Discussion: The Challenges of Augmentation Mastopexy in the Massive Weight Loss Patient

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Despite the relatively high incidence of complications, single-stage augmentation mastopexy has become an accepted procedure in selected patients. In appropriate patients, tissue-based complications have averaged 10 percent, implant-based complications have averaged approximately 3 percent, and reoperation rates have been reported to range from 10 to 23 percent.1–4 These studies have reported on a relatively heterogenous cohort and have not specifically addressed a more challenging, increasing population of individuals who present for the procedure: massive weight loss patients.
The present authors are to be commended for sharing their clinical experience with single-stage augmentation-mastopexy in this challenging group of patients. Their retrospective analysis of 30 patients over a 9-year period sheds some light on the extremely intricate operative procedure in this complex patient population. Their work complements other reports on augmentation mastopexy and highlights how important it is to share our clinical experiences, irrespective of the findings.
Using different mastopexy techniques, submuscular implant placement and round, smooth, mostly high-profile silicone gel implants, the authors found a significant degree of recurrent breast ptosis and implant malposition. Recurrent breast ptosis occurred within 3 months (16.7 percent) after surgery and was associated with increased age and left implant size. Implant malposition was noted to increase over time (62 percent at 12 months). It was associated with higher body mass indexes. Although only 6 percent of their patients returned for revision, the high incidence of tissue- and implant-related complications was attributable to the tissue-based abnormalities present in these patients and/or choice of operative procedure used to manage them.
How can these problems be minimized? The first thing the surgeon should address is patient expectation. A patient with inelastic, mobile, deflated tissue with asymmetric constricted breasts needs to be counseled about a realistic breast size and shape she can safely achieve. The surgeon and patient must moderate their goals or they will be at high risk for disappointment. Subsequently, the surgeon needs to look at the surgical options he or she can control to provide the best solution to realize the stated objective.
Management of the skin envelope is the first variable to consider when planning the operation. The mastopexy pattern should be planned to carefully elevate the nipple-areola complex and remove enough skin and at times parenchyma, to address the inelastic ptotic tissue and provide support for the new breast. In this report, 63 percent of the patients had grade III ptosis. Only 43 percent were managed using a Wise pattern or inverted-V procedure. Circumareolar and circumvertical procedures were performed in 36 and 20 percent of the patient cohort, respectively. These techniques are less likely to adequately address the poor-quality tissues seen in massive weight loss patients and could be the reason early recurrent breast ptosis and/or implant malposition was seen in this study.
The next variable to address is the implant and its interface with the chest and breast. The results shown in Figures 4 through 6 typify the problems encountered when imbalance between the implant and breast exists after surgery. Choosing the appropriate size, shape, and position of implant is critical to help avoid these unfavorable outcomes.
Selecting an implant whose size and base diameter do not supersede those of the tighter reconstructed breast mound is essential for avoiding implant malposition. In addition, an implant with less projection forms a more stable base and allows for safer positioning of the soft tissue above it. When the implant pocket warrants expansion, blending the breast parenchyma implant interface by radial scoring/resection and stabilizing a lowered inframammary crease with sutures or acellular dermal matrix are other techniques that could improve the operative result.
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