67 Inverted-T Mastopexy

Jacob G. Unger and G. Patrick Maxwell

Abstract

Inverted-T mastopexy is a powerful procedure to create lasting and elegant breast shape improvement. This chapter shows a step-by-step approach to reliably create predictable and aesthetic breast contours in mastopexy surgery. You will learn operative techniques, as well as preoperative guidance and postoperative care of these patients. Video is included for a visual guide to help elucidate the particular key steps of this surgery.

Mastopexy – breast lift – autoaugmentation – breast fat grafting – inverted-T mastopexy – superior pedicle – breast ptosis repair

67 Inverted-T Mastopexy

Key Points

Mastopexy can be used to create a better overall breast shape and a more youthful appearance to the breast.
Mastopexy will improve breast proportions, but will not lead to long-term upper pole fullness.

67.1 Preoperative Steps

67.1.1 History

Take a detailed family and past medical history, especially in regards to breast cancer.
Take a detailed past surgical history regarding any previous breast surgeries, which may impact pedicle choice.

67.1.2 Analysis

Evaluate the breast for overall shape, degree of ptosis, skin quality, breast volume, patient height, sternal length, and breast asymmetries.
Measure key points of sternal notch to nipple, nipple to inframammary fold (IMF), and base width to determine the best pedicle to utilize.

67.2 Operative Steps

See Video 67.1.

67.2.1 Top-Down Approach—Setting the Nipple Height

Mark the IMF on each side, the lateral mammary folds, the sternal notch, and the midline.
Mark the new nipple position preoperatively with the patient in the seated position.
Determine ideal nipple position based on Pitanguy’s point, sternal height, patient height, and overall breast volume: Usually between 20 and 23 cm of sternal notch to nipple distance (SN-N).
Mark 2 cm above ideal nipple position for the upper aspect of the circumvertical portion of the pattern.
Determine the pedicle to be used. Typically, for < 5 cm of elevation use superior pedicle, for 5 to 10 cm of elevation, utilize superomedial pedicle, and for >10 cm of elevation consider inferior pedicle unless already experienced with superomedial pedicle technique.
Utilize a 13 cm circumvertical pattern for a 38 mm cookie cutter nipple, and 14 cm pattern for a 42 mm cookie cutter.
The width of the inferior opening of your circumvertical drawing will be the future width of your vertical pillars, most commonly 4 to 6 cm apart (Fig. 67.1).
Inscribe nipple with a #15 blade after using cookie cutter around the nipple-areolar complex (NAC).
Tailor-tack your nipple vertically into position with three staples to the top of your circumvertical drawing. First staple at 12 o’clock, and then 10 o’clock and 2 o’clock (Fig. 67.2).

Fig. 67.1 The width of the inferior opening of your circumvertical drawing will be the future width of your vertical pillars, most commonly 4 to 6 cm apart.

Fig. 67.2 Tailor-tack your nipple vertically into position with three staples to the top of your circumvertical drawing. First staple at 12 o’clock, and then 10 o’clock and 2 o’clock.

67.2.2 Setting the Vertical Pillars

Take the inferior aspect of your circumvertical pattern and bring medial to lateral; this is the coning of the breast step.
Begin to tailor-tack the skin by imbricating in a straight line from the 6 o’clock position of the nipple marching inferiorly (top-down).
Keep the medial and lateral pillars on similar stretch. There should be physiologic tension on your staples but they should not be struggling to stay together.
Continue to create this staple line until the nipple–IMF distance is your desired length. This is best measured via cephalic-most staple to fold, which represents infra-areola to fold distance (which is nipple to IMF − 2 cm) (remember final NAC diameter is 38 mm) (Fig. 67.3).

Fig. 67.3 Create a staple line until the nipple–inframammary fold (IMF) distance is your desired length. This is best measured via cephalic-most staple to fold, which represents infra-areola to fold distance (which is nipple to IMF − 2 cm) (remember final nipple-areolar complex [NAC] diameter is 38 mm).