Internal Mastopexy Technique in Breast Explant Surgeries

Goals/Purpose: In recent years, breast augmentation surgeries with breast prostheses have become the most commonly performed procedures worldwide; currently there are around 50 million women with silicone implants. Recently, we have come across an increase in the number of patients in our offices requesting breast removal, a procedure called breast explant. The main reasons for this are: dissatisfaction with the aesthetic result, change in lifestyle habits and concern about the presence of silicone in your body/systemic symptoms. Removing the implant always raises concerns about the remaining volume of breast tissue and its relationship with the skin envelope. To resolve this issue, mastopexy techniques, glandular flaps and fat grafting are widely used. Internal mastopexy is an excellent alternative for restoring breast contour, without the need for classic mastopexy scars, for patients with good skin quality. The objective of this work is to describe the application of the internal mastopexy technique in patients undergoing explant surgery.

Methods/Technique: Patients who sought the private clinic, from January 2022 to May 2024, who wanted to have their silicone implants removed and met the following criteria were included: Estimated remaining breast volume > 30%, good quality skin without or with few stretch marks and areola with a diameter < 6 cm. The remaining breast volume ratio was assessed clinically and with imaging examination (ultrasound, mammography and/or magnetic resonance imaging).Preoperative markings include the midline, footprint and mammary fold, native and current, in cases of bottoming out. Liposuction of the lateral region of the chest is routinely performed on patients to improve the lateral contour of the breast and to perform fat grafting, when indicated. In all patients, the incision was made in the sulcus, taking advantage of the previous scar, but extended to approximately 8 to 10 cm.

The patients underwent general anesthesia and were positioned with their arms abducted at 90 degrees. Breast explant was performed through an incision in the sulcus, using monopolar cautery and with total capsulectomy in all cases, regardless of the implant inclusion plane (subglandular or submuscular). After the explant, internal mastopexy was performed. The technique is based on a basic premise: when a breast implant is placed, the footprint automatically expands in all directions. When proceeding with the explant, in turn, we must perform exactly the opposite movement, reducing the dimensions of the breast. Based on the principles of geometry, keeping the volume constant, if we reduce the radius of the base we will be able to increase the height of the cone. This movement allows us to concentrate the residual volume of the breast in a smaller area, allowing greater projection of the breast cone with the same volume. The main objective is to narrow the circummammary ligament by sliding the deep layer of the superficial fascia and fixing the tissue with suture lines. In this way, all of the breast tissue is repositioned and concentrated in the central portion of the new breast cone. Tissue recruitment is performed from the lateral and upper portions of the chest, upper abdomen and midline with circular suture lines, like the hours of a clock.

Depending on the volume of residual breast, one to three suture lines can be performed. Larger, heavier and lateralized breasts require greater displacement and support. The thread used was 2-0 vicryl. Fat grafting may or may not be associated with the case. As there is complete closure of the dead space with the sutures, suction drains were not used. After finishing the sutures, the surgical wound synthesis is performed. Based on this concept, several sutures are performed in order to reduce the breast footprint by structurally relocating the breast tissue, reversing the distortion generated by the prosthesis, internally reconstructing the breast structure, thus relocating the tissues as needed. This is an alternative in selected patients.

Results/Complications: During the study period, 12 cases were operated on, all female patients. The mean age of the patients was 42.4 years (SD 6.2). Of these, 8 (66%) had prostheses in the subglandular plane. The average number of implants removed was 315 (180-420) ml. All patients reported being satisfied after surgery. There were no cases of need for reintervention or need for traditional mastopexy as a rescue alternative. One patient (8.33%) presented unilateral right breast hematoma without the need for reintervention. All capsules removed during surgery were sent for anatomopathological analysis, with all results being normal. In figure 1 you can see a post-operative view of internal mastopexy after implantation, a result of 4 months.

Conclusion: Complications arising from the use of silicone implants are receiving greater attention and, therefore, leading to an increase in prosthesis removal surgeries. We describe an alternative to explant surgery, without the need for skin resection, called internal mastopexy. This technique proved to be effective and safe and easily reproducible.