Preoperative MRI to Improve Aesthetic Outcomes in Secondary Mastopexy Augmentation: A Step-by-Step Approach.

Background: Secondary mastopexy augmentation is challenging because of compromised blood supply to the nipple areola complex (NAC). The operating surgeon often relies on clinical judgment and may perform a more conservative elevation of the NAC to minimize the risk of nipple necrosis. Despite this, the danger of necrosis persists. In our experience, MRI with contrast has enhanced preoperative planning in both cosmetic and reconstructive cases. Objectives: The goals of this article are to describe our use of preoperative MRI in identifying the blood supply to the NAC, evaluating dermo glandular thickness, decreasing surgical complications, and improving outcomes in secondary mastopexy augmentation. Methods: A consecutive series of secondary mastopexy augmentation procedures performed in 2021 were reviewed. In each case, preoperative maximum intensity projection (MIP) and/or high-resolution T1-weighted contrast enhanced MRI imaging was reviewed to elucidate the blood supply to the NAC and quantify the dermo glandular thickness. The imaging was used to formulate the operative plan. Preoperative and postoperative photographs were compared. Results: Eight cases were performed, four of which were selected to demonstrate our method using breast MRI with contrast in step-by-step approach. Patient satisfaction was high. The NAC survived in all cases. Conclusions: Surgeons can utilize preoperative breast MRI for strategic operative planning when performing secondary mastopexy augmentation. Visualization of the blood supply to the NAC and dermo glandular flap thickness are vitally important when performing a more aggressive lift of the breast.

The 3-Dimensional "Croissant Mastopexy": Indications and Outcomes.

ABSTRACT: Crescent mastopexy is an operation that is often maligned and infrequently used. However, it can be a useful adjunct both in primary augmentation mammaplasty and in secondary breast revision cases. The key to achieving good results with this procedure lies in conceptualizing the operation in 3 dimensions rather than 2. Most publications about the surgical technique describe deepithelialization (or at most full-thickness skin resection) of a crescent-shaped area superior to the areola and a single-layer closure of the defect. Improved outcomes are achieved if a full-thickness composite segment of tissue-skin, subcutaneous fat, and a wedge of breast parenchyma-is resected and the resulting defect closed in multiple layers. A more fitting descriptive term for this procedure, one that conveys the 3-dimensional nature of the tissue resection, is "croissant mastopexy." Croissant mastopexy has been used by the author in primary augmentation in women with mild to moderate ptosis, in patients with asymmetrical nipple position and in patients with tuberous breast deformity. The procedure is also applicable in secondary cases, but precautions must be taken to ensure that blood supply to the nipple is not compromised. When properly executed, croissant mastopexy yields good results without undue stretching of the superior half of the areola and with acceptable scars.

Managing Necrosis of the Nipple Areolar Complex Following Reduction Mammaplasty and Mastopexy.

The objectives of this article are to explain the mechanisms of injury that result in ischemia of the nipple areolar complex (NAC) after reduction mammaplasty or mastopexy, to offer recommendations about the management of this complication, and to illustrate reconstructive techniques that can be used to correct deformities arising from necrosis of the NAC. With these goals in mind, the article is divided into 3 sections: prevention of ischemia of the NAC, management of the ischemic nipple, and reconstruction after ischemic necrosis of the nipple and areola. Necrosis of all or part of the NAC is a devastating complication after breast surgery. However, with properly timed and well-executed reconstructive procedures, it is possible in most cases to restore a natural-appearing NAC.

The double-bubble deformity: cause, prevention, and treatment.

BACKGROUND: The double-bubble deformity is a widely recognized complication of breast augmentation, but there have been very few articles in the peer-reviewed literature devoted exclusively to this topic. METHODS: Prior publications addressing the anatomy of the inframammary fold and its relationship to the double-bubble deformity are systematically reviewed. Disagreements among authorities regarding the precise anatomical structure of the inframammary fold are addressed. The cause and surgical correction of the double-bubble deformity are discussed in detail as they relate to the anatomy of the fold. RESULTS: The key to understanding the causes and correction of the double bubble lies in an appreciation of the anatomy of the inframammary fold. Correction of the deformity varies depending on whether or not patients had preexisting anatomical features predisposing them to development of a double bubble. CONCLUSION: A variety of surgical strategies, including use of a dual-plane pocket, form-stable shaped implants, capsulorrhaphy, pocket plane conversion, and use of acellular dermal matrices can play a role in prevention and treatment of the double-bubble deformity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Breast implant rupture: causes, incidence, clinical impact, and management.

BACKGROUND: Rupture has long been considered one of the key complications of silicone-gel breast implants. The incidence of rupture has been correlated with implant generation, and extensive data on current-generation breast implants, including prospective multicenter clinical trials, are now available from numerous sources. METHODS: Device-retrieval data from breast implant manufacturers were reviewed to identify common factors that likely contribute to rupture. The cumulative incidence of rupture from a prospective clinical study was estimated in multiple ways using the Kaplan-Meier method to demonstrate the need for a uniform calculation methodology. RESULTS: The complexity of identifying, analyzing, and understanding rupture is addressed, and the clinical management of rupture in older generation breast implants lacking highly cohesive gels and barrier layers is reviewed. The data suggest that iatrogenic damage is the most frequent cause of rupture. Data from one manufacturer's prospective breast implant core study are presented to address the complexity of rupture-rate calculations-a single-time-point rupture rate varies from 9.0 to 12.2 percent, depending on which statistical parameters are used. CONCLUSIONS: The significant contribution of iatrogenic damage to overall rupture rate suggests that rupture may be more often operator-related than device-dependent. In addition, there is a critical need to implement uniform statistical methodology using follow-up data only through the patient's last magnetic resonance imaging scan, as rupture rates can vary greatly depending on the statistical methodology selected. Adoption of a uniform standard for rupture rate calculations would enable both patients and surgeons to base clinical decisions on more accurate and consistent information. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Approaching revisional surgery in augmentation and mastopexy/augmentation patients.

BACKGROUND: Breast augmentation and mastopexy augmentation procedures are becoming more common. The young plastic and reconstructive surgeon is often challenged revisional surgery operations in these patients. These cases are challenging, require significant operative time, and can be associated with a high revision rate. It is important for the young surgeon to have an approach to deal with these common and difficult scenarios. METHODS: A retrospective chart review was conducted on all patients who underwent a revision augmentation or revision mastopexy augmentation procedure between 2008 and 2010 by the authors. The most commonly encountered mitigating circumstances in the revision augmentation or revision mastopexy augmentation populations were identified and an algorithm was created on how to address these difficult problems. RESULTS: Between July 1, 2008 and July 1, 2010, 264 patients underwent revision augmentation or revision mastopexy augmentation procedures. The most commonly encountered patient scenarios were recurrence of ptosis, recurrent capsular contracture, implant malposition, rippling, and desiring a reduction in implant size. We encountered many mitigating circumstances that complicated the revisions. We devised a stepwise algorithmic approach to address these problems based on the following factors: (1) blood supply to the nipple-areola complex, (2) need to change implant plane, (3) patient desire to reduce or increase in breast implant volume, (4) need for total en bloc capsulectomy or capsulorrhaphy, (5) incision approach used to perform the capsulectomy, and (6) patient-related factors that need to be medically optimized or treated before, during, and after surgery. By adhering to these steps, outcomes can be accomplished more reliably and safely. CONCLUSION: Specialized preoperative planning is necessary to consistently deliver safe and aesthetic revision augmentation and revision mastopexy augmentation results. It is important for the operative surgeon to carefully consider the potential adverse effect of implants and prior mastopexy or reduction incisions and patterns on the blood supply to the nipple-areola complex. With educated planning, successful results can be achieved in most cases, and the risk of serious complications can be minimized.

Effects of Singulair (montelukast) treatment for capsular contracture.

BACKGROUND: Capsular contracture (CC) is one of the most common complications of breast augmentation surgery. Leukotrienes are implicated in the inflammatory cascade and have been postulated to be involved in the formation of CC. Therefore, leukotriene antagonists Accolate and Singulair have been prescribed by plastic surgeons off-label to treat and prevent CC. To date, there are no studies investigating the efficacy of Singulair on CC. OBJECTIVE: The authors retrospectively review a series of patients treated with Singulair to determine whether it improves CC after breast implant surgery. METHODS: Nineteen patients treated with Singulair by the senior surgeon (NH) after implant placement from March 2006 to November 2009 were included in this study. Follow-up on Singulair efficacy was obtained by a combination of office chart review and standardized telephone questionnaire. Results were characterized as complete improvement, improvement, no change, or worse. RESULTS: Seventeen patients presented with CC resulting from a variety of breast operations. Two patients who had a history of recurrent CC were prescribed Singulair prophylactically immediately after surgery. Twenty-one breasts with existing CC were included in the total. Two (11%) patients became worse, three (16%) patients had no change, five (26%) improved, seven (37%) completely improved, and two (11%) were prevented from having CC formation. CONCLUSION: Our preliminary study shows that Singulair improves CC. Breasts with mild CC (Baker score < III) appeared to have better improvement with Singulair compared to those with more severe contracture (Baker score III and IV). Singulair is well tolerated with minimal side effects and can be administered to patients after breast implant surgery to improve CC.

Transumbilical breast augmentation.

Transumbilical breast augmentation was first described in the literature more than 15 years ago. Since its introduction, this procedure has been controversial and has never been widely adopted by plastic surgeons. This article reviews the history of transumbilical breast augmentation; describes a simplified, nonendoscopic approach to insertion of saline implants via the umbilicus; and discusses the advantages, disadvantages, and limitations of this technique.

The effect of silicone implants on the diagnosis, prognosis, and treatment of breast cancer.

BACKGROUND: Because of the prevalence of breast cancer, many augmented women eventually will develop the disease. This article reviews what is known about the effect of implants on the detection, prognosis, and treatment of carcinoma of the breast. METHODS: Observations were made on 4082 breast cancer patients (3953 nonaugmented and 129 augmented) treated over a 23-year time span. Findings in the two groups were compared and differences analyzed statistically. Mammograms of all women with palpable lesions were reviewed to assess mammographic sensitivity in patients with and without implants. Cosmetic outcomes in augmented patients treated with breast conservation therapy were reviewed. RESULTS: Augmented patients presented more frequently with palpable lesions, invasive tumors, axillary nodal metastases, and false-negative mammograms. However, there was no significant difference in stage of disease, tumor size, recurrence rates, or survival between the two groups. Augmented patients treated with breast conservation therapy often experienced poor cosmetic results and frequently required reoperation. CONCLUSIONS: Despite the diminished sensitivity of mammography in women with implants, augmented and nonaugmented patients are diagnosed at a similar stage of disease and have a comparable prognosis. Implants may impair mammography but appear to facilitate tumor detection on physical examination. Magnetic resonance imaging and breast ultrasound may be useful adjuncts, but conventional mammography remains the most reliable tool for diagnosing early breast cancer in augmented patients. Breast implants do not interfere with mastectomy or breast reconstruction but may compromise the outcome of breast conservation therapy.

Secondary mastopexy in the augmented patient: a recipe for disaster.

BACKGROUND: Augmentation mammaplasty is popular procedure, but one that is associated with a relatively high rate of revisionary surgery. Over time, the augmented breast frequently becomes ptotic and patients may return requesting mastopexy. Experience has shown that secondary mastopexy in the augmented breast is fraught with potential complications, including fat necrosis, skin flap loss, and nipple ischemia. METHODS: Factors that contribute to increased morbidity when mastopexy is performed in the previously augmented breast are analyzed; the surgical options available for correcting ptosis in these cases are systematically reviewed. RESULTS: The long-term presence of implants typically results in changes in breast anatomy and physiology, including parenchymal atrophy, tissue thinning, and diminished skin blood supply. These factors greatly increase the surgical risks of secondary mastopexy. CONCLUSIONS: When planning and executing mastopexy in the previously augmented patient, the plastic surgeon must carefully consider the potential adverse effect of implants on the blood supply to the breast. With thoughtful planning and cautious operative technique, good results can be achieved in most cases, and the risk of serious complications can be minimized.

Breast cancer diagnosis and prognosis in augmented women.

BACKGROUND: Recent years have witnessed growing concerns about the possible adverse effects of implants on breast cancer diagnosis and treatment. Numerous reports describe how implants might interfere with mammography and impair the ability to detect cancer. Several publications document the diminished sensitivity of mammography in augmented patients with palpable tumors. However, epidemiologic studies comparing stage of disease at time of diagnosis in augmented and nonaugmented women are equivocal. The purpose of this study was to review the authors' experience with a large number of breast cancer patients to determine whether implants impair early diagnosis or adversely affect prognosis. METHODS: The authors reviewed their prospective database, which contains detailed information on 3953 nonaugmented and 129 augmented breast cancer patients. Various parameters of the two groups were compared and differences were analyzed using appropriate statistical methodology. RESULTS: The authors' data reveal that augmented patients present with a statistically greater frequency of palpable lesions, have a slightly greater risk of invasive tumors, and have an increased likelihood of axillary lymph node metastases. Despite this, there was no statistically significant difference in stage of disease between augmented and nonaugmented patients; mean tumor size, recurrence rates, and breast cancer-specific survival were virtually identical in both groups. CONCLUSIONS: Based on these findings, the authors conclude that despite the diminished sensitivity of mammography in women with implants, augmented and nonaugmented patients are diagnosed at a similar stage and have a comparable prognosis. While implants may impair mammography, they appear to facilitate detection of palpable breast cancers on physical examination.

A long-term study of outcomes, complications, and patient satisfaction with breast implants.

BACKGROUND: Breast implants have been used worldwide for more than 40 years. Despite extensive clinical experience, there is continued concern about the safety of these devices. The purpose of this study was to compare the efficacy, complication rates, frequency of reoperation, and degree of patient satisfaction with different types of implants. METHODS: This is a consecutive, population-based study consisting of all patients receiving implants at a multidisciplinary breast center between 1979 and 2004 (25 years). A prospective implant database was constructed and maintained in Excel, and statistical analysis was performed using SAS 8.2. Various outcomes, including infections, hematomas, undesirable waviness, capsular contracture, deflation, rupture, reoperation, and patient satisfaction, were monitored. RESULTS: Data were collected on 3495 implants in 1529 women. The longer implants were in place, the greater the cumulative risk of developing contracture; hematoma significantly increased the risk of contracture; smooth and textured implants had similar contracture rates; polyurethane foam-covered implants had a reduced risk of contracture persisting for at least 10 years after implantation. There was a relatively high rate of reoperation and a relatively short interval between primary surgery and reoperation; the most common indication for reoperation was capsular contracture. Implant recipients expressed a high overall level of satisfaction. CONCLUSIONS: Breast implants are associated with a significant rate of local complications and reoperation. There are marked differences in outcomes as a function of implant surface type and surgical indication. Despite relatively frequent complications and reoperations, implant recipients are largely satisfied.

Long-term safety and efficacy of polyurethane foam-covered breast implants.

BACKGROUND: Polyurethane foam-covered silicone gel-filled breast implants, introduced in the 1970s, were used in more than 110,000 American women. Because of concerns about possible toxicity, they were withdrawn from the US market in 1991. These implants remain popular in many parts of the world. OBJECTIVE: The goal of this study was to evaluate long-term experience with polyurethane foam-covered implants and compare outcomes and complication rates with other types of implants. METHODS: This population-based study was comprised of all individuals receiving either polyurethane breast implants (n = 568) or other types of silicone gel-filled breast implants (n = 963) for augmentation, reconstruction, or secondary revision surgery between 1981 and 2004 (23 years). A prospective implant database was established and maintained in Microsoft Excel (Redmond, WA). Data were extracted from chart review and questionnaires mailed to 719 patients (response rate, 48%). Various parameters, including infections, hematomas, excessive waviness, capsular contracture, rupture, systemic side effects, reoperation rates, and patient satisfaction were monitored. Statistical analysis was performed using SAS 9.1 (SAS Institute, Cary, NC). RESULTS: The incidence of capsular contracture was dramatically lower with polyurethane foam-covered implants compared to smooth or mechanically textured implants; this beneficial effect persisted at least 10 years after implantation. Aside from a transient skin rash, there was no increase in morbidity or complications associated with polyurethane implants. CONCLUSIONS: Polyurethane foam-covered implants result in long-term reduction in the risk of capsular contracture and appear to have a safety profile similar to other silicone gel-filled devices.

Recent Advances in Breast Reconstruction.

The incidence of breast cancer in the United States is high and appears to be increasing. The American cancer Society has estimated that one in nine American women (11 percent) will eventually develop breast carcinoma. Recently there has been a dramatic shift away from mastectomy and toward breast-conserving therapy (Iumpectomy, axillary node dissection and whole breast irradiation). In some centres the majority of breast cancer patients are now treated with conservation therapy. Some patients, however, are not candidates for radiation, because of the size, location or histology of their tumour and are still best treated by mastectomy and reconstruction. Women who develop local recurrence following radiation therapy are likewise candidates for mastectomy with reconstruction. Additionally, there is a large group of women who had mastectomies in years past who have not had reconstruction. Thus many patients may potentially benefit from breast reconstruction.