Mastopexy introduction



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Mastopexy following Explantation

    1. number of reports of palpable or mammographically detectable masses present in the breast following explantation when the capsule had been left

    2. 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

  1. explantation alone

  2. implant exchange

  3. mastopexy with implant

  4. 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
LONG TERM RESULTS

Mastopexy is a temporary procedure - one should expect some recurrence with time.

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

Benelli Round Block Mastopexy +/- reduction

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 MAMMOPLASTY

PTOSIS


Caused 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

? lower IMF

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

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