4. Discussion
Various techniques of mastopexy-augmentation are described in the literature. On the one hand, autologous mastopexy-augmentation techniques are promoted in the literature because of their safety and natural aesthetic results [
3]. For instance, a dermal or glandular flap can be created to avoid pseudoptosis in the long term and to provide breast support [
14]. Di Summa et al. described a technique based on the creation of dermal triangular flaps in order to create lower pole fullness and prevent ptosis [
15]. Instead of an implant placement, autologous fat grafting can be used as well. Gentile et al. described natural and aesthetically pleasing results even in the correction of breast deformities with or without adipose-derived stem cell enrichment [
4,
7].
In this study, we focused on patients desiring a substantial breast augmentation along with mastopexy and we compared three different planes of implant placement:
In the subglandular approach, the breast implant is placed over the pectoralis major muscle and under the mammary gland. This technique is suitable for patients with sufficient upper pole fullness [
16]. One of the main advantages of this technique is that there are lower rates of implant displacement and animation deformity compared to submuscular or dual plane approaches [
17].
In the dual plane approach, the breast implant is partially placed under the pectoralis major muscle. In this case, the abdominal insertion of the pectoralis major muscle is dissected along the inframammary fold, preserving the sternal insertion, and the implant is placed underneath the muscle without closing the muscle and suturing it back to its abdominal insertion. Three types of dual plane are commonly described: In type I dual plane, no additional subglandular dissection is performed. In type II dual plane, the mammary gland is dissected and detached from the pectoralis major muscle up to the lower border of the areola. Finally, in type III dual plane, the subglandular dissection reaches the upper border of the areola. The dual plane technique is claimed to provide a more natural result, especially in skinny patients, in whom the upper pole fullness is missing [
8]. Moreover, the technique is claimed to reduce capsular contracture and hematoma compared to the subglandular implant placement [
17,
18,
19].
In the modified dual plane, as described in the Materials and Methods section, the caudal part of the sternal insertion of the pectoralis major muscle is released and a triangular incision is performed at the abdominal insertion [
9].
In this study, we found a higher complication rate (p = 0.01) in group I with the subglandular implant placement (63.2%), followed by group II with the dual plane technique (46.9%); the lowest complication rate was registered in group III with the modified dual plane approach (22.7%). Wound dehiscence was the most common complication affecting 42.1% of the patients in group I, 15.6% in group II, and 11.4% in group III. Infection occurred in 26.3% of the patients in group I, 9.4% in group II, and 4.5% in group III. There was a numerically higher wound dehiscence and infection rate in group I.
Moreover, in the group with modified dual plane, we noticed that it not only had the lowest complication rate, but bigger implants were used (367.7 ± 68.4 cc) compared to groups I and II (326.6 ± 92.8 cc and 314.1 ± 61.2 cc respectively) with the subglandular and dual plane approaches. In this regard, some authors recommend smaller implants for lower complication rates [
20,
21], but other studies did not find a correlation between the size of the implant and the complication rate [
22,
23,
24].
Finally, the modified dual plane technique was the fastest surgical approach with a mean intraoperative time of 01:54 ± 00:57 h compared to subglandular and dual plane surgery (02:33 ± 00:59 h and 02:08 ± 00:55 h respectively). Reduced intraoperative time is positively correlated with a better patient outcome [
25,
26] and is a cost-saving factor.
In a review of 615 consecutive patients who underwent single-stage mastopexy-augmentation between 1992 and 2011, Stevens et al. concluded that combined surgery can be safe and effective with appropriate patient selection and experienced surgeons. He reported a revision rate of 16.9% with poor scarring (5.7%), wound-healing problems (2.9%), and deflation of saline implants (2.4%) being the most common complications [
2]. Accordingly, Qureshi et al. recommended mastopexy-augmentation as a safe option for correction of shape and volume [
5]. A review by Khavanin et al. including 23 studies and 4856 cases reported a pooled total complication rate of 13.1%; recurrent ptosis was the most common complication (5.2%), followed by poor scarring (3.7%). Infection, hematoma, and seroma had incidences of less than 2% each. The revision rate was 10.7% [
27]. In a study of 384 patients, Cárdenas-Camarena et al. reported a complication rate of 18%, and appropriate patient and technique selection were emphasized [
28]. Swanson reported a complication rate of 32.9% for vertical augmentation-mastopexy with a revision rate of 15.5%. Complications included persistent ptosis, delayed wound healing, scar deformities, and asymmetry. In this survey, 13.3% of the patients had persistent nipple numbness. Of the 252 analyzed patients, 90 participated in a survey and 94.4% reported that they would repeat surgery. In conclusion, the author confirmed the safety and applicability of this technique [
29]. In summary, variable complication rates are reported in the literature, but all the authors consider mastopexy-augmentation a safe procedure.
With regard to the outcome of revisions in mastopexy-augmentation, Spear et al. published a study of 20 patients who underwent revision surgery. Of the 34 operated breasts, ten implants were originally subglandular and 24 partially or totally submuscular. Capsular contracture in 11 patients (55%), nipple ptosis in 11 (55%), implant malposition in seven (35%), dissatisfaction with implant size in six (30%), poor scarring in five (25%), breast ptosis in 4 (20%), nipple malposition in two (10%), and patient preference in one (5%) were reasons for revision. Five of the 20 patients (25%) had a revision of a previous revision [
19]. In our study, similarly high complication rates were found. However, when comparing the complication rates of different studies, consideration of the definition of complications, inclusion of long-term complications, inclusion of massive weight loss patients, smoking status, etc. is of utmost importance. Moreover, as most patients were operated upon by the senior author and developer of the modified dual plane technique, fewer complication rates and better outcomes were expected with this technique compared to the others.
A particular patient group to consider in mastopexy-augmentation is the massive weight loss patient population. In this regard, Coombs et al. reported an implant malposition rate of 61.9% within 12 months postoperatively and a revision rate of 6.6%. Implant malposition correlated significantly to higher current body mass index but not to implant size, according to this study [
30].
With regard to the limitations of our study, the patients in group I had a significantly higher BMI and weight compared to those in group II and group III. It is known that elevated BMI and body weight represent risk factors for higher complication rates in surgery in general [
31,
32,
33,
34] and especially in breast reconstruction [
34]. Hence, this may contribute to the higher number of complications we encountered in group I. The effect of overweight and obesity on postoperative complications has been widely studied in the past few decades. In fact, it has been shown that obese patients have a reduced adipose tissue blood flow [
35,
36,
37] leading to chronic hypoxia of tissue and thus to tissue dysfunction and inflammation [
38,
39,
40]. These studies report that oxygen supply is reduced in subcutaneous fat, probably causing delays in wound healing and increased infection risk after surgery. Moreover, obese and especially post-bariatric patients additionally tend to be malnourished [
41,
42]. Deficiencies in proteins and micronutrients such as vitamins and minerals contribute to impaired wound healing, as adequate collagen synthesis and granulation tissue formation are not supported [
43,
44]. Generally, simultaneous mastopexy-augmentations are common in post-bariatric patients, and for the aforementioned reasons patients have a higher risk for complications compared to healthy individuals. Thus, a high complication rate in surgical post-bariatric ptotic breast reconstruction is expected. In our study, we did not take into account whether a patient was post-bariatric or not, so this is surely an important limitation. However, in our study there were few post-bariatric patients, and most of the patients were of normal BMI and weight or slightly overweight (23.0 ± 3.0 kg/m
2 and 64.3 ± 9.4 kg in group II, 23.5 ± 1.9 kg/m
2 and 64.5 ± 5.5 kg in group III, 26.2 ± 4.2 kg/m
2 and 72.2 ± 11.8 kg in group I).
Not including active smokers is another important limitation to the study, as this may have influenced the complications and outcomes substantially. However, patients who quit smoking only 3 weeks before surgery were considered non-smokers, and it was not recorded whether and when they started smoking again. Moreover, 57 (60%) of the patients had an unknown history of risk factors, which is a major limitation to the study.
Another limitation of the study was that we did not include subfascial and submuscular implant placement as a surgical technique, so we cannot exclude that those techniques may have lower complication rates compared to the modified dual plane technique. However, recent studies suggest a significantly increased risk of rupture when performing a totally submuscular plane approach [
45]. In our study, we observed one rupture in the dual plane group (group II). Further limitations are the retrospective character of the study and the small patient number per study group. This substantially limited the comparison between groups. With only 19 patients in group I, we had a small patient cohort for the subglandular plane, and future studies with larger patient cohorts are required for the comparison and validation of a new technique. Moreover, we did not adjust for multiple testing. As a final limitation, the incisional approach (periareolar, circumvertical, and inverted T) was not evaluated separately for complications, but it is known that wound healing problems are especially encountered where incisions collide (which is the case with inverted T incision) as the wound edges are poorly vascularized [
46].
The high complication rate in the subglandular approach may be explained by the unpredictable change in soft tissue when simultaneous mastopexy occurs. If the implant is placed in a submuscular or partially submuscular plane, it has better stability, and changes in the soft tissue above do not influence the implant; thus, deformities and wound dehiscence are prevented. In summary, in this study, a high complication rate was observed compared to other studies in the literature with regard to the subglandular and dual plane approaches. However, complications also depend on the surgeons’ experience with and adherence to the particular technique. The modified dual plane approach had a comparable outcome to other studies that approve single-stage mastopexy-augmentation as a safe and applicable technique. This means that our newly proposed modified dual plane technique is a valid option for patients who desire breast lift and increase in volume.