Lowering Complication Rates in Augmentation-Mastopexy
Simultaneous breast augmentation and breast lift can be a tricky procedure which historically is known to have a relatively high rate of revision (between eight and 17% in some studies). The reason for this has everything to do with quality of breast skin and breast tissues that patients have who present to my office for this procedure. The other reason for this is that the two portions of the operation are in direct opposition to each other.
The operation by definition is one in which both components are competing with each other. Namely, most women have a nipple position that is too low and excess breast tissue that is too saggy. The ‘lift’ portion of the operation serves to correct nipple position and reduce the amount of excess skin (i.e. reduce the skin envelope). Simultaneously, these patients have lost volume in their breast tissue as a result of post-partum deflation, weight loss, or both. The ‘breast implant’ portion of this operation serves to correct this (i.e. increase the breast mound). The mastopexy effectively pushes the breast northward. The breast implant, by way of weight and gravity, effectively pushes the breast southward. This is where the competing forces arise.
We as plastic surgeons strive to perform these operations in one stage wishing to have as low of a complication rate and revision rate as possible. In doing so, there are some guiding principles used by Dr. Brenner that help to achieve success in this operation:
- Choose an implant that is not too big, and place in the sub-muscular position.
- Choose an implant that matches (and is slightly smaller than) the breast base diameter. The mid-point of the implant should ultimately live just beneath the nipple.
- Use as much of the patient’s own breast tissue as possible. For some patients this means simply removing the skin from the lower portion of the breast and utilizing the underlying breast tissue to cover the lower pole of the breast.
- Measure the vertical limb (vertical scar) length, to a short (but size appropriate) length. This will help to insure that the nipple position remains correct long term.
- Use a superior or superior-medial breast pedicle in order to help maintain fullness in the upper portion of the breast.
A recent retrospective study by Beale, et al. (PRS Vol.133, No. 3, Mar 2014, p543e) confirmed many of these findings. They described a one-stage mastopexy-augmentation technique that uses a relatively conservative approach which provided the investigators with relative safety and predictability in this operation. They used an inferior pedicle technique, not a superior pedicle technique. They did use a relatively small sub-muscular breast implant (average volume was <200cc). They performed the operation only in women who required 4cm or less of nipple elevation. The pre-operative marking technique described routinely resulted in a nipple to fold distance of 6 cm. (This distance is OK, but will only allow smaller implants to be centered beneath.) Interestingly, the rates of revision in this study were very similar to previous studies. However, they did have more revisions for thinks like change in implant size and scar revision, and less for things like implant malposition.
For more information on Dr. Brenner’s published technique (which differs from that of Beale, et al.), click here.