standard 3 cm inframammary fold (IMF) incision through which superwet tumescent infiltration was placed. This was followed by removal of fatty aspirate from the breast via power-assisted liposuction (PAL), of which 25 cc was defined as the minimal amount. The infiltration solution was not detailed. The fatty aspirate volume was used as the measure of breast volume reduction and appeared to be determined by the fat tumescent interface level on settlement over 10 to 15 minutes. PAL was concentrated in the lower pole of the breast and minimally under the nipple-areola complex (NAC) and upper pole. The end point of PAL was a uniform 2 cm breast soft tissue thickness. After PAL, breast augmentation was then performed using a dual plane I pocket dissection (97% of cases) without intentionally lowering the IMF. Predominantly smooth round gel implants were next placed via a Keller Funnel (Stuart, FL), followed by standard closure. Postoperatively, patients were advised to continuously wear a highly supportive sports bra with an inferiorly positioned silicone insert for 6 months. In the authors’ series, change in the sternal notch-nipple distance was the primary outcome of interest, which was used as a proxy for measuring lifting of the NAC. This was measured based on computerized analysis of pre- and postoperative photographs taken at least 12 months after surgery, using the interaxillary distance measurement as a reference. While the authors noted an average 6% overall reduction in the SN-N distance after LAM, 2.5% of patients did not experience a lift (5 breasts in 4 patients) and in 6.5% of patients SN-N actually increased (12 breasts in 10 patients). Complications requiring revisions were similar between the groups and uniformly low. From these findings, the authors concluded that LAM is a safe and reliable solution for the mildly ptotic fatty breast. The authors should be commended for their analyses and publishing this novel study. Several points, however, merit further discussion. While the SN-N distance is an important parameter of NAC elevation, it is not the only parameter to assess the ideal NAC position on the breast footprint. It would have been of interest to see the change in relationship between the NAC position and the IMF − this could be easily assessed by transcribing the NAC position and IMF to the midline and measuring the distance between the two for each breast. A similar measurement could be done for the uppermost extent of the breast to identify changes in the upper pole. This would have perhaps provided interesting data on whether the breast footprint and or the relative position of the NAC changed postoperatively. As the authors have shown in their study and in studies by others,2-7 liposuction can elevate the NAC and breast mound but it remains interesting to postulate what the exact mechanism is. Preferentially removing volume from the lower pole and decreasing the gravitational pull of the breast may afford the upper pole an opportunity to retract. Conversely, liposuctioning the upper pole and causing local mechanical trauma may be a more direct way of achieving the same result and inducing scar formation that will strengthen the new lifted position. In their study, the authors’ technique addressed both theories, in that the entire breast was liposuctioned but preferentially in the lower pole. Contradicting the mechanism of both these theories, however, is immediate breast augmentation. How can reliable retraction occur with the force of the implant causing expansion of the overlying tissues? Conceptually, a staged approach may therefore be more reliable, although this may not interest patients seeking augmentation. Furthermore, while it seems intuitive to securely support the breast as the authors have done, the extent of this required, in both magnitude and duration, and the ability to sustain it, is debatable. For instance, it would be naive to assume that all patients will wear a bra continuously for 6 months. The uncertainties highlighted above only add to the list of other variables that influence this technique and require special consideration, such as remaining breast mass, amount and depth of liposuction, native tissue elasticity, and resultant intrabreast scar strength. Therefore, while LAM as a concept has been demonstrated by the authors, it is not entirely predictable at this time and its adoption should be approached with care. The method by which the authors chose their implant volumes also merits further clarification. In their series, the volume of the implants placed was determined based on adding the preoperatively chosen sizer volume with the amount of pure fatty aspirate removed. In making this determination it is important to be precise with the measurement of fat/parenchyma in the aspirate, which may not be that accurate with the method suggested by the authors. Secondly, the authors’ technique likely requires a consignment of implants of different volumes available intraoperatively. The nuance in this scenario is that implant profile or projection is the variable that should be preferentially altered while keeping other implant variables relatively constant when choosing between different implants. Regardless of whether one prescribes to “tissue-based” or “dimensional analyses” planning systems8 in selecting breast implants, implants chosen should ideally have base diameter and height measurements that approximate the native breast footprint to achieve the most natural and aesthetic results. The implants chosen for the LAM patients were upsized (average, 490 g) compared to the MAM patients (average, 450 g) and the RAM patients (average, 430 g) − perhaps this suggests that more of a lift was attempted by using a larger sized implant in the LAM group. The authors make note that conceptually, the breast benefits from having minimal fibrofatty tissue and a predominant prosthetic component, as a means of achieving a more rounded, firmer, stable, and longer-lasting breast. It is from these beliefs that they support liposuction as a means of not only lifting the NAC but also equalizing and defatting breast volumes prior to implant augmentation. In their series, the authors performed on average 150 cc of fat removal on LAM breasts, with an upward limit of 750 cc in some patients. Fat volume removed was in essence replaced with implant volume. It is important to note, however, that this practice deviates from modern-day principles of creating the ideal “bio-prosthetic” breast. It is well established, for instance, that patients with smaller implants (or smaller implant to breast ratio) experience less short-term and long-term implant-related complications.9,10 Soft tissue thickness is in fact desirable to soften the breast contours and provide implant coverage. In thin patients, a basic tenet of using the subpectoral pocket is to provide needed upper pole coverage and implant camouflage. These same ideas are espoused in modern postmastectomy implant-based breast reconstruction, in which “total envelope fat grafting”11 is now advocated and often used in staged procedures to achieve better periprosthetic soft tissue thickness and aesthetic outcomes. In scenarios where there is unfavourable positional ptosis of breast tissues or mild NAC ptosis, one may therefore be better served to use fascial suspension techniques12 in conjunction with implant augmentation to create a projected and rejuvenated breast shape while preserving natural tissues. Furthermore, PAL to a breast destroys or at least alters residual breast parenchyma and LAM will typically be indicated in younger patients who generally have better skin quality. LAM in this group may potentially be problematic, in that investigative mammography and ultrasonography may be compromised in the young breast − the very population we need to diligently monitor. A deep parenchymal resection from the base of the breast13 to address volume asymmetries prior to augmentation may therefore be less disruptive to the overall parenchymal architecture and a safer operation in younger patients. In a separate subgroup analyses, the authors compared their results of patients who had unilateral LAM with their opposite side (which had breast augmentation only) and reported that the LAM side had statistically significant greater NAC lifting. It is important to highlight, however, that all augmentations were performed using a dual plane I pocket, a technique which is not designed to lift the NAC.14 While further discussions on the merit and credibility of different dual planes dissections on NAC lifting can be found elsewhere, suffice to say a more valuable comparison would be contralateral augmentation with a dual plane III pocket and/or anatomic implants, both of which, in theory, predispose to greater lower pole expansion and have been purported to provide a “lifting” effect to the NAC. We once again congratulate the authors for sharing their novel technique, and commend their efforts in detailing their concepts, patient selection methods, and technical steps. We appreciate the discussion and look forward to their future studies and those by others reporting the long-term results of LAM. Disclosures The authors declared no conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Harris R, Raphael P, Harris SW. Liposuction-Augmentation Mammaplasty. Aesthet Surg J . 2018; 38( 4): 385- 397. 2. Gray LN. Liposuction breast reduction. Aesthetic Plast Surg . 1998; 22( 3): 159- 162. Google Scholar CrossRef Search ADS PubMed  3. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg . 2001; 108( 4): 1006- 1010; discussion 1011. Google Scholar CrossRef Search ADS PubMed  4. Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr Surg . 1993; 92( 7): 1276- 1284; discussion 1285. Google Scholar PubMed  5. Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuction breast reduction. Plast Reconstr Surg . 2004; 114( 1): 55- 60; discussion 61. Google Scholar CrossRef Search ADS PubMed  6. Habbema L. Breast reduction using liposuction with tumescent local anesthesia and powered cannulas. Dermatol Surg . 2009; 35( 1): 41- 50; discussion 50-52. Google Scholar PubMed  7. Mellul SD, Dryden RM, Remigio DJ, Wulc AE. Breast reduction performed by liposuction. Dermatol Surg . 2006; 32( 9): 1124- 1133. Google Scholar PubMed  8. Adams WPJr, Mckee D. Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation. Plast Reconstr Surg . 2016; 138( 5): 987- 994. Google Scholar CrossRef Search ADS PubMed  9. Somogyi RB, Brown MH. Outcomes in primary breast augmentation: a single surgeon’s review of 1539 consecutive cases. Plast Reconstr Surg . 2015; 135( 1): 87- 97. Google Scholar CrossRef Search ADS PubMed  10. Tebbetts JB, Teitelbaum S. High- and extra-high-projection breast implants: potential consequences for patients. Plast Reconstr Surg . 2010; 126( 6): 2150- 2159. Google Scholar CrossRef Search ADS PubMed  11. Hammond DC, O’Connor EA, Scheer JR. Total envelope fat grafting: a novel approach in breast reconstruction. Plast Reconstr Surg . 2015; 135( 3): 691- 694. Google Scholar CrossRef Search ADS PubMed  12. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy. Plast Reconstr Surg . 2006; 117( 1): 86- 94. Google Scholar CrossRef Search ADS PubMed  13. Somogyi RB, Stavrou D, Southwick G. Correction of small volume breast asymmetry using deep parenchymal resection and identical silicone implants: an early experience. Aesthet Surg J . 2015; 35( 4): 394- 401. Google Scholar CrossRef Search ADS PubMed  14. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. Plast Reconstr Surg . 2001; 107( 5): 1255- 1272. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Commentary on: Liposuction-Augmentation Mammaplasty

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Publisher
Mosby Inc.
Copyright
© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
D.O.I.
10.1093/asj/sjx215
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Abstract

The authors’ describe a novel technique of combining liposuction with breast augmentation to achieve lifting of the nipple-areola complex (NAC) and/or volume equalization prior to implant-based breast augmentation with same sized silicone implants.1 They compared their results with two other techniques, mastopexy-augmentation mammoplasty (MAM) and reduction-augmentation mammoplasty (RAM). The authors’ series on liposuction-augmentation mammaplasty (LAM) consisted of 125 patients (198 breasts). The authors’ LAM technique began with a standard 3 cm inframammary fold (IMF) incision through which superwet tumescent infiltration was placed. This was followed by removal of fatty aspirate from the breast via power-assisted liposuction (PAL), of which 25 cc was defined as the minimal amount. The infiltration solution was not detailed. The fatty aspirate volume was used as the measure of breast volume reduction and appeared to be determined by the fat tumescent interface level on settlement over 10 to 15 minutes. PAL was concentrated in the lower pole of the breast and minimally under the nipple-areola complex (NAC) and upper pole. The end point of PAL was a uniform 2 cm breast soft tissue thickness. After PAL, breast augmentation was then performed using a dual plane I pocket dissection (97% of cases) without intentionally lowering the IMF. Predominantly smooth round gel implants were next placed via a Keller Funnel (Stuart, FL), followed by standard closure. Postoperatively, patients were advised to continuously wear a highly supportive sports bra with an inferiorly positioned silicone insert for 6 months. In the authors’ series, change in the sternal notch-nipple distance was the primary outcome of interest, which was used as a proxy for measuring lifting of the NAC. This was measured based on computerized analysis of pre- and postoperative photographs taken at least 12 months after surgery, using the interaxillary distance measurement as a reference. While the authors noted an average 6% overall reduction in the SN-N distance after LAM, 2.5% of patients did not experience a lift (5 breasts in 4 patients) and in 6.5% of patients SN-N actually increased (12 breasts in 10 patients). Complications requiring revisions were similar between the groups and uniformly low. From these findings, the authors concluded that LAM is a safe and reliable solution for the mildly ptotic fatty breast. The authors should be commended for their analyses and publishing this novel study. Several points, however, merit further discussion. While the SN-N distance is an important parameter of NAC elevation, it is not the only parameter to assess the ideal NAC position on the breast footprint. It would have been of interest to see the change in relationship between the NAC position and the IMF − this could be easily assessed by transcribing the NAC position and IMF to the midline and measuring the distance between the two for each breast. A similar measurement could be done for the uppermost extent of the breast to identify changes in the upper pole. This would have perhaps provided interesting data on whether the breast footprint and or the relative position of the NAC changed postoperatively. As the authors have shown in their study and in studies by others,2-7 liposuction can elevate the NAC and breast mound but it remains interesting to postulate what the exact mechanism is. Preferentially removing volume from the lower pole and decreasing the gravitational pull of the breast may afford the upper pole an opportunity to retract. Conversely, liposuctioning the upper pole and causing local mechanical trauma may be a more direct way of achieving the same result and inducing scar formation that will strengthen the new lifted position. In their study, the authors’ technique addressed both theories, in that the entire breast was liposuctioned but preferentially in the lower pole. Contradicting the mechanism of both these theories, however, is immediate breast augmentation. How can reliable retraction occur with the force of the implant causing expansion of the overlying tissues? Conceptually, a staged approach may therefore be more reliable, although this may not interest patients seeking augmentation. Furthermore, while it seems intuitive to securely support the breast as the authors have done, the extent of this required, in both magnitude and duration, and the ability to sustain it, is debatable. For instance, it would be naive to assume that all patients will wear a bra continuously for 6 months. The uncertainties highlighted above only add to the list of other variables that influence this technique and require special consideration, such as remaining breast mass, amount and depth of liposuction, native tissue elasticity, and resultant intrabreast scar strength. Therefore, while LAM as a concept has been demonstrated by the authors, it is not entirely predictable at this time and its adoption should be approached with care. The method by which the authors chose their implant volumes also merits further clarification. In their series, the volume of the implants placed was determined based on adding the preoperatively chosen sizer volume with the amount of pure fatty aspirate removed. In making this determination it is important to be precise with the measurement of fat/parenchyma in the aspirate, which may not be that accurate with the method suggested by the authors. Secondly, the authors’ technique likely requires a consignment of implants of different volumes available intraoperatively. The nuance in this scenario is that implant profile or projection is the variable that should be preferentially altered while keeping other implant variables relatively constant when choosing between different implants. Regardless of whether one prescribes to “tissue-based” or “dimensional analyses” planning systems8 in selecting breast implants, implants chosen should ideally have base diameter and height measurements that approximate the native breast footprint to achieve the most natural and aesthetic results. The implants chosen for the LAM patients were upsized (average, 490 g) compared to the MAM patients (average, 450 g) and the RAM patients (average, 430 g) − perhaps this suggests that more of a lift was attempted by using a larger sized implant in the LAM group. The authors make note that conceptually, the breast benefits from having minimal fibrofatty tissue and a predominant prosthetic component, as a means of achieving a more rounded, firmer, stable, and longer-lasting breast. It is from these beliefs that they support liposuction as a means of not only lifting the NAC but also equalizing and defatting breast volumes prior to implant augmentation. In their series, the authors performed on average 150 cc of fat removal on LAM breasts, with an upward limit of 750 cc in some patients. Fat volume removed was in essence replaced with implant volume. It is important to note, however, that this practice deviates from modern-day principles of creating the ideal “bio-prosthetic” breast. It is well established, for instance, that patients with smaller implants (or smaller implant to breast ratio) experience less short-term and long-term implant-related complications.9,10 Soft tissue thickness is in fact desirable to soften the breast contours and provide implant coverage. In thin patients, a basic tenet of using the subpectoral pocket is to provide needed upper pole coverage and implant camouflage. These same ideas are espoused in modern postmastectomy implant-based breast reconstruction, in which “total envelope fat grafting”11 is now advocated and often used in staged procedures to achieve better periprosthetic soft tissue thickness and aesthetic outcomes. In scenarios where there is unfavourable positional ptosis of breast tissues or mild NAC ptosis, one may therefore be better served to use fascial suspension techniques12 in conjunction with implant augmentation to create a projected and rejuvenated breast shape while preserving natural tissues. Furthermore, PAL to a breast destroys or at least alters residual breast parenchyma and LAM will typically be indicated in younger patients who generally have better skin quality. LAM in this group may potentially be problematic, in that investigative mammography and ultrasonography may be compromised in the young breast − the very population we need to diligently monitor. A deep parenchymal resection from the base of the breast13 to address volume asymmetries prior to augmentation may therefore be less disruptive to the overall parenchymal architecture and a safer operation in younger patients. In a separate subgroup analyses, the authors compared their results of patients who had unilateral LAM with their opposite side (which had breast augmentation only) and reported that the LAM side had statistically significant greater NAC lifting. It is important to highlight, however, that all augmentations were performed using a dual plane I pocket, a technique which is not designed to lift the NAC.14 While further discussions on the merit and credibility of different dual planes dissections on NAC lifting can be found elsewhere, suffice to say a more valuable comparison would be contralateral augmentation with a dual plane III pocket and/or anatomic implants, both of which, in theory, predispose to greater lower pole expansion and have been purported to provide a “lifting” effect to the NAC. We once again congratulate the authors for sharing their novel technique, and commend their efforts in detailing their concepts, patient selection methods, and technical steps. We appreciate the discussion and look forward to their future studies and those by others reporting the long-term results of LAM. Disclosures The authors declared no conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Harris R, Raphael P, Harris SW. Liposuction-Augmentation Mammaplasty. Aesthet Surg J . 2018; 38( 4): 385- 397. 2. Gray LN. Liposuction breast reduction. Aesthetic Plast Surg . 1998; 22( 3): 159- 162. Google Scholar CrossRef Search ADS PubMed  3. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg . 2001; 108( 4): 1006- 1010; discussion 1011. Google Scholar CrossRef Search ADS PubMed  4. Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr Surg . 1993; 92( 7): 1276- 1284; discussion 1285. Google Scholar PubMed  5. Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuction breast reduction. Plast Reconstr Surg . 2004; 114( 1): 55- 60; discussion 61. Google Scholar CrossRef Search ADS PubMed  6. Habbema L. Breast reduction using liposuction with tumescent local anesthesia and powered cannulas. Dermatol Surg . 2009; 35( 1): 41- 50; discussion 50-52. Google Scholar PubMed  7. Mellul SD, Dryden RM, Remigio DJ, Wulc AE. Breast reduction performed by liposuction. Dermatol Surg . 2006; 32( 9): 1124- 1133. Google Scholar PubMed  8. Adams WPJr, Mckee D. Matching the Implant to the Breast: A Systematic Review of Implant Size Selection Systems for Breast Augmentation. Plast Reconstr Surg . 2016; 138( 5): 987- 994. Google Scholar CrossRef Search ADS PubMed  9. Somogyi RB, Brown MH. Outcomes in primary breast augmentation: a single surgeon’s review of 1539 consecutive cases. Plast Reconstr Surg . 2015; 135( 1): 87- 97. Google Scholar CrossRef Search ADS PubMed  10. Tebbetts JB, Teitelbaum S. High- and extra-high-projection breast implants: potential consequences for patients. Plast Reconstr Surg . 2010; 126( 6): 2150- 2159. Google Scholar CrossRef Search ADS PubMed  11. Hammond DC, O’Connor EA, Scheer JR. Total envelope fat grafting: a novel approach in breast reconstruction. Plast Reconstr Surg . 2015; 135( 3): 691- 694. Google Scholar CrossRef Search ADS PubMed  12. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy. Plast Reconstr Surg . 2006; 117( 1): 86- 94. Google Scholar CrossRef Search ADS PubMed  13. Somogyi RB, Stavrou D, Southwick G. Correction of small volume breast asymmetry using deep parenchymal resection and identical silicone implants: an early experience. Aesthet Surg J . 2015; 35( 4): 394- 401. Google Scholar CrossRef Search ADS PubMed  14. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. Plast Reconstr Surg . 2001; 107( 5): 1255- 1272. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery JournalOxford University Press

Published: Apr 1, 2018

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