Skin reduction using “smile mastopexy” technique in breast reconstruction

Introduction

Implant-based immediate breast reconstruction continues to gain popularity with patients due to the improved cosmesis. Contributing to this improvement is the preservation of most, if not all, of the skin envelope and the nipple–areolar complex (NAC). In 1991, Toth and Lappert introduced the idea of preoperative plastic surgery planning and skin-saving techniques in patients undergoing simple or radical modified mastectomy. In women with small or non-ptotic breasts, preservation of the NAC and skin envelope is straightforward and the mastectomy is possible through several incision options. However, in patients with very large or ptotic breasts, achieving an aesthetically appealing result following mastectomy poses a significant challenge. Their large breast size introduces major challenges for the reconstructive surgeon due to the excessive skin flap and added risk of skin necrosis. Preservation of NAC has been traditionally contraindicated in these patients due to ischemic concerns and the risk of nipple–areolar necrosis. In addition, women with mammary hypertrophy and excess skin often require larger implants and the ability to achieve adequate control of the mastectomy pocket becomes challenging. Moreover, many of these patients present with comorbidities such as obesity, diabetes mellitus and cardiovascular disease, which can increase their perioperative risk profile.

Classically, in women with large or ptotic breasts, the excess skin and NAC was excised in an elliptical fashion over the center or apex of the breast. One of the primary limitations of this approach is that the skin redundancy is addressed only in the vertical vector; thus the final appearance of the breast can include lateral dog ears, a poorly projecting breast due to loss of conus and ultimately can lead to poor cosmesis. To address these issues, multiple alternative techniques for skin reduction at the time of mastectomy have been published; however, they are fraught with many pitfalls. Among these, Wise pattern-based designs, with multiple variations, are the most widely used. These techniques allow for skin reduction in both vertical and horizontal dimensions. They can be done in staged fashion as a breast reduction before mastectomy but this requires a staged surgical approach requiring two operations that can further complicate an already complex situation. Alternatively, this can be done at the time of mastectomy by creating an inferiorly based adipodermal flap (ADF) with or without NAC preservation. The infolding of ADF in the lower pole of the breast can provide extra thickness and, if used as an autoderm, it may replace the need for acellular dermal matrix (ADM) for lower pole support or pectoralis muscle draping in case of submuscular reconstruction.

The inverted-T or Wise pattern also has its pitfalls. In some patients, it may be difficult to precisely determine the amount of transverse reduction, which in turn can result in overly narrowed lower pole if the angles of the vertical limbs are too wide. In addition, Wise-pattern mastectomy is characterized by a higher rate of surgical complications related to wound healing that is primarily related to the stress and tension sustained by the medial and lateral flaps (from 7 to 9 cm long) at the inverted-T suture point. Sometimes, this causes wound dehiscence and exposure of the implant, and may result in explantation. Nava et al . created an inferior pedicle type ADF that is sutured superiorly to the pectoralis muscle, providing implant coverage. They reported that 14% of patients had skin necrosis leading to implant exposure. Other studies have reported similarly high rates (up to 30% major complications) using the Wise pattern and these correlate with larger resection specimen weights.

Another approach of skin reduction for very large breast is the “buttonhole mastopexy” technique, which is based on a superior skin flap draping over a large inferior ADF and allows for preservation of NAC in ptotic breasts. It is however, indicated only in the extreme cases of ptosis where there is a minimum of 8 cm of distance from the new nipple location to the inferior border of the superior flap. Otherwise, the design must be converted to Wise pattern (with associated healing issues previously discussed) in order to recruit skin to the lower pole. The “bell pattern” technique has also been described to address excess skin in both directions without losing the conus but it does not allow for nipple preservation and scar orientation, which is less than ideal.

Another hallmark of an aesthetically appealing implant-based breast reconstruction is the absence of visible rippling. A common pitfall to all the above aforementioned techniques of skin reduction during mastectomy is the inability to add any additional thickness to the upper pole of the breast. The use of ADM has been promoted in part to improve flap thickness; however, it is unlikely that the incorporation of a thin layer of ADM adequately prevents or minimizes the rippling issue. Alternatively, fat grafting has become a common procedure to help camouflage implant visibility and rippling. Although often effective, improvement is sometimes modest and multiple fat grafting sessions may be necessary.

To address some of the shortcomings of these skin reduction techniques, the senior author (KM) has described a novel technique named the “smile mastopexy” (SM). This technique allows for skin reduction in both horizontal and vertical vectors, preserves the NAC, and adds extra thickness to the upper pole through its ADF design. In addition, the design of the final scar allows for further skin envelope adjustments if necessary. It can be used in both one- and two-stage immediate breast reconstruction.

An algorithmic approach for managing the skin envelope in patients undergoing mastectomy and immediate two-stage implant-based reconstruction has been described ( Algorithm 24.1 ). All patients with small/non-ptotic breasts (grade 0–1 ptosis) undergoing mastectomy and immediate implant-based two-stage breast reconstruction are approached through an inferolateral or lateral incision. Patients with grade 2 or 3 ptosis will often require skin envelope reduction. In our experience, these patients have upper pole excess but the differentiating factor is the presence or absence of lower pole excess (nipple [N]:inframammary fold [IMF]). If N:IMF is 7 cm or less, the upper pole is reduced through a “half-snitch” (bat wing) design, which allows the nipple to be lifted without reducing the N:IMF distance. On the other hand, if N:IMF is greater than 7 cm, the patient may be a candidate for the SM design. Lastly, in any case where the lower pole has stretched or there are asymmetries of the NAC after stage one, a “snitch lift” (full or half) is designed and performed at the second stage. The basis for this nomenclature is derived from its resemblance to the “golden snitch” in the Harry Potter series (J.K. Rowling and Warner Bros. Entertainment Inc.) (see later). In order to safely perform these nipple-sparing procedures, all patients must qualify oncologically for nipple sparing.

Algorithm 24.1

Treatment algorithm for managing skin envelope at the time of mastectomy. (From Movassaghi K, Stewart CN. The “Smile Mastopexy”: A Novel Technique to Aesthetically Address the Excess Skin Envelope in Large, Ptotic Breasts While Preserving Nipple Areolar Complex During Prosthetic Breast Reconstruction. Aesthet Surg J. 2022;42(6):NP393–NP403.)

With regard to mesh support, ADM is not usually used in these cases; however, resorbable mesh products such as poly-4-hydroxybutyrate (P4HB) are sometimes used for lateral pocket support to minimize risk of lateral malposition. All cases are performed in an outpatient facility. Patients follow standard protocol for tissue expansion and subsequent second-stage reconstruction using the final breast implant.

Surgical technique

Preoperative markings

In a standing position, the new nipple location is determined by the anterior projection of the IMF and its junction with the meridian of the breast (Pitanguy point). The upper incision is marked in a curvilinear fashion through this point making sure that the medial extent does not extend beyond the assumed location of a brassiere. Next, 7 cm is measured from the middle of IMF toward Pitanguy’s point, which then becomes the new N:IMF distance. The lower line is then marked through this second point paralleling the lower pole of the breast and connecting with the medial and lateral extent of the upper line. The intervening skin will become the designated ADF ( Figs. 24.1 & 24.2 ; Video 24.1 ). The NAC is delineated with a 4.2-cm diameter cookie-cutter.