Mastopexy introduction
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- AUGMENTATION MAMMOPLASTY
Mastopexy following Explantation goal of explantation is to remove the implant and capsule, if possible, without implant rupture Reasons for capsule removal: number of reports of palpable or mammographically detectable masses present in the breast following explantation when the capsule had been left presence of residual silicone particles within the capsule dissection of a subpectoral implant is more difficult than that of a subglandular (risk of pneumothorax) Postoperatively, the breast mound drops inferiorly producing a glandular or pseudoptosis. Options after explantation explantation alone implant exchange mastopexy with implant mastopexy alone. Rohrich Algorithm for mastopexy alone post explantation 
OTHER CONSIDERATIONS Parenchymal Transposition Flaps of lower pole breast tissue to the upper pole to attain fullness above. IMF is formed by attachment of the dermis to the underlying fascia. To re-position the crease, these attachments need to be divided and re-created with sutures. Skin Patients with inelastic, striated skin receive minimal lasting support from skin tightening. The skin below the NAC bears the brunt of the force and heals slowly, especially if the patient is a smoker. Lateral folds will become more prominent post-op and therefore must be dealt with as part of the plan. COMPLICATIONS EARLY
1. Haematoma: Uncommon. If large - return to theatre. 2. Infection: Uncommon - associated with poor vascularity - smokers etc. 3. NAC Necrosis: Uncommon - only occasionally seen in heavy smokers. LATE
1. Asymmetry: May need revision. 2. Recurrent Ptosis The most common problem following mastopexy. Often associated with weight loss. A loss of 5kg will significantly be reflected in breast shape. It is said to occur most predictably with “skin only” mastopexy where the lower pole ptotic breast tissue is not excised at the initial procedure. 3. Upper pole flattening: Should be noted in pre-op assessment. Treated with appropriate sized implants. 4. Implant Related Problems 5. Scar problems
Patient satisfaction is directly related to pre-operative decisions - the more time spent discussing the options with the patient pre-operatively, the less likely the need to justify the result. CONCLUSIONS 1. Mastopexy is not a single operation but rather one that must be individualised to fit the patient’s deformity and desires. It bridges the spectrum of aesthetic breast surgery from augmentation to glandular reduction. 2. None of the currently accepted techniques are without problems. None of the solutions are permanent and there is always a trade off to be made - scars +/- implants. 3. As with any aesthetic procedure, careful pre-operative assessment - both physical examination and discussion of aesthetic goals with patient, will minimise the problems post operatively. 4. For the minor ptosis - augmentation +/- NAC elevation appears to give the most satisfactory results. 5. For more severe ptosis, lower pole resection and augmentation to achieve upper pole fullness offer the best and most predictable long term results. MASTOPEXY Essentially aesthetic in nature so consideration of scarring is critical Classification of Ptosis —Regnault I nipple descends to level of inframammary fold II nipple below fold but above lowest contour of breast III nipple reaches lowest contour of breast Pseudoptosis—loose, lax breast with nipple above inframammary fold Majority of gland is below IMF Ptosis is also a lateralization of the breast Grabb and Smith pg 744 Nipple—IMF > 7cm ptosis that can’t be corrected by implant alone
Best for moderate ptosis and small reductions (<250gm) +/- reduction or augmentation reshape gland and redrape without tension (tension flattens breast) mark midline and breast meridian sup margin of new nipple point 2cm above IMF less skin excision laterally than medially excision appears elliptical when standing and round when lying de-epithelialise s/c flaps raised to IMF elevate sup dermoglandular pedicle and divide inferiorly the remaining breast to create lat and med glandular flaps resection for reduction as necessary if poor quality gland of low volume—no flaps raised—inferior gland plication only glandular flaps arranged to reduce size of base of breast and provide conical shape suspend superior flap to deep fascia lat and medial flaps folded to midline—usually lat over med to medialise the breast this also reduces the base of the breast—more conical breast lacing suture to maintain shape—with straight needle round block cerclage stitch to prevent pull and widening of areola (Mersilene) Goez modification Less of a sup dermoglandular flap Central mound pedicle Absorbable mesh (Vicryl) over gland Ide-ep skin is used to suspend breast to pec fascia and surround gland—it lies over the top of the Vicryl mesh AUGMENTATION MAMMOPLASTYPTOSISCaused by post-partum involution of gland, volume loss after weight loss or lax stretching skin Stretching of Cooper’s ligaments Due to discrepancy between volume and envelope Correction can be increase volume Reduce envelope Combination Augmentation mastopexy is a combination Ideal
Sternal notch to nipple 19-25cm Equilateral triangle nipple—nipple—sternal notch Nipple to IMF 4-8cm Mild ptosis increase volume alone Smaller scar Less affect on sensation If more severe ptosis—increase volume alone and accept some residual ptosis Moderate and Severe ptosis require augmentation mastopexy Superior crescent mastopexy Elevates NAC a little Can excise small sup component of areola to account for post-op areolar stretch Doesn’t address envelope Concentric Mastopexy Benelli If truly concentric—won’t elevate nipple Will reduce envelope Can reduce areolar diameter Eccentric Mastopexy Nipple elevation—mild Reduces envelope Can reduce Nipple projection Vertical Scar More reduction in envelope More elevation of nipple Minimal scar—vertical Inverted tear drop skin excision Minimise skin excision initially as implant takes up envelope Formal Mastopexy For advanced ptosis Wise pattern or incision wide enough to excise NAC and then raise flaps and resect as appropriate Wise pattern with minimal angle—enough to excise NAC and long limbs Place nipple at IMF or up to 2cm above Raise skin flaps superiorly to level of new nipple, not further Insert implant and redrape skin Directory: Study-Notes -> Breasts -> Aesthetics Aesthetics -> Breast Augmentation Introduction Study-Notes -> Inability of the velopharyngeal sphincter to close completely during production of the oral (nonnasal) sounds of speech Study-Notes -> Programming in c Download 0.96 Mb. Share with your friends:
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