Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types

In breast augmentation, surgeons usually choose a pocket location for the implant behind breast parenchyma (retromammary), partially behind the pectoralis major muscle (partial retropectoral), or totally behind pectoralis major and serratus (total submuscular). Each of these implant pocket locations has specific indications, but each also has a unique set of tradeoffs. When applied to a wide range of breast types, each pocket location has limitations. Glandular ptotic and constricted lower pole breasts offer unique challenges that often are not solved without tradeoffs when using a strictly retromammary, partial retropectoral, or total submuscular pocket. This article describes specific indications and techniques for a dual plane approach to breast augmentation in several different breast types, introducing techniques that combine retromammary and partial retropectoral pocket locations in a single patient to optimize the benefits of each pocket location while limiting the tradeoffs and risks of a single pocket location. A total of 468 patients had dual plane augmentation between January of 1992 and March of 1998 using the specific techniques of dual plane augmentation described in this article. All patients were treated as outpatients and received general anesthesia. Indications, operative techniques, results, and complications for this series of patients are presented. Dual plane augmentation mammaplasty adjusts implant and tissue relationships to ensure adequate soft-tissue coverage while optimizing implant-soft-tissue dynamics to offer increased benefits and fewer tradeoffs compared with a single pocket location in a wide range of breast types.     

Breast reconstruction with an external oblique abdominis muscle turnover flap and a bipedicled abdominal skin flap

A new technique of breast reconstruction is demonstrated using a turnover flap of the external oblique abdominis muscle together with a sheath of the rectus muscle to enlarge the submuscular pectoralis major pocket for the implant. To overcome a tight skin, a bipedicled abdominal skin flap is transposed for breast reconstruction. In so doing, a natural-looking breast is formed by a simple operative technique with rare complications. The technique has been applied in 11 patients with good results.     

Anterior thoracic hypoplasia: a separate entity from Poland syndrome

SUMMARY: Women presenting with anterior thoracic depression, breast hypoplasia, and subsequent asymmetry are often diagnosed with Poland syndrome regardless of pectoralis involvement, or are placed in the generic category of breast asymmetry or skeletal dysplasias. Recently, though, the term "sunken chest" has been used to describe forms of chest wall depression that previously may have fallen under generic skeletal dysplasias. The authors believe that, combined with hypoplasia of the ipsilateral breast, superior location of the nipple-areola complex compared with the contralateral side, and normal pectoralis muscles, this represents a previously undefined and real condition called anterior thoracic hypoplasia. During the past 4 years, the authors have treated eight women who have presented with a diagnosis of Poland syndrome or pectus excavatum, all of whom share the same characteristics-unilateral sunken anterior chest wall, hypoplasia of the breast, superiorly placed nipple-areola complex, normal pectoralis muscle, and normal sternal position. All of the patients underwent correction of breast asymmetry and unilateral anterior thoracic hypoplasia with augmentation mammaplasty, a method that when tailored for each side yields good aesthetic results. The average age of the patients was 31 years and the average chest size was 34. Cup size, as measured by the patient's standard bra, was a B on the nonaffected side in all patients and an A on the affected side in all patients except one. Of the eight patients, seven had the right anterior chest and breast involved, whereas one patient had involvement on the left. For all of the patients, the nipple and areola of the hypoplastic side were smaller and in a more superior position compared with the contralateral side on visual inspection. In the eight patients, a total of 19 augmentations (15 primary augmentations and four revisions) and one mastopexy were performed. Ten inframammary-fold approaches and nine periareolar approaches were used, and all of the implants were placed in a partial submuscular position, except for two implants placed in a subglandular position that were converted to partial submuscular positions in a secondary setting. In all the women, the sternal head of the pectoralis muscle was present and the pectoralis muscle appeared to be equal in size compared to the contralateral side. Nine different types of implants were used. Average implant fill volume measured 412 cc on the hypoplastic side and 257 cc on the contralateral side. In follow-up, all of the patients were satisfied with their operation and rated their aesthetic outcome as very good to excellent. The authors believe that anterior thoracic hypoplasia is a real, previously misdiagnosed and undescribed condition, and that both chest wall and breast deformities can be corrected safely and with excellent results using proper augmentation planning and implant selection.     

Breast cancer after augmentation mammaplasty: treatment by skin-sparing mastectomy and immediate reconstruction

Breast conservation has been associated with poor cosmetic outcome when used to treat breast cancer in patients who have undergone prior augmentation mammaplasty. Radiation therapy of the augmented breast can increase breast fibrosis and capsular contraction. Skin-sparing mastectomy and immediate reconstruction are examined as an alternative treatment.Six patients with prior breast augmentation were treated for breast cancer by skin-sparing mastectomy and immediate reconstruction. One patient underwent a contralateral prophylactic skin-sparing mastectomy. Silicone gel implants had been placed in the submuscular location in five patients and in the subglandular position in one patient a mean of 10.2 years (range, 6 to 20 years) before breast cancer diagnosis. The mean patient age was 41.3 years (range, 33 to 56 years). Four independent judges reviewed postoperative photographs to grade the aesthetic results in comparison with the opposite native or reconstructed breast.The American Joint Committee on Cancer staging was stage 0 in one patient, stage I for four patients, and stage II for one patient. Five of the six patients presented with a palpable breast mass. Latissimus dorsi flap reconstruction was performed in four patients (bilaterally in one) and a transverse rectus abdominis muscle (TRAM) flap was used in two patients. Three patients were treated by skin-sparing mastectomy with preservation of the breast implant (two patients with latissimus flaps, and one patient with a TRAM flap). The tumor location necessitated the removal of implants in two patients (one patient with a latissimus flap and one with a TRAM. A saline implant was placed under the latissimus flap after gel implant removal. The patient who underwent bilateral skin-sparing mastectomies desired explantation and placement of saline implants. No remedial surgery was performed on the opposite breast to achieve symmetry. Complications occurred in two patients at the latissimus dorsi donor site (seroma in one patient, and seroma and infection in one). Five patients underwent complete nipple reconstructions. The mean duration of follow-up was 33.6 months (range, 15.5 to 70.3 months), and there were no recurrences of breast cancer. The aesthetic results were judged to be good to excellent in all cases.Skin-sparing mastectomy and immediate reconstruction can be used in patients with prior breast augmentation, with good to excellent cosmetic results. Depending on the tumor and implant location, the implant may be preserved without compromising local control.     

Maximizing breast projection after free-nipple-graft reduction mammaplasty

In 1922, Thorek described standard free-nipple reduction mammaplasty for gigantomastia. This technique provided a simple and effective way to perform reduction mammaplasty. However, the technique is frequently criticized for producing a breast and nipple with poor projection. Even with the standard modification of the original technique, the resultant breast and nipple may be wide and flat, with unpredictable nipple-areola pigmentation. To create a breast mound and nipple with projection and even pigmentation, the free-nipple-graft breast reduction technique is presented. The Wise pattern skin reduction markings and the superiorly based parenchymal reduction technique are used. After the nipple-areola complex is removed, as a free graft, the inferior pole of the breast is then amputated along the Wise pattern skin markings, leaving lateral and medial pillars of breast tissue, with the apex of the resection corresponding to the new nipple location. The lateral and medial pillars of the superiorly based breast mound are then sutured together. Key interrupted sutures are placed, beginning at the most inferior and posterior point of the pillars, while recruiting tissue centrally to increase the projection. The intersecting point of the inverted T, at 7 cm from the new nipple position, is then sutured to the fasciae of the pectoralis major muscle. If more central projection is desired, the vertical limb design can be lengthened. The tissue inferior to the 7-cm mark is de-epithelialized and tucked under the central breast, if needed, contributing further to the final breast parenchyma projection. The skin of the vertical limb of the Wise pattern is then closed with a dog-ear at the apex to further contribute to nipple projection. The nipple is replaced as a free, thick, split-thickness skin graft. The breast is temporarily closed, and the medial and lateral breast tissue excess is liposuctioned to create a more conical breast. Excessive medial and lateral skin is then resected, keeping the inframammary crease incision under the breast mound. Twenty-five patients underwent free-nipple-graft reduction mammaplasty using this technique between 1992 and 2000. An average of 1600 g of breast tissue per breast was removed. The average follow-up period was 36 months. Patient satisfaction has been very high.     

The management of anterior chest wall deformity in patients presenting for breast augmentation

Anterior chest wall asymmetry is sometimes encountered in patients presenting for consideration of breast augmentation. The chest wall asymmetry or deficiency may be significant enough to consider reconstruction at the same time as breast augmentation in a small number of cases. Customized and prefabricated chest wall implants have been used in a variety of conditions including Poland syndrome, pectus excavatum, and sunken anterior chest. Careful moulage preparation and on-table implant modification are needed to "seat" these implants on the skeletal chest wall under the pectoralis major muscle. The chest wall implant provides a base for the subsequent breast prostheses and fills up a bony deficit that cannot be camouflaged by the breast prostheses alone.     

The correction of capsular contracture by conversion to "dual-plane" positioning: technique and outcomes

Little has been published regarding the treatment of patients with long-established capsular contracture after previous submuscular or subglandular breast augmentation. This study reviews 7 years of experience in treating established capsular contracture after augmentation mammaplasty by relocating implants to the "dual-plane" or partly subpectoral position. A retrospective chart review was performed on all patients who were treated for capsular contracture using this technique between 1993 and 1999. Data collected included the date of the original augmentation, the original implant location, date of revision and type of implant used, length of follow-up, outcome, and any ensuing complications. Different surgical techniques were used, depending on whether the prior implant was located in a subglandular or submuscular plane. All patients had revisions such that their implants were relocated to a dual plane, with the superior two thirds or so of the implant located beneath the pectoralis major muscle and the inferior one third located subglandularly. Of 85 patients reviewed, 54 had their original implants in a submuscular position and 31 had their initial augmentation in a subglandular position. Of the 54 patients whose implants were initially submuscular, 23 patients (43 percent) had silicone gel implants, 15 patients (28 percent) had double-lumen implants, and the remaining 16 patients (30 percent) had saline implants. Of the 31 patients whose implants were initially subglandular, 20 patients (65 percent) had silicone gel implants, three patients (10 percent) had double-lumen implants, and the remaining eight patients (26 percent) had saline implants. Fifty-one patients (60 percent) had replacement with saline implants (37 smooth saline, 14 textured saline), whereas 34 (40 percent) had silicone gel implants (seven smooth gel, 27 textured gel). The average time from previous augmentation to revision was 9 years 9 months. The average follow-up time after conversion to the dual-plane position was 11.5 months. Only three of 85 patients required reoperation for complications, all of which involved some degree of implant malposition. Of patients converted to the dual plane, 98 percent were free of capsular contracture and were Baker class I at follow-up, whereas 2 percent were judged as Baker class II. There were no Baker level III or IV contractures at follow-up. The dual-plane method of breast augmentation has proved to be an effective technique for correcting established capsular contracture after previous augmentation mammaplasty. This technique appears to be effective when performed with either silicone or saline-filled implants.     

Poland's syndrome: correction of thoracic anomaly through minimal incisions

A method that minimizes residual scarring following Poland's syndrome correction by latissimus dorsi muscle transposition and placement of a submuscular breast implant is described. In order to reduce any resulting unsightly scarring and, in particular, eliminate the anterior thoracic scar, both a dorsal S-shape and an axillary incision were made and the muscle flap was raised. A prosthesis was then inserted and the muscle flap sutured to the anterior chest wall through an anterior incision symmetrical to the inferior border of the contralateral areola. The latter is a previously undescribed approach that produces good cosmetic results.     

Pectoralis major "trapdoor" flap for silicone breast implant medial knuckle deformities.

Loss of breast parenchyma through surgery and physiologic involution can lead to problems of subglandular silicone breast implant palpability and even contour irregularities. This can give rise to patient concern and detracts from the aesthetics of the breast augmentation, particularly when it occurs medially. We present a simple solution to this problem on the medial side of the breast in the form of a small segmental medially based pectoralis major "trapdoor" flap that augments the implant soft-tissue cover intracapsularly, at the site where it is deficient. The technique, which has been used with success in five patients over 3 years, is described.     

An improved technique for immediate retropectoral reconstruction after subcutaneous mastectomy

Subcutaneous mastectomy is becoming an operation of choice in certain cases of premalignant and other breast pathology. We describe a technique for simultaneous subcutaneous mastectomy and retropectoral implantation of a silicone prosthesis. Gentle blunt prepectoral, retromammary dissection is performed through an axillary incision as far inferiorly as the inframammary fold, where a fibrous bridge between the anterior surface of the pectoralis major muscle and the skin prevents dissection any lower. Through the same incision, the retropectoral space is dissected to about 5 cm below the inframammary fold. A second incision is made in the inframammary fold to join the retromammary plane of the first dissection. The gland is then dissected subcutaneously and removed through the inframammary incision. A silicone implant is introduced retropectorally through the axillary incision, thus avoiding splitting the pectoralis major. Satisfactory results have been obtained in 23 bilateral and 14 unilateral cases; it is important that the dissection be performed carefully in order to prevent the implant from riding up too high in its musculoaponeurotic sling.     

A direct surgical approach to correct the inverted nipple

Inverted nipples are cosmetically unpleasing to the patient and can become inflamed due to mechanical difficulty with cleaning the nipple-areola complex. A surgical technique for the permanent repair of inverted nipples is described. The rationale for the surgical approach is that the major pathophysiologic basis for nipple inversion is shortened lactiferous ducts. Briefly outlined, under local anesthesia, the nipple is everted with a skin hook and held in gentle traction while a small incision is made on each side at the nipple-areola junction. Breast ducts are then divided by sharp dissection, and a drain is inserted through the tunnel under the nipple. The drain is removed in 7 to 10 days. The patient must be informed before the procedure that breast-feeding will not be possible afterward because breast ducts will be permanently divided. Advantages to the procedure are (1) no scars on the areola, (2) no stricture from sutures, (3) adequate blood and nerve supply to the nipple, and (4) decreased risk of hematoma.     

The fate of breast implants with infections around them.

In a retrospective study of 41 infected breasts following the insertion of implants, a high incidence of postoperative hematoma was noted. When infection occurred, cultures usually demonstrated the causative organism to be Staphylococcus aureus. Treatment by conservative drainage and vigorous antibiotics was generally successful in salvaging those implants which had been inserted through an areolar incision for simple augmentation, or under the pectoralis muscle (or a dermal pedicle) after a subcutaneous mastectomy. Those patients whose augmentations had been done through an inframammary incision, or whose implant after a subcutaneous mastectomy was under the skin flap, had a statistically higher incidence of implant loss. Most breasts will salvaged implants became firm.     

Nipple or areolar reduction with simultaneous breast augmentation

Patients requesting nipple or areolar reduction often desire simultaneous breast augmentation. A technique is described for implant placement by means of a nipple base incision with either nipple reduction or intraareolar reduction. Nipple reduction is accomplished by removing a ring of skin from the base of the nipple, while areolar reduction is performed by removing a donut-shaped area of skin whose inner diameter is at the nipple base. The elasticity of the areolar skin allows for access for saline implant placement. The resulting scar is well concealed. Results from 15 patients demonstrate that the technique is safe, practical, and appears to pose no increased risk of sensory changes to the nipple.     

Transaxillary subpectoral augmentation mammaplasty: long-term follow-up and refinements

Transaxillary subpectoral augmentation locates the scar in a less visible position in multiple body positions than approaches that locate scars on the aesthetic unit of the breast. In 90 patients, 63 with 2 to 5 years of follow-up, using the surgical technique described, the Baker III/IV capsular contracture rate was 5.6 percent. There was no occurrence of hematoma, periprosthetic space infection, permanent loss of nipple sensation, or significant axillary wound morbidity. Scar results suggest that the axilla is an anatomically favorable location for both high-quality final appearance and minimal visibility. The transaxillary subpectoral approach is an excellent alternative to inframammary and periareolar approaches in all types of breasts requiring augmentation except the ptotic breast or breasts requiring extremely large prostheses.     

Breast and subscapular pain following submuscular placement of breast prostheses

The technique of placing the breast prosthesis beneath the pectoralis major and the serratus anterior muscles appears to minimize the incidence of the firm breast following breast reconstruction commonly seen with other techniques. However, in 8 of 146 individuals I have noted a problem with pain in the lateral aspect of the breast mound and the subscapular area, along with a depressed deformity superomedially and an unsightly bulge inferolaterally and/or laterally. Surgical exploration of the breast mound showed no abnormalities within the submuscular compartment. However, in all instances, the serratus anterior muscles were found to be detached from the ribcage all the way to the point beyond the posterior axillary line. While continuous pressure exerted on the serratus muscles by the implant appears to play an important role in the pathogenesis of this clinical entity, the onset of problems was usually delayed. Removal of the implants or repair of the cavity defects is necessary for patients who have developed this problem.     

Autologous fat graft in nipple reconstruction

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction.     

Comparison of the Postoperative Incidence Rate of Capsular Contracture among Different Breast Implants: A Cumulative Meta-Analysis

BackgroundA large number of clinical studies have reported that the different materials used in breast implants were a possible cause of the different incidence rates of capsular contracture observed in patients after implantation. However, this theory lacks comprehensive support from evidence-based medicine, and considerable controversy remains.ObjectivesIn this study, a cumulative systematic review examined breast augmentation that used implants with textured or smooth surfaces to analyze the effects of these two types of implants on the occurrence of postoperative capsular contracture.MethodsWe conducted a comprehensive search of literature databases, including PubMed and EMBASE, for clinical reports on the incidence of capsular contracture after the implantation of breast prostheses. We performed a cumulative meta-analysis on the incidence of capsular contracture in order from small to large sample sizes and conducted subgroup analyses according to the prosthetic material used, the implant pocket placement, the incision type and the duration of follow-up. Relative risks (RR) and 95% confidence intervals (CI) were used as the final pooled statistics.ResultsThis meta-analysis included 16 randomized controlled trials (RCTs) and two retrospective studies. The cumulative comparison of textured and smooth breast implants showed statistical significance at 2.13 (95% CI, 1.18-3.86) when the fourth study was entered into the analysis. With the inclusion of more reports, the final results indicated that smooth breast implants were more likely to be associated with capsular contracture, with statistical significance at 3.10 (95% CI, 2.23-4.33). In the subgroup analyses, the subgroups based on implant materials included the silicone implant group and the saline implant group, with significant pooled statistical levels of 4.05 (95% CI, 1.97-8.31) and 3.12 (95% CI, 2.19-4.42), respectively. According to implant pocket placement, a subglandular group and a submuscular group were included in the analyses, and only the subglandular group had a statistically significant pooled result of 3.59 (95% CI, 2.43-5.30). Four subgroups were included in the analyses according to incision type: the inframammary incision group, the periareolar incision group, the transaxillary incision group and the mastectomy incision group. Among these groups, only the pooled results of the inframammary and mastectomy incision groups were statistically significant, at 2.82 (95% CI, 1.30-6.11) and 2.30 (95% CI, 1.17-4.50), respectively. Three follow-up duration subgroups were included in the analyses: the one-year group, the two- to three-year group and the ≥five-year group. These subgroups had statistically significant results of 4.67 (95% CI, 2.35-9.28), 3.42 (95% CI, 2.26-5.16) and 2.71 (95% CI, 1.64-4.49), respectively.ConclusionIn mammaplasty, the use of textured implants reduces the incidence of postoperative capsular contracture. Differences in implant pocket placement and incision type are also likely to affect the incidence of capsular contracture; however, this conclusion awaits further study.     

Camouflage and the Augmentation Mammaplasty

Augmentation mammaplasty has become a safe and accepted surgical procedure since the introduction of silicone prosthesis. Proper selection of the type and size of the implant and careful attention to making the line of incision as nearly invisible as possible are important for a natural-appearing breast. Placement of a silicone gel filled prosthetic implant through a periareolar incision achieves excellent contour and consistency in the augmented breast, with an essentially invisible scar.     

Elimination of the vertical scar in reduction mammaplasty.

We describe a technique to eliminate the vertical portion of the inverted-T incision in patients who have combined enlargement of the breasts and moderate to severe ptosis. Initial preoperative markings are made, placing the new nipple site at the level of the transposed inframammary crease. The nipple-areola complex is then retained on a vascularized pedicle, with major reduction of the breast tissue being done in the medial and lateral quadrants. The nipple and breast tissue are then tucked underneath the superior skin segment and placed in this new position as one would do with the umbilicus in an abdominoplasty. Excess vertical skin is removed, and horizontal excess is collected at the midline as a small dog-ear. We have found that this dog-ear reduces markedly with time, rounding out the inferior portion of the breasts. The remaining small amount of excess skin can then be removed under local anesthetic at a later date. We have performed this procedure on 20 patients, with follow-up from 6 to 24 months.     

Reduction mammaplasty with the "owl" incision and no undermining

Reduction mammaplasty has traditionally been done using the Wise pattern of incision. Because of the box-like effect in breast shape, the lack of projection, and the long scars associated with the inverted T incision, two techniques have emerged as alternatives: the vertical reduction of Lassus/Lejour and the "round block" periareolar technique popularized by Benelli. Each of these techniques has its pros and cons.The "owl" incision combines the features of the large periareolar reduction (Benelli's) and the vertical reduction (Lassus/Lejour); the horizontal inframammary scar is either made very short or completely eliminated. Volume reduction is done through a heart-shaped parenchymal resection, leaving the nipple-areolar complex over a supero-central pedicle. Maintenance of the central parenchyma behind the nipple-areolar complex and mobilization of the vertical pillars toward the center of the breast give excellent projection and diminish the lateral fullness. Enlargement of the periareolar skin resection diminishes the length and pleating of the vertical scar; conversely, inclusion of the vertical component to the periareolar technique eliminates the pleating effect of the periareolar incision. The short horizontal excision eliminates any resultant "dog ears" in the new inframammary fold. Thus, the discrepancy in the length of scars is better distributed. There is no skin or parenchymal undermining, so drains are not needed. Excellent results are obtained immediately on the operating table, and large volumes of glandular resection and correction of severe ptosis can be accomplished without compromising vascularity of either the nipple-areolar complex or the skin flaps.Ninety-four patients in a 7-year period were operated upon using this technique. Seventy-two had bilateral reductions up to 1900 gm per breast, 12 had unilateral reduction for symmetry following breast reconstruction, and 10 were patients with severe ptosis. Complications were rare and of a minor nature. No conversion to free grafts was done, even in the larger resections. One case required minor revision under local anesthesia, one case required bilateral re-reduction, and another case required unilateral re-reduction for continued growth of breast tissue. Almost 90 percent of the patients underwent procedures as outpatients.The owl-type incision and the supero-central pedicle flap are elements of a reduction mammaplasty technique that provides excellent projection and shape with minimal visible scars. It takes advantage of the positive features of the periareolar and vertical reduction techniques and minimizes their negative features. The new design of parenchymal resection improves the vascularity of the residual flaps. Additionally, it may better preserve the sensation to the nipple-areolar complex and lactation is not compromised.