CHAPTER 30 Superior Pedicle Extension Mastopexy

Key Points

1. The superior pedicle vertical scar mastopexy resuspends inferior pole breast tissue to recreate breast projection and superior medial cleavage.

2. Suturing of the lower pole medial and lateral pillars provides a stable column to support the newly elevated nipple–areola complex (NAC) with the added benefit of narrowing the breast base width.

3. Details of preoperative markings include ending the vertical scar 1–3 cm above the native inframammary crease to prevent migration onto the abdomen and relocating the NAC at the level of the inframammary crease to prevent high riding NACs postoperatively.

4. If an implant is to be placed, more conservative marking of the medial and lateral pillars should be done with less skin excision so as to facilitate closure of the inferior pole.

5. Stable closure of the inferior pole pillars using two layers is essential to maintain shape and position and prevent complications of recurrent ptosis, bottoming out and a widened vertical scar.

Introduction

In all types of ancient art, including that of the early Greek, Egyptian, and even Christian cultures, the uncovered female breast is commonly depicted. Its inclusion on sculpture, paintings, and drawings conveyed themes of fertility, beauty, and femininity. Despite the modernization of both art and society, the same holds true of the female breast today. Current trends emphasize the beauty and vitality associated with youth, and as such a full and lifted breast line has come to represent an often sought after aesthetic ideal in art, advertising and day to day living.

Over the course of a woman’s life, there are many factors which invariably alter breast form and contour. Pregnancy, lactation, weight fluctuation, and gravity contribute to diminished elasticity, change in fat content and elongation of connective tissue supporting elements, resulting in mammary ptosis. This inevitability has led to the rise in popularity of mastopexy procedures which seek to restore and maintain a well supported and attractive breast form.

The plastic surgery literature is replete with a multitude of mastopexy techniques, all of which correct ptosis, restore superior medial cleavage, and relocate the NAC to the central portion of the breast mound. Many of these, however, are associated with lengthy scars and early recurrence of ptosis. Surgical experience and innovation have more recently led to more refined procedures that deliver improved results and fewer complications, thereby leading to a higher satisfaction rate for both surgeons and patients. Specifically, the vertical mastopexy procedure as popularized by Lassus and Lejour relies on a superiorly based dermoglandular element for resuspension of the breast. The superior pedicle is invaginated in such a way to add retroareolar projection and superior pole fill. Lower pole medial and lateral pillars are sutured together to provide support, elevation and narrowing of the breast width which has proven to be longstanding years following the procedure. For these reasons, the superior pedicle flap mastopexy procedure has become our mastopexy procedure of choice in that it delivers reproducible and sustainable results, few complications, and shorter scars on the breast.

Patient Selection

Mastopexy procedures attempt to recreate a non-ptotic breast and as such all patients with second and third degree ptosis are appropriate candidates. There is, however, a subset of patients who yield consistently superior results and are ideally suited for the procedure. Younger women often possess better skin elasticity and a higher percentage of glandular tissue. In these patients the sutures placed in the dissected lower pole pillars tend to hold better thereby maintaining breast shape and elevation. Breasts composed of more fat than fibrous tissue present poorer quality tissue for sutures to hold and tend to become more distorted over time with widening of the scars in the process.

Breast parenchyma volume must also be assessed preoperatively. Patients with larger breasts are often best treated with some degree of parenchymal resection, as the additional weight will be subject to gravity postoperatively and predispose to recurrent ptosis. By contrast, those with volume involution and skin excess may be best served with simultaneous implant placement to recreate superior medial pole fill.

Regardless of technique and possible combination with augmentation, all mastopexy patients need to be counseled in terms of realistic expectations and potential complications, including hematoma, asymmetries, sensory changes and nipple–areolar necrosis. Patients need to understand that their immediate results are subject to gravity, aging and tissue settling, and may be somewhat temporary in contradistinction to scars that are permanent. In addition, some degree of superior pole flattening and skin laxity may persist postoperatively and maneuvers of manually elevating the breast are usually not achievable even with the most sound of surgical techniques.

Indications

The youthful and aesthetically pleasing breast shape is that of a cone with a base diameter ranging from 10–12 cm. The NAC is located at the most projecting part of the cone and usually corresponds to the level of the fourth intercostal space. Composed of adipose tissue and glandular elements, the breast is not a static structure and is subject to multiple external factors which will cause fluctuation in the volume and quality of the tissues. Pregnancy, for example, causes the breast tissue to expand and overlying skin to stretch, often to the extent that inherent tissue elasticity cannot overcome these changes once the hormonal impetus ceases. Weight fluctuation can have a similar effect, stretching skin and suspensory ligaments to a degree that they can no longer maintain an elevated breast position, even with weight loss. Long-standing breast implants can cause attenuation of the supporting network and fibrous portion of breast tissue, leading to a condition of breast volume involution and skin excess. This will be exacerbated by age, which diminishes the amount of glandular tissue and gravity which constantly pulls the breast inferiorly. The result in all these cases is mammary ptosis.

Speaking generally, ptosis refers to relative descent of the NAC in relation to the breast mound with elongation of the distance between the nipple and suprasternal notch. The historical classification system used to define ptosis was elaborated by Regnault and defines three degrees of ptosis based on the relationship of the nipple to the inframammary fold (Fig. 30.1). A situation where the nipple lies at the level of the inframammary fold but above the level of glandular tissue is called first degree ptosis. In these cases, an augmentation mammaplasty is often adequate to correct the condition. In second degree ptosis, the nipple lies below the level of the submammary fold but above the lower contour of breast tissue. Third degree ptosis is characterized by a nipple located below the inframammary fold and at the lowest contour of the breast. Both second and third degree ptosis require some degree of skin reduction and tissue rearrangement for correction. Patients with this degree of ptosis are deemed appropriate mastopexy candidates. The condition of pseudoptosis is unique in that the nipple remains above the inframammary fold but the skin and glandular elements have fallen below the crease. This is usually corrected with augmentation.

Fig. 30.1 Degrees of breast ptosis based on nipple position relative to inframammary crease.

Reprinted with permission from Boehm KA, Nahai F. Mastopexy. In: Nahabedian MY, editor. Cosmetic and reconstructive breast surgery, A volume in the Procedures in Reconstructive Surgery series. New York: Saunders; 2009.