Lack of better outcomes in breast surgery should not be traced to pati

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Patients undergoing mastopexy often present with paucity of breast parenchyma as well as overstretched periareolar skin secondary to multiparity or weight loss.
To provide lower pole support that does not involve skin, a new technique uses an autologous internal dermal perforator flap.

WITH THE ADVENT OF MEDICAL health care reform, there is an increasing emphasis on the long-term outcomes of various techniques and procedures. This has led plastic surgeons to question the long-term results of many of the techniques that have been employed over the past few decades. There is now a paradigm shift in how we approach many areas of the body to obtain longer lasting results. For example, we have learned that we must use cartilage grafts in the nose to enable better long-term outcomes and help prevent long-term contractures that lead to nasal deformity. However, this discussion has not taken place around cosmetic breast surgery. We continue to see immediate post-operative results in our literature and the expectation is that if the results last up to a year, we can call the technique a success! The dogma has been that the combination of loose parenchymal tissue and stretched skin cannot provide a reliable support for the weight of the breast tissue and implant over a long period of time. What has followed is a classic example of blaming the patient's poor tissue quality for the lack of better outcomes in breast surgery.

Patients undergoing mastopexy often present with paucity of breast parenchyma as well as overstretched periareolar skin secondary to multiparity or weight loss (figure 1). The primary complaint of these patients includes the position of the nipple as well as the lack of projection. They invariably undergo a combination of mastopexy and or augmentation, which looks good for the first six months. However, many of these patients are disappointed after the first or second year of surgery and seek further procedures to maintain the shape and projection of the breast.

Some may end up with a periareolar augmentation mastopexy, while some end up "upsizing" their implants to consecutively larger implants with hopes of elevating the nipple and maintaining the superior pole projection (figure 2). Unfortunately, with time and gravity, the weight of the implant will overstretch the lower pole of the breast resulting in predictable sequela:

Implant malposition
Flattening of the breast profile
Nipple dystopia
Loss of superior pole projection
Widened areolar complex
Traction rippling
Hypertrophic scarring

Most traditional techniques revolve around placing the breast support on the inferior pole skin, which, as we know, stretches over time. So, the question is, how do we help provide lower pole support that does not involve the skin? There have been a number of solutions proposed (see References) including dermal slings based on the lower pole, placement of inferior acellular dermal matrix, and even internal mesh support. This article discusses a novel technique utilizing an autologous internal dermal perforater flap that can provide long-term support for this group of challenging patients.

THE TECHNIQUE The Internal Autologous Bra (IAB) is based on the success of the use of acellular dermal matrix (ADM) on reconstructive breast patients. ADM has proven to be a reliable tool for providing an internal inferior pole support during placement of tissue expanders after mastectomy. We performed a number of fresh cadaver dissections that showed a predictable perforater vascular supply to the inferior pole of the breast at approximately 2 cm from the lateral edge of the pectoralis major muscle and 2 cm superior to the pectoralis attachment (figure 3).

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Lack of better outcomes in breast surgery should not be traced to patients' tissue quality

Article-Lack of better outcomes in breast surgery should not be traced to patients' tissue quality

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