Surgical correction of the “small” postpartum ptotic breast

Surgical correction of the “small” postpartum ptotic breast

Scientific Forum Surgical Correction of the “Small” Postpartum Ptotic Breast Manuel García Velasco, MD; Pablo Arizti, MD; and Rodrigo García Toca, MD...

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Scientific Forum

Surgical Correction of the “Small” Postpartum Ptotic Breast Manuel García Velasco, MD; Pablo Arizti, MD; and Rodrigo García Toca, MD From the Hospital Angeles de las Lomas, Valle de las Palmas, Hulxqullucan, Mexico. Drs. Velasco and Arizti are members of the Mexican Association of Plastic, Aesthetic and Reconstructive Surgery.

Background: In our experience, most women seeking correction of the “small” ptotic breast have a history of previous pregnancies and breastfeeding. Objective: We propose a classification of postpartum ptosis into 4 groups and describe the appropriate surgical treatment for each category of ptosis. Methods: We defined categories of ptosis on the basis of the remnant mammary gland, skin condition, position of the nipple-areolar complex (NAC), and distance from the NAC to the inframammary fold (IMF). Patients in group 1 (n = 15), with the NAC in good position, were treated with the use of simple subglandular augmentation mammaplasty. Patients in group 2 (n = 8), with grade I ptosis in which the nipple required elevation of no more than 3 cm and the distance from the inferior border of the areola to the IMF was less than 4 cm, were treated with the use of crescent-moon mastopexy. Patients in group 3 (n = 20), who demonstrated a higher degree of skin flaccidity and grade I or II ptosis and in whom the distance from the NAC inferior border to the IMF was between 4 and 6 cm, were treated with the use of circumareolar mastopexy. Patients in group 4 (n = 24), with moderate to severe skin flaccidity and ptosis in whom the distance from the NAC to the IMF was more than 4 cm, were treated with the use of modified vertical mastopexy. Results: Eight-five percent of patients were satisfied with their results. Unfavorable results were related to dissatisfaction with breast shape and postoperative scarring; such results occurred most often in group 4 patients. Complications were within reasonable limits, including 2 cases of hematoma and 3 cases of decreased NAC sensibility in group 3 patients and minor dehiscence in 3 patients in group 4. Conclusions: Careful patient evaluation and choice of technique, as determined by the classification proposed in this paper, enabled us to achieve high rates of patient satisfaction with low rates of complications and revision. (Aesthetic Surg J 2004;24:199-205)

M

ost articles concerning the treatment of what has historically been called the “small ptotic breast” recommend the use of implants plus the correction of the skin envelope1–11 through the use of various procedures, including periareolar mastopexy, crescent-moon skin resection, and the traditional vertical or inverted-T technique.12–17 Hammond et al18 have published criteria for proper evaluation to achieve a good result. In our experience, most patients who complain of this condition have a history of pregnancies and breastfeeding, in some cases after weight loss. Ptosis usually resulted from postdelivery and breastfeeding involution changes characterized by different degrees of atrophy of the mammary gland, skin flaccidity, and ptosis of the

nipple-areolar complex (NAC). In this article we propose a classification of postpartum ptosis into 4 groups on the basis of anatomic findings and the appropriate surgical treatment for each group.

Methods Sixty-seven postpartum women were treated from 1999 through 2002 for the correction of the small ptotic breast. Those patients whose condition was caused by weight loss or who did not require the use of implants were excluded from the study. In all patients selected, ptosis developed after 2 or more pregnancies and breastfeeding. They presented with different degrees of atrophy of the breast parenchyma, skin flac-

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A

B

C

D

Figure 1. Classification of postpartum mammary sequelae A, Group 1; B, group 2; C, group 3; D, group 4. See text for details.

Table 1. Implants used for correction of postpartum mammary sequelae Round implants (cc) Group

Range

Mean

Range

Mean

30 16 40 48

180–270 180–210 90–210 90–180

210 190 170 140

195–255 215–235 155–375 165–235

255 225 240 200

1 2 3 4

cidity, and ptosis of the NAC. Most of them desired restoration of the prepartum breast contour; 25 women wanted slightly more volume than they had had before. Classification

Patients were classified into 4 groups according to the severity of ptosis as defined by the remnant mammary gland, skin condition, and the position of the NAC19 and its distance to the inframammary fold (IMF), as follows. Group 1 patients were those with breast atrophy whose NAC was in good position (Figure 1, A).

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Group 2 patients were those with grade I ptosis, in whom the nipple needed to be elevated no more than 3 cm and the distance from the inferior border of the areola to the IMF was less than 4 cm (Figure 1, B). Group 3 comprised patients who demonstrated moderate skin flaccidity and grade I to II ptosis, in whom the distance from NAC inferior border to the IMF was between 4 and 6 cm. We also included in this group patients with slightly more severe conditions who refused surgery resulting in a vertical scar (Figure 1, C). Group 4 patients were those with moderate to severe

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Table 2. Complications Group 1 2 3 4

No. of breasts 30 16 40 48

Hematoma

Infection

Dehiscence

— — 2 1

— — — —

— — — 3

Decreased NAC sensitivity — — 3 —

Table 3. Unfavorable results Group 1 2 3 4

No. of breasts 30 16 40 48

NAC distortion — 2 6 —

Scar

Shape

— 1 — 7

— — — 7

Group 2

skin flaccidity and ptosis (grade II or III) in whom the distance between the NAC and the IMF was more than 4 cm (Figure 1, D). We determined the specific technique to be used in each case on the basis of the classification. Subglandular positioning of the implant was selected when the amount of breast parenchyma was sufficient to camouflage the implant border after surgery. When more severe atrophy of the gland was present, we opted for subpectoral placement.

Results Nearly all patients received silicone gel–filled implants, which are available for use in Mexico. Two patients asked specifically for saline solution–filled implants; 1 of them requested that these implants be replaced with silicone gel–filled implants 1 year after the first surgery. The size and form of the implants used for each of the groups are summarized in Table 1. The techniques used and the results achieved for each group are presented separately. The complications observed in each group, as well as the results, are compared in Tables 2 and 3. Group 1

Patients in group 1 did not require repositioning of the NAC or skin resection. We performed a simple subglandular augmentation mammaplasty to “fill up” the skin envelope, using a periareolar incision on the inferior border. Fifteen patients underwent the procedure, with good results and no complications.

Surgical Correction of the “Small” Postpartum Ptotic Breast

Patients in group 2 underwent a modified crescentmoon upper-areolar skin resection that has been described by several authors.6–8 We applied this technique in cases that did not require more than 2.5 cm of NAC elevation. The crescent moon was outlined on the upper half-border of the areola, on a line directed to the clavicle 5 cm from the suprasternal notch. We made no circumareolar incisions. The skin within the crescent moon was resected in a transmammary approach. All patients in this group had breast parenchyma sufficient to permit subglandular placement of the implant. Eight patients underwent the procedure (Figure 4). Proper patient selection is the key to successful results. The main disadvantage of the technique is the possibility of ovoid distortion of the NAC, but this occurred in just 1 case. In addition, 1 patient complained of a visible scar, which faded in time. Group 3

Patients in this group required greater correction of the NAC and demonstrated moderate skin flaccidity. A modified periareolar mastopexy was the technique of choice. We resected skin conservatively, focusing on the upper portion. Preoperative markings were made with the patient standing. The desired upper border of the NAC was marked symmetrically on both sides on the breast meridian. We determined the amount of skin to be resected by pinching the skin with the fingers. The resec-

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Figure 2. Preoperative markings for a group 3 patient. Markings for a group 2 patient were similar, except that the incisions stopped at the lateral and medial borders of the areola.

Figure 3. Preoperative markings of a group 4 patient.

tion must be conservative to avoid unnecessary tension on the suture and unaesthetic flattening of the NAC. If needed, a larger resection can be performed once the implant is placed. The area was deepithelialized and the skin undermined through a transglandular approach on the inferomedial portion of the breast. A pocket was dissected in accordance with the amount of soft tissue in the upper pole of the breast, as previously determined. We closed the incision with a technique described by Benelli, 20 using a 3-0 Prolene (Ethicon, Johnson & Johnson, Brazil) suture. Twenty patients underwent circumareolar mastopexy (Figure 5). A subglandular approach was used in 18 cases and a subpectoral approach in 2. Two patients underwent revision, in 1 patient for placement of larger implants and in the other to replace saline implants with silicone gel implants. Shape and volume were satisfactory in the other 18 patients. Prolonged edema of the NAC occurred in 4 patients; in 2 of these cases, removal of the round block suture was necessary. Other complications and unfavorable results are listed in Tables 2 and 3.

resection and a higher elevation of the NAC than did those in group 3. Vertical dermal mastopexy was the chosen technique. If the distance between the inferior border of the NAC and the IMF was more than 7 cm, we performed a small horizontal skin resection at the level of the IMF. This surgical approach was also indicated if the patient wanted a permanent reduction of the areolar diameter and was not concerned about the resulting scar. Preoperative markings were made with the patient standing (Figure 3). We outlined the new position of the NAC using the Wise pattern; the upper border (point A) was obtained with the use of the Pitanguy maneuver.21 The inferior borders of the pattern were marked as points B and B´. We estimated the amount of skin to be removed by pinching the tissue below the areola, taking into consideration the distension created by the future implant. The area of skin incision was drawn with 2 parallel lines, 4 to 5 cm from points B and B´ to points C and C´, which met 1 cm above the IMF, 8 cm from the midline (point D). The skin was deepithelialized and the flaps slightly elevated. We used a transmammary approach. When the upper pole was very atrophic (3 cases), the subpectoral plane was dissected. Implant size was always smaller than that in the other groups. The wound was closed in 3

Group 4

Patients in group 4 required a greater amount of skin

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A

C

D

Figure 4. A, C, Preoperative views of a 36-year-old woman classified as group 2. B, D, Postoperative views 1 year after crescent-moon mastopexy with 215-cc contour retroglandular implants.

planes vertically. If horizontal skin resection was required, points C and C´ were sutured to point D and the remnant “dog ears” were removed. Twenty-four patients underwent vertical modified mastopexy (Figure 6); 8 required horizontal skin resection. In 4 cases, the desired breast mound was not achieved because of incorrect implant placement that produced the appearance of glandular ptosis. We observed a nice lateral contour of the breast in all cases with vertical mastopexy. Three patients had wound problems (minor dehiscence) at the junction of the incision with the vertical scar.

Discussion Overall, 85% of patients were satisfied with their results (Table 4). Unfavorable results were mainly the result of dissatisfaction with breast shape and postoperative scarring. However, only 3 patients required revision surgery. We were not able to compare the results of sub-

Surgical Correction of the “Small” Postpartum Ptotic Breast

Table 4. Patient satisfaction rates Group 1 2 3 4

No. of patients

Unsatisfied

Revision

1 1 2 3

1 0 1 1

15 8 20 24

pectoral versus subglandular implant placement; this issue will be the subject of a future article. Complication rates were within acceptable limits. Patients with postpartum mammary sequelae require careful evaluation and the correct choice of surgical procedure. The unsatisfactory results described in the past17,21 can be avoided through selection of the correct technique, based on the classification described in this article, and with the use of an implant to restore the vol-

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A

B

C

D

Figure 5. A, C, Preoperative views of a 35-year-old woman classified in Group 3. B, D, Postoperative views 6 months after circumareolar mastopexy with 235-cc contour implants.

A

B

C

D

Figure 6. A, C, Preoperative views of a 35-year-old woman with severe ptosis, classified as group 4. B, D, Postoperative views 1 year after modified vertical mastopexy with 120-cc round implants.

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ume the patient had before or to increase it slightly. The use of larger implants may result in secondary breast ptosis caused by the weight of the implant or in an unaesthetic double-bubble deformity.

Conclusion Postpartum breast ptosis is a condition that requires careful evaluation and choice of technique. By classifying this condition according to the degree of severity and defining specific treatments for each classification, we have achieved high rates of patient satisfaction and low rates of complication and revision. ■

References 1. Hinderer UT. Reduction and augmentation mammaplasty: remodeling mammaplasty with superficial and retromammary mastopexy. Int Micr J Aesthetic Plast Surg 1972-E. 2. Gasperoni C, Salgarello M, Gargani G. Experience and technical refinements in the “donut” mastopexy with augmentation mammaplasty. Aesthetic Plast Surg 1988;12:111–114. 3. Spear SL, Kassan M, Little JW. Guidelines in concentric mastopexy. Plast Reconstr Surg 1990;85:961–966. 4. De la Fuente A, Martin del Yerro JL. Periareolar mastopexy with implants. Aesthetic Plast Surg 1992;16:337–341. 5. Elliot LF. Circumareolar mastopexy with augmentation. Clin Plast Surg 2002;29:337–347. 6. Pucket CL, Meyer VH, Reinisch JF. Crescent mastopexy and augmentation. Plast Reconstr Surg 1985;75:533–539.

11. Handel N. Augmentation mastopexy. In: Spear S, ed. The Breast: Principles and Art. Philadelphia: Lippincott-Raven;1998: 921. 12. Arié G. Una nueva técnica de mastoplastía. Rev Lat Am Chir Plast 1957;3:23-25. 13. Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg 1976;3:339–347. 14. Gruber RP, Jones HW Jr. The donut mastopexy: indications and complications. Plast Reconstr Surg 1980;65:34–38. 15. Hinderer UT. Circumareolar dermo-glandular plication: a new concept for correction of breast ptosis. Aesthetic Plast Surg 2001;25:404–420. 16. Zur JJ. Operation der hypertrophischen Hängebrust. Deustsche Med Wochnschr 1925;51:1103-1106. 17. Dartigues L. Traitement chirurgical du prolapsus mammarie. Arch Franco-Belges de Chir 1925;28:313-315. 18. Hammond DC, Hidalgo D, Slavin S, et al. Revising the unsatisfactory breast augmentation. Plast Reconstr Surg 1999;104:277–283. 19. Regnault P. Breast ptosis: definition and treatment. Clin Plast Surg 1976;3:193–203. 20. Benelli L. A new periareolar mammaplasty: round block technique. Aesthetic Plast Surg 1990;14:93–100. 21. Pitanguy I. Une nouvelle technique de plastie mammaire. Étude de 245 cas coséqutifs et présentation d’une technique personelle. Ann Chir Plast 1962;7:199-204. 22. Baran CN, Peker F, Ortak T, et al. Unsatisfactory results of periareolar mastopexy with or without augmentation and reduction mammoplasty: enlarged areola with flattened nipple. Aesthetic Plast Surg 2001;25:286–289. Accepted for publication December 8, 2003.

7. Nigro DM. Crescent mastopexy and augmentation. Plast Reconstr Surg 1985;76:802–803.

Manuel García Velasco, MD, Consulsortio 550, Vlalldad de la Baranca s/n Valle de las Palmas, Hulxqullucan 52763, Mexico; e-mail: [email protected].

8. Snow JW. Crescent mastopexy and augmentation. Plast Reconstr Surg 1986;77:161–162.

1090-820X/$30.00 Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc.

9. Owsley JQ Jr. Simultaneous mastopexy and augmentation for correction of the small, ptotic breast. Ann Plast Surg 1979;2:195–200.

doi:10.1067/j.asj.2004.02.001

10. Karnes J, Morrison W, Salisbury M, et al. Simultaneous breast augmentation and lift. Aesthetic Plast Surg 2002;24:148–154.

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