Materials
and Methods
Patient
Selection
Several categories of breast shapes may benefit from this technique:
- Ptotic
breasts with well-formed hanging breasts or even atrophic breasts
- Highly
formed, firm, and glandular breasts
- Cone-shaped
breasts with small bases
- Mild to
moderate cases of tubular breasts
- Double-bubble
(waterfall deformity) in class III to IV firm breasts
Technique
After the
decision to use the radial cut incisions in the treatment of the aforementioned
deformities, a submammary pocket is created under general endotracheal
anesthesia. Radial cuts are made behind the breast tissue. The breast
tissue is then spread in different directions (Fig 1). The openings created
by this technique are made with relative uniformity, so that the expansion
of the breast tissue will be symmetrical. Usually, three radial cuts are
made, producing a six-prong star (Fig 2). Then, with blunt dissection
or, if necessary, with the aid of a sound or other blunt instrument, these
cuts are deepened as needed to accommodate the implant. Care should be
taken to carry these cuts far enough peripherally to
open and
expand the small base of the breast and expand the base of the postoperative
breast (Fig 3). After the implant is placed and the opening is considered
satisfactory, the operation is terminated by regular repair of the skin.
If any residual deformity is present, this resistance is resolved by dissection
at the proper site. The old crease of the breast is usually the most resistant
part of this procedure. Cuts made vertically along the crease usually
provide a satisfactory result. That is, if the crease is from medial to
lateral, the cuts will be superior / inferior in direction. In some cases
in which this technique is used but the correction is not adequate, the
most resistant areas (usually the dense glandular tissue) are excised.
This is especially necessary for advanced cases of tubular breasts and
extremely glandular breasts.
|
|
| Fig
1. Posterior views showing radial incisions. (A) Before incisions
are spread and widened. (B) After widening of incisions and expansion
of the base. |
Fig
2. Lateral view of the breasts with implants showing the location
of the radial incisions and their relationship to the implant. |
Classification
of Double-bubble Deformities
| Type |
Implant
Location |
Result |
| I |
High
or correct |
Breast
tissue hangs
over implant ("waterfall"
over a rock) |
| II |
Low
or correct |
Breast
tissue sits
separately and superior |
|
 |
 |
| Fig
3. Lateral view showing how the radial incisions help to redistribute
and change the center of gravity, resulting in a nice unity of breast
tissue and the implant. (A) Implant without radial incision. (B) Implant
with radial incision. |
Fig 4. An example
of a type I deformity with breast tissue sliding down over the implant. |
Results
I have tried
this technique with a diverse group of patients of different age groups
for a variety of deformities. With proper patient selection and technical
management, generally satisfactory results have been achieved.
Fig 5. (A) Preoperative
view of a type II deformity. (B) Postoperative view. Correction with radial
incision and reconstruction of a new submammary crease in a higher position.
Fig 6. (A) Preoperative
view of a ptotic breast with a narrow base. (B) Postoperative view. Implantation
with radial incisions and a lowering of the submammary crease.
Discussion
Visual separation
of the breast tissue from the implant is a notable deformity of the postaugmented
breast. This deformity may even be seen in the case of regularly augmented
breasts with initially good results. After the breasts become firm, the
breast tissue hangs loosely over the firmly attached implant, creating
a double-bubble, or as I have named it, a "waterfall deformity."
This technique is especially useful in the treatment of this secondary
breast deformity. After the implant is removed and the new implant is
ready for insertion, radial cuts are made in the breast tissue so that
the breasts can drape nicely over the implant. This can be likened to
a cap being fitted properly to a person's head. In a secondary deformity
of the breast, in which capsular contracture is encountered, special attention
must be paid to the surrounding tissue, which will be firm and scarred,
even after removal of the capsule. In general we have seen two kinds of
double-bubble deformities (Table): The type I implant is at an anatomically
proper level or is too high, but loose breast tissue hangs over the implant
(Fig 4). The type II implant is either in its proper location or is too
low, with breast tissue sitting above it and high (Fig 5A). The type II
deformity is usually the result of trying to lower the submammary crease
to lift the postimplanted breast without using the recommended radial
cuts. In treatment of type II deformities, in addition to opening the
breast tissue with radial cuts, reconstruction of a new submammary crease,
usually to its original location, may be necessary (Fig 5B).
Conclusion
In summary,
radial cuts at the undersurface of the breast with opening of the breast
tissue have proved very useful in breast implantations in patients with
ptotic breasts, breasts with a small base, mild to moderate cases of tubular
breasts, or in primary cases of augmentation mammaplasty (Fig 6). This
technique is also extremely useful in surgical treatment of secondary
deformities of the postaugmented breasts.
Presented at the Southern Society of Plastic and Reconstructive Surgeons,
Boca Raton, Florida, June 5-9, 1999.
Open Discussion
Samuel W. Parry, MD (New Orleans, LA): Hamid, in your
abstract I believe there is one sentence (I don't see it right now) where
I believe you said you sometimes remove some breast tissue? This seems
counterintuitive to what you are trying to accomplish.
Dr Massiha: Yes. In the severe tubular and cylindrical breast, removing
the posterior part of the breast helps to open up the tissue and decreases
the anteroposterior dimension of the breast in which it is coming straight
out of the body. So by decreasing that length, the cylinder is shortened
and is opened. By adding the radial cuts to it, you get the desired cone
shape to the breast.
Sherry S. Collawn, MD (Birmingham, AL): In your patient
with the double-bubble, how did you recreate your inframammary fold?
Dr Massiha: For the lower pole, I just use the original incision and remove
the implant. I had marked where I wanted the new fold in the sitting position
beforehand. I put 2-0 nylon sutures in the same spot to get the line.
Then I put the old implant in, inflate it, and sit the patient up to see
if I like it. Then I go ahead and insert the new implant and finish it.
If I don't like it, I may change my sutures. I'd like to make one comment
about breasts that have a very strong submammary crease that needs to
be lowered. You have to make small cuts in the fibrous band that is normally
there. With finger pressure it cannot be done, but with small cuts it
helps a lot to erase the old crease and create a new fold.
Back |
