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periareolar mastopexy: A novel, two-stage, single-operation approach to management of the contralateral breast in implant reconstruction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 485e493
Demystifying trans-axillary augmentation/ periareolar mastopexy: A novel, two-stage, single-operation approach to management of the contralateral breast in implant reconstruction Nina Kropf a, Christina N. Cordeiro b, Colleen M. McCarthy b, Peter G. Cordeiro b,* a
Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University Vienna, Austria Plastic and Reconstructive Surgery Service, Department of Surgery; Memorial Sloan-Kettering Cancer Center, New York, NY 1275, USA
b
Received 11 March 2010; accepted 19 June 2010
KEYWORDS Breast surgery; Mammaplasty; Breast implants; Mastopexy; Augmentation
Summary Background: Following unilateral tissue expander/implant reconstruction, combined augmentation/mastopexy of the contralateral breast may be performed in an attempt to improve breast symmetry. Combined augmentation/mastopexy can be a very difficult operation, even for the surgeon with substantial experience. To simplify the technical approach to this complex problem, the senior author (PGC) has developed a ‘two-stage, single-operation’ approach. The purpose of this study is to review the safety and efficacy of this approach to the contralateral breast in the setting of unilateral, implant-based reconstruction. Methods: A retrospective review of all combined trans-axillary augmentation/periareolar mastopexies performed from 1998 to 2007 was undertaken. Only patients who had a history of prior unilateral mastectomy and immediate expander placement were included. Photographic documentation of long-term aesthetic results was evaluated by two independent observers. Results: In total, 26 combined, trans-axillary augmentation/periareolar mastopexies were performed in patients, who had initiated unilateral, postmastectomy, tissue expander/ implant reconstruction on the contralateral side. No patient desired revisional surgery for inadequate ptosis correction or malpositioning of the nipple. A total of 69% of patients had a ‘very good to excellent’ overall aesthetic result. Of those patients who were deemed to have a ‘good’ aesthetic result, the development of a capsular contracture in the reconstructed breast detracted from the overall aesthetics.
* Corresponding author. Tel.: þ1 212 639 2521; fax: þ1 212 717 3677. E-mail address: [email protected] (P.G. Cordeiro). 1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.06.018
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N. Kropf et al. Conclusion: The two-stage, single-operation approach to unilateral augmentation/mastopexy described here can produce a good aesthetic result and allow for adequate oncologic followup. In particular, excellent results are seen in patients with grade I or II ptosis and goodquality skin preoperatively. Monitoring of the breast for cancer, using mammography, is still possible with this technique. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Tissue expander/implant reconstruction is the most commonly used technique for reconstruction of the breast after mastectomy.1 Although a vast majority of patients undergoing unilateral mastectomy are considered candidates for postmastectomy implant-based reconstruction, the ideal candidate would have a contralateral breast that matches the implant with respect to breast size and shape. Because the overwhelming majority of women do not have such a breast, however, modifying the contralateral breast following unilateral, implant-based reconstruction becomes essential to achieve or approach symmetry. Contralateral augmentation alone is an excellent technique for the patient, who has a very small breast without ptosis or pseudoptosis. By contrast, if the contralateral breast has any degree of ptosis, then, the performance of a mastopexy, in addition to the augmentation, is necessitated to maximise symmetry and achieve the best aesthetic result. Combined augmentation/mastopexy can be a very difficult operation, even for the surgeon with substantial experience.2 In a single-stage procedure, estimating how much skin to excise and/or how much to augment the patient can be a tremendous challenge. This procedure can be even more challenging when trying to match a breast reconstructed using an implant e a breast that has essentially no ptosis and sits high on the chest wall. Many surgeons instead recommend performing the mastopexy and augmentation in two separate operations, although there is an ongoing debate as to which procedure is to be performed first.2e12 Subjecting the patient to a second operation and requiring them to live with the inadequately lifted augmentation or a nonaugmented mastopexy is not an ideal situation. This is particularly true for a patient with breast cancer, who has already undergone two operations just to achieve the reconstructed breast mound (Figure 1). To simplify the technical approach to this complex problem, the senior author has developed a ‘two-stage, single-operation’ approach to the problem. First, a transaxillary sub muscular augmentation of the contralateral breast is performed. Next, an accurate estimate of the exact skin resection required is performed with a temporary periareolar tacking suture. The periareolar mastopexy is then completed and the breast mound is readjusted over the implant. The purpose of this study is to review the safety and efficacy of this approach to the contralateral breast in the setting of unilateral, implant-based reconstruction. Complications, overall aesthetic results, resultant breast symmetry and recurrent ptosis will be evaluated. Patient selection, technical pearls and the impact of this procedure on the continued oncologic surveillance of the contralateral breast will be discussed.
Methods Study design A retrospective review of all combined trans-axillary augmentation/periareolar mastopexies was performed. Consecutive cases performed by the senior surgeon (PGC) from December 1998 to January 2007 were evaluated. Only patients who had a history of prior unilateral mastectomy and immediate expander placement were included. Similarly, only patients who underwent a combined trans-axillary augmentation/periareolar mastopexy of the contralateral breast at the time of the exchange procedure were considered eligible for review. Demographic, oncologic, reconstructive and complication data were retrieved from a prospectively maintained, clinical database. Photographic documentation of long-term aesthetic results was evaluated by two independent observers. Disagreements were resolved by discussion. Breast ptosis was evaluated using the Regnault classification system.13 The overall aesthetic results were evaluated using the rating scale first described by Garbay et al., and later adapted by Lowery and colleagues.14,15 This scale evaluates five variables (i.e., symmetry of breast volume, symmetry of breast contour, placement of the breast mounds on the chest wall, appearance of the inframammary folds and breast scars), each on a 3-point scale. Summary scores are then produced and overall aesthetic results classified as ‘excellent, very good, good or fair’ on a 4-point ordinal scale. Inter-observer reliability of the overall aesthetic results was determined by calculation of a linear weighted kappa coefficient. Stata statistical software was used. Radiographic imaging was performed according to the oncologic standard of care for screening of the contralateral breast.
Patient selection All of the options for breast reconstruction are discussed with the patient. If a patient elects to have reconstruction with an implant, then, management of the contralateral breast must also be addressed. In general, the best candidates for augmentation/mastopexy are women with AeB cup breasts and minimal-to-no breast ptosis. Skin quality contributes greatly to the result and, therefore, patients with the most elastic skin and minimal striae will tend to have the best results. Ideally, patients with grade I or II ptosis are selected for this type of procedure to maximise the result. However, in the patient with a grade III ptosis, who is warned about the potential for recurrent ptosis, this procedure is still an option.
Augmentation mastopexy to achieve symmetry after breast reconstruction
487
Figure 1 AeC. Preoperative assessment: AP, Left oblique and Right oblique views. A 40-year-old female patient with grade I ptosis bilaterally. D-F. Postoperative assessment: AP, Left oblique and Right oblique views. 16 months following left mastectomy and initiation of tissue expander/implant reconstruction of the left breast. 12 months following combined, trans-axillary augmentation/mastopexy of the right breast using a 225 cc saline implant. Concurrently, a 450 cc saline implant was placed in the left breast. Overall aesthetic result graded as ‘very good’.
Ideally, the nipple will not require greater than 2e3 cm of elevation. In addition, the planned overall diameter of the periareolar skin resection should not be greater than 8e10 cm. This will minimise the chance of having a poor outcome with regard to the periareolar scar. The quality of the breast tissue will also influence the result. The best results will generally be obtained in patients with a softer, fatty type of breast, which is much more likely to drape over the implant.
This allows a better match to the reconstructed breast, which essentially has only skin overlying a breast implant.
Surgical technique Preoperative markings All combined augmentation/mastopexies are performed at the time of the exchange procedure. Preoperative markings
488 are routinely performed with the patient in the upright, standing position. On the native, ptotic breast, the desired nipple position is marked and the periareolar skin excision approximated. Reconstructed breast Intra-operatively, the reconstructed breast is addressed first. Following removal of the temporary expander, the inframammary fold is reconstructed using 0/0 silk sutures to approximate the deep dermis to the anterior chest wall. A circumferential capsulotomy is typically performed in an attempt to facilitate the draping of the skin and soft tissues over the implant. A sizer is then used to select the optimal size and shape of implant. Trans-axillary subpectoral augmentation Once the size and shape of the reconstructed breast are determined, attention is turned to the contralateral breast. A 3-cm, trans-axillary incision is made in a skin fold at the lowest portion of the axillary hairline. A subpectoral pocket is bluntly dissected using Dingman breast dissectors. Once this dissection is complete, a round sizer is placed and filled with appropriate amount of saline. The patient is then routinely evaluated in the upright position. Any adjustments to the submuscular pocket are then made to maximise the symmetry of inframammary folds. Periareolar mastopexy With the sizer in place, it is also possible to then gauge how much skin needs to be excised and in what specific pattern the periareolar resection is to be performed. A 2/0 nylon test suture is placed circumferentially along the outer margin of the planned skin excision and cinched down to create a neo-areola approximately 3 cm in diameter. Once the exact periareolar incision and skin excision are estimated, the outer margin of the periareolar incision is marked and the suture released. A 3.8-mm cookie cutter is then used to mark the inner circle of the periareolar skin excision. The intervening skin between the inner and outer margins is then de-epithelialised. Once de-epithelialisation is complete, the dermis is incised 2 mm inside the outer margin of the periareolar excision. Breast skin flaps are then elevated circumferentially. Care is taken to perform the initial dissection so that the resultant flaps are quite thin (just below the dermis) to avoid significant bunching of the skin following placement of the permanent, periareolar suture. As the dissection proceeds down to the chest wall, progressively thicker flaps are elevated. Closure Once flap elevation is complete, a 2/0 clear nylon suture is placed in the deep dermis as a periareolar suture using a Keith needle and is cinched down to create a neo-areola 3 cm in diameter. The final inset of the areolar skin to the circumferential breast skin is completed using 4/0 Vicryl sutures in the more superficial dermis. Skin-edge approximation is achieved using Dermabond. Implant selection An anatomic implant is selected for the reconstructed breast; a round implant is chosen for the augmented breast
N. Kropf et al. as this creates a more anatomic shape once positioned appropriately under the breast mound. The use of sizers allows for adjustments to be made to the submuscular pocket to maximise breast volume, the symmetry of inframammary fold position and the appropriate amount of skin resection.
Results Demographics In total, 26 combined, trans-axillary augmentation/periareolar mastopexies were performed to create symmetry with a contralateral postmastectomy, tissue expander/ implant reconstruction. All patients underwent immediate reconstruction with placement of a tissue expander. At the time of the exchange of the temporary tissue expander for a permanent implant, a simultaneous augmentation/mastopexy was performed (Figure 2). Mean patient age was 43.9 years (range: 32e53 years; n Z 26). Preoperatively, three patients had grade I ptosis, 14 had grade II ptosis and nine grade III ptosis. Fifty-four percent (14/26) of patients had a history of neo-adjuvant chemotherapy; 3.8% (1/26) received adjuvant chemotherapy. Thirty-nine percent (10/26) of patients had a history of post-exchange radiotherapy.
Implant selection In all 26 patients, McGhan round, moderate-profile, saline-filled implants were used to augment the contralateral breast. Mean implant volume was 250 cc (range: 120e450 cc). In the reconstructed breast, the mean volume of permanent implants placed was 480.80 cc (range: 315e720 cc).
Complications The total complication rate was 19.2% (5/26). One patient with insulin-dependent diabetes mellitus (IDDM) type I developed cellulitis of the reconstructed breast, which resolved after a course of oral antibiotics. There were no cases of partial/complete nipple necrosis and/or delayed wound healing. Rupture/leakage of a saline implant occurred in two patients at 18 months and 6 years, respectively. In one case, a grade III capsular contracture of the augmented breast was noted 4 years following surgery (Figure 3).
Aesthetic results Photographic documentation of long-term results was available in 16 patients (Table 1). Mean follow-up was 41.8 months (range: 12e107 months). Recurrent ptosis (grade I) occurred in three patients. Two out of three of these patients were diagnosed with grade III ptosis, preoperatively. Pseudoptosis occurred in two additional patients in whom the indication for the procedure was grade III ptosis. No patient desired revisional surgery for
Augmentation mastopexy to achieve symmetry after breast reconstruction
489
Figure 2 A-C. Preoperative assessment: AP, Left oblique and Right oblique views. A 40-year-old female patient with grade II ptosis bilaterally. D-F. Postoperative assessment: AP, Left oblique and Right oblique views. Twelve months following left mastectomy and immediate tissue expander/implant reconstruction of the left breast. Nine months following combined, transaxillary augmentation/mastopexy of the right breast using a 240-cc saline implant. Overall aesthetic result graded as ‘excellent’.
inadequate ptosis correction or malpositioning of the nipple (Figures 1e3). Sixty-nine percent (12/16) of patients had a ‘very good to excellent’ overall aesthetic result. Of those four patients who were deemed to have a ‘good’ aesthetic result, the development of a capsular contracture in the reconstructed breast detracted from the overall aesthetic result. No patient was deemed to have a ‘fair’ overall aesthetic result. Overall inter-observer reliability of the overall aesthetic results was moderate, with a linear weighted kappa (k) of 0.67 (95% confidence interval (CI) 0.42e0.92).
Oncologic surveillance of the contralateral breast Ninety-two percent of patients (24/26) completed a radiologic, screening examination as part of their routine annual follow-up. Based on mammographic (n Z 2) and magnetic resonance (MR) (n Z 1) imaging, three patients were deemed to have a suspicious finding in their augmented breast. All three patients went on to have a stereotactic biopsy of their augmented breast revealing benign pathology in two cases and ductal carcinoma in situ (DCIS) in one case. This latter patient went on to have mastectomy and immediate tissue
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N. Kropf et al.
Figure 3 A-C. Preoperative assessment: AP, Left oblique and Right oblique views. A 40-year-old female patient with grade III ptosis bilaterally. D-F. Postoperative assessment: AP, Left oblique and Right oblique views. Two years following left mastectomy and immediate tissue expander placement left breast. Following completion of postoperative tissue expansion, this patient then received adjuvant chest wall radiation prior to the exchange procedure. She is seen here 16 months following combined, transaxillary augmentation/mastopexy of the right breast using a 360-cc saline implant. She has since developed a grade III capsular contracture of the radiated, reconstructed breast. Overall aesthetic result graded as ‘good’.
expander/implant augmented breast.
reconstruction
of
her
previously
Discussion Implant reconstruction can result in a non-ptotic breast with a contour that is fuller in the upper pole yet somewhat flattened in the inferior pole. The reconstructed contour
will almost never match a natural breast, particularly if the natural breast has some component of ptosis, flattening of the upper pole and/or skin excess. Thus, in the setting of unilateral, implant-based reconstruction, a patient may elect to undergo a contralateral symmetrisation procedure. For patients with any degree of breast ptosis, augmentation mammaplasty alone will result in a poor aesthetic result because the natural breast tissue will ‘droop’ off the
Augmentation mastopexy to achieve symmetry after breast reconstruction Table 1
Peri-operative and Post-operative Findings (n Z 16)
Peri-operative assessment
Post-operative results
Contralateral breast undergoing mastopexy/ augmentation
Reconstructed breast
Pre-op Ptosis
Volume of permanent implant (cc)
volume of permanent implant (cc)
HIstory of radiation
1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3
240 225 240 200 200 240 240 240 300 300 180 210 240 270 300 360
500 450 720 315 390 450 560 620 470 520 450 360 350 450 450 495
NO NO NO NO POST NO NO POST PRE NO NO NO NO POST NO PRE
a b
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Contralateral breast following mastopexy /augmentation: Post-op Ptosis
Overall aesthetic results
0 0 0 0 0 0 1 0 0 0 1 0 1 Pseudoptosis Pseudoptosis 0
Excellent Very gooda Very Gooda Excellent Excellent Excellent Very good Goodb Excellent Excellent Goodb Gooda Very good Very good Very good Goodb
Development of grade II capsular contracture reconstructed breast. Development of grade III capsular contracture reconstructed breast.
implant, creating a double-bubble deformity.16 Thus, for the majority of patients, the performance of both an augmentation mammaplasty and a mastopexy is indicated.2e12 Augmentation mastopexy is, however, one of the most difficult aesthetic breast procedures to perform and, even in experienced hands, unsatisfactory outcomes can occur.2e12 Stevens et al., for example, reported that the revisional rate following single-stage augmentation/ mastopexy was 14.6% and that the most common indication for revision was the desire to place a different size implant.19 Spear et al. recently reported on a series of patients who presented for revisional surgery following augmentation/mastopexy. In the majority of patients, recurrent ptosis, dissatisfaction with implant size and poor scarring were major indications for revisional surgery. The average duration to revision was 7 years, and most patients had two or more indications for revision.11 When combined augmentation/mastopexy is used to modify the contralateral breast after reconstruction, it is even more difficult because one is trying to match an implant-shaped reconstruction. The technique outlined here simplifies the procedure. Performing the trans-axillary augmentation first allows the surgeon to establish the desired breast volume. Once the augmentation has been performed and the volume perfectly adjusted, tailor-tacking of the periareolar mastopexy over the established breast mound is facilitated. We have found the periareolar test suture to be quite useful because it can be tailortacked and repeated multiple times to best estimate both how much skin and where the skin should be resected.
This completely takes the guesswork out of a complicated procedure. Clearly, an augmentation/mastopexy can be performed through a single, periareolar incision; however, in our experience, this makes the procedure much more complicated because it is hard to decide initially how much skin to excise, how to design the periareolar skin excision and how to gauge the volume of the desired implant. In addition, using a periareolar approach necessitates violating the breast tissue to place the implant in a subpectoral position. The implant, by definition, would then be in a dual plane: partly underneath the breast tissue, and partly underneath the muscle. One of the distinct advantages of the trans-axillary, submuscular approach to augmentation is that it prevents distortion of the breast parenchyma, which can facilitate diagnostic follow-up. We have noted that when elevating the circumferential mastopexy skin flaps, the implant is never seen to be communicating with the breast tissue; rather, it remains in a separate plane underneath the muscle and/or muscle/fascia. Thus, in principle, the native breast parenchyma can easily be examined and visualised by mammography, ultrasound and/or MR imaging.17 Our findings would suggest that diagnostic follow-up was not masked or hindered by the augmentation/mastopexy. Our oncologic surgeons feel that this approach to the contralateral breast is very acceptable, even in the high-risk breast cancer patient, particularly if other methods of monitoring, such as MRI and ultrasound, can be added to mammography. One of the obvious drawbacks to this approach is the additional incision made in the subaxillary region. The
492 literature suggests, however, that preservation of axillary lymphatic drainage after trans-axillary augmentation allows for sentinel lymph node detection, should the need arise.18 Furthermore, the axillary skin incision is almost imperceptible, if placed within a skin crease. By adding a periareolar skin excision over an augmented breast, overall breast projection will tend to decrease. This may be advantageous when trying to match a breast reconstructed using an implant as it often has much less lower pole projection. Although no patient in our series elected to pursue revisional surgery, both recurrent ptosis and pseudoptosis did occur. Based on our results, it appears that the greatest predictor of recurrent ptosis is the extent of preoperative breast ptosis as well as the quality of the skin. Patients with poor-quality skin that is inelastic are most likely to have recurrent ptosis. Thus, patient selection with regard to tissue quality is the most likely predictor of success. With respect to the breast-reconstruction patient, there are often no other good options in patients with small ptotic breasts and, to some extent, a ‘less than optimal’ result is very much appreciated by the patient who may not have any other options. Thus, we tend to extend the indications for this procedure in the reconstruction patient even if the quality of the breast skin is not ideal. Similarly, any periareolar mastopexy technique will potentially have a lesser aesthetic outcome when one evaluates the quality of the periareolar incision.11,19 The greater the amount of skin excision, the more likely that one will have a poor-quality scar. This includes scar asymmetries, irregular edges as well as widening of the areola diameter. Modifications to the approach over time have included better selection with regard to the maximum amount of skin excision (8e10 cm) making the initial periareolar incision 38 mm (we initially used a 42-mm cookie cutter) and cinching the final closure down to approximately 30 mm because one can anticipate some widening. We have also found that use of a permanent nylon suture as opposed to a PDS or other resorbable suture also appears to minimise the chances of widening. Our best aesthetic results have been in patients with good-quality skin, grade 1e2 ptosis and soft, flaccid breast tissue as opposed to a very firm or constricted breast. In the setting of unilateral implant-based reconstruction, the goal of combined augmentation/mastopexy of the contralateral breast should be to: (1) augment the volume of the breast, providing enough upper-pole fullness to match the contralateral reconstructed breast; and (2) to minimise excess projection of the lower pole. Any procedure undertaken to improve symmetry of the contralateral breast should also not interfere with follow-up for breast cancer in patients, who already have an increased risk of disease. The two-part, single-operation approach to unilateral augmentation/mastopexy described here can produce a good aesthetic result and allow for adequate oncologic follow-up. Most importantly, it converts a very challenging technical procedure into a simpler one by breaking down the combined procedure into two separate elements. This approach can produce excellent results, particularly in patients with grade I or II ptosis and good-quality skin. As with any augmentation/mastopexy procedure, recurrent
N. Kropf et al. ptosis and poor-quality scars tend to be the most common long-term sequelae. Monitoring of the breast for cancer using mammography is still possible with this technique.
Conflicts of interest None.
Funding None.
Ethics This research protocol was reviewed and approved by the Institutional Review Board at Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
References 1. Surgeons, A. S. o. P. Procedural Statistics, www.plasticsurgery. org; 2006. 2. Spear SL. Augmentation/mastopexy: ‘surgeon, beware’. Plast Reconstr Surg 2006;118:133Se4S. discussion 135S. 3. Banbury J, Yetman R, Lucas A, et al. Prospective analysis of the outcome of subpectoral breast augmentation: sensory changes, muscle function, and body image. Plast Reconstr Surg 2004;113:701e7. discussion 708-711. 4. Elliott LF. Circumareolar mastopexy with augmentation. Clin Plast Surg 2002;29:337e47. v. 5. Georgiade NG, Serafin D, Riefkohl R, et al. Is there a reduction mammaplasty for ‘all seasons?’. Plast Reconstr Surg 1979;63: 765e73. 6. Owsley Jr JQ. Simultaneous mastopexy and augmentation for correction of the small, ptotic breast. Ann Plast Surg 1979;2: 195e200. 7. Puckett CL, Meyer VH, Reinisch JF. Crescent mastopexy and augmentation. Plast Reconstr Surg 1985;75:533e43. 8. Spear SL, Boehmler. 4th JH, Clemens MW. Augmentation/mastopexy: a 3-year review of a single surgeon’s practice. Plast Reconstr Surg 2006;118:136Se47S. discussion 148S-149S, 150S-151S. 9. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg 2001;107:1294e9. discussion 1300. 10. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast Reconstr Surg 1990;85:961e6. 11. Spear SL, Low M, Ducic I. Revision augmentation mastopexy: indications, operations, and outcomes. Ann Plast Surg 2003; 51:540e6. 12. Spear SL, Pelletiere CV, Menon N. One-stage augmentation combined with mastopexy: aesthetic results and patient satisfaction. Aesthetic Plast Surg 2004;28:259e67. 13. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg 1976;3:193e203. 14. Garbay JR, Rietjens M, Petit JY. Esthetic results of breast reconstruction after amputation for cancer. 323 cases. J Gynecol Obstet Biol Reprod (Paris) 1992;21: 405e12. 15. Lowery JC, Wilkins EG, Kuzon WM, et al. Evaluations of aesthetic results in breast reconstruction: an analysis of reliability. Ann Plast Surg 1996;36:601e6. discussion 607. 16. Burden WR, Kelley PM. Endoscopic breast subpectoral augmentation for second-degree breast ptosis. Ann Plast Surg 2001;46:238e41.
Augmentation mastopexy to achieve symmetry after breast reconstruction 17. Young VL, Watson ME. Breast implant research: where we have been, where we are, where we need to go. Clin Plast Surg 2001;28:451e83. vi. 18. Sado HN, Graf RM, Canan LW, et al. Sentinel lymph node detection and evidence of axillary lymphatic integrity after
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transaxillary breast augmentation: a prospective study using lymphoscintography. Aesthetic Plast Surg 2008;32:879e88. 19. Stevens WG, Freeman ME, Stoker DA, et al. One-stage mastopexy with breast augmentation: a review of 321 patients. Plast Reconstr Surg 2007;120:1674e9.
Demystifying trans-axillary augmentation/ periareolar mastopexy: A novel, two-stage, single-operation approach to management of the contralateral breast in implant reconstruction Nina Kropf a, Christina N. Cordeiro b, Colleen M. McCarthy b, Peter G. Cordeiro b,* a
Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University Vienna, Austria Plastic and Reconstructive Surgery Service, Department of Surgery; Memorial Sloan-Kettering Cancer Center, New York, NY 1275, USA
b
Received 11 March 2010; accepted 19 June 2010
KEYWORDS Breast surgery; Mammaplasty; Breast implants; Mastopexy; Augmentation
Summary Background: Following unilateral tissue expander/implant reconstruction, combined augmentation/mastopexy of the contralateral breast may be performed in an attempt to improve breast symmetry. Combined augmentation/mastopexy can be a very difficult operation, even for the surgeon with substantial experience. To simplify the technical approach to this complex problem, the senior author (PGC) has developed a ‘two-stage, single-operation’ approach. The purpose of this study is to review the safety and efficacy of this approach to the contralateral breast in the setting of unilateral, implant-based reconstruction. Methods: A retrospective review of all combined trans-axillary augmentation/periareolar mastopexies performed from 1998 to 2007 was undertaken. Only patients who had a history of prior unilateral mastectomy and immediate expander placement were included. Photographic documentation of long-term aesthetic results was evaluated by two independent observers. Results: In total, 26 combined, trans-axillary augmentation/periareolar mastopexies were performed in patients, who had initiated unilateral, postmastectomy, tissue expander/ implant reconstruction on the contralateral side. No patient desired revisional surgery for inadequate ptosis correction or malpositioning of the nipple. A total of 69% of patients had a ‘very good to excellent’ overall aesthetic result. Of those patients who were deemed to have a ‘good’ aesthetic result, the development of a capsular contracture in the reconstructed breast detracted from the overall aesthetics.
* Corresponding author. Tel.: þ1 212 639 2521; fax: þ1 212 717 3677. E-mail address: [email protected] (P.G. Cordeiro). 1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.06.018
486
N. Kropf et al. Conclusion: The two-stage, single-operation approach to unilateral augmentation/mastopexy described here can produce a good aesthetic result and allow for adequate oncologic followup. In particular, excellent results are seen in patients with grade I or II ptosis and goodquality skin preoperatively. Monitoring of the breast for cancer, using mammography, is still possible with this technique. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Tissue expander/implant reconstruction is the most commonly used technique for reconstruction of the breast after mastectomy.1 Although a vast majority of patients undergoing unilateral mastectomy are considered candidates for postmastectomy implant-based reconstruction, the ideal candidate would have a contralateral breast that matches the implant with respect to breast size and shape. Because the overwhelming majority of women do not have such a breast, however, modifying the contralateral breast following unilateral, implant-based reconstruction becomes essential to achieve or approach symmetry. Contralateral augmentation alone is an excellent technique for the patient, who has a very small breast without ptosis or pseudoptosis. By contrast, if the contralateral breast has any degree of ptosis, then, the performance of a mastopexy, in addition to the augmentation, is necessitated to maximise symmetry and achieve the best aesthetic result. Combined augmentation/mastopexy can be a very difficult operation, even for the surgeon with substantial experience.2 In a single-stage procedure, estimating how much skin to excise and/or how much to augment the patient can be a tremendous challenge. This procedure can be even more challenging when trying to match a breast reconstructed using an implant e a breast that has essentially no ptosis and sits high on the chest wall. Many surgeons instead recommend performing the mastopexy and augmentation in two separate operations, although there is an ongoing debate as to which procedure is to be performed first.2e12 Subjecting the patient to a second operation and requiring them to live with the inadequately lifted augmentation or a nonaugmented mastopexy is not an ideal situation. This is particularly true for a patient with breast cancer, who has already undergone two operations just to achieve the reconstructed breast mound (Figure 1). To simplify the technical approach to this complex problem, the senior author has developed a ‘two-stage, single-operation’ approach to the problem. First, a transaxillary sub muscular augmentation of the contralateral breast is performed. Next, an accurate estimate of the exact skin resection required is performed with a temporary periareolar tacking suture. The periareolar mastopexy is then completed and the breast mound is readjusted over the implant. The purpose of this study is to review the safety and efficacy of this approach to the contralateral breast in the setting of unilateral, implant-based reconstruction. Complications, overall aesthetic results, resultant breast symmetry and recurrent ptosis will be evaluated. Patient selection, technical pearls and the impact of this procedure on the continued oncologic surveillance of the contralateral breast will be discussed.
Methods Study design A retrospective review of all combined trans-axillary augmentation/periareolar mastopexies was performed. Consecutive cases performed by the senior surgeon (PGC) from December 1998 to January 2007 were evaluated. Only patients who had a history of prior unilateral mastectomy and immediate expander placement were included. Similarly, only patients who underwent a combined trans-axillary augmentation/periareolar mastopexy of the contralateral breast at the time of the exchange procedure were considered eligible for review. Demographic, oncologic, reconstructive and complication data were retrieved from a prospectively maintained, clinical database. Photographic documentation of long-term aesthetic results was evaluated by two independent observers. Disagreements were resolved by discussion. Breast ptosis was evaluated using the Regnault classification system.13 The overall aesthetic results were evaluated using the rating scale first described by Garbay et al., and later adapted by Lowery and colleagues.14,15 This scale evaluates five variables (i.e., symmetry of breast volume, symmetry of breast contour, placement of the breast mounds on the chest wall, appearance of the inframammary folds and breast scars), each on a 3-point scale. Summary scores are then produced and overall aesthetic results classified as ‘excellent, very good, good or fair’ on a 4-point ordinal scale. Inter-observer reliability of the overall aesthetic results was determined by calculation of a linear weighted kappa coefficient. Stata statistical software was used. Radiographic imaging was performed according to the oncologic standard of care for screening of the contralateral breast.
Patient selection All of the options for breast reconstruction are discussed with the patient. If a patient elects to have reconstruction with an implant, then, management of the contralateral breast must also be addressed. In general, the best candidates for augmentation/mastopexy are women with AeB cup breasts and minimal-to-no breast ptosis. Skin quality contributes greatly to the result and, therefore, patients with the most elastic skin and minimal striae will tend to have the best results. Ideally, patients with grade I or II ptosis are selected for this type of procedure to maximise the result. However, in the patient with a grade III ptosis, who is warned about the potential for recurrent ptosis, this procedure is still an option.
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Figure 1 AeC. Preoperative assessment: AP, Left oblique and Right oblique views. A 40-year-old female patient with grade I ptosis bilaterally. D-F. Postoperative assessment: AP, Left oblique and Right oblique views. 16 months following left mastectomy and initiation of tissue expander/implant reconstruction of the left breast. 12 months following combined, trans-axillary augmentation/mastopexy of the right breast using a 225 cc saline implant. Concurrently, a 450 cc saline implant was placed in the left breast. Overall aesthetic result graded as ‘very good’.
Ideally, the nipple will not require greater than 2e3 cm of elevation. In addition, the planned overall diameter of the periareolar skin resection should not be greater than 8e10 cm. This will minimise the chance of having a poor outcome with regard to the periareolar scar. The quality of the breast tissue will also influence the result. The best results will generally be obtained in patients with a softer, fatty type of breast, which is much more likely to drape over the implant.
This allows a better match to the reconstructed breast, which essentially has only skin overlying a breast implant.
Surgical technique Preoperative markings All combined augmentation/mastopexies are performed at the time of the exchange procedure. Preoperative markings
488 are routinely performed with the patient in the upright, standing position. On the native, ptotic breast, the desired nipple position is marked and the periareolar skin excision approximated. Reconstructed breast Intra-operatively, the reconstructed breast is addressed first. Following removal of the temporary expander, the inframammary fold is reconstructed using 0/0 silk sutures to approximate the deep dermis to the anterior chest wall. A circumferential capsulotomy is typically performed in an attempt to facilitate the draping of the skin and soft tissues over the implant. A sizer is then used to select the optimal size and shape of implant. Trans-axillary subpectoral augmentation Once the size and shape of the reconstructed breast are determined, attention is turned to the contralateral breast. A 3-cm, trans-axillary incision is made in a skin fold at the lowest portion of the axillary hairline. A subpectoral pocket is bluntly dissected using Dingman breast dissectors. Once this dissection is complete, a round sizer is placed and filled with appropriate amount of saline. The patient is then routinely evaluated in the upright position. Any adjustments to the submuscular pocket are then made to maximise the symmetry of inframammary folds. Periareolar mastopexy With the sizer in place, it is also possible to then gauge how much skin needs to be excised and in what specific pattern the periareolar resection is to be performed. A 2/0 nylon test suture is placed circumferentially along the outer margin of the planned skin excision and cinched down to create a neo-areola approximately 3 cm in diameter. Once the exact periareolar incision and skin excision are estimated, the outer margin of the periareolar incision is marked and the suture released. A 3.8-mm cookie cutter is then used to mark the inner circle of the periareolar skin excision. The intervening skin between the inner and outer margins is then de-epithelialised. Once de-epithelialisation is complete, the dermis is incised 2 mm inside the outer margin of the periareolar excision. Breast skin flaps are then elevated circumferentially. Care is taken to perform the initial dissection so that the resultant flaps are quite thin (just below the dermis) to avoid significant bunching of the skin following placement of the permanent, periareolar suture. As the dissection proceeds down to the chest wall, progressively thicker flaps are elevated. Closure Once flap elevation is complete, a 2/0 clear nylon suture is placed in the deep dermis as a periareolar suture using a Keith needle and is cinched down to create a neo-areola 3 cm in diameter. The final inset of the areolar skin to the circumferential breast skin is completed using 4/0 Vicryl sutures in the more superficial dermis. Skin-edge approximation is achieved using Dermabond. Implant selection An anatomic implant is selected for the reconstructed breast; a round implant is chosen for the augmented breast
N. Kropf et al. as this creates a more anatomic shape once positioned appropriately under the breast mound. The use of sizers allows for adjustments to be made to the submuscular pocket to maximise breast volume, the symmetry of inframammary fold position and the appropriate amount of skin resection.
Results Demographics In total, 26 combined, trans-axillary augmentation/periareolar mastopexies were performed to create symmetry with a contralateral postmastectomy, tissue expander/ implant reconstruction. All patients underwent immediate reconstruction with placement of a tissue expander. At the time of the exchange of the temporary tissue expander for a permanent implant, a simultaneous augmentation/mastopexy was performed (Figure 2). Mean patient age was 43.9 years (range: 32e53 years; n Z 26). Preoperatively, three patients had grade I ptosis, 14 had grade II ptosis and nine grade III ptosis. Fifty-four percent (14/26) of patients had a history of neo-adjuvant chemotherapy; 3.8% (1/26) received adjuvant chemotherapy. Thirty-nine percent (10/26) of patients had a history of post-exchange radiotherapy.
Implant selection In all 26 patients, McGhan round, moderate-profile, saline-filled implants were used to augment the contralateral breast. Mean implant volume was 250 cc (range: 120e450 cc). In the reconstructed breast, the mean volume of permanent implants placed was 480.80 cc (range: 315e720 cc).
Complications The total complication rate was 19.2% (5/26). One patient with insulin-dependent diabetes mellitus (IDDM) type I developed cellulitis of the reconstructed breast, which resolved after a course of oral antibiotics. There were no cases of partial/complete nipple necrosis and/or delayed wound healing. Rupture/leakage of a saline implant occurred in two patients at 18 months and 6 years, respectively. In one case, a grade III capsular contracture of the augmented breast was noted 4 years following surgery (Figure 3).
Aesthetic results Photographic documentation of long-term results was available in 16 patients (Table 1). Mean follow-up was 41.8 months (range: 12e107 months). Recurrent ptosis (grade I) occurred in three patients. Two out of three of these patients were diagnosed with grade III ptosis, preoperatively. Pseudoptosis occurred in two additional patients in whom the indication for the procedure was grade III ptosis. No patient desired revisional surgery for
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Figure 2 A-C. Preoperative assessment: AP, Left oblique and Right oblique views. A 40-year-old female patient with grade II ptosis bilaterally. D-F. Postoperative assessment: AP, Left oblique and Right oblique views. Twelve months following left mastectomy and immediate tissue expander/implant reconstruction of the left breast. Nine months following combined, transaxillary augmentation/mastopexy of the right breast using a 240-cc saline implant. Overall aesthetic result graded as ‘excellent’.
inadequate ptosis correction or malpositioning of the nipple (Figures 1e3). Sixty-nine percent (12/16) of patients had a ‘very good to excellent’ overall aesthetic result. Of those four patients who were deemed to have a ‘good’ aesthetic result, the development of a capsular contracture in the reconstructed breast detracted from the overall aesthetic result. No patient was deemed to have a ‘fair’ overall aesthetic result. Overall inter-observer reliability of the overall aesthetic results was moderate, with a linear weighted kappa (k) of 0.67 (95% confidence interval (CI) 0.42e0.92).
Oncologic surveillance of the contralateral breast Ninety-two percent of patients (24/26) completed a radiologic, screening examination as part of their routine annual follow-up. Based on mammographic (n Z 2) and magnetic resonance (MR) (n Z 1) imaging, three patients were deemed to have a suspicious finding in their augmented breast. All three patients went on to have a stereotactic biopsy of their augmented breast revealing benign pathology in two cases and ductal carcinoma in situ (DCIS) in one case. This latter patient went on to have mastectomy and immediate tissue
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N. Kropf et al.
Figure 3 A-C. Preoperative assessment: AP, Left oblique and Right oblique views. A 40-year-old female patient with grade III ptosis bilaterally. D-F. Postoperative assessment: AP, Left oblique and Right oblique views. Two years following left mastectomy and immediate tissue expander placement left breast. Following completion of postoperative tissue expansion, this patient then received adjuvant chest wall radiation prior to the exchange procedure. She is seen here 16 months following combined, transaxillary augmentation/mastopexy of the right breast using a 360-cc saline implant. She has since developed a grade III capsular contracture of the radiated, reconstructed breast. Overall aesthetic result graded as ‘good’.
expander/implant augmented breast.
reconstruction
of
her
previously
Discussion Implant reconstruction can result in a non-ptotic breast with a contour that is fuller in the upper pole yet somewhat flattened in the inferior pole. The reconstructed contour
will almost never match a natural breast, particularly if the natural breast has some component of ptosis, flattening of the upper pole and/or skin excess. Thus, in the setting of unilateral, implant-based reconstruction, a patient may elect to undergo a contralateral symmetrisation procedure. For patients with any degree of breast ptosis, augmentation mammaplasty alone will result in a poor aesthetic result because the natural breast tissue will ‘droop’ off the
Augmentation mastopexy to achieve symmetry after breast reconstruction Table 1
Peri-operative and Post-operative Findings (n Z 16)
Peri-operative assessment
Post-operative results
Contralateral breast undergoing mastopexy/ augmentation
Reconstructed breast
Pre-op Ptosis
Volume of permanent implant (cc)
volume of permanent implant (cc)
HIstory of radiation
1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3
240 225 240 200 200 240 240 240 300 300 180 210 240 270 300 360
500 450 720 315 390 450 560 620 470 520 450 360 350 450 450 495
NO NO NO NO POST NO NO POST PRE NO NO NO NO POST NO PRE
a b
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Contralateral breast following mastopexy /augmentation: Post-op Ptosis
Overall aesthetic results
0 0 0 0 0 0 1 0 0 0 1 0 1 Pseudoptosis Pseudoptosis 0
Excellent Very gooda Very Gooda Excellent Excellent Excellent Very good Goodb Excellent Excellent Goodb Gooda Very good Very good Very good Goodb
Development of grade II capsular contracture reconstructed breast. Development of grade III capsular contracture reconstructed breast.
implant, creating a double-bubble deformity.16 Thus, for the majority of patients, the performance of both an augmentation mammaplasty and a mastopexy is indicated.2e12 Augmentation mastopexy is, however, one of the most difficult aesthetic breast procedures to perform and, even in experienced hands, unsatisfactory outcomes can occur.2e12 Stevens et al., for example, reported that the revisional rate following single-stage augmentation/ mastopexy was 14.6% and that the most common indication for revision was the desire to place a different size implant.19 Spear et al. recently reported on a series of patients who presented for revisional surgery following augmentation/mastopexy. In the majority of patients, recurrent ptosis, dissatisfaction with implant size and poor scarring were major indications for revisional surgery. The average duration to revision was 7 years, and most patients had two or more indications for revision.11 When combined augmentation/mastopexy is used to modify the contralateral breast after reconstruction, it is even more difficult because one is trying to match an implant-shaped reconstruction. The technique outlined here simplifies the procedure. Performing the trans-axillary augmentation first allows the surgeon to establish the desired breast volume. Once the augmentation has been performed and the volume perfectly adjusted, tailor-tacking of the periareolar mastopexy over the established breast mound is facilitated. We have found the periareolar test suture to be quite useful because it can be tailortacked and repeated multiple times to best estimate both how much skin and where the skin should be resected.
This completely takes the guesswork out of a complicated procedure. Clearly, an augmentation/mastopexy can be performed through a single, periareolar incision; however, in our experience, this makes the procedure much more complicated because it is hard to decide initially how much skin to excise, how to design the periareolar skin excision and how to gauge the volume of the desired implant. In addition, using a periareolar approach necessitates violating the breast tissue to place the implant in a subpectoral position. The implant, by definition, would then be in a dual plane: partly underneath the breast tissue, and partly underneath the muscle. One of the distinct advantages of the trans-axillary, submuscular approach to augmentation is that it prevents distortion of the breast parenchyma, which can facilitate diagnostic follow-up. We have noted that when elevating the circumferential mastopexy skin flaps, the implant is never seen to be communicating with the breast tissue; rather, it remains in a separate plane underneath the muscle and/or muscle/fascia. Thus, in principle, the native breast parenchyma can easily be examined and visualised by mammography, ultrasound and/or MR imaging.17 Our findings would suggest that diagnostic follow-up was not masked or hindered by the augmentation/mastopexy. Our oncologic surgeons feel that this approach to the contralateral breast is very acceptable, even in the high-risk breast cancer patient, particularly if other methods of monitoring, such as MRI and ultrasound, can be added to mammography. One of the obvious drawbacks to this approach is the additional incision made in the subaxillary region. The
492 literature suggests, however, that preservation of axillary lymphatic drainage after trans-axillary augmentation allows for sentinel lymph node detection, should the need arise.18 Furthermore, the axillary skin incision is almost imperceptible, if placed within a skin crease. By adding a periareolar skin excision over an augmented breast, overall breast projection will tend to decrease. This may be advantageous when trying to match a breast reconstructed using an implant as it often has much less lower pole projection. Although no patient in our series elected to pursue revisional surgery, both recurrent ptosis and pseudoptosis did occur. Based on our results, it appears that the greatest predictor of recurrent ptosis is the extent of preoperative breast ptosis as well as the quality of the skin. Patients with poor-quality skin that is inelastic are most likely to have recurrent ptosis. Thus, patient selection with regard to tissue quality is the most likely predictor of success. With respect to the breast-reconstruction patient, there are often no other good options in patients with small ptotic breasts and, to some extent, a ‘less than optimal’ result is very much appreciated by the patient who may not have any other options. Thus, we tend to extend the indications for this procedure in the reconstruction patient even if the quality of the breast skin is not ideal. Similarly, any periareolar mastopexy technique will potentially have a lesser aesthetic outcome when one evaluates the quality of the periareolar incision.11,19 The greater the amount of skin excision, the more likely that one will have a poor-quality scar. This includes scar asymmetries, irregular edges as well as widening of the areola diameter. Modifications to the approach over time have included better selection with regard to the maximum amount of skin excision (8e10 cm) making the initial periareolar incision 38 mm (we initially used a 42-mm cookie cutter) and cinching the final closure down to approximately 30 mm because one can anticipate some widening. We have also found that use of a permanent nylon suture as opposed to a PDS or other resorbable suture also appears to minimise the chances of widening. Our best aesthetic results have been in patients with good-quality skin, grade 1e2 ptosis and soft, flaccid breast tissue as opposed to a very firm or constricted breast. In the setting of unilateral implant-based reconstruction, the goal of combined augmentation/mastopexy of the contralateral breast should be to: (1) augment the volume of the breast, providing enough upper-pole fullness to match the contralateral reconstructed breast; and (2) to minimise excess projection of the lower pole. Any procedure undertaken to improve symmetry of the contralateral breast should also not interfere with follow-up for breast cancer in patients, who already have an increased risk of disease. The two-part, single-operation approach to unilateral augmentation/mastopexy described here can produce a good aesthetic result and allow for adequate oncologic follow-up. Most importantly, it converts a very challenging technical procedure into a simpler one by breaking down the combined procedure into two separate elements. This approach can produce excellent results, particularly in patients with grade I or II ptosis and good-quality skin. As with any augmentation/mastopexy procedure, recurrent
N. Kropf et al. ptosis and poor-quality scars tend to be the most common long-term sequelae. Monitoring of the breast for cancer using mammography is still possible with this technique.
Conflicts of interest None.
Funding None.
Ethics This research protocol was reviewed and approved by the Institutional Review Board at Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
References 1. Surgeons, A. S. o. P. Procedural Statistics, www.plasticsurgery. org; 2006. 2. Spear SL. Augmentation/mastopexy: ‘surgeon, beware’. Plast Reconstr Surg 2006;118:133Se4S. discussion 135S. 3. Banbury J, Yetman R, Lucas A, et al. Prospective analysis of the outcome of subpectoral breast augmentation: sensory changes, muscle function, and body image. Plast Reconstr Surg 2004;113:701e7. discussion 708-711. 4. Elliott LF. Circumareolar mastopexy with augmentation. Clin Plast Surg 2002;29:337e47. v. 5. Georgiade NG, Serafin D, Riefkohl R, et al. Is there a reduction mammaplasty for ‘all seasons?’. Plast Reconstr Surg 1979;63: 765e73. 6. Owsley Jr JQ. Simultaneous mastopexy and augmentation for correction of the small, ptotic breast. Ann Plast Surg 1979;2: 195e200. 7. Puckett CL, Meyer VH, Reinisch JF. Crescent mastopexy and augmentation. Plast Reconstr Surg 1985;75:533e43. 8. Spear SL, Boehmler. 4th JH, Clemens MW. Augmentation/mastopexy: a 3-year review of a single surgeon’s practice. Plast Reconstr Surg 2006;118:136Se47S. discussion 148S-149S, 150S-151S. 9. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg 2001;107:1294e9. discussion 1300. 10. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast Reconstr Surg 1990;85:961e6. 11. Spear SL, Low M, Ducic I. Revision augmentation mastopexy: indications, operations, and outcomes. Ann Plast Surg 2003; 51:540e6. 12. Spear SL, Pelletiere CV, Menon N. One-stage augmentation combined with mastopexy: aesthetic results and patient satisfaction. Aesthetic Plast Surg 2004;28:259e67. 13. Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg 1976;3:193e203. 14. Garbay JR, Rietjens M, Petit JY. Esthetic results of breast reconstruction after amputation for cancer. 323 cases. J Gynecol Obstet Biol Reprod (Paris) 1992;21: 405e12. 15. Lowery JC, Wilkins EG, Kuzon WM, et al. Evaluations of aesthetic results in breast reconstruction: an analysis of reliability. Ann Plast Surg 1996;36:601e6. discussion 607. 16. Burden WR, Kelley PM. Endoscopic breast subpectoral augmentation for second-degree breast ptosis. Ann Plast Surg 2001;46:238e41.
Augmentation mastopexy to achieve symmetry after breast reconstruction 17. Young VL, Watson ME. Breast implant research: where we have been, where we are, where we need to go. Clin Plast Surg 2001;28:451e83. vi. 18. Sado HN, Graf RM, Canan LW, et al. Sentinel lymph node detection and evidence of axillary lymphatic integrity after
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transaxillary breast augmentation: a prospective study using lymphoscintography. Aesthetic Plast Surg 2008;32:879e88. 19. Stevens WG, Freeman ME, Stoker DA, et al. One-stage mastopexy with breast augmentation: a review of 321 patients. Plast Reconstr Surg 2007;120:1674e9.