Operative Technique in Plastic Surgery – Kevin C.Chung

■ Type II dual plane: Complete division of pectoralis major muscle origin
across the inframammary fold, stopping at the medial aspect, with
synchronous retromammary pocket plane formation to the level of the inferior
border of the areola
• Lower pole envelope more stretched, areola to inframammary fold distance
under stretch between 5.5 and 6.5 cm
• Most of the parenchyma should be above the inframammary fold.
• Mobile breast tissue over the pectoralis muscles
■ Type III dual plane: Complete division of pectoralis major muscle origin
across the inframammary fold, stopping at the medial aspect, with
synchronous retromammary pocket plane formation to the level of the
superior border of the areola
• Markedly stretched lower pole envelope, areola to inframammary fold
distance under stretch between 7 and 8 cm
• Most of the parenchyma lies below the inframammary fold.
FIG 4 • Preoperative markings of a 25-year-old female
undergoing breast augmentation. Dual plane technique
type I was used on the right breast, and dual plane
technique type II on the left. The lower pole envelope of
the right breast is minimally stretched, compared to the
more stretched lower envelope on the left breast.
• Breast parenchyma slides off the surface of the pectoralis.
• Constricted lower poles

■ The same patient may benefit from different types of dual plane
augmentation on the two breasts (FIG 4).
T E C H N I Q U E S
■ Inframammary Approach With a Smooth Round
Silicone Implant, Partial Subpectoral Placement,
and Dual Plane Type II Placement
Incision and Dissection
■ Tegaderm is placed on top of the nipple-areola complex (NAC).
■ Local anesthesia containing a mix of lidocaine and Marcaine with
epinephrine is injected into the marked incision and as a breast block.
■ The inframammary incision is made sharply through the dermis and the
superficial layer of the fat until the Scarpa fascia is encountered.
■ A double skin hook is placed followed by an Army-Navy retractor and
dissection is continued with Bovie electrocautery cephalad with care not to
violate the Scarpa fascia.
■ The breast tissue is divided, and the pectoralis muscle fascia is identified.
■ Suprafascial dissection is carried accordingly to create a type II dual plane
dissection.
■ After dual plane dissection, the pectoralis muscle is grasped and divided till
the areolar space under the muscle is identified.
■ A lighted retractor is then placed below the pectoralis major muscle and
strong upward traction is placed so as to separate the pectoralis major from
the pectoralis minor muscle (TECH FIG 1).
■ The initial fiber incision is made medially, where pectoralis major is
absent.
■ Pocket dissection is performed with the monopolar electrocautery and there
is no use of blunt dissection.
■ Submuscular dissection proceeds from medial to lateral in a clockwise
fashion for the left breast and in an anticlockwise fashion for the right breast,
until the pocket is of appropriate size.

TECH FIG 1 • Dual plane dissection type II is
performed before proceeding with pocket creation.
Use of a lighted retractor to separate the pectoralis
major from the pectoralis minor muscle.
■ Care is taken to avoid any contact with the ribs so as to decrease
postoperative pain.
■ Care is taken to disinsert the medial origin of the pectoralis major muscle so
as to achieve adequate expansion of the lower pole.
■ Care is taken to not disinsert the sternal fibers of the muscle.
■ Meticulous hemostasis is achieved.
Implant Insertion and Closure
■ Tester gel implants are inserted, and the patient is placed in the upright
seated position. If there are areas for additional dissection, these are marked.
■ The pockets are irrigated with triple antibiotic solution.
■ The formal implants are then placed in a sterile manner using the no-touch
technique.
■ The implant is transferred to the Keller funnel avoiding any contact with
the operating table or the surgeon’s gloves (TECH FIG 2A).
■ A Deaver retractor is used by the assistant to facilitate placement of the
implant (TECH FIG 2B).
■ Closure is performed in three layers:
■ 2-0 Vicryl is used for the breast parenchyma (TECH FIG 2C,D).
■ 4-0 Monocryl is used for interrupted deep dermal sutures, followed by a
running subcuticular 4-0 Monocryl suture.

■ The patient is placed again in an upright seated position for final assessment
(TECH FIG 2E).
TECH FIG 2 • A,B. The Keller funnel is used for
placement of the implants. The no-touch technique is
used. There is direct transfer of the implant to the
funnel without touching the implant. C. Deeper layer
that will be closed is grasped with forceps. D. Closure
of the deeper breast tissue is performed before skin
closure. E. Patient at the seated upright position with
the implants in place.

PEARLS AND PITFALLS
Hemostasis
■ Meticulous hemostasis should be achieved to avoid postoperative
hematoma and an inflammatory response that may lead to capsular
contracture.
Pectoralis
muscle
■ The most medial fibers of the pectoralis major muscle should be
released to avoid a constricted lower pole. Carefully not to disinsert
the sternal fibers as that can lead to window-shading and decreased
implant coverage.
Dual plane
■ Advantage of increasing implant and breast parenchyma interface,
expanding the lower pole, and allowing for changes of the nipple-
areolar complex.
Implant
placement
■ The no-touch technique is used at all times, to avoid implant
contamination.
Dissection
■ Dissection should be accurate to accommodate the implant and
overdissection should be avoided at all times.
Ribs
■ Contact with the ribs should be avoided, so as to decrease
postoperative pain.
FIG 5 • A. Preoperative frontal view of a 25-year-old
woman with micromastia. B. Patient 1 month after
submuscular breast augmentation with a 345-mL
smooth round implant with moderate projection. Dual

plane augmentation type I was performed on the right,
and dual plane augmentation type II was performed on
the left.
POSTOPERATIVE CARE
■ Patients are discharged at the same day of surgery after they recover in the
postoperative anesthesia care unit.
■ Postoperative medications
■ Oral analgesics
■ Seven-day course of oral antibiotics
■ Paper tape is used to cover the incisions.
■ A soft bra is used.
■ Activity
■ Patients are instructed to avoid heavy lifting, no more than 10 lb, for 10 days.
■ Light exercise is permitted starting postoperative day 1. Additional exercises
such as arm abduction and arm elevation are encouraged, to achieve
stretching of the pectoralis major muscle and accelerate recovery by
decreasing pain.
■ Patients may shower on postoperative day 1.
■ Manual massage for round implant starts as soon as tolerated by the patient
with the aim to prevent capsular contracture.
■ Follow-up appointments are scheduled for day 1, 1 week, 3 weeks, 3 months,
6 months, and 1 year.
OUTCOMES
■ A clinical example of a patient with inframammary breast augmentation with
smooth round silicone implants and dual plane augmentation is shown in FIG
5.
COMPLICATIONS
■ Hematoma formation is rare and ranges from 0.5% to 1%.
■ Infection is rare and occurs in less than 1% of the patients.
■ Double-bubble deformity may occur due to violation of Scarpa fascia at the
level of the inframammary fold, with subsequent caudal migration of the
implant in relationship to the breast mound.
■ The cause of capsular contracture is inflammation, which in turn may be due

to tissue trauma, bacteria, and blood.
■ The use of the Keller funnel has been shown to lead to a statistically
significant reduction in the incidence of reoperations performed due to
capsular contracture within 12 months of primary breast augmentation.7
REFERENCES
1. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National
Data Bank Statistics. Aesthet Surg J. 2017;37(suppl 2):1-29.
2. Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg.
2012;130(4):597-611.
3. Roostaeian A, Adams WP Jr. Three-dimensional imaging for breast
augmentation: is this technology providing accurate simulations? Aesthet Surg
J. 2014;34:857-875.
4. Swanson E. Prospective outcome study of 225 cases of breast augmentation.
Plast Reconstr Surg. 2013;131:1158-1166.
5. Alderman AK, Bauer J, Fardo D, Abrahamse P, Pusic A. Understanding the
effect of breast augmentation on quality of life: prospective analysis using the
BREAST-Q. Plast Reconstr Surg. 2014;133:787-795.
6. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft tissue
relationships in a wide range of breast types. Plast Reconstr Surg.
2001;107:1255-1272.
7. Flugstad NA, Pozner JN, Baxter RA, et al. Does implant insertion with a
funnel decrease capsular contracture? A preliminary report. Aesthet Surg J.
2016;36(5):550-556.

4
CHAPTER
Breast Augmentation with
Round and Anatomic
Implants
Bill Kortesis and Charalambos “Babis” Rammos
DEFINITION
■ Round implants are most commonly used in the United States.
■ They are symmetrical in height and width and have varying projections for a
given volume, typically designated as low, moderate, high profile, and extra
high.
• The more the projection increases for a fixed volume, the more the width of
the device decreases (FIG 1A).
■ Round implants may be smooth or textured and may be filled with either
saline or silicone gel.
• Fourth and fifth generation round silicone devices, currently used in the
market, are designed with thinner shells and a more cohesive gel.
■ Anatomic (shaped) implants have become an important alternative for breast
augmentation.
■ Shaped implants are textured to reduce movement and can have differences
in height, projection, and width.
• They have greater projection in the caudal portion and less projection in the
cephalic portion (FIG 1B), mimicking the natural shape of the breast.
■ The more cohesive and dense silicone gel (fifth generation) allows the
implant to maintain its shape, and resist the natural forces exerted by the soft
tissue envelope.
■ Orientation markings on the device position it properly in the breast pocket.
ANATOMY
■ The breast extends from the 2nd or 3rd rib down to the 6th or 7th rib (cephalad

to caudad) and from the lateral sternum to the anterior axillary line (medial to
lateral).
■ The major blood supply to the breast is from the internal mammary artery.
■ Lateral and anterior branches of the second through sixth intercostal nerves
provide innervation to the skin overlying the breast.
PATHOGENESIS
■ Micromastia occurs as a developmental phenomenon either as primary
mammary hypoplasia or due to chest wall pathology such as Poland syndrome.
■ It may also present as an involutional process, due to weight loss or after
pregnancy and lactation.
■ Micromastia may lead to a negative body image and have a deleterious effect
on quality of life.
■ According to the American Society for Aesthetic Plastic Surgery (ASAPS)
2015 statistics, breast augmentation was the second most common aesthetic
surgical procedure performed, with approximately 306 000 cases.1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Goals and expectations of the patient are discussed in detail during
consultation.
■ A thorough personal and family history is performed.
■ History of any breast disease and breast cancer
■ History of pregnancy
■ Desire for future pregnancy
■ Mammogram: Screening mammogram is obtained for any patient over 35
years of age.
■ Physical examination
■ Current height and weight
■ Current breast size and desired breast size
■ Palpation for any breast masses, lymph nodes, or nipple discharge
■ Observation of breast ptosis and degree of ptosis, and the need for
synchronous mastopexy

FIG 1 • A. Lateral view of a moderate projection (left),
full projection (center), and extra full projection (right)
400 mL smooth round silicone gel implant. As the
projection increases, the height and the width of the
device decrease. B. Moderate height, full projection
(left) and full height, full projection (right) anatomic 420-
mL gel implants as seen from above.

FIG 2 • Three-dimensional photograph of a 24-year-old
female using the VECTRA 3D imaging device. A.
Breast measurements. B. Preoperative frontal, lateral,
and oblique views. C. Simulated images obtained using
a 320-mL shaped implant.
■ Observation of chest wall and breast asymmetries, such as differences in
inframammary fold height, nipple-areolar complex height, breast volume, and
breast shape
IMAGING
■ The authors use the VECTRA 3D imaging and simulation system for all
patients interested in breast augmentation. The device takes a 3D photograph
that can then be visualized in the monitor, with the addition of breast
measurements (FIG 2A,B).
■ Using different implant shapes and sizes, a simulated postsurgical result is

produced, allowing the patients to have a visual image of the outcome (FIG
2C).
■ The use of the VECTRA 3D imaging system provides a high degree of
accuracy for breast volume (90%) and contour (98.4%).2
SURGICAL MANAGEMENT
■ Main objectives of breast augmentation:
■ Enhancement of breast shape and volume
■ Improve self-esteem and quality of life.3 A prospective analysis using the
BREAST-Q showed that breast augmentation is associated with high patient
satisfaction and significant improvements in quality of life.4
■ Main indications for use of a round implant:
■ Desire for a fuller look
■ Good skin quality and overall breast anatomy
■ Concerns about device rotation
■ Main indications for use of an anatomic implant:
■ Thin patients with little breast volume. In this patient population, the final
shape of the breast will be determined by the device itself.
■ Patients with deficiency at the inferior pole
■ Patients with chest height-width disproportions, such as patients who have a
very long, but not very wide chest, or have a very wide, but not very long
chest.
■ Patients with breast asymmetries. By using a variety of heights, widths, and
projections, these asymmetries may be overcome.
■ Patients who do not want a full round upper pole appearance.
■ Main factors to consider when using shaped implants rather than round
implants:
■ Incision length needs to be slightly longer because of the filling material
traits.
■ Orientation: Precise placement of the implant is critical as disorientation will
lead to distortion of the breast shape.
■ Implant height needs to be chosen wisely to avoid overfilling or underfilling
of the upper pole of the breast.
■ Lowering the inframammary fold is important.
• Different methods have been described for the projected postoperative
inframammary fold, including those by Caplin.5

• The authors prefer to use the nipple to inframammary fold at stretch and
the implant width (Table 1).
■ For either type of implant, the main steps of the procedure are the same:
■ Make the incision and aim cephalad with attention not to violate Scarpa
fascia.
■ Create a dual plane.
■ Identify the pectoralis major muscle edge and incise.
■ Create a subpectoral pocket with care not to elevate the pectoralis minor
muscle.
■ Place tester implants (sizers).
■ Exchange tester implants for the formal implants.
■ Close the wound in layers.
Preoperative Planning
■ At the time of consultation
■ Breast measurements
• Breast width at its widest point.
• Nipple to inframammary fold (N-IMF) distance.
• Sternal notch to nipple distance.
• Breast height.
■ Assessment of breast parenchyma and skin
• Elasticity: This is performed with deflection of the skin, and observation for
resistance.
• Pinch test: This is performed at the superior and medial portion of the
breast, between the examiner’s thumb and index finger. A result of less than
2 cm is usually an indication for placement of the implant in the subpectoral
plane.
■ Choice of implant volume. Sizers are placed in a bra and compared to the
images obtained by the 3D imaging.
Table 1 Calculations for Lowering the Inframammary Fold for Anatomic
Implants
Breast Implant Width
Nipple to Fold Distancea
11.0 cm
7.0 ± 0.5 cm
11.5 cm
7.5 ± 0.5 cm

12.0 cm
8.0 ± 0.5 cm
12.5 cm
8.5 ± 0.5 cm
10.0 cm
9.0 ± 0.5 cm
13.5 cm
9.5 ± 0.5 cm
14.0 cm
10.0 cmb
aUnder maximal stretch.
bNo more than 10 cm.
FIG 3 • The markings are made in the preoperative area
and reviewed with the patient. A. Markings for round
implants. B. Markings for shaped implants.
■ Preoperatively, the following markings are made with the patient in the upright
standing position (FIG 3):
■ Midline, from sternal notch to xiphoid

■ Inframammary fold
• For anatomic implants, the projected postoperative fold position is based on
the aforementioned measurements.
■ Superior, medial, and lateral borders of the breast. The medial borders are
marked 1.5 cm lateral to the midline, so as to prevent synmastia
■ Breast meridian
■ Marking of the incision
• For round implants using an inframammary approach, the marking is placed
below the inframammary fold, centered at the breast meridian, most often 4
cm in length, 2 cm medial, and 2 cm lateral to the meridian.
• For shaped implants using an inframammary approach, the marking is
placed at the expected postoperative inframammary fold, centered at the
breast meridian, most often 5 cm in length, 2.5 cm medial, and 2.5 cm
lateral to the meridian.
Positioning
■ The patient is brought to the operating room and placed in the supine position
on the operating table with the arms extended up to 90 degrees and well
secured to the arm boards.
■ The shoulders should be at the same height.
Approach
■ Incision placement
■ Inframammary
• Placement of the incision at the inframammary fold for round implants and
at the expected postoperative inframammary fold for anatomic implants.
• Wide exposure, better visualization
• Easier manipulation of the inframammary fold position
• Easier placement of the implant
■ Periareolar
• Incision is made at the inferior border of the areola
• Scar generally heals well
• Wide exposure
• Approach involves either dissecting straight down through the breast or
creating a lower breast flap to the level of the inframammary fold.
■ Transaxillary

• Incision is placed at the axilla, lateral to the edge of the pectoralis major
muscle
• Hidden scar, not close to the breast
• More challenging pocket dissection
• Natural-appearing results have been reported with this approach and the use
of shaped implants.6
■ Pocket
■ Partial subpectoral
• Submuscular pocket is created with release of the lateral border of the
pectoralis major attachments and its inferomedial attachments.
• Lower part of the implant is covered by the underside of the breast, and
superior part of the implant is covered by the pectoralis major muscle.
■ Subglandular
• Pocket is created between the underside of the breast and the anterior fascia
of the pectoralis muscle.
• Less technically challenging
■ Subfascial
• Pocket is created between the anterior fascia of the pectoralis major muscle
and the muscle itself.
• Additional coverage of the implant provided by the fascial layer.
■ With either type of implant, the authors most often use the inframammary
approach, with placement of the implant in a partial subpectoral plane, and
creation of a dual plane.
■ Alternatively, implants can be placed in the subfascial plane.
T E C H N I Q U E S
■ Inframammary Approach With Partial
Subpectoral Placement and Dual Plane Creation
Incision and Dissection
■ Tegaderm is placed on top of the nipple-areolar complex (TECH FIG 1A).
■ Local anesthesia containing a mix of lidocaine and Marcaine with

epinephrine is injected into the marked incision and as a breast block.
■ The inframammary incision is made sharply through the dermis and the
superficial layer of the fat until Scarpa fascia is encountered (TECH FIG
1B).
■ A double skin hook is placed followed by an Army Navy retractor, and
dissection is continued with bovie electrocautery cephalad with care taken
not to violate Scarpa fascia (TECH FIG 1C).
■ The breast tissue is divided, and the pectoralis muscle fascia is identified
(TECH FIG 1D,E).
■ Suprafascial dissection is carried accordingly to create a dual plane
dissection (TECH FIG 1F).
■ After dual plane dissection, the pectoralis muscle is grasped and divided till
the areolar space under the muscle is identified.
■ A lighted retractor is then placed below the pectoralis major muscle, and
strong upward traction is placed so as to separate the pectoralis major from
the pectoralis minor muscle.
Pocket Creation
■ Pocket dissection is performed with the monopolar electrocautery and
without use of blunt dissection.
■ Submuscular dissection proceeds from medial to lateral in a clockwise
fashion for the left breast and in an anticlockwise fashion for the right breast,
until the pocket is of appropriate size.
■ Care is taken to avoid any contact with the ribs so as to minimize
postoperative pain.

TECH FIG 1 • A. Tegaderm is applied over the nipple-
areolar complex. B. Inframammary incision made to
the level of Scarpa fascia. C. Dissection continues in a
cephalad direction. D,E. After breast tissue division,
the pectoralis major muscle is encountered. F. Dual
plane dissection is performed before proceeding with
pocket creation.

TECH FIG 2 • A,B. The medial origin of the pectoralis
major muscle is identified and will be incised to
achieve lower pole expansion.
■ The medial origin of the pectoralis major muscle is disinserted so as to
achieve adequate expansion of the lower pole (TECH FIG 2).
■ Meticulous hemostasis is achieved.
Implant Placement
■ Tester implants are placed and the patient is placed in the upright seated
position (TECH FIG 3A).
■ If there are areas for additional dissection, these are marked.
■ The pockets are irrigated with triple antibiotic solution.
■ The formal implants are then placed in a sterile manner using the no-touch
technique.
■ The packaging is opened, and the implant is transferred to the Keller
funnel, avoiding any contact with the operating table or the surgeon’s
gloves (TECH FIG 3B–D).
■ A Deaver retractor is used by the assistant to facilitate placement of the
implant (TECH FIG 3E).
Completion
■ Closure is performed in three layers:

■ 2-0 Vicryl is used for the breast parenchyma (TECH FIG 4A,B)
■ 4-0 Monocryl for interrupted deep dermal sutures, followed by a running
subcuticular 4-0 Monocryl suture (TECH FIG 4C)
■ The patient is placed again in an upright seated position for final assessment
(TECH FIG 4D).
■ Paper tape is placed over the incisions (TECH FIG 4E).
TECH FIG 3 • A. Patient in the upright seated position
with tester gel implants placed. B–E. The no-touch
technique incorporating the Keller funnel is used for
placement of the implants.

TECH FIG 4 • A. Deeper layer that will be closed is
grasped with forceps. B. Closure of the deeper breast
tissue is performed before skin closure. C. Skin
closure is performed. D. Patient at the seated upright
position with the formal implants in place. E. Paper
tape placed over the incisions.
■ Inframammary Approach with Subfascial
Placement
■ The technique is similar to the partial subpectoral technique in terms of
marking, incision placement, implant insertion, and closure.
■ The difference pertains to the pocket dissection.
■ The pocket is created between the anterior fascia of the pectoralis major
muscle and the muscle itself, providing an additional layer of coverage for
the implant.
■ The pocket is dissected laterally to the lateral edge of the pectoralis major
muscle.
PEARLS AND PITFALLS

Hemostasis
■ Meticulous hemostasis should be achieved to avoid postoperative
hematoma and an inflammatory response that may lead to
capsular contracture.
Pectoralis
muscle
■ The most inferior medial fibers of the pectoralis major muscle
should be released to avoid a constricted lower pole.
Dual plane
■ Advantage of increasing implant and breast parenchyma interface,
expanding the lower pole, and allowing for changes of the nipple-
areolar complex.
Implant
orientation
■ Proper orientation of shaped implants is verified to avoid
distortion of the shape of the breast.
Implant
placement
■ The no-touch technique is used at all times, to avoid implant
contamination, and excessive force is avoided to prevent damage
of the device.
Incision
placement
■ For round implants, the inframammary incision should be placed
slightly lower in regard to the inframammary fold, to avoid a high
rising scar onto the breast.
Projected
inframammary
fold
■ Lowering of the inframammary fold for anatomic-shaped
implants is performed as needed based on preoperative
measurements.
Dissection
■ Dissection should be accurate to accommodate the implant, and
overdissection should be avoided at all times.
Ribs
■ Contact with the ribs should be avoided, so as to decrease
postoperative pain.

FIG 4 • A. Preoperative frontal and lateral views of a 38-
year-old woman with micromastia (above). B. Images
obtained at 3-month follow-up after subfascial breast
augmentation with a 300-mL smooth round implant with
moderate projection.
POSTOPERATIVE CARE
■ Patients are discharged at the same day of surgery after they recover in the
postoperative anesthesia care unit.
■ Postoperative medications include oral analgesics and a 7-day course of oral
antibiotics.
■ A soft bra is used.
■ Patients are instructed to avoid heavy lifting, no more than 10 lb, for 10 days.
■ Light exercise is permitted starting postoperative day 1. Additional exercises,
such as arm abduction and arm elevation, are encouraged to achieve
stretching of the pectoralis major muscle and to accelerate recovery by

decreasing pain.
■ Patients may shower in postoperative day 1.
■ Manual massage
■ For round implants, manual massage of the implant starts as soon as tolerated
by the patient with the aim to prevent capsular contracture.
■ For anatomic implants, no manual massage is performed.
■ Follow-up appointment is scheduled for day 1, 1 week, 3 weeks, 3 months, 6
months, and 1 year.
OUTCOMES
■ Clinical examples of patients with breast augmentation with round and
anatomic implants are shown in FIGS 4 and 5, respectively.
FIG 5 • A. Preoperative frontal and lateral views of a 24-
year-old woman with micromastia. B. Images obtained
at 3-month follow-up after submuscular breast
augmentation with a 255-mL moderate height, full

projection–shaped implant.
COMPLICATIONS
■ Hematoma formation is rare and ranges from 0.5% to 1%.
■ Infection is rare and occurs in less than 1% of the patients.
■ Double-bubble deformity may occur due to violation of Scarpa fascia at the
level of the inframammary fold, with subsequent caudal migration of the
implant in relationship to the breast mound.
■ Rotation rate with the use of anatomic implants has been reported to be less
than 2.5% at 6 years.7
■ The cause of capsular contracture is inflammation, which in turn may be due
to tissue trauma, bacteria, and blood.
■ The use of the Keller funnel has been shown to lead to a statistically
significant reduction in the incidence of reoperations performed due to
capsular contracture within 12 months of primary breast augmentation.8
■ Shaped, highly cohesive implants have lower rates of capsular contracture.9
■ Anatomic implants have low rates of rupture.10
REFERENCES
1. American Society for Aesthetic Plastic Surgery. 2015 Cosmetic Surgery
National Data Bank Statistics. ASAPS

2. Roostaeian A, Adams WP Jr. Three-dimensional imaging for breast
augmentation: is this technology providing accurate simulations? Aesthet Surg
J. 2014;34:857-875.
3. Swanson E. Prospective outcome study of 225 cases of breast augmentation.
Plast Reconstr Surg. 2013;131:1158-1166.
4. Alderman AK, Bauer J, Fardo D, et al. Understanding the effect of breast
augmentation on quality of life: prospective analysis using the BREAST-Q.
Plast Reconstr Surg. 2014;133:787-795.
5. Caplin DA. Indications for the use of MemoryShape breast implants in
aesthetic and reconstructive breast surgery: long-term clinical outcomes of
shaped versus round silicone breast implants. Plast Reconstr Surg. 2014;134(3
suppl):27S-37S.
6. Sim HB, Sun SH. Transaxillary endoscopic breast augmentation with shaped
gel implants. Aesthet Surg J. 2015;35:952-961.

7. Hammond DC, Migliori MM, Caplin DA, et al. Mentor contour profile gel
implants: clinical outcomes at 6 years. Plast Reconstr Surg. 2012;129:1381-
1391.
8. Flugstad NA, Pozner JN, Baxter RA, et al. Does implant insertion with a
funnel decrease capsular contracture? A preliminary report. Aesthet Surg J.
2016;36:550-556.
9. Maxwell GP, Van Natta BW, Murphy DK, et al. Natrelle style 410 form-stable
silicone breast implants: core study results at 6 years. Aesthet Surg J.
2012;32:709-717.
10. Heden P, Bronz G, Elberg JJ, et al. Long-term safety and effectiveness of
style 410 highly cohesive silicone breast implants. Aesthetic Plast Surg.
2009;33:430-436.

5
CHAPTER
Female to Male
Transgender Breast Surgery
Ann R. Schwentker
DEFINITION
■ Transgender person: individuals who identify with a gender that is distinct
from their assigned sex at birth.
■ Gender dysphoria: emotional stress caused by differences between a person’s
assigned sex and his/her gender identity.
■ Transition: a period of formal transformation of one’s gender identity that may
include changing name, clothing, preferred pronouns, gender-affirming
hormones, and/or surgery.
■ Female to male, trans man: a person assigned female gender at birth who
identifies as male.
■ Male to female, trans woman: a person assigned male gender at birth who
identifies as female.
ANATOMY
■ The anatomy may vary widely, depending on the patient’s body habitus.
■ All patients have excess glandular breast tissue. Other factors that influence
surgical planning include the following:
■ Whether or not there is areolar enlargement
■ Nipple position
■ The amount of skin excess
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The World Professional Association for Transgender Health ()
has published a Standards of Care manual that should be consulted in
determining an individual’s suitability for surgery. In particular, it is desirable

that patients be supported by a mental health professional to manage their
dysphoria.
■ Thorough breast exam including any masses, asymmetry, nipple/areolar size
and position, ptosis, and skin excess.
■ The importance of nipple sensation to the patient should be assessed. All
available techniques may reduce or eliminate nipple sensation and erectile
function1 and make breast-feeding impossible, which may dissuade some
patients.
IMAGING
■ Any masses should be imaged and worked up as for a female with a breast
mass.
■ Patients who above age 45 should have a preoperative mammogram. It is not
possible to remove 100% of breast tissue with this procedure, and patients
should discuss with their medical doctors whether postoperative mammograms
are necessary.
NONOPERATIVE MANAGEMENT
■ Many patients begin transitioning by wearing binders. These can cause chafing
and intertrigo, which should be treated prior to surgery.
■ Patients may experience significant breast gland involution after starting
testosterone therapy. Although this is not sufficient to avoid surgery, it may
alter the surgical plan in small-breasted patients.
SURGICAL MANAGEMENT
■ Insurance coverage for transgender surgery is variable. Comorbidities that may
increase the chance of insurance coverage for surgery include the following:
■ Breast cancer, breast mass, or BRCA positivity
■ Fibrocystic disease with documented intractable pain
■ Intertrigo
■ Symptoms of macromastia
Preoperative Planning
■ Patients with small areolae and very small (A cup) breasts may be candidates
for periareolar mastectomy.
■ If there is significant skin excess, a breast amputation will almost always be
preferable.

Positioning
■ The patient is positioned supine with the arms at 90 degrees and securely
wrapped to arm boards (FIG 1). The table is placed so that the patient can be
moved to a seated position during surgery.
FIG 1 • Intraoperative positioning.
T E C H N I Q U E S
■ Periareolar Mastectomy
■ This results in fewer scars but makes it more difficult to control nipple size
and position.
■ If the areola is small, a semicircular infra-areolar incision is made. This may
also be made within the areola to further camouflage the scar.2
■ If the areola is enlarged or there is slight skin excess, a periareolar donut is
designed and de-epithelialized, with a full-thickness semicircular incision
inferiorly.
■ 3 to 4 mm of breast tissue is preserved on the deep surface of the areola for
blood supply. This dissection is performed sharply.
■ The remainder of the breast gland is separated from the subcutaneous tissue
using primarily blunt dissection at the level of the breast capsule. The gland
may also be detached from the pectoralis fascia on its deep surface using
blunt dissection.
■ Hemostasis is obtained, and a closed suction drain is placed.

■ The incision is closed by gathering the skin around the areola to position the
nipple inferiorly and laterally, using absorbable sutures.
■ Breast Amputation With Free Nipple Grafts
Video p4-c005
■ The large inframammary scar may be positioned at the inferior border of the
pectoralis, and the free nipple grafts allow control of nipple size and position.
■ The nipple is removed as a 28 × 22 mm (or desired shape/size) oval full-
thickness skin graft, thinned, and placed on moist gauze.
■ The inferior incision is marked just below the inframammary fold to be sure
that the retaining ligaments are removed because the fold is a distinctly
female structure. It is horizontal medially and can curve superiorly in its
lateral portion to follow the curve of the pectoralis major muscle.
■ The superior incision is marked by pulling the breast down over the
inframammary fold and transposing the fold anteriorly, taking care to remove
all areolar tissue.
■ The incision should not be extended too far medially or laterally, as extra
dog ears can be addressed with tailoring or an in-office local procedure at a
later date. Ideally, the incision is the width of the pectoralis muscle.
■ The breast gland is removed as in a mastectomy, dissecting at the level of the
breast capsule, preserving all subcutaneous fat and the pectoralis fascia.
Dissection proceeds up to the clavicle.
■ The inferior skin flap is undermined if necessary and advanced to align with
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the inferior border of the pectoralis major muscle. This both hides the scar
and decreases tension on the final closure.
■ The incisions are closed over drains, advancing the dog ears toward the
middle of the breasts to shorten the scars.
■ The nipple position is marked using paper patterns with the patient in the
seated position.
■ The nipple location is de-epithelialized, and the nipples sutured into position
with long Vicryl sutures and fast-absorbing gut.
■ The nipples are dressed with tie-over xeroform bolsters.
PEARLS AND PITFALLS
Nipple position
■ Male nipples vary widely in size and position but are
typically oval (wider transversely), lower, and more lateral
than female.3
■ It can be helpful to have patients bring a photo of their ideal
nipple size/shape/position for planning purposes.
Hematoma/seroma
■ Closed suction drains are used until drainage decreases.
■ Compression (ACE or binder) is used for 6 weeks.
■ Lifting is limited for 6 weeks.
IMF incision
placement
■ It is critical to remove the skin and ligaments of the IMF to
avoid the depression that will result if this is simply released
from the fascia and advanced.
■ The inferior incision can then be advanced as in a reverse
abdominoplasty to allow the incision to align precisely with
the inferior border of the pectoralis muscle, which
camouflages the scar.
Biopsy
■ The removed tissue is biologically female breast tissue and
as such should always be sent for pathologic examination.

FIG 2 • A. Preoperative photograph. Note small areolae
and breasts with limited skin excess. B. Postoperative
photograph of same patient 1 year after periareolar
mastectomy. No areolar reduction was performed. Note
the mild hypertrophic scar on the right, which later
underwent revision.
POSTOPERATIVE CARE
■ Drains remain until drainage decreases below 30 cc in two consecutive 24-
hour periods.
■ Nipple bolsters are left for 10 to 14 days. The nipples are then treated with
Bacitracin and large Band-Aids for another week or until scabbing resolves.
Scar massage begins at 4 weeks.
■ A circumferential ACE bandage is used for 1 week, and then, patients may
transition to binder or spandex undershirt.
■ Lifting and upper body exercise are strictly limited for the first 6 weeks.
Thereafter, bulking up the pectoralis muscles is strongly encouraged, as it
assists with camouflaging the scars.
OUTCOMES
■ Satisfaction in this patient population is generally high1,4 (FIGS 2 to 4).
■ Minor revisions (scar revision, nipple revision, dog ears) are commonly
required.3,4
COMPLICATIONS
■ Hematoma requires urgent return to the operating room and evacuation.3
■ Seroma may often be treated with aspiration and compression. The skin flaps

are anesthetic for several weeks, and this is well tolerated.
■ Nipple loss is extremely rare and generally results from premature loss of
bolsters. Either tattooing or nipple reconstruction may be performed.
■ Hypertrophic scarring is managed with scar massage, Kenalog injection,
and/or revision as indicated.
FIG 3 • A,B. Preoperative photograph. Note large,
heavy, pendulous breasts with enlarged areolae. C,D.
Postoperative photograph of same patient 4 months
after breast amputation with free nipple grafts.

FIG 4 • A,B. Preoperative photograph. Note pendulous
breasts with significant skin excess. C,D. Postoperative
photograph of same patient 1 month after breast
amputation with free nipple grafts. Note that wrinkling of
the medial dog ears has not yet resolved in this early
photograph.
REFERENCES
1. Nelson L, Whallett EJ, McGregor JC. Transgender patient satisfaction
following reduction mammaplasty. J Plast Reconstr Aesthet Surg.
2009;62(3):331-334.
2. Atiyeh BS, Chahine F, El-Khatib A, et al. Gynecomastia: simultaneous
subcutaneous mastectomy and areolar reduction with minimal inconspicuous
scarring. Aesthetic Plast Surg. 2015;39(6):916-921.
3. Beer GM, Budi S, Seifert B, et al. Configuration and localization of the
nipple-areola complex in man. Plast Reconstr Surg. 2001;108(7):1947-1952.
4. Berry MG, Curtis R, Davies D. Female-to-make transgender chest
reconstruction: a large consecutive, single-surgeon experience. J Plast
Reconstr Aesthet Surg. 2012;65(6):711-719.

6
CHAPTER
Section II: Mastopexy
Mastopexy: Periareolar,
Vertical, and Wise Pattern
R. Ter Louw and Scott Spear†
DEFINITIONS
■ Ptosis of the breast is described by the Regnault classification (FIG 1).
■ Grade 1: minor ptosis; the nipple is at the level of the inframammary fold,
above the lower contour of the gland.
■ Grade 2: moderate ptosis; the nipple is below the level of the inframammary
fold, above the lower contour of the gland.
■ Grade 3: major ptosis; the nipple is below the level of the inframammary
fold, at the lower contour of the gland.
■ Mastopexy—masto meaning breast, pexy meaning to lift or fixate.
■ Periareolar mastopexy results in a scar camouflaged in the junction of the
pigmented areolar and unpigmented breast skin.
■ Concentric mastopexy, eccentric, “donut” mastopexy
■ Vertical or circumvertical mastopexy results in a scar camouflaged in the
junction of the pigmented areolar and unpigmented breast skin with a vertical
extension along the breast meridian down toward the inframammary fold.
■ There may be a transverse scar as well if there is too much skin to be tailored
in the circumareolar and vertical components.
■ Wise pattern mastopexy is planned from the outset to result in a scar around
the areola, a vertical extension along the breast meridian down to the
inframammary fold, with a horizontal scar hidden in the inframammary fold.

FIG 1 • Regnault classification of breast ptosis. Grade 1:
nipple-areolar complex at the level of the inframammary
fold. Grade 2: nipple-areolar complex below the level of
the inframammary fold. Grade 3: nipple-areolar complex
at the lowest portion of the breast.
ANATOMY
■ The arterial supply of the breast is predominantly based off internal mammary
perforators and the lateral thoracic artery.
■ Sensation to the nipple is derived from the 4th posterior intercostal nerve.
■ Cooper ligaments suspend the breast, originating on the pectoralis fascia and
inserting into the dermis of the breast.
■ The borders of the breast:
■ Superior—clavicle
■ Inferior—inframammary fold
■ Lateral—latissimus muscle

■ Medial—sternum
PATHOGENESIS
■ Decreased elasticity of breast tissue with aging
■ Hormone-induced inflation and deflation of breast tissue
■ Stretch of Cooper ligaments
■ Deflation of breast envelope following breast feeding
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History
■ Current cup size, height, and weight
■ Childbearing, breast-feeding, and future family planning
■ Personal and familial cancer history
■ Prior breast surgery, biopsies, radiation
■ Date of last mammogram
■ Examination1
■ Regnault classification of ptosis
■ Soft tissue evaluation: skin laxity, density of glandular tissue
■ Soft tissue masses, axillary lymphadenopathy, nipple discharge
■ Critical measurements
• Nipple to sternal notch
• Nipple to inframammary fold
• Breast width
• Nipple to midline
• Areolar diameter
• Patient weight, height, and bra size
■ Symmetry of nipple position and breast size should be noted and mentioned
to the patient in the initial consultation. If present before surgery, asymmetry
will persist postoperatively to some degree.
■ Chest wall deformities as well as the presence or absence of pectoralis major
and latissimus muscles should be noted.
IMAGING
■ A yearly screening mammogram is recommended beginning at age 40, or 10
years earlier than a primary relative’s diagnosis of breast cancer.
DIFFERENTIAL DIAGNOSIS

■ Tuberous breast deformity
■ Pseudoptosis
SURGICAL MANAGEMENT
Preoperative Planning2–4
■ Preoperative planning in the mastopexy patient is critical for obtaining an
aesthetic result.
■ Mastopexies have been the source of a disproportionate amount of litigation,
so the surgeon should not take these operations lightly. Understanding the
indications and limitations for each type of mastopexy will aid in avoiding
trouble.
■ Periareolar mastopexy is most useful in patients who need limited movement
of the nipple-areolar complex.
■ It allows for movement of the nipple-areola complex approximately 2 cm.
Attempting to move the nipple more than 2 cm will result in flattening of the
breast mound.
■ Periareolar mastopexy is ideal for grade 0 or 1 ptosis, glandular ptosis, or in
the setting of combined augmentation mastopexy (FIG 2A,B).
■ Vertical mastopexy is a versatile operation that allows the surgeon to resite the
nipple, regardless of the degree of ptosis, while reshaping the breast mound
and tailoring the skin envelope (FIG 2C–F).

FIG 2 • A,B. Preoperative photographs of an ideal
patient for periareolar mastopexy with grade 1 ptosis
and deflated breast parenchyma. C,D. Preoperative

photographs of a patient with grade 2 breast ptosis with
planned vertical mastopexy and augmentation
mammaplasty. E,F. Preoperative photos of a patient
before undergoing revision mastopexy for treatment of
pseudoptosis. G,H. Preoperative photos of patient with
grade 2 ptosis and asymmetry after mild weight loss.
She requested mastopexy while maintaining breast
volume.
■ Wise pattern mastopexy is typically reserved for patients with significant skin
redundancy that do not want a decrease in breast volume (FIG 2G,H).
■ Patients with nipple to inframammary fold distance of 12 cm or greater may
be good candidates for this procedure, with the trade-off of an additional
horizontal scar under the breast.
■ In vertical mastopexies, the decision to incorporate a horizontal incision is a
function of removing dog ears at the IMF. The true Wise pattern mastopexy
requires marking and committing to the surgical incisions with the patient in
the standing position.
■ The entire Wise pattern incision pattern can be de-epithelialized to maintain
breast volume.
Positioning
■ The patient should be positioned supine on the operating room table with the
hips at the flexion point of the bed to facilitate the sitting position
intraoperatively.
■ The arms may be tucked at the patient’s side or out on arm boards but should
be secured and padded adequately.
T E C H N I Q U E S
■ Periareolar Mastopexy
Planning and Markings
■ The concentric or donut mastopexy is indicated for patients with minimal or

grade 1 breast ptosis.
■ The surgeon should not attempt to achieve an aggressive movement of the
nipple-areolar complex with this technique as it may excessively flatten the
contour of the breast, produce a dilated widened areola, or result in poor
circumareolar scarring.
■ The concentric mastopexy should be applied only to patients with
reasonably aesthetic nipple position within the minimally ptotic breast.
■ If the nipple is not within the breast meridian, eccentric or crescentic
mastopexy should be considered.
■ The patient is marked in the anatomic standing position, with arms at the
sides.
■ The midline, inframammary fold, and breast meridian are marked.
■ The overall breast symmetry and NAC are assessed.
■ The proposed nipple position is transposed from the IMF to the anterior
breast skin.
■ The outer mastopexy circumference is typically marked freehand (TECH
FIG 1A).
■ The outer markings skirt the edges of the areola medially and laterally.
■ The critical upper and lower limits of the typically oval outer periareolar
pattern are determined superiorly by the desired new upper border location
for the superior edge of the areola and inferiorly by the length of skin
desirable to leave between the lower edge of the areola and the IMF
(typically 5–8 cm depending on the size of the breast)

TECH FIG 1 • A. Markings begin by identifying the
midline, inframammary fold, and breast meridian for
each breast. The estimated degree of nipple elevation
is marked at the 12 o’clock position, addressing any
asymmetry in nipple height that may be present.
Finally, the outer diameter of the new nipple areolar
border is drawn, with the skin to be de-epithelialized
shaded in red. B. Three rules to aid preoperative
planning of periareolar mastopexies. (Adapted from
Spear SL, Kassan M, Little JW. Guidelines in
concentric mastopexy. Plast Reconstr Surg.
1990;85(6):961–966.)
■ The inner pattern is usually drawn as a round circle using a “cookie cutter”
pattern of 38 to 42 mm.
■ Basic guidelines for concentric mastopexy described by Spear et al.5
provide guidelines for nipple-areolar marking (TECH FIG 1B).

• First and most importantly: Diameter outside − diameter original should
be equal to or less than (diameter original − diameter inner), meaning it is
preferable to remove more pigmented skin than unpigmented skin.
• Second: Diameter outside should ideally be no more than two times the
diameter inside.
• Third: Diameter final = ½ (diameter outside + diameter inside).
Incisions and Closure
■ A 38- or 42-mm cookie cutter is used to mark the proposed nipple-areola
diameter with the assistant applying mild tension.
■ The inner circle is incised first, followed by the outer circle for efficiency in
using the applied counter-tension.
■ The remaining donut (often eccentric) is de-epithelialized with a no. 10 or 15
blade. The nipple blood supply is adequate from underlying parenchymal
perforators in the native breast unless there is an implant behind the breast.
Thus, a full-thickness skin incision may be made circumferentially.
■ Limited superficial circumferential subcutaneous undermining with
electrocautery can be performed to decrease tension with closure.
■ Closure needs to be carefully done and meticulous and is performed with
each suture bite directly opposite to the previous other side to equally
distribute areolar tissue along the larger outer diameter.
■ If areolar widening is a concern, a carefully placed permanent purse string or
wagon wheel (eg, Gore-Tex) suture may be used.
■ Mild periareolar wrinkling is common in the immediate postoperative
period, but routinely settles in 1 to 2 months.
■ Severe wrinkling or puckering implies poor closure technique or overly
aggressive skin excision.
■ Vertical Mastopexy
Planning and Markings6,7
■ The addition of a vertical incision to the mastopexy significantly increases
its utility.
■ Vertical mastopexy can adequately correct all grades of ptosis.
■ The patient should be marked in the standing position and should begin with
midline, IMF, and breast meridian (TECH FIG 2A,C,F).

■ The breast meridian marking should be carried inferiorly onto the patient’s
abdomen, as it will aid in placement of the vertical mastopexy markings
(TECH FIG 2B).
TECH FIG 2 • Preoperative marking photographs of a
vertical mastopexy in a patient with grade 2 ptosis. A.
The markings begin with midline, breast meridian, and
inframammary folds. Next, the vertical mastopexy
incision is marked by placing the superior most part of
the keyhole incision approximately 2 cm above

proposed nipple position or the IMF. B. The inferior
part of the vertical incision stops 2 cm above the IMF.
C–E. Preoperative markings for a third patient, who
was undergoing vertical mastopexy with
augmentation. C. Preoperative markings begin with
marking the midline, breast meridian, the
inframammary fold, and the proposed nipple position.
The upper border of the breast tissue marked with the
dotted black line. The proposed location of the upper
border of the implant is estimated 8 to 10 cm below
the clavicle. D. Moderate tension is placed on the
breast skin to cone the breast and estimate the width
of skin to be excised from the vertical extent of the
vertical mastopexy. E. After the pinch test, the vertical
incision is then drawn and stops 2 cm above the
inframammary fold. F. Preoperative markings for in a
different patient undergoing vertical revision
mastopexy for treatment of pseudoptosis begin with
midline, breast meridian, and inframammary folds in
black marker. Midline 1-cm increments are marked
from IMF in the superior direction to aid with improving
symmetry of nipple position. Finally, the vertical
mastopexy is incision marked with the inferior most
point stopping 2 cm above the IMF.
■ The proposed nipple position is transposed from the IMF to a comparable
point on the front of the breast bilaterally.
■ The new nipple position should then be measured for symmetry.
■ Periareolar markings can be drawn with the aid of a keyhole or freehand.
■ The vertical component is marked by medial and lateral displacement of
the breast (TECH FIG 2D,E). By gently displacing the breast laterally, the
medial vertical incision can be marked at the breast meridian. Likewise, the
breast is displaced medially, and the lateral vertical incision can be marked
at the breast meridian.

■ If the patient is also undergoing augmentation, the proposed upper border of
the implant is marked as well, as shown in TECH FIG 2C–E.
Incisions and Closure
■ A vertical mastopexy incision popularized by Lejour is described here.3,8
■ First, a 38- or 42-mm cookie cutter is used to mark the nipple.
■ It is incised with a no. 10 or 15 blade followed by incision of the outer
periareolar marking (TECH FIG 3A).
■ The incision is carried to the level of the dermis.
■ The intervening skin segment is de-epithelialized with preservation of the
subdermal plexus (TECH FIG 3B).
■ The vertical incisions can then be carried out through the dermis.
■ When glandular rearrangement is planned, electrocautery is used to
vertically incise the glandular tissue to the level of the chest wall.
■ The gland is then elevated off of the chest wall from medial to lateral.
■ Attention is then paid to creating skin flaps in the plane between breast
parenchyma and subcutaneous fat along the vertical mastopexy incision.
■ Medial and lateral glandular pillars have been created and may be used for
autoaugmentation of the breast (TECH FIG 3C).
■ Rotation of the medial or lateral glandular pillar in the subglandular plane
moves the ptotic breast tissue to a more aesthetically pleasing position.

TECH FIG 3 • A. Intraoperative photograph following
nipple incision guided by 42-mm cookie cutter. Incision
around nipple with 42-mm cookie cutter and incision
around the planned periareolar de-epithelized portion.
B. Intraoperative photograph after de-epithelialization.
The remainder of the skin within vertical mastopexy
incision may be excised just below level of the dermis.
C. Medial and lateral parenchymal pillars are created
to allow for autoaugmentation of the breast. D.
Demonstration of a periareolar wagon wheel Gore-Tex
suture technique to prevent widening of the nipple-
areolar complex.
■ The pillars are then approximated with 2-0 PDS to shape the breast mound.
The skin is approximated with staples, and the patient is brought to sitting
position on the operating room table for visual inspection.
■ The periareolar incision may be closed with a regular or interlocking

pursestring Gore-Tex suture if areolar widening is a concern (TECH FIG
3D).
Other Techniques
■ The standard vertical mastopexy relies upon glandular pillars and skin for
support. The Graf technique uses a chest wall–based, inferior glandular flap
to augment the upper pole.
■ The glandular flap is passed through a sling of superficial two-thirds of
pectoralis muscle to provide further support.
■ Its utility and longevity are well described by Graf et al.9
■ Acellular dermal matrix (ADM) is well established in the setting of breast
reconstruction. ADM is yet another option for providing support to the
glandular pillars, or it can be used in lieu of the pectoralis loop for support in
the Graf procedure.
■ The parenchymal pillars are sewn together with absorbable suture.
■ Then ADM is fashioned to the lower pole under mild tension to help
support the breast mound (TECH FIG 4).
TECH FIG 4 • A. Intraoperative view of medial and
lateral pillars being sutured together with absorbable
monofilament suture. B. Intraoperative view
demonstrating medial and lateral pillars sutured
together. C. The pillars are supported with an inferior
sling of acellular dermal matrix to prevent the
recurrence of pseudoptosis or “bottoming out.”
■ Wise Pattern Mastopexy
Planning and Markings
■ The planned inverted T incision pattern allows for resection of redundant

skin and glandular tissue in patients with more significant ptosis.
■ This technique is similar to the Wise pattern used in reduction
mammaplasty, with the goal to primarily reshape the breast mound, rather
than reducing the volume.
■ The patient is marked in the anatomic standing position, with arms at the
sides (TECH FIG 5).
TECH FIG 5 • Preoperative markings for Wise pattern
mastopexy begin by marking the midline, breast
meridian, upper border of the breast, and
inframammary folds in black marker. The
inframammary fold is then transposed anteriorly onto
the breast skin to estimate nipple placement. This is
represented by the lower horizontal dotted black line.
The keyhole breast template is used to mark new
nipple diameter and vertical incision, also in black
marker. The red marker represents the
dermoglandular pedicle, which will be de-epithelialized
to maintain nipple blood supply.
■ The midline, inframammary fold, and breast meridian are marked, and
overall breast symmetry and NAC is assessed.
■ The proposed nipple position is transposed from the IMF bilaterally. The
top of the proposed areola is marked 2 cm above the new nipple position.
The keyhole marker is used to trace the periareolar incision.