Quantifying Longitudinal Changes in Aesthetic Breast Surgery
This study uses pre- and post-operative measurements in aesthetic breast surgery to enable the surgeon to both predict results and to manage patient expectations.
Observations carried out in patients undergoing either breast reduction, augmentation or mastopexy-augmentation by a single surgeon compares the dimensions of patients presenting for these procedures, what can be achieved by surgery and how the rejuvenated breast changes over time.
Methods/Technique:
The established practice of the senior author is to routinely perform standard measurements pre-operatively and at each post-operative visit. These measurements were tracked over several post-operative visits to elicit the trends in standard parameters over time. 100 patients who had undergone each of breast reduction, breast augmentation and mastopexy/augmentation were analysed, pooling the measurements into defined post-operative time points to allow comparison. Breast reduction (BBR) was undertaken using the method previously described by the senior author using a superomedial pedicle and vertical skin incision, which is not cinched up intraoperatively. Breast augmentation was generally performed through an inframammary fold incision into a subglandular position, and mastopexy-augmentation was performed using a superior pedicle technique with a vertical pattern access incision, usually with a subglandular implant.
Results/Complications:
In total, over 3000 measurements were recorded and analysed and the average length of follow-up was 54.9 weeks (range 1-286 weeks).
Breast Reduction Cohort
Pre-operatively the BBR group had a mean suprasternal notch to nipple (SSN-Nip) distance of 29.83cm on right and left respectively, with a suprasternal notch to inframammary fold (SSN-IMF) distance of 23.02cm. The nipple to inframammary fold (Nip-IMF) distance was 13.80cm and 14.09cm on right and left respectively. Intraoperatively, the nipple was placed at a mean SNN-Nip of 23.51cm. In the post-operative period this nipple position was maintained (23.50cm), while the SSN-IMF distance shortened by almost 1cm. There was evidence of a trend towards further nipple descent, but even after 3 years this change was not considered significantly different (Mean SSN-Nip 23.98cm, t-test p=0.33). Interestingly the SSN-IMF shortening which was observed in the initial post-operative phase was also maintained.
Breast Augmentation Cohort
The group presenting for augmentation had a mean SSN-Nip distance of 20.27cm and 20.28 cm on the right and left respectively, with the inframammary fold found on average just marginally below at 20.58cm. The nipple to inframammary fold distance was 6.98cm(R) and 7.14cm (L). The immediate post-operative measurements showed the SSN-Nip distance drop by approximately 2cm, with the inframammary fold dropping by 1.5cm, which was statistically significant (p<0.001). These measurements showed increasing descent of the breast gland, with all distances increasing by a further 1cm during the second year post-operative year. During the third and fourth post-operative year this descent slowed, with no significant change during these time periods. In contrast, the inframammary fold regained its position at 2cm below its pre-operative position by year 4, after stretching maximally to almost 23.5cm at the one year time point.
Mastopexy-Augmentation Cohort
The group opting for mastopexy-augmentation had a longer mean SSN-Nip distance of 23.34cm(R) and 23.49(L), and a lower inframammary fold at 21.41cm compared to the augmentation alone group. The Nip-IMF distance was also longer at 9.06cm (R) and 9.12 (L). Intra-operatively the nipple was placed at mean SSN-Nip of 23.51cm. Even within the immediate post-operative period this had dropped by under 2cm, but the inframammary fold dropped by just under 1cm in the immediate post-operative period. However, in comparison to the augmentation alone group, this cohort did not show evidence of breast gland descending further throughout later time points.
Conclusion:
This study has pooled measurements from a variety of important time points in the post-operative recovery to draw conclusions regarding the average outcomes of 3 aesthetic breast procedures. It can be seen that the breast ages differently according to the procedure completed in addition to the baseline measurements of these 3 groups was markedly different at presentation. This information can guide surgical planning of nipple position, as intra-operative nipple placement in mastopexy-augmentation must take into account the observation that the nipple drops by 2cm compared to a breast reduction where the intraoperative nipple position remains largely static. The variation in the position of the inframammary fold challenges the opinion that this is a reliable anatomical landmark, as this study has demonstrated that its position changes throughout the post-operative course. This should encourage the use of other landmarks, such as the upper breast border, for pre-operative planning.