Split Inferior Pedicle for One Stage Augmentation Mastopexy
We describe the one-stage surgical technique that has been used by the senior author for the past 30 years for all his primary grade 2 and 3 augmentation/mastopexies. The article provides a safe, simple and reproducible approach to a challenging procedure. The use of the inferior pedicle for the mastopexy, in a presence of a sub-musculofascial augmentation, rather than a lesser procedure as described in the literature, gives us the freedom to relocate the breast in front of the implant with a tighter skin brassiere. The major benefit of this procedure is that it provides a long-lasting result and makes any future maintenance procedures related to aging of the breast, easily manageable without running the risk of bottoming, implant extrusion, or necrosis.
Methods/Technique
:In our chart review, we identified 124 patients who underwent primary one-stage augmentation /mastopexies in the past 30 years. As we will demonstrate in our intraoperative pictures we start preoperatively by marking only the midclavicular and inframammary fold lines with the patient in the upright position.
Breast augmentation is then performed with smooth round silicone implants, using a 4 cm inframammary fold incision centered exactly under the nipple/areola complex. A sub- musculofascial augmentation is then performed as described by Dr. Bostwick. The sub-musculofascial plane is then approximated completely in two layers at the muscle layer and the subcutaneous tissue layer. With the implants in place and the patient in the upright position, we then complete the Wise pattern markings for an 8-9 cm. in width, inferior pedicle with its base centered over the closed augmentation incision.
The inferior pedicle is then de-epithelialized and sectioned in the usual fashion. Lateral, medial and superior skin excisions may include underlying tissue, if needed, for better contouring of the breast with the implants in place. Since 2006 we include a transverse plication of the pedicle as described by Dr.Mark Rubin, and thereby shortening the length of the pedicle. We choose to mark the new nipple-areolar position after the closure of the T incision.
Results/Complications
:One hundred and twenty-four patients ranging from 26-61 years old underwent one-stage augmentation mastopexy with a split inferior pedicle and approximately 40% of these were smokers. The follow up of the cases ranges from 2 months to 20 years. From 1990-1999, some of our patients were lost to follow up due to the relocation of our practice from Florida to Greece. We present only the primary correction of Grade 2 and Grade 3 ptosis with augmentation mastopexy using the Wise pattern. We do not include vertical and crescentic excision combined with augmentation or any secondary procedures related to the correction of double bubble, waterfall phenomenon, capsular contracture or corrective procedures related to the aging of the breast. Minor complications included three augmentation and one mastopexy hematomas that needed evacuation; four superficial T-point sloughing; and six marginal areolar superficial sloughs. We did not have any infections, implant extrusions or nipple loss.
We do not consider as complications secondary maintenance procedures related to aging and scar revisions.
Conclusion
:The technique described is a combination of an inframammary fold sub-musculofascial breast augmentation and an inferior pedicle mastopexy centered over the augmentation incision. Therefore, the inferior pedicle is transversely split at the inframammary fold by the augmentation incision. Even though it sounds unorthodox for the vascularity of the inferior pedicle this incision does not compromise the viability of the flap. This technique has been proven to be a workhorse in our practice.
The advantages of this procedure for a long-lasting result are derived from the use of the smooth silicone implants, the coverage of the implants at the inferior pole by the musculofascial layer and the versatility of the tightening of the skin brassiere that the inferior pedicle with the Wise pattern allows. This procedure also makes it technically easy to perform any long term revisions the patient may benefit from, in the decades to come.