Research Article
Impact of Skin Laxity on Selection of Breast Implant during Augmentation Mammoplasty
Ahmed Tharwat Nassar*
Department of Plastic Surgery, Menoufia University, Egypt
*Corresponding author: Ahmed Tharwat Nassar, Department of Plastic Surgery, Menoufia University, Egypt
Published: 29 Jun, 2018
Cite this article as: Nassar AT. Impact of Skin Laxity on
Selection of Breast Implant during
Augmentation Mammoplasty. Clin Surg.
2018; 3: 2003.
Abstract
Introduction: Breast augmentation is one of the most common aesthetic surgical procedures.
Physical characters of the patients markedly affect choice of size and projection of the implant.
Aim: Analyze the effect of skin laxity on the size and projection of breast implant.
Patients and Methods: Retrospective analysis of the effect of degree of skin laxity of patients had
breast augmentation on the size and projection of the implant. Patients decided into groups each
group have almost similar cheat wall diameter, age and marital stat. study included 20 patients
received breast augmentation between January 2014 to January 2016 at Mawada privet hospital,
Menoufia. All implants were inserted through inframammary approach and were place in sub
glandular pocket.
Results: Relation between degree of skin laxity and size of breast implant show (Correlation
coefficient) (r) (0.73) close to +1 which means that the two variables are closely related with each
other with significant p value <(0.001). Also significant relation between the degree of skin laxity
and implant projection also with deferent intraoperative steps during the procedure.
Conclusion: Degree of skin laxity directly affects the size and projection of the breast implant.
Introduction
Physical characteristics and patient desires are the most important factors in selecting implant
size and profile during augmentation mammoplasty. Also incisions, pocket plane, and implant
characteristics, including shape, texture and volume, are important factors during surgical planning
[1].
Other factors like psychology, aesthetic sense, and anatomy must be assessed. Psychological
and emotional stability is a mandatory demands simple personal criteria of the patients as style of
dress, makeup, previous aesthetic procedures, community, and occupation reflect personality and
aesthetics. Anatomic limitations must be explained to the patient [2].
Tebbetts and Adams [3,4], described a decision support process that enables surgeons to address
all pre- operative assessment and operative planning decisions by prioritising five critical decisions
in breast augmentation: 1) optimal soft-tissue coverage/pocket location for the implant; 2) implant
volume (weight); 3) implant type, size, and dimensions; 4) optimal location for the inframammary
fold; and 5) incision location.
Tissue characteristics and skin quality are equally important factors. Patients with atrophic tissue
and poor skin elasticity make concealment of the implant whether visual or tactile very challenging
they also carry the risk of late lower pole descent. Implant size is markedly affected by these factors
and avoiding large size silicone implants are the best choice in these patients [5].
The skin stretch (SS) is measured by grasping the skin of the medial areola and pulling the breast
maximally anteriorly. The SS distance correlates to the anterior-posterior excursion measured with
a caliber [6].
Types and these are subdivided based on envelope quality and N: IMF on stretch
Breast Type I (very tight) SS <1.5 cm
Breast Type II (tight) SS 1.5 cm to 2 cm
Breast Type III (average) SS 2 cm to 3 cm
Breast Type IV (loose) SS 3 cm to 4 cm with N: IMF <9 cm
Breast Type V (very loose) SS 3 cm to 4 cm with N: IMF >9 cm
This represents the integration of BBW, SS, N: IMF, and breast
type to create a blueprint for implant selection for implant-specific
tissue-based planning [6].
Skin Stretch (SS) is one of the important factors that determine
suitable fill volume. If the patient is a breast type 1 or 2, the optimal
fill volume is reduced further (60 mL and 30 mL, respectively). Any
adjustments to the optimal fill based on the patient desires are made.
Breast type provides a simpler construct to correlate envelope quality
and tissue-based implant selection [6].
Figure 1
Figure 1
Correlation between skin laxity grade and size of breast implant. It
showed significant positive correlation between skin laxity grade and size of
breast implant (p value <0.001).
Patients and Methods
In this random study 20 patients were included between the
periods of January 2016 to June 2017. Menoufia University Hospitals,
Mawada privet hospital, Menoufia Governorate and AL kawakab
privet hospital, Cairo, Egypt were the places where cases had are
operated on.
Patients was divided into 3 groups according to degree of Skin
Stretch (SS) group one skin stretch from 0 to 2 cm called (Grad one)
laxity, group two from 2 cm to 4 cm and called (Grad two) and group
three above 4 cm and called (Grad three).
Skin stretch or skin pinch test was used to assess the skin laxity.
Skin stretch test was done by attaching the nipple gently and pulling
the skin up while the patient was lying down the distance, the nipple
could pass through was measured before pulling zero point of the
measuring caliper was at the level of nipple at resting position.
All patients have informed with deferent operative and post
operative details and informed consent was taken preoperative
photography was taken for all patients. Preoperative examination
including breast examination and chest wall measurement was
done from mid line to anterior axillary line on each side. Routine
preoperative laboratory investigations was done, preoperative
sonomammography was done for all patients.
Expected breast implant size was determined according to chest
wall base, degree of skin laxity and the patient desire three pairs of
implants were prepared, for each case each pair of it has the same size
and projection. All implants were rounded, silicone gel fill, textured
and all of them were (poly tech) implant.
Combination of third generation cephalosporin and gram
positive antibiotic were given Intra Venous (IV) to all our patients
after induction of anaesthesia and before wound creation. General
anaesthesia was used in all patients, mean operative time 101 minutes
± 16.8. Inframammary incision and sub glandular placement of the
implant was used in all cases. No drains were used in any of the
patients in this study. Patient was discharged next day after surgery
on third generation cephalosporin IV and intra muscular analgesic
for 4 days shifted to oral treatment for one week including oral
levofloxacin and analgesic.
First wound exposure was done after 5 to 7 days; Stitches were
removed after 14 days. Supportive elastic bandage used to support
breast during this time.
Correlation between degree of skin laxity and implant size and
profile was studied to detect the effect of skin laxity on preoperative
decision making and implant selection.
Also skin laxity was correlated to different intraoperative steps
related to implant including pocket creation, retraction and implant
insertion.
Table 1
Table 2
Results
Age of patients was between 20 to 40 years. 6 of them were single,
12 were married, 1 was divorced and 1 was widow. 8 of the patients
had no previous lactation, 1 of them lactated once before, 5 patients
lactated 2 times and the remaining 6 patients have 3 previous lactation
experiences before (Table 1).
General anaesthesia was used in all patients, mean operative
time 101 minutes ± 16.8. Infra mammary incision and sub glandular
placement of the implant was used in all cases (Table 2).
Group 1 skin laxity group included 6 patients, Group 2 skin laxity
group included 5 patients and Group 3 skin laxity group included 9
patients. Unilateral Chest wall width (implant base) from 12 cm to
15 cm. Creation of subglandular pocket was easy in 14 cases and was
somehow more difficult in the remaining 6 cases; this was similar to
retraction and implant delivery (Table 3).
Implant profile was moderate in 2 cases, high in 10 cases and
extra high in 8 cases. Implant size was between 220 cm3 to 450 cm3
with average 382.5 cm3 ± 57.9 cm3 (Table 3).
Table 4 analyzing the relation between skin laxities and implant
profile also between pocket creations, retraction and implant delivery.
It showed significant p value (0.009) for relation between implant
profile and degree of skin laxity with low chi square X2 13.4. Also
significant p value (0.001) describing the relation between degree of
skin laxity and pocket creation, retraction and implant delivery.
In this study correlation coefficient (r) which describe the relation
between skin laxity degree and implant size was (0.73) close to +1
which means that the two variables are closely related with each other.
Also significant p value (0.001) was found. Diagrammatic analyze of
the relation between degree of skin laxity and implant size with the
linear as shown in Figure 1.
Table 3
Discussion
In this study a trial to re-emphasis the relation between the
degree of skin laxity and the size and projection of implant was done.
Detecting how much the skin laxity affects the choice of the implant
and should be considered and well assessed preoperative to achieve
suitable size which may satisfy the patient needs.
Analyzing the relation between the degree of skin laxity and
profile of the implant showed in Table 4 positive relation between
them with p value (0.009). So in creased skin laxity leads to choosing
higher implant profile to accommodate this increase.
Also there was positive linear relation between the degree of skin
laxity and the size of implant even within patient with equal chest
wall diameter and plant base (Figure 1). This also accompanied with
significant be value between both the skin laxity degree and the
implant size (p value <0.001).
Tebbetts and Adams [3] mentioned that having determined an
optimal volume for each patient’s envelope should be done before
selecting implant type and dimensions and this to help controlling
the distribution of that volume within the breast. For any specific
volume, implant width, projection, and height can vary. Both also
stated that optimal volume for a breast soft-tissue envelope is the least
volume that is required to either
1. Achieve the desired result in a previously unstretched breast
(or)
2. Adequately fill already stretched envelope but with
optimal soft-tissue coverage to minimise unfavorable tissue effects by
the implants.
Adams and Mckee [7] concluded that there is some evidence to
support tissue-based planning as a superior approach to implant size
selection planning; studies that used tissue based planning reported
lower re operation rates compared with industry standards and
accepted literature values.
Table 4
Table 4
Effect of degree of skin laxity and implant size, pocket create retraction
and implant delivery.
Conclusion
Many factors affect the choice of breast implant one of these factors is the degree of skin laxity. Degree of skin laxity directly affects the size and projection of breast implant. Depending only on chest wall diameter without accurate assessment of skin laxity and stretchability will affect the post operative out come and patient satisfaction.
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