Goals/Purpose:
Due to increasing obesity rates and an ever more aging population, a
greater portion of women presenting for breast augmentation are candidates for
simultaneous mastopexy. American plastic
surgeons have decades of experience with simultaneous augmentation mastopexy,
but mostly employing skin-only lifts.
Increasingly surgeons are embracing vertical mastopexy techniques with
simultaneous augmentation. The potential
aesthetic benefits are numerous and great, but there are vastly different
tissue tension dynamics. Narrowing and
projection over an unyielding implant combined with nipple transposition can
create a tight precarious end to a vertical lift in contrast to what would have
been simple, quick and low tension with a skin only lift or periareolar
techniques. In our experience, we have
found that the dynamics and tissue tensions of a vertical lift over an implant
can be safely and predictably navigated with maneuvers designed to accommodate
skin and parenchymal tension issues. Scars with these techniques can be
consistently good or excellent and complications low.
Methods/Technique:
We have adapted vertical mastopexy to simultaneous augmentation with a number
of safety measures that do not compromise effectiveness. Using medial and lateral displacement with
some rotation away from the breast meridian, the vertical ellipse is drawn
coming to a point cephalically for planned future top of areola or to the
curvilinear top of present areola if no nipple repositioning is
anticipated. The implant is placed
through a vertical incision in skin to be removed with a muscle splitting
approach. By approaching the inferior
pocket from above, splitting muscle 7 1/2 to 8 centimeters off midline, one can
completely close the muscle split and keep separate implant and mastopexy
surgical fields. It allows adequate
muscle division and there is maximum implant position control with no extra
inframammary scar.
Conceptually the vertical ellipse drawn on the breast is composed of two parts: the cephalic-most 7 cm that accommodates the increased projection and minimizes periareolar tension, and the more inferior ellipse much of which is excised with parenchyma to supply the power for the lift and narrowing. (Fig. 1)
FIGURE 1
Tension safety for the cephalic area is accomplished with 1/2 cm narrowing adjustments of the ellipse and checking tension at the planned 6:00 areolar closure after implant placement and prior to deepithelialization. Tension safety for the more inferior ellipse requires a version of tailor tacking that seeks not just kissing of skin edges, but also allows for 1 cm overlap. This is because traditional tailor tacking recruits the unprojected breast's skin slide but cannot simulate or predict the actual tension after excising parenchyma, closing the pillars and creating more projection over an implant. A superior-medial pedicle is easily created within the cephalic deepithelialized ellipse which facilitates nipple transposition moving both cephalically and out due to the implant and lift-mediated projection. Completion of tension safety is through late commitment and preparation of the recipient site as described by Hidalgo(1) with light tension running stitch over the repositioned nipple-areola and then areolar marking and deepithelialization. (Fig. 2)
FIGURE 2
Results/Complications:
These safety measures were applied over 5 years and 70 consecutive
patients. Mean follow-up was 9 months,
with all at least 4 months except 3 at 5 weeks and one
two weeks. There were no severe complications, delayed healing, infections or
nipple-areola loss to any degree. 16% of
136 breasts had minor revisions under local anesthesia most commonly for persistent
areola pigment along the vertical scar, roundness of an areola, or periareolar
lift. No hypertrophic scars occurred in
136 breasts with the exception of one following a minor revision periareolar
lift where creation of tension was unavoidable.
There were no capsule contractures or implant malpositions except the
following and only case that required general anesthesia for revision. This was a single breast following an extreme
asymmetry case in which aggressive parenchymal removal on one side led to
gradual implant displacement through the muscle split closure anteriorly into a
partial submammary pocket. It was
repaired with submuscular capsulotomy and muscle reclosure.
Conclusion:
Surgeons and patients can enjoy the many benefits of vertical mastopexy augmentation
as safety measures have been developed to manage the unique technical issues
that accompany such powerful lift, projection and narrowing over a new implant.
CASE 1
CASE 2
REFERENCES:
1) Hidalgo, David A, Vertical mammaplasty. Plast. Reconstr. Surg. 115: 1184, 2005.