Simultaneous Augmentation/Mastopexy: A Retrospective 5-Year Review of 332 Consecutive Cases
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.
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- 146 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. 148 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) 150 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. 152 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 firstname.lastname@example.org 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 155 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. Article Collections – Body Contouring The Body Contouring article collection on PRSJournal.com represents a pre-made article search on relevant topics in Body Contouring, as evaluated and chosen by the PRS Editorial Board and the PRS Section Editors. The col- lection contains some of the most educational and very best articles published in Plastic and Reconstructive Surgery over the last 10 years. This is just one of 15 articles in the collection. See more at www.PRSJournal.com 156