What is Soft Tissue Failure?
Soft tissue failure means that the soft tissue of the breast is unable to support the weight of the breast, resulting in subsequent stretching of the breast after surgery. In all cases, there is always stretching of the breast tissue following surgery, but in this case, the degree of stretching, particularly of the lower portion of the breast is greater than desired. By definition, a sagging breast demonstrates soft tissue failure. If there wasn't inability of the breast skin to support the underlying tissue, there would not be sagging of the breast in the first place. So why perform a procedure to lift the breast that relies on suboptimal stretched tissue to support the breast? This makes no sense! Sometimes, the amount of stretching after a breast lift is not too bad and the patient is satisfied with the result of their surgery. Add the weight of an implant, and the risk of a breast with excessive stretching after surgery increases.
This is a perfect example of soft tissue failure.
From Left to Right, Top to Bottom:
Pre Op - The bottom of the breast is much lower that the lower breast crease.
2 days following circumvertical mastopexy with augmentation - The bottom of the breast has been elevated and is only slightly below the lower breast crease. The distance from the lowest point on the areola along the lower breast to where the crease meets the chest wall is now shorter than before surgery.
5 months following surgery - The lower breast has stretched almost to where it was before surgery. The lowest part of the breast and distance from bottom of areola to where the crease meets the chest wall is now greater than it was immediately after surgery.
4 years following surgery - The lower breast has stretched back to where it was before surgery. The lowest part of the breast and distance from bottom of areola to where the crease meets the chest wall is now similar to what it was before surgery.
What Can Be Done to Manage Soft Tissue Failure?
There are now options to support the breast after a breast lift, both with and without an implant. Some of the options are to use dermis, which is a component of skin. The dermis can be taken from a human cadaveric donor (Alloderm) or from a pig (Strattice). Alloderm is much more expensive than Strattice and I am not aware of any data that inidicates that it is superior over Strattice. I have stopped using Strattice in favor of another option because dermis will stretch with time. Again, it makes no sense to use a product that stretches to provide support to the soft tissues. I am now using a product called GalaFlex mesh. This is made of an artificial material called P4HB. GalaFlex does not stretch at all, is quickly incorporated into the tissues (the tissue grows into the mesh holes) and it resists infection. The best part of this product is that it is absorbed after about 1-2 years. When it is absorbed, it is replaced by a layer of scar tissue. Scar tissue can be friend or foe. In this case it is your friend. The scar tissue is your tissue and adds strength to the lower breast tissue and provides additional support going forward. The term "internal bra" is bandied about by many plastic surgeons and means different things to different surgeons from the placement of a few sutures to placement of soft tissue support. I like to think of the mesh as an internal "strapless-bra", much like the adhesive strapless demi bras that some women use with garments that preclude the use of a more traditional bra with straps.
Thge judgment to use internal soft tissue support is based upon surgeon experience and expertise. There are several different products and different ways to implant the material. For periareolar and some circumvertical lifts, its use might not be warranted. For other circumvertical and most all Wise pattern (anchor) lifts, I believe that there is a real advantage to using the material. After seeing some lifts, particularly those with implants stretch more after surgery than I would have liked, I believe that the use of soft tissue support is warranted in these cases. I tell the patients to think of it like an "insurance policy" to lower the chance of needing to go back to revise the breast lift later on.
Breast Lift and the Internal Bra
GalaFLEX Surgical Mesh
When performing a breast lift, the GalaFlex is placed into the breast so that it lies on top of the breast parenchyma (glandular and fatty tissue) and under the skin. When an implant is placed without a lift, the GalaFlex is placed into the pocket between the implant and the breast. When a breast lift is performed with an implant, the GalaFlex may be placed either inside the pocket with the implant, or more commonly, between the breast parenchyma and the skin. In the latter situation, the GalaFlex will provide support to the implant, breast parenchyma and skin. When placed inside the pocket, the GalaFlex only provides support to the implant. The only situations I would consider placing the GalaFlex inside the implant pocket rather than between the breast parenchyma and skin would be if there was a capsule contracture and I wanted to reduce the risk of another capsule contracture, or, if I was using the GalaFlex in a breast implant revision to create a new pocket under the muscle when the implant was previously placed above the muscle. That is an entirely different discussion!
When using GalaFlex, I usually prefer to perform a Wise pattern (anchor) mastopexy rather than a Circumvertical (lollipop) mastopexy. The reason for this is that with the former, more skin is elevated off the surface of the lower breast, allowing me to put a larger piece of GalaFlex over the breast tissue. I have performed several circumvertical mastopexies with GalaFlex and have come to the conclusion that the amount of GalaFlex that I am able to place into the breast with this type of breast lift is probably not adding to the support of the breast, and if so, minimally. As of now, I prefer to use a Wise pattern (anchor) lift when I place GalaFlex. The lower crease scar is made only as long as it needs to be to accomplish an adequate breast lift. Many times, it is not visible when looking at the breast from the front or sides.
Soft Tissue Support in Wise Pattern Mastopexy (lift) Without Implants
I reserve this type of lift for patients with the most challenging breast tissues: massive weight loss patients, patients with pendulous breasts with grade III ptosis (breasts pointing downwards) and those with large pendulous breasts in whom a breast reduction is not desired.
These patients are challenging because the breast tissues are usually quite compromised, the nipples have to move the greatest distance upward, and the shape of the breast has gone from round to flat with most of the breast volume lying below the level of the lower breast crease.
All the breast lift techniques up to the present involved removing excess breast skin, moving the nipple upward and using the skin envelope as the controller of breast shape. Soft tissue support (ie GalaFlex) can be added for additional support, but this is the essence of the procedure.
For patients with more challenging breasts, I go a step further. I perform a procedure called Dermal Suspension and Parenchymal Reshaping Mastopexy (breast lift). That is quite a mouthful! In my office, we have nicknamed it a "breast lift on steroids." There are no steroids involved, but the procedure goes well beyond that of the previously described lifts. This procedure was actually described in 2008 by my friend and colleague Peter Rubin, a plastic surgeon at the University of Pittsburgh. This was originally created for the massive weight loss patients (I will show an example of one of my massive weight loss patients who underwent this procedure shortly). I have expanded the use of the technique for non-massive weight loss patients as well. I have also added the use of soft tissue support which was not described in the original article.
In this procedure, the skin overlying the entire breast is elevated off the breast parenchyma (gland and fat). Excess breast tissue from the lower inner and outer breast is also elevated. Lastly, a small piece of dermis (the skin layer below the surface of the skin or epidermis) is used as an anchor to the upper chest wall muscle so to actually provide support to the breast from above. All other breast lift procedures do not incorporate this feature.
The next step is to bring the extra "wings" of breast tissue from the lower inner and outer breast towards the central breast mound and suture them so that the breast parenchyma assumes a more rounded shape rather than a flattened shape as it did before surgery.
Now that the breast assumes a more rounded shape, soft tissue support is placed along the lower breast, and even sometimes on the upper portion to reinforce the repairs and preserve the shape of the breast. This mitigates against further sagging due to the influence of gravity placing stress on the overstretched, poor tissue quality skin of the lower breast.
This is the final result. Voila!
The below photos demonstrate a patient who underwent a Wise pattern (anchor) mastopexy (lift) without implants. The patient lost over 150 pounds; her obesity followed by massive weight loss resulted in severe compromise to the quality of her breast tissues (skin, glandular and fat). GalaFlex was used for soft tissue support of the lower breast.
The above photos demonstrate a patient who underwent a Wise pattern (anchor) mastopexy (lift) without implants. The patient lost over 150 pounds; her obesity followed by massive weight loss resulted in severe compromise to the quality of her breast tissues (skin, glandular and fat). GalaFlex was used for soft tissue support of the lower breast.
Soft Tissue Support in Wise Pattern Mastopexy (lift) With Implants
In patients who require a Wise pattern (anchor) lift and desire simultaneous breast augmentation with implants, I perform a breast augmentation first. Next, I reposition the nipple and excise excess skin around the newly enlarged breast mound. Once I have the breast shaped the way I like, I then add the soft tissue support. This is placed in the same layer as when I perform this lift without implants, that is, the supporting material is placed on top of the breast parenchyma (gland and fat) and under the skin.
Some like to use the term "internal bra." I think this is a misnomer - the support is not really lifting the breast, but rather, it incorporates into the underside of the lower breast skin. While the breast skin can easily stretch, this material does not, and therefore the lower breast skin becomes much more resilient to stretching. This mitigates against further drooping of the breast.
The below illustration shows how this is performed.
The above photos demonstrate a patient who underwent a Wise pattern (anchor) mastopexy (lift) with implants. The patient has not only poor quality tissue, but also significant asymmetry as well. GalaFlex was used for soft tissue support of the lower breast.
The above photos demonstrate a patient who underwent a Wise pattern (anchor) mastopexy (lift) with removal of implants and replacement with smaller implants. GalaFlex was used for soft tissue support of the lower breast.
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SECTIONS - Breast Lift/Mastopexy with Implants
Chapters - Breast Augmentation Guide
- Motiva Breast Implants
- Intro to Breast Augmentation
- Five key decisions you need to make
- One-Day Recovery Breast Augmentation
- Anesthesia – General, Sedation or Local?
- Breast Lift (Mastopexy) with/without Implants or Fat
- What else should I know about breast augmentation?
- Important Things to Consider When You Decide to Move Forward With Breast Augmentation
- Revision of breast augmentation
- ALCL and Breast Implant Illness
