INTRODUCTION
Combined mastopexy with implant placement would appear to be simple, but is in
fact an architecturally challenging intervention, with technical difficulties,
risks, and non-durable results1.
There has been no consensus regarding ideal technique1-3, with
reported postsurgical revision rates reaching 54%4-6.
The surgery has been performed in patients with inverted T mastopexy with
prostheses who develop ptosis relapse (grade III and IV) with prosthesis
displacement. We present a variation of the mirror “D” technique7 with long-lasting results and a high
degree of patient satisfaction.
The changes described include the form of marking, positioning of the patient
during surgery, and surgical techniques. The mirror “D” technique consists of
combined resection of skin and breast parenchyma, use of a medial pedicle8, a new submuscular prosthesis9,10, and a vertical scar11.
OBJECTIVE
To provide lasting results and reduce the rate of recurrence of ptosis with
prosthesis displacement.
METHODS
Results obtained with the mirror “D” technique for secondary mastopexy with
replacement of prostheses were evaluated in 90 female patients aged 30-60 years
old, with no exclusion by race, between July 2013 and July 2015 and living in
the city of São Paulo, Vale do Paraíba and the north coast. Surgery was
performed by the author at the Hospital Antoninho da Rocha Marmo in São José dos
Campos, SP, with the approval of the Ethics Committee of the hospital and with
signed informed consent, according to the principles of the Declaration of
Helsinki (001/ADM/HARM/2018).
Patients had undergone inverted T mastopexy with subglandular prostheses and
complained of grade III and IV ptosis relapse with prosthesis displacement, with
or without capsular contracture and/or unsightly scarring. The patients were
evaluated weekly during the first month, then monthly for 6 months, then every 3
months for 2 years following surgery.
RESULTS
Marking
Marking is performed in supine position with arms next to the trunk (Figure 1); this position accentuates the
mammary groove up to 1 cm more compared with marking in upright
position.
Figura 1 - Horizontal marking with arms next to the body.
Figura 1 - Horizontal marking with arms next to the body.
When properly positioned, a midline incision is marked from the sternal notch
to the umbilicus.
The groove formed naturally by the positioning of the breasts in decubitus
position is marked.
According to the position naturally adopted by the breasts, point A is marked
9 cm from the midline and 10 cm from the inframammary groove.
According to the groove naturally formed in decubitus position, point B is
marked at the level of the groove, 10 cm from the midline. Point C is marked
6 cm from the inframammary groove by following the junction line from point
A to point B. Using a bidigital block maneuver, point D is marked according
to the maximum extent of skin resection.
>Closure in mirror “D” technique is performed by the linear apposition of
points A and B and an arc extended laterally from point A to point B through
D, including the areola superiorly, according to the limits of point D for
inferior continuation of the arc. The junction of points C and D at the end
of surgery will coincide with the location of the lower edge of the new
position of the areola and beginning of the vertical scar. This is found
approximately 6 cm from the groove marked at the beginning, while point B
guides the end of the vertical scar.
Technique
Schwartzman Maneuver: Surgery begins with marking of the
areola with a 4 cm areolotome, followed by decortication of skin
over the tissue that gives rise to the medial pedicle flap;
Preparation of the medial flap: The medial flap is
marked with a 5-cm base, measuring at least 1 cm around the areola.
The tissue is removed by maintaining a thickness of at least 2 cm
from the lateral edge to the base of the flap8.
Preparation of the submuscular pocket: Marking is
performed to the level of subcutaneous tissue. Inferior periareolar
mammotomy is performed to remove the prosthesis. A new submuscular
inframammary pocket is created at the level of point B (Figure 2). The anatomical limits
of the submuscular pocket are: clavicle superiorly at 2 cm from the
medial line, not exceeding the anterior axillary line laterally, and
inferiorly up to the mammary groove, partially releasing the tendon
insertion in the inferior medial direction.
Figura 2 - Preparation of the submuscular pocket.
Figura 2 - Preparation of the submuscular pocket.
Placement of the prosthesis: The mammary parenchyma
underlying the marking protects the muscle to avoid disruption
during placement of prostheses. We use textured, high-profile, round
silicone implants, with volumes varying from 225 to 400 mL (Figure 3).
Figura 3 - Placement of the prosthesis.
Figura 3 - Placement of the prosthesis.
Resection for
symmetrization: Pulling the flap superiorly, a line
is drawn parallel to the midline, coinciding with the A-B line; an
incision is made perpendicular to the muscle (Figure 4). The lateral portion of the breast is
freed in the lateral direction, on the projection of a D arc. Once
the lateral portion is released, the flap is pulled along a vector
directed toward the notch (superomedially), followed by resection of
tissue that exceeds the projection of the incision in AB (Figure 5 and 6). After resection of the
parenchyma, the lateral muscular support of the prosthesis becomes
apparent, preventing communication with the previous subglandular
pocket; severe atrophy of the tissues in these cases is also evident
(Figure 7).
Figura 4 - Medial resection of the parenchyma.
Figura 4 - Medial resection of the parenchyma.
Figura 5 - Lateral resection of the parenchyma.
Figura 5 - Lateral resection of the parenchyma.
Figura 6 - Resection of skin and underlying parenchyma for
symmetrization.
Figura 6 - Resection of skin and underlying parenchyma for
symmetrization.
Figura 7 - Final resection of the parenchyma.
Figura 7 - Final resection of the parenchyma.
Capsulotomy or capsulectomy: In grade I and II capsular
contracture, capsulotomy is performed (Figure 8) with radiating incisions until the
mammary parenchyma is reached. Capsulectomy is used in grades III
and IV contracture.
Sutures: Closure of muscle is performed with nylon 2.0,
and mammary parenchyma is sutured with inferomedial traction on the
lateral parenchyma for medialization, thus approaching the medial
and lateral pillars with inverted nylon 2.0 sutures. Sutures are
placed to join pillars and muscle at each point (Figure 9). Suturing is performed
in planes and the final closure of the skin is performed with
inverted colorless nylon 4.0.
Figure 9 - Suture (closure in planes).
Figure 9 - Suture (closure in planes).
Marking of Areola: The junction of points C and D (Figure 10) coincides with the
location of the bottom edge of the new position of the areola and
beginning of the vertical scar, and is found approximately 6 cm from
the groove marked in the beginning, while point B guides the end of
the vertical scar.
Figura 10 - Marking of areola.
Figura 10 - Marking of areola.
Portovac drain is placed: For drainage of the
subglandular pocket.
Dressing: Is performed with Micropore tape crisscrossing
directly on the scar, and is maintained for 10 days (Figure 11).
Figura 11 - Final closure of the skin and placement of Micropore
dressing.
Figura 11 - Final closure of the skin and placement of Micropore
dressing.
RESULTS
No surgical revision was required in any of the cases. There was no postsurgical
infection or necrosis of the nipple-areolar complex or scar (Figures 12 to 20).
Figure 12 - 3 weeks postoperative scar.
Figure 12 - 3 weeks postoperative scar.
Figura 13 - Preoperative aspect.
Figura 13 - Preoperative aspect.
Figure 14 - 2 years postoperative aspect.
Figure 14 - 2 years postoperative aspect.
Figura 15 - Preoperative aspect.
Figura 15 - Preoperative aspect.
Figure 16 - 2 years postoperative aspect.
Figure 16 - 2 years postoperative aspect.
Figura 17 - Preoperative aspect.
Figura 17 - Preoperative aspect.
Figure 18 - 6 months postoperative aspect.
Figure 18 - 6 months postoperative aspect.
Figura 19 - Preoperative aspect.
Figura 19 - Preoperative aspect.
Figure 20 - 6 months postoperative aspect.
Figure 20 - 6 months postoperative aspect.
The average resection of the parenchyma measured 80 g, ranging from 25 g to 350 g
(Figure 21). Resection of different
volumes was performed in 98% of cases, with an average difference between
breasts of 50 g, ranging from 20 to 200 g.
Figura 21 - Complications.
Figura 21 - Complications.
The prostheses removed in 80 patients (88.8%) were textured, and were
polyurethane covered in 10 patients (11.1%); volumes ranged between 200 and 460
mL (Figure 22).
Figura 22 - Glandular amputation.
Figura 22 - Glandular amputation.
The average new standard commercial prosthesis volume was 300 mL, ranging between
225 and 400 mL; prostheses were textured and round, with high profile (Figure 23).
Figura 23 - Types of prostheses removed.
Figura 23 - Types of prostheses removed.
The average final breast volume increase (mean of breast implant volume
subtracted from mean dry volume) was 250 g (textured silicone, high profile,
round, 200 mL = 200 g). The length of the vertical scar was stable with time,
measuring 6.0 cm in the immediate postoperative period and averaging 6.5 cm
after 2 years.
Four (4.4%) cases of partial epidermolysis of the nipple-areolar complex were
successfully treated with conservative measures (dressing with alginate
hydrogel) (Figure 24).
Patients who underwent the mirror “D” technique rated their results at two
different time points using predetermined criteria (Tables 1 and 2).
Table 1 - Degree of satisfaction in 90 patients.
| After 6 months |
Poor |
Fair |
Good |
Excellent |
Total |
| Quality of scar |
__ |
__ |
6 |
6.6% |
18 |
20% |
66 |
73.3% |
90-100% |
| Aesthetic format |
__ |
__ |
3 |
3.3% |
22 |
24.4% |
65 |
72.2% |
90-100% |
| Symmetry |
__ |
__ |
4 |
4.4% |
24 |
26.6% |
62 |
68.8% |
90-100% |
| Total |
Table 1 - Degree of satisfaction in 90 patients.
Table 2 - Durability of results in 90 patients.
| After 24 months |
Poor |
Fair |
Good |
Excellent |
Total |
| Quality of scar |
__ |
__ |
2 |
2.2% |
25 |
27.7% |
63 |
70% |
90-100% |
| Aesthetic format |
__ |
__ |
1 |
1.1% |
33 |
36.6% |
56 |
62.2% |
90-100% |
| Symmetry |
__ |
__ |
4 |
4.4% |
34 |
37.7% |
52 |
57.7% |
90-100% |
| Total |
Table 2 - Durability of results in 90 patients.
Figura 24 - Implants used.
Figura 24 - Implants used.
DISCUSSION
This variation of the mirror “D” technique was used in 90 patients, with a high
degree of satisfaction.
The mirror “D” technique uses specific markings with the patient in dorsal
decubitus and arms next to the trunk. This position accentuates the mammary
groove up to 1 cm more compared with marking in upright position, resulting in a
more suitable format and natural final result, while facilitating placement of
the prosthesis in the submuscular plane.
In this position, the breasts naturally assume symmetric spatial adjustment that
is easily visualized in the positioning of the nipple-areola complex (NAC). This
cancels the asymmetry induced by gravity that is seen in upright position,
resulting in naturally symmetrical breasts in the postoperative period9,12,13.
These patients present with severe tissue atrophy14-16 (skin,
parenchyma, muscle), requiring small changes in the preparation of the
submuscular pocket that now includes an inframammary opening (previously at the
level of the second costal arch in the midclavicular line), in addition to
preservation of the parenchyma (resection prior to placement of the prosthesis);
we avoid any communication with the old pocket, providing improved lateral
support of the prosthesis, and thus, avoiding lateralization.
After resection and closure of the parenchyma, the mirror “D” marking technique
along with the submuscular breast prosthesis provide symmetrical, medialized
breasts without tension on the NAC, and with parallel vertical scars (with a
difference of 1 cm between point A and B); the results have a high rate of
patient satisfaction.
CONCLUSION
The mirror “D” technique is a good option in secondary mastopexy, resulting in
correction despite the increased complexity of the desired results caused by
severe atrophy of tissues in these patients4,7,15 as a result
of previous surgery. The benefits include symmetrical breasts, parallel vertical
scars, decreased tension on the NAC, lasting results, and a high degree of
patient satisfaction.
COLLABORATIONS
|
JCSL
|
Completion of surgeries and/or experiments; writing the manuscript or
critical review of its contents.
|
|
PE
|
Analysis and/or interpretation of data.
|
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1. Sociedade Brasileira de Cirurgia Plástica, São
Paulo, SP, Brazil.
2. Clínica Juan Sánchez, São José dos Campos, SP,
Brazil.
3. Universidade Federal de São Paulo, Escola
Paulista de Medicina, São José dos Campos, SP, Brazil.
4. Clínica Dra. Patrícia Erazo, São Paulo, SP,
Brazil.
5. Universidade Santa Cecília, São Paulo, SP,
Brazil.
Corresponding author: Juan Carlos Sánchez
López, Rua Santa Clara, 1035 - Vila Icaraí - São José dos Campos, SP,
Brazil. Zip Code 12243-630. E-mail:
comercial@drjuan.com.br
Article received: August 25, 2017.
Article accepted: September 5, 2018.
Conflicts of interest: none.
