Journal of Plastic, Reconstructive & Aesthetic Surgery (2019) 72, 243–272

Review

Systematic review of outcomes and complications in nonimplant-based surgery

a , d , ∗ b a Pietro G. di Summa , Carlo M. Oranges , William Watfa , c b d Gianluca Sapino , Nicola Keller , Sherylin K. Tay , d b a Ben K. Chew , Dirk J. Schaefer , Wassim Raffoul

a Department of Plastic, Reconstructive and Aesthetic Surgery, Lausanne University Hospital, Lausanne, Switzerland b Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, Basel University Hospital, Basel, Switzerland c Department of Plastic and Reconstructive Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy d Canniesburn Unit, Glasgow Royal Infirmary, Glasgow, Scotland, UK

Received 21 April 2018; accepted 28 October 2018

KEYWORDS Summary Background: Mastopexy is one of the most performed cosmetic surgery procedures Mastopexy; in the U.S. Numerous studies on mastopexy techniques have been published in the past decades, Risks; including case reports, retrospective reviews, and prospective studies. However, to date, no lift; study has investigated the overall complications or satisfaction rates associated with the wide Hammock lift; spectrum of techniques. Glandular Objectives: This review aims to assess the outcomes of the various mastopexy techniques, rearrangement; without the use of implants, thus focusing on associated complications, and to provide a sim- Bottoming out; plified classification system. Methods: This systematic review was performed in accordance with the PRISMA guidelines. PubMed database was queried in search of clinical studies describing nonprosthetic mastopexy techniques, which reported the technique, indication, and outcomes. Results: Thirty-four studies, published from 1980 through 2016, were included and repre- sented 1888 treated patients. Four main surgical technique categories were identified: dermal reshape, glandular reshape, glandular reshape associated with perforator flaps, and glandular

∗ Corresponding author at: Department of Plastic, Reconstructive and Aesthetic Surgery, Lausanne University Hospital, Lausanne, Rue du Bugnon 46, 1011 Lausanne, CH, Switzerland. E-mail address: [email protected] (P.G. di Summa). https://doi.org/10.1016/j.bjps.2018.10.018 1748-6815/ © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. 244 P. G . di Summa, C.M. Oranges and W. Watfa et al.

reshape with mesh support. Despite varying techniques, mastopexy was generally found to be a reliable esthetic procedure with unsatisfactory breast shape, thus accounting for only 1.3% of the patients. The overall complication rate was 10.4%. The most represented complications were -related (3%, including hypertrophic or unesthetic appearance) and –- related problems (2.9%; including distortion, asymmetry, and reduction in sensation). Conclusions: Mastopexy techniques achieve high patient satisfaction and can be tailored ac- cording to patient needs and clinical presentation. Complication rates and morbidity are rela- tively low. However, a significant number of issues related to , asymmetry, and potential ptosis recurrence should be highlighted in the information provided to patients. © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El- sevier Ltd. All rights reserved.

Contents

Introduction ...... 244 Material and methods ...... 245 Search strategy...... 245 Selection criteria...... 245 Data extraction ...... 245 Results ...... 245 Discussion ...... 266 Dermal reshape (Type 1) ...... 268 Outcome ...... 268 Complications ...... 268 Glandular reshape (Type 2)...... 268 Outcome ...... 269 Complications ...... 269 Glandular reshape associated with perforator flaps (Type 3) ...... 269 Outcome ...... 269 Complications ...... 269 Glandular reshape associated with synthetic mesh (Type 4) ...... 270 Outcome ...... 270 Complications ...... 270 Conclusion ...... 270 Disclosures...... 270 Funding ...... 270 Supplementary material...... 270 Appendix ...... 270 References...... 270

Introduction gain this youthful esthetic ideal of minimal breast ptosis, many authors have proposed a support or “hammock” for Mastopexy is the seventh most performed cosmetic surgery the lower pole. The literature reveals many descriptions procedure in the U.S. according to the latest American So- ranging from autologous dermal support 4,5 to the use of 1 ciety for Aesthetic Plastic Surgery (ASAPS) statistics. synthetic matrices to support the lower pole. 6–8 Some Extensive data in the literature show numerous studies authors have even proposed the use of a pectoral muscle in which a wide array of operative techniques is described. component to increase result durability. 9–11 These techniques range from a simple dermal manipulation, Many of the described surgical procedures aim to with or without glandular reshaping, through the use of der- improve breast projection and upper pole fullness by mal flaps fixed to the , to the use of synthetic remodeling some of the breast gland in addition to re- mesh or sheets. section. Recently introduced by Kirwan et al., the concept The esthetically ideal youthful breast should have min- of “autoaugmentation” refers to the use of an autologous, imal ptosis, without any part of its lower pole lying on the usually glandular, flap to increase upper pole fullness, chest wall. In addition, the nipple should be located 5–7 cm thus avoiding the use of an implant. 2 The most common 2 from the inframammary crease along the breast meridian. autoaugmentation performed among surgeons remains the Apart from the role of the in breast suspension, use of a secondary inferior flap that is advanced upward breast ptosis is partly due to the lower pole breast bulk into a space created under the superiorly based primary weighing on Cooper’s ligaments that will eventually weaken NAC pedicle. 3,12–24 Others have described alternative ap- and provide little breast support. 3 In an attempt to re- Systematic review of outcomes and complications 245 proaches that use a superiorly or superomedially based Four reviewers (C.M.O., G.S., W.W., and P.D.S.) indepen- glandular advancement flap. 3,25–29 dently screened the search results for inclusion, through Thus far, all techniques described to lift and reshape the the assessment of titles and abstracts. The references of breast include either one or a combination of the following included studies were reviewed for other suitable studies, components: dermal, glandular, and glandular associated and this showed that 12 additional important papers that with a flap or synthetic mesh. However, to date, no study had been missed. has investigated the overall complications or satisfaction rates associated with the wide spectrum of techniques. This comprehensive review aims to assess the outcomes Data extraction of published mastopexy techniques (excluding prosthetic mastopexy-augmentation procedures) and to provide a Four reviewers (C.M.O., G.S., W.W., and P. D . S ) indepen- clearer and workable classification system. From an ed- dently extracted data from the full texts of all included ucational point of view, the reader should be able to studies and populated a predesigned standardized table de- differentiate between the main mastopexy techniques. A veloped for this purpose. clear understanding of the reported outcomes and compli- The following data (where available) were extracted cations for each of the techniques will allow the reader to from full texts: first author, year of publication, study de- determine a safe and effective surgical plan. sign; inclusion and exclusion criteria; number of patients; number of procedures; age; sex; indication for surgery; body site; type of surgery; surgical technique; and primary and secondary outcomes. Material and methods Because of the heterogeneity of the studies, statis- tical meta-analysis of the data was impossible. Instead,

Search strategy we performed qualitative and descriptive analyses of the outcomes. This review was conducted according to guidelines set forth in the Preferred Reporting Items for Systematic reviews and

Meta-Analysis (PRISMA). 30 Results A systematic literature search was conducted using PubMed to identify all articles involving surgical treatment A total of 814 full-text articles were initially identified. of the breast ptosis. The following search terms were used: After application of exclusion criteria, 41 articles were re- (“OR” functions of the following) mastopexy, breast lifting, tained, published from 1980 through 2016 ( Figure 1 ). Char- breast lift), “AND” (“OR” functions of the following) etiol- acteristics in all included articles are summarized in Table 1 . ogy, epidemiology, classification, indications, treatment. Six of them were prospective studies, while 35 were Publications were restricted to include English language retrospective studies. None of the studies were randomized studies only. No publication date restrictions were applied. or controlled. After excluding 7 articles that included less The review was performed between January and March than 10 patients, an overall of 1888 treated patients were 2017. represented (age range, 17–72 years). Four main techni- cal approaches and their subcategories were identified ( Figures 2 –8): dermal reshape mastopexy (Type 1, n = 82), Selection criteria mastopexy with glandular reshape (Type 2, n = 1489), mastopexy with glandular reshape associated with perfo- Inclusion and exclusion criteria were established before the rator flap (Type 3, n = 35), and mastopexy with associated search. Eligible levels of evidence included randomized con- supportive mesh (Type 4, n = 282). Considering the variety trolled trials (RCTs), prospective studies, retrospective ob- of differences in glandular reshaping techniques, subcate- servational studies, case–control studies, case series, and gories were identified according to the examined literature. case reports. Review articles and conference abstracts were Particularly, among glandular reshape (Type 2) techniques, excluded. we could recognize superiorly based (Type 2a), inferi- Only articles written in English were selected, thus de- orly/posteriorly based (Type 2b), and superomedially based scribing female patients undergoing mastopexy for breast (Type 2c) glandular remodeling techniques; all of these ptosis. Mastopexy surgery type included simple dermal techniques directed to breast autoaugmentation. Similarly, tightening, glandular remodeling, local autologous flap aug- among perforator flap reshape (Type 3) techniques, we mentation mastopexies and mastopexies associated with could recognize flaps depending on thoracic/anterior inter- the use of matrices. Exclusion criteria included articles in costal artery perforator [ICAP] (Type 3a) and lateral ICAP which mastopexy was combined with prosthesis and breast (Type 3b) vessels. lift associated with parenchymal reduction and also stud- All mastopexy procedures were bilateral. Many stud- ies on secondary mastopexy. Studies that did not ade- ies investigated outcomes using satisfaction questionnaires. quately define the subjects with unclear description of the Despite the lack of uniformity among studies, high satisfac- mastopexy technique, outcomes, or complications were ex- tion rates were generally reported. Complications occurred cluded. To avoid quantitative bias, studies including less in 197 (10.4%) of the 1888 patients. than 10 patients were also excluded from our quantitative The overall incidence of scar-related complications (in- analysis. They were, however, kept in the descriptive table cluding hypertrophic or unesthetic appearance) that po-

( Table 1 ) for qualitative description. tentially required revision surgery was 3%. 29 -related 246 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

2); 4;

page 13),

2)

= scar scar

=

the

4; 3

areola nipple

n =

small

n =

1);

(

= n

= of (third

n

in (

= next (

n nipple n

recurrence n nipple

( very

wound reversible

, on

mastopexy

7), 1)

1; reported

2

ptosis revision = =

flap =

= n n

breast, discomfort, speeding hypertrophic ( of insufficient reduction breast breast after ( healing, minimal retraction, hypertrophic n decrease sensation month), n Globular-shaped Scar None Delayed Complications Skin continued

(

of

(all

3.5 and

3–6

6 stable

to applied

retained,

years. satisfied,

in

(duration results);

satisfied outcome

recurrence

of

months satisfaction up

up.

breast. shape and improved, outcome

mentioned).

patients

the

9–42 ptosis all not

patients

ptosis sensation at follow in patients with follow-up: months-2 projection. Follow-up: months. results months follow-up. without of is Effective medium-sized ptotic All Successfully Pleasing Long-term Pleasing including General

with small

excess

severe of

large-sized

proposed

NAC

or

to ptosis , breast, breast

pole

authors

degree specified

the

(“Snoopy deformity”), ptotic moderate-sized ptotic gynecomastia. macromastia breast ptotic lower Prominent Mild Moderate Medium- Not by Indications

1 3a 2a/b 2a 2a Group

to

to

Flap by flap flap

is

NAC)

pedicle pedicle or

flap superior

Technique” to cranially

technique

the

or according IMF-N

Thoracic

to or

Over” fascia T T Circumareolar T T circumareolar Superior Superior Superior Bipedicled

de-epithelialization Redistribution/ Autoaugmentation Lower Fasciocutaneous Inferior SN-N distance inferior dermoglandular (opposite deep bipedicled anchored the (“Flip/flap”) De-epithelialized NAC: “Donut” mastopexy NAC: Parenchymal “Hexagonal NAC: “Fold NAC: Autoaugmentation NAC: Autoaugmentation Scar: Scar: Scar: Scar: Scar: Mastopexy

30 34

29–50 20–42; 19–57; patients

of reported reported

mean, mean, Not Range, Not Range, Range, (y) Age

Africa

USA USA Sweden South USA location Geographic studies.

of

included

13 12 10 22 124 patients No. 41

all

of

design

review review study review review Retrospective Prospective Retrospective Retrospective Study Retrospective

al., Characteristics

1998 1998

Year

et

1982 (first

1

al., al.,

1980 1991 et et Table Author listed), Gruber Elsahy, Svedman, Fayman Flowers Systematic review of outcomes and complications 247

)

1

7,

page =

=

n

scar,

n scars,

next

2

on =

hypertrophic

n dehiscence,

1 19 1

1;

necrosis,

necrosis, = = =

=

n unesthetic n hypercorrection, n n scar, Hypertrophic Skin Fat Prolonged Complications Partial continued

(

and

upper

chest years

and for

the

ptosis.

with cases

2 of

of

out. out,

position. upper

of in

upper breast

the

line. with

of patient avoidance

the maintained satisfaction term to

to

the appearance

and at

outcome least

satisfactory

fullness fullness fullness, and

surgeon

at

attraction moderate long technique

increases pole turgid for postoperation solves pole deficiency pole prevention bottoming bottoming anchoring breast wall of toward meridian mastopexy together implant. of Results in regard shape Early result and evaluation. Recommended Prevention Appropriate Maintenance The including General

lower

and

of

IMF mammary

emptiness

proposed

bottoming ptosis

secondary

and

authors pole

in

the

out mastopexy, pseudoptosis, stabilization pole, sufficient volume Upper Moderate Recurrent by Indications

2b 2bm 2am 2a Group

a

a

by by by by

flap

as

pedicle pedicle pedicle pedicle

flap support

pectoralis

based fascia

based to

technique

glandular

pole J

under

T, J Vertical T Superior Superior Superior Superior

posterior dermoglandular inferior flap loop/sling myofascial inferiorly lower superiorly dermoglandular “Hammock” flap attached pectoralis NAC: Autoaugmentation NAC: Autoaugmentation NAC: Autoaugmentation NAC: Autoaugmentation Scar: Scar: Scar: Scar: Mastopexy

35

19–58, patients

of reported reported reported

mean, Not Not Not Range, (y) Age

and

USA Russia Italy Spain Brazil location Geographic

of

24 390 3 28 patients No.

design )

review review review review Retrospective Retrospective Perspective Retrospective Study

continued

(

2005

Year al.,

(first

1999 1 Plaza

et al.,

la

2002 2004 et Table Author listed), Botti, Graf Borovikov, De 248 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

page

1; scar,

=

n next

conversion 1

on =

hypertrophic

for n

reported 2;

horizontal

=

need to n scar, None Complications , continued

(

to

of

pain

and the

ptosis

no

of of breast

8.8/10; plane

fascia fullness, by

8.4/10;

of problem

excessive

less and muscle. 7.8/10;

8.4/10.

into corrected

time. Breast the

satisfaction breast

pole is are outcome

the standard

cancer and with

OR contraction

lateral

posterior skin eliminated rotation breast. ptosis with mastopexy. screening and PEC and less anatomical dissect from correction, satisfaction symmetry, satisfaction upper 9.1/10; postoperative medial fullness, satisfaction contour, Disadvantage: Satisfaction The Avoids including General

loss,

lift

ptosis

proposed

of

body

weight

authors

grades the

Upper Massive All by Indications

3b 2bm Group

by flap

and

the

flap

T

T the

pedicle behind

fascial

to based

technique ICAP

pedicle around

wall an

Extended Vertical, Inferior Superior,

using rotated inferior anchored chest Superomedial, Superolateral inferiorly dermoglandular suspended pectoralis strip NAC: Autoaugmentation NAC: Autoaugmentation Scar: Scar: Mastopexy

46

31–62; patients

of reported

mean, Range, Not (y) Age

USA Australia location Geographic

of

5 52 patients No.

design )

review review Prospective Retrospective Study

continued

( al., Year

(first al.,

1

et

et

2006 2006 Table Author listed), Kwei Ritz Systematic review of outcomes and complications 249

2 )

=

3; n

2;

page

=

=

lift,

n scar

n decrease

NAC sensation next

using

month), on

1

reported nipple

=

(treated cortisone), reversible in (third elevation, inadequate n Hypertrophic Inadequate Complications None continued

(

of

roll a

the

need

true scar all pole; the

at

of

of

a

of result wall were fullness

in

out.

majority

the

autologous areolar lateral with better

satisfaction upper with

the result

pole

outcome

shape

years periareolar

chest vertical

for

less minimal addition

a

10 patients

surgeon’s evaluation cases; of pleased result. breast permanent at follow-up. empty the large mastopexy decreases for and distension. used , ensures upper without and bottoming Natural Autoaugmentation Pleasing Lateral including General

with

loss

around pole

proposed

skin

weight

authors upper

areola

the

excess the Empty Massive by Indications

2b 3am 2b Group

flap flap

T

under

T

J,

pedicle pedicle pedicle

loop/sling flap

technique inferior

posterior thoracic

an a a

Extended Vertical, T Superior Superior Superior

using dermoglandular “Double-Flap technique” using dermoglandular using Inferolateral glandular pectoralis NAC: Autoaugmentation NAC: Autoaugmentation NAC: Autoaugmentation Scar: Scar: Scar: Mastopexy

18–70 patients

of reported reported

Not Not Range, (y) Age

Canada Brazil Greece location Geographic

of

110 24 10 patients No.

design )

review review review Retrospective Retrospective Retrospective Study

continued

( al.,

2007

Year al.,

et (first

50

1

et al.,

et 2007 2008 Table Author listed), Foustanos Kirwan Graf 250 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

2

3; 2; 3;

8; skin

= page

= = =

3;

wound

n = wound

n

n n

3;

= out, n

1;

5

= 3; n

next

necrosis, = n =

=

nipple n n nipple pathologic

on n

extrusion,

of

flap 2; 3,

2

= =

=

necrosis, hematoma, mesh n asymmetry, loss sensation, bottoming n scars, dehiscence, dehiscence, skin n , , Complications Seroma, continued

(

a

low

flap

upper

the breast and

time.

negates

the the

of with to

rib an

the recurrent appearing

of of

dissection bra.

satisfaction

with adequate

to as same was during

outcome

fullness the

ability

case, implantation,

the

no acting internal ptosis observed. allows rotation into superomedial portions breast. pole youthful breast adequate projection ptosis time. periosteum the augment at

In Suturing Mesh Perforator Maintenance including General

in

a

with

tissue ptosis and

loss prevent

bypass,

breast

after

to

or proposed skin region. resulting

loss. rigid

lateral

weight

gastric

used

authors

recurrent

contralateral the be

the

the of correction rather reconstruction prosthesis. subcutaneous in thoracic patients from laparoscopic banding, exercise-induced weight Can Redundant Massive by Indications

4 3b 2b Group

to

at

to

are by

mesh

J

pedicle lateral with

flaps braided pedicle flap)

rib pedicle

with

secured

secured

technique

is The periosteum

intercostal

perforator

and

levels. Vertical

mound

,

(LICAP medial second rib

T Extended T Central Superior Inferior

Mastopexy reinforcement lateral artery flap dermoglandular pedicle the periosteum permanent suture. and raised the lower NAC: Central NAC: Autoaugmentation NAC: Central Scar: Scar: Scar: Mastopexy

9 −

41.7 48.5 \

17–65; 40–54; patients +

18–60,

of

mean, mean, mean 43.7 Range, Range Range, (y) Age

Nether-

lands Belgium USA The location Geographic

of

170 6 91 patients No.

design )

review review review Retrospective Retrospective Retrospective Study

continued

( al.,

2008 al.,

Year

(first

et

1 et

al.,

Bruijn

et 2009 2009 Table Author listed), de Hamdi Rubin Systematic review of outcomes and complications 251

)

page

next

on

reported

Complications None continued

(

of

to

the

of

and

on

the in

all

use

good after of

volume outcome to

in

volume

performed ptosis

the

based

satisfaction stable and

contour

breast results

and outcome

increasing

and evaluated

projection breast.

implant. the

surgical

while the apparent the shape of without an was according analyses before surgery pre- postoperative measurements. considered excellent cases; results long-term follow-up evaluation. Optimization The Esthetic Correction including General

their

of

desire

tissue.

ptotic

patients

proposed

who with

for

small authors

the

with breasts repositioning breasts autogenous Suitable by Indications

2b Group

flap NAC

the thoracic

based

technique the

to

behind

autoprosthesis T Superomedial

pedicle inferiorly dermoglandular for fixed wall NAC: De-epithelialized Scar: Mastopexy

48

patients

age,

of

Mean (y) Age

Germany location Geographic

of

27 patients No.

design )

review Retrospective Study

continued

( al.,

Year

(first

et 1

2009 Table Author listed), Honig 252 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

3

page

= scar,

n

2

1,

next =

sharp

=

n

on n hematoma, nipple

2, 1,

= =

fovea, hypertrophic n n asymmetry, Persistent Complications Seroma, continued

(

on

year score who range

with

was or in

high).

high

25 1

(2), months

poor

degree

to

two

3

months: years

(4):

or

as

(5%

the

to (16 19%) 3 very

showing 2 3.55,

breasts,

therapists satisfaction after

results reported assessment of average life. outcome

at

at

surgery, asked by (3),

changes

(69 high

95% two average photographic photographic

repercussions longer the

overall

minimal breasts, null 81%) sensitivity after no social satisfaction was and score 9.62; 9.84 of done the series patients beauty and receptionists, were the results or (1), good excellent average 2.5–4.0 The Results: Patients Esthetic including General

no

and breast

was

pedicle

the ptosis.

of implies one-stage in

alterations

a proposed

a it

and

interruption neurovascular

of

authors

negligible.

that technique technique

the

overcomes choice because dermal so section lymphatic are successful implant explantation, allowing explantation correction associated The The by Indications

1 2c Group

rotational

sulcus without

technique

superomedial interruption

with

T Vertical N/A Superomedial

dermal and blockage pedicle glandular mastopexy NAC: Mastopexy NAC: Extended Scar: Scar: Mastopexy

47.7

22–69; patients

of reported

Mean, Range, Not (y) Age

Italy Australia location Geographic

of

54 25 patients No.

design )

review review Retrospective Retrospective Study

continued

( 2009 2009

Year

(first

1

al., al.,

et et Table Author listed), Panettiere Corduff Systematic review of outcomes and complications 253

)

page

scar,

1;

necrosis, next

=

n on

healing, fat re-operation,

1

2; 4; 1

=

= = =

pathologic n n n n Seroma, Complications Delayed continued

(

the an

site

of while

of of of

cost

vessel

the which is

out”

the

persist with the

the

following

easily

as

with MLW the

the

to

donor of of pedicle

satisfaction gain loss. in reduction.

breasts particularly pole,

outcome can

augmentation more time. across

is potential

vascularity

flap robust patients, hypertrophy achieved weight preserved weight vertical scar incorporate brachioplasty excision. with natural-looking ptotic avoiding and complications implant augmentation. complication “bottoming associated inferior breast Achievement fullness upper appears with commonly Extension Robust The Combating including General

the

has

axilla

its

site

of or

this

lateral that the inferior the

of the the

out)

excess,

and

of to

proposed

donor pedicle

wall developed.

authors across reduces extension easily

technique

the

flap chest and vertical scar can incorporate brachioplasty excision. overcomes shortfalls inferior technique tendency descent (pseudoptosis bottoming been Transposition The by Indications

3b 2b Group

a

fill

to

around

T create

then

and pedicle pedicle.

flap

to

inferior inferior

technique are

together

tissue mastopexy:

parenchymal

pole

thoracic of

medial middle

Extended T Large Inferior

pedicle perforator upper pedicle The lateral columns sutured superiorly cone the NAC: Lateral NAC: Triplicated Scar: Scar: Mastopexy

patients

of reported reported

Not Not (y) Age

Kingdom United Australia location Geographic

of

6 50 patients No.

design )

review review Perspective Retrospective Study

continued

(

2010 2010

Year

(first

1

al., al.,

et et Table Author listed), Thornton Katsaros 254 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

page

1

the

=

2;

n of next

=

on n

extrusion material, Complications Seroma, continued

(

to

by the no

and

to

into

breast to

events

were judged

future

Four

one

average ptosis. offered have

meshes meshes.

posed

and

tissue, were average

the

of

asymmetry

to

satisfaction

breasts, and not outcome providing as

were satisfaction

reported.

mild

eliminating

rated

host risk

adverse absorbable have excellent. the material

outcomes

eventually incorporates the thus the infection nonabsorbable synthetic while necessary biomechanical strength persistence support tissue by synthetic rated excellent. patients judged ptosis have None to of no were was to All Patient This including General

a

in

even mesh

a skin

of

the proposed

resulting

provides

support, satisfactory,

authors

addition

the

between layers more thereby more long-lasting outcome. The by Indications

4 Group

tissue

adjunct pedicle

an

technique

as wrapped

periareolar

FortaPerm

Vertical Posterior

the

of

matrix around to double-skin technique NAC: Use Scar: Mastopexy

17–41 patients

of

Range, (y) Age

Brazil location Geographic

of

5 patients No.

design )

study Perspective Study

continued

( al., Year

(first

1

et

2010 Table Author listed), Goes Systematic review of outcomes and complications 255

)

1

page 6;

2;

1

= fat

=

n = =

2; n

n

n next

=

n on

nipple

reported

of

necrosis, sensation, infection, hematoma, Seroma, None Complications Loss continued

(

8

a

a the

the

skin

the

of

after

of

base,

using

central be and

want

and

patients of

of

the

breast

of

(Figures

with

were in

can

not All

satisfaction projection,

nipple the cases

shape. shape implant

breast

outcome breast

youthful

implant. do in 9).

mound narrowing lower raising inframammary crease, achievement more breast scar vertical techniques optimization breast breast removal who new shape, projection, upper fullness obtained and patients satisfied postoperative results. Restoration Minimization Satisfactory including General

to

a of

the on

of

after

would inferior

adding

after youthful

would

desire wide,

the

the selected

Patients

the an

capsular greatly

use a by supply

breasts of

of

the of proposed

who is

of of

of but

thoracic

removal

central

more

without implant the to

were

reposition

a implant authors

a

basis blood perforating

safety

the patients

preoperatively the presence low-lying lacking projection. expressed have breast addition implant. like augmentation mammaplasty breast removal reject new implant because contracture. nipple–areola complex enhanced the the branches internal artery pedicle.

Patients In The by Indications

2a 2b 2b Group

of

the

to

the

base implant

pedicle pedicle

medial

of the

tissue

or

technique

ligament

the central

projec-

narrowing breast

pedicle breast

+ raising

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glandular restore mound tion lower and inframammary crease. autoaugmentation after removal vertical, inverted-T Posteroinferomedial pedicle vertical Wuringer NAC: Transposition NAC: Inferior NAC: Retaining Scar: Scar: Scar: Mastopexy

54

40

22–47 16–68; patients

age,

of

mean Range, Mean Range, (y) Age

Africa

USA Germany South location Geographic

of

34 27 106 patients No.

design )

review review review Retrospective Retrospective Retrospective Study

continued

( 2010 al.,

Year

(first

al.,

et 1

al., et

Deventer

2010 2010 et Table Author listed), Kim Honig van 256 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

page

1

next

=

healing, on n

3

=

n Delayed Complications Seroma, continued

(

0

to

was

and

of is

cone,

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upper under

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implant. with

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frequently

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weight

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in skin

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flap

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of reported

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USA Egypt location Geographic

of

48 8 patients No.

design )

review review Retrospective Retrospective Study

continued

( al.,

2011

Year

(first et

1

al.,

2011 et

Table Author listed), Gheita \ Akyurek Systematic review of outcomes and complications 257

)

loss page

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scars,

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Recurrent At including General

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Support a

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of

mean, Mean, Range, Range, (y) Age

Africa

Italy South location Geographic

of

112 15 patients No.

design )

review review Retrospective Perspective Study

continued

( 2012 2012

Year

(first

1

al., al.,

Deventer

et et Table Author listed), van Persichetti 258 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

page

next

on healing,

reported 1

=

n None Complications Delayed continued

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to

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to dermal the

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strong

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31

34–71 patients

28–43,

of

mean, Range, Range (y) Age

USA Turkey location Geographic

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the

to

design )

Editor review Letter Retrospective Study

continued

( al.,

Year al.,

(first et

1

et

2012 2013 Table Author listed), Doft Gumus Systematic review of outcomes and complications 259

)

1; 13

page 2;

= =

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35

48

38–57, patients

age,

of reported

mean Mean Range, Not (y) Age

Kingdom United USA USA location Geographic

of

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design )

review review review Retrospective Retrospective Retrospective Study

continued

(

2013 2013 2014

Year

(first

1

al., al., al.,

et et et Table Author listed), Kelemen Gurunlouglu Hammond 260 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

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7 40 patients No.

design )

review review Retrospective Retrospective Study

continued

( al.,

al., Year

(first

et

1 et

2015 2015 Table Author listed), Patel Miotto Systematic review of outcomes and complications 261

)

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107 patients No.

design )

review Retrospective Study

continued

( al.,

Year

et (first

1

2015 Table Author listed), Kirwan 262 P. G . di Summa, C.M. Oranges and W. Watfa et al.

)

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2016

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reshape. reshape reshape

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Dermal Glandular Glandular Glandular 2016 et

Table Author listed), Ors Ikander 1. 2. 3. 4. 264 P. G . di Summa, C.M. Oranges and W. Watfa et al.

Figure 1 PRISMA flowchart.

Figure 2 Illustration explaining the dermal reshape technique (Type 1). Preoperative drawings include breast midline, IMF, and breast meridian. After de-epithelialization of the drawing, a significant amount of skin is removed through a circumareolar (A), 34 short circumvertical (B), 36 or inverted “T ”incision (C). 35 The skin envelope is reduced, and the NAC is lifted to the desired position. Incisions are closed with subcutaneous and dermal sutures. complications (dehiscence or generally delayed healing) oc- incidence of infection was the highest where mesh was curred overall in 0.6%. This was particularly observed in used (Type 4; infection 1.8%). In mastopexy with associated dermal reshape (Type 1) mastopexy, with a subgroup inci- supportive mesh, Van Deventer et al., reported a Strep- dence of 8.5%. Other notable complications had low overall tococcus milleri infection resulting in surgical exploration incidence and included hematoma (0.6%), seroma (0.5%), and partial excision of the mesh. 9 Other authors presented and (0.4%). Not unexpectedly, the subgroup infections that were treated empirically with antibiotic Systematic review of outcomes and complications 265

Figure 3 Superiorly based glandular remodeling for autoaugmentation (Type 2a). Preoperative drawings are based on Wise pattern, with preservation of a superiorly based parenchymal flap. After skin incision, the superior flap is raised over the pectoralis fascia (A). The flap is rotated cranially underneath and sutured high on the fascia to increase upper pole volume (B). 3 , 29 The medial and lateral pillars below are sutured together to narrow the breast base and add support. 4 , 27 , 28 , 39 , 40 The skin flaps are then redraped and closed in the standard fashion. Inferiorly/posteriorly based glandular remodeling for autoaugmentation (Type 2b). Preoperative drawings are based on Wise pattern. After skin excision, the NAC is isolated on a superiorly based pedicle, which is undermined over the fascia up to the level of the clavicle. The inferior flap is advanced upward into the space created and is sutured high on the pectoralis fascia to increase upper pole fullness (C, D). 2 , 12 –24 Sometimes the flap advanced under a sling of the muscle to guarantee durability in its new position. 8 , 10 , 11 Closure of the medial and lateral pillars over the flap optimizes projection. 31 The skin envelope is then redraped and closed in the standard fashion with the NAC in the desired position. Extended superomedial pedicle remodeling for autoaugmentation (Type 2c). Preoperative drawings are based on standard Wise pattern inverted-T mastopexy, and the desired NAC position is marked (E). Creation of a wide pedicle of approximately 4 cm is marked extending to encompass the superomedial intercostal vascular axis. The subglandular dissection is continued in a cranial direction, thereby creating a subglandular pocket behind the upper pole in the direction of the clavicle. The lower gland is then rotated through 90 ° into the upper pocket (F). 25 , 26 The lateral gland comes to lie beneath the upper pole. The skin envelope is then re-draped and closed in the standard fashion with the NAC in the desired position. 266 P. G . di Summa, C.M. Oranges and W. Watfa et al.

Figure 4 Glandular reshape was associated with an anterior ICAP flap (Type 3a) (A). Preoperative drawings are based on standard Wise pattern inverted-T mastopexy and the desired NAC position is marked. The superior flap containing the NAC is undermined over the fascia to dissect and prepare a retroglandular pocket for the flap. The larger the available flap for auto-augmentation, the narrower the keyhole angle will be to allow tension-free closure. The incision extends toward the LD anterior border. Then the thoracic flap with its lateral portion is de-epithelialized and fixed on the anterior chest wall. 41 , 44 The upper portion of the gland is sutured to the muscle plane at the second intercostal space, with medial and lateral pillars sutured together to improve the breast shape. The lateral gland comes to lie beneath the upper pole. The skin envelope is then re-draped and closed in the standard fashion with the NAC in the desired position. Illustration explaining the glandular reshape associated with a lateral ICAP flap (Type 3b) (B). Standard Wise pattern inverted-T mastopexy with parenchymal flaps is performed with the superior flap being undermined over the fascia to prepare a retroglandular pocket for the flap. The incision extends toward the LD anterior border. The dissection plane is above the muscle fascia. Once the posterior branch of the LICAP is visualized, the largest perforator is preserved, and the surrounding tissue is freed. A pedicle of length 3–5 cm is prepared until its origin at the level of the rib. Sufficient length of the pedicle will allow folding of the flap on itself to fill the central part of the breast. 46 Plication of the gland will increase projection. 43 , 45 , 46 –48 The skin envelope is then re-draped and closed in the standard fashion, with the NAC in the desired position. therapy with no specific laboratory investigations of bacte- upper pole fullness, facilitated by glandular reshaping and rial or mesh contamination. 7,18 reinforcement of the lower pole with the ultimate aim of a Unsatisfactory shape was present overall in 1.2% when long-lasting result WITH time. With regard to breast projec- combining suboptimal outcomes for both upper and lower tion improvement, the term “auto-augmentation” was first poles. However, the need for reoperation in such cases was applied to procedures using an autologous (typically glan- extremely rare. 31 dular) flap to increase upper pole fullness in contrast to the Nipple–areola complex (NAC) complications such as use of an implant. asymmetry, distortion, and necrosis were particularly rep- While other reviews have been published recently 32,33, resented in the dermal reshape (Type 1) group, exceeding no comprehensive literature review describing and classi- 15%. In other subgroups, the incidence did not exceed 1%. fying all mastopexy techniques according to surgical and Concerning NAC sensation, the worse performing subgroup anatomical concepts has been undertaken. Moreover, a was matrix-associated reshape (Type 4), with 5.7% report- combined publication of overall and technique-related out- ing a decrease/loss of sensation. Fat necrosis (0.9%) was comes and complications after mastopexy is lacking. We in- mainly linked to glandular remodeling mastopexies (Type 2) cluded 41 articles on 1928 patients treated by mastopexy and was generally managed conservatively. There were no without prosthesis, of which only the 34 articles including serious or life-threatening complications. All complications more than 10 patients were considered for quantitative out- and subgroup complications are reported in Table 2 . come ( n = 1888). Reported mastopexy procedures since the 1980 s were analyzed, which ranged from simple NAC eleva- tion to autologous augmentation using perforator flaps and Discussion the application of a supportive mesh. Techniques have been clearly classified below, with a standardized summary table. Mastopexy is the seventh most common cosmetic surgery In addition to its role in reporting the outcome and compli- procedure in the U.S. 1 During the recent decades, many cations of different techniques, this review could serve as mastopexy techniques have been described, all having com- an educational guide to orientate the reader in the mul- mon goals of improving breast projection and increasing the titude of described mastopexy techniques. The proposed Systematic review of outcomes and complications 267

Figure 5 Glandular reshape associated with mesh support (Type 4). The NAC pedicle is de-epithelialized. The breast gland is remodeled to obtain the desired conical shape with the appropriate upper pole lift. This new gland configuration should be fixed to the pectoral fascia by placing sutures before applying the synthetic mesh (A). The gland is then wrapped (usually at its lower pole as a brassiere) with the synthetic mesh to reinforce the shape and add support (B). 7 , 9 The mesh borders are sutured to the anterior chest wall over the pectoral fascia or over the rib periosteum with long-lasting resorbable sutures. Suturing of the mesh over the chest wall should ideally start at the meridian of the lower pole and ascend along the medial and lateral IMF, with an aim to create a conical shape. 6 The skin flaps are then redraped and closed in the standard fashion.

Table 2 Complications observed after mastopexy with all techniques ( N = 1888). Complications Type 1 Type 2 Type 3 Type 4 All Types ( N = 82) ( N = 1489) ( N = 35) ( N = 282) ( N = 1888) No. % No. % No. % No. % No. % Scar-related complications 7 8.5 41 2.8 1 2.9 7 2.5 56 3 (hypertrophic/unesthetic/scar revisions) Hematoma ––9 0.6 ––2 0.7 11 0.6 Seroma ––9 0.6 ––––9 0.5 Unsatisfactory breast volume (Inadequate ––1 0.1 ––––1 0.1 volume (very big/very small)) Unsatisfactory breast shape (insufficient breast 2 2.4 11 0.7 ––––13 0.7 lift/insufficient upper pole fullness/recurrence case) Wound healing-related complication (delayed ––11 0.7 ––––11 0.6 wound healing/) Lower pole unsatisfactory shape (bottoming ––7 0.5 ––3 1 10 0.5 out/conversion to T scar) NAC-related complication (nipple 13 15.9 8 0.5 ––3 1 24 1.3 retraction/nipple asymmetry/necrosis) NAC sensation (decrease/loss/reversible) ––14 0.9 ––16 5.7 30 1.6 Fat necrosis ––13 0.9 ––––13 0.7 Skin flap necrosis ––5 0.3 ––3 1 8 0.4 Infection ––2 0.1 ––5 1.8 7 0.4 Edema 2 2.4 ––––––2 0.1 Mesh extrusion N/A N/A N/A N/A N/A N/A 2 0.7 2 0.1 Total number of complications 24 29.3 131 8.8 1 2.9 41 14.5 197 10.4 268 P. G . di Summa, C.M. Oranges and W. Watfa et al. classification is intended to simplify and regroup a variety Glandular reshape (Type 2) of techniques found in the literature. Overall satisfaction and complication rates across the Glandular reshape mastopexy is the most used technique, spectrum of mastopexy techniques were determined. The with 1492 cases described in this literature review (77% great heterogeneity of the study populations is acknowl- of all cases). This technique provides for increased upper edged, while potential selection bias and lack of uniformity pole fullness, with stable results at over 2 years being re- in measured outcomes prevented a proper meta-analysis ported. 3,13 Many procedural variations have been described and statistical comparisons among groups. Moreover, the with regard to gland dissection and pedicle isolation. largely favorable reported outcome despite many differ- Superior pedicle techniques (Type 2a) (used in 340 pa- ent techniques suggests that author-related biases cannot tients out of 1492, approximately 23% of glandular reshape be excluded. These biases were critically analyzed, high- mastopexy) are generally characterized by a dermoglandu- quality studies selected, and a systematic analysis in terms lar superior pedicle, which is de-epithelialized and raised on of surgical anatomy was performed to provide the reader a prepectoral plane to reposition the NAC while also filling with a clear classification of different techniques and their the upper pole. Further variations to the superiorly based potential complications. flap, which is anchored as a “hammock” to the pectoralis fascia, are the de-epithelialized lateral and medial flaps to

further increase medial and superior projection. 27 Muscular components of the pectoralis major can be integrated with Dermal reshape (Type 1) this technique, using the superior pedicled dermoglandular flap to improve upper pole fullness and a myofascial sup- A direct de-epithelialization with reduction in the skin en- portive flap to redefine the IMF and protect from bottoming velope can result in breast tightening and uplift. out. 10 The most used glandular reshape technique to im- prove breast contour and lift is the inferior pedicle-based

Outcome mastopexy (Type 2b), popularized by Botti et al., in 1999. 13 This technique recalls the publication of Ribeiro et al., on

Among the three articles published between 1980 and 2016, glandular remodeling in breast reductions. 38 According to generally favorable outcomes in terms of patient satisfac- the authors’ statements, this technique assures upper pole tion and low morbidity were noted. fullness while preventing or limiting bottoming out with

time. 13,15 The concept of “autoaugmentation” without the use of an implant is related to the role of the inferior gland,

which is used as an autologous prosthesis. 2,14 The inferior

Complications gland that is mobilized and responsible for breast projection does not interfere with NAC vascularization, which is still Gruber et al., reported esthetically unsatisfactory areola maintained on a superior pedicle of at least 2 cm thickness. 2 spreading and hypertrophic scars in more than half of While choosing between 2a and 2b techniques is largely au- treated patients. 34 Ptosis recurred in almost 15% of the thor dependent and shares the same indications (moderate patients. Direct tension on the dermis and skin may have to severe ptosis, weight loss, and need for upper pole full- been the cause of NAC distortion and scarring. For these ness), the gland reshaping technique is often dictated by reasons, circumareolar and circumvertical dermal reshape the technique that best maintains soft tissue vascularity. mastopexies have historically been one of the most liti- When the patient requires a minimal to moderate NAC el- gious procedures performed. However, more recent reports evation (up to 6 cm) and has a small breast, a superior pedi- 35 showed a very high overall satisfaction (95%) and lower cle may be more suitable. For ptosis with particularly lax scar morbidity 36 using purse string periareolar closure. 37 lower pole, glandular reshape (Type 2b) techniques are par- ticularly suitable. Moreover, when patients have previously undergone breast augmentation through infra-areolar inci- Technical Box: sion and desire implant removal with autologous mastopexy, √ Applied to small to moderate volume breasts. an extended superiorly based glandular flap may be com- √ promised. In such cases, inferiorly based autoaugmentation Applied in excessive skin envelope without a great 22 need for NAC lift. techniques are most certainly indicated. √ Different patterns of incision (circular 34, Finally, the literature review showed 65 cases of ex-

circumvertical 36, and inverted-T 35). tended superolateral or rotational glandular techniques √ (Type 3c) and represented the minority of glandular re- Advantages: The technique is simple, reproducible, 25,26 and fast and requires no NAC pedicle because there shaping mastopexies (4%). In this technique, upper pole

is no dermal interruption. fullness is created by the recruitment of glandular volume √ Drawbacks: Less long-lasting result because of designed on a superomedial pedicle, similar to a breast

skin quality dependence and lack of glandular reduction technique but without parenchyma resection.

reshape/support. The authors suggest avoidance of this technique in smokers, as the glandular edges may be poorly perfused and induce

liponecrosis and further complications. 26 Systematic review of outcomes and complications 269

Outcome Glandular reshape associated with perforator flaps (Type 3) All authors agree that in the former group, results may be better maintained than those in the latter group across Sixty-seven patients out of 1928 cases included in this re- 14 , 16 the years with regard to breast shape and position. Es- view (3.5%) underwent autoaugmentation mastopexy using thetic results were considered good to excellent in almost local flaps based on different perforasomes to assure vas- all cases, thus maintaining projection without the need for cularization. The anatomy of perforators and perforasomes implants, narrowing the lower breast base, raising the in- originating from the has been largely framammary crease, and achieving a more youthful breast studied. 41,42 The main indication for this technique is the shape. patient with massive weight loss (MWL), where perforators have particularly reliable caliber and flap perfusion is as-

sured. 43 Perforator flaps for mastopexy were divided into Complications two categories: Type 3a (thoracic/anterior ICAP flaps) and 3b (lateral ICAP flaps). The flap can be extended laterally Glandular reshape techniques have been associated with a and associated with myofascial components. relatively low complication rate (8.8%). Among these tech- niques, seroma and hematoma were minimal (less than 1%). Outcome Although fat necrosis could be potentially underestimated because of not being always clinically evident, symptomatic In the authors’ statement, patients were satisfied by the fat necrosis after gland mobilization was 0.9%. No clear pleasant shape 48, with better projection, appropriate nip- association of fat necrosis with smoking patients was de- ple position, and shape at 12 months postoperatively. 41 Oth- scribed in the literature analyzed. ers have stated that a more natural looking breast, even Despite the common T-shape scar closure, scar-related if moderately ptotic, should be preferred in patients with complications occurred in 2.8%, which was significantly MWL, thereby avoiding the cost and complication of im- lower than that in the dermal reshape group. This goes plant surgery. 43 Satisfaction was generally favorable, with in line with the concept of improving the breast contour Akyurek et al reporting good to excellent outcomes in 75% by acting on the glandular structure rather than relying on of the operated cases. 49 the skin envelope only. This explains the limited number of cases where the breast shape was unsatisfactory, with ptosis Complications recurrence or need for reoperation (1.2%). In these cases, bottoming out was evident in less than 1% of cases. The patient should be advised of higher complication rates due to extensive undermining, possibly jeopardizing lym- phatic drainage. Wound healing and scar-related complica- Technical Box: tions (globally accounting for 2.9%) are similarly attributed

√ to longer incisions, poorer skin quality, and suboptimal pa-

√ Most common technique. tient nutritional state. Remodeling can be achieved using superior (2a),

√ inferior (2b), and superomedial (2c) pedicles. Applied in moderate to severe breast ptosis with Technical Box:

empty upper pole. 15, 24 √ √ In type 2a: pedicle is limited to the central part of Indication for this technique is the patient with 39 the gland or can encompass the entire inferior √ massive weight loss (MWL). pole of the breast (“extended”), with the length of Perforator flaps are divided into two categories: the lateral wings of the flap not exceeding three type 3a (thoracic/anterior ICAP flaps) and 3b 4,28,40 √ times their base width. (lateral ICAP flaps). 13 , 14 √ The gland can sutured to the deep fascia or to Practically, the lower pole of a Wise pattern can 15 the rib periosteum in the medial superior portion be advanced cranially without the need of

of the breast at about the level of the third 41 √ perforator skeletonization.

√ intercostal space. LICAP flaps can be also inset in the Myofascial flap may be added for support and retroglandular region under a pectoralis major

protection from bottoming out. 49 √ √ sling. Advantage: It produces a long-lasting result because In patients with MWL, the axillary “back roll” excess

√ the breast does not rely only on the skin envelope. can be isolated on the lateral intercostal artery Drawback: Gland remodeling needs to be performed perforators (LICAP) and transferred cranially to to maintain an effective vascularization to the provide upper pole fullness and superomedial

glandular flaps, and an excessive remodeling should 51 √ projection. be avoided in smokers considering the risk of Advantage: Can be combined with other upper body

liponecrosis. 43,47 √ dermolipectomy. Drawback: Requires more technical skills and operative time. 270 P. G . di Summa, C.M. Oranges and W. Watfa et al.

Glandular reshape associated with synthetic Conclusion mesh (Type 4) After comprehensively analyzing the literature published Glandular reshape associated with synthetic mesh was the since 1980 to present, we could identify four main techni- last group revealed by this comprehensive review. The mesh cal approaches to mastopexy without the use of implants; acts as an internal breast support to replace the function all correlated to high satisfaction rates for patients and of the weakened suspension of Cooper’s ligaments. With surgeons. Indeed, the largely favorable reported outcomes 287 described cases (14.9% of patients analyzed in this re- despite many different techniques indicate that author- view), this technique reduces recurrent breast ptosis with related and publication biases cannot be excluded. stable long-term results. 7,9 Indications for this technique in- This review showed a low rate of infective complica- clude patients with high expectations, large ptotic breasts tions (0.4%), with a satisfactory breast shape and less than with thin skin of poor quality, 9 or contralateral symmetrizing 1.5% incidence of insufficient upper pole fullness, insuffi- mastopexy following a relatively rigid cient breast lift, or bottoming out. This was particularly ev- with a prosthesis. 7 ident when a glandular reshape was performed. The type of mesh used was either polyester/polyglactin Supplementary autoaugmentation procedures using lo- or Vicryl/Prolene. In most cases, the mesh was placed over cal flaps based on intercostal perforators are particularly the gland and sutured to the chest wall. 32 Meshes were well indicated in cases of MWL, thereby resulting in desir- tolerated and easy to remove if necessary. 7 able patient satisfaction despite the price of increased scarring and wound-related complications. Circumvertical or inverted-T scars were the most used patterns, and

Outcome patients should be advised of likely cosmetic outcomes according to the pre-existing skin excess, breast ptosis,

Patient satisfaction with this technique was rated from av- and residual volume. They should be fully counseled of the erage to excellent. 6 potential complications, which include scar (3%)- and NAC (2.9%)-related problems. Given the variety of indications and surgical techniques, it should be performed by highly qualified board-certified Complications plastic surgeons to ensure efficacy and safety. The fourfold increased rate of infection (1.8%) compared to the overall infection rate of mastopexy (0.4%) could be Disclosures expected in this group because of the addition of a for- eign body. Another significant increase was noticed in the The authors declared no potential conflicts of interest with rate of complications related to NAC sensation (5.7 vs. 1.6% regard to the research, authorship, and publication of this overall). This may be accounted for by the necessary de- article. gloving of the breast skin in preparing the mesh recipient site. However, other nipple-related complications such as nipple retraction, asymmetry, and necrosis remained low Funding (1%). This observation potentially indicates that the breast parenchyma is effectively supported with consequent re- The authors received no financial support for the research, duction in traction applied to the NAC. authorship, and publication of this article.

Technical Box: Supplementary material

√ Indication is patients with poor skin quality 9 or Supplementary material associated with this article can be

7 found, in the online version, at doi: 10.1016/j.bjps.2018.10. √ recurrent cases. No interference with monitoring for 018 . was reported, and the mesh was not radiologically

6 √ evident during follow-up. Advantage: Reduces recurrent breast ptosis with Appendix

√ stable long-term results. Drawback: Higher infection rate. Illustration summarizing the 41 retained articles divided into the four main technique approaches with subcate- gories. ∗use of a pectoral muscular component; ICAP: Inter- We have to acknowledge that this review has some limi- costal Artery Perforator tations. First, there is a need to standardize outcomes (e.g., breast Q, measurements of key breast parameters, com- plication profile, and breast cancer assessment follow-up). References Prospective databases should be developed with these prin- ciples to reduce bias error and offer a more objective as- 1. Surgeons ASoP., https://www.plasticsurgery.org/news/plastic- sessment for this broad spectrum of techniques. surgery-statistics ; 2016 . Systematic review of outcomes and complications 271

2. Kirwan L . Breast autoaugmentation. Can J Plast Surg Surg 2013; 37 (2):349–53 [published Online First: Epub Date]|. 2007; 15 (2):73–6 . doi: 10.1007/s00266- 013- 0079- 3 . 3. Flowers RS , Smith EM Jr . "Flip-flap" mastopexy. Aesthet Plast 20. Gurunluoglu R , Kubek E , Arton J . Dual pedicle mastopexy tech- Surg 1998; 22 (6):425–9 . nique for reorientation of volume and shape after subglandular 4. Gumus N. A versatile modification of dermoglandular hammock and submuscular removal. Eplasty 2013; 13 :e48 . flap for mastopexy: Extended hammock. J Plast Surg Hand Surg 21. Hammond DC, O’Connor EA. The lower island flap transpo- 2013; 47 (4):252–7 [published Online First: Epub Date]|. doi: 10. sition (LIFT) technique for control of the upper pole in cir- 3109/2000656X.2012.753080 . cumvertical mastopexy. Plast Reconstr Surg 2014; 134 (4):655– 5. Ross GL. One stage mastopexy augmentation in the ptotic 60 [published Online First: Epub Date]|. doi: 10.1097/PRS. patient. The superiorly based dermal flap for autologous re- 0000000000000521 . inforcement of the inferior pole. J Plast Reconstr Aesthet 22. Kirwan L, Wazir U, Mokbel K. Breast auto-augmentation: A ver- Surg 2015; 68 (9):1248–54 [published Online First: Epub Date]|. satile method of breast rehabilitation-a retrospective series of doi: 10.1016/j.bjps.2015.05.005 . 107 procedures. Arch Plast Surg 2015; 42 (4):438–45 [published 6. Goes JC, Bates D. Periareolar mastopexy with FortaPerm. Aes- Online First: Epub Date]|. doi: 10.5999/aps.2015.42.4.438 . thet Plast Surg 2010; 34 (3):350–8 [published Online First: Epub 23. Ikander P, Gad D, Gunnarsson GL, et al. Simple reshaping of Date]|. doi: 10.1007/s00266- 009- 9462- 5 . the breast in massive weight loss patients: Promising prelimi- 7. de Bruijn HP, Johannes S. Mastopexy with 3D preshaped mesh nary results. Ann Plast Surg 2017; 78 (2):145–8 [published Online for long-term results: Development of the internal bra system. First: Epub Date]|. doi: 10.1097/SAP.0000000000000816 . Aesthet Plast Surg 2008; 32 (5):757–65 [published Online First: 24. D’Aniello C, Cuomo R, Grimaldi L, et al. Superior pedicle Epub Date]|. doi: 10.1007/s00266- 008- 9186- y . mammaplasty without parenchymal incisions after massive 8. Graf R , Biggs TM . In search of better shape in mastopexy and re- weight loss. J Invest Surg 2016:1–11 [published Online First: duction mammoplasty. Plast Reconstr Surg 2002; 110 (1):309–17 Epub Date]|. doi: 10.1080/08941939.2016.1240837 . discussion 18-22 . 25. Corduff N, Taylor GI. Rotation mastopexy: An anatomi- 9. van Deventer PV, Graewe FR, Wuringer E. Improving the cal approach. Aesthet Plast Surg 2009; 33 (3):377–85 discus- longevity and results of mastopexy and sion 86-7[published Online First: Epub Date]|. doi: 10.1007/ procedures: Reconstructing an internal breast support sys- s00266- 009- 9340- 1 . tem with biocompatible mesh to replace the support- 26. Miotto GC, Eaves FF 3rd. The circumrotational technique for ing function of the ligamentous suspension. Aesthet Plast mastopexy. Aesthet Surg J 2015; 35 (7):796–809 [published On- Surg 2012; 36 (3):578–89 [published Online First: Epub Date]|. line First: Epub Date]|. doi: 10.1093/asj/sjv093 . doi: 10.1007/s00266- 011- 9845- 2 . 27. Gheita A, Moftah A. Breast ptosis managed by mastopexy using 10. Borovikov A. Use of myofascial flaps in aesthetic . the triple flaps procedure. Aesthet Plast Surg 2011; 35 (1):107– Aesthet Surg J 2004; 24 (4):331–41 [published Online First: Epub 15 [published Online First: Epub Date]|. doi: 10.1007/ Date]|. doi: 10.1016/j.asj.2004.04.002 . s00266- 010- 9545- 3 . 11. Ritz M , Silfen R , Southwick G . Fascial suspension mastopexy. 28. Kim P, Kim KK, Casas LA. Superior pedicle autoaugmenta- Plast Reconstr Surg 2006; 117 (1):86–94 . tion mastopexy: A review of 34 consecutive patients. Aesthet 12. Fayman MS . Short scar mastopexy with flap transposition. Aes- Surg J 2010; 30 (2):201–10 [published Online First: Epub Date]|. thet Plast Surg 1998; 22 (2):135–41 . doi: 10.1177/1090820X10366009 . 13. Botti G. Vertical Scar mammaplasty: Stable padding of the 29. Elsahy NI . The hexagonal technique for mastopexy and superior pole by means of a posteriorly based pedicle auto- reduction mammoplasty. Aesthet Plast Surg 1982; 6 (2): prosthesis. Aesthet Surg J 1999; 19 (2):116–23 [published Online 107–115 . First: Epub Date]|. doi: 10.1053/aq.1999.v19.97039 . 30. Moher D , Liberati A , Tetzlaff J , Altman DG , Group P . Preferred 14. Foustanos A, Zavrides H. A double-flap technique: An alterna- reporting items for systematic reviews and meta-analyses: The tive mastopexy approach. Plast Reconstr Surg 2007; 120 (1):55– PRISMA statement. Ann Intern Med 2009; 151 (4):264–9 W64 . 60 [published Online First: Epub Date]|. doi: 10.1097/01.prs. 31. Katsaros J, Harvey I, Caplash Y. The triplicated inferior 0000263320.57385.a2 . pedicle—a new method for breast reduction and mastopexy. J 15. Rubin JP, Gusenoff JA, Coon D. Dermal suspension and Plast Reconstr Aesthet Surg 2010; 63 (7):1131–5 [published On- parenchymal reshaping mastopexy after massive weight loss: line First: Epub Date]|. doi: 10.1016/j.bjps.2009.05.041 . Statistical analysis with concomitant procedures from a 32. Hidalgo DA, Spector JA. Mastopexy. Plast Reconstr Surg prospective registry. Plast Reconstr Surg 2009; 123 (3):782– 2013; 132 (4):642e–656e [published Online First: Epub Date]|. 9 [published Online First: Epub Date]|. doi: 10.1097/PRS. doi: 10.1097/PRS.0b013e31829fe4b4 . 0b013e31819ba1a8 . 33. Wong C, Vucovich M, Rohrich R. Mastopexy and reduction mam- 16. Honig JF, Frey HP, Hasse FM, Hasselberg J. Inferior pedicle au- moplasty pedicles and skin resection patterns. Plastic Reconstr toaugmentation mastopexy after breast implant removal. Aes- Surg Global open 2014; 2 (8):e202 [published Online First: Epub thet Plast Surg 2010; 34 (4):447–54 [published Online First: Epub Date]|. doi: 10.1097/GOX.0000000000000125 . Date]|. doi: 10.1007/s00266- 010- 9471- 4 . 34. Gruber RP , Jones HW Jr . The "donut" mastopexy: Indications 17. Honig JF, Frey HP, Hasse FM, Hasselberg J. Autoaugmentation and complications. Plast Reconstr Surg 1980; 65 (1):34–8 . mastopexy with an inferior-based pedicle. Aesthet Plast Surg 35. Panettiere P, Marchetti L, Accorsi D. The ’underwire bra’ 2009; 33 (3):302–7 [published Online First: Epub Date]|. doi: 10. mastopexy: A new option. J Plast Reconstr Aesthet Surg 1007/s00266- 009- 9310- 7 . 2009; 62 (7):e231–5 [published Online First: Epub Date]|. 18. van Deventer PV, Graewe FR. Enhancing pedicle safety in doi: 10.1016/j.bjps.2009.03.015 . mastopexy and breast reduction procedures: The posteroin- 36. Doft MA, Hardy KL, Ascherman JA. The "fish" mastopexy. Plast feromedial pedicle, retaining the medial vertical ligament of Reconstr Surg 2012; 129 (5):865e–866e [published Online First: Wuringer. Plast Reconstr Surg 2010; 126 (3):786–93 [published Epub Date]|. doi: 10.1097/PRS.0b013e31824a9ea7 . Online First: Epub Date]|. doi: 10.1097/PRS.0b013e3181e5f7da . 37. Hammond DC, Khuthaila DK, Kim J. The interlocking Gore- 19. Kelemen N, Kannan RY, Offer GJ. A stacked technique Tex suture for control of areolar diameter and shape. Plast of mastopexy: Volume redistribution mastopexy with infe- Reconstr Surg 2007; 119 (3):804–9 [published Online First: Epub rior flap and superomedially based pedicle. Aesthet Plast Date]|. doi: 10.1097/01.prs.0000251998.50345.e9 . 272 P. G . di Summa, C.M. Oranges and W. Watfa et al.

38. Ribeiro L . A new technique for reduction mammaplasty. Plast 46. Patel NB, Wong MS. Extended fasciocutaneous flaps for au- Reconstr Surg 1975; 55 (3):330–4 . tologous augmentation mastopexy with upper body lift af- 39. de la Plaza R, de la Cruz L, Moreno C. Mastopexy utilizing a ter massive weight loss: An early experience. Ann Plast Surg dermoglandular hammock flap. Aesthet Surg J 2005; 25 (1):31–6 2015; 74 (Suppl 1):S41–5 [published Online First: Epub Date]|. [published Online First: Epub Date]|. doi: 10.1016/j.asj.2004. doi: 10.1097/SAP.0000000000000413 . 11.006 . 47. Kwei S, Borud LJ, Lee BT. Mastopexy with autologous augmen- 40. Ors S. Autoaugmentation mastopexy modification prevents tation after massive weight loss: The intercostal artery perfora- bottoming-out deformity and areola distortion: A preliminary tor (ICAP) flap. Ann Plast Surg 2006; 57 (4):361–5 [published On- report. Aesthet Plast Surg 2016; 40 (4):497–506 [published On- line First: Epub Date]|. doi: 10.1097/01.sap.0000222569.59581. line First: Epub Date]|. doi: 10.1007/s00266- 016- 0652- 7 . d9 . 41. Persichetti P, Tenna S, Brunetti B, Aveta A, Segreto F, 48. Svedman P . Correction of breast ptosis utilizing a "fold over" Marangi GF. Anterior intercostal artery perforator flap au- de-epithelialized lower thoracic fasciocutaneous flap. Aesthet tologous augmentation in bariatric mastopexy. Plast Reconstr Plast Surg 1991; 15 (1):43–7 . Surg 2012; 130 (4):917–25 [published Online First: Epub Date]|. 49. Akyurek M. Vertical mastopexy and lateral intercostal artery doi: 10.1097/PRS.0b013e318262f38a . perforator (LICAP) flap with pectoralis muscle sling for au- 42. Losken A, Holtz DJ. Versatility of the superomedial pedi- tologous tissue breast augmentation in the bariatric patient. cle in managing the massive weight loss breast: The Ann Plast Surg 2011; 66 (1):29–35 [published Online First: Epub rotation-advancement technique. Plast Reconstr Surg Date]|. doi: 10.1097/SAP.0b013e3181d6e28a . 2007; 120 (4):1060–8 [published Online First: Epub Date]|. 50. Graf RM, Mansur AE, Tenius FP, Ono MC, Romano GG, Cruz GA. doi: 10.1097/01.prs.0000278004.24650.e6 . Mastopexy after massive weight loss: Extended chest wall- 43. Thornton DJ, Fourie le R. Autologous augmentation-mastopexy based flap associated with a loop of pectoralis muscle. Aes- after bariatric surgery: Waste not want not!. Aesthet Plast thet Plast Surg 2008; 32 (2):371–4 [published Online First: Epub Surg 2010; 34 (4):519–24 [published Online First: Epub Date]|. Date]|. doi: 10.1007/s00266- 007- 9062- 1 . doi: 10.1007/s00266- 010- 9479- 9 . 51. Hamdi M, Van Landuyt K, Blondeel P, Hijjawi JB, Roche N, Mon- 44. Oranges CM, Tremp M, di Summa PG, et al. Gluteal augmen- strey S. Autologous breast augmentation with the lateral inter- tation techniques: A comprehensive literature review. Aesthet costal artery perforator flap in massive weight loss patients. J Surg J 2017; 37 (5):560–9 [published Online First: Epub Date]|. Plast Reconstr Aesthet Surg 2009; 62 (1):65–70 [published On- doi: 10.1093/asj/sjw240 . line First: Epub Date]|. doi: 10.1016/j.bjps.2007.10.046 . 45. Oranges CM, Haug M, Schaefer DJ. Body contouring. Plast Reconstr Surg 2016; 138 (5):944e–945e [published Online First: Epub Date]|. doi: 10.1097/PRS.0000000000002724 .