Augmentation Mammoplasty and Mastopexy

Calobrace, M. Bradley; Mays, Chet

doi:10.1007/978-3-030-78028-9_2

M. Bradley Calobrace^3,4,5 &
Chet Mays^6,4

2627 Accesses

Abstract

Achieving a successful outcome in aesthetic breast surgery requires excellent preoperative and intraoperative decision-making and expert surgical execution. Thoughtful consideration of the patient’s desired aesthetic result in conjunction with the anatomic characteristics of her breast and chest wall provide insight into the optimal surgical approach to achieve a successful outcome. The most common procedures performed for correction include a breast augmentation, a breast lift (mastopexy), or a breast lift in conjunction with an augmentation (augmentation mastopexy). This chapter will highlight the preoperative evaluation and decision-making to select the optimal procedure for aesthetic improvement in the breast. When a patient needs a mastopexy with an augmentation, the decision to perform simultaneously or as a staged procedure will be reviewed. The operative technical strategies will likewise be outlined in detail to safely execute these procedures. The details, decisions, and experience-based pearls involved in this operation can provide guidance to perform these operations with expert precision.

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Two-Stage Augmentation Mastopexy

Technique in Simultaneous Augmentation Mastopexy

Principles of Breast Augmentation: The Process of Augmentation Mastopexy and Criteria for Staging

Keywords

Introduction

Achieving a successful outcome in aesthetic breast surgery requires an assessment of the patient’s desired look in conjunction with the anatomic characteristics of the breast. Whereas many patients have simply underdeveloped breasts or congenitally mal-shaped breasts, other patients seek correction for undesirable changes that have occurred. The shape and size of the breasts may experience significant deleterious effects over time secondary to pregnancy, weight fluctuations, and aging. Breast augmentation can provide improvement in shape, size, and symmetry, and improved body proportion in patients with micromastia. Patients with more significant changes resulting in breast ptosis may require only a breast augmentation when it is mild, but will often need a mastopexy when more significant ptosis exists. In patients with more significant ptosis and volume loss, a successful breast procedure may include not only adding much needed volume and shape stability that is offered with a breast implant but also tightening of the ptotic skin envelope and repositioning of the low nipple-areolar complex through a mastopexy, either simultaneously or in a staged fashion. Fat grafting can also be utilized with or without the use of an implant to improve upper pole fullness and cleavage. Thoughtful consideration of the patient’s desired aesthetic result in conjunction with the anatomic characteristics of her breast and chest wall provide insight into the optimal surgical approach to achieve a successful outcome.

Preoperative Planning

One of the most critical steps in achieving excellence in aesthetic breast surgery is the preoperative evaluation. The preoperative evaluation through a thorough assessment should identify not only the appropriate implant to achieve optimal results but also the location of the incision; the implant pocket; asymmetries of the breast, chest wall, and/or nipple-areolar complex; and the potential need to lower the inframammary fold. The preoperative markings create a road map for the planned procedure. This includes marking the inframammary fold, midline, and meridian of the breast. The base diameter, intermammary line, and dual-plane planning can be also helpful in strategizing the surgical plan (Fig. 2.1).

Critical to success is determining the appropriate approach—breast augmentation, mastopexy, augmentation mastopexy, and/or fat grafting. Evaluation of the soft tissue coverage, including quality of skin and breast tissue, amount of breast parenchyma, the footprint of the breast, and the level of ptosis, is essential to determining the optimal approach:

Breast Assessment of the Soft Tissue

Quality of the skin and breast tissue
Amount of breast parenchyma
Footprint of the breast
Level of breast ptosis

When using an implant, precise pocket creation and appropriate implant choice are the best safeguards against postoperative implant malposition issues. Likewise, the most common reason for revisional surgery after a breast surgery with implants is capsular contracture [1, 2]. There is strong evidence that biofilm development from bacterial contamination is a significant causative component in the development of capsular contracture [3,4,5,6], Part of the operative planning, therefore, should include efforts to minimize this risk when possible. The list below summarizes some of the implant and surgical technique options that have been associated with lower capsular contractures [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23].

Options Associated with Reduced Capsular Contracture Incidence

No-touch technique [7,8,9]
Nipple shields [8]
Pocket irrigation with triple antibiotics [10]
Insertion sleeve [9]
Submuscular implant pocket [11,12,13]
Textured implants [11, 13,14,15,16,17,18]
Inframammary incision [13,14,15,16,17,18,19]
Cohesive-shaped implants [20,21,22,23]

Breast Augmentation

Achieving a successful outcome in breast augmentation requires excellent preoperative and intraoperative decision-making and expert surgical execution. Thoughtful consideration of the patient’s desired aesthetic result in conjunction with the anatomic characteristics of her breast and chest wall provides insight into the optimal surgical approach to achieve a successful outcome. There are many incisional approaches to breast augmentation, including inframammary, periareolar, transaxillary, and transumbilical. The inframammary approach has increasingly become the preferred incisional approach, and is the most commonly performed today.

Implant Selection

The selection of the appropriate implant is determined not only by the objective findings during the examination but also by the patient’s expectations and desired final outcome. Today’s implants can be saline or silicone, textured or smooth, and come in a variety of projections. The base diameter of the chest is considered one of the most important determinants in sizing of the implant. Classically, the final base diameter of the breast will be the diameter of the implant plus the width increase provided by the soft tissue contributions. Thus, the final desired breast width minus the soft tissue contributions should provide guidance to the implant base diameter. (Implant Base Diameter = Desired breast width − (½ Medial pinch + ½ Lateral pinch.)

Patient Positioning

Patients are placed on the operating room table in the supine position. The arms are secured to the arm board with soft gauze wraps at 45 degrees to stabilize the patient in the upright position (Fig. 2.2). This relaxes the pectoralis muscle, providing a more accurate assessment of the implant position and the redraping of the overlying breast tissue. Alternatively, some surgeons prefer placing the arms alongside the patient on the operative table, but an arm board at 90 degrees should be avoided, as it does not allow accurate assessment of the breast when the patient is placed in the upright position.

Infiltration of Local

Prior to surgical preparation, 50 ml of a local field block is injected of 1/4% lidocaine, 1/8% bupivicaine, and 1:400,000 epinephrine (Table 2.1). The injection is placed in the dermis along the planned incision line, and as a field block with injections along the inframammary fold, the medial pectoral border, the anterior axillary line, and finally, deep to the breast parenchyma in a fanning fashion throughout the area of planned pocket creation (Fig. 2.3).

Table 2.1 Breast local anesthetic formula

Full size table

These injections provide assistance not only in operative hemostasis but also in the management of postoperative pain.

Surgical Preparation and Sterile Draping

After local infiltration, nipple shields (created by placing a small piece of Tegaderm over each nipple-areolar complex) provide a barrier against potential bacterial contamination [8] (Fig. 2.4). The patient is prepped with chlorhexidine and draped to provide a sterile field, with the entire chest and bilateral breasts visible for assessment during the procedure. The sterile dressings must be secured to prevent disruption in the sterile field while placing the patient in the upright position.

Inframammary Incision

The inframammary fold has become the preferred incision location for most surgeons today. There are many advantages, and some disadvantages, which must be considered to ensure the appropriateness of the IMF approach:

Advantages

Well-hidden scar in the fold of the breast.
Incisional length is unlimited and thus can accommodate any and all implant choices.
Excellent visualization for dissection of the implant pocket.
The ability to control the IMF position during incision closure.
Can be used for any complication revision.
Lower capsular contracture rates.
Minimal issue of a scar contracture creating deformity.
Potentially less nipple-sensation changes.

Disadvantages

The scar is located on the breast.
Scar may be more visible if breast fold is absent or if the scar becomes pigmented.
Must determine final IMF position preaugmentation and place scar precisely in planned new fold.
Scar position is more vulnerable to irritation from the bra.

The size of the incision depends on the location but, in general, should be as small as possible and yet large enough to safely dissect the pocket and place the implant without distortion or injury to the device. In general, the incision length increases with increases in implant size, gel cohesiveness, optimal fills, and texturization of the implant. Additionally, the quality of the scar is often better if a slightly larger scar is utilized, reducing the stretch and retraction injury placed on the scar. Incision length ranges include: 3–4.5 cm for saline implants, 4–6 cm for silicone round implants, and 4.5–7 cm for shaped cohesive silicone implants.

Inframammary Fold Positioning

Predicting the final position of the inframammary fold is critical to determining the placement of all breast incisions, but especially the inframammary incision. This can be a challenging task, as so many variables contribute to the final position of the fold. The inframammary fold is formed by the fusion of the anterior and posterior leaves of the superficial fascia, which is intimately associated with the dermis at the lowest aspect of the inferior pole of the breast [24]. During preoperative markings, the native inframammary fold is identified and marked in the sitting position. The true IMF position is determined by performing an IMF expansion test. The breast is grasped and autorotated inferiorly to identify the inferior extent of the attachments of the inframammary fold (Fig. 2.5). This is the best predictor of where the fold will naturally sit after breast augmentation. The amount of lower pole skin required and the ultimate position of the fold is a function of many factors, including the type of implant (saline vs. silicone and round vs. shaped), size of implant, pocket location, and the strength and stability of the soft tissue of the lower pole. The distance measured from the nipple to true fold under maximal stretch assesses the amount of lower pole skin available to accommodate the selected implant. An acceptable standard that has been used is an implant with a base diameter of 11 cm requiring 7 cm, a base diameter of 12 cm requiring 8 cm, and a base diameter of 13 cm requiring a 9 cm nipple to fold distance [25]. A more comprehensive evaluation has been described using tissue-based planning principles [26]. In the High Five System analysis, variables are analyzed including implant volume, patient’s base width, implant base width, anterior pulled skin stretch, and nipple-to-fold distance under maximal stretch. Based on the selected implant, a reference chart provides the desired nipple-to-fold distance on maximal stretch, which if longer than the measured distance, will require IMF lowering.

In determining fold position, our team has found three alternative methods extremely useful by using the implant dimensions and fill volume (Table 2.2).

Table 2.2 Techniques for determining lower pole skin requirements nipple to inframammory fold

Full size table

If the desired N-IMF distance is equal or less than the measured N-IMF distance, then the fold does not require lowering. The distance can be adjusted based upon expectation for lower pole stretch postoperatively. It is important to recognize that inframammary fold lowering is less often required when placing a larger smooth saline or silicone implant, especially if higher profile, secondary to lower pole stretch over time [27, 28]. However, when implant choice or soft tissue characteristics predict less lower pole stretching, inframammary fold lowering may be required [13, 29]. Likewise, shaped implants are not only textured but also have a greater volume of a more cohesive gel present in the lower pole of the implant, thus requiring more lower pole skin to accommodate the implant [20,21,22,23, 30, 31]. The list below identifies some implant and soft tissue characteristics that may be associated with a greater need to lower the inframammary fold due to less postoperative stretching of the lower pole [13, 20,21,22,23, 26,27,28,29,30,31, 39].

Characteristics Associated with Less Stretching of the Lower Pole

Textured implants
Cohesive implants
Shaped implants
Silicone compared to saline implants
Lower profile implants
Smaller implants
Tight, firm breast skin

Incision

The inframammary incision provides direct access and visualization of the pocket with the least injury to surrounding structures. After determining the inframammary fold position (either the native true fold position or the planned lowered position), a paramedian line is drawn through the center of the breast and bisects the newly drawn inframammary fold. The incision’s medial extent begins 1 cm medial to the paramedian line and extends laterally for the appropriate distance as previously described (Fig. 2.6). The initial incision is made with a 15-blade and dissection is then carried out with electrocautery through the skin and subcutaneous tissue, beveling upward while rotating the breast off of the chest wall. The dissection proceeds subcutaneous for approximately 1 cm and then deep through the superficial fascia and toward the lateral pectoral border deep on the chest wall. This technique preserves a small cuff of superficial fascia at the incision, which helps to protect the IMF and will prove useful during closure (Fig. 2.7).

Implant Pocket

There continues to be divergent thought with regard to the optimal pocket for breast implants. The subglandular/subfascial pocket is the most natural for the implant, with avoidance of animation deformities seen with submuscular implants, enhanced correction of constricted breast or ptotic breasts, ease of dissection, and less postoperative discomfort for the patient [32,33,34,35]. The submuscular pocket advantages have included lower capsular contracture rates, enhanced coverage of the implant to minimize issues of wrinkling, provides a more natural upper pole, and provides enhanced support for the breast implant [11,12,13, 32,33,34, 36]. Undoubtedly, the issues of wrinkling and need for enhanced coverage with saline implants provided the impetus for submuscular pockets becoming the preferred pocket by US surgeons [29, 37, 38]. It has been widely accepted that an upper pole pinch test of 2 cm is required to place an implant in the subglandular/subfascial pocket to reduce the risk of upper pole implant visibility or wrinkling. With the availability of silicone implants, both round and shaped, optimally filled with increased cohesiveness and simultaneous fat grafting, optimal pocket choice may be even more elusive.

No matter which pocket is selected, it is helpful during the marking process to identify as accurately as possible the pocket size necessary to accommodate the selected implant. This will provide a pocket that maintains the implant in a control position and minimizes the risk of postoperative implant malposition. In breast augmentation with round implants, the accurate placement of the inframammary fold and control of the medial and lateral extent of the pockets provide ideal implant positioning to achieve the desired cleavage and minimize lateral migration of the implant [29]. When using a shaped implant, a controlled pocket including the superior extent is even more essential to minimize the risk of implant rotation postoperatively [23, 30, 31].

Dual-Plane Submuscular Pocket

The importance of optimizing soft tissue coverage in breast augmentation cannot be overstated. Inadequate coverage, often combined with oversized implants, can lead to parenchymal atrophy and skin stretching, resulting in wrinkling and palpability of the implants and other associated breast deformities [27, 28]. The dual plane, initially described by Tebbetts, maximizes coverage and support of the breast implant while minimizing the disadvantages of submuscular placement, including animation deformities and pseudoptosis of the breast tissue overlying the submuscular implant (i.e., waterfall deformity) [36].

When performing a dual-plane pocket, the lateral pectoral border is identified, and fascia incised to expose the underlying muscle. Upward retraction of the breast tissue will usually elevate the lateral border, allowing further dissection and placement of the retractor beneath the overlying pectoralis muscle (Fig. 2.8). A very helpful “rule” is to never cut through the muscle that cannot be elevated. The inability to tent the muscle up off the chest wall may indicate that the muscle fascia is extremely adherent, but more likely that the identified muscle is actually not the pectoralis, but rather the serratus, rectus, or an intercostal muscle. Continuing the dissection through an intercostal could inadvertently penetrate the pleural space, resulting in a pneumothorax. Once the edge of the pectoralis is safely elevated and the subpectoral space is identified, dissection is carried upward centrally to the superior extent of the pocket. Dissection is then carried laterally to identify the pectoralis minor, and then carried directly over the fascia until the lateral border of the pocket is reached. Dissection is then continued along the lateral border of the pocket, identifying and staying superficial to the serratus muscle until the inferior extent of the pocket at the inframammary fold is reached. The muscle is then released along the planned inframammary fold, staying 1 cm superior to the fold to account for postoperative caudal muscle descent (Fig. 2.9). Dissection directly at the fold will often lead to a fold that is lower than planned as the muscle retracts inferiorly. As you carry your dissection medially along the IMF, it is critically important to stop the dissection at the most medial extent along the sternum. Preservation of the most caudal attachment of the pectoralis muscle at the transition point (TP) along the sternum is critical to minimize the chance of window shading of the pectoralis with subsequent medial implant exposure and animation deformities. A transition zone (TZ) of tapered muscle release connects the transition point to the main body of medial pectoral muscle along the sternum (Fig. 2.10).

The extent of the pocket is completed by defining the medial pectoral border by dividing the accessory slips of pectoralis muscle that insert along the ribs, preserving the main body of the muscle as it inserts along the sternum. Dividing these muscles with electrocautery rather than blunt dissection improves postoperative cleavage and maintains prospective hemostasis.

The dual-plane approach ultimately creates a subglandular pocket in the inferior breast pocket. The levels of dual plane represent the amount of muscle released from the inferior breast tissue and resultant inferior subglandular pocket (Fig. 2.11). Division of the inferior pectoralis muscle just above the inframammary fold during initial pocket dissection created a dual-plane level 1. The level of dual plane required varies, and each surgery can be tailored to provide the optimal level based on soft tissue requirements and implant selection. In general, creating a subglandular pocket inferiorly is required to either redrape the skin and breast tissue more accurately over the implant, or for expansion and exposure of the lower pole, such as in a tuberous or constricted breast. The release of the caudal edge of the muscle is performed incrementally, creating the least amount of release that will adequately address the lower pole (Fig. 2.12). Placement of a retractor into the breast pocket and elevating superiorly while rocking the breast tissue over the retractor will assist in assessing the effects of the implant on the overlying skin and breast tissue once placed in the pocket. When a dual plane is created for expansion and exposure in a tight envelope, the level will depend on the need to access the parenchyma for scoring and expansion. This usually requires at least a level 2 and often a level 3 to expose the retroareolar tissue.

Subglandular/Subfascial Pocket

The subglandular or subfascial pocket can be easily developed through the inframammary incision, and this dissection is performed without the need for muscle division or dual-plane creation. Once the incision is made and the lateral pectoral border has been identified, the dissection is carried out either above (subglandular) or deep to (subfascial) the pectoralis fascia. This is important, as inadvertent overdissection can lead to implant medialization, visibility, and potentially symmastia. The subfascial plane can be a more challenging dissection as there is no natural plane present for this dissection. The subfascial pocket is often preferred over a subglandular pocket when shaped implants are used, as it potentially provides a more precise and stable pocket in the upper pole to avoid implant rotation.

Implant Placement

Once the pocket has been created, it is irrigated with triple antibiotic betadine solution (50 ml of povidone-iodine, 1 g of cefazolin sodium, and 80 mg of gentamycin mixed in 500 ml of normal saline) or 50% povidine-iodine saline solution and hemostasis is assessed [10]. It is the goal during the operation to achieve prospective hemostasis with minimal blood staining; however, a final assessment is mandatory prior to implant placement. The implants are soaked in the irrigation solution prior to insertion. Gloves are changed and rinsed with the irrigation solution to remove any lint or powder.

The implant is then placed either manually or with the assistance of an insertion sleeve such as the Keller funnel [9] (Fig. 2.13). The funnel provides a minimal to “no touch” technique, which has been associated with lower capsular contracture rates [7]. The funnel allows for easier implant placement with potentially smaller incision requirements, compared to manual placement. Repeated removal and insertions of the implant should be avoided to minimize implant or incision damage, potential contamination, and pocket overdissection.

Closure

Prior to incision closure, the patient should be placed in the upright position to assess implant position, fold position, symmetry, and the adequacy of the dual plane (Fig. 2.14). Any additional adjustments of the dual plane can be accomplished after the patient is placed back in the recumbent position by simply retracting the breast tissue superiorly off the implant, identifying the caudal edge of the muscle, and releasing it incrementally off the overlying breast tissue to the desired level.

A significant advantage of the inframammary approach is the ability to accurately and effectively control the fold position during closure of the incision. The cuff of superficial fascia that was preserved during the initial incision is utilized to secure the fold during closure. Although in our practice all inframammary folds are “locked-down” during incisional closure, it could be argued that a well-developed stable IMF that has not been violated or lowered during the procedure is potentially stable, and may only require a more superficial closure. However, when the fold is unstable due to either inherent weakness in the fold structure or from disrupting it with fold lowering, closure should include stabilization of the fold structure. This is accomplished by securing caudal edge of the scarpa’s fascia present on the lower incisional edge to the underlying deep fascial structures with an absorbable suture such as 2-0 vicryl (Fig. 2.15). This is usually done by simply incorporating the superficial and deep fascia together during a running closure. It may also be performed by first placing three to four interrupted sutures on the lower flap, securing scarpa’s fascia to the underlying deep fascia, followed by closure of the incision. The incision is closed in three layers: scarpa’s fascia superiorly to scarpa’s fascia, and deep fascia inferiorly, deep dermis, and subcuticular.

Case Examples (Figs. 2.16 and 2.17)

Management of Breast Ptosis

Introduction

Breast ptosis is one of the most common issues seen for evaluation in a plastic surgeon’s office. It can be developmental or more commonly acquired, secondary to weight loss, hormonal changes, pregnancy, and aging. Mild breast ptosis can often be corrected with a breast augmentation, but when more significant ptosis is present, a breast augmentation will not provide the correction of ptosis present and a mastopexy is required, with or without an implant. When evaluating the ptotic breast, the volume status of the breasts should be a part of the initial assessment, as this will determine whether a mastopexy is adequate and whether augmentation with an implant or fat is indicated.

Mastopexy

A mastopexy alone is reserved for a patient in whom the major concern is breast ptosis and not an issue of breast volume or upper pole fullness, as the procedure repositions the breast with only limited removal or transposition of breast tissue. There are many types of mastopexy techniques described to address the ptotic breast. The techniques are often described in reference to the final scar placement, such as the circumareolar technique [40], circumvertical technique [41, 42], and inverted-T scar technique [43, 44]. However, there is much more variation in the techniques, including the vascular pedicle orientation, management of the parenchyma, and additional ancillary procedures, to enhance the results. Long-term success of any mastopexy procedure is partially influenced not only by the scar technique but also, and maybe more importantly, by the pedicle selection and management of the parenchyma [42]. Thus, in general, the mastopexy can be performed with an inferior/central pedicle technique or a superior or superomedial technique, which describes the pedicle blood supply and the surgical approach. Secondarily, the skin excision pattern is determined and variable based on the surgeon’s preference with excising excess skin along the inframammary fold, or maintaining a purely vertical approach and limiting the scar to only a periareolar vertical, with the excess skin reestablished on the abdominal skin below the fold if indicated.

Preoperative Evaluation

The amount of ptosis present should also be assessed. Ptosis has classically been described, as per Regnault, based on the relationship of the NAC with the inframammary fold, but this falls short of adequately identifying and characterizing the breast ptosis [45]. A more complete assessment of ptosis is summarized in Table 2.3.

Table 2.3 Assessment of breast ptosis

Full size table

Patients with different grades of ptosis may have completely different breast compositions, including the quality of breast tissue and skin, the quantity of breast tissue present, and the vertical excess present. Assessment should also include evaluation of the skin thickness and elasticity, the quantity and distribution of subcutaneous fat, the composition and firmness of the breast parenchyma, the integrity of the Cooper’s ligaments, the nature and position of the underlying musculature, and the shape and slope of the underlying chest wall. All these aspects of the breast composition influence the shape of the breast and, ultimately, the outcome after the augmentation mastopexy.

The preoperative evaluation is used to determine the mastopexy technique that will achieve an optimal outcome that meets the patient’s desired results. For patients with less ptosis and minimal vertical excess, a circumareolar or circumvertical mastopexy can be performed without the need for skin removal along the fold. In our experience, if the distance from the new nipple position to the fold is less than 10–12 cm, most likely only a vertical or a vertical with small horizontal wedge or j-extension will be adequate for correction, usually employing a superior pedicle. To avoid the inframammary scar with a circumvertical mastopexy, the tissue at the base of the breast is resected internally, causing elevation of the fold with the excess vertical length tucked under the new breast fold, eliminating the need for the horizontal scar. However, we often choose to remove excess skin along the fold if necessary, no matter whether the flap is inferiorly or superiorly based. Not removing the skin at the fold increases the risk of fold malposition, scar irregularities or dog ears, or elongation of the lower pole with bottoming out over time.

The decision on whether to utilize a superior pedicle or inferior pedicle must be determined. That decision is based mostly on the amount of ptosis, the quality of the breast tissue, and the position of the nipple-areolar complex. For patients with good-quality breast tissue and the amount of nipple-areolar complex (NAC) elevation is less than 5–6 cm, a superior pedicle is utilized and a circumvertical mastopexy with inverted-T scar (Fig. 2.18). The superior pedicle also allows for the use of the lower pole tissue for autoaugmentation. The NAC can be elevated to a greater extent through the use of a superomedial or medial pedicle as well, and this is based on the surgeon’s preferred approach and the likelihood of success with the approach. In breasts with poor-quality tissue with associated laxity, and breasts requiring significant volume reductions and ptosis where NAC elevation is greater than 6 cm, an inferior pedicle inverted-T mastopexy is our preferred technique (Fig. 2.19). Often, a mesh reinforcement is secured across the inferior pedicle to limit the lower pole stretch due to the extra volume of the pedicle being retained in the lower pole.

Relevant Surgical Anatomy

When performing a mastopexy, an understanding and assessment of the vascular anatomy is critical to performing the procedure safely. The breast has a rich blood supply from multiple sources, including the internal mammary artery perforators, the lateral thoracic arteries, the thoracoacromial, and the anterolateral and anteromedial intercostal perforators. The superior pedicle is supplied by the second branch of the internal mammary artery (IMA) that emerges deep from the second interspace and courses superficial across the medial upper breast to enter the NAC slightly medial to the midline and approximately 1 cm deep. The medial pedicle is supplied by the third branch of the IMA that emerges from the third interspace and similarly courses superficially across the breast parenchyma to the medial aspect of the NAC. The inferior pedicle and central pedicle are supplied by the fourth branch of the IMA that courses deeply across the medial breast to enter through Wuringer’s septum approximately 1–2 cm above the IMF and just medial to the breast paramedian line. The inferior pedicle also has additional blood supply through contribution from intercostal perforators along the IMF [46] (Fig. 2.20).

Preoperative Markings

Appropriate preoperative markings provide a road map and are essential to planning and performing mastopexy surgery. The markings guide the surgeon in providing symmetrical NAC placement and mastopexy design. The patient is sitting upright during the markings. A line is initially drawn along the midline of the breasts and bilaterally down the meridians. The meridian lines bisect the breast equally and may not intersect through the nipple if there is NAC malposition. The inframammary folds are then drawn, noting any asymmetries to be addressed at surgery. The position of the IMF is then drawn on the anterior breast through the meridian incision. The breasts are then rotated medially and laterally to mark the location of the vertical incisions. Placement of the areola is then marked, starting approximately 2 cm above the nipple position and extending the curved drawing down to meet the medial and lateral vertical markings. This areolar opening marking should produce an areolar opening of approximately 42 mm. Approximately 7 cm below the bottom of the keyhole opening, a line is drawn marking the inferior extent of the vertical incision. Curved transverse lines are then drawn from these medial and lateral points extending down to the IMF. When performing a superior pedicle, approximately 2–3 cm above the fold a U-shaped line connects the medial and lateral vertical markings to define the extent of skin resection (Fig. 2.21). With inferior pedicles, the entire lower segment between the two medial and lateral vertical lines is deepithelialized, making this line unnecessary (Fig. 2.22).

Intraoperative Markings

Once the patient is under anesthesia and has been prepped for the operative procedure, all markings are confirmed and retraced as necessary. The symmetry of the drawings is also confirmed. If any questions exist as to the accuracy of the markings, tailor tacking can be performed in many cases to reconfirm the markings. Tailor tacking is performed with a stapler and the patient is placed in an upright position to confirm design, symmetry, and NAC positioning. In the supine position, the staples are removed, and the selected pedicle is designed and then marked out. For the superior pedicle, the pedicle is positioned in the superior keyhole from the 8 o’clock to 4 o’clock position. If utilizing an inferior pedicle, the markings include at least a 1-cm cuff around the areola, and is designed between the vertical and lateral pillars extending down to the IMF. The pedicle is designed with a width of approximately 6–8 cm based on the length of the pedicle, ensuring that the length-to-width ratio does not exceed 3:1.

Inferior Pedicle Inverted-T Mastopexy with or Without Mesh Reinforcement

The patient is positioned as has been described and preinjected. Each breast is placed under maximal stretch, and the areolas are marked with a 42-mm cookie cutter (range 38–45 mm depending on desired aesthetics) and superficially incised with a 15-blade scalpel (Fig. 2.23). Incisions are then made along the planned skin resection for the inverted-T mastopexy. The inferior pedicle is then deepithelialized from the inframammary fold up to the NAC, ensuring to include at least a 1-cm cuff of dermis around the NAC (Fig. 2.24). Care is taken to preserve the subdermal plexus during the deepithelialization. Dissection is then carried out around the entire deepithelized inferior pedicle, ensuring not to narrow the base of the pedicle at its attachments to the chest wall perforators by beveling outward to maintain its integrity and bulk (Fig. 2.25). The medial and lateral dermoglandular segments are then resected. The upper breast skin flaps are then undermined to the pectoral fascia, excising fat and glandular tissue as necessary for shaping. In an inverted-T inferior pedicle mastopexy, volume reduction is not generally the goal, so the amount of tissue resected is limited to the skin resection and additional breast tissue and fat, as required, to create the desired size and contour of the final breasts.

In our experience, success in any mastopexy or reduction procedure is more likely long term if the new breast shape is created by parenchymal resection and shaping, as opposed to skin envelope reduction. Additionally, reduction in long-term bottoming out or pseudoptosis postoperatively is best assured through unloading the lower pole of the breast, usually accomplished with tissue resection or rearrangement as with a superior pedicle technique.

With the inferior pedicle technique, the pedicle is located in the lower pole, and thus, resection or tissue rearrangement is not possible. To help address this, we have found stabilizing the inferior pedicle can be valuable in planning final shape and potentially reducing the lower pole stretch postoperatively. The inferior pedicle is rather unstable after resection of surrounding tissue and will generally fall laterally into the dissected space. The inferior pedicle is positioned centrally in the pocket and 2-0 vicryl sutures are placed from the pedicle to pectoralis fascia to stabilize its position (Fig. 2.26). It is helpful, if possible, to secure the pedicle from the dermis to the fascia for the best suture purchase, but this is not always feasible. The inferior pedicle has to be stabilized in a position that allows the NAC to be brought through the keyhole once the position of the NAC is confirmed and the opening created. Although these pectoralis-to-pedicle sutures can be used to provide some stabilization, long-term stability is not always reliable.

To ensure stability, we now placed a piece of poly-4-hyroxybutyrate mesh (GalaFLEX; Galatea Corp., Lexington, Mass.) reinforcement across the inferior pedicle, stabilized with 2-0 vicryl sutures on the medial and lateral pectoralis fascia [47] (Fig. 2.27). The size of the mesh is variable but, in general, a piece 5 × 15 cm per side has been adequate to create stability of the pedicle. This mesh resorbs in 12–18 months, but with retention of wound strength often four to five times the strength of the native tissue. The mesh should be placed snug enough to stabilize the pedicle, but without compressing or compromising the circulation through the inferior pedicle.

The wounds are irrigated, and hemostasis is established with electrocautery. The nipple-areolar complex circulation is assessed for arterial and venous bleeding from the cut edges. The skin is then temporarily brought together with staples to confirm the final shape. The patient is then placed in the upright position to assess the volume, contour, and symmetry of the breast (Fig. 2.28). Tailor tacking to make some final adjustments in the shape of the breast is almost always performed to create the optimal postoperative outcome.

In contrast to the a superior pedicle technique described in the following section, one of the advantages in the inferior pedicle technique is that the keyhole is planned but not excised until nearly the end of the procedure to allow for adjustments in the NAC position during final tailor tacking. Therefore, while the patient is upright, the position of the nipple-areolar complex can be selected. A cookie cutter is placed at the apex of the vertical incision and positioned in an aesthetically pleasing location. The inferior areola to inframammary fold position is generally 5–7 cm based on the final breast size. Symmetry is confirmed by measuring the distance from the midline to medial areola, and by placing a suture at the sternal notch and checking that equal distance is achieved to the top of each areola (see Fig. 2.49 in the “Augmentation Mastopexy” section). With the patient supine, the staples are removed, and the keyhole and any additional tissue marked during tailor tacking are excised. The pockets are irrigated with bacitracin saline solution and hemostasis is ensured. Deep parenchymal sutures of 2-0 vicryl are then placed along the vertical incision, bringing the medial and lateral pillars together at the midline. The incisions are then closed with interrupted 3-0 PDS dermal sutures. The vertical and horizontal scars are closed with a 4-0 monocryl running subcuticular suture. The areolas are then closed with a simple running 5-0 nylon suture. Steri-strips are placed over the incision. Contour tape is then placed along the lateral breast border and inframammary fold. The breasts are wrapped with a kerlix and ace wrap to provide gentle compression and support (Fig. 2.29).

Superior Pedicle Circumvertical Mastopexy with Inverted-T Scar

Each breast is placed under maximal stretch, and the areolas are marked with a 42-mm cookie cutter (range 38–45 mm depending on desired aesthetics) and incised with a 15-blade scalpel. Utilizing a 10-blade, the entire area within the marks is then deepithelized and cauterized for hemostasis (Fig. 2.30).

The lateral and medial flaps are dissected straight down toward the chest wall. The lateral and medial pillars are then developed, keeping them at least 2 cm thick (Fig. 2.31). If there is additional breast tissue deep to the developed pillars, this is either resected if it is not needed, or mobilized from lateral to medial and sutured to the main pedicle with 2-0 vicryl suture to maintain volume.

Option 1—Standard Approach

This central main pedicle located in the lower pole is then dissected off the pectoralis fascia, starting inferiorly and progressing superiorly under the central pedicle to the upper portion of the breast. This allows the entire breast to be effectively mobilized superiorly. With retractors under the breast, approximately four 2-0 vicryl Marchac sutures are placed between the deep breast parenchyma and the pectoralis fascia [44]. This central pedicle in the lower pole is then sutured in an elevated position approximately 1–2 cm above the IMF. This stabilizes the tissue in a higher position during the healing process and elevates the inframammary fold. Care must be taken not to elevate too much or aggressively evacuate the lower pole, as this can lead to a flattening in the lower pole or retraction of the IMF, superiorly creating a contour defect along the fold (Fig. 2.32).

Option 2—Lower Island Flap Autoaugmentation

An alternative to the above-described approach is to use the central pedicle in the lower pole as a flap to transposition into the upper pole, as originally described by Ribiero and more recently by Hammond [48, 49]. Instead of elevating this central lower island flap off of the fascia, a flap is created that is based off the central pedicle just above the IMF (Fig. 2.33). This flap is dissected circumferentially, and then incrementally dissected to free its attachment to create a mobile flap still attached to the deep fourth branch of the IMA that courses through Wuringer’s septum. Once the flap has been dissected and released for mobilization, the remainder of the breast above the flap is elevated off of the pectoralis fascia (Fig. 2.34). The lower island flap is then transposed into the upper pole and sutured into place with approximately four 2-0 vicryl sutures (Fig. 2.35).

Once the parenchyma is positioned and stabilized, tailor tacking is performed to confirm the shape of the breast. Tailor tacking begins at the inferior areola (6 o’clock position) and proceeds inferiorly toward the IMF. The ideal inferior areola-to-fold distance varies based on the size of the breast, but is usually 6–7 cm. Adjustments are made with the tailor tacking to create the desired breast shape. Markings for the horizontal wedge excisions are then extended medially and laterally to create the inverted-T scar (Fig. 2.36). Once confirmed, all staples are removed, and the horizontal wedge is excised. The pockets are irrigated with bacitracin saline solution and hemostasis is ensured. Deep parenchymal sutures of 2-0 vicryl are then placed along the vertical incision, bringing the medial and lateral pillars together at the midline (Fig. 2.37). The incisions are then closed with interrupted 3-0 PDS dermal sutures. The vertical and horizontal scar are closed with a 4-0 monocryl running subcuticular suture. The areolas are then closed with a simple running 5-0 nylon suture. Steri-strips are placed over the incision. Contour tape is then placed along the lateral breast border and inframammary fold. If a drain is used, a biopatch is placed at the base of the drain as it exits the skin, and the drain is secured with a 2-0 nylon. The breasts are wrapped with a Kerlix and ace wrap.

Postoperative Care and Expected Outcomes

The patients are instructed to leave all dressings on for 24 hours. The wraps are then removed, and a sports bra is worn for the following 4 weeks. Dressing changes with antibiotic ointment and gauze are used over incisions for 1 week. Patients can shower after 48 hours. The contour tape is removed at day 4 through 7. Nylons around the areolas are removed 6–8 days postoperatively. The subcuticular monocryls are clipped on the ends as they exit the skin at 2 weeks. Scar management with silicone gel or silicone sheeting is initiated on all patients at 2 weeks. Patients are allowed to resume activities of daily living almost immediately. Exercise is usually allowed at 4 weeks, with heavy lifting at 6 weeks.

Patients are counseled that they can expect swelling and firmness to develop as their breasts heal. The breasts will continue to soften over time, and the breast will relax over the first few months. The results are stable after 6 months, but scars can continue to improve over the first year, and some additional relaxation of the breast with loss of upper pole volume can continue for even longer. Whereas inferior pedicle shape looks relatively normal shortly after the procedure, superior pedicle technique may take longer to obtain its natural shape.

Case Examples

Case 1

Sixty-four-year-old female with asymmetric grade 3 ptosis with a SN-N distance of 34 cm on the right and 32 cm on the left (Fig. 2.38). Due to the amount of ptosis requiring significant NAC elevation of greater than 6 cm, an inferior pedicle inverted-T mastopexy reduction was performed. The inferior pedicle was supported with a soft tissue scaffolding (Galaflex). She has uplifted, stable, symmetric breasts with no bottoming out as demonstrated in her 4-month postoperative results.

Case 2

Twenty-nine-year-old female with 34 DD cup breasts desiring a smaller, more uplifted appearance (Fig. 2.39). Her SN-N distance was 26 cm with grade 2 ptosis; thus, only requiring a few cm of NAC elevation. A superior pedicle inverted-T mastopexy was performed with a lower island flap autoaugmentation. Her postoperative photographs at 2 months demonstrate an uplifted C cup with good upper pole volume thus far.

Case 3

Thirty-five-year-old wearing a 32 DD cup complained of saggy, heavy breasts (Fig. 2.40). She presented with grade 3 ptosis on the right and grade 2 ptosis on the left. She desired an uplifted, full C cup appearance. She underwent a superior pedicle inverted-T mastopexy with removal of 152 g from the right and 86 g from the left breast. Her 3-month results reveal good uplifted volume with improved symmetry.

Case 4

Thirty-four-year-old female with breast asymmetry presenting with grade 3 ptosis on the left and grade 2 ptosis on the right (Fig. 2.41). She underwent a bilateral inferior pedicle inverted-T mastopexy. For symmetry, 37 g was removed from the right and 176 g from left. Six months’ postoperative result reveals symmetric lifted breasts.

Augmentation Mastopexy

Patients with ptosis and volume deficiencies, or those desiring significant upper pole volume, require placement of an implant with the mastopexy to achieve their desired shape. The success of the augmentation mastopexy is multifactorial, but implementing the optimal surgical technique based on patient factors can significantly contribute to the long-term success of the procedure. The details, decisions, and experience-based pearls involved in this operation can provide guidance to perform this operation with expert precision.

To achieve these objectives, the breast augmentation and the mastopexy can be performed either simultaneously or as a staged procedure. Much controversy has existed over the years as to the safety of doing this procedure as one stage [50,51,52]. Detractors believe a two-stage procedure produces superior aesthetic results and is a much safer approach compared to a one-stage procedure. However, significant data and reports have emerged over the past few years demonstrating the safety and efficacy of these procedures being performed simultaneously [53,54,55,56,57]. However, there are patients for whom a staged procedure may be more appropriate, as listed below:

Relative Indications for a Staged Augmentation Mastopexy

Obesity: BMI >30
Large, pendulous breasts—need volume reduction
Significant breast ptosis—NAC elevation >5–6 cm
Vertical excess >8–10 cm (or possibly >6 cm)
Unrealistic expectations (patient would not accept reoperation rate > 20%)
Smoker refusing to quit >4 weeks
Previous surgery impacting blood supply

Additional Considerations for a Staged Augmentation Mastopexy

Significant breast asymmetry
Borderline case—may be acceptable for mastopexy or augmentation alone
Previous breast radiation
Large implant volume or “augmented” look desired
Massive weight loss patient
Immunocompromised patient
History of hypertrophic scarring
Multiple medical comorbidities
Surgeon uncomfortable performing a single-stage procedure based on the breast anatomy of the patient or surgeon inexperience

Blood Supply

To ensure the most reliable blood supply to the NAC and skin flaps in an augmentation mastopexy, the superior pedicle and occasionally the superomedial pedicles are utilized. The superficial position of these vessels in the upper pole allows the implant placement and mastopexy without interfering with the blood supply. However, these vessels take origin along the sternal border in the medial aspect of the implant pocket, and can be inadvertently sacrificed when aggressive medial pectoral muscle division is performed.

The inferior pedicle is not utilized in an augmentation mastopexy, as its blood supply through the deep fourth branch of the IMA is sacrificed with development of the implant pocket, and its secondary blood supply along the inframammary fold is divided with the mastopexy. Thus, an augmentation mastopexy with an inferior pedicle design is not truly supplied by pedicle blood supply in most cases, and the best one can hope for is random blood supply. If the remainder of the mastopexy is performed dividing deep into the flaps with an assumption that the inferior pedicle will provide circulation, the division of much needed superficial perforators both medially and laterally can lead to devastating consequences, including loss of NAC or breast flap viability, and resultant necrosis. Thus, the preferred pedicles enter the breast superiorly and superficially, providing a more reliable and robust blood supply (Figs. 2.42 and 2.43).

Additionally, implant and pocket selection affect the blood supply to the overlying breast. The subpectoral pocket maintains the musculocutaneous perforators (unless an extensive dual plane is performed) and is less likely to interfere with the blood supply compared to a subglandular/subfascial pocket. Likewise, larger implants placed in any pocket, but especially the subglandular/subfascial pocket, may result in undue tension on the mastopexy closure that can also create vascular compromise to the NAC or overlying skin flaps, resulting in skin or NAC necrosis.