Phẫu Thuật Thẩm Mỹ Vòng 1: Các Khái Niệm Và Kỹ Thuật (Aesthetic Breast Surgery)

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Part II • Technique
T
he major di erence between a breast reduction and a mastopexy is that the
breast reduction removes skin and breast tissue, whereas the mastopexy removes
skin and rearranges the breast tissue. The parenchyma that is removed in a breast
reduction needs to be moved in a mastopexy.
Skin unctions poorly as a brassiere. Skin expansion is an essential component
o plastic surgery, because skin, which includes dermis, stretches. Some breast
reductions in young patients with tight skin hold well when the skin is used or
support, but this is not the case or most mastopexy patients who have skin that
is inelastic and stretches with gravity. It is important or surgeons to understand
that pushing breast parenchyma up and then securing it with skin or dermal
f aps (even overlapping) is a strategy that is likely to ail with time.
There are various ways to rearrange breast parenchyma. The excess skin then
adapts to the new breast shape. In some patients—especially massive-weight-loss
patients—the skin has very poor elasticity, and a vertical skin resection pattern
will need to be converted to an inverted-T skin pattern. The principles o the
vertical approach with rearrangement o the in erior vertical quadrant still apply.
MY EVOLU TION
When I started using a vertical pattern or breast reductions, I mistakenly as-
sumed that it was the vertical skin resection pattern that gave my patients an
improved breast shape, as compared with the shape I had previously achieved
when per orming in erior pedicle inverted-T breast reductions. But when I used
the vertical skin pattern (even with overlapped dermis) to try to hold up the ptotic
breast tissue, the tissue bottomed out, and glandular ptosis recurred.
This patient underwent a le t breast reduction with a superior pedicle and re-
moval o 275 g o tissue. A right mastopexy was also per ormed with a superior
pedicle. No tissue was removed on the right side, and the dermis was over-

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Chapter 9 • Mastopexy
lapped. The follow-up at 6 years shows that the breast reduction was suc-
cessful, but the mastopexy bottomed out (glandular ptosis). Although
the nipple stayed in the place marked preoperatively, the breast assumed
its original shape. The skin brassiere did not work on the right breast. The
result is maintained on the left side, because an inferior wedge of breast
tissue was removed, and the skin was not relied on to support the breast.
To understand why this occurred, I carefully reviewed my mastopexy results.
This patient did not have much glandular ptosis and had a skin-tightening pro-
cedure only. Two months postoperatively the small amount of excess gland bot-
tomed out. She is shown 3 years postoperatively with some recurrent glandu-
lar ptosis but with correction of the nipple ptosis.
Preoperative

2 months postoperatively

3 years postoperatively

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Part II • Technique
Alternatively, this patient underwent rearrangement of the inferior wedge of
breast tissue (held under a pectoralis strip), rather than a skin brassiere proce-
dure only. She is shown 15 months postoperatively without the bottoming out
seen in the previous patient.
I realized then that the skin (and dermis) was not reliable as a brassiere to sus-
pend the breast tissue—even when there was only a small amount of glandular
ptosis. When I tried to pull the lateral pedicle around and hold it in place with
a breast reduction or a mastopexy, the tissue relapsed over time, and the lat-
eral fullness recurred. It became clear that the parenchyma itself needed to be
rearranged. Although there has long been a controversy in breast surgery about
whether or not sutures could hold tissue in place, I became convinced that the
tissue needed to be separated and rearranged. Sutures could be used to hold
the parenchyma together long enough to allow healing, but I do not believe
that sutures (either absorbable or permanent) will last under tension. The body
is just too good at dynamic remodeling of any tissue under tension.

This patient had a lateral pedicle or the nipple-areola complex, and the in erior
breast tissue was rearranged with a medially based in erior f ap. A lateral pedicle
can be pulled medially, but it tends to retract laterally. This is less obvious in a
mastopexy, such as this one, than in a large breast reduction. The patient’s re-
sult is good, but the breast base is not narrowed as much as I would pre er.
Tension on the skin is not going to hold up ptotic breast tissue, and
tension on the parenchyma is likely to stretch the tissue back out
to its original location.
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Chapter 9 • Mastopexy
I now believe that the tissue needs to be released, separated, and
rearranged in a mastopexy. Sutures should only be used to hold
tissue together long enough for healing to occur, but should
not be relied on to hold tissue in place under any tension.

My review o patient results also showed me that what looked good ini-
tially o ten did not last. It is humbling to review results beyond the f rst
ew weeks or even months postoperatively. I thought that the vertical ap-
proach was giving my patients better upper pole ullness, but I was wrong.
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Part II • Technique
This patient series demonstrates why surgeons should be skeptical o their results
until a ull year has elapsed. This woman had a medial pedicle vertical mastopexy.
She is shown 16 days postoperatively, when it appeared that a good upward li t
would result. She is also shown 3 months, 8 months, and 14 months postop-
eratively. H er breasts dropped back to their original shape, and she lost the ini-
tial improvement in upper pole ullness.
Surgeons must continue to follow their patients to determine whether
surgery has been successful.
Preoperative

16 days postoperatively

H ow much time is required to best assess results? Obviously, time and gravity,
weight changes, and pregnancy can affect results. I followed my patients, and
it became clear that (barring other factors) 1 year is enough time to make a
good assessment. (Scar quality is an exception.) Nipple ptosis correction lasts,
but glandular ptosis correction cannot be achieved with skin tightening proce-
dures alone.
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Chapter 9 • Mastopexy
3 months postoperatively

8 months postoperatively

14 months postoperatively

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Part II • Technique
This woman had a bilateral mastopexy, with an in erior f ap placed under a pec-
toralis strip, and removal o 60 g o tissue rom the right breast and 70 g rom
the le t breast. She is shown 1 year and 3 years postoperatively. The results at
1 year are maintained 2 years later.
Preoperative

3 years postoperatively
1 year postoperatively

This patient underwent a bilateral mastopexy using an in erior f ap held up with
a strip o pectoralis muscle. She had 70 g o tissue removed rom the right breast
and 65 g removed rom the le t breast. An additional 390 cc o at was removed
with liposuction. She is shown 1 year and 2 years postoperatively. The result
appears to be stable at 1 year.
Analysis o my results has convinced me that assessment o the
f nal result should be delayed or a ull year. Results a ter 1 year
appear to remain stable i weight and pregnancy changes do not
occur. I a surgeon wishes to claim that a procedure has value, re-
sults should be shown at least 1 ull year a ter surgery.
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Chapter 9 • Mastopexy
Preoperative

2 years postoperatively
1 year postoperatively

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Part II • Technique
Many patients request a circumareolar mastopexy or doughnut-type procedure.
They seem reluctant to accept a vertical scar. I do not like the attening o the
breasts and the lack o correction o the lower pole ullness that occur with cir-
cumareolar mastopexies. I also do not like the “starburst” appearance o wrin-
kling around the areola. This patient is shown 2 years a ter her surgery (per-
ormed elsewhere). The result is not aesthetic.
The vertical approach allows the surgeon to rearrange the in erior pole to achieve
a long-lasting li t. Closure o the medial and lateral pillars around the in erior
ap narrows the breast base and increases breast projection. The skin circum-
erence can be matched to the desired areolar circum erence to prevent widen-
ing. The vertical incision usually heals well. An inverted-T skin resection will be
needed only when there is a signif cant amount o excess inelastic skin.
A circumareolar doughnut-type mastopexy is inappropriate or pa-
tients with glandular ptosis. I the in erior breast tissue is not re-
arranged, then the result will be a f attened breast with no correc-
tion o the glandular ptosis. The starburst wrinkling does not
always settle.
SU RGICAL PRINCIPLES
As previously mentioned, the surgical principles or a mastopexy are basically
the same as those or a breast reduction (see Chapter 6). The major di erence
is that the lower pole parenchyma is separated and removed in a breast reduc-
tion, while it is separated and rearranged in a mastopexy.

Many patients hope that a breast li t will not only raise the breast on the chest
wall, but will also f ll and round out the upper pole. Neither o these requests
can be achieved with a mastopexy alone, although projection is def nitely im-
proved. An implant is needed to raise the upper breast border. A mastopexy-
augmentation can raise the upper breast border to some degree, but almost al-
ways with some lowering o both the lower breast border (in ramammary old)
and the lower pole.
ANALYSIS OF BREAST DIMENSIONS
When examining the patient, the surgeon needs to stand back to e ectively eval-
uate all three breast dimensions. We need to “see what we are looking at” and
understand what can and cannot be changed with all our breast borders and
the shape o the breast on that ootprint (breast base).
Breast Footprint
The breast ootprint consists o our borders: the upper breast border, medial
breast border, lateral breast border, and in erior breast border (in ramammary
old). These borders are quite variable rom patient to patient.
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Chapter 9 • Mastopexy
Both o these patients are high breasted. The breast ootprint, or base, sits high
on the chest wall, even though there is some breast ptosis. Both the upper breast
border (arrows) and lower breast border (in ramammary old) are high. The
vertical ootprint in both o these patients is quite narrow vertically.

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Part II • Technique
Both of these patients are low breasted. Not only are the breasts ptotic, which
needs to be assessed separately, but the breast footprint (or base) is attached
low on the chest wall. The upper breast border (arrows) on both breasts is low.
The position of the lower breast border cannot be assessed in these views. (It
is not as relevant.) The upper breast border is the most important part of the
footprint in predicting what can and cannot be achieved with a mastopexy.
The distance from the clavicle to the upper breast border remains the same post-
operatively as it was preoperatively in both a breast reduction and a mastopexy.
The upper breast border rises when an implant is used, as long as the implant
does not drop into the lower pole of the breast.
The lower breast border (inframammary fold) is frequently elevated in a vertical
breast reduction and sometimes in a vertical mastopexy. The lower breast bor-
der drops in almost all breast augmentations and is almost always lowered (un-
intentionally) in a mastopexy-augmentation.

Breast shape
confined to footprint
Breast shape
hanging over footprint
Breast Shape: The Third Dimension
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Chapter 9 • Mastopexy
The breast shape needs to be assessed a ter the ootprint is evaluated. The breast
mound can be conf ned to the breast ootprint, or it can hang slightly o the
ootprint. Both shapes are normal and do not constitute ptosis.
We have been taught that the indications or a mastopexy depend on the rela-
tionship between the nipple and the in ramammary old. I do not think this is
a good guideline. The in ramammary old may be very high or very low. There-
ore the surgeon should look at the actual breast shape.
Regnault developed the ollowing classif cation o ptosis, which has been used
or years to determine when a mastopexy is needed.
• Grade 1 (minor): Nipple is at the level o the in ramammary old
• Grade 2 (moderate): Nipple is below the level o the in ramammary old
but above the lower contour o the breast
• Grade 3 (major): Nipple is below the level o the in ramammary old and
at the lower breast contour

With this classi ication, mastopexy is appropriate whenever the nipple is be-
low the level o the in ramammary old. The problem with this classi ication is
that the in ramammary old varies considerably in normal-shaped breasts, and
it can be a misleading landmark to use when trying to determine when a
mastopexy should be per ormed. Surgeons recognize that this classi ication is
not use ul or tuberous breasts, because the in ramammary old is not at a nor-
mal level. It is important or surgeons to also recognize that this guideline
may not apply to all their patients and that they may need to alter their basis
or decision making.
I believe that the best landmark or determining whether or not to use a
mastopexy is the upper breast border and that the ollowing classif cation may
be more help ul when planning mastopexy corrections. It requires assessment
o glandular ptosis and nipple ptosis separately.
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Part II • Technique
Glandular
ptosis
Nipple and
glandular
ptosis
Pseudoptosis
1. Glandular ptosis: Excess gland in the lower pole o the breast
2. Nipple ptosis: Nipple position lower than two thirds the distance down
the ideal breast mound (measured rom the upper breast border)
3. Pseudoptosis: Unacceptable bottoming out o the in ramammary old
Glandular Ptosis
Glandular ptosisis the presence o too much gland in the lower pole. For these
patients, an in erior wedge needs to be either moved or removed. The upper
breast border will not change a ter a mastopexy, and the surgeon needs to vi-
sualize the f nal breast mound in relation to this border. Any gland that alls be-
low this ideal shape needs to be rearranged and not just held up with a skin
brassiere. The key is to move the lower pole o breast tissue. The easiest way to

move it is to remove it. H owever, the decision to do so will depend on the
breast size desired by the patient.
Nipple Ptosis
N ipple ptosis is described as a nipple position that is lower than two thirds the
distance down the ideal breast mound, measured rom the upper breast bor-
der. The ideal nipple position is between hal and two thirds the distance down
the ideal breast mound. The ideal breast mound is determined by the desired
size in relation to the upper breast border. In most C to D cup patients this will
be about 10 cm below the upper breast border. The upper breast border is at
the junction o the breast and the chest wall. It is o ten at the same level as the
striae. Li ting the breast up with one hand (which creates a old) can make this
demarcation more obvious. The upper breast border is always below the preax-
illary ullness, and it is lower than desired in low-breasted patients. Surgeons
are aware that it is best to aim or a f nal nipple position that is at the junction
o the middle and lower third o the breast mound. Nipples that end up too
high are virtually impossible to correct.
The shape o the breast and the nipple position should be assessed separately.
The two low-breasted patients shown on p. 440 have the same amount o glan-
dular ptosis; however, the patient on the le t has no nipple ptosis. The patient on
the right does have nipple ptosis, and, in both patients, the location o the in-
ramammary old is irrelevant.
Pseudoptosis
Pseudoptosis is bottoming out o the in ramammary old. Bottoming out can
occur in two ways: glandular ptosis and pseudoptosis.
Pseudoptosis can occur with or without glandular ptosis, but is o ten associated
with nipples that appear to be positioned too high. The nipples may have ac-
tually been placed too high, but sometimes this is an illusion, because there is
too much volume in the lower pole. Removal o this lower pole excess can re-
duce the breast mound and, there ore, adapt the mound to the existing nipple
position. The actual nipple location is not moved, but will not look as high i
the mound is adjusted (see Chapter 8).
Because the level of the inframammary fold varies among patients,
it should not be used as a guide for determining the need for a
mastopexy. Instead, surgeons should consider the degree of glan-
dular ptosis and nipple ptosis.
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Chapter 9 • Mastopexy

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Part II • Technique
Patient Examples
Nipple Ptosis
When the nipple is too low on a good breast mound, it can be elevated. When
nipple ptosis and glandular ptosis are present, both need to be corrected.
Both of these patients have nipple ptosis, with only a small amount of glandu-
lar ptosis. The treatment will focus mainly on movement of the nipple. Re-
arrangement of the inferior wedge will be necessary, primarily to improve pro-
jection.
Glandular Ptosis
Both of these patients have only glandular ptosis. The nipples are not ptotic.
The nipples do not need to be moved, but the correction will involve re-
arrangement of the lower pole of the breast.

Combined Nipple and Glandular Ptosis
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Chapter 9 • Mastopexy
These patients have nipple ptosis and glandular ptosis. Both the nipple position
and the ptotic lower pole need to be addressed.
Pseudoptosis
Pseudoptosis usually occurs after a previous inferior pedicle inverted-T–type
breast reduction when the inframammary fold drops. The gland is not ptotic,
but the lower border of the footprint has been pushed down. In this patient
the problem has been compounded by placing the nipples too close to the up-
per breast border.

The indication or mastopexy is breast ptosis; however, the stan-
dard def nitions o ptosis are given in relation to the in ramammary
old. I believe the def nition should be based on the relationship o
the desired breast mound to the upper breast border. Our def ni-
tions o ptosis need to be revisited.
When planning treatment o glandular ptosis, the mound shape and
size should be assessed relative to the upper breast border, which
does not change postoperatively. Nipple ptosis and glandular pto-
sis o ten occur together, but the surgeon needs to address each con-
dition independently. Pseudoptosis results when the in erior breast
border drops postoperatively.
When a mastopexy-augmentation is performed—and sometimes an inferior
pedicle inverted-T breast reduction (see Chapter 8)—the inferior breast border
(inframammary fold) will drop to a lower level, resulting in pseudoptosis. This
lengthening of the vertical breast footprint is often less attractive than having a
narrower breast footprint, with the breast shape hanging down to some degree
off the breast footprint (true ptosis).
Most mastopexy, breast reduction, and mastopexy-augmentation
patients have a breast shape that hangs o the breast ootprint to
some degree. Patients o ten wish to avoid any postoperative ap-
pearance o breast ptosis, but usually there will still be some breast
tissue that hangs over the lower breast border, with breast skin
touching chest wall skin. I usually explain to patients that they will
still be able to hold a pencil under their breast. This is o ten an
easier concept or them to understand.
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Part II • Technique

Treatment
VERTICAL WEDGE RESECTION PRINCIPLE
Many breast reduction patients have good skin elasticity. For them, a skin
brassiere can be e ective in holding the breast shape. Un ortunately, most
mastopexy patients have already shown that their skin cannot maintain its shape
under tension, and a skin brassiere is not likely to last.
The best approach or achieving a long-lasting shape in a mastopexy patient is
to rearrange the lower pole in some ashion. Ribeiro described an in erior ap.
(H e called it an in erior pedicle, but it does not include the nipple-areola com-
plex. For that he used a superior pedicle). H e separated the in erior ap rom
the surrounding parenchyma, and then repositioned it up on the chest wall and
closed the medial and lateral pillars around it. H e was able to achieve a good
mastopexy with improved projection, but rarely with any long-standing im-
provement in upper pole ullness. Gra then popularized Daniel’s modif cation
o Ribeiro’s ap, where the ap is actually held up higher on the chest wall with
a pectoralis strip. Suturing o the in erior ap to the chest wall to improve
upper pole ullness does not last. Closure o the pillars around the ap can hold
it up; however, I have not ound that suturing parenchyma to the chest wall is
e ective.
The breast is not attached to the chest wall or to the pectoralis ascia. This was
evident during my training, when I would sweep my f nger under the breast tis-
sue to create a subglandular pocket or an implant. As mentioned previously,
I also tried suturing breast tissue up higher on the chest wall in 77 patients, but
the improvement in upper pole ullness and elevation o the upper breast bor-
der did not last more than 5 months in any patient (see Chapter 1).
In actuality, when we do achieve adherence o breast parenchyma to pectoralis
ascia, we usually call that scar contracture. We then need to release the scar that
adheres to the pectoralis ascia to prevent the breast rom moving unnaturally
with pectoralis muscle contraction. The reason that the pectoralis sling works
is because only the in erior ap is held against the chest wall. The remaining
parenchyma moves reely over the chest wall—held in place by skin- ascial at-
tachments at the in ramammary old, and not by adherence o the breast itsel
to the chest wall.
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Chapter 9 • Mastopexy

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Part II • Technique
McKissock said it best: “The thought that suturing the in erior pedicle to the
chest wall will suspend the breast or a prolonged period o time is naive. It is
a continuously recurring concept perpetuated by wish ul thinking rather than
unbiased observation. It is not a new idea. It has lured generations o surgeons
as intelligent as ours into a period o trial and acceptance that will take another
generation to undo. Perhaps its intrinsic seductiveness is so great that plastic
surgery is doomed orever to repeated cycles o this idea being rediscovered and
rediscarded.”
The goals that we are trying to achieve with a mastopexy are presented in the
box below.
Goals of Mastopexy
• Rearrangement o the breast mound
• Reduction o lower pole glandular ptosis
• Repositioning o the nipple to a more centralized position on the
breast mound
• Elevation o the breast ootprint
• Improvement in upper pole ullness
Only the f rst three goals can be achieved with a pure mastopexy. A breast im-
plant is required or the last two goals—and sometimes they are elusive. The
easiest and most reliable mastopexy is a small breast reduction with removal o
the in erior wedge.
Decision Making
TISSU E REARRANGEMENT OPTIONS
There are several ways to rearrange the lower pole parenchyma. All involve a
variation o the in erior wedge principle where the in erior wedge o parenchyma
that is removed in a breast reduction is moved in a mastopexy. The most reli-
able method is that o Ribeiro, where the in erior wedge is created as an in e-
rior ap and then moved up and held in place by closing the medial and lateral
pillars underneath it. This is detailed later in this chapter (see p. 478). Other
options or mastopexy are described in the ollowing text, with associated re-
sults. My pre erred method is the in erior ap (Ribiero) with or without the
pectoralis strip (Daniel and Gra ).

Inferior Flap (Ribeiro)
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Chapter 9 • Mastopexy
The in erior (Ribeiro) type o ap is shown above, with a superior pedicle or
the nipple-areola complex. The in erior wedge o breast tissue that would be
removed in a breast reduction is deepithelialized and completely separated rom
lateral, in erior, and medial attachments. The blood supply to the ap comes
rom the deep artery and vein that per orate the pectoralis muscle just above
the f th rib and just medial to the breast meridian. The lower border o the
deepithelialized ap is cephalad to the blue orceps, showing how much the ap
can—and should—be mobilized. The medial and lateral pillars are then closed
beneath the ap.

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Part II • Technique
Preoperative

16 months postoperatively
1 week postoperatively
This woman underwent a mastopexy using a medial pedicle or the nipple-
areola complex and an in erior Ribeiro-type f ap, with removal o 15 g o tissue
rom the right breast and 85 g rom the le t breast. She is shown 1 week and
16 months postoperatively. The preoperative suprasternal notch-to-nipple dis-
tance was 23 cm. Sixteen months a ter surgery this distance is 24 cm. She lost
about 25% o her nipple sensation. The distance rom the lower areolar border
to the in ramammary old measures 10 cm on both sides. H er suprasternal
notch-to-in ramammary old distance was 23 cm preoperatively and is 22 cm
postoperatively.
Analysis
The initial result looked good, with correction o the glandular pto-
sis. At 6 months, however, there is recurrence o glandular ptosis. I have had
better success with placement o the in erior f ap under a pectoralis strip, as de-

The method described by Daniel and popularized by Gra is shown in this pa-
tient. The in erior f ap is deepithelialized (arrows) and completely separated
rom the rest o the breast tissue on all our sides. The f ap is created as a central
f ap with its blood supply rom the deep system. The f ap must not tether in e-
riorly. The strip o pectoralis muscle is elevated as shown, with the hemostat
under it. It is partial thickness, about 2 cm wide and 6 to 8 cm long.
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Chapter 9 • Mastopexy
scribed in the ollowing patient and on pp. 479 through 481. To prevent
bottoming out and recurrent glandular ptosis, more in erior tissue should
be removed.
Inferior Flap H eld by Pectoralis Strip (Daniel/ Graf)
The in erior f ap is then placed under the strip o pectoralis muscle and secured
deep to the superior pedicle. The muscle strip is shown between the arrows.
The muscle strip is created so that there is no compression on the f ap. The
breast tissue deep to the superior pedicle is elevated o the pectoralis ascia, and
the in erior f ap is sutured up to hold it in place until healing occurs. The f ap

452
Part II • Technique
will not adhere to the pectoralis ascia. The medial and lateral pillars are
brought together below the in erior ap. The breast base is narrowed,
and the breast is coned. Better projection is achieved with this technique,
but it is di f cult to improve upper pole ullness.
The patient is shown 1 year (minus 3 weeks) a ter surgery. No tissue was re-
moved. The in erior ap was held up under a pectoralis strip. H er suprasternal
notch-to-nipple distance was 21 cm preoperatively. A superior pedicle was used.
Postoperatively the nipple position remains 21 cm rom the suprasternal notch.
The distance rom the lower border o the areola to the in ramammary old is
7 cm on the right and 6 cm on the le t. The distance rom the suprasternal notch
to the in ramammary old measured 22 cm preoperatively and is 21 cm post-
operatively.
Analysis
When no tissue is to be removed, a secure method o tissue re-
arrangement is needed to achieve a good, long-term result. Note that there is
no improvement in upper pole ullness, but the breast has been narrowed and
coned. Glandular ptosis has been corrected.

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Chapter 9 • Mastopexy
In this patient, I tried to use both a medially based in erior ap with a lateral
extension and a superior augmentation ap. She had a laterally based pedicle
or the nipple-areola complex.
Medially based
rearrangement flap
Augmentation
flap
Medially Based Inferior Flap
When I realized that I needed to rearrange breast tissue and could not
rely on a skin brassiere or support, I tried a medially based ap o in e-
rior breast tissue with a lateral extension and rotated it up to rearrange
the breast tissue. I also took some o the superior tissue above the pedi-
cle to f ll up the upper pole. The medially based ap worked well, but the
upper pole augmentation ap was inconsistent. I now pre er the Ribeiro
in erior ap, because I believe it has a more reliable blood supply. I o ten
worried that the lateral extension o the medially based in erior ap might
become necrotic.

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Part II • Technique
The patient is shown 6 months and 1 year postoperatively. H er nipple sensa-
tion improved by 25% (better than the preoperative level) postoperatively. At
6 months, the distance rom the lower border o the areola to the in ramam-
mary old measures 8 cm on the le t and 8.5 cm on the right. At 1 year, the dis-
tance is 9 cm on the le t and 10 cm on the right.
Analysis
A good mastopexy with improved projection was achieved. Un or-
tunately, the initial improvement in upper pole ullness was short lasting. A ull
year is needed or a proper assessment. My reviews have shown that changes
still occur during the f rst year; however, beyond this time, the result (without
an implant) is quite stable, unless there have been weight or pregnancy changes.
Superior Pedicle Extension Flap
Other methods o rearranging the lower pole parenchyma include various pedi-
cle extension aps. The superior pedicle extension ap also rearranges the in e-
rior wedge o parenchyma by separating it rom the medial and lateral pillars but
keeping it attached to the pedicle. The in erior wedge is then olded up under
Preoperative

1 year postoperatively
6 months postoperatively

A superior pedicle extension ap was per ormed in this patient; this ap has an
excellent blood supply. The lower, in erior wedge o breast tissue was recruited
and turned up under the nipple-areola complex. Only skin was removed, but
she did have 625 cc o at removed with liposuction in the preaxillary and lat-
eral chest wall areas along the in ramammary old.
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Chapter 9 • Mastopexy
the pedicle. The superior pedicle extension ap has a good blood supply,
but it can be di f cult to inset, and it tends to lose some o its initial cor-
rection. It does improve projection but it is rarely long enough to actually
f ll the upper pole.

The patient is shown 1 month and 3 1⁄2 years a ter surgery. She described a sud-
den sensation o the breasts “dropping” a ter a ew months, and she was dis-
appointed with the results. H er nipples were marked 22 cm rom the supraster-
nal notch preoperatively, and they measured 22 cm at 3 1⁄2 years a ter surgery.
She has 80% return o sensation. The distance rom the lower border o the are-
ola to the in ramammary old measured 9 cm, and the distance rom the
suprasternal notch to the in ramammary old remained unchanged at 22 cm.
Analysis
I believe that some o the superior pedicle extension ap slipped
rom its turned over position and dropped down into the lower pole. It makes
sense to incorporate an extension o the superior pedicle, because it has such
good blood supply, but it can be di f cult to old under. It can be an e ective
method o per orming a mastopexy, but it does not help with upper pole ull-
ness. The patient did have an initial improvement in upper pole ullness. Un-
ortunately, this was deceiving, and, when it dropped, she elt that she did not
get a good result. This subsequent dropping does not help with managing pa-
tient expectations.
456
Part II • Technique
Preoperative

3 1⁄2 years postoperatively
1 month postoperatively

Medial Pedicle Extension Flap
A medial pedicle extension ap does not have as reliable a blood supply
as a superior pedicle extension ap, but it has the advantage o being able
to rotate up into position rather than needing to be olded under the pedi-
cle. Although it should theoretically be able to f ll the upper pole because
o its upward rotation, I have not ound this to be reliable. I believe that
the in erior ap, separated rom the nipple-areola complex, has a better
blood supply and is more e ective or long-term reshaping.
457
Chapter 9 • Mastopexy
A medial pedicle extension ap is shown above. This ap is less likely to have
as good a blood supply as a superior pedicle extension ap unless a true super-
omedial pedicle extension ap is used where the arteries (arrows) are preserved
to both a superior and medial pedicle. The arterial supply to a superior pedicle
is excellent, but a true superior pedicle (or superior pedicle extension ap) is
more di f cult to inset. A medial pedicle extension ap has the advantage o ro-
tating into position, which can help f ll the upper pole more success ully. A true
superomedial extension ap combines the best o both the medial ap (with its
ability to rotate) and the superior ap (with its excellent blood supply).

The patient is shown 1 month and 11 months a ter surgery. She had 125 g o
tissue removed rom the right breast and 225 g removed rom the le t breast.
An additional 50 cc o at was removed with liposuction. H er nipples were
marked at 23.5 cm on the right and 24 cm on the le t. Postoperatively the
suprasternal notch-to-nipple distance measured 25 cm on both sides. The
suprasternal notch-to-in ramammary old measurement remains unchanged
at 21 cm. She retained excellent nipple sensation, and the distance rom the
lower border o the areola to the in ramammary old is 7 cm on both sides post-
operatively.
Analysis
All o the extension f aps tend to be under some tension. They are
likely to slide back to some degree, which makes them less satis actory in the
long term. The in erior f ap is not under tension, because it has been completely
separated rom the surrounding tissue, and it is maintained on its own blood
supply. All the f aps described here will be subject to the e ects o gravity, but
the pectoralis strip does help resist the downward pull.
458
Part II • Technique
Preoperative

11 months postoperatively
1 month postoperatively

With this technique, much o the medially based breast tissue is rotated up and
rearranged, as was done or this woman. She also requested some breast reduc-
tion; there ore 240 g was removed rom her right breast, and 225 g was removed
rom the le t breast. The method described by Cordu is more elegant than the
operative sequence shown here, but the principles remain the same.
459
Chapter 9 • Mastopexy
Complete Medially Based Rotation Flap (Corduff)
Cordu has described a complete rotation o the breast with the blood supply
maintained medially. She has achieved excellent results with this technique.
I think it may be somewhat more di f cult to achieve consistent results with this
method because o a longer learning curve, but the principle is sound.

The patient is shown 21 months postoperatively. She lost about 25% o her nip-
ple sensation. The distance rom the lower border o the areola to the in ra-
mammary old measures 12 cm bilaterally.
Analysis
The improvement is partly the result o reduction o the in erior
pole. The medially based pedicle that carried the rest o the breast tissue did
not, ultimately, contribute to upper pole ullness. Projection was, however, im-
proved. I think the result was a bit disappointing, because some o the gland
dropped out again into the lower pole.
Laterally Based Rotation Flap
A laterally based rotation ap (without the nipple, which is di erent rom me-
dial rotation shown previously) should also have the advantage o being able to
rotate up under the upper pole, but it relies on some tension to hold it in place.
I ound that, when using a lateral pedicle in a vertical breast reduction, the ten-
sion used to pull the pedicle around resulted in relapse, with excess ullness in the
lateral quadrant o the breast.
A lateral rotation ap and a lateral pedicle extension ap have the same prob-
lems with recurrence o lateral ullness. I do not think that the lateral pedicle
or the lateral rotation ap has as good a blood supply, because my Doppler
investigations showed that the superf cial branch o the lateral thoracic artery,
which is the main blood supply to a lateral pedicle, is less reliable and o ten en-
460
Part II • Technique

The patient is shown 5 years postoperatively, a ter signif cant weight loss. Weight
loss a ects mainly the upper pole. Some o the lateral ullness, especially on the
right side, has recurred.
461
Chapter 9 • Mastopexy
The ull-thickness medially based pedicle can be moved without undermining
to allow the lateral ap to rotate upward to achieve a mastopexy. It can be seen,
however, that even at the end o the procedure, it is di f cult to actually rotate
much o the lateral tissue upward, even under some tension.
ters the pedicle lower than the usual design, where the hal o the base o the
lateral pedicle is in the areolar opening and hal o the base extends about 4 cm
down the vertical limb o the skin resection pattern.

462
Part II • Technique
She is shown 18 months a ter the revision. She regained some o her weight,
which added ullness in the upper pole. (Weight gain occurs mainly in the up-
per pole.)
Analysis
The lateral ap and the lateral pedicle extension ap are likely to re-
lapse, because the lateral tissue is under tension as it is pulled into position.
I f nd that the in erior ap can be rearranged without tension. Because both
gravity and tension are enemies o a good result, I believe it is better to at least
avoid long-term relapse by avoiding lateral tension, since gravity is inevitable.
Treatment then involved removal o an in erior vertical wedge o breast tissue
between the vertical markings. The X marks indicate areas o upper pole ull-
ness loss.

This patient is shown 7 years a ter a lateral rotation f ap. No parenchyma was
removed. H er nipples were marked 20 cm rom the suprasternal notch be ore
surgery. This distance measured 20 cm postoperatively. She had complete re-
turn o her nipple sensation, and the distance rom the lower border o the are-
ola to the in ramammary old measured 7 cm on both sides.
Analysis
There is no improvement in upper pole ullness, although projec-
tion is improved. The lateral excess parenchyma relapsed with lateral ullness
and bottoming out, and the nipple appears too high. No breast tissue was re-
moved; a lateral rotation f ap was used to rearrange the parenchyma. The up-
per pole remains unchanged. I the rearrangement had been more success ul at
moving the in erior pole, the nipple might have appeared to be better central-
ized on the breast mound.
463
Chapter 9 • Mastopexy

Whatever mastopexy method is chosen, the principle o moving the
in erior glandular tissue up without tension is the most reliable
method or achieving—and maintaining—an improved breast shape,
with correction o the ptosis and centralization o the nipple on the
f nal breast mound. Moving the breast ootprint, with elevation o
the upper breast border and f lling o the upper pole, requires an
implant; it cannot be achieved with rearrangement o the breast
parenchyma alone. H olding the in erior ap with a pectoralis strip
is a good way to avoid the e ects o gravity. It can result in some
ullness o the upper pole but can be di f cult to predict. Various
pedicle extension aps can be used to move the in erior wedge o
breast tissue; however, the true in erior ap, as described by Ribeiro
(with or without the pectoralis sling popularized by Gra ), is the
most reliable mastopexy procedure in my practice.
PLANNING
Nipple Repositioning
The new nipple position should be determined both vertically and horizontally.
Surgeons need to understand how specif c surgical maneuvers will a ect the de-
sign. For example, implant placement in many developmental breast asymmetry
patients will result in the medial breast skin stretching more than the lateral breast
skin. A laterally based pedicle or the nipple-areola complex may cause the nip-
ple to appear to be too medial as the lateral tissue retracts back into its original lo-
cation. The new nipple should be placed at the junction o the desired vertical
nipple location with the desired horizontal location. This means that the breast
meridian must be drawn in its ideal position and not in its existing position.
464
Part II • Technique
The breast meridian on the patient on the le t is placed medial to the existing
meridian. In the patient on the right, the new breast meridian is placed lateral
to the existing breast meridian.

More important, surgeons need to understand what will happen to the new nip-
ple position in the vertical direction. My measurements have shown that the
nipples will drop (as measured rom the suprasternal notch) about 2 cm when
primary breast augmentation is per ormed. This distance remains unchanged
rom the original design when a breast reduction is per ormed, and it drops
slightly in a mastopexy. I the nipple is placed, or example, 24 cm rom the
suprasternal notch in a vertical breast reduction, the nipple remains at that level
postoperatively, even years later. It does drop slightly with a mastopexy i an in-
erior ap is used. When a mastopexy-augmentation is per ormed, the nipple
will drop at least 2 cm rom the position marked preoperatively.
The ideal nipple position is measured in relation to the upper breast
border, a landmark that does not change after a breast reduction
or mastopexy. The ideal nipple position is usually about 10 cm from
the upper breast border and about 10 cm from the chest wall mid-
line, as drawn in the air and not around the curve of the breast.
Skin Resection Pattern
A vertical skin resection pattern can usually be used with most mastopexies.
With some massive-weight-loss patients or in patients with a signif cant excess o
poor quality skin, an inverted-T skin resection pattern may be necessary. The
skin resection pattern is independent o what is done to the parenchyma.
It may be a poor choice to try to use poor quality skin as a brassiere to hold up
the breast parenchyma. It is better to rearrange the breast parenchyma and hold
it up with the closure o the lateral and medial pillars and then allow the skin
to redrape over the new breast shape.
465
Chapter 9 • Mastopexy

466
Part II • Technique
Wise Brassiere Pattern
The concept of using the Wise pattern—not just the keyhole opening—
as a template for the remaining parenchyma is good for all breast proce-
dures. Closure of the Wise pattern leaves behind a nicely coned breast
shape. It is important to close both the parenchyma and the skin without
tension and to remove (usually with a combination of direct excision and
liposuction) all tissue beyond the Wise pattern. The Wise pattern design
provides an excellent short-term result, and the absence of tension on the
parenchyma and skin provides an excellent long-term result.
The Wise pattern is a good design for breast surgery. When this pattern is closed,
the shape is coned. The superior breast tissue is left behind in the Wise pattern,
and the lower breast tissue is removed (inferior wedge) in a breast reduction
and moved in a mastopexy. This patient had a small breast reduction, which is
the easiest form of mastopexy with 140 g of tissue from the right breast and
205 g from the left breast. Another 75 cc of fat was removed with liposuction.

The patient is shown 8 months after her small breast reduction. Her nipples were
marked 20 cm from the suprasternal notch preoperatively. This distance is
21 cm on both sides postoperatively. The suprasternal notch-to-inframammary
fold distance has remained the same. The distance from the lower border of the
areola to the inframammary fold measures 5 cm bilaterally.
Analysis
A small breast reduction is the easiest way to predictably manage the
inferior wedge, because it is removed. This case illustrates the effect of using
the Wise pattern principle in reduction and mastopexy surgery. It is equally ap-
plicable to mastopexy-augmentation. Removal or rearrangement of the inferior
wedge allows closure of the pillars, which cones the breast and improves pro-
jection. By removal (directly and with liposuction) of tissue beyond the borders
of the Wise pattern, the pillars can be closed without tension on the skin and
parenchyma. This lack of tension on the skin and parenchyma prevents wound-
healing complications and ensures a long-lasting result without relapse.
467
Chapter 9 • Mastopexy

Pedicle Design
I have ound that I can achieve the best design or a breast reduction with a me-
dial or superomedial pedicle, because the base o the pedicle rotates into posi-
tion, providing an elegant curve to the lower pole o the breast. When a supe-
rior pedicle is used with a breast reduction, the removal o the lower pole and
undermining o the pedicle ( requently needed to acilitate insetting o the pedi-
cle) o ten leave an empty area in eriorly, which results in a concave lower pole
in the immediate postoperative period.
Conversely, a superior pedicle is o ten a good choice or a mastopexy, because
the entire in erior ap can be used or rearrangement. Sometimes the medial
pedicle encroaches on the design o the in erior ap. I regularly use both pedi-
cles, depending on nipple position and the resultant size o the in erior ap.
In the past I used the lateral pedicle, because I thought it would have better
sensation than either a superior or medial pedicle. I am concerned now that it
does not have quite as reliable a blood supply (see Chapter 2, pp. 90 and 91).
PATIENT SELECTION AND EVALU ATION
The key to patient selection is understanding what can and cannot be achieved
with a mastopexy. The patient and surgeon need to understand that the breast
cannot be elevated on the chest wall and that low-breasted patients will remain
low breasted.
Size
It is important to f rst understand whether or not a patient is happy with her
current breast size (not shape) in an unpadded brassiere. I not, we then dis-
cuss either a breast reduction (i she eels that she is too large) or a mastopexy-
augmentation (i she eels that she is too small).
U pper Pole Fullness
The patient and surgeon also need to understand that upper pole ullness is elu-
sive without an implant. I the patient wants more roundness in the upper pole,
then we discuss placement o an implant, with or without removal o in erior
pole tissue. The skin removed in a mastopexy usually weighs about 20 g on each
side. In addition, I o ten remove some at at the lower end o the vertical inci-
sion to prevent a pucker. I warn patients that I almost always remove at least
30 g on each side, and I explain that this measures about the same as the vol-
ume o a shot glass. I sometimes use at injections to try to improve chest wall
468
Part II • Technique

irregularities, but results are too unpredictable in my hands to try to f ll the
upper pole or raise the upper breast border. I either o these goals is desired,
I use an implant.
Many patients believe that their breasts are at and that they do not have any
volume in the upper pole. They should be in ormed o the di erence between
projection and upper pole ullness. They can achieve a def nite improvement in
projection (perkiness) with a mastopexy alone, but an implant may be required
to achieve upper pole ullness.
Shape
Surgeons o ten discuss breast ptosis by relating the nipple position to the in-
ramammary old. This can be misleading. We need to di erentiate between
nipple ptosis and glandular ptosis. When the nipple is low, it can be moved into
a more centralized position with a nipple-areolar pedicle. A more centralized
position is not actually centered; it is about a third to hal the distance up the
breast mound and slightly lateral to the breast meridian. A breast augmentation
alone is indicated when the breast mound can be adapted to the existing nip-
ple position. Only rarely can a breast be treated by moving or removing the
lower pole without moving the nipple to a new position.
The main problem with breast ptosis is in evaluating the amount o glandular
(not nipple) ptosis and deciding how best to approach it. Glandular ptosis is
best evaluated in relation to the breast mound and the existing level o the up-
per breast border, rather than in relation to the in ramammary old. Glandular
ptosis is quite di erent rom pseudoptosis, where the nipple may actually be in
a good position but the in ramammary old has dropped, urther exaggerating
the excess volume in the lower pole. I there is a small amount o glandular pto-
sis with a low nipple, then moving the nipple and using the skin brassiere to
hold the shape may be quite e ective.
When there is a signif cant amount o glandular ptosis with excess volume in
the lower pole, regardless o the nipple position, then this excess needs to be
either removed or moved. The skin brassiere (especially poor quality skin) can-
not be relied on to hold up any signif cant amount o weight.
I a patient with glandular ptosis wants upper pole ullness, then a reduction-
augmentation may be the best choice (see Chapter 10). It can be di f cult to
both rearrange the in erior pole and add an implant while still maintaining blood
supply to the in erior ap. It may be better or a long-lasting result to remove the
in erior wedge and then use a larger implant to f ll the upper pole.
469
Chapter 9 • Mastopexy

This patient had glandular and nipple ptosis. She had good upper pole fullness
that did not require any treatment, whereas the lower pole did need treatment.
A combination of procedures was performed that involved removing breast tis-
sue (60 g from the right breast and 130 g from the left breast) and moving the
remaining inferior wedge of breast tissue, which was mobilized and held up un-
der a pectoralis strip. No liposuction was performed. She is shown 6 months
postoperatively. H er nipples were marked 23 cm from the suprasternal notch
preoperatively. Six months after surgery this distance measures 23.5 cm on the
right and 23 cm on the left. The distance from the lower border of the areola
to the inframammary fold measures 6 cm on the right and 7 cm on the left. She
has full recovery of sensation on the left but, at 6 months, she still has no sen-
sation on the right. The suprasternal notch–inframammary fold distance is un-
changed at 22 cm.
470
Part II • Technique

This patient did not have good upper pole ullness. Better projection could be
achieved with a vertical mastopexy, but she would need an implant i she wanted
a round upper pole.
She had an in erior f ap moved up and held under a pectoralis strip, along with
a superior pedicle or the nipple-areola complex. She had only skin removed
rom the right breast, and 30 g o tissue was removed rom the le t breast. She
is shown 28 months a ter surgery, with complete return o sensation. The nip-
ple was marked 22.5 cm rom the suprasternal notch preoperatively; this dis-
tance is 23 cm postoperatively. The distance rom the lower border o the are-
ola to the in ramammary old measures 5 cm on both sides. The distance rom
the suprasternal notch to the in ramammary old is unchanged at 22 cm.
The decision to perform a mastopexy should not be determined
based on the position of the nipple relative to the inframammary
fold. Surgeons need to be able to visualize both the nipple and the
gland in relation to the desired breast mound.
471
Chapter 9 • Mastopexy

472
Part II • Technique
This patient underwent a mastopexy to correct asymmetry. The upper breast
border is marked with a dotted line 12 cm below the clavicle. The markings in
the photo on the right show that the le t nipple will not be moved much. The
le t nipple is already higher than the in ramammary old.
OPERATIVE APPROACH
Inferior Vertical Flap
MARKINGS AND DESIGN
The patient is photographed and marked in a private area while she is standing.
I f nd it best to sit with my eyes at the patient’s breast level or some o the
markings.
The markings or a vertical mastopexy are very much the same as those or a
vertical breast reduction. Care must be taken not to place the nipple too high
in a patient with very poor upper pole ullness. It is important that the nipple
is at the most projecting part o the breast and not on the upper pole slope.
U pper Breast Border
The key landmark in breast surgery is the upper breast border. It will be at the
same level postoperatively in a mastopexy as it was preoperatively. Sometimes
the junction between the chest wall and the upper breast border is well demar-
cated. When the junction is not clear, the level can be marked by pushing the
breast up on the chest wall. The upper breast border is where a crease orms
between the breast and the chest wall. A patient’s striae o ten give an indica-
tion o the level o the upper breast border. It is this level that will determine
whether a patient is high breasted or low breasted.
2
9-1 Preoperative
markings

New Nipple Position
The new horizontal and vertical nipple positions need to be determined. The
horizontal level is at the desired breast meridian. The vertical location is deter-
mined by the upper breast border.
473
Chapter 9 • Mastopexy
Desired breast meridian
Desired nipple position
Upper breast border
Desired breast mound shape
10 cm
10 cm
H orizontal Position
The breast meridian should be drawn through the desired nipple position and
not through the existing nipple position. Some nipples are positioned too ar
laterally, and some are positioned too ar medially. The nipples are o ten on di -
erent meridians. It is important or the surgeon to be able to visualize the f -
nal breast shape to draw the desired breast meridian. A good guideline or the
new nipple position is about 10 cm rom the chest midline, as measured in the
air over the chest and not around the curve o the breast. In the patient shown
on the opposite page, the desired breast meridian and the existing breast merid-
ian are very close.
Vertical Position
The height o the new nipple position is best determined in relation to the up-
per breast border, since this will remain unchanged. A good starting guideline
is to place the new nipple position 10 cm down rom the upper breast border.
This can then be adjusted depending on the size o the breast and the patient.
It is best not to place the nipple too medial or too high. An ideal nipple posi-
tion is slightly lateral o the midline o the breast and a hal to a third the dis-
tance up the breast mound. It is very di f cult to lower a nipple that has been
placed too high.
2
9-1 Preoperative
markings

474
Part II • Technique
Inverted-T pattern
Skin resection pattern
remains 2-4 cm above the
inframammary fold
Areolar opening 14-16 cm circumference
2 cm
Superior pedicle
Superomedial pedicle
Medial pedicle
Areolar Opening
2
9-1 Preoperative
markings
I usually mark the areolar opening 2 cm above the new nipple position. I then
draw the areolar opening design freehand, but a template can also be used. I
tend to make the areolar opening on most mastopexies between 4 and 5 cm in
diameter. A large paperclip is an easily obtained and appropriate template, be-
cause it is 16 cm long. A circle with a 5 cm diameter has a circumference of
16 cm; an areola with a 4.5 cm diameter has a circumference of 14 cm. The large
paperclip can be fashioned into a circle and then spread as needed to design a
new opening. The template will need to be wider in a larger breast. Sometimes
it will need to be canted laterally or medially to make sure all the excess pig-
mentation is removed. It is important not to take too much excess skin, because
this is not a skin brassiere operation, and tension on the skin closure can lead
to wound-healing problems.
The areolar opening does not need to be designed in a mosque- or dome-shaped
pattern, but it needs to form a circle once it is closed. This can be tested dur-
ing the marking by pinching the skin. It can be easily adjusted intraoperatively
by trimming any excess skin.

The skin resection pattern in this patient is marked as a U shape and does not ex-
tend down to the existing inframammary fold. The cross-hatching indicates that
the right inframammary fold would be better moved up to match the left side.
The patient was intubated, and Doppler imaging was used to locate the superior
pedicle arterial supply (red arrows), which comes from the internal mammary
system at the second interspace and enters the areolar opening just medial to
the breast meridian. This artery is very reliable and is usually found about 1 cm
deep to the skin surface. It is not necessary to locate this artery with Doppler
sonography. This was part of a study in which I used this imaging to map the
arterial supply in 83 patients (see Chapter 2, pp. 90 and 91). The skin resec-
tion pattern is marked as a snowman shape, and the tissue in the body of the
snowman is the inferior wedge that will be moved up.
Skin Resection Pattern
The skin resection pattern of a vertical mastopexy is similar to that of a breast
reduction. It should be designed to facilitate removal of the inferior wedge and
not to close a skin brassiere. During the marking process (and while the patient
is on the table), the skin can be pinched to ensure that there will be no tension
on the skin closure. Generally, the vertical limbs of this design match the ver-
tical limbs in the inverted-T design. Instead of drawing 5 cm vertical limbs,
which are then extended laterally and medially to join the inframammary fold,
the vertical limbs are joined together about 2 to 4 cm above the inframammary
fold. It is best to design the skin excision as a U rather than a V shape, because
the U shape facilitates adequate soft tissue removal just above the inframam-
mary fold. Postoperative puckers are more a problem of excess subcutaneous
tissue and less one of excess skin.
475
Chapter 9 • Mastopexy
2
9-1 Preoperative
markings

476
Part II • Technique
I the skin resection pattern is brought down close to the in ramammary old,
the f nal scar will lie below the old. There are two main reasons or this. First,
when an ellipse is closed, the scar is lengthened. Second, the in ramammary old
rises, o ten unintentionally. Some o the lower breast skin becomes chest wall
skin.
Pedicle Design
A medially based pedicle is usually drawn with hal o the base in the areolar
opening and hal o the base along the vertical limb o the skin resection pat-
tern. A superior pedicle or a superomedial pedicle can also be used. It can be
easier to use a pure superior pedicle with an in erior ap or breast tissue re-
arrangement. The sides o a superior pedicle can be sa ely back cut, because the
artery usually enters the pedicle just medial to the breast meridian, about 1 cm
deep to the skin sur ace. It will be necessary to raise the pedicle o the pectoralis
ascia to place the in erior ap under the upper pole o the breast.
TECH NIQU E
Positioning and Inf ltration
The procedure is per ormed with the patient in the supine position under gen-
eral anaesthesia. The arms are placed outward on arm boards at an angle less
than 90 degrees.
I do not inf ltrate the incisions, because the veins are just under the dermis. It is
important to preserve them to acilitate venous drainage. The veins drain mainly
in a superomedial direction. I o ten per orm liposuction in the lateral chest wall,
preaxillary olds, and along the in ramammary old during a breast reduction.
I use a tumescent type o inf ltration in heavier patients. Most mastopexy pa-
tients do not need much liposuction, and I rarely per orm tumescent inf ltra-
tion, but I sometimes use about 20 cc o lidocaine 0.5% with 1/ 400,000 epi-
nephrine per side.
Pedicle Creation
Both the medial and superior pedicles are easily deepithelialized. It is impor-
tant not to damage the veins just under the dermis. The pedicles are created
ull thickness down to the chest wall. A superior pedicle will be elevated o the
pectoralis ascia to create a pocket to receive the in erior ap, but this will not
a ect blood supply because both the artery and the veins, which travel sepa-
rately, are superf cial.
2
9-4 Deepithelialization
2
9-3 Infiltration
2
9-2 Intraoperative
review of markings

477
Chapter 9 • Mastopexy
An in erior ap is shown in this patient. The skin has been le t attached to the
in erior ap to more clearly demonstrate its creation. The superior pedicle has
been deepithelialized. The in erior ap must be completely separated on all our
sides. It may be tempting to leave some attachments in eriorly to help raise the
in ramammary old, but this may lead to retraction postoperatively (see p. 486).
It may also be tempting to try to preserve some o the blood vessels that curve
up around the level o the in ramammary old, but the ap needs to be com-
pletely mobile rom the surrounding tissue. It must, however, be attached as a
chest wall ap, because the blood supply enters the ap just medial to the breast
meridian and just above the f th rib.
Inferior Flap Creation
The in erior ap is deepithelialized to maintain some structure to the ap rather
than to preserve veins. The ap is created ull thickness down to the chest wall
similar to an in erior pedicle. The blood supply to the in erior ap (and in erior
pedicle) comes rom the deep system. It originates rom the ourth interspace
and enters the ap just above the f th rib, usually just medial to the breast
meridian. The surgeon can palpate the f th rib and make sure that the ap
is not undermined. The artery and veins to the ap are contained within
Würinger’s septum, which is more easily identif ed with a medial pedicle breast
reduction, because the vessels are sacrif ced. The septum has a thin superior lea
and a thin in erior lea between which lie both the artery and vein (along with
branches) rom the deep system. These vessels need to be preserved to supply
the in erior ap.
2
9-5 Creation of
inferior wedge

478
Part II • Technique
The in erior ap needs to be completely released rom the in erior dermis and
any tethering f bers. Some vessels rom the f th interspace curve around into
the breast at the level o the in ramammary old, and some o these will need
to be sacrif ced to completely ree the in erior ap. Any tension on the ap must
not pull on the in ramammary old. These f bers need to be released or a post-
operative de ormity will result.
I any volume needs to be removed either or a reduction or to correct asym-
metry, it is best removed rom the tissue lateral to the in erior ap. It is impor-
tant to leave a lateral pillar about 1 to 2 cm thick. Any tissue can be then re-
moved rom under the lateral ap. Extra tissue can then be removed just above
the in ramammary old, either by direct excision or liposuction, to tailor the in-
ramammary old curve.
Repositioning the Inferior Flap (Ribeiro)
The in erior ap (Ribeiro) is then tucked up under the upper pole o the breast
and sutured to surrounding tissue to hold it in place while healing occurs. The
ap will not adhere to pectoralis ascia, but it will heal to surrounding parenchyma.
The pillars are then brought together beneath the ap and sutured together.
2
9-5 Creation of
inferior wedge