Introduction

Breast augmentation is one of the most common aesthetic procedures performed today. The operation has a low complication rate when compared with simultaneous mastopexy and augmentation. The latter not only results in obvious breast scarring but also carries a high morbidity with a high revision rate. Excellent outcome is uncommon and only a minority of patients are able to achieve such results [1]. Conventional mastopexy is commonly performed using the Wise pattern [2], vertical [3] or periareolar scarring [4, 5]. Augmentation mammoplasty in patients with early ptosis can be challenging and may achieve less than desirable results. Quite often, patients are not keen to accept conventional scarring since it can be associated with high surgical morbidity and a high revision rate. The muscle splitting submuscular technique has produced acceptable results [6] in patients with early ptosis. In this procedure, the effect is partly contributed by gapping of the split muscle which results in an en bloc internal lift of the breast parenchyma attached to the upper pectoralis [7]. Augmentation in submuscular plane using the muscle splitting biplane technique [6] is combined with the available prepectoral space for skin envelope rearrangement. The procedure involves internal glandulopexy and is resigned to reposition the breast envelope over pectoralis at a higher level, creating a better nipple areolar and inframammary crease (IMC) relationship as defined by Regnault [8]. In these selected cases of early ptosis, patients can have an option of augmentation with internal glandulopexy avoiding the conventional mastopexy scarring. The technique can also be used unilaterally for the correction of minor nipple areolar position asymmetry in the vertical axis. The philosophy of simultaneous use of submuscular augmentation using expander mammary prosthesis and subglandular dissection for envelope repositioning for the correction of ptosis has been used in the past. The breast parenchyma, in those cases, was mobilised from the pectoralis and supported externally for ptosis correction. Limited nipple areolar repositioning using either a periareolar or a short vertical scar remained a possible option and was a part of the primary planning [9].

Patients and methods

Between June 2005 and October 2008, 44 patients had a multiplane procedure for simultaneous submuscular augmentation with internal glandulopexy. These patients presented with a minor degree of ptosis and were not keen on conventional external envelope scarring.

Patient selection

The IMC is used as the guideline and in selected patients with early ptosis and nipple not lower than 1.5 cm from IMC, the multiplane procedure was performed. A nipple areolar complex (NAC) lower than 1.5 cm from IMC, or patients with excess skin envelope in horizontal axis, are not considered suitable for a multiplane procedure. When performed unilaterally, patients with a vertical nipple areolar asymmetry of less than 1.5 cm can also benefit from this procedure. High-profile, soft cohesive gel textured silicone implants were used in all but one case. This allows the breast envelope to drape better over the round implant and compliment the technique.

The procedure was performed in 44 consecutively selected patients (12 unilateral glandulopexy for improvement of nipple level asymmetry not exceeding 1.5 cm and 32 bilateral for bilateral ptosis in which nipple level was not lower than 1.5 cm below the IMC). Average age of patients was 33.5 years (range 19–50). All but one patient had round, high profile cohesive gel silicone implants with an average size of 354 cm3 (range 260–440) in bilateral and 350 cm3 (range 300–440) in unilateral procedures respectively. The average preoperative suprasternal notch to NAC measurement in unilateral (n = 12) and bilateral (n = 32) procedures was 22.2 (range 19–24) and 23.2 (range 20–26) cm respectively (Table 1). The average preoperative NAC distance to IMC distance in bilateral and unilateral cases was 8.03 cm (range 6–12) and 7.2 cm (range 4–9) respectively (Table 2).

Table 1 Preoperative and postoperative nipple areolar complex measurements in subglandular, partial submuscular, unilateral and bilateral multiplane planes
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Table 2 Preoperative and postoperative nipple areolar complex to inframammary crease measurements in submuscular, subglandular and multiplane procedure either in unilateral or bilateral procedure
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Operative technique

The procedure is performed under general anaesthesia in the supine position with full muscle relaxation. The arms are abducted and supported at an angle less than 90° to minimise brachial plexus stretch. Lignocaine 1% with adrenaline (1:200,000) is used along the incision lines (IMC). The incision is placed in the IMC starting 6 to 7 cm from the midsternal line and is usually 4.5 to 5 cm in length that extends laterally into the submammary crease. In the submuscular biplane technique, the subglandular pocket extends between the lower border of the areola and the existing IMC vertically, and from the junction of middle and lower third of the sternum to the anterior axillary fold in the horizontal plane respectively (Fig. 1). Once subglandular dissection is completed, the breast parenchyma on its posterior aspect is marked, using 2–0 silk stitches, 2–3 cm below the muscle parenchymal junction.

Fig. 1
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Anterior view of an illustration showing extent of subglandular and submuscular pocket, in a muscle splitting biplane

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The submuscular pocket is reached medially at a level corresponding to the junction of middle and lower third of sternum, the muscle fibres are separated using the tip of long forceps or split using electrocautery. The index finger is inserted through the gap and the preoperatively marked pocket is dissected. A light retractor is passed through the gap and pectoralis is split, up and laterally to the anterior axillary fold using an electrocautery. Splitting needs to be slowed down and is combined with coagulation in the lateral part of pectoralis to avoid bleeding. Adequacy of the pocket is checked using the ballooning maneuver [10]. Once adequate muscle split is complete, further subglandular dissection begins anterior to the superior split muscle and continues up to 4 or 5 cm above the upper split pectoralis. This dissection allows breast envelope to be mobilised over upper split pectoralis (Fig. 2a). Hemostasis is achieved and the breast envelope is mobilised and draped by lifting the breast parenchyma from its marked points (silk stitches). It is then anchored and stitched to the lower border of the upper split pectoralis (Fig. 2a–b). The author initially used 3–0 vicryl absorbable sutures and in later cases replaced it with 2–0 vicryl continuous and 2–0 ethilon interrupted sutures to anchor the mobilised skin envelope. These stitches are help to stabilise the mobilised envelope in its new position and once implant is inserted, the two raw surfaces created on the anterior aspect of the pectoralis and posterior surface of the breast gland are splinted by the round high profile cohesive gel silicone implant internally and the compressive dressings and support garments externally.

Fig. 2
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a Side view of a dissected multiplane in simultaneous subglandular and submuscular pockets through an inframammary approach. Lifting and draping of mobilised parenchyma at a higher position in subglandular plane. b Implant placed in submuscular pocket

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The implants are inserted into the muscle splitting submuscular position (Fig. 2c) and wound closure is performed in three layers using 3–0 continuous and 4–0 interrupted vicryl stitches. Compressive external dressings and a support brassiere are applied before transferring the patient to the recovery room. This procedure is performed as a day case without drainage. A support brassiere is worn for 4–6 weeks and routine activities can be resumed after 2 weeks; exercise and heavy work can be delayed for up to 4 weeks. In the early recovery period, the upper breast may appear fuller and this can take 3 to 4 weeks to settle down.

Results

Postoperative supra-sternal notch to NAC distance, 22.0 cm (range 19.5–23) in unilateral (n = 12) and 22.4 cm (range 20–26) in bilateral cases (n = 32) respectively, showed a reduction in the suprasternal notch to NAC distance when compared with preoperative measurements (Table 1). Postoperative NAC to inframammary complex distance in bilateral and unilateral breasts was 9.3 cm (range 7–11) and 9.1 cm (range 7–10) respectively (Table 2). Preoperative and postoperative photographic clinical results were aesthetically acceptable when compared with the average standard augmentation mammoplasty result (Figs. 3 and 4). The results also were acceptable when a unilateral procedure was performed for the improvement of the NAC vertical level asymmetry. In these cases the contralateral breast is used as a control to compare with unilateral simultaneous a submuscular augmentation with the subglandular internal glandulopexy through an inframammary incision (Fig. 5a–d). One patient had a unilateral periprosthetic infection which was treated with antibiotics and passive discharge; this healed by secondary intention. Of the 12 unilateral and 32 bilateral procedures, nipple sensation was recorded in eight unilateral and 28 bilateral cases. Only one patient with a bilateral procedure reported a bilateral loss of nipple sensation; this returned after 6 to 8 weeks. Two patients showed residual ptosis following the extended biplane technique and only one requested revision; a bilateral vertical scar mastopexy was performed.

Fig. 3
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a–b Preoperative views of ptotic breasts in a mother after three pregnancies and weight loss. c–d Postoperative views after 1 year with 300 cm3 high profile cohesive gel silicone implants in multiplane pocket

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Fig. 4
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a–b Preoperative views of a 47-year-old patient with noticeable ptosis. c–d Postoperative views after 1 year with 350 cm3 high profile cohesive gel silicone multiplane pocket

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Fig. 5
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a–b Preoperative views of a 21-year-old patient with left grade A ptosis and nipple areolar complex 0.5 cm lower than the right. c–d One year postoperative results after augmentation mammoplasty with 400 cm3 round high profile cohesive gel silicone implants. Left unilateral multiplane approach was used to improve vertical nipple areolar complex asymmetry with acceptable improvement

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Discussion

The report of breast enlargement using a silicone breast implant was first published in 1964 [11]; however, description of augmentation mastopexy goes back to 1960 by Gonzales-Ulloa [12] and was soon followed by Regnault [13]. Augmentation can be achieved by placing an implant in one of the described planes; on the other hand, mastopexy requires skin reduction using one of the conventional external designs. Both of these procedures, when performed separately, carries limited surgical morbidity. However, when two procedures (simultaneous augmentation with mastopexy) are combined, it assumes a new dimension. The two procedures have diagonally opposite vectors acting in opposite directions and is the reason for its increased complication rate [7]. The complications may include partial or complete NAC viability, nipple sensory disturbances and its positioning. Breast envelope, wound and scar related complications are also seen in a higher proportion. Similarly implant interrelationship with the NAC and breast envelope can be less than adequate [14]. High revision rates in patients with simultaneous breast augmentation with mastopexy are common and make it a likely event [15] and surgeons have been warned to beware of the procedure [16]. On the other hand, revision rate of 16.7% with a 3.5-year follow-up in primary augmentation mastopexy was considered satisfactory when compared with 20% after 5 years follow-up of primary saline filled augmentation mammoplasties [17]. Skin envelope expansion with internal [18] or external [19] injection domes has been used to allow intermittent and gradual envelope expansion of adjustable implants to avoid a tight skin envelope or NAC vascular compromise. Apart from some minor routine complications, the procedure-related outcome in the current series has shown two inadequate results with failure of the intent. The low incidence of poor results in the current series is due to an adequate informed consent and adherence to the selection criteria; however, a long-term follow-up is essential to assess the longevity of the results.

With an NAC less than 1.5 cm lower than the IMC, the multiplane procedure gives minimal and inconspicuous scarring with a low complication rate. It also has a potential of achieving better results than augmentation alone. The postoperative suprasternal to NAC showed NAC at a higher place than its preoperative position extending support to the clinical outcome. The difference was noted in unilateral as well as bilateral multiplane procedure for simultaneous augmentation and internal glandulopexy. The position of NAC in bilateral and unilateral procedures was 0.8 and 0.2 cm higher than their preoperative position respectively. On the contrary, postoperative measurements in both, partial submuscular and subglandular planes, showed that even after having smaller implants, the nipple areolar position was lower than its preoperative position (Table 1). The gain in NAC measurement or drop of NAC in its postoperative position was less in submuscular than subglandular plane [20]. However, both these planes showed a net increase in their postoperative measurements as opposed to bilateral multiplane procedures for simultaneous augmentation and internal glandulopexy (Table 1). The data of NAC to IMC measurements were also compared between the multiplane procedure and the augmentation mammoplasty alone in subglandular and partial submuscular pockets. The results of the groups showed a net gain in measurement between NAC and IMC (Table 2). In its postoperative state, the expansion of the lower pole or NAC to IMC measurements was least in the submuscular pocket. Inclusion of the muscular layer in the breast envelope provides more stability to the envelope and is the reason for the long-lasting results in submuscular pocket [21, 22]. Measurements in the subglandular pocket and the multiplane procedure were higher due to the subglandular position of the implants. In this plane lack of muscle inclusion in the envelope allows more natural expansion. The net difference between preoperative and postoperative nipple to IMC measurements was higher in the multiplane procedure and was possibly due to the bigger-sized implant used in this group as well as the larger skin envelopes as expected in a ptotic breast (Table 2). However, it is difficult to standardise or conclude results in lower pole of the breast due to the varying nature of tissue characteristics in each breast envelope.

The cephalic or superior NAC positioning following internal glandulopexy as opposed to downward lowering of the NAC in augmentation mammoplasty alone suggests that, in selected patients, the multiplane procedure does provide a lift or mastopexy to the breast. When the technique is applied in selected cases of minor or early ptosis, the procedure can potentially avoid an external conventional mastopexy with associated scarring and surgical morbidity. Aesthetic results are comparable to augmentation mammoplasty alone with the advantages of no visible scarring. Though an independent panel did not make this observation, a unilateral procedure for the correction of nipple areolar positional asymmetry, provided the contralateral breast as a control. Postoperative recovery, healing and appearance of the two breasts in those cases were comparable and aesthetically acceptable (Fig. 5a–d). The vast majority of patients expressed a high satisfaction rate when the procedure is performed in selected cases. However, the procedure is not a replacement of conventional mastopexy. In a small minority of patients, a conventional external envelope reduction and nipple areolar mobilisation remain a possible option for revision following inadequate results and needs to be included in the informed consent.

Ptosis correction in augmentation mammoplasties with a similar philosophy has been used in the past by mobilising breast parenchyma from the pectoralis and was taped and supported externally while the expander mammary prosthesis was used in a partial submuscular position for augmentation [9]. The multiplane procedure is an operation with a similar concept where two planes are used simultaneously through an inframammary approach. The muscle splitting submuscular plane is used to place the implant for augmentation and the prepectoral/subglandular plane is dissected for breast envelope mobilisation and draping at a higher position on the chest wall. The procedure is an extension of the muscle splitting biplane pocket and in selected cases of early ptosis, can be used to improve the NAC and IMC inter-relationship. The multiplane procedure is best performed with augmentation in selected cases with no skin envelope excess in the horizontal axis. The commonly used Regnault’s classification for ptosis is a quantification of the descent of the NAC in a vertical dimension and does not take into account the skin envelope excess in the horizontal axis. Patients with excess skin in the horizontal axis or plane, regardless of the degree of the ptosis, are not suitable for this procedure. The multiplane procedure also provides an opportunity to improve vertical axis NAC asymmetries, where the discrepancy between the two sides is less than 1.5 cm (Fig. 5a–d) The procedure has been used equally and effectively in patients with secondary ptosis of the breast envelope and implant rippling following augmentation mammoplasty in the subglandular plane (Fig. 6a–d).

Fig. 6
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a–b Anterior and side views of a patient showing secondary ptosis and implant rippling following augmentation in subglandular pocket using 300 cm3 cohesive silicone gel implants. c–d Ten months postoperative views after converting subglandular pocket into multiplane procedure for simultaneous submuscular augmentation and internal glandulopexy in subglandular plane using same size implants through inframammary crease incision. Lift of the breast and level of the nipple position is improved when preoperative and postoperative levels are compared with the elbow joint

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Conclusion

In selected cases, the multiplane procedure is an option which provides acceptable results in patients with early ptosis. The procedure does not involve obvious external scarring and does not carry extra morbidity. However, the technique is not indicated or aimed to correct moderate to severe ptosis.