Augmentation mastopexy

Introduction: a historical perspective

Single-stage augmentation mastopexy was initially described more than 50 years ago by Regnault and Gonzalez-Ulloa. In 2003, Spear published Augmentation/mastopexy: “surgeon, beware” , warning plastic surgeons of the potential risks associated with combining these procedures, namely patient dissatisfaction and unpredictable outcomes. Since then, we and others have published large series of single-stage mastopexy augmentation demonstrating safety with careful planning and patient selection. While single-stage augmentation mastopexy is gaining traction, it is arguably still considered to be one of the most difficult cosmetic breast surgeries. The challenge lays in reconciling opposing goals that are to increase the volume of a breast and change its shape, while simultaneously decreasing the skin envelope. Success in augmentation mastopexy, one- or two-stage, can be expected with proper planning, technique, and patient education. This chapter illustrates indications and patient selection for one- and two-stage augmentation mastopexy, techniques for safe execution, caveats, postoperative care, complications, outcomes, and secondary procedures.

Pertinent Anatomy

The nipple–areolar complex (NAC) has a robust blood supply that can accommodate various surgical manipulations without disturbing vascular function. Moreover, there is substantial vascular variability and overlap among arterial sources to the breast ( Fig. 5.1A ). Primary arterial sources are the internal mammary (i.e. internal thoracic) arterial perforators and branches from the lateral thoracic artery, the intercostal arteries, and the thoracoacromial axis ( Fig. 5.1B ). The dominant blood supply to the breast comes from the internal mammary system, which interconnects with other sources. These perforators traverse the anterior thoracic wall just lateral to the sternum and course through the medial pectoralis major muscle. They can be encountered directly when dissecting the medial subpectoral pocket. The second, third, or fourth internal mammary perforators (primarily the second) serve as the main blood supply for the superior or superomedial pedicle and run superficially at a depth of approximately 2 cm to supply to nipple–areola complex. The thoracoacromial and lateral thoracic artery perforators supply the breast superiorly and laterally, whereas the intercostal arteries supply it anteromedially and anterolaterally. When planning primary and secondary augmentation mastopexy, it is imperative to consider pedicle thickness and the remaining blood supply to the nipple–areola complex because previous procedures may have compromised local vasculature. Several in-depth articles are available regarding vascular anatomy of the breast.

Subpectoral placement of the breast implants does not disrupt the musculocutaneous perforators and is less likely to interfere with blood supply. On the contrary, if the implant is placed in the subglandular or subfascial plane and significant tissue undermining is performed, the blood supply may be severely compromised. Vascular supply to the tissue can also be compromised if the implant size is too large placing undue tension on the skin edges, leading to tissue necrosis.

Definition and classification of ptosis

In patients with hypomastia, diagnosis of breast ptosis is critical in the decision-making algorithm to determine the type of mastopexy necessary when combined with an augmentation. Regnault ( Fig. 5.2 ) is the most well-known classification system for breast ptosis and it is defined by the location of the nipple to the inframammary fold. Other classification schemes are essentially modifications of this system based on skin elasticity, glandular volume, and parenchymal distribution.

Diagnosis, patient presentation, and counseling

In the case of augmentation mastopexy, it is the rare patient who presents knowing exactly what they need to achieve their desired appearance. The surgeon must often use lay terminology and also astutely pick up on body language and hand gestures to fully understand the patient's desires. Patients generally fall into two categories when they present for aesthetic breast surgery:

• 1.

  One group is the smaller-breasted patient who seeks augmentation and does not recognize they have a certain degree of ptosis. These patients should be encouraged to view before and after photos demonstrating various mastopexy incision designs in patients of different skin types. We recommend showing examples with excellent, fair, and poorly healed scars for honest communication. In the patient who is a good candidate for augmentation mastopexy but is unwilling to accept the breast scars associated with the mastopexy then augmentation mastopexy is not performed. Based on their desires, these patients may be better suited for augmentation alone; however, they must be willing to accept the limitations of breast shape that can be achieved with augmentation alone.

• 2.

  The second group comprises patients requesting a breast lift but who also wants fuller breasts that can only be achieved with an additional augmentation. These patients present a particular challenge because they may not have emotionally accepted the idea of using an implant and will require extra time to process this consideration. Should they be willing to accept implant augmentation, the surgeon should point out the anticipated implant maintenance; implant exchange in the future is typically not an “if” but “when” scenario. In general, patients requiring augmentation mastopexy are often older than patients desiring enlargement with implants. Patient factors such as weight loss, pregnancy, and breast feeding are often at play and their sequelae of increased tissue laxity, parenchyma loss, striae, and nipple ptosis require a mastopexy to create an aesthetic breast shape. In the initial consultation, it is very important to distinguish the tuberous-breasted patient, which can present additional challenges that are not within the scope of this chapter.

A summary of indications and contraindications for augmentation mastopexy are summarized ( Box 5.1 ).

Anatomic factors in augmentation mastopexy

Several anatomic factors warrant special consideration in augmentation mastopexy:

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  Skin elasticity should be evaluated – patients with poorly elastic skin and lack of soft tissue support may be prone to malposition. Consideration to adjunctive use of support materials such as acellular dermal matrix (ADM) or mesh (e.g. poly-4-hydroxybutyrate (P4HB) or polydioxanone (PDO)) should be given.

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  Soft tissue thickness may affect the visibility of implant edges and rippling. In patients with less breast tissue increasing silicone implant cohesivity, avoiding the use of saline implants, and adjunctive fat grafting can improve implant visibility or unsightly rippling.

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  Chest wall morphology and asymmetry should be assessed from worm’s eye view. Patients with pectus excavatum or pectus carinatum may be prone to medial or lateral malpositions, respectively. One can consider soft tissue support (ADM, mesh) to help secure implant position. Rib cage asymmetries should be pointed out to the patient preoperatively as this may affect the apparent projection of the breast and, in select cases, may justify the use of different implant volumes/projections.

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  Lateral chest and axillary adiposity can distract from an otherwise beautiful augmentation mastopexy and may be a source of patient dissatisfaction postoperatively. These areas should be carefully discussed with each patient and, if needed, suction lipectomy can be considered.

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  Inverted nipples , if present, may be addressed at the time of augmentation mastopexy or in a staged fashion. The authors have published a simple duct-sparing technique for inverted nipple correction that can be reviewed at the reader’s discretion.

Selecting the appropriate mastopexy incision

Once the patient’s aesthetic goals have been clarified, the surgeon can then select the appropriate mastopexy incision ( Fig. 5.3 ) through which an implant may be placed and the breast shaped. A variety of options are available depending on the degree of ptosis present.