During surgery,
after removal of the implant or the expander, the crease is created by
suturing the anterior capsular tissue to the posterior part of the capsule
at the Hamid Massiha, MD, FACS anterior chest wall. Nonabsorbable sutures
are used after implant insertion. The patient then is placed in a semisitting
position. If correction is not adequate, sutures are placed in a more
proper location. I have used this technique in the last 20 years with
good, long-lasting results. The submammary crease, and its continuation
laterally and medially, is the most important determining factor in beauty
and contour of the female breast. Irregularities in this area of anatomy
are detected easily by simple observation. Asymmetry after breast augmentation
is frequent (Fig 1C), not only in the submammary crease, but frequently
at the lateral boundaries of the mammary pocket and less frequently at
the medial aspect. At times we have seen cases that have transgressed
the mid-line, creating a severe deformity. In any and all of these kinds
of deformities, this method of correction works well (Fig 1D).
Patients
and Methods
The patient
is marked carefully in a sitting position (see Figs 1A, B). The patient
is then anesthetized (I use general anesthesia in my practice), and proper
prepping and draping are completed. Entry is made into the breast capsule
area using previous incisions. The implant is removed and the capsule
is evaluated. The capsule is then incised and the pocket is expanded.
The capsule is then deeply sutured to the chest wall at the appropriate
site, preferably with 2-0 Prolene sutures. As much subscapular soft tissue
is incorporated as possible. Incising the capsule along the line of repair
may be helpful. Suture placement is guided by preoperative markings. Although
interrupted sutures can be used, I find running sutures easier to place
and fully functional After completion of the repair, the old implant is
introducedto the newly formed pocket, If the shape is satisfactory and
the new crease is in a desirable location, the old implant is replaced
with a new one, and the wound is closed (Figs 2-4).
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Fig
2. (A) Lateral view showing the lower breast with a low submammary
crease. (B) Desired correction. (C) The correction is made by lifting
the submammary crease and decreasing the distance from the nipple
to the crease.
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Fig
3. (A-C) The sutures at the top of the new crease are all internal
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Fig
4. (A, B) Shown is how the capsule and surrounding soft tissue at
the lower parts of the pocket are sutured to the chest wall. The
capsule is incised superficially to create a better healing surface
before suturing.
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Whether the
implant is too high [Fig 5A] or otherwise improperly situated, the capsule
may be revised into a more satisfactory shape with this technique.
In the case of an implant being too high, simply dissecting the inframammary
crease area is not enough. Because the skin is usually tight in the inferior
chest wall area, it does not have enough laxity to accept and maintain
a filled implant. An excessively large pocket at the inframammary crease
(or lateral or medial crease, as needed) must be created, and the expander
placed there (see Fig 5B). After a few weeks and after the expander is
expanded adequately, the patient is taken to the operating room, the expander
is removed, a new submammary or lateral crease is created, and a permanent
implant is placed (see Fig 5C).
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Fig
5. (A) Preoperative view of the deformity after multiple attempts
at breast reconstruction on the right side. (B) The same patient
after removal of her implant and expansion to an extremely low level.
(C) Postoperative view with the new crease and lower breast, with
enough skin pulled up for the breast to stay relaxed and full.
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| Fig
6. (A) A patient after multiple unsuccessful attempts at breast reconstruction.
(B) Crease reconstruction. |
Results
have used
this technique in a diverse group of deformities in 200 cases ranging
from postaugmentation deformities to severe deformities (Fig 6A) resulting
from breast reconstruction with implants. This is an effective and reliable
method. In the past 20 years that I have used it, no failures have been
observed. With careful attention to detail, this simple method is suitable
for all sorts of breast deformities that result from capsular malformations
(see Figs 5 and 6).
Discussion
This paper
expands on a previous article on postimplantation breast deformity. In
the correction of certain kinds of postaugmentation double-bubble deformities,
reconstruction of a new submammary crease is essential. In addition, this
technique has proved to be very simple and useful in correcting a variety
of deformities that result from the breast reconstruction and augmentation.
Whether these deformities are the result of the patient's own soft-tissue
defect is uncertain, though it is readily observed that some people have
more elastic skin than others, even in youth. Regardless, this technique
is effective in ameliorating the problem. During the correction of these
deformities, careful marking is essential. After the crease is reconstructed
it will not "give" in terms of stretch nor will it self-correct. Thus, no overcorrection is needed and should be avoided.
This method is also needed in some cases of mastopexy in breasts with
previously inserted implants. In these patients, if the capsule is not
modified from the inside, mastopexy alone will not render excellent results.
For example, if the implant is already too medial, mastopexy alone is
not capable of bringing the implant to a more normal central location.
I prefer sub mammary and periareolar incisions. Although the operation
may be performed through a 5 to 6-cm submammary incision, exposure through
a periareolar incision is superior , especially for medial and lateral
suturing. In patients in whom the implant is too high, conventional opening
of inferolateral space is prone to failure or overcorrection. The current
technique opens up a larger space and creates a new crease in the desired
location. Also, if needed, inframammary skin from the area can be mobilized to increase the nipple-to-crease distance.
In severe high-implant deformities after breast reconstruction, use of
an expander is necessary, especially in the inframammary area. The new
crease is reconstructed at the second stage at the time of implant replacement.
Adding inframammary skin to the lower portion of the breast improves
roundness at the same time. Sometimes sutures placed into the capsular
tissue may cause dimpling. However, in the inframammary area, they are
rarely visible and usually improve with time. It is possible that incising
the capsule at the proposed suture site may enhance breast configuration,
although this has been difficult to confirm.
Conclusion
This technique
of reconstructing submammary and perimammary creases for correction of
deformities after breast augmentation and reconstruction is a very
simple and useful. No additional external incisions are needed. Results
are permanent, although further stretching of the breast tissue will
continue as years go by. This technique has worked well in my hands.
It is easy to do and it is easy to teach.
Presented
at the Southeastern Society of Plastic and Reconstructive Surgeons. Bermuda,
June 4-8, 2000.
Reference
1 Massiha
H. Augmentation in ptotic and densely glandular breast: prevention, treatment,
and classification of double- bubble deformity. Ann Plast Surg 2000;44(2):143-146
Open Discussion
Felmont
F. Eaves, MD (Charlotte, NC): Concerning inframammary fold
control, some of the newer suture materials will give tensile strength
. for up to a year and a half. Do you think there is any advantage in
a patient like this in fixing the fold? And how long do you think you
actually have to be able to control that level postoperatively? Is permanent
suture material really part of that?
Dr Massiha: I have not seen one of these from the inside after
surgery. But from my experience on redo facelifts, when I identify the
3-0 Prolene sutures I have previously placed into the SMAS and remove
them, nothing falls back. Applying that knowledge to this situation, I
would imagine that something that lasts 6 months or more would be enough.
Also, please be certain that the knots don't face toward the implant or
they may erode the implant. Be certain they are buried.
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