INTRODUCTION
In hypomastia patients with the need for implant placement, mastopexy is a common
surgery and may provide satisfactory results for the patient and the surgeon.
However, this procedure presents a high rate of poor outcomes and reoperations.
Moreover, the implant volumes have increased over the years, which may
accelerate postoperative ptosis and increase the patient’s demand for better
aesthetic results. Even patients with more evident ptosis and flaccidity expect
to achieve results similar to those of patients with normal breasts, which led
us to incorporate some technical changes in the procedure.
The development of these technical modifications was based on the cases of
significant encapsulation and hypomastia suggesting a change in the location of
the implant pocket and closure of the previous pocket by anchoring the breast to
the muscle.
Subfascial detachment was performed, and the breast tissue was attached to the
pectoralis major muscle using fixation points. The need to attach the lower pole
of the breast led us to approach the muscle more inferiorly than in the
dual-plane technique and perform anatomical detachment, which helped reduce
postoperative pain and increase implant coverage by the muscle.
Several authors1-7 have proposed including implants in
submuscular pockets using the dual-plane technique to reduce the tendency of
ptosis in the postoperative period, prevent rippling, and provide more natural
contours to the implanted breasts.
The presence of breast flaccidity and ptosis limit maintenance of the aesthetic
result obtained with implant placement because of the tendency of the breast and
the implant to sag, even when fixation is performed adequately and subfascial or
subglandular implants are used8-11, especially
in cases in which the pectoral fascia is fragile and has limited capacity to
support the implants.
The alternative in these cases is placing the implants in the submuscular pocket,
which has the advantage of supporting the weight of the implants and concealing
the contour of the implants, leading to more natural results, especially for
patients with significant hypomastia. The disadvantage of this type of implant
is postoperative pain and the possibility of implant dislocation in the upper
portion of the breast and/or breast ptosis, resulting in an unsightly appearance
(double bubble deformity).
Even a submuscular implant may not prevent ptosis, as skin and glandular sagging
is significant in these cases, potentially leading to breast ptosis and
compromising the surgical result.
OBJECTIVE
The objective of this study was to describe the technique of placement of
submuscular implants with anatomical detachment in combination with tight
anchoring of the breast to the pectoralis major muscle using attachment points
and to analyze the aesthetic results in those who underwent the operation.
METHOD
A total of 23 mastopexy procedures with inverted T scars combined with the
inclusion of submuscular implants were performed from April 2015 to July 2017.
All surgeries were executed bilaterally using round-shaped high-profile textured
breast implants (volumes of 255-355 mL) in patients with evident breast ptosis
and flaccidity. Twenty-two patients from the private clinic and one patient from
the University Hospital of the State University of Londrina were included. The
same surgeon performed surgery on all patients under thoracic epidural
anesthesia following a protocol of prevention of thromboembolism, use of
prophylactic antibiotic, and hospitalization for 24 hours.
Surgical procedure
The patients underwent operation in the horizontal dorsal decubitus position
with abduction of the upper limbs at 90º. Infusion of epinephrine solution
(1:500,000) on the surgical markings allowed for easy removal of excess skin
and elevated the nipple-areola complex. These marks were previously
performed with the patient in a seated position.
Surgery was initiated with an incision on the inframammary fold and
subfascial elevation to the level of the nipple-areola complex with an
electrocautery scalpel to preserve blood supply and integrity of the
pectoral fascia. From this point, detachment was subglandular by creating a
pocket sufficient to accommodate most of the breast base, while attempting
to keep the detachment at safe levels to preserve breast sensitivity and
blood supply, as proposed by Spear12.
The next step was to attach the breast to the pectoralis major muscle using
9-12 stitches with absorbable 3.0 multifilament thread (Figure 1). During this procedure, the breast was held
upright by two 2.0-cotton thread stitches positioned at the apex of the new
mammary cone (Figure 2). At the end of
the procedure, breast fixation was adequate compared to the non-operated
side (Figure 3).
Figura 1 - Point of attachment of the breast tissue to the pectoralis
muscle.
Figura 1 - Point of attachment of the breast tissue to the pectoralis
muscle.
Figura 2 - Position of the breast during attachment.
Figura 2 - Position of the breast during attachment.
Figura 3 - Stable fixation of the breast tissue compared to the
non-fixated side.
Figura 3 - Stable fixation of the breast tissue compared to the
non-fixated side.
After tissue fixation, the pectoralis major muscle was dissected as
anatomically as possible by 1) approaching the muscle from its inferior
portion, separating it from the proximal portion of the rectus abdominis
muscle; 2) making a small incision in the sternal attachment to preserve the
pectoral fascia; and 3) dissecting the pectoralis major muscle in the
transition with the serratus muscle in the direction of the muscle
fibers.
This surgical approach is intended to expose the muscle (Figures 4 and 5)
and leave it as free as possible from the muscle sheath in the lower portion
to prevent superior implant dislocation. We emphasize that the muscle was
not sectioned extensively. As a routine procedure, drainage was not
performed, hemostasis in the detached areas was rigorous, and hypotension
was prevented for the safer control of hemostasis.
Figure 4 - Surgical markings for muscle detachment in the lower portion
of the breast. Source: Sobotta Atlas of Human Anatomy. Vol. 2.
Rio de Janeiro: Guanabara Koogan 2008.
Figure 4 - Surgical markings for muscle detachment in the lower portion
of the breast. Source: Sobotta Atlas of Human Anatomy. Vol. 2.
Rio de Janeiro: Guanabara Koogan 2008.
Figura 5 - Significant detachment of the lower portion of the pectoralis
muscle.
Figura 5 - Significant detachment of the lower portion of the pectoralis
muscle.
Submuscular detachment was performed using electrocautery coagulation and an
illuminated retractor, limiting the detachment to the superior aspect of the
submuscular pocket, and leaving the pectoralis minor muscle intact. In the
lateral aspect of the submuscular pocket, the detachment was close to the
costal arch, creating a pocket that provided good muscular coverage for the
implant.
Following this, excess skin was removed, the nipple-areola complex was
repositioned, the margins were suture using 2.0 nylon threads, and cutaneous
closure was performed using subdermal and intradermal sutures with
absorbable threads.
For an initial evaluation of the results, a file was prepared with photos of
the breasts of 12 patients randomly chosen in the following profiles:
frontal, oblique, and lateral (right side) in the preoperative period and 3
months after surgery. The evaluations were made by two plastic surgeons and
two non-medical individuals, including a patient who underwent
abdominoplasty and another patient who received a breast implant without
fixation.
The overall aesthetic result, symmetry of the nipple-areola complex, and
degree of breast ptosis were evaluated using a score from 1 to 10 as
follows: 1-4, unsatisfactory; 5-6, satisfactory; and 7-10, good.
RESULTS
The surgical technique was reproducible. Only one aesthetic result was considered
satisfactory (Figure 6) whereas the other
results for the symmetry of the nipple-areola complex (Figure 7) and presence of ptosis (Figure 8) were considered good by the evaluators.
Figura 6 - Assessment of the aesthetic result.
Figura 6 - Assessment of the aesthetic result.
Figura 7 - Evaluation of the symmetry of the nipple-areola complex.
Figura 7 - Evaluation of the symmetry of the nipple-areola complex.
Figura 8 - Assessment of the presence of ptosis.
Figura 8 - Assessment of the presence of ptosis.
There was one case of massive unilateral hematoma, with the need for surgical
drainage, and no cases of seroma. Furthermore, three patients presented small
skin lesions at the junction of the T scars on the inframammary fold, which
healed spontaneously. There were complaints of mild pain and no cases of
extrusion or implant infection. Two patients had a transient decrease in areolar
sensitivity, and three patients had unilateral superior dislocation of the
implant with slight asymmetry.
DISCUSSION
Some limitations of implant placement using the dual-plane technique in cases of
ptosis and flaccidity led us to search for surgical alternatives. We sought to
provide greater implant coverage using the pectoralis major muscle, approaching
the muscle anatomically to allow full use of this muscle for implant coverage
and reduce postoperative pain.
Stable fixation of the breast to the muscle tissue was included in this surgical
strategy to minimize the risk of breast ptosis (double bubble deformity).
Although several studies did not emphasize the intensity of postoperative pain,
this factor is relevant and often increases patient resistance to use implants
in the submuscular pocket.
Daher et al.8 reported that the degree of
satisfaction in mastopexy procedures with submuscular and subglandular implants
was 90-96%, and the rate of reoperation was 6.58%. These authors also reported
that the use of submuscular implants caused postoperative pain but did not
describe breast attachment to the muscle. Implant volumes ranged from 150 mL to
400 mL. This result was different from ours; our patients did not have
significant complaints of pain, despite the use of stitches to attach the breast
to the muscle and significant muscular detachment.
Daniel1 describes a dual-plane method using
a 3 cm-wide muscle sheath of the lower portion of the pectoralis major muscle to
prevent ptosis. The implant volume varied from 135 mL to 550 mL and ranged from
215 mL to 285 mL in most cases. In this surgical strategy incisions are made in
the inferior region of the pectoralis major muscle and the implant is not
covered extensively; consequently, rippling in the upper portion may occur. In
our study, we tried to cover the implant extensively, and consequently, minimize
the chances of rippling.
Sanches et al.6 described the use of large
submuscular pockets to accommodate implants by using a small disinsertion of the
inferomedial portion of the pectoralis major muscle without the use of stitches
to attach the breast to the muscle tissue, and implant volumes ranged from 200
mL to 240 mL. Despite the extensive muscle detachment, the authors did not
attach the mammary tissue to the muscle, and the attachment proposed herein may
be an important contribution of our study. We believe that this attachment helps
maintain the long-term result.
Khan5 described the use of internal
fixation for mild degrees of ptosis via the inframammary access without removing
skin, the use of a muscle-splitting pocket, upper pole detachment above the
upper border of the muscle and sutures, and attachment of the lower pole of the
breast with fixation points in the fascia of the upper portion of the pectoralis
major muscle. Implant volumes ranged from 260 mL to 440 mL. We believe it is
essential to remove excess skin to help fixation in cases of more obvious
ptosis.
Bruschi et al.2 described a pectoralis
muscle-splitting technique in periareolar mastopexy using a mixed pocket and
attachment of the lower pole of the breast to the upper portion of the
pectoralis major muscle. However, the number of stitches was not mentioned.
Implant volumes ranged from 250 mL to 355 mL.
One of the advantages was that attaching the breast to the pectoralis major
muscle caused more stable and permanent positioning of the breasts,
significantly reducing the tendency of the tissue to slide over the muscle. In
addition to better positioning, the muscular approach was more anatomical,
reduced postoperative pain, and provided better implant coverage by the muscle,
with more natural results.
This procedure reduced postoperative ptosis, complaints, and retouching. We
emphasize that the presence of severe ptosis and flaccidity are
contraindications to this approach, and the patients need to collaborate in the
late postoperative period by routinely using a bra and avoid weight
variations.
The disadvantage of using these technical modifications is a longer surgical
time. However, the increase in the number of operations decreases the difference
in surgical time compared to the use of a subfascial implant. Another limitation
of using submuscular implants is the increased risk of implant dislocation,
compromising the aesthetic result. In addition to the strategies already
mentioned to reduce this possibility, more compressive dressings in the upper
pole of the breast and implant stabilizers were used.
There were three cases of asymmetry due to unilateral superior dislocation of the
implants, and in two of these cases, there were no significant complaints by the
patients. In only one case, asymmetry was significant because of excessive
implant dislocation and excess residual skin, and retouching was scheduled to
reposition the implant and remove excess skin.
The detachment of the lower portion of the pectoralis muscle without extensive
muscle sectioning usually helps keep the implant in the correct position using
compressive dressings and breast implant stabilizers; this procedure also
reduces pain. The cases in which it was difficult to reposition the implants can
be attributed to asymmetries of the chest with irregularities in the costal arch
and/or prolonged muscle contraction due to pain or fear of immobilization of the
upper limbs and relaxation of the shoulders.
CONCLUSION
The treatment of breast ptosis associated with flaccidity and/or hypomastia
involving the placement of a submuscular implant and anchoring of the breast to
the pectoralis muscle using fixation points is a reproducible technique with
good aesthetic results (Figures 9 and
10).
Figura 9 - A, B e C: Preoperative;
D, E e F: Postoperative.
Figura 9 - A, B e C: Preoperative;
D, E e F: Postoperative.
Figura 10 - A, B e C: Preoperative;
D, E e F: Postoperative.
Figura 10 - A, B e C: Preoperative;
D, E e F: Postoperative.
The obtained results should be long-lasting, considering the changes proposed to
reduce postoperative pain and the risk of glandular ptosis and are advantageous
compared to other available options because the period of implementation of
these technical modifications is less than two years.
ACKNOWLEDGMENTS
To Renato Silva Freitas, Luciano Sampaio Busato, Marco Aurelio L. Gamborgi, and
André Auesvald, directors of the regional branch of the Brazilian Society of
Plastic Surgery (Sociedade Brasileira de Cirurgia Plástica-SBCP) of Paraná,
Brazil, for encouraging the improvement of the technical modifications presented
in this study.
To Milton Keita Maeda and José Garcia Junqueira Neto for the significant
contribution to the development of the surgical strategies.
COLLABORATIONS
ACJ
|
Completion of surgeries and/or experiments; writing the manuscript or
critical review of its contents.
|
ABDS
|
Writing the manuscript or critical review of its contents.
|
REFERENCES
1. Daniel MJB. Inclusão de Prótese de Mama em Duplo Espaço - Prêmio
Georges Arié 2004. Rev Soc Bras Cir Plást. 2005;20(2):82-7.
2. Bruschi S, Bochiotti MA, Ruka E, Fraccalvieri M. "Slip Sliding"
technique. A new method to perform mastopexy-augmentation. Eur J Plast Surg.
2015;38(2):117-22. DOI: http://dx.doi.org/10.1007/s00238-014-1027-4
3. Khan UD. Muscle-spliting, subglandular, and partial submuscular
augmentation mamoplasties: a 12-year retrospective analysis of 2026 primary
cases. Aesthetic Plast Surg. 2013;37(2):290-302. DOI: http://dx.doi.org/10.1007/s00266-012-0026-8
4. Khan UD. Augmentation mastopexy in muscle-spliting biplane: outcome
of first 44 consecutive cases of mastopexy in a new pocket. Aesthetic Plast
Surg. 2010;34(3):313-21. DOI: http://dx.doi.org/10.1007/s00266-009-9434-9
5. Khan UD. Multiplane technique for simultaneous submuscular breast
augmentation and internal glandulopexy using inframammary crease incision in
selected patients with early ptosis. Eur J Plast Surg. 2011;34(5):337-43. DOI:
http://dx.doi.org/10.1007/s00238-010-0521-6
6. Sanchéz J, Carvalho AC, Erazo P. Mastopexia com prótese: técnica em
"D" espelhado. Rev Bras Cir Plást. 2008;23(3):200-6.
7. Soares AB, Franco FF, Rosim ET, Renó BA, Hachmann JOPA, Guidi MC, et
al. Mastopexia com uso de implantes associados a retalho de músculo peitoral
maior: técnica utilizada na Disciplina de Cirurgia Plástica da Unicamp. Rev Bras
Cir Plást. 2011;26(4):659-63. DOI: http://dx.doi.org/10.1590/S1983-51752011000400021
8. Daher JC, Amaral JDLG, Pedroso DB, Cintra Júnior R, Borgatto MS.
Mastopexia associada a implante de silicone submuscular ou subglandular:
sistematização das escolhas e dificuldades. Rev Bras Cir Plást.
2012;27(2):294-300. DOI: http://dx.doi.org/10.1590/S1983-51752012000200021
9. Carramaschi FR, Tanaka MP. Mastopexia Associada à Inclusão de
Prótese Mamária. Rev Bras Cir Plást. 2003;18(1):26-36.
10. Alfaro HMO, Cunha GSR, Vasconcelos FRP, Cosac O, Rosset EGG, Lima
DM. Avaliação da ptose pós-operatória em pacientes ex-obesas e não-obesas
submetidas a mastopexia com implantes. Rev Bras Cir Plást. 2012;27(3 Suppl.
1):80.
11. Wada A, Millan LS, Gallafrio ST, Gemperli R, Ferreira MC. Tratamento
da ptose mamária e hipomastia utilizando técnica de mamoplastia com pedículo
súpero-medial e implante mamário. Rev Bras Cir Plást. 2012;27(4):576-83. DOI:
http://dx.doi.org/10.1590/S1983-51752012000400018
12. Spear S. Augmentation/Mastopexy: "Surgeon, Beware". Plast Reconstr
Surg. 2003;112(3):905-6. PMID: 12960875 DOI: http://dx.doi.org/10.1097/01.PRS.0000072257.66189.3E
1. Universidade Estadual de Londrina, Londrina,
PR, Brazil.
2. Universidade Federal do Paraná, Curitiba, PR,
Brazil.
Corresponding author: Antonio Chiquetti Junior, Rua Paes Leme,
1264, sala 601 - Jardim das Américas, Londrina, PR, Brazil. Zip Code 86010-610.
E-mail: chiqueti@sercomtel.com.br
Article received: December 15, 2017.
Article accepted: June 22, 2018.
Conflicts of interest: none.