Key Points

Introduction

In all types of ancient art, including that of the early Greek, Egyptian, and even Christian cultures, the uncovered female breast is commonly depicted. Its inclusion on sculpture, paintings, and drawings conveyed themes of fertility, beauty, and femininity. Despite the modernization of both art and society, the same holds true of the female breast today. Current trends emphasize the beauty and vitality associated with youth, and as such a full and lifted breast line has come to represent an often sought after aesthetic ideal in art, advertising and day to day living.

Over the course of a woman’s life, there are many factors which invariably alter breast form and contour. Pregnancy, lactation, weight fluctuation, and gravity contribute to diminished elasticity, change in fat content and elongation of connective tissue supporting elements, resulting in mammary ptosis. This inevitability has led to the rise in popularity of mastopexy procedures which seek to restore and maintain a well supported and attractive breast form.

The plastic surgery literature is replete with a multitude of mastopexy techniques, all of which correct ptosis, restore superior medial cleavage, and relocate the NAC to the central portion of the breast mound. Many of these, however, are associated with lengthy scars and early recurrence of ptosis. Surgical experience and innovation have more recently led to more refined procedures that deliver improved results and fewer complications, thereby leading to a higher satisfaction rate for both surgeons and patients. Specifically, the vertical mastopexy procedure as popularized by Lassus and Lejour relies on a superiorly based dermoglandular element for resuspension of the breast. The superior pedicle is invaginated in such a way to add retroareolar projection and superior pole fill. Lower pole medial and lateral pillars are sutured together to provide support, elevation and narrowing of the breast width which has proven to be longstanding years following the procedure. For these reasons, the superior pedicle flap mastopexy procedure has become our mastopexy procedure of choice in that it delivers reproducible and sustainable results, few complications, and shorter scars on the breast.

Patient Selection

Mastopexy procedures attempt to recreate a non-ptotic breast and as such all patients with second and third degree ptosis are appropriate candidates. There is, however, a subset of patients who yield consistently superior results and are ideally suited for the procedure. Younger women often possess better skin elasticity and a higher percentage of glandular tissue. In these patients the sutures placed in the dissected lower pole pillars tend to hold better thereby maintaining breast shape and elevation. Breasts composed of more fat than fibrous tissue present poorer quality tissue for sutures to hold and tend to become more distorted over time with widening of the scars in the process.

Breast parenchyma volume must also be assessed preoperatively. Patients with larger breasts are often best treated with some degree of parenchymal resection, as the additional weight will be subject to gravity postoperatively and predispose to recurrent ptosis. By contrast, those with volume involution and skin excess may be best served with simultaneous implant placement to recreate superior medial pole fill.

Regardless of technique and possible combination with augmentation, all mastopexy patients need to be counseled in terms of realistic expectations and potential complications, including hematoma, asymmetries, sensory changes and nipple–areolar necrosis. Patients need to understand that their immediate results are subject to gravity, aging and tissue settling, and may be somewhat temporary in contradistinction to scars that are permanent. In addition, some degree of superior pole flattening and skin laxity may persist postoperatively and maneuvers of manually elevating the breast are usually not achievable even with the most sound of surgical techniques.

Indications

The youthful and aesthetically pleasing breast shape is that of a cone with a base diameter ranging from 10–12 cm. The NAC is located at the most projecting part of the cone and usually corresponds to the level of the fourth intercostal space. Composed of adipose tissue and glandular elements, the breast is not a static structure and is subject to multiple external factors which will cause fluctuation in the volume and quality of the tissues. Pregnancy, for example, causes the breast tissue to expand and overlying skin to stretch, often to the extent that inherent tissue elasticity cannot overcome these changes once the hormonal impetus ceases. Weight fluctuation can have a similar effect, stretching skin and suspensory ligaments to a degree that they can no longer maintain an elevated breast position, even with weight loss. Long-standing breast implants can cause attenuation of the supporting network and fibrous portion of breast tissue, leading to a condition of breast volume involution and skin excess. This will be exacerbated by age, which diminishes the amount of glandular tissue and gravity which constantly pulls the breast inferiorly. The result in all these cases is mammary ptosis.

Speaking generally, ptosis refers to relative descent of the NAC in relation to the breast mound with elongation of the distance between the nipple and suprasternal notch. The historical classification system used to define ptosis was elaborated by Regnault and defines three degrees of ptosis based on the relationship of the nipple to the inframammary fold (Fig. 30.1). A situation where the nipple lies at the level of the inframammary fold but above the level of glandular tissue is called first degree ptosis. In these cases, an augmentation mammaplasty is often adequate to correct the condition. In second degree ptosis, the nipple lies below the level of the submammary fold but above the lower contour of breast tissue. Third degree ptosis is characterized by a nipple located below the inframammary fold and at the lowest contour of the breast. Both second and third degree ptosis require some degree of skin reduction and tissue rearrangement for correction. Patients with this degree of ptosis are deemed appropriate mastopexy candidates. The condition of pseudoptosis is unique in that the nipple remains above the inframammary fold but the skin and glandular elements have fallen below the crease. This is usually corrected with augmentation.

Fig. 30.1 Degrees of breast ptosis based on nipple position relative to inframammary crease.

Reprinted with permission from Boehm KA, Nahai F. Mastopexy. In: Nahabedian MY, editor. Cosmetic and reconstructive breast surgery, A volume in the Procedures in Reconstructive Surgery series. New York: Saunders; 2009.

Operative Techniques

Preoperative markings are made with the patient in the upright position. The midline of the chest is drawn with a second line marked from the midclavicular point to the nipple. The native inframammary crease is marked and represents what will ultimately be the lower extent of breast dissection. The vertical axis of the breast is noted from the inframammary fold onto the upper abdomen. This distance is dependent upon the chest wall diameter and native breast position, but typically ranges from 10 to 14 cm.

To determine the desired nipple position, an index finger is placed in the inframammary crease and this level transposed anteriorly onto the previously marked breast meridian (Fig. 30.2). Again, this distance usually is somewhere between 10 and 14 cm from the sternal midline and 18–22 cm from the suprasternal notch. These markings should be compared between the right and left sides and adjusted as needed to achieve symmetry.

Fig. 30.2 Preoperative determination of nipple–areolar placement.

Reprinted with permission from Boehm KA, Nahai F. Mastopexy. In: Nahabedian MY, editor. Cosmetic and reconstructive breast surgery, A volume in the Procedures in Reconstructive Surgery series. New York: Saunders; 2009.

Attention is now directed to marking the medial and lateral pillars which will ultimately support the elevated breast. To mark the medial line, the breast is pushed laterally and the line denoting the vertical axis of the breast on the upper abdomen now continued superiorly onto the breast mound itself (Fig. 30.3). The same technique is used to draw the lateral line but the breast is pushed medially. It is often best to be somewhat conservative in pushing the breast medially and laterally to denote vertical lines. As most breast parenchyma is preserved, overzealous skin removal can create undue tension across the vertical closure resulting in poor scarring or wound breakdown. These two lines are now connected by a curved marking made 1–3 cm above the existent crease. If this line is placed too low, the resultant vertical scar will conspicuously extend onto the upper abdomen.

Fig. 30.3 Marking the medial and lateral pillars.

Reprinted with permission from Boehm KA, Nahai F. Mastopexy. In: Nahabedian MY, editor. Cosmetic and reconstructive breast surgery, A volume in the Procedures in Reconstructive Surgery series. New York: Saunders; 2009.

A curved line is also used to connect the medial and lateral markings at their superior border, with the ellipse extending about 2 cm above the desired postoperative position for the nipple (Fig. 30.4). The length of the periareolar marking should range from 14 to 16 cm to prevent a large discrepancy in size between the preserved areola and the newly marked opening. This will minimize periareolar skin redundancy and facilitate closure. Additionally, when marking the new desired point for the superior border of the areola, it should be placed just at the level of the inframammary crease. This will minimize the risk of a high riding nipple postoperatively. The areola to be preserved is marked with a 38–42 mm cookie cutter, without putting the areola or breast skin on any stretch.

Fig. 30.4 Final markings for superior pedicle vertical mastopexy.

The procedure itself is undertaken under general anesthesia with the patient supine, arms abducted 90 degrees and adequately secured in anticipation of the sitting position later in the case. For both vasoconstriction and hydrodissection, 0.5% lidocaine with 1 : 200,000 epinephrine can be infiltrated into the skin between the medial and lateral markings, sparing the area immediately supplying the NAC. A mammostat is placed around the base of the breast to aid in handling the breast as well as minimizing blood loss (Fig. 30.5). The skin between the preserved areola and previously made markings is now completely de-epithelialized. With the mammostat released, the medial and lateral markings along the de-epithelialized lower pole are now incised down to the level of the pectoralis fascia (Fig. 30.6). This is done by directing a 10 blade perpendicular to breast tissue down to the fascia. Along the lower breast, hooks are used to elevate the skin edges such that a flap of 1–1.5 cm thickness is elevated with electrocautery down to the level of the marked native inframammary crease (Fig. 30.7). At the level of the crease, the cautery is redirected perpendicular to the chest wall such that the incision is once again carried through breast tissue to pectoralis fascia.

Fig. 30.5 Intraoperative use of a mammostat.

Fig. 30.6 Incising the lower pole tissue according to the medial and lateral pillars marked preoperatively.

Fig. 30.7 Flap elevation along the inframammary crease.

Now freed along its medial, lateral and inferior edges, this de-epithelialized inferior pole parenchyma is elevated at the level of the pectoralis fascia using the electrocautery. This elevation extends from the inframammary crease, deep to and past the areola and into the superior pole. In this way, a retroareolar pocket is created. Vascularity to the NAC is provided by the intact superiorly based dermoglandular elements. While in a breast reduction, this now elevated inferior tissue would be sharply excised, in the case of a mastopexy it is used to recreate projection and medial cleavage by transposing it into the newly created retroareolar pocket (Fig. 30.8). An Allis clamp is used to position this tissue high in the superior pole and 2-0 Vicryl sutures are used to tack the parenchyma to the sturdy pectoralis fascia. If additional volume is necessary, an implant can be placed in either the subglandular or subpectoral position at this point in the procedure.

Fig. 30.8 Elevation of the lower pole tissues. In the case of a breast reduction this tissue can be excised and discarded, while in a mastopexy it is tucked into the created retroareolar pocket for additional projection and fill.

The newly created lower pole medial and lateral pillars are now brought together to prevent descent of the NAC. A 7 mm Blake drain is placed to obliterate the dead space behind the two pillars and evacuate any fluid which might accumulate and put tension on the vertical closure. The columns are then reapproximated in two layers with 2-0 Vicryl sutures extending from the base of the areola to the inferior skin edge (Fig. 30.9A, B). If any size discrepancy exists between the two sides, some parenchymal resection can be performed on the pillars or tacked tissue to equalize the volumes. These sutured pillars serve as a stable column of breast tissue which the NAC rests upon, keeping it adequately supported in its newly elevated position. Bringing these pillars together will also effectively narrow the base of the breast diameter.

Fig. 30.9 A The newly created medial and lateral pillars. B Suturing the pillars together provides support for the now elevated NAC.

The areola is inset first with a layer of interrupted 3-0 Monocryl dermal sutures followed by a 4-0 Monocryl intracuticular suture. The skin margins along the vertical limb are also closed with a layer of 3-0 Monocryl dermal sutures. No undermining of the skin edges is done so as to minimize risk of tissue ischemia and incisional break-down. The most inferior aspect of the vertical scar is closed as a purse string and then run as an intracuticular suture along the remaining length of the vertical scar, pulling tight along the way to gather the redundant skin edges and shorten the scar (Fig. 30.10).

Fig. 30.10 Closure includes drain placement and a purse string suture at the base of the incision to accommodate the skin redundancy.

At the close of the case, Steri-strips are placed over the incisions and around the NAC. The patient is placed in a surgical bra which she is to wear continuously for three weeks.

Pitfalls and How to Correct

While this technique eliminates the lengthy horizontal scar traditionally seen in mastopexy cases, it is sometimes at the expense of poorer quality scars. Puckering secondary to relative skin excess along the vertical limb can persist even after adequate time for scar massage and settling. Additionally, tension at the inferiormost edge of the incision can lead to widening and scar hypertrophy, sometimes initiated by frank wound breakdown and healing by second intent in these areas. Meticulous closure and, in particular, incorporation of a purse string at the inferior edge can help to alleviate tension from the onset and optimize the potential for adequate healing. Early on in the postoperative phase, scar massage and silicone sheeting may be of some help in flattening scars. Kenalog injections can also be of some utility. Inevitably, some scars will remain widened or puckered despite all conservative measures. Most of these can be revised under local anesthesia with a reasonable expectation of improved quality and color. The potentially higher likelihood of vertical scar revision is offset by obviating the need for a long horizontal scar all together.

The advantage of a vertical-scar-only is compromised if that scar extends onto the abdomen. This leaves a rather conspicuous mark on patients, difficult to hide in bathing suits and certain types of apparel. This complication is best avoided by marking the lower curve connecting the medial and lateral lines well above the existent inframammary fold. It should be several centimeters above the native crease, and somewhat higher in those who are larger breasted. In those cases where scar length proves problematic, a secondary procedure under local anesthesia can be performed after the breast has settled. A triangular wedge of skin can be excised at the inferior-most edge and closed as a horizontal limb in the inframammary fold. The resultant horizontal scar is significantly shorter than that associated with more traditional inverted T scar techniques. This same technique can be used to eliminate a puckered or unsightly scar in this same region and leave a flatter scar.

Early recurrent ptosis or shape asymmetries usually stem from failure to adequately suture the medial and lateral pillars together. Without a stable column, the superior breast tissue will succumb to gravity and splay the inferior columns. The result is a recurrent ptosis, a high riding NAC secondary to the bottoming out phenomenon, and a widened vertical scar. Once again, the best treatment is avoidance of this situation in the first place. Intraoperatively, it is essential to ensure that adequate reapproximation of the pillars is performed with sutures placed in substantial tissue for a minimum of two layers. While surgical experience is the best guide in determining adequate tightness, a general guide is an immediate postoperative shape that is flat in the inferior pole and almost excessively full in the superior pole. Gravity, skin relaxation, and edema resolution will ultimately round out the lower pole and create the desired shape. In those cases of a minor asymmetry, some differential skin excision along the vertical limb can be corrective. Occasionally, an inframammary fold skin excision can correct minor nipple position asymmetries. More often however, in cases of poor shape or noticeable asymmetry, the vertical incision should be formally opened in a reoperative setting so that the pillars’ sutures can be tightened or loosened depending on the desired effect.

Postoperative Care

This procedure can be performed on an outpatient basis or as a 23 hour overnight stay. Patients are maintained on several days of antibiotics and narcotics and instructed to limit heavy lifting and strenuous upper body activity for one month postoperatively. Drains are kept in place until the volume falls to less than 30 cc/24 hours. Patients are asked to remain in a supportive bra for the first 4 weeks until early scar formation will maintain the dissected and rearranged tissues. Tapes are kept over the scars for the first few weeks after which patients can begin with aggressive scar massage. Any decisions regarding scar revision are delayed for a minimum of 6 months.

Conclusion

Compared to more traditional mastopexy techniques, the novelty of the superior pedicle vertical scar mastopexy lies in the fact that it incorporates glandular reshaping and suturing for maintenance of form, rather than a mere dermal brassiere. In trying to recreate superior pole fullness, it is more intuitive to preserve a superior glandular element and reposition the ptotic, inferior pole for additional projection and retroareolar fill. By producing superior shape, stability and shorter scars, it has proven to be a worthwhile technique of increasing popularity.