Intra-Capsular Versus Extra-Capsular Breast Mastopexy of Previously Augmented Breast

INTRODUCTION
Primary combination of breast augmentation
with or without breast lift is a common procedures
frequently sought by the patients to enhance the
appearance of breasts. Nowadays mastopexy of
already augmented breast became almost as popular
as the primary procedure due to the increase of
poor outcomes of the primary procedure and also
increased patients' demands of a better breast shape
[1,2].
259
Unlike the primary one, mastopexy of the augmented
breast is more challengeable to the surgeons
due to the preexisting scars, stretched thin skin,
lack of breast tissues, capsular contraction, breast
implant complications and higher patients' expectations
[3].
Two main surgical concepts had been proposed
for the mastopexy of the augmented breast to attain
the desired result; whether doing mastopexy and
plication of the capsule without manipulation of
the implant (extra-capsular) or doing the mastopexy
procedure with capsular violation and rearranging
local breast tissues with or without changing the
breast implant (intra-capsular) [4].
Many approaches have been described for the
mastopexy. Simple crescent skin excision from the
superior pole of the areola; this will only lift the
breast few centimeters and so helpful in moderate
and large ptosis, in addition neither reshaping of
the breast nor change of implant is accessible [5].
Circum-areolar mastopexy is often useful in
secondary cases where it is helpful in mild and
moderate ptosis with great flexibility, advantages
of this technique is that implant manipulation with
proper skin tightening can be achieved without
adding more scars [6]. Disadvantages are widening
of the areolar scar and violation of the NAC vascularity.
Conventional mastopexy, using superior,
superomedial or superolateral pedicles, is the most
efficient means by which both the horizontal and
vertical dimensions of the skin brassiere can be
reduced, however more scars will be added [7].
Combination of multiple concepts is mandatory
to achieve best aesthetic result, and so we performed
this study to evaluate result of two different techniques
of mastopexy for patients with previously
augmented breast.
PATIENTS AND METHODS
During the period from January 2013 to April
2016, the study was performed on sixty patients
seeking breast reshaping after they had previous
breast augmentation for cosmetic purposes. All
patients had ptosis of the overlying breast tissue
with the implants drooped down in addition to
excessive atrophy of the overlying breast tissue.
Inclusion criteria were: Previous circum-areolar
or inframammary sub-glandular breast augmentation
with silicone implants, grade 2 or 3 breast
ptosis and the position of nipple areola complex
ranging from 23-27cms (measured from the suprasternal
notch to the areola).
Exclusion criteria included: Evident capsular
contracture, ruptured implant, history of diabetes,
history of lactation within the year prior to surgery
and history of medical breast disorders. An informed
consent for the procedure and approval of
the study was signed by all patients included.
Patients were divided into two groups: Group
A: included 30 patients who underwent extracapsular
circum-areolar mastopexy and Group B:
including another 30 patients who underwent intracapsular
circum-areolar mastopexy.
Surgical technique:
Preoperative marks are designed to identify the
proper amount of skin excision to tighten overlying
skin and suspended breast parenchyma. The breast
meridian, inframammary fold location, new NAC
position and the periareolar patterns are marked
in the standing position.
In group A; the areola is incised at a diameter
of 4.5- 5cms, then the outer periareolar pattern is
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incised and de-epithelialization of the skin in
between is done. The dermis is divided in the upper
half only between 9 and 3 o'clock leaving a 1cm
dermal rim and dissection starts cranially elevating
a superior glandular flap without violation of the
implant capsule. Dissection continues till the level
of 2nd rib creating a pocket in the superior pole.
After good hemostasis, plication of the capsule is
done using a running absorbable monofilament 2-
0 suture and fixing it to the pectoral fascia at the
2nd rib level.
In group B; the areola is incised at a diameter
of 4.5-5cms, then the outer periareolar pattern is
incised and de-epithelialization of the skin in
between is done. The dermis is divided in the lower
pole only from 3-9 o'clock leaving a 1cm dermal
rim. Excision of lower central parenchyma is done
and the lower pole of implant capsule is then
incised, the implant is removed and the superior
border of the capsule is incised and dissection is
continued superiorly to allow migration of implant
upwards. Next medial and lateral flaps in the lower
breast pole are then dissected from the skin to
allow breast reshaping inferiorly. Insertion of the
new silicone implant then the 2 medial and lateral
flaps are sutured using interrupted absorbable
monofilament 3-0 sutures and fixed to the pectoralis
muscle fascia.
For both groups; a 3-0 non-absorbable suture
is used to form a purse string suture to fix the
areolar size then the areola is closed with interrupted
and running 4-0 absorbable monofilament sutures.
Follow-up after complete healing was scheduled
at 3, 6, and 12 months post operatively. Front,
lateral and oblique lateral views were taken each
visit (Figs. 1,2).
Fig. (1): Preoperative (A) and postoperative (B) Photos showing a 37 years old patient from group B with
previous sub-muscular breast augmentation through circum-areolar incision having intra-capsular
mastopexy.
(A) (B)
Egypt, J. Plast. Reconstr. Surg., July 2018 261
A questionnaire was performed to assess patients'
satisfaction covering the five aspects of the
result of their surgery; scar, sensation, shape,
projection and satisfaction and finally they were
asked if they could recommend this operation to
her friends or not (Table 1). This questionnaire
was performed by using the Likert scale, a psychometric
scale commonly used in survey research.
Statistical evaluation of differences between the
two groups as regarding age, BMI, complication
rate and sensation was done.
RESULTS
There was no significant difference between
the two groups in age (36±8 versus 38±9 years),
mean ± SD body mass index was 26±4 versus
27±5. Post-operative follow up period ranged from
12- 15 months. Complications were classified into
early and late complications (Tables 2,3).
Table (1): Likert Scale; items involved in the questionnaire
and their method of evaluation.
Scar: How do you consider
the cosmetic result of the
wound?
Sensation: Do you have any
problem with sensitivity? (for
example; numbness, lost sensation,
erectile dysfunction)
Shape: Are u satisfied with the
final shape? (size, symmetry,
NAC complex, projection, general
shape and body harmony)
Do you recommend it to your
friends?
Overall satisfaction: How you
define your general satisfaction
of the surgery?
Question/Likert item
Extremely poor
Poor
Barely acceptable
Good
Excellent
Always
Often
Sometimes
Rarely
Never
Extremely poor
Poor
Barely acceptable
Good
Excellent
Strongly disagree
Disagree
Neither agree nor
disagree
Agree
Strongly agree
Extremely poor
Poor
Barely acceptable
Good
Excellent
Patient answer
12345
12345
12345
123
45
12345
Score
Table (2): Early complications in both groups.
Wound Dehiscence
Hematoma
Wound Infection
Seroma
NAC necrosis
Total
11000
2
Group A
10000
1
Group B
Table (3): Late complications in both groups.
Asymmetry (minor)
Widening of the areola
Sensation loss
Total
210
3
Group A
110
2
Group B
Fig. (2): Preoperative (a) and postoperative (b) photos showing a 48 years old patient from group A with
previous sub-glandular breast augmentation through infra-mammary incision having extra-capsular
mastopexy.
(A) (B)
In group A; the overall rate of complications
in group A was 17%, while in group B was 10%.
Wound dehiscence was encountered in 3% of cases
of each group. In these cases; there was skin dehiscence
at the purse-string which was left to heal
by secondary intention.
Results of the questionnaire performed by all
patients were evaluated using the Likert scale.
These results showed patients opinion on scars,
sensation, final shape and projection. Patients of
group B showed obviously superior results as
regarding shape and projection that persisted for
the first year post-operative. Despite that patients'
opinion on shape and scar was higher 4.56 (±0.67)
in group A, in comparison to 4.1 (±0.60) in group
B, but overall satisfaction was higher in group B
4.2 (±0.69) (Table 4).
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reshaping, capsular surgery and implant manipulation.
The conventional mastopexy, based on the Wise
pattern skin excision has been greatly adopted by
surgeons due to its proven versatility as it tightens
the skin envelop both vertically and horizontally
in addition to the feasibility of internal breast
parenchyma suturing, correction of high grades of
ptosis, managing breast asymmetry and changing
the breast implant if needed. However it usually
adds scars to the breast and due to the anatomical
and physiological changes in the breast after previous
augmentation, excessive dissection is somehow
hazardous [10].
Unlike the previous, circum-areolar mastopexy
is usually used only in minimal degrees of ptosis;
it is useful in secondary mastopexy due to the
limited amount of dissection and thus does not
interfere with vascular supply to NAC.
Although many techniques were described for
reshaping of previously augmented breasts however
no single technique has proved superiority over
others in lifting the breast and thus the combination
of various techniques became mandatory to provide
solutions to all arguments faced by surgeons and
achieve good final results. In previously augmented
patients undergoing secondary mastopexy, there
is more reliance on skin resection, flap undermining
and dermal adhesion than on parenchymal sutures.
In this study we performed mastopexy in 60
patients who had previously done breast augmentation
using the circum-areolar approach with two
different modifications for internal reshaping of
the breast tissues to maximize the benefit of the
technique without addition of more scars.
In group A, rearrangement of the breast tissue
was done by transfixing the capsule into the pectoral
fascia this has the advantages of; bringing the
implant to a more higher level to add superior
fullness, no violation of the capsule, improving
the long life of the result, does not engage with
the lower pole which is usually the thinnest part
of the breast. However, it has some disadvantages
in being more complex and does not offer the
ability to change the implant if requested by the
patient. Also it carries the risk of interference with
the vascular supply of the nipple due to extensive
dissection.
On the contrary group B patients had mastopexy
with capsular tightening and parenchymal rearrangement
in the lower pole of the breast and this
has the advantages of pushing the implant upwards
Table (4): Results of the questionnaire evaluated by Likert
score.
Scar
Sensation preserved
Final shape and projection
Recommendation
Overall satisfaction
4.2 (±0.97)
4.73 (±0.56)
3.9 (±0.67)
3.3 (±0.64)
3.06 (±0.65)
Mean Score ±SD
(Group A)
4.3 (±0.99)
4.71 (±0.56)
4.56 (±0.60)
4.74(±0.67)
4.57 (±0.69)
Mean Score ±SD
(Group B)
Table (5): Objective evaluation of both groups.
Group A
Group B
13
26
Excellent
13
3
Good
01
Average
40
Poor
Objective evaluation was carried on by a plastic
surgeon not involved in the surgeries, through
comparison between pre and post-operative photos
and by inspection of the final results of breast
(volume, shape, symmetry, position of nipple areola
complex, longevity of results for one year and
cotton test for sensation. Overall results were
classified into excellent; good; average and poor
(Table 5).
DISCUSSION
In an ideal situation, patients undergoing breast
mastopexy surgery desire to have beautifully shaped
and positioned breasts without scars. Surgeons can
offer corrections for breast size, volume, ptosis
and shape but with scars as visible sequelae of the
operation. These scars also have psychological
impact on patients that require follow-up and
reassurance [8].
Secondary mastopexy in the previously augmented
patient is an increasingly important topic
whose complex surgical and medico-legal implications
worth careful attention. As the patients of
augmented women get older, many of them usually
require combination of breast mastopexy, capsular
surgery with or without implant exchange [9].
Many methods have been proposed for combined
breast mastopexy augmentation varied from
just crescent excision from the upper pole of the
areola to conventional Wise pattern mastopexy in
order to serve combination of breast uplift with
Egypt, J. Plast. Reconstr. Surg., July 2018 263
and forming a strong and stable shelf underneath
the implant through the capsular flaps and pillars
to maintain the lifting result for a very long period
of time, feasibility of implant exchange as done in
all patients, better reshaping of the breast with
ability to and also provide coverage of the lower
pole of the implant. The disadvantage of this technique
is the hazardous dissection of the lower pole.
Although such combined secondary surgery
carries increased risks, because of the adverse
effects of implants on breast anatomy and physiology
in the form of tissue atrophy, thinning and
stretching, and reduction of blood supply to the
skin and nipple, [11] we didn't report any complication
related to vascular compromise due to careful
dissection of the parenchymal flaps in a relatively
shallow plane to preserve skin blood supply.
Hartzell et al., [12] stated that capsular excision
and rearrangement of local tissues in secondary
cases can produce an undesired change in implant
location. However in our study, we found that
excision of a part of the capsule will decrease the
space available for the implant and force it up to
fill the superior pole of the breast and thus group
B patients showed more projection, better shape
and longevity of the mastopexy, also this is attributed
to the internal suturing of parenchyma and
fixing it to the pectoral fascia.
As in all circum-areolar techniques, we did not
address the excess skin in the lower pole in our
study, however, most of the patients experienced
high overall satisfaction with good breast shape
and long term preserved lift without facing unfortunate
results.
Both extra and intra capsular techniques for
mastopexy of previously augmented breast can be
used easily for treatment of breast reshaping reduction
with satisfactory results. Despite this we
think that extracapsular technique is safer, while
the intracapsular technique is very attractive to
both patient and surgeon due to its good breast
contour and shape, upper pole fullness, also longevity
of NAC projection and breast contour.
Conclusion:
In mastopexy augmentation reshaping of breast
pillars to support the breast is very important to
prevent recurrence.