Primary and revision-augmentation mammoplasty is a commonly performed procedure. The incidence of implant related mammoplasties for both primary and revision mammoplasties is on the rise and is due to the information available on the product, premarket surveys, enhanced implant safety, and regular quality checks.[
A retrospectively collected data were analyzed in the Excel Spread Sheet (Microsoft). Between January 2008 and October 2013, 25 patients had MIM following their augmentation mammoplasty in subglandular pocket. Relevant data of 25 patients who had their revision surgery in multiplane pocket was further analyzed. Six months postoperatively, patients were asked whether they were very satisfied, satisfied or dissatisfied with the outcome of the surgery.
All patients are examined in standing and supine position. Supine position allows any excess pocket extension in lateral dimension. Breast ptosis with or without upper and medial quadrant rippling is an indication for the conversion technique. Lower and lower lateral skin envelope rippling is unlikely to be improved by muscle splitting conversion or any other submuscular technique. Degree of capsular contracture is noted, and information is gathered about the size and profile of the existing implants.
All procedures are performed under general anesthetic with full muscle relaxation and as a day case. Patients were placed in the supine position with arms abducted in less than 90°. Inframammary crease was used for the pocket access.
After explantation of the device, pocket was examined for its dimensions and extent and nature of the capsule. In grade 1 or 2 capsular contractures, only lower pole capsulotomies were performed. Breast presenting with advanced capsules, partial or complete capsulectomy was performed. The next step was to identify Pectoralis Major and marked by light scoring on the posterior layer of capsule, starting from the junction of the middle and lower third of sternum medially and going up and laterally to the anterior axillary fold. This line of the muscle split was transposed and marked anteriorly by scoring the anterior layer of the capsule, this scoring should ideally be at or just below the nipple level in the midline.
Pectoralis split was commenced medially at the junction of the middle and lower third of the sternum. Pectoralis muscle is pinched and lifted off the sternal margin using Gillis toothed forceps, and a small incision is made using cutting diathermy. The incision should be large enough to allow index finger, and once the finger is inserted, submuscular dissection was performed using index finger extending up to the 2nd intercostal space and to the anterior axillary line laterally. Once the submuscular dissection is completed, incision is usually large enough allowing the breast retractor to be inserted with its distal end pointing towards anterior axillary fold. Muscle split begins medially using cutting diathermy, and once the split gets closer to the anterior axillary fold, the dissection is slowed down. Here, coagulation of the muscle is performed before splitting or cutting it up further. The maneuver avoids inadvertent bleeding resulting from damage to thoracoacromial axis branches.
Once pectoralis split is completed, the lateral capsulotomy is extended upward to join the lateral extent of muscle split. The lower border of the upper split pectoralis is now stitched to the breast envelope below the marked and scored anterior capsule using 2-0 Vicryl interrupted stitches vicryl (Ethicon)
(a) Intraoperative picture showing scored anterior skin envelope marked with a Vicryl suture held at its loose end. Below and to the right in the picture, lower edge of the upper split muscle is also marked with Vicryl suture; (b) anterior capsule/wall of the pocket on the left and lower free edge of upper split muscle on the right, held separately in forceps before suturing; (c) tied suture knot between the marked anterior capsule/wall of envelope and lower edge of the upper split pectoralis major in place
Wound closure is done using continuous 2-0 Vicryl to deep fascial layer, subcutaneous 3-0 Vicryl interrupted and intradermal 4-0 continuous Monocryl stitch (Mononcryl (Ethicon). Once the wound closed and dressed, external support to breast envelope is provided using adhesive dressings. The external supportive dressings are applied starting from the lower pole and pulling, supporting, and stabilizing the breast envelope at a higher and desirable position. Support garments are applied, and patients are discharged on the same day.
Postoperatively, there is often some puckering of the skin envelope due to internal stitches. This puckering almost always disappears within 4-6 weeks after surgery
(a) Illustration showing side profile of an implant in subglandular pocket; (b) illustration showing dissected muscle splitting pocket with anchoring stitch placed between lower border of upper split muscle and breast envelope at a level just under the nipple areolar complex (NAC). Note the relative position of the sixth rib and the nipple areolar complex; (c) illustration showing the implant placed in muscle splitting pocket with a tied anchoring stitch between muscle and breast envelope. Note the puckering of the skin below NAC, gathered skin above NAC and relative position of the sixth rib; (d) implant in its new muscle splitting position with puckering and skin gathering settled
Patients are reviewed 2 and 4 weeks later to check for wound healing. Patients are generally allowed to drive and return to work 10 days following surgery. Patients involved in physically demanding work are advised to take 3 weeks off work.
The group included 25 patients with an average age 36.6 years (range: 25-54 years) with mean implant duration 6.4 years (range: 1.5-13 years), 23 of the patients were nonsmokers, 1 smoker and 1 patient’s smoking status was not mentioned. Eighteen patients presented with grade I capsular contracture, 3 patients with grade II ptosis and 4 patients had a combination of grade I and II capsular contracture. Pseudoptosis was present in 6, class B ptosis in 6, A/B ptosis in 3, sliding ptosis or water-down deformity in 5 and rippling in 5 patients. Average size implant from the initial surgery was 334.4 mL (range: 250-340 mL) and the mean implant size selected for revision surgery was 416 mL (range: 260-525 mL). Of 25 patients, 21 patients had a bilateral procedure whereas the technique was used unilaterally in 4 patients for the correction of asymmetry. Mean follow-up time was 18 months (range: 6-48 months). All patients had a single intravenous dose of predominantly Augmentin and followed by an oral course for 5 days, there was no infection noted in the series. In the current series, no patient required revision surgery following MIM. Patient satisfaction data were retrieved from the spreadsheet, 20 patients (80%) were very satisfied with the outcome and 5 patients were satisfied with the results, no patients showed dissatisfaction with the procedure.
Augmentation mammoplasty is primarily done either in front or behind the muscles.[
The multilane technique was initially described for primary cases with a limited experience for ptosis and rippling correction in patients following augmentation mammoplasty in subglandular pocket.[
The augmentation mammoplasty with the internal mastopexy in prepectoral or subglandular pocket in revisionary cases has a marked advantage over simultaneous augmentation mammoplasty with the internal mastopexy in primary cases. In primary cases, especially those presenting with large size breasts, initial acceptable results may later show sliding ptosis of the NAC over the mound of the implant. However, when MIM is performed in secondary cases, initial mammoplasty in sub glandular pocket has generally compressed the breast tissue over a period of time. This comparatively thinner layer of the breast envelope is far easier to be elevated, anchored, and secured at a higher position on the muscle, in a predictable way and with longevity of results. The current series has a mean follow-up of 18 months (range: 6-48 months) with high satisfactory results. Despite the much desired scar-less MIM in selected cases, a longer follow-up will be desirable for a comparison with other conventional mastopexy techniques used today. The obvious disadvantage of MIM is the indirect measurements for a nipple areolar repositioning as compared to precise markings used in conventional skin reducing and nipple areolar mobilizing techniques. Minor asymmetry, if present, is well-tolerated and accepted by patients due to the normally occurring asymmetries in breast and NAC.[
(a) Preoperative anterior view of a 39-year-old patient 9 years following her mammoplasty in subglandular pocket. Patient had 260 mL high profile Perouse Plastie (540T3) cohesive gel silicone implants with preoperative sternal notch to nipple areolar complex (NAC) of 24.5 cm; (b) three months following augmentation mammoplasty using multiplane technique. Patient had 380 g MHP CUI Allergan Prosthesis. The improvement of ptosis is masked by a large size NAC even after postoperative reduction in the sternal notch to NAC distance to 23.5 cm
(a-c) Preoperative views of a 29-year-old patient who had 380 mL cohesive gel silicone implants placed in subglandular pocket with preoperative suprasternal notch to nipple areolar complex (NAC) distance of 23 cm right and 24 cm on left side. Patient presented with marked ptosis, rippling and asymmetry of breasts; (d-e) two months following the corrective surgery using 460 mL cohesive gel silicone. There is marked puckering of the right breast during early postoperative period; (f-h) postoperative pictures taken 5 months following surgery with good breast lift and symmetry. Her postoperative suprasternal notch to NAC distance was measured 20.5 cm both sides
(a-c) A 43-year-old patient, following augmentation mammoplasty with 430 mL Poly Implant Prothese implants, in subglandular pocket. Patient presented with rippling, breast asymmetry associated with noticeably lowered nipple areolar complex (NAC) along with short NAC to the inframammary crease distance. Her preoperative suprasternal notch to NAC distance was 24.5 bilaterally; (d-f) ten months following the revision surgery with nice symmetry of the breasts and an adequate NAC to inframammary crease interrelationship. Her postoperative suprasternal notch to NAC distance was measured as 24 cm bilaterally
(a-c) Preoperative views of a 41-year-old patient following augmentation mammoplasty in sub glandular plane with 350 mL cohesive gel silicone implants. Patient presented with ptosis, rippling and absolute lack of the upper pole fullness; (d-f) postoperative views 6 weeks after revision surgery in multiplane internal mastopexy using 350 mL cohesive gel silicone implants. Patient showing upper pole fullness, lack of rippling along with rejuvenated breasts appearance
Even though the study did not include a very large number of patients, the outcome showed a very high satisfaction rate. A larger series with a longer follow-up, comparison of breast morphometrics with other conventional skin reducing and nipple mobilizing mastopexies will be desirable.
The technique allows avoidance of external scars in selected patients and can be a good choice especially in those who are not keen on conventional external scarring. With a mean follow-up of 18 months (range: 6-48 months) all patients had an acceptable results, and no further corrective surgery has been performed in the series analyzed.
Nil.
There are no conflicts of interest.