One Stage Correction of Hypoplastic–Tuberous Breast with the Hockey-Stick Muscle Splitting Dual Plane Breast Augmentation Technique and the Northwood Index
A lot of different techniques have been described for the correction of tuberous breast. We believe that two abnormalities are presented in tuberous breast:
- Herniation of breast tissue through the nipple – areola complex.
- Skin shortening at the level of Inframammary Fold (IMF) only.
We descripe a new technique which combines the Northwood index and the the muscle–splitting dual plane (MUST technique) breast augmentation technique for pocket dissection
Methods/Technique:
We used the Northwood Index (NI) as described by Dr Pacifico in 2005. The NI is the ratio derived between the areola herniation to areola diameter, in the true lateral view photo of the breast. The herniation is measured in cm and it is the maximum anteroposterior distance between the base of the nipple and the edge of the areola. The diameter is measured in cm as the maximum diameter of the areola. When the index was above 0.4, we performed peri-areola tightening and released the skin at the level of IMF. When the Index was below 0.4, we released only the IMF. In all patients we use round silicone implants to restore the volume and the muscle–splitting dual plane technique (MUST technique) for the pocket dissection
Surgical technique
All the operations were performed under GA with the patient in a supine position with the arms abducted in 80 degrees. At the induction of the anaesthesia one dose of intravenous antibiotic was given. No patient received postoperative antibiotics. The inframammary fold incision was used in all the patients Infiltration of 5cc of lidocaine with adrelanine 1:200000 performed at each of the incisions sites. The scalpel used to cut the epidermis and the dermis and following that the dissection was performed to the level of the pectoralis fascia using the unipolar foot switching needlepoint electrocautery forceps in the cutting mode. The pectoralis fascia is recognized and the dissection continues under the fascia and in front of the muscle with the same unipolar foot switching needlepoint electrocautery forceps in. the coagulation mode. The length of the electrocautery is 24cm fascilitating the dissection at the upper part of the pocket
we divide the muscle in 3 different levels regarding the volume of the implant.
Level 1 is at the projection of the lower part of the areola to the muscle surface, when the implant is larger than 350cc
Level 2 is at the projection of the nipple to the muscle surface, for implants between 200-350cc
Level 3 is at the projection of the upper part of the areola to the muscle surface, when the implant is less than 200cc.
We do that in order to avoid the rolling of the muscle above the upper part of the implant.
The incision of the muscle is following the muscle fibres medially, and laterally the incision is curved horizontally. Under the muscle the dissection is performed closely to the under surface of the muscle so we could leave the thin areolar tissue down (minimize pain and seroma). Division of the white tendinous origins of the pectoralis major muscle is important. The blood loss during the dissection must be minimal (less than 5ccof blood).
The upper 1/3 or 1/2 of the implant is located under the muscle and the lower 2/3 or 1/2 under the pectoralis fascia. Closure is performed in three layers with Monocryl 3/0 and 4/0. No drains, bandages or straps are used. Steril strips are the only dressing that is used.
Extensive parenchyma scoring with horizontal and vertical cuts that is performed to the lower surface of the breast in order to expand the inferior pole.
From March 2007 to May 2013, we have performed the aforementioned technique in 81 tuberous breasts. Mean age of patient was 27 years old. Mean follow-up was 3 years.
Results/Complications:
Three patients developed double-bubble deformity . No hematoma or infection of the implant was observed. No revision was necessary. Three patients developed infection at the site of periareolar incision but this was resolved with antibiotics. One patient developed seroma two months after surgery
Conclusion:
We advocate a one-stage surgical correction of tuberous breast. Based on the Northwood index we can decide whether we will perform peri-areola correction with release of IMF or only release of IMF for correction of the tuberous breast. The muscle-splitting dual plane technique can combine the advantages of the subfascial and partially submuscular pockets and eliminate the trade offs of these techniques especially in challenging cases of breast augmentation, such as the the tuberous breasts. The extra benefits of the technique are: the maximum stretching of the lower pole in tuberous breast, the better control of the lower part of the breast and the elimination of the “open breast” deformity of the submuscular pocket.