Grade I	Nipple at the level of the IMF, above the lower contour of the gland
Grade II	Nipple below the IMF, above the lower contour of the gland
Grade III	Nipple below the IMF and at the lower contour of the gland
Pseudoptosis	Normal nipple position with glandular tissue below the IMF

IMF, inframammary fold.

Preoperative History and Considerations

Appropriate and thorough preoperative evaluation will allow the surgeon to select and plan a suitable operation. Choosing the proper technique begins with designing incisions based on scar placement and length. Minimizing scar appearance is fundamental to any operation in plastic surgery. However, scars should not be avoided if they are necessary to provide adequate and durable results. A balance must be accomplished between scar placement and efficacy because the final result will depend on the harmony of the breast shape and scar appearance.

The terms ‘short scar’ or ‘limited scar’ have been used interchangeably and applied to many different techniques. As a result, virtually any procedure that leaves a final scar shorter then the classic inverted-T has been classified as such. Explanation of these terms can be essential when counseling patients who are demanding minimal incision lengths and maximal results.

For each patient, the surgeon should develop a strategy for reshaping and positioning the breast parenchyma and determine the need, if any, for additional soft tissue augmentation with an implant or autologous flap. Breast shaping can be elaborate or simple and may include combinations of suturing, local flaps, muscle slings, or placement of internal mesh support.²^–⁵

Combining augmentation with mastopexy can be accomplished safely for many patients. Clearly, adding an implant to an already complex operation will increase the number of variables that the surgeon must consider. Many women with ptotic breasts focus more on the loss of upper pole volume that has occurred as their breasts have aged, than on the change in nipple position that has accompanied it. An implant can be a very powerful tool in restoring youthful fullness to the upper pole.

Patient assessment

The initial consultation for mastopexy should include a detailed discussion of the patient’s goals and expectations and a careful review of medical and psychiatric histories. As with any breast surgery, a personal and family history of breast disease or cancer should be obtained. The surgeon should specifically note a history of any previous breast surgery or radiation therapy. Preoperative mammography is recommended for any patient who has significant risk factors and those over 35 years of age.

Prior surgical history should include previous augmentation or reduction procedures. When possible, operative notes detailing techniques and implant devices used should be reviewed. Information about past or planned pregnancies and changes in weight and/or brassiere size can also aid in preoperative assessment.

Preoperative planning and dimensional analysis

Management of patient expectations is crucial to ensuring satisfaction. The ideal breast aesthetic may vary greatly between patients and surgeons. Every attempt should be made to understand the patient’s motivations and anticipated results. Patients who are unrealistic or unwilling to accept the necessary scars should be avoided.

Preoperative physical exam should include measurements as well as an assessment of tissue qualities and distribution. Significant asymmetries will be noted in most patients when carefully examined.⁶ It is important to recognize and point out any pre-existing asymmetries, spinal curvature, or chest wall deformities because these may be difficult to correct and can become noticeable in the postoperative period. Preoperative photographs with multiple views are obtained on all patients and maintained as part of the office record.

Thorough palpation of the breast and axilla should be performed and documented. Any palpable masses or lymph nodes must be evaluated before proceeding with surgery. Measurements of breast width (BW), breast height (BH), intermammary distance, nipple to suprasternal notch (N : SSN), and nipple to inframammary fold (N : IMF) should be made and documented. Measurements can aid in planning the operation, recognizing asymmetries, and tracking postoperative results.

The soft tissue envelope should be characterized and the desired resultant breast form planned (Box 18.1). Once accomplished the surgeon can assimilate the information to select an appropriate implant, if desired, and plan the mastopexy approach. Use of the BioDIMENSIONAL® preoperative planning system (INAMED Corporation) can be used on patients requiring ptosis correction with augmentation.

Box 18.1 Steps in preoperative planning and dimensional analysis

• Careful analysis and measurement of the dimensions and shape of the existing breast

• Analysis of the character and evaluation of the adequacy of the soft tissue envelope

• Development of an anatomically well-defined goal for the breast shape after mastopexy or mastopexy augmentation

• Selection of the implant size, shape, height, width and projection to accomplish the individual patient’s goals

• Selection of the surgical approach (incisions) and implant location

Patient marking

Preoperative markings are made with the patient in an upright position and begin with:

• midline;

• current IMF;

• planned nipple position.

Additional marks, determined by the patient’s tissue characteristics, are then made as guidelines for resection.

Nipple position is established using the current IMF as a guide, by making the mark along the breast meridian while manually palpating the fold. The location of this point is confirmed by checking its distance from the suprasternal notch and mid-clavicle bilaterally. This is usually 20 ± 3 cm from the suprasternal notch.

At this point, the surgeon should determine the planned excision pattern (Figs 18.1 and 18.2) and proceed with the appropriate marks. The degree of mastopexy will vary from a periareolar approach to a full inverted-T scar based on the amount of ptosis present. Variations in incision patterns are the same for augmentation mastopexy and mastopexy alone and are gradually increased to accommodate increasing amounts of breast tissue and ptosis.

• Minor ptosis is usually addressed with a periareolar approach, either concentrically or eccentrically designed. This pattern places the scar at the border of the pigmented areola and the breast skin. A point is first made just superior to the planned nipple position and represents the planned position of the upper areolar border. This should be no more than 3 cm above the transposed inframammary fold mark. The areola to be preserved is outlined using a standard nipple marker at 38-42 mm. The distance from the nipple to the planned position of the upper areolar border can be used as the radius for designing a concentric pattern.⁷ Often it is necessary to adjust this to a more oval shaped or eccentric configuration to correct for asymmetries and variations in tissue distribution.

• When addressing moderate ptosis, a vertical excision is marked. This is done by first repeating the initial steps above to determine the position of the new nipple and upper areolar border. The distance from the center of the nipple to the new upper areolar border is then used to set the width of the planned vertical excision.⁷ The vertical limbs are drawn connecting to a point 1-2 cm above the IMF. Adjusting the distance between the vertical limbs will accommodate individual tissue characteristics and asymmetries. This is often done when tailor-tacking as described below.

• Patients with more severe ptosis usually require greater nipple elevation and a horizontal excision to achieve adequate correction. The horizontal component will vary from a traditional wise pattern marking to a shorter version that is adapted into the vertical pattern described above. Marking this pattern begins as described as above and places the horizontal scar along the IMF with the T junction designed to rest along the breast meridian. When planning simultaneous augmentation, these marks are made conservatively to allow for the excess tension that will be created when an implant is placed. This helps to avoid problems with healing at the T junction.

Fig. 18.1 An individualized approach to skin tightening and excision is applied with increasing degrees of mammary ptosis.¹ Thus lesser degrees of ptosis require no or little skin excision whereas increasing degrees require the most skin tightening or excision. A, Periareolar approach with internal rearrangement or insertion of implant. B, Periareolar excision. C, Circumareolar with vertical excision. D, Circumareolar plus ‘J’ excision, which with increasing ptosis, turns into a wider ‘J’ or ‘B’ excision. E, Circumareolar with vertical and small transverse excision. F, Wise pattern-type excision. With all these skin patterns an implant may be inserted, internal tissue rearrangement performed, or simply skin tightening.

Fig. 18.2 The addition of a periareolar purse string gives enhanced power to the skin tightening adjustments and uplifts the lower skin excess, so that all vertical to ‘T’ type scars are minimized with the addition of the purse string. A, Periareolar purse string mastopexy. B, Extended periareolar purse string mastopexy. C, Circumvertical periareolar mastopexy. D, ‘J’ to ‘B’ excison plus periareolar purse string mastopexy. E, Transverse ‘T’ excision plus periareolar purse string mastopexy. F, Wise type pattern plus periareolar purse string mastopexy.

Regardless of the pattern chosen, all marks are customized to the individual patient, carefully measured, and confirmed with tailor-tacking in the operating room before proceeding with excision.

Operative Approach

The patient is placed supine on the operating room table with the arms carefully secured at 90 ° angles to the torso. Patient positioning is crucial to permit for upright posture in the operating room as necessary. After induction of general anesthesia the patients are sterilely prepped to allow complete visualization of the anterior chest and shoulders.

When planning a simultaneous augmentation, the author’s preference is to divide the operation into two parts.

• First, a dimensionally based breast augmentation is completed.

• Then, the patient is placed in the sitting position at 90 °, and preoperative markings are tailor-tacked and adjusted before completing the mastopexy.⁸

Implant selection and placement

Implant selection and placement are judged according to the preoperative measurements.

Decisions on implant size, shape, surface texture, and filling material are made based on the soft tissue components present. Selection of an implant with enhanced projection can offer the mechanical advantage of raising the position of the nipple-areola complex. In patients with minor amounts of ptosis, this approach can sometimes alleviate the need for a mastopexy. Likewise, it may in a sense ‘downstage’ a patient from one degree of ptosis to the next. Therefore, a patient who would need a circumvertical scar to achieve an adequate result may only need a periareolar tightening once the implant is in place. Our preference is to use form-stable highly cohesive gel anatomical implants with enhanced projection (F or X) for optimal results.

Selection of an implant with enhanced projection can raise the position of the nipple-areola complex and sometimes alleviates the need for a mastopexy or may ‘downstage’ a patient from one degree of ptosis to the next

Once a device is selected, the surgeon must determine the implant’s location.

• Patients who have a superior pole pinch test result of 2 cm or more can be considered for subglandular or subfascial implant placement. The subfascial plane may offer additional soft tissue coverage and support.9,10

• Thinner patients will be at risk for implant palpability and visibility and may also risk blood supply to the nipple-areola complex when concurrent mastopexy is performed. For these patients, a subpectoral dissection is planned. During submuscular implant placement, our preference is to release the inferior portion of the pectoralis major muscle leaving the implant in a partial subpectoral position (Figs 18.3 and 18.4).

Fig. 18.3 In performing the ‘two operations in one’ augment mastopexy, the implant is inserted via a periareolar (A) or inframammary (B) approach. It is placed in its desired respective pocket (subpectoral, subfascial or subglandular), and the parenchyma is sutured off securing the implant in its proper position. Here the implant is located in a subglandular pocket.

Fig. 18.4 Once the implant is secured, the second step of the ‘two operations in one’ is performed. Here a periareolar purse string mastopexy is applied to the soft tissue envelope over the implant secured in its pocket.

At this point, the preoperative markings are confirmed with tailor-tacking in the sitting position before proceeding with mastopexy. When using the periareolar approach, the outer and inner circumferences are incised and the intervening skin is de-epithelialized. Often the dermis is then incised at the periphery to create a ledge for closure.

When no glandular resection or undermining is performed, nipple vascularity is maintained via perforating vessels. If the vascularity is potentially compromised, care is taken to preserve the sub-dermal plexus during de-epithelialization and dermal incisions are avoided.

Closure is secured with a non-absorbable Gore-Tex® suture on a straight needle using a ‘pin-wheel’ or ‘wagon-wheel’ technique.¹¹ When correctly placed, this suture controls the areolar diameter, helps to prevent areolar widening, and reduces periareolar wrinkling and pleats by evenly distributing tissues. A running subcuticular 5-0 Monocryl is then placed superficially, with care not to disrupt the previous suture (Fig. 18.5). (Post-operative results are in Figure 18.6.)

Fig. 18.5 32-year-old female with pseudoptosis to first degree ptosis treated with subpectoral placement of a 280 mL silicone gel implant with a periareolar purse string mastopexy. A, Preoperative frontal view. B, Postoperative frontal view. C, Preoperative lateral view. D, Postoperative lateral view.

Fig. 18.6 A 30-year-old patient with first to second degree ptosis treated with subfacial placement of 250 mL silicone gel implants with periareolar purse string mastopexy. A, Preoperative frontal view. B, Postoperative frontal view. C, Preoperative lateral view. D, Postoperative lateral view.

Moderate ptosis

Patients with moderate degrees of ptosis often require a vertical component to the scar with or without a short horizontal excision (Figs 20.7–20.9). The vertical component can be part of the preoperative design or added intraoperatively to distribute excess tissue encountered with the periareolar excision. In either situation, the inferior extent of the resection is kept at least 1-2 cm above the location of the IMF. As above, the preoperative markings are used as a guide and are confirmed and adjusted before making incisions.

Tightening of the lower pole helps redistribute fullness superiorly to a more desired location, improving breast shape and projection. This may be helpful when correcting glandular or pseudoptosis as well, and in this instance can sometimes be done without a periareolar scar. In addition, if the breast appears flattened or the lower pole prominent after the periareolar excision, vertical skin plication can offer correction. In cases where a vertical excision can be easily predicted, access for implant placement in any plane can be gained through the center of the vertical incision.