Augmentation mammaplasty is one of the most popular cosmetic surgical procedures, with more than 334,000 procedures performed in 2004.'
One cause for concern among postaugmentation patients is implant ptosis (IP). IP is the descent of the breast implant below its desired position. This can be quantified as a lengthening of the nipple to inframammery fold (IMF) distance, out of proportion to the other breast proportions.
IP can result from several different causes. A lengthening of the nipple to IMF distance, while not necessarily lowering the IMF, is a natural postaugmentation phenomenon secondary to gravity in patients who have thin
breast skin and little subcutaneous adipose tissue. Another cause of IP is descent of the IMF. This cause can be attributed to overzealous dissection of the IMF at surgery, or complete disruption of the IMF during procedures that cross this boundary, such as the transumbilical breast augmentation (TUBA) procedure.
Once IP occurs, it can exacerbate the "double-bubble" effect of the breast. It may also distort the nipplebreast relationship. This may result in "bottoming-out" of the breast, so that the nipple appears too high above the transverse breast meridian and points upwards, and may also cause the implants to sit too low on the chest wall. Treatment options to reposition the breast implant and re-create the IMF include both internally and externally based procedures. External procedures have the disadvantage of causing visible scars and do not address the problems that arise in patients with thin skin and those with little subcutaneous tissue.
More recently, the techniques of anchoring a capsular flap or creating a sling to the pectoralis major musclehave been described.Although successful in addressing breast implant ptosis, these techniques have the disadvantage of causing unnatural tethering of the breast with arm abduction. Internal plication of the capsule at the planned IMF is another well-described option, as is the use of cadaveric dermis sutured to the atrophic capsule to reposition the ptotic breast and implant .Although the latter technique usually leads to excellent initial results,
its long-term outcome is less certain because of the previously mentioned patient variables-namely, thin breast skin and little adipose tissue.
Another internal approach to treatment of IP uses a circumareolar incision. This approach is similar to the inframammary approach for plication, with the addition of an internal splint. The splint is the posterior capsule and soft tissue, and adds tissue between the skin and the implant, especially in the lower pole. This not only gives
a more natural appearance to the breast, but improves the durability of the repair by adding tissue thickness. Although others have described procedures to aid in maintaining the position of the replaced implant after capsulotomy/capsulectomy, we propose a novel technique that uses the capsule to maintain the position of the new implant. This obviates the need for capsulectomy. This technique can be used for the repositioning the implant
and the inframammary fold, regardless of prior implant placement in the subglandular or submuscular plane.
Materials and Methods
All patients were informed of the nature of the surgery, as well as the risks and benfits, and agreed to participate in the study. Preoperatively, the IMF was marked with the patient in the sitting position. The "ideal" position of the implant and IMF was determined by physically manipulating the breast to the desired position and shape with the implant in place and marking the new IMF. This automatically produced the anchor point at the inferior edge of the autologous splint. IN most patients with IP, the implant falls below the transverse breast meridian( set at the nipple), If the distance is to small, the larger portion of the implant is above the transverse breast meridian. The distance from the nipple to the new IMF should optimally be 5 to 10 cm but varies based on patients' and breast size.
The procedure was performed through either a periareolar or inframammary incision. Next, a capsulotomy was performed and the implant was removed. The posterior capsule was then elevated from either the pectoralis major muscle with the muscle fascia (subglandular implants) or the antererior chest wall (submuscular implants). Approximately one half of the posterior capsule, creating, a "sandwich." The splint edge was sutured to the periosteum of the anterior rib at the level of the new inframammary fold. This elevated the implant above the transverse meridian of the breast, therebyraising the nipple to a more youthful position. The poorly distensible capsule was scored radially to allow for contouring of the anterior breast capsule. This internal autologous splint elevated and medialized the implant. The new implant
was then placed in the submuscular position.
Results
The procedure was performed in 11 women, aged 24 to 52 years, who had received bilateral breast implants and developed Grade 11-111 ptosis. Surgery took place from 4 months to 8 years after the original augmentation. Implants placed both in the subglandular (n = 4) and submuscular (n = 7) positions were included in the project. Follow-up was from 1 to 3 years after surgery. The technique was used to treat capsular contracture and implant malposition (Figure 3), disrupted inframammary folds (Figure 4), and also to produce a more natural postaugmentation appearance (Figure 5). No additional incisions were made on the breast, and no unnatural restrictions to full motion of the arms
resulted from the surgery. Long- term follow-up demonstrated good positioning of the nipple-areolar complex. Patients expressed high levels of satisfaction with their results upon subjective questioning. Asymmetry of the IMF occurred in one patient; otherwise, no complications were noted.
Discussion
The autologous internal breast. bplint is a novel, reproducible technique for the treatment of postaugmentation ptosis and implant displacement by both medializing and elevating the implant as necessary. This
technique makes use of the capsule in the repair, providing a strong "splint" to maintain the breast implant in the proper position. It adds longevity to a previously accepted technique. It also adds soft tissue to thin, inferior pole areas. We find the new technique useful for implant displacement, such as inferior and horizontal correction of folds caused by the creation of excessively large lateral pockets for the implant in the initial procedure, and for the correction of symmastia. It also involves less surgical trauma to the breast than a capsulotomy; we believe this will lower the risk of a future capsular contracture. The technique was used to treat patients with capsular contracture and implant malposition, disrupted inframammary folds and also was
used to achieve a more natural-appearing postaugmentation appearance. Long-term follow-up demonstrated
a longer-lasting result with little impact on patient function and no breast distortion with movement. Although our cases were performed through previous
incisions, the technique may also be coupled with a standard mastopexy procedure.
Conclusion
The autologous internal breast splint described here results in an aesthetically pleasing breast with the planned correction of IP. This technique may solve many of the problems associated with postaugmentation breast ptosis and warrants further investigation.
References
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American Society for Aesthetic Plastic Surgery; 2005.
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3. Voice SD, Carlsen LN. Using a capsular flap to correct breast implant
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4. Giese S. Power breast lift Il-anatomic sling mastopexy. Presented at
The Northeastern Society of Plastic Surgeons 19th Annual Meeting.
Bermuda, October, 2002.
5. Duncan D. Correction of implant rippling using allograft dermis.
Aesthetic Surg J 2001;21:81-84.
6. Baxter RA. lntracapsular allogenic dermal grafts for breast implantrelated
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