Mastopexy and Mastopexy-Augmentation

Mastopexy and Mastopexy-Augmentation Abstract Mastopexy and mastopexy-augmentation are aesthetic breast surgeries that seek to create youthful, beautiful appearing breasts. Age, hormonal changes, or weight loss can lead to alterations that require addressing the skin envelope and breast parenchyma. Many surgical approaches have been described including periareolar, vertical, and Wise pattern techniques, but most modern mastopexies include manipulation of the breast parenchyma to improve the longevity of breast ptosis correction. Mesh support of the ptotic breast is an extension of this paradigm shift and seeks to restore the lost strength of the support structures of the breast. Despite initial controversy, single stage mastopexy-augmentation has been demonstrated to be a safe option for appropriately selected and informed patients who desire both correction of shape and volume. Revisions may still be necessary based on patient and surgeon goals for correction. Evolving technologies will likely continue to enhance the ability of aesthetic plastic surgeons to provide pleasing, durable correction of breast ptosis. Learning Objectives The reader is presumed to have basic knowledge and understanding of breast anatomy and mastopexy and mastopexy-augmentation procedures. After reading this review, the reader should be able to: Identify a suitable candidate for mastopexy vs mastopexy-augmentation. Discuss common techniques and potential pitfalls of different mastopexies including the use of mesh and special circumstances including explantation mastopexy. Identify potential risks and benefits of single stage mastopexy-augmentation. The American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this Continuing Medical Education (CME) examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. Aesthetic surgery of the breast encompasses a spectrum of options from mastopexy to mastopexy-augmentation. Reducing the discrepancy between skin envelope and breast parenchyma and can either be addressed from the “outside-in” with skin redraping, from the “inside-out” with parenchymal augmentation, or a combination of the two. Mastopexy aims to create a beautiful breast by primarily addressing shape and differs from augmentation where the primary goal is to alter the size of the breast. The two procedures are, however, not completely discordant and can actually complement one another as they address different parts of the breast (skin vs parenchyma). Over the past ten years, there has been a paradigm shift in our understanding of the results, staging, and safety of mastopexy and mastopexy-augmentation. Mastopexies continue to be in the top five surgeries offered by members of the American Society for Aesthetic Plastic Surgery (ASAPS) as of 2016 and have increased in number sevenfold when compared to 1997.1 Recent studies of litigation in aesthetic breast surgery have shown relatively low number of litigated cases in mastopexy and mastopexy-augmentation when compared to augmentation and reduction, which are the most commonly litigated aesthetic breast procedures. This is a change from prior when periareolar mastopexy-augmentation was once considered the most litigious procedure. These trends suggest that mastopexy and mastopexy-augmentation techniques have become safer and more acceptable to better-informed patients.2,3 Preoperative Evaluation The preoperative consultation is an opportunity to understand the patient’s goals and anatomy, and help the patient navigate a treatment choice that will help them achieve a beautiful appearing breast. Patients should be asked if they are bothered by the shape or size of the breasts or both. This can help differentiate between the need for a mastopexy, augmentation, or mastopexy-augmentation. However often the patient’s complaints may not match their physical exam. Objective assessment by the plastic surgeon needs to be made in the context of a patient’s goals to optimize the outcome that they are seeking. History should include a summary of previous surgeries, existing asymmetries, and a breast health evaluation. This includes past history of breast cancer, abnormal mammograms, and desire for future breast feeding. Patient’s weight history should be documented including any major changes or surgical weight loss. Patients being evaluated for secondary mastopexy or mastopexy-augmentation should be asked for previous operative reports, if available. While scars and examination can provide a roadmap, operative notes can provide essential information that may help avoid devastating complications associated with compromised blood supply to the nipple and incisions. Obtaining these operative records can often be challenging if not impossible. Breast Analysis Physical examination should include assessment of body mass index (BMI) as well as breast measurements. These include base width, sternal notch to nipple distance, nipple to inframammary fold distance, areola diameter and inter-nipple distance. Three-dimensional (3D) imaging software has emerged as a new way to obtain these measurements as well. Reviewing the imaging with the patient is also a very useful educational tool. Often the anatomy and asymmetries are more visible to the patient in a photo than the mirror. A critical assessment of asymmetries including the size, shape, nipple position, and areolar geometry should be performed and reviewed with the patient. Asymmetries may require correction or can persist and be more noticeable after surgery, particularly if augmentation is also being considered. The location of the breast and its footprint on the chest wall should be assessed. As described by Hall-Findlay, a patient can be “high” or “low” breasted depending on where the breast sits on the chest wall relative to the clavicle and humerus.4 Manipulation of the breast footprint is limited, but the upper breast border can be altered by placement of an implant or fat grafting. Chest wall abnormalities and asymmetries as well as scoliosis should be assessed. Examining the breasts with the patient supine can help assess asymmetries in projection. The location of the nipple relative to the inframammary fold as well as gland should be noted as this traditionally measures the degree of ptosis (Table 1, Figure 1). The density of the breasts and degree of superior pole involution should be examined. An assessment of the soft tissue dynamics including the motion of the skin relative to the parenchyma as well as upper pole fullness must be made and is of particular importance in massive weight loss and postpartum women.5 Table 1. Regnault’s Classification of Breast Ptosis Grade  Degree  Description  Pseudoptosis  -  Nipple at the IMF but gland below the IMF  I  Mild  Nipple at or within 1 cm below the IMF  II  Moderate  Nipple below the IMF but above the lowest point of the breast  III  Severe  Nipple at the lowest point of the breast  Grade  Degree  Description  Pseudoptosis  -  Nipple at the IMF but gland below the IMF  I  Mild  Nipple at or within 1 cm below the IMF  II  Moderate  Nipple below the IMF but above the lowest point of the breast  III  Severe  Nipple at the lowest point of the breast  IMF, inframammary fold. View Large Figure 1. View largeDownload slide Grades of breast ptosis based on nipple and gland position relative to the inframammary fold (IMF). Figure 1. View largeDownload slide Grades of breast ptosis based on nipple and gland position relative to the inframammary fold (IMF). Informed consent is a critical portion of any mastopexy consultation and includes a discussion of risks of the procedure including possible need for revisions. When combined with augmentation, a separate discussion of the risks of the devices themselves must be made. If augmentation is being performed with fat grafting alone, discussion of fat grafting risks should also be made. Photodocumentation is imperative and also helps with patient discussions about asymmetries that exist preoperatively. Specific discussion of scars as well as risk of changes in sensitivity to the nipples should be addressed. Often, drawings and photographs of postoperative results can help establish realistic expectations of scar placement and visibility. Imaging Routine imaging of the breast with mammography is not indicated outside the guidelines of the US Preventive Services Task Force, whose 2016 recommendations were based on age over 40 and risk.6 Three-dimensional imaging and simulation in the office can complement routine 2D photographs for the purposes of preoperative consultation, though there is little evidence to support its use. Patients being evaluated for secondary mastopexy or mastopexy-augmentation with a history of implants, rupture, or capsular contracture may have imaging including ultrasound and/or MRI whose review can be helpful. Surgical Approach Skin only mastopexy has fallen out of favor since the time of Benelli who favored parenchymal redistribution in addition to skin redraping.7 This was a major paradigm shift in aesthetic surgery of the breast. Operations that manipulated the skin alone relied on removal of excess skin to buttress and support breast parenchyma. This often lead to unacceptable scaring, incomplete correction of upper pole hollowing, and recurrent ptosis. Modern aesthetic surgery of the breast recognizes the importance of addressing parenchymal involution from aging or postpartum changes and involves some sort of parenchymal redistribution or manipulation in addition to skin excision and redraping (Table 2). Table 2. Different Mastopexy Types: Their Indications, Advantages, and Disadvantages Mastopexy type  Indications  Advantages  Disadvantages  Periareolar  Grade I or II ptosis, nipple asymmetry  Scar hidden at areolar border, can be combined with augmentation  Flattening, deprojection of breast, widened scar  Vertical - SPAIR  All grades of ptosis  Ptosis correction and removal of glandular tissue, little settling  Bottoming out, periareolar widening, pleating, suture spitting  Vertical - Hall-Findlay  All grades of ptosis  Ptosis correction and removal of glandular tissue, structural support of elevated nipple with pillar unification, can be combined with augmentation  Final appearance may take months, persistent asymmetry  Wise pattern  Grade II or III ptosis  Greatest control of skin excision relative to parenchyma, easily adapted from reduction techniques, can be combined with augmentation  Largest scar burden, bottoming out  Mastopexy type  Indications  Advantages  Disadvantages  Periareolar  Grade I or II ptosis, nipple asymmetry  Scar hidden at areolar border, can be combined with augmentation  Flattening, deprojection of breast, widened scar  Vertical - SPAIR  All grades of ptosis  Ptosis correction and removal of glandular tissue, little settling  Bottoming out, periareolar widening, pleating, suture spitting  Vertical - Hall-Findlay  All grades of ptosis  Ptosis correction and removal of glandular tissue, structural support of elevated nipple with pillar unification, can be combined with augmentation  Final appearance may take months, persistent asymmetry  Wise pattern  Grade II or III ptosis  Greatest control of skin excision relative to parenchyma, easily adapted from reduction techniques, can be combined with augmentation  Largest scar burden, bottoming out  SPAIR, short-scar periareolar inferior-pedicle reduction. View Large Periareolar Mastopexy Periareolar mastopexies can be used in patients with grade I or II ptosis or nipple asymmetry with little skin redundancy (Figure 2). It can be used to elevate the nipple at most 2 cm. The markings for mastopexy can be drawn as an eccentric oval around the entire circumference of the areola with preferential height difference superiorly to elevate the nipple. A skin only donut mastopexy differs from a Goes or Benelli mastopexy in that the parenchyma is not manipulated. A crescentic mastopexy is a variation of this where a crescent is drawn above the nipple and an incision is not made circumferentially around the areola. Spear et al described rules when designing a periareolar mastopexy, seeking to reduce widening of scars and pleating.8 Figure 2. View largeDownload slide Periareolar mastopexy incisions and final scar location. Figure 2. View largeDownload slide Periareolar mastopexy incisions and final scar location. The cited benefit of this technique is hiding the scar at the areolar-breast junction. However, the periareolar mastopexy removes skin in a concentric pattern and this can lead to flattening and deprojection of the breast when the areola is inset within the new larger, concentric circle of breast skin. Pleating can occur as the redundancy of the outer circle gathers during the inset. If there is circumferential violation of the dermis to the parenchyma such that the nipple relies on a central mound pedicle, there is a risk of decreased nipple sensitivity with this technique. Some have advocated the use of a permanent or barbed suture to maintain the areolar diameter with time with the thought that increased tension leads to widening of the scar.9 However, periareolar mastopexies have high rates of revision and patient dissatisfaction. In 2001, periareolar mastopexy and augmentation was considered the highest litigated procedure in plastic surgery, though recent data suggest decreased litigation in mastopexy-augmentation procedures. Additionally, physician satisfaction has been lowest with this technique.10 This mastopexy can be accompanied by parenchymal redistribution as described by Benelli.7 With the Benelli technique, augmentation is only safe in the submuscular plane because of blood supply disruption with manipulation of the parenchyma. Periareolar mastopexy has been combined with mesh support by Goes in which a wedge of superior breast tissue is excised, parenchymal flaps united, and mesh placed over the newly shaped breast and tacked to the chest wall.11 With the Goes periareolar technique, breast augmentation should only be done secondarily in the submuscular plane if desired. Vertical Mastopexy Vertical mastopexies have evolved from the described techniques of Lassus, Peixoto, Arie, Pitanguy, Marchac, and Lejour for reduction mammaplasty (Figure 3). They incorporate correction of ptosis with removal of glandular tissue for maintenance of correction and include an extension of the periareolar scar with a vertical component down the meridian of the breast (Figure 4). All grades of breast ptosis have been addressed with vertical mastopexies. Physician satisfaction has been highest with the short-scar periareolar inferior-pedicle reduction (SPAIR) and Hall-Findlay mastopexy techniques.10 Figure 3. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 48-year-old woman taken 1.5 years after bilateral mastopexy with circumvertical technique. Figure 3. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 48-year-old woman taken 1.5 years after bilateral mastopexy with circumvertical technique. Figure 4. View largeDownload slide Vertical mastopexy incisions and final scar location. Figure 4. View largeDownload slide Vertical mastopexy incisions and final scar location. The SPAIR mastopexy developed by Hammond transposes the nipple on an inferior pedicle.12 The technique can incorporate a Gore-Tex periareolar closure as well as pin-wheel or interlocking pattern of periareolar suture placement.13,14 Suspension sutures are used to tack the pedicle superiorly to the chest wall with the goal of maintaining glandular elevation. Skin is then tailor-tacked and excised with closure in a vertical orientation. Sometimes, the redundancy of the skin inferiorly may require excision of the dog ear in a “J” or “T” pattern. There is little settling involved with the final shape of the breast when compared to other techniques. However, bottoming out remains a shortcoming of the technique as it relies on an inferior pedicle. Periareolar widening, pleating, and changes in nipple sensation are all drawbacks of the technique.15 Placement of an implant is not traditionally performed with the SPAIR technique. The Hall-Findlay technique uses a variety of pedicles but most commonly a superomedial or medial pedicle for the nipple-areola complex (NAC) and involves suturing of the medial and lateral pillars of the breast after an inferior wedge of tissue is removed.16 The markings are made such that the inferior most portion of skin excision is above the native inframammary fold (IMF) as the IMF tends to rise in this technique and a lower excision can lead to eventual scar presence on the abdomen. The unification of pillars is thought to provide structural support to the elevated NAC and also narrow the breast. The technique is based on the hypothesis that glandular tissue in the inferior portion of the breast creates a downward pull to the breast, leading to ptosis and bottoming out seen in techniques based on an inferior pedicle. By removing the tissue destined to descend and building structure with the lateral and medial pillars, this technique seeks to maintain a lifted breast. Similar to the SPAIR technique, inferiormost skin redundancy can be addressed with a dog ear excision as a “J” or “T” or gathered with boxing stitches. The mastopexy can be complemented with placement of subglandular or submuscular implant placement without concern for blood supply to the nipple which comes from the second or third internal mammary perforators. The Hall-Findlay technique is often considered a circumvertical mastopexy. Vertical mastopexies tend to create an almost inverted breast shape at the conclusion of the case with exaggerated upper pole fullness and sloped inferior pole. It can take weeks to months for the breast to settle and gain its final appearance. This requires frequent contact and reassurance of patients from providers. Wise Pattern Mastopexy Wise pattern or inverted-T mastopexy has traditionally been used in patients with severe excess of skin relative to breast parenchyma in a patient with severe ptosis. It was first described by Wise in the 1950s with the development of templates for making a skin only mastopexy. However, with developments in reduction mammaplasty techniques, the Wise pattern mastopexy was modified with parenchymal alterations and pedicle designs.17,18 Hence, plastic surgeons familiar with the Wise pattern, inferior pedicle mammaplasty reduction procedure often feel very comfortable with this mastopexy technique. Incisions are made around the areola with extensions for the vertical limbs as in a vertical mastopexy (Figure 5). However, the incisions are carried out laterally and medially to the borders of the breast and carried down and along the inframammary fold. Manipulation of the parenchyma combined with a Wise pattern scar can take on many variations. Ship et al first described double superior pedicles that were “criss-crossed” and also tacked to the pectoralis fascia with a skin resection in a Wise pattern. Since then, techniques have been described by numerous authors with variations in parenchymal manipulation under a Wise-pattern skin excision.19-22 Figure 5. View largeDownload slide Wise pattern mastopexy incisions and final scar location. Figure 5. View largeDownload slide Wise pattern mastopexy incisions and final scar location. This technique has the greatest amount of scar relative to the breast vs other techniques. When associated with an inferior pedicle, it can also have the bottoming out seen in reduction mammaplasty and in a survey of ASAPS members was found to have the greatest frequency of bottoming out.10 This is most likely secondary to the inferior pedicle rather than the skin resection pattern. Additionally, one of the problems with the inverted-T mastopexy is healing at the T-junction, especially when an implant is added. Explantation Mastopexy Patients with a previous history of breast augmentation with an implant may desire explantation without replacement for a number of reasons including but not limited to capsular contracture. When possible, previous operative reports can provide information about plane of dissection and pedicle for NAC blood supply to reduce the risk of complications explantation-mastopexy. Preexplantation level of ptosis has been identified as an important factor in deciding on mastopexy technique either at the time of explantation or in a delayed fashion.23 Explantation-mastopexy has been performed with a vertical technique with high levels of satisfaction.24 Smoking, need for nipple elevation greater than 4 cm, and breast parenchyma thickness less than 4 cm have been identified as possible reasons to delay mastopexy after explantation.25 Patients with a history of saline augmentation can undergo replacement with silicone implants and saline deflation can be useful before implant exchange.26 Wu and Grotting have recommended waiting 4 weeks after deflation to allow for “elastic breast recoil” and gland normalization before proceeded with secondary mastopexy.27 This may also allow for more accurate surgical planning as well as more accurate patient education. When considering replacing an implant the patient has a better sense of their native volume as does the surgeon and this can allow for a more accurate choice for a new implant. Techniques to restore volume including using an inferior dermoglandular flap for autoaugmentation at the time of explantation-mastopexy have been described by Ribiero.28,29 In the authors’ experience, replacement of breast implants in patients with Baker Grade III and IV capsular contractures can be complex. Following capsulectomy, the soft tissue envelope can be patulous with poor lateral support for a fresh breast implant. The breast parenchyma can adhere to the contracted capsule, propped up essentially by the capsule and implant. Simply replacing the device in this new pocket can be problematic. To address this redundant soft tissue envelope several strategies may be considered. One is to place larger breast implants but this, more than likely, will lead to rapid progression towards device migration and malposition. The use of acellular dermal matrices in revisionary breast surgery has been well described.30 Alternatively, some capsule can be retained and used as a capsular flap or capsulorrhaphy to support the lateral pocket or supplemented with a synthetic or biologic mesh. This often combined with a mastopexy to reduce the outer soft tissue lamella so that it matches, along with nipple position, the volume of the breast implant. A staged approach can also be considered. In the first stage, the capsulectomy and explant can be performed and a suction drain placed. The skin envelope can contract, soft tissue healing can occur, and a fresh pocket can be dissected months later to match the new implant, and centralize the nipple-areola, taking advantage of skin retraction to eliminate or limit the need for a skin reducing mastopexy. Little has been published on the topic of mastopexy after explantation for capsular contracture and warrants investigation. Mastopexy in the Massive Weight Loss Patient Mastopexy in the massive weight loss (MWL) patient is a particularly unique and challenging operation as it can be at the far end of the spectrum of excess skin and involuted breast parenchyma.31 This is coupled with wound healing considerations and nutrition specific to patients who have experienced large fluctuations in weight from diet and exercise or surgical weight loss.32 These patients have distortion of the normal footprint of the breast, often with a lateral axillary roll, medialization of nipples, deflated upper pole, and lax inframammary fold. Techniques to restore the shape and volume of the breast include mastopexy (Video 1, available as Supplementary Material online at www.aestheticsurgeryjournal.com), mastopexy with auto-augmentation, and mastopexy-augmentation with an implant. A recent study by Coombs et al identified that mastopexy-augmentation in MWL carries high rates of recurrent ptosis within 3 months (16.7%) and implant malposition (61.9%).31 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Close Rubin has suggested an algorithm for aesthetic breast surgery in MWL patients based on the severity of ptosis, shape of the breast, and degree of involution.33 He describes a technique of dermal suspension autoaugmentation mastopexy using the medial and lateral parenchymal flaps to augment the volume of the breast. His technique involves anchoring of the new breast mound on the chest wall and redraping the skin over the autoaugmented breast. The technique has the advantage of utilizing the lateral axillary fullness to augment the breast mound itself and also address the axillary roll. Multiple parenchymal flaps have been described for autoaugmentation. These include the anterior intercostal perforator flap (ICAP), lateral intercostal perforator flap (LICAP), the spiral flap, a rotation-advancement flap using a superomedial pedicle, and lateral breast flap.34-38 When combined with implant placement, the lateral breast flap has been described for inferior pole coverage of the implant.39 Mastopexy With Mesh Support The use of mesh represents another paradigm shift in mastopexy, but long term follow up with mesh use demonstrating its usefulness is still lacking. Mesh seeks to restore support to a breast that has lost strength in its suspensory system and thereby reduce recurrent ptosis and prolong the longevity of mastopexy results. Mastopexy with mesh support has been described by a number of authors dating back to the 1980s when Marlex Mesh was used to anchor the breast tissue to the second rib.40 More recently, 3D knitted polyester mesh has been used as an “internal bra system” with greater than 4.5 year follow up without major complications.41 Histologic and mechanical studies of explanted mesh have demonstrated induction of collagen formation around the mesh, enhancing the overall strength of the mesh without resultant palpability or extreme stiffness.42 Other groups have also reported success with biocompatible meshes.43 Porcine collagen matrix or FortaPerm (Organogenesis, Canton, MA) has been used by Goes in periareolar mastopexy with reported long term maintenance of elevated breast position.44 Most recently, Adams and Moses described their experience with central mound mastopexy and the use of a poly-4-hydroxybutyrate resorbable scaffold for lower pole support and reported stable results at 1 year without major complications.45 No series of mastopexy with mesh have reported interference with mammography or oncologic safety. Only one case report exists of a chronic abscess in patient who underwent mastopexy with a polypropylene mesh.46 Mastopexy and Fat Grafting Fat has been used in composite breast augmentation and as a simultaneous implant exchange with fat for revision breast implant surgery.47,48 It also has been used as an adjunct in mastopexies following explantation and treatment of double-bubble deformities.49 Its use in mastopexy alone has not been well described in the literature. Mastopexy-Augmentation Augmentation of the breast can be combined with mastopexy in a single or two-staged fashion using autologous breast tissue, implants, or fat (Video 2, available as Supplementary Material online at www.aestheticsurgeryjournal.com). Details of breast augmentation alone are beyond the scope of the present review but augmentation can be performed with an implant in the submuscular or subfascial/subglandular plane (Figure 6). The surgeon must be mindful about blood supply to the NAC when performing an augmentation in conjunction with mastopexy. Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Close Figure 6. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 36-year-old woman taken 5 years after bilateral mastopexy-augmentation using Allergan Style 15, 339 cc bilaterally in dual-plane pocket with circumvertical mastopexy. Figure 6. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 36-year-old woman taken 5 years after bilateral mastopexy-augmentation using Allergan Style 15, 339 cc bilaterally in dual-plane pocket with circumvertical mastopexy. Many of the autoaugmentation options are similar to those applied for MWL patients, as described above. They can also include a superior pedicle dermoglandular flap aimed at restoring central mound projection and narrowing the width of the breast.50 Breast augmentation can also be performed with autologous fat and its techniques are described elsewhere.51 Prosthetic augmentation and mastopexy at a single stage has been a largely controversial topic since 2003 when Spear published “Augmentation/Mastopexy: ‘Surgeon, Beware” though one of the first publications on the topic dates to the late 1970s.52 A series of publications that described the safety and revision rate of such procedures have stimulated healthy discussion about the safety of single-stage mastopexy-augmentation in well-selected and informed patients.53 Stevens et al published a series of reports of one-stage mastopexy augmentation with revision rates between 8.6% to 16.7% with his largest series of 1192 mastopexy-augmentations having a 16.9% revision rate most commonly associated with the implant.54-56 Calobrace et al also published a series of 332 mastopexy-augmentations with a complication rate of 22.9% and revision rate of 23.2%.57 Swanson specifically looked at tissue perfusion in mastopexy-augmentation with a vertical technique and concluded that simultaneous mastopexy-augmentation with an implant does not compromise perfusion to the NAC based on a medial pedicle.58 A recent meta-analysis of 23 studies with 4856 cases of single-stage mastopexy-augmentation found an overall complication rate of 13.1%.59 Pooled complication rates include recurrent ptosis (5.2%), poor scarring (3.74%), capsular contracture (2.97%), asymmetry (2.94%), seroma (1.42%), hematoma (1.37%), infection (0.93%) with a reoperation rate of 10.65%.59 Proponents of single-stage mastopexy-augmentation argue that the revision rate for this procedure is significantly less than the 100% rate of a second procedure with staged mastopexy-augmentation. Ultimately, surgeon comfort and appropriate patient selection will dictate whether to stage or not. Patient Positioning Patients undergoing mastopexy or mastopexy-augmentation are positioned supine on the operating table with their arms extended on arm boards with appropriate padding. The arms and head should be secured in such a way that the patient can be positioned in the upright position for intraoperative assessment of symmetry, shape, and position of the breast and NAC without causing harm. Positioning and securing the arms on arm boards allows for the arms to be manipulated from an abducted to adducted position; with the patient upright, this can help assess nipple position and allow for intraoperative adjustments as necessary. It is also helpful to drape out the upper shoulders to help with judgement of symmetry. Postoperative Care Patients are typically placed in a supportive surgical bra at the end of the case to support the newly lifted breast. This acts like a splint to offload the effects of gravity as the healing process begins. Drains are not routinely used in mastopexy and mastopexy-augmentation procedures. There is no clinical evidence for the routine use of postoperative antibiotics beyond the consensus statement by the American Association for Plastic Surgeons for perioperative antibiotics for surgical site infections.60 Patients may require narcotic pain medication or muscle relaxants, particularly if an augmentation was also performed in the subpectoral plane. Typically, if there are incisions in the inframammary crease, patients are kept in a surgical or sports bra for about a month and then weaned to an underwire bra. Physical activity depending on the nature of the mastopexy and augmentation is slowly graduated to full activity typically by 4 to 6 weeks. Revisions in the authors’ experience are typically held off until 6 months postprocedure. Postoperative Complications, Revisions, and Outcomes A recent database study of complications in aesthetic breast procedures has revolutionized our ability to assess complications after these surgeries on a magnitude never before possible and found a complication rate of 1.15% in mastopexy and 1.86% in mastopexy-augmentation.61 The complication rate of mastopexy-augmentation was found to be significantly higher than that for mastopexy alone. Obesity was associated with infections in mastopexy, which had the lowest complication rate of any aesthetic breast procedure examined. Mastopexy-augmentation was found to have a higher incidence of infection; older patients who had mastopexy-augmentation were also more likely to have a hematoma.61 A survey of physician reported complications after mastopexy found that suture spitting, excess scarring, and bottoming out were the most commonly encountered complications. Of these, suture spitting was reported to be most common with the SPAIR technique, excess scarring with the periareolar technique, and bottoming out with the limited inverted-T technique.10 Periareolar mastopexies had the highest revision rate at 50%. The risks associated with single stage mastopexy-augmentation have been reviewed above. Risks of procedures include hematoma, infection, nipple-areola necrosis, implant visibility and rippling, asymmetry and malposition. Capsular contracture can occur as with primary breast augmentation. Revisions can be performed at the patient and surgeon’s discretion and often involve bottoming out, recurrent ptosis, malposition, and scarring. CONCLUSION Mastopexy and mastopexy-augmentation exist on a spectrum of surgical options to restore a youthful, pleasing shape and volume to a breast that has undergone changes associated with aging or postpartum involution. These aesthetic surgeries are offered to breast reconstruction patients who undergo contralateral balancing procedures for symmetry as well. Many techniques have been described and the field has seen major paradigm shift including rearrangement of breast parenchyma, use of mesh support, and increasing evidence demonstrating the safety of single stage mastopexy-augmentation. While once considered a highly litigated and risky procedure, improved techniques and better patient education on the part of aesthetic surgeons has transformed the way mastopexy and mastopexy-augmentation is currently offered to patients. With the rise of noninvasive devices such as radiofrequency and ultrasound energy technologies, aesthetic surgery of the breast is likely to continue to see novel and innovative ways to meet patient goals and expectations. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential 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. Cosmetic Surgery National Data Bank Statistics. Aesthet Surg J . 2017; 37( suppl 2): 1- 29. 2. Paik AM, Mady LJ, Sood A, Eloy JA, Lee ES. A look inside the courtroom: an analysis of 292 cosmetic breast surgery medical malpractice cases. Aesthet Surg J . 2014; 34( 1): 79- 86. Google Scholar CrossRef Search ADS PubMed  3. Gorney M. Ten years’ experience in aesthetic surgery malpractice claims. Aesthet Surg J . 2001; 21( 6): 569- 571. Google Scholar CrossRef Search ADS PubMed  4. Hall-Findlay EJ. The three breast dimensions: analysis and effecting change. Plast Reconstr Surg . 2010; 125( 6): 1632- 1642. Google Scholar CrossRef Search ADS PubMed  5. Vegas MR, Martin del Yerro JL. 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Mastopexy preferences: a survey of board-certified plastic surgeons. Plast Reconstr Surg . 2006; 118( 7): 1631- 1638. Google Scholar CrossRef Search ADS PubMed  11. Góes JC. Periareolar mammaplasty: double skin technique with application of polyglactine or mixed mesh. Plast Reconstr Surg . 1996; 97( 5): 959- 968. Google Scholar CrossRef Search ADS PubMed  12. Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using the short scar periareolar inferior pedicle reduction technique. Plast Reconstr Surg . 2008; 121( 5): 1533- 1539. Google Scholar CrossRef Search ADS PubMed  13. Hammond DC, O’Connor EA, Knoll GM. The short-scar periareolar inferior pedicle reduction technique in severe mammary hypertrophy. Plast Reconstr Surg . 2015; 135( 1): 34- 40. Google Scholar CrossRef Search ADS PubMed  14. Chapman J, Ingram S. The gore-tex suture in periareolar closure: a modified closure technique. Aesthetic Plast Surg . 2016; 40( 6): 885- 886. Google Scholar CrossRef Search ADS PubMed  15. Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast Reconstr Surg . 1999; 103( 3): 890- 901; discussion 902. Google Scholar CrossRef Search ADS PubMed  16. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg . 2002; 29( 3): 379- 391. Google Scholar CrossRef Search ADS PubMed  17. Ship AG, Weiss PR, Engler AM. Dual-pedicle dermoparenchymal mastopexy. Plast Reconstr Surg . 1989; 83( 2): 281- 290. Google Scholar CrossRef Search ADS PubMed  18. Goulian D. Dermal mastopexy. Clin Plast Surg . 1976; 3( 2): 171- 175. Google Scholar PubMed  19. Flowers RS, Smith EMJr. “Flip-flap” mastopexy. Aesthetic Plast Surg . 1998; 22( 6): 425- 429. Google Scholar CrossRef Search ADS PubMed  20. Graf R, Biggs TM. In search of better shape in mastopexy and reduction mammoplasty. Plast Reconstr Surg . 2002; 110( 1): 309- 317; discussion 318. Google Scholar CrossRef Search ADS PubMed  21. Svedman P. Correction of breast ptosis utilizing a “fold over” de-epithelialized lower thoracic fasciocutaneous flap. Aesthetic Plast Surg . 1991; 15( 1): 43- 47. Google Scholar CrossRef Search ADS PubMed  22. Foustanos A, Zavrides H. A double-flap technique: an alternative mastopexy approach. Plast Reconstr Surg . 2007; 120( 1): 55- 60. Google Scholar CrossRef Search ADS PubMed  23. Rohrich RJ, Beran SJ, Restifo RJ, Copit SE. Aesthetic management of the breast following explantation: evaluation and mastopexy options. Plast Reconstr Surg . 1998; 101( 3): 827- 837. Google Scholar CrossRef Search ADS PubMed  24. Schneider MS, Gouverne ML. Explantation and mastopexy: the vertical mammaplasty technique to optimize breast shape. Aesthet Surg J . 1997; 17( 1): 18- 21. Google Scholar CrossRef Search ADS PubMed  25. Rohrich RJ, Parker TH3rd. Aesthetic management of the breast after explantation: evaluation and mastopexy options. Plast Reconstr Surg . 2007; 120( 1): 312- 315. Google Scholar CrossRef Search ADS PubMed  26. Stevens WG, Pacella SJ, Hirsch E, Stoker DA. Patient retention and replacement trends after saline breast implants: are deflations inflationary? Aesthetic Plast Surg . 2009; 33( 1): 54- 57. Google Scholar CrossRef Search ADS PubMed  27. Wu C, Grotting JC. Preoperative saline implant deflation in revisional aesthetic breast surgery. Aesthet Surg J . 2015; 35( 7): 810- 818. Google Scholar CrossRef Search ADS PubMed  28. Gurunluoglu R, Sacak B, Arton J. Outcomes analysis of patients undergoing autoaugmentation after breast implant removal. Plast Reconstr Surg . 2013; 132( 2): 304- 315. Google Scholar CrossRef Search ADS PubMed  29. Ribeiro L, Accorsi AJr, Buss A, Marcal-Pessoa M. Creation and evolution of 30 years of the inferior pedicle in reduction mammaplasties. Plast Reconstr Surg . 2002; 110( 3): 960- 970. Google Scholar CrossRef Search ADS PubMed  30. Maxwell GP, Gabriel A. Acellular dermal matrix for reoperative breast augmentation. Plast Reconstr Surg . 2014; 134( 5): 932- 938. Google Scholar CrossRef Search ADS PubMed  31. Coombs DM, Srivastava U, Amar D, Rubin JP, Gusenoff JA. The challenges of augmentation mastopexy in the massive weight loss patient: technical considerations. Plast Reconstr Surg . 2017; 139( 5): 1090- 1099. Google Scholar CrossRef Search ADS PubMed  32. Small KH, Constantine R, Eaves FF3rd, Kenkel JM. Lessons learned after 15 years of circumferential bodylift surgery. Aesthet Surg J . 2016; 36( 6): 681- 692. Google Scholar CrossRef Search ADS PubMed  33. Rubin JP. Mastopexy after massive weight loss: dermal suspension and total parenchymal reshaping. Aesthet Surg J . 2006; 26( 2): 214- 222. Google Scholar CrossRef Search ADS PubMed  34. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast reshaping: the spiral flap. Ann Plast Surg . 2006; 56( 5): 481- 486; discussion 486. Google Scholar CrossRef Search ADS PubMed  35. Losken A, Holtz DJ. Versatility of the superomedial pedicle in managing the massive weight loss breast: the rotation-advancement technique. Plast Reconstr Surg . 2007; 120( 4): 1060- 1068. Google Scholar CrossRef Search ADS PubMed  36. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap. Ann Plast Surg . 2006; 57( 4): 361- 365. Google Scholar CrossRef Search ADS PubMed  37. Hamdi M. A mastopexy with lateral intercostal artery perforator (LICAP) flaps for patients after massive weight loss. Ann Plast Surg . 2007; 58( 5): 588; author reply 588. Google Scholar CrossRef Search ADS PubMed  38. Akyurek M. Vertical mastopexy and lateral intercostal artery perforator (LICAP) flap with pectoralis muscle sling for autologous tissue breast augmentation in the bariatric patient. Ann Plast Surg . 2011; 66( 1): 29- 35. Google Scholar CrossRef Search ADS PubMed  39. Calvert JW, Dickinson BP, Patel A, Brenner K. Lateral breast flap with superomedial pedicle breast lift. Aesthet Surg J . 2011; 31( 6): 658- 666. Google Scholar CrossRef Search ADS PubMed  40. Johnson GW. Central core reduction mammoplasties and Marlex suspension of breast tissue. Aesthetic Plast Surg . 1981; 5( 1): 77- 84. Google Scholar CrossRef Search ADS PubMed  41. 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  42. de Bruijn HP, ten Thije RH, Johannes S. Mastopexy with mesh reinforcement: the mechanical characteristics of polyester mesh in the female breast. Plast Reconstr Surg . 2009; 124( 2): 364- 371. Google Scholar CrossRef Search ADS PubMed  43. 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  44. Goes JC, Bates D. Periareolar mastopexy with FortaPerm. Aesthetic Plast Surg . 2010; 34( 3): 350- 358. Google Scholar CrossRef Search ADS PubMed  45. Adams WPJr, Moses AC. Use of poly-4-hydroxybutyrate mesh to optimize soft-tissue support in mastopexy: a single-site study. Plast Reconstr Surg . 2017; 139( 1): 67- 75. Google Scholar CrossRef Search ADS PubMed  46. Dixon JM, Arnott I, Schaverien M. Chronic abscess formation following mesh mastopexy: case report. J Plast Reconstr Aesthet Surg . 2010; 63( 7): 1220- 1222. Google Scholar CrossRef Search ADS PubMed  47. Auclair E, Blondeel P, Del Vecchio DA. Composite breast augmentation: soft-tissue planning using implants and fat. 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Google Scholar CrossRef Search ADS PubMed  52. Owsley JQJr. Simultaneous mastopexy and augmentation for correction of the small, ptotic breast. Ann Plast Surg . 1979; 2( 3): 195- 200. Google Scholar CrossRef Search ADS PubMed  53. Beale EW, Ramanadham S, Harrison B, Rasko Y, Armijo B, Rohrich RJ. Achieving predictability in augmentation mastopexy. Plast Reconstr Surg . 2014; 133( 3): 284e- 292e. Google Scholar CrossRef Search ADS PubMed  54. Stevens WG, Freeman ME, Stoker DA, Quardt SM, Cohen R, Hirsch EM. One-stage mastopexy with breast augmentation: a review of 321 patients. Plast Reconstr Surg . 2007; 120( 6): 1674- 1679. Google Scholar CrossRef Search ADS PubMed  55. Stevens WG, Macias LH, Spring M, Stoker DA, Chacón CO, Eberlin SA. One-stage augmentation mastopexy: a review of 1192 simultaneous breast augmentation and mastopexy procedures in 615 consecutive patients. Aesthet Surg J . 2014; 34( 5): 723- 732. Google Scholar CrossRef Search ADS PubMed  56. Stevens WG, Stoker DA, Freeman ME, Quardt SM, Hirsch EM, Cohen R. Is one-stage breast augmentation with mastopexy safe and effective? A review of 186 primary cases. Aesthet Surg J . 2006; 26( 6): 674- 681. Google Scholar CrossRef Search ADS PubMed  57. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous augmentation/mastopexy: a retrospective 5-year review of 332 consecutive cases. Plast Reconstr Surg . 2013; 131( 1): 145- 156. Google Scholar CrossRef Search ADS PubMed  58. Swanson E. Safety of vertical augmentation-mastopexy: prospective evaluation of breast perfusion using laser fluorescence imaging. Aesthet Surg J . 2015; 35( 8): 938- 949. Google Scholar CrossRef Search ADS PubMed  59. Khavanin N, Jordan SW, Rambachan A, Kim JY. A systematic review of single-stage augmentation-mastopexy. Plast Reconstr Surg . 2014; 134( 5): 922- 931. Google Scholar CrossRef Search ADS PubMed  60. Ariyan S, Martin J, Lal Aet al.   Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons. Plast Reconstr Surg . 2015; 135( 6): 1723- 1739. Google Scholar CrossRef Search ADS PubMed  61. Gupta V, Yeslev M, Winocour Jet al.   Aesthetic breast surgery and concomitant procedures: incidence and risk factors for major complications in 73,608 cases. Aesthet Surg J . 2017; 37( 5): 515- 527. Google Scholar CrossRef Search ADS PubMed  © 2018 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

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Abstract

Abstract Mastopexy and mastopexy-augmentation are aesthetic breast surgeries that seek to create youthful, beautiful appearing breasts. Age, hormonal changes, or weight loss can lead to alterations that require addressing the skin envelope and breast parenchyma. Many surgical approaches have been described including periareolar, vertical, and Wise pattern techniques, but most modern mastopexies include manipulation of the breast parenchyma to improve the longevity of breast ptosis correction. Mesh support of the ptotic breast is an extension of this paradigm shift and seeks to restore the lost strength of the support structures of the breast. Despite initial controversy, single stage mastopexy-augmentation has been demonstrated to be a safe option for appropriately selected and informed patients who desire both correction of shape and volume. Revisions may still be necessary based on patient and surgeon goals for correction. Evolving technologies will likely continue to enhance the ability of aesthetic plastic surgeons to provide pleasing, durable correction of breast ptosis. Learning Objectives The reader is presumed to have basic knowledge and understanding of breast anatomy and mastopexy and mastopexy-augmentation procedures. After reading this review, the reader should be able to: Identify a suitable candidate for mastopexy vs mastopexy-augmentation. Discuss common techniques and potential pitfalls of different mastopexies including the use of mesh and special circumstances including explantation mastopexy. Identify potential risks and benefits of single stage mastopexy-augmentation. The American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this Continuing Medical Education (CME) examination online by logging on to the CME portion of ASJ’s website (http://asjcme.oxfordjournals.org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on the article. Aesthetic surgery of the breast encompasses a spectrum of options from mastopexy to mastopexy-augmentation. Reducing the discrepancy between skin envelope and breast parenchyma and can either be addressed from the “outside-in” with skin redraping, from the “inside-out” with parenchymal augmentation, or a combination of the two. Mastopexy aims to create a beautiful breast by primarily addressing shape and differs from augmentation where the primary goal is to alter the size of the breast. The two procedures are, however, not completely discordant and can actually complement one another as they address different parts of the breast (skin vs parenchyma). Over the past ten years, there has been a paradigm shift in our understanding of the results, staging, and safety of mastopexy and mastopexy-augmentation. Mastopexies continue to be in the top five surgeries offered by members of the American Society for Aesthetic Plastic Surgery (ASAPS) as of 2016 and have increased in number sevenfold when compared to 1997.1 Recent studies of litigation in aesthetic breast surgery have shown relatively low number of litigated cases in mastopexy and mastopexy-augmentation when compared to augmentation and reduction, which are the most commonly litigated aesthetic breast procedures. This is a change from prior when periareolar mastopexy-augmentation was once considered the most litigious procedure. These trends suggest that mastopexy and mastopexy-augmentation techniques have become safer and more acceptable to better-informed patients.2,3 Preoperative Evaluation The preoperative consultation is an opportunity to understand the patient’s goals and anatomy, and help the patient navigate a treatment choice that will help them achieve a beautiful appearing breast. Patients should be asked if they are bothered by the shape or size of the breasts or both. This can help differentiate between the need for a mastopexy, augmentation, or mastopexy-augmentation. However often the patient’s complaints may not match their physical exam. Objective assessment by the plastic surgeon needs to be made in the context of a patient’s goals to optimize the outcome that they are seeking. History should include a summary of previous surgeries, existing asymmetries, and a breast health evaluation. This includes past history of breast cancer, abnormal mammograms, and desire for future breast feeding. Patient’s weight history should be documented including any major changes or surgical weight loss. Patients being evaluated for secondary mastopexy or mastopexy-augmentation should be asked for previous operative reports, if available. While scars and examination can provide a roadmap, operative notes can provide essential information that may help avoid devastating complications associated with compromised blood supply to the nipple and incisions. Obtaining these operative records can often be challenging if not impossible. Breast Analysis Physical examination should include assessment of body mass index (BMI) as well as breast measurements. These include base width, sternal notch to nipple distance, nipple to inframammary fold distance, areola diameter and inter-nipple distance. Three-dimensional (3D) imaging software has emerged as a new way to obtain these measurements as well. Reviewing the imaging with the patient is also a very useful educational tool. Often the anatomy and asymmetries are more visible to the patient in a photo than the mirror. A critical assessment of asymmetries including the size, shape, nipple position, and areolar geometry should be performed and reviewed with the patient. Asymmetries may require correction or can persist and be more noticeable after surgery, particularly if augmentation is also being considered. The location of the breast and its footprint on the chest wall should be assessed. As described by Hall-Findlay, a patient can be “high” or “low” breasted depending on where the breast sits on the chest wall relative to the clavicle and humerus.4 Manipulation of the breast footprint is limited, but the upper breast border can be altered by placement of an implant or fat grafting. Chest wall abnormalities and asymmetries as well as scoliosis should be assessed. Examining the breasts with the patient supine can help assess asymmetries in projection. The location of the nipple relative to the inframammary fold as well as gland should be noted as this traditionally measures the degree of ptosis (Table 1, Figure 1). The density of the breasts and degree of superior pole involution should be examined. An assessment of the soft tissue dynamics including the motion of the skin relative to the parenchyma as well as upper pole fullness must be made and is of particular importance in massive weight loss and postpartum women.5 Table 1. Regnault’s Classification of Breast Ptosis Grade  Degree  Description  Pseudoptosis  -  Nipple at the IMF but gland below the IMF  I  Mild  Nipple at or within 1 cm below the IMF  II  Moderate  Nipple below the IMF but above the lowest point of the breast  III  Severe  Nipple at the lowest point of the breast  Grade  Degree  Description  Pseudoptosis  -  Nipple at the IMF but gland below the IMF  I  Mild  Nipple at or within 1 cm below the IMF  II  Moderate  Nipple below the IMF but above the lowest point of the breast  III  Severe  Nipple at the lowest point of the breast  IMF, inframammary fold. View Large Figure 1. View largeDownload slide Grades of breast ptosis based on nipple and gland position relative to the inframammary fold (IMF). Figure 1. View largeDownload slide Grades of breast ptosis based on nipple and gland position relative to the inframammary fold (IMF). Informed consent is a critical portion of any mastopexy consultation and includes a discussion of risks of the procedure including possible need for revisions. When combined with augmentation, a separate discussion of the risks of the devices themselves must be made. If augmentation is being performed with fat grafting alone, discussion of fat grafting risks should also be made. Photodocumentation is imperative and also helps with patient discussions about asymmetries that exist preoperatively. Specific discussion of scars as well as risk of changes in sensitivity to the nipples should be addressed. Often, drawings and photographs of postoperative results can help establish realistic expectations of scar placement and visibility. Imaging Routine imaging of the breast with mammography is not indicated outside the guidelines of the US Preventive Services Task Force, whose 2016 recommendations were based on age over 40 and risk.6 Three-dimensional imaging and simulation in the office can complement routine 2D photographs for the purposes of preoperative consultation, though there is little evidence to support its use. Patients being evaluated for secondary mastopexy or mastopexy-augmentation with a history of implants, rupture, or capsular contracture may have imaging including ultrasound and/or MRI whose review can be helpful. Surgical Approach Skin only mastopexy has fallen out of favor since the time of Benelli who favored parenchymal redistribution in addition to skin redraping.7 This was a major paradigm shift in aesthetic surgery of the breast. Operations that manipulated the skin alone relied on removal of excess skin to buttress and support breast parenchyma. This often lead to unacceptable scaring, incomplete correction of upper pole hollowing, and recurrent ptosis. Modern aesthetic surgery of the breast recognizes the importance of addressing parenchymal involution from aging or postpartum changes and involves some sort of parenchymal redistribution or manipulation in addition to skin excision and redraping (Table 2). Table 2. Different Mastopexy Types: Their Indications, Advantages, and Disadvantages Mastopexy type  Indications  Advantages  Disadvantages  Periareolar  Grade I or II ptosis, nipple asymmetry  Scar hidden at areolar border, can be combined with augmentation  Flattening, deprojection of breast, widened scar  Vertical - SPAIR  All grades of ptosis  Ptosis correction and removal of glandular tissue, little settling  Bottoming out, periareolar widening, pleating, suture spitting  Vertical - Hall-Findlay  All grades of ptosis  Ptosis correction and removal of glandular tissue, structural support of elevated nipple with pillar unification, can be combined with augmentation  Final appearance may take months, persistent asymmetry  Wise pattern  Grade II or III ptosis  Greatest control of skin excision relative to parenchyma, easily adapted from reduction techniques, can be combined with augmentation  Largest scar burden, bottoming out  Mastopexy type  Indications  Advantages  Disadvantages  Periareolar  Grade I or II ptosis, nipple asymmetry  Scar hidden at areolar border, can be combined with augmentation  Flattening, deprojection of breast, widened scar  Vertical - SPAIR  All grades of ptosis  Ptosis correction and removal of glandular tissue, little settling  Bottoming out, periareolar widening, pleating, suture spitting  Vertical - Hall-Findlay  All grades of ptosis  Ptosis correction and removal of glandular tissue, structural support of elevated nipple with pillar unification, can be combined with augmentation  Final appearance may take months, persistent asymmetry  Wise pattern  Grade II or III ptosis  Greatest control of skin excision relative to parenchyma, easily adapted from reduction techniques, can be combined with augmentation  Largest scar burden, bottoming out  SPAIR, short-scar periareolar inferior-pedicle reduction. View Large Periareolar Mastopexy Periareolar mastopexies can be used in patients with grade I or II ptosis or nipple asymmetry with little skin redundancy (Figure 2). It can be used to elevate the nipple at most 2 cm. The markings for mastopexy can be drawn as an eccentric oval around the entire circumference of the areola with preferential height difference superiorly to elevate the nipple. A skin only donut mastopexy differs from a Goes or Benelli mastopexy in that the parenchyma is not manipulated. A crescentic mastopexy is a variation of this where a crescent is drawn above the nipple and an incision is not made circumferentially around the areola. Spear et al described rules when designing a periareolar mastopexy, seeking to reduce widening of scars and pleating.8 Figure 2. View largeDownload slide Periareolar mastopexy incisions and final scar location. Figure 2. View largeDownload slide Periareolar mastopexy incisions and final scar location. The cited benefit of this technique is hiding the scar at the areolar-breast junction. However, the periareolar mastopexy removes skin in a concentric pattern and this can lead to flattening and deprojection of the breast when the areola is inset within the new larger, concentric circle of breast skin. Pleating can occur as the redundancy of the outer circle gathers during the inset. If there is circumferential violation of the dermis to the parenchyma such that the nipple relies on a central mound pedicle, there is a risk of decreased nipple sensitivity with this technique. Some have advocated the use of a permanent or barbed suture to maintain the areolar diameter with time with the thought that increased tension leads to widening of the scar.9 However, periareolar mastopexies have high rates of revision and patient dissatisfaction. In 2001, periareolar mastopexy and augmentation was considered the highest litigated procedure in plastic surgery, though recent data suggest decreased litigation in mastopexy-augmentation procedures. Additionally, physician satisfaction has been lowest with this technique.10 This mastopexy can be accompanied by parenchymal redistribution as described by Benelli.7 With the Benelli technique, augmentation is only safe in the submuscular plane because of blood supply disruption with manipulation of the parenchyma. Periareolar mastopexy has been combined with mesh support by Goes in which a wedge of superior breast tissue is excised, parenchymal flaps united, and mesh placed over the newly shaped breast and tacked to the chest wall.11 With the Goes periareolar technique, breast augmentation should only be done secondarily in the submuscular plane if desired. Vertical Mastopexy Vertical mastopexies have evolved from the described techniques of Lassus, Peixoto, Arie, Pitanguy, Marchac, and Lejour for reduction mammaplasty (Figure 3). They incorporate correction of ptosis with removal of glandular tissue for maintenance of correction and include an extension of the periareolar scar with a vertical component down the meridian of the breast (Figure 4). All grades of breast ptosis have been addressed with vertical mastopexies. Physician satisfaction has been highest with the short-scar periareolar inferior-pedicle reduction (SPAIR) and Hall-Findlay mastopexy techniques.10 Figure 3. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 48-year-old woman taken 1.5 years after bilateral mastopexy with circumvertical technique. Figure 3. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 48-year-old woman taken 1.5 years after bilateral mastopexy with circumvertical technique. Figure 4. View largeDownload slide Vertical mastopexy incisions and final scar location. Figure 4. View largeDownload slide Vertical mastopexy incisions and final scar location. The SPAIR mastopexy developed by Hammond transposes the nipple on an inferior pedicle.12 The technique can incorporate a Gore-Tex periareolar closure as well as pin-wheel or interlocking pattern of periareolar suture placement.13,14 Suspension sutures are used to tack the pedicle superiorly to the chest wall with the goal of maintaining glandular elevation. Skin is then tailor-tacked and excised with closure in a vertical orientation. Sometimes, the redundancy of the skin inferiorly may require excision of the dog ear in a “J” or “T” pattern. There is little settling involved with the final shape of the breast when compared to other techniques. However, bottoming out remains a shortcoming of the technique as it relies on an inferior pedicle. Periareolar widening, pleating, and changes in nipple sensation are all drawbacks of the technique.15 Placement of an implant is not traditionally performed with the SPAIR technique. The Hall-Findlay technique uses a variety of pedicles but most commonly a superomedial or medial pedicle for the nipple-areola complex (NAC) and involves suturing of the medial and lateral pillars of the breast after an inferior wedge of tissue is removed.16 The markings are made such that the inferior most portion of skin excision is above the native inframammary fold (IMF) as the IMF tends to rise in this technique and a lower excision can lead to eventual scar presence on the abdomen. The unification of pillars is thought to provide structural support to the elevated NAC and also narrow the breast. The technique is based on the hypothesis that glandular tissue in the inferior portion of the breast creates a downward pull to the breast, leading to ptosis and bottoming out seen in techniques based on an inferior pedicle. By removing the tissue destined to descend and building structure with the lateral and medial pillars, this technique seeks to maintain a lifted breast. Similar to the SPAIR technique, inferiormost skin redundancy can be addressed with a dog ear excision as a “J” or “T” or gathered with boxing stitches. The mastopexy can be complemented with placement of subglandular or submuscular implant placement without concern for blood supply to the nipple which comes from the second or third internal mammary perforators. The Hall-Findlay technique is often considered a circumvertical mastopexy. Vertical mastopexies tend to create an almost inverted breast shape at the conclusion of the case with exaggerated upper pole fullness and sloped inferior pole. It can take weeks to months for the breast to settle and gain its final appearance. This requires frequent contact and reassurance of patients from providers. Wise Pattern Mastopexy Wise pattern or inverted-T mastopexy has traditionally been used in patients with severe excess of skin relative to breast parenchyma in a patient with severe ptosis. It was first described by Wise in the 1950s with the development of templates for making a skin only mastopexy. However, with developments in reduction mammaplasty techniques, the Wise pattern mastopexy was modified with parenchymal alterations and pedicle designs.17,18 Hence, plastic surgeons familiar with the Wise pattern, inferior pedicle mammaplasty reduction procedure often feel very comfortable with this mastopexy technique. Incisions are made around the areola with extensions for the vertical limbs as in a vertical mastopexy (Figure 5). However, the incisions are carried out laterally and medially to the borders of the breast and carried down and along the inframammary fold. Manipulation of the parenchyma combined with a Wise pattern scar can take on many variations. Ship et al first described double superior pedicles that were “criss-crossed” and also tacked to the pectoralis fascia with a skin resection in a Wise pattern. Since then, techniques have been described by numerous authors with variations in parenchymal manipulation under a Wise-pattern skin excision.19-22 Figure 5. View largeDownload slide Wise pattern mastopexy incisions and final scar location. Figure 5. View largeDownload slide Wise pattern mastopexy incisions and final scar location. This technique has the greatest amount of scar relative to the breast vs other techniques. When associated with an inferior pedicle, it can also have the bottoming out seen in reduction mammaplasty and in a survey of ASAPS members was found to have the greatest frequency of bottoming out.10 This is most likely secondary to the inferior pedicle rather than the skin resection pattern. Additionally, one of the problems with the inverted-T mastopexy is healing at the T-junction, especially when an implant is added. Explantation Mastopexy Patients with a previous history of breast augmentation with an implant may desire explantation without replacement for a number of reasons including but not limited to capsular contracture. When possible, previous operative reports can provide information about plane of dissection and pedicle for NAC blood supply to reduce the risk of complications explantation-mastopexy. Preexplantation level of ptosis has been identified as an important factor in deciding on mastopexy technique either at the time of explantation or in a delayed fashion.23 Explantation-mastopexy has been performed with a vertical technique with high levels of satisfaction.24 Smoking, need for nipple elevation greater than 4 cm, and breast parenchyma thickness less than 4 cm have been identified as possible reasons to delay mastopexy after explantation.25 Patients with a history of saline augmentation can undergo replacement with silicone implants and saline deflation can be useful before implant exchange.26 Wu and Grotting have recommended waiting 4 weeks after deflation to allow for “elastic breast recoil” and gland normalization before proceeded with secondary mastopexy.27 This may also allow for more accurate surgical planning as well as more accurate patient education. When considering replacing an implant the patient has a better sense of their native volume as does the surgeon and this can allow for a more accurate choice for a new implant. Techniques to restore volume including using an inferior dermoglandular flap for autoaugmentation at the time of explantation-mastopexy have been described by Ribiero.28,29 In the authors’ experience, replacement of breast implants in patients with Baker Grade III and IV capsular contractures can be complex. Following capsulectomy, the soft tissue envelope can be patulous with poor lateral support for a fresh breast implant. The breast parenchyma can adhere to the contracted capsule, propped up essentially by the capsule and implant. Simply replacing the device in this new pocket can be problematic. To address this redundant soft tissue envelope several strategies may be considered. One is to place larger breast implants but this, more than likely, will lead to rapid progression towards device migration and malposition. The use of acellular dermal matrices in revisionary breast surgery has been well described.30 Alternatively, some capsule can be retained and used as a capsular flap or capsulorrhaphy to support the lateral pocket or supplemented with a synthetic or biologic mesh. This often combined with a mastopexy to reduce the outer soft tissue lamella so that it matches, along with nipple position, the volume of the breast implant. A staged approach can also be considered. In the first stage, the capsulectomy and explant can be performed and a suction drain placed. The skin envelope can contract, soft tissue healing can occur, and a fresh pocket can be dissected months later to match the new implant, and centralize the nipple-areola, taking advantage of skin retraction to eliminate or limit the need for a skin reducing mastopexy. Little has been published on the topic of mastopexy after explantation for capsular contracture and warrants investigation. Mastopexy in the Massive Weight Loss Patient Mastopexy in the massive weight loss (MWL) patient is a particularly unique and challenging operation as it can be at the far end of the spectrum of excess skin and involuted breast parenchyma.31 This is coupled with wound healing considerations and nutrition specific to patients who have experienced large fluctuations in weight from diet and exercise or surgical weight loss.32 These patients have distortion of the normal footprint of the breast, often with a lateral axillary roll, medialization of nipples, deflated upper pole, and lax inframammary fold. Techniques to restore the shape and volume of the breast include mastopexy (Video 1, available as Supplementary Material online at www.aestheticsurgeryjournal.com), mastopexy with auto-augmentation, and mastopexy-augmentation with an implant. A recent study by Coombs et al identified that mastopexy-augmentation in MWL carries high rates of recurrent ptosis within 3 months (16.7%) and implant malposition (61.9%).31 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Video 1 Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Close Rubin has suggested an algorithm for aesthetic breast surgery in MWL patients based on the severity of ptosis, shape of the breast, and degree of involution.33 He describes a technique of dermal suspension autoaugmentation mastopexy using the medial and lateral parenchymal flaps to augment the volume of the breast. His technique involves anchoring of the new breast mound on the chest wall and redraping the skin over the autoaugmented breast. The technique has the advantage of utilizing the lateral axillary fullness to augment the breast mound itself and also address the axillary roll. Multiple parenchymal flaps have been described for autoaugmentation. These include the anterior intercostal perforator flap (ICAP), lateral intercostal perforator flap (LICAP), the spiral flap, a rotation-advancement flap using a superomedial pedicle, and lateral breast flap.34-38 When combined with implant placement, the lateral breast flap has been described for inferior pole coverage of the implant.39 Mastopexy With Mesh Support The use of mesh represents another paradigm shift in mastopexy, but long term follow up with mesh use demonstrating its usefulness is still lacking. Mesh seeks to restore support to a breast that has lost strength in its suspensory system and thereby reduce recurrent ptosis and prolong the longevity of mastopexy results. Mastopexy with mesh support has been described by a number of authors dating back to the 1980s when Marlex Mesh was used to anchor the breast tissue to the second rib.40 More recently, 3D knitted polyester mesh has been used as an “internal bra system” with greater than 4.5 year follow up without major complications.41 Histologic and mechanical studies of explanted mesh have demonstrated induction of collagen formation around the mesh, enhancing the overall strength of the mesh without resultant palpability or extreme stiffness.42 Other groups have also reported success with biocompatible meshes.43 Porcine collagen matrix or FortaPerm (Organogenesis, Canton, MA) has been used by Goes in periareolar mastopexy with reported long term maintenance of elevated breast position.44 Most recently, Adams and Moses described their experience with central mound mastopexy and the use of a poly-4-hydroxybutyrate resorbable scaffold for lower pole support and reported stable results at 1 year without major complications.45 No series of mastopexy with mesh have reported interference with mammography or oncologic safety. Only one case report exists of a chronic abscess in patient who underwent mastopexy with a polypropylene mesh.46 Mastopexy and Fat Grafting Fat has been used in composite breast augmentation and as a simultaneous implant exchange with fat for revision breast implant surgery.47,48 It also has been used as an adjunct in mastopexies following explantation and treatment of double-bubble deformities.49 Its use in mastopexy alone has not been well described in the literature. Mastopexy-Augmentation Augmentation of the breast can be combined with mastopexy in a single or two-staged fashion using autologous breast tissue, implants, or fat (Video 2, available as Supplementary Material online at www.aestheticsurgeryjournal.com). Details of breast augmentation alone are beyond the scope of the present review but augmentation can be performed with an implant in the submuscular or subfascial/subglandular plane (Figure 6). The surgeon must be mindful about blood supply to the NAC when performing an augmentation in conjunction with mastopexy. Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjx181 Close Figure 6. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 36-year-old woman taken 5 years after bilateral mastopexy-augmentation using Allergan Style 15, 339 cc bilaterally in dual-plane pocket with circumvertical mastopexy. Figure 6. View largeDownload slide (A, C) Preoperative and (B, D) postoperative photographs of a 36-year-old woman taken 5 years after bilateral mastopexy-augmentation using Allergan Style 15, 339 cc bilaterally in dual-plane pocket with circumvertical mastopexy. Many of the autoaugmentation options are similar to those applied for MWL patients, as described above. They can also include a superior pedicle dermoglandular flap aimed at restoring central mound projection and narrowing the width of the breast.50 Breast augmentation can also be performed with autologous fat and its techniques are described elsewhere.51 Prosthetic augmentation and mastopexy at a single stage has been a largely controversial topic since 2003 when Spear published “Augmentation/Mastopexy: ‘Surgeon, Beware” though one of the first publications on the topic dates to the late 1970s.52 A series of publications that described the safety and revision rate of such procedures have stimulated healthy discussion about the safety of single-stage mastopexy-augmentation in well-selected and informed patients.53 Stevens et al published a series of reports of one-stage mastopexy augmentation with revision rates between 8.6% to 16.7% with his largest series of 1192 mastopexy-augmentations having a 16.9% revision rate most commonly associated with the implant.54-56 Calobrace et al also published a series of 332 mastopexy-augmentations with a complication rate of 22.9% and revision rate of 23.2%.57 Swanson specifically looked at tissue perfusion in mastopexy-augmentation with a vertical technique and concluded that simultaneous mastopexy-augmentation with an implant does not compromise perfusion to the NAC based on a medial pedicle.58 A recent meta-analysis of 23 studies with 4856 cases of single-stage mastopexy-augmentation found an overall complication rate of 13.1%.59 Pooled complication rates include recurrent ptosis (5.2%), poor scarring (3.74%), capsular contracture (2.97%), asymmetry (2.94%), seroma (1.42%), hematoma (1.37%), infection (0.93%) with a reoperation rate of 10.65%.59 Proponents of single-stage mastopexy-augmentation argue that the revision rate for this procedure is significantly less than the 100% rate of a second procedure with staged mastopexy-augmentation. Ultimately, surgeon comfort and appropriate patient selection will dictate whether to stage or not. Patient Positioning Patients undergoing mastopexy or mastopexy-augmentation are positioned supine on the operating table with their arms extended on arm boards with appropriate padding. The arms and head should be secured in such a way that the patient can be positioned in the upright position for intraoperative assessment of symmetry, shape, and position of the breast and NAC without causing harm. Positioning and securing the arms on arm boards allows for the arms to be manipulated from an abducted to adducted position; with the patient upright, this can help assess nipple position and allow for intraoperative adjustments as necessary. It is also helpful to drape out the upper shoulders to help with judgement of symmetry. Postoperative Care Patients are typically placed in a supportive surgical bra at the end of the case to support the newly lifted breast. This acts like a splint to offload the effects of gravity as the healing process begins. Drains are not routinely used in mastopexy and mastopexy-augmentation procedures. There is no clinical evidence for the routine use of postoperative antibiotics beyond the consensus statement by the American Association for Plastic Surgeons for perioperative antibiotics for surgical site infections.60 Patients may require narcotic pain medication or muscle relaxants, particularly if an augmentation was also performed in the subpectoral plane. Typically, if there are incisions in the inframammary crease, patients are kept in a surgical or sports bra for about a month and then weaned to an underwire bra. Physical activity depending on the nature of the mastopexy and augmentation is slowly graduated to full activity typically by 4 to 6 weeks. Revisions in the authors’ experience are typically held off until 6 months postprocedure. Postoperative Complications, Revisions, and Outcomes A recent database study of complications in aesthetic breast procedures has revolutionized our ability to assess complications after these surgeries on a magnitude never before possible and found a complication rate of 1.15% in mastopexy and 1.86% in mastopexy-augmentation.61 The complication rate of mastopexy-augmentation was found to be significantly higher than that for mastopexy alone. Obesity was associated with infections in mastopexy, which had the lowest complication rate of any aesthetic breast procedure examined. Mastopexy-augmentation was found to have a higher incidence of infection; older patients who had mastopexy-augmentation were also more likely to have a hematoma.61 A survey of physician reported complications after mastopexy found that suture spitting, excess scarring, and bottoming out were the most commonly encountered complications. Of these, suture spitting was reported to be most common with the SPAIR technique, excess scarring with the periareolar technique, and bottoming out with the limited inverted-T technique.10 Periareolar mastopexies had the highest revision rate at 50%. The risks associated with single stage mastopexy-augmentation have been reviewed above. Risks of procedures include hematoma, infection, nipple-areola necrosis, implant visibility and rippling, asymmetry and malposition. Capsular contracture can occur as with primary breast augmentation. Revisions can be performed at the patient and surgeon’s discretion and often involve bottoming out, recurrent ptosis, malposition, and scarring. CONCLUSION Mastopexy and mastopexy-augmentation exist on a spectrum of surgical options to restore a youthful, pleasing shape and volume to a breast that has undergone changes associated with aging or postpartum involution. These aesthetic surgeries are offered to breast reconstruction patients who undergo contralateral balancing procedures for symmetry as well. Many techniques have been described and the field has seen major paradigm shift including rearrangement of breast parenchyma, use of mesh support, and increasing evidence demonstrating the safety of single stage mastopexy-augmentation. While once considered a highly litigated and risky procedure, improved techniques and better patient education on the part of aesthetic surgeons has transformed the way mastopexy and mastopexy-augmentation is currently offered to patients. With the rise of noninvasive devices such as radiofrequency and ultrasound energy technologies, aesthetic surgery of the breast is likely to continue to see novel and innovative ways to meet patient goals and expectations. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. 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Aesthetic Surgery JournalOxford University Press

Published: Apr 1, 2018

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