The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part XI  Breast Surgery
Pectoralis major muscle
Implant
Pectoralis major muscle
Implant
When a breast implant is placed under the pectoralis major muscle with little or no
release in an attempt to provide maximal muscle coverage to reduce the potential of
capsular contracture, the implant can be located too high in relation to the position
of both the breast and the nipple-areola complex. The result is an unaesthetic breast
contour with a rounded upper pole and a nipple-areola complex position that is too
low. When the pectoralis muscle is released along the inferomedial border, the im-
plant can then be positioned lower on the chest wall under the ptotic breast mound
to create a more pleasing contour with a properly positioned nipple-areola complex.
However, in these cases, the muscle may then only cover a small portion of the im-
plant, leaving the device in a space that is mostly subglandular.
Thus it is reasonable to question the utility of placing the implant in the submuscu-
lar pocket at all in an attempt to reduce the rate of capsular contracture, since most
of the implant is in fact in contact with the gland. Therefore, in patients with ade-
quate thickness of soft tissue in the upper pole of the breast, generally regarded as
2 cm or more, the subglandular pocket can be used to good effect. In fact, subglan-
dular implant placement can have a slightly more prominent nipple-areola complex

elevating effect than even partial subpectoral placement, because all of the projec-
tion of the implant is applied in an unrestricted fashion to the overlying soft tissue,
with a mild lifting effect on the nipple position. Many surgeons favor the subglan-
dular pocket as a means of providing maximal lift in augmentation mastopexy, be-
cause placing the implant under the muscle can limit the projection of the device
somewhat, resulting in less elevation of the nipple-areola complex. However, in pa-
tients with a thinner soft tissue thickness in the upper pole of the breast (less than
2 cm), the lifting effect of subglandular placement must be weighed against the cre-
ation of a sharp step-off in the upper pole. In these patients, the breast-implant in-
terface in the upper pole can be softened by placing the implant in the subpectoral
pocket to create a more natural contour, even though the muscle covers only a small
portion of the implant. For such patients, shaping the upper pole takes precedence
over concerns regarding the lift effect of the implant, and the partial subpectoral
space is the preferred pocket for implant placement in thinner patients.
Operative Technique
Periareolar Approach
When contemplating periareolar techniques to assist in the management of the patient
with breast ptosis, one must realize that periareolar approaches are excellent tech-
niques for lifting the position of the nipple-areola complex, but they are much less
successful for reducing a redundant skin envelope. When a periareolar approach is
used to try to reduce the skin envelope while lifting the position of the nipple-areola
complex, because of the size of the resulting periareolar defect it is likely that com-
plications will develop, such as wound healing, distortion of areolar shape or size,
flattening of breast projection, and/or unaesthetic scar formation. For this reason,
performing a periareolar nipple-areola complex lifting procedure in conjunction with
an augmentation is limited to patients who generally need 3 cm or less of nipple-
areola complex lifting. Such patients can be treated quite consistently and success-
fully using a periareolar approach. In fact, this subset of patients probably falls out
of the augmentation mastopexy category, typically recognized as being technically
challenging and prone to complications, because adding a small periareolar lift to a
breast augmentation using a periareolar incision is not a technically challenging pro-
cedure and is easily done. With that in mind, there are several technical maneuvers
that can be applied to periareolar surgery that can help ensure success.
Periareolar Purse-String Suture
One of the recognized complications related to periareolar surgery is postoperative
areolar spreading. This tendency of the areola to spread can be minimized in two
ways. First, it must be recognized that the areolar dermis is quite elastic, and a given
areolar diameter diagrammed into a relaxed native areola will stretch many mil-
limeters once it is placed under tension by an unsupported periareolar closure. For
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Chapter 66  Augmentation Mastopexy

this reason, any time an areolar diameter is diagrammed as part of an areolar re-
duction or lifting procedure, the intended diameter must be measured with the are-
ola under maximal stretch to limit the effect of immediate stretch on the resulting
postoperative areolar diameter. In a related fashion, any time a periareolar manipu-
lation is attempted, it is advisable to make the periareolar defect completely peri-
areolar to minimize asymmetrical forces from distorting the shape of the areola. One
example of this is the use of a crescent-shaped superior areolar resection in an at-
tempt to lift the areola without creating a completely periareolar scar. The unfortu-
nate result of such a procedure can be lifting of the areola at the expense of creating
a distorted and vertically oblong areolar shape.
Second, once the periareolar defect has been created, it must be supported with a
permanent purse-string suture. By supporting the outer periareolar defect with a
purse-string suture, the stress of the closure is absorbed by the purse-string, thus re-
lieving the tension on the areola as it rests within the defect defined by the purse-
string as it is closed down. Although many types of sutures can be used for this pur-
pose, two design attributes of the suture become important in providing long-term
success. First, a permanent suture material is much more reliable; the long-term sup-
port provided by a permanent suture allows the new soft tissue relationships created
in the postoperative breast to stabilize over time, reducing the tension on the areola.
Therefore, even if the suture fails after a year or more, the likelihood of areolar spread-
ing is minimized because of scar support of the closure, in addition to whatever soft
tissue accommodation has taken place over time. If an absorbable suture is used for
this purpose, disintegration of the suture with loss of support can occur before the de-
fect has stabilized, possibly leading to areolar spreading. Second, a monofilament su-
ture offers technical advantage when the suture is cinched down, since it slides
through the outer dermal diameter more easily without catching or bunching. Per-
haps the best material currently available that satisfies both of these concerns is su-
ture made of a polytetrafluoroethylene (PTFE) material, otherwise known as Teflon.
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Part XI  Breast Surgery
PTFE or Teflon suture is commonly used in cardiovascular and dental surgery be-
cause of its handling characteristics and nonreactivity. It is a permanent, strong,
monofilament suture with little “memory” and smooth handling characteristics, all

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Chapter 66  Augmentation Mastopexy
of which makes it the ideal material to use as a purse-string suture. It slides through
the tissue matrix of an outer periareolar incision smoothly, allowing precise control
of the size of the periareolar defect. By cutting the curved needles of a standard car-
diovascular suture strand and threading the suture onto a Keith needle, passage of
the suture can be facilitated, allowing the strand to be placed in the fewest number of
passes possible. Currently PTFE suture is available from several manufacturers in
several different sizes. There is an advantage to using a suture strand that is roughly
the size of a standard 3-0 suture attached to a straight (Keith) needle.
Interlocking Purse-String Suture
In an attempt to further stabilize the periareolar defect and minimize postoperative
areolar spreading, an interlocking purse-string suture can be used.
This patient presented for revision after a previous periareolar augmentation mas -
to pexy. The interlocking suture technique is planned to control the size and shape
of the areola. A 40 mm areolar diameter is diagrammed with the areola under max-
imal tension and the inner and outer incisions are made. The intervening skin is deep-
ithelialized and the location for the dermal incision designed to leave behind a small
dermal cuff is made. After release of the dermis, the defect can be seen to enlarge
slightly.

Eight matching and evenly spaced points are marked on the areolar and periareolar
incision lines. The PTFE suture is woven into the defect connecting the outer dermal
cuff with small bites of the areolar dermis at eight evenly spaced points. The PTFE
interlocking purse-string suture is cinched down to the desired diameter. Final clo-
sure is performed with a subcuticular absorbable monofilament.
In this technique, the same PTFE suture used in a standard purse-string technique is
chosen; however, at eight evenly spaced locations around the periareolar defect, a
small bite of the areolar dermis is incorporated into the placement of the suture.
When the purse-string is cinched down, the areolar dermis is “locked” into the peri -
areolar closure in a way that further stabilizes the dimensions of the defect and there-
fore the dimensions and shape of the areola. This technique has proved a very use-
ful adjunct to periareolar surgery and provides secure, consistent control over the
size and shape of the areola.
Markings
In preparation for periareolar mastopexy, the patient is marked in the upright posi-
tion. The most important decision to be made is where to position the top of the are-
ola. Quite simply, this becomes an artistic determination. By grasping the areola with
the index finger and the thumb at the point at which the superior areolar incision
will be made, the areola can be lifted in relation to the remainder of the breast. The
areola is lifted just to the point where it is positioned at the point of maximum pro-
jection in relation to the breast mound, and this point is marked. The areola is then
allowed to fall and the magnitude of the areolar lift can then be seen. By gently curv-
ing an oval around the medial, inferior, and lateral extent of the existing areola, the
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Part XI  Breast Surgery

dimensions of the periareolar pattern can then be determined. The marks are applied
on each breast with care to ensure that the top of each pattern is symmetrically lo-
cated from side to side.
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Chapter 66  Augmentation Mastopexy
To determine the top of the periareolar pattern, the superior aspect of the proposed
periareolar incision is grasped and manually lifted up to the desired location. After
marking the top of the periareolar pattern, the remainder of the incision is curved
around the medial, inferior, and lateral extent of the existing areola to set the final
pattern. It typically assumes the shape of an elongated oval.
Surgery
At surgery, the proposed areas of deepithelialization are infiltrated with a dilute so-
lution of lidocaine with epinephrine to provide a vasoconstrictive effect and minimize
bleeding. The areola is maximally and evenly stretched out to allow a 40 to 44 mm
areolar diameter to be marked with the aid of a multidiameter areolar marker. The
inferior half of the proposed areolar defect is incised and a small strip of dermis along
the inner aspect of the incision is deepithelialized. The exposed dermis along the inside
rim of the periareolar incision is then divided with Bovie cautery in such a way as to
create a 5 mm dermal shelf. This shelf will serve as a very strong architectural frame-
work to support the eventual purse-string suture. Access to the breast is obtained ei-
ther by dissecting directly through the breast or by following the breast fascia infe-
riorly and curving down and around the breast to the level of the inframammary
fold. There is theoretical advantage to using the inferior approach, since dissecting
directly through the breast may expose the prosthesis to bacterial contamination
from divided breast ducts, which potentially predisposes the breast to capsular con-
tracture formation. Once the underside of the breast had been reached, any desired
breast pocket can be developed. Care must be taken to ensure that the inframam-
mary fold is properly positioned and the pocket is developed to the desired limits.
At this point, either the final implant or a sizer is inserted into the breast pocket and
the proposed periareolar closure is temporarily stapled into position. With the pa-
tient placed in the upright position, adjustments in the elevation of the nipple-

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Part XI  Breast Surgery
areola complex can be made as needed to create the desired result. Once the final
pattern is determined, the remainder of the periareolar defect is deepithelialized and
the dermal shelf is created around the entire defect. An interlocking PTFE suture is
placed and the areola is inset, with final closure with a subcuticular 4-0 absorbable
monofilament suture.
Thus the volume of the augmented breast is set first, then the degree of final lift is
determined. By sequencing the procedure in this fashion, the ability to adjust not
only the volume of the implant, but also the final position of the nipple-areola com-
plex is maximized, and miscalculations in either variable can be minimized. This ap-
proach is particularly useful in cases of preoperative asymmetry of the nipple-areola
complex. By adjusting the position of each nipple-areola with the pocket dissected
and the implant in place, the final position of the nipple-areola complex can be set in
a controlled, predictable fashion.
This 35-year-old woman requested a periareolar augmentation mastopexy. Her pre-
operative markings show that the top of the areola will be lifted 3 cm to a point es-
timated to be 6 cm above the inframammary fold. This marking pattern is common
for patients who present for augmentation mastopexy. The existing nipple position is
1 to 2 cm above the inframammary fold line. I placed 350 cc high profile smooth
round silicone gel implants in the subglandular plane. Her 1-year postoperative re-
sult is shown.

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Chapter 66  Augmentation Mastopexy
Circumvertical Approach
When a periareolar approach will not be sufficient to provide the desired result, a
circumvertical pattern is required. In these cases, a tailor-tacked vertically oriented
inferior pole skin takeout is added to the periareolar pattern. This technique allows
lifting of the nipple-areola complex, narrowing of the breast base diameter, and
restoration of breast projection. Compared with the periareolar technique alone, the
circumvertical pattern is a very effective method that can be used to not only lift the
nipple-areola complex but also to reduce an excessive and ptotic skin envelope. This
technique is so powerful that the need to resort to the use of an inverted-T pattern
to manage the skin envelope is greatly reduced.
At times it can be difficult to predict preoperatively when a periareolar pattern will
be sufficient to provide the desired result as opposed to when the addition of a ver-
tical segment will be required. Simply put, whenever a vertical inferior pole skin
tightening results in improvement of the breast contour, it is wise to add it. This
school of thought values shape over scar and it must be recognized that the vertical
scar more often than not heals in an imperceptible fashion when evaluated over time.
In most instances, the improvement in the shape of the breast and the reduction in
stress that is placed on the periareolar closure more than make up for the disadvan-
tage of having to add the vertical scar. Familiarity with the CV pattern is one of the
most powerful skills an aesthetic and reconstructive breast surgeon can acquire.
This 36-year-old woman presented for periareolar augmentation mastopexy with a
smooth round silicone gel implant. The preoperative marks are shown; note that
both nipples lie below the level of the inframammary fold.

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Part XI  Breast Surgery
A right capsulectomy and a bilateral periareolar revision were performed. The
9-month postoperative result shows persistent mild periareolar distortion.
The 1-year postoperative result shows mild widening of each areola, along with a
mild capsular contracture on the right.
A bilateral periareolar scar revision was planned using the interlocking PTFE suture
technique.

The areola was incised at 40 mm and the dermal shelf created. The interlocking su-
ture was marked, and the PTFE suture was attached to a Keith needle. The inter-
locking suture in shown in place, cinched down to the desired diameter. The final
closure is shown.
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Chapter 66  Augmentation Mastopexy
The patient’s original lateral pre-
operative appearance and her final
7-month postoperative appearance
are shown.
The final result at 7 months is shown, with correction of the periareolar distortion.

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Part XI  Breast Surgery
Markings
As with the periareolar pattern, the patient is marked in the upright position. The
top of the periareolar pattern is determined as before, and implant size and location
is estimated based on the patient’s wishes. The vertical segment is added by simul-
taneously lifting the position of the nipple-areola complex to the desired location,
then pinching the skin of the lower pole together in a vertical line extending directly
down from the bottom of the areola to the inframammary fold until a pleasing shape
is created.
This 47-year-old woman presented for bilateral augmentation mastopexy; the cir-
cumvertical technique was planned. Circumvertical marks are shown. Note that the
top of the periareolar pattern is positioned 6 cm above the inframammary fold line.
By drawing in the medial and lateral extent of this proposed skin excision, the gen-
eral position of the vertical segment is estimated. The final vertical pattern will be
determined intraoperatively once the implant is in place. However, identifying the
general location of the vertical segment in this fashion allows an access incision to
the breast to be drawn that will ultimately fall within the segment of skin that will
be removed. Using this strategy allows free access to the breast for developing the
pocket and positioning the implant without any concern about creating an addi-

tional cutaneous scar. With this in mind, a line is drawn within the center of the pro-
posed skin excision, and it is this incision that will serve as the access portal to the
breast to develop the pocket and place the implant. For more excessive skin envelopes,
the inferior aspect of the vertical excision will curve out laterally along the infra-
mammary fold rather then extend down below the fold. In these patients, the pat-
tern assumes more of a canted V or a tornado-funnel shape, as opposed to a sym-
metrical V extending straight down the meridian of the breast. By curving the incision
out laterally, more skin can be removed for a better breast shape without any of the
wound-healing difficulties associated with traditional vertical skin patterns.
Surgery
As with the periareolar approach, all of the areas that will either be incised or deep-
ithelialized are infiltrated with a dilute solution of lidocaine with epinephrine. The
procedure is begun by first incising through the previously marked vertical skin in-
cision. The desired pocket is created with care to preserve the location of the infra-
mammary fold. The implant can then be inserted or, perhaps more preferably, a sizer
can be used to add the desired volume to the breast. With the sizer or implant in
place, the skin pattern as it was drawn preoperatively is tailor-tacked into place with
staples and the patient is placed in the upright position, preferably all the way up to
90 degrees, if possible. This maneuver provides a very accurate assessment of the
shape of the breast and the position of the nipple-areola complex. At this point, any
alteration that is required to optimize the result can be made. Changes in the volume
or projection of the implant, further defining of the pocket, or alteration of the po-
sition of the nipple-areola complex can all be made to provide the most shapely and
aesthetic result possible.
As with a periareolar augmentation mastopexy, the operative strategy is to finalize
the volume addition first and then tailor the skin envelope to fit this new breast size.
Sequencing the procedure in this fashion provides a controlled and highly repro-
ducible procedure that will minimize the likelihood of complications. Once these de-
cisions have been finalized, the borders of the proposed skin takeout are marked with
a surgical marker and the staples are removed after returning the patient to the supine
position. The borders of the skin pattern, including the periareolar as well as the ver-
tical components, are incised and the redundant skin deepithelialized. The same
5 mm dermal shelf used in periareolar procedures is created and the final implant is
inserted. The vertical incision is closed in layers using an absorbable 4-0 monofila-
ment suture. The patient is then returned to the upright position and the shape of
the resulting periareolar defect is assessed. If it is not circular at this point, the open-
ing is redrawn to approximate a perfect circle, and additional skin is deepithelial-
ized as needed. Finally, an interlocking PTFE suture is placed to control the periare-
olar defect, and the areola is inset with a running subcuticular 4-0 absorbable
monofilament suture to complete the closure. The wounds are dressed with tissue
adhesive (Dermabond) and covered with an occlusive dressing (Opsite).
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Part XI  Breast Surgery
Once the pocket has been developed and the sizer or implant has been placed, the
skin pattern is tailor-tacked into position to assess the shape and size of the breast
(left).
After assessing the desired result, the edges of the plicated skin envelope are marked
with a surgical marker and the staples removed (right). Here, the pattern can be seen
to curve laterally along the inframammary fold just slightly because of the excess of
the skin envelope. At the base of the pattern, the access incision used to create the
pocket can be seen. Note that this incision falls within the confines of the vertical
pattern that will be removed.
The redundant skin is deepithelialized and the final implant inserted into the pocket.
The access incision is securely closed to prevent implant herniation as well as inad-
vertent lowering of the inframammary fold.

The areolar and periareolar margins are marked in preparation for placement of the
interlocking PTFE suture. The PTFE suture is woven into the defect in an interlock-
ing fashion, aligning the eight fixation points as accurately as possible. The final clo-
sure is completed.
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Chapter 66  Augmentation Mastopexy
The appearance of the right breast is shown after a 200 cc round smooth silicone
gel implant was placed in the partial subpectoral pocket in conjunction with a
circumvertical skin tightening. The difference in the appearance of each breast is
readily apparent. The immediate appearance after operative correction of both breasts
is also shown.
The early postoperative appearance reveals an aesthetic breast shape with good sym-
metry; the nipple is positioned at the apex of the breast mound created by proper
positioning of the implant beneath the breast.

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Part XI  Breast Surgery
A bilateral circumvertical augmentation mastopexy was planned for this 44-year-old
woman. Preoperative marks are shown; note that the top of the periareolar pattern is
marked 6 cm above the inframammary fold line.
Her results are shown 1 year postoperatively.

Postoperative Care
The patient dons a support brassiere after surgery and is advised to wear the gar-
ment for at least the first week. When anatomically shaped implants are used, the
support garment takes on greater importance, because the external support can help
to hold the asymmetrical implant in the proper position while the pocket matures.
In these cases, the patient is advised to wear the garment continuously for 6 weeks.
No special straps, bands, or other external breast-shaping devices are required, since
proper execution of a sound surgical plan will provide the desired result. Patients
are seen 1 week postoperatively, when sutures are removed, and then at 6 weeks,
6 months, and 1 year. Typically the result will have matured by 6 months; however,
full scar maturation can take a year or longer.
Complications
Using the described approach will afford the operating surgeon the maximal con-
trol over the final result and complications should be few. However, it is the nature
of the procedure that complications may develop. As noted previously, it is useful to
view augmentation mastopexy as more of a reconstructive procedure rather than a
strictly controlled and focused aesthetic procedure such as primary breast augmen-
tation. As a result of the increased number of variables that are being manipulated,
the complexity of the procedure is greater and it is unavoidable that complications
will develop. By doing the two components of the procedure together, however, the
majority of the work is accomplished at the first procedure. Therefore, when problems
do develop postoperatively, they are typically of less magnitude and are easier to treat
then when the operation is staged. Although common complications inherent in any
breast procedure such as infection, hematoma, delayed healing, capsular contracture
and unattractive scarring may develop, there are several complications that are unique
to augmentation mastopexy that merit specific mention.
Loss of Shape
Patients with breast ptosis severe enough to require mastopexy are a self-selected
group of patients who are prone to postoperative settling of the skin envelope. In
particular, patients who have undergone a large (more than 50-pound) weight loss are
particularly prone to this problem. As well, simple aging or postoperative changes
in weight, either up or down, can affect how the skin envelope complements the un-
derlying volume of the implant. In each instance, ptosis of the breast parenchyma,
the skin envelope, or the nipple-areola complex can become progressively worse over
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Part XI  Breast Surgery
time to the point where the shape of the breast is adversely affected. Typically, the
implant will appear superiorly malpositioned on the chest wall with the soft tissue
of the breast variably falling off the bottom of the inferior pole. It should be noted
that these changes can occur whether the procedure is performed as a combined pro-
cedure or is done using a staged approach. Whatever the circumstance, typically all
that is required to correct the deformity is to reapply the skin pattern using a tailor
tack approach. Often the procedure can be performed using only local anesthesia.
By retightening the skin envelope, the harmony of the breast with the breast implant
can be restored creating a pleasing breast shape. It should be noted that mild cap-
sular contracture can often contribute to an altered breast shape postoperatively. In
these cases, it is important to treat the capsular contracture first and then retailor
the skin envelope to provide the optimal result. Typically the amount of skin retai-
loring required to reshape the breast is minimal and easily done compared to the ini-
tial procedure and retightening the skin envelope is a straightforward operation. It
is the unusual patient who requires a third skin tightening although such a proce-
dure would be easily performed. The advantage of using the circumvertical pattern for
these patients is that the pattern used to retighten the skin envelope is the same as
was used initially, therefore no new scar is created. Such patients serve as an exam-
ple of how powerful the C-V pattern is when used as a breast-shaping technique.
This 34-year-old woman is shown several years after undergoing a periareolar aug-
mentation mastopexy. The position of her nipple-areola complex is low, and much
of the breast has descended inferiorly off the lower pole of the implant. Preoperative
marks show the plan for circumvertical tightening of the skin envelope without ma-
nipulating the implant. The 1-year postoperative result demonstrates an aesthetic im-
provement in the appearance of the breast.

Over several years, the patient had a mild weight gain and seemed to develop a dis-
proportionate increase in the size of her breasts. Although the shape of her breasts
was acceptable and the position of the nipple-areola complex was correct, she wanted
a smaller breast size.
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Chapter 66  Augmentation Mastopexy
Preoperative marks are shown in preparation for an implant exchange; a mild cir-
cumvertical skin tightening was planned in anticipation of the creation of a mildly
redundant skin envelope as a result of placing a smaller implant.

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Part XI  Breast Surgery
The 1-year postoperative result shows mild areolar asymmetry. A repeat circumver-
tical skin tightening was planned using the interlocking PTFE technique.
The 1-year postoperative result is shown. This case demonstrates the utility of the cir-
cumvertical pattern in managing several different postoperative concerns without the
need to create additional scarring, yet it provides exacting control over the final result.

Asymmetry
For the same reasons noted for the loss of breast shape, it should not be a surprise
that a small asymmetry in the shape or size of the breast or nipple-areola complex
can develop postoperatively. Fortunately, correction of these asymmetries is just as
straightforward. Because most of the work was done at the first procedure, the gen-
eral relationship between the skin envelope and the implant can be seen directly once
the result has stabilized. It then becomes a straightforward procedure to exchange
an implant as needed, to lift or tighten the skin envelope, or reposition the nipple-
areola complex using the interlocking PTFE technique. Such procedures are easily
performed individually or together, and restoration of an aesthetic, symmetrical
breast shape is usually easily performed.
Areolar Distortion or Widening
Problems with the size, shape, or position of the nipple-areola complex are compli-
cations specific to augmentation mastopexy. Fortunately, the interlocking technique
has a particular advantage in these cases. Because scar has formed around the peri-
areolar closure, the elasticity of the surrounding tissues is typically reduced. As a re-
sult, redoing the periareolar closure with or without a reduction in the size of the
areola is facilitated, since the scar tends to hold the PTFE suture with a greater se-
curity than the dermal shelf created at the initial procedure. Also, the magnitude of
the change in the diameter of the areola is usually less significant in a revision pro-
cedure; therefore less stress is placed on the periareolar closure.
One caveat to redoing an areolar closure relates to the shape of the breast. If the pro-
jection of the breast is flattened as a result of the periareolar incision or the dimen-
sions of the periareolar defect are greater than 8 to 10 cm, it may be wise to add a
vertical component to the skin pattern. This maneuver will tend to counteract the
propensity of the breast to flatten and will help restore projection. The dimensions
of the periareolar defect will become less significant, and stress on the periareolar
closure will be reduced. As with other skin envelope complications, such revisions
are easily performed and can often be done with a local anesthetic with a high de-
gree of control and predictability.
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Part XI  Breast Surgery
Results
This 43-year-old woman sought augmentation mastopexy. She had ptosis of the
nipple-areola complex but did not want any type of vertical scar. The preoperative
marks for periareolar augmentation mastopexy represent the limit to what can be
done successfully using only a periareolar approach. The patient is shown 6 months
after placement of 300 cc round smooth silicone gel implants in the subglandular
plane. The size and shape of the breasts are acceptable, and the nipple-areola com-
plex is at the point of maximal projection. However, the aesthetics of the periareolar
scar have been compromised because of the magnitude of the periareolar lift. To
avoid such areolar distortion would have required the use of a vertical segment in
addition to the periareolar component.

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Chapter 66  Augmentation Mastopexy
This 41-year-old woman requested an augmentation mastopexy. Not only did her
nipple-areola complex require lifting, but also the skin envelope needed to be re-
duced. Therefore a circumvertical pattern was planned to manage the skin envelope.
The preoperative marks show the degree of lift for the nipple-areola complex. On
the right, a 275 cc smooth round silicone gel implant was placed subglandularly,
and a 250 cc implant was placed on the left. She is shown 2 years postoperatively;
a full, rounded breast has been created, with the nipple located at the apex of the
breast mound.
Concluding Thoughts
Augmentation mastopexy is one of the most challenging of all aesthetic breast pro-
cedures. However, with careful planning and judicious management of the redun-
dant skin envelope, excellent results can be obtained in one operation.

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Part XI  Breast Surgery
Clinical Caveats
 Periareolar mastopexy should be limited to patients who predominantly need lift-
ing of the nipple position, preferably a lift of 3 cm or less.
 The circumvertical approach is appropriate for patients who require reduction of
an excess skin envelope in addition to lifting of the nipple.
 The interlocking suture technique provides extra control over the position, size,
and shape of the areola.
 Tailor-tacking can be used to predetermine final breast shape before actual inci-
sions are made.
 Ideally the augmentation is performed first, then the mastopexy, to be certain that
the two maneuvers optimally complement each other.
 Overaugmentation in an augmentation mastopexy patient may lead to dissatis-
faction because the breasts are too large.
Annotated Bibliography
Cannon CL III, Lindsey JT. Conservative augmentation with periareolar mastopexy reduces
complications and treats a variety of breast types: a 5-year retrospective review of 100
consecutive patients. Ann Plast Surg 64:516-521, 2010.
This clinical paper documents the safety and efficacy of periareolar mastopexy.
Elliott LF. Circumareolar mastopexy with augmentation. Clin Plast Surg 29:337-347, 2002.
An excellent review that outlines the advantages and results associated with combined
primary augmentation mastopexy.
Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture for control of areolar
diameter and shape. Plast Reconstr Surg 119:804-809, 2007.
The original paper describing the use of the interlocking PTFE suture to control the are-
ola during periareolar surgery.
Hedén P. Mastopexy augmentation with form stable breast implants. Clin Plast Surg 36:91-
104, vii, 2009.
An excellent review by a recognized authority on the use of anatomically shaped cohe-
sive gel implants in conjunction with mastopexy to treat breast ptosis.
Spear SL, Dayan JH, Clemens MW. Augmentation mastopexy. Clin Plast Surg 36:105-115,
vii; discussion 117, 2009.
An excellent review by noted experts that outlines the technical challenges, results, and
complications associated with augmentation mastopexy.
Stevens WG, Spring M, Stoker DA, et al. A review of 100 consecutive secondary augmenta-
tion/mastopexies. Aesthet Surg J 27:485-492, 2007.
A review of 100 consecutive secondary augmentation mastopexies.

2393
Chapter 66  Augmentation Mastopexy
Suggested Readings
Davison SP, Spear SL. Simultaneous breast augmentation with periareolar mastopexy. Semin
Plast Surg 18:189-201, 2004.
Hammond DC. The periareolar approach to breast augmentation. Clin Plast Surg 36:45-48,
vi, 2009.
Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using the short scar periareolar infe-
rior pedicle reduction technique. Plast Reconstr Surg 121:1533-1539, 2008.
Rancati A, Nava M, Tessari L. Simultaneous augmentation and periareolar mastopexy: se-
lecting the correct implant. Aesthetic Plast Surg 34:33-39; discussion 40-41, 2010.
Spear SL, Boehmler JH IV, Clemens MW. Augmentation/mastopexy: a 3-year review of a sin-
gle surgeon’s practice. Plast Reconstr Surg 118(7 Suppl):136S-147S; discussion 148S-149S,
150S-151S, 2006.
Stevens WG, Stoker DA, Freeman ME, et al. Is one-stage breast augmentation with mastopexy
safe and effective? A review of 186 primary cases. Aesthet Surg J 26:674-681, 2006.

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Control and Precision
in Mastopexy

JAMES C. GROTTING, STEPHEN M. CHEN
CHAPTER 67

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Part XI  Breast Surgery
P
erhaps no other aesthetic procedure is characterized by as much anticipation
by the patient—and long-term potential for dissatisfaction—as mastopexy, the
procedure for treating ptosis. The problem with this aesthetic breast deformity is that
all the forces that lead to its occurrence continue postoperatively to strongly influ-
ence the end result. This is the reason that mastopexy has traditionally been viewed
as a semipermanent procedure.
The goal of mastopexy is well understood by both patients and surgeons—that is,
to construct a breast that is beautifully shaped, has long-term stability, and is ap-
propriately sized. Nipple positioning must be precise, with preserved sensibility,
shape, and size. Preservation of lactation and minimal visible scarring are essential.
Sometimes patients have a breast shape in mind that they had earlier in life or be-
fore pregnancy or weight loss. Other patients, as a result of genetics or constriction,
may have developed a “droopy” breast shape, even in adolescence, that has long been
a source of dissatisfaction or embarrassment. Patient education is essential; many
women enter the plastic surgeon’s office with the misconception that ptosis can be
corrected simply by the addition of a breast implant.
It is interesting that most patients indicate the shape they desire by lifting (pulling)
the gland above the nipple-areola complex to lift and tighten the lower pole. However,
most of the procedures that we have to offer to treat ptosis consist of tightening the
lower pole to push the gland up from below. In this chapter we will focus on proce-
dures that have produced the most reliable results and on recent trends toward re-
duction of scar length.

Common Causes of Breast Shape Deformities
Clearly, understanding the forces that have produced a certain breast shape is im-
portant so that one can design a strategy to correct it. Most women who have had
one or more pregnancies experience an adverse effect on breast shape. The processes
of lactation and hormonal influences produce breast enlargement that stretches skin,
supporting ligaments, and even the ductal and glandular structure itself. Once these
changes overtax the ability of the elastic tissues to recover, the result is a loss of the
ability of the breast to maintain its position on the chest wall. The smaller the breast
to begin with, the more likely it is that the breast will not become overly ptotic;
women with large breasts invariably become more ptotic after pregnancy. Ptosis re-
sulting from weight gain and subsequent weight loss produces similar damage to
breast shape. This etiologic factor is fast becoming one of the most common reasons
patients seek mastopexy as weight-loss surgery becomes more and more prevalent.
Changes in the breast caused by aging can also produce symptoms similar to macro-
mastia. As women try to counteract drooping breasts by tightening their bra straps,
more pressure is placed across the shoulders, resulting in neck and shoulder pain.
Furthermore, the moisture in the inframammary fold area caused by skin-on-skin
contact can produce intertrigo or fungal dermatitis.
One other common category of breast ptosis is seen long term after a breast aug-
mentation procedure. Not uncommonly, these patients were originally treated (and,
it could be argued, inappropriately) with breast implants to correct minor ptosis. Of-
ten the surgeon may place a larger implant in the subglandular position to attempt to
improve the droop. The long-term price paid for this approach is greater stress on
all elements of the breast architecture and “rock-in-a-sock” deformities of the breast.
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Chapter 67  Control and Precision in Mastopexy
Common Causes of Breast-Shape Deformities
 Changes after pregnancy
 Weight gain and subsequent loss
 Aging
 Long-term changes after breast augmentation
 Developmental deformities during adolescence

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Part XI  Breast Surgery
Classification of Breast Ptosis
Regnault’s classification of breast ptosis remains a helpful way to communicate or
record the severity of a deformity. By this classification, minimal or first-degree breast
ptosis is present when the nipple position is within 1 cm of the anterior reflection of
the inframammary fold and above the lower contour of the gland, whereas moder-
ate or second-degree breast ptosis is defined as a nipple position 1 to 3 cm below the
fold but still above the lower contour of the gland. In severe or third-degree breast
ptosis, the nipple position is more than 3 cm below the fold and below the lower
contour of the skin and gland.
Pseudoptosis is another variant of breast shape in which the nipple is actually at or
above the level of the fold but the majority of the gland is below, producing the im-
pression that ptosis is present. It is important to recognize this deformity so that the
corrective plan does not result in positioning the nipple too high.
Patient Evaluation
In one sense, many of the patients who complain of breast ptosis can be viewed as
having “too much skin” for the amount of breast tissue they have. However, equally
important is the quality of the skin and breast parenchyma in designing an appro-
priate procedure for them. Some patients with breast ptosis also have an element of
macromastia, which exacerbates the shape problem. Although the goals of some pa-
tients may be to retain a large size with a perfect shape, these two elements often be-
Moderate ptosis
Severe ptosis
Minimal ptosis

come mutually exclusive with time. In other words, the effect of gravity alone on a
large mass of breast tissue will invariably result in recurrence of ptosis. Therefore a
reduction of some breast parenchyma may be an important component of the treat-
ment plan. Conversely, adding mass with a breast implant can potentially expedite
the recurrence of ptosis by the same mechanism.
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Chapter 67  Control and Precision in Mastopexy
The primary question that must be addressed is whether the patient would benefit
from the use of an implant. A good question to ask the patient is, “Can you make
your breasts look the way you want them to look in a bra?” If the answer is “Yes,”
then the patient can usually be treated with a mastopexy alone. If she is doing some-
thing to enhance volume (for example, wearing a padded bra or using an insert), she
may also benefit from an implant. Of course, the problem with a combination of
masto pexy and implants is that, in a sense, the two operations are working against
each other. The natural tendency after an augmentation is for the tissues to eventu-
ally move down and out—exactly the opposite of what the mastopexy is designed
to do. Therefore we prefer to delay implant placement in patients who are ambiva-
lent about being larger. Persoff has chosen to solve this dilemma by using a postop-
eratively adjustable Spectrum (Mentor) implant. Obviously, there are patients in
whom good shape or adequate size cannot be achieved without the addition of an
implant, and in these individuals the plan must include an implant. Further, practi-
cal considerations such as cost and time away from work or family may dictate that
an augmentation and mastopexy be combined in one procedure.
Once the decision has been made regarding placement of an implant, the evaluation
continues with a few helpful measurements. Specifically, the distance from sternal
notch to nipple on each side identifies asymmetry. Photographs are also indispens -
able for this judgment. The distance between the nipple and the inframammary fold
will also help determine whether a periareolar, vertical, or inverted-T approach is
necessary. As the distance shortens, it is more likely that only a periareolar approach
will be required. If the areola is large and the distance short, the situation is ideal for
Preoperative Physical Characteristics to Observe During
Initial Evaluation
 Skin quality: Thickness, color, striae, and amount of excess skin
 Fat: Quality and content
 Fibrous tissue: Quality and content
 Nipple: Size and shape
 Areola: Size, shape, and color

the periareolar approach. Conversely, as striae increase in number, it is more likely
that additional skin will need to be excised because of the unpredictability of skin
retraction in these patients. The need for additional volume must be balanced by the
quality of support from the parenchyma and skin. If the quality is poor to begin
with, it is foolish to assume that the long-term result will remain good, and the sur-
geon must augment the supporting structures.
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Part XI  Breast Surgery
With the patient standing, the surgeon gathers the lower pole with the hand to sim-
ulate the upper pole fullness and medial cleavage desired. This movement allows the
surgeon to see the patient’s reaction to the new shape. Some patients will view this
and agree that that appearance is what they want; others will offer additional infor -
mation that will help define their goals. The surgeon can make a mental note of how
far the nipple must be elevated. If minor elevations are necessary, one might consi -
der a periareolar technique (or even a semicircular skin excision). Only the most severe
cases require an inferior pedicle or a medial or lateral pedicle so that the nipple-
areola complex can be rotated without tension. The pedicle will also influence the
position of the implant above or below the muscle. For example, an inferior pedicle
would preclude use of a subglandular implant in most cases.
Operative Technique
Selection of Technique
Mastopexy techniques generally fall into the simple skin-tightening-only procedures,
or the parenchymal remodeling methods. Because skin is elastic, skin-only techniques
tend to produce a shorter-lasting correction and are appropriate if less elevation is
required or if one does not wish to violate the parenchyma at all (for example, op-

posite breast corrections with breast reconstruction). This can be likened to proce-
dures of the face, where we now recognize that tightening only the skin will not yield
a natural, long-lasting result. With patients who have both hypomastia and ptosis,
the surgeon must decide whether to try to correct ptosis with an implant alone. In
general, correcting ptosis with large subglandular implants ultimately leads to a lower
breast position, a short distance from the lowered inframammary fold to the iliac
crest, and difficulty in fitting clothing. Although patients may initially accept the ap-
pearance, in time many return to the plastic surgeon’s office seeking correction. Im-
proved nipple position on a lowered glandular profile is not an adequate tradeoff for
the original problem of shape and size. Correction, of course, requires some type of
mastopexy and usually smaller implants.
The differences between skin-only mastopexy techniques and parenchymal remod-
eling techniques can be summarized as follows:
 Skin-only techniques: Less permanent
 Parenchymal remodeling: Longer-lasting correction of ptosis techniques
The issue of implant size must be considered if implants are to be used. Mastopexy
patients already have stretched-out skin, and large devices very likely cannot be sup-
ported long term by the tissues, so it is generally safer and more predictable to place
a smaller base–width implant with less volume. Because patients often confuse size
with shape, a reasonable strategy for the patient with larger volumes of native tis-
sue is for her to live with the lift alone for the first year and consider tweaking the
result with an implant if she really desires more size at the 1-year mark. Many of
these patients will realize that the shape is what they desire more than just increased
cup size. When the breast parenchyma is very thin, soft, and fatty, it generally will
not hold shape well, and therefore we prefer skin-only tightening in this group of
patients and virtually always include an implant.
Skin Incision and Ultimate Scar Shape Versus
Dermoglandular Pedicle
Many surgeons confuse skin incision and pedicle location as being interchangeable
when in fact they are two independent variables. Skin incisions are based on the
amount of excess skin that needs to be removed to produce a more pleasing breast
shape, whether it be smaller and rounder or larger and rounder. Pedicles about the
breast are numerous, whether they are located superiorly, inferiorly, superomedially,
laterally, are bipedicled, and so on. The important concept is that the nipple must
be given a base to survive and the underlying gland must be shaped so that it will
aid in a long-lasting correction of a deflated breast.
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Chapter 67  Control and Precision in Mastopexy

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Part XI  Breast Surgery
Periareolar Techniques
No mastopexy technique is as seductive as the periareolar technique. By this we mean
that as tempting as it is to confine incisions to the areola-skin interface, the method
can lead to poor results if applied to the wrong patient. Clearly, all patients and sur-
geons would prefer to keep scars concealed and as short as possible, as long as a
beautiful shape can be produced. When the proper technique is executed in a prop-
erly selected patient, the periareolar technique confines incisions and therefore po-
tential scars to the areola-skin interface. Resulting scars in this area are usually al-
most unnoticeable if the surgeon diligently makes the incision precisely where the
areola and breast skin meet. If the incision extends either onto the areola or the skin,
more noticeable and less satisfactory scars can result, and the primary benefit of this
technique is lost. Subsequent correction of these poorly positioned scars may lead
to further spreading of the areola and poor aesthetic results.
The periareolar approach is most appropriate in cases of mild to moderate breast
ptosis where there is adequate, firm glandular parenchyma. If a patient has mild to
moderate breast ptosis but a small or atrophic gland, a small implant may be added
in certain periareolar techniques to achieve a pleasing breast shape.
The simplest periareolar technique involves excising or deepithelializing skin around
the areola. Depending on the degree of ptosis and the location of the nipple, the skin
excisions can be designed in a doughnut or crescent shape.
Small, mildly ptotic breasts with adequate breast parenchyma respond best to this
technique. However, this technique can be modified to accommodate moderate de-
grees of ptosis and for patients who lack adequate breast parenchyma. The usual
modification in such a case is the addition of a small implant to take the place of
breast tissue and to fill the skin envelope. Usually nipple position remains low after
this augmentation, and simultaneous removal of skin around the areola allows ele-
vation of the nipple-areola complex to a more anatomically desirable position. It is
difficult to achieve more than 2 to 3 cm of nipple elevation using these simple skin-
only designs.
As with all periareolar techniques, the main advantage is a minimal incision with
placement where the resulting scar can best be camouflaged. Even if an implant is
needed, this can be placed through the same periareolar incision used to excise the
excess skin.
The primary disadvantages have to do with the requirement for meticulous preci-
sion in the placement of the incision and the amount of skin excised. Even with pre-
cision, the resulting scar can widen because of excessive tension on the closure,

either as a result of overaggressive skin excision or trying to use this procedure to
treat significant breast ptosis. If a patient requires more than 3 cm of nipple eleva-
tion, we usually opt for a vertical incision. Sometimes the weight of the implant can
put too much tension on the closure. In addition, the patient’s skin quality (thick-
ness and elasticity) can be a major factor in the quality of the final scar. It is not a
coincidence that women with poor skin quality are most likely to present with com-
plaints of ptosis.
Excessive tension on the closure may also cause the breast to assume a flattened shape
with poor projection. This must be avoided, because a good scar loses its value if
placed on a misshapen breast.
Periareolar Mastopexy Without Parenchymal Reshaping
Technique
The position of the nipple-areola complex determines the amount of skin to be ex-
cised. It is critical to resect only the amount of skin necessary to raise the nipple to
correct the ptosis. Additional consideration must be made for any excess areola that
is to be removed.
The lines of excision are marked on the breast with the patient in a sitting or stand-
ing position in the preoperative area. Symmetry is ascertained using the sternal notch-
to-nipple distance and the sternum-to-nipple distance. In the operating room, the
amount of the areola that is to remain is marked under tension using an areolar
marker. According to Spear et al, the amount of nonpigmented skin excised should
be less than the amount of pigmented skin excised. The skin between these two marks
is infiltrated with 0.5% lidocaine with 1:200,000 epinephrine to facilitate deepithe-
lialization. Once the epidermis is removed, the edge of the dermis can be elevated.
The skin around the outer edge of the exposed dermis is elevated off the gland for a
short distance superiorly. The freed dermis can then be tacked to the gland under
the elevated skin for additional support for the new nipple position. A purse-string su-
ture of 4-0 Gore-Tex or Mersilene is then placed in the deep dermis of the skin edge.
This is then cinched to the approximate size of the areola and tied. The areola is
tacked to the skin with half-buried horizontal mattress sutures, followed by a run-
ning Monocryl or PDS subcuticular stitch.
The Benelli Periareolar Mastopexy Technique
Dissatisfied with the limits of simple periareolar techniques, Benelli devised modifi-
cations of periareolar mastopexy so that the periareolar technique could be applied
to larger breasts with increasing degrees of ptosis. In addition, Benelli’s technique
could be applied in cases of breast hypertrophy as well as tumor excision, with the
main goal of limiting the scar.
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Chapter 67  Control and Precision in Mastopexy

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Part XI  Breast Surgery
Benelli’s technique treats the skin and gland as two separate components. The peri-
areolar approach affords access to the underlying gland, which is then separated
from the overlying skin. A vertical dermatoglandular flap is created with lateral and
medial extensions that are subsequently crisscrossed to make the glandular mound
cone shaped. The tissue contiguous with the vertical flap inferiorly can either be ex-
cised or imbricated, depending on the volume needed for good breast shape. The end
result is a narrower breast with a tightened inferior pole. The skin envelope is then
redraped over this newly formed glandular scaffold. A “round block” cerclage stitch
is used as in the doughnut mastopexy to help control tension at the areola-skin junc-
tion. As can be seen, this technique allows a more precise shaping of the breast with
the inverted-T incision through the gland, while requiring no additional incisions to
the skin.
This technique expands the range of periareolar mastopexy to incorporate greater
degrees of ptosis as well as the ability to treat glandular excess. As with the skin-only
techniques, an implant can be used to provide superior pole fill.
The Benelli technique is not beneficial for women who have severe degrees of ptosis
and/or very poor skin quality. Potential pitfalls of this technique include its steep
learning curve as well as the temptation to apply this technique when it is not indi-
cated. The usual complications that arise when attempting this are a flattened ap-
pearance of the breast and a widened areola as a result of overresection of the skin
and/or improper glandular support. The unwary surgeon may produce a very un-
satisfactory outcome using this concept.
Technique
Preoperative markings are performed with the patient upright by first marking the
midline and estimated meridian of the newly shaped breast (usually located 6 cm
from the midline in a position medial to the original breast meridian). Point A, the
future superior border of the areola, is marked 2 cm above the anterior projection
A
B
D
C

of the inframammary fold in line with the new breast meridian. Point B, the future
inferior border, is marked with the patient recumbent and is located 5 to 12 cm above
the inframammary fold after taking the final estimated volume and the amount of
skin resection into consideration. Points C and D (the medial and lateral limits of
the new nipple) are equidistant from the meridian. Point C averages 8 to 12 cm from
the midline. Like point B, these marks are based on the anticipated final volume.
Point S is the point at which the breast meridian intersects the inframammary fold.
The opposite breast is marked in a similar manner, depending on the degree of asym-
metry inherently present. The resection margins are simulated by pinching together
points A and B and then C and D to verify adequate skin coverage without tension.
A wetting solution consisting of saline solution (1000 ml), epinephrine (0.25 mg),
and 2% lidocaine (20 ml) is infiltrated subcutaneously in the area that will be de-
tached. The ellipse and surrounding 3 cm are not infiltrated to preserve the vascu-
larity of the skin edges. The prepectoral area is also infiltrated.
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Chapter 67  Control and Precision in Mastopexy
A
B
D
C
The desired areolar diameter is marked and the periareolar ellipse deepithelialized.
The deepithelialized dermis is incised from the 2 o’clock to the 10 o’clock positions.
The dissection is extended toward the inframammary fold in the subcutaneous plane.
The dissection continues to the upper-outer quadrant of the breast, with the dissec-
tion becoming more superficial to preserve the vessels coming from the lateral tho-
racic artery. Next glandular dissection is initiated with a semicircular incision ap-
proximately 3 cm from the inferior areolar edge to preserve innervation and the
blood supply to the areola. Dissection is continued to the prepectoral space in the
avascular central space, preserving the peripheral blood supply.

2406
Part XI  Breast Surgery
The inferior glandular flap is then cut vertically beyond the breast meridian up to
the fascia. Four flaps will thus have been elevated: (1) a superior dermoglandular flap
supporting the areola, (2) a glandular medial flap, (3) a glandular lateral flap, and
(4) a detached skin flap.
These glandular flaps will be reassembled and repositioned to decrease the base of
the breast, thus promoting the lifted appearance. If necessary, these flaps can be
trimmed to reduce unwanted fullness. Volume reduction at the distal ends of the flaps
will limit their length.
On completion of the gland resection, the gland is lifted by stitching the superior
flap high up on the pectoralis fascia to produce an exaggerated bulge in the superior
pole of the breast. The nipple should be raised by this maneuver as well. Over the
next few weeks, the superior roundness will flatten from the effects of gravity.

Next the medial and lateral flaps are folded over one another and sutured in place
by rotating and folding the medial flap behind the areola, fixing its distal portion to
the pectoralis muscle with superficial stitches. Then the lateral flap is crossed over
and fixed to the medial flap. The movement of these flaps reduces the base of the
breast, forming a glandular cone on which to place the areola.
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Chapter 67  Control and Precision in Mastopexy
If the gland requires no resection, a plication invagination can be performed to
achieve conization and elevation of breast shape.
The areola is fixed to the superior border of the ellipse through a 1 cm dermal win-
dow made near the superior skin edge (the 12 o’clock position). This allows the knot
to be buried and the areola to be supported without tension on the skin. Support for
the breast shape is achieved by full-breast lacing. Braided polyester suture material
on a long straight needle is used to create large inverted sutures along the underside
of the gland. The superior stitch should pass through the superior dermoglandular
flap, allowing control of the anterior projection of the nipple-areola complex. These
full-breast lacing sutures should be applied without tension, their goal being to pro-
vide passive support of the newly created conical breast. Tying these lacing sutures
too tight can result in glandular necrosis.

The skin is redraped over the breast. A round block cerclage stitch is passed in the
deep dermis in purse-string fashion. It is then cinched around an areolar template of
the desired diameter, ensuring even distribution of the skin pleats. The block stitch
is then tied, burying the knot in the previously created dermal window. Further reg-
ulation of the projection of the areola is accomplished by an inverted dermoareolar
stitch, which takes a large vertical bite in the areola and a large horizontal bite in
the dermal ellipse. This helps to evenly distribute any remaining deep pleats around
the areola.
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Part XI  Breast Surgery
A diametrical transareolar U suture (point) is placed to serve as a barrier and to help
prevent areolar protrusion. It also can be used to give a circular shape to the areola
in cases in which the areola tends to be ovoid. A 4-0 Vicryl intradermal suture around
the areola completes the procedure.
The site is dressed with a wet compress on the areola and dry compresses on the de-
tached skin, held in place by an adhesive bandage of moderate compression to pre-
vent hematoma. These are removed on postoperative day 2, along with any drains,
and are replaced with a sterile, ultrathin, semiocclusive polyurethane foam adhesive
pad. This dressing covers the areola and scar and maintains all of the detached skin
in place. This pad will be changed weekly. The patient wears a mammary support
bra day and night for 2 months.

Góes Periareolar Technique With Mesh Support
João Carlos Sampaio Góes of Brazil expanded the use of periareolar techniques by in-
troducing his double-skin technique whereby a resistant lining of the breast is cre-
ated with the use of a layer of prosthetic mesh. The “double skin” refers to the use
of a doughnut-shaped, periareolar, deepithelialized dermal flap that is used to sup-
port the gland under the remaining normal skin, which will be closed around the
reshaped gland. The mesh provides increased support of the new breast shape during
the healing and skin contraction processes rather than depending on stretched-out
breast parenchyma and skin.
Sampaio Góes treats the glandular unit separate from the overlying skin. He creates
an internal brassiere by using the anterior pectoral fascia, inframammary connec-
tive ligaments, a periareolar dermal flap that is used as an internal lining, and a mixed
mesh originally composed of Vicryl and Prolene (Ultrapro by Ethicon). This is en-
veloped by the external skin.
This method is very useful for correcting ptosis or for small reductions of mammary
hypertrophy with or without ptosis. The reduction volume should ideally be less than
500 g. As with all breast surgery, better aesthetic results are obtained in younger pa-
tients who have firm tissues, more elastic skin, and little fatty tissue.
In addition to limiting the scar to the periareolar region, the main advantage of this
technique is the use of the mixed mesh to create a long-lasting correction for the
ptotic breast. The mechanism is an intense fibrosis around the mesh, which causes
scarring. This results in an initially rigid breast for the first few months, which then
softens as the scar matures. However, despite the fact that internal scarring occurs,
the mesh that remains is integral to maintaining the correction. Ultimately, the breast
feels normal on palpation—the mesh is not palpable, and it does not interfere with
mammographic evaluation.
The drawbacks of this technique lie in the steep learning curve associated with this
technically difficult operation. In addition, there are the theoretical problems of mesh
extrusion, infection, or skin necrosis. It is imperative to carefully dissect the skin flaps
and to place the mesh meticulously to avoid suboptimal results and/or disastrous
outcomes.
There has also been considerable resistance to placing permanent foreign bodies
within the breast parenchyma among U.S. surgeons because of concerns about mam-
mographic artifacts or palpability; de Bruijn and colleagues in Belgium have ad-
dressed this with the use of a three-dimensional polyester mesh that does not cause
artifacts on mammography and is not palpable. Histologically, there is minimal scar-
ring and a deposition of a thin layer of collagen about the mesh that results in in-
creased firmness of the breast parenchyma to provide a long-lasting correction.
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Chapter 67  Control and Precision in Mastopexy

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Part XI  Breast Surgery
The technique begins with the preoperative marking. The most important concept
is to leave adequate skin to cover the new breast mound. With that in mind, four car-
dinal points are marked. Point A is the level of the top of the new areola; point B is
the distance from the inframammary fold (on average, 7 cm); point C is the distance
from the midline to the medial margin at the level of the nipple (usually 9 cm); and
point D is the distance from the anterior axillary line to the lateral margin at the
level of the nipple (usually 12 cm).
A
B
D
C
12
9
7
19
Pectoralis
fascia
Pectoralis
major
muscle
Wedge of upper
hemisphere to be
resected
External
skin lining
Internal
skin lining
Wedge of lower
hemisphere to be
resected
Technique
The marked area is deepithelialized to the nipple. The
outer border is incised and a skin flap is developed
superiorly, with progressive thickening of this flap as
one approaches the chest wall. The undermining con-
tinues for another 5 cm once the pectoralis fascia is
reached. The direction is then changed inferiorly un-
der the gland to approximately a third of the retro-
mammary space. Perforators will be encountered and
should be preserved. Inferiorly, a thin flap is devel-
oped down to the inframammary fold.

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Chapter 67  Control and Precision in Mastopexy
External
skin lining
Internal
skin lining
Mammary gland
Mammary gland
Internal skin lining
Mesh
External skin lining
Excessive tension on the closure can also result in the breast assuming a flattened
shape with poor projection. This must be guarded against, because a good scar loses
its value if placed on a misshapen breast.
After the skin and breast parenchyma are separated into
components, any excess tissue can be resected in a wedge
shape at the superior and inferior poles of the breast
mound. None of the tissue at the base of the mound should
be excised. The gland is then shaped by suturing the gland
together superiorly and affixing it to the chest wall to pro-
vide fill of the upper pole of the breast. Likewise, the infe-
rior resection is sutured together and then fixed to the in-
framammary connective ligaments and the anterior pectoral
fascia. The deepithelialized flap is stretched out over the
new breast mound, attaching it superiorly to the connec-
tive ligaments of the breast and inferiorly to the anterior
pectoral fascia. This creates the internal skin lining.
The next step places the mesh over the newly created
mound and internal skin lining to function as a brassiere
that will elevate the breast and provide a stable base for
achieving a conical shape. The mesh is affixed to the ante-
rior pectoral fascia at the base of the breast mound.
The external skin lining is brought up over the breast
mound and closed around the areola with a circular, con-
tinuous, deep intradermal suture of Mersiline 2-0 on a
straight needle. A continuous intradermal Monocryl 4-0
suture is used to fix the areola skin to the external skin lin-
ing. Dressing consists of triangular pieces of Micropore tape
covering the whole gland, which is left in place for 20 days.
Tegaderm also works well for this purpose. Suction drains
are removed after approximately 5 days.

Vertical Mastopexy Without Implants
We believe that some type of parenchymal remodeling is essential to produce a longer-
lasting lift effect in a mastopexy without implants. As mentioned previously, a ver-
tical or inverted-T deepithelialization with skin tightening alone is appropriate only
in certain patients. These are the women for whom the surgeon deliberately chooses
not to violate the parenchyma for follow-up imaging considerations, such as oppo-
site breast mastopexy for matching a reconstructed breast. Otherwise, it is my view
that rearrangement of the parenchyma gives a more satisfactory long-term lift. The
way that we most commonly way accomplish this is with a superiorly based flap
from the midline of the lower pole turned underneath to provide fill to the upper
pole. The medial and lateral pillars developed by the flap are approximated to tighten
the lower pole and narrow the breast if it is too wide.
Marking
The breast is marked with the patient standing with her arms at her sides. We pre-
fer to sit in front of her on a stool, which can be raised and lowered so that the sur-
geon always views the patient from the same perspective, regardless of how tall she
is. By doing that, the surgeon can learn from past errors with nipple position and so
forth, and the line of sight will be very similar on the next patient so markings can
be adjusted.
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Part XI  Breast Surgery
The inframammary fold is marked on each side. The new nipple position is assessed.
This is determined by a combination of data points. First the inframammary fold is
transposed to the anterior surface of the breast and marked. Then the lower pole
breast tissue is gathered to simulate the pexy to see if the nipple seems to elevate to the
marked point. The point is checked against the midhumeral horizontal line and the
distance between the sternal notch and the new nipple position is measured, usually
20 to 23 cm. Symmetry and distance from the sternal notch are checked. If any of

the parameters are vastly disparate, adjustments are made. Final nipple position is
usually determined intraoperatively after the vertical closure, so the initial point
merely represents a best guess. The next mark is the midline of the breast on its an-
terior surface. We aim toward the lateral border of the neck as if a tape measure were
draped around the neck, as some surgeons have recommended. The midpoint of the
inframammary fold is also an important landmark because this is where the bottom
of the vertical limbs will be centered.
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Chapter 67  Control and Precision in Mastopexy
The breast is then gently distracted laterally so that the medial pillar can be marked
in line with the midline superiorly and inferiorly. The mark is joined with the infe-
rior mammary midline with a curvilinear line that ends a few centimeters above the
inframammary fold. The same maneuver in the opposite direction defines the lateral
pillar. It is most important to view the shape and volume of the tissues left behind
(outside of the pillar markings), because these will determine the ultimate shape of
the breast.
Once the vertical markings are positioned, these are drawn into a parabolic shape
inferiorly, ending 2 to 3 cm above the native fold. Superiorly, the lines are curved up
to the new nipple point, taking no additional skin around the nipple-areola complex
initially.

The top of the vertical closure is estimated by the pinch technique so that not too
much skin will be required to be gathered in the periareolar closure. The secret to
good periareolar scars is to make certain this is closed without excessive tension. For
smaller mastopexies, the periareolar circle is marked for deepithelialization if we are
confident that the nipple position has been properly determined. The greater the de-
gree of ptosis, the less likely we are to commit to the new nipple position definitively.
From the top of the vertical closure, one measures down 5 to 6 cm and makes an-
other mark that will represent the approximate position of the new fold. The breast
tissue below that point will comprise the bottom of the superiorly based flap or will
be trimmed. Any convexities in the axillary area that may need suction contouring
must be marked.
The design of the flap will depend on the need to accentuate the upper pole. If a small
amount of breast tissue needs to be resected, it is this flap tissue that is most readily
available for trimming.
Technique
After the patient is placed under general anesthesia, we make certain that she is cen-
tered on the operating table and that her arms are properly secured so we can sit the
patient up for intraoperative assessment of the result. After the patient is draped, we
place pendulum sutures at the sternal notch and the xyphoid. Skin staples or Adair
clamps can then be used to verify that not too much tissue has been marked for the
pillar closure, making horizontal approximation too tight. The nipple is marked with
a 42 mm template and then 0.5% lidocaine with 1:200,000 epinephrine is infiltrated
to help control bleeding.
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Part XI  Breast Surgery

After the entire segment between the medial and lateral pillars and the periareolar
skin has been deepithelialized, the breast is elevated off the pectoralis fascia. Unless
the bases of the pillars are to be trimmed, it is unnecessary to undermine much me-
dially and laterally. However, it is important to dissect up to the top of the superior
pole so that the flap can be placed as high as possible.
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Chapter 67  Control and Precision in Mastopexy
Once the breast is undermined, a flap is placed in the subpectoral pocket and the
medial and lateral cuts are made, isolating the flap on its superior blood supply. The
cuts are stopped at the previous mark, which will also represent the 6 o’clock posi-
tion of the future exteriorized nipple-areola complex. If no implant is to be used, a
subglandular dissection is performed. With saline implants, we prefer a subpectoral
pocket, but with smaller implants and particularly silicone gel devices, we often use
the subglandular pocket.

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Part XI  Breast Surgery
The flap is then folded underneath into the upper pole and sutured with 2-0 Vicryl
pop-offs. The pillars are then reapproximated, beginning at the top, then the most
inferior point, followed by a few sutures in between. If the flap has been trimmed
off, the undersurface of the gland is sutured as high up in the infraclavicular space
as possible. A bite of lateral breast parenchyma is also grasped at the inferior extent
of the lateral contour and sutured medially in the midline to help cone the breast
and keep it from falling laterally toward the axilla. A 15 Fr Blake drain is placed
along the lateral gutter and the vertical portion temporally stapled. Note the upper
pole fill and the improved nipple position in relation to the breast mass (above, right).
The opposite breast can then be shaped in the same way and to the same point of
vertical stapling. Next the patient is positioned upright, and with the nipple tem-
plate, the final nipple position is marked. Sometimes a temporary periareolar purse-
string suture can take up some loose skin in this area before final markings are made
with the template. Final deepithelialization is completed, followed by layered skin
closure.
The dressing, consisting of large, rectangular sheets of Tegaderm, supports the final
breast shape. The nipple should not be compressed by the dressing. We use a rolled-
up ABD pad taped into a “hotdog” shape and held in place along the curve of the
new inframammary fold using Tegaderm. Although the drain can be removed the
following day, the Tegaderm dressing is left in place for 2 weeks.

After the final dressings are removed, the patient is advised to wear a good supporting
bra day and night for 8 weeks. Scars are treated with Mederma or Scarguard.
Use of Implants With Mastopexy
The most conservative approach when an implant is also planned is to place the im-
plant first and tailor-tack the skin over the implant to make certain the markings are
correct. We prefer to place the implant in the subpectoral position if the patient
chooses a saline implant or if the upper pole tissues are excessively thin (pinch thick-
ness less than 3 cm). A silicone gel implant can be placed in the subglandular position
with less concern about visibility or palpability. We often use at least a small flap
into the upper pole, even in the presence of an implant. The flap can be sutured to
the undersurface of the breast itself or to the pectoralis fascia. Rarely is it possible
to achieve too much upper pole fullness in a mastopexy.
Selection of saline or silicone implants follows a discussion with the patient and ex-
amination of the quality of tissue both skin and parenchyma. Saline implants tend
to be more palpable and visible. Because of this, we tend to use saline implants in
cases in which the patient prefers them and the skin and parenchyma are thicker. Sil-
icone implants can be used in either position; however, the underlying parenchyma
needs to be firm to support the additional stress if the implants are to be placed in
the subglandular position. It is always best to scale down the size and dimensions of
implants in augmentation mastopexy cases to minimize downward forces on the
newly lifted tissues.
Wise Vertical Scar With a Long Horizontal Scar
The Wise pattern vertical scar with a long horizontal scar is based on the reduction
technique of the same name. The long horizontal component is necessary to allow
adequate resection of the skin envelope. This technique is best suited for women with
moderate to severe breast ptosis with poor-quality skin and/or a large amount of skin
excess and a moderate amount of glandular tissue. The skin markings are familiar
to most plastic surgeons trained in the United States because of the popularity of the
Wise breast reduction technique. However, unlike the reduction technique, removal
of breast parenchyma is usually not needed.
Proponents of this technique favor the ability to see the final shape while the patient
is still on the table and the chance to remove the skin excess, both of which decrease
the rate of reoperation. This technique is performed at the expense of longer scars.
The horizontal component runs along the inframammary fold from the medialmost
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Chapter 67  Control and Precision in Mastopexy

to the lateralmost aspect of the breast, sometimes even farther laterally along the
chest wall. The medial limbs must not join in the center of the chest. This area is
most prone to hypertrophic scarring and any extension of scar length should not be
performed in this direction.
Long-term complications of this procedure include recurrent ptosis or bottoming out
of the mastopexy. This occurs because the breast shape is maintained by the skin en-
velope rather than support from the gland.
Technique
Markings proceed using the standard Wise pattern. With the patient in the upright
position, the breast meridian is marked. The level of the inframammary fold is trans-
posed anteriorly to intersect with the meridian to mark the level of the new nipple.
The Wise keyhole pattern is spread to encompass the original areola. It is placed so
that the superior aspect of the pattern lies 2 cm higher than the level of the new nip-
ple. The markings are checked by pinching together the medial and lateral limbs to
assess tension. The closure should be snug to compensate for the eventual skin re-
laxation, but not tight enough to compromise vascularity. The vertical limbs are ex-
tended medially and laterally to intersect with the inframammary fold.
In the operating room, the portion of the areola to be preserved is marked with an
areolar marker of the appropriate diameter. The area within the marks is deepithe-
lialized. Transdermal incisions are made along the upper portion of what would be
the vertical bipedicle flap of a reduction mammaplasty on either side of the nipple-
areola complex. If there is an abundance of deepithelialized breast tissue below the
inframammary fold, the gland is dissected off the pectoralis muscle, starting from
the inframammary fold and proceeding upward, creating a superiorly based der-
moglandular pedicle. The dissection continues until the pocket can accept the excess
inferior glandular tissue. This tissue is folded behind the breast and attached to the
pectoralis fascia high enough to eliminate gross glandular redundancy. The skin is
closed in standard fashion with little or no further undermining. The nipple-areola
complex is positioned and sutured into place.
Biologic Meshes
Mastopexy, and more frequently augmentation mastopexy, is plagued with recur-
rent ptosis. The “holy grail” in this problem involves creation of a durable internal
brassiere that is resistant to stretching out over time. This problem is exacerbated
when an implant adds weight and strain on breast parenchyma and skin. The use of
acellular dermal matrix as well as autologous dermal slings have been used to help
create an internal brassiere by reinforcement of the worn-out parenchyma.
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Part XI  Breast Surgery