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

480
Part II • Technique
These photos (o a di erent patient) show the in erior f ap held up under a pec-
toralis strip. The f ap has been ully mobilized upward under the superior pedi-
cle. The pillars are then sutured together beneath the f ap, and the dermis is closed.
Dermal Closure
The dermis is closed with deep interrupted 3-0 Monocryl Plus. It is important
not to place too many sutures to avoid constriction o the blood supply to the
skin. Only enough sutures to achieve dermis-to-dermis apposition are needed.
Usually, our interrupted dermal sutures are used around the areola.
Pillar Closure
The pillars are then closed beneath the in erior f ap to help support it and to
prevent it rom sliding back in eriorly. The f ap is less likely to slide when it is
held with the pectoralis strip. In this manner, upper pole ullness can be im-
proved to some degree. Without the pectoralis strip, the in erior f ap is excel-
lent or tissue rearrangement and or improving breast projection, but it is un-
likely to actually improve upper pole ullness. I use 3-0 Monocryl Plus or pillar
closure, dermal closure, and subcuticular closure.
2
9-7 Closure of pillars
2
9-8 Closure of dermis

481
Chapter 9 • Mastopexy
At the conclusion o the procedure, the breast appears to be pushed upward.
The in erior ap will settle down and f ll the lower pole, even when it is held
up under a pectoralis strip. This concave in erior pole seen while the patient is
on the table is not needed in a medial pedicle vertical breast reduction. It is,
however, o ten seen with a superior pedicle and when overcorrecting, initially,
the elevation o the in erior ap.
Liposuction
At this stage, any liposuction is per ormed in the lateral chest wall or preaxil-
lary areas and sometimes just above the in ramammary old.
The icon on the le t shows the in erior ap placed under a strip o pectoralis
muscle (Gra ). The icon on the right shows the in erior ap without the pec-
toralis strip (Ribeiro). The icon on the right indicates areas where liposuction
may be per ormed. Some mastopexy patients will need some liposuction tai-
loring, but many are thin and will not. The icon on the right also shows some
parenchymal excision lateral to the in erior ap (green). Many combinations are
possible: the in erior ap can be used with or without the pectoralis strip,
parenchyma can be le t in situ or excised, and liposuction may or may not be
per ormed.

482
Part II • Technique
Skin Closure
The skin is closed with subcuticular 3-0 Monocryl. It is important that this clo-
sure is relatively loose so that the blood supply to the skin edges is not impaired.
There is no attempt to shorten the vertical scar. Gathering o the incision is not
necessary, and it can result in constriction, leading to wound-healing problems.
POSTOPERATIVE CARE
Drains
I rarely use drains or any breast surgery. Drains do not prevent hematomas.
Although seromas do occur, they tend to resolve without treatment.
Tape and Bandages
I no longer use Steri-Strips, but instead cover incisions or 3 to 4 weeks with
Micropore paper tape (3M, St. Paul, MN). Initially, the tape does not look as i
it will adhere once it has been applied; however, within minutes it is di f cult to
remove. Patients are allowed to shower the day a ter surgery. The tape is di f -
cult to remove 1 or 2 weeks a ter surgery.
Patients wear a brassiere to hold the bandages in place and not or compres-
sion. Although I would like to apply compression to any areas where I per-
ormed liposuction, I do not want to apply compression to the nipple-areola
complex.
PROBLEMS AND COMPLICATIONS
Complications or mastopexy are similar to those or breast reduction. The main
complication that is unique to rearrangement o the in erior ap is the scar re-
traction that can occur i the ap is not completely separated rom the sur-
rounding tissue (see p. 486).
Nipple Necrosis
Fortunately, I have had only one patient with a partial (edge) nipple necrosis
in my series o mastopexies. She is shown below. Most mastopexy patients re-
quire shorter pedicles, which may be benef cial or blood supply. I also o ten
use a superior pedicle. The blood supply is excellent, as long as it is not com-
pressed with insetting. Because the blood supply to the superior pedicle is su-
2
9-9 Skin closure
2
9-10 Wrap-up

483
Chapter 9 • Mastopexy
perf cial, the pedicle can be sa ely elevated o the pectoralis ascia to receive the
deepithelialized in erior ap. I do not have much experience with massive-
weight-loss patients. I believe that a discussion o these patients should be sep-
arate rom that o other patients.
The medially based pedicle was probably based too low on the vertical limb.
The X markings indicate where the tip o the lateral rotation ap was to be
moved. I now believe that a superomedial pedicle is a better choice, because it
can contain the artery to both the superior and medial pedicles. This ap may
not have included the artery rom the third interspace. This probably resulted
in a more random patterned blood supply, which could not reach the end o
the pedicle.
This patient had bilateral mastopexies using a lateral rotation ap and a pure me-
dial pedicle. The necrotic tissue was allowed to separate spontaneously, and no
treatment was used. It might have better to use a more superomedial pedicle.

484
Part II • Technique
This patient started to develop a hematoma in the recovery room. She was taken
back to surgery within a couple o hours. A small artery at the medial aspect o
the superior pedicle had f lled the potential dead space below the pedicle. The
artery had been per orated by one o the deep dermal sutures. There was no
bleeding around the pectoralis loop.
H ematoma
My hematoma rate with mastopexies is much worse ( our patients—one with
implant removal) than my rate with breast reductions. I suspect that I need to
be more meticulous with hemostasis, although one recent patient developed a
hematoma rom one o the dermal sutures near the pedicle.
This patient developed a hematoma about 8 days a ter an in erior ap was placed
under a pectoralis strip. The hematoma occurred when she was reaching up in
the shower.

485
Chapter 9 • Mastopexy
This patient underwent removal of double-lumen implants and a bilateral
mastopexy. There was no evidence of hematoma at the time of discharge, but
she had a hematoma when she returned 10 days after surgery. Much of the
blood appeared to be interspersed within the tissues. It resolved without fur-
ther surgery. She is shown 15 months after the mastopexy.

Inferior Flap Retraction
In erior ap retraction is not so much scar contracture as it is retraction o the
tissues around the in ramammary old because o incomplete release o the in-
erior ap rom its surrounding tissues. The in erior ap is chest wall based; the
blood supply comes rom the per orator rom the ourth intercostal space.
Although it may be tempting not to dissect the ap in eriorly, either to main-
tain extra blood supply or to elevate the in ramammary old, this will result in
retraction. The problem can be compounded i the dissection did not leave any
at on the dermis o the in erior skin. In this case, true scar contracture can occur.
486
Part II • Technique
Both o these patients are marked or a revision a ter an in erior ap mastopexy
with the ap held up under a pectoralis strip. The markings show the area
o retraction. A horizontal skin excision was not included in the revision. Flap
retraction can be di f cult to correct, especially i there is a component o scar
contracture.
Puckers
Puckers occur when an ellipse is closed. In an inverted-T skin closure, the el-
lipse is horizontal, and the puckers can occur laterally and medially. In a verti-
cal skin closure, the ellipse is vertical, and the puckers occur superiorly and in-
eriorly. The problem pertains to both a skin and parenchymal elliptical excision.
O ten the reason or an in erior pucker is excess subcutaneous at more than
excess skin. Adding a small T can compound the problem by adding a lateral
and medial pucker. It can be di f cult to know exactly where to place the hori-
zontal scar. The same problem happens when trying to add a J or an L. An-
other pucker can result. It can be di f cult to achieve a good result.

487
Chapter 9 • Mastopexy
Vertical Correction
This patient developed small puckers that were revised 1 year after the original
mastopexy. A small vertical skin excision was performed with a horizontal fat
excision.
The patient is shown 2 months after correction of the puckers. It is often not
necessary to add a horizontal skin excision.

488
Part II • Technique
This patient underwent a mastopexy using an in erior f ap held under a pec-
toralis strip. She is shown with bilateral puckers that were treated a year a ter
surgery with a small vertical skin excision and a horizontal at excision on either
side o the vertical scar.
H orizontal Correction
This patient had an in erior f ap held up under a pectoralis strip (see pp. 504
and 505 or her ull case description). H er puckers extend below the in ra-
mammary old; there ore a horizontal excision is indicated. The pucker is lo-
cated between the original in ramammary old and the new in ramammary old.

489
Chapter 9 • Mastopexy
Because this patient had a scar that extended below the inframammary fold on
the right side, the decision was made to add a horizontal skin excision to both
breasts. It is important to keep the scar above the inframammary fold and to
curve it upward, because it will curve downward otherwise.
J and L Pucker Prevention
If a J or an L is added when there is too much skin for a vertical scar only, it is
important to curve the excision out laterally, well above the inframammary fold.
Often the fold will rise (especially when parenchyma is resected inferiorly), and
the scar can end up below the new inframammary fold.

490
Part II • Technique
Skin Tension
There is no reason to try to tighten the skin closure. The idea of using a skin
brassiere to hold up the breast parenchyma is successful only in patients with
good skin elasticity. Most mastopexy patients have already shown that their skin
will stretch.
When skin is closed under tension, as in this patient, blood supply to the skin
edges is constricted and wound-healing problems are more likely.
The patient is shown 3 weeks and 2 years after surgery. The initial tight closure
will eventually stretch out. Fortunately, wound-healing problems did not oc-
cur. Both skin and dermis stretch under tension. (This principle is used with
skin expanders).

491
Chapter 9 • Mastopexy
Scar Deformity
This patient had a bilateral mastopexy, with a deepithelialized in erior ap placed
under a pectoralis strip. Only skin was removed rom the right breast and 70 g
o tissue was removed rom the le t breast. She is shown 1 year, 21 months, and
32 months postoperatively. It can be di f cult to treat hypertrophic scars. I have
not ound much improvement with either topical treatment or silicone sheet-
ing. Steroid injections can help but at the risk o scar widening and develop-
ment o telangiectasia.
Preoperative

1 year postoperatively
21 months postoperatively

32 months postoperatively

492
Part II • Technique
RESU LTS
Small Breast Reductions
Small breast reductions are the easiest mastopexies, because the in erior
wedge o breast tissue is removed. It is technically easier to remove the
in erior tissue than it is to move it.
This patient had nipple ptosis and glandular ptosis. The upper breast border
was marked with a dotted line. The new nipple position was placed 7 cm rom
the upper breast border. This distance is shorter than in most patients, because
the f nal breast size was going to be relatively small. The upper breast border
measured 13 cm rom the clavicle in this 5 eet 2 inches–tall patient.
The new areola was marked 2 cm above the new nipple position and had a cir-
cum erence o 14 cm. The skin resection pattern was marked at least 2 cm above
the in ramammary old. The le t old was lower than the right old. The cross-
hatching indicates where more aggressive liposuction was to be per ormed.

493
Chapter 9 • Mastopexy
The patient was intubated, and a Doppler examination helped identify the de-
scending artery (red arrows) from the second interspace. The artery supplies a su-
perior pedicle. It usually enters the new areolar opening just medial to the breast
meridian about 1 cm deep to the skin surface. A superomedial pedicle was de-
signed to include this artery. An inferior wedge of breast tissue was removed;
110 g was excised from the right breast, and 140 g was excised from the left
breast. Liposuction was used to remove an additional 75 cc of fat.

494
Part II • Technique
She is shown 12 months after surgery. The nipple had been placed 20 cm from
the suprasternal notch, and it measures 20 cm postoperatively. The areolar di-
ameter is 4.5 cm on each side, corresponding to a 14 cm areolar circumference.
The distance from the lower border of the areola to the inframammary fold
measures 5 cm on both sides. She has a 75% return of sensation on both sides.
Analysis
A small breast reduction gives a predictable and good result for a pa-
tient who desires a mastopexy. This patient had a nipple at the lower border of
the gland; however, both the nipple ptosis and glandular ptosis needed to be
addressed. In this case, the nipple was placed at the level of the inframammary
fold so that it will be about a third the distance up the resultant breast mound.
The inframammary fold can be misleading. Because the upper breast border
will remain unchanged, it is a better landmark for determining the new nipple
position.

495
Chapter 9 • Mastopexy
This patient had nipple ptosis and glandular ptosis, and she was slightly low
breasted. Her upper breast border was marked with a dotted line. The new nip-
ple position was marked so that its f nal location would be about a third to hal
the distance up the breast mound. In this case, that position is the same as the
in ramammary old level.
H er skin resection pattern was marked at least 2 cm above the level o the in-
ramammary old. She had a medially based pedicle, and an in erior wedge o
breast tissue was removed. She had 185 g removed rom the right breast and
195 g removed rom the le t breast. Another 150 cc o at was removed with
liposuction. The vertical incision was not gathered.

496
Part II • Technique
The patient is shown 13 months after surgery. Postoperative measurements
were not performed on this patient. She has had good correction of both nip-
ple and glandular ptosis, with the nipple now being one third the distance up
the resultant breast mound.
Analysis
A small breast reduction is the easiest way to perform a mastopexy.
It is relatively easy to treat nipple ptosis, but the surgeon must recognize when
glandular ptosis exists and either excise the vertical wedge or rearrange it. We
know that excision gives a permanent correction. Various forms of rearrange-
ment are available with varying degrees of success.

497
Chapter 9 • Mastopexy
This patient had signif cant nipple ptosis and mild glandular ptosis. She had a
small medial pedicle small breast reduction with 160 g removed rom the right
breast and 75 g removed rom the le t breast. Another 200 cc o at was re-
moved with liposuction.

498
Part II • Technique
She is shown 10 months and 21⁄2 years after surgery. She has full return of sen-
sation on the right breast and about 75% return on the left side. The new nip-
ple position was marked 23 cm from the suprasternal notch preoperatively, and
this distance is 24 cm postoperatively. The vertical distance (from the lower
border of the areola to the inframammary fold) measures 6 cm on the right and
5.5 cm on the left. Her areolar circumference was marked at 15 cm on the right
and 14 cm on the left, but both areolas stretched to 6 cm in diameter (match-
ing a 19 cm circumference).
Analysis
It is important to determine the new nipple position in relation to
the upper breast border. The nipple can be placed higher when there is already
good upper pole fullness. Smaller breasts may have a 5 to 6 cm distance from
the lower border of the areola to the inframammary fold, but larger breasts need
a longer distance to accommodate the increased projection.
Preoperative

21⁄2 years postoperatively
10 months postoperatively

499
Chapter 9 • Mastopexy
Inferior Flap Secured Under a Pectoralis Strip
This patient underwent a mastopexy using a superior pedicle. The in erior f ap was
placed under a strip o pectoralis muscle. Only skin was removed. She had 200 cc
o at removed with liposuction in the preaxillary and lateral chest wall areas.
The f ap was completely separated rom the surrounding tissue. The deepithe-
lialized area is held in the orceps. Even with this amount o release, the lower
skin needs to be completely ree to prevent retraction. The f ap has slipped un-
der a strip o muscle (between arrows).
The vertical incision was not gath-
ered. Small puckers were le t to re-
solve. It is tempting to suture the
puckers down to the chest wall, but
this can lead to scarring that re-
quires later release.

500
Part II • Technique
The patient is shown 3 weeks postoperatively with the paper tape still in place.
She is also shown 3½ months and 6 years after surgery. The nipples were marked
23 cm from the suprasternal notch preoperatively, and at 6 years postopera-
tively this distance measures 24 cm. The distance from the inferior border of
the areola to the inframammary fold is 6 cm bilaterally. The distance from the
suprasternal notch to the inframammary fold was 23 cm before surgery, and it
is 22 cm 6 years postoperatively. She has 80% return of sensation.
Preoperative

3 weeks postoperatively

501
Chapter 9 • Mastopexy
Six years postoperatively there is retrac-
tion of the lower pole when the patient
raises her arms.
3 1⁄2 months postoperatively
6 years postoperatively
Analysis
The nal result cannot be assessed at only a few months after sur-
gery. Even at 6 years there is retraction of the lower pole when the patient’s
arms are raised. The surgeon needs to con rm that the skin above the infra-
mammary fold is completely released. Note that the upper breast border and
the upper pole have remained unchanged from their preoperative level.

502
Part II • Technique
This patient had nipple ptosis and mild glandular ptosis. She was relatively high
breasted. The most important surgical maneuver will be to move the nipples.
Because there was not much glandular ptosis, a skin-only mastopexy would be
satis actory, but rearrangement o the in erior wedge o breast tissue would pro-
vide a better result. A small reduction would also give an excellent result.
The upper breast border was marked with a dotted line. The new nipple position
was marked at what would be its f nal ideal position on the desired f nal breast
mound. Note that the new nipple position was placed slightly higher than the
in ramammary old, which was at a slightly di erent level on each side.

503
Chapter 9 • Mastopexy
The areola was marked 2 cm above the new nipple position. The areola was de-
signed reehand, to be closed as a circle. The circum erence was 14 cm, corre-
sponding to a 4.5 cm diameter. Note that the skin resection pattern was marked
at least 2 cm above the in ramammary old.
The in erior f ap was deepithelialized and separated rom the surrounding tissue,
except or an attachment to the deep vascular system. The in erior f ap was held up
under a pectoralis strip. She is shown 13 months a ter surgery. She has complete
return o sensation. The new nipple position had been marked 19.5 cm rom
the suprasternal notch. At ollow-up this distance is 20.5 cm on the right and
21 cm on the le t. The vertical 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 areolar
diameter is 4.5 cm on each side. The distance rom the suprasternal notch to the
in ramammary old remains unchanged but with a slight elevation on the right.
Analysis
Any amount o glandular ptosis needs to be either removed, as in a
small breast reduction, or moved, as in this patient. Nipple ptosis is treated with
movement o the pedicle. The nipple position should be placed in relation to
the upper breast border, usually down about 8 to 10 cm, depending on the
amount o existing upper pole ullness and the size o the resultant breast.

504
Part II • Technique
A deepithelialized in erior ap was created
and completely separated rom the sur-
rounding tissue; however, it was le t attached
to the deep per orating vascular system that
enters the ap just above the f th rib.
This patient has nipple ptosis and glandular ptosis. She wanted her breasts to
be about one bra size smaller. Note that the dotted line marks the upper breast
border and that the desired breast meridian is not drawn through the existing
nipple position. The new nipple was marked in relation to the upper breast bor-
der, and not in relation to the in ramammary old. The new nipple position was
actually placed higher than the in ramammary old but about 10 cm below the
upper breast border. The skin resection pattern was marked at least 2 cm above
the in ramammary old. The right in ramammary old was lower than the le t.
All the measurements seen in these photographs are not necessary to per orm
a good mastopexy, but I use them to study what happens a ter surgery. A sur-
geon just needs to note the upper breast border, mark the breast meridian and
the new nipple position, and then draw the areolar opening, the skin resection
pattern, and the pedicle design.

505
Chapter 9 • Mastopexy
The patient is shown at 13 months a ter surgery. H er new nipple position had
been marked at 24 cm rom the suprasternal notch. This distance is 25 cm at
ollow-up. She has complete return o sensation. Her areolar circum erence was
marked at 16 cm bilaterally, and both areolas measured 5 cm in diameter post-
operatively. Her vertical distance ( rom the lower border o the areola to the in-
ramammary old) is 9 cm on the right and 10 cm on the le t. She later under-
went a pucker revision (see pp. 488 and 489).
Analysis
The new nipple was placed above the existing in ramammary old.
It was more important to place it in relation to the level o the upper breast bor-
der. Note that the upper aspect o the breast ootprint does not change a ter
surgery. It is also notable that with larger breasts the distance rom the lower
border o the areola to the in ramammary old becomes progressively longer—
9 cm in this case. A long distance is necessary and produces a good result. This
distance o 5 cm was used as a rule or in erior pedicle inverted-T–type proce-
dures, because the skin was being used as a brassiere, and stretching o the skin
was inevitable. With the vertical-type procedures described previously, the gland
is shaped and the skin is draped. The skin does not stretch, because it is not
placed under tension.
The excess breast tissue was removed lateral to the in erior f ap. A superior
pedicle was actually used and not the medial pedicle that is seen marked
on the photographs. She had 220 g removed rom the right breast and
225 g removed rom the le t breast. Another 300 cc o at was removed
with liposuction. The in erior f ap was held up under a pectoralis strip.
Note that the vertical incision was not gathered. My experience showed
that the scar inevitably stretched out (see Chapter 6, pp. 382 and 383).
When it did not stretch, the scar remained pleated, and a revision was
needed. Gathering also inter eres with blood supply to the skin edges,
and wound-healing problems occur.

506
Part II • Technique
Although this patient had some nipple ptosis, her main problem was glandular
ptosis. She liked the size o her breasts in an unpadded brassiere but was
amenable to a slight reduction in volume.
H er upper breast border was marked with a dotted line. H er breast meridian
was placed slightly medial to the existing nipple position. H er new nipple po-
sition was placed at the desired location, knowing what the f nal breast mound
shape would be. The ideal nipple position is about a third to hal way up the f -
nal breast mound. A superior pedicle was used. An in erior ap was deepithe-
lialized and placed under a pectoralis strip. She had 20 g o breast tissue re-
moved rom the right breast and 30 g removed rom the le t breast (not
including skin). Another 125 cc o at was removed with liposuction. Note that
the vertical incision was not cinched or gathered.
Preoperative
Immediately postoperatively

507
Chapter 9 • Mastopexy
The patient is shown 4 days postoperatively. There is some bruising from the
liposuction. Upper pole fullness is improved, but this will be lost with time. The
paper tape is left in place for 3 to 4 weeks.
She is shown 1 month, 4 months, and 1 year after surgery. The upper breast
border has not changed. Projection is improved, whereas upper pole fullness is
not improved.
1 month postoperatively

4 months postoperatively

1 year postoperatively

508
Part II • Technique
She is shown 2 1⁄2 years after surgery. The nipple was placed 21 cm from the
suprasternal notch. Postoperatively this distance measures 22 cm. The areolar
circumference on both sides was 14 cm, and, postoperatively, the diameter of
the areola is 4.5 cm (which has a 14 cm circumference). The vertical distance
(from the lower border of the areola to the inframammary fold) measures 8 cm
on both sides. She has complete return of sensation.
Analysis
Both nipple ptosis and glandular ptosis are improved. The upper
breast border and upper pole fullness initially appear to be improved. Final re-
sults, however, are not seen until at least 1 year after surgery. Note that the
shape and footprint of the upper half of the breast remain unchanged. The goal
should be to adjust the lower pole of the breast to achieve good results with a
mastopexy.
Preoperative

2 1⁄2 years postoperatively

509
Chapter 9 • Mastopexy
This patient had nipple ptosis and glandular ptosis. She was also low breasted.
A lateral pedicle was per ormed. (Now I pre er to use a superior pedicle.) A
deepithelialized ap was placed under a pectoralis strip. No breast tissue was re-
moved rom the right, and only 30 g was removed rom the le t. Liposuction
was not per ormed.
She is shown 5 years postoperatively a ter signif cant weight gain. H er nipple
was placed 23 cm rom the suprasternal notch. This distance measures 26.5 cm
on the right and 25.5 cm on the le t. This measurement is longer when patients
have gained weight. H er vertical distance ( rom the lower areolar border to the
in ramammary old) is 10 cm bilaterally.
Analysis
Note how much the weight gain has f lled the upper pole. I have
ound that weight gain and weight loss almost always a ect the upper pole—
and not the lower pole—either be ore or a ter surgery. Filling the upper pole
(with either weight gain or an implant) will stretch the skin, resulting in a longer
measurement rom the suprasternal notch to the nipple.

510
Part II • Technique
Gathering o the vertical incision resulted in permanent pleats on both sides.
Shortening this distance is not only unnecessary, but skin does not retract that
well.
This patient had very poor upper pole ullness. She was low breasted with nip-
ple ptosis and glandular ptosis. An in erior f ap was deepithelialized and com-
pletely separated rom surrounding tissue. The f ap was le t attached to the chest
wall where the blood supply per orates the pectoralis muscle. She had a medially
based pedicle. Breast tissue was removed rom the area lateral to the in erior
f ap—170 g rom the right breast and 195 g rom the le t breast. She had only
a minimal amount o liposuction.

511
Chapter 9 • Mastopexy
She is shown 11 months a ter surgery. She lost about 25% o sensation on both
sides. H er nipple position had been placed 24 cm rom the suprasternal notch;
postoperatively this distance is 26 cm. H er vertical distance ( rom the lower
border o the areola to the in ramammary old) measures 9 cm on the right and
10 cm on the le t.
Analysis
I should have removed more o her glandular ptosis, especially be-
cause she desired even smaller breasts. On review o her results, it is clear that
she developed some bottoming out, because I did not remove enough o the
lower pole parenchyma.
REFLECTIONS
The key to per orming a good mastopexy is to understand that the skin is not
very reliable as a brassiere. For a longer-lasting result, it is better to rearrange
the in erior parenchyma. The in erior wedge o breast tissue that is removed
in a breast reduction should be moved in a mastopexy. Various amounts o
parenchyma can be removed at the same time that some o the in erior wedge
is moved to both reduce volume and correct glandular ptosis. Di erent amounts
o tissue can be removed rom each breast to correct any asymmetry.
A small breast reduction is the easiest mastopexy. An in erior wedge o breast
tissue is removed, and the pillars are brought together. The breast base is nar-
rowed, and the breast is coned.
When a patient likes the size o her breasts in an unpadded brassiere, she will
need to have that in erior wedge o breast tissue rearranged. Although there are
various pedicle extension f aps and parenchymal rotation f aps, I obtain consis-
tent results with the in erior f ap held up under a pectoralis strip.

When a patient wants more upper pole ullness, an implant will be needed. A
mastopexy alone can correct nipple and glandular ptosis, and it can improve
projection. An implant is needed, however, to raise the upper breast border and
to increase upper pole ullness.
Concepts to Recall
• The upper breast border is the most important landmark or determin-
ing new nipple position.
• Skin cannot be relied on to act as an e ective brassiere.
• The ptotic lower pole parenchyma needs to be repositioned and held
with remaining parenchyma, rather than pushed up and held with skin
or dermis.
• The medial and superior pedicles are the best choices to allow re-
arrangement o the in erior pole parenchyma.
• The Wise pattern is a good pattern or visualizing the f nal breast shape.
• The breast base is narrowed and breast projection is improved but it is
di f cult to improve upper pole ullness.
• An in erior wedge o breast tissue, with closure o lateral and medial pil-
lars, is an e ective way to rearrange the ptotic lower pole.
• An in erior wedge o breast tissue held under a pectoralis strip with closure
o medial and lateral pillars is a more e ective way to rearrange the ptotic
lower pole.
• An in erior wedge o breast tissue held under a pectoralis strip can give
only a minor improvement in upper pole ullness.
• Pedicle extension aps are e ective—although less reliable—methods o
rearranging the ptotic lower pole. The same applies to medial and lateral
rotation aps.
• There are three separate components to a mastopexy:
– Pedicle design and creation
– Parenchymal rearrangement
– Skin resection pattern
• The key to preventing complications is to avoid tension on both the pil-
lar closure and skin closure.
Part II • Technique
512

BIBLIOGRAPH Y
Def nitions o Ptosis
Kirwan L. A classif cation and algorithm or treatment o breast ptosis. Aesthet Surg J
22:355-363, 2002.
Regnault P. Breast ptosis. Def nition and treatment. Clin Plast Surg 3:193-203, 1976.
In erior Wedge Principle
Daniel MJB. Mammaplasty with pectoral muscle ap. Presented at the Sixty- ourth Scien-
tif c Meeting o the American Society o Plastic and Reconstructive Surgeons, Mon-
treal, Oct 1995.
Gra R, Auersvald A, Bernardes A, et al. Reduction mammaplasty and mastopexy with
shorter scar and better shape. Aesthetic Surg J 20:99-106, 2000.
Gra R, Biggs TM. In search o better shape in mastopexy and reduction mammaplasty.
Plast Reconstr Surg 110:309-317, 2002.
Gra R, Biggs TM, Steely RL. Breast shape: a technique or better upper pole ullness.
Aesthetic Plast Surg 24:348-352, 2000.
Gra RM, Mansur AE, Tenius FP, et al. Mastopexy a ter massive weight loss: extended
chest wall-based ap associated with a loop o pectoralis muscle. Aesthetic Plast Surg
32:371-374, 2008.
McKissock PK. Discussion o Mathes SJ, Nahai F, Hester TR. Avoiding the at breast in re-
duction mammaplasty. Plast Reconstr Surg 66:63-68; discussion 69-70, 1980.
Ribeiro L. A new technique or reduction mammaplasty. Plast Reconstr Surg 55:330-334,
1975.
Ribeiro L, Accorsi A, Buss A, et al. Creation and evolution o 30 years o the in erior pedi-
cle in reduction mammaplasties. Plast Reconstr Surg 110:960-970, 2002.
Pedicle Extension Flaps
Kim P, Kim KK, Casas LA. Superior pedicle autoaugmentation mastopexy: a review o
34 consecutive patients. Aesthet Surg J 30:201-210, 2010.
Losken A, Holtz DJ. Versatility o the superomedial pedicle in managing the massive weight
loss breast: the rotation-advancement technique. Plast Reconstr Surg 120:1060-1068,
2007.
Mastopexy Techniques
Bartels RJ, Strickland DM, Douglas WM. A new mastopexy operation or mild or moder-
ate breast ptosis. Plast Reconstr Surg 6:687-691, 1976.
Becker H . Subareolar mastopexy: update. Aesthet Surg J 23:357-363, 2003.
Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthic Plast
Surg 14:93-100, 1990.
Botti G. Vertical scar mammaplasty: stable padding o the superior pole by means o a pos-
teriorly based pedicle autoprosthesis. Aesthet Surg J 19:116-123, 1999.
Chiari AJ. The L short scar mammaplasty: a new approach. Plast Reconstr Surg 90:233-
246, 1992.
Colwell AS, Breuing KH . Improving shape and symmetry in mastopexy with autologous
or cadaveric dermal slings. Ann Plast Surg 61:138-142, 2008.
513
Chapter 9 • Mastopexy

Cordu N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesthetic Plast Surg
33:377-385, 2009.
Erol OO, Spira M. A mastopexy technique or mild to moderate ptosis. Plast Reconstr
Surg 65:603-609, 1980.
Exner K, Scheuf er O. Dermal suspension f ap in vertical-scar reduction mammaplasty. Plast
Reconstr Surg 109:2289-2298, 2002.
Foustanos A, Zavrides H . A double-f ap technique: an alternative mastopexy approach.
Plast Reconstr Surg 120:55-60, 2007.
Góes JC. Periareolar mammaplasty: double skin technique with application o mesh sup-
port. Clin Plast Surg 29:349-364, 2002.
Góes JC, Bates D. Periareolar mastopexy with FortaPerm. Aesthetic Plast Surg 34:350-
358, 2010.
Goulian D. Dermal mastopexy. Clin Plast Surg 3:171-175, 1976.
H ammond DC, Al onso D, Khuthaila DK. Mastopexy using the short scar periareolar in-
erior pedicle reduction technique. Plast Reconstr Surg 121:1533-1539, 2008.
H ammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture or control o
areolar diameter and shape. Plast Reconstr Surg 120:804-809, 2007.
Qiao Q, Sun J, Liu C, et al. Reduction mammaplasty and correction o ptosis: dermal bra
technique. Plast Reconstr Surg 111:1122-1130, 2003.
Rohrich RJ, Thornton JF, Jakubietz RG, et al. The limited scar mastopexy: current con-
cepts and approaches to correct breast ptosis. Plast Reconstr Surg 114:1622-1630,
2004.
Rubin JP. Mastopexy a ter massive weight loss: dermal suspension and total parenchymal
reshaping. Aesthet Surg J 26:214-222, 2006.
Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg 107:1294-
1299, 2001.
Stevens GW, Stoker DA, Freeman ME, et al. Mastopexy revisited: a review o 150 con-
secutive cases or complications and revision rates. Aesthet Surg J 27:150-154, 2007.
Whidden PG. The tailor-tack mastopexy. Plast Reconstr Surg 62:347-354, 1978.
514
Part II • Technique

Mastopexy-
Augmentation
Chapter10
515
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516
Part II • Technique
T
he challenge when per orming mastopexy-augmentation is that the surgery
combines opposing orces—both elevation and descent as well as skin stretch-
ing and tightening. An implant can e ectively f ll the upper pole o the breast,
but in doing so it will also stretch the skin and pull down breast tissue. The nip-
ple can be easily raised, but the lower pole must be addressed; rearrangement
is almost impossible. The best approach is the minus-plus technique described
by Regnault and Daniel, with excision o lower pole excess as a reduction-
augmentation.
The problem with attempting to rearrange the in erior wedge parenchyma in a
mastopexy-augmentation is that placement o an implant damages the blood
supply to the in erior ap. The deep system that originates rom the internal
mammary artery at the ourth interspace penetrates the pectoralis muscle just
above the f th rib. It enters the deep sur ace o the breast and is the primary
blood supply to an in erior pedicle and an in erior ap. Regardless o whether
the implant pocket is to be subpectoral or subglandular, its creation requires
cauterization o the deep artery and vein.
The breast responds to gravity and to tension; this response is exaggerated by
the presence o an implant. It is seductive to think that an implant will hold up
breast tissue; in reality, the opposite occurs. Even with tissue ingrowth into the
implant sur ace, the breast will drop. Although capsular contracture can li t a
breast because the capsule is attached to the breast tissue, once the capsule is
released, the breast tissue inevitably descends to its original position.
Capsular contracture in this patient’s le t breast raised the implant, pulling the
attached breast tissue upward and inward. This is not a permanent condition;
with release o the capsule, the breast tissue resumes its downward progression.

517
Chapter 10 • Mastopexy-Augmentation
It is evident that the implants and the breast tissue are acting independently in
this woman. She has bilateral capsular contractures, but even these contractures
cannot elevate the breast tissue and skin. The breast tissue responds to gravity in
the same manner as it does in a mastopexy or reduction.
The implant and breast tissue can respond together or separately to the forces of
gravity, but in this woman, the waterfall effect of the breast tissue dropping off
the implant demonstrates the implant’s inability to successfully elevate the breast
tissue.

This independence of movement becomes even more obvious with a subpec-
toral implant, in which contraction of the pectoralis muscle can raise the im-
plant but does not affect the breast tissue. This patient had a circumareolar
doughnut mastopexy. The lower pole of her breast was not corrected with this
operation, and her glandular ptosis persists.
The in erior wedge principle applies to mastopexy-augmentation,
just as it does to mastopexy and breast reduction. With a breast re-
duction, the in erior wedge is removed and the breast tissue le t be-
hind is in the superior pole, which prevents gravity rom pulling
the gland back down. With a mastopexy, the in erior wedge is
moved and repositioned; again, it is less likely to respond to gravity
(especially when the in erior f ap is held up under a pectoralis strip).
518
Part II • Technique

519
Chapter 10 • Mastopexy-Augmentation
With a mastopexy-augmentation, the ability to use the in erior ap is eliminated,
because the implant has damaged the blood supply. The in erior wedge needs
to be removed and a larger implant used to compensate. The idea o a minus-
plus technique or a reduction-augmentation may seem counterintuitive, but I
rely on these principles time and again when approaching this problem. I have
not been able to f gure out how to rearrange the in erior pole while simultane-
ously inserting an implant. The breasts can look good initially, but the gland
will drop back down, resulting in glandular ptosis.
Measurements are not necessary or per orming good surgery, but to be good
surgeons we need to use measurements to understand what happens over time.
I have measured suprasternal notch-to-nipple distance be ore and a ter a
mastopexy-augmentation, and just as in a pure breast augmentation, the
suprasternal notch-to-nipple distance drops about 2 cm, on average, rom its
marked position. This di ers rom a breast reduction or mastopexy, in which
the suprasternal notch-to-nipple distance stays as marked.
An implant adds weight to the breast, stretches the skin, and lowers the nipple.
This distance can increase several centimeters and does not become stable until
a ter 1 year o ollow-up. The weight o the implant also lengthens the nipple-
to-in ramammary old distance, and this length progressively increases over time,
depending on the size (weight) o the implant.
Assessment
BREAST FOOTPRINT
Analysis o the breast ootprint is as important or mastopexy-augmentation as
it is or other breast surgery. An implant will raise the upper breast border, but
the amount o this elevation is limited—sometimes to the patient’s dismay.
Many patients opt or larger and larger implants in an e ort to elevate the breast
on the chest wall, but this strategy is minimally e ective and only serves to de-
press the lower breast border, increasing the amount o glandular ptosis.

520
Part II • Technique
A comparison of these two patients reveals that the distance from the clavicle
to the upper breast border measures 11 cm in the high-breasted patient (above)
and 13 cm in the low-breasted patient (below). Although the main landmark is
the upper breast border, it is obvious in these women that their inframammary
folds are at different levels, with the fold positioned higher on the chest wall in
the high-breasted patient.
It is important for the surgeon to stand back and assess all four footprint borders
and then the shape that sits on that footprint. Some patients are high breasted
and some are low breasted.

521
Chapter 10 • Mastopexy-Augmentation
Techniques to Alter the Breast Footprint
Upper Breast Border
The surgeon must explain to low-breasted patients that larger and larger
implants will not f ll the upper pole o the breast as much as they desire.
This woman had a mastopexy-augmentation with 310 g sub ascial cohesive sil-
icone gel CMH implants; 5 g o tissue was removed rom the right in erior
breast and 100 g rom the le t breast. She is shown 16 months postoperatively.
The patient requested still larger breasts; her implants were replaced with re-
sponsive gel Style 120 500 cc implants on each side. She is shown 1 year a ter
the second surgery. The arrows mark the upper breast border. Although the
larger implants raised the upper breast border slightly, they also caused the lower
pole to drop. Although patients seem to want very high implants, the upper
breast border should not be higher than the preaxillary old. The upper breast
border should not be higher than the preaxillary old.
Preoperative

16 months postoperatively

1 year postoperatively

522
Part II • Technique
This low-breasted woman wanted overly large implants to f ll her upper pole
and upper chest wall area. A mastopexy-augmentation was per ormed, with
CMH 365 g implants placed in the subglandular position. The implants raised
the upper breast border, but it is important to note how much the in ramam-
mary old was lowered (by comparing the old to the lower rib margin). The
mastopexy-augmentation was e ective in raising the nipples and the lower bor-
der o the breasts (as noted by comparing them to the elbow crease). Low-
breasted patients are o ten disappointed, even a ter extensive preoperative dis-
cussions stressing the need or having realistic expectations.
Lower Breast Border
My breast augmentation measurements have shown that the in ramam-
mary old drops at least 1 to 2 cm (usually unintentionally) when an im-
plant is inserted. This also occurs with mastopexy-augmentation. Gravity
always wins—and both the ootprint and the breast shape are a ected by
the weight o an implant.

523
Chapter 10 • Mastopexy-Augmentation
Medial and Lateral Breast Borders
The implant should be chosen so that the base diameter f ts the desired
breast base diameter rather than the existing breast base diameter. Some-
times the medial and lateral breast borders require expansion; other times
they need to be reduced. In most situations an implant is used to expand
the borders and liposuction (or direct excision) is used to reduce the
borders.
To widen her breast ootprint, this patient required an implant that was wider
than the base diameter o her existing breast. It would have been a mistake to se-
lect an implant based on her existing breast base diameter. She had bilateral
mastopexy-augmentation with a superior pedicle and sub ascial placement o
350 cc smooth-walled silicone gel moderate plus prof le implants on each side.
She did not have glandular ptosis, so only skin was removed. She is shown
3 years postoperatively with 90% return o sensation. H er breast ootprint ex-
tends out slightly past the anterior axillary old.

524
Part II • Technique
The concept o using a breast implant to match the existing breast diameter
works only in ideal circumstances; the surgeon must assess the situation and
make decisions that f t the presenting problem. In this case, this woman’s ex-
isting breast base diameter was too wide and needed to be reduced. It would
not have been appropriate to choose a wide-based implant to f t the existing
breast base. She had a mastopexy-augmentation with placement o 322 cc tex-
tured cohesive gel implants and removal o 80 g o tissue rom the lower pole
o each breast. Liposuction reduced and narrowed the lateral breast border;
700 cc o at was removed, producing a pleasing lateral contour.
BREAST SH APE
Many patients desire a breast shape that is completely conf ned to the breast
ootprint. But breasts are like awnings: they tend to hang o the ootprint to
some extent.

525
Chapter 10 • Mastopexy-Augmentation
Although this patient had minimal ptosis, a small amount o her breast shape
hung o the ootprint. Following mastopexy-augmentation (per ormed or
asymmetry), her breast shape is almost completely conf ned to the breast oot-
print. This was not achieved by elevating the breast (the nipple was elevated);
breast shape was improved by lowering the in ramammary old, which is an in-
evitable outcome when an implant is placed.
This patient’s glandular ptosis appears to have been corrected a ter a mastopexy-
augmentation. This was achieved partly by excising breast tissue (55 g) but also
by lowering the in ramammary old by approximately 2 cm. Smooth-walled
Style 15 397 cc responsive gel implants were placed in a subglandular position
in both breasts. Nipple ptosis was corrected by the mastopexy. The supraster-
nal notch-to-nipple distance measured 22.5 cm preoperatively, and the new
nipple position was marked at 21 cm. It stretched back out to 22.5 cm post-
operatively.

526
Part II • Technique
The surgeon must evaluate both glandular and nipple ptosis in re-
lation to the upper breast border rather than to the inframammary
fold. The ideal nipple position will be about 8 to 10 cm below the
upper breast border in a woman with an average C or D cup
brassiere. I place the nipple in the same location that I do with a
mastopexy, because the implant in a mastopexy-augmentation will
not only raise the upper breast border but will also drop the nip-
ple from its marked position.
Glandular ptosis is independent o nipple location, and it should be corrected
by removing an in erior wedge o tissue. The problem with a mastopexy-
augmentation is that the in erior ap will not have a good blood supply; its re-
moval is necessary to avoid recurrent glandular ptosis.
The more glandular ptosis that a patient has, the more gland that needs to be
removed, regardless o nipple position. Nipple ptosis is relatively simple to cor-
rect by moving the nipple to a higher location. Glandular ptosis is more di f -
cult to correct: the surgeon must assess the amount o glandular ptosis to de-
termine how much gland needs to be removed and there ore how large an
implant is required.

527
Chapter 10 • Mastopexy-Augmentation
Techniques to Alter Breast Shape
Removal of the inferior wedge of parenchyma not only prevents recurrent glan-
dular ptosis but also permits the breast to be narrowed and coned, creating ex-
tra projection even without the addition of an implant. I have tried using the
pectoralis fascia as a sling to help hold the implant up, but this has failed, be-
cause fascia stretches with weight and time.
The principle of leaving the Wise pattern behind and removing the inferior
wedge of ptotic tissue applies equally well to a mastopexy-augmentation as to
a breast reduction. Unfortunately, I have not found an effective way to move
that inferior wedge in a mastopexy-augmentation in the way that I can in a pure
mastopexy.

528
Part II • Technique
Nipple Ptosis
If the patient presents with nipple ptosis and has very little excess gland
in the lower pole, a small, inferior wedge excision can be performed, along
with nipple repositioning and breast augmentation.
This woman had nipple ptosis. A mastopexy-augmentation was performed, in
which a superior pedicle was used with no parenchymal excision; only skin was
removed. She had bilateral subfascial augmentation with CMH 310 g cohesive
silicone gel implants. When the primary problem is nipple ptosis, the nipple
should be moved, but it is not necessary to remove an inferior wedge of breast
tissue. The patient is shown 1 year postoperatively with complete sensation re-
turn. Her suprasternal notch-to-nipple measured 23 cm preoperatively and the
new nipple position was marked at 20 cm for surgery. The suprasternal notch-
to-nipple distance stretched out to 22 cm bilaterally at 1 year postoperatively,
and the inframammary fold dropped 2 cm.