For 7–9 cm lifts, the markings are the same, except that the inframammary marking is “notched” centrally in an inverted-V fashion to increase the height of the inferior pole by 1–2 cm. If this modification does not provide the desired 5–7 cm height for the inferior pole then the excess skin in the central inframammary fold may be rearranged during the closure, moving it from the horizontal plane to the vertical plane to gain a few cm at the meridian of the breast.

The mastopexy-nipple-sparing mastectomy is an oncologic-plastic team effort, with the plastic surgeon initially assisting the oncologic surgeon on the mastectomy, followed by both surgeons operating simultaneously to perform the sentinel lymph node biopsy or axillary lymphadenectomy, contralateral mastectomy, buttonhole mastopexy, and expander insertion. Prior to raising the mastectomy flaps, the areola is circumscribed keeping its diameter at 4–4.5 cm, and the transverse incision is made as marked preoperatively to raise the upper flap superficial to the anterior mammary fascia. The inferior flap dissection starts medially and laterally because of a well-defined anterior mammary fascial plane, and then proceeds towards the areola. On reaching the areola the dissection is carried through the breast, leaving a 5 mm thick layer of breast tissue attached to the areola. At this point a generous biopsy is obtained from the base of the areola for permanent sections and the periphery of the subareolar tissue tagged with 6–8 medium-size hemoclips for future guidance in the complete removal of the breast tissue at the time of expander implant exchange. As the dissection moves inferiorly towards the inframammary fold, care is taken not to dissect beyond the inframammary fold to avoid damaging the intercostal blood supply to the inferiorly based dermal-fat flap.

After completion of the mastectomy, the entire inferior flap is deepithelialized to create a broad-based 15–20 cm dermal-fat flap carrying the preserved nipple-areola (Fig. 7.2a). The expander (Mentor CPX3, Irvine, CA) is then fixed in place over the pectoralis major muscle using absorbable sutures (Fig. 7.2b) and the upper flap retracted down to cover the dermal-fat flap (Fig. 7.2c) and suture it to the inframammary margin of the deepithelialized flap. Because the upper flap is longer than the inframammary incision, suturing proceeds from both ends, easing the skin towards the meridian of the breast; the scalloping of the skin centrally flattens out postoperatively. Finally, the skin and subcutaneous fat in the predetermined nipple-areola location is cored out (4.5 cm diameter) to exteriorize the nipple-areola and suture it in place (Fig. 7.2d). The wounds are routinely drained with a single fluted drain .

For 7–9 cm nipple displacements in which the distance between the lower border of the upper flap and the proposed lower border of the areola is less than 5 cm, the buttonhole mastopexy has to be modified to increase the vertical length of the lower pole of the breast. As mentioned earlier, “notching” the inframammary incision at the meridian of the breast will increase the height of the lower pole by 1–2 cm. Another maneuver that increases the inframammary-to-areola distance is shifting the excess skin of the upper flap from the horizontal plane into the vertical plane during the skin closure at the meridian of the breast. This skin shift creates a dog-ear deformity in the vertical plane that is corrected by deepithelializing the excess skin, infolding it, and repairing the skin margins for a final inverted-T suture line. Minor dog-ear deformities that are not corrected primarily may be repaired during the second-stage implant exchange .