Summary

The goals of a mastopexy are to restore the shape and volume of the breast following development of ptosis. Ptosis occurs commonly in response to aging and breastfeeding. A low nipple position on the breast mound is able to be corrected by addressing the skin envelope, however maintenance of upper pole fullness and a youthful shape of the breast is the challenge to surgeons. Techniques using local glandular flaps and implants have been suggested to address this.

The rotation mastopexy is a technique based on an anatomical approach.¹ The lower half of the breast gland, carrying the nipple–areola complex is raised as a large flap based on a superomedial vascular supply. This is rotated in a craniolateral direction through 90° placing lateral glandular tissue into a pocket underneath the upper pole, so augmenting the upper pole with autogenous tissue, which is well vascularized. Excess skin is excised without tension and closed in a vertical fashion.

Key Points

Patient Selection

Using Regnault’s² classification this technique is suitable for patients with Grade 1, Grade 2, and Grade 3 ptosis. After breastfeeding and with aging, the breast tissue drops to a varying degree with associated skin and ligamentous stretch. The breast also flattens and widens with some bulk of the breast tissue sitting laterally. The aim of the mastopexy is to restore tissue to the upper pole and create a breast mound with a round shape and projection (Figs 29.1–29.3). This should be done discarding a minimal amount of tissue in order to retain as much volume as possible.

Fig. 29.1 Rotation mastopexy.

Preoperative photographs A frontal, B left lateral oblique and C right lateral oblique. Fifteen month postoperative photographs D frontal, E left lateral oblique and F right lateral oblique. Twenty-six month postoperative photographs G frontal, H left lateral oblique and I right lateral oblique.

With permission from Corduff N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesth Plast Surg 2009;33:377, Springer.

Fig. 29.2 Rotation mastopexy.

Preoperative photographs A frontal, B left lateral oblique and C right lateral oblique. Fifteen month postoperative photographs D frontal, E left lateral oblique and F right lateral oblique. Twenty-three month postoperative photographs G frontal, H left lateral oblique and H right lateral oblique.

With permission from Corduff N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesth Plast Surg 2009;33:377, Springer.

Fig. 29.3 Rotation mastopexy.

Preoperative photographs A frontal, B left lateral oblique and C right lateral oblique. Six month postoperative photographs D frontal, E left lateral oblique and F right lateral oblique. Twenty-three month postoperative photographs G frontal, H left lateral oblique and I right lateral oblique.

With permission from Corduff N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesth Plast Surg 2009;33:377, Springer.

The technique is also suited to those patients who have breast ptosis in association with breast implants in situ (Fig. 29.4). In a patient who has had breast implants in situ for many years it is not unusual to find the tissue in the central and upper poles to be thinned out, with the bulk of the breast tissue to be lying below the implant. Many of these patients have put on some weight and there is sufficient volume to recreate an adequate breast mound from the available tissue without having to use new implants.

Fig. 29.4 Removal of implants with rotation mastopexy.

Preoperative photographs A frontal, B left lateral oblique and C right lateral oblique (dotted lines showing fullness correspond to long-standing implants in situ). Fourteen month postoperative photographs D frontal, E left lateral oblique and F right lateral oblique. 35 month postoperative photographs G frontal, H left lateral oblique and I right lateral oblique.

With permission from Corduff N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesth Plast Surg 2009;33:377, Springer.

The guide for suitability for this technique is selection of patients in whom it is felt there is sufficient volume of tissue to recreate an adequate breast mound once the ptosis is addressed.

Indications

In restoration of the breast shape to a more youthful appearance, volume needs to be restored to the upper pole. The skin envelope is reduced and the nipple restored to an aesthetically correct position on the new breast mound. Commonly, adaptation of breast reduction techniques³ are used in a mastopexy, resecting mainly skin and a smaller amount of breast tissue. Following surgery the tightened skin envelope relaxes over time and the upper pole fullness is often lost leaving a less than optimal result. Ideally a technique should be used that reshapes the breast without relying on the skin envelope to hold it. Techniques have been described using small glandular flaps transposed to increase projection,^4–9 but these do not adequately fill out the upper pole. Alternatively combining the reduction approach with an implant to fill out the upper pole^10–14 is well described but associated with a significant complication rate.^13,14

In those patients for explantation of breast prostheses, mastopexy at the time of implant removal is often a good option in that it will avoid a secondary deformity. Otherwise there is a risk that the pocket will contract down in an irregular fashion and lead to a subsequent deformity that can be hard to fix, especially in a patient whose tissues are not as elastic as they once were.¹⁵

It has been suggested that leaving the capsule behind can lead to increased seroma formation.¹⁶ This has not been the experience of the author. The approach to explantation is to leave the capsule behind if it is not heavily calcified and there is no free silicone present around the implant. Otherwise as much of the capsule that can be safely removed is excised. (Often some of the posterior capsule in the subpectoral pocket is left where it is closely adherent to the ribs.)

The plane of dissection is developed anterior to the capsule in the case of a subglandular implant, or a new plane developed anterior to the pectoralis major in the case of a subpectoral implant. In the latter situation after removal of the implant with or without capsule the muscle is tacked down to the chest wall with interrupted sutures.

Anatomy

The blood supply to the breast has been described before.¹ The dominant supply to the integument of the anterior chest is from: the internal thoracic artery medially, especially from the second and third intercostal spaces; the lateral thoracic artery laterally; the anterior intercostal arteries inferiorly, especially from the fourth and fifth intercostal spaces in the region of the pectoralis major origin inferiorly and; from the acromiothoracic perforator and supraclavicular vessels superiorly. These vessels anastomose in the vicinity of the nipple–areola complex (Figs 29.5 and 29.6).

Fig. 29.5 A, B The dominant blood supply arises from the lateral thoracic artery, acromiothoracic artery, perforators from the internal thoracic artery and perforators from the anterior intercostal arteries. The vessels course in the subcutaneous fat outside the breast gland, compressed there as the gland develops. They pass to a subareolar plexus from which the gland is supplied retrogradely. Minor vessels pass directly to the deep aspect of the gland from the anterior intercostal perforators.

Fig. 29.6 Radiographic lead oxide cadaver injection studies of the arterial supply to the skin in A anterior, B lateral and C cross-section views. D, a venous injection study, is shown for comparison. The major cutaneous perforators are highlighted as they emerge from the deep fascia. Arrows identify the nipple position.

The breast in the female is a modified sweat gland. Like a tissue expander, it has enlarged from the skin at the nipple into the subcutaneous tissues, elongating these vessels from their fixed skin origins and compressing them towards the periphery of the gland (Figs 29.5B and 29.6) to form a vascular hood. Within the boundary of this vascular perimeter there is a relatively avascular mobile plane between the under surface of the breast and the fascia over pectoralis major. This is utilized by the surgeon when introducing a breast prosthesis, after first dividing the vascular perimeter inferiorly.

The dominant supply to the breast is by vessels which penetrate the gland from the ‘vascular hood’ following the connective tissue framework between the breast lobules. Many of these penetrating vessels arise from the sub-areolar network. This arrangement of blood supply provides the anatomical basis for: (i) entering the avascular plane between the breast and pectoralis major centrally; (ii) raising a large flap of glandular tissue based on the vessels coursing towards the subareola plexus from the internal thoracic artery via the second and third intercostal spaces (Fig. 29.7), which (iii) then supply the rest of the glandular tissue retrogradely with penetrating vessels from the subareola plexus (Fig. 29.8); and (iv) leaving the glandular tissue in the upper pole well vascularized from the acromiothoracic and supraclavicular vessels (Fig. 29.7).

Fig. 29.7 The lower breast gland is raised off the prepectoral fascia and divided laterally, leaving it vascularized by the superomedial vascular axis.

Fig. 29.8 A schematic diagram across the lower pole flap showing the superomedial vascular axis supplying the subareolar plexus which in turn retrogradely vascularizes the lower half of the breast gland raised as a glandular flap.

Operative Technique

Markings

The patient is marked in the sitting position. The inframammary creases are marked (Fig. 29.9) and the new nipple position placed at the level of the inframammary crease using a tape measure placed under the breasts as a guide. The midmammary line is marked on each breast bisecting the breast mound and the new nipple position placed on this line (Fig. 29.10).

Fig. 29.9 The level of the inframammary creases is marked over the lower sternum.

Fig. 29.10 The new nipple positions are marked at the level of the inframammary creases on the mid mammary lines.

From this marking an ellipse is drawn skirting the existing areola, to a point about 2 cm above the inframammary crease along the midmammary line (Fig. 29.11). The new, reduced areola circumference is marked (Fig. 29.12).

Fig. 29.11 A An ellipse is drawn from the new nipple position, skirting the areola to B a point approximately 2 cm above the inframammary crease marking on the midmammary line.

Fig. 29.12 The new areola circumference is marked.

Surgical technique

The patient is positioned on the operating table before induction of anesthesia. To enable surgery in the upright position it is necessary to safely secure the head and arms prior to induction of anesthesia. The arms are placed in stirrups with the patient sitting up. A pillow is placed under the knees. The arms are held in position with tape. The patient is then laid flat for induction of anesthesia. The head is taped in position on a head ring (Fig. 29.13).

Fig. 29.13 The patient is positioned in the sitting position with the arms supported in stirrups. The arms and head are taped into position and a pillow placed behind the knees.

A broad-spectrum antibiotic is administered at the induction of anesthesia.

The breasts are infiltrated laterally, medially and inferiorly with 100 ml 0.2% ropivacaine (Naropin, Astra) as a field block injected in a ‘U’ at the periphery of the breast gland (Fig. 29.14).

Fig. 29.14 Local anesthetic infiltration injected subcutaneously in a ‘U’ around the periphery of the breast.

A desired areola is marked within the ellipse. From this new areola a wide pedicle of approximately 4 cm is marked extending superomedially to the medial edge of the drawn ellipse to encompass the superomedial intercostal vascular axis (Fig. 29.15). The areola skin outside the desired areola circumference is de-epithelialized to protect the underlying superficial venous plexus. The area of the pedicle is de-epithelialized and then the rest of the skin within the ellipse is excised (Fig. 29.15).

Fig. 29.15 A pedicle is drawn and de-epithelialized in the superomedial area of the ellipse. The areola skin outside the new reduced areola is also de-epithelialized to protect the underlying superficial venous plexus.

The elliptical skin incision is deepened through the subcutaneous fat down to the breast gland (Fig. 29.16). Peripheral to the ellipse a plane is developed between the gland and the subcutaneous fat. Inferiorly this is taken down to the inframammary fold, medially, to over approximately the fifth intercostal space and laterally to approximately the fifth space at the base of the breast (Fig. 29.17). The dissection can extend quite far laterally, even to the midaxillary line to reach the perimeter of the attachment of the breast gland at the pre-pectoral fascia.

Fig. 29.16 The elliptical skin incision is deepened through the subcutaneous fat down to the breast gland.

Fig. 29.17 The lower gland is freed from the subcutaneous fat, medially, inferiorly and laterally from about the level of the fifth intercostal space down.

The freed lower gland is then lifted off the prepectoral fascia. It is at this stage that any implants can be removed (see below.) In continuity a subglandular pocket is created behind the upper pole by dissecting in the plane of the loose areolar tissue nearly to the clavicle in the central breast area. The superomedial perforators can be seen appearing peripherally in the loose areolar layer underneath the breast gland (Fig. 29.18).

Fig. 29.18 The lower gland is lifted off the prepectoral fascia. In continuity a central subglandular pocket is created underneath the upper pole. The superomedial perforators can be seen appearing peripherally in the loose areolar layer underneath the breast gland.

An incision is made superolaterally through the full thickness of the upper gland at the level of the apex of the ellipse, lifting just enough subcutaneous tissue to allow the incision to cross to the upper apex of the skin ellipse (Fig. 29.19) The lower gland is left in continuity with the upper pole via its broad superomedial attachment.

Fig. 29.19 A, B The superolateral gland is divided, leaving a broad superomedial attachment.

B With permission from Corduff N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesth Plast Surg 2009;33;377, Springer.

The mobilized lower gland is rotated craniolaterally into the upper pocket (Fig. 29.20). It is then stitched with a couple of supporting 0 Prolene sutures (Johnson and Johnson, Somerville, NJ) to the prepectoral fascia, high in the upper pocket.

Fig. 29.20 A, B The lower glandular flap is rotated craniolaterally through 90° placing lateral glandular tissue into the upper subglandular pocket.

B With permission from Corduff N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesth Plast Surg 2009;33:377, Springer.

The patient is brought to a sitting position. The lateral skin flap is grasped with a pair of tissue forceps under a little tension. A line is drawn between the two apices of the ellipse and then excess skin and subcutaneous fat resected. Care is taken not to resect too much so as to give a soft, tension free lower pole curve (Fig. 29.21A). The procedure is repeated with the medial skin flap (Fig. 29.21B).

Fig. 29.21 A With a pair of tissue forceps the lateral skin flap is drawn medially and excess skin resected. B The procedure is repeated with the medial skin flap.

Excess glandular tissue may be trimmed at this point, often in the lateral area, to give a pleasing breast mound shape. A few supporting 0 Prolene sutures can be placed laterally between the gland and prepectoral fascia to hold the new breast mound shape.

The skin is loosely closed in a vertical fashion with some deep interrupted 3-0 Monocryl sutures. A small transverse extension is made in the inframammary crease to excise the ‘dog ear’ at the lower end of the closure. A new position is drawn for the areola encircling the apex of the vertical closure and a circular opening made in the skin (Fig. 29.22). The areola is brought into this opening. The skin closure is completed with 3-0 Monocryl deep dermal everting sutures.

Fig. 29.22 A, B The skin is closed in a vertical fashion.

B With permission from Corduff N, Taylor GI. Rotation mastopexy: an anatomical approach. Aesth Plast Surg 2009;33:377, Springer.

Drains are not normally used, but if the patient is thought to be particularly ‘oozy’ then it may be prudent to use some small low suction drains.

Removal of Breast Implants

Once the lower pole of the breast gland has been mobilized, if there are implants present, then they will be easily accessible beneath the gland. If the capsule is thick and calcified or there is the presence of any free silicone gel, then the implant and capsule should be removed as one, if possible. Otherwise the capsule can be left in situ. Sometimes the capsule can be so adherent to the underlying ribs or extend high into the axilla that it may be prudent to leave some behind, even in the presence of free silicone. If the implants are subpectoral, after explantation, the muscle is tacked down to the underlying chest wall with interrupted sutures, before the subglandular dissection of the upper pole.

Postoperative Care

The day after surgery the wounds are covered with Hypofix (Smith and Nephew, Hull, UK) tape. The patient can shower and dry the tapes with a hair dryer. The tapes are removed after 2 weeks and new ones applied for a further 2 weeks.

The patient wears her surgical bra day and night for 6 weeks and then day only for a further 6 weeks.

Operative Steps

Pitfalls and How to Correct

Circulatory compromise

Problems with circulation, with subsequent fat necrosis, and at the worst nipple loss, can be potentially catastrophic. These patients are less likely to be as forgiving as breast reduction patients as they are seeking surgery purely for cosmetic improvement as opposed to relief of physical symptoms. The author has not seen a vascular compromise with this particular procedure but has experienced it in breast reduction surgery (Fig. 29.23) and expects one day to see it in this scenario too. The nipple–areola complex color can be regarded as a barometer of circulation within the whole of the flap of which it is part. Ultimately, the skin of the areola may recover but the fat behind is unlikely to do so and fat necrosis can ensue.

Fig. 29.23 A Postoperative ischemia of pedicle areola and B subsequent areolar deformity in reduction mammaplasty.

The commonest circulation problem seen is venous congestion with darkening of the areola and rapid venous return. During dissection it is important to respect the subareolar venous complex which lies very superficial and can extend widely in the case of a stretched areola. Arterial compromise can also occur with the areola becoming pale and cool with sluggish venous return. In the first instance, if circulatory compromise is seen intraoperatively then the sutures should be released and the flap re-inset. Theoretically, rotation of the flap around its pedicle can cause a circulatory compromise if the circulation is not robust. If the circulation does not improve then the breast should be ‘left open’ with the flap not inset and a large dressing applied. The circulation is likely to recover and the flap can be inset the following week after ‘delay’ of the flap. Similarly if there is circulatory compromise postoperatively full release of the sutures and a delayed closure can alleviate the problem.

Asymmetry

Postoperative asymmetry is more prevalent than with other mammaplasty operations. One reason is due to potentially more tethering of the rotated pedicle on one side than the other. One must think in a three-dimensional approach to avoid this. One must not only consider the height of the nipple on the breast mound (at the apex of the ellipse) but also the degree of freedom of the nipple to fall forward once the rotated flap is sutured into its new pocket giving central projection. Thankfully much of this asymmetry is temporary and resolves as the breast swelling settles and the breasts soften (Fig. 29.24 and see Fig. 29.2). It would be unusual to need a surgical revision for correction (certainly no more than with other breast surgeries).

Fig. 29.24 Postoperative asymmetry due to tethering of the rotated pedicle showing improvement over time. Photographs taken A preoperatively, B 8 months, C 14 months, and D 20 months postoperatively.