Cardenas-Camarena published his experience with 384 patients undergoing one stage mastopexy-augmentation.³ His complication rate of 18%, all described as minor, was very favorable. His approach was to first insert the implant and then plan the skin excision around the newly implanted breast. He provided guidelines for the pattern of skin excision based primarily on the degree of ptosis of the nipple–areola complex (NAC) and on the distance from the NAC to the inframammary fold (IMF).

In 2007 Stevens reported on 321 consecutive one stage mastopexy-augmentations.⁴ Approximately two-thirds of these were primary procedures and one-third were in patients with previous breast augmentation or previous breast lifts. Complications over an average 40 month follow up were rare and included saline implant deflation, poor scarring, recurrent ptosis and areola asymmetry. The total revision rate was 14.6% with three-quarters of these being implant related and one-quarter being tissue related. He compared these results favorably to a 13% revision rate in his breast implant only patients and an 8.6% revision rate in his mastopexy only patients. Stevens noted that revision was most common in smokers, those undergoing a circumareolar lift and patients having augmentation with saline implants. He concluded with the statement that ‘although a revision rate of 14.6% is significant, it is far from the 100% reoperation rate required for a staged procedure.’⁴

Spear has written about his experience with combined breast augmentation and breast lift and cautions about the increased risks and revisions associated with this approach.⁵ He noted a 10-fold increase in complications when comparing primary augmentation mastopexy with primary augmentation only. As a guideline, he recommended that women undergoing breast augmentation could avoid a simultaneous mastopexy if the nipple sits at or above the IMF, if the nipple and areola are visible on the front of the breast with some inferior non-areola skin being visible, if the breast overhangs the IMF by no more than 2 cm and if the nipple to IMF distance is less than or equal to 8 cm under maximum stretch.

It is important to differentiate between primary one stage augmentation mastopexy and secondary procedures that are performed following a previous implant or lift. Handel’s paper titled ‘Secondary mastopexy in the augmented patient: a recipe for disaster’,⁶ highlights some of the key issues that must be considered in this complex patient population. Over time, augmented breasts, especially those placed in a subglandular plane, become ptotic and develop thinning of the overlying breast tissue. The majority of these soft tissue effects are seen in the lower pole of the breast. Often, there are associated contractures of the surrounding capsules. Correction of this deformity may require explantation only, mastopexy with explantation or mastopexy with or without implant exchange or pocket change⁷ (Figs 27.1 and 27.2).

Fig. 27.1 AP and oblique views of patient following explantation only.

Fig. 27.2 A Preoperative view of patient with high riding implants and B 6 month postoperative view following explantation and mastopexy.

Handel makes several recommendations for dealing with these patients. Preoperative deflation of a saline implant allows the patient to see the breast in a deflated state and allows the surgeon to better assess the quality and quantity of remaining breast tissue. This simple step will provide valuable information that may affect the choice of operation selected by the patient. If a mastopexy is required, undermining should be minimized and capsulectomy should only be performed when necessary. It is important to make note of previous breast scars, especially as they relate to the vascular supply of the NAC. Since inferior pole tissues are often attenuated, use caution in selecting an inferior based pedicle. It may often be best to excise the thin lower pole tissues and select a superiorly based pedicle, where tissues are of better quality. Finally, in circumareolar incisions, especially with a subglandular implant, it is important to bevel the plane of dissection acutely due to the thin nature of the tissue between the skin and the underlying implant. Failure to recognize this may lead to vascular compromise of the nipple (Fig. 27.3).

Fig. 27.3 Minimal tissue thickness between the skin and the breast implant capsule dictate the need for acute beveling of periareolar incisions in order to maintain adequate vascular supply to the nipple.

This chapter will focus primarily on one-stage mastopexy-augmentation including key aspects of patient selection, preoperative planning and marking, operative technique, postoperative care and recommendations for avoiding complications. When appropriate, discussion of secondary, two-stage procedures will be included.

Patient Selection

In primary mastopexy-augmentation surgery, factors that affect the outcome can be classified into technical, choice of procedure and perhaps most important, patient selection. Women who are considered for this procedure either have some form of congenital abnormal breast development such as a tuberous or constricted breast, or have developed ptosis and hypoplasia secondary to pregnancy and lactation, weight loss or gravitational change.

The fundamental decision that must be made between patient and surgeon is what is the best operation to most closely meet the patient’s goals and objectives of surgery. This may be a mastopexy, an augmentation or a combination of both. Although some patients can only be adequately treated with a combined procedure, every consideration should be made to addressing the patient’s concerns with a single procedure, if possible (Figs 27.4 and 27.5). Initially, the patient’s goals must be clearly reviewed. Are the concerns related to size, shape, symmetry, NAC position, areola size, stretch marks or some combination? Which of these is most important to correct and what is the patient prepared to trade off in order to obtain this correction? Essentially, a risk benefit analysis must be applied after a thorough discussion about options and complications. If a mastopexy and augmentation are to be performed together, a further decision of whether or not to perform the surgery in one stage or two stages is necessary. A one-stage approach should be reserved for healthy patients, non-smokers with few risk factors for impaired healing. These patients should be certain that they desire both a lift and an implant, otherwise the issue most important to the patient is treated first. Once healed, the patient can determine if they require the second procedure to satisfy their goals. A decision tree can be helpful in performing this analysis (Fig. 27.6).

Fig. 27.4 A, B Preoperative views of patient with grade 2 ptosis. C, D 1 year postoperative views following subpectoral augmentation with full height, extra projection 360 g implant. No breast lift was performed.

Fig. 27.5 A, B Preoperative views of patient with ptosis and good breast volume. C, D Six week postoperative views following vertical scar mastopexy using an inferior flap secured under a pectoralis sling.⁹

Fig. 27.6 Decision tree for mastopexy-augmentation.

A focused history is taken and includes general health, previous surgery especially related to the breast, history of radiation therapy, family history of breast cancer and date of most recent mammogram. Patients over the age of 40 are recommended to have a mammogram prior to elective breast surgery if not done within the previous year. Smoking history is reviewed as patients undergoing a combined augmentation and lift must not be active smokers. Patients are asked about their plans for future breastfeeding. If this issue is of significant importance to the patient, they are recommended to delay any elective breast surgery until they are finished having children.

Physical examination focuses on overall body proportions and the relationship of breast size to the rest of the body. Breasts are examined for size, shape, symmetry, nipple position and stretch marks. Ptosis is assessed as defined by Regnault.⁸ It is important to assess the quality of the breast tissue and skin in all zones of the breast. This information is helpful in deciding whether tissue should be excised and if so, then from which zone. Standard measurements of sternal notch to nipple, nipple to IMF, breast width and nipple to midline are documented. Finally, a breast examination is performed for abnormal masses.

Indications

The specific indications for performing a one-stage mastopexy-augmentation can be summarized as follows:

1. A patient who desires both an increase in breast size as well as a lift of the breast tissue.

2. A patient with ptosis who has inadequate tissue to shape a breast without the addition of volume.

3. A patient with tuberous breast deformity requiring augmentation and correction of areola herniation or hypertrophy.

4. A patient without risk factors for impaired wound healing including smoking, radiation, multiple breast scars or significant systemic medical condition.

5. A patient with realistic expectations and is willing to accept the scars associated with a mastopexy.

Operative Technique (Table 27.1)

Markings

The operative technique begins with preoperative markings. These markings are done prior to entering the operating room. Markings are done with the patient in a standing or sitting position. A mark is made in the sternal notch and the meridian of each breast is drawn freehand. Distance from the meridian to the midline is measured to ensure symmetry. The dimensions of the implant pocket are drawn as for a breast augmentation; medially at the lateral border of the sternum, laterally at the anterior axillary fold, inferiorly at the IMF. Every attempt is made to preserve the existing fold, but in cases of inferior pole constriction, lowering of the fold will be necessary. The initial temporary mark for the new NAC position is made along the meridian line. When performing a mastopexy or breast reduction, the nipple is generally marked at the level of the IMF with the superior border of the areola above the fold. In a mastopexy with augmentation, the nipple needs to be positioned slightly higher. The rationale for this is that an implant will sit above most IMFs whereas natural breast tissue will tend to descend resulting in some degree of pseudoptosis. Of course, markings at this stage are only temporary and will be adjusted once the implant is in place. Although it is much easier to correct a NAC that is too low rather than too high, the more common error is to leave the NAC too low.

Table 27.1 Summary of operative steps for primary mastopexy-augmentation

1. Preoperative markings

Standing position

Mark dimensions of implant pocket

Temporary markings for skin excision

2. Position on OR table

Arms symmetrical, preference for 90° abduction

3. Infiltration of local anesthetic with epinephrine to incisions

4. Limited incision within the planned area of skin excision

Design to maximize soft tissue coverage over implant

Design to minimize vascular disruption to the NAC

5. Atraumatic dissection of breast implant pocket

6. Hemostasis and irrigation of implant pocket

7. Insertion of implant

8. Tailor tack skin for planned excision

9. Sit patient up to 90°

Assess implant position, adequacy of skin tension and breast shape, NAC position, overall symmetry

10. De-epithelialize skin/excise tissue when indicated

11. Limited skin flap elevation

12. Two layer closure

13. Control areola diameter with periareolar suture when indicated

14. Final assessment of symmetry and nipple position

15. Apply bandage and postoperative bra

Once the height of the NAC is determined, the remainder of the markings are dependent upon the planned skin pattern of excision. Whether marking out a crescent lift, a circumareolar excision, a vertical skin pattern or a Wise pattern excision, markings should be very conservative with the expectation that more skin will be excised at the time of tailor tacking (Fig. 27.7).

Fig. 27.7 Preoperative markings. A Implant pocket and B mastopexy pattern.

The decision as to what type of a lift to perform can be very complex and is affected by many variables. In general, it is unwise to make fewer scars at the expense of a pleasing breast shape. For example, an over aggressive circumareolar lift will cause excess tension on the front of the breast leading to a flattened shape with loss of projection, lateral displacement of the breast implant and widened areola scars. Breasts that would benefit from narrowing of the base may do well with circumvertical patterns and breasts that require tightening in both the horizontal and vertical dimensions may do best with a full Wise pattern lift. Certain decisions will dictate the eventual choice of skin pattern; how far does the NAC need to be moved, how much skin excess is there in both a horizontal and vertical direction, is there redundant lower pole or lateral breast tissue to excise, are there stretch marks to excise and if so where are they located, are there preexisting breast scars and where are they located, does the areola size need to be reduced? The patient’s views on what degree of scarring they are willing to accept is obviously important. Proper education of the patient regarding the effects of various skin patterns on the eventual breast shape is an important part of this decision process.

When selecting the type of mastopexy to perform immediately following implant placement, consideration must be given to the pattern of the blood supply within the breast. The lift may be performed with minimal undermining of tissues, avoiding the creation of a defined pedicle. If a pedicle is used to carry the nipple complex, the surgeon should be aware that the blood supply of an inferior pedicle will have been disrupted by the implant insertion, making that choice unavailable. In this circumstance, a superior, lateral, or medial pedicle should be selected.

Induction

Thirty minutes prior to surgery, patients are given 1000 mg of acetaminophen and 200 mg of Celebrex. This combination helps to decrease postoperative narcotic use. The patient is positioned supine with arms abducted at 90°. It is important to ensure that the armboards are placed exactly symmetrical on the bed. Arms are securely fastened to protect the axilla and elbow when sitting the patient upright. A single dose of intravenous antibiotic is given, the chest is prepped and draped in a wide fashion from above the clavicle to the umbilicus. For patients undergoing subpectoral placement of the implants, short acting muscle relaxants are given to facilitate pocket dissection with minimal retraction.

Surgery begins with infiltration of local anesthetic and epinephrine (adrenaline) to the planned incision sites. The breast augmentation is performed first. An incision is made somewhere within the boundaries of the planned skin excision. The exact orientation and location of the incision should be selected to minimize vascular interruption to the NAC and maximize tissue thickness over the implant. For example, in breasts that have thin, attenuated lower poles, it may be best to avoid an incision near the IMF, where a layered closure of tissue over the implant will be difficult.

Technique

Options for the plane of dissection include subglandular, subfascial, subpectoral, or dual plane. Subpectoral or subfascial pockets have the potential for providing some stability and support to the implant which may result in less stretching of the overlying tissues with time. A subpectoral location is necessary when there is inadequate breast tissue to cover the implant, especially in the upper pole. Although placing the implant under the muscle maximizes soft tissue coverage, patients should be made aware that there are tradeoffs with this approach. As women age, the breast tissue will tend to become ptotic. With the implant under the muscle, it will be held in a superior position, rather than descending with the breast tissue. This ‘waterfall’ deformity will require further lifting of the breast for correction (Fig. 27.8).

Fig. 27.8 A, B Previous subpectoral augmentation with residual ptosis of the breast tissue causing a ‘waterfall’ deformity.

Pocket dissection is performed under direct visualization using a lighted mammary retractor. Dissection is done with electrocautery in an atraumatic manner. No blunt dissection is performed. This approach will minimize both postoperative discomfort and the presence of blood around the implant. Precise dissection of the pocket is performed to the predetermined markings. This is especially critical when using an anatomic shaped gel implant where the implant must fit tight within the pocket to avoid rotation and malposition. Following dissection, pockets are checked for symmetry with digital palpation. Irrigation is performed with an antibacterial or antiseptic solution and a final check is made to ensure complete hemostasis.

At this point, a decision is made whether to insert the permanent implant or to use a temporary sizer. Essentially, the decision comes down to whether one wishes to fix the volume of the implant and tailor the skin and breast around it versus using a sizer that can be adjusted for volume once the breast shape is fixed. In cases of asymmetry where different size implants will be used, sizers are extremely helpful.

Implant selection

There are many implant choices today for use in breast augmentation (Table 27.2). The advantages and disadvantages of each implant type are beyond the scope of this discussion but several points are worth noting. Saline filled implants have the benefit of acting as a sizer in that they can be progressively inflated to desired tension, allowing for flexibility in volume selection. Of course, adequate tissue coverage is necessary to minimize rippling and palpability of the device. Saline implants have a firmer feel than gel implants and are likely to produce a fuller look in the upper pole (Fig. 27.9). Stevens found that in his experience with one stage mastopexy-augmentation, 31% of the implants used were saline however they accounted for 49% of the revisions. These were primarily performed for deflation and rippling.⁴

Table 27.2 Implant options in breast augmentation

Fig. 27.9 A, B Preoperative views of patient undergoing asymmetric vertical scar mastopexy and subglandular saline implants 260 cc on right, 240 cc on left. C, D One year postoperative views.

There is a role for both round and shaped implants in combined augmentation with mastopexy. Shaped stable cohesive gel implants are an excellent choice in patients with a tight or constricted lower pole as seen in the tuberous breast deformity (Fig. 27.10). As well, the differential fill volume in the lower pole of the implant provides more lift of a slightly ptotic NAC than a round device. This is particularly useful in patients with postpartum ptosis and may allow the patient to either do without a lift or to have less of an aggressive lift (Fig. 27.11). In patients with looser skin envelopes, and especially when the selected implant diameter is narrower than the diameter of the breast, a round implant is preferred. Use of a shaped device in this situation may result in rotation or malposition of the implant due to inadequate soft tissue support.

Fig. 27.10 Tuberous breast correction with circumareolar lift and anatomic full height, full projection 375 g cohesive gel implants. A Preoperative view and B six month postoperative view.

Fig. 27.11 Correction of postpartum ptosis with circumareolar lift and shaped full height, full projection 290 g cohesive gel implants. A, B Preoperative and C, D 6 weeks postoperative views.

When choosing the implant size, smaller is better! Most patients undergoing a mastopexy with implant insertion are there because their soft tissues have stretched. This says something important about the underlying elasticity of the patient’s skin envelope. Adding more weight and volume than necessary will add an additional load to the tissues, accelerating the process of natural gravitational descent of the breast.

Shaping the breast

Once the implant is inserted, the soft tissues directly over the implant are closed with an absorbable suture. The skin is tacked together with either sutures or staples, following the preoperative skin pattern. Inspection of the breast is then carried out in a supine position looking for symmetry of the lateral position of the implant and the medial contour of the breast. The patient is placed upright to 90° to assess the IMFs, nipple position, lateral breast profile and overall symmetry. Adjustments are made to the pattern of skin excision as necessary.

Once it has been determined how much skin to remove, the patient is returned to a supine position and the tacking sutures are removed. The areola is incised with use of an appropriate diameter nipple marker and the skin within the pattern is de-epithelialized. Limited undermining of the skin flaps is carried out to minimize further vascular disruption to the NAC and to the skin flaps. Undermining is only carried as far as necessary to allow for closure with a comfortable degree of tension. In breasts where there is excess tissue in the lower pole, there may be benefit to excising some of the tissue. Otherwise, it may eventually become ptotic, and given the fact that the implant will provide adequate volume, the tissue becomes redundant. When performing a mastopexy only, repositioning the lower pole tissues as described by Graf and Biggs ⁹ is an excellent alternative to excising the ptotic tissue. This approach is contraindicated in combined procedures as the blood supply to the inferior chest wall flap will have been disrupted during implant insertion.

Closure is carried out in two layers with multiple subdermal sutures followed by a running subcuticular stitch. An absorbable monofilament suture is used. In situations where there is excess tension on the areola, a permanent suture is used to control the areola diameter. This is most always necessary in circumareolar techniques. Ideally, the suture should be non-absorbable and glide easily when tightened. A variety of approaches to placing this suture have been described.¹⁰^,¹¹ The interlocking Gore-Tex approach published by Hammond is a very effective option that would appear to provide long term control.¹¹ Examples of various mastopexy-augmentation approaches are illustrated in Figs 27.12–27.14.

Fig. 27.12 A, B Preoperative views of patient undergoing circumareolar lift and 350 g shaped cohesive gel subglandular implant. C, D Six months postoperative view.

Fig. 27.13 A, B Preoperative views of patient undergoing vertical mastopexy and subpectoral 290 g shaped cohesive gel implant. C, D Five year postoperative views.

Fig. 27.14 A, B Preoperative views of patient undergoing Wise pattern mastopexy and subglandular 270 cc saline implant on right, 240 cc on left. C, D Six month postoperative views.

In primary surgery, drains are not routinely used. In cases where there has been excision of breast tissue, more bleeding than expected, or secondary surgery requiring a pocket change or capsulectomy, a closed suction drain is used. The drain is inserted through a separate incision and placed in an area where there is a long subcutaneous tunnel to minimize tracking of organisms when the drain is removed.

The tuberous breast

A specific situation that often requires some type of mastopexy along with an implant insertion is the tuberous or constricted breast. This deformity includes a constellation of findings; hypoplastic breast, ptosis, constricted base of the breast, areola herniation, areola hypertrophy, and often asymmetry. Severe forms of tuberous breast usually require a two-stage approach including an initial phase of tissue expansion followed by implant insertion and correction of the areola.

In type 1, 2, and most type 3 tuberous breasts, a one stage approach is indicated.¹² If there is areola hypertrophy or herniation, a circumareolar approach is selected. In cases where there is also ptosis with redundant skin in the lower pole, a circumvertical approach is used. Dissection is carried through the breast to the pectoral muscle. Ideally, a subglandular pocket is selected as this will provide the most direct stretch against the constricted breast tissues. In patients with minimal tissue in the upper pole, a dual plane pocket is used. Aggressive radial scoring is performed. Often, it is necessary to score through the breast to the level of the dermis. A shaped form stable cohesive gel implant is an ideal choice for this patient population.¹³ The implant provides an added degree of resistance to the tight lower pole tissues, assisting in both short term and long term shape. The shape of the device has greater lower pole projection which is ideal in patients with deficiency in this area. The tapered upper portion also provides a natural contour to the superior part of the breast. Tuberous breasts generally have a narrow base with minimal lateral tissue. The implant is used to assist in providing a wider base and more natural lateral contour. As a result, rippling and implant edge palpability is common. This is less likely to occur with a form stable device than it is with a softer gel or saline filled implant (Fig. 27.15).

Fig. 27.15 Type 3 tuberous breast deformity.

A, B Preoperative views. C, D Intraoperative views following circumareolar lift and subglandular medium height, full projection 295 g shaped cohesive gel implant. E, F Six week postoperative views.

Secondary mastopexy-augmentation

Secondary mastopexy-augmentation is defined as a breast lift or implant insertion following a previous augmentation, lift, or reduction. These cases are complex due to the alteration of internal anatomy, impaired vascular supply to the NAC and thinning of the breast tissue and skin secondary to the previous surgery or surgeries. In situations where an implant has been used, additional problems such as implant malposition or capsular contracture may need to be addressed.

A decision is made whether to perform the procedure in one or two stages. Although each specific patient is unique based upon their medical history, previous breast procedures, scars, and quality of tissue, certain recommendations can be made. These are illustrated in the cases presented below.

Perhaps the most common problem seen is a patient who has undergone previous subglandular breast augmentation. Often, the implants are large for both the size of the patient and the overlying soft tissue envelope. There is thinning of the breast tissue, ptosis of the NAC and often a contracture of the surrounding capsule (Fig. 27.16). Options for correction include explantation or explantation with mastopexy (Fig. 27.17). This latter option can only be considered if there is an adequate amount of tissue to create a breast with reasonable shape. In patients with saline implants, preoperative deflation in the office allows an assessment of breast volume and shape. This can be a very helpful and educational maneuver but requires that the patient be completely committed to a further operation. A third option involves implant exchange, either subglandular or in a new subpectoral pocket, along with a mastopexy. This is the option most commonly selected by the patient as it allows for correction of ptosis while maintaining breast size.