Treatment of breast ptosis by placing subfascial silicone implants followed by inverted “T” mastopexy

Introduction: The treatment of breast ptosis using mastopexy associated with the placement of silicone prosthesis in a single surgical procedure is a challenge for surgeons. There are several techniques described in the literature. This study aims to describe the placement of silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, totally separating it from the rest of the breast parenchyma in the treatment of patients with breast ptosis. Moreover, analyze the aesthetic results of operated patients. Methods: During the period from September 2017 to February 2019, 64 mastopexies with an inverted “T” scar were performed associated with silicone breast implants placed in the subfascial plane, bilaterally, textured high-profile round prostheses whose volumes ranged from 180ml to 380ml, in patients with breast ptosis. Results: The average age was 34 years, ranging from 19 to 55 years. The postoperative follow-up time was 1 to 18 months. The main complications were: 3 cases (4.6%) of residual skin flaccidity in the 8-month follow-up; two cases (3.1%) of unsightly scars; one case (1.5%) of partial areola necrosis. There was no case of infection or seroma. Conclusion: The technique of placing silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, totally separating it from the rest of the breast parenchyma, was effective in the treatment of patients with breast ptosis. ■ ABSTRACT


INTRODUCTION
Breast ptosis is characterized by laxity and excess skin on the breasts, which can be associated, in most cases, with atrophy of the breast content or volume. The leading causes of breast ptosis are age, gravity, breastfeeding, and weight loss.
The surgery that corrects or treats breast ptosis is mastopexy. It aims to restore the breast's shape 1 . When thinking about restoring the breast's shape, this means not only repositioning them or bringing them to the "ideal" position. It also means remodeling it in its size and consistency, making it firmer. Still, in that same opportunity, an item that should not be overlooked is the nipple-areolar complex (NAC) 2 . The NAC must be located at the apex of the mammary "cone". It must be repositioned and adequate in its size so that it is proportional to the size of the "new" breast, making it more harmonious and youthful. In other words, aspects that should be valued in mastopexy as a whole for the surgery's success are breast location, shape, size, consistency, and NAC position.

OBJECTIVE
The objective of this study is to describe the placement of silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, totally separating it from the rest of the breast parenchyma in the treatment of patients with breast ptosis. Moreover, analyze the aesthetic results of operated patients.

METHODS
During the period from September 2017 to February 2019, 64 mastopexies with an inverted "T" scar (as described by Pitanguy) were performed, associated with silicone breast implants placed in the subfascial plane, bilaterally, textured high-profile round prostheses whose volumes ranged from 180ml to 380ml in patients with breast ptosis. All patients came from a private clinic, operated by the same surgeon, under thoracic epidural anesthesia, following a thromboembolism prevention protocol, using prophylactic antibiotics, and using a 4.8 suction drain, as well as hospitalization for 24 hours.

Operative technique
The patient was operated on in the supine position, with a back tilt at 30o, abduction of the upper limbs at 90o, infiltration of saline solution (SS) with adrenaline in the proportion of 1: 250,000 in the marks previously performed in standing (orthostatic position).

Placement of the silicone implant
The surgery was started with skin and subcutaneous cell tissue (SSCT) incision in the inframammary fold (IMF), subfascial dissection to accommodate the previously chosen silicone breast implant. The subfascial pocket extended to the second intercostal space. Hemostasis of bleeding vessels was performed, irrigation of the prosthesis pocket with a solution of 100ml of SS with 1g of cefazolin and 80mg of gentamicin, using 50ml of the solution on each side (right and left), placement of a Mentor HP textured silicone implant and finally, closing or synthesis of the subfascial pocket with 3.0 monofilament thread in separate points (Figures 1 and 2).

Mastopexy
Then, the mastopexy itself started, with an incision in skin and SSCT over the marks made with methylene blue up to the pectoralis major muscle fascia, removing the breast tissue at the lower breast pole.
When the aponeurosis is found, it is avoided to incise or damage it, keeping it intact, and then it is broadly dissected superiorly and laterally, freeing all breast tissue from the fascia, but keeping it adhered in its periphery to the pectoralis major muscle. Periareolar de-epithelialization (Schwartzmann maneuver) is then carried out between Pitanguy's "ABC" points ( Figures 3, 4, 5, 6, 7, and 8), followed by the NAC's rise (Figure 9) through the Silveira Neto maneuver 6 (medial dermal pedicle). The next step is the removal of the excess tissue, followed by approximation of the medial and lateral columns with nylon 3.0 thread in separate points, "assembling" the breast (Figures 10 and 11), placing a suction drain, subdermal suture with thread monofilament 4.0 in separate stitches and intradermal suture with 5.0 monofilament thread ( Figure 12).

RESULTS
The average age of the 64 patients included in this study was 34 years, ranging from 19 to 55 years. Forty patients had grade 2 ptosis from the Regnault Classification, and twenty-four had grade 3 ptosis. The postoperative follow-up time was from 1 to 18 months, with 41 patients having a follow-up longer than six months (Figures 13 and 14) and 23 with fewer than six months. followed by partial suture dehiscence (Table 1). No case of infection or seroma. The patient who presented necrosis of 75% of NAC was one of the cases of grade 3 ptosis and smoker.

DISCUSSION
The option for mastopexy alone without introducing a silicone breast implant often does not bring total aesthetic satisfaction to the patient and the surgeon 23 . There are complaints in the late postoperative period of lower upper breast pole projection and breast consistency loss. In search of more effective results, surgeons opted for mastopexy with a single-time prosthesis 7 . The advantages would be many: better shape, projection, symmetry, adequate positioning of the NAC, and, if necessary, increased volume 23 .
The main benefit of locating the implant in the retroglandular plane is that it is less painful in the immediate postoperative period than the retromuscular plane. It allows for a more uniform distribution of the breast parenchyma on the silicone implant, leaving the breast more harmonious. The disadvantages would be the insufficient coverage of the implant, leaving the prosthesis more exposed, and the chance of flaccidity and pseudoptosis in the late postoperative period. With that in mind, some surgeons use the retromuscular plane 8,9 , which in addition to being more painful, brings the risk in the late postoperative period of glandular ptosis on the muscle and the implant, determining the aspect of "waterfall" (waterfall deformity).
The use of the fascia of the pectoralis major muscle as an option to cover the implant and its advantages over both retromuscular and retroglandular techniques became popular due to Graf et al. 's description in 1999 13 and 2003 14 . This plan was chosen based on this premise for the location and positioning of silicone implants in this study.
Some other aspects differentiate this study, and they are: the implant placement is the first important step of the surgery, and the access route is through the IMF; there is an extensive dissection of the fascia, on its anterior face completely separating it from the rest of the breast. So, what are the intentions of these tactics? When opting for this silicone implantation initially, the idea is to avoid the exposure for an extended period, as it is a fast and safe procedure, bringing less risk of contamination. Some authors implant the silicone at the time of breast assembly 23 , exposing the prosthesis to the external environment for much longer. The access route through the IMF has lower capsular contracture rates than the areolar route 18 , probably due to implant contamination by bacteria from the mammary ducts normal flora; the areolar approach is the option of other authors 12 . The wide disconnection of the fascia anterior face, isolating the prosthesis/fascia (CPF) "set" from the rest of the breast (parenchyma), be it glandular and/or fatty, allows technical ease to assemble the breast, approaching the pillars and performing the maneuvers 6 needed to reposition the NAC, for example. The breast parenchyma distribution over the CPF is done homogeneously, without exposure of the silicone (previously implanted in the subfascial plane) and, with practicality and range of movements, as there is a disconnection between the parenchyma and the deep fixation tissues (fascia) of the breast. It should be noted, however, that the fascia obviously remains attached to the pectoralis major muscle throughout its periphery, except for the 3 to 4 cm where it was incised to place the silicone, so it is on the periphery of anatomical structures that adhesion zones are formed, where are vessels, nerves and lymphatics; and they interconnect superior and inferior through thin ligaments 22 .
Concerning complications, the values were similar to those in the literature 21,23 . However, this study is concise compared to others 23 . The fact that there was no case of capsular contracture is perhaps not due to the subfascial technique itself, but due to the short period (18 months), especially in cases that were operated on less than six months ago. The complications observed here (one case of partial necrosis of the NAC, unsightly scars, and pseudoptosis) refer to the immediate and recent postoperative period. It should be noted that the case of NAC necrosis was in a smoking patient. The study's continuity is necessary to obtain more practical and real data in relation, for example, to the capsular contracture index, through a more extensive sample, and, mainly, a longer time for analysis and comparison with the literature. Like other authors [13][14][15][16][17] , some details could be observed concerning the subfascial plane. They are implant stability, peripheral protection of the silicone prosthesis making its edges less visible and less palpable, little bleeding during dissection, little pain postoperative, less postoperative edema, as there is the preservation of the lymphatics, as described 13,14,22 and, consequently, easy recovery and faster return to daily activities.

CONCLUSION
The study demonstrated that the technique of placing silicone breast implants in the subfascial plane, followed by an extensive anterior dissection of the pectoralis major muscle fascia, completely separating it from the rest of the breast parenchyma, was effective in the treatment of patients with breast ptosis.

ACKNOWLEGMENTS
Special acknowlegments to Mr. Egídio for his collaboration during the reviews.