Reoperative transaxillary breast surgery: using the axillary incision to treat augmentation-related complications

Reoperative Transaxillary Subfascial Breast Augmentation and Fat Grafting: Technical Highlights and a Step-by-Step Video Guide

SUMMARY

Reoperative procedures after breast augmentation are frequently more complex than primary cases because of local complications and insufficient soft-tissue coverage. Although the transaxillary incision is often indicated in primary breast augmentation, limitations of this approach include secondary surgery and correcting complications after using this approach via the same incision. Combining the transaxillary technique with a subfascial pocket has been suggested to avoid breast scarring and the limitations of submuscular pockets represented by breast animation. With advances in autogenous fat grafting (AFG) techniques, implant coverage alternatives and more natural outcomes have been reported from more superficial implant pockets. Simultaneous AFG with silicone implants (defined as hybrid breast augmentation) has been evaluated recently as an attractive procedure. These two techniques combine to provide breast projection and natural cleavage while camouflaging implant edges. AFG is also important to reduce the intermammary distance and achieve a smoother transition between the breasts. The transaxillary approach can be useful in reoperative breast augmentation and avoids additional scarring on the breast. This article and the accompanying videos provide a detailed, step-by-step guide to reoperative hybrid breast augmentation using a subfascial transaxillary approach, with a predictable and optimized surgical outcome.

Reoperative Transaxillary Approach Algorithm: Extending the Surgical Alternatives for Secondary Breast Augmentation in the Era of Scarless Surgery

BACKGROUND

Although the transaxillary approach (TAA) is useful in primary breast augmentation (BA) surgery, drawbacks of this technique include the need to correct complications arising from reuse of the axillary incision.

OBJECTIVES

The purpose of this study was to assess the outcomes of secondary BA procedures performed via the TAA in a cohort of patients operated on by a single surgeon and to provide an algorithm for reoperative TAA technique selection.

METHODS

Sixty-two patients (122 breasts) underwent secondary TAA BA, which was indicated for capsular contracture (CC) in 35 patients (56.4%). Periods for analysis included less than 10 days, 1, 3, 6, and 12 months, and then at 2-year intervals postprocedure.

RESULTS

Forty-three patients (69.3%) had a previous premuscular (PM) pocket; in 35 (81.3%) of these patients the new pocket was kept in the same position. Nineteen patients (30.7%) had a previous submuscular pocket, and 15 patients (78.9%) had the new pocket transferred to the PM plane. Ten cases of complications were observed in 8 patients (16.1%), Baker grade II/III CC in 3 (4.8%), and axillary banding in 2 (3.2%), during a mean follow-up of 72 months (range, 6-170 months). Fifty-nine patients (95.1%) were either very satisfied or satisfied with their aesthetic result.

CONCLUSIONS

Recent progress in surgical techniques has led to significant improvements in aesthetic outcomes following BA. The TAA can play a useful role in secondary BA cases and our results show this procedure to be useful, with acceptable complication rates, and the added bonus of avoiding additional scarring on the breast.

LEVEL OF EVIDENCE: 4

Contralateral Augmentation with a Transmidline Scarless Technique During Unilateral Breast Reconstruction Using Implants

BACKGROUND

Unilateral breast reconstruction can be a challenge when attempting to achieve an aesthetically pleasing and symmetrical breast mound on the contralateral side. This study investigates the outcomes of using a contralateral augmentation transmidline scarless (CATS) technique to simultaneously augment the contralateral breast using implants.

METHODS

Between January 2004 and July 2016, patients undergoing unilateral implant-based breast reconstruction and simultaneous contralateral implant augmentation using a transmidline access were studied. Characteristics and complications using this technique were assessed.

RESULTS

Sixty-five (91.5%) of 71 patients used the CATS technique for unilateral breast reconstruction using implants with contralateral breast implant augmentation. The remaining 6 cases used a preexisting chest scar. In the assessment of complication rates between the reconstructed and augmented sides, the reconstructed side had a statistically significant higher rate of implant exposure (P = 0.04) and total complications (P = 0.02). In comparing the revision rates between these 2 groups, the need for implant change (P = 0.04) and the total revision rates (P = 0.01) were higher in the reconstructive side. Use of saline implants had a higher rate of chest wall and breast skin necrosis (P = 0.03) in comparison with silicone implants. There was not a statistically significant difference in complications when comparing timing of reconstructions (immediate versus delayed).

CONCLUSIONS

The CATS technique can be performed safely, with a desirable aesthetic outcome, and also symmetry with minimal risk of symmastia during unilateral breast reconstruction using implant-based reconstruction.

Use of selective serotonin reuptake inhibitors antidepressants and bleeding risk in breast cosmetic surgery

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressant prescribed currently. Data regarding SSRI use among plastic surgery patients may differ between different populations, but the incidence could be as high as 10 %. It is known that SSRIs decrease platelet serotonin storage and platelet function, and their association with postsurgical bleeding in mastectomy patients and orthopedic surgery patients is well established. An increased risk of postsurgical bleeding among plastic surgery patients may have important clinical implications, but this has not been evaluated to date. The authors therefore conducted a hospital-based study with prospectively collected data to examine the association between the use of SSRIs and postsurgical bleeding. To the authors' knowledge, this is the first study to evaluate the effects of SSRIs on bleeding risk in the breast cosmetic surgery population.

METHODS

All patients who underwent breast cosmetic plastic surgery procedures (breast augmentation, breast reduction, or mastopexy) at our institution between January of 2001 and December of 2011 were reviewed. The patients were divided into two groups by SSRI use history: a no-use group and an active-use group. The primary end point for a bleeding event was the need for intervention. Patients were further subcategorized by type of breast surgery performed, body mass index, and age. Descriptive statistics tabulated the frequency of a bleeding event within the groups. Logistic regression was applied to evaluate the risk of a bleeding event according to the use of SSRIs. The odds ratios (ORs) with their 95 % confidence intervals (CIs) associating SSRI use with postoperative bleeding were computed.

RESULTS

During the study period, 2,285 patients had breast cosmetic surgery, and 33 of these patients (1.44 %) experienced a bleeding event (hematoma requiring surgical draining). Of the 196 patients (8.58 %) in the active-use group, 9 (4.59 %) experienced a bleeding event. Of the 2,089 patients in the no-use group, 24 (1.15 %) presented with bleeding. The patients using SSRIs had a 4.14-fold greater risk of breast hematoma needing intervention than the patients who were not users (OR, 4; 95 % CI, 1.90-9.04). Logistic regression also showed that bleeding events were more common among the SSRI users regardless of the type of procedure performed, the body mass index, or the age group.

CONCLUSIONS

Use of SSRIs is associated with a fourfold increased risk of bleeding after breast cosmetic surgery (from 1.44 to 4.59 %). The decision of psychologically vulnerable patients to stop SSRIs before surgery should not be made without a complete discussion of the risks and benefits.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Striae distensae after breast augmentation

BACKGROUND

One known but not fully understood complication after breast augmentation is the new onset of stretch marks (striae distensae) on the surgically treated breast. To date, all publications on this subject have been case reports. No report has fully described the actual incidence, risk factors, or management of striae distensae after breast surgery.

METHODS

This study prospectively followed patients who underwent primary breast augmentation using silicone implants in a single group practice from 2007 to 2011. New-onset striae distensae were actively investigated. Time from surgery to the moment of striae onset, patient age, nulliparity, use of oral contraceptives, overweight, personal history of stretch marks, and other variables were evaluated.

RESULTS

A total of 409 patients were included in the study. In 19 cases (4.6%), new-onset striae distensae after breast augmentation were observed. The population with striae distensae was significantly younger than the total population (29.56 vs 20.91 years; p=0.012). Striae distensae also were more common in nulliparous than in multiparous women (8.29 vs 0.52%; p=0.006), overweight women (17.77 vs 3.02%; p=0.016), women using oral contraceptives (7.89 vs 0.55%; p=0.008), and women with a personal history of stretch marks (8.97 vs 3.36%; p=0.031). No relation was shown regarding implant pocket type, size, or profile.

CONCLUSION

Striae distensae may be a common but underreported complication after breast augmentation. In this series, striae distensae developed in 4.6% of the patients within 1 year after breast augmentation. Severity may vary from inconspicuous small marks (classifications 1 and 2) to wide red and active striae rubra (classifications 3 and 4). Nulliparity, use of oral contraceptives, overweight, personal history of stretch marks, and younger age were related to a higher incidence of striae distensae. The increased rates in these groups may be associated with their exposure to higher estrogen levels and the important role of this hormone in facilitating the formation of striae distensae. Further studies are needed to show whether changes in these risk factors (i.e., weight loss, contraceptive withdrawal) may help to decrease striae distensae rates is these populations.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.