Algorithm drives decision on staging augmentation mastopexy
"Breast augmentation mastopexy is one of the most difficult procedures we perform in plastic surgery," says William P. Adams Jr., M.D., a University Park, Texas, plastic surgeon in private practice. To decide whether to perform this procedure in one stage or two, he says he employs a specific algorithm that incorporates key measurements of the breast envelope.
Overall, "This is not an easy procedure," he says. Augmentation seeks to expand the envelope and parenchyma and increase breast mass, while mastopexy seeks to reduce the envelope, compress the parenchyma and decrease the breast mass. "It's basically two procedures with opposite forces. That's why fundamentally it's very difficult, with a higher rate of complications."
In one study, combining breast augmentation and mastopexy into a single procedure resulted in a fivefold reoperation rate and a 10-fold complication rate versus breast augmentation alone (Spear SL, Boehmler JH 4th, Clemens MW. Plast Reconstr Surg. 2006;118(7 Suppl):136S-147S; discussion 148S-149S, 150S-151S).
"If you look at the Regnault classification of ptosis," Dr. Adams says, "it's very nonspecific. When I think about breast augmentation or augmentation mastopexy, it is all about accurately assessing the tissues of the breast in a predictable way. That allows me to make more sound decisions about these procedures. Characterizing the envelope of the breast is the most critical factor in deciding between one- and two-stage augmentation mastopexy."
Dr. Adams says that when he began practicing 15 years ago, "I never staged augmentation mastopexy. Then I evolved to the point where I was staging every patient. Now, I'm trying to develop objective criteria to help me determine whether I'll do one stage versus two."
MEASUREMENTS TAKEN Dr. Adams says he checks the nipple-to-fold measurement, the skin stretch measurement and the vertical excess. For the skin stretch measurement, he recommends pulling medial to the areola and measuring the anterior-posterior distance with a caliper.
"The nipple-to-fold measurement is taken on stretch, from the nipple to the fold. For a one-stage procedure, I'd like to see a skin stretch less than 4 cm, or a nipple-to-fold measurement of less than 10 cm," he says.
To measure the vertical excess, "Just mark the nipple position for your mastopexy. Then measure down to wherever you intraoperatively set the nipple-to-fold distance. For me, if it's a 12 cm breast, I set the nipple fold at 8 cm," Dr. Adams says. The difference between these two figures is the vertical excess. "For a one-stage procedure, we want the vertical excess to be less than 6 cm."
Furthermore, Dr. Adams says he always uses the dual plane II or III implantation approach to optimize the soft tissue interface at the lower pole of the breast.