The Application of Mesh Support in Periareolar Breast ...



The Application of Mesh Support in Periareolar Breast Surgery: Clinical and Mammographic Evaluation

Alan Landecker, M.D., Eduardo Carneiro Lyra, M.D., Leonardo José Henríquez, M.D., Renata Sampaio Góes, B.S., Paulo Godoy, B.S., João Carlos Sampaio Góes, M.D., Ph.D.

Numerous different techniques have been described for the treatment of breast hypertrophy and/or ptosis. Unfortunately, recurrent ptosis after mammaplasty can occur regardless of the employed technique. To avoid this problem, different kinds of supporting devices have been described with variable rates of success.

Recently, the development of minimal incision approaches such as the periareolar techniques have significantly reduced the magnitude of scars without compromising the aesthetic results. In the periareolar double-skin technique for mammaplasty and mastopexy developed by the senior author (JCSG), a mixed mesh composed of Poliester and Polyglactine 910 is applied before redraping the skin over the newly shaped breast architecture. By inducing a scarring reaction which functions as an internal brassiere, the mesh helps maintain long-lasting anterior projection and helps avoid the recurrence of ptosis (1,2).

However, the true implications of incorporating mesh into breast surgery have never been clarified and surgeons have been reluctant to apply any kind of prosthetic material into the breast fearing inflammation, an unfavorable aesthetic outcome, palpable or visible deformities, and interference with the mammographic evaluation of breast cancer.

In this paper we analyze the aesthetic, clinical, and mammographic implications of utilizing mesh as a supportive device in periareolar breast surgery.

Method: Eighteen (18) patients (mean age = 42), with breast hypertrophy and/or ptosis were submitted to the double-skin periareolar mammaplasty technique, with placement of mixed mesh. Clinical assessment was performed by three breast surgeons who knew that the patients underwent the application of mesh and were actively working on cancer surveillance.

After a mean follow-up period of 30 months, a standard mammogram was performed in each patient and analyzed by both the surgeons and an expert radiologist. The evaluated factors were hyperemia, calcifications, contour irregularities, capsular contraction, thickening and/or widening of the scar with extrusion of the mesh, and any palpable and/or hardened areas.

Results: According to our clinical observations, there were no mesh-related abnormalities in the breast, the mesh was not palpable after the operation, and there was no recurrent ptosis. In terms of mammographic imaging, the mesh was visible as a very fine line in the periphery of the breast’s parenchyma (measuring 0.2 mm on the lateral views) in three patients (17%). The mesh did not interfere with the visualization and analysis of the breast´s parenchyma.

In seven patients (39%), benign localized microcalcifications were detected in the breast and no further investigation was carried out. In two patients (11%), grouped calcifications were detected and biopsied; histopathologic analysis demonstrated epithelial hyperplasia with atypia. In two patients (11%), nodules smaller than 1 cm were detected and biopsied; histopathologic analysis demonstrated a fibroadenoma in one patient and an invasive ductal carcinoma in the other.

Discussion: Mammography remains the ideal screening method for detecting non-palpable breast cancer and any factor that can possibly interfere with this exam should be avoided. Although the application of non-absorbable elements has never been shown to be such a factor, some authors believe that avoiding them is the only guarantee of a reliable clinical and radiological surveillance of breast cancer.

Postoperative mammographic alterations are frequently observed in mammaplasties that do not employ prosthetic devices. Located mainly in the lower hemisphere, they are more noticeable during the first 6 months after surgery and tend to become less visible with time. The exceptions are parenchymal calcifications, which occur after 1 - 2 years and do not disappear. However, factors such as the degree of inflammation, fibrosis, calcification, and interference with mammography induced by the presence of mesh in the breast have never been studied.

Various different materials have been used to manufacture mesh. Among the absorbable materials, polyglactine has been extensively studied and used with excellent results in traumatic lacerations of the kidney and spleen. The most utilized non-absorbable materials are polyester and polypropylene, which induce a thick and well vascularized capsule that anchors itself around the mesh (3-6).

The periareolar double-skin technique was originally performed using an absorbable mesh composed of Polyglactine 910(2). Although the preliminary results were satisfactory, ptosis eventually recurred due to resorption of the polyglactine after 21 – 90 days and loss of tensile strength was shown to occur after 15 days. Outcomes were later improved by using a mixed mesh composed of 60% polyglactine and 40% non-absorbable polyester (1,7). This mesh combined the initial shaping properties of the polyglactine with the polyester’s durability. As a result, the ideal shape and anterior projection of the newly shaped breast were maintained for longer periods of time.

Our results demonstrate that the presence of mesh did not lead to surgical complications, palpability after the operation, or the formation of densities, spiculations or microcalcifications. The gross calcifications that were present in the minority of cases were seen in peripheral breast tissue far from the mesh.

Additionally, mammographic interpretation was carried out uneventfully and there was no interference with the diagnosis and treatment of even minute lesions such as benign localized microcalcifications, grouped calcifications (epithelial hyperplasia with atypia) and small nodules.

Conclusion: The periareolar mammaplasty with mesh support is capable of producing excellent and long-lasting aesthetic results. The presence of mesh does not induce visible or palpable deformities and mammographic abnormalities. In terms of surveillance mammograms, the presence of the mesh did not interfere with the diagnosis of minute lesions such as calcifications and small nodules.

Finally, we hope that the evidence presented in this paper will encourage surgeons to consider the utilization of mesh in breast surgery more liberally. In this way, some of the most unfavorable long-term outcomes such as loss of projection and recurrence of ptosis might be avoided. Also, the availability of a stronger supporting system may lead to the development of even more satisfactory breast surgery techniques in future.

1. Góes JCS. Periareolar mastopexy and reduction with mesh support. In: Raven-Lippincott, ed. Breast Surgery. Philadelphia, 1998; 51: 697-708.

2. Goes JCS. Periareolar mammaplasty: double skin technique with application of Polyglactine 910 mesh. Rev Soc Bras Cir Plast 7:1, 1992.

3. Soares BM, King MW, Marcis Y, et al. In vitro characterization of a fluoro-passivated gelatin-impregnated polyester mesh for hernia repair. J Bioned Master Res 32:259,1996.

4. Bellon JM, Contreras LA, Bujan J, et al The use of biomaterials in the repair of abdominal wall defects: a comparative study marlex mesh and dual mesh (PTFE). J Biomater Appl 12:121,1997.

5. Bellon JM, Contreras LA, Bujan J, et al. Tissue response to polypropylene meshes used in the repair of abdominal wall defects. Biomaterials 19:669,1998.

6. Schumpelick U, Klosterhalfen B, Müller M, Klinge U. Minimized polypropylene mesh for preperitoned netplasty (PNP) of incisional hernias. Chirurg 70:422,1999.

7. Góes JCS, Bostwick J III, Benelli L, Courtiss EH, Lejour M. Minimizing scars in breast surgery . (Expert Exchange). Perspect Plast Surg 7:59,1993.

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