INTRODUCTION
Wise pattern mastopexy with a keyhole incision is necessary for patients with significant ptosis and volume loss requiring shortening of the vertical dimension of the breast. The autoaugmentation recycles the tissue that would otherwise be excised from the medial and lateral breast, allowing optimization of breast volume.
INDICATIONS
This procedure is very good for patients who have never had breast reduction and who have significant ptosis. This procedure lends itself well to women who have excess axillary fullness that can be remedied by rotating the tissue out of the axilla into the chest. This procedure may be combined with submuscular breast augmentation with implants if it is anticipated that volume achieved will be insufficient with autoaugmentation alone.
MARKINGS
The patient is marked in the upright position. The central axis of the breast is marked bilaterally and transposed below the inframammary fold (IMF). The new nipple position is marked on this central axis at the level of the IMF, 23 cm from the sternal notch. Limbs of 8-9 cm in length are designed from the nipple to define the new nipple-inframammary distance, and the distance between these two limbs varies depending upon the degree of breast narrowing the surgeon aims to achieve, usually on the order of 6-8 cm. Symmetry can be checked by com- paring each side against the sternal notch. A wire nipple marker can be used to plan on the ultimate 4-cm nipple areolar complex (NAC) centered around the apex of the limbs drawn. The IMF is marked. Marks are then drawn connecting the distal portion of the limbs medially and laterally to the IMF mark. The degree of axillary reduction laterally is judged on the basis of a pinch test. An inferior pedicle centered around the central axis of each breast and no less than 7 cm is marked which will include the tissue in the new nipple areolar position (Figure 17-1). The new nipple areolar position is measured again as well as the existing NAC position to determine preoperative asymmetry. This should be confirmed with the patient.
DETAILS OF PROCEDURE
The patient is brought into the operating room and anesthesia is induced. Arms are positioned at 90 degrees from the body, and egg crate is placed on the arm boards to prevent nerve compression. The knees are placed on a pillow to encourage flexion, and antiembolism support stockings and sequential compression devices are initiated prior to anesthesia. Markings on the breast are determined to be symmetric with regard to midpoint marked on the IMF on each breast and the width and position of the inferior pedicle. The breasts are prepared and draped in sterile fashion, placing a lower body forced warming blanket to avoid hypothermia. A 42-45 mm nipple areolar cookie cutter is used to designate the new nipple areolar diameter on the existing NAC, and this mark is incised (Figure 17-2). The inferior pedicle is then de-epithelialized up to the new NAC position with a knife or with large mayo scissors, preserving the NAC (Figure 17-3). After this, the cautery may be used to remove skin from the medial and lateral triangles (Figure 17-4).
Skin flaps are developed superiorly, at least 2 cm in thick- ness. Skin flaps are elevated up to the clavicle. The medial and lateral triangles of tissue are then elevated off the pectoralis major fascia from lateral toward the central pedicle, maintaining good supply and chest wall attachment of the central pedicle (Figure 17-5). The medial and lateral tissue is then sutured to the central pedicle with running #2-0 braided absorbable suture, being careful to avoid suturing this tissue to the dermis of the central pedicle so that the NAC is not deformed or tethered (Figure 17-6). Careful hemostasis is achieved and the wound is irrigated. Intercostal blocks inferior to the ribs may be performed with lidocaine, bupivacaine, or a mixture of the two for postoperative comfort. The augmented central pedicle may be sutured to the chest wall superiorly just below the clavicle and medially and laterally to the pectoralis major fascia to centralize it and stabilize position. Sutures (#3-0 monofilament absorbable) are then placed to approximate the skin flaps centrally under the NAC and at the fold.
Staples may then be used to approximate the inframammary closure. A 10-mm flat Jackson-Pratt drain is placed in the space, exiting out the lateral position and sutured into position with a #3-0 nylon suture. The patient is flexed on the operating room bed to elevate the back and assess symmetry. Superior tissue may need to be removed from the central pedicle to achieve symmetry, or the medial or lateral augmenting tissue may need to be reduced or discarded altogether. The skin flaps vertically and horizontally are approximated with buried dermal interrupted #3-0 monofilament absorbable sutures, as is the NAC. A #4-0 monofilament absorbable running intracuticular suture is placed (Figure 17-7). Interrupted #4-0 monofilament permanent sutures may be used to reinforce closure. The wounds are then washed and dressed with petrolatum gauze and absorbent pads. The patient is placed into a bra which is soft, supportive, and snug but not tight. The patient should then be extubated and the urine catheter removed if one was placed at the beginning of the case.
POSTOPERATIVE CARE
Mastopexy with autologous augmentation as a solo procedure may be performed as an outpatient. Before leaving the recovery room, the patient must be able to urinate, ambulate, and take adequate oral fluids. The patient may stay in the hospital overnight for monitoring and pain management. If the patient stays in hospital, the drains are often removed the following morning. If output overnight is more than 50 cc, the drains may be left in for a week until the first postoperative visit. Oral antibiotic is continued until drain removal.
The patient returns 1 week after surgery for the first postoperative visit. Sutures are removed. Physical limitations within the upper body last for a month. Patients may shower several days after the procedure, and a soft support bra is recommended for 2 months.
Scar management with massage and cocoa butter or scar cream should be instituted 2 weeks after surgery as long as there are no open wounds. If small open wounds occur, most often under the NAC or at the IMF, they are treated locally with antibiotic ointment, cleansing, and bandaging.
PITFALLS
Many women pursuing breast lift after massive weight
loss have previously had breast reduction. In these cases, the medial and lateral breast tissue may be vascularly compromised, so it should be discarded to avoid possible fat necrosis. Judicious elevation of this tissue must also be performed in women who smoke, are diabetic, or who are older than 50 years. Vascular compromise may also be present in women who have had extended brachioplasty down the chest wall performed.
Despite attempts to reduce axillary fullness, women may be left with a torso that is still too wide that may benefit from vertical excision in the axilla in the future, particularly in conjunction with future brachioplasty.
Breast shaping sutures may actually cause more harm than good. In suturing tissue for autoaugmentation, sutures to the de-epithelialized dermis of the central pedicle should be avoided as they may unfavorably pull on the NAC. Similarly, sutures to the chest wall should be placed carefully to avoid a distorted appearance and may require modification after the skin flaps are approximated and
the patient is elevated on the operating room table.
TIPS
Preoperative discussion may touch on the merits of lifting
versus augmentation to improve fullness and ptosis. Some patients may require both to achieve their goals. It is always safe to isolate the breast lift and the breast augmentation to improve healing and predictability of result. When augmenting at the time of breast lift, augmentation is most safely performed in the submuscular position to avoid devascularizing the breast tissue, as it preserves thoracoacromial attachments to the breast and nipple. Implant augmentation may result in a tense closure. If there are concerns about closure being too tight, augmentation should be aborted and planned for a later time. This possibility is best discussed preemptively with the patient prior to surgery.
For augmentation-mastopexy, which procedure should be performed first: the augmentation or the mastopexy? The primary, most important procedure for the patient should be performed first. In a massive weight loss patient with significant ptosis and involutional change, the mastopexy design should be created first. The chest wall is longer and may be more barrel-shaped in the weight loss patient making the pectoralis major muscle more difficult to place. Augmentation through the lateral pectoralis after the skin flaps are elevated eases implant placement in this patient population. In a patient interested in augmentation who has ptosis, the augmentation should be performed first, followed by a tailored mastopexy for tightening.