Four-step Augmentation Mastopexy: Lift and Augmentation at Single Time (LAST)

Abstract

Background: Augmentation mastopexy is one of the most difficult challenges plastic surgeons face, especially concerning sustainability of upper pole fullness and lower pole ptosis correction. We describe our technique for augmentation mastopexy that provides inferolateral muscular support for the implant and standardizes a sequence of surgical stages to resolve multiple situations and present the outcomes of patients who underwent such an approach. Methods: Our technique proposes the following: (a) modified subpectoral pocket, with muscular inferolateral support for the implant; (b) independent approaches to the submuscular (implant) pocket and parenchymal resection/reshaping; and (c) pre-established 4-step surgical sequence. Data from office files of our private practice were collected for 266 patients who underwent the technique from October 2015 to January 2019. Patient perception about esthetic outcomes, photographs from multiple postoperative follow-ups, and surgical complications/reoperation rates were analyzed. Results: Overall mid-term and long-term results (39 months) were positive for lift and augmentation at single time mastopexy; >90% of patients reported satisfaction with their esthetic outcomes, including absence of ptosis. No major complications occurred. The total revision rate was 16%, but it became <5% in 2018 as the learning curve progressed. Conclusions: Augmentation mastopexy is complex, and the myriad of approaches and possibilities may cause confusion when selecting the most suitable one. The 4-step sequence provides a reliable option, offering a predefined execution plan, whereas inferolateral muscular support prevents recurrence of lower pole ptosis. Other surgeons’ experience with lift and augmentation at single time mastopexy and further studies are necessary to validate these findings.

The “Shirt Pocket” Technique—An Alternative for Augmentation-Mastopexy

“… 10 However, this procedure frequently requires retouch or reoperation (~8–28%), mainly because of early postoperative recurrence of the glandular ptosis. 2 7 11 Early recurrence may occur due to the submuscular approach, creating the double-bubble deformity, or after the pure subglandular approach, which was increased after the recommendation for using smooth implants to avoid the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). 12 …”

“…According to the literature, many techniques and surgical maneuvers have been described in an attempt to avoid or slow up complications. 1 2 3 4 5 7 10 11 Graf et al highlighted that the use of the pectoralis fascia is more effective to cover breast implants by giving an additional soft-tissue coverage of the superior pole of the breast. 6 Considering the subglandular approach, Mansur and Bozola described the use of an inferior pedicle flap to protect and provide support of the inferior aspect of the breast when augmentation-mastopexy is performed.…”

“… 13 Ono and Karner performed a submuscular pocket with a lateral muscle sling to receive the implant before resection and lift the breast with good results. 2 Borestein and Abrahami proposed a median myotomy at the most tensioned part of the pectoralis major muscle to avoid postoperative double-bubble complications or waterfall deformity. They also stated that the dual-plane approach is a better way to perform breast augmentation than subglandular procedures, and it should be the default approach for mastopexy with implants.…”

“… 1 Despite the several described surgical techniques to achieve the best pocket plane in these kind of procedures, early postoperative glandular ptosis is a very common and undesirable event, which promotes frustration for both patients and plastic surgeons. 2 It is also known that the subglandular technique is more likely to have this type of complication. 1 Thus, several surgical tactics have been described to achieve a long-lasting result, with better maintenance of the breast shape.…”

“… 3 4 Among these procedures, the most used are the dual-plane techniques which are based on the cranial dissection of the pectoralis major muscle to create the implant pocket. 1 2 3 5 To improve their results, Graf et al described the use of the deep fascia of the pectoralis to cover breast implants. 6 They highlighted that the subfascial approach allowed soft-tissue coverage of the superior pole without the downside of raising the muscle.…”