15018752330
发表时间:2015-12-09 浏览次数:893次
Introduction
Augmentation mammoplasty is a commonly performed procedure. The procedure helps to enhance breast cup size by filling out an empty breast skin envelope. Following implantation skin gets further stretched and thinned down due to the pressure exerted by implants in a tight space. Explantation alone following augmentation mammoplasty is not very common. Removal of prosthesis results in loose, empty and often a ptotic breast skin envelope leaving patient worse off than prior to the procedure. Ptosis and skin excess may necessitate mastopexy that may further reduce breast volume resulting in loss of female proportion and body silhouette. This anticipated loss of feminine curves and accompanied loss of confidence is the reason that the explantation alone following aesthetic augmentation mammoplasty is not commonly performed. Breast remodeling in these patients is often challenging and extremely important and should be offered by a surgeon as an option, where possible. A case report is presented where autologous breast tissue is used in the form de-epithelialized inferior dermoglandular flap for volume conservation and breast remodeling along with simultaneous mastopexy using Wise pattern markings following bilateral explantation of breast implants.
Case report
A 42-year-old mother of 4 children and a care assistant presented with
neck and back ache. She had augmentation mammoplasty 5 years ago using
450 mL Eurosilicone anatomical implants. She considered her breasts too
large and was concerned with resultant neck and backache. She requested
removal of implants without replacement. She requested reduction of her
breast cup size down from E to C.
Examination showed a cup size
of 34 E with jugular notch to nipple areola complex distance of 26 cm.
Her nipple to inframammary crease distance, was 11 cm bilaterally with a
bilateral sliding ptosis of the skin envelope.
Preoperative
discussion primarily centered on the size of her breast and breast
esthetics following explantation alone. She was informed that her
breasts were likely to look very saggy if explantation alone was
performed and if a simultaneous mastopexy was carried out, especially
using a Wise Pattern markings, resultant tissue excision would reduce
her breast to a small B cup at the most. Autologous breast remodeling
was discussed either using fat transfer as a secondary procedure or
using de-epithelialized inferior dermoglandular flap as volume
conservation and remodeling in the same setting. She showed her interest
in the later procedure. The procedure was planned under general
anesthetic and as a day case.
Markings and technique
Patient was marked in standing
position. Neo nipple areolar complex (NAC) was marked at 21 cm using
infra-mammary crease as a reference [Figure 1].
Wise pattern markings were used for skin reduction with a medially
based flap. A transversely oriented skin area, to be de-zepithelialized,
was marked and cross-hatched below 7 cm vertical limbs of the markings [Figure 2].
Procedure was done under general anesthesia with the patient in supine
position and arms abducted < 90°. Patient received a single dose of
Cephalosporin intraoperatively. Cross-hatched area and medially based
flap was de-epithelialized leaving 4.5 cm Neo NAC. Intervening tissue
between the markings and de-epithelialized area was excised (right 87 gm
and left 119 gm) [Figure 3]. Both implants were removed, and both showed malorientation, fold flaw failures with a rupture on the right side [Figure 4].
De-epithelialized inferior dermoglandular flap was pulled up and
stitched to pectoralis major, without tension and using 2-0 vicryl
sutures [Figure 5].
Hemostasis was performed, and skin closure done using 3-0 vicryl and
4-0 monocryl and 4-0 monocryl was used suture to NAC. No drains were
used, and patient was discharged on the same day. The patient was
followed one and 3 weeks postoperatively, she had no neck or backache,
her bra cup size was measured 34 C and was extremely pleased with the
results [Figure 6], [Figure 7] and [Figure 8].
Discussion
Augmentation mammoplasty is one of the most commonly performed
procedure by plastic and aesthetic surgeons today. Implant related
mammoplasties for both primary and revision mammoplasties is considered a
safe procedure with a high satisfaction rate and is due to the
information available on the product, premarket surveys, enhanced
implant safety and regular quality checks in place. [1] It is not surprising that in 2012 alone 330,631 implant related mammoplasties were performed in USA. [2]
On the other hand, breast implant explantation without implant
replacement following primary augmentation mammoplasty is very uncommon,
the prevalence of the procedure or its incidence is lacking in the
literature. In author's own experience, only three patients have
requested explantation without breast implant replacement after
performing over 4,000 implant related cosmetic mammoplasties. The rarity
of the procedure makes it difficult to compile the effects on the
patient or record the management of the loss of volume or resultant
deformity. Explantation of breast prosthesis results in empty stretched
and thinner skin envelope that is often accompanied with breast ptosis.
The inferior de-epithelialized dermoglandular flap has been described
for breast reconstruction with an aim to cover the prosthesis in the
lower part of the breast. The de-epithelialized flap maximizes implant
coverage adding an extra layer of autologous tissue to minimize its
extrusion. [3],[4]
The inferior dermoglandular flap has also been described when
simultaneous augmentation mammoplasty is performed with mastopexy. [5]
Volume enhancement using autologous fat transfer is safe and commonly
performed today for cosmetic as well as reconstructive procedures since
the publication of the article by Coleman. [6]
However, in cases following explantation of prosthesis, the patients
are left with quite large empty space with a thin breast skin envelope
that can make the autologous fat transfer not an easy option. Volume
restoration and aesthetic appearance following explantation can be even
more challenging if there is an associated ptosis. However, if a patient
presents with a markedly ptotic breast, the use of the excess skin can
be materialized. In these cases, wise pattern mastopexy can be performed
with the use of an inferior dermoglandular flap. This de-epithelialize
flap conserves breast volume and helps to remodel the breast in this
group of selected cases. The procedure can also be staged where
explantation can be performed initially followed by mastopexy at least 3
months later to adjust any recoil of the breast. Vertical scar
mastopexy can be a possible option to conserve breast tissue, but these
markings for mastopexy may not be able to give adequate fullness or
projection with a risk of bottoming down of the breast, especially when
these patients presents with significant ptosis of breasts, excessive
jugular notch to NAC or nipple to inframammary crease measurements. [7]
In recently described Four Flaps augmentation mastopexy, limited use of
the width of the transverse inferior dermoglandular flap is recommended
to avoid boxy appearance. [5]
In current case report, author has made use of the full transverse
width for the de-epithelialized flap in order to maximize the autologous
volume conservation as well as better breast projection and without any
compromise to the aesthetic outcome. Ladizinsky et al. [8]
have modified the bostwick flap in their article suggesting full
thickness incision in the medial and lateral inferior borders of the
autoderm flap to optimize the implant coverage, limiting the medial and
lateral transverse incisions and making vertical component short and
narrow to minimize vascular compromise to breast envelope following
subcutaneous mastectomy. No such measures are required in the use of
inferior dermoglandular flap for autologous breast remodeling following
explantation. The current case report is a useful technique that is
aimed to conserve maximum possible autologous breast tissue and to
minimize the physical and psychological morbidity associated following
explantation in these patients.
In conclusion, wise pattern
markings with a medially based NAC flap for mastopexy and its
combination with inferior dermoglandular flap is a good option for
breast remodeling and autologous breast volume conservation in patients
requesting for explantation and presenting with breast ptosis.
References
1.Khan UD. Combining muscle splitting biplane with multilayer capsuloraphy for the correction of bottoming down following subglandular augmentation. Eur J Plast Surg 2010;33:259-69.
2.The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank Statistics; 2012. Available from: http://www.surgery.org/sites/default?files/2012stats.pdf. [Last accessed on 2014 Sep 10].
3.Bostwick J. Prophylactic (risk-reducing) mastectomy and reconstruction. Plastic and Reconstructive Breast Surgery. Vol. II. St. Louis: Quality Medical Publishing; 1990. p. 1369-73.
4.King IC, Harvey JR, Bhaskar P. One-stage breast reconstruction using the inferior dermal flap, implant, and free nipple graft. Aesthetic Plast Surg 2014;38:358-64.
5.Forcada EM, Fernández MC, Aso JV, Iglesias IP. Augmentation mastopexy: maximal reduction and stable implant coverage using four flaps. Aesthetic Plast Surg 2014;38:711-7.
6.Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg 2007;119:775-85.
7.Khan UD. Aesthetic surgery of the breast. In: Mugea TT, Shiffman MA, editor. Use of nipple-areolar to inframammary crease mesurments to reduce bottoming out following augmentation mastopexy. Berlin: Springer; 2015. p. 649-56.
8.Ladizinsky DA, Sandholm PH, Jewett ST, Shahzad F, Khalil A. Breast reconstruction with Botswick autoderm technique. Plast Reconstr Surg 2013;132:261-70.