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. 2024 Mar 11;48(20):4144–4155. doi: 10.1007/s00266-024-03917-2

Technical Refinements for Reducing Reoperations in Single-Stage Augmentation Mastopexy: A Retrospective Matched Cohort Study

Matteo Marino 1, Mario Alessandri-Bonetti 2, Riccardo Carbonaro 2, Francesco Amendola 1,✉
PMCID: PMC11543704  PMID: 38467848

Abstract

Background

The goals of mastopexy differ significantly from those of augmentation mammoplasty. Mastopexy is designed to lift and reshape the breasts, while augmentation mammoplasty is designed to increase the volume of the breasts. This conflict causes that one-stage augmentation mastopexies showed a revision rate from 8.7 to 23.2%. The aim of our study is to present some technical refinements for reducing the risk of implant exposure and reoperation.

Methods

We designed a retrospective matched cohort study, including 216 consecutive patients, undergone augmentation mastopexy between January 2013 and December 2022. We divided them in two groups: Group A undergone an inverted-T superomedial pedicled augmentation mastopexy and Group B undergone our inverted-T modified augmentation mastopexy. The groups were matched for clinical and surgical variables, with the surgical technique the only difference between the two.

Results

Complications were registered in ten patients (9.3%) in Group A (two wound breakdowns at T with implant exposure and eight wound dehiscences), six of which required surgical revision. In contrast, only three patients (2.8%) in Group B reported a complication, which was wound dehiscence without implant exposure in all cases. None of the dehiscence required surgical revision. The difference between complication and revision rates was statistically significant.

Conclusions

Separating the implant and the mastopexy dissection planes reduces the implant exposure and the reoperation rate in one-stage augmentation mastopexy.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://link.springer.com/journal/00266.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-024-03917-2.

Keywords: Mastopexy, Augmentation mastopexy, Breast implant, Augmentation mammoplasty, Inverted T mastopexy

Introduction

As outlined by Spear [1] and later remarked by Lee [2] and Sanniec [3], the goals of mastopexy differ significantly from those of augmentation mammoplasty: the former is designed to lift and reshape the breast, reducing the surface of the skin envelope, while the latter increases the breast volume, counteracting the surface reduction of the mastopexy. Additionally, the amount of scarring associated with augmentation mammoplasty is typically minimal, whereas mastopexy generally requires larger and less concealable scars. These differences account for a revision rate as high as 23% [4–10] in one-stage augmentation mastopexy.

Detailed surgical planning, a stepwise approach, and meticulous intraoperative techniques are the key points to minimize the risk of complications and to enhance the results. Nevertheless, implant exposure with subsequent removal represents the most serious local complication, and it is often exacerbated by the wound dehiscence usually presenting at the T-junction in classic inverted-T mastopexy.

This study describes the outcomes of a modified technique for single-stage augmentation mastopexy used for over ten years. We retrospectively compared two single-operator cohorts of patients: one undergoing a classic inverted-T with superomedial pedicle augmentation mastopexy and the other undergoing a modified inverted-T with an extended glandular pedicle augmentation mastopexy in which the glandular flaps are designed to protect the implant from exposure and lower the complication rate. The technique consists in the combination of the subcutaneous glandular dissection performed in vertical [11] and peri-areolar [12, 13] mastopexy, the inferior dermo-glandular flap [14, 15] and the classic approach for augmentation mammoplasty with an incision at the inframammary fold.

Materials and Methods

We retrospectively analyzed consecutive patients undergone augmentation mastopexy between January 2013 and December 2022. All patients were evaluated, planned, and operated on by the same surgeon (M. M.). Every patient signed a detailed and personalized informed consent prior to the operation.

When deciding if mastopexy was needed in addition to implant placement, we typically assessed the position of the nipple-areola complex (NAC) with the arm raised to 90°. Abduction mimics the expected lift from a simple implant placement. If the NAC was less than 1 cm lower than the ideal new position, we planned a circular areolapexy. Therefore, patients undergone circular areolapexy were excluded from the study. If the NAC was more than 1 cm lower than the expected position, we planned an inverted-T mastopexy.

The patients were divided into two groups: Group A, patients receiving augmentation mastopexy following the classic inverted-T technique with a superomedial pedicle; and Group B, patients treated with the personal technique described below. Each implant was placed in a partial, submuscular, dual-plane pocket. The choice between a round or shaped implant was based on the patient’s preferences regarding upper pole fullness and global appearance of the breast. The degree of breast ptosis was evaluated using the Regnault scale [16]. The follow-up protocol was equal for all included patient's drains removal at 2–3 days after surgery and follow-up visits at 7, 15, 30, 180, and 360 days follow-up. The personal technique of the Group B was introduced in patients operated from February 2017, in the attempt of reducing the implant exposure in case of dehiscences at the T-junction.

Demographic and operative data were retrospectively collected from a prospectively maintained database. Patient demographics included age, body mass index, smoking status, history of previous breast surgery. The primary outcomes were overall complications and implant failure rates. The secondary outcomes were infections, wound dehiscences, and capsular contractures rates. The two groups were matched on degree of ptosis, comorbidities, and implant volume. This study was conducted in accordance with the Declaration of Helsinki.

Surgical Technique

With the patient standing, the midline, inframammary fold, and breast meridian are marked. The distance between the sternal notch and nipple is marked. The ideal position of the superior border of the nipple-areola complex (NAC) is then marked on the breast meridian, and the distance is checked for symmetry. A point is marked 5 cm inferior to this point and 2 cm from each side to obtain the three reference points for designing the dome of the keyhole. The markings were then continued at the inferior pole for conservative skin excision. With the arms abducted and skin under tension, the inferior pole height was marked at 7.5 cm and an inferior horizontal excision was planned. The implant was then chosen based on the breast base; projection and volume were adjusted according to the patient′s desire. The NAC position on the most projected point of the implant was considered a fixed point, and the level of the IMF was modified accordingly. (Video 1, Supplementary Digital Content 1).

Intraoperatively, under general anesthesia and with the patient in the supine position, an inframammary incision was placed in the upper half of the planned horizontal lozenge of the inverted-T (Figure 1A). The subpectoral plane was addressed using Ellis′s retractors and blunt elevation with closed Metzenbaum scissors. A dual-plane type II breast pocket was prepared, with soft tissue dissection performed using monopolar electrocautery. A silicon drainage was placed in each pocket, gloves were changed, and the implant was inserted. Every implant received a triple antibiotic immersion prior to its insertion [17]. The lower-pole glandular flap was then sutured to the deep fascia at the level of the new IMF to close the pocket and avoid future dislocation.

Fig. 1.

Fig. 1

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Intraoperative details. A The inframammary incision for the implant placement is set at the upper half of the excisional horizontal area in the mastopexy design. B Complete de-epithelization is performed after the implant has been placed and its access closed. C The medial and lateral pillars and elevated in a subcutaneous, supra-glandular plane, similarly to that followed during a mastectomy. D The NAC is lifted, and the pillars are sutured

Full de-epithelization was performed in the area marked preoperatively (Figure 1B). The medial and lateral pillars were then subcutaneously dissected, following the same plane as the nipple-sparing mastectomy (Figure 1C). After full dissection and closure of the upper and lower areolar borders, the dermal strip of the lower pole was incised to consent to the lifting of the NAC (Figure 1D, Video 2 supplementary Digital Content 2). Eventually, the inferior T-point between the inferior pole and IMF was sutured, and all incisions were closed with monofilament absorbable subcutaneous stitches. A mild elastic dressing is applied.

Statistical Analysis

Descriptive statistics were used for demographics, and surgical outcomes data among groups were recorded as frequencies and percentages for categorical variables and as means and standard deviations for numerical variables.

For numerical variables, the T-test was utilized. For categorical variables, differences were measured using the Chi-square and Fisher exact tests. The analyses were performed using SPSS statistics software (IBM, 1 New Orchard Road, Armonk, New York 10504-1722, United States).

Results

A total of 216 female patients were included in this study, 107 in group A and 109 in group B. Median age (28 versus 25 years, respectively) and number of active smokers (9.5 versus 10.5 sig/die, respectively) were not significantly different between the groups (p > .05). No comorbidities were present in the two groups. Most patients in both groups had Grade III breast ptosis (n. 86 versus 77, respectively), without a significant difference. Anatomic implants were used in 86 (80%) patients of the Group A and 87 (79%) patients of the Group B, with a mean volume of 290 cc (± 39) in Group A and 300 cc (± 44) in group B. The median nipple-to-fold length passed from 12 cm preoperatively to 8 cm postoperatively.

The average breast lift was 6 cm for Group A (from a median sternal notch-to-nipple distance of 25 cm to 19 cm) and 5 cm for Group B (median 25–20 cm). The overall average follow-up period was 45 ± 15 months, with no significant difference between the groups (46 months for Group A versus 43 months for Group B, p = .17).

Complications were registered in ten patients (9.3%) in Group A (two wound breakdowns at T with implant exposure and eight wound dehiscences without implant exposure), six of which required surgical revision. In contrast, only three patients (2.8%) in Group B reported a complication, which was wound dehiscence without implant exposure in all cases. None of the dehiscence required surgical revision. One dehiscence in Group A and one in Group B occurred in active smokers. The difference between complication and revision rates in the two groups was statistically significant (p = .045 and .035, respectively). Patient characteristics and outcomes are summarized in Table 1. The results of pre- and postoperative day 30 of the case shown in the surgical technique paragraph are shown in Figure 2. Example cases at 1 year follow-up are shown in Figure 3 for Group A and in Figure 4 for Group B. Example case of a 10 year follow-up for Group B is shown in Figure 5. A complete list of patients and their data are reported in Table 2.

Table 1.

Patients characteristics

Group A Group B P value
Wise pattern Chimeric mastopexy
N 107 109
Median age (years) 28 25 NS
Smokers (N) 12 8 NS
Ptosis
Grade II (n) 25 33 NS
Grade III (n) 82 76 NS
Implant
Round (N) 21 22 NS
Shaped (n) 86 87 NS
Mean volume (CC) 290 300 NS
SN-N distance (cm)
Mean pre 25 25 NS
Mean post 19 20 NS
Complications (n) 10 3 < .05
Dehiscence (n) 8 3 NS
Exposure (n) 2 0 NS
Revision (n) 6 0 < .05
FU (months) 46 43 NS
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Fig. 2.

Fig. 2

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Preoperative (above) and postoperative results at day 30 (below) of the case presented in figure 1

Fig. 3.

Fig. 3

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Preoperative (above) and postoperative results at one year (below) of a sample case for Group A

Fig. 4.

Fig. 4

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Preoperative (above) and postoperative results at one year (below) of a sample case for Group B

Fig. 5.

Fig. 5

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Preoperative (above) and postoperative results at 10 years (below) of a sample case for Group B

Table 2.

Complete patients data

S-N distance N-IMF distance
N Age Smoke Ptosis Mastopexy Impl. type Impl. volume Pre Post Delta Pre2 Post3 Delta Complications Reoperation FU
6 18 II Wise Shaped 320 24 21 3 13 7 6 25
10 24 II Wise Round 275 23 20 3 13 8 5 62
11 29 II Wise Shaped 335 24 21 3 13 7 6 46
16 32 II Wise Shaped 245 23 20 3 13 8 5 53
28 27 II Wise Shaped 285 25 21 4 13 9 4 25
30 27 II Wise Shaped 235 23 21 2 11 9 2 Exposure Exchange 58
40 33 II Wise Shaped 245 23 20 3 12 7 5 33
41 30 II Wise Shaped 315 23 19 4 12 8 4 63
43 31 10 II Wise Round 275 24 21 3 13 8 5 63
44 41 II Wise Shaped 265 24 20 4 10 9 1 66
53 41 II Wise Shaped 355 23 19 4 11 8 3 56
57 19 II Wise Shaped 270 25 21 4 13 8 5 Dehiscence Revision 45
58 21 14 II Wise Shaped 305 24 20 4 11 7 4 56
60 25 II Wise Shaped 285 23 21 2 10 9 1 63
1 26 III Wise Shaped 320 26 20 6 10 8 2 69
2 39 III Wise Shaped 330 23 18 5 10 8 2 67
3 27 III Wise Shaped 345 25 20 5 10 9 1 46
4 26 III Wise Shaped 285 24 19 5 11 7 4 53
5 22 III Wise Shaped 260 24 18 6 10 9 1 46
7 21 III Wise Shaped 280 25 19 6 12 9 3 44
8 20 12 III Wise Shaped 310 26 18 8 13 7 6 Dehiscence Revision 51
9 22 III Wise Shaped 355 27 18 9 10 8 2 26
12 22 III Wise Shaped 260 24 19 5 13 8 5 56
13 21 III Wise Round 275 25 19 6 13 7 6 55
14 25 III Wise Shaped 330 28 20 8 12 8 4 49
15 28 III Wise Round 250 26 21 5 11 8 3 44
17 26 III Wise Shaped 230 26 19 7 13 9 4 60
18 24 5 III Wise Shaped 315 25 20 5 10 7 3 22
19 31 III Wise Shaped 295 23 18 5 12 8 4 31
20 19 III Wise Shaped 255 26 20 6 10 8 2 20
21 31 III Wise Round 250 25 20 5 13 8 5 Dehiscence Revision 60
22 23 III Wise Shaped 285 26 20 6 10 8 2 59
23 21 III Wise Shaped 230 23 18 5 11 9 2 53
24 23 III Wise Shaped 290 27 21 6 12 8 4 69
25 31 III Wise Round 325 25 19 6 13 9 4 67
26 22 III Wise Round 250 25 18 7 10 9 1 40
27 27 8 III Wise Shaped 315 28 21 7 13 7 6 24
29 40 III Wise Shaped 240 26 21 5 12 8 4 70
31 26 III Wise Shaped 315 26 20 6 10 9 1 Dehiscence 28
32 29 III Wise Shaped 345 25 19 6 13 9 4 35
33 26 III Wise Shaped 235 24 19 5 13 9 4 52
34 32 III Wise Shaped 290 26 18 8 12 9 3 46
35 37 III Wise Shaped 290 28 19 9 12 7 5 18
36 26 III Wise Shaped 340 26 21 5 13 7 6 67
37 27 III Wise Shaped 320 25 18 7 12 8 4 46
38 27 III Wise Round 300 23 18 5 12 9 3 50
39 19 III Wise Shaped 305 26 19 7 11 9 2 61
42 36 10 III Wise Shaped 240 25 20 5 12 8 4 21
45 28 III Wise Shaped 280 26 20 6 13 7 6 52
46 35 III Wise Round 375 25 20 5 11 8 3 29
47 41 III Wise Shaped 270 26 20 6 10 8 2 49
48 40 III Wise Shaped 235 24 19 5 11 8 3 67
49 32 III Wise Shaped 270 26 21 5 11 9 2 58
50 27 III Wise Round 250 26 18 8 13 7 6 57
51 18 III Wise Shaped 335 26 21 5 11 7 4 Dehiscence None 40
52 35 14 III Wise Round 300 26 18 8 10 8 2 41
54 22 III Wise Shaped 315 27 19 8 12 9 3 25
55 20 III Wise Shaped 295 25 20 5 12 8 4 19
56 23 III Wise Shaped 310 26 18 8 11 7 4 22
59 23 III Wise Shaped 335 28 20 8 13 8 5 40
61 32 III Wise Shaped 290 26 18 8 11 7 4 49
62 35 III Wise Shaped 280 26 18 8 12 7 5 21
172 22 6 III Wise Shaped 230 27 19 8 11 7 4 39
173 19 III Wise Shaped 240 23 18 5 13 8 5 47
174 19 III Wise Round 325 27 21 6 11 7 4 51
175 24 III Wise Shaped 355 27 21 6 11 7 4 20
176 30 III Wise Shaped 335 25 18 7 12 9 3 19
177 25 III Wise Shaped 335 23 18 5 11 7 4 63
178 37 II Wise Shaped 365 23 20 3 10 8 2 61
179 18 8 II Wise Shaped 265 23 21 2 13 7 6 62
180 32 III Wise Shaped 330 26 18 8 11 7 4 69
181 37 II Wise Shaped 255 22 19 3 12 7 5 32
182 31 III Wise Shaped 255 26 19 7 11 8 3 37
183 37 III Wise Round 275 26 19 7 13 7 6 Dehiscence 35
184 34 III Wise Shaped 360 26 21 5 13 9 4 51
185 36 II Wise Shaped 330 23 19 4 12 9 3 52
186 25 6 III Wise Round 250 23 18 5 13 9 4 43
187 24 III Wise Round 300 26 19 7 13 7 6 53
188 30 III Wise Shaped 240 25 19 6 13 9 4 54
189 29 III Wise Round 250 24 18 6 11 8 3 24
190 35 III Wise Shaped 285 24 19 5 10 7 3 56
191 29 III Wise Shaped 320 27 21 6 13 7 6 54
192 26 III Wise Round 250 29 20 9 12 9 3 49
193 22 III Wise Shaped 240 26 18 8 12 7 5 50
194 33 III Wise Shaped 340 27 20 7 12 9 3 Dehiscence Revision 36
195 34 III Wise Shaped 365 23 18 5 11 9 2 59
196 34 II Wise Shaped 370 23 19 4 13 8 5 66
197 27 II Wise Shaped 310 24 20 4 11 7 4 40
198 20 II Wise Round 275 23 21 2 10 9 1 33
199 30 8 II Wise Shaped 345 23 19 4 12 8 4 70
200 21 10 II Wise Shaped 280 22 19 3 11 8 3 34
201 29 III Wise Shaped 315 27 19 8 12 8 4 19
202 18 III Wise Shaped 235 27 21 6 13 7 6 70
203 29 III Wise Round 325 23 18 5 11 8 3 69
204 30 III Wise Shaped 355 26 21 5 12 7 5 53
205 34 III Wise Shaped 270 24 19 5 10 9 1 19
206 32 III Wise Shaped 305 26 20 6 12 7 5 Exposure Exchange 25
207 29 II Wise Shaped 280 23 19 4 13 7 6 67
208 34 III Wise Round 275 28 21 7 12 9 3 42
209 25 III Wise Round 375 27 20 7 10 7 3 64
210 29 II Wise Shaped 245 25 21 4 10 7 3 64
211 32 III Wise Shaped 240 24 19 5 10 9 1 58
212 23 III Wise Shaped 295 24 18 6 10 9 1 Dehiscence 55
213 34 III Wise Shaped 345 28 21 7 13 9 4 49
214 33 III Wise Shaped 255 24 18 6 10 7 3 49
215 30 III Wise Shaped 260 25 20 5 10 9 1 27
216 34 III Wise Shaped 315 28 20 8 11 9 2 26
63 20 II Hybrid Shaped 305 23 19 4 12 7 5 52
66 26 II Hybrid Shaped 255 23 19 4 11 7 4 34
71 22 II Hybrid Shaped 355 25 21 4 12 9 3 36
72 21 II Hybrid Shaped 370 25 21 4 11 9 2 69
75 30 II Hybrid Shaped 310 24 20 4 10 8 2 39
81 22 10 II Hybrid Shaped 285 23 20 3 13 8 5 Dehiscence None 36
88 29 II Hybrid Round 350 23 20 3 13 7 6 63
89 26 II Hybrid Round 300 23 19 4 12 7 5 51
90 22 II Hybrid Shaped 280 23 19 4 12 7 5 23
93 27 II Hybrid Shaped 255 24 20 4 13 8 5 61
94 22 12 II Hybrid Shaped 295 23 19 4 13 9 4 66
101 24 II Hybrid Shaped 360 23 19 4 11 9 2 32
102 28 II Hybrid Shaped 305 24 21 3 10 7 3 45
107 25 II Hybrid Shaped 355 24 21 3 12 7 5 63
111 20 II Hybrid Shaped 230 23 21 2 13 8 5 26
117 20 II Hybrid Round 350 25 21 4 12 7 5 58
120 29 8 II Hybrid Shaped 305 25 21 4 13 7 6 49
121 22 8 II Hybrid Shaped 295 23 19 4 10 8 2 66
122 21 II Hybrid Round 325 23 19 4 13 8 5 30
124 24 II Hybrid Round 250 23 21 2 12 7 5 54
129 30 II Hybrid Shaped 345 23 19 4 10 7 3 44
130 28 II Hybrid Shaped 260 23 20 3 10 9 1 62
131 25 II Hybrid Round 375 24 21 3 10 9 1 23
134 30 II Hybrid Shaped 370 24 20 4 13 8 5 35
135 29 II Hybrid Shaped 360 23 21 2 10 7 3 67
145 25 II Hybrid Shaped 285 23 20 3 13 8 5 55
64 22 III Hybrid Round 350 27 20 7 11 7 4 36
65 20 III Hybrid Shaped 340 25 19 6 12 9 3 29
67 24 III Hybrid Shaped 290 28 19 9 11 8 3 41
68 20 III Hybrid Shaped 270 24 18 6 10 8 2 32
69 23 III Hybrid Shaped 315 28 20 8 12 9 3 18
70 28 III Hybrid Shaped 340 26 21 5 11 8 3 22
73 25 III Hybrid Shaped 230 27 18 9 12 7 5 Dehiscence None 59
74 23 III Hybrid Shaped 230 23 18 5 11 8 3 22
76 28 III Hybrid Shaped 320 26 18 8 10 7 3 34
77 29 III Hybrid Round 250 27 19 8 13 8 5 18
78 26 III Hybrid Shaped 355 27 20 7 10 8 2 64
79 23 III Hybrid Shaped 305 27 21 6 12 7 5 47
80 21 14 III Hybrid Round 250 25 19 6 10 9 1 37
82 25 III Hybrid Round 325 25 20 5 13 9 4 42
83 23 III Hybrid Shaped 330 26 19 7 12 7 5 54
84 31 III Hybrid Shaped 360 27 21 6 12 8 4 24
85 30 III Hybrid Shaped 330 24 18 6 11 9 2 54
86 28 III Hybrid Shaped 335 26 21 5 12 8 4 32
87 25 III Hybrid Shaped 230 27 18 9 11 8 3 53
91 20 III Hybrid Round 300 26 21 5 10 9 1 26
92 24 III Hybrid Shaped 305 23 18 5 13 8 5 50
95 30 III Hybrid Shaped 370 27 21 6 12 8 4 27
96 23 III Hybrid Round 350 28 19 9 12 8 4 36
97 30 III Hybrid Shaped 260 26 20 6 10 8 2 37
98 25 III Hybrid Shaped 355 24 19 5 11 7 4 51
99 30 III Hybrid Shaped 295 28 20 8 13 8 5 63
100 23 III Hybrid Shaped 260 26 18 8 13 7 6 65
103 26 III Hybrid Shaped 290 26 20 6 13 7 6 51
104 21 III Hybrid Shaped 255 25 18 7 12 8 4 70
105 31 III Hybrid Round 325 27 20 7 10 8 2 63
106 23 III Hybrid Shaped 230 25 19 6 10 8 2 68
108 27 III Hybrid Shaped 295 24 19 5 12 8 4 19
109 28 III Hybrid Shaped 245 25 18 7 12 9 3 68
110 29 III Hybrid Shaped 230 27 20 7 12 7 5 66
112 31 12 III Hybrid Shaped 230 27 21 6 11 8 3 41
113 20 III Hybrid Shaped 295 25 20 5 10 9 1 20
114 29 III Hybrid Round 375 28 21 7 12 8 4 42
115 20 III Hybrid Shaped 340 28 19 9 11 7 4 26
116 24 III Hybrid Shaped 340 24 18 6 12 9 3 Dehiscence None 65
118 25 III Hybrid Shaped 265 27 18 9 13 7 6 47
119 30 III Hybrid Shaped 265 25 19 6 11 9 2 64
123 28 III Hybrid Round 275 24 18 6 11 9 2 67
125 29 III Hybrid Shaped 280 25 18 7 11 9 2 62
126 22 III Hybrid Shaped 265 24 18 6 12 7 5 61
127 32 III Hybrid Shaped 335 27 19 8 11 7 4 53
128 20 III Hybrid Shaped 230 26 21 5 12 7 5 42
132 31 III Hybrid Shaped 290 28 20 8 12 8 4 27
133 22 III Hybrid Round 250 27 21 6 10 7 3 53
136 28 III Hybrid Shaped 230 24 18 6 10 9 1 61
137 21 III Hybrid Round 325 23 18 5 11 8 3 59
138 28 III Hybrid Shaped 355 28 21 7 13 9 4 19
139 26 III Hybrid Shaped 285 27 19 8 11 8 3 49
140 31 III Hybrid Shaped 265 26 21 5 10 7 3 36
141 30 III Hybrid Shaped 320 26 18 8 10 8 2 47
142 21 III Hybrid Shaped 295 28 20 8 12 7 5 18
143 20 III Hybrid Shaped 235 24 18 6 13 8 5 42
144 25 III Hybrid Shaped 320 26 21 5 13 9 4 23
146 27 III Hybrid Shaped 255 28 21 7 13 7 6 32
147 26 II Hybrid Shaped 360 23 19 4 13 8 5 27
148 20 III Hybrid Shaped 365 23 18 5 10 7 3 48
149 31 5 III Hybrid Shaped 285 23 18 5 13 9 4 59
150 21 II Hybrid Shaped 370 24 21 3 12 7 5 34
151 25 III Hybrid Shaped 330 24 19 5 12 9 3 68
152 23 III Hybrid Shaped 340 26 20 6 12 7 5 31
153 23 II Hybrid Shaped 285 25 21 4 10 7 3 28
154 31 III Hybrid Shaped 345 25 20 5 13 9 4 39
155 21 III Hybrid Shaped 335 29 20 9 13 7 6 64
156 29 III Hybrid Round 375 25 18 7 11 9 2 40
157 28 III Hybrid Shaped 280 28 21 7 10 8 2 69
158 22 III Hybrid Round 375 28 20 8 13 8 5 44
159 30 III Hybrid Shaped 260 29 21 8 10 8 2 59
160 32 III Hybrid Shaped 240 24 18 6 12 8 4 22
161 23 III Hybrid Round 300 29 20 9 11 7 4 28
162 26 III Hybrid Shaped 240 28 20 8 10 7 3 42
163 26 II Hybrid Shaped 365 23 20 3 12 8 4 29
164 29 III Hybrid Shaped 280 29 21 8 13 7 6 22
165 30 III Hybrid Round 300 28 20 8 13 8 5 47
166 20 II Hybrid Shaped 310 24 20 4 10 9 1 43
167 20 II Hybrid Shaped 265 23 20 3 10 7 3 30
168 21 10 III Hybrid Shaped 295 24 18 6 12 8 4 38
169 29 III Hybrid Shaped 345 26 19 7 11 9 2 46
170 28 III Hybrid Shaped 290 25 18 7 11 9 2 29
171 24 II Hybrid Round 300 24 21 3 11 8 3 26
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Discussion

Mastopexy and augmentation mammoplasty have opposite surgical goals, with the increase in the breast volume contrasting the skin reduction. Consequently, single-stage procedures reported relatively high frequencies of complications, among which wound dehiscence with implant exposure represents the most serious local complication.

Khanavin et al. [18] performed a systematic review and meta-analysis of the outcomes of single-stage augmentation mastopexy from 23 retrospective cohort studies. They reported a pooled complication rate of 13.1% (6.7–21.3% CI) and a pooled reoperation rate of 10.65% (6.7–15.4% CI). The inverted-T resulted in a lower rate of ptosis recurrence (3.2%). A major limitation of their study was the evident heterogeneity among studies, both in quality and level of evidence; nevertheless, their study is the only meta-analysis available to date on single-stage augmentation mastopexy. With our modifications, combining the approach of three different breast operations, we lowered the complication rate from 9.3 to 3% and the revision rate from 5.6% to none. By integrating techniques from three distinct breast operations, we reduced the complication rate from 9.3 to 3% and eliminated the revision rate, which was 5.6% in Group A. Interestingly, even if three wound dehiscences were registered in the modified technique group, none of them resulted in implant exposure or needed reoperation.

Stevens et al. [9] reported on 615 consecutive patients undergoing single-stage mastopexy. Implant infection with explanation occurred in 0.8%, poor scarring in 5.7%, and wound-healing problems in 2.9% of patients. The global revision rate was 16.9%. The major limitation of their study is the extreme variability of their cohort: they included different procedures (both primary and secondary mastopexy), implant materials (silicone and saline), surgical techniques (circumareolar, vertical, and inverted-T), and pocket location (both sub glandular and submuscular). Messa et al. [10] reported similar outcomes in their 1183 consecutive single-stage augmentation mastopexy cohort. Although, they also included circumareolar, vertical, and inverted-T techniques. In contrast, in our study, we included only a specified type of augmentation mastopexy, reporting a 2.8% of complications with no revisions.

Sanniec et al. [3] reported one of the largest single-operator case series in the literature, with 251 single-stage augmentation mastopexies. In their study, the mastopexy technique was like our inverted-T, including the preservation of the inferior dermal flap at the T; though, the elevation of the two parenchymal pillars was conducted at full thickness, connecting the skin incision directly to the implant pocket. They reported 14% of total complications, 3.6% revisions, and 0.8% implant removal. On the contrary, our modified technique achieved sensibly lower rates and no revisions.

Our modified chimeric technique reunites the advantages of three different approaches in breast surgery. The inframammary incision and submuscular placement of the implant reduce the risk of infection and capsular contracture [19]; the inferior pole de-epithelized flap, beveling the access of the implant pocket from the inframammary part of the inverted-T wound, offers vascularized coverage to the inferior profile of the implant and avoids direct exposure in the case of a wound breakdown. This was partially derived from the Balcony technique described by De Vita et al. [20]. Finally, subcutaneous dissection with elevation of thin and pliable medial and lateral pillar flaps, derived from the peri-areolar and vertical mastopexy techniques, optimizes skin re-draping, and maximizes control over nipple position and lower pole height.

The main limitation of this study stands in the retrospective nature, which does not allow a strict control of confounding biases, even if they had been reduced by the cohort matching, the single operator procedures, the equality among the types of implants, and the degree of breast lift. A prospective study might help confirming that the described technique is able to reduce the rate of complication and revision in augmentation mastopexy.

Conclusions

Our chimeric technique of single-stage augmentation mastopexy improves the safety profile of this intervention, reducing overall complications and minimizing the risk for wound dehiscence and implant exposure.

Supplementary Information

Below is the link to the electronic supplementary material.

Download video file (59.7MB, mp4)

This video shows the preoperative planning and design for our technique of single-stage augmentation mastopexy. (MP4 61102 KB)

Download video file (41.5MB, mp4)

This video shows an intraoperative technical tip. After implant placement and de-epithelization, the medial and lateral pillars are elevated. The central sling of dermis has to be incised, in order to facilitate the lifting of the NAC. (MP4 42476 KB)

Funding

Open access funding provided by Università degli Studi di Milano within the CRUI-CARE Agreement.

Declarations

Conflict of interest

The authors declare that they have no conflicts of interest to disclose.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent

An information pamphlet was provided to every patient at least one week prior the operation, and written informed consent was obtained on the operation day.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

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Associated Data

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Supplementary Materials

Download video file (59.7MB, mp4)

This video shows the preoperative planning and design for our technique of single-stage augmentation mastopexy. (MP4 61102 KB)

Download video file (41.5MB, mp4)

This video shows an intraoperative technical tip. After implant placement and de-epithelization, the medial and lateral pillars are elevated. The central sling of dermis has to be incised, in order to facilitate the lifting of the NAC. (MP4 42476 KB)

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