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Page 12 of 14 Khan. Plast Aesthet Res 2018;5:45 I http://dx.doi.org/10.20517/2347-9264.2018.58

Table 4. Profile of the cohesive gel silicone implants used in periareolar, vertical scar cat’s tail and Wisw pattern markings
Type of procedure
Implant profile P value
PA VSCT WP
High profile 5 (45.5%) 6 (20.7%) 1 (10.0%) 0.017
Moderate profile 1 (9.1%) 19 (65.5%) 7 (70.0%)
Extra high profile 5 (45.5%) 4 (13.8%) 2 (20.2%)
PA: periareolar; VSCT: vertical scar Cat’s tail; WP: Wise pattern

In the series Moderate profile implants were most commonly used in VSCT and WP scars mastopexy as
compared to extra high implants used in PA mastopexy with implants [Table 4].

Another safety feature of having an intervening layer of robust tissue, between closure lines and implant,
is the potential advantage of implant not being exposed should there be any skin envelope breakdown.
This wound breakdown is not uncommon following Wise pattern markings at the junction of vertical and
horizontal closure. Wound breakdown with resultant exposure or extrusion of implant necessitates implant
removal with a time lapse to allow healing to consolidate before further insertion of the prosthesis is con-
sidered possible. The intermediate layer can enable the wound to be treated conservatively obviating the
explantation of the device with its concomitant morbidity and patient’s disappointment and distress. Even
though there is a lack of techniques described to preserve function and add safety to the procedure, a re-
cently published Balcony Technique, has described the preservation and use of lower half of subcutaneous
layer of breast tissue as an intermediate layer of balcony sandwiching implant between itself and pectoralis
[19]
muscle . This preserved layer of tissue acts, as a safety net in Wise pattern closure where T-junction wound
breakdown is not uncommon. However, lower half of balcony tissue layer requires its dissection separately
and once achieved, is discontinuous with the upper half of the breast. The balcony technique is novel on its
own but layered mastopexy provides continuity of the intermediate tissue layer without additional dissection
that enhances arterial supply to the pedicle with wider area for venous and lymphatic drainage and is associ-
ated with least cutaneous sensation and lactation potential discontinuity and disruption. Other breast con-
serving single stage mastopexy with augmentation procedures have been described. The least invasive being
simple deepithelialisation with a temporary overinflated expander and once the mastopexy is completed, the
[20]
expander would be replaced with suitable smaller size implants in the same setting .
Owsley has described breast conserving single stage augmentation mastopexy. The technique involves cir-
cumferential skin undermining between proposed new NAC level and existing inframammary crease. Pock-
et for implant is approached by incising lower edge of the breast and inflatable devices placed and skin only
[21]
excision performed as Wise pattern . Similarly minimal tissue excision in Wise pattern inferior pedicle flap
[22]
or periareolar markings with submuscular implants is described . However almost all of these techniques
have limitations in that they are suitable for hypoplastic or small ptotic breasts. Preservation of tissue in low-
er pole of the breast may result in redundancy and secondary ptosis of lower pole. Layered single stage aug-
mentation mastopexy addresses this issue, with excision of tissue in the lower central pole allowing breast
tissue to mould and drape over the implant for natural and aesthetic rejuvenation. The Layered single stage
augmentation mastopexy technique also allows the procedure to be performed in less than ideal patients
who present with hypertrophy with ptosis without much risk to the safety of the nipple. However, the out-
come of these procedures where larger reductions are performed for mastopexy, is less than ideal in aesthetic
terms. The aim and priority of an ideal procedure has to be safety of the procedure as well as good aesthetic
outcome with longer lasting results. I prefer to operate on this particular group of patients as a staged pro-
cedure where reduction and mastopexy should be performed first and augmentation mammoplasty should
follow later.

The weakness of the study is that there was no objective and scientific assessment of enhanced arterial sup-
ply, better venous and lymphatic drainage performed. There were no tests carried out for claimed sensation