Mastopexia associada a implante de silicone submuscular ou subglandular : sistematização das escolhas e dificuldades Mastopexy associated with submuscular or subglandular silicone implants : indications and complications

Background: Throughout history, the breasts are considered important to the femininity and self-esteem of women. In augmentation mammoplasty, organ function must be preserved. Indications for the best tissue plane for coverage of silicone implants and association with mastopexy can be challenging. The aim of this study was to evaluate a series of cases of mastopexy associated with silicone implants. Methods: A retrospective descriptive study was performed in patients who underwent mastopexy at the Plastic Surgery Unit of the Hospital Daher Lago Sul (Brasília, DF, Brazil). From July 2008 to July 2011, 243 patients with a mean age of 31.4 years underwent surgery. In 149 patients, the subglandular technique was used and in 94 patients, the submuscular technique was used. Implant volume ranged from 150 mL to 400 mL. Results: There were 174 cases of combined procedures. Four patients who underwent surgery using the subglandular technique developed capsular contracture (grade II). We followed up 7 cases of pseudoptosis with the submuscular technique and 14 cases of mammary ptosis with the subglandular technique. Eight patients experienced a mobile implant resulting from muscle activity. The reoperation rate was 6.58%. Conclusions: Treatment of mammary Trabalho realizado no Serviço de Cirurgia Plástica do Hospital Daher Lago Sul, Brasília, DF, Brasil. Artigo submetido pelo SGP (Sistema de Gestão de Publicações) da RBCP. Artigo recebido: 31/3/2012 Artigo aceito: 7/6/2012 1. Membro titular da Sociedade Brasileira de Cirurgia Plástica (SBCP), regente do Serviço de Cirurgia Plástica do Hospital Daher Lago Sul, Brasília, DF, Brasil. 2. Membro titular da SBCP, preceptor do Serviço de Cirurgia Plástica do Hospital Daher Lago Sul, Brasília, DF, Brasil. 3. Especialista em Cirurgia Geral, membro aspirante da SBCP, médico residente do Serviço de Cirurgia Plástica do Hospital Daher Lago Sul, Brasília, DF, Brasil. José Carlos Daher Jefferson Di lamartini GalDino Do amaral DioGo BorGes PeDroso riCarDo Cintra Júnior

Where aesthetic surgery of the breast is concerned, augmentation mammoplasty is the most commonly performed procedure in Brazil, according to data from the DataFolha and the Brazilian Society of Plastic Surgery 2 .This surgical procedure aims to give the breasts a better shape, but it must also preserve the function of these organs, due to their importance in breastfeeding.Factors such as chronic pain, capsular contracture, and excessive pressure of the implant over the parenchyma can cause problems with breastfeeding 3 .
In daily surgical practice, inserting a silicone implant, particularly in the subglandular plane, appears to be a simple procedure, even for surgeons in training.However, the indications for the best tissue plane to use for coverage of the implant and for association with mastopexy can easily become challenging, eventually requiring secondary procedures 4,5 .When choosing the best surgical technique, the surgeon must aim to achieve the most natural and long-lasting results.The technique of mammary augmentation with subpectoral implants, associated with mastopexy or not, is one of the options available to the surgeon.
The submuscular implant may be placed in 3 different planes: completely submuscular, including the large pectoral muscle, external obliques, anterior serratus, and rectus abdominal; completely subpectoral, in which the implant lies beneath the pectoral muscle and is covered by pecto ral fascia or by the adipose layer in the lower segment; and partly subpectoral, in which a part of the muscle will serve as coverage for the upper pole of the breast 6,7 .
Significant weight loss, pregnancy, prolonged breast feeding, and involution of the mammary tissue after meno pau se are common causes of ptosis, which can be associated with hypomasty, leading to the desire for a combination of prostheses and mastopexy 8 .
The aim of this study was to evaluate a series of cases of mastopexy associated with mammary implants, in order to discuss complications associated with mammary implants, and the indications and complication rates among patients undergoing surgeries using the subglandular or submuscular techniques.Moreover, we discuss indications and strategies applicable to mastopexy with submuscular prostheses.

METHOD
This retrospective descriptive study reviewed the medical records of patients who underwent augmentation mam moplasty associated with mastopexy in the Plastic Sur ge ry Unit of the Hospital Daher Lago Sul (Brasília, DF, Bra zil).From July 2008 to July 2011, 243 patients underwent surgery: 149 using the subglandular technique and 94 using the submuscular technique.The mean age of the patients at the time of the surgery was 31.4 years, ranging from 17 to 63 years.All patients were preoperative ly investigated using mammary ultrasonography and ma m mography, cardiology, and histopathological examina tion of the product of mammary resection.
General anesthesia was administered to 202 patients and patients epidural with morphine to 41. Implant volumes ranged from 150 mL to 400 mL.Daher JC et al.
The degree of satisfaction of both the surgeon and the patient with the final result was classified as good, limited, or bad, according to the technique used.Photographic records were also taken, and complication and reoperation rates were analyzed.

Description of the Technique
General anesthesia and/or an epidural with morphine for postoperative analgesia were usually used at our institution.
All patients underwent preoperative marking and either racket incision or classic Pitanguy technique, depending on the degree of ptosis and amount of excessive skin (Figure 2).
The criteria to indicate placement of implants in the sub muscular plane were as follows: thin skin with a lot of stretch marks, patients with previous bariatric surgery, scarce mammary glands and adipose tissue, capsular contractures, or limited results with the subglandular technique and subsequent patient request.
Access to the retromammary area was achieved according to the Pitanguy technique, with vertical bipartition of the breast.In the cases of submuscular implants, a subpectoral zone was prepared with an oblique line in the direction of the fibers of the large pectoral muscle in the retroareolar area acting as an opening, over the 4 th or 5 th costal arch.Detachment of the subpectoral zone was performed by direct visualization and by using optic fiber and electric cauterization.
The key points of this technique are the complete separation of the medial insertion of the pectoral muscle at the sternal margin up to the 4 th intercostal space and preservation of the prolongation of the fascial/adipose tissue, which maintains the connection between the dissected muscles and the thorax.With these maneuvers, mobility of the implant with activity of the pectoral muscle and possible upward dislocation is avoided.In addition, good coverage of the lower pole is allowed, since the muscles do not lose their connection to the ribs and sternum (Figures 3 and 4).
A vacuum tube drain was placed in the submuscular area, with an exit hole in the axillary region.Round, textured, high-profile implants were used in most patients, while po lyurethane was used in some of the cases.The area was closed by partially bringing together the margins of the large pectoral muscle by using nylon 3.0.At this point, the area was hermetically closed; however, in most cases, it is difficult to avoid compression of the prosthesis and laceration of the fibers of the large pectoral muscle.Therefore, the intention, instead, is to maintain the margins of the muscles in the position shown in Figure 5, until the process of wound healing allows the connection to be made definitively, and  Mastopexia associada a implante de silicone submuscular ou subglandular the implants remain surrounded by a pocket that will sustain them in the indicated position.
After inserting the submuscular prosthesis and joining together the separated margins of the pectoral muscle, assembly of the breast was performed in order to obtain a good cleavage.In the case of larger breasts, in which the prosthesis was aggregated to improve the cleavage, careful resection of the lower quadrants was performed, since other wise excess tissue would result in pseudoptosis and undesirable results.After such resections, the medial and lateral pillars of the gland were assembled with nylon 3-0 to finish coverage of the implant not achieved using the pectoral muscle.
Elevation of the areolar-papillary complexes was performed using the upper (Pitanguy) or medial (Silveira Neto) pedunculus, depending on the demands of each case.The subcutaneous layer was closed using simple sutures of nylon 4-0, the deep subdermal layer was closed with nylon 5-0, and the intradermal layer was closed with a continuous suture of nylon 4-0.

RESULTS
The average duration of hospital stay was 24 h, and patients who underwent combined surgeries were discharged within 48 h.There were 174 cases of combined procedures: the most common being liposuction, followed by abdominoplasty.
One patient who underwent the subglandular technique had an anesthetic transoperative complication, when infusion of muscle relaxant in the cellular subcutaneous tissue after loss of venous access went unnoticed.The patient was transferred to the intensive therapy unit as a consequence of erratic absorption of the medication.
Three patients evolved with expansive hematoma in the immediate postoperative period, with reoperation being needed for drainage.Of these patients, 2 underwent the sub muscular technique and 1 the subglandular technique.Two patients who underwent the surgery with the subglandular technique suffered from infection and extrusion of the prosthesis, which was treated with removal of the implant, antibiotic administration, and reoperation within 4-6 months, without complications.Four patients who underwent the subglandular technique developed capsular contracture (Baker's grade II), and 2 underwent reoperation in the submuscular plane.All the 7 cases of surgery with the submuscular technique showed pseudoptosis, with the breast sliding over the implant and the patient complaining that the prosthesis was too high.Four of these cases were not severe and 3 required reoperation.Fourteen patients who underwent surgery using the subglandular technique developed mammary ptosis; 5 of these underwent reoperation, with 2 changing to the submuscular plane.Eight patients who underwent the surgery using the submuscular technique complained of implant mobility with activity of the pecto ral muscle (Figure 6).One of these patients underwent reoperation by request, and a double plane technique was used the second time.
The reoperation rate was 6.58%.No cases of prosthesis dislocation were observed.
During outpatient follow-up on postoperative days 3, 7, 14, 30, 90, 180, and 360, there were 19 cases of seroma, which resolved by spontaneous drainage or reabsorption without the need for puncture.Two patients had stretch marks on the breasts, which were partially cleared by chemical exfoliation.There was 1 case of partial necrosis of the areolar-papillary complex, where the technique of Silveira Neto had been used, and was treated with pigmentation.In 1 patient, there was persistent paresthesia in the areolas after      were treated with re-synthesis and 5 with a second intention wound healing.Twenty-seven patients evolved with scar hypertrophy, which was treated using silicone tape and/or triamcinolone infiltration.Figures 7 to 10 show the degree of satisfaction of the surgeon and the patients, according to the technique employed.

DISCUSSION
The options for breast surgery faced by plastic surgeons daily are as follows: • augmentation mammoplasty with subglandular implants; • augmentation mammoplasty with submuscular implants; • mastopexy associated with augmentation mammoplasty with subglandular implants; and • mastopexy associated with augmentation mammoplasty with submuscular implants.At our unit, augmentation mammoplasties and hypomasties are corrected with subglandular or subfascial implants, leading to a more natural look.In serious hypomasties, where there is not much gland, skin, and subcutaneous tis sue, subpectoral implants are indicated, based on our ex perience in mammary reconstructions with little covera ge tissue.When mastopexy associated with silicone implants is indicated, we use subglandular implants, whenever possible, believing that a more natural appearance is achieved when the implant is smaller than the existent mammary gland.

Difficulties
If the implant is large and voluminous and the tissue is fragile and thin, there may be dislocation of the implant with deterioration of the predefined shape, falling, and lateral dislocation, amongst other complications (Figure 11).6 months of follow-up.Seven cases of partial dehiscence we re observed, without exposure of the implants.Of these, 2 Mastopexia associada a implante de silicone submuscular ou subglandular  Submuscular implants associated with mastopexy are reserved for patients with little dermoglandular tissue that would not support the newly created mammary cone.The subpectoral implant fixes the implant in a defined position in the anterior thoracic wall, without dislocation.In this way, a new skin and dermoglandular tissue "bra" is created over the muscle fascia pocket, with a stable shape and volume (Figure 12).Although this appears to be a logical option, there are several complications that must be considered and prevented.
1.The gland may slide over the implant (which will remain stable and surrounded by the capsule behind the pectoral muscle), making the breasts hang on the volume of the silicone.This happens when the gland is very large and heavy (Figure 13).To avoid this situation, the glandular tissue must be emptied, similarly to adenomastectomy, and the volume of the new breast will effectively be the volume of the implant.2. Bad positioning of the areola must be avoided by marking it in a higher position, while respecting the marking principles of Pitanguy's point "A."Ana tomical distance between the clavicle and point "A" must be maintained.If this measurement is too long or the mammary cone is not proportional, there will be a tendency for falling into the subglandular implants or ptosis of the mammary parenchyma over the implant (pseudopto sis) (Figure 14).

Difficulties in assembly of the breast and synthesis
of the tissues can occur, since closure of the original area of the areola is a limiting factor to the volume of the implant that can be used.This must be previously evaluated by the surgeon and discussed with the Daher JC et al.
patient.Non-observance of this rule will make closure of the original area of the transposed areola difficult, leading to artificial results (retractable belts in the middle of the breast and dehiscence) (Figure 5).It is known that flat implants, subglandular implants, and the presence of bacteria over the implant (subclinical infections) are associated with a larger incidence of cap sular contracture, but there is doubt as to whether submuscular implants have lower rates of capsular contracture, since better tissue coverage would hide this complication 6,[9][10][11][12][13] .The submuscular plane may be associated with more pos toperative pain, more hematomas, and mo bilization or dis location of the implants with muscle activity 9,14 .These possible complications may be circumvented with better postoperative analgesia, routine use of vacuum drains, and appropriate detachment of the large pectoral muscles.
Thin patients who lack coverage in the upper pole of the breasts, those who might have breastfed for long periods, those with thin skin of bad quality and a lot of stretch marks, patients of older age, ex-obese patients who have undergone large weight losses and lipodystrophies, and those who present with prostheses with capsular contracture and spontaneously request the technique are best indicated for the submuscular technique [6][7][8]15 .
In ex-obese patients and in those with lipo-substituted breasts, amputation of the lower segment of the breast is indicated to avoid possible early ptosis with the "double breast" effect.Patients with familial or previous history of breast cancer, histological risk factors, and mutations of the BRCA 14 genes and those with pronounced ptosis are indicated for mastology 16 ; in these patients, we perform an amplified resection of the mammary tissue (subcutaneous adenomastectomy) and avoid the sliding of the remaining mammary tissue over the prosthesis, thereby resulting in a final aesthetic result.The size and shape of the mammary implant is usually accepted by the patients and ensures more durable results.

CONCLUSIONS
Treatment of mammary ptosis associated with aug mentation mammoplasty demands complex technical combi na-tions and careful preoperative analysis to define the best techniques to be used, which decreases the need for surgical revision and allows stable, long-lasting, and harmo nious results.

Figure 2 -
Figure 2 -Markings are made depending on the amount of excessive skin and degree of ptosis.

Figure 3 -Figure 4 -
Figure 3 -In A, section of the medial insertion of the pectoral muscle up to the 4th costal arch.In B, implant surrounded by muscle.A B

Figure 5 -
Figure 5 -Schematic representation of the difficulty of closure of the areola (in red), if the volume of the implant is inadequate.A = Pitanguy's point.

Figure 6 -
Figure 6 -Mobility of the implant with activity of the pectoral muscle.

Figure 7 -
Figure 7 -Degree of satisfaction of the surgeon, by using the subglandular technique.

Figure 8 -
Figure 8 -Degree of satisfaction of the surgeon, by using the submuscular technique.

Figure 9 -
Figure 9 -Degree of satisfaction of the patient, by using the subglandular technique.

Figure 10 -
Figure 10 -Degree of satisfaction of the patient, by using the submuscular technique.

Figure 14 -
Figure 14 -Schematic representation of the correct placement of the areola, in which hs = hi and sliding of point A next to the parenchyma causes hs > hi.hi = inferior length of the new mammary cone; hs = superior length of the new mammary cone.