The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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Fig. 78.15 (a,b) Liposuction-only is a good way to correct some asymmetries. This patient had liposuction performed on her left breast only.
(c,d) She is shown at 1 year after surgery.
The patient shown in Fig. 78.24 shows the downside to a free
nipple graft procedure. She had 760 g removed from the right
breast and 1,030 g removed from the left breast. She is shown at
11 days after surgery when the bolus dressing was removed. She
is also shown at 18 months after the surgery with underresection
of the inferior pole (and too high nipple placement). She had
widening of the areolas and some depigmentation.
The patient shown in Fig. 78.25 shows more serious depigmen-
tation. She had 2,025 g removed from the right breast and 1,770
g removed from the left breast. It is difficult to thin a free nipple
graft enough so that it takes while still allowing enough dermis
to give a good result. This depigmentation is a more serious
problem in dark-skinned patients. It can improve with time, but
this patient is shown at 8 days after surgery when the bolus was
removed and at 4 months postoperatively.
A free nipple graft may be indicated in order to avoid a bulky
pedicle, but it is usually not needed from a blood supply stand-
point. The blood vessels are stretched as the breast develops,
and the main concern with a long pedicle is that the surgeon
may not be able to include the dominant blood vessels. Gheita
has shown that a very long, thinned, superior pedicle can be
used in these overly large breasts. The blood supply to a superior

78 Alternative Approaches to Breast Reduction
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pedicle is in the subcutaneous tissue with the veins located just
beneath the dermis and the arteries usually about a centimeter
deep.
78.6.8 Long Superior Pedicle Breast
Reduction
Gheita has shown that a long, thinned superior pedicle in
gigantomastia may be better than free nipple grafts. This is
especially true in dark-skinned patients, who are at greater risk
for depigmentation.
This long superior pedicle has challenged our older concepts
about blood supply to the nipple. The only pedicle that is supplied
by deep perforators is the inferior (and central) pedicle. The rest of
the blood supply to the nipple is in the subcutaneous tissue with
the veins draining just under the dermis. The blood supply to the
superior pedicle comes mainly from the second interspace, and
this is a strong and consistent artery.
Fig. 78.16 Inferior pedicle, inverted-T breast reduction. The blood supply to an inferior pedicle comes from the chest wall via the artery and vein
that penetrate through the breast parenchyma to supply the nipple. This system is enclosed in a type of septum that separates the upper-pole breast
tissue from the lower pole. Thin membranes enclose the artery and venae comitantes at the level of the fourth interspace. The main artery and vein
enter the breast just medial to the breast meridian, but there are some lateral branches that lie above the fifth rib. The inferior pedicle also has blood
supply through the inframammary fold, which is one of the “zones of adherence” in the body. (Reproduced with permission from Hall-Findlay EJ.
Aesthetic Breast Surgery: Concepts and Techniques. New York, NY: Thieme Medical Publishers; 2010.)
Fig. 78.17 The markings are performed using the Wise pattern to deter-
mine the shape of the skin brassiere. The inferior pedicle is designed as a
chest wall–based pedicle with a base of usually 8 cm. The vertical limbs
of the Wise pattern are kept at 5 to 7 cm (depending on the size of the
reduction) with the realization that these limbs will stretch over time.
The horizontal excision follows the Wise pattern and curves up along the
inframammary fold, much as the underwire of a brassiere does.

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Figs. 78.18 (a–d) An inverted-T, inferior pedicle breast reduction can give a good result, especially when the breasts are not too large.

78 Alternative Approaches to Breast Reduction
1227
Fig. 78.19 (a,b) Unfortunately, when a breast is excessively large, a boxy type of shape can result. This boxy shape is far less frequently seen when
a superomedial pedicle vertical approach is used. (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and
Techniques. New York, NY: Thieme Medical Publishers; 2010.)

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Fig. 78.20 (a,b) This patient achieved a good shape with her inverted-T, inferior pedicle breast reduction, but she started developing thick scars.
(c,d) She is shown at a full year after her surgery with even thicker scars. The scars are bad around the areola and vertically, but they are worse along
the inframammary fold.

78 Alternative Approaches to Breast Reduction
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Fig. 78.21 (a–f) This patient underwent a no-vertical-scar breast reduction. The result is good, but the breasts are a bit wide postoperatively.
Fig. 78.22 (a–f) This patient shows a more typical result from a no-vertical-scar breast reduction, with a wide boxy shape and puckered, irregular
skin in the inframammary fold.

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Fig. 78.23 (a) This patient underwent a free nipple graft breast reduction with a relatively short inframammary fold scar. (b) She had 1,355 g
removed from the right breast and 1,325 g removed from the left breast. (c,d) She is shown at 6 days after surgery when the bolus dressing was
removed and then at 4 months. She actually obtained a fairly good result except that the nipples were placed too close to the upper breast border,
and there was not enough inferior breast tissue removed. She retained more nipple projection than is usual with this technique.

78 Alternative Approaches to Breast Reduction
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Fig. 78.24 Free nipple graft procedure. (a,b) This patient shows the downside to a free nipple graft procedure. (c) She had 760 g removed from the
right breast and 1,030 g removed from the left breast. (d) She is shown at 11 days after surgery when the bolus dressing was removed. (e,f) She is
also shown at 18 months after the surgery with underresection of the inferior pole (and too high nipple placement). She had widening of the areolas
and some depigmentation. (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts and Techniques. New York, NY:
Thieme Medical Publishers; 2010.)
Fig. 78.25 Free nipple graft breast reduction. (a) This patient underwent a free nipple graft breast reduction. (b) She had 2,025 g removed from the
right breast and 1,770 g removed from the left breast. (c) It is difficult to thin a free nipple graft enough so that it takes while still allowing enough
dermis to give a good result. She is shown at 8 days after her surgery. (d) This is the result at 4 months after surgery. This depigmentation is a more
serious problem in dark-skinned patients, but it can improve with time. (Reproduced with permission from Hall-Findlay EJ. Aesthetic Breast Surgery:
Concepts and Techniques. New York, NY: Thieme Medical Publishers; 2010.)

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A true superomedial pedicle incorporates the artery from both
the second and the third interspace, and it therefore has a dual
axial blood supply. The true superomedial pedicle is important in
smaller breasts because the inferior border of the medial pedicle
becomes the medial pillar. This gives an elegant curve to the lower
pole of the breast. This medial blood supply is not needed in these
long superior pedicles, which have too much bulk and can give too
much inferior-pole tissue.
The patient shown in Fig. 78.26a shows very long superior
pedicles (at least 20 cm) with good blood supply to the nipples.
These pedicles actually could have been thinned more because
the artery is usually about only 1 cm deep to the skin. The veins
travel just under the dermis.
The patient shown in Fig. 78.26b,c shows how difficult it can be to
sufficiently reduce the parenchyma. She had 2,500 g removed from
the right breast and 2,100 g from the left breast. More breast tissue
should have been removed laterally, but this can be difficult because
some of the excess is from the pedicle itself. A secondary revision may
be needed, but the nipples look better than after a free nipple graft.
The patient shown in Fig. 78.27 had 2,600 g removed from the
right breast and 2,500 g from the left breast using a long, thinned,
superior pedicle for the nipple. She did have a small area of nipple
necrosis on the right areola, but the result is better than it would
have been if a free nipple graft had been used. If circulation does
not look acceptable intraoperatively, the procedure can be con-
verted to a free nipple graft.
Fig. 78.26 (a) Very long superior pedicles (at least 20 cm) can be used instead of a free nipple graft. There is good blood supply to the nipples through
this type of superior pedicle. These pedicles actually could have been thinned more because the artery is usually about only 1 cm deep to the skin.
The veins travel just under the dermis. (b,c) This result, however, shows how difficult it can be to sufficiently reduce the parenchyma. She had 2,500 g
removed from the right breast and 2,100 g from the left breast. More breast tissue should have been removed laterally, but this can be difficult because
some of the excess is from the pedicle itself. A secondary revision may be needed, but the nipples look better than after a free nipple graft.
Fig. 78.27 (a,b) This patient had 2,600 g removed from the right breast and 2,500 g from the left breast using a long, thinned, superior pedicle for
the nipple. She did have a small area of nipple necrosis on the right areola, but the end result is better than it would have been if a free nipple graft
had been used. If circulation does not look acceptable intraoperatively, the procedure can be converted to a free nipple graft

78 Alternative Approaches to Breast Reduction
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78.7 Outcomes
As with many procedures, the key to a good outcome starts
with managing patient expectations. The surgeon needs to first
assess the breast footprint, then the breast mound, and finally
the nipple position. There are numerous methods to achieve a
good breast reduction, but following the principles of remov-
ing weight to work with gravity rather than against it will
lead to a better long-lasting result. The surgeon should assess
where the breast is in excess and remove that excess—and it
is usually inferior and lateral. Any breast technique, therefore,
that removes inferior and lateral breast tissue is the procedure
that is most likely to achieve a good result that stands the test
of time.
78.8 Results
The results of breast reduction depend not only on the tech-
nique but on the care of the surgeon. Even when the skin is
used as a brassiere, wound healing will be better if tension is
avoided on the skin closure. The shape of the breast will last
better if there is no tension on the closure of the parenchyma—
the body adapts to tension, and the parenchyma will tend to
revert to its original position if it is closed under tension. The
lateral pedicle is a good example of this because it is often
pulled medially to shape the breast, but over time, it tends
to slide back laterally. The problem with a lateral pedicle is
that it makes removal of the lateral excess breast tissue more
difficult.
78.9 Concluding Thoughts
There are many alternative procedures for performing a
satisfactory breast reduction. Much depends on the patient’s
wishes, her anatomy, and the skill and expertise of the surgeon.
There is no right answer for everyone. In our practices, we can
achieve better results with a true superomedial vertical breast
reduction because the tissue is removed where it is in excess.
The shape is good because it relies on an inferior vertical
wedge excision, which better controls the base diameter. The
shape is better and lasts longer (even with weight changes and
pregnancy) because the inferior and lateral tissue is removed,
which prevents damage from the effects of gravity.
An inverted-T skin resection pattern may need to be added to a
vertical procedure if there is too much loose redundant skin. An
inferior pedicle almost always requires an inverted-T skin resec-
tion pattern. The inferior pedicle, inverted-T procedure became
the workhorse for breast reduction when it was introduced in the
1970s because it was consistent, predictable, and reliable. The
problem is that the inferior heavy breast tissue is left behind, and
the superior breast tissue is removed, so gravity could do more
damage over time and with pregnancy.
When a patient is young and has a good breast shape with
good skin elasticity, a parenchyma-only breast reduction can be
used through an inframammary incision only. When a patient
is older and has a good breast shape with good skin elasticity, a
liposuction-only breast reduction can be used. The principle of
weight removal allows the nipple and the breast itself to rise with
either of these procedures.
In gigantomastia patients, a free nipple graft procedure can be
used as an amputation-reduction procedure. It can give a good
shape and adequate resection, but there are problems with a
lack of nipple projection and depigmentation, especially in dark-
skinned patients. A no vertical scar procedure can be used, but
the results are not predictably successful. Some surgeons are
surprised at how a long, thin superior pedicle can be used in very
large patients, but the volume of the pedicle can prevent adequate
resection.
Surgeons need to have several choices at their disposal so that
the best procedure can be adapted to the patient.
Clinical Caveats
• Remove the excess where it is: usually inferior and lateral.
• A skin brassiere should be used only when the skin has good
elasticity.
• Removal of parenchyma-only in the situation of good shape
and good skin elasticity can result in the shortest scars—
liposuction-only or posterior parenchymal resection.
• An inferior pedicle, inverted-T breast reduction may
succumb to gravity over time. The more superiorly based
pedicles are better at withstanding gravity, pregnancy,
and weight changes because the inferior breast tissue is
removed.
• A free nipple graft can be used, but it often results in depig-
mentation and poorly projecting nipples.
• A long, thinned, superior pedicle has challenged our concepts
of blood supply to the breast, and it can be a better choice in
gigantomastia.
Suggested Reading
[1] Asplund OA, Davies DM. Vertical scar breast reduction with medial flap or glan-
dular transposition of the nipple-areola. Br J Plast Surg 1996;49(8):507–514
[2] Chiari Júnior A. The L short-scar mammaplasty: a new approach. Plast Reconstr
Surg 1992;90(2):233–246
[3] Corduff 1, Taylor GI. Subglandular breast reduction: the evolution of a minimal
scar approach to breast reduction. Plast Reconstr Surg 2004;113(1):175–184
[4] Courtiss EH, Goldwyn RM. Reduction mammaplasty by the inferior pedicle tech-
nique. An alternative to free nipple and areola grafting for severe macromastia or
extreme ptosis. Plast Reconstr Surg 1977;59(4):500–507
[5] Gheita A. Mammaplasty: the ´super flapµ or the superior pedicle extra long flap
for massive breasts with marked ptosis or gigantomastia. Aesthetic Plast Surg
2009;33(3):461–470
[6] Gradinger GP. Reduction mammoplasty utilizing nipple-areola transplantation.
Clin Plast Surg 1988;15(4):641–654
[7] Hall-Findlay E-. The three breast dimensions: analysis and effecting change. Plast
Reconstr Surg 2010;125(6):1632–1642
[8] Hall-Findlay EJ. Aesthetic Breast Surgery: Principles and Techniques. St. Louis, MO:
Quality Medical Publishing; 2010
[9] Lalonde DH. No vertical scar breast reduction: a good alternative to the T-scar
inferior pedicle breast reduction. Can J Plast Surg 2000;8(1):36
[10] Mc.issock P.. Reduction mammaplasty with a vertical dermal flap. Plast Recon-
str Surg 1972;49(3):245–252
[11] Passot R. La correction esthetique du prolapsus mammaire par la procédé de la
transposition du mamelon. Presse Med 1925;33:317

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[12] Psillakis JM, Cardoso de Oliveira M. History of reduction mammaplasty. In: Gold-
wyn RM, ed. Reduction Mammaplasty. Boston, MA: Little, Brown; 1990: 1–15
[13] Robbins TH. A reduction mammaplasty with the areola-nipple based on an
inferior dermal pedicle. Plast Reconstr Surg 1977;59(1):64–67
[14] Skoog T. A technique of breast reduction: transposition of the nipple on a cuta-
neous vascular pedicle. Acta Chir Scand 1963;126:453–465
[15] Spear SL, Howard MA. Evolution of the vertical reduction mammaplasty. Plast
Reconstr Surg 2003;112(3):855–868, quiz 869
[16] Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast
Reconstr Surg (1946) 1956;17(5):367–375
[17] Würinger E, Mader N, Posch E, Holle J. Nerve and vessel supplying ligamentous
suspension of the mammary gland. Plast Reconstr Surg 1998;101(6):1486–1493

79 Control and Precision in Mastopexy
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79 Control and Precision in Mastopexy
James C. Grotting and Stephen M. Chen
Abstract
Mastopexy is a challenging procedure due to the expectations
set forth by both patient and surgeon. The ability to re-create a
more youthful and beautiful breast is tempered by the quality of
the breast tissue, the skill of the surgeon, and the final desired
outcome. This chapter highlights several different degrees of
correction and the methods employed.
Keywords
mastopexy, mastopexy-augment, fat grafting, breast shaping
79.1 Introduction
Perhaps no other aesthetic procedure is characterized by as much
anticipation by the patient—and long-term potential for dissat-
isfaction—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
influence 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 appropriately 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 before 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 (NAC) 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. This
chapter focuses on procedures that have produced the most reli-
able long-term result (Fig. 79.1).
79.2 Common Causes of
Breast-Shape Deformities
Clearly, understanding the forces that have produced a certain
breast shape is important 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
breast’s ability 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 resulting
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 macromastia.
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 augmentation procedure. Not uncommonly, these
patients were originally treated (and, it could be argued, inappro-
priately) with breast implants to correct minor ptosis. Often 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” deformity of the breast. With
more women opting for removal and/or replacement of implants
due to recurrent capsules, ruptures, or the desire for a different
appearance, the surgeon must be vigilant to look for the signs
and symptoms of breast implant–associated anaplastic large-cell
lymphoma (BIA-ALCL) and to have the implants and capsules
appropriately evaluated by a pathologist as indicated.
Fig. 79.1 A patient demonstrates her desired postoperative appear-
ance by lifting her breast.

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XI Breast Surgery
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
79.2.1 &ODVViÀFDWiRn RI %reDVW 3WRViV
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 reflec-
tion of the inframammary fold (IMF) and above the lower con-
tour of the gland, whereas moderate 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 (Fig. 79.2).
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 impression 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.
79.3 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 appropriate
procedure for them. Some patients with breast ptosis also have an
element of macromastia, which exacerbates the shape problem.
Although the goals of some patients may be to retain a large size
with a perfect shape, these two elements often become 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 treatment plan. Conversely, adding
mass with a breast implant can potentially expedite the recur-
rence of ptosis by the same mechanism. The long-term success of
a mastopexy involves an element of unweighting the lower pole
of the breast so that it will not tax the skin reduction. Ultimately,
there is a continuum of skin issues ranging from average tone to
completely stretched out, coupled with a continuum of breast
parenchymal issue ranging from thinned out to overly abundant.
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 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 something to enhance volume (e.g., wearing a padded bra or
using an insert), she may also benefit from an implant. Of course,
the problem with a combination of mastopexy 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
eventually 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 ambivalent about being larger. Fat
grafting and fat transfer techniques have been revolutionary for
adding volume to the breast with or without an implant. The
advantages of using fat are the potential for improvement in
overall aesthetics due to additional body contouring, the addition
of volume without a foreign object, and subtle improvement of
contour with minimal additional open surgery. The disadvantages
of fat transfer include variability of fat survival, irregularities, and
potential for fat necrosis and donor site morbidities. That being
said, fat is an invaluable resource in the setting of mastopexy.
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,
practical considerations such as cost and time away from work
Fig. 79.2 Regnault’s classification of breast ptosis. (Adapted from
Regnault P. Breast ptosis: definition and treatment. Clin Plast Surg.
1976; 3:193-203.)

79 Control and Precision in Mastopexy
1237
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 measure-
ments. 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
IMF 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 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 surgeon must augment the supporting
structures. Siting the final position of the nipple prior to placing
the implant may result in a malpositioned NAC. Elizabeth Hall-
Findlay demonstrated that the distance from the sternal notch to
the nipple increased by 2 cm upon placement of an implant.
With the patient standing, the surgeon gathers the lower pole
with the hand to simulate the upper pole fullness and medial
cleavage desired (Fig. 79.3). This “Lassus” maneuver 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 information 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 consider a periareolar technique (or even a
semicircular skin excision). More severe cases require a vertical
or superomedial approach so that the NAC 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.
79.4 2SerDWiYe 7eFKniTue
79.4.1 SeOeFWiRn RI 7eFKniTue
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
nipple elevation is required or if one does not wish to violate the
parenchyma at all (e.g., opposite breast corrections with breast
reconstruction). This can be likened to procedures of the face,
where we now recognize that tightening only the skin will not
yield a natural, long-lasting result.
The differences between skin-only mastopexy techniques
and parenchymal remodeling techniques can be summarized as
follows:
• Skin-only techniques: less permanent
• Parenchymal remodeling: longer-lasting correction of ptosis
by internal repositioning of the gland
With patients who have both hypomastia and ptosis, the
surgeon must decide whether ptosis can be corrected with an
implant alone. In general, correcting ptosis with large subglandu-
lar implants ultimately leads to a lower breast position, a short
distance from the lowered IMF to the iliac crest, and difficulty in
fitting clothing. Although patients may initially accept the appear-
ance, in time many return to the plastic surgeon’s office seeking
correction. Improved nipple position on a lowered glandular pro-
file 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 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 supported long-term by
the tissues, so it is generally safer and more predictable to place
an optimal base-width implant with less projection. Think of the
implant as providing core volume only or serving as the foundation
upon which the corrected breast shape will sit. Because patients
often confuse size with shape, a reasonable strategy for the patient
with larger volumes of native tissue is for her to live with the lift
alone for the first year and consider tweaking the result with an
implant or fat grafting 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. In fact, many patients with
ptosis specifically state that they do not wish to be bigger. :hen
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.
A final issue is related to the superior breast border, which can
be located by “folding” the breast up. Where it creases against the
chest wall is where the gland begins. Ideally, it should be at the
superior extent of the anterior axillary fold. If it is lower than this,
a decision should be made as to whether it needs to be raised.
:e agree with Elizabeth Hall-Findlay that it is difficult to gain any
elevation of the superior breast border without using an implant
or autologous fat grafting.
Fig. 79.3 The surgeon can simulate the postoperative appearance of a
mastopexy by gathering the lower-pole skin.

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XI Breast Surgery
79.4.2 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, or laterally, whether they are bipedi-
cled, 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.
79.5 3eriDreRODr 7eFKniTueV
No mastopexy technique is as seductive as the periareolar tech-
nique. 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 surgeons
would prefer to keep scars concealed and as short as possible, as
long as a beautiful shape can be produced. When the proper tech-
nique is executed in a properly selected patient, the periareolar
technique confines incisions, and therefore potential scars, to the
areola–skin interface. Resulting scars in this area are usually almost
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 de-
epithelializing 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. The more skin that is
excised and the more the shape of the excision becomes oval, the
more likely the complication of areolar widening or ending up out
of round.
Small, mildly ptotic breasts with adequate breast parenchyma
respond best to this technique. However, this technique can be mod-
ified to accommodate moderate degrees 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 elevation of the NAC 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 precision in the placement of the incision and the
amount of skin excised. Even with precision, 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 pro-
cedure to treat significant breast ptosis. If a patient requires more
than 3 cm of nipple elevation, 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 (thickness 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 complaints 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.
79.5.1 Periareolar Mastopexy without
Parenchymal Reshaping
7eFKniTue
The position of the NAC determines the amount of skin to be
excised. 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 standing position in the preoperative area. Symmetry is
ascertained using the sternal notch–to-nipple (SN-N) 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 de-epithelialization. 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 suture of 4–0 Gore-Tex
(:. L. Gore and Associates, Flagstaff, A=) or Mersilene (-ohnson
Johnson, New Brunswick, NJ) is then placed in the deep dermis of the
skin edge (Fig. 79.4). 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 running poliglecaprone
(Monocryl, Johnson & Johnson, New Brunswick, NJ) or polydioxa-
none suture (PDS) subcuticular stitch (Fig. 79.5).
79.5.2 GyeV 3eriDreRODr 7eFKniTue :iWK
Mesh Support
João Carlos Sampaio Góes of Brazil expanded the use of peri-
areolar techniques by introducing his double-skin technique,
whereby a resistant lining of the breast is created with the use
of a layer of prosthetic mesh. The “double skin” refers to the use
of a doughnut-shaped, periareolar, de-epithelialized dermal flap
that is used to support the gland under the remaining normal
skin, which will be closed around the reshaped gland. The mesh

79 Control and Precision in Mastopexy
1239
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 over-
lying skin. He creates an internal brassiere by using the anterior
pectoral fascia, inframammary connective ligaments, a periareo-
lar dermal flap that is used as an internal lining, and a mixed mesh
originally composed of polyglactin (Vicryl, Johnson & Johnson,
New Brunswick, NJ) and Prolene (Ultrapro, Johnson & Johnson,
New Brunswick, NJ). This is enveloped 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 patients
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 dissect the skin flaps carefully
and to place the mesh meticulously to avoid suboptimal results
and/or disastrous outcomes.
Until recently, there has also been considerable resistance
to placing permanent or absorbable meshes within the breast
parenchyma among U.S. surgeons because of concerns about
mammographic artifacts or palpability; de Bruijn and colleagues
in Belgium have addressed this with the use of a three-dimen-
sional polyester mesh that does not cause artifacts on mammog-
raphy and is not palpable. Histologically, there is minimal scarring
and a deposition of a thin layer of collagen about the mesh that
results in increased firmness of the breast parenchyma to provide
a long-lasting correction. Currently, dermal matrices and long-
term resorbable scaffolds such as poly-4-hydroxybutyrate (P4HB
or GalaFlex, Galatea Surgical, Lexington, MA) have been used for
this purpose with reasonable success.
7eFKniTue
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 cardinal points are
marked. Point A is the new level of the top of the areola; point
B is the distance from the IMF (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; Fig. 79.6).
The marked area is de-epithelialized to the nipple. The outer
border is incised and a skin flap is developed superiorly, with
Fig. 79.4 A round block cerclage stitch may be passed in the deep
dermis in a purse-string fashion. (Adapted from Benelli LC. Periareolar
Benelli mastopexy and reduction. In: Spear SL, ed. Surgery of the
Breast: Principles and Art. Philadelphia: Lippincott-Raven; 1998.)
Fig. 79.5 A diametrical transareolar U suture may be used to control areolar shape and protrusion. (Adapted from Benelli LC. Periareolar Benelli
mastopexy and reduction. In: Spear SL, ed. Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven; 1998.)

1240
XI Breast Surgery
progressive thickening of this flap as one approaches the chest
wall. The undermining continues for another 5 cm once the pec-
toralis fascia is reached. The direction is then changed inferiorly
under the gland to approximately a third of the retromammary
space. Perforators will be encountered and should be preserved.
Inferiorly, a thin flap is developed down to the IMF (Fig. 79.7).
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 provide fill of the upper pole of the
breast. Likewise, the inferior resection is sutured together and
then fixed to the inframammary connective ligaments and the
anterior pectoral fascia. The de-epithelialized 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 (Fig. 79.8).
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 anterior pectoral fascia at the base of
the breast mound (Fig. 79.9).
The external skin lining is brought up over the breast mound
and closed around the areola with a circular, continuous, deep
intradermal suture of Mersilene 2–0 on a straight needle. A con-
tinuous intradermal Monocryl 4–0 suture is used to fix the areolar
skin to the external skin lining. Dressing consists of triangular
pieces of Micropore tape (3M, St. Paul, MN) covering the whole
gland, which is left in place for 20 days. Tegaderm (3M, St. Paul,
MN) also works well for this purpose. Suction drains are removed
after approximately 5 days.
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.
79.5.3 Vertical Mastopexy without
Implants
We believe that some type of parenchymal remodeling is essen-
tial to produce a longer-lasting lift effect in a mastopexy without
implants unless the parenchyma is thin and unsupportive. As
mentioned previously, a vertical or inverted-T de-epitheliali-
zation 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 opposite breast mastopexy for matching a
reconstructed breast. Another example would be when the length
and width of the tissue between the vertical markings amounts
to less than 50 grams of poor fat volume. Otherwise, it is our view
that rearrangement of the parenchyma gives a more satisfactory
long-term lift. The way that we most commonly 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
Fig. 79.6 Markings for the Góes periareolar mastopexy technique.
(Adapted from Góes JCS. Periareolar mastopexy and reduction with
mesh support. In: Spear SL, ed. Surgery of the Breast: Principles and
Art. Philadelphia: Lippincott-Raven; 1998.)
Fig. 79.7 Sagittal section of planned glandular resection and
subcutaneous flaps in the Góes periareolar mastopexy technique.
(Adapted from Góes JCS. Periareolar mastopexy and reduction with
mesh support. In: Spear SL, ed. Surgery of the Breast: Principles and
Art. Philadelphia: Lippincott-Raven; 1998.)

79 Control and Precision in Mastopexy
1241
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 prefer to sit in front of her on a stool that can be
raised and lowered so that the surgeon 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.
The IMF is marked on each side. The new nipple position is
assessed. This is determined by a combination of data points.
First the IMF 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 whether 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 anterior
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 IMF is also an important
landmark because this is where the bottom of the vertical limbs
will be centered (Fig. 79.10).
The breast is then gently distracted laterally so that the medial
pillar can be marked in line with the midline superiorly and inferi-
orly. The mark is joined with the inferior mammary midline with
a curvilinear line that ends a few centimeters above the IMF. 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 (Fig. 79.11).
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 NAC initially (Fig. 79.12).
Fig. 79.8 Wedge resection of the gland following separation of breast
skin and gland components. (Adapted from Góes JCS. Periareolar
mastopexy and reduction with mesh support. In: Spear SL, ed. Surgery
of the Breast: Principles and Art. Philadelphia: Lippincott-Raven; 1998.)
Fig. 79.9 Placement of mesh over the newly created breast mound.
(Adapted from Góes JCS. Periareolar mastopexy and reduction with
mesh support. In: Spear SL, ed. Surgery of the Breast: Principles and
Art. Philadelphia: Lippincott-Raven; 1998.)

1242
XI Breast Surgery
The top of the vertical closure is estimated by the pinch technique
(“Lassus maneuver”) 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 de-
epithelialization if one is confident that the nipple position has been
properly determined. The greater the degree of ptosis, the less likely
we are to commit to the new nipple position definitively (Fig. 79.13).
From the top of the vertical closure, one measures down 5 to
6 cm and makes another mark that will represent the approxi-
mate position of the new fold. The breast tissue below that point
will constitute 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 accentu-
ate the upper pole. If a small amount of breast tissue needs to
be resected, this flap tissue is the most readily available for
trimming.
7eFKniTue
After the patient is placed under general anesthesia, we make
certain that she is centered on the operating table and that her
arms are properly secured so we can sit the patient up for intra-
operative assessment of the result. After the patient is draped,
we place pendulum sutures at the sternal notch and the xiphoid.
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 epi-
nephrine is infiltrated in the epidermal–dermal junction where
de-epithelialization is planned to help control bleeding.
Fig. 79.10 Vertical mastopexy markings. (a) Marking of inframammary fold. (b) Marking of new nipple position.
Fig. 79.11 The breast is distracted laterally to mark the medial pillar.
Fig. 79.12 The breast is distracted medially to mark the lateral pillar.
a
b

79 Control and Precision in Mastopexy
1243
The entire segment between the medial and lateral pillars and
the periareolar skin is de-epithelialized, and the breast is elevated
off the pectoralis fascia. Unless the bases of the pillars are to be
trimmed, it is unnecessary to undermine much medially and later-
ally. 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 (Fig. 79.14).
Once the breast is undermined, a laparotomy sponge 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
angled in about 60° and stopped at the previous mark, which will
also represent the 6 o’clock position of the future exteriorized
nipple–areola complex. It is important not to empty the lower
pole too much (Fig. 79.15).
The flap is then folded underneath into the upper pole and
sutured with 2–0 Vicryl sutures. The pillars are then reapproxi-
mated, 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 infraclavic-
ular space as possible. A bite of lateral breast parenchyma is also
Fig. 79.13 Vertical mastopexy markings. (a) The medial and lateral pillars are continued inferiorly in a curvilinear fashion to meet several
centimeters above the inframammary fold. (b) The top of the vertical closure is determined using the pinch technique. (c) Final appearance of
markings for vertical mastopexy.
Fig. 79.14 The skin is de-epithelialized and the central gland under-
mined at the level of the pectoral fascia.
Fig. 79.15 Vertical mastopexy technique. (a) The gland is fully undermined. (b) Medial and lateral cuts are made in the breast parenchyma, isolating
the glandular flap on its superior blood supply.
a
b
c
a
b

1244
XI Breast Surgery
grasped at the inferior extent of the lateral contour and sutured
medially in the midline of the breast to help cone the breast and
keep it from falling laterally toward the axilla. A 15 French Blake
drain is placed along the lateral gutter and the vertical portion
temporally stapled. 1ote the upper-pole fill and the improved
nipple position in relation to the breast mass (Fig. 79.16).
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 template, 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 de-epithelialization is completed,
followed by layered skin closure.
The dressing, consisting of large, rectangular sheets of Tegaderm,
supports the final breast shape and is applied in such a way as
to avoid skin shear and tear and compression of the nipples (Fig.
79.17). The dressing is kept in place for 2 weeks, and the patient
wears a surgical bra. 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 (Merz Pharmaceuticals,
Frankfurt, Germany) or Scarguard (Scarguard Labs, Great Neck, NY).
79.6 Use of Implants with
Mastopexy
The most conservative approach when an implant is also
planned is to place the implant 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 exces-
sively thin (pinch thickness < 3 cm). A silicone gel implant can
be placed in the subglandular position with less concern about
visibility or palpability. In some cases, the upper-pole fullness is
further augmented by the use of a small flap, even in the pres-
ence 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. The use
of autologous fat to feather out the upper pole is also an effective
way to disguise implant visibility but involves additional cost
and potential donor site morbidity.
Selection of saline or silicone implants follows a discussion
with the patient and examination 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. Silicone implants can be used in either position; however,
the overlying parenchyma needs to be firm to support the addi-
tional 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 down-
ward forces on the newly lifted tissues. The implant provides the
core volume, and the reshaped parenchyma sits on the implant
foundation. Fat grafting in the upper pole can be used to increase
the fullness of the superior breast and can either camouflage
the appearance of the edges of the implant or allow the use of a
smaller implant in this position, or both. By filling in the upper
pole, this does not cause traction on the breast mound as would
a larger implant.
Fig. 79.16 Vertical mastopexy technique. (a) The glandular flap is tucked underneath the areola. (b) Appearance following glandular repositioning
and tailor-tacking of the vertical incision. A saline implant is shown with the fill tube in place.
Fig. 79.17 Final appearance following vertical mastopexy with
Tegaderm dressing in place.
a
b

79 Control and Precision in Mastopexy
1245
79.6.1 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 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 may not be needed if it
can be used as a parenchymal flap and shifted to the upper pole
pedicled superiorly. If not, it is often best removed because it will
gradually lead to recurrent ptosis otherwise.
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 reop-
eration. This technique is performed at the expense of longer
scars. The horizontal component runs along the IMF from the
medialmost 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 envelope rather than
support from the gland.
7eFKniTue
Markings proceed using the standard Wise pattern. With the
patient in the upright position, the breast meridian is marked.
The level of the IMF is transposed anteriorly to intersect with the
meridian to mark the new level of the 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 nipple (the “A” point of Pitanguy). 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 relaxation, but not so tight as to compromise vas-
cularity. The vertical limbs are extended medially and laterally
to intersect with the IMF. One must ensure that the medial and
lateral extensions together are equal to, if not longer than, the
length of the inframammary incision.
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 de-epithelialized. Transdermal inci-
sions are made along the upper portion on either side of the NAC.
If there is an abundance of de-epithelialized breast tissue below
the IMF, the gland is dissected off the pectoralis muscle, starting
from the IMF and proceeding upward, creating a superiorly
based dermoglandular 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 the standard fashion with little or no further
undermining. The NAC is positioned and sutured into place. This
technique is most commonly used in our practice for opposite
breast corrections in breast reconstruction, having the advan-
tage of minimal internal scarring of the parenchyma for clear
mammograms.
79.7 Biologics versus Standard
Meshes
Mastopexy, and more frequently augmentation mastopexy, is
plagued with recurrent 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.
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. More recently, there have been
novel meshes composed of the same material as PDS, which have
been used to create a framework for collagen deposition to give a
more stable scar to hold the breast parenchyma.
79.7.1 Placement of Meshes Between
Implant and Breast Parenchyma
To correct bottoming out with a dual-plane type of augmenta-
tion, dermal meshes can be used as an inferior sling to connect
the pectoralis muscle around the implant to the chest wall, effec-
tively fixing the location of the IMF and supporting the weight of
the implant (Fig. 79.18).
Maxwell and Gabriel have demonstrated the effective use of
acellular dermal matrix to correct pocket deformities throughout
the breast, whereas Colwell and Breuing have used these dermal
matrices in primary mastopexies to have additional support for
the stretched-out breast parenchyma. Adams et al have used
a similar strategy with the GalaFlex mesh. Regardless of the
location that these meshes or dermal matrices are placed in,
they require fixation to stable structures, either the fascia of the
pectoralis or the reflection of the IMF. They permit the surgeon
to shape the glandular structures more effectively, rather than
relying on the skin envelope for long-term shaping of the breast.
To minimize complications arising from seroma or infection, the
surgeon ideally should create a pocket of the dermal matrix that
is sandwiched between two vascularized surfaces to maximize
vascular ingrowth and incorporation. However, they can be used
to support the implant directly inside an old capsule or against
native breast tissue. The drawback to these procedures has been
the cost of acellular dermal matrices. The newer mesh is placed
in the same fashion and has a distinct cost advantage. However,
long-term studies are not available to show the durability at 5 and
10 years postprocedure.
79.8 Liposuction
Liposuction has been used to reduce breast size and, with
concomitant skin retraction, can potentially modestly raise the
level of the 1AC. The most obvious benefit is provision of a breast
lift with minimal scarring. The preservation of neurovascular

1246
XI Breast Surgery
structures is another advantage. The limitations of this proce-
dure lie in the fact that the majority of the substance removed
from the breast is fat, not breast parenchyma. In addition, the
patient must have supple, elastic skin to achieve the greatest
benefit.
The advent of ultrasound-assisted lipectomy has allowed
more-aggressive cases to be tried because the procedure can
assist in skin retraction and hence greater nipple elevation
than could be accomplished with standard suction-assisted
lipectomy.
The ideal patient for this procedure has mild breast hypertrophy
resulting from an overabundance of fat, minimal ptosis, and good
skin quality. The indications for this procedure are also expanded
to women who have already had a breast reduction procedure and
want a small adjustment. The benefits are that further manipu-
lation of the pedicle is avoided, and there is a decreased risk of
devascularization or nerve injury.
The breast is usually accessed through two small stab incisions
above the IMF at the medial and lateral aspects of the breast,
and another one at the areola. The placement of these incisions
facilitates a more uniform removal of fat by allowing overlap.
When this technique is employed correctly, there is minimal
risk of damage to the neurovascular supply of the nipple and
hence a decreased risk of nipple necrosis or loss of sensation
(Fig. 79.19).
The main disadvantage of this treatment is its limited applica-
tion. Only a small subset of women fit the strict criteria for this
procedure. On the wrong patient, this technique will produce
suboptimal results that may be very difficult to correct.
79.9 Mastopexy to Correct the
Overaugmented Breast
One of the increasingly common operations that we perform is to
revise patients who underwent augmentation years earlier with
large saline implants and now have breasts that are too large and
too low. Many other presentations can occur, including ptosis
with capsular contracture, which can produce bizarre asym-
metrical configurations for which a treatment plan is difficult to
develop. Some of these patients have had large implants placed
inappropriately in an attempt to treat breast ptosis by ´filling upµ
the deflated skin envelope because the patient would not accept
additional scars. Others have simply gained breast size from a
weight increase over the decades.
Our approach to these patients, especially when they have
saline implants in place, is to perform a preliminary in-office
deflation of their implants to set up the breast for definitive cor-
rection. This simple procedure is done with a local anesthetic; an
18-gauge needle is inserted into the implant through the lower
pole while compressing the device with the opposite hand until
it is completely deflated. The patient then has an opportunity
to live with her natural breast shape and size for 3 or 4 weeks
while the ligaments shorten and the skin recovers from the over-
stretched condition. This has the advantage of giving the patient
the opportunity to decide whether she even needs or wants
additional volume with implants or fat grafting as well as shape
correction with a mastopexy. Some patients have a satisfactory
shape and can simply undergo reaugmentation, usually in a new
Fig. 79.18 Biologic mesh to support submuscular implant (a) Oblique view. (b) Sagittal section.

79 Control and Precision in Mastopexy
1247
plane, and their implants are often replaced with silicone gel
devices.
Many of these reoperative patients have the idea that they must
have implants to give them the shape they want, but the two-stage
approach allows them to see that they have adequate parenchyma
to produce breasts of suitable size if a mastopexy alone can be
performed. It is much easier to plan the definitive correction
after implant deflation than to try to accomplish everything in a
single stage. This approach decreases the chances of the patient’s
needing yet another revision.
79.10 Postoperative Care
Postoperative care following a mastopexy starts in the operating
room. Because of our preference for parenchymal reshaping to
maintain a more permanent result, the breast should be held in
its exaggerated shape for the first several weeks after surgery;
that is, the fullness of the upper pole, with a flattened lower pole
shape, must be splinted to assist in solid internal healing to keep
the breast shape high and round.
The use of Tegaderm has been exceedingly helpful in this regard.
We use large sheets cut longitudinally so that two long, narrow
sheets can be used as a clear, supportive dressing. Care must be
taken not to pull the Tegaderm over the skin, because this will
create shear forces that can cause blistering. Rather, the breast is
held in the desired position and the Tegaderm is simply laid down
flat against the skin to hold it in place. The first sheet goes from
lateral to medial, from the nipple down to the IMF. This material
can also be used to support the drain and maintain its position.
The second sheet goes across the upper pole, overlapping the
lower sheet at approximately the level of the nipple. We usually
cut out a small segment to avoid flattening the nipple. 1ext, we
place the patient in a support bra, which helps maintain the final
shape. An advantage of using Tegaderm is that when the patient
takes off the bra, she can shower normally without losing support.
If a drain is used, it is ordinarily removed on the first postoperative
day. With a smaller mastopexy, we may choose not to use a drain at
all. Typically, a mastopexy procedure is not associated with anything
more than minor pain. Oral analgesics are sufficient, and ketorolac
tromethamine (Toradol, Farmak, Olomouc, Czech Republic) has also
been helpful in patients who are sensitive to narcotics.
The patient is seen at 1 week postoperatively for a checkup. At
2 weeks postoperatively, the patient returns after removing all
of the remainder of the Tegaderm in the shower in the morning.
The breasts are simply gently washed, patted dry, or dried with a
hairdryer, and the patient puts the support bra back on. The peri-
areolar nonabsorbable sutures are then removed in the clinic. We
recommend that the patient wear a support bra day and night for
8 weeks following mastopexy. “Push-up” bras that accentuate the
upper pole are helpful during this period to encourage the breast
to heal in a high, round position. An underwire bra often helps
define the new IMF shape and position. Scar treatment begins 3
weeks postoperatively with such over-the-counter preparations as
Mederma or Scarguard. Typically, we do not consider scar revisions
for 1 year after surgery. However, if a small amount of redundant
tissue exists at the inferiormost portion of the vertical scar at
6 months postoperatively and is bothersome to the patient, we
may consider a small revision in the office. :e make every effort
to eliminate these small revisions as they result in office cost, and
patients interpret even a minor second surgery as a failed first one.
79.11 Outcomes and Complications
Although patients who undergo mastopexy always look better
than they might have looked had they not had the operation, the
result must be considered semipermanent. Invariably, a little
Fig. 79.19 Breast liposuction. (a) Medial and lateral access incisions. (b) Superior-pole access incisions.
a
b

1248
XI Breast Surgery
shape is lost over time, and the nipple descends. If bottoming
out occurs, the nipple position may be disproportionately high.
These shape issues are ordinarily addressed at 1 to 2 years post-
operatively to let the tissues settle before any revision is offered.
The 37-year-old woman shown in Fig. 79.20 underwent ver-
tical mastopexy to treat pseudoptosis. Notice the error on the
right in placing the nipple too high on the breast mound. She is
shown before and 1 year after surgery. The lateral views show
the considerable breast elevation that has been achieved, clearly
demonstrating that the nipple position is too high.
Bleeding and infection are rarely seen after a mastopexy. Nipple
and areolar deformities can usually be prevented by avoiding tension
on the closure. We do not excise too much skin and make certain
that the pedicle moves freely to the new nipple position. If the scar
is wide or the shape of the areola is irregular, these problems can be
corrected rather easily by re-excision and closure in the proper shape.
As in the case of reduction mammaplasty, breastfeeding following
mastopexy may or may not be successful. In patients who do become
pregnant after mastopexy, we encourage them to try breastfeeding,
but to be aware that they may have to supplement the nutritional
needs of the baby. It is important to advise patients that additional cor-
rections may be desirable when pregnancies occur after mastopexy.
It is not uncommon to encounter some problems with implant
malposition when a mastopexy is done concomitantly. As opposed
to breast augmentation alone, where malposition problems may be
addressed as early as 3 months postoperatively, we are reluctant to
correct the augmentation-mastopexy patient for at least 6 months
because we have seen many cases in which the deformity either
improves on its own or is not fully stabilized during this time frame.
Of course, correction of these problems is aimed at either changing
the level of the implant by capsulotomy or capsulorrhaphy or revis-
ing the mastopexy if the implant is in the proper location. Typically,
mastopexy revisions are possible by skin-only techniques.
Chronic pain following mastopexy can be enigmatic. Occasionally
this is caused by ongoing fibrocystic breast disease, condrochon-
dritis, or sutures that have inadvertently encircled sensory nerve
fibers. The latter is usually diagnosed by pinpoint tenderness
laterally with shooting pain and can be attributed to the neuroma.
A small amount of lidocaine or bupivacaine in the area is usually
diagnostic. Fortunately, this usually resolves without treatment.
Most patients remain pleased with mastopexy results, particu-
larly as the years go by and the scars fade. We have seen patients
in whom the scars become virtually invisible. If the shape remains
satisfactory, the scars are well accepted by most patients.
79.12 Results
The 44-year-old patient shown in Fig. 79.21 had tissues that were
very fatty without much glandular substance. An implant was
necessary to lend adequate volume and shape. Additional factors
included lack of support from any type of glandular flap. Therefore,
the plan included placing an implant with an appropriate base diam-
eter. This patient chose saline; however, our preference is a round or
shaped silicone gel device in most cases. She is shown 1 year after
placement of a saline-filled implant with a final volume of 360 mL in
the subpectoral position and a skin-tightening vertical mastopexy.
In the 40-year-old patient shown in Fig. 79.22 we considered
adding an implant, but because she could achieve her desired
shape and size in a bra, we decided a mastopexy alone was all that
Fig. 79.20 Vertical mastopexy complicated by superior malposition of the nipple. (a) Preoperative appearance, frontal view. (b) One year postop-
erative appearance, frontal view. (c) Preoperative appearance, lateral view. (d) One year postoperative appearance, lateral view. (e) Preoperative
appearance, oblique view. (f) One year postoperative appearance, oblique view.
a
d
c
f
b
e

79 Control and Precision in Mastopexy
1249
was needed. She underwent a vertical mastopexy in which the
superiorly based parenchymal flap from the lower pole was folded
underneath the upper pole to create some additional upper-pole
convexity. She is shown 7 months postoperatively. If this patient
desires additional fullness, an implant can be added later after the
mastopexy is healed and stable.
The 38-year-old woman shown in Fig. 79.23 had an unusual
asymmetry in which the larger breast had a higher, smaller NAC.
Both breasts required a mastopexy to reshape the parenchyma;
the plan included reducing the volume on the left so that the
parenchymal volumes could be equalized. This approach allowed
implants of equal size and shape to be placed. When the ratio of
breast parenchymal volume to implant volume and dimensions is
equal, the evolution of shape over time is much more likely to result
in a long-lasting, symmetrical correction. The correction included
an autoaugmentation with a superiorly based parenchymal flap
on the right with a 150-mL smooth silicone gel implant. On the
left breast, a 154-g reduction was performed in the inferior pole,
and a 150-mL silicone gel implant was placed. Although her result
was satisfactory at 9 months postoperatively, by 2 years there was
a worsening of the shape on the right side. This was associated
with a 5-pound weight loss that was significant in this very petite
patient.
The 37-year-old woman shown in Fig. 79.24 underwent a
vertical mastopexy with a small, 200-g reduction. The patient is
shown before and 1 year after surgery.
The 36-year-old woman shown in Fig. 79.25 presented with
asymmetry. She is shown preoperatively and 3 months after
vertical mastopexy in which 30 g of tissue was resected from the
right and 200 g from the left breast.
The 42-year-old woman shown in Fig. 79.26 underwent
explantation of 360-mL saline implants and subsequent
Fig. 79.21 Vertical mastopexy with placement of subpectoral saline implant. (a) Preoperative appearance, frontal view. (b) One year postoperative
appearance, frontal view. (c) Preoperative appearance, lateral view. (d) One year postoperative appearance, lateral view. Notice that the NAC ended
up slightly low as a result of recurrent ptosis. It is best to mark the NAC about 2 cm higher when placing an implant as the implant will stretch out the
upper pole resulting in a low NAC position long term.
a
c
b
d

1250
XI Breast Surgery
Fig. 79.22 Vertical mastopexy. (a) Preoperative appearance, frontal view. (b) Seven-month postoperative appearance, frontal view. (c) Preoperative
appearance, lateral view. (d) Seven-month postoperative appearance, lateral view.
a
c
b
d

79 Control and Precision in Mastopexy
1251
Fig. 79.23 Vertical mastopexy augmentation in a patient with significant breast asymmetry. (a) Preoperative appearance, frontal view. (b) Nine-
month postoperative appearance, frontal view. (c) Two-year postoperative appearance, frontal view. (d) Preoperative appearance, oblique view. (e)
Nine-month postoperative appearance, oblique view. (f) Two-year postoperative appearance, oblique view.
Fig. 79.24 Vertical mastopexy with small reduction. (a) Preoperative appearance, frontal view. (b) One-year post-operative appearance, frontal view.
(c) Preoperative appearance, lateral view. (d) One-year postoperative appearance, lateral view. (e) Preoperative appearance, oblique view. (f) One-year
postoperative appearance, oblique view. Notice that the use of a smooth saline implant subpectorally will often move inferolaterally long term if the
tissues are thin and no mesh support added.
a
a
d
d
c
c
f
f
b
b
e
e

1252
XI Breast Surgery
Fig. 79.25 Vertical mastopexy with small reduction in patient with breast asymmetry. (a) Preoperative appearance, frontal view. (b) Three-month
postoperative appearance, frontal view. (c) Preoperative appearance, lateral view. (d) Three-month postoperative appearance, lateral view. (e)
Preoperative appearance, oblique view. (f) Three-month postoperative appearance, oblique view.
Fig. 79.26 Vertical mastopexy following saline implant removal. (a) Preoperative appearance, frontal view. (b) Nine-month postoperative appear-
ance, frontal view. (c) Preoperative appearance, lateral view. (d) Nine-month postoperative appearance, lateral view. (e) Preoperative appearance,
oblique view. (f) Nine-month postoperative appearance, oblique view.
a
a
d
d
c
c
f
f
b
b
e
e

79 Control and Precision in Mastopexy
1253
vertical mastopexy. She is shown preoperatively and 9 months
postoperatively.
The 47-year-old woman shown in Fig. 79.27 had severe ptosis
and glandular excess. An inverted-T reduction with superome-
dial pedicle was performed. She is shown before and 4 years
after surgery.
The 43-year-old woman shown in Fig. 79.28 who had a previ-
ous augmentation mastopexy underwent explantation of 200 mL
implants and then mastopexy with an inverted-T pattern. She is
shown before and 9 months after surgery.
The 24-year-old woman shown in Fig. 79.29 had macromastia
as well as breast asymmetry, with the right side larger than the
Fig. 79.27 Inverted-T reduction in patient with severe ptosis. (a) Preoperative appearance, frontal view. (b) Four-year postoperative appearance,
frontal view. (c) Preoperative appearance, lateral view. (d) Four-year postoperative appearance, lateral view. (e) Preoperative appearance, oblique
view. (f) Four-year postoperative appearance, oblique view.
Fig. 79.28 Inverted-T mastopexy following saline implant removal in a patient with previous mastopexy augmentation. (a) Preoperative appearance,
frontal view. (b) Nine-month postoperative appearance, frontal view. (c) Preoperative appearance, lateral view. (d) Nine-month postoperative
appearance, lateral view. (e) Preoperative appearance, oblique view. (f) Nine-month postoperative appearance, oblique view.
a
a
d
d
c
c
f
f
b
b
e
e

1254
XI Breast Surgery
Fig. 79.29 Breast liposuction in a patient with macromastia and breast asymmetry. (a) Preoperative appearance, frontal view. (b) One-month
postoperative appearance, frontal view. (c) Breast markings for planned liposuction. (d) Preoperative appearance, right lateral view. (e) One-month
postoperative appearance, right lateral view.
a
d
c
b
e

79 Control and Precision in Mastopexy
1255
left; 100 mL of tissue was liposuctioned from the left breast and
350 mL from the right. She is shown before and 1 month after
liposuction.
The 37-year-old woman shown in Fig. 79.30 was treated for
severe ptosis. A Wise pattern mastopexy with a superior pedicle
was done. No reduction was performed on the left breast, and 100
g of tissue was resected from the right. She is shown before and 3
months after surgery.
The 57-year-old woman shown in Fig. 79.31 had moderate
ptosis and breast atrophy. Augmentation with 275-mL implants
was performed, followed by vertical mastopexy. She is shown
preoperatively and 1 year postoperatively.
79.13 Concluding Thoughts
At present, all mastopexy techniques are imperfect. Although
surgeons are doing a better job of reducing overall scar length,
we still struggle to obtain a beautiful, stable, long-lasting shape
that will justify the scarring. Most women will accept the scars
if the shape is attractive. The periareolar techniques work best
if the breast tissue is relatively fibrous and there is minimal skin
excess or laxity. We await the development of a suitable internal
mesh to use in the Góes technique. In the meantime, we have
found that the vertical techniques provide the best, most pre-
dictable results, with or without the use of implants.
Fig. 79.30 Inverted-T mastopexy with small reduction in patient with severe ptosis. (a) Preoperative appearance, frontal view. (b) Three-month
postoperative appearance, frontal view. (c) Preoperative appearance, lateral view. (d) Three-month postoperative appearance, lateral view. (e)
Preoperative appearance, oblique view. (f) Three-month postoperative appearance, oblique view.
Fig. 79.31 Augmentation and vertical mastopexy in a patient with breast atrophy and moderate ptosis. (a) Preoperative appearance, frontal view.
(b) One-year postoperative appearance, frontal view. (c) Preoperative appearance, lateral view. (d) One-year postoperative appearance, lateral view.
(e) Preoperative appearance, oblique view. (f) One-year postoperative appearance, oblique view.
a
a
d
d
c
c
f
f
b
b
e
e

1256
XI Breast Surgery
Clinical Caveats
Periareolar Mastopexy without Parenchymal Reshaping
• This technique is suitable only in mild to moderate ptosis
cases in which a minimal amount of nipple elevation is
required.
• The amount of nonpigmented skin excision should be less
than the amount of pigmented skin excision.
GRpV 3eriDreRODr 7eFKniTue ZiWK 0eVK SuSSRrW
• The surgeon should accept a slightly larger areolar size in
relation to the base width of the breast.
• The amount of skin removed lateral to the nipple–areola
complex (NAC) should be limited.
• Flap dissection should be performed very carefully so that the
skin flaps drape smoothly over the mesh.
• The space between the mesh and skin should be drained for
at least 1 week.
• This technique is very well adaptable to commercially avail-
able meshes in the United States.
Vertical Mastopexy without Implants
• The nipple position is set approximately 2 cm below the usual
A-point. (The A-point in breast surgery refers to the anterior
projection of the inframammary fold (IMF) onto the breast.
With inverted-T techniques, this represents the new position
of the nipple. With vertical mastopexy, it represents the top
of the areola.)
• The surgeon should be cautious in marking the medial and
lateral pillars, keeping in mind that minimal, if any, breast
tissue will be excised.
• Parenchymal shaping sutures are used in the superior pole
and in the lateral pillars to assist in shaping of the breast.
• The new nipple-areolar position is marked with an areolar
template with the patient in the upright position before final
suturing.
• Securing the breast with either Tegaderm or Micropore paper
tape for 2 to 3 weeks helps to mold the final breast shape.
Liposuction Only
• The key to success with liposuction is correct patient
selection.
• The ideal patient is one in whom the NAC is already in a good
position.
• Liposuction-only candidates should have a majority of fat
rather than fibroglandular breast tissue.
Wise Pattern
• The surgeon should attempt to tailor the horizontal compo-
nent of the scar within the new IMF to help camouflage it.
• The pattern is useful for reoperative cases when the breasts
have been overaugmented.
• A two-stage approach is planned with in-office deflation at
least 4 weeks before the definitive correction.
• The surgeon meets with the patient 1 week before the final
correction to determine whether an implant is needed, and if
so, what type and size.
Biologic Meshes
• Biologic meshes are useful adjuncts in primary cases in which
the breast parenchyma and skin are very stretched out.
• Mesh is invaluable in revisional cases of augmentation mas-
topexy where the breast parenchyma is lacking.
• Final correction must be achieved while the patient is still on
the operating table, because there will be very little settling
over time.
• Ideally, a “lamellar” structure will be created to coapt acellular
dermal matrix to vascularized tissue, such as a skin flap and/
or breast parenchyma.
• These matrices must be drained to avoid seroma formation
and to enhance the revascularization and incorporation of the
matrix.
• The greatest drawback is the cost of acellular dermal matrix.
More cost-effective biologic meshes are now commercially
available.
Suggested Reading
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[3] Brink RR. Evaluating breast parenchymal maldistribution with regard
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[5] Colwell AS, Breuing KH. Improving shape and symmetry in mastopexy with
autologous or cadaveric dermal slings. Ann Plast Surg 2008;61(2):138–142
[6] de Bruijn HP, Johannes S. Mastopexy with 3D preshaped mesh for long-term
results: development of the internal bra system. Aesthetic Plast Surg
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[7] de Bruijn HP, ten Thije RH, Johannes S. Mastopexy with mesh reinforcement: the
mechanical characteristics of polyester mesh in the female breast. Plast Reconstr
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[8] Chiari Júnior A. The L short-scar mammaplasty: a new approach. Plast Reconstr
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[10] Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr Surg
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[11] Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using the short scar periareolar
inferior pedicle reduction technique. Plast Reconstr Surg 2008;121(5):1533–1539
[12] Hammond DC, O’Connor EA. The lower island flap transposition (LIFT) technique
for control of the upper pole in circumvertical mastopexy. Plast Reconstr Surg
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[15] Góes JCS. Periareolar mammaplasty: double skin technique. In: Hinderer UT, ed.
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[16] Gray LN. Re-evaluating lipoplasty-only breast reduction. Aesthet Surg J
2006;26(1):72–75
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reduce large breasts. Plast Reconstr Surg 1991;87(4):709–717

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[23] Maxwell GP, Gabriel A. Use of the acellular dermal matrix in revisionary aesthet-
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[24] Persoff MM. Vertical mastopexy with expansion augmentation. Aesthetic Plast
Surg 2003;27(1):13–19
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Reconstr Surg (1946) 1956;17(5):367–375

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XI Breast Surgery
80 Mastopexy and Breast Reduction in Massive-Weight-Loss
Patients
J. Peter Rubin and Jonathan Toy
Abstract
This chapter describes the unique features and aesthetic defor-
mities commonly observed in the breast after weight loss and
highlights a technique that enables restoration of breast shape
with autologous tissues. The dermal suspension mastopexy is
a parenchymal operation that reshapes and suspends native
breast tissue to the chest wall while eliminating lateral rolls of
skin and fat. This procedure can be performed concurrently with
other body contouring procedures in well-selected patients.
Patient selection and details of the operative technique are
presented.
Keywords
mastopexy, weight loss, dermal suspension, ptosis, breast
surgery
80.1 Introduction
The rate of obesity continues to rise in the United States at an
alarming rate, with more than 35% of the population considered
obese. To lower their risk of obesity-related medical conditions,
many people have sought to lose weight either through bariatric
surgical procedures or lifestyle modification³diet and exercise.
After massive weight loss, defined as the loss of more than 23 kg
(50 pounds), the individual is often left with redundant skin
and excess subcutaneous tissue. For this reason, an increasing
number of patients are seeking plastic surgery consultation for
correction of these deformities.
After the abdomen, the next body area with which many
women are most concerned is their breasts and their appear-
ance after massive weight loss. Many of these women had full
breasts before their weight loss and have severe deformities after
reaching their goal weight. Extensive and asymmetrical volume
deflation, descent and medialization of the nipple–areola
complex, and distortion of shape, including breast flattening,
coupled with an excess of inelastic skin relative to the breast
parenchyma, makes breast deformities difficult to treat. During
the evolution of breast reduction and mastopexy procedures
after massive weight loss, plastic surgeons have focused on key
aesthetic goals: repositioning of the nipple–areola complex,
minimization of scar and proper scar placement, achieving ade-
quate projection and medial fullness of the breast, and long-term
stability of the results.
The technique of dermal suspension, parenchymal reshaping,
and selective autologous tissue volume augmentation (autoaug-
mentation) in massive-weight-loss patients was developed with
the principles of prior breast reshaping procedures in mind.
Earlier techniques in breast reduction and mastopexy relied on
dermal support to maintain shape and were dependent on skin
resection patterns. Bottoming out of parenchyma and recurrent
breast ptosis were negative features of the techniques relying on
these principles. The introduction of the vertical mammaplasty
by Lassus and expanded on by Lejour heralded more long-lasting
and reliable methods of parenchymal reshaping, with less reliance
on the dermal envelope for shape. Others developed methods
of dermal suspension to elevate breast tissues as well as tech-
niques to increase upper-pole fullness with sutures to affix the
parenchyma to surrounding structures. Graf and Biggs devised a
dermoglandular pedicle that is passed under a partial-thickness
loop of pectoralis muscle and fixed to the pectoralis fascia under
the breast. Closure of medial and lateral pillars behind the flap
helps to secure elevation.
The approach to the breasts of massive-weight-loss patients
differs from techniques used for non-weight-loss patients. Short-
scar techniques in general have a limited role because of the need
for more extensive skin resection. In our technique of dermal
suspension, parenchymal reshaping, and selective autoaugmen-
tation, the vascularity of the nipple–areola complex is ensured
with a central dermoglandular pedicle. A modification of the
traditional Wise pattern allows control of the skin envelope and
nipple position, along with mobilization of fasciocutaneous flaps
and parenchymal reshaping.
Advantages and Disadvantages of Mastopexy
and Breast Reduction in Massive-Weight-Loss
Patients
Advantages
• A lateral axillary roll deformity can be eliminated.
• Autoaugmentation of the breast may be achieved with the
use of tissue in the lateral axillary roll.
• The skin envelope can be easily controlled.
• Parenchymal reshaping is facilitated, especially restoration of
the lateral curvature of the breast.
• Long-lasting elevation of the parenchyma is achieved by
multiple points of fixation to the chest wall.
Disadvantages
• Scars are long.
• Operative time is increased because of the large areas to be
de-epithelialized.
• A high degree of intraoperative tailoring is required.
This chapter highlights the anatomical changes observed in the
breast after weight loss and presents details of a versatile tech-
nique to achieve an aesthetically pleasing result.

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
1259
80.2 Goals of Breast-Reshaping
Surgery
• To use all available breast tissue while maintaining the ability
to recruit additional autologous tissue
• To address nipple position
• To restore superior pole projection
• To reshape the skin envelope without relying on it for support
• To eliminate the lateral skin roll
• To create a discrete ´lateral sweepµ or well-defined lateral
curvature to the breast shape
80.3 Indications and
Contraindications
Indications for dermal suspension and parenchymal reshaping
with selective autoaugmentation include severe ptosis with
deflated breast shape and adequate parenchymal volume to
build a breast mound. Although not required to perform this
procedure, a lateral skin roll allows recruitment of chest wall
tissue into the breast mound.
There are relatively few contraindications to the procedures
mentioned. Patients who are current users of tobacco products
are instructed to stop at least for 1 month before and after
surgery. We routinely screen patients with a positive history of
tobacco use with a cotinine urine test before surgery. Patients
who have had previous breast surgery must be carefully eval-
uated to ensure that their old scars will not compromise any
planned procedure. Patients with active intertrigo or diffuse
fibrocystic disease may also not be ideal candidates. Also,
inadequate parenchymal volume to build a breast mound is a
relative contraindication, although lateral roll volume needs to
be considered and may add sufficient volume. Finally, patients
with a body mass index (BMI) higher than 35 may not be ideal
candidates, and the patient’s specific body fat distribution is
considered. For example, a higher-BMI patient with a gynoid
body type who is fairly lean in the upper half of her body may
still be a good candidate.
80.3.1 3DWienW 3rRÀOeV
Good candidates for dermal suspension and parenchymal
reshaping with selective autoaugmentation include those with
parenchymal deficiency relative to skin with breast deflation and
lateral skin roll. Poor candidates include those with no lateral
skin roll, a short nipple-to-inframammary fold distance, and
minimal breast ptosis.
The 40-year-old massive-weight-loss patient shown in Fig.
80.1 had lost 61 kg (135 pounds) before breast surgery and
presented with a BMI of 33.8. She was a good candidate for the
dermal suspension/parenchymal reshaping technique. These
images demonstrate extensive breast ptosis and parenchymal
deflation with a significant increase in the distance from the
nipple to the inframammary fold; she had a sizable lateral
skin roll.
The 44-year-old massive-weight-loss patient shown in Fig. 80.2
was not an ideal candidate for the dermal suspension/parenchy-
mal reshaping technique. Although she had lost more than 45 kg
(100 pounds) after gastric bypass surgery (a BMI change from 41.8
to 25.4), her breasts were not extensively deflated, and she had
moderate ptosis. There was only modest parenchymal volume
and minimal lateral skin roll for autoaugmentation. Postoperative
images 3 months after a combined mastopexy-augmentation
with saline implants and Wise pattern skin resection demonstrate
excellent nipple repositioning and improvement in breast shape
and projection. The use of the Wise pattern skin resection was
necessary to adequately control the breast envelope and deal with
the skin excess.
80.4 Pertinent Anatomy
Women who have undergone massive weight loss have char-
acteristic breast deformities that distinguish them from other
women seeking correction of volume loss and breast ptosis. The
Pittsburgh Rating Scale describes the spectrum of deformities
Fig. 80.1 (a–c) Anatomical findings that make a patient a good candidate for this procedure, including extensive breast ptosis and parenchymal defla-
tion with a significant increase in the distance from the nipple to the inframammary fold. She has a lateral skin roll. The full case is shown in Fig. 80.12.
a
c
b

1260
XI Breast Surgery
seen after massive weight loss, with most patients exhibiting
the more severe grades. This scale was designed to classify
postbariatric deformities, in recognition that the standard
ptosis grading scale was not descriptive enough to characterize
the unique changes in breast shape that occur in this popula-
tion. The least severe deformities involve grade I or II ptosis
or macromastia. The midrange deformities (Pittsburgh Scale
severity of 2 out of 3) demonstrate grade III ptosis and can still
be treated with traditional breast-reshaping techniques. The
most severe deformities (Pittsburgh Scale severity of 3 out of 3)
have one or both of the findings unique to the massive-weight-
loss patient: severe volume depletion with a flattened breast
shape and/or a prominent lateral roll of skin and fat that merges
the breast mound with the upper back tissues. Additionally, in
any patient who has undergone massive weight loss, the nipples
may appear overly medialized. Failure to recognize this finding
and move the nipples laterally along a true breast meridian is
a pitfall of breast reshaping in massive-weight-loss patients
(Table 80.1).
The changes in breast shape after weight loss, in the most
severe form, are characterized by two findings that pose signifi-
cant technical challenges. The first finding is volume loss with a
stretched skin envelope and flattening of the breast against the
chest wall (Fig. 80.3).
Fig. 80.2 Anatomical findings that indicate a different technique than dermal suspension mastopexy should be considered. (a–c) This patient has
moderate ptosis, a small amount of parenchymal volume, and minimal lateral skin roll for autoaugmentation. (d–f) Postoperative images 3 months
after a combined mastopexy-augmentation with smooth, round implants and Wise pattern skin resection demonstrate excellent nipple repositioning
and improvement in breast shape and projection.
Table 80.1 Grading scale for severity of breast deformities after
weight loss
Severity
grade
Deformities noted
Recommended treatment
0
Normal
Normal
1
Ptosis grade I or II or severe
macromastia
Traditional mastopexy
(with preference for vertical
technique), standard breast
reduction techniques, or
implant augmentation ±
elevation of nipple through
limited mastopexy scars.
2
Ptosis grade III, moderate
volume loss, or constricted
breast
Traditional mastopexy
(often requiring Wise
pattern). Consider implant
augmentation to accompany
mastopexy.
3
Severe lateral roll and/or
severe volume loss with
loose skin
Parenchymal reshaping
techniques with dermal
suspension. Consider
autoaugmentation. Avoid
implant augmentation if
existing volume will create a
reasonable result.
Adapted with permission from Song AY, Jean RD, Hurwitz DJ, Fernstrom
MH, Scott JA, Rubin JP. A classification of contour deformities after
bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;
116:1535–1544.
a
d
c
f
b
e

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
1261
The second finding is a roll of skin and fat on the lateral border
of the breast extending onto the chest wall. This roll of skin and
fat obscures the lateral curve of the breast, an important aesthetic
unit. The technique of dermal suspension and selective autoaug-
mentation described in this chapter can correct these deformities
and restore breast shape by using available parenchyma to build
projection and recruiting the lateral chest wall tissue into the breast
mound. In any massive-weight-loss patient, the surgeon must also
be aware that the nipple position may be abnormally medial and
should be repositioned along a true breast meridian (Fig. 80.4).
80.5 Preoperative Assessment
In evaluating any massive-weight-loss patient, the surgeon should
take a detailed history, including the type of weight-loss surgery,
Fig. 80.3 Two characteristic findings that pose significant technical challenges. (a) The first finding is volume loss with a stretched skin envelope and
(b) flattening of the breast against the chest wall.
Fig. 80.4 (a,b) The second characteristic finding is a roll of skin and fat on the lateral border of the breast extending onto the chest wall. This roll of
skin and fat obscures the lateral curve of the breast, an important aesthetic unit.
a
a
b
b

1262
XI Breast Surgery
time since the surgery, and the patient’s starting and current BMIs.
The patient should be as close to the goal weight as possible and at a
stable weight, no more than a 2 kg (5-pound) change per month, for 3
months. This weight stabilization often occurs 12 to 18 months after
gastric bypass. For a patient with a BMI over 35, the surgeon should
consider referring the patient back to the weight-loss specialists to
optimize her diet and exercise programs and optimize the BMI.
Physical examination of the breast should include a careful search
for masses. Parenchymal volume should be assessed, along with the
presence and size of a lateral roll of skin and fat. The surgeon should
determine whether the native breast parenchyma and lateral roll
together would provide adequate volume for a breast reshaping pro-
cedure. Prior scars should be noted and considered in terms of their
impact on blood supply in the selected procedure. Mammography is
performed in accordance with the American Cancer Society guidelines.
80.6 Preoperative Planning
80.6.1 &KRiFe RI 7eFKniTue
Many procedures have been described for correction of the breast
deformities seen in massive-weight-loss patients. The severity of
each of the aforementioned deformities, the preferred breast size of
the patient, and the surgeon’s experience will all influence the type
of procedure offered. Each patient is unique, and the chosen proce-
dure must not only address each aspect of the breast deformity but
also be able to deliver the size and shape that the patient desires.
80.6.2 Excessive Breast Volume
(Pittsburgh Grade 1)
Some patients, despite massive weight loss, maintain significant
breast volume despite varying degrees of ptosis. Patients who
desire to be smaller than their current size will require a breast
reduction. Although short-scar techniques have increased in pop-
ularity, the skin redundancy and poor skin elasticity will result in
a large inferior dog-ear that will require horizontal excision. The
pitfall of the short-scar technique in these patients would be to
chase the dog-ear inferiorly. This would leave an unsightly scar
below the inframammary fold. A predictable shape and size can
be achieved using a Wise pattern skin excision. This excision will
often need to be carried out laterally onto the breast to excise
redundancy in this area. A medial or inferior pedicle can be used
depending on the nipple to fold distance and the experience of
the surgeon. Due to the medial positioning of the nipple in many
patients who have undergone massive weight loss, it may be dif-
ficult to get adequate nipple rotation if a medial pedicle is chosen.
This must be given consideration in the preoperative planning.
Liposuction of the lateral fold can also be a useful adjunctive
procedure to assist in contouring the lateral fold of the breast.
80.6.3 ,nDdeTuDWe %reDVW 9ROume
(Pittsburgh Grades 1 or 2)
Patients who have experienced significant breast involution as
a result of massive weight loss will require breast implants if
larger breasts are desired and a prominent lateral chest roll is
not available to recruit into the breast mound (see next section).
This autologous augmentation is almost always a better choice
than implant augmentation. Young patients who have good skin
tone can be considered for an isolated breast augmentation. In
patients where there is excessive skin redundancy or an enlarged
nipple–areola complex, a concomitant mastopexy may be neces-
sary. In complicated cases where there is significant asymmetry
or a loose inframammary fold, a staged mastopexy-augmentation
may be necessary to achieve the best aesthetic outcome.
80.6.4 AdeTuDWe %reDVW 9ROume Dnd
Severe Changes (Pittsburgh
Grade 3)
The majority of patients who have undergone massive weight loss
present with significant breast ptosis and skin redundancy but
maintain adequate breast volume. Even if the native parenchyma
appears to have reduced volume, the lateral skin and fat roll adja-
cent to the breast mound, when added to the existing parenchyma,
can create adequate size. During the consultation these patients
often state that they want a breast reduction because of the sig-
nificant skin redundancy and ptosis when in reality they require a
mastopexy. The parenchymal volume is often sufficient to achieve
a good size and shape, but there is rarely much to spare. During the
physical examination, the surgeon must determine whether there
is adequate breast volume and whether there is a lateral skin roll
with sufficient volume. For patients with sufficient parenchymal
volume, severe ptosis, and a lateral skin fold, we recommend dermal
suspension of the breast tissue to the chest wall with parenchymal
reshaping and autoaugmentation from the lateral skin roll. In diffi-
cult cases, where there is significant asymmetry, the smaller breast
can be augmented using autologous tissue to match the larger
breast. If the autoaugmentation is not sufficient, the larger breast
may need to be reduced to match the smaller breast.
The surgical plan is as follows:
• Mark with a Wise pattern, encompassing the lateral roll of tissue.
• De-epithelialize the entire Wise pattern area.
• Deglove the breast parenchyma.
• Elevate the medial and lateral parenchymal flaps.
• Suspend the dermal edge of flaps to the rib periosteum.
• Plicate the dermis to shape the breast.
• Place sutures along the lateral edge of the breast to define its
curvature and reinforce the suspension (there are multiple
points of fixation).
• Redrape the skin.
• Release any dermis that is tethering the nipple.
• Close the skin.
80.6.5 Markings
The incision design is based on an extended Wise pattern that
preserves both the inferior and the central pedicle. The midline,

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
1263
inframammary fold, and sternal notch are marked as in tradi-
tional mastopexy. A point 4 to 5 cm from the sternal notch is
marked along the clavicle, and a new breast meridian is marked
in the position at which the nipple will be placed. This line often
lies lateral to the current nipple position as a result of the medial-
ized position of the nipple in a massive-weight-loss patient. The
new nipple position is gauged in relation to the inframammary
fold and raised 2 cm along the new breast meridian. A keyhole
pattern is then drawn, with vertical limbs of 5 cm. The distance
from the nipple to the top of the keyhole should be noted, as
this is the length of the central dermal suspension element. The
lateral extent of the Wise pattern extends onto the lateral skin
roll and is used for breast autoaugmentation. The robust lateral
thoracic perforators allow mobilization of a significant amount
of tissue to the breast. Although other authors have advocated
the use of tissue that extends onto the back, we often discard
the tissue beyond the posterior axillary line because of concerns
about vascularity and potential fat necrosis (Fig. 80.5).
80.7 2SerDWiYe 7eFKniTue
A 42-mm cookie-cutter is used to mark the circumference of the
new nipple–areola complex. The entire dermis lying within the
Wise pattern is de-epithelialized. A pedicle base of approximately
10 cm is then marked. The medial and lateral extents of this
pedicle are determined by the desired pivot points for the arc of
rotation of the medial and lateral flaps. The dermis is scored in all
areas except the pedicle base (in order to preserve the supporting
dermis and enable a ´hammockµ effect). Flaps 1 to 1.5 cm thick
are then raised, and the breast is completely degloved down to
the pectoralis major fascia. During this dissection, the flaps are
constantly monitored to ensure uniform thickness. Dissection
continues along the fascia to the level of the clavicles. The second
intercostal perforating artery is often visualized medially and
should be preserved because this perfuses the tissue flap that
has been elevated from the breast parenchyma in the degloving
step (Fig. 80.6).
Care must be exercised not to release the attachments medi-
ally over the sternum, or symmastia may result. Medially, it is
important to preserve perforators, including the perforator from
the second intercostal artery. The lateral and medial flaps are then
elevated down to the chest wall and mobilized. These flaps remain
attached to the previously delineated 10 cm central pedicle, which
is not undermined. Dissection of these flaps is limited to the min-
imal amount of tissue necessary to rotate the flaps to preserve the
blood supply. These flaps are normally discarded in a traditional
inferior pedicle breast reduction.
Fig. 80.5 The procedure design is based on an extended Wise pattern that preserves both the inferior and the central pedicle and enables
mobilization of fasciocutaneous flaps. The entire area within the Wise pattern is stripped of epidermis, and the broad dermal surface area allows for
aggressive shaping of the breast by plication.

1264
XI Breast Surgery
Once the breast parenchyma is degloved and the medial and
lateral flaps are elevated, dermal suspension is performed in
a specific sequence, with the patient in a sitting position. The
central dermal extension is suspended to the periosteum of the
second rib along the new breast meridian with two permanent 0
braided sutures to ensure stability. This is performed by placing
the fingers of the nondominant hand in the intercostal spaces,
ensuring safe fixation to the rib periosteum. If the inframammary
fold is low or the central dermal extension is short, the central
pedicle may need to be suspended to the third rib. The suspension
should bring the pedicle and the nipple–areola complex to the
desired nipple position. The final decision as to which rib to fixate
the parenchyma to is made while the patient is on the operating
table (Fig. 80.7).
The lateral breast flap is mobilized and rotated superiorly and
medially to shape the lateral border of the breast parenchyma.
This flap is commonly fixated to the rib periosteum of the third rib
just inferior to where the central pedicle was suspended with two
permanent sutures. The size and length of the lateral flap can be
reduced to selectively adjust the amount of autoaugmentation to
achieve the desired size. The medial flap is then rotated superiorly
and laterally to the level of the fourth rib periosteum and fixated
in a similar manner. This flap is suspended medial to the new
breast meridian to restore superomedial fullness to the breast. It
is helpful to redrape the breast skin flaps after each fixation step
to confirm that the correct level of dermal suspension has been
achieved (Fig. 80.8).
Once the dermal flaps have been suspended to the desired
position, the breast parenchyma is shaped using 2–0 braided
absorbable sutures. The lateral dermal flap is plicated to the
Fig. 80.6 The breast is completely degloved and a pocket developed over the pectoralis major fascia. Medial and lateral fasciocutaneous flaps are
elevated.
Fig. 80.7 The first suspension suture (1–0 braided nylon) is placed
from the dermis at the top of the keyhole pattern to the periosteum
of the second rib along the breast meridian. This sets the axis of the
breast relative to the chest wall. If the second rib sets the new nipple
position too high, the fixation can be placed at the third rib.

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
1265
central dermal pedicle, first with interrupted sutures, followed
by a running overlay suture. This is repeated for the medial flap.
In some patients, suturing the dermis of the medial flap to the
central pedicle dermis will distort the medial contour. In these
cases, the breast parenchyma of the medial flap is sutured to
the parenchyma of the central pedicle. Once the desired shape
of the lateral and medial breast parenchyma has been achieved,
the inferior plication is performed to increase nipple projection.
The distance from the inframammary fold to the nipple–areola
complex is measured and an inferior plication is performed to set
this distance at 5 cm.
Dermal suspension and parenchymal reshaping are both
performed with the patient in the sitting position. To minimize
asymmetry, each of the previously outlined steps is performed
sequentially on both breasts. The patterns of plication cannot be
predicted preoperatively; adjustments must be made intraoper-
atively to achieve the desired shape. Additional rows of plication
may be required. The surgeon should be satisfied with the shape
of the parenchyma while the patient is on the operating table and
should not leave the operating room if he or she is not happy with
the dermal plication and the breast shape and projection after skin
flaps are redraped. If the shape is not optimal, removal of previous
plication sutures or further plication is necessary (Fig. 80.9).
To further define the lateral sweep of the breast, the dermis
of the lateral flap is secured to the serratus fascia. In addition
to defining the lateral border of the breast, these sutures help
increase nipple projection and minimize the risk of lateral hernia-
tion of the breast parenchyma. The lateral flap is not fixated to the
rib periosteum to avoid potential injury to the long thoracic nerve
and the thoracodorsal vessels and nerve.
The breast flaps are redraped, and the final breast shape
and projection are assessed. Closure begins with a half-buried
2–0 polypropylene suture that secures both breast flaps in an
inverted-T fashion to the inframammary fold. This is tied over an
iodine-impregnated petrolatum gauze bolster to protect the skin
and is left in place for 1 week. The remainder of the skin is tem-
porarily reapproximated with staples. The vertical limb is closed
in two layers with absorbable sutures, and the horizontal incision
is closed with a running deep dermal suture. One drain is draped
around the pedicle before closure and is brought out laterally
through the incision (Fig. 80.10).
The nipple–areola complex is occasionally tethered by the
dermis and requires release to bring the nipple to the proper
position. If this is not performed, the nipple may have a retracted
appearance postoperatively. Because of the robust blood supply
from the pedicle, the dermis around the areola may be safely
scored halfway around its circumference. The nipple–areola
complex is secured to the skin flaps with an absorbable suture in
one layer. Cyanoacrylate glue is used along all suture lines to seal
the incisions (Fig. 80.11).
80.8 Postoperative Care
Gauze fluffs are placed over all incisions, and the chest is wrapped
with an elastic (Ace) wrap until the first postoperative visit. The
drains are removed when the output is less than 30 mL per day.
The bolster stitch is also removed during this visit. Patients are
instructed to wear a sports bra for 6 weeks to allow complete
healing of all incision lines. We recommend the use of a sports
bra that has a zipper in the front, for patient comfort. The patient
Fig. 80.8 The lateral breast flap is mobilized, rotated, and secured to rib periosteum. This flap is the “workhorse” for this procedure, serving to
establish lateral curvature of the breast. Moreover, the lateral dermal edge of the flap is secured to the underlying fascia with multiple permanent
sutures to provide stable suspension. The medial flap is also secured to rib periosteum with permanent sutures, and the plication pattern is designed
for further breast shaping.

1266
XI Breast Surgery
Fig. 80.9 The plication is performed with absorbable 2–0 braided suture. The pattern of plication is customized for each patient and can vary
tremendously based on the aesthetic goals.
Fig. 80.10 The plication is completed and the lower pole shaped so that the areolar to inframammary fold distance is 5 cm. The plication can be
performed with a combination of running and interrupted sutures.

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
1267
is instructed to minimize strenuous activity and not to lift any-
thing heavier than 4.5 kg (10 pounds) for the first 3 weeks, after
which activity can slowly increase. Patients can begin wearing
an underwire bra at 6 weeks postoperatively.
This procedure can be performed on an outpatient basis if no
other procedure is performed at that time. If it is combined with
other body-contouring procedures, we often keep the patient
overnight in the hospital.
80.9 Combined Procedures
Patients who present for body contouring after massive weight
loss often have multiple anatomical areas that they want cor-
rected. The technique of mastopexy with dermal suspension and
autoaugmentation can be combined with other body-contouring
procedures in selected patients. Many patients request combined
mastopexy with abdominal recontouring. For these women, the
abdominal recontouring procedure should be performed first.
Because the abdominal recontouring procedure will lower the
inframammary fold, intraoperative adjustments may need to
be made to the inferior line of de-epithelialization before the
mastopexy is performed. Similarly, if a fleur-de-lis abdomino-
plasty is to be performed, the inframammary fold may also be
rotated medially, and the markings may require adjustment. In
patients with loose inframammary folds, we consider deferring
the mastopexy to a second stage to achieve the best aesthetic
outcome.
This technique can easily be combined either with an upper
body lift or with brachioplasty. When it is performed in combi-
nation with an upper body lift, the markings from the upper back
lift will blend into the lateral skin roll excision for the mastopexy,
leaving a single incision line. The lateral flap for the mastopexy is
marked as usual and extends no farther than the posterior axillary
line. The patient is positioned prone, and the upper back lift is per-
formed first. The patient is then turned to the supine position for
the mastopexy. The lateral incision of the mastopexy is then closed
with no dog-ears by blending it into the upper back incision. When
combining a mastopexy with brachioplasty, we attempt to merge
the caudally directed axillary incision of the brachioplasty with
the lateral incision of the mastopexy. We try to avoid an inverted-T
point in the axilla if possible. The patient should be informed that
there may be redundancy at the posterior axillary line that can be
corrected with an upper body lift at a later time.
Fig. 80.11 The breast flaps are redraped, and the dermis adjacent to the areola is selectively scored to release any tethering. The central pedicle
blood supply protected nipple viability.

1268
XI Breast Surgery
Fat grafting has recently become a popular technique for soft
tissue augmentation. However, fat grafting has little role in the
primary correction of severe breast ptosis resulting from massive
weight loss. Once a patient has completely recovered from mas-
topexy with dermal suspension and parenchymal reshaping, fat
grafting may be useful to correct any contour deformities or areas
in which more fullness is desired. It could be a useful ancillary
procedure in patients with significant skin redundancy and
insufficient breast volume who desire a larger breast size without
using implants. In these select cases, the patient may benefit from
a two-stage procedure in which she undergoes a dermal suspen-
sion mastopexy in the first stage, followed by fat injections in a
second stage to augment breast size.
80.10 Problems and Complications
This technique has proved very safe and reliable. Complications
include hematoma (< 1%), seroma (< 3%), and minor wound
dehiscence at the T point (5%). The generous central pedicle
blood supply, combined with the increased vascular network
within the pedicle that is so commonly observed in weight-loss
patients, helps prevent nipple loss. In fact, we have had no
nipple necrosis in more than 120 dermal suspension mastopexy
cases.
Wound dehiscence at the vertical incision and/or triple
point is managed with débridement and gauze dressings in
an office visit. These have all healed well with conservative
measures. We routinely place a half-buried 2–0 polypropyl-
ene suture at the T point and remove this in the office 5 to 7
days postoperatively. This helps reinforce the closure at that
juncture.
Seromas have been observed in the lateral region of the breast
after drain removal and have all been treated with needle aspira-
tion in the office. 1one has required reoperation.
One must always be wary of fat necrosis at the distal end of
any transposed flap. :e have not observed this in the lateral chest
wall flap used for autologous augmentation, but we take several
measures to avoid this complication. First, the lateral extent of the
flap is limited to the region of the posterior axillary line. :e do
not extend this flap onto the midback. Second, the edge of the flap
is checked for signs of arterial bleeding. Third, we exclude active
smokers.
80.11 Results
The 40-year-old woman shown in Fig. 80.12 with a BMI of
33.8 lost 61 kg (135 pounds) before surgery. The lateral view
of the surgical markings demonstrates an important point
in the preoperative planning of this operation. The resection
required to capture the lateral skin fold can extend beyond
the tissue within the Wise pattern used for autologous aug-
mentation. This flexibility allows the lateral skin envelope to
be adequately contoured, with adjustment of the amount of
tissue mobilized to the breast. The results are seen 7 months
postoperatively.
The 49-year-old woman shown in Fig. 80.13 lost 74 kg (163
pounds) after a laparoscopic gastric bypass procedure. Her BMI
at the time of surgery was 27. She had significant preoperative
asymmetry. By selectively resecting the breast parenchyma and
by using lateral fold flaps of different volumes, postoperative
symmetry can be dramatically improved. She is shown 1 year
postoperatively.
Fig. 80.12 A 40-year-old woman with a body mass index of 33.8 and 135 lb weight loss shown (a–d) preoperatively and (e–h) 7 months after dermal
suspension mastopexy.
a
e
d
c
g
h
b
f

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
1269
Fig. 80.13 A 49-year-old woman with a body mass index of 27 and 163 lb weight loss is shown (a–c) preoperatively and (d–f) 1 year after dermal
suspension mastopexy. Asymmetry is addressed during the procedure by selectively resecting breast parenchyma on the larger side.
Fig. 80.14 A 37-year-old patient with a body mass index of 22.6 and 136 lb weight loss. Although she has small breast volume with no true lateral
skin fold, the procedure allowed very good control of the skin envelope and parenchymal reshaping. She is shown (a–c) preoperatively and
(d–f) 18 months postoperatively.
a
a
d
d
c
c
f
f
b
b
e
e

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XI Breast Surgery
The 37-year-old patient shown in Fig. 80.14 with a BMI of
22.6 had lost a total of 62 kg (136 pounds). She had a small
breast volume with no true lateral skin fold. Despite these
findings, the procedure allowed very good control of the skin
envelope and parenchymal reshaping. She is shown 18 months
postoperatively.
The 42-year-old woman shown in Fig. 80.15 with a BMI of
25 underwent a combined fleur-de-lis abdominoplasty and
mastopexy. To prevent running the incision onto the chest, we
stopped the incision at the xyphoid process. Four months after her
initial procedure, the patient was left with a small dog-ear at the
cephalad aspect of the fleur-de-lis incision. If a dog-ear remains
after 3 months postoperatively, we excise it in the office with the
patient under local anesthesia. By waiting, we can minimize the
cephalad extension of the scar. The patient is shown 4 months
postoperatively (before the dog-ear excision) and at 7 months
from her initial procedure.
80.12 Breast Reduction in
Massive-Weight-Loss Patients
In a massive-weight-loss patient with ptosis and adequate or
excessive parenchymal volume, a good option is breast reduction
with a Wise pattern skin resection in conjunction with a tradi-
tional or extended medial pedicle. The Wise pattern allows resec-
tion of excess skin and precise control of the dermal envelope.
The vascularly robust medial pedicle provides a pleasing medial
curve to the breast shape and allows excellent repositioning of
the nipple–areola complex. Upper-pole fullness may be achieved
by parenchymal elevation with suturing to the rib periosteum
or pectoralis fascia. A decrease in the amount of pseudoptosis or
bottoming out is an added benefit. Small to large parenchymal
resections are possible, and the added benefit of familiarity of
technique with most surgeons makes this an appealing alterna-
tive in massive-weight-loss patients (Fig. 80.16, Fig. 80.17).
Fig. 80.15 A 42-year-old woman with a body mass index of 25 and 150 lb weight loss underwent a combined fleur-de-lis abdominoplasty and dermal
suspension mastopexy. To prevent running the incision onto the chest superiorly, we stopped the incision at the xyphoid process. After healing
and scar contracture at the site if the dog-ear, this excess skin was excised in the office. The patient is shown (a–d) preoperatively, (e–h) 4 months
postoperatively at the time of dog-ear excision, and 7 months postoperatively (3 months after dog-ear excision).
a
e
d
c
g
h
b
f

80 Mastopexy and Breast Reduction in Massive-Weight-Loss Patients
1271
Figs. 80.16 For the massive-weight-loss breast-reduction patient, a medial pedicle approach enables restoration of breast shape in the setting of
parenchymal resection. The medial pedicle, once rotated, helps maintain medial fullness and projection.

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XI Breast Surgery
The 56-year-old woman shown in Fig. 80.17 with a BMI of
29.5 after weight loss induced by lifestyle changes alone (no
gastric bypass) manifested macromastia, severe ptosis, and mod-
erate lateral chest skin excess. True macromastia is uncommon
in weight-loss patients. These cases can be managed with a Wise
pattern and medial pedicle to support the nipple. The medial ped-
icle, once rotated, helps maintain medial fullness and projection.
Approximately 550 g of breast tissue was removed from each breast.
The patient is shown preoperatively and 6 months postoperatively.
80.13 Concluding Thoughts
Following massive weight loss, patients often have sufficient
breast volume to achieve an aesthetic shape. Dermal suspension
with parenchymal reshaping and selective autoaugmentation
is a versatile technique that enables the surgeon to effectively
address the major breast deformities seen in the massive-weight-
loss patient.
Fig. 80.17 A 56-year-old woman with a body mass index of 29.5 after weight loss induced by lifestyle changes alone (no gastric bypass) manifested
macromastia, severe ptosis, and moderate lateral chest skin excess. The patient is shown (a,b) preoperatively and (c,d) 6 months postoperatively
after medial pedicle breast reduction with approximately 550 g resected from each breast
a
c
b
d