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Systematic Review of Outcomes and Complications in Nonimplant-Based Mastopexy Surgery

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2019) 72, 243–272 Review Systematic review of outcomes and complications in nonimplant-based mastopexy 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 Plastic Surgery 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 Breast 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. Ptosis 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 scar-related (3%, including hypertrophic or unesthetic appearance) and nipple–areola- 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 scars, 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 pectoral fascia, to the use of synthetic remodeling some of the breast gland in addition to skin 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 dermis 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.
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