AesthPlastSurg https://doi.org/10.1007/s00266-021-02363-8
QuantitativeAnalysisofNippletoInframammaryFoldDistance VariationinTuberousBreastAugmentation:Isthere aProgressiveLowerPoleExpansion?
StefanoAvvedimento1 • PaoloMontemurro2 • EmanueleCigna3 • AntonioGuastafierro4 • BarbaraCagli5 • AdrianoSantorelli6
Received:17March2021/Accepted:15May2021 SpringerScience+BusinessMedia,LLC,partofSpringerNatureandInternationalSocietyofAestheticPlasticSurgery2021
Abstract
Introduction Inpatientswithshortnippletoinframammaryfold(N-IMF)distance,asintuberousbreast,the cohesivityandgeldistributionofshapedimplantsworkas acontrolledtissueexpander,progressivelyadaptingthe tissuestotheimplant’sshape.Thisphenomenontranslates intoagradualincreaseoftheN-IMFdistanceovertime, butthetrueextenttowhichthisoccurshasnotbeen quantifiedtodate.ThisstudyaimstoquantifythepostoperativevariationoftheN-IMFdistanceintuberous breasttreatedwithshapedcohesivesiliconebreast implants.
Methods Wedidaretrospectivereviewofaprospective maintaineddatabaseofallconsecutivepatientswith bilateralGroulleauIandIItuberousbreastswhounderwent primarybreastaugmentationbetweenApril2017andMay 2018atourinstitution.
Toquantifythelowermammarypole’smorphological changes,weevaluatedtheN-IMFdistanceundermaximal
stretchasanendpoint.Werecordedthisvalueattime0 (preoperative),immediatepost-op(equivalenttothedistanceplannedpreoperatively)andatmonth1,month6and 1-yearpost-op.ThenwecalculatedtheaverageN-IMF distancevariationofoursampleofpatientswitha99% intervalofconfidenceforeachbreastobtained.ComparisonswereperformedusingtheSigntestandtheMannWhitneyUtest.
1 PlasticSurgeryDept,VilladeFiori,Naples,Italy
2 Akademikliniken,Stockholm,Sweden
3 DipartimentodiRicercaTraslazionaleedelleNuove TecnologieinMedicinaeChirurgia,Universita ` degliStudidi Pisa,Pisa,Italy
4 MultidisciplinaryDepartmentofMedical-Surgicaland DentalSpecialties,PlasticSurgeryUnit,Universita degli StudidellaCampania’’LuigiVanvitelli’’,Naples,Italy
5 DepartmentofPlastic,ReconstructiveandAestheticSurgery, CampusBio-MedicoUniversityofRome’’,Rome,Italy
Results Theaverageimplantweightwas353g(range 290-450;SD ±46.147).Ofthe54breastsanalyzed,the immediatepost-opN-IMFdistancewasonaverage2.43 cmlongerthanthepreopIMFwitha99%confidence intervalbetween2.01and2.86andSDof ±1.22.Themean differencebetweenthepreopN-IMFdistanceandafter1,6 and12monthswasrespectively2.78cm(SD,1.56)(99% CI,2.24–3.34),3.08cm(SD,1.57)(99%CI,2.53–3.64), and3.36(1.55)(99%CI,2.82–3.91)Comparingimmediate postoperativenippletoinframammaryfolddistance(NIMF)tothe1,6and12monthsN-IMFvalues,anaverage of4.23%(CI1.3–7.16),7.74%(CI4.25–11.23)and 10.84%(CI7.21–14.49)ofskinlength,wasgained respectively.Accordingtoimplants’weight,subgroup analysisshowedthatimplants [ 400gwereassociated withsignificantlyhigherN-IMFdistanceincrease (p \0.05)comparedtoimplants \ 400g.
Conclusions OurfindingssuggestthatasignificantprogressivepostoperativeincreaseinN-IMFdistanceshould beexpectedinallcasesoftuberousbreastaugmentation withanatomicalimplantsovera1yearperiod.Thisaspect mayhaveanimportantimplicationontheIMFincisionand thenewfoldpositionpreoperativeplanning.
LevelofEvidenceIV
Keywords Plasticsurgery Tuberousbreast Anatomical implants Lowerpoledeformity & AdrianoSantorelli santoadri@me.com
6 PlasticsurgeonPrivatepractice,ViaMorghen88, 80129Napoli,Italy
Table1 Mean,standard deviation(SD)and99% confidenceintervalofthe N-IMFdistance
Immediatepostop1monthpostop6monthspostop1yearpostop Mean(cm) ± SD2.43 ± 1.222.78 ±
Table2 Skinlengthgainedatdifferentpost-optimepointscomparedwithimmediatepost-opvalues
Post-optimepoints%expansioncomparedwithimmediatepost-opvalues(meanand99%confidenceintervals)
1month ?4.23%(CI1.3–7.16)
6months ?7.74%(CI4.25–11.23)
1year ?10.84%(CI7.21–14.49)
Table3 Subgroupanalysisofimplants’weightranges:%ofskinlengthgainedat1yearpost-opcomparedwithimmediateposto p values
Implantsweightranges(n=numberofbreasts)1yearpost-opexpansioncomparedwithimmediatepost-opvaluesSDCI99%
290–340g(n=27) ?8.60% ± 7.354.67–12.53
345–395g(n=16)
StatisticalcomparisonbetweeneachgroupusingtheMann-WhitneyUtest:290-340gvs345-395g:nosignificantdifference(p[0.05).290-340g and345-395gvs400-450g:significantdifference(p\ 0.05).
0.63–1.18),ofskinlength,wasgainedrespectively(Figs.2, 3).
Methodologically,tohavea‘‘true’’valueofthelower poleexpansion,theinframammaryscarincisionshouldbe positionedpreciselyatthenewIMFandstronglyfixatedat thislevelwithoutanychangesinitspositionovertime.To achieveawell-definedandcorrectlypositionedIMFwith thescarlyingexactlyinit,weuseafour-layerwound closuretechnique:arunningbarbedsutureispassed
betweenthethoracicfascia,attheleveloftheimplant’s lowerpoleandScarpa’sfasciaattheinferioredgeofthe wound(firstlayer);betweentheScarpa’sfasciaofthe superiorwoundedgeandScarpa’sfasciaoftheinferior woundedge(secondlayer);inthedeepdermis(third layer);andintradermally(fourthlayer)[18].
TheanchoredIMFactsasafixedpointfromwhichthe skinisstretchedandincreasesitssurfaceareatoreducethe implant’smechanicalload[19].
Fig.2a A21-year-oldwomenwithmildhypoplasiaoflower quadrants(preoperativeN-IMFdistance:6cm)Anatomicalimplant of425gusedviaasubmammaryincisionwithadual-planetechnique
andareolarreduction. b Postoperativeappearanceafter1month(NIMFdistance:7,5cm)and c 1yearshowsaprogressivelowerpole expansion(N-IMFdistance:9cm)
Fig.3a A28-year-oldwomenwithmildhypoplasiaofthelower medialquadrantpreoperativeN-IMFdistance:6cmright).Anatomicalimplantof350gusedviaasubmammaryincisionwithadual-
Contrarily,theincreaseoftheN-IMFdistanceobserved incasesofinferiorimplantdisplacement,dropoftheIMF, andhighridingscar,isonlyanapparentexpansionofthe lowerpole.Inthiscase,theincreaseddistanceisdueto pathologicalrecruitingoftheabdominalskinratherthana realskinexpansion.Accordingly,weexcludedonepatient thatdevelopedbilateralbottomingoutfromtheanalysis.
Biomechanically,stretch-inducedskingrowthissimilar totheskingrowthobservedusingatissueexpander.The implantinducesaphenomenonofmechanicalcreep deformationcharacterizedbyincrementaltissuestretching andelongationbeyonditsintrinsicextensibility[20].
Manyfactors,includingbreasttypeandmorphology, implantcharacteristics,andsurgicaltechnique,caninfluencethedegreeofthisprogressiveexpansion.Todecreasetheimpactofconfoundingfactors,weanalyzeda homogenoussubgroupofpatientswithsimilaranatomical characteristics(nearlyaveragebreastvolumewithaslight underdevelopedlowermedialquadrantusuallycombined withahighinframammaryfold)[21]andtreatedwiththe samesurgicaltechnique.Inmostofthesecases,acombinationofsiliconecohesiveanatomicalimplantsandglandularscoringcanachievepropercontourofthelowerpole, avoidingmorecomplextechniques[22, 23].
Anotherinterestingfindingwasthathigherimplant weight([400g)wasassociatedwithamoresignificant degreeofN-IMFdistancelengtheningovertime.Implants weightappearstobeaprincipaldeterminingfactoron breastskindynamicsafterbreastimplantation[24, 25].
However,regardingtheimplantitself,weightand/or volumeisjustoneofmanyfactorsthatmayinfluencehow fartheN–IMFdistancestretches.Anatomicalimplantsof similarvolumemayvarysignificantlyintermsofshape andsize,impactingthedegreeoflowerpolestretching.For instance,higherprojectedimplantsmightcauseadditional pressuresagainstthemammaryparenchyma,contributing toadditionalstretchingandthinningofbreastenvelope comparedwiththelowandmediumprojectedones[26].
planetechnique. b Appearanceat6months(N-IMFdistance:8cm) and c 12monthspostoperativelyshowsagoodlowerpoleexpansion (N-IMFdistance:9cm)
Unfortunately,therewerenosubgroupstoevaluate differentimplantprojections,heightandwidth,andtheir effectsontheN-IMFdistanceinourstudybecauseofthe smallsample.Anothersourceofmeasurementbiasmight betheoccurrenceof‘‘silent’’rotationwithanatomical implants[27].Althoughwedidnotidentifyanyclinically evidentimplantrotation,evensmallundetectedrotations mayalterthevolumedistributionatthelowerpoleandso thecorrectevaluationofthelowerpolestretching.
ImplicationonImplantSelectionandIMFIncision Position
Differentmethodstocalculatetheexactpositionofthe inframammaryfoldincisionhavebeenproposed,[28–30] butnoneconsidershowthenippletoinframammaryfold distancevariesinthepostoperativeperiod.
Thedynamicmorphologicalmodificationsofthebreast afteraugmentationmammaplastyinfluencethecosmetic surgicaloutcomeintheshortandlong-term[15]and shouldbethereforetakenintoaccountduringthechoiceof theimplantandthepreoperativeplanning.
Thisisespeciallytrueinthetuberousbreast,wherethe breast’sintrinsiccharacteristicsrestrictthenumberof possibleusableimplants.
Implantheightisthesinglemostimportantdimension onwhichisbasedthechoiceoftheimplantandthelocationoftheIMFincision[31, 32].Theimplant’sheight determinestheimplant’sverticalpositiononthechestand thepositionofthenewinframammaryfold[33].Toestimatethepostoperativenippleposition,weaskthepatient toabductbotharmsto45 abovethehorizontalplaneby placingbothhandsatopherhead.Thenewnippleposition isprojectedtothestablesternalmidline,andhalfofthe implant’sheightismarkeddistally.Ahorizontallineis extendedlaterallytodelineatetheInferiorlowerpole(ILP) linefromthismark.Thisrepresentsaguideonwherethe implant’sinferiorpoleandtheIMFincisionshouldlieon
thechestforthebreast’snaturalappearance.TheILPline helpstosimulatetheeffectofdifferentimplants’heights ontheupperandlowerpoleofthebreast.(Fig.4).The desiredheightischosendependingonwheretheexisting inframammaryfoldis,justsothattheimplantlowerpole wouldcomeincloserconnectionwiththeexistinginframammaryfoldandsotheIMFincision[34].
Theuseofanatomicalimplantsintuberousbreastallows remainingclosetotheexistingbordersofthenativebreast, bringingthemajorityofthevolumeinthelowerpoleand elevatingthenipple-areolacomplex[35, 36].
Comparedtoroundimplants,shapedimplantsprovide greaterversatility,thankstotheirwiderrangeofwidth/ height/projectioncombinations.Aconstrictedinferiorpole andshortnippletoinframammaryfolddistance(asin tuberousbreast)arebestservedbylower-heightanatomical implantstoallowclosercontactwiththeexistinginframammaryfold.Usingafull-heightanatomicalimplantora roundimplantinabreastwithashortlowerpolewould necessitateaconsiderableloweringoftheexistingIMFto positiontheNACadequately.Thiswouldincreasetherisk fordouble-bubbledeformity,especiallyiftheglandistight andwelldefined[37].Furthermore,theirform-stablenaturehastheeffectofmaintainingitsdimensionsandform againstthenaturaltendencyofthebreasttissuetocontract afterthereleaseandscoringmanoeuvres[8, 38].Theoretically,thenewIMFlocation(determinedbythe implant’sverticalheight)shouldbepositionedconservatively,slightlyhigherthanwhatmaybedictated,[31] expectingaslowprogressiveincreasingoftheN-IMF distanceoveroneyear.Moreover,avoidinganexcessive
Fig.4 Differentimplantlowerpole(ILP)linescorrespondingto differentimplantsheight(10cm,11cmand12cm).Choosingan implantheightwithanILPtoofarfromtheexistinginframammary foldincreasesdouble-bubbledeformityrisk
loweringofthefoldcouldreducetheriskofcomplications suchasbottomingoutanddoublebubbledeformity[39].
However,sincemostpatientswithtuberousbreasthave ahighandconstrictedIMF,loweringthefoldtoaccommodatetheimplantisusuallynecessarytoobtainanaturallyshapedbreast.
Inallourcases,wesurgicallyloweredthefold.Thefold wasloweredonaverage2.4cm,reflectingtheneedto recruitextraskintothebreast’slowerpole,thusgivinga morenaturalappearance[40].
Inallcases,weusedaninframammaryfold(IMF) incision,addingperiareolarproceduresonlyincasesof severeareolarenlargement,herniationandpositional asymmetries.Sinceinthemajorityoftuberousbreastsitis necessarytolowerahighridingsub-mammarycrease,an IMFapproachpermitsbettercontrolandstabilizationof thefoldthatcanbewelldefinedandfirmlyanchoredtoits newpositionreducingtherisksforcomplicationssuchas implantdislocation,bottomingoutandmigrationofthe scar.[18, 41]
Otherauthorspreferaperiareolarapproachthatgives easieraccesstomanipulatetheglandandeliminatesthe riskofanymalpositionoftheinframammaryscar[3].We prefertoavoidanyaccesstothepocketthroughaperiareolarincisionsinceithasbeendemonstratedtoincrease theriskofcapsularcontracture[42].Whenareductionof theareolardiameterisneeded,weaddaperiareolarincisiontotheprocedure.Unfortunately,itwasnotpossibleto assesiftherewereanydifferencebetweenpatientswho hadanIMFincisionplusanareolardiameterreductionand patientswhohadonlyanIMFscar.
Oneoftheprimaryconcernsinusinganatomical implantsistheriskofbreastimplant-associatedanaplastic large-celllymphoma(BIA-ALCL),whichmightberelated toimplanttexturing.TheFDAhasreported573uniqueand pathologicallyconfirmedbreastimplant-relatedcases worldwide,with33disease-relateddeaths[43].Sinceall theanatomicalimplantsaretextured,theiruseshouldbe limitedwhentherearestrongindications(tuberousbreast orshortlowerpole,selectedbreastasymmetries,selected secondarycases)[44].Althoughnotexplicitlyevaluatedin ouranalysis,furtherdatacollectionisrequiredtoprecisely determinehowthesurface(smoothvstextured)andthe implant’sshapeaffectthepostoperativebreastmorphologicalchangesafteraugmentation.
Conclusions
Althoughthecurrentstudyisbasedonasmallsampleof participants,thefindingssuggestthatasignificantprogressivepostoperativeincreaseinN-IMFdistanceshould beexpectedinallcasesoftuberousbreastaugmentation.
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