Conventional wisdom holds that plastic surgeons need to be familiar with a number of different surgical techniques to treat different degrees of breast ptosis and breast volume [1]. The traditional recommendation is to use a periareolar resection for cases of minor ptosis, vertical mammaplasty for more moderate degrees of breast ptosis, and an inverted-T technique for major ptosis [1, 2]. In 1979, Georgiade et al. [3] dismissed the concept of an “all seasons mammaplasty .” At that time, almost all plastic surgeons in North America were using a Wise pattern and inferior pedicle. In 1999, Hall-Findlay [4] published her seminal article describing a vertical mammaplasty with a medial pedicle. The vertical mammaplasty with a medial, superior, or superomedial pedicle is now used exclusively by a growing number of plastic surgeons [5–11], including the author, who abandoned the Wise pattern in 2002.

A periareolar resection removes extra tissue from around the areola, but provides minimal breast mound elevation (Fig. 7.1) [12]. By omitting a lower pole tissue resection, the effectiveness of this mastopexy technique is compromised [12, 13]. Periareolar mastopexy, popularized by Benelli [14], has fallen into disfavor as plastic surgeons recognize its limitations [13, 15] and the frequent areolar distortion that accompanies this technique (Fig. 7.1) [13]. The author reserves periareolar mastopexies for areola reduction or small adjustments in the position of the nipple/areola (Fig. 7.2). In this application, the label “mastopexy” might be an overstatement, in that breast shape is minimally affected.

Measurements confirm a long-held belief among surgeons that a Wise pattern and inferior pedicle produce a boxy shape with a flat upper pole [12, 16]. Upper and lateral portions of the breast are resected, with (illogical) preservation of the lower pole tissue. Closure of a horizontal ellipse reduces projection and constricts the lower pole while increasing width [12]. Unfortunately, patients after a Wise pattern mammaplasty often resemble preoperative candidates for a vertical augmentation mastopexy [5]. The vertical technique provides greater upper pole projection, breast projection, and more conical lower poles [16]. Not surprisingly, patients prefer the aesthetic result of the vertical method [17].

With over 100 published methods [12], mammaplasty continues to be a subject of confusion for plastic surgeons. Numerous skin patterns and pedicles are used [2, 18]. Algorithms can be complicated [19]. Since 2002, the author has used a simple algorithm in selecting cosmetic breast procedures (Fig. 7.3) [20]. This algorithm differs from others in its simplicity. Almost all cosmetic cases may be treated with either a breast augmentation or a vertical mammaplasty individually or in combination. This algorithm does not include revisions of course, or occasional procedures such as a nipple reduction or areola reduction or lift (Fig. 7.1) that are also cosmetic in nature.

Augmentation mastopexy is still regarded as a particularly difficult and risky procedure by many plastic surgeons [22]. Spear and others caution that this procedure not only combines complication rates but multiplies them [21–23]. The conventional view is that the operations are at cross-purposes: the implant stretches the skin envelope while the mastopexy tightens it [15, 22–27]. Many surgeons advocate staging the procedures in patients deemed to be at higher risk, such as women with greater degrees of ptosis [25–27].

In discussions of risk, the mastopexy method is often overlooked [20]. The surgical technique is important because different dissections are likely to differ in their degree of safety. Almost all published series include patients treated with different methods [23, 25–32]. In two recent large series, the vertical method was used in 40% of patients in one study [26] and in 10% of patients in the other study [32]. When different methods are being used, it is difficult to sort out the risk of the combination from the risk of the individual procedures. The author [20] studied augmentation mastopexy using the vertical technique exclusively and the most pertinent findings are included in this chapter.

Clinical [5] and intraoperative breast perfusion data [33] obtained in patients treated with vertical augmentation mastopexy suggest that the dangers attributed to the combined surgery do not derive from combining techniques after all. The increased risk to nipple/areola perfusion is related to the mastopexy technique [5, 12]. The limitations of nonvertical techniques are exposed when an implant is introduced [5]. For example , adding an implant may create pressure on a long, inferiorly based pedicle, further reducing nipple/areola perfusion and possibly tipping the balance to necrosis (Fig. 7.4) [5]. In a periareolar mastopexy, the breast area being stretched has already undergone skin resection, increasing tissue tension [5]. When using the vertical method, staging is unnecessary. Any patient who is a candidate for breast augmentation and vertical mastopexy performed individually is a candidate for the combined procedure [5].

When the vertical technique is used, the methods are no longer at cross-purposes, but synergistic. These advantages of combinations are summarized below [5].

Today, women are often confronted with a choice between procedures – augmentation with implants (and more recently fat injection), mastopexy, and augmentation mastopexy. Measurement data helps us avoid recommending a mastopexy to a woman who wants to keep her volume, but just have her breasts lifted, a very common scenario. A woman who lifts her breasts up with the cups of her hands and says “This is what I want” is usually best served with an augmentation mastopexy [5]. If a woman wants to remain about the same breast size , she needs upper pole addition and lower pole subtraction. Women understand that stuffing the upper pole with tissue from the lower pole works well on the drawing board but not in reality because of the malleable nature of breast tissue.

All procedures are performed on an outpatient basis in a state-licensed ambulatory surgery center using total intravenous anesthesia and a laryngeal mask airway. This type of anesthesia avoids intraoperative hypotension and preserves the calf muscle pump, reducing the risk of venous thromboembolism [34, 35]. Doppler ultrasound screening is performed preoperatively, the day after surgery, and approximately 1 week after surgery [36, 37]. Chemoprophylaxis is not used. Patients typically receive cefazolin 1 g IV preoperatively, followed by three doses of cephalexin 500 mg p.o. q12h.

A vertical elliptical resection pattern is marked preoperatively (Figs. 7.5 and 7.6). A medially based pedicle [4] and intraoperative nipple siting are used. A mosque-dome or keyhole preoperative pattern is not used. The lower end of the ellipse is marked preoperatively just above the existing inframammary fold (Fig. 7.5).

Before performing the mastopexy, the breast implant is placed submuscularly, with partial release of the inferior sternal origin of the pectoralis muscle. As in breast augmentation, the degree of muscle release is critical. If the muscle is inadequately released, the intermammary space may be too wide. Over-release can cause the dreaded symmastia, with continuity from one breast to the other – the breasts may resemble buttocks. In patients with existing breast implants, the pocket is usually expanded superiorly to accommodate the new implant at a higher level on the chest wall. Implants have typically settled since the original surgery, or the patient may desire a larger size . Subpectoral placement of the breast implant adds a layer of tissue cover and is preferred by most surgeons [5, 23, 24, 26–32]. However, prepectoral placement is a valid alternative, particularly in women with adequate breast tissue, and avoids an animation deformity [20].

There is a general preference for silicone gel implants [18], although some surgeons more commonly insert saline implants [5, 23]. Silicone gel implants have traditionally been favored for a more natural feel characteristic and possibly less rippling [38]. However, in a woman who has a moderate breast volume, this difference may be negligible, particularly in a subpectoral pocket. Form-stable implants are not used by the author because they have not been shown to produce a superior outcome [39–41], and have disadvantages, including firmness, rotation, expense, and texturing, which is linked to late seromas, double capsules, and anaplastic large cell lymphoma (ALCL) [42, 43]. Mean implant volumes in other studies vary from 306 cc to 450 cc [23, 26, 27, 31, 32, 44]. In this study, the average implant volume was 372 cc, 20 cc less than the average for breast augmentations without mastopexy [45], and similar to the mean volume in the study by Calobrace et al. (392 cc) [26]. It is best to insert the implant before committing to the mastopexy incisions so as to avoid an overly tight repair. The same caution needs to be exercised in choosing an implant size for an augmentation mastopexy as in a breast augmentation [33]. It has been suggested that, logically, larger implants should have a higher complication rate [27]. However, neither this study nor the study by Calobrace et al. [26] substantiates this claim. Larger implants correlate with greater patient satisfaction [45, 46].

Some investigators promote tissue-based measurements as a means to determine implant size [47–49], and this subject is discussed in more detail in Chap. 3. Tissue-based measurements do not include patient input in size selection, and tend to produce low recommended implant sizes (e.g., mean volume, 289 cc) [48] that are likely to disappoint at least 20% of patients [48]. There are no patient-reported outcome studies that support this method, which supplants the patient’s desires with the surgeon’s. Another method used to predict implant size is having the patient stuff her bra with implants. However, about 16% of women still report an inadequate size [50], possibly because an implant placed on top of the breast does not accurately simulate an implant within the breast. My own method is to have patients show me photographs on their handheld devices and look at photographs of other patients. This gives me a qualitative idea of an appropriate implant size, but is admittedly not scientific. I am an advocate of measurements, but these measurements are for comparison of preoperative and postoperative breast shape and size; they are not used for size determination . Any system that does not include patient choice is unlikely to achieve patient satisfaction with the result, which is the goal of cosmetic surgery [45, 51]. Computer simulations do not yet have this capability because the software is not based on actual tissue measurements derived from patients [52, 53]. A zero reoperation rate is impractical because women may change their minds about implant size after having the surgery [45].

The lower pole resection width is difficult to predict in a mastopexy, particularly when an implant is inserted simultaneously. Intraoperative adjustments are needed to avoid under- or over-resection. The final lower pole resection margins are determined after insertion of the breast implant and creation of the new breast mound, not necessarily aligning with the preoperative markings (Fig. 7.5). The deepithelialized right medial pedicle extends from approximately 1 o’clock to 4 o’clock (8 o’clock to 11 o’clock on the left breast) along the areola margin , to include the third and fourth anterior cutaneous sensory branches (Fig. 7.8) [54]. The deep branch of the lateral branch of the fourth intercostal nerve provides consistent nipple innervation [54]. A parenchymal attachment deep to the nipple/areola complex is maintained in an effort to preserve this deep innervation.

The lower pole resection raises the inframammary fold [55] and the implant lowers the inframammary fold [55]. Therefore, the lower end of the incision relative to the new inframammary fold is unknown until after implant insertion and creation of the new breast mound. A vertical mastopexy elevates the inframammary fold [55] because a lower pole tissue wedge is removed and the medial and lateral pillars are brought together, tightening the breast circumference. The length of the vertical scar is longer than for a Wise pattern, typically 10–12 cm (Fig. 7.5) [4, 5]. The vertical method does not constrict the lower pole, unlike the Wise pattern mammaplasty [16]. Direct excision is used rather than liposuction so as to adequately remove denser breast tissue along with fat from the lower pole and to limit tissue trauma.

The new nipple/areola site is determined after insertion of the breast implant and creation of the new breast mound (Fig. 7.6). The nipple is positioned in reference to the breast mound, not to a predetermined level or distance to the sternal notch [56]. A 39-mm areola marking ring is preferred because the areola tends to stretch about 1 cm postoperatively [56], and women prefer areola diameters that do not exceed 5 cm [46]. Although many surgeons prefer to sit the patient up during surgery, I do not find this position necessary to correctly site the nipple. A short inverted-T modification is used when the vertical scar extends below the level of the new (elevated) inframammary fold. The length of this horizontal scar is shorter than the inframammary component of the Wise pattern, just long enough to remove the inferior dog ear. No drains are used. Videos demonstrating this procedure are available at the Plastic and Reconstructive Surgery Global Open website: http://​journals.​lww.​com/​prsgo/​pages/​default.​aspx [57].

The intercostal perforating arteries from the internal mammary artery provide the dominant superficial circulation to the nipple and areola in 70% of women (Fig. 7.9) [58, 59].

Measurements of nipple/areola perfusion [33] reveal that implant sizes up to 575 cc may be safely inserted using a vertical method and medial pedicle (Figs. 7.10, 7.11, and 7.12).