Mastopexy with the splitting of the upper pectoral muscle and inferior muscle flap
Mastopexia com splitting de músculo peitoral superior e cinta muscular inferior

INTRODUCTION

Mastopexies are among the most performed aesthetic procedures globally but still have a high patient dissatisfaction rate, with high rates of secondary surgeries for review (8-20%)^1,2. The difficulties associated with this procedure derive from the antagonistic principle that the two techniques involved in it exert. The increase, due to tissue expansion, while mastopexy involves remodeling with excision of parenchyma and skin³.

Several techniques have been described in consideration of those above and the search for improvement and a lower complication rate. Type of incision, dissection plan, envelope model are some of the variables in which they are sought as an alternative^4-9.

Kahn described a technique with biplanar dissection of the pectoralis major muscle, creating a superior envelope for prosthesis inclusion in this space. Some of this modality’s advantages are the transition and smoother contours and more accelerated postoperative recovery¹⁰.

In our clinic, located in Ibitinga, in São Paulo’s interior, we chose to perform this technique in association with the tactics described by Milton Jaime Daniel, in which the lower pole is fixed and covered through a lower flap of the pectoralis major muscle¹¹ (Figure 1). A natural aspect is achieved through this combination in the thoraco-mammary transition, with soft upper pole and maintenance of the breasts’ position and projection.

Figure 1 - Split in the upper region and lower pectoralis muscle brace major.

Figure 1 - Split in the upper region and lower pectoralis muscle brace major.

OBJECTIVES

Describe the surgical technique and evaluate the results of augmentation mastopexies performed in the author’s private clinic from January 2017 to May 2019.

METHODS

According to Regnault’s Classification, a retrospective study was conducted of patients with grade II or III mammary ptosis in 1976¹², operated from January 2017 to May 2019, at the Dr. Jerome Clinic analysis of medical records. In the preoperative examination, most patients had flaccid skin. According to the technique described below, all of them were submitted to mastopexy with breast implants and the association of the lower support flap of the pectoralis major muscle with a superior split of the same.

This study was conducted according to the Declaration of Helsinki for human studies.

Surgical description

Skin marking

With the patient in an orthostatic position, the thorax’s midline, the breast meridian and the inframammary groove are defined. The upper edge of the areolas is marked exactly as described by Pitanguy in 1962¹³, projection of the inframammary groove in the breast meridian, point A. Then points B and C are determined by digital clamping maneuver, and point D is located in the previously marked breast groove (Figure 2).

Figure 2 - From preoperative marking to incision, dissection and preparation of the upper and lower flaps, in addition to the inclusion of implants.

Figure 2 - From preoperative marking to incision, dissection and preparation of the upper and lower flaps, in addition to the inclusion of implants.

Anesthesia and surgical technique

General anesthesia and infiltration in the breasts with 1% xylocaine solution and 1:200,000 adrenaline are used.

With the patient positioned in the supine position and a slight elevation of the back (30 degrees), the areolar incision is made with the Schwartzman maneuver, crossing the region from point A to points B and C. It is made resection in the larger or smaller keel, depending on breast size and preoperative planning, until reaching the pectoralis major muscle’s aponeurosis, preserving the lateral and medial pillars using the electric scalpel.

The upper implant pocket’s preparation is performed through the subfascial plane’s dissection until the breast’s areolar part. From this location, the pectoralis major muscle is split, reaching a size close to that of the implant base. The lower pocket is performed through an incision in the pectoralis major muscle, in the sense of its fibers, 3 cm from its inferior insertion, towards the sternal and axillary region (Figure 2).

Rigorous hemostasis and positioning of the prosthesis are performed, where the upper part will be in the subfascial plane and the lower part in the submuscular plane. The starting point of breast assembly is performed by joining the lateral abutments with the pectoralis major muscle. Subsequent stitches are only in breast tissue. Both were using Vicryl 2-0.

Partial release of the areolar dermis

Cutaneous excess is assessed using digital clamping and tailor tacking using 2-0 nylon. With these maneuvers, a greater ascension of the nipple-areola complex (NAC) is achieved (Figure 2). With the evaluation of the shape and symmetry of the breasts, cutaneous excesses are removed. To prevent the breast scar from becoming too long, lateral and medial compensations are performed, ending with an inverted T scar. The nipple-areola complex is repositioned, and it must be located at the apex of the cone and with an approximate distance of 6cm from the new mammary fold. The dermis suture is made with simple inverted stitches and on the skin with intradermal stitches using 4-0 monocryl thread. Drains are not used, and hospital discharge usually occurs 8 hours after the surgery, using surgical mesh for 30 days.

The dermis suture is done with simple inverted stitches and on the skin with intradermal stitches using 4-0 monocryl thread.

No drains are used, and hospital discharge usually occurs after 8 hours of completing the surgery, using surgical mesh for 30 days.

RESULTS

A total of 192 patients were submitted to mastopexy with an upper split implant and lower pectoralis muscle fixation (double space) (Table 1). The patients had a mean age of 43 years, ranging from 19 to 68 years. Bmi ranged from 16-38Kg/m², with an average value of 23Kg/m². The average time of the procedure was 150 minutes. The volume of the implants ranged from 125 to 625ml, with a mean value of 265ml.

Table 1 - Characteristics of patients and complications.

Seven patients presented seroma in the postoperative period (3.6%), and in three (1.5%), the condition persisted for six months even after clinical treatment with compressive mesh, oral corticosteroids and antibiotic therapy. Thus, we opted for the bilateral removal of implants. Two patients have already undergone a new procedure with prostheses’ inclusion, with the same technique described here, the same brand and volume as the previous ones.

There were unaesthetic scars (2.6%) in five cases, two in areolar contour and three in the horizontal part, which required a new approach under local anesthesia and sedation, 12 months after the first surgery. Three patients presented small sufferings of the nipple-areola complex (1.5%), with epitheliosis, which was already readdressed, with scar revision. Breast asymmetries were observed in 5 patients (2.6%). Three underwent a surgical procedure to release the lower part of the breast’s muscle that presented the prosthesis in the highest position. One episode of hematoma was described (0.5%) but without clinical repercussion and need for approach. There were no cases of infection, contracture or skin necrosis.

Postoperative follow-up ranged from 1 to 13 months, and in all cases, it was noticed the maintenance of the projection in the upper pole of the breast, with satisfaction with the aesthetic result, with no recurrence of the breast ptosis (Figures 3 to 6).

Figure 3 - A, B and C: Preoperative; D, E and F: Postoperative.

Figure 3 - A, B and C: Preoperative; D, E and F: Postoperative.

Figure 4 - Pre- and postoperative.

Figure 4 - Pre- and postoperative.

Figure 5 - Pre- and postoperative.

Figure 5 - Pre- and postoperative.

Figure 6 - Pre- and postoperative.

Figure 6 - Pre- and postoperative.

DISCUSSION

Since the original description by Gonzales-Ulloain 1960¹⁴ and Regnaultin1966¹⁵, breast augmentation combined with mastopexy remains a challenging and controversial procedure in plastic surgery, not only for its results but also for its potential complications^16,17.

The smooth transition in the breast’s upper pole and natural appearance made us choose to make a sandwich of the pectoralis major muscle in its part above the areola, as recommended by Khan in 2007¹⁰. This technique provides better coverage of the upper and lateral pole¹⁸; another advantage is that there is no dissection of the muscle fibers of its insertion, preserving function and decreasing the chance of lateralization, displacements of the prosthesis and deformities of animation¹⁹.

In this superior plane, the complications related to the inclusion of the prosthesis in the total submuscular plane are avoided, such as: displacements, deformities, asymmetries and rupture; and associated with subglandulars as visible, palpable and rippling prostheses¹⁸.

One of the common concerns among the authors is to avoid mammary ptosis. Daniel’s pectoral muscle flap in 1994¹¹provides muscle support in the lower pole of the breast, preventing the implant’s ptosis and its displacement to the armpit, maintaining the upper pole of the projected breast. The prosthesis is placed in double space, with its lower pole submuscular and the rest in the subfascial space. In addition to decreasing the chance of ptosis, this lower flap offers additional coverage and protection, reducing the chance of extrusion and exposure of implants²⁰.

We opted for silicone-polyurethane based on studies that suggest that its velcro sticks to the breast tissues with less displacement of the same within the manufactured pocket and lower rates of capsular contracture²¹.

The total number of complications presented, 10.9% of the cases, is lower than that reported in the literature and the number of secondary surgeries performed - 3.15%. Asymmetry and seroma were the main causes of new approaches. The first, mainly related to the lower pedicle preparation, occurred in 2.9% of the patients, but 80% of them were reoperated. The surgical procedure performed was to enlarge the musculature release since the complaint was the highest prosthesis concerning the contralateral breast. Seroma occurred early in 1.5% of patients and remained despite clinical therapy. Secondary mastopexy was chosen in 100% of them, using the same surgical technique. The other complications, such as unaesthetic scarring and epidermolysis of NAC, were managed with small procedures performed under local anesthesia¹⁷.

The postoperative evaluations show the effectiveness of this technique, with minimal ptosis rate, one of the most cited complications in mastopexies. There were no cases of flattening of the mammary cone, which were more related to periareolar incisions⁴. The patients were satisfied with the surgical outcome.

The learning curve did not show a hindrance, with an average time of 150 minutes. The greatest difficulty at the beginning of this technique was dissection for bipartition of the pectoralis major muscle in its upper part.

The limitations present in this study are the retrospective character and be based on a single institution and a single surgeon’s experience.

CONCLUSION

The mastopexy with double-space implantation, using a flap of the pectoralis major muscle in its lower third and the bipartition of the pectoralis muscle in the upper portion (split pectoralis major muscle), proved to be a reproducible and effective method in the prevention of post-breast ptosis operation, maintaining the projection of the upper pole of the breast, in addition to providing greater coverage of the implant and reducing its exposure risk.