What is the recommended surgical technique and incision for a patient with grade 1 ptosis undergoing breast augmentation with anatomical teardrop textured breast implants?

Surgical Technique for Anatomical Textured Implants with Grade 1 Ptosis

For patients with grade 1 ptosis undergoing breast augmentation with anatomical teardrop textured implants, the inframammary fold incision with dual-plane (subpectoral) placement is the optimal approach, as this combination minimizes capsular contracture, reduces malposition risk, and provides superior control for implant positioning while addressing the mild ptosis without requiring mastopexy. 1

Incision Selection

The inframammary fold (IMF) incision is the preferred approach for anatomical textured implants based on the following evidence:

• Inframammary incisions demonstrate significantly lower rates of capsular contracture, malposition, and secondary procedures compared to periareolar or axillary approaches in primary breast augmentation with textured anatomical devices 1

• The IMF incision provides optimal exposure for precise pocket dissection and accurate implant positioning, which is critical for anatomical implants that must maintain proper orientation 1, 2

• Periareolar and axillary incisions carry significantly increased risk of moderate-severe malposition (adjusted model, p<0.05), which is particularly problematic for shaped implants that can rotate 1

Incision Placement Technique

• Position the incision at the existing inframammary fold or at the planned new fold location if lowering is required to accommodate the implant dimensions 3

• The incision should be placed directly over the area requiring dissection, not requiring tunneling, as tunneling compromises cosmesis and surgical precision 3

• Make the incision length sufficient (typically 4-5 cm) to permit implant insertion without excessive force that could damage the textured surface 4

Pocket Placement

Dual-plane (subpectoral) placement is strongly recommended for this clinical scenario:

• Subpectoral placement significantly reduces capsular contracture risk compared to subglandular placement (adjusted hazard ratio favoring subpectoral, p<0.05) 1

• The combination of textured surface devices with subpectoral placement provides additive benefit in preventing capsular contracture 1

• For grade 1 ptosis specifically, high-projection anatomical implants in the subpectoral plane can elevate the nipple position without requiring mastopexy in 92.9% of cases with glandular ptosis 5

Addressing Grade 1 Ptosis

Anatomical textured implants can correct mild ptosis without concurrent mastopexy through the following approach:

• Select a high-projection anatomical implant with appropriate height to fill the lower pole and elevate the nipple-areola complex relative to the new inframammary fold 5

• The shaped implant provides more volume in the lower pole compared to round implants, effectively lifting the breast tissue and nipple position 5

• This approach successfully avoids mastopexy scars in over 90% of patients with glandular ptosis and nipple placement below the IMF 5

Critical Technical Considerations

Implant Rotation Prevention

• The rotation risk with microtextured anatomical implants is 2.6% in primary augmentation, which is acceptable and not significantly associated with implant projection or height 5

• Precise pocket dissection matching implant base dimensions minimizes rotation risk 5

• Textured surface devices demonstrate significantly lower malposition rates compared to smooth devices (adjusted model, p<0.05) 1

Hemostasis Requirements

• Meticulous hemostasis is critically important to prevent hematoma formation, which produces changes difficult to interpret on examination and can lead to capsular contracture 4

• Achieve complete hemostasis before implant insertion, as hematomas can be long-lasting and compromise outcomes 4

Closure Technique

• Close all incisions with subcuticular technique to optimize cosmetic results and minimize visible scarring 4

• Perform layered closure with separate approximation of deeper tissues before skin closure 4

• Avoid excessive tension on the incision that could cause distortion when the patient is upright 4

Textured Implant Safety Considerations

Important counseling points regarding textured implants:

• Most cases of BIA-ALCL are associated with textured implants, typically presenting 8-10 years post-implantation with delayed peri-implant effusion 6

• Patients require informed consent discussion about BIA-ALCL risk with textured devices 6

• Surveillance imaging (ultrasound or MRI) should begin at 5-6 years postoperatively, then every 2-3 years thereafter for silicone implants 7

Common Pitfalls to Avoid

• Never use periareolar incisions for anatomical implants in ptosis cases, as they significantly increase malposition and secondary procedure rates 1

• Avoid axillary approaches, which carry the highest risk of capsular contracture and malposition with anatomical devices 1

• Do not create a pocket larger than the implant base dimensions, as this increases rotation risk 5

• Never reapproximate breast tissue under tension, as this causes distortion when upright 4