Materials
and Methods
Patient
Selection
Several categories of breast shapes may benefit from this technique:
1. Ptotic
breasts with well-formed breasts or even atrophic breasts
2. Highly formed, firm, and glandular breasts
3. Cone-shaped breasts with small bases
4. Mild to moderate cases of tubular breasts
5. Double-bubble (waterfall deformity) in class III to IV firm breasts
Technique
After the decision to use the radial cut incisions in the treatment of
the aforementioned deformities, a submammary pocket is created under general
endotracheal anesthesia. Radial cuts are made behind the breast tissue.
The breast tissue is then spread in different directions (Fig 1). The
openings created by this technique are made with relative uniformity,
so that the expansion of the breast tissue will be symmetrical. Usually,
three radial cuts are made, producing a six-prong star (Fig 2). Then,
with blunt dissection or, if necessary, with the aid of a sound or other
blunt instrument, these cuts are deepened as needed to accommodate the
implant. Care should be taken to carry these cuts far enough peripherally
to open and expand the small base of the breast and expand the base of
the postoperative breast (Fig 3).
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Fig
1. Posterior views showing radial incisions. (A) Before incisions
are spread and widened. (B) After widening of incisions and expansion
of the base.
|
 |
Fig
2. Lateral view of the breasts with implants showing the location
of the radial incisions and their relationship to the implant.
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 |
F(f5
3. Lateral view showing how the radial incisions help to redistribute
and change the center of gravity, resulting in (1 nice unity of
breast tissue and the implant (A) Implant without radial incision.
(B) Implant with radial incision.
|
After the
implant is placed and the opening is considered satisfactory, the operation
is terminated by regular repair of the skin. If any residual deformity
is present, this resistance is resolved by dissection at the proper site.
The old crease of the breast is usually the most resistant part of this
procedure. Cuts made vertically along the crease usually provide a satisfactory
result. That is, if the crease is from medial to lateral, the cuts will
be superior/inferior in direction. In some cases in which this technique
is used but the correction is not adequate, the most resistant areas (usually
the dense glandular tissue) are excised. This is especially necessary
for advanced cases of tubular breasts and extremely glandular breasts.
| Classification
of Double-bubble Deformities |
|
| Type |
Implant Location |
Result |
|
| I |
High
or correct |
Breast
tissue hangs over implant ("waterfall" over a rock) |
| II |
Low
or correct |
Breast
tissue sits separately and superior |
|
Results
I have tried
this technique with a diverse group of patients of different age groups
for a variety of deformities. With proper patient selection and technical
management, generally satisfactory results have been achieved.
Discussion
Visual separation
of the breast tissue from the implant is a notable deformity of the postaugmented
breast. This deformity may even be seen in the case of regularly augmented
breasts with initially good results. After the breasts become firm, the
breast tissue hangs loosely over the firmly attached implant, creating
a double-bubble, or as I have named it, a "waterfall deformity." This
technique is especially useful in the treatment of this secondary breast
deformity. After the implant is removed and the new implant is ready for
insertion, radial cuts are made in the breast tissue so that the breasts
can drape nicely over the implant. This can be likened to a cap being
fitted properly to a person's head. In a secondary deformity of the breast,
in which capsular contracture is encountered, special attention must be
paid to the surrounding tissue, which will be firm and scarred, even after
removal of the capsule. In general we have seen two kinds of double-bubble
deformities (Table): The type I implant is at an anatomically proper level
or is too high, but loose breast tissue hangs over the implant (Fig 4).
 |
| Fig
4. An example of a type I deformity with breast tissue sliding down
over the implant. |
The type
II implant is either in its proper location or is too low, with breast
tissue sitting above it and high (Fig 5A). The type II deformity is usually
the result of trying to lower the summary crease to lift the postimplanted
breast without using the recommended radial cuts. In treatment of type
II deformities, in addition to opening the breast tissue with radial cuts,
reconstruction of a new sub mammary crease, usually to its original location,
may be necessary (Fig 5B).
 |
Fig
5. (A) Preoperative view of a type II deformity. (B) Postoperative
view. Correction with radial incision and reconstruction of a new
submammary crease in a higher position.
|
 |
Fig
6. (A) Preoperative view of a ptotic breast with a narrow base.
(B) Postoperative view. Implantation with radial incisions and a
lowering of the submammary crease.
|
Conclusion
In summary,
radial cuts at the undersurface of the breast with opening of the breast
tissue have proved very useful in breast implantations in patients with
ptotic breasts, breasts with a small base, mild to moderate cases of tubular
breasts, or in primary cases of augmentation mammaplasty (Fig 6). This
technique is also extremely useful in surgical treatment of secondary
deformities of the postaugmented breasts.
Presented
at the Southern Society of Plastic and Reconstructive Surgeons, Boca Raton,
Florida, June 5-9, 1999.
Open Discussion
Samuel
w. Parry, MD (New Orleans, LA): Hamid, in your abstract I believe
there is one sentence (I don't see it right now) where I believe you said
you sometimes remove some breast tissue? This seems counterintuitive to
what you are trying to accomplish.
Dr Massiha: Yes. In the severe tubular and cylindrical breast,
removing the posterior part of 146 the breast helps to open up the tissue
and decreases the anteroposterior dimension of the breast in which it
is coming straight out of the body. So by decreasing that length, the
cylinder is shortened and is opened. By adding the radial cuts to it,
you get the desired cone shape to the breast.
Sherry S. Collawn, MD (Birmingham, AL): In your patient with the
double-bubble, how did you recreate your inframammary fold?
Dr Massiha: For the lower pole, I just use the original incision
and remove the implant. I had marked where I wanted the new fold in the
sitting position beforehand. I put 2-0 nylon sutures in the same spot
to get the line. Then I put the old implant in, inflate it, and sit the
patient up to see if I like it. Then I go ahead and insert the new implant
and finish it. If I don't like it, I may change my sutures. I'd like to
make one comment about breasts that have a very strong submammary crease
that needs to be lowered. You have to make small cuts in the fibrous band
that is normally there. With finger pressure it cannot be done, but
with small cuts it helps a lot to erase the old crease and create a new
fold.
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