6-Year Results after Myointegrating the Breasts

Goals/Purpose: A woman’s selection of an aesthetic operation and her surgeon is dependent upon expectation of results. Changing patient demographics and demands for improved and long-lasting breast aesthetic results without foreign material necessitates innovation. Many women with darker skin tones or a history of hypertrophic scarring, regard vertical breast scars as unacceptable, consequently refusing traditional mastopexies and reductions. Breast shape and position are adversely affected by gravity, often resulting in late dissatisfaction. BIA-ALCL, “breast implant illness” and FDA warnings have decreased the desire for implants. The purpose of this study is to propose alternative aesthetic breast operations that are not mechanically dependent on skin envelope tightening, without vertical scars nor implantation of foreign materials. Computer aided design has proven value and is applicable to aesthetic breast surgery.

Methods/Technique: Pre-operatively, women undergo three-dimensional computer imaging to determine breast volume. Physical measurements of chest circumference, length of the horizontal axillary line (HAL), distance from the cephalad areola border to HAL, distance from the nipple to inframammary fold (IMF), distance from HAL to the new IMF, lateral chest wall roll off and chest wall thickness are determined. Women choose their desired cleavage and volume change. From these parameters, equations are used to create a surgical blueprint that determines the breast’s volume, radius, footprint; cone’s length, footprint and almond skin pattern. At surgery, the almond pattern containing the areola is deepithelized, then incised creating a central mound. The dermis is rotated into an oblique cone with two long and one short straps elevated from the base. Each long strap entrains breast tissue, then is passed in and out of the pectoral major muscle and the base of the cone, twice and sutured to themselves with 2-0 PDS. The short strap entrains breast tissue and is sutured at the sternum with 2-0 Ethibond. The long straps transfer cone weight to the pectoralis major muscle, also transpose, reshape and increase breast projection. The short straps determine cleavage. All three straps control the angle of inclination of the cone. The cephalad skin flap is advanced over the cone and closed with 3-0 Vicryl subcutaneous and 3-0 PDS subcuticular, creating an inferior curvilinear scar. The areola is delivered through a hole in the cephalad flap and closed with 4-0 PDS subcuticular.

Results/Complications: From January 1^st to December 31^st, 2015, 77 women underwent myointegration of their breasts. Self-evaluation questionnaires were returned from 34 women (44%) with a mean follow up of 6 years 8 months. The desire for surgery was 44% cosmetic, 3% functional and 53% combined. Seventy-nine percent stated that vertical scars prevented them from prior surgery. The demographics were 65% Caucasian, 17% Afro-American, 15% Hispanic and 3 % Middle Eastern. Mean height, weight and BMI were 5’4”, 152 lbs. and 26.0 kg/m² respectively. The weight removed from each breast varied from 0 to 760 grams, with a mean of 220 grams. Post-operative mean BMI increased to 26.2kg/m². None of the patients required post-operative return to the operating room. One woman underwent mastectomy and reconstruction five years later for positive BRCA. Prior to her mastectomy, MRI scan with contrast displayed the vascularized cone and revascularized straps. Her pathologist reported revascularization of the straps. Office revisions under local anesthesia were performed in 56%. Areola revisions in 12%, inframammary revisions in 50%, seroma drainage in 3% and fat necrosis drainage in 6%. Breast position and shape were better in 88% and 91% respectively. Breast projection and upper pole fullness were increased in 58% and 56% respectively. Cleavage was better in 50%. Appearance naked and in clothing were better in 82% and 88% respectively. Seventy percent appeared thinner and 25% appeared taller. Areola and inframammary scars were acceptable in 88% and 72% respectively. Nipple sensation increased in 29%, unchanged in 56% and decreased in 15%. Pain was eliminated in 24%, decreased in 39% and unchanged in 36%. Ninety-one percent of women could go braless, 82% reported improved quality of life and 88% would do it again. Overall results were excellent in 47%, good in 32%, fair in 18% and poor in 3%.

Conclusion: Every woman requesting breast surgery presents unique anatomy and desires that can be quantitated, then mathematically analyzed to derive the optimal solution. Surgery generates scars, but the almond pattern eliminates vertical scars and T junctions, while concealing scars at the areola-cutaneous junction and in or near the new elevated inframammary fold. The central mound preserves major lactiferous ducts and nerves to the nipple areola complex. Myointegration relieves or decreases neck, shoulder or back pain by weight transfer and elevates the center mass of the breast. Strap entrainment and positioning allows the surgeon to custom design breast position, shape, projection, inclination, cleavage and upper pole fullness. These improvements in breasts aesthetics, breast physiology and the women’s psychology are long lasting.