8 Mastopexy Techniques—Basic Principles



10.1055/b-0040-177585

8 Mastopexy Techniques—Basic Principles

Elizabeth J. Hall-Findlay


Summary


Numerous techniques have been described to perform a mastopexy. This chapter reviews key concepts in understanding the footprint and how to get good, consistent, predictable results. Assessment of ptosis is re-evaluated to make surgical planning easier. The concept of parenchymal rearrangement is emphasized versus the failure of the skin as a brassiere. Different methods are reviewed, and emphasis is placed on the inferior flap of Ribeiro as being the most effective.




8.1 Introduction


The most common complication after mastopexy is recurrent ptosis. This problem results from a lack of understanding of the principles of aesthetic breast surgery. Most patients who are candidates for mastopexy have already proven that their skin has functioned poorly as a brassiere. Trying to tighten up the skin envelope and then expecting the skin to hold the shape against gravity is doomed to failure.


The key to achieving good consistent results in mastopexy surgery is first to understand the role of the breast footprint. The surgeon then needs to understand the difference between nipple ptosis and glandular ptosis and then to plan accordingly. Correcting nipple ptosis is the easy part. Correcting glandular ptosis entails an understanding of what true ptosis is and how important parenchymal reshaping is to the final outcome.


We have been taught over the years that the inframammary fold (IMF) is the best landmark for determining ptosis. 1 Unfortunately, this classification is misleading because it relates only to nipple ptosis and does not take into account glandular ptosis. The upper breast border is a better landmark than the IMF for planning a mastopexy.



8.2 Key Concepts



8.2.1 Breast Footprint


The actual attachment of the breast to the chest wall (footprint or base 2 ,​ 3 ) varies significantly from patient to patient, and the breast borders can be only minimally changed with surgery. Some patients are “high-breasted” and some patients are “low-breasted.” It is important to understand that the breast borders can be altered only by adding or removing volume. The upper breast border can be elevated only with an implant (or fat injections), and the lower breast border (IMF) can be elevated when weight is removed, but it descends when weight is added. The medial and lateral breast borders are adjusted by adding volume (implant) or removing volume (liposuction). It is less about the skin than it is about the volume and weight (Fig. 8‑1, Fig. 8‑2). 4 ,​ 5 ,​ 6 ,​ 7 ,​ 8

Fig. 8.1 Mastopexy in patient with high footprint. (a,b) Patient aged 41 at presentation. The black arrow marks the higher upper breast border, which does not change after a mastopexy. She was 5 ft 2 in (157 cm) tall, weighed 110 lb (50 kg), and had skin only removed from both breasts. (c,d) Patient at 15 months after surgery, which involved “moving” the glandular ptosis via an inferior flap; in her case, the inferior flap was held up under a pectoralis sling. Although the sling can be powerful, the flap sometimes remains as a bump, and it is better to let both the flap and the breast parenchyma settle as a unit.
Fig. 8.2 Mastopexy in patient with low footprint. (a,b) Patient aged 46 at presentation. The black arrow marks the relatively low upper breast border, which does not change after a mastopexy or a breast reduction. She was 5 ft 3 in (160 cm) tall, weighed 122 lb (55 kg), and had 64 grams removed from the right breast and 181 grams from the left breast along with 250 mL of liposuction. (c,d) Patient at 9 months after surgery, which involved removing the glandular ptosis. 8 Note also how the upper breast border (large arrows) has not changed postoperatively.


8.2.2 Nipple Ptosis


The nipple needs to be “centralized” on the breast mound. The surgeon needs to understand not only the footprint but what can and cannot be achieved with manipulating the breast mound in order to determine the ideal nipple position. On an average “C-cup” breast on an average woman, the ideal nipple position is about 8–10 cm below the upper breast border and about 8–10 cm from the chest midline (drawn as a straight line, not curved around the breast). 9 Although some surgeons state that breasts look best with the nipple at 55% up from the bottom of the breast just above the horizontal meridian, 10 this could lead to patient dissatisfaction. Over time, breasts tend to bottom out, and high nipples are very difficult for patients to hide in clothing and bathing suits without suffering “nipple slip.” The high nipple might look good in magazines with the back arched and the arms elevated to reduce glandular ptosis, but the high nipple can be a problem in clothing (Fig. 8‑3).

Fig. 8.3 Nipple ptosis. (a,b) Patient aged 23 at presentation with nipple ptosis and only a small amount of glandular ptosis. She was 5 ft 5 in (165 cm) tall, weighed 164 lb (74 kg), and had skin only removed from both breasts. (c,d) Patient at 6 years after surgery, which involved some glandular ptosis correction but mainly nipple ptosis correction. She did have an inferior flap held up with a pectoralis sling (which was probably not necessary).


8.2.3 Glandular Ptosis


The surgeon needs to determine how much of the gland is sagging, or ptotic, and correct it. Ptotic gland tissue can be either removed (breast reduction) or moved (mastopexy). Although nipple ptosis can be easily corrected by repositioning, the breast mound needs to be corrected with parenchymal reshaping. Adjusting the skin brassiere will not correct glandular ptosis. The location of the IMF is less important than the actual amount of ptotic gland (Fig. 8‑4).

Fig. 8.4 Glandular ptosis. (a,b) Patient aged 18 at presentation with glandular ptosis but without nipple ptosis, so the position of the nipple in relation to the inframammary fold (IMF) is irrelevant. She was 5 ft 8 in (173 cm) tall and weighed 153 lb (69 kg). (c,d) Correction of glandular ptosis by removal of 371 grams from the right breast and 263 grams from the left breast. She had another 150 mL of fat removed with liposuction. The nipples were, however, too lateral, and they needed to be moved to the ideal breast meridian. (e,f) Patient at 2 years after her breast reduction. Her IMF was raised 2 cm by removing the tissue just above the fold. This removed weight, which then allowed the fold to rise.

It is clear from the above that the Regnault 1 classification of breast ptosis (nipple position in relation to the IMF) can be misleading. What is important is an assessment of the breast mound—both the amount of glandular ptosis and the degree of nipple ptosis. The position of the IMF can be misleading in planning. It is important, however, for the surgeon to understand that the upper portion of the footprint will not change. The upper breast border is a better landmark for decision making (Spear S; personal communication).



8.2.4 Skin Brassiere versus Parenchymal Reshaping


Gravity wins. Skin is not a particularly good brassiere, especially when it has already shown that it is not good at holding the breast up, as occurs with most patients presenting for a mastopexy (Fig. 8‑5).

Fig. 8.5 Principles of mastopexy. (a) This patient underwent a breast reduction with removal of glandular ptosis on her left breast and a mastopexy only on her right breast using overlapping dermal flaps. She is shown at 6 years after surgery. Her nipple ptosis has been corrected, but she still has glandular ptosis on the right. This result shows that dermal flaps are not successful in the long term at correcting glandular ptosis. We know that skin stretches with tension (skin expansion), and unless the parenchyma is corrected, the skin will not act as a good brassiere. The parenchyma either needs to be “removed.” as in a reduction (left breast), or “moved,” as should have been performed on the right breast. (b) Patient had 150 g of ptotic gland removed from the right breast later during the subsequent correction.


8.2.5 The Wise Pattern


The Wise pattern (not just the keyhole opening) is important for the surgeon to use as a template for the parenchyma (and not the skin)—for what should be left behind. Dr Robert Wise developed the pattern from a deconstructed brassiere. 11 Note that when the pattern is closed, it results in a nice coned breast shape. He used it for a skin pattern, but it is better used for the parenchymal pattern (Fig. 8‑6a,b).

Fig. 8.6 Wise pattern. (a,b) The original Wise pattern was developed by Robert Wise from a brassiere design. He used it for the skin pattern, but it is actually better as a pattern for the parenchyma that is left behind. The pattern, when closed, gives a good cone shape to the breast. (c,d) The pattern concept is shown. Parenchyma beyond the limits of the Wise pattern is removed by direct excision and tailored out (cross-hatched areas) by liposuction. (Reproduced from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. New York, NY: Thieme Medical Publishers; 2011.) (e,f) The Wise pattern design shown on the breasts. An inferior vertical wedge of skin and breast tissue is removed, and when the pattern is brought together, it results in a nicely projected breast shape.

All tissue beyond the Wise pattern is removed in a breast reduction. 12 A vertical wedge of breast tissue and skin is removed inferiorly, and then any excess tissue beyond the limits of the Wise pattern is removed by direct excision, followed by tailoring out by peripheral liposuction. The pillars are brought together (without tension), giving good projection to the remaining breast. Note that lower pole tissue is recruited by this maneuver, while the inframammary fold rises. In a mastopexy, this inferior tissue is “moved” rather than “removed” (Fig. 8‑6c–f).


We have come to learn as plastic surgeons that we are much better at pulling excess tissue downward (abdominoplasty) than we are at pulling excess upward (facelifting). The key to successful breast surgery is to realize that we cannot “lift” the breast on the chest wall, and our most long-lasting results occur when we “remove” or “move” the heavy inferior pole and cone the remaining upper pole. Skin can act as a good brassiere when it is young and retains good elasticity, but we are often presented with patients with poor skin quality. We are well aware that our best clothing is made with good-quality fabric, but often in surgery we are forced to compromise with poor-quality material (skin). We must instead work against gravity, which means that we should address the lower pole tissue and not try to raise or lift or push tissue upward.



8.3 Anatomy


The breast is a subcutaneous fourth-intercostal-space structure that is attached to the skin at the level of the nipple. Posteriorly the breast has only loose attachments to the pectoralis fascia (which is why we used to sweep a subglandular pocket easily with our fingers for insertion of a breast implant).


The breast is only very loosely attached to the chest wall; it is instead held in place by skin–fascial attachments at the IMF and over the sternum (much like the gluteal fold and the sacrum for the buttocks; Fig. 8‑7). When a woman lies on her side, the upper breast folds over the sternum and the lower breast slides out laterally. When a woman stands on her head, the breast slides toward her chin. There are no significant lateral or superior skin–fascial attachments. The zones of adherence are medial and inferior, and they are not attachments from the breast but separate skin–fascial attachments. 9 ,​ 12

Fig. 8.7 Anatomy of breast. (a) The breast is a subcutaneous structure attached to the skin at the nipple; it is only loosely attached to the pectoralis fascia. The breast is held in place by skin–fascial attachments (zones of adherence) to the chest wall. (b) The inframammary fold and the attachments over the sternum are much like the attachments at the gluteal crease and the sacrum; they are not breast structures. (Reproduced from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. New York, NY: Thieme Medical Publishers; 2011.)

Attempts to suture the breast tissue to the pectoralis fascia are unlikely to succeed. Any actual adherence to the fascia results in scar contracture and retraction of the breast tissue with muscle movement. McKissock stated that the concept of suturing up breast tissue to the chest wall is so seductive that it is doomed to be tried (and fail) repeatedly. 13 On the other hand, removal of weight inferiorly will allow the IMF to rise with aggressive resection above the fold with a breast reduction or re-reduction. 14


The main blood supply consists of an artery and vein from the fourth intercostal space (from the internal mammary system) that enter the posterior surface of the breast just above the fifth rib just medial to the breast meridian. The rest of the blood supply is in the subcutaneous tissue superficial to the breast parenchyma, and it is pushed outward as the breast develops. The veins travel separately and drain mainly superomedially. The lateral aspect of the breast is supplied by the superficial branch of the lateral thoracic system, but the major blood supply is from the internal mammary vessels (Fig. 8‑8). 15 ,​ 16

Fig. 8.8 Blood supply to the breast. (a,b) The blood supply to the breast is mainly in the subcutaneous tissue curving up around and superficial to the breast parenchyma. Most of the blood supply is from the internal mammary (thoracic) system with some input from the superficial branch of the lateral thoracic artery. The only deep artery that courses through the parenchyma (along with venae comitantes) to supply the nipple and areola comes from the internal mammary artery at the fourth (usually) intercostal space, and it passes along the internal aspect of the chest wall, pierces the intercostal and pectoralis muscles, and then travels through the parenchyma to the nipple. There are some lateral branches (in Würinger’s septum), and of course there are vessels that supply the parenchyma itself. The rest of the blood supply starts deep around the edge of the sternum and then courses up in the subcutaneous tissue, not through the parenchyma. The veins travel separately from the arteries, and they course just under the dermis (as is seen during de-epithelialization of the pedicle). (Reproduced from Hall-Findlay EJ. Aesthetic Breast Surgery: Concepts & Techniques. New York, NY: Thieme Medical Publishers; 2010.)

Innervation to the nipple is not just from the lateral fourth intercostal nerve (both deep and superficial) but also from the medial intercostal nerves as well. 17 In analyzing patient-reported sensation after vertical breast reduction, it was clear that the sensation from a medially based pedicle was about equal to that from an inferior pedicle (85% return of normal to near-normal sensation) but superior to both a lateral pedicle (76%) and a superior pedicle (67%). 8


Breast reduction and mastopexy cut through the ducts, but many of them reconnect. Cruz-Korchin has carefully studied breastfeeding after a medial-pedicle vertical breast reduction and found that the results were the same as in patients with large breasts and no surgery: about 60% were able to breastfeed, and 25% of those patients needed to supplement with formula. 18



8.4 Mastopexy Design


Knowledge of the anatomy will allow us to design methods to “move” that ptotic gland. Usually, the nipple needs to be moved, and knowledge of the various blood supplies to the pedicle is important. Most mastopexies, as described in this chapter, involve a superior or superomedial pedicle to move the nipple and an inferior flap to move or rearrange the ptotic gland.


There are various designs available to move the redundant gland, but the most effective is the inferior flap of Ribeiro described in Section 8.4.4. 4 ,​ 5 A medial pedicle extension flap can be effective, but it does not allow much movement of the inferior parenchyma. A superior pedicle extension flap is turned up under the superior pedicle, but the breast can be difficult to close, and there is very little upward advancement of the parenchyma. None of these methods work as well as the inferior flap. 19 ,​ 20



8.4.1 Medial Pedicle Extension Flap


The design and execution of a medial pedicle extension flap are shown in Fig. 8‑9. Note that it is somewhat difficult to inset, thereby achieving only minimal glandular ptosis correction. For this patient, the result shows that the extension flaps did not make much, if any, difference.

Fig. 8.9 Medial pedicle extension flap. (a,b) Patient aged 44 at presentation. She weighed 173 lb (78 kg), and was 5 ft 8 in. (173 cm) tall. She had a medial pedicle extension flap in addition to removal of 240 grams from the right and 255 grams from the left breast. (c) Breast markings. (d) The flap elevated and de-epithelialized. (e) The flap being rotated into position. (f,g) Postoperative at 9 months.


8.4.2 Superior Pedicle Extension Flap


The superior pedicle has an excellent blood supply, and the extension can be created from the inferior wedge that would be removed in a breast reduction. It can then be turned up under the areola to give the breast more fullness. Unfortunately it is difficult to inset without pulling the areola under with it, as shown in Fig. 8‑10. There is also tension on the flap, and it can give way. The patient shown felt both breasts “drop” at 3 months postoperatively.

Fig. 8.10 Superior pedicle extension flap. (a,b) Patient aged 68 at presentation. She was 5 ft 3 in (160 cm) tall and weighed 135 lb (61 kg). (c) Breast markings. (d) The flap elevated and de-epithelialized. (e) The flap being rotated into position. (f,g) Patient at 4 years postoperative.


8.4.3 Other Rearrangement Flaps


After realizing that the skin brassiere (including dermal flaps) was not effective at correcting glandular ptosis, the author tried multiple different methods of rearranging the breast parenchyma before finding that the inferior flap, discussed in the next section, was the most reliable. The patient in Fig. 8‑11 underwent a lateral pedicle along with two medial flaps (one above the pedicle into the upper pole and one below the pedicle to the midpoint of the breast) to rearrange the breast tissue.

Fig. 8.11 Lateral pedicle with two medial flaps. (a,b) Patient aged 44 years at presentation. She was 5 feet 4 inches (163 cm) tall and weighed 170 lb (77 kg). (c) Breast markings. (d) The medially based flaps de-epithelialized and elevated. (e) The flaps mobilized. The medially based upper flap was used in an attempt to fill the upper pole, and the medially based lower flap was used to correct the glandular ptosis. (f,g) The patient shown 1 year postoperatively.


8.4.4 Inferior Chest Wall–Based Flap (Ribeiro)


The inferior flap, as described by Liacyr Ribeiro, 5 has proven to be the most effective method of rearranging breast tissue for a mastopexy. The flap can be mobilized better than the other flaps described. This is the tissue that would be “removed” in a breast reduction and can be “moved” in a mastopexy. The flap can be better mobilized than any of the other flaps described in the preceding sections, and the breast and the flap move together. The flap does not heal to pectoralis fascia; rather, the anterior surface of the flap heals to the posterior surface of the pedicle. Later, if the patient decides to have an implant, there is still a good plane between the pectoralis fascia and the inferior flap. Unfortunately Ribeiro’s article was entitled “inferior pedicle,” so it was missed in the English literature, but in fact he used a superior pedicle with an inferior flap.


This is the type of flap used in the patients shown in Fig. 8‑1 and Fig. 8‑3; Fig. 8‑12 shows the interoperative photos from the latter. Both patients did have an inferior flap held up with a pectoralis sling, as described by Daniel and Graf, 6 ,​ 7 but the pectoralis strip is not necessary. The author no longer uses the sling because sometimes the breast tissue descends around the flap, especially in a massive-weight-loss patient, leaving an unsightly bump. The original description provided by Ribeiro is the method that gives the author the best result. 4 ,​ 5 It is best if both the breast and the flap settle together.

Fig. 8.12 Inferior flap of Ribeiro. I have used the pectoralis strip 6 ,​ 7 to hold the flap up but it is not necessary. (a) The inferior flap (the wedge of skin and parenchyma that would be removed in a breast reduction) is de-epithelialized. (b) The flap is mobilized by separating it on all four sides but leaving it as a chest wall–based flap (blood supply is the same as that for an inferior pedicle coming up through the muscles at the fourth intercostal space just medial to the breast meridian). (c) The superior pedicle is elevated off the chest wall, and the flap is sutured to pectoralis fascia to hold it until the anterior surface of the flap can heal to the posterior surface of the pedicle. The flap does not end up healing to the pectoralis fascia.


8.5 Operative Technique


There have been numerous descriptions of inverted T and vertical mastopexy techniques, and all have their merits. 21 ,​ 22 ,​ 23 ,​ 24 ,​ 25 ,​ 26 ,​ 27 ,​ 28 ,​ 29 ,​ 30 ,​ 31 ,​ 32 ,​ 33 ,​ 34 ,​ 35 ,​ 36 ,​ 37 ,​ 38 The best mastopexy for a surgeon to perform is the mastopexy that individual surgeon performs the best. All of the long-lasting results involve rearrangement of the breast parenchyma. The following approach describes the technique that has worked the best in the author’s hands. 5 The author believes that it is important to move the excess breast tissue where it is in excess (inferior and lateral). It is important in a breast reduction to “remove” the glandular ptosis, and in a mastopexy it is important to “move” the glandular ptosis. 8



8.5.1 Markings



Upper Breast Border

The upper breast border is a better landmark for determining new nipple position than the IMF, as Scott Spear also maintained (Spear S, personal communication). The upper breast border will not change after surgery from its preoperative position with either a breast reduction or a mastopexy. The IMF, on the other hand, is quite variable from patient to patient (Fig. 8‑1). Some patients have a long vertical breast footprint, and other patients have a very narrow vertical footprint. Although the upper breast border remains the same after a breast reduction or a mastopexy, the IMF can be adjusted.


The upper breast border (small vertical arrows in Fig. 8‑13a) is the junction between the chest wall and the takeoff of the breast. It starts at the junction of the preaxillary fullness (large horizontal arrows) and the outward curvature of the breast. If it is not obvious, the breast can be folded up (not just pushed up), as shown in Fig. 8‑13b, and the line of demarcation will become more clear (smaller vertical arrows).

Fig. 8.13 Principles of marking. The principles of marking for a breast reduction (removal of inferior wedge) and for a mastopexy (moving of the inferior wedge) are much the same. This breast reduction/mastopexy patient shows how the upper breast border does not change after surgery and how the new breast meridian should be drawn though the ideal position, not through the existing nipple position. Aged 53 at presentation, the patient was 5 ft 9 in (175 cm) tall and weighed 140 lb (63 kg). (a) Marking showing the upper breast border and ideal breast meridian. (b) The upper breast border can be demonstrated by folding up the breast (not pushing it up). The upper breast border starts laterally at the junction of the preaxillary fold and the outward curve of the breast. (c) The final result at 18 months after removal of 230 grams from the right breast and 190 grams from the left breast.

The patient in Fig. 8‑13 shows that the surgeon needs to evaluate not only glandular ptosis but also nipple position in all directions, not just elevation. Note that in the postoperative (18 months) photo (Fig. 8‑13c), the upper breast border has not changed from its original position.

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