Endoscopically assisted approach to mastopexy avoids breast scarring
TUCSON, ARIZ. — Transaxillary mastopexy presents technical challenges, but it is a worthwhile technique for women seeking breast enhancement due to decreased morbidity and no unsightly breast scars, says Robert M. Dryden, M.D.
"Many women are reluctant to have a mastopexy because of the extent of the surgery and the potential for having ugly scars," says Dr. Dryden, president, Arizona Centre Plastic Surgery, Tucson, Ariz., and clinical professor, department of ophthalmology, University of Arizona School of Medicine, Tucson. "The transaxillary approach is challenging, because the suturing needs to be done through a small entry site. However, the procedure is very effective in providing lift, can be enhanced with augmentation, and not only avoids a visible scar but also eliminates or reduces the chance of other complications — such as dehiscence and infection — that accompany a larger incision procedure."
"There is definitely a learning curve, so better results should be expected with increased experience, and perhaps (that) explains the results of the first procedure," Dr. Dryden says.
CANDIDATES, PROCEDURE Women with grade I or II ptosis are the best candidates for transaxillary mastopexy, he says. Grade III ptosis presents more of a challenge, but Dr. Dryden reports that he has also operated on these women with good results.
To perform the procedure, Dr. Dryden infuses 360 mL of tumescent solution prepared by mixing 1,000 mL normal saline, 150 mL 1 percent lidocaine, 12.5 mL 8.4 percent sodium bicarbonate, 1 mL 1:1,000 epinephrine and 0.25 mL triamcinolone acetonide 40 mg/mL. The axillary incision is hidden in a crease, but it is placed at a site a little farther anterior in the axilla compared to that used when performing a transaxillary augmentation alone.
"This incision location provides improved intraoperative visibility," Dr. Dryden says.
Next, a pocket is created in the subglandular plane, and then the superior breast tissue — which can be identified easily via endoscopy — is sutured to the pectoralis fascia and muscle superiorly overlying the second rib, at the level of the manubrium, or higher. Three to five sutures are placed using 2-0 PDS on a CT-1 taper point needle (both from Ethicon).
"It's important to use this heavy-duty needle, because trying to find a broken needle in the pectoralis major would be like searching for a needle in a haystack, something that we found out when we first started doing the transaxillary technique," Dr. Dryden says.
ADDING AUGMENTATION Since the lifted breast usually does not have the desired full, rounded appearance, the transaxillary mastopexy is generally performed in conjunction with augmentation. In the combined procedure, an expander, 1.5 times the size of the implant, may be used as well to create a generous pocket and for hemostasis.
"Placing an implant also helps with the outcome of the lift. The lift alone generally causes a drop in the inframammary crease, but the implant will help to support the breast," Dr. Dryden says.
Postsurgery, women are prescribed a six-day course of antibiotic treatment as infection prophylaxis. The most important element of their postoperative care is the need to wear a supportive bra (one with nonstretchable straps) around-the-clock (24 hours, seven days a week) — even when showering — for at least six months.
"The supportive bra will permit the occurrence of scar contraction and healing, which is what will be relied on to maintain the lift," Dr. Dryden says.