Challenging Breast Augmentations: The Influence of Preoperative Anatomical Features on the Final Result

Abstract

Background

Achieving satisfactory results may be difficult in augmentation mammaplasty patients in the presence of breast, chest wall, or vertebral deformities. These deformities have not been classified previously, and the impact of each deformity or combination of deformities has not been defined.

Objectives

The aims of this study are to determine the complicating factors in augmentation mammaplasty, to classify these factors according to their influence on surgical outcome, and to develop an identification system for simplifying the recognition of challenging cases.

Methods

We retrospectively analyzed photographs and records of 100 consecutive patients who underwent augmentation mammaplasty. We observed suboptimal results in 18 cases. Preoperative deformities of the breast, chest wall, and vertebra were recorded in order to determine which factor or factors had complicated the surgeries. Eventually, the relationship between suboptimal surgical results and complicating factors was evaluated.

Results

We observed that some deformities alone caused suboptimal results, whereas others did not. Deformities that caused suboptimal results alone were called major complicating factors, and any others were called minor complicating factors. We observed that suboptimal results were also obtained in patients who had four minor complicating factors. Patients who had suboptimal results because of major or minor complicating factors were considered challenging cases.

Conclusions

In this study, complicating factors for augmentation mammaplasty were defined and classified as major or minor depending on their effect on the surgical outcome. We suggest an identification system that simplifies the recognition of challenging cases in breast augmentation.

Level of Evidence: 4

Therapeutic

Augmentation mammaplasty is a common procedure with a high patient satisfaction rate.^1,2 Consistently achieving aesthetic results in augmentation mammaplasty depends on many factors that the surgeon must consider. Some of these are under the control of the surgeon such as implant choice, surgical technique, and preoperative patient education. However, there are additional factors that can affect the final outcome including existing breast, chest wall, or vertebral deformities. These deformities are not uncommon and they can lead to suboptimal outcomes unless they are noted and managed by the surgeon. In some cases, an existing deformity might become more noticeable during an augmentation mammaplasty. Preoperative identification of these deformities is important for preoperative patient education and for operative planning. Many of these deformities (such as pectus excavatum, scoliosis, and tuberous breast deformity) have been previously described, and authors have reported successful breast augmentations using multiple variations in these cases.^3-13 The aim of this study is to classify preoperative deformities according to the degree that they can influence the aesthetic outcome in breast augmentation, and to develop a preoperative identification system in order to recognize challenging augmentation mammaplasty cases.

METHODS

We retrospectively analyzed 100 consecutive patients who underwent augmentation mammaplasty between January 2011 and October 2012. All patients were operated on by a single surgeon. Augmentation mastopexy patients were excluded from this study, although patients with minimal ptosis who received an implant alone were included. We also excluded patients who required breast reconstruction techniques (expanders or flaps), such as cases of severe Poland's syndrome. The study was approved by the Department of Plastic, Reconstructive and Aesthetic Surgery at Gulhane Military Medical Academy (Ankara, Turkey), complied with the declaration of Helsinki guidelines, and informed consent was obtained from all patients.

The breast augmentation was done through an inframammary or a periareolar incision and gel implants were used in all patients. All patients received round implants except for two, who received anatomical implants at their request. The profile (moderate or high) and surface (smooth or textured) of the implant was decided according to preoperative breast volume, skin quality of the breast, and patient request. If the patient had nipple asymmetry (in case of vertical or lateral nipple-areola complex [NAC] malposition) or had tuberous breasts, a periareolar incision was used. In all other patients an inframammary incision was used. Our preference is for smooth implants for dual-plane pockets, and textured implants for subglandular pockets. We obtained standard front, left/right lateral, and left/right oblique views of the patients, preoperatively and postoperatively.

Three experienced plastic surgeons (FZ, YK, HK) with more than 10 years in practice independently evaluated the preoperative and postoperative photographs. Any evident abnormality in breast volume, NAC position, inframammary fold (IMF) position, or breast projection was defined as a suboptimal result. Intraclass correlation coefficient (ICC) was also calculated to assess the inter-observer reliability. The authors then reviewed the patients' records and developed a list of factors that could possibly have downgraded the outcome of the procedure, and the incidence of each of these deformities was identified. The number of preoperative deformities for each patient was determined, and the relationships between the suboptimal surgical results and these deformities were evaluated. Preoperative deformities were considered complicating factors and were then classified into major or minor factors. Major complicating factors were those that singularly led to a suboptimal outcome, and minor factors were those that led to a suboptimal outcome if they were present in combination (Table 1).

Table 1.

Table Demonstrates the Classification of the Complicating Factors Arising From Breast, Thoracic Wall and Vertebral Deformities

	Breast Deformities	Thoracic Wall Deformities	Vertebral Deformities
Major complicating factors	Tuberous Breasta Poland syndrome	Pectus carinatum Pectus excavatum	Scoliosis
Minor complicating factors	Volume asymmetry Severe hypoplasia Mild ptosis Pseudoptosis Lateralized nipple Constricted baseb Asymmetry of IMFc Vertical nipple asymmetry	Long thorax Flaming rib	Subtle vertebral deformities

Complicating factors has been divided into two main group as major and minor. ^aType 3 tuberous breast according to Grolleau classification. ^bType 1-2 tuberous breast according to Grolleau classification. ^cIMF, Inframammary fold.

RESULTS

The average age of the 100 female patients was 26 (range, 21 to 38 years), and the average follow-up was 18 months (range, 10 to 36 months). Eighteen patients (18%) had suboptimal surgical results. ICC was found to be good and statistically significant for inter-observer reliability (ICC = 0.083, P < .001), showing enough consistency among the three observers. The average number of deformities per patient was 0.98 (range, 0 to 5 deformities). Breast, chest wall, or vertebral deformities were detected in 70 patients (70%). Whereas 19 of the patients had one deformity, the remaining 51 patients had more than one. The types and rates of deformities are shown in Table 2. The most common deformity was IMF asymmetry, which was found in 21 patients. Lateral nipple malposition (asymmetry in the horizontal axis) was found in 13 patients, and asymmetry in the vertical axis was also found in 13 patients.

Table 2.

The Types and the Rate of Breast, Chest Wall or Vertebral Deformities

	Deformity	Patient (%)
Breast	Asymmetry of IMF	21
	Severe hypoplasia	15
	Vertical nipple asymmetry	13
	Lateral malposition of nipple (bilateral)	9
	Volume asymmetry	8
	Constricted base	6
	Pseudoptosis (unilateral)	6
	Lateral malposition of nipple (unilateral)	4
	Pseudoptosis (bilateral)	4
	Tuberous breast	2
	Poland syndrome	1
Chest wall	Flaming rib	3
	Long thorax	2
	Pectus excavatum	2
	Pectus carinatum	1
Vertebra	Subtle vertebral deformities	2
	Scoliosis	1

IMF, Inframammary fold.

Suboptimal outcomes resulted from either one major or at least four minor complicating factors. All patients who had no major complicating factor and had fewer than four minor factors had good results. Patients with suboptimal surgical results because of complicating factors were considered challenging cases. The types of deformities in these challenging cases are detailed in Table 3. Seven of these patients had major complicating factors, and the remaining 11 patients had four or more minor factors. Although the challenging cases constituted 18% of our series, the reoperation or revision surgery rate was 5% and included fat grafting, implant exchange, implant reposition, and scar revision.

Table 3.

Details of the Challenging Cases Group

Deformity/Complicating Factors	Reason of Suboptimal Result	Patient (%)
Lateralized nipple Asymmetry of IMF Constricted base Severe hypoplasia	4 minor	2
Pseudoptosis Asymmetry of IMF Volume asymmetry Vertical nipple asymmetry	4 minor	6
Pectus excavatum	1 major	2
Pectus carinatum	1 major	1
Long thorax Severe hypoplasia Vertical nipple asymmetry Subtle vertebral deformity	4 minor	1
Tuberous breast	1 major	2
Poland syndrome Volume asymmetry Vertical nipple asymmetry	1 major 2 minor	1
Scoliosis Pseudoptosis Volume asymmetry	1 major 2 minor	1
Severe hypoplasia Constricted basea Volume asymmetry Vertical nipple asymmetry Flaming rib	5 minor	2
Total		18

Seven patients in this challenging case group presented major complicating factor, and the remaining had at least four minor factors. IMF, Inframammary fold. ^aType 1 and 2 tuberous breast according to Grolleau classification.

DISCUSSION

Proper surgical planning and patient education are important determinants of outcome in breast augmentation surgery. Any existing deformities in the breast or chest wall will make the surgery more challenging and affect the cosmetic outcome, thus these deformities should be considered. Preoperative identification of these deformities is one of the most important factors in surgical planning. Breast asymmetry is one of the most common deformities encountered. Its incidence has been reported to be 88% by Rohrich et al³ (n = 100) and 81.1% by DeLuca-Pytell et al⁴ (n = 375). However, not all asymmetry cases are challenging.

Recognition of these deformities preoperatively is important not only for patient counselling but also for surgical planning. Challenging cases in breast augmentation can be described as the cases that require more than the standard techniques to obtain optimal results. The distinction between major and minor complicating factors was done according to the degree of the effect of a specific deformity on the surgery or the outcome. In our study, major complicating factors were defined as those that could, if occurring alone, lead to a suboptimal result; the other complicating factors were defined as minor. Minor complicating factors have less of an effect on the final outcome and might even pass unnoticed if not corrected. However, when there is more than one minor complicating factor, it becomes more challenging to overcome these problems. Moreover, minor complicating factors can be easily overlooked if the preoperative examination is not sufficiently careful. In our study, we found that when there were four or more minor complicating factors, a suboptimal result was obtained. There were no patients with three or fewer minor complicating factors who had suboptimal results, which is why we determined the cut-off point to be four.

It is worthwhile to note that suboptimal results in our study were not evaluated or defined based on patient satisfaction because there were satisfied patients with suboptimal results. Similarly, there were patients who were not satisfied overall but were not categorized as suboptimal (such as patients who were not satisfied with volume). Future studies may be needed to determine the relationship and correlation between suboptimal results and patient satisfaction. The complicating factors we encountered in our series are presented in Table 2, but it is possible that additional major or minor complicating factors such as kyphosis or sunken chest can exist in other surgeons' series.

The relationship between body mass index (BMI) and augmentation mammaplasty is not studied enough in the literature. Some studies show that patients with high or low BMI have more postoperative complications.^14,15 In our series, we did not determine the patients' BMI, but it is known that patients with low BMI are prone to breast hypoplasia with diminished skin envelope, which can make a case challenging. In our study, severe hypoplasia of the breast was considered a minor complicating factor. In contrast, patients with high BMI are more prone to requiring reduction or augmentation mastopexy. Augmentation mastopexy patients were excluded from this study, and in this series we had no patients who were overweight.

Pectus excavatum is a deformity that is usually treated by a thoracic surgeon in childhood. Different techniques, such as thoracic surgery combined with mammaplasty,^5,6 customized implants,^7,8 and cartilage shaving⁹ have been used in augmentation mammaplasty in the presence of chest wall deformities. Thoracic surgery appears to be mandatory in severe cases, especially if it is accompanied by a cardiovascular anomaly. Nevertheless, camouflage surgery should be primarily considered in mild and moderate cases. When this deformity is mild or moderate, it is easily overlooked or underestimated by both the surgeon and the patient. Thus, mild or moderate deformities are perhaps much more important in decision making during augmentation mammaplasty. If the pectus excavatum deformity is not managed during surgery, the deformity will be more prominent after surgery. Moscona et al¹⁰ determined that camouflage of the deformity could be achieved with medial placement of the implants. However, this should be limited because it might result in lateral malposition of the nipple off the center of the breast mound. Another option for camouflaging the deformity is lipofilling, which is an easy method that can be performed repeatedly (Figure 1).

Figure 1.

(A, C) Preoperative and (B, D) one year postoperative photographs of a 32-year-old woman with pectus excavatum deformity (one major complicating factor). Some medial placement of the breast implant and lipofilling to the sternum was planned to correct the deep depression on the sternum. The distance between the medial ends of both implant pockets (dual plane) was planned to be 3 cm (A). Breast augmentation with bilateral 275 cc round, smooth surface breast implant (Mentor Corporation, Santa Barbara, CA) was performed, and fat transfer was repeated after six months. Please note the lateral malposition of the implant in the left breast.

Scoliosis deformity, even if subtle, may present as breast asymmetry.¹¹ There is a correlation between the severity of scoliosis and the difference in breast volumes.¹² In a case with apparent breast asymmetry, it is important to determine whether the asymmetry is caused solely by volumetric difference or if there is a contribution of vertebral deformity. Although in both instances the goal is to eliminate the asymmetric appearance, we believe that scoliosis is a major complicating factor in augmentation mammaplasty because even if the volume asymmetry is compensated for by different size implants, it is generally impossible to correct the asymmetric illusion caused by vertebral scoliosis in these patients (Figure 2). Because the frontal view displays the patient's shoulders, it is a direct and easy way of recognizing vertebral deformities. However, for legal concerns, it may be recommended to obtain a preoperative dorsal view as well in any patient with a serious vertebral deformity.

Figure 2.

(A, C, E) Preoperative and (B, D, F) two year postoperative photographs of a 37-year-old woman with scoliosis, right breast pseudoptosis, and volume asymmetry (one major and two minor complicating factors). A scoliosis deformity can be noticed when the patient's axillary folds (horizontal line) and waist lines (white arrows) are bilaterally compared. Breast asymmetry was corrected only using inframammary incision because the patient was refused mastopexy incision. Bilateral 325 cc round textured breast implants (Mentor Corporation, Santa Barbara, CA) were used.

NAC position can be asymmetric on both the vertical and horizontal axes. Asymmetrically placed NAC on the horizontal axis was first described by Khan.¹³ The author reported that the rate of asymmetrically positioned NAC in the horizontal plane was 12%. We found this rate to be 13% in our study. Augmentation mammaplasty could have resulted in more prominent nipple lateralization if it had been performed without regarding the lateral nipple malposition. Lateralization of an implant pocket, which was proposed by Khan,¹³ may be performed in mild lateral NAC malposition, but it may cause two significant effects in moderate or severe cases: (1) increasing the intermammary distance in bilateral cases; and (2) breast asymmetries in unilateral cases. Our preference in patients with moderate or severe horizontal NAC malposition is to perform crescentic de-epithelialization on the medial side of the nipple through perinipple-areaola complex incision.

There are challenges in obtaining satisfactory augmentation results in severe hypoplastic breasts because of inadequate breast tissue. The implant should be large enough to satisfy the patient but should not cause excessive tension on the soft tissue envelope. Over-augmentation of the breast may increase the risk of sensory loss in the nipple.¹⁶ In addition, the possibility of palpability of the implant may contribute to obtaining a suboptimal result. The patient's body type (such as asthenic or pyknic) should also be considered in the process of implant selection. A patient with an asthenic body type has a diminished chest circumference and increased chest height (long thorax). An anatomically shaped breast implant may be a better option than a round implant in these situations¹⁷ (Supplementary Figure 1).

All of the surgical techniques that have been described for correcting breast ptosis include vertical or perinipple-areaola complex scarring. The “donut” mastopexy permits either correcting minor ptosis or inserting the implant with the upward shifting of the NAC by a perinipple-areaola complex approach.^18,19 Dual-plane augmentation is a common technique that has been shown to be sufficient in patients with mild ptosis.²⁰

DeLuca-Pytell⁴ reported the rate of tuberous breast deformity as 73%. However, Zambacos²¹ expressed that this rate was quite high compared with his observations. In the present study, our findings were similar to those from Zambacos' previous report. In our series, we determined Type 1 (lower medial quadrant deficiency) and Type 2 (deficiency in both lower quadrants) in six patients and Type 3 (all four quadrants deficient with constriction of breast base horizontally and vertically) in three patients, according to the Grolleau classification system.²² Although correction methods for tuberous breast deformity have been described in the literature, there is no doubt that this deformity is a challenging factor. In cases of base constriction (Types 1 and 2), the deformity can be corrected only by parenchymal or soft tissue scoring. Therefore, Types 1 and 2 deformities (according to the Grolleau classification)²² are considered minor complicating factors, and Type 3 deformities are considered a major complicating factor.

The minor deformities that patients are unaware of should be revealed at the time of surgical planning. If these minor deformities go unnoticed by the surgeon, standard augmentation techniques may greatly increase the existing deformity. In addition, the patient may not be aware of the preoperative deformity, but because of focusing on her breasts postoperatively, she may notice these mild deformities for the first time. Therefore, revealing and identifying the deformity with meticulous preoperative evaluation, and explaining it to the patient, are very important. Our study is a retrospective study. Thus, we did not use these complicating factors during the preoperative evaluation of our series. However, after the results of our study, we are using these risk factors for the preoperative evaluation and counseling of the patients, currently.

Evaluation of breast augmentation surgery outcomes is not yet standardized. Although different objective and reproducible measurement methods such as surveys,²³ measurements,²⁴ and photographic evaluations²⁵ have been proposed, none of them has been clinically useful because they are very complex or expensive. Objective/numeric measurements lack evaluation of the overall breast appearance, which is another important limitation of these techniques. As a result, the evaluation of augmentation mammaplasty remains mostly based on visual outcome measures and remains subjective. However, although it is not widely used, we believe that three-dimensional photography will add to the evaluation methods for these cases. Even if the optimal postoperative aesthetic outcome could not be achieved, the patient could be satisfied just because of the self-esteem improvement. Thus, instead of using a patient satisfaction survey, we preferred to perform photographic analysis in accordance with our study's purpose.

Even though asymmetry is a common breast deformity, not all asymmetry cases are challenging. However, considerable numbers of challenging cases are asymmetric. The patient should be informed about possible staged operations, alternative treatment options, and suboptimal results if the case is challenging.²⁶ The patient's refusal of the offer may further complicate the surgeon's work.²⁷ The rate of challenging cases was 18% in our study. Documentation of this rate is important in order to attract the attention of surgeons because it directs them to meticulous surgical planning. We suggest preoperative photographic analysis of patients because the minor deformities that go unnoticed during physical examination can be identified in the patients' images. When we encounter challenging cases, we should find alternative solutions because there is usually another way to satisfy the patients' expectations.

There are a number of drawbacks to this study. Our series was limited to 100 patients only, and larger series may be needed to confirm the cut-off point of four minor complicating factors that we found in this study. Our goal was to highlight the differences in impact between major and minor complicating factors. Additionally, it would be useful to perform a prospective study to evaluate the relationship between suboptimal outcomes and BMI, to implement the classification system and determine its clinical relevance. Patient satisfaction scores may also be added in further studies to evaluate the correlation between surgeon and patient satisfaction. Finally, surgeon-related factors could obviously change the outcomes of breast augmentation surgery. Our series was composed of 100 breast augmentations performed by a single experienced surgeon.

CONCLUSION

In this study, complicating factors in augmentation mammaplasty were defined and classified, yielding a new identification system to aid in recognizing challenging cases. This identification system is easy to apply and is important for the surgeon for correct planning of the surgical procedure and for preoperative patient counselling. This system can be improved with additional studies, and algorithmic approaches can also be developed for correcting each specific complicating factor. Approximately one out of every five augmentation mammaplasty patients has deformities of the breast, chest wall, or vertebrae that can downgrade the cosmetic outcome if not recognized preoperatively.

Supplementary Material

This figure contains supplementary material located online at www.aestheticsurgeryjournal.com.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.