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• W2312681472 abstract "Sir:FigureMammaplasties are common procedures, with a high degree of patient satisfaction. However, revision operations may be necessary because of recurrent skin laxity with ptosis, atrophy of the breast parenchyma, or progressive hypertrophy. The overall number of patients undergoing revision surgery, though, is low, and there are only a few studies evaluating outcomes of secondary mammaplasties. With the intention of obtaining a more harmonious breast with more upper pole fullness, the inferior pedicle mastopexy technique was described by Ribeiro in 1975.1 This technique has changed the paradigms of aesthetic breast surgery, especially when combined with the pectoralis muscle flap described by Daniel.2 Substantial improvements of the results were observed because the muscle sling constantly supports the pedicle in a superior position, which increases upper pole fullness and delays the recurrence of ptosis.3 The objective of this study was to evaluate the inferior pedicle mastopexy technique in combination with a pectoralis muscle flap in secondary mammaplasties with respect to technical feasibility, aesthetic outcome, and complications. Sixty-five patients (n = 130 breasts) were reviewed retrospectively (2007 to 2012). The operations in our series were performed as follows: the inferior pedicle mastopexy technique pedicle had a base of 6 cm, a thickness of 2 cm, and a length of 8 cm; and the pectoralis muscle flap was 2 cm wide and 7 cm long. The inferior pedicle was held in place by the muscle sling and also secured to the pectoralis fascia in the superior aspect of the breast using 2-0 nylon stitches. The lateral and medial pillows were reapproximated with interrupted 2-0 nylon and a layered wound closure was performed. No drains were used. Twenty-two patients were treated with mastopexy alone and 43 were combined reduction mastopexies. All patients underwent mammographic, ultrasonographic, and photographic evaluation preoperatively and postoperatively, and selected cases underwent magnetic resonance imaging (Fig. 1).Fig. 1: Breast magnetic resonance imaging scan showing fullness of the upper pole (A), pectoralis muscle flap (B), inferior pedicle mastopexy technique (C), and breast tissue (D).The patient age ranged from 34 to 62 years (mean, 56 years). All patients were discharged to home on the day of surgery and reevaluated on postoperative days 7, 14, 30, 90, and 180. Figure 2 illustrates the typically achievable result. Among the 65 patients, there were complications included three cases of fat necrosis (4.6 percent), two cases of partial nipple-areola complex necrosis (3.1 percent), and four cases of partial wound dehiscence (6.2 percent).Fig. 2: Photographs obtained 6 years after initial reduction mastopexy (above), 6 months after revision mastopexy using the technique popularized by Ruth Graf (center), and 4 years postoperatively, showing the final result (below).In two cases, we observed inadequate augmentation of the superior pole of the breast. In all of the remaining cases, both patients and surgeons were eventually very satisfied with the overall aesthetic result and especially the improved upper pole projection. There is limited information in the literature regarding the surgical outcomes of secondary mammaplasties, and there are no reports regarding outcomes in secondary mammaplasties using the inferior pedicle technique in combination with a pectoralis muscle sling.4,5 As observed by Lee et al., a prolonged time interval between primary and secondary breast operations may allow for adequate revascularization, reducing the incidence of complications. All of our patients presented at least 5 years after their initial operation, which may have aided in achieving reproducible results, with a low incidence of complications. However, the overall rate of complications in secondary procedures remains high. Most common are seroma formation and fat necrosis. We encountered this last complication in three cases, diagnosed by mammography and ultrasound. These patients were treated by resection of the compromised areas, but no sooner than 6 months postoperatively. Of interest, the cases of fat necrosis all occurred in the distal portion of the flap, suggesting that either the dimensions of the flaps regarding its length and width were disproportionate or that perfusion of the flaps was reduced because of pressure of the pectoralis sling along the base of the pedicle. We found that one of the ways to avoid fat necrosis in the distal portion the flap is to change the design and make it shorter (6 cm in length instead of 8 cm). Although it is theoretically possible, we do not believe that the muscle sling was responsible for the fat necrosis of the flap. Daniel, when describing this technique, did not mention a single case of fat necrosis. A similar study evaluating 132 patients did also not find any cases of fat necrosis. An optimal aesthetic mastopexy result requires providing good skin coverage of the breast parenchyma, symmetric nipple-areola complex position, and adequate superior pole fullness, all of which we found can be safely achieved using the described technique, even in secondary procedures. It can be concluded that using the inferior pedicle technique in combination with a pectoralis muscle sling presents a viable option with a high aesthetic benefit and a low incidence of complications for cases of secondary mammaplasty. Lincoln Graça Neto, M.D., M.Sc., Ph.D. Luiz Roberto Reis de Araújo, M.D., M.Sc. Maurício Baggio, M.D. P. Niclas Broer, M.D. Ruth Graf, M.D., M.Sc., Ph.D. Institute of Reconstructive Plastic Surgery, New York University, New York, N.Y. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article." @default.
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• W2312681472 date "2013-01-01" @default.
• W2312681472 modified "2023-09-26" @default.
• W2312681472 title "The Ruth Graf Technique in Secondary Mammaplasty" @default.
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