Dr. Mentz and Dr. Patronella work to improve safety and results with combined breast implant and breast lifts. 

Salvage Strategy of Delayed Implant Inflation for a Compromised Nipple Areolar Complex During Augmentation Mastopexy.

Henry A. Mentz, III, MD, FACS, FICS, Christopher K. Patronella, MD, FACS, Amado Ruiz-Razura, MD, FACS, German Newall, MD, FACS, James F. Boynton, MD, Janna Siarski, BS 

Abstract

Augmentation mastopexy is an operation frequently sought after but fraught with complications. Delayed implant inflation is a surgical strategy which may reduce these complications and allow for a single intraoperative session. Over a two year period, 1840 breast cases were performed by our group, 1444 (78%) were breast augmentation and 396 (22%) were mastopexy. In the 396 mastopexy were performed, 236 (60%) of these were augmentation mastopexy. Twelve (5.1%) of these patients experienced various forms of intraoperative ischemia including venous congestion, arterial inflow, or simply areolar increased tension. In these selected cases the implants were left partially deflated with the ports externalized. Implants were later inflated in the clinic under local anesthesia without further circulation compromise (except for one). In retrospect, most of these cases had additional risks which were identified as underlying systemic disease (82%), previous breast surgery (73%), history of smoking (25%), and use of hormones or birth control pills (33%). Other identified risks include patients who require substantial areolar reduction, patients choosing larger implants (greater than 300 cc), and patients who exhibit substantial asymmetry. Patients with impaired blood supply include patients with previously placed subglandular implants, an old wide implant pocket, required capsulectomy, previous mastopexy or reduction, and thinned breast parenchymal atrophy. Follow up ranged from 8 to 30 months. Within the 12 patients who received this salvage maneuver, seven (58%) had complications. Four (30%) patients had revision surgery for asymmetry, one (5%) patient had postoperative hematoma, one (5%) patient with subsequent ischemia and necrosis, and one (5%) patient with local infection not requiring implant removal. There were no instances of capsular contracture or seroma. Although the complication rate was high for these selected patients, these were high risk patients with impending nipple necrosis which was salvaged with this strategy of late implant inflation. Presently, we recommend this strategy of delayed inflation in cases where there is any risk of nipple areolar complex circulation compromise and in cases with systemic disease, history of smoking, hormone use, substantial asymmetry, large areola, previous breast surgery, and choice of a large implant. Further studies are underway to evaluate this format for all augmentation mastopexy procedures.

Introduction

Augmentation mastopexy has been reviewed in recent years. In an article by Dr. Spear published in PRS in 2003 [[1]], he suggested surgeons beware of this operation because of increased complications and litigation as a result of this combination.  Three years later in 2006, Dr. Spear reviewed three years of mastopexy cases [[2]]. Of these 78 mastopexies, 53 were combination augmentation mastopexies, representing 68% of his total mastopexies; 23 were primary and 30 were secondary procedures. The complication rate was 8.8% and revision rate 14% [2]. Dr. Handle in 2006 reviewed mastopexy in the augmented patient and suggested it was a recipe for disaster [[3]]. He acknowledged higher risks and recommended proper planning and attention to detail. Our two year experience represents 1840 breast cases. Of these, 1444 (78%) were augmentation cases and 396 (22%) were mastopexy cases. In the 396 mastopexies, 236 (60%) were augmentation mastopexies. This was a smaller percentage than Dr. Spear's paper [2].  Problems surrounding augmentation mastopexies include hematoma, infection, implant extrusion, loss of sensation, visible or poor scars, malposition of the nipple, malposition of the breast implant, a high rate of revision surgery, and most significantly vascular compromise leading to loss of the nipple areolar complex. [1-15]

The safest strategy in augmentation mastopexy is sequential surgery. However, combination surgery is often undertaken when patients and plastic surgeons have a preference for a single event, in patients with previous breast augmentations wishing for mastopexy, and in patients with previous mastopexies or reductions requesting breast augmentation and revision surgery. Generally combination procedures of augmentation mastopexy can be satisfying because of the improvement in contour that the mastopexy provides and the increase in upper pole fullness that the augmentation provides. 

It is most important is to recognize patients who are at high risks. The circulation risks are higher in combination surgery because of increased skin tension and impaired blood supply. Skin tension is increased in patients who require substantial areolar reduction, patients who choose larger implants (greater than 300 cc), and patients who exhibit substantial asymmetry. Patients with impaired blood supply include patients with previously placed subglandular implants, an old large or wide implant pocket, required capsulectomy, previous mastopexy or reduction, thinned breast because of parenchymal atrophy, history of smoking, and systemic disease. [2-3]

Occasionally after augmentation with mastopexy, there is intraoperative evidence of vascular compromise to the nipple areolar complex. It may manifest itself by the presence of cyanosis, congestion, swelling, increase or decrease in capillary perfusion, and excess skin tension. Traditional salvage strategies have included surgical and nonsurgical maneuvers. Surgical strategies include suture removal and implant removal. These strategies also result in delayed closure and delayed implant placement. There are times however when suture release is a necessary part of release of surgical tension. Nonsurgical maneuvers include the use of vasodilators like nitro-paste, the use of leeches for venous congestion, the use of hyperbaric oxygen [3], use of steroids, and blood thinners. 

The most important objective is to reduce surgical risks and avoid disasters [1]. Several ways to reduce risks include careful planning, staging the mastopexy and augmentation, limiting the implant size, limiting the undermining, performing more superficial undermining, allowing more generous flaps so that there is less tension on the closure, and finally the use of saline implants to provide salvage strategy. 

We present a new and simple "Salvage Maneuver" to release excess tension and vascular compromise without the need for secondary surgery. 

Materials and Methods

236 patients received combination surgery in the last two years. Twelve (5.1%) had progressive intraoperative ischemia which included darker color and venous congestion, lighter color and arterial inflow insufficiency, or simply increased tension on the areolar. The implants were deflated during surgery and normal color returned. The implant tubing and port were shortened and externalized. Reinflation of the implant was performed between 4 and 18 days after surgery and the tubing was removed. The patients with intraoperative ischemia exhibited higher than average preoperative risks. Nine (82%) had systemic diseases, eight (73%) had previous breast surgery, three (25%) had a history of smoking, and four (33%) had taken hormones or birth control pills. Of the eight who had had previous breast surgery, all of these patients (eight) had previous breast augmentation. Two of these patients had multiple breast augmentations, three had previous mastopexies or reductions, and three had previous combination mastopexy augmentation surgeries. The operative technique utilized was a Wise keyhole pattern surgery with minimal dissection and no dermal excision in order to preserve subdermal vasculature. After the implants had been filled, these 12 ischemic patients exhibited signs of vascular compromise. Since viability was challenged the "Salvage Maneuver" was executed. 

Saline implants are built with adequate valve technology so that ports can be removed postoperatively. The port tubing may be shortened so that one or two inches of port excess are necessary to come out of the wound. Later strategies have included buried ports with suture leaders. Exteriorized injection ports have been used for some time. Dr. Becker in PRS 2004 published a series of 33 patients with exteriorized tubing used from one to five days without incidents of infection or capsular contracture [15]. Jackson in 2004 utilized externalized ports from 10-76 days with no evidence of infection. [ Reference?]

The average implant utilized was 300 cc. The average salvage fill was 131 cc and more recently 100cc have been used. The average final implant fill was 385 cc. All salvage patients utilized saline implants with externalized ports and the secondary inflation was performed between 4 and 18 days postoperatively in the clinic without difficulty. 

Implants were refilled in the clinic after revascularization had occurred and inflammation subsided. The desired volume of the implant was reinjected with a closed system and patients were encouraged to participate in choosing the final fill volume. Implants were adjusted for symmetry and projection. After observation of more than one hour, the tubing and valves were removed and the port defects were closed. Patients received oral antibiotics for five days postoperatively and dressing changes were performed three times per day. Incisions and injection ports were carefully monitored for signs of infection, capsular contracture, or leak. Flap vasculature was also monitored carefully with home healthcare nursing and frequent office visits. 

Results

Twelve of 236 augmentation mastopexies were treated with this salvage maneuver in the last 24 months. All 12 patients exhibited compromise to the nipple areolar circulation at the time of surgery.   Followup ranged from 8 to 30 months. Within the 12 patients who received the salvage maneuver, seven had complications. Four patients had revision surgery, one patient had postoperative hematoma, one patient with subsequent ischemia and necrosis, one patient with local infection not requiring implant removal. There were no instances of capsular contracture or seroma. 

Conclusion

Breast augmentation and mastopexy are common operations and often patients seek combination surgery [1-15]. The safest strategy is for sequential surgery, generally performing the mastopexy first, with later augmentation. However, many patients who seek this combination have had previous surgery making it difficult to segregate the operations. Furthermore, most patients who have not had previous surgery generally prefer the convenience of a single surgical event. Most importantly, every patient carries with them a specific set of preoperative risks. It is most important to identify high risk patients and discuss both sequential surgery and the salvage option before surgery. The circulation risks are higher in combination surgery because of increased skin tension and impaired blood supply. Additional risks include patients with systemic disease, previous breast surgery, history of smoking, use of hormones or birth control pills, patients who require substantial areolar reduction, patients choosing larger implants (greater than 300 cc), patients who exhibit substantial asymmetry, patients with previously placed subglandular implants, an old wide implant pocket, required capsulectomy, previous mastopexy or reduction, and thinned breast parenchymal atrophy [2-3]. When in the operating room, when vascular compromise is evident, we believe this "Salvage Maneuver" can help avoid serious complications, specifically nipple areolar complex necrosis. Because of the catastrophic impact of a necrotic pedicle, we feel that this salvage maneuver may allow plastic surgeons to avoid this disaster in high risk patients. Furthermore, in patients with any compromise whatsoever including venous congestion, arterial inflow, or simply increased tension, we believe that this option allows for reduced risk of vascular insult in the postoperative period and should be used when necessary. Since risks of capsular contracture and infection are relatively low compared to a necrosis event, this salvage strategy allows for a reduction in substantial risks with very little postoperative compromise. Further studies will be necessary and are underway to evaluate this strategy further and to evaluate this strategy for all augmentation mastopexy procedures.

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