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2014; Lippincott Williams & Wilkins; Volume: 133; Issue: 2 Linguagem: Inglês

10.1097/01.prs.0000437252.47833.de

1529-4242

Raffi Gürünlüoğlu,

Body Image and Dysmorphia Studies

Sir: I appreciate Dr. Swanson’s time in writing a commentary on our article.1 I am happy to address his criticisms in this communication. I began performing the autoaugmentation technique after breast implant removal approximately 6 years ago, long before it was reported for the first time in the literature.2 In the early years of the evolution of this technique, I was skeptical regarding the outcomes. I performed a very close follow-up of patients undergoing this procedure. At that time, the BREAST-Q had not yet been developed. Therefore, I used a five-point standard scale to help understand the overall patient satisfaction regarding breast morphology and size. A high level of satisfaction in these few pilot patients encouraged me to pursue this approach in others with similar clinical scenarios over the past 6 years. With the introduction of the BREAST-Q3 in 2009, we also incorporated this questionnaire as part of the preoperative evaluation of patients. Therefore, preoperative BREAST-Q data were immediately available for analysis. However, we were able to include only the 20 patients between the fourth quarter of 2009 and the end of 2011. The 100 percent survey completion rate can simply be explained by our commitment to close postoperative follow-up and willingness to assess patient-reported outcomes in this small cohort. The BREAST-Q has also been validated in independent clinical samples by its originators.4 Using the BREAST-Q reduction/mastopexy module, we quantified satisfaction with breast size/shape; feel to touch; and one’s appearance clothed, unclothed, and in a bra. Therefore, improvement in breast scores cannot be attributed simply to successful treatment of the complications. Neither can the improvement be singularly attributed to use of the inferior dermaglandular flap. We also used the concept of vertical mammaplasty and mastopexy. Investigation of outcomes using different techniques—explantation alone or explantation and mastopexy without the use of an inferior dermaglandular pedicle following breast implant removal—would be the subject of another study. We specifically aimed to investigate patients’ perceptions of their outcomes after remodeling in the breast, not the effects created separately by each component. Marked improvement of breast, psychosocial, and sexual functioning scores on group and individual level responses assists in validating the efficacy of the technique and provides worthwhile information, as it relates to a number of patients seeking implant removal because of various factors. I appreciate Dr. Swanson’s drawing on lateral photographs of case 1. First, there was displacement superiorly of the implant secondary to severe capsular contracture. Second, the presence of concomitant hematoma resulted in a marked increase in the volume of the left breast. Dr. Swanson did not take these variables into account, which resulted in his inaccurate interpretation of superior pole fullness. Also, Dr. Swanson not only introduced bias when placing the vertical line far anteriorly in the postoperative photograph, but also compared two photographs that were not standardized, which skewed his calculations. Risk of bias and variability in posture and positioning of patients cannot be totally eliminated in this type of evaluation.5 I included the right-side lateral photographs for a fair comparison (Fig. 1). Measurements of breast parameters are valuable, but they do not necessarily correlate with patient satisfaction, which was the main objective for why we analyzed the data by patient-reported outcomes.Fig. 1: (Left) Preoperative and (right) postoperative right-side views of the patient in case 1.I agree with Dr. Swanson’s comments on the absence of a net increase in breast volume. However, our study does not claim that there was. By transposing existing breast tissue in the lower pole, some portion of the volume loss secondary to implant removal was replaced. In the majority of patients, there was size reduction as expected. Removal of relatively smaller implants in large breasts may explain why a net decrease was not significant enough to result in a change of brassiere size in the few patients. In nearly all cases, we found the inferior parenchymal pedicle almost already dissected because of previous implantation. In most cases of subglandular implants, the pocket also extended up to underneath the superior pedicle. We simply separated the inferior parenchymal pedicle from the superior pedicle carrying the nipple-areola complex. No more damage to sensory innervation of the nipple-areola complex than usual using superior or superomedial pedicle mastopexy with vertical mammaplasty was created. When I use this technique, I simply tack the flap into position on top of the pectoralis major muscle, similar to that also proposed by Dr. Hammond.1,6 A sling of pectoralis major muscle can be used to assist in securing the flap superiorly.7 However, the need for this approach can certainly be debated. Total or nearly total capsulectomy, quilting sutures, and drains assist in tissue adherence. The size of the thoracic flap (approximately 100- to 200-g implant) described by Graf et al.7 was smaller than the inferior parenchymal flap that we used. It is possible that breast characteristics in our cohort were different. However, more importantly, this was related to the extension of incisions medially and laterally in our technique to increase the size of the flap (average, 225 cm3). In the presence of a previous inframammary scar, the extended base also contributed to the blood supply of the flap. The use of a somewhat limited or “short” inverted-T skin pattern, however, did not negate our ability to use the principles of vertical mammaplasty. The described technique is not a substitute for breast implants. It does not claim that outcomes would be far superior than implant exchange procedures with regard to superior pole fullness and breast size. In our cohort, most patients had their implants placed during the early adulthood period. It is likely that most patients experienced breast enlargement and ptosis over time following pregnancies and weight gain during middle age. These possible changes enabled us to take advantage of the enlarged soft-tissue envelope and ptotic lower pole for optimal remodeling. Patients with asthenic body configuration who have large implants and thin breast tissue and skin overlying the implant, particularly in the lower pole, and also those who have a relatively short distance between the areola and inframammary fold, will not be good candidates for the described technique. Breast implants are unfortunately not lifetime devices.8 Refusal of implant replacement by patients facing significant and recurrent complications over many years should be considered as a strong indication for explantation.9 Nevertheless, standard surgical options, alternatives, and the potential risk of reduction in superior pole fullness and breast size were discussed with all patients on two separate occasions before their informed decisions. Most patients undergoing this procedure had Medicaid or private payer insurance. In a few patients, authorization for explantation and the use of a dermaglandular flap plus mastopexy or implant exchange was granted to cover each procedure. In most patients, insurance approval was granted only for “medically necessary” capsulectomy and explantation, and the use of the dermaglandular flap or augmentation with breast implants was equally considered “cosmetic” and not medically necessary. Therefore, motivation to undergo such a procedure was based mainly on patient preference. DISCLOSURE The author declares that he does not have a financial interest in any of the products or devices mentioned in this Reply or the communication being discussed. Raffi Gurunluoglu, M.D., Ph.D. Plastic and Reconstructive Surgery Denver Health Medical Center University of Colorado Health Sciences Center 777 Bannock Street Denver, Colo. 80204 [email protected]