Many women should be well-informed about all of the factors involved in breast surgery.
For example, a woman may approach a plastic surgeon’s office with requests for breast augmentation, but after the initial consultation truly bothersome features about the prospective patient’s breasts may be uncovered. As a result, a breast lift may instead be the appropriate procedure of choice.
Alternatively, women interested in simple augmentation may be surprised to learn that they may not be satisfied with that. They may require a breast lift in addition to an augmentation. In fact, in some women, a breast implant alone would suffice.
In addition, it may be straightforward enough to perform either a breast augmentation or a mastopexy, but the situation becomes complex when you do a combination augmentation mastopexy.
In the end, patient satisfaction relates to the discoveries made between physician and patient in the initial consultation—all to better manage patient expectations following the procedure.
The more aware you are about the patient’s desires, the ability to deliver informed consent information, and to secure a patient’s commitment with reasonable expectations, the better for both patient and surgeon.
The FDA has reported that breast augmentation leads to an 18% to 22% rate of reoperation. The number of complications that can grow out of an augmentation-lift combination procedure makes informed consent a top priority for any woman interested in breast surgery.
These risks from combination augmentation-mastopexy procedures include the following:
- Risk of breast implant exposure;
- Risk of infection; and,
- Risk of excessive scarring.
In 2004, Spear et al produced augmentation-mastopexy outcome data involving 34 patients over a 6-year period. Of the 34 patients, 41% had grade 1 ptosis, 41% had grade 2 ptosis, 3% had grade 3 ptosis, and 12% had grade 4 ptosis.
With 50% of the participants responding, 54% desired revision surgery with an expressed desire for a greater lift of the breasts.
Without question, the informed consent process assists with patient satisfaction beginning with the initial consultation.
GOOD OUT OF THE GATE
Undoubtedly, an initial consultation with a woman who desires breast surgery may last more than 1 hour. Don’t be surprised if a second consultation may be required in order to make a proper breast implant selection.
A careful preoperative evaluation that involves both an anatomical and dimension analysis helps plastic surgeons and patients to recognize the limitations of the breast surgery procedure. In this way, the plastic surgeon and the patient may work together to develop the appropriate treatment plan (see sidebar below).
The plastic surgeon’s three primary goals during initial and preoperative consultations are to satisfy the following needs:
- Determine if the patient is a good candidate for the requested procedure(s);
- Identify the changes that the patient wants; and
- Ensure informed consent.
BREAST IMPLANT CHARACTERISTICS AND MEASUREMENTS
One of the most crucial components in the preoperative phase is in the selection of the breast implants. The most appropriate characteristics of breast implants for women must be calculated with accuracy and documented in the patient chart.
The precision of the plastic surgeon’s patient measurements, including breast width, breast size, breast shape, nipple size, nipple shape, chest wall, and chest wall muscle, plays a significant role in the outcome of the procedure.
The comparison between breast width and breast implant width should be documented in the chart. As well, measurements must be taken for the distance between the clavicle area, cleavage, midline, and lateral breast area.
Accurate conversions to meet manufacturer’s specifications, including breast size and shape equating to volume (cc’s), cleavage and lateral breast linking to width, and fullness associated with projection, are critical.
|Figure 1. Mastopexy may consist of repositioning breast tissue, reshaping the nipple and areola, reshaping the breast itself, and reducing the skin envelope.|
|Figure 2. In small-breasted women, medial positioning may achieve cleavage with a smaller, narrower breast implant.|
BREAST LIFT CHOICES
The primary reasons for the breast augmentation/breast lift combination procedure are ptosis and breast contour irregularities.
Mastopexy may consist of repositioning breast tissue, reshaping the nipple and areola, reshaping the breast itself, and reducing the skin envelope.
Women interested in improving their breasts may select from a variety of techniques, including the following:
- Breast implants with a surgical adjustment to accommodate any other imperfection that the patient wishes to alter;
- Breast implants and the periareolar mastopexy;
- Vertical mastopexy;
- Inverted T mastopexy; and,
- Variations thereof.
PSEUDOPTOSIS IN WOMEN DESIRING GREATER SIZE
Interestingly enough, women desiring a larger breast size who have pseudoptosis may be satisfied with an improvement through a breast implant alone, not requiring the breast lift procedure. This is because the nipple-areola complex (NAC) may be rotated both anteriorly and superiorly during the procedure.
Breast implants in women with pseudoptosis work well to fill out the lower pole of the breast, which allows the nipple to move to a higher position on the larger breast.
Often, the first technique for plastic surgeons to explore is the periareolar mastopexy.
Women with minimal to moderate ptosis, shape irregularity, and secondary deformity may be served well by periareolar mastopexy.
During this procedure, one of the most critical components involves the prevention of lateralization of the NAC. This may be accomplished when the ellipse is oriented along the midclavicle line, and final skin resection is performed after the implant has been inserted.
Large breast implants appear to reduce the disparity between internal volume and skin envelope. Women with shape irregularity usually respond well to periareolar mastopexy when the NAC is elevated and the skin envelope is redraped over the breast implant.
Women who are well-suited for periareolar mastopexy typically do well with mobilization of the breast mound.
Breast Surgery Checklist
for Busy Plastic Surgeons
- Evaluate the patient’s desire for breast enhancement;
- Define and grade ptosis;
- Evaluate asymmetry and adjustments necessary for asymmetry;
- Assess skin quality;
- Assess glandular fat quality, quantity, and consistency;
- Outline the limitations of the breast surgery procedure;
- Review breast implant types and placement location advantages and disadvantages;
- Review prevention tools to limit the risk of complications, such as capsular contracture;
- Review complications that may arise, including breast wrinkling, asymmetry between the breasts, breast implant visibility, capsular contracture (Baker III and IV), breast implant malposition, breast implant deflation, hematoma, infection, altered sensation of the nipple and/or breast, breast pain, and incisional scarring;
- Review potential complications that may arise with a possible necessity of reoperation;
- Review alternatives to the proposed procedure; and,
- Ensure that the patient understands the breast implants and breast surgery procedures do not have a lifetime guarantee.
A woman requiring a minimal breast lift may fare well with excess skin deepithelized only. In the case of a woman requiring a moderate lift, undermining is needed in order to be able to redrape the skin.
In the end, short scar procedures work best when disparity between breast volume and skin excess is minimal. In addition, it is important for plastic surgeons to evaluate the breast shape in association with the degree of ptosis, skin quality, and the appearance of stretch marks. In such cases, a more extensive mastopexy may be required.
REVISION PERIAREOLAR MASTOPEXY
Another common request among women is secondary revision breast surgery.
Women with previous subglandular breast implant placement may benefit from the insertion of a large breast implant. Again, larger breast implants may reduce the disparity between breast volume and skin excess.
Women who indicate a bottoming out of their subglandular breast implant and a NAC-to-inframammary fold (IMF) distance of 10 or more centimeters require special care in revision surgery.
Maintaining nipple-areola viability is especially a concern in revision breast surgery. The excess skin between the NAC and the IMF is best addressed with an elliptical skin resection, which is closed with a horizontal incision.
In addition, it is important for you to educate patients about future revision surgery if they have preexisting skin laxity and breast ptosis. Larger breast implants typically require greater skin excision than smaller breast implants at the time of revision surgery.
Plastic surgeons may use a pattern that allows for adjustment in both horizontal and vertical planes. In addition, tailor tacking the proposed skin envelope resection to evaluate skin excision patterns is important before approaching skin excision. Final skin excision adjustments may be made with the breast implant in place for optimal results.
|Figure 4. Maintaining nipple-areola viability is especially a concern in revision breast surgery.|
If the NAC is in a good position and has an aesthetic shape, it is not advised to alter the NAC. Maintaining NAC viability is important in revision breast surgery procedures.
DO TWO TECHNIQUES APPLY IN ASYMMETRY?
Depending upon the extent of asymmetry between the breasts, plastic surgeons may use one technique for one breast and a different technique for the other.
For example, women with asymmetry may require that one breast have a periareolar mastopexy or a vertical mastopexy, whereas the other breast may require a short, inverted T incision.
|Figure 5. For women with adequate tissue coverage but poor skin quality, you may want to recommend subglandular placement of textured breast implants.|
In small-breasted women, one aspect that may not change following breast surgery is cleavage. Medial positioning may achieve cleavage with a smaller, narrower breast implant, but this can present difficulty in terms of managing patient expectations—the results are often aesthetically undesirable.
UTILIZING TECHNOLOGY TO SUPPORT RESULTS
Recent technology improvements in breast surgery is a definite benefit for women with pseudoptosis.
Managing glandular ptosis with biplanar dissection and fixation may be accomplished with the assistance of postsurgical shaping garments, which can be designed to add greater shape after the procedure.
Currently, plastic surgeons can use differential volume and projecting implants to allow for greater precision in breast augmentation in those patients with glandular asymmetries or chest wall deformities.
MANAGING PTOSIS AND SKIN QUALITY
Subglandular placement of breast implants may be the best placement location, but precision in diagnosis of breast characteristics and managing patient expectations are two factors that must be considered.
For women with adequate tissue coverage but poor skin quality, you may want to recommend subglandular placement of textured breast implants, although there may be a higher capsular contracture rate.
This recommendation may also be helpful for women with pseudopsostis and poor skin quality.
In addition, women with insufficient breast tissue coverage and poor skin quality may be more likely to benefit from subpectoral placement of smooth or textured breast implants, but the biplanar approach is the optimal choice in this case—in order to prevent visualization of the implant in the superior pole.
Pain management is more likely a consideration with subpectoral augmentation than with prepectoral placement.
MASTOPEXY AND BREAST REDUCTION
In patients with severe breast asymmetry and large glandular discrepancies, a breast reduction and mastopexy combination may be required.
The final breast shape and scar quality are the two most important factors to consider. Simply put, the more excessive skin relative to breast tissue, the longer the scar will be.
Plastic surgeons who attempt to reduce the length of the scar usually compromise the final breast shape and appearance.
A simultaneous breast augmentation and breast lift combination may be the most complex plastic surgery procedure to perform.
Some plastic surgeons prefer to stage the procedure in order to reduce the risks, and in order to better estimate the nipple location after the breasts drop after the initial breast augmentation procedure.
In any case, the benefits of the breast lift procedure cannot be ignored. The trade-off for the scar may be a small price a woman pays for a breast enhancement that will last for many years.
Laurie A. Casas, MD, FACS, is a board-certified plastic surgeon and an associate professor of surgery at the Northwestern University Feinberg School of Medicine in Chicago. She can be reached at (847) 657-5884.