INTRODUCTION
The inclusion of breast implants is increasingly common in mastopexies, with a
wide variety of techniques described for positioning of the implant and breast
modelling, to address flaccidity and ptosis.
An accurate preoperative assessment and the choice of the best augmentation
mastopexy technique are crucial for good results, with no universal technique
used to treat all types of breasts.
In 1960, Gonzales-Ulloa1 reported the use
of an alloplastic material with mastopexy for the first time. In 1969, Goulian
& Conway2 recommended the use of
silicone implants for a repeat surgery after a mastopexy for cases of hypomastia
associated with ptosis. The placement of the implant in the submuscular position
was initially described by Dempsey & Latham, in 19683.
Mastopexy with a breast implant has a high rate of dissatisfaction, which
necessitates reinterventions. However, many authors argue that it is still
better than submitting the patient to two surgical procedures: a mastopexy
followed by an implant surgery4,5.
A capsular contracture is the most frequent complication associated with
mastopexy and implants6,7,8, and may arise anywhere from a few months to a long period of time
after surgery, making the breast hard, sore, and deformed (HSD triad) in
variable degrees. The cause of capsular contracture is multifactorial 9,10 and is related to an inflammatory reaction caused by an increase
in factors such as subclinical infections and irritating factors, with increased
cell proliferation associated with the presence of myofibroblasts.
According to Camirand et al.11, muscle
contraction over the implant exerts a protective factor which leads to a
capsular contracture. In addition to the submuscular planes (total, partial with
muscle disinsertion in varying degrees, partial submuscular with dilatation, and
construction of a pocket which may be superomedial or inferolateral), a breast
implant can be placed in the supramuscular planes (subglandular or
subfascial).
There is a layer of loose areolar retromammary fat between the pectoral fascia
and the breast capsule (Giraldés ligament or breast suspender and its
extensions, Cooper›s suspensory ligaments) called the Chassaignac space,
constituting a plane of easy detachment because it is relatively avascular and
not very resistant12. The laxity of the
Chassaignac space may be responsible for the loss of breast support by promoting
its slide in relation to the thorax13.
In order to obtain more harmonious and long lasting results in augmentation
mastopexies, we developed an adaptable, reproducible and versatile technique of
implant coverage with the pectoralis major muscle, creating a new relation
between the breast, the implant, and the pectoralis major and minor muscles,
which can be used in cases of mastopexy or even in isolated augmentations.
OBJECTIVE
The objective of this study is to describe the double pocket technique for
augmentation mastopexies with submuscular implant and evaluate the preliminary
results of this technique.
METHODS
Sample
A retrospective analysis was done for all patients submitted to mastopexy
with submuscular implants with the double pocket from November 2009 to March
2012. A total of 80 female patients were operated by the author, with ages
ranging from 17 to 54 years, with a mean of 32 years.
All patients underwent a history and physical examination, and were informed
of the surgical plan, location and size of the scar, evolution and
postoperative care.
All patients received a printed copy, were guided, and signed an informed
consent form containing information on the influence of the individual
characteristics on the evolution and surgical outcome, the adequacy between
expectations and possibilities, and the possible need for surgical
replacement to complement the result in the future.
The choice of volume and shape of the breast implant was based on the
patient’s preferences during consultation on the placement of molds on the
breasts14.
Patients with uncompensated comorbidities, body mass index greater than 35
and smoking more than 5 cigarettes per day were excluded from the study.
Surgical Technique
The need for skin removal and repositioning of the nipple areola complex
(NAC) was evaluated with the patients in an orthostatic position to
determine and mark reference points.
Photographs were taken of the patients in standardized positions before and
after the surgery.
The patients were submitted to intravenous anesthesia with an intercostal or
an epidural block and remained in supine position during the surgery, while
an anesthesiologist continuously monitored the progress.
Antibiotic prophylaxis, asepsis, antisepsis, hemostasis, and minimal
manipulation of the implant were performed.
The technique can be used in a wide variety of clinical presentations; from
small breasts without sagging or tuberous breasts, to breasts with large
flaccidity and ptosis, as in patients after a massive weight loss.
The subglandular detachment was performed through an access route, which
varied from periareolar, vertical, or inframammary fold, with partial
removal of the Chassaignac space, and identification of the pectoralis major
fascia.
To gain access to the intermuscular plan (between the pectoralis major and
minor), a blunt dissection was performed in the direction of the fibers of
the pectoralis major, starting from the insertion of the muscle (rib edge)
toward its origin, dividing the muscle in two muscular flaps (one
superomedial and other inferolateral) (Figure 1) thus preserving the fibers, insertion, vascularization,
innervation, and function of the muscle.
Figure 1 - Approach via the inframammary fold with removal of the
Chassaignac space and dilatation of the muscle fibers, forming
two straps of the pectoralis major muscle. Dissection between
the pectoralis major and minor muscles to construct the
intermuscular implant pocket.
Figure 1 - Approach via the inframammary fold with removal of the
Chassaignac space and dilatation of the muscle fibers, forming
two straps of the pectoralis major muscle. Dissection between
the pectoralis major and minor muscles to construct the
intermuscular implant pocket.
The implant was placed between the two pockets formed between the muscular
fibers of the pectoralis major, remaining subglandular only in its anterior
portion (Figure 2).
Figure 2 - An intermuscular implant in a double pocket, formed by the
loops of the pectoralis major muscle, after its partition,
without detachment in the inframammary fold.
Figure 2 - An intermuscular implant in a double pocket, formed by the
loops of the pectoralis major muscle, after its partition,
without detachment in the inframammary fold.
With this technique, the implant was placed on top of the pectoralis minor,
covered in its inferolateral and superomedial portions by the pectoralis
major, and with the scar capsule formed later on the pectoralis minor,
providing stronger adherence to the thoracic wall. On each side the scar
capsule was limited by loops formed by the pectoralis major muscle and the
anterior portion adhered to the breast capsule. Thus, there was integration
between the thoracic wall, the pectoralis major and minor muscles, the
parenchyma and the breast implant, through the scar capsule (Figure 3a, 3b, 3c).
Figure 3 - A: Schematic drawing showing the relationship of
the scar capsule with the implant, between the pectoral major
and minor muscles, and the breast tissue; B:
Magnetic resonance image showing the positioning of the implant
between the pectoralis major, minor and the breast tissue;
C: Secondary breast image, showing the
preservation of muscle fibers in the peri-implant scar capsule.
Figure 3 - A: Schematic drawing showing the relationship of
the scar capsule with the implant, between the pectoral major
and minor muscles, and the breast tissue; B:
Magnetic resonance image showing the positioning of the implant
between the pectoralis major, minor and the breast tissue;
C: Secondary breast image, showing the
preservation of muscle fibers in the peri-implant scar capsule.
To avoid the possibility of cranial migration of the implant, a suture was
performed with 2.0 polyglycolic acid sutures, encompassing the recently
divulged edges of the pectoralis major and minor muscle, near the axilla,
creating a barrier against the rise of the implant (Figure 4).
Figure 4 - Implant in a double pocket with a suture between the edges of
the pectoralis major and pectoralis minor. Author’s personal
archive.
Figure 4 - Implant in a double pocket with a suture between the edges of
the pectoralis major and pectoralis minor. Author’s personal
archive.
After rigorous hemostasis and placement, the implant was partially covered by
the loops of the pectoralis major muscle (forming a superomedial pocket and
another inferolateral pocket), another suture with polyglycolic acid 2.0 was
performed to prevent the muscle from sliding to the sides of the implant,
and uncovering the implant, but avoiding closure of the pocket of the
pectoralis major.
In mastopexies, before the assembly of the breasts, the need for a breast
tissue flap is evaluated, which may vary between a superior pedicle
flap15, inferior flap16, bipediculated flap, or without flap
with advancement of the lateral pillars of the breast over the muscle. In
order to reduce skin tension, the breast is assembled with 3.0 polyglycolic
acid threads anchored in the mammary capsule, based on the ligament
mammoplasty technique17.
When necessary, the excess skin was resected corresponding to the prior
marks, and the NAC was repositioned. A suture with colorless mononylon 4.0
was performed in the subdermal plane and with poliglecaprone 4.0 in the
intradermal plane.
Postoperative care
The patients were discharged with a nonsteroidal anti-inflammatory drug
(Ketoprofen) and cephalosporin (Cefadroxil) for 8 days. The sutures were
covered by tape (Micropore®, 3M) after surgery, which was exchanged
every 7 days during the first month. Surgical brassieres were used for 45
days, and a compressive band was positioned in the upper pole of the breast
for 20 days which included rest, and prevented the abduction of limbs and
sports activities for 60 days.
RESULTS
Between November 2009 and April 2012, a total of 80 patients were operated, with
ages ranging from 17 to 54 years (mean = 33 years).
The volume of the implants (Silimed®,
Eurosilicone®, Perthese® and
SCI® brands, with textured surface and a high or super
high round format) ranged between 220 and 380 cc (mean = 260 cc).
A secondary mammoplasty with change of the implant plane was performed in 15
cases (18%). Surgery associated with mammoplasty was performed in in 38 cases
(25%). There were 16 cases (20%) of liposculpture and 22 cases (27%) of
lipoabdominoplasty.
There were no intraoperative complications. The hospitalization time was up to 30
hours.
The scars ranged from periareolar, periareolar and vertical, and vertical
periareolar and fold locations depending on the degree of sagging, ptosis and
size of the implant (Figures 5-9).
Figure 5 - 39-year-old patient, with 18 months postoperative aspect, who
underwent liposculpture and mastopexy with a submuscular implant of
200 mL in the right breast and 240 mL in the left breast in double
pocket, without a flap and resulting periareolar and vertical scar.
Figure 5 - 39-year-old patient, with 18 months postoperative aspect, who
underwent liposculpture and mastopexy with a submuscular implant of
200 mL in the right breast and 240 mL in the left breast in double
pocket, without a flap and resulting periareolar and vertical scar.
Figure 6 - 29-year-old patient, with 3 months postoperative aspect,
submitted to lipoabdominoplasty and mastopexy with submuscular
implant of 260 mL in double pocket, with the upper pedicle flap and
resulting periareolar, vertical and horizontal scar.
Figure 6 - 29-year-old patient, with 3 months postoperative aspect,
submitted to lipoabdominoplasty and mastopexy with submuscular
implant of 260 mL in double pocket, with the upper pedicle flap and
resulting periareolar, vertical and horizontal scar.
Figure 7 - 29-year-old patient, with 5 months postoperative aspect,
submitted to mastopexy with submuscular implant of 280 mL in double
pocket, with the upper pedicle flap and resulting periareolar and
vertical scar.
Figure 7 - 29-year-old patient, with 5 months postoperative aspect,
submitted to mastopexy with submuscular implant of 280 mL in double
pocket, with the upper pedicle flap and resulting periareolar and
vertical scar.
Figure 8 - 41-year-old patient, with 3 months postoperative aspect,
submitted to lipoabdominoplasty and mastopexy with a submuscular
implant of 280 mL in double pocket with inferior pedicle flap and
resulting periareolar, vertical and horizontal scar.
Figure 8 - 41-year-old patient, with 3 months postoperative aspect,
submitted to lipoabdominoplasty and mastopexy with a submuscular
implant of 280 mL in double pocket with inferior pedicle flap and
resulting periareolar, vertical and horizontal scar.
Figure 9 - 25-year-old patient, with 6 months postoperative aspect,
submitted to liposculpture with miniabdominoplasty and mastopexy
with submuscular implant of 300 mL in double pocket, with the upper
pedicle flap and resulting periareolar, vertical, and horizontal
scar.
Figure 9 - 25-year-old patient, with 6 months postoperative aspect,
submitted to liposculpture with miniabdominoplasty and mastopexy
with submuscular implant of 300 mL in double pocket, with the upper
pedicle flap and resulting periareolar, vertical, and horizontal
scar.
An ecchymosis developed on the unilateral side in 1 case (1.25%), with a hematoma
observed for more than 3 days. As it was small in volume on USG and without any
growth, it was treated without surgery.
No patient presented with infection or implant extrusion.
Capsular contracture was seen in 1 case (1.25%), with good response to
zafirlukast, USG, and manual lymphatic drainage18,19.
A late unilateral seroma, observed in 1 case after 60 days (1.25%), was confirmed
by USG and re-operated after 6 months, as it evolved with pseudoptosis and
asymmetry.
A superficial epitheliolysis of the skin at the junction of the vertical and
horizontal scar occurred in 2 cases (2.5%), which were treated with daily
dressings until healing.
A scar refinement was performed in 2 cases (2.5%): 1 case of an enlarged scar and
1 case of a hypertrophic scar.
In 3 cases (3.75%) a skin ellipse was withdrawn from the breast sulcus after 6
months, due to horizontal flaccidity. These patients had thin skin and stretch
marks.
Mobilization of the implant by contraction of the pectoral muscle was
spontaneously reported by 4 patients (5%), with no interference in their daily
activities, without requiring intervention (Figures 10A-B).
Figure 10 - A: Patient with contraction of the pectoralis major,
without elevation of the implant and with a cone shape of the
breast. A natural look with pectoral muscles relaxed, and with
elevated upper limbs; B: 45-year-old patient, with 18
months postoperative aspect, submitted to mastopexy with a
submuscular implant of 260 mL in double pocket, with the upper
pedicle flap and resulting periareolar, vertical and horizontal
scar.
Figure 10 - A: Patient with contraction of the pectoralis major,
without elevation of the implant and with a cone shape of the
breast. A natural look with pectoral muscles relaxed, and with
elevated upper limbs; B: 45-year-old patient, with 18
months postoperative aspect, submitted to mastopexy with a
submuscular implant of 260 mL in double pocket, with the upper
pedicle flap and resulting periareolar, vertical and horizontal
scar.
There was no complaint of paresthesia in the breast or NAC after 3 months.
The follow-up duration ranged from 3 months to 24 months.
DISCUSSION
Several techniques have been described in the literature regarding the
positioning of an implant. It may be placed in the subglandular position but to
provide greater coverage of the implant with better results, a subfascial
placement has been described. However, when positioning the implant in a
vertical position, an alteration in its format20 is observed which can cause the rippling seen on the breast
surface in cases of flaccid breasts or less breast tissue, thus justifying the
need for greater coverage and support of the implant (Figure 11).
Figure 11 - Round high profile implant placed on a 45 degree inclined
surface, revealing a change in the format with formation of ripples
in your upper region. Author’s personal archive.
Figure 11 - Round high profile implant placed on a 45 degree inclined
surface, revealing a change in the format with formation of ripples
in your upper region. Author’s personal archive.
The objective of this paper is not to compare the present technique with other
traditional ones. However, traditional submuscular techniques involve
disinsertion of the pectoralis from the ribcage which leaves the implant covered
by muscle only in its upper part, which may cause the implant to slip and make
the implant palpable in the inframammary fold7.
In the “envelope flap” technique21, the
author shows that, in order to position the implant in a submuscular position,
besides the disinsertion, it is necessary to weaken the pectoralis major to
avoid limiting the movement of the implant during contraction of the pectoralis
major.
In techniques in which the implant is completely covered by muscle, muscle
contraction causes a flattening with reduction of breast projection with a
possible displacement of the implant towards the axillary region 22,23.
In double space techniques, where the implant is partially submuscular24-28, a muscular contraction can cause compression of the
implant, change its shape and position, and project the breast in the medial lap
in the lateral muscle pocket technique; while lateralization of the NAC or
depression of the medial lap with lateralization of the implant may occur in the
upper muscular pocket technique.
However, in the technique presented here, the muscle loops cover the implant in
regions of greater fragility after breast augmentation surgery: inferolateral
and superomedial quadrants.
In the superomedial quadrant, the muscle flap covers a good portion of the
implant, and provides a more natural contour in the lap of the breast
(tear- drop), which avoids visualization of the contour of
the implant and rippling, and prevents symmastia by medially limiting the
pocket.
In the inferolateral quadrant, given a good coverage of the implant, the muscle
flap restricts the pocket laterally, preventing the implant from sliding towards
the thorax, in addition to providing an inferior support to the implant.
Due to the lack of muscle disinsertion and reduction of the fold in the described
technique, the implant is supported by the muscular fibers, preventing its
downward slip, with a double inframammary fold. Compression by the fibers of the
lateral muscular flap keeps the medial neck of the breast fuller and avoids
rippling.
In this technique, the area where the implant is not covered by muscle coincides
with the region where the breast parenchyma is thicker, the retroareolar region.
By lateralizing the muscle fibers and bypassing the force vector of the muscle
by contracting the pectoralis major, the implant is projected forwards rather
than upwards.
This allows for a higher cone-shaped breast, and avoids the rise of the implant.
Despite the fixation of the pectoralis major to the pectoralis minor muscle
superiorly and the approximation of the loops anteriorly to the implant, a slip
of the fibers or rupture of the fibers can occur, causing an asymmetry in the
positioning of the implant.
In cases where the breasts have little flaccidity with ptosis, and an
inframammary fold detachment can be constructed to fit the NAC, the breast has
low implantation, and one can palpate the implant in the fold and have a double
fold; for this reason, we did not lower the fold.
A muscle surrounding the implant can prevent the formation of seromas, infections
and capsular contractures, by promoting increased local blood circulation,
facilitating the absorption of liquids and massaging the scar capsule during
muscular contraction.
CONCLUSION
The technique described in this paper presented a low index of scar enlargement
or dehiscence, which can be attributed to the support of the implant by the
muscle and the placement of breasts in deep planes using the mammary capsule as
support, without skin tension.
By respecting the anatomy of the pectoralis muscle, this technique was shown to
be safe in preserving the insertion, innervation, and irrigation of the pectoral
muscles29, allowing the maintenance
of muscle function and the smaller detachment of the breast which allowed a
lesser extent of injury to the nourishing vessels of the breast.
Therefore, the submuscular double pocket technique provided an adequate coverage
and good support of the implant, retained the positioning of the inframammary
fold, avoided a deformity of the breast upon contraction of the
pectoralis, obtaining good results, with a low index of
reinterventions for different types of breasts.
Another study with a larger number of cases with a longer follow-up is currently
being carried out to confirm the preliminary results reported here.
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1. Clínica Debs, Porto Velho, RO,
Brazil.
2. Clínica Debs, Patrocínio, MG,
Brazil.
3. Clínica Rosique, Ribeirão Preto, SP,
Brazil.
Autor correspondente: Leandro Debs Procópio, Av.
Carlos Gomes, nº 2119 - São Cristóvão, Porto Velho, RO, Brazil, Zip Code
76804-037. E-mail: doutorleandro@bol.com.br
Article received: July 25, 2018.
Article accepted: April 21, 2019.
Conflicts of interest: none.
