- Email: [email protected]
Use of myofascial flaps in aesthetic breast surgery
Scientific Forum
Use of Myofascial Flaps in Aesthetic Breast Surgery Alexei Borovikov, MD From the National Medico-Surgical Center, Moscow, Russia.
Background: The long-term stability of the breast shape, once it is achieved, should be included among the principal concerns of aesthetic mammaplasty. This goal presents a particular challenge to the surgeon treating a patient who is concerned with breast lift but also wants to preserve or even increase cup size. Objective: This report details the use of a lower myofascial supportive flap (MFF) to prevent secondary breast ptosis in various clinical situations. Methods: The conceptual approach was to use the MFF to reconstruct or make up for deficiencies of the superficial fascial system collagen network, which in this surgeon’s view plays a key role in determining breast position and shape. The MFF flap was raised in the region of the pectoralis major and adjacent muscles based at the inframammary fold (IMF) level and sutured near the lower areola border, with the goal of recreating the IMF, stabilizing the nipple-fold distance, and providing long-term support to counteract the effects of gravity through the creation of a “balcony” flap within which the lower breast pole rests. The procedure was performed in various clinical situations, including primary mastopexy, secondary mastopexy to correct for “bottoming out” after previous surgery, mastopexy with augmentation, implant exchange plus mastopexy, and simple primary augmentation. Results: The use of the MFF provided an aesthetic breast shape while maintaining upper-pole fullness. Morbidity was highest among patients who underwent primary or secondary mastopexy and lowest among those who underwent simple primary augmentation. However, in the latter group, morbidity was notably higher than in patients who underwent simple primary augmentation without the use of the MFF. Conclusions: The MFF technique can provide better long-standing breast support than other procedures aimed at preventing or minimizing secondary breast ptosis. It is indicated most clearly for patients who are unwilling to give up breast volume for improved breast shape and who are unhappy with the results of previous standard mastopexy or augmentation. It is less useful in patients undergoing primary breast lift. Limitations include increased duration of surgery and increased trauma. (Aesthetic Surg J 2004;24:331-341)
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t is generally accepted that aesthetic mammaplasty must be guided by the following principal goals: reshaping of the glandular component of the breast, tailoring of the skin envelope to match the new shape of the parenchymal cone, and safe and geometrically correct transportation of the nipple. We believe that the provision of long-term stability of the breast shape, once it is achieved, is as important as the other three goals. In addition, resistance to late breast ptosis in some patients should also be listed as a principal goal of mammaplasty. This last goal is the primary focus in cases in which mammaplasty is performed to increase breast projection, volume, or both, be it through mastopexy, either alone or combined with augmentation; revision mastopexy for late breast ptosis, or another procedure. The patient’s
desire to preserve or even increase cup size rules out breast reduction and thus presents a special challenge to the surgeon. Reduction mammaplasty alleviates the problem of late postoperative ptosis known as “bottoming out” by decreasing the effect of the force of gravity through a reduction of breast mass and projection. By contrast, the effects of gravity and the tendency toward ptosis increase as a result of procedures performed to increase breast projection (any mastopexy) and breast volume (mastopexy plus augmentation). Patients who are particularly concerned with breast lift and decline the proposal to reduce the breast tend to be less forgiving of late ptotis, unlike patients who ask primarily for volumetric changes and would most likely appreciate the results of
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reduction or augmentation while being more tolerant of possible late ptosis. One method for preventing secondary breast ptosis is gland suspension through the use of sutures1 or fascial strips.2 A second group of techniques depends on upward transposition of the glandular flap, designed from the lower part of the parenchyma, based inferiorly3 or superiorly on the dermoglandular nipple-areola pedicle.4,5 This “autoprosthesis” fills the upper breast pole beneath the superior breast tissue. A third set of methods is used to create an internal lower-breast “brassiere” or supporting “balcony” through the use of dermal or fascial strips,6–8 Marlex tape (CP Chem, Overijse, Belgium),9 silicone sheets,10 or synthetic mesh. This third group of antigravitational maneuvers also includes the lower myofascial supportive flap (MFF).11,12 In our view, the advantage of the MFF is that the contractile muscular portion of the flap provides active breast support from below through a balcony reconnection with normal muscle through the scar tissue, so that it acts like the tendineous extension of the muscle and by its tonus at rest, whereas all the other techniques listed here are able to render only passive and therefore temporary support. The following are variations of the technique that were used in 5 typical clinical situations.
Group 1: Primary Mastopexy Surgical procedure
The lower supportive myofascial flap was first used in 3 cases when we began using the technique. Later on, we resumed performance of the mastopexy with an autoprosthesis, as described by Ribiero3 and Graf.13 The technical details are given as they apply to this group because it is easier to describe the principles of this method on an intact breast. Skin reduction was vertical-periareolar. The skin was undermined in the lower third of the breast circumference to free the medial and lateral glandular flaps (pillars) for later joining at the meridian and imbrication to create a conical breast shape. The nipple-areolar complex (NAC) was transported onto the upper pedicle because the lower breast segment had to be lifted away from the pectoral fascia. The desired level of the inframammary fold (IMF) was marked on the freed fascia; it was often lower than the preexisting one. An 8- to 9-cm horizontal incision of the fascia and underlying pectoralis major muscle was made 5 to 6 cm cranial to the marked new IMF. The MFF was raised as
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Figure 1. Intraoperative view of the raised MFF.
a trapdoor hinged at the new IMF line, opening the ribs. This maneuver required a vertical cut of the rectus fascia medially and serratus anterior muscle laterally (Figure 1). The caudal edge of the obtained glandular cone was firmly fixed to the new IMF line from inside the flap so that the MFF covered the lower parenchyma from outside. The cranial edge of the MFF was sutured to the glandular cone, close to the lower border of the areola (Figure 2, B and C). After immobilization of the glandular cone had been achieved and confirmed, the patient was placed in a sitting position, and the medial and lateral breast contours were assessed. With the immobile MFF as an anchor, the medial or lateral excess tissue (or both, as applicable) was selectively pulled to the flap until the desired breast shape was achieved (Figure 2, D). The skin envelope was sutured under no tension, with purse-stringing at both the subdermal and dermal levels (Biosyn [Tyco, Gosport, UK] or PDS 4/0 [Ethicon, Somerville, NJ]). Purse-stringing allowed compression of the skin edges to each other for several days while the scar formed, then completely disappeared after some weeks, leaving a narrow linear scar. Precise trimming of any minor skin excess was avoided because the skin edges were already in ripples and because the final breast shape was achieved before and independent of skin sutures. Results
Postoperative morbidity (bruising and swelling) developed in all patients but resolved without special treatment. Prolonged hypercorrection of breast shape
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Figure 2. The scheme of MFF use in primary mastopexy. Depicted are the parenchyma, deep fascia, and muscle layer. The skin envelope is not shown. A, Ptotic parenchyma. The arrow denotes the vector of NAC transport. B, NAC transport with the supraareolar plication complete. The subareolar gland is imbricated. The MFF is raised 5 cm high on the basis of the line of the new IMF. The arrow shows the vector of parenchymal pull to the new IMF. C, The parenchyma is fastened to the new IMF. The MFF is fixed to the subareolar gland and covers the lower slope of the glandular cone. D, The frontal view shows that both medial and lateral glandular excesses can be separately pulled to the breast meridian and fastened to the anchor of the MFF. This diminishes the width and increases the projection of the breast mound. Suturing of various glandular parts to each other is not as predictable geometrically because of the mobility of the gland over the chest wall. E, The level of the preexisting IMF. F, The new IMF level.
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Figure 3. A, Preoperative view of a 36-year-old woman who desired a primary breast lift. B, Early postoperative view, 3 weeks after primary breast lift, shows marked hypercorrection. C, A pleasing aesthetic result 4 months after surgery.
occurred in 1 of the 3 patients who underwent this procedure. The beaklike profile of the breast, which normally disappears within a couple of months after Lejour vertical mammaplasty, persisted for 3 months in this patient. We were considering transsection of the muscle balcony to promote ptosis, but by the fourth month the breast had taken on an aesthetically pleasing shape (Figure 3).
Use of Myofascial Flaps in Aesthetic Breast Surgery
Group 2: Secondary Mastopexy to Correct Bottoming Out After Primary Mastopexy or Reduction Mammaplasty Surgical procedure
It was not possible to use glandular autoprosthesis flaps in these cases because it was not known which pedicle was used for NAC transport in the primary surgery.
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Figure 4. A, Preoperative view of a 41-year-old woman who was frustrated by the results of skin mastopexy but rejected breast reduction. B, Postoperative view 3 months after secondary mastopexy with scar visible. SFS passive resistance to gravity was still high, as in any traditional mastopexy. C, Postoperative view after 13 months (relaxed muscle). SFS passive resistance naturally subsided with time. The scar is no longer visible and the upper slope is concave. D, Muscle contraction brought the late postoperative (13 months) breast shape closer to the early postoperative shape (compare with part B). Muscle activity compensated for the weakening supportive function of the SFS. The results will stand as long as muscle contractility is retained.
The MFF was therefore the only technique available for the prevention of recurrent ptosis. Incisions followed the previous scars and were followed by reduction of the overextended skin in the lower breast pole. Minimal or no NAC transport was performed because upward nipple rotation was one of the main patient complaints after primary surgery. Parenchymal modification and raising of the MFF was performed as described for the patients in group 1. The skin was sutured with marked rippling to reduce scar length. To the same end, defatting, hemi-purse-string sutures, and V-Y plasty were undertaken to correct dog-ears. Results
Early postoperative morbidity—prolonged swelling and lower-pole induration—developed in all 4 patients in
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this group. Localized collections were not noted, but bruising persisted for as long as 3 weeks and spread to the abdominal wall. Breast-shape stability was confirmed in 2 patients, 8 months after surgery in 1 and 13 months after surgery in the other (Figure 4).
Group 3: Mastopexy With Augmentation Surgical procedure
Like many surgeons, we do not practice “treatment of ptosis by implant,”14 and we always complement augmentation with mastopexy when the nipple-IMF distance exceeds 8 cm, “overhanging” of the lower pole exceeds 2 cm, or both. Because mastopexy, in our opinion, must not depend on skin tension (ie, the shape of the breast should be stable before skin closure), use of the MFF is the only way to achieve breast stabilization.
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Figure 5. MFF in augmentation with mastopexy. A, Ptotic parenchyma and lengthened upper slope of the glandular cone. NAC transposition is not needed because NAC is going to be lifted by the increased projection alone, with no need for surgical transport. B, Release of the superficial fascial network from inside to allow the parenchyma to spread over the implant surface. MFF is raised 4 cm high. Arrows show the approximation of the glandular edge and the MFF. C, A stable breast form is obtained before skin suturing through fastening of the glandular lower edge to the MFF upper edge.
Figure 6. Completion of the augmentation with mastopexy. The implant pocket is closed securely by the MFF (arrow). Note lax skin edges, sutured under no tension.
The skin-reduction approach was subperiareolar or vertical. Minimal or no NAC transport was performed. Parenchymal modification was opposite that of “vertical mammaplasty” (ie, the glandular cone was flattened so that the extended inner surface of the upper dermoglandular flap could cover the maximal implant surface)
Use of Myofascial Flaps in Aesthetic Breast Surgery
(Figure 5, B). If the implant pocket was submuscular, the gland was still dissected from the fascia so that the gland could be redraped and its inner surface increased. In this procedure, the MFF was raised only 4 cm because its role was not to overlap the whole breast’s lower pole, as in groups 1 and 2 , but to reach the lower border of parenchyma edge to edge. In cases involving creation of a submuscular pocket, the horizontal sectioning of the pectoralis major muscle divided the muscle into an upper-muscle pocket flap and a lower MFF. No attempt was made to approximate the MFF with the upper muscle flap (which, in any event, was impossible). Instead, the lower edge of the upper muscle flap was left free while the upper edge of the MFF was firmly sutured to the freed parenchyma. The caudal (lower) limit of the flap dissection (the plane of dissection) was 2 cm lower than the level of the new IMF. We considered lowering of the IMF necessary to prevent recurrent ptosis. This procedure enabled us to obtain both a stable IMF and the strong “tenting” of the spread parenchyma to the fast anchor–MFF (Figure 5, C). “Tenting” refers to the stretching of the flaccid parenchyma downward until flaccidity was eliminated, so that there was no more excess glandular tissue that might hang down from the implant and produce an untoward “snoopy” or “doublebubble” breast shape. The implant pocket was totally isolated from the subcutaneous plane (Figure 6), and the caudal implant edge was not palpable.
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Figure 7. A, Preoperative view of a 27-year-old woman. B, Disfiguring early postoperative (3 weeks) hypercorrection after augmentation supplemented with minor subareolar skin reduction and MFF support. C, Aesthetic breast shape 1 year after surgery.
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Figure 8. A, Preoperative view of a 29-year-old woman. B, Postoperative view 1 year after augmentation with both periareolar and vertical skin reduction and MFF support. C, Note how MFF muscle contraction lifts the breast.
Results
Excessive upper-pole fullness persisted longer than usual in all 5 patients who underwent this procedure (Figure 7). We believe this was caused by a quicker-thanexpected resumption of contractility of the MFF muscle portion (Figure 8). However, in 2 patients seen at 1-year follow-up, breast shape was aesthetically pleasing and complete upper-pole fullness was preserved. The other 3 patients were lost to follow-up after the removal of stitches.
Group 4: Implant Exchange With Mastopexy Surgical procedure
The patients in group 4 represent a growing number of patients who present with untoward sequelae of the treatment of ptosis by means of implant placement.
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Correction of ptosis achieved by the filling of a lax skin envelope with a large implant can lift the ptotic breast for only a short time. The patient begins to notice hanging of the augmented breast and the disappearance of upper-pole fullness no more than a couple of months after such an operation. As in group 3, we saw no alternative to the MFF in achieving and maintaining breast elevation through revision surgery. Skin reduction was vertical (width-shortening) and periareolar (NAC cranialization). After the implant was removed, the thickness of the glandular wall was assessed. A large implant pushes breast tissue out of the way during the process of ptosis, which leads to significant thinning of implant coverage over the central breast area around the NAC (Figure 9, A). Parenchymal modification consisted of rebuilding of the glandular cone with the nipple at its apex. Purse-
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Figure 9. MFF in implant exchange with mastopexy. A, Deformation of ptotic parenchyma by the implant. Arrows indicate pressure, which eventually thins the central and especially lower parenchyma, where the implant can be palpated immediately under the skin. B, MFF mobilization and parenchymal modification. The arrows indicate supra-areolar plication for NAC transportation, plication of the central parenchyma from inside the gland as a means of thickening it, and the approximation of the lower glandular edge to the MFF. C, The implant of any (preferably smaller) size is covered and entrapped by the joined MFF and lower glandular edge rather than by the skin.
Figure 10. The imbrication suture on the ventral capsule is tightened, thereby increasing the glandular thickness between the NAC and ventral capsule.
string or Z-sutures were applied on the capsule from inside the pocket to gather the tissues centrally (Figure 10), thereby thickening the gland behind the NAC (Figure 9, B). The capsule was sectioned to allow formation of a new pocket. The MFF was marked on the back capsule over the pectoralis muscle. Because the thickness of the lower-pole tissues was inadequate, the height of the MFF should have been sufficient to cover the lower part of the implant and isolate it from the skin sutures (Figure 11).
Use of Myofascial Flaps in Aesthetic Breast Surgery
Figure 11. The capsule is the anterior wall of the MFF, which fully isolates the implant pocket from the subcutaneous space.
In some patients, primary augmentation was accompanied by mastopexy with imprudent NAC cranialization. Subsequent breast ptosis led to upward eversion of the NAC. In such cases, the gland and NAC were shifted caudally by means of strong pulling and by fastening of the subareolar edge of the parenchyma to the MFF as to an anchor (Figure 9, C). The newly implanted endoprostheses were usually smaller than the explanted ones. The usual practice of selecting larger implants for repeat implantation was not
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Figure 12. A, Preoperative view of a 34-year-old woman unhappy with quickly progressing ptosis 1 year after breast augmentation with McGhan style 410 implants (390 cc). B, Postoperative view 7 months after mastopexy and implant exchange for McGhan style 110 implants (240 cc).
applicable in this setting because the procedure produced successful lifting of the breast without overextending the skin with a larger filler. Results
Six patients underwent the procedure. Postoperative aesthetic improvement of ptosis was pronounced. Only 1 patient returned for evaluation, 7 months after surgery (Figure 12). The indications for MFF were most clear in this group, and its implementation was facilitated by the presence of an additional capsular layer.
Group 5: Simple Primary Augmentation Surgical procedure
Because breast ptosis, as well as palpability of the lower implant edge, is a common late sequela of subglandular augmentation, we always suture the lower gland edge to the fascia. In cases in which such suturing was not feasible, we used a “mini” MFF. A small MFF was raised 2 to 3 cm high and 6 to 7 cm wide after pocket dissection (Figure 13, A and B). On the upper edge of the wound, a small glandular flap was freed from the skin (Figure 13, C) to be sutured with the MFF after implant placement (Figure 13, D). The skin was sutured in 2 layers with compressing purse-stringing (Figure 13, E). Drains were always used in these cases. Results
The myofascial supportive flap was used in 15 cases of primary augmentation. Greater morbidity was noted in the
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early postoperative period compared with morbidity in routine augmentation cases where no MFF was used, as evidenced by more discharge through the drains and early asymmetry caused by temporary fluid collections in 3 cases, all of which resolved spontaneously. The effects of the procedure, such as elevation of the breast mound and increased projection, were noted as early as 2 months after subglandular implantation (Figure 14). In all cases, the lower edge of the implant could not be palpated through the skin. We believe that at least 2 to 3 years of follow-up are needed to evaluate the merits of the technique in this patient cohort. Overall, the indications for MFF use are clearest in cases of secondary corrective mammaplasty. In primary mammaplasty procedures, we prefer to reserve the MFF as a powerful but more traumatic tool. Given otherwise equal conditions, the aesthetic gain achieved through use of the MFF is most obvious when implants are placed. The implant serves as an internal splint, preventing the disfigurement of the lower parenchymal pole that can be seen early after “pure” mastopexy, be it primary or secondary.
Discussion In attempting to discover the reasons for late bottoming out after mammaplasty, we noticed that ptosis was more pronounced in cases in which less breast reduction was performed. This represented a bitter paradox for patients who had requested a breast lift without volumetric changes but experienced some of the most unsatisfactory results for precisely that reason. Consequently, the
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Figure 13. A, Raising of the mini MFF. B, The mini MFF is raised and turned over, opening the rib. C, The small glandular flap is liberated from the skin on the upper wound edge. D, Approximation of the lower MFF and the upper glandular flap. E, Shortening of the skin incision and compression of the skin edges through plication of both deep subdermal and superficial intradermal layers with the single running suture (Biosyn 3/0).
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Figure 14. A, Preoperative view of a 30-year-old woman. B, Postoperative view 2 months after subglandular augmentation with mini MFF. C, Obvious effects of muscle contraction.
need to ensure lasting antigravitational stability of the breast form achieved through surgery became one of the guiding principles of mammaplasty for us, along with universally recognized goals such as glandular modification, envelope redraping, and safe NAC transport.
Use of Myofascial Flaps in Aesthetic Breast Surgery
It is clear that postoperative ptosis and flattening become more extensive as breast mound projection and glandular mass increase. This is why breast reduction (decrease of both mass and projection) is the best strategy against ptosis and flattening, which are both caused
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by gravitational pull. However, the patient’s desires often include breast elevation but exclude breast reduction, which requires increased projection of the breast mound cone. Among the techniques used to achieve this goal, in our experience the least effective appears to be the Wise skin mastopexy. Scrutiny of the late results of the Lejour mastopexy (without breast mass reduction) also showed inevitable bottoming out within 1 year of surgery. Similarly, late results of use of the lower glandular flap transposition as an autoprosthesis (after Ribeiro) showed that initial upper-pole fullness always slipped downward. Flap fixation under the muscle belt (described by Graf) was introduced to us in Dr. Thomas Biggs’ lecture in Ekaterinburg, Russia, in 2000. Within a few weeks of adopting this technique, we encountered a patient who had experienced typical bottoming out after undergoing some form of skin mastopexy 6 months earlier. She wanted to repeat the breast lift but rejected our offer to reduce the breast volume. We could not raise any glandular flap because we did not know which pedicle had been used for the NAC transport during the previous surgery. Although it was not difficult to re-create and lift the glandular cone, the problem we faced was how to ensure long-lasting elevation of the breast cone with increased projection in a patient who had already expressed her particular concern with ptosis. The possibility of using the pectoralis major muscle in mastopexy seemed like a good alternative at that time (October 2000), and it prompted us to raise the lower pectoralis MFF as a supporting balcony. In that first case, the muscle was cautiously split along the fascicles, which resulted in the flattening of the lower lateral segment of the breast after surgery. In later procedures we ignored the orientation of the muscle fascicles and raised the MFF horizontally at its upper edge and almost vertically at the medial and lateral borders, rather than obliquely. Although we assumed that this technique was original, shortly after performing our first procedures we discovered an article by Caldeira and Lucas15 that included the concept of the oblique lower pectoralis major flap. At the ISAPS Congress in Istanbul, Turkey (May 2002), Dr. Hinderer referred us to the key sources.11,12 Later, Fontana and Muti kindly sent to us the reprint of their original MFF description and commented that the functioning of the flap improved as more muscle was included, a finding that corresponded to our own clinical experience.
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In a personal communication, Hinderer mentioned that he had tried the technique with success but was unhappy with the development of hematoma in 1 case and has since preferred his own “dermal brassiere” breast suspension. We also noted the development of large and sometimes long-lasting bruises in most cases. Despite this complication, in our view the achievement of predictable breast-shape stability outweighed the temporary morbidity resulting from the technique. Nevertheless, the increased morbidity after MFF has convinced us to resume using the Graf mastopexy in cases of primary breast lift (group 1), although the MFF has become our method of choice in other situations. We believe that breast position and shape are determined by the consistency of the superficial fascial system (SFS) collagen network, which separates and retains the parenchymal lobules (Cooper suspension system) and subcutaneous fat lobules (retinacula cutis network). Any SFS abnormalities reveal themselves as breast shape (cosmetic) problems, whereas parenchymal abnormalities manifest as breast diseases. Lax breast shape is caused by a too-loose SFS framework suspension and shaping properties. Breast reshaping therefore essentially involves reconstruction of lost SFS structures, functions, or both. With respect to mastopexy, the SFS system is imbricated in the assembly of the cone. The lower supportive MFF takes over the load of breast weight from the weakened SFS framework. By adding the lower MFF, we also reconstruct the attenuated SFS fixation at the IMF level, which is a natural antigravitational mechanism.
Conclusion The MFF technique presents numerous benefits to the patient. An MFF 5 cm high, based at the IMF, and fixed just under the areola reliably prevents overextension of the lower breast pole, stabilizes the nipple-IMF distance, and relieves tension from the skin sutures. Fastening the gland to the MFF creates an immobile IMF. The MFF serves as an anchor to fix the glandular mass pulled toward the breast meridian and therefore improving the overall breast shape. It also hides and protects the lower edge of the implant. Finally, the MFF muscle regains its contractility, constantly and actively counteracting the force of gravity, in contrast to other mastopexy techniques that suspend the breast only passively (ie, temporarily). Indications for MFF are as wide and as deep as the surgeon’s concern with predictable avoidance of late
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postoperative ptosis. It is most useful for a specific cohort of demanding patients who are unwilling to give up breast volume for improved breast shape and are unhappy with the results of previous standard mastopexy or augmentation. It is least useful in patients undergoing primary breast lift (group 1 in this study). In other patient cohorts, the benefits of the MFF technique outweigh the increased morbidity associated with the procedure. ■
References
9. Johnson GW. Central core reduction mammaplasties and marlex suspension of breast tissue. Aesthetic Plast Surg 1981;5:77-84. 10. Bustos RA. Periareolar mammoplastie with silicon supporting lamina. Plast Reconstr Surg 1992;89:646-657. 11. Garcia Padron J. Tecnica de sosten muscular en la mastoplastia de reduccion. III Congreso Ibero-Latinoamericano y V Congreso National de Cirugia Plastica, Valencia, Spain; 1980. 12. Fontana AM, Muti E. Appunti sulla mastoplastica riduttiva (Una tecnica di mastopessi). Riv Ital Chir Plast 1982;14:139. 13. Graf RM, Ayersvald A, Afranio B, et al. Reduction mammaplasty and mastopexy with shorter scar and better shape. Aesthetic Surg J 2000;20:99–106.
1. Girard C. Uber mastoptose und mastopexy. Langenbecks Arch Klin Chir 1910;92:829.
14. Regnault P. The hypoplastic and ptotic breast: combined operation and prosthetic augmentation. Plast Reconstr Surg 1966;37:31-37.
2. Göbel R. Uber Autoplastische freie Fascien und Aponeurosentransplantation nach Martin Kirchner. Arch Klin Chir 1927;146:463–478.
15. Caldeira AML, Lucas A. Pectoralis major muscle flap: a new support approach to mammaplasty, personal technique. Aesthetic Plast Surg 2000;24:58–70.
3. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg 1975;55:330-334.
Accepted for publication November 13, 2004.
4. Figallo E. Surgical treatment of mammary ptosis without hypertrophy. Plast Reconstr Surg 1977;60:189-196. 5. Vogt T. Reduction mammoplasty: Vogt technique. In: Georgiade NG, ed. Aesthetic Breast Surgery. Baltimore, MD: Williams & Wilkins; 1983: 271. 6. Lewis GK. A method of mastopexy with fascia lata transplants. J Int Coll Surg 1956;26:346-353.
Presented at the ASAPS/ASERF/ISAPS International Symposium, Boston, MA, May 16, 2003. Reprint requests: Alexei Borovikov, MD, Botanicheskaja Ulitsa, 29, P.O. 276, Box 17, Moscow 127276, Russia; e-mail: [email protected]. Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$30 doi:10.1016/j.asj.2004.04.002
7. de Silva G. Mastopexy with dermal ribbon for supporting the breast and keeping it in shape. Plast Reconstr Surg 1964;34:403. 8. Hinderer U. Reduction and augmentation mammaplasty: remodelling mammaplasty with superficial and retromammary mastopexy. Int Micr J Aesthet Plast Surg 1972.
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Use of Myofascial Flaps in Aesthetic Breast Surgery Alexei Borovikov, MD From the National Medico-Surgical Center, Moscow, Russia.
Background: The long-term stability of the breast shape, once it is achieved, should be included among the principal concerns of aesthetic mammaplasty. This goal presents a particular challenge to the surgeon treating a patient who is concerned with breast lift but also wants to preserve or even increase cup size. Objective: This report details the use of a lower myofascial supportive flap (MFF) to prevent secondary breast ptosis in various clinical situations. Methods: The conceptual approach was to use the MFF to reconstruct or make up for deficiencies of the superficial fascial system collagen network, which in this surgeon’s view plays a key role in determining breast position and shape. The MFF flap was raised in the region of the pectoralis major and adjacent muscles based at the inframammary fold (IMF) level and sutured near the lower areola border, with the goal of recreating the IMF, stabilizing the nipple-fold distance, and providing long-term support to counteract the effects of gravity through the creation of a “balcony” flap within which the lower breast pole rests. The procedure was performed in various clinical situations, including primary mastopexy, secondary mastopexy to correct for “bottoming out” after previous surgery, mastopexy with augmentation, implant exchange plus mastopexy, and simple primary augmentation. Results: The use of the MFF provided an aesthetic breast shape while maintaining upper-pole fullness. Morbidity was highest among patients who underwent primary or secondary mastopexy and lowest among those who underwent simple primary augmentation. However, in the latter group, morbidity was notably higher than in patients who underwent simple primary augmentation without the use of the MFF. Conclusions: The MFF technique can provide better long-standing breast support than other procedures aimed at preventing or minimizing secondary breast ptosis. It is indicated most clearly for patients who are unwilling to give up breast volume for improved breast shape and who are unhappy with the results of previous standard mastopexy or augmentation. It is less useful in patients undergoing primary breast lift. Limitations include increased duration of surgery and increased trauma. (Aesthetic Surg J 2004;24:331-341)
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t is generally accepted that aesthetic mammaplasty must be guided by the following principal goals: reshaping of the glandular component of the breast, tailoring of the skin envelope to match the new shape of the parenchymal cone, and safe and geometrically correct transportation of the nipple. We believe that the provision of long-term stability of the breast shape, once it is achieved, is as important as the other three goals. In addition, resistance to late breast ptosis in some patients should also be listed as a principal goal of mammaplasty. This last goal is the primary focus in cases in which mammaplasty is performed to increase breast projection, volume, or both, be it through mastopexy, either alone or combined with augmentation; revision mastopexy for late breast ptosis, or another procedure. The patient’s
desire to preserve or even increase cup size rules out breast reduction and thus presents a special challenge to the surgeon. Reduction mammaplasty alleviates the problem of late postoperative ptosis known as “bottoming out” by decreasing the effect of the force of gravity through a reduction of breast mass and projection. By contrast, the effects of gravity and the tendency toward ptosis increase as a result of procedures performed to increase breast projection (any mastopexy) and breast volume (mastopexy plus augmentation). Patients who are particularly concerned with breast lift and decline the proposal to reduce the breast tend to be less forgiving of late ptotis, unlike patients who ask primarily for volumetric changes and would most likely appreciate the results of
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reduction or augmentation while being more tolerant of possible late ptosis. One method for preventing secondary breast ptosis is gland suspension through the use of sutures1 or fascial strips.2 A second group of techniques depends on upward transposition of the glandular flap, designed from the lower part of the parenchyma, based inferiorly3 or superiorly on the dermoglandular nipple-areola pedicle.4,5 This “autoprosthesis” fills the upper breast pole beneath the superior breast tissue. A third set of methods is used to create an internal lower-breast “brassiere” or supporting “balcony” through the use of dermal or fascial strips,6–8 Marlex tape (CP Chem, Overijse, Belgium),9 silicone sheets,10 or synthetic mesh. This third group of antigravitational maneuvers also includes the lower myofascial supportive flap (MFF).11,12 In our view, the advantage of the MFF is that the contractile muscular portion of the flap provides active breast support from below through a balcony reconnection with normal muscle through the scar tissue, so that it acts like the tendineous extension of the muscle and by its tonus at rest, whereas all the other techniques listed here are able to render only passive and therefore temporary support. The following are variations of the technique that were used in 5 typical clinical situations.
Group 1: Primary Mastopexy Surgical procedure
The lower supportive myofascial flap was first used in 3 cases when we began using the technique. Later on, we resumed performance of the mastopexy with an autoprosthesis, as described by Ribiero3 and Graf.13 The technical details are given as they apply to this group because it is easier to describe the principles of this method on an intact breast. Skin reduction was vertical-periareolar. The skin was undermined in the lower third of the breast circumference to free the medial and lateral glandular flaps (pillars) for later joining at the meridian and imbrication to create a conical breast shape. The nipple-areolar complex (NAC) was transported onto the upper pedicle because the lower breast segment had to be lifted away from the pectoral fascia. The desired level of the inframammary fold (IMF) was marked on the freed fascia; it was often lower than the preexisting one. An 8- to 9-cm horizontal incision of the fascia and underlying pectoralis major muscle was made 5 to 6 cm cranial to the marked new IMF. The MFF was raised as
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Figure 1. Intraoperative view of the raised MFF.
a trapdoor hinged at the new IMF line, opening the ribs. This maneuver required a vertical cut of the rectus fascia medially and serratus anterior muscle laterally (Figure 1). The caudal edge of the obtained glandular cone was firmly fixed to the new IMF line from inside the flap so that the MFF covered the lower parenchyma from outside. The cranial edge of the MFF was sutured to the glandular cone, close to the lower border of the areola (Figure 2, B and C). After immobilization of the glandular cone had been achieved and confirmed, the patient was placed in a sitting position, and the medial and lateral breast contours were assessed. With the immobile MFF as an anchor, the medial or lateral excess tissue (or both, as applicable) was selectively pulled to the flap until the desired breast shape was achieved (Figure 2, D). The skin envelope was sutured under no tension, with purse-stringing at both the subdermal and dermal levels (Biosyn [Tyco, Gosport, UK] or PDS 4/0 [Ethicon, Somerville, NJ]). Purse-stringing allowed compression of the skin edges to each other for several days while the scar formed, then completely disappeared after some weeks, leaving a narrow linear scar. Precise trimming of any minor skin excess was avoided because the skin edges were already in ripples and because the final breast shape was achieved before and independent of skin sutures. Results
Postoperative morbidity (bruising and swelling) developed in all patients but resolved without special treatment. Prolonged hypercorrection of breast shape
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Figure 2. The scheme of MFF use in primary mastopexy. Depicted are the parenchyma, deep fascia, and muscle layer. The skin envelope is not shown. A, Ptotic parenchyma. The arrow denotes the vector of NAC transport. B, NAC transport with the supraareolar plication complete. The subareolar gland is imbricated. The MFF is raised 5 cm high on the basis of the line of the new IMF. The arrow shows the vector of parenchymal pull to the new IMF. C, The parenchyma is fastened to the new IMF. The MFF is fixed to the subareolar gland and covers the lower slope of the glandular cone. D, The frontal view shows that both medial and lateral glandular excesses can be separately pulled to the breast meridian and fastened to the anchor of the MFF. This diminishes the width and increases the projection of the breast mound. Suturing of various glandular parts to each other is not as predictable geometrically because of the mobility of the gland over the chest wall. E, The level of the preexisting IMF. F, The new IMF level.
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Figure 3. A, Preoperative view of a 36-year-old woman who desired a primary breast lift. B, Early postoperative view, 3 weeks after primary breast lift, shows marked hypercorrection. C, A pleasing aesthetic result 4 months after surgery.
occurred in 1 of the 3 patients who underwent this procedure. The beaklike profile of the breast, which normally disappears within a couple of months after Lejour vertical mammaplasty, persisted for 3 months in this patient. We were considering transsection of the muscle balcony to promote ptosis, but by the fourth month the breast had taken on an aesthetically pleasing shape (Figure 3).
Use of Myofascial Flaps in Aesthetic Breast Surgery
Group 2: Secondary Mastopexy to Correct Bottoming Out After Primary Mastopexy or Reduction Mammaplasty Surgical procedure
It was not possible to use glandular autoprosthesis flaps in these cases because it was not known which pedicle was used for NAC transport in the primary surgery.
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Figure 4. A, Preoperative view of a 41-year-old woman who was frustrated by the results of skin mastopexy but rejected breast reduction. B, Postoperative view 3 months after secondary mastopexy with scar visible. SFS passive resistance to gravity was still high, as in any traditional mastopexy. C, Postoperative view after 13 months (relaxed muscle). SFS passive resistance naturally subsided with time. The scar is no longer visible and the upper slope is concave. D, Muscle contraction brought the late postoperative (13 months) breast shape closer to the early postoperative shape (compare with part B). Muscle activity compensated for the weakening supportive function of the SFS. The results will stand as long as muscle contractility is retained.
The MFF was therefore the only technique available for the prevention of recurrent ptosis. Incisions followed the previous scars and were followed by reduction of the overextended skin in the lower breast pole. Minimal or no NAC transport was performed because upward nipple rotation was one of the main patient complaints after primary surgery. Parenchymal modification and raising of the MFF was performed as described for the patients in group 1. The skin was sutured with marked rippling to reduce scar length. To the same end, defatting, hemi-purse-string sutures, and V-Y plasty were undertaken to correct dog-ears. Results
Early postoperative morbidity—prolonged swelling and lower-pole induration—developed in all 4 patients in
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this group. Localized collections were not noted, but bruising persisted for as long as 3 weeks and spread to the abdominal wall. Breast-shape stability was confirmed in 2 patients, 8 months after surgery in 1 and 13 months after surgery in the other (Figure 4).
Group 3: Mastopexy With Augmentation Surgical procedure
Like many surgeons, we do not practice “treatment of ptosis by implant,”14 and we always complement augmentation with mastopexy when the nipple-IMF distance exceeds 8 cm, “overhanging” of the lower pole exceeds 2 cm, or both. Because mastopexy, in our opinion, must not depend on skin tension (ie, the shape of the breast should be stable before skin closure), use of the MFF is the only way to achieve breast stabilization.
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Figure 5. MFF in augmentation with mastopexy. A, Ptotic parenchyma and lengthened upper slope of the glandular cone. NAC transposition is not needed because NAC is going to be lifted by the increased projection alone, with no need for surgical transport. B, Release of the superficial fascial network from inside to allow the parenchyma to spread over the implant surface. MFF is raised 4 cm high. Arrows show the approximation of the glandular edge and the MFF. C, A stable breast form is obtained before skin suturing through fastening of the glandular lower edge to the MFF upper edge.
Figure 6. Completion of the augmentation with mastopexy. The implant pocket is closed securely by the MFF (arrow). Note lax skin edges, sutured under no tension.
The skin-reduction approach was subperiareolar or vertical. Minimal or no NAC transport was performed. Parenchymal modification was opposite that of “vertical mammaplasty” (ie, the glandular cone was flattened so that the extended inner surface of the upper dermoglandular flap could cover the maximal implant surface)
Use of Myofascial Flaps in Aesthetic Breast Surgery
(Figure 5, B). If the implant pocket was submuscular, the gland was still dissected from the fascia so that the gland could be redraped and its inner surface increased. In this procedure, the MFF was raised only 4 cm because its role was not to overlap the whole breast’s lower pole, as in groups 1 and 2 , but to reach the lower border of parenchyma edge to edge. In cases involving creation of a submuscular pocket, the horizontal sectioning of the pectoralis major muscle divided the muscle into an upper-muscle pocket flap and a lower MFF. No attempt was made to approximate the MFF with the upper muscle flap (which, in any event, was impossible). Instead, the lower edge of the upper muscle flap was left free while the upper edge of the MFF was firmly sutured to the freed parenchyma. The caudal (lower) limit of the flap dissection (the plane of dissection) was 2 cm lower than the level of the new IMF. We considered lowering of the IMF necessary to prevent recurrent ptosis. This procedure enabled us to obtain both a stable IMF and the strong “tenting” of the spread parenchyma to the fast anchor–MFF (Figure 5, C). “Tenting” refers to the stretching of the flaccid parenchyma downward until flaccidity was eliminated, so that there was no more excess glandular tissue that might hang down from the implant and produce an untoward “snoopy” or “doublebubble” breast shape. The implant pocket was totally isolated from the subcutaneous plane (Figure 6), and the caudal implant edge was not palpable.
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Figure 7. A, Preoperative view of a 27-year-old woman. B, Disfiguring early postoperative (3 weeks) hypercorrection after augmentation supplemented with minor subareolar skin reduction and MFF support. C, Aesthetic breast shape 1 year after surgery.
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Figure 8. A, Preoperative view of a 29-year-old woman. B, Postoperative view 1 year after augmentation with both periareolar and vertical skin reduction and MFF support. C, Note how MFF muscle contraction lifts the breast.
Results
Excessive upper-pole fullness persisted longer than usual in all 5 patients who underwent this procedure (Figure 7). We believe this was caused by a quicker-thanexpected resumption of contractility of the MFF muscle portion (Figure 8). However, in 2 patients seen at 1-year follow-up, breast shape was aesthetically pleasing and complete upper-pole fullness was preserved. The other 3 patients were lost to follow-up after the removal of stitches.
Group 4: Implant Exchange With Mastopexy Surgical procedure
The patients in group 4 represent a growing number of patients who present with untoward sequelae of the treatment of ptosis by means of implant placement.
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Correction of ptosis achieved by the filling of a lax skin envelope with a large implant can lift the ptotic breast for only a short time. The patient begins to notice hanging of the augmented breast and the disappearance of upper-pole fullness no more than a couple of months after such an operation. As in group 3, we saw no alternative to the MFF in achieving and maintaining breast elevation through revision surgery. Skin reduction was vertical (width-shortening) and periareolar (NAC cranialization). After the implant was removed, the thickness of the glandular wall was assessed. A large implant pushes breast tissue out of the way during the process of ptosis, which leads to significant thinning of implant coverage over the central breast area around the NAC (Figure 9, A). Parenchymal modification consisted of rebuilding of the glandular cone with the nipple at its apex. Purse-
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Figure 9. MFF in implant exchange with mastopexy. A, Deformation of ptotic parenchyma by the implant. Arrows indicate pressure, which eventually thins the central and especially lower parenchyma, where the implant can be palpated immediately under the skin. B, MFF mobilization and parenchymal modification. The arrows indicate supra-areolar plication for NAC transportation, plication of the central parenchyma from inside the gland as a means of thickening it, and the approximation of the lower glandular edge to the MFF. C, The implant of any (preferably smaller) size is covered and entrapped by the joined MFF and lower glandular edge rather than by the skin.
Figure 10. The imbrication suture on the ventral capsule is tightened, thereby increasing the glandular thickness between the NAC and ventral capsule.
string or Z-sutures were applied on the capsule from inside the pocket to gather the tissues centrally (Figure 10), thereby thickening the gland behind the NAC (Figure 9, B). The capsule was sectioned to allow formation of a new pocket. The MFF was marked on the back capsule over the pectoralis muscle. Because the thickness of the lower-pole tissues was inadequate, the height of the MFF should have been sufficient to cover the lower part of the implant and isolate it from the skin sutures (Figure 11).
Use of Myofascial Flaps in Aesthetic Breast Surgery
Figure 11. The capsule is the anterior wall of the MFF, which fully isolates the implant pocket from the subcutaneous space.
In some patients, primary augmentation was accompanied by mastopexy with imprudent NAC cranialization. Subsequent breast ptosis led to upward eversion of the NAC. In such cases, the gland and NAC were shifted caudally by means of strong pulling and by fastening of the subareolar edge of the parenchyma to the MFF as to an anchor (Figure 9, C). The newly implanted endoprostheses were usually smaller than the explanted ones. The usual practice of selecting larger implants for repeat implantation was not
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Figure 12. A, Preoperative view of a 34-year-old woman unhappy with quickly progressing ptosis 1 year after breast augmentation with McGhan style 410 implants (390 cc). B, Postoperative view 7 months after mastopexy and implant exchange for McGhan style 110 implants (240 cc).
applicable in this setting because the procedure produced successful lifting of the breast without overextending the skin with a larger filler. Results
Six patients underwent the procedure. Postoperative aesthetic improvement of ptosis was pronounced. Only 1 patient returned for evaluation, 7 months after surgery (Figure 12). The indications for MFF were most clear in this group, and its implementation was facilitated by the presence of an additional capsular layer.
Group 5: Simple Primary Augmentation Surgical procedure
Because breast ptosis, as well as palpability of the lower implant edge, is a common late sequela of subglandular augmentation, we always suture the lower gland edge to the fascia. In cases in which such suturing was not feasible, we used a “mini” MFF. A small MFF was raised 2 to 3 cm high and 6 to 7 cm wide after pocket dissection (Figure 13, A and B). On the upper edge of the wound, a small glandular flap was freed from the skin (Figure 13, C) to be sutured with the MFF after implant placement (Figure 13, D). The skin was sutured in 2 layers with compressing purse-stringing (Figure 13, E). Drains were always used in these cases. Results
The myofascial supportive flap was used in 15 cases of primary augmentation. Greater morbidity was noted in the
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early postoperative period compared with morbidity in routine augmentation cases where no MFF was used, as evidenced by more discharge through the drains and early asymmetry caused by temporary fluid collections in 3 cases, all of which resolved spontaneously. The effects of the procedure, such as elevation of the breast mound and increased projection, were noted as early as 2 months after subglandular implantation (Figure 14). In all cases, the lower edge of the implant could not be palpated through the skin. We believe that at least 2 to 3 years of follow-up are needed to evaluate the merits of the technique in this patient cohort. Overall, the indications for MFF use are clearest in cases of secondary corrective mammaplasty. In primary mammaplasty procedures, we prefer to reserve the MFF as a powerful but more traumatic tool. Given otherwise equal conditions, the aesthetic gain achieved through use of the MFF is most obvious when implants are placed. The implant serves as an internal splint, preventing the disfigurement of the lower parenchymal pole that can be seen early after “pure” mastopexy, be it primary or secondary.
Discussion In attempting to discover the reasons for late bottoming out after mammaplasty, we noticed that ptosis was more pronounced in cases in which less breast reduction was performed. This represented a bitter paradox for patients who had requested a breast lift without volumetric changes but experienced some of the most unsatisfactory results for precisely that reason. Consequently, the
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Figure 13. A, Raising of the mini MFF. B, The mini MFF is raised and turned over, opening the rib. C, The small glandular flap is liberated from the skin on the upper wound edge. D, Approximation of the lower MFF and the upper glandular flap. E, Shortening of the skin incision and compression of the skin edges through plication of both deep subdermal and superficial intradermal layers with the single running suture (Biosyn 3/0).
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Figure 14. A, Preoperative view of a 30-year-old woman. B, Postoperative view 2 months after subglandular augmentation with mini MFF. C, Obvious effects of muscle contraction.
need to ensure lasting antigravitational stability of the breast form achieved through surgery became one of the guiding principles of mammaplasty for us, along with universally recognized goals such as glandular modification, envelope redraping, and safe NAC transport.
Use of Myofascial Flaps in Aesthetic Breast Surgery
It is clear that postoperative ptosis and flattening become more extensive as breast mound projection and glandular mass increase. This is why breast reduction (decrease of both mass and projection) is the best strategy against ptosis and flattening, which are both caused
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by gravitational pull. However, the patient’s desires often include breast elevation but exclude breast reduction, which requires increased projection of the breast mound cone. Among the techniques used to achieve this goal, in our experience the least effective appears to be the Wise skin mastopexy. Scrutiny of the late results of the Lejour mastopexy (without breast mass reduction) also showed inevitable bottoming out within 1 year of surgery. Similarly, late results of use of the lower glandular flap transposition as an autoprosthesis (after Ribeiro) showed that initial upper-pole fullness always slipped downward. Flap fixation under the muscle belt (described by Graf) was introduced to us in Dr. Thomas Biggs’ lecture in Ekaterinburg, Russia, in 2000. Within a few weeks of adopting this technique, we encountered a patient who had experienced typical bottoming out after undergoing some form of skin mastopexy 6 months earlier. She wanted to repeat the breast lift but rejected our offer to reduce the breast volume. We could not raise any glandular flap because we did not know which pedicle had been used for the NAC transport during the previous surgery. Although it was not difficult to re-create and lift the glandular cone, the problem we faced was how to ensure long-lasting elevation of the breast cone with increased projection in a patient who had already expressed her particular concern with ptosis. The possibility of using the pectoralis major muscle in mastopexy seemed like a good alternative at that time (October 2000), and it prompted us to raise the lower pectoralis MFF as a supporting balcony. In that first case, the muscle was cautiously split along the fascicles, which resulted in the flattening of the lower lateral segment of the breast after surgery. In later procedures we ignored the orientation of the muscle fascicles and raised the MFF horizontally at its upper edge and almost vertically at the medial and lateral borders, rather than obliquely. Although we assumed that this technique was original, shortly after performing our first procedures we discovered an article by Caldeira and Lucas15 that included the concept of the oblique lower pectoralis major flap. At the ISAPS Congress in Istanbul, Turkey (May 2002), Dr. Hinderer referred us to the key sources.11,12 Later, Fontana and Muti kindly sent to us the reprint of their original MFF description and commented that the functioning of the flap improved as more muscle was included, a finding that corresponded to our own clinical experience.
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In a personal communication, Hinderer mentioned that he had tried the technique with success but was unhappy with the development of hematoma in 1 case and has since preferred his own “dermal brassiere” breast suspension. We also noted the development of large and sometimes long-lasting bruises in most cases. Despite this complication, in our view the achievement of predictable breast-shape stability outweighed the temporary morbidity resulting from the technique. Nevertheless, the increased morbidity after MFF has convinced us to resume using the Graf mastopexy in cases of primary breast lift (group 1), although the MFF has become our method of choice in other situations. We believe that breast position and shape are determined by the consistency of the superficial fascial system (SFS) collagen network, which separates and retains the parenchymal lobules (Cooper suspension system) and subcutaneous fat lobules (retinacula cutis network). Any SFS abnormalities reveal themselves as breast shape (cosmetic) problems, whereas parenchymal abnormalities manifest as breast diseases. Lax breast shape is caused by a too-loose SFS framework suspension and shaping properties. Breast reshaping therefore essentially involves reconstruction of lost SFS structures, functions, or both. With respect to mastopexy, the SFS system is imbricated in the assembly of the cone. The lower supportive MFF takes over the load of breast weight from the weakened SFS framework. By adding the lower MFF, we also reconstruct the attenuated SFS fixation at the IMF level, which is a natural antigravitational mechanism.
Conclusion The MFF technique presents numerous benefits to the patient. An MFF 5 cm high, based at the IMF, and fixed just under the areola reliably prevents overextension of the lower breast pole, stabilizes the nipple-IMF distance, and relieves tension from the skin sutures. Fastening the gland to the MFF creates an immobile IMF. The MFF serves as an anchor to fix the glandular mass pulled toward the breast meridian and therefore improving the overall breast shape. It also hides and protects the lower edge of the implant. Finally, the MFF muscle regains its contractility, constantly and actively counteracting the force of gravity, in contrast to other mastopexy techniques that suspend the breast only passively (ie, temporarily). Indications for MFF are as wide and as deep as the surgeon’s concern with predictable avoidance of late
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postoperative ptosis. It is most useful for a specific cohort of demanding patients who are unwilling to give up breast volume for improved breast shape and are unhappy with the results of previous standard mastopexy or augmentation. It is least useful in patients undergoing primary breast lift (group 1 in this study). In other patient cohorts, the benefits of the MFF technique outweigh the increased morbidity associated with the procedure. ■
References
9. Johnson GW. Central core reduction mammaplasties and marlex suspension of breast tissue. Aesthetic Plast Surg 1981;5:77-84. 10. Bustos RA. Periareolar mammoplastie with silicon supporting lamina. Plast Reconstr Surg 1992;89:646-657. 11. Garcia Padron J. Tecnica de sosten muscular en la mastoplastia de reduccion. III Congreso Ibero-Latinoamericano y V Congreso National de Cirugia Plastica, Valencia, Spain; 1980. 12. Fontana AM, Muti E. Appunti sulla mastoplastica riduttiva (Una tecnica di mastopessi). Riv Ital Chir Plast 1982;14:139. 13. Graf RM, Ayersvald A, Afranio B, et al. Reduction mammaplasty and mastopexy with shorter scar and better shape. Aesthetic Surg J 2000;20:99–106.
1. Girard C. Uber mastoptose und mastopexy. Langenbecks Arch Klin Chir 1910;92:829.
14. Regnault P. The hypoplastic and ptotic breast: combined operation and prosthetic augmentation. Plast Reconstr Surg 1966;37:31-37.
2. Göbel R. Uber Autoplastische freie Fascien und Aponeurosentransplantation nach Martin Kirchner. Arch Klin Chir 1927;146:463–478.
15. Caldeira AML, Lucas A. Pectoralis major muscle flap: a new support approach to mammaplasty, personal technique. Aesthetic Plast Surg 2000;24:58–70.
3. Ribeiro L. A new technique for reduction mammaplasty. Plast Reconstr Surg 1975;55:330-334.
Accepted for publication November 13, 2004.
4. Figallo E. Surgical treatment of mammary ptosis without hypertrophy. Plast Reconstr Surg 1977;60:189-196. 5. Vogt T. Reduction mammoplasty: Vogt technique. In: Georgiade NG, ed. Aesthetic Breast Surgery. Baltimore, MD: Williams & Wilkins; 1983: 271. 6. Lewis GK. A method of mastopexy with fascia lata transplants. J Int Coll Surg 1956;26:346-353.
Presented at the ASAPS/ASERF/ISAPS International Symposium, Boston, MA, May 16, 2003. Reprint requests: Alexei Borovikov, MD, Botanicheskaja Ulitsa, 29, P.O. 276, Box 17, Moscow 127276, Russia; e-mail: [email protected]. Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$30 doi:10.1016/j.asj.2004.04.002
7. de Silva G. Mastopexy with dermal ribbon for supporting the breast and keeping it in shape. Plast Reconstr Surg 1964;34:403. 8. Hinderer U. Reduction and augmentation mammaplasty: remodelling mammaplasty with superficial and retromammary mastopexy. Int Micr J Aesthet Plast Surg 1972.
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