Mastopexy in GII Ptosis: Evaluation of Owl Technique Combined with Inferiorly Based Flap

INTRODUCTION
Aesthetic breast surgery became mandatory
procedure almost all-over the world. One of the
highly demanded procedures is augmentation mastopexy.
Mastopexy of small ptotic breasts presents
207
one of the greatest challenges to the plastic surgeons.
The aesthetic goals are to obtain a more
youthful appearance, reduced ptosis, and improved
projection [1].
The pathophysiology of breast ptosis relates to
elongation of the connective tissue reticular network
by either stretching, atrophy, loss of elasticity or
fibrolipomatous changes. All may lead to increasingly
pendulous ptotic breasts with further loss of
firmness, projection, and downward pointing nipples.
Also, females with a small tuberous breast
deformity or patients undergoing unilateral mastectomy
with contra-lateral ptotic breast all are
seeking mastopexy with or without augmentation
[2].
Different techniques were described for mastopexy
as well as for mammary augmentation.
Recently combining the two procedures became
achievable in which implant was used with breast
lift in hypoplastic and ptosed breasts. Owing to
the higher cost, being unnatural material, and
several complications ranging from capsular contractures,
bleeding, ruptures, wrinkling, infection,
mammographic shadows, capsular calcifications,
and bad positioning, so there was a shift to the
auto augmentation mastopexy using autologous
tissue [3]. When using implants in one-stage augmentation/
mastopexy, Castello et al., highlighted
the fact that “criticism is logical” as the two procedures
have opposing vectors: Filling and stretching
the breast with the implant versus removing
excess skin and tightening the breast [4].
Different methods for autoaugmentation mastopexy
mentioned in the literature used the breast
tissue that is mobilized as flap to fill the defective
parts. Extended superomedial pedicle was used
and rotated to fill the defects in many situations
by Alberto et al. [3]. Also, turnover lateral intercostal
artery perforator (LICAP) flap secured with a
pectoralis muscle sling, along with mastopexy for
post bariatric ptosed empty breasts was mentioned
[5].
Ribeiro described the deepithelialized inferior
dermo-lipo-glandular pedicle flap as a robust pedicled
flap that may be mobilized to increase the
upper pole fullness and projection [6,7]. The same
flap was used by Loustau [8] and inserted beneath
the parenchyma of a superior based nipple-areolar
complex (NAC) bearing flap. Noemi Kelemen et
al., used the same flaps with some additions by
“stacking” the superomedially based NAC pedicle
and medial/lateral glandular pillars on top of the
inferiorly based dermoglandular flap [9]. Franz
Honig used the same flap to enhance the desired
fullness in the upper pole of the breast after removal
of breast implant and to avoid insertion of another
implant [10].
The inferior dermoglandular flap also provides
good vascularization of the lower portion of the
breast. This is because the inferior-based flap
originates from a dermolipoglandular pedicle that
is based on the fourth, fifth, and sixth intercostal
perforating vessels of the internal mammary vessel.
Even the dermis of the flap can be divided, as long
as the inferior portion of the transversely oriented
septum of the breast is not violated, because the
perforators are located along the septum [10]. In
addition, the inferior pedicle allows elevation of
the IMF and reduction of the base for optimum
aesthetic results [11].
In 2002, Ramirez described the owl technique,
which combines the periareolar features in the
“round block” technique of Benelli and the vertical
reduction of Lassus and Lejour. The shorter scars
are useful as they force the surgeon not to rely on
the skin envelope for correction of ptosis. The
surgeon must search for other tools, like parenchymal
redistribution, to support the elevated breast
[12].
The aim of this study is to evaluate the effectiveness
of inferiorly-based pedicle flap, combined
with Owl incision, in autoaugmentation mastopexy
for patients with small to moderately sized ptotic
breasts who desire repositioning of their breasts
without insertion of a breast implant nor lipofilling.
PATIENTS AND METHODS
23 female patients randomly selected seeking
augmentation mastopexy of moderately ptosed
breasts without implant insertion. (Sample size
calculation was carried out to determine the appropriate
sample size. The alpha value is set at p<0.05
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and power (b) of 90% is chosen. A paired difference
in outcome (N-SN) is expected to be 33%±33%
decrement (from 32 to 21cm). The sample size
was 19 participants. However, with a dropout rate
of 15%, the required sample size was 23 participants).
The study was carried out in Plastic and
Reconstructive Surgery Department in Kasr Al-
Aini Hospitals during the period from January
2018 to July 2018.
Inclusion criteria:
- Moderately ptosed breast (second degree ptosis)
according to Regnault [13] classification system.
- Patients wishing augmentation mastopexy without
implant insertion nor lipofilling.
Exclusion criteria:
- Previous breast surgery.
- Lactating females.
- Nipple discharge or bleeding.
- History of breast lumps.
- Uncontrolled diabetes and hypertension.
- Very small atrophied breast.
- Higher grades of ptosis.
- Psychologicall unstable patients.
- Skin problems (pyoderma gangrenosum, intertrigo).
Preoperative assessment:
- Preoperative laboratory investigations and breast
scanning.
- Preoperative marking while the patient in the
standing position: Marking the distances between
the nipple and the suprasternal notch (N-SN),
between the nipple and the infra-mammary fold
(N-IMF), and the inter-mammary distance (IMD)
as well as recording the bra cup size.
- The inferior pedicle flap marked: Upper border
is 2cm below NAC.
Operative technique:
Under general anesthesia, after deepithelialization
of the peri-areoalar and pedicle area, the
superior pedicle carrying the NAC is separated
from the lower triangular flap (Fig. 1). The superior
flap carrying the NAC is undermined till the level
of the second d rib to create a pocket beneath it
(Fig. 2). The inferior deepithelialized pedicle is
dissected from its medial, lateral margins till the
pectoralis fascia. The dermis is completely incised
at its lower margin. The flap is not dissected deeply
from the pectoralis fascia to preserve the integrity
of its blood supply (Fig. 3).
Egypt, J. Plast. Reconstr. Surg., January 2020 209
The inferior flap is folded underneath the
superior pedicle carrying the NAC and fixed to
the pectoralis major fascia at the level of the
second rib with 3-4 polypropylene sutures (Fig.
4). Closure of the periareloar incision via a
round block technique using a purse-string
suture and finally, the vertical limb in sutured
in layers.
Fig. (1): The superior pedicle carrying the NAC is separated
from the lower triangular flap.
Fig. (2): The superior flap carrying the NAC is undermined
till the level of the second d rib to create a pocket
beneath it.
Fig. (3): The inferior deepithelialized pedicle is dissected
from its medial, lateral and lower margins. No
dissection from the pectoralis fascia to preserve the
integrity of its blood supply.
Fig. (4): Inferior flap folded underneath the superior pedicle
carrying the NAC and fixed to the pectoralis major
fascia at the level of the second rib.
Post-operative assessment tools:
Follow-up period done at 3,6 and 12 months
using:
- Post-operative photos.
210 Vol. 44, No. 1 / Mastopexy in GII Ptosis
- Justifying measurements and parameters: Measurement
of (N-SN), (N-IMF), and (IMD).
- Bra cup size.
- Patient satisfaction questionnaire (Table 1).
Table (1): Patient satisfaction questionnaire.
Name :
Height:
Address:
Marital status
Menstrual history:
Duration since underwent auto-augmentation mastopexy:
Bra cup size before surgery:
Degree of satisfaction regarding breast lift degree:
Excellent
Degree of satisfaction regarding scar:
Excellent
Degree of satisfaction regarding breast and nipple areola sensation:
Excellent
Degree of satisfaction regarding postoperative pain toleration:
Excellent
Degree of satisfaction regarding breast cup size:
Excellent
Degree of satisfaction regarding breast shape:
Excellent
Degree of satisfaction regarding breast projection:
Excellent
Very good
Very good
Very good
Excellent
Excellent
Excellent
Excellent
Good
Good
Good
Excellent
Excellent
Excellent
Excellent
Fair
Fair
Fair
Excellent
Excellent
Excellent
Excellent
Not satisfied
Not satisfied
Not satisfied
Excellent
Excellent
Excellent
Excellent
Age:
Weight:
Married
Regular
Separated
Irregular cycles
Single
Post-menopausal
Bra cup size after surgery:
RESULTS
In the study population (23 cases), the age was
between 27-50 years with mean age 36.96±6.24
SD the BMI was between 23.4-30.8 with mean
value 27.46±5.30 SD.
1- Anthropometric measures (Fig. 5):
There was significant decrease in (N-SN) and
(N-IMF) distances. The right breast (N-SN) distance
from 31.21±3.99 SD preoperative to 21.13±2.07
SD 3 months postoperative, 22.17±1.89 SD 6
months post-operative, and 23.43±2.21 SD 1-years
post-operative with significant p-value <0.0015.
The left breast (N-SN) distance with mean preoperative
of 31.28±4.33 SD, and 3 months postoperative
of 21.41±1.92 SD at 6 months post-operative
was 22.28±21.12 SD and at 1 year was 23.76±3.36
SD with highly significant p-value 0.004. As regard
N-IMF the mean preoperative value was 13.04±1.01
SD for the right side, became 10.35±0.88 SD after
3 months and 10.67±0.87 SD after 6 months and
at 1 year became 11.13±0.97 SD with significant
p-value 0.000 and for the left N-IMF the preoperative
value was 12.98±1.03 SD, 10.37±0.92 SD at
3 months, 10.57±0.89 SD at 6 months, 10.93±0.93
SD at 1 year with significant p-value 0.000. As
regards IMD, it was 21.78±1.40 SD preoperative,
became 19.96±1.32 SD at 3 months, 20.48±1.16
SD at 6 months, 20.85±1.22 SD at 1 year with
significant p-value 0.002.
2- Bra cup size (Fig. 6):
As regard change in cup size, 3 cases (13.04%)
showed increase by 2 degrees, and 11 cases (48%)
showed increase by 1 degree.
8 cases (35%) showed no considerable change
in cup size and 1 case (4.3%) showed decrease in
cup size by 1 degree. As a conclusion, there was
a mean increase in cup size 1.65±1.77 SD 3, 6
months and 1-year post-operative, with significant
p-value of 0.001.
3- Patient satisfaction (Fig. 7):
39.2% (9) of patients claimed to have an excellent
breast lift, 34.8% (8) a very good breast lift,
13% (3) good lifting and 13% (3) fair lift, with a
Egypt, J. Plast. Reconstr. Surg., January 2020 211
mean preoperative satisfaction of 1.43±0.59 SD
and postoperative mean satisfaction value of
3.0±1.04 SD and significant p-value 0.004.
In addition, 43.5% (10) claimed to have excellent
breast size, 34.8% (8) very good size and
21.7% (5) good size, with a mean preoperative
breast size satisfaction of 2.13±0.69 SD and a mean
post-operative breast size satisfaction of 3.22±0.80
SD and significant p-value of 0.002.
As regard breast shape 34.8% (8) patients
claimed to have excellent breast shape, 39.1% (9)
very good breast shape, 17.4% (4) good breast
shape and 8.7% (2) fair shape, with a mean preoperative
satisfaction value of 1.35±0.57 SD, and
mean post-operative satisfaction value of 3.0±0.95
SD, and p-value significance of 0.001.
As regard breast projection, 34.8% (8) of study
population claimed to have excellent projection,
34.8% (8) very good projection, 17.4% (4) good
projection and 13% (3) fair projection, with a mean
preoperative satisfaction value of 1.30±0.47 SD,
and a mean post-operative satisfaction value of
2.91±1.04 SD, significant p-value 0.0003.
As regard nipple areola sensation, 21.7% (5)
of population claimed to have excellent nipple
areola sensation, 39.1% (9) very good sensation,
26.1% (6) good sensation, 13% (3) fair sensation
and none of the study population claimed to have
lost sensation.
As regard scar shape 26.1% (6) claimed to have
very good scar, 43.5% (10) good scar, 26.1% (6)
fair scar shape, 4.3% (1) bad scar.
As regard postoperative pain tolerance 17.4%
(4) had excellent pain tolerance, 43.5% (10) very
good pain tolerance, 21.7% (5) had good pain
tolerance and 17.4% (4) fair pain tolerance.
Fig. (5): Comparative values of N-SN, N-IMF, IMD pre-operative and 3, 6 months and 1-year
post-operative.
35
30
25
20
15
10
5
0
Mean RT
N-SN
Mean LT
N-SN
Mean N-IMF
RT side
Mean N-IMF
LT side
Mean IMD
Pre-op
Post 3 months
Post 6 months
Post 1 year
Fig. (6): Change in mean cup size preoperative and 3, 6
months, 1-year post-operative.
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Mean cup size
Pre-op 3 months 6 months 1 year
Pre-op
3 months
6 months
1 year
Fig. (7): Incidence of post-operative patient satisfaction after
1 year among study population.
25
20
15
10
5
0
Breast lift
Breast size
Breast
projection
Breast shape
Nipple
sensation
Scar shape
Pain
tolerance
Fair
Good
Very good
Excellent
212 Vol. 44, No. 1 / Mastopexy in GII Ptosis
Fig. (8): 32 years old female (A-C): Pre-operative, (D-F): 3 months post-operative, and (G-I): 9 months post operative.
(A) (B) (C)
(D) (E) (F)
(G) (H) (I)
Egypt, J. Plast. Reconstr. Surg., January 2020 213
DISCUSSION
Mastopexy of small and medium-size breasts
without a decline in size, while improving their
projection, and maximizing the fullness of the
upper pole, has always been a great challenge for
surgeons. An anatomic-based approach relying on
reshaping and tightening the breast parenchyma,
supporting the NAC in its new position and proper
redraping of the skin envelope must be adopted to
optimize the results [14].
The first challenge faced by the surgeon is the
desire of the patient to obtain a “fuller” breast
while she expresses no desire to use breast implants
and at the same time is not candidate for augmentation
with autologous fat. Here, as we do not
increase the real size of the breast, we have to
increase the apparent size and to augment the
projection. Different method for autoaugmentation
mastopexy were mentioned in the literature using
the excessive tissue that may be present in some
parts of the breast and redistributing it (ensuring
its blood supply is maintained) to achieve an aesthetic
looking breast.
In our technique, we recognized the importance
of the inferior dermoglandular flap as a tool very
(A) (B) (C)
(D) (E) (F)
Fig. (9): 43 years old female (A-C): Pre-operative, (D-F): 3 months post-operative, and (G-I): 9 months post operative.
(G) (H) (I)
Fig. (10): Dissection of a pocket superiorly makes in-setting of the inferior flap easier and
with less tension on the wound.
214 Vol. 44, No. 1 / Mastopexy in GII Ptosis
useful in providing the upper breast cleavage,
augmenting the projection and increasing the apparent
volume. Compared with the lateral pedicle
advocated in some reduction mammaplasty procedures
for autoaugmentation, which offers limited
recruitment of tissue, the inferior pedicle is designed
to give a better breast shape, with upper fullness
and more volume [15].
However, mastopexy without any breast parenchyma
reduction carries much pressure on the
wound closure: The made-smaller skin envelope
has to fit around the same original-size parenchyma,
without any tension on the wound. We adopted
Noemi et al., technique as he dissected underneath
the medial and lateral flaps, as well as deep to the
superior pedicle to create a pocket. This dissection
created a room in the upper and medial breast to
incorporate the inferior demoglandular flap with
easier redraping of the skin over the new breast
(Fig. 10).
The second challenge faced by the surgeon is
the scar. Here the surgeon is facing two opposing
goals: To increase the amount of skin removed to
treat the redundancy and tighten the breast, and at
the same time to satisfy the patient’s desire for a
scar as much hidden as possible. Despite the fact
that the classic inverted T pattern is known to have
extensive scar length, poor long-term shape, and
stretching the already thin skin, still it has its
“advocators” among the surgeons. “Cut as you go”
skin excision, is an expression used when the lateral
and medial extents of the IMF incision are determined
intraoperatively and may even exceed the
preoperative limits, following the inferior curve
of the breast and upward toward the anterior axillary
fold. This is claimed to narrow the breast base,
making it less boxy [9]. In periareolar techniques,
the challenge is to maintain the areolar diameter
without long term stretching as the tension on the
skin favors scar widening. This is more commonly
seen when augmentation is added to mastopexy.
On the other hand, when vertical scar component
is added, this tension is diminished [8].
In our study, we used the owl technique which
combines the features of the vertical reduction and
the large periareolar reduction. This allows important
skin envelope reduction while maintain the
breast projection. We adopted the addition of the
purse-string suture in closing the periareolar incision
to ensure good-quality scars and avoid areolar
enlargement [16]. This scar pattern yielded a high
patient satisfaction rate regarding the breast projection,
and the scar perception.
The third challenge faced in autoaugmentation
mastopexy is providing longevity to the results,
with no post-operative bottoming-out or decrease
in size (atrophy of the flap). The milestones to
obtain long term results are adding as much possible
tissue to the inferior dermoglandular flap, ensuring
a robust reliable blood supply to the flap and
providing good attachment to the flap. When Kim
[17] elevated the inferior glandular flap on a superior
dermal pedicle blood supply. There was 6.8%
incidence of seroma and fat necrosis of distal flap
during follow-up. This denotes affected vascularity
due to excessive length of the flap and the fact that
the superior-based dermoglandular pedicle was
elevated off the pectoralis fascia. In our study, we
kept the connection between the pectoralis fascia
and the deep surface of the inferior to ensure robust
pedicled blood supply to maintain the long-term
viability of the flap. We also followed Honïg et
al., steps [10] by making the inferior flap 2-4cm
thick and incorporating in its width all the distance
Egypt, J. Plast. Reconstr. Surg., January 2020 215
between the lateral and medial borders of the breast
pillars. This recruited a large portion of dermoglandular
tissue from the lower pole to the upper
pole of the breast. For fixation of the flap superiorly,
we used exclusively the pectoralis muscle fascia.
We agree with Honïg that the pectoralis muscle
fascia achieves durable autologous breast parenchymal
suspension and avoids adding extra tension
on the wounds. In our study only 1 patient presented
by re-ptosis after 1 year after losing 6kg of her
weight post-operatively.
Conclusion:
While the autoaugmentation technique could
allow the plastic surgeon to partially win the struggle
with gravity, the inferiorly-based parenchymal
flap that is fixed to the pectoralis major muscle
improves the breast projection and upper pole
cleavage. It represents a lightweight flap with good
outcomes in the long-term follow-up. A circumvertical
scar is well appreciated by the patients although
has a high learning curve. Adding solid
objective assessment tools (anthropometric measures
taken before the surgery and at regular followup)
to the subjective tools (patient’s satisfaction)
endorses the results and gives data for different
statistics.