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Key Points
- Simultaneous breastlift and augmentation involves maneuvers that can be counterproductive to each other, expert says
- Assessment of ptosis with Regnault classification scheme provides direction in determining whether patient needs combined procedure and what approach to use if mastopexy will be performed
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Cuzalina-Angelo
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ORLANDO, FLA. — Simultaneous breastlift and augmentation presents multiple challenges, specifically because it becomes harder to control all of the variables affecting the outcome when combining the two procedures. To increase the likelihood of success, surgical planning must recognize that no single method is best to treat all types of ptosis. It also must respect the importance of maintaining good blood supply to the nipple-areolar complex and, as appropriate, include the option for a staged procedure, says Angelo Cuzalina, M.D., D.D.S.
A private practitioner in Tulsa, Okla., who specializes in cosmetic surgery, Dr. Cuzalina discussed combined breast implant and mastopexy during the International Society of Cosmetogynecology Workshop presented by the American Academy of Cosmetic Surgery (AACS). Dr. Cuzalina was the recipient of the 2010 International Society of Cosmetogynecology Award for Outstanding Contributions to Cosmetic Surgery.
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Superomedial pedicle of the right breast (left) showing area for tissue reduction in the shaded region. Results (right) after tacking sutures at the trifurcations. (Photos credit: Angelo Cuzalina, M.D., D.D.S.)
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"For many reasons, simultaneous breastlift and augmentation is one of the most difficult of all cosmetic surgery procedures. First, no two breasts are the same, and each patient is seeking a different endpoint, sometimes with unrealistic expectations," says Dr. Cuzalina, who is also president-elect of the AACS. "In addition, the surgery involves maneuvers that can be counterproductive to each other, since skin is being removed and tightened, while an implant stretches the skin even further. Tension on the incision line, tissue undermining and pressure from within the pocket can adversely affect the blood supply. Positioning of both the nipple and inframammary fold also becomes more challenging during simultaneous lift and augmentation.
"While there is no dogmatic way to approach the simultaneous procedure, it is helpful to remember a few basic guidelines," Dr. Cuzalina continues. "Avoid the temptation to always do a periareolar mastopexy in order to use the shortest incision possible, understand that it is sometimes good to also remove tissue to maintain implant position long-term and while patients may resist the idea, keep in mind that a staged approach, performing mastopexy first and then augmentation three months later, is always an option with a tried-and-true safety record."
ASSESSING PTOSIS Assessment of ptosis using the Regnault classification scheme provides some useful direction in determining whether the patient needs a combined procedure and what approach to use if mastopexy will be performed, Dr. Cuzalina says.
For the patient with "pseudoptosis," where the nipple lies above the inframammary fold, implantation alone is typically all that is needed. For grade I ptosis, where the nipple is at the fold, several options exist, but an implant alone may also be appropriate for women in this category whose breasts are very light with a soft, placid, inframammary fold.
Otherwise, women with grade I ptosis are likely to benefit more with mastopexy plus augmentation. Depending on a number of factors, the mastopexy may be performed via a periareolar, crescent or vertical approach.
