7 Mastopexy

Synopsis

Breast ptosis is a common problem caused by several different factors: pregnancy, weight changes, aging, delayed effect of breast implants and developmental deformities.

Mastopexy and augmentation-mastopexy techniques are varied and can be applied to different breast shape deformities.

Mastopexy techniques can be periareolar, vertical or based on the inverted-T techniques, as well as being performed in some instances by liposuction alone.

Preoperative deflation prior to mastopexy or augmentation-mastopexy is a safe and effective technique that offers the patient and surgeon many benefits.

Introduction

The desire for the aesthetic breast has long been captivating to humankind, and its allure permeates many feminine descriptions in classic literature. In the ‘Reeve’s Tale’, from his novel The Canterbury Tales, Geoffrey Chaucer describes Malyne, the young and lusty daughter of the miller Symkyn, as follows:

This wenche thikke and wel ygrowen was, with camus nose and yen greye as glas, with buttokes brode, and brestes rounde and hye, but right fair was hir heer, I wol nat lie.

(Chaucer G, Donaldson ET. Chaucer’s poetry: an anthology for the modern reader. New York: Ronald Press; 1958:133.)

Though written in Middle English and dating back to c1387–1400, this excerpt from the Reeve’s Tale clearly conveys that Chaucer’s youthful character Malyne, with her “rounde and hye” breasts, is particularly attractive to her suitors. In their pursuit of the aesthetic breast, plastic surgeons have relied heavily on the mastopexy, an operation often referred to by the lay public as the “breast lift.” In performing mastopexies, plastic surgeons address breast ptosis, a word whose etymologic root is Greek for “falling.” What was true in Chaucer’s time still holds today: that the “falling” or sagging breast is not the aesthetic ideal. Techniques for addressing the ptotic breast were borne from reduction mammaplasty procedures, essentially exchanging significant parenchymal resections for parenchymal reshaping and redraping the skin envelope. It is not surprising to note the confusion among patients between what is a breast reduction and what is truly a mastopexy. In fact, even among plastic surgeons there are gray areas between the two operations. For example, the patient with primarily breast skin excess and a much more minor component of glandular excess would likely benefit from a small parenchymal reduction in addition to skin resection and parenchymal redistribution. But does that constitute reduction mammoplasty? Mastopexy is a parenchymal reshaping that may or may not require a small parenchymal reduction. Reduction mammaplasties always require parenchymal reduction. What defines the difference between mastopexy and reduction mammoplasty, is whether the patient truly exhibits symptoms of macromastia – the affirmative being the case of a reduction mammoplasty. The issue is further confused from a general standpoint when you consider that some plastic surgeons treat breast ptosis with augmentation alone or in combination with mastopexy in certain instances. Plastic surgeons must be clear that ptosis as a separate entity from macromastia and gigantomastia is treated differently from cases of macromastia or gigantomastia that happen to have ptosis. Typically, the ptotic breast has a paucity of breast parenchyma in relation to a lax, excessive skin envelope. Contrarily, the cardinal finding of the hypertrophic breasts seen in cases of macromastia, gigantomastia, etc., is a predominance of parenchyma without skin excess. The vast majority of patients undergoing surgical intervention to treat ptosis of the breast are treated with skin resection and redraping over a repositioned breast mound – the operation that is the mastopexy.

History

As mastopexy operations began to evolve from the various methods of reduction mammoplasty, surgeons began to devise different techniques that emphasized minimizing the cutaneous scarring, while maximizing the vascular perfusion of the skin flaps and the nipple areolar complex. The greatest strides toward this end have come in the last century. Basic elements of mastopexy, such as transposition of the nipple areola and de-epithelialization to preserve perfusion and sensation, had been published by 1924.¹^–³ Dartigues addressed the issue of minimizing the cutaneous incisions used in mastopexy as well in 1924, submitting a method for correcting breast ptosis via a single infra-areolar vertical scar. The year before, Lötsch described a joining of techniques – adding a periareolar incision to a single vertical infra-areolar incision. This idea put forth by Lötsch caught the interest of Claude Lassus, who modified the technique from 1964 to 1980, developing what would ultimately become the classic vertical technique attributed to him for both mastopexy and reduction mammoplasty.⁴ In similar fashion, the vertical mastopexy and reduction techniques of Lassus adapted from Lötsch were again modified at the end of the 20th century. Lejour added the adjunctive use of suction-assisted lipectomy to the technique in 1994, which allowed easier contouring of the gland and stabilized the construct of the newly-shaped breast.⁵ Another variation of this technique was submitted by Hall-Findlay, who modified the placement of the nipple-areolar complex pedicle from the superior position to the medially-placed position and used no skin undermining or adjunctive liposuction.⁶ Hall-Findlay went on to further modify her technique for vertical mastopexy to use a laterally-based dermoglandular pedicle, which allowed her to auto-augment the breast by rotating the inferior and lateral glandular tissues beneath the nipple-areolar complex.⁷ Despite these several changes in technique that, among other things, minimize scarring, classic patterns that result in larger or more lengthy scars remain popular among many plastic surgeons, even today. The pattern of Wise, described in the mid-20th century, is a perfect example. Due to its ease of application, even in the most severe degrees of ptosis, the Wise pattern reduction mammoplasty remains popular, despite coming with the cost of a wide, inverted-T scar in addition to a periareolar scar.⁸ Other technical modifications, such as the use of mesh in the Góes technique, or the placement of a flap of autologous tissue beneath a loop of pectoralis major muscle by Graf and Biggs, have been added more recently to prolong the duration of the aesthetic result.^9,¹⁰

Basic science/disease process

The pathophysiology of breast ptosis is multifaceted – but can be conceptualized as being the result of the combination of expansion and aging, or separately as a result of a congenital deformity. In its classic description, breast ptosis is the result of inadequate parenchyma or parenchymal maldistribution in the face of excess, lax skin and connective tissues. The ligaments described by Sir Astley Cooper run from the pectoralis muscular fascia, through breast parenchyma, and insert into the dermis (Fig. 7.1). Parenchymal changes with aging (accentuated by the case of the patient with an implant), weight changes in the obese, and pregnancy, are also accompanied by specific alterations in the integrity of Cooper’s ligaments, the breast’s fascial components, and the overlying skin. These processes essentially function as tissue expansion, as the parenchyma ebbs and flows with the tides of hormonal fluctuations in pregnancy or menopause, or with the weight fluctuations in the obese having lost massive amounts of weight, or with the expanded breast that is created with a breast implant. The skin becomes thin and stretched, and supporting structures, such as Cooper’s ligaments and the superficial and deep layers of the superficial breast fascia, lose their inherent elasticity. The breast parenchyma, once held in place on the chest wall by and within these structures, becomes mobile and descends with the constant pull of gravity. Adding the effects of time with aging only exacerbates these pathophysiologic changes. The loss of elastic recoil of the skin and connective tissue, coupled with involutional atrophy of the parenchymal mound, results in an unshapely, falling, and unaesthetic breast.

Fig. 7.1 Profile anatomic view of the hemisected human breast. The ligaments described by Sir Astley Cooper are clearly demonstrated to run from the posterior, or deep, breast fascia, which is intimately associated with the pectoralis major muscle fascia, to the anterior, or superficial, breast fascia, and insert into the dermis. The parenchyma, which is encapsulated within these fascial borders, changes with aging, implants, weight changes, and pregnancy. These types of parenchymal changes result in alterations to the integrity of Cooper’s ligaments, the breast’s fascial components, and the overlying skin and fat.

Breast ptosis in its various degrees is defined by its anatomic relationship to the inframammary fold. The original classification scheme for breast ptosis was set forth by Regnault,¹¹ who in 1976 described the degrees of breast ptosis (Fig. 7.2). Grade I ptosis, or mild ptosis, was defined as having the nipple within 1 cm of the inframammary fold and being above the lower pole of the breast. Grade II, or moderate, breast ptosis exists when the nipple is 1–3 cm below the inframammary fold but still is above the lower pole of the breast. In grade III (severe) ptosis, the nipple is more than 3 cm below the inframammary fold and is situated below the lower breast contour. There is a fourth category of breast ptosis, commonly known as glandular or pseudoptosis, in which the nipple rests above the inframammary fold but the majority of breast tissue rests below and gives the appearance of ptosis.

Fig. 7.2 Breast ptosis classification as described by Regnault. (A) Minimal ptosis: the nipple is at the level of or just inferior to the inframammary crease. (B) Moderate ptosis: the nipple is 1–3 cm below the inframammary crease. (C) Severe ptosis: the nipple is >3 cm below the inframammary crease.

(Redrawn from: Georgiade GS, Georgiade NG, Riefkohl R. Esthetic breast surgery: In: McCarthy JG, ed. Plastic surgery. Philadelphia: WB Saunders; 1991:3839.)

An additional caveat to the Regnault classification was submitted by Brink, which takes into account other causes of the ptotic breast, such as parenchymal maldistribution, and posits an algorithm by which they can be surgically addressed (Table 7.1, Fig. 7.3). One example of such parenchymal maldistribution is the tuberous breast deformity, also known as the tubular breast or constricted breast, which manifests as a high inframammary fold, hypoplastic lower pole, and nipple-areolar complex resting on the inferior-most aspect of the breast.¹² Other classic features of the tuberous breast include herniation of the nipple-areolar complex as well as a constriction of the base of the breast.¹³ The tuberous breast deformity consists of a spectrum of different presentations to include some or all of these findings, the more severe cases representing the more challenging cases to correct (Fig. 7.4). Tuberous breasts can occur unilaterally, with the contralateral breast being unaffected, or can present to similar or vastly different degrees in bilateral cases. There are three classes of tuberous breast as described by Grolleau (Fig. 7.5). Type I deformities manifest as deficiency only in the lower medial quadrant, leaving the inferomedial shaped like an italic S and the inferolateral aspect comparably oversized. Both the inferomedial and inferolateral quadrants are deficient in the type II anomaly, leaving a paucity of skin in the infraareolar segment, which causes the areola to point downward. Finally, in a type III deformity, all four quadrants are deficient, and the breast base is constricted both horizontally and vertically.¹⁴ Von Heimburg describes a second classification scheme for the tuberous breast deformity (Table 7.2). In von Heimburg class I tuberous breasts, there is parenchymal hypoplasia of the inferomedial breast quadrant, similar to that described by Grolleau. The von Heimburg class II tuberous breast is also similar in description to Grolleau’s classification, with hypoplasia of the inferomedial and inferolateral breast parenchyma, and an adequate amount of periareolar skin. The third class of tuberous breast described by von Heimburg manifests as hypoplastic parenchyma inferomedially and inferolaterally, but with limited or inadequate periareolar skin. The fourth and final class of tuberous breast deformity described by von Heimburg is presents with hypoplastic parenchyma in all four breast quadrants.¹⁵ Various techniques, such as periareolar nipple-areolar reduction, radial scoring, dermoglandular flaps, autologous and alloplastic augmentation, and tissue expansion, among others, have been used for the correction of this deformity.

Table 7.1 Procedural specifics for forms of breast ptosis

Fig. 7.3 (A–D) Different types of breast ptosis. IMF, inframammary fold.

(Redrawn after: Brink RR. Management of true ptosis of the breast. Plast Reconstr Surg 1993; 91:657–662.)

Fig. 7.4 (Top) Normal breast development with forward and peripheral expansion. (Bottom) Development of a tuberous breast, with limited peripheral expansion and exaggerated forward expansion.

(Redrawn from: Grolleau JL, Lanfrey E, Lavigne B, et al. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg 1999; 104(7):2040–2048.)

Fig. 7.5 Classification system for breast base anomalies. Type I breasts have hypoplasia of the lower medial quadrant. Type II breasts have hypoplasia of both lower quadrants. Type III breasts have hypoplasia of all four quadrants.

Table 7.2 von Heimburg’s tuberous breast classification

Class	Anatomic features
von Heimburg class I	Hypoplasia of lower medial quadrant
von Heimburg class II	Hypoplasia of both lower quadrants with adequate areolar skin
von Heimburg class III	Hypoplasia of both lower quadrants with limited areolar skin
von Heimburg class IV	Hypoplasia of all quadrants

(From von Heimburg D, Exner K, Kruft S, et al. The tuberous breast deformity: classification and treatment. Br J Plast Surg 1996; 49:339–345. Reprinted with permission from the British Association of Plastic Surgeons.)

Diagnosis and patient presentation

Patient evaluation

Most patients present for consultations with certain notions as to what they should expect from the operation itself. These predetermined ideas often come from surfing the internet and perusing before-and-after photographic images, in addition to talking to other people who have undergone mastopexy. Analysis by the patient can take into account how pretty or aesthetic the breast is postoperatively, as well as some or all of the aspects a plastic surgeon might evaluate, such as the breast shape, position on the chest wall, nipple areolar complex position on the breast mound, and scarring. Often, this can be helpful during the patient evaluation, answering some preliminary questions and setting a conceptual basis upon which the surgeon can explain the rationale for the technique to be implemented. In cases where patient expectations are out of line with a reasonable outcome, the predetermined notions must be addressed and misunderstandings must be resolved preoperatively. For example, the patient with very large, ptotic breasts desiring to maintain her large breast size in addition to having the breasts be replaced to a more uplifted position will be uniformly disappointed. Without a reduction, the results in this type of patient will not only likely be inadequate with regard to the degree of lift but also with regard to the longevity of the lifted result. So patient expectations are a key component of the patient analysis, and questions to assess these predetermined notions during the evaluation can be helpful to the patient and the surgeon.

Many patients are initially seen requesting implants, thinking that the implants lift the breast. Implants never lift the breasts in and of themselves, and this part of the consultation can be confusing to patients because this counters their preconceived notions. On the contrary, other patients present desiring a breast lift but are advised to get implants by surgeons who may not be confident in their ability to achieve a long-lasting and well-shaped mastopexy. The end result can be an implant breast construct that is too large for the patient’s frame and fails to satisfy the patient’s goals.

We find that one of the most helpful questions that can be posed to a patient is “can you make your breasts look the way you want them to in a bra?” If the answer is yes, then perhaps a mastopexy alone is the best recommendation. If the answer is no, and the patient relies on adding volume by stuffing or padding, then adding an implant may be necessary. Of course, combinations of small reductions and implants – the “Addition/Subtraction Concept” – can be a very satisfactory approach.

Discussing the typical pattern of the incisions and the expected scars is important. Patients will often have in mind a smaller scar pattern, hoping for a “lollipop” or “doughnut” lift, instead of the “anchor” scar. These patients may even accept a suboptimal mastopexy in order to avoid additional scar placement. However, if you as a surgeon agree to meet these types of demands, then you should also be aware that if the patient is unhappy later with the result of this trade-off, they may forget about the conversation about shorter scars for a more limited result! The plastic surgeon must take into account the degree of skin laxity, the excess amount of skin in relation to the parenchyma, the position or malposition of the parenchyma, and degree of nipple-areolar complex elevation anticipated – and then incorporate that physical examination information with the patient’s history of chest or breast surgery, the patient’s history of scarring, including hypertrophic scarring or keloid formation, the patient’s desires with regard to scar placement, and the surgeon’s experience and technical ability to achieve the most aesthetic and durable result.

Measurements are another key component to the diagnosis and treatment of the patient with breast ptosis. Such marks, such as the sternal notch to nipple distance, define current nipple position on the breast and chest wall and can help define symmetry. The nipple to inframammary fold distance quantitates the skin of the lower breast pole, as well as assisting in defining symmetry. The breast base diameter gives a width of the breast on the chest wall, allowing for implant selection in the case where mastopexy is to be performed in conjunction with augmentation. These measurements, in addition to the classification of the degree of ptosis, can be quite useful in planning, as well as achieving an aesthetic result.

Preoperative breast imaging, in the form of high-resolution digital color photography is another important tool for documentation to demonstrate the degree of preoperative ptosis, as well as the degree of improvement postoperatively. The advent of three-dimensional imaging and computerized image-enhancing software has diversified the options for plastic surgeons to demonstrate to patients the implant sizes, asymmetries, and expected outcomes during consultations, as well as their postoperative improvement. Some of these concepts are covered in greater detail in Chapter 2.

A careful conversation describing the rationale of the pattern to be used and the expected scars can go a long way toward warding off disappointment in the postoperative period. Further, specific counseling as far as the risks, benefits, and alternatives to the proposed surgical intervention should be documented as part of the informed consent. It is often useful to have the patient come back for a second visit prior to surgery, especially in cases where the operation may be delayed for any reason. At that time, the details of the previous evaluation, having been documented in detail, can be easily covered again and any new concerns can be raised and addressed. We use an interactive computerized consultation system that allows the patient to revisit the consultation as well as teaching materials online using any internet connection as often as they wish.

Patient selection

The majority of patients presenting for mastopexy procedures typically fall into three categories: those who indeed would benefit from mastopexy, those who need an augmentation with mastopexy, and those who need a formal reduction mammaplasty. The analysis of the quality and amount of skin in relation to the mass and anatomic distribution of the breast parenchyma usually dictates which procedure is necessary. The ideal mastopexy patient has a normal volume of breast parenchyma and a minimal-to-moderate excess of skin that is of good quality. When patients present with minimal glandular mass and breast ptosis, consideration must be given to the skin amount and quality – as this patient will likely need a mastopexy in addition to an augmentation with an implant, either as combined or staged operations. Conversely, the patient who presents with an overabundance of parenchyma and ptosis will need a breast reduction.

Part of the informed consent process and patient evaluation is a determination of the patient’s surgical risk. Risk factors for surgery, such as age, history of recent weight loss, cardiopulmonary health, medications and recent changes to medication regimen, history of stroke, hepatic or renal insufficiency, abnormal bleeding or clotting tendencies, and possibilities the patient is or may become pregnant, etc., must be thoroughly completed and documented. The patient’s breast history is important to acquire and completely document and discuss. Any history of breast changes/masses, nipple-areolar changes or discharge, mammography, previous breast surgery, pregnancies and breast-feeding, radiation therapy to the chest or breast, and personal or family history of breast cancer must be explored with the patient in detail. It is the practice of the authors to have patients over 35 years of age obtain a recent mammogram, unless a normal one has been documented in the year prior, before proceeding with surgery.

Treatment/surgical technique

The vast array of surgical options and approaches for mastopexy is best condensed into a classification scheme based on scar pattern. Generally, mastopexy techniques are described by the scar pattern from the skin reduction. There are four basic scar patterns for mastopexy techniques: periareolar, vertical, J or L, and inverted-T. More specifically, however, each of these broad categories of scar pattern has techniques within them that cross the boundaries of this basic classification scheme. This comes as a direct result of the multiple modifications of each technique that surgeons have developed in an attempt to reduce scarring, yet still address the degree of glandular ptosis in relation to the degree of skin quality and excess. The basic tenets for implementation and application of each of the mastopexy techniques, as well as their inherent risk-benefit analysis, are detailed in the following sections, in which the specifics of the techniques are also discussed.

Periareolar techniques

Generally, the periareolar technique is best-suited for patients with mild to moderate breast ptosis and in whom the parenchyma is adequate from a volume standpoint. Firmer parenchyma is preferable to softer tissues in implementing this technique. The incisions for this technique range from a superior crescent of excised skin to a complete donut. Patients who present with mild to moderate breast ptosis but with inadequate parenchymal volume can be treated with an implant via the periareolar technique. The obvious advantage of the periareolar technique, be it for mastopexy, augmentation, or augmentation-mastopexy, which is described later in the chapter, is that the incision is camouflaged in the aesthetic transition from breast skin to the skin of the nipple-areola. Disadvantages of periareolar techniques relate to precise skin excision and ultimately a limited degree of cephalic nipple-areolar complex movement. Other disadvantages include possible scar widening and decreased breast projection. Removal of too much skin leads to an unaesthetic widening of the areola. Widened scars are multifactorial in nature and can be the result of excessive tension on the closure, which can result from the weight of the implant or aggressive skin excision. The patient’s skin quality, such as its thickness, elasticity, and degree of aging/damage, can also contribute to widened periareolar scars. Achieving a well-hidden scar and appropriate nipple areolar elevation at the expense of creating an aesthetically-flat, misshapen breast is also not ideal and should be avoided or corrected when possible. Loss of projection with the periareolar techniques, however, can be used to achieve goal the aesthetic in some cases, such as the tuberous breast deformity, but caution must be taken to avoid flattening of the breast.

Small, mildly ptotic breasts with adequate parenchyma respond best to these techniques. Modifications can be made, however, to accommodate moderate degrees of breast ptosis as well as inadequate parenchymal volume using periareolar mastopexy approaches. Typically, the modification required is the addition of a small implant to replace the lacking parenchyma, simultaneously filling the skin envelope. This results in an aesthetic breast mound, though it often can also result in a low-set nipple-areolar complex on the breast. Excising skin around the nipple-areola at the same operative setting elevates the nipple-areolar complex to a more aesthetic location and completes the periareolar mastopexy. Usually, the amount of lift obtained is limited to 1–2 cm.

In an effort to limit complications associated with periareolar mastopexy techniques, Spear et al. designed a series of rules to follow.^16,¹⁷

Rule 1: D_outside ≤ D_original + (D_original − D_inside). The amount of nonpigmented skin excised should be less than the amount of pigmented skin excised. In doing so, there will be no undue tension on the new areola that could cause subsequent widening. This should prevent a postoperative areola larger than the original. The distance from the edge of the areola to the outer diameter located on the normal breast skin should roughly equal the distance to the inner diameter, which should be located within the areola.

Rule 2: D_outside <2 × D_inside. The design of the outside diameter should be no more than two times the inside diameter in order to minimize the discrepancy in circle sizes, thereby reducing tension on the closure. This should prevent against an overly-ambitious plan to remove skin, and, as a result, limit the risk of poor scars and overly-flattened breasts. Keep in mind, however, that some leeway exists in the case of skin envelope laxity, the degree of which is ultimately a judgment call.

Rule 3: D_final = (D_outside + D_inside). This final rule helps predict the final areolar size, which is particularly useful in asymmetry cases, as well as those in whom no round block suture is employed (Fig. 7.6).

Fig. 7.6 Periareolar design guides as described by Spear et al. D, diameter.

(Modified from: Michelow BJ, Nahai F. Mastopexy. In: Achauer BM, Erikson E, Guyuron B, et al., eds. Plastic surgery: indications, operations and outcomes, Vol. 5. St Louis: Mosby; 2000.)

Concentric mastopexy without parenchymal reshaping

The amount of skin to be excised is determined by the position of the nipple-areola complex. One must take care to excise only the amount of skin necessary to raise the nipple-areola complex to the proper level for correction of the ptosis. Consideration must be given to any excess areola that is to be removed. The lines of excision are marked on the breast with the patient in a sitting or standing position in the preoperative area. Symmetry is checked by comparing sternal notch to nipple distance and sternum to nipple distance. In the operating room, the amount of the areola that is to remain is marked on the stretched breast with an areolar marker. The skin between these two marks is infiltrated with 0.5% lidocaine with 1 : 200 000 epinephrine to facilitate de-epithelialization. Once the skin is removed, the edge of the dermis can be elevated. At the same time, the remaining skin around the exposed dermis can be elevated off the gland for a short distance superiorly. The freed dermis can then be tacked to the gland under the elevated skin, giving additional support to the breast. A purse-string suture of 4-0 Gore-Tex^® or Mersilene is then placed in the deep dermis of the skin edge. This is then cinched to the approximate size of the areola and tied. The areola is then approximated to the skin with half-buried horizontal mattress sutures, followed by a running, subcuticular 4-0 Monocryl or polydioxanone closure.

Periareolar Benelli mastopexy

The Benelli mastopexy technique is an extension of the donut mastopexy that was borne from dissatisfaction with the limitations of the simpler periareolar methods of mastopexy.^18,¹⁹ The Benelli modifications allow the periareolar technique to be used to treat larger breasts with increasing degrees of ptosis. This technique can be combined with reduction techniques when necessary to ensure the best possible result while remaining true to the idea of a minimal scar. The fundamental concept behind the Benelli mastopexy is treatment of the skin and the gland as two separate components. The glandular tissue of the breast is accessed through the periareolar incision and separated from the overlying skin component. Superior, medial, and lateral dermoglandular flaps are created, with resection of intervening tissues and thinning of the flaps as is indicated for cases of macromastia. Glandular reassembly consists of reducing the glandular width, tightening the lower pole, and coning the breast construct by crisscrossing the medial and lateral dermoglandular flaps. The skin envelope is redraped over this newly formed glandular scaffold. A round block cerclage stitch is used as in the donut mastopexy to help control tension at the areola-skin junction. As can be seen, this technique allows precise shaping of the breast by the inverted T type of incision through the gland, while requiring no additional incisions in the skin.

Because this technique affords access to the gland, and thus more flexibility in reshaping the gland, the indications for this procedure can be broadened to include patients with larger breasts or greater degrees of ptosis while still satisfying the requirement of minimal scars. It can be used on breasts with minimal glandular tissue by forgoing the glandular incision in favor of plication while simultaneously adding an implant. It can be used as described for larger breasts requiring a modest degree of reduction. This technique, however, is not recommended for breasts that are mainly fat or have a large amount of skin excess, especially if skin is of poor quality. Also, this technique is not indicated in large breasts for which a formal reduction may be the more appropriate procedure. The main advantages are the improved ability to shape the gland and recontour the breast and the commitment to minimizing the scar. The disadvantages of this technique include those of the donut and crescent mastopexies. In addition, care must be taken on incision and reconstruction of the gland to avoid damage to the vascular supply of the gland and overlying skin. There is a significant learning curve associated with Benelli’s technique. If there is an over-resection of skin or inadequate glandular support, the breast has a marked tendency toward a flattened appearance along with widening of the nipple-areola complex.

Technique

Preoperative marking is initiated by marking the midline and the estimated meridian of the newly shaped breast with the patient in the upright position. The new meridian is often medial to the breast meridian approximately 6 cm from the midline. The future superior border of the areola, point A, is marked on the meridian approximately 2 cm above the anterior projection of the inframammary fold. The future inferior border of the areola, point B, is marked with the patient supine approximately 5–12 cm above the inframammary fold on the basis of the estimated final breast volume and the expected skin retraction. The medial and lateral limits of the new areola, points C and D, are marked on the basis of estimates of the final breast volume. These limits are equidistant from the previously-marked meridian, and point C averages 8–12 cm from the midline (Fig. 7.7). The opposite breast is marked with reference to the already marked breast. The preoperative markings are verified by pinching together the superior and inferior points and then the medial and lateral points, ensuring that enough skin will remain to adequately cover the breast tissue without tension.

Fig. 7.7 Markings for Benelli mastopexy. (A) Future superior point of the nipple; (B) future inferior point of the nipple; (C) medial limit of the nipple; (D) lateral limit of the nipple. Point C averages 8–12 cm from the midline. S is the point where the breast meridian intersects the inframammary fold.

(Redrawn after: Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg 1990; 14:93–100.)

Infiltration with dilute saline (1000 mL), epinephrine (0.25 mg) and lidocaine 2% (20 mL) is performed subcutaneously in the area that will be detached. The ellipse and surrounding 3 cm is not infiltrated to preserve vascularity of the skin edges. The prepectoral area is also infiltrated. The desired areolar diameter is marked, and the periareolar ellipse is de-epithelialized. The de-epithelialized dermis is incised from the 2-o’clock to the 10-o’clock position. The dissection is extended toward the inframammary fold in the subcutaneous plane (Fig. 7.8). The dissection continues to the upper outer quadrant of the breast and becomes more superficial to preserve the vessels coming from the lateral thoracic artery.

Fig. 7.8 Dissection of the breast during Benelli mastopexy. Incision of dermis from the 2-o’clock to the 10-o’clock position with dissection to the inframammary fold subcutaneously.

(Redrawn after Benelli LC. Periareolar Benelli mastopexy and reduction. In: Spear SL, ed. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven; 1998:685.)

Glandular dissection is then initiated with a semicircular incision approximately 3 cm from the inferior areola edge to preserve innervation and blood supply to the areola. Dissection is continued to the prepectoral space in the avascular central space, preserving the peripheral blood supply. The inferior glandular flap is then cut vertically beyond the breast meridian up to the fascia. Four flaps will have thus been created: a superior dermoglandular flap supporting the areola, a glandular medial flap, a glandular lateral flap, and the detached skin flap (Fig. 7.9). These glandular flaps will be reassembled and repositioned to decrease the base of the breast, thus promoting the lifted appearance. If necessary, these flaps can be trimmed to reduce unwanted fullness. Volume reduction should be performed at the distal ends of the flaps to limit their length.

Fig. 7.9 Four flaps of the Benelli mastopexy: superior dermoglandular flap supporting glandular medial and lateral flaps, and detached skin flap.

(Redrawn after Benelli LC. Periareolar Benelli mastopexy and reduction. In: Spear SL, ed. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven; 1998:685.)

Once the appropriate resection is complete, the gland is initially lifted by placing a stitch in the glandular tissue of the superior flap and fixating this to the pectoralis fascia (Fig. 7.10). This should elevate the areola and cause an exaggerated convexity in the superior pole of the breast (Fig. 7.11). This exaggerated convexity will disappear within a few weeks secondary to gravity and the weight of the breast. Next, the medial and lateral flaps are folded over one another and sutured in place. Because most ptosis involves a lateral migration of the breast, the goal here is to medialize the breast. Therefore, the crisscross mastopexy is begun by rotating and folding the medial flap behind the areola, fixing its distal portion to the pectoralis muscle with superficial stitches (Fig. 7.12). The lateral flap is then crossed over and fixed to the medial flap (Fig. 7.13). The movement of these flaps reduces the base of the breast, forming a glandular cone on which to place the areola. If the gland requires no resection, a plication invagination can be performed to achieve an elevated conical breast shape (Fig. 7.14). The areola is fixated to the superior border of the ellipse through a 1-cm dermal incision made near the superior skin edge. This allows the knot to be buried and the areola to be supported without tension on the skin (Fig. 7.15). Support for the breast shape is achieved by full-breast lacing. Braided polyester suture on a long straight needle is used for the large inverted sutures along the underside of the gland. The superior stitch should pass through the superior dermoglandular flap, allowing control of the anterior projection of the nipple-areola complex. These full-breast lacing sutures should be applied without tension, their goal being to provide passive support of the newly formed conical breast. Tying these lacing sutures overly tight can result in glandular necrosis. The skin is redraped over the breast, and a round block cerclage stitch is passed in the deep dermis in purse-string fashion (Fig. 7.16). It is then cinched around a tube of the desired diameter, ensuring even distribution of the skin pleats. The block stitch is then tied, burying the knot in the previously formed dermal window. Further regulation of the projection of the areola is accomplished by an inverted dermoareolar stitch that takes a large vertical bite in the areola and a large horizontal bite in the dermal ellipse. This helps distribute any remaining deep pleats evenly around the areola. A diametrical transareolar U suture is placed to serve as a barrier and help prevent areola protrusion (Fig. 7.17