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Getting the Most out of Augmentation-Mastopexy

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Getting the Most out of Augmentation-Mastopexy CME 09/12/2019 on FLEYIVGvEagp17sopd7feT1nW3NEh04n7A5o1Nc3Pc1yeAYwAeBzFH03q3QA2KAGm9ESHjlM8dLD6qM1HQxYiIoZrjtPEuCn4NWKg58hUj17m7x3X3uECAAs8PV9bUkmzL4lE+LdX3FolQN6XibP3kSVFkaSsy511R6tlYKqEWg= by https://journals.lww.com/plasreconsurg from Downloaded Getting the Most Out of Augmentation-Mastopexy Downloaded Konrad Sarosiek, M.D. Learning Objectives: After reviewing the article, the participant should be able G. Patrick Maxwell, M.D. to: 1. Understand the tenets of proper patient selection. 2. Be familiar with from Jacob G. Unger, M.D. https://journals.lww.com/plasreconsurg the assessment of patients for augmentation-mastopexy. 3. Be able to plan an Nashville, Tenn. operative approach and execute the critical steps. 4. Be able to recognize com- mon complications and have a basic understanding of their management. 5. Be aware of emerging adjunctive techniques and technologies with respect to augmentation-mastopexy. Summary: Despite being a multivariable and complex procedure, augmen- tation-mastopexy remains a central and pivotal component of the treatment by FLEYIVGvEagp17sopd7feT1nW3NEh04n7A5o1Nc3Pc1yeAYwAeBzFH03q3QA2KAGm9ESHjlM8dLD6qM1HQxYiIoZrjtPEuCn4NWKg58hUj17m7x3X3uECAAs8PV9bUkmzL4lE+LdX3FolQN6XibP3kSVFkaSsy511R6tlYKqEWg= algorithm for ptotic and deflated breasts among plastic surgeons. Careful pre- RELATED VIDEO CONTENT IS AVAILABLE operative planning, combined with proper selection of approach and implant, ONLINE. can lead to success. Physicians need to understand that there is a high fre- quency of reoperation cited in the literature with regard to this procedure, and discussions before the initial operation can help alleviate common misun- derstandings and challenges inherent in this operation. (Plast. Reconstr. Surg. 142: 742e, 2018.) ince its first description by Gonzalez-Ulloa better results and improve patient outcomes when in 1960, augmentation-mastopexy has con- combining mastopexy with breast augmentation tinued to evolve into its many permutations in an effort to decrease complications. S 1,2 and become a close ally of the plastic surgeon. Although the majority of cosmetic breast sur- As litigation has become commonplace within the gery has been aimed primarily at combating post- medical community, plastic surgery has also felt partum deflation and age-related changes, the its reach, and augmentation-mastopexy remains landscape has begun to shift. In the year 2016, over one of most litigated procedures in the cosmetic 216,000 bariatric procedures were performed, and population.3 Perhaps the root of dissatisfaction the numbers are expected to continue to rise.8–10 and pursuit of litigation is the perpetual chal- As massive weight loss patients become a grow- lenge augmentation-mastopexy poses: the com- ing portion of the plastic surgery practice, special bination of two procedures working against one circumstances need to be considered in working another.4,5 By definition, a breast augmentation with their specific tissue characteristics and their centers on using volume to expand breast tissue, perioperative care. Although a complete review of whereas mastopexy constitutes reducing the soft- augmentation-mastopexy is beyond the scope of tissue envelope by the excision and redraping of this article, we focus on the most common meth- skin and parenchyma.6,7 Thus, we are creating a ods of reconstruction and highlight some of the smaller pocket and subsequently trying to fill it new emerging techniques, surgical and nonsurgi- with more volume. Several authors have pointed cal, being discussed today. out that the combination of these two operations does not simply add the individual complications numerically, but rather results in an exponential increase.5 Therefore, an abundance of articles Disclosure: Dr. Sarosiek has no financial interests have since been published portraying modifica- to disclose. Dr. Maxwell is a paid consultant to Al- tions of widely accepted techniques to produce lergan. Dr. Unger is a member of the Allergan speak- on ers bureau. No funding was received for this article. 09/12/2019 From the Department of Plastic Surgery, Vanderbilt Related Video content is available for this University Medical Center; and Maxwell Aesthetics. article. The videos can be found under the Received for publication March 7, 2018; accepted June 19, “Related Videos” section of the full-text article, 2018. or, for Ovid users, using the URL citations pub- Copyright © 2018 by the American Society of Plastic Surgeons lished in the article. DOI: 10.1097/PRS.0000000000004961 742e www.PRSJournal.com Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 142, Number 5 • Augmentation-Mastopexy PREOPERATIVE ASSESSMENT will lead to a greater chance for success and reduced complications.18,19 One of the more dire Patient Evaluation examples, an elevation of homocysteine levels A thorough patient evaluation is clearly in bariatric patients, can result in a hypercoag- paramount, with extensive emphasis placed on ulable state with a predisposition for recurrent the patient’s expectations (e.g., breast size, nip- venous thrombosis.20,21 ple position, scarring) and emotional sense.11 Knowledge of previous breast surgery, elective Being diligent to identify characteristics of psy- or reconstructive, will inevitably affect surgical chological disorders such as body dysmorphic planning regarding approach, incision, implant disorder before a surgical intervention can pocket, and closure. Obtaining prior operative help prevent untoward outcomes.12 A review of reports can help avoid common pitfalls, such as a patient’s history with a focus on desires for injury to a previous pedicle, with potentially dev- future breastfeeding, weight loss, abnormal astating outcomes. bleeding, occupation, history of cancer with or without radiation therapy, and behavioral habits Physical Examination such as smoking or illicit substance use must be A comprehensive, detailed physical exami- performed.13 A multitude of studies have dem- nation is required. Specifically, assessments of onstrated adverse effects associated with smok- skin quality, tone, and elasticity are used in com- ing, including an increased risk of necessitating bination with metric measurements for opera- revision surgery; thus, current recommenda- tive planning. With the patient standing, the tions do not endorse operating on smokers.14,15 surgeon must first appreciate any discrepancies Haeck et al. have created an evidence-based between both breasts; not only are these discrep- patient safety advisory, which includes a check- ancies those that are perceived by the surgeon’s list and is available on the American Society eye, but inquiry into the patient’s concerns are of Plastic Surgeons website free of charge13,16 warranted as well, ensuring adequate commu- (https://www.plasticsurgery.org/for-medi- nication between the surgeon and patient. The cal-professionals/resources-and-education/ degree of ptosis is assessed by examination of the patient-safety-resources/patient-selection). nipple position with regard to the inframammary Evaluation of the massive weight loss patient fold in accordance with the Regnault classifica- demands a thorough understanding of the weight tion system22 (Table 1). Bilateral measurements loss procedure, whether it was a restrictive pro- include but are not limited to the following: base cedure (i.e., sleeve gastrectomy) or a combined diameter; sternal notch–to-nipple, nipple-to– restrictive and malabsorptive (i.e., Roux-en-Y), inframammary fold, nipple-to-nipple, and nipple- and its effect on the patient’s nutritional status.17 to-midline distances; nipple diameter; and upper Patients having undergone combined restrictive pole soft-tissue pinch test.11,23 Obtaining these and malabsorptive procedures tend to experi- measurements has been described elsewhere and ence higher levels of complications secondary is beyond the scope of this article; however, in to nutritional deficiencies, especially early in Figure 1, we include a few basic parameters in a the postoperative state. Deficiencies of various typical patient (Fig. 1). (See Video, Supplemen- micronutrients can affect wound healing and tal Digital Content 1, which displays preoperative need to be tested preoperatively. Understanding markings. This video is available in the “Related the roles of protein; vitamins A, B, and C; argi- Section” of the full-text article on PRSJournal. nine; glutamine; iron; zinc; and selenium and com or at http://links.lww.com/PRS/D72.) their optimization before surgical intervention Despite being able to record these measurements Table 1. Ptosis Classification*† Nipple Location Type Degree Relative to IMF Description Pseudoptosis Above Breast tissue below IMF, whereas nipple is above Grade 1 Mild 0–1 cm below Nipple position at the IMF Grade 2 Moderate 1–3 cm below Nipple position below the IMF but above the majority of the breast Grade 3 Severe >3 cm below Nipple position below the IMF and at the lower pole of the breast IMF, inframammary fold. *From Regnault P. Breast ptosis: Definition and treatment.Clin Plast Surg. 1976;3:193–203. †Classification of ptosis based on nipple position relative to an axis extending from the IMF. 743e Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • November 2018 Fig. 1. Standard breast measurements. SN, sternal notch; MCP, midclavicular plane; IMF, inframammary fold. above-to-below
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