Polydioxanone Mesh Reinforcement of the Lower Pole in Patients Undergoing Wise-Pattern Breast Reduction / Mastopexy

Goals/Purpose: Breast reduction / mastopexy continues to be among the most common procedures performed by plastic surgeons^1. The Wise-pattern technique remains a popular approach given its relative simplicity and reproducibility. A common criticism of this technique, however, is the long-term tendency for patients to develop "bottoming out" or pseudoptosis resulting from parenchymal descent, particularly when an inferior pedicle is used for nipple transposition². To limit this tendency, many techniques utilizing biosynthetic mesh for lower pole support have been described, though safety data is often lacking³.

The goals of this study are to examine both the safety of polydioxanone (Durasorb®) mesh when used for lower pole support in patients undergoing Wise-pattern breast reduction or mastopexy, and lower pole breast stability in the post-operative period.

Methods/Technique: This is a retrospective review of a single surgeon’s (KM) experience utilizing polydioxanone mesh (Durasorb®) for lower pole reinforcement in patients undergoing Wise-pattern breast reduction or mastopexy.

A chart review was performed identifying all patients who underwent lower pole mesh reinforced, Wise-pattern breast reduction or mastopexy as either stand-alone procedures or in conjunction with breast implant removal. Patient demographics and post-operative complications were identified. Minor complications included cellulitis, T-junction or other incisional breakdown, and non-operative hematoma or seroma. Major complications included partial / compete nipple necrosis or any complication requiring re-operation. Complication rates were compared to those determined in a large, multi-center study utilizing a common, absorbable biosynthetic mesh (Poly-4-Hydroxybutyrate or P4HB) for lower pole support in patients undergoing inferior/central pedicle breast reduction/mastopexy⁴ Lower pole breast stability was assessed by nipple-inframammary fold (N-IMF) measurements recorded at 30 and 90 days post-operatively.

Surgical Technique

Wise-pattern markings were performed in a standard fashion. When implant removal was combined with reduction / mastopexy a superiorly based nipple pedicle was utilized. When reduction or mastopexy were performed in the absence of implant removal, an inferiorly based nipple pedicle was utilized. After completing parenchymal / skin resection, a 10x25cm piece of polydioxanone mesh (Durasorb®) was cut in half longitudinally and, after soaking in betadine solution, each half was sewn to the chest wall straddling the lower pole breast parenchyma (Image 1). Equal mesh tension was set across both breasts by the senior surgeon with the patient in an upright position. Closure was then performed in a standard fashion over a 15 French Jackson-Pratt drain with particularly attention to superficial fascial closure over the mesh.

Results/Complications: A total of 32 patients (62 breasts) were identified for inclusion in the study. 18/32 patients (34 breasts) underwent reduction/mastopexy alone while 14 patients (28 breasts) underwent reduction/mastopexy in combination with implant removal. Patient demographics are listed in Table 1. Average follow-up time was 112 days (range 30-370). Post-operative complications are listed in Table 2. Cellulitis occurred in 1/62 breasts (1.6%) and was managed with outpatient antibiotics. Incisional breakdown occurred in 8/62 breasts (13%) all of which were treated with local wound care. No major complications were identified. Of the 5 patients (9 breasts) who underwent N-IMF measurements, average elongation of the lower pole was 0.6cm (range 0-1cm) (Figure 1).

Conclusion: Our preliminary data demonstrate that the use of polydioxanone mesh for lower pole support in patients undergoing inferior pedicle, Wise-pattern breast reduction / mastopexy is safe. Complication rates are similar to those identified in comparable procedures utilizing P4HB biosynthetic mesh. Utilization of polydioxanone mesh appears to stabilize the lower pole over time, though longer term follow-up and correlation with clinical manifestation of pseudoptosis is needed.

Age (years)	50.5 avg . (range 17-72)
BMI	26.8 avg . (range 20.8 - 37.6)
Diabetes	1/32 (3%)
Current Smoker	1/32 (3%)
Former Smoker	7/32 (22%)
Breast Specimen Weight (grams)	138 avg . (range 10 - 925)

Table 1. Patient Demographics

Cellulitis	1/62 (1.6%)
T-junction, or other incisional breakdown	8/62 13%
Hematoma	0/62 (0%)
Seroma	0/62 (0%)
Partial / Complete Nipple Necrosis	0/62 (0%)
Re-operation	0/62 0%)

Table 2. Complication Rates

References:

1. American Society of Plastic Surgeons 2020 surgical statistics. Available at: https://www.plasticsurgery.org/news/plastic-surgery-statistics

2. Brown RH, Izaddoost S, Bullocks JM. Preventing the "bottoming out" and "star gazing" phenomena in inferior pedicle breast reduction with an acellular dermal matrix internal brassiere. Aesth Plast Surg. 2010;34:760-767. doi:10.1007/s00266-010-9538-2.

3. Atiyeh B, Ghieh F, Chahine F, Oneisi O. Ptosis and bottoming out following mastopexy and reduction mammoplasty. Is synthetic mesh internal breast support the solution? A systematic review of the literature. Aesth Plast Surg. 2022;46:25-34. doi:10.1007/s00266-021-02398-x.

4. Adams WP, Baxter R, Glicksman C, Mast BA, Tantillo M, Van Natta BW. The use of poly-4-hydroxybutyrate (P4HB) scaffold in the ptotic breast: a multicenter clinical study. Aesthet Surg J. 2018;38(5):502-518. doi:10.1093/asj/sjy022.