Evaluating the Effect of Implantable Mesh in Mammaplasty

Evaluating the Effect of Implantable Mesh in Mammaplasty Adams et al1 revive the concept of an internal bra. Proponents of implanted mesh have long claimed improved breast projection and maintenance of breast shape.2-5 De Bruijn and Johannes and van Deventer et al abandoned mesh sheets and tried using mesh that was preshaped into a cone.3,4 However, measurements on matched photographs fail to support its efficacy.6,7 Because the Regnault classification relates the nipple level rather than the gland level to the inframammary fold, a patient may still have glandular ptosis despite a favorable Regnault rating.8 One-dimensional measurements with a tape measure are laborious, imprecise, and antiquated. Inexplicably, no before-and-after measurements are provided.1 The change in measurements between various times after surgery (ie, not comparing with measurements before surgery) are given instead. Patient satisfaction scores are likely to be favorable simply because breast reduction provides symptomatic relief, whether mesh is used or not. Other studies of mastopexy and reduction patients treated without mesh show similar patient satisfaction scores.9,10 Lateral photographs are most valuable because they allow comparison of the gland level and nipple level.11,12 Surprisingly, the authors provide plenty of frontal and oblique views, but no lateral photographs. Adams et al do provide 3-dimensional lateral images for one patient (Figure 1). However, the right and left postoperative images are magnified 23% and 28% respectively compared with the preoperative images. Góes also magnified and tilted his postoperative lateral photograph (42% and 11°).6,7 Figure 1. View largeDownload slide (A) Preoperative and (B) postoperative right lateral 3D images of a 58-year-old woman 1 year after a right breast reduction (resection weight unknown) and left mastopexy, performed using a central mound technique and mesh. The images have been matched for size and orientation using the Canfield Mirror 7.4.1 imaging system (Canfield Scientific, Fairfield NJ), correcting an original 23% magnification and a slight (1°) upward tilt of the postoperative image, and accounting for the oblique black margins. Breast projection and upper pole projection are essentially unchanged. The images are calibrated to approximate those of Figure 2, with a torso length of about 30 cm. MPost, level of maximum postoperative breast projection. Adapted from Figure 7, Adams et al.1 Figure 1. View largeDownload slide (A) Preoperative and (B) postoperative right lateral 3D images of a 58-year-old woman 1 year after a right breast reduction (resection weight unknown) and left mastopexy, performed using a central mound technique and mesh. The images have been matched for size and orientation using the Canfield Mirror 7.4.1 imaging system (Canfield Scientific, Fairfield NJ), correcting an original 23% magnification and a slight (1°) upward tilt of the postoperative image, and accounting for the oblique black margins. Breast projection and upper pole projection are essentially unchanged. The images are calibrated to approximate those of Figure 2, with a torso length of about 30 cm. MPost, level of maximum postoperative breast projection. Adapted from Figure 7, Adams et al.1 Mesh implantation requires parenchymal exposure.1 A “mastopexy-wrecking” lower pole bulge is preserved. The mesh method is inapplicable to a vertical mammaplasty because the lower pole tissue is resected and the flaps are not undermined to allow a surface on which to place the mesh. This surgical film is approved for reinforcement of fascial defects, not breast surgery.13 There is no evidence that placing mesh on the intact deep dermis of a deepithelialized inferior pedicle (ie, not bridging a hernia) prevents horizontal stretching of the buried pedicle. A traditional inverted-T, inferior pedicle mammaplasty (paradoxically) trades projection for width. This is the geometric effect of closing a horizontal ellipse. A vertical mammaplasty does the reverse, trading width for projection by closing a vertical ellipse.11,12 A central mound method does neither and requires major undermining, jeopardizing skin circulation and nipple/areola innervation, with no benefit in breast projection or lower pole elevation.12 Measurements comparing the traditional inverted-T, inferior pedicle to vertical mammaplasty show improved breast projection and upper pole projection after a vertical mammaplasty and more conical lower poles.14 The long “anchor” scar (Figure 1), constriction of the lower pole, boxy lower poles, and nipple overelevation (evident in almost all the figures) are all characteristic features of the Wise pattern and inferior pedicle.12,14 The only randomized study comparing the aesthetic result finds that women prefer the vertical mammaplasty, both in terms of shape and reduced scarring.9 The authors defend the lack of a control group by stating that some of their surgeons believed it would be unethical not to offer mesh and that all patients insist on having mesh if given the choice.1 The surgeon survey found that 100% of participating surgeons preferred to use mesh in all patients and the 1-year result was satisfactory in 100% of patients – a testament to surgeon bias. At 6 months there were 3 patients with results deemed unsatisfactory by the surgeon (n = 59), but none at 1 year (n = 56). It is unclear what is meant by “satisfactory.” The questionnaire (the authors’ Appendix A) asks surgeons how well the mesh performed, not the quality of the surgical result.1 The title of the authors’ Table 7 specifies a (hypothetical) “comparison to procedure without mesh.”1 Remarkably, Adams et al1 suggest that the results using mesh exceed those of augmentation/mastopexy. The authors favorably compare their all-satisfactory surgical evaluations with a Brazilian study of 20 postbariatric augmentation/mastopexies in which the 3 surgeons rated the results “regular, good, or optimal” in 91.6% of patients, as opposed to 100% in the authors’ study. A comparison between mammaplasty with mesh (Figure 1) and a vertical augmentation/mastopexy (Figure 2) makes clear the superiority of augmentation/mastopexy. Many plastic surgeons offer breast implants to the majority of women presenting for mastopexy.11 Indeed, it may be unethical to withhold the breast implant option from women, telling them that the internal bra (cost of mesh: $12006) will perform just as well. True, breast implants come with complications, but so does mesh.1 A breast implant is a superior alternative for the very reason the authors acknowledge – breast tissue is too malleable to provide a lasting boost in upper pole volume.11 Figure 2. View largeDownload slide Left lateral photographs of a 41-year-old woman (A) before and (B) 13 months after a vertical augmentation/mastopexy using 330 cc saline-filled implants (smooth, round, Natrelle Style 68 MP, Allergan plc, Dublin, Ireland). The resection weight was 47 g. She underwent a simultaneous abdominoplasty and liposuction of the abdomen and flanks. Breast projection and upper pole projection are increased by the implant. MPost, plane of maximum postoperative breast projection. Figure 2. View largeDownload slide Left lateral photographs of a 41-year-old woman (A) before and (B) 13 months after a vertical augmentation/mastopexy using 330 cc saline-filled implants (smooth, round, Natrelle Style 68 MP, Allergan plc, Dublin, Ireland). The resection weight was 47 g. She underwent a simultaneous abdominoplasty and liposuction of the abdomen and flanks. Breast projection and upper pole projection are increased by the implant. MPost, plane of maximum postoperative breast projection. Before recommending mesh to our patients, plastic surgeons should be aware of its lack of proven efficacy, the need for a suboptimal mastopexy design to accommodate the mesh, and the availability of a superior alternative (breast implants) at about the same cost. Disclosures Dr Swanson receives royalties from Springer Nature (New York, NY). Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Adams WPJr, Baxter R, Glicksman C, Mast BA, Tantillo M, Van Natta BW. The use of poly-4-hydroxybutyrate (P4HB) scaffold in the ptotic breast: a multicenter clinical study. Aesthet Surg J . 2018; 38( 5): 502– 518. Google Scholar CrossRef Search ADS   2. Góes JC. Periareolar mastopexy: double skin technique with mesh support. Aesthet Surg J . 2003; 23( 2): 129- 135. Google Scholar CrossRef Search ADS PubMed  3. de Bruijn HP, Johannes S. Mastopexy with 3D preshaped mesh for long-term results: development of the internal bra system. Aesthetic Plast Surg . 2008; 32( 5): 757- 765. Google Scholar CrossRef Search ADS PubMed  4. van Deventer PV, Graewe FR, Würinger E. Improving the longevity and results of mastopexy and breast reduction procedures: reconstructing an internal breast support system with biocompatible mesh to replace the supporting function of the ligamentous suspension. Aesthetic Plast Surg . 2012; 36( 3): 578- 589. Google Scholar CrossRef Search ADS PubMed  5. Adams WPJr, Toriumi DM, Van Natta BW. Clinical use of GalaFLEX in facial and breast cosmetic plastic surgery. Aesthet Surg J . 2016; 36( Suppl 2): S23- S32. Google Scholar CrossRef Search ADS PubMed  6. Thunderdome: Mastopexy—Dueling Perspectives . Annual Meeting of the American Society of Plastic Surgeons. Los Angeles, CA, September 23–27, 2016. 7. Swanson E. The myth of breast autoaugmentation. In: Evidence-Based Cosmetic Breast Surgery . New York, NY: Springer; 2017: 107- 120. Google Scholar CrossRef Search ADS   8. Swanson E. Why the nipple is an unreliable marker for measuring breast ptosis. Aesthet Surg J . 2017; 37( 2): NP24- NP26. Google Scholar CrossRef Search ADS PubMed  9. Cruz-Korchin N, Korchin L. Vertical versus Wise pattern breast reduction: patient satisfaction, revision rates, and complications. Plast Reconstr Surg . 2003; 112( 6): 1573- 1578; discussion 1579. Google Scholar CrossRef Search ADS PubMed  10. Swanson E. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg . 2013; 66( 7): 937- 949. Google Scholar CrossRef Search ADS PubMed  11. Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg . 2013; 131: 802e- 819e. Google Scholar CrossRef Search ADS PubMed  12. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg . 2011; 128( 6): 1282- 1301. Google Scholar CrossRef Search ADS PubMed  13. U.S. Food and Drug Administration Product Classification. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/classification.cfm?ID=5724. Accessed February 5, 2018. 14. Swanson E. Comparison of vertical and inverted-T mammaplasties using photographic measurements. Plast Reconstr Surg Glob Open . 2013; 1( 9): e89. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Evaluating the Effect of Implantable Mesh in Mammaplasty

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Oxford University Press
Copyright
© 2018 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/sjy056
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Abstract

Adams et al1 revive the concept of an internal bra. Proponents of implanted mesh have long claimed improved breast projection and maintenance of breast shape.2-5 De Bruijn and Johannes and van Deventer et al abandoned mesh sheets and tried using mesh that was preshaped into a cone.3,4 However, measurements on matched photographs fail to support its efficacy.6,7 Because the Regnault classification relates the nipple level rather than the gland level to the inframammary fold, a patient may still have glandular ptosis despite a favorable Regnault rating.8 One-dimensional measurements with a tape measure are laborious, imprecise, and antiquated. Inexplicably, no before-and-after measurements are provided.1 The change in measurements between various times after surgery (ie, not comparing with measurements before surgery) are given instead. Patient satisfaction scores are likely to be favorable simply because breast reduction provides symptomatic relief, whether mesh is used or not. Other studies of mastopexy and reduction patients treated without mesh show similar patient satisfaction scores.9,10 Lateral photographs are most valuable because they allow comparison of the gland level and nipple level.11,12 Surprisingly, the authors provide plenty of frontal and oblique views, but no lateral photographs. Adams et al do provide 3-dimensional lateral images for one patient (Figure 1). However, the right and left postoperative images are magnified 23% and 28% respectively compared with the preoperative images. Góes also magnified and tilted his postoperative lateral photograph (42% and 11°).6,7 Figure 1. View largeDownload slide (A) Preoperative and (B) postoperative right lateral 3D images of a 58-year-old woman 1 year after a right breast reduction (resection weight unknown) and left mastopexy, performed using a central mound technique and mesh. The images have been matched for size and orientation using the Canfield Mirror 7.4.1 imaging system (Canfield Scientific, Fairfield NJ), correcting an original 23% magnification and a slight (1°) upward tilt of the postoperative image, and accounting for the oblique black margins. Breast projection and upper pole projection are essentially unchanged. The images are calibrated to approximate those of Figure 2, with a torso length of about 30 cm. MPost, level of maximum postoperative breast projection. Adapted from Figure 7, Adams et al.1 Figure 1. View largeDownload slide (A) Preoperative and (B) postoperative right lateral 3D images of a 58-year-old woman 1 year after a right breast reduction (resection weight unknown) and left mastopexy, performed using a central mound technique and mesh. The images have been matched for size and orientation using the Canfield Mirror 7.4.1 imaging system (Canfield Scientific, Fairfield NJ), correcting an original 23% magnification and a slight (1°) upward tilt of the postoperative image, and accounting for the oblique black margins. Breast projection and upper pole projection are essentially unchanged. The images are calibrated to approximate those of Figure 2, with a torso length of about 30 cm. MPost, level of maximum postoperative breast projection. Adapted from Figure 7, Adams et al.1 Mesh implantation requires parenchymal exposure.1 A “mastopexy-wrecking” lower pole bulge is preserved. The mesh method is inapplicable to a vertical mammaplasty because the lower pole tissue is resected and the flaps are not undermined to allow a surface on which to place the mesh. This surgical film is approved for reinforcement of fascial defects, not breast surgery.13 There is no evidence that placing mesh on the intact deep dermis of a deepithelialized inferior pedicle (ie, not bridging a hernia) prevents horizontal stretching of the buried pedicle. A traditional inverted-T, inferior pedicle mammaplasty (paradoxically) trades projection for width. This is the geometric effect of closing a horizontal ellipse. A vertical mammaplasty does the reverse, trading width for projection by closing a vertical ellipse.11,12 A central mound method does neither and requires major undermining, jeopardizing skin circulation and nipple/areola innervation, with no benefit in breast projection or lower pole elevation.12 Measurements comparing the traditional inverted-T, inferior pedicle to vertical mammaplasty show improved breast projection and upper pole projection after a vertical mammaplasty and more conical lower poles.14 The long “anchor” scar (Figure 1), constriction of the lower pole, boxy lower poles, and nipple overelevation (evident in almost all the figures) are all characteristic features of the Wise pattern and inferior pedicle.12,14 The only randomized study comparing the aesthetic result finds that women prefer the vertical mammaplasty, both in terms of shape and reduced scarring.9 The authors defend the lack of a control group by stating that some of their surgeons believed it would be unethical not to offer mesh and that all patients insist on having mesh if given the choice.1 The surgeon survey found that 100% of participating surgeons preferred to use mesh in all patients and the 1-year result was satisfactory in 100% of patients – a testament to surgeon bias. At 6 months there were 3 patients with results deemed unsatisfactory by the surgeon (n = 59), but none at 1 year (n = 56). It is unclear what is meant by “satisfactory.” The questionnaire (the authors’ Appendix A) asks surgeons how well the mesh performed, not the quality of the surgical result.1 The title of the authors’ Table 7 specifies a (hypothetical) “comparison to procedure without mesh.”1 Remarkably, Adams et al1 suggest that the results using mesh exceed those of augmentation/mastopexy. The authors favorably compare their all-satisfactory surgical evaluations with a Brazilian study of 20 postbariatric augmentation/mastopexies in which the 3 surgeons rated the results “regular, good, or optimal” in 91.6% of patients, as opposed to 100% in the authors’ study. A comparison between mammaplasty with mesh (Figure 1) and a vertical augmentation/mastopexy (Figure 2) makes clear the superiority of augmentation/mastopexy. Many plastic surgeons offer breast implants to the majority of women presenting for mastopexy.11 Indeed, it may be unethical to withhold the breast implant option from women, telling them that the internal bra (cost of mesh: $12006) will perform just as well. True, breast implants come with complications, but so does mesh.1 A breast implant is a superior alternative for the very reason the authors acknowledge – breast tissue is too malleable to provide a lasting boost in upper pole volume.11 Figure 2. View largeDownload slide Left lateral photographs of a 41-year-old woman (A) before and (B) 13 months after a vertical augmentation/mastopexy using 330 cc saline-filled implants (smooth, round, Natrelle Style 68 MP, Allergan plc, Dublin, Ireland). The resection weight was 47 g. She underwent a simultaneous abdominoplasty and liposuction of the abdomen and flanks. Breast projection and upper pole projection are increased by the implant. MPost, plane of maximum postoperative breast projection. Figure 2. View largeDownload slide Left lateral photographs of a 41-year-old woman (A) before and (B) 13 months after a vertical augmentation/mastopexy using 330 cc saline-filled implants (smooth, round, Natrelle Style 68 MP, Allergan plc, Dublin, Ireland). The resection weight was 47 g. She underwent a simultaneous abdominoplasty and liposuction of the abdomen and flanks. Breast projection and upper pole projection are increased by the implant. MPost, plane of maximum postoperative breast projection. Before recommending mesh to our patients, plastic surgeons should be aware of its lack of proven efficacy, the need for a suboptimal mastopexy design to accommodate the mesh, and the availability of a superior alternative (breast implants) at about the same cost. Disclosures Dr Swanson receives royalties from Springer Nature (New York, NY). Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Adams WPJr, Baxter R, Glicksman C, Mast BA, Tantillo M, Van Natta BW. The use of poly-4-hydroxybutyrate (P4HB) scaffold in the ptotic breast: a multicenter clinical study. Aesthet Surg J . 2018; 38( 5): 502– 518. Google Scholar CrossRef Search ADS   2. Góes JC. Periareolar mastopexy: double skin technique with mesh support. Aesthet Surg J . 2003; 23( 2): 129- 135. Google Scholar CrossRef Search ADS PubMed  3. de Bruijn HP, Johannes S. Mastopexy with 3D preshaped mesh for long-term results: development of the internal bra system. Aesthetic Plast Surg . 2008; 32( 5): 757- 765. Google Scholar CrossRef Search ADS PubMed  4. van Deventer PV, Graewe FR, Würinger E. Improving the longevity and results of mastopexy and breast reduction procedures: reconstructing an internal breast support system with biocompatible mesh to replace the supporting function of the ligamentous suspension. Aesthetic Plast Surg . 2012; 36( 3): 578- 589. Google Scholar CrossRef Search ADS PubMed  5. Adams WPJr, Toriumi DM, Van Natta BW. Clinical use of GalaFLEX in facial and breast cosmetic plastic surgery. Aesthet Surg J . 2016; 36( Suppl 2): S23- S32. Google Scholar CrossRef Search ADS PubMed  6. Thunderdome: Mastopexy—Dueling Perspectives . Annual Meeting of the American Society of Plastic Surgeons. Los Angeles, CA, September 23–27, 2016. 7. Swanson E. The myth of breast autoaugmentation. In: Evidence-Based Cosmetic Breast Surgery . New York, NY: Springer; 2017: 107- 120. Google Scholar CrossRef Search ADS   8. Swanson E. Why the nipple is an unreliable marker for measuring breast ptosis. Aesthet Surg J . 2017; 37( 2): NP24- NP26. Google Scholar CrossRef Search ADS PubMed  9. Cruz-Korchin N, Korchin L. Vertical versus Wise pattern breast reduction: patient satisfaction, revision rates, and complications. Plast Reconstr Surg . 2003; 112( 6): 1573- 1578; discussion 1579. Google Scholar CrossRef Search ADS PubMed  10. Swanson E. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg . 2013; 66( 7): 937- 949. Google Scholar CrossRef Search ADS PubMed  11. Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg . 2013; 131: 802e- 819e. Google Scholar CrossRef Search ADS PubMed  12. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg . 2011; 128( 6): 1282- 1301. Google Scholar CrossRef Search ADS PubMed  13. U.S. Food and Drug Administration Product Classification. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/classification.cfm?ID=5724. Accessed February 5, 2018. 14. Swanson E. Comparison of vertical and inverted-T mammaplasties using photographic measurements. Plast Reconstr Surg Glob Open . 2013; 1( 9): e89. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Aesthetic Surgery JournalOxford University Press

Published: Apr 25, 2018

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