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Simultaneous Augmentation/Mastopexy: A Retrospective 5-Year Review of 332 Consecutive Cases

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					                                                                                         COSMETIC

Simultaneous Augmentation/Mastopexy:
A Retrospective 5-Year Review of 332
Consecutive Cases
M. Bradley Calobrace, M.D.
                                      Background: Of all mastopexies performed in the authors’ facility, approxi-
     Donald R. Herdt, B.S.            mately 77 percent of patients have an implant placed simultaneously. The
     Kyle J. Cothron, M.D.            unique challenges and safety concerns associated with the simultaneous aug-
                    Louisville, Ky.   mentation/mastopexy procedure merit a deeper evaluation of its use and as-
                                      sociated risks.
                                      Methods: A retrospective analysis of 430 mastopexy operations, including 332
                                      simultaneous augmentation mastopexies, was performed. Patient demograph-
                                      ics, patient selection, and operative approach were evaluated and correlated
                                      with surgical outcomes. Complications and reoperation rates were measured
                                      and compared with published reports in the literature.
                                      Results: For simultaneous augmentation/mastopexy procedures, the overall
                                      complication rate was 22.9 percent (primary cases, 20.4 percent; secondary
                                      cases, 28.9 percent). Tissue- and implant-related complication rates were 15.1
                                      and 7.8 percent, respectively. The overall reoperation rate was 23.2 percent
                                      (primary cases, 20.0 percent; secondary cases, 30.9 percent). Tissue- and im-
                                      plant-related reoperation rates were 13.3 and 9.9 percent, respectively. The most
                                      common complications were capsular contracture (13 of 332), poor scarring (11
                                      of 332), and recurrent ptosis (11 of 332). They were also the most common
                                      indications for reoperation (11 of 332 for each one). The mastopexy-only
                                      reoperation rate of 10.2 percent was comparable to the tissue-related reopera-
                                      tion rate of 13.3 percent.
                                      Conclusions: Although the measured reoperation rate (23.2 percent) may be
                                      higher than that of either procedure performed independently, the revision rate
                                      of combining the procedures was not more than additive. With appropriate
                                      patient selection and a carefully planned operative approach, the authors be-
                                      lieve a one-stage procedure can be safely performed with acceptable compli-
                                      cation and reoperation rates. (Plast. Reconstr. Surg. 131: 145, 2013.)
                                      CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.




T
     he simultaneous augmentation/mastopexy                     results,1– 6 with its use even being discouraged by
     entails the inherent challenge of expanding                some.3 However, there are admittedly many ad-
     breast volume and concurrently reducing                    vantages to performing these procedures simulta-
the skin envelope. The operation indeed holds                   neously, the most obvious being the avoidance of
special challenges nonconcomitant with the indi-                a second operation in many patients. This has
vidual procedures alone. It has been suggested                  obvious advantages for the patient: it is econom-
that performing the simultaneous procedure in-                  ically less burdensome, reduces risks inherent in
troduces a significant degree of added risk and                 an additional operation, and avoids disappoint-
uncertainty in the prediction of postoperative                  ment in the result in the interim between the two
                                                                operations. In our experience, patients over-
 From private practice and the Division of Plastic Surgery,
 Department of Surgery, University of Louisville School of
 Medicine.                                                        Disclosure: Dr. Calobrace is a consultant for Men-
 Received for publication January 12, 2012; accepted July 19,     tor Corporation and Allergan. The other authors
 2012.                                                            have no financial disclosures. There was no fund-
 Copyright ©2012 by the American Society of Plastic Surgeons      ing received for this study.
 DOI: 10.1097/PRS.0b013e318272bf86

                                                 www.PRSJournal.com                                                 145
                                                     Plastic and Reconstructive Surgery • January 2013

whelmingly prefer to undergo augmentation and            toma. The categorization of the hematoma was
mastopexy concurrently rather than have a staged         determined by its location; a hematoma within the
procedure. Therefore, the simultaneous augmen-           breast implant pocket was categorized as implant-
tation/mastopexy has routinely been used in our          related and a hematoma isolated to the mastopexy
practice as the preferred approach for breast pto-       flap without blood within the implant pocket was
sis. We have found the combined procedure                considered tissue-related. Patients were catego-
worthwhile, considering patient safety and effi-         rized as having recurrent ptosis for either stretch
cacy, as in the experience reported by others.7–12       deformities of the lower pole or ptosis of the breast
The objective of this study was to review our 5-year     tissue over the implant (i.e., Snoopy’s nose defor-
experience of consecutive simultaneous augmen-           mity). Partial necrosis included all cases of isch-
tation mastopexies, evaluating patient selection,        emia-induced necrosis of breast flap or nipple-
surgical approach, and associated complication           areola complex irrespective of whether a surgical
and reoperation rates.                                   reoperation was required.
                                                              Reoperations were categorized as implant-re-
         PATIENTS AND METHODS                            lated or tissue-related as a function of the com-
    A 5-year history (January of 2005 to December        plication. The only additional reoperations in-
of 2009) of simultaneous augmentation/mas-               cluded that were not a result of a complication
topexy operations was studied retrospectively. All       were for implant size change. For cases requiring
operations were performed by the senior author           multiple reoperations for the same complication,
of this study (M.B.C.). Data were collected for 430      only the first reoperation was documented, as has
patients who underwent mastopexy surgery, in-            been previously described.13,14
cluding 332 patients who underwent simultaneous
augmentation mastopexies. This study focused on
the 332 simultaneous augmentation/mastopexy              Preoperative Assessment
patients, with the 98 mastopexy-only cases exam-              Although the majority or mastopexies were
ined for comparison. Patient demographics, pre-          performed concurrently with the augmentation
operative assessment, and operative approach             (332 of 430), mastopexy alone (98 of 430), with or
were evaluated and correlated against rates of           without a staged augmentation, was selected for
complications and reoperations. The patient de-          some patients. In our practice, patients with obe-
mographics measured included age, sex, height,           sity, large pendulous breasts requiring significant
preoperative weight, smoking status, history of          nipple-areola complex elevation ( 6 cm) or sig-
previous breast surgery, and gravida status. Smok-       nificant breast volume reduction, and/or unwill-
ers consented to discontinue smoking a minimum           ingness to completely stop smoking for a mini-
of 2 weeks before surgery, although serum nico-          mum of 2 weeks before surgery were all less likely
tine levels were not obtained for verification of        to be selected for a combined procedure. In pa-
compliance. Mastopexy type was documented for            tients considered appropriate for a simultaneous
each breast, as were implant specifications includ-      procedure, mastopexy approach and implant se-
ing fill, shape, volume, profile, and pocket posi-       lection were an integral part of preoperative plan-
tion. All additional breast procedures concurrent        ning. Planning the exact approach can be some-
with augmentation/mastopexy surgery were noted           what uncertain, as the spectrum of breast ptosis is
(e.g., implant removal, pocket exchange). The pa-        a continuum. Therefore, the mastopexy approach
tients who underwent mastopexy alone during the          was not determined completely preoperatively but
same period were primarily compared for compli-          rather planned presumptively based on the fol-
cation and reoperation rates. Statistical significance   lowing: the Regnault level of ptosis15 with respect
was evaluated using Fisher’s exact test.                 to the location of the nipple-areola complex in
    Complications were noted as unilateral or bi-        relationship to the inframammary fold, the loca-
lateral and categorized as tissue-related or im-         tion of the nipple-areola complex in relationship
plant-related. The definition of implant-related         to the overall breast mound, the amount of breast
complications included Baker grade III/IV cap-           overhanging the inframammary fold, and ulti-
sular contracture, implant malposition, peripros-        mately the vertical excess present, measured as the
thetic seroma, implant failure, infection, and           distance from the new nipple position to the in-
implant-related hematoma. Tissue-related compli-         framammary fold under stretch (Fig. 1).
cations encountered included partial necrosis, re-            Patients with a need for nipple-areola complex
current ptosis, areolar asymmetry, poor scarring,        repositioning or reshaping and whose need for
breast asymmetry, and mastopexy-related hema-            breast lifting was minimal were selected for a cir-

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Volume 131, Number 1 • Simultaneous Augmentation/Mastopexy




   Fig. 1. Preoperative assessment. (Left) Patient with grade 1 ptosis with the nipple-areola complex located at the bottom of
   the breast mound with 1 cm of breast overhanging the inframammary fold and no vertical excess. A circumareolar incision
   would be selected for this patient preoperatively. (Right) Patient with grade 1 ptosis, nipple-areola complex located in center
   of breast mound, 4 cm of breast overhanging the inframammary fold, and vertical excess. This patient would be selected
   for a circumvertical approach with possibly a short inframammary fold elliptical incision.


cumareolar mastopexy. These were often patients                     pole volume. We have observed that the place-
primarily interested in augmentation, and the lift                  ment of an implant with the mastopexy more pre-
was considered necessary to achieve an optimal out-                 dictably produced the desired improvement in
come. This included patients with tuberous breasts                  breast shape. Implant selection required factoring
and grade 1 or 2 ptosis with minimal breast over-                   in the changes in breast width resulting from a
hanging the fold ( 3 cm). Patients with more severe                 significant mastopexy and the anticipated toler-
ptosis (grade 2 or 3) and/or significant overhang (3                ance of the ptotic skin envelope for the desired
to 4 cm or greater) required a more significant lift                implant. This was often the smallest implant that
through a vertical (with or without a short horizontal              could effectively achieve the desired breast shape.
scar) or inverted-T approach. Although the final
determination was made intraoperatively, preoper-
ative assessment was critical to patient counseling                 Preoperative Markings and Surgical Technique
and surgical planning. A patient with significant ver-                   Preoperative markings were performed with
tical breast skin excess of greater than 8 to 10 cm was             the patient in the upright position. The inframam-
considered more likely to need a greater circum-                    mary fold, midline, and breast median were ini-
areolar excision to remove vertical excess or a hor-                tially drawn. The proposed new nipple position
izontal ellipse of skin removed as part of the vertical             was marked by simulating the mastopexy and lo-
approach. The greater the vertical excess, the                      cating the ideal position, taking into consider-
greater the elliptical resection and resultant length               ation its location on the breast mound and rela-
of the inframammary scar.                                           tionship to the inframammary fold.
     Implant selection was based on dimensional                          In the circumareolar approach, the new areola
characteristics of the chest wall and soft-tissue en-               superior border was marked 2 cm above the new
velope, taking into consideration the patient’s de-                 planned nipple position and the inferior areola
sires as well. In patients requiring primarily an                   location was marked approximately 6 to 8 cm
augmentation, implant selection was performed                       above the fold. An oval was drawn from the two
as with any standard breast augmentation. In a                      points around the areola to create the desired
patient who primarily required a breast lift, im-                   shape. The areola was marked from 38 to 42 mm
plants were often selected to achieve a desired                     in diameter and incised. The augmentation was
shape or improvement in upper pole volume with                      performed through an inferior areola incision
less adherence to strict dimensional consider-                      with implant placement in a subglandular or dual-
ations. In our experience and as recently docu-                     plane subpectoral pocket. The excess circumareo-
mented by others,16 currently existing mastopexy-                   lar skin was deepithelialized and the outer dermis
alone techniques have fallen short in their ability                 was released with undermining of the breast flaps
to effectively increase breast projection or upper                  for a few centimeters. The breast tissue was closed

                                                                                                                                 147
                                                               Plastic and Reconstructive Surgery • January 2013

as a deep separate layer to skin closure and a 3-0                   final skin pattern for excision was determined only
Gore-Tex (W. L. Gore & Associates, Flagstaff,                        after the implant was in place to ensure optimal
Ariz.) purse-string suture. Ethibond (Ethicon,                       tightening and symmetry. A superior dermal pedi-
Inc., Somerville, N.J.) was used in all cases to min-                cle was used in all cases, maintaining dermal at-
imize circumareolar spreading (Fig. 2).                              tachment in the superior half of the areola. The
    With vertical and inverted-T mastopexies, the                    circumareolar skin was deepithelialized and all
augmentation was performed first through an in-                      remaining skin in the vertical and inferior poles
cision extending vertically from the nipple-areola                   was excised. Breast flaps were undermined and
complex to 2 cm above the inframammary fold so                       mobilized sufficiently to allow closure with mini-
that the implant could be placed in the desired                      mal tension. The breast tissue was closed over the
pocket (Fig. 3). Pocket decision was determined                      implant on the deep surface of the vertical breast
based on soft-tissue coverage and/or preexisting                     parenchyma just superficial to the implant. Any
pocket location in secondary cases, with the pre-                    significant breast tissue present in the lower pole
ferred pocket being dual-plane submuscular in                        overlying this closure was routinely debulked to
the majority of cases. Tailor tacking, a critical tech-              reduce tension on closure and potentially reduce
nique in our combined procedures, was per-                           pseudoptosis postoperatively. The resection of lower
formed starting at the planned new nipple posi-                      pole breast tissue when indicated was possible
tion and extending inferiorly toward the fold,                       through the consistent use of a superior dermal
creating the desired breast shape and lift. If the                   pedicle. Skin was closed in multiple layers (Fig. 3).
vertical limb from nipple to fold was longer than
8 to 10 cm, the vertical excess was reduced through                                           RESULTS
expanding the circumareolar excision or perform-                         The follow-up period for this study was 1 to 6
ing an elliptical excision along the fold. Thus, the                 years, with a mean follow-up of 1.5 years. Of the




 Fig. 2. (Above, left) Preoperative view of a 34-year-old woman with grade 1 ptosis on the right breast and pseudoptosis on the left.
 (Above, right) Asymmetric operative plan with a circumvertical augmentation/mastopexy on the right and a circumareolar
 approach on the left. (Below, left) Immediate results postoperatively. (Below, right) Postoperative view 4 months after the
 patient underwent augmentation/mastopexy with a 350-cc moderate-plus profile silicone gel implant on the right and a 375-cc
 moderate-plus profile on the left.


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Volume 131, Number 1 • Simultaneous Augmentation/Mastopexy




Fig. 3. (Above, left) Preoperative view of a 36-year-old woman with grade 3 ptosis requiring an inverted-T augmentation/
mastopexy. (Above, right) Intraoperative view with tailor tacking of the left breast and implant sizers in place. (Below, left)
Intraoperative view with the superior dermal pedicle maintained in the superior half of the areola, vertical incision inferior to
the areola for access to implant pocket, and minimally undermined breast flaps prepared for closure. (Below, right) Immediate
postoperative results with 425-cc moderate profile saline implants.



332 patients undergoing simultaneous breast aug-                  silicone-filled implants increased progressively
mentation/mastopexy surgery, 235 were primary                     throughout the course of the study, from 61 per-
breast cases and 97 were secondary breast cases.                  cent of total implants used in 2005 to 85 percent
The average patient age was 37 years (range, 16 to                in 2009. Implant profiles were 48 percent moder-
72 years). The average body mass index of patients                ate-plus, 34 percent moderate, and 18 percent
was 24.7 (range, 15.6 to 43) (Tables 1 and 2). All                high. One patient received an anatomical form-
patients in this study were women, with 81 percent                stable cohesive gel implant. Pockets used for im-
of patients (269 of 332) being postpartum. Smok-                  plant placement included 84 percent (278 of 332)
ers composed 18 percent of patients (60 of 332)                   dual-plane submuscular pocket, 12 percent (41 of
undergoing simultaneous surgery.                                  332) subglandular, and 4 percent (13 of 332) sub-
    Of the 332 augmentation/mastopexy cases, bi-                  fascial. Subglandular placement was used more
lateral mastopexy surgery was performed on 322                    often in secondary cases (25.8 percent, 25 of 97)
patients, with 10 patients undergoing mastopexy                   as compared with primary cases (6.8 percent, 16 of
surgery unilaterally. As for the mastopexy ap-                    235), likely reflecting preexisting pocket location
proach, 40 percent were inverted-T, 40 percent                    (Table 1). In primary cases, subglandular implant
were vertical (with or without a short inframam-                  placement declined over the course of this study,
mary incision), and 20 percent were circumareo-                   with 11 of 16 cases in 2005 and none in 2009.
lar (Table 2).                                                         There were no deaths, pulmonary embolisms,
    Bilateral breast augmentations were performed                 deep venous thromboses, or major tissue losses of
in 326 patients, with six being unilateral. The im-               any type resultant from surgery. There were two
plant selection was 73 percent (241 of 332) sili-                 implant infections resulting in implant extrusion.
cone and 27 percent saline (91 of 332), with an                   The overall complication rate for simultaneous
average implant fill volume of 392 cc. The use of                 augmentation/mastopexy surgery was 22.9 per-

                                                                                                                             149
                                                                  Plastic and Reconstructive Surgery • January 2013

Table 1. Demographic and Operative Statistics for                    were tissue-related, 15.1 percent (50 of 332) as
Primary and Secondary Augmentation Mastopexies                       compared with implant-related, 7.8 percent (26 of
                                    Augmentation/                    332). The three most common complications
                                      Mastopexy                      were, in descending order, capsular contracture
                                                                     (13 of 332), poor scarring (11 of 332), and recur-
                               Primary          Secondary    p
                                                                     rent ptosis (11 of 332) (Table 3). There was no
Average age 1 SD              35.0 9.6         41.6 11.2     0.05    apparent correlation between complication rates
Smokers                         18.7%             16.5%      0.05
Average G/P status             1.9/1.2           1.9/1.6     0.05    and smoking status, body mass index, pocket lo-
Average BMI 1 SD              24.1 3.6         24.1 3.6      0.05    cation, or mastopexy approach.
     18.5                        1%                1%        0.05        The overall reoperation rate was 23.2 percent
     25                         34.9%             38.1%      0.05
     30                          6.4%              5.2%      0.05    (77 of 332) for our simultaneous augmentation/
Mastopexy incision                                                   mastopexy cases, with 20.0 percent (47 of 235) for
   Circumareolar                23.8%              10.6%     0.05
   Vertical                     44.9%              27.5%     0.05    primary cases and 30.9 percent (30 of 97) for
   Inverted-T                   31.3%              61.9%     0.05    secondary cases. Secondary patients were associ-
Silicone                        69.8%              79.4%     0.05    ated with a statistically significant higher rate of
Implant placement
   Submuscular                  89.8%              69.1%     0.05    reoperation (p 0.0447). The most common in-
   Subfascial                    3.4%               5.2%     0.05    dications for reoperation were capsular contrac-
   Subglandular                  6.8%              25.8%     0.05    ture (11 of 332), poor scarring (11 of 332), and
Average implant
     fill 1 SD              389.7 84.7         395 130.5     0.05    recurrent ptosis (11 of 332). Of the 23.2 percent
     300                       11.2%             21.0%       0.05    overall reoperation rate, tissue-related indications
   300–399                     42.1%             31.6%       0.05
   400–499                     33.0%             20.0%       0.05    constituted 13.3 percent (44 of 332) and implant-
     500                       13.7%             27.4%       0.05    related indications constituted 9.9 percent (33 of
G/P, gravida/para; BMI, body mass index.                             332) (Table 4 and Fig. 4). There was no apparent
*p values indicate statistically significant variance.               correlation between reoperation rates and smok-
                                                                     ing status, body mass index, pocket location, or
Table 2. Demographic and Operative Statistics for                    mastopexy approach.
Augmentation/Mastopexy and Mastopexy-Only                                Of the 98 mastopexy-only cases evaluated for
Operations                                                           comparison, 75 were primary breast cases and 23
                                                                     were secondary cases. The average body mass in-
                            Augmentation/
                              Mastopexy   Mastopexy-                 dex for members of this group was statistically
                                Total       Only             p*      higher at 26.5 as compared with 24.1 for the si-
Average age 1 SD, yr            37 10.5          43.1 11.4   0.05    multaneous group (Table 2). This most likely rep-
Smokers                          18.1%             17.3%     0.05    resents a selection bias against performing the
Average G/P status              1.9/1.7            2.1/1.8   0.05    simultaneous procedure on overweight patients.
Average BMI 1 SD               24.1 3.6          26.5 4.8    0.05
     18.5                         0.9%               0%      0.05    There was also a higher prevalence of inverted-T
     25                          35.8%             49.0%     0.05
     30                           6.0%             23.5%     0.05
Mastopexy incision
   Circumareolar                 20.0%               3.7%    0.05
   Vertical                      39.8%              15.2%    0.05    Table 3. Tissue- and Implant-Related Complications
   Inverted-T                    40.2%              80.7%    0.05    in 332 Simultaneous Augmentation/Mastopexies
Silicone                         72.6%
Implant placement                                                                              Primary Secondary     Total
   Submuscular                   83.7%                               Complication             (% of 235) (% of 97) (% of 332)
   Subfascial                     3.9%                               Tissue-related
   Subglandular                  12.4%                                 Poor scarring           5 (2.1)     6 (6.2)    11 (3.3)
Average implant                                                        Recurrent ptosis        7 (3.0)     4 (4.1)    11 (3.3)
     fill 1 SD               391.5 100                                 Areolar asymmetry       7 (3.0)     2 (2.1)     9 (2.7)
     300                        14.2%                                  Partial necrosis        6 (2.6)     3 (3.1)     9 (2.7)
   300–399                      39.5%                                  Breast asymmetry        5 (2.1)     2 (2.1)     7 (2.1)
   400–499                      28.9%
     500                        17.4%                                  Hematoma                2 (0.9)     1 (1.0)     3 (0.9)
                                                                       Total                  32 (13.6)   18 (18.6)   50 (15.1)
G/P, gravida/para; BMI, body mass index.                             Implant-related
*p values indicate statistically significant variance.                 Capsular contracture    9 (3.8)     4 (4.1)    13 (3.9)
                                                                       Implant malposition     3 (1.3)     3 (3.1)     6 (1.8)
                                                                       Hematoma                1 (0.4)     1 (1.0)     2 (0.6)
cent (76 of 332). Secondary cases displayed a com-                     Infection               1 (0.4)     1 (1.0)     2 (0.6)
                                                                       Seroma                  1 (0.4)     1 (1.0)     2 (0.6)
plication rate of 28.9 percent (28 of 97), whereas                     Implant failure         1 (0.4)     0 (0.0)     1 (0.3)
the complication rate for primary cases was 20.4                       Total                  16 (6.8)    10 (10.3)   26 (7.8)
percent (48 of 235). The majority of complications                   Grand total              48 (20.4)   28 (28.9)   76 (22.9)


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Volume 131, Number 1 • Simultaneous Augmentation/Mastopexy

Table 4. Tissue- and Implant-Related Indications for                 rates for mastopexy alone were 12.2 percent (12 of
Reoperation in 332 Simultaneous Augmentation/                        98) and 10.2 percent (10 of 98), respectively.
Mastopexies
Indications for            Primary Secondary     Total                                     DISCUSSION
Revision                  (% of 235) (% of 97) (% of 332)
                                                                         The combination of a mastopexy performed si-
Tissue-related                                                       multaneously with a breast augmentation is not a novel
  Poor scarring             5 (2.1)      6 (6.2)     11 (3.3)
  Recurrent ptosis          7 (3.0)      4 (4.1)     11 (3.3)        concept and was initially described by Gonzalez-Ulloa17
  Areolar asymmetry         6 (2.6)      2 (2.1)      8 (2.4)        and shortly thereafter by Regnault18 in the 1960s.
  Breast asymmetry          5 (2.1)      2 (2.1)      7 (2.1)        However, there have been no definitive studies
  Partial necrosis          2 (0.9)      2 (2.1)      4 (1.2)
  Hematoma                  2 (0.9)      1 (1.0)      3 (0.9)        clearly establishing its safety and efficacy. There are
  Total                    27 (11.5)    17 (17.5)    44 (13.3)       several small retrospective studies advocating the
Implant-related                                                      combined approach to breast ptosis,7–12 whereas oth-
  Capsular contracture      7 (3.0)      4 (4.1)     11 (3.3)
  Desired size change       6 (2.6)      3 (3.1)      9 (2.7)        ers report the risks inherent in the simultaneous
  Implant malposition       3 (1.3)      3 (3.1)      6 (1.8)        approach, promoting caution and consideration for
  Hematoma                  1 (0.4)      1 (1.0)      2 (0.6)        staging the procedure to improve safety and quality
  Infection                 1 (0.4)      1 (1.0)      2 (0.6)
  Seroma                    1 (0.4)      1 (1.0)      2 (0.6)        of results.1– 6 It has been suggested that the variables
  Implant failure           1 (0.4)      0 (0.0)      1 (0.3)        involved in a combination augmentation/mas-
  Total                    20 (8.5)     13 (13.4)    33 (9.9)        topexy could lead to increased risk of poor scarring,
Grand total                47 (20.0)    30 (30.9)    77 (23.2)
                                                                     nipple-implant malalignment, nipple malposition,
                                                                     or implant extrusion.5 What has often been lacking
                                                                     in the reported literature are clear descriptions of
incisions used for mastopexy alone versus the si-                    the perioperative decision making and surgical ap-
multaneous group (81 percent versus 40 percent)                      proach and their impact on the final result, details
(Table 2), reflecting a greater need to excise lower                 that might help explain the varying experiences in
pole volume. The complication and reoperation                        combination augmentation mastopexies. Regard-




                  Fig. 4. (Left) With an overall tissue-related reoperation rate of 13.3 percent, the differences in
                  tissue-related indications for reoperation in primary (11.5 percent, 27 of 235) versus secondary
                  (17.5 percent, 17 of 97) cases are shown. (Right) With an overall implant-related reoperation
                  rate of 9.9 percent, the differences in implant-related indications for reoperation in primary
                  (8.5 percent, 20 of 235) versus secondary (13.3 percent, 13 of 97) cases are shown.


                                                                                                                        151
                                                           Plastic and Reconstructive Surgery • January 2013

less of physician bias, it is our experience that pa-           terpretation of results within this study is that com-
tients prefer a simultaneous operation to achieve a             plication rates represent only the risk associated
lift with augmentation, and this has been our pre-              with operations performed, while ignoring that
ferred approach.                                                the risk of procedures declined. For example, we
     Although we have described general indica-                 found no significant correlation between smoking
tions for simultaneous versus staged procedures,                history or body mass index and resulting compli-
ultimately a combination of factors must be as-                 cation rate. It may be tempting to downgrade the
sessed for each individual, considering the antic-              significance of these factors. However, these re-
ipated outcome of both the surgeon and the pa-                  sults may in part be attributable to patient selec-
tient. Unfortunately, there is no simple algorithm              tion, as patients with higher body mass indexes or
that adequately assesses the appropriate approach               significant smoking history/unwillingness to quit
for each case. The most pertinent factors in our                smoking were more likely considered better can-
decision making included unwillingness to stop                  didates for a staged procedure. Indeed, of the 98
smoking at least 2 weeks before surgery, obesity,               patients within this study who underwent mas-
extremely large breasts requiring significant vol-              topexy alone (22.8 percent), all were excluded
ume reduction, or severe ptosis requiring nipple-               from the simultaneous procedure either because
areola complex elevation greater than 6 cm.                     they desired smaller, nonaugmented breasts, or
     Reflective of the propensity to stage the pro-             because the above-mentioned selection criteria
cedure in obese patients, 23.5 percent of the mas-              mandated a staged approach.
topexy-alone group had a body mass index greater                    Reoperations were categorized as “indications
than 30, as compared with 6 percent in the simul-               for reoperation,” which was for the most part re-
taneous group. One important caveat to the in-                  flective of the complications seen in the study, as




   Fig. 5. (Above) Preoperative views of a 43-year-old woman following a 60-pound weight loss with breast ptosis. (Below)
   Postoperative views 3 years after the patient underwent a simultaneous inverted-T mastopexy with placement of 375-cc
   moderate-plus profile smooth silicone gel implants in the dual submuscular position.


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Volume 131, Number 1 • Simultaneous Augmentation/Mastopexy

demonstrated by our overall complication rate of                 nipple necrosis, which have been implicated when
22.9 percent and our reoperation rate of 23.2 per-               using the combined procedure.3,4
cent. There are a couple of exceptions worth not-                     Although some have described the risk of the
ing. There were nine reoperations for size change                combined procedure as being greater than that of
that were not considered complications. Likewise,                each individual procedure,3 our data demonstrate
in the nine cases of partial necrosis documented                 tissue and implant-related reoperation rates sim-
as a complication of this procedure, only four of                ilar to the individual procedures when considered
these cases required reoperation, which consti-                  separately. We report a tissue-related reoperation
tuted a small procedure under local anesthesia. All              rate of 13.6 percent for simultaneous augmenta-
of these patients had very small tissue openings                 tion/mastopexy, as compared with our measured
( 2 cm). Eight occurred in inverted-T mas-                       reoperation rate of 10.2 percent for mastopexy
topexies at the intersection of the vertical and                 alone observed in this study. These reoperation
inframammary scar and the one other case was a                   rates are similar to an 8.6 percent reoperation rate
small opening along the incision in a circumareo-                for mastopexy alone reported by Stevens et al.9 In
lar mastopexy case. There were two implant in-                   addition, our implant-related reoperation rate of
fections, both requiring explantation and subse-                 9.6 percent measured for the simultaneous pro-
quent reoperation for placement of a new                         cedure does not appear greater than reoperation
implant. Importantly, there were no instances of                 rates reported for augmentation. In the Mentor
disastrous complications such as major skin flap or              6-year core data, a 19.4 percent reoperation rate




   Fig. 6. (Above) Preoperative views of a 39-year-old woman with 350-cc high-profile smooth silicone gel implants desiring
   smaller, more uplifted breasts. (Below) Postoperative views 1 year after the patient underwent a secondary procedure with
   implant exchange to smaller 200-cc moderate plus profile smooth silicone gel implants with a simultaneous inverted-T
   mastopexy and capsulorrhaphy.


                                                                                                                           153
                                                          Plastic and Reconstructive Surgery • January 2013

was noted in 551 primary breast augmentation                   metic procedure and is higher than that of either
patients.19 Allergan 6-year core data demonstrated             individual procedure performed alone, the reop-
a 28 percent reoperation rate in 445 patients.20 In            eration rate of combining the two procedures is
our study, the most common implant-related indi-               not more than additive when compared with pub-
cations for reoperation were capsular contracture,             lished values. Likewise, our findings are within a
implant size change, and implant malposition.                  range of other similar case series. Codner et al.
These are consistent with their findings: Mentor re-           reported a series of 178 simultaneous augmenta-
ported capsular contracture and size change and                tion/mastopexy cases over a 15-year period with
Allergan reported capsular contracture and implant             an overall reoperation rate of 25.8 percent, in-
malposition as the most common indications for                 cluding 16.3 percent for tissue-related and 9.5 per-
reoperation in primary augmentation.19,20                      cent for implant-related indications.13 Stevens et
     When comparing the reoperation rate in-                   al. reported an overall reoperation rate of 14.6
volved in the staged procedure against that of the             percent, including 10.9 percent for tissue-related
simultaneous procedure, the staged approach en-                and 3.7 percent for tissue-related indications.9
tails an inherent minimum 100 percent reopera-                     The efficacy of our results was not a major
tion rate in addition to the reoperation rates for             focus of this study and has been assessed only as a
each procedure separately. This far exceeds the                function of the reoperation rate described and as
reoperation rate of 23.2 percent measured in this              a subjective analysis of the results obtained. Pho-
study. Although the rate of 23.2 percent for the               tographs of patients with ptosis in both primary
combined procedure may seem high for a cos-                    and secondary cases have been included as rep-




   Fig. 7. (Above) Preoperative views of a 24-year-old postpartum woman with breast ptosis. (Below) Postoperative views
   1 year after the patient underwent a simultaneous inverted-T mastopexy with placement of a 325-cc moderate profile
   silicone gel implant.


154
Volume 131, Number 1 • Simultaneous Augmentation/Mastopexy




   Fig. 8. (Above) Preoperative views of a 37-year-old, G3P2 woman with breast ptosis. (Below) Postoperative views 1 year after
   the patient underwent a simultaneous periareolar mastopexy with placement of 375-cc moderate plus profile silicone im-
   plants in the dual-plane submuscular pocket location.


resentative examples (Figs. 5 through 8). Al-                      should be part of preoperative counseling with
though patient satisfaction surveys were not a part                appropriate candidates for the procedure. How-
of this particular study, this additional informa-                 ever, with careful consideration given to the peri-
tion could provide important additional informa-                   operative decision making and operative ap-
tion in future studies to more clearly determine                   proach, our data demonstrate the effectiveness of
the efficacy of augmentation with a mastopexy,                     a one-stage procedure with acceptable complica-
either simultaneously or as a staged procedure.                    tion and reoperation rates.
                                                                                                    M. Bradley Calobrace, M.D.
                                                                                              Calobrace Plastic Surgery Center
                  CONCLUSIONS                                                                            2341 Lime Kiln Lane
    In our practice, patients prefer a combined                                                           Louisville, Ky. 40222
procedure when an augmentation and mastopexy                                                           drbrad@calobrace.com
are required, and it has been our primary ap-
proach for the majority of patients. Although a                                           REFERENCES
23.2 percent reoperation rate may be considered                     1. Hoffman S. Some thoughts on augmentation/mastopexy and
too high for a purely cosmetic procedure, staging                      medical malpractice. Plast Reconstr Surg. 2004;113:1892–1893.
the operation, which is commonly posed as the                       2. Nahai F, Fisher J, Maxwell PG, Mills DC II. Augmentation
alternative, does not appear to offer any advantage                    mastopexy: To stage or not. Aesthetic Surg J. 2007;27:297–305.
                                                                    3. Spear SL. Augmentation/mastopexy: “Surgeon beware.”
of safety in the majority of cases in this study. We                   Plast Reconstr Surg. 2003;112:905–906.
acknowledge the inherent difficulty posed in a                      4. Spear SL, Boehmler JH, Clemens MW. Augmentation/mas-
combined approach, and a potential reoperation                         topexy: A 3-year review of a single surgeon’s practice. Plast


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                                                                  Plastic and Reconstructive Surgery • January 2013

      Reconstr Surg. 2006;118:136S–147S; discussion 148S–149S,        13. Codner MA, Mejia JD, Locke MB, et al. A 15 year experience
      150S–151S.                                                          with primary breast augmentation. Plast Reconstr Surg. 2011;
 5.   Spear SL, Giese SY. Simultaneous breast augmentation and            127:1300–1310.
      mastopexy. Aesthet Surg J. 2000;20:155–163.                     14. Handell N, Cordray T, Gutierrez J, Jensen JA. A long-term
 6.   Spear SL, Pelletiere CV, Menon N. One-stage augmentation            study of outcomes, complications, and patient satisfaction
      combined with mastopexy: Aesthetic results and patient sat-         with breast implants. Plast Reconstr Surg. 2006;117:757–767;
      isfaction. Aesthetic Plast Surg. 2004;28:259–267.                   discussion 768–772.
 7.   Gallent IM, Pons MR, Drever M. Vertical scar mastopexy with     15. Regnault P. Breast ptosis: Definition and treatment. Clin Plast
      an implant. Aesthetic Plast Surg. 2003;27:406–410.                  Surg. 1976;3:193–203.
 8.   Karnes J, Morrison W, Salisbury M, Schaeferle M, Beckham        16. Swanson E. A retrospective photometric study of 82 pub-
      P, Ersek RA. Simultaneous breast augmentation and lift.             lished reports of mastopexy and breast reduction. Plast Re-
      Aesthetic Plast Surg. 2000;24:148–154.                              constr Surg. 2011;128:1282–1301.
 9.   Stevens WG, Freeman EM, Stoker DA, Quardt SM, Cohen             17. Gonzalez-Ulloa M. Correction of hypertrophy of the breast
      R, Hirsch EM. One-stage mastopexy with breast augmentation:         by exogenous material. Plast Reconstr Surg Transplant Bull.
      A review of 321 patients. Plast Reconstr Surg. 2007;120:1674–       1960;25:15–26.
      1679.                                                           18. Regnault P. The hypoplastic and ptotic breast: A combined
10.   Stevens WG, Stoker DA, Freeman ME, Quardt SM, Hirsch                operation with prosthetic augmentation. Plast Reconstr Surg.
      EM, Cohen R. Is one-stage breast augmentation with mas-             1966;37:31–37.
      topexy safe and effective? A review of 186 primary cases.       19. Cunningham B. The Mentor core study on silicone Memory
      Aesthet Surg J. 2006;26:674–681.                                    Gel breast implants. Plast Reconstr Surg. 2007;120:19S–29S;
11.   Tessone A, Millet E, Weissman O, et al. Evading a surgical          discussion 30S–32S.
      pitfall: Mastopexy-augmentation made simple. Aesthetic Plast    20. Spear LS, Murphy DK, Slicton A, Walker PS; Inamed Silicone
      Surg. 2011;35:1073–1078.                                            Breast Implant U.S. Study Group. Inamed silicone breast
12.   Persoff MM. Mastopexy with expansion-augmentation.                  implant core study results at 6 years. Plast Reconstr Surg. 2007;
      Aesthet Surg J. 2003;23:34–39.                                      120:8S–16S; discussion 17S–18S.




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Description: Background: Of all mastopexies performed in the authors’ facility, approximately 77 percent of patients have an implant placed simultaneously. The unique challenges and safety concerns associated with the simultaneous augmentation/ mastopexy procedure merit a deeper evaluation of its use and associated risks. Methods: A retrospective analysis of 430 mastopexy operations, including 332 simultaneous augmentation mastopexies, was performed. Patient demographics, patient selection, and operative approach were evaluated and correlated with surgical outcomes. Complications and reoperation rates were measured and compared with published reports in the literature. Results: For simultaneous augmentation/mastopexy procedures, the overall complication rate was 22.9 percent (primary cases, 20.4 percent; secondary cases, 28.9 percent). Tissue- and implant-related complication rates were 15.1 and 7.8 percent, respectively. The overall reoperation rate was 23.2 percent (primary cases, 20.0 percent; secondary cases, 30.9 percent). Tissue- and implant-related reoperation rates were 13.3 and 9.9 percent, respectively. The most common complications were capsular contracture (13 of 332), poor scarring (11 of 332), and recurrent ptosis (11 of 332). They were also the most common indications for reoperation (11 of 332 for each one). The mastopexy-only reoperation rate of 10.2 percent was comparable to the tissue-related reoperation rate of 13.3 percent. Conclusions: Although the measured reoperation rate (23.2 percent) may be higher than that of either procedure performed independently, the revision rate of combining the procedures was not more than additive. With appropriate patient selection and a carefully planned operative approach, the authors believe a one-stage procedure can be safely performed with acceptable complication and reoperation rates. (Plast. Reconstr. Surg. 131: 145, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.