Augmentation-mastopexy can be undertaken as a single-stage procedure, but a two-stage approach is generally thought to be more predictable. Many patients with combined breast volume deficiency and skin excess can be managed successfully with either augmentation or mastopexy alone. Augmentation-mastopexy is only required for patients who require additional breast volume and have skin excess that cannot be compensated for by augmentation or mastopexy alone. It may be more cost effective in the short term to undertake augmentation- mastopexy in a single stage, but the long-term costs as a result of high revision rates can offset this. It is not necessarily safer to undertake a single- rather than a two-stage procedure, although the number of general anesthetic procedures will be reduced. Augmentation-mastopexy techniques are associated with high revision rates of up to one in five, although this may be reduced to less than 1 in 10 by staging the procedure. Augmentation-mastopexy is one of the most common causes for malpractice claims. It represents a real challenge for the surgeon who has to balance the two opposing factors, namely, skin excess and volume deficiency, with augmentation and mastopexy techniques, essentially working against one another. The order of augmentation-mastopexy will be guided by the clinical situation and either stage may be undertaken first. In general, if the primary goal is ptosis correction, then the mastopexy should be performed first. If the primary goal is to improve projection or upper pole fullness, then the implant should be placed first.1
Ptosis derives from the Greek, meaning “falling.” The term is used to describe the descent of the breast parenchyma that traditionally occurs with advancing age and various physiologic changes. Ptosis is essentially the main indication for mastopexy, and ptosis combined with more significant volume deficiency represents an indication for augmentation-mastopexy. Regnault classified breast ptosis in 19761: Grade I: Mild ptosis; the NAC lies at the level of the IMF. Grade II: Moderate ptosis; the NAC lies below the IMF but remains above the most dependent part of the breast parenchyma. Grade III: Severe ptosis; the NAC lies well below the IMF and is the most dependent part of the breast on the inferior aspect. Pseudoptosis is also called glandular ptosis and is present when the NAC is above or at the level of the IMF, but the bulk of the breast parenchyma has descended below the level of the fold. In a normal breast, the NAC and the majority of breast tissue should lie above the IMF.
Lee et al1 have developed an algorithm to guide selection of augmentation-mastopexy procedures (Fig. 53.1). The following three key measurements need to be considered: 1. NAC anterior skin stretch 2. NAC-to-IMF vertical skin stretch 3. Vertical skin and parenchymal excess Skin stretch refers to nipple excursion on light anterior traction and provides information on the laxity in the anteroposterior (AP) plane. Nipple-to-IMF distance on maximal stretch provides information on the laxity in the vertical dimension. Vertical excess is the anticipated excess skin/parenchyma to be resected. A two-stage augmentation-mastopexy procedure is advocated for this patient because of her large skin excess. Furthermore, she is likely to need an inverted-T or Wise-pattern approach to adequately deal with this excess. Fig. 53.1 Algorithm for selecting mastopexy, one-stage augmentation-mastopexy, or two-stage mastopexy. (N-IMF, Nipple-to-IMF distance; SS, skin stretch; VE, vertical excess.) (Adapted from Lee MR, Unger JG, Adams WP. The tissue triad: a process approach to augmentation mastopexy. Plast Reconstr Surg 134(2):215–225, 2014.) Hypomastia/Ptosis VE >6 cm VE <6 cm SS >4 cm or N-IMF >10 cm SS <4 cm or N-IMF <10 cm Breast Two-stage mastopexy One-stage mastopexy
The best indication for a single-stage augmentation-mastopexy is the patient in whom augmentation alone will not quite correct the deformity and yet the vertical skin excess remains modest. To place figures on this, patients with anterior skin stretch of >4 cm or NAC-to-IMF distance on stretch of >10 cm typically benefit from both augmentation and mastopexy. Once this is established, assessment of the vertical skin excess is made. To do this, the required NAC-to-IMF distance is calculated based on the new planned NAC position and the implant size selected. The difference between the vertical skin present and what is required is the vertical skin excess. In patients with mild/modest vertical excess, a single-stage approach should work well. Such patients typically have less than 6 cm of vertical excess.1 Other contraindications to single-stage augmentation-mastopexy are a tuberous breast deformity (which is usually challenging to treat and has high variability of breast shape and size characteristics), significant side- to-side asymmetry, and in patients where a subglandular implant is preferred. In patients with poorly shaped breasts and asymmetry, performing mastopexy first can be very helpful as this allows a fairly aggressive approach to mastopexy without the need to worry about the effects of the implant on vascularity and tissue healing. It allows shape, volume, and NAC alterations to be made. In some cases, patients will be sufficiently pleased with the outcome that they will choose to avoid the second augmentation stage. Beyond this tissue triad approach as described by Lee et al,1 consideration needs to be given to the patient’s aims. If a patient has a ptotic breast, then mastopexy will help. However, if they are unhappy about the upper pole volume, then it is likely they will need to consider augmentation to address it. Therefore, if both elements are important to them, augmentation-mastopexy may be indicated. The presence of less than 2 cm of breast tissue below the IMF suggests minimal ptosis or pseudoptosis. In this case, where the breasts are underfilled, the patient will probably do well without mastopexy and by having the empty soft tissue envelope filled with a suitable size implant.
Selection of a skin pattern for an augmentation-mastopexy depends on the anticipated amount of skin excess after augmentation. The guidelines for selection are as follows: A periareolar pattern is recommended for patients with minimal ptosis. • The nipple is less than 2 cm below the IMF. • The NAC is at or above the breast border (and does not point inferiorly). • No more than 3 or 4 cm of associated breast ptosis is present. A vertical pattern is recommended for patients with moderate ptosis. • The nipple is greater than 2 cm below the IMF. • Horizontal skin excess and minimal vertical skin excess are present. A Wise pattern is recommended for patients with severe ptosis. • The nipple is greater than 2 cm below the IMF. • Both vertical and horizontal skin excess are present. As this patient has horizontal skin excess without vertical skin excess in the presence of moderate ptosis, she could be managed with a vertical scar approach, according to these guidelines. The use of a short T-scar can be useful when undertaking a vertical scar technique if it is found that there remains an excess of skin which is difficult to absorb in the vertical scar alone.1–3
Often, there has been debate about the order of performing augmentation-mastopexy as well as whether to do it as a single- or two-stage procedure. It is wise to plan things defensively such that you have not committed to any step until you are sure about this and that it is needed. For this reason, it is best to place the implant first during a single-stage augmentation-mastopexy before committing to the final skin resection. This will avoid over-resection of skin and having to compromise on implant volume or incur overly tight wound closure. All planned markings should be made preoperatively with the patient upright. This allows the correct NAC position to be determined. However, there may be some alterations required on table which can be assessed with tailor tacking once the implant is in place. It is also important to obtain the best outcome at each stage for the patient who will have to live with things following surgery and this is particularly relevant when a two-stage procedure is selected. In general, it is best to perform the mastopexy first in any staged procedure and this is particularly true where asymmetry correction is planned. A vertical skin excess of more than 6 cm is also an indication for a two-stage procedure as is a notch-to-nipple distance greater than 30 cm. Performing the mastopexy first in these cases allows the best shape and symmetry to be obtained and facilitates the best interim outcome for the patient. Once the shape has been optimized, if further volume is still desired, it is straightforward to subsequently augment the reshaped breasts in the second procedure.1–3
Two large series have published reoperation rates of 15–20% for single-stage augmentation-mastopexy procedures. Therefore, it is prudent to counsel patients to expect this level of risk from a conservative standpoint. Data from Lee et al show lower revision rates than this with similarly low rates of approximately 7% for either the single-stage or the two-stage procedure. The authors applied their algorithm to determine the appropriate augmentation- mastopexy procedure for each patient. This highlights that careful patient selection and preoperative planning can help reduce risk and optimize outcomes in augmentation-mastopexy, but it doesn’t change the fact that a one-stage procedure can be challenging to get just right.1–3