GRAB + NELIGAN (combo)

1. Breast Aesthetics
Mastopexy,
Mastopexy-Augmentation Mammoplasty
By:
Dr.Akasha Amber

2. Mastopexy
• Lay public; breast lift
• Ptosis (Greek; falling)
• Confusion; reduction or mastopexy?
• Reshaping the breast with or without
parenchymal reduction(Peter C.Neligan)
• Lifting and reshaping breast by redistributing
tissue without reducing volume (Grabb &
Smith’s)

3. Anatomy

4. How does a ptotic breast appear???
• Parenchymal sagging, ptotic skin envelope and
upper pole emptiness

5. Pathophysiology
Ptosis
Skin
stretched,
thinned out,
excess
Inadequate
parenchyma,
maldistribution
Loss of
integrity of
Cooper’s
ligament
Inelastic
facial
support
Involutional
atrophy of
parenchyma
over time
Effect of
gravity

6. Etiological Factors
• Aging
• Breast implant
• Gravity effects
• Hormonal effects on parenchyma during
pregnancy, lactation & menopause
• Weight fluctuations in obese
• Congenital deformity ( tubular breast)
• Asymmetry of contralateral breast in post-
ablative breast reconstruction

7. Grades Of Breast Ptosis
Regnault’s classification

9. Grades Of Breast Ptosis
Regnault’s classification

10. Goals
• Restoring youthful firm breast
• Correction of ptosis
• Minimize scarring
• Slow down recurrence/longevity of procedure
• Reshaping/redistributing parenchyma
• Tightening ptotic skin envelope
• Maintaining nipple areola vascularity

11. History
• Dartiques: minimizing cutaneous incision
• Lösch: circumareolar incision to vertical scar
• Claude Lassus: classic vertical scar technique
• Lejour: adjunctive suction assisted lipectomy
• Hall-Findlay: medial NAC pedicle, no SAL, no undermining of flaps, Laterally based
pedicle
• Wise: wise pattern reduction mammoplasty, inverted T scar with periareolar
incision
• Góes: use of mesh
• Graf and Biggs: adding autologous tissue flap in loop of pectoralis major muscle

12. Tuberous breast deformity
• Tubular/constricted
• High IMF, hypoplastic lower
pole, NAC inferior most
aspect
• Herniation of NAC
• Unilateral or bilateral(same
or varying degrees)
• Classification by Grolleau &
Von Heimburg

14. Patient evaluation/selection
• Patient education
• Predetermined notions and patient’s expectation with
regard to the final results, and misunderstandings
resolved
• Techniques with their rationale explained
– Special discussion about incision pattern and expected
scars, weighing risks over benefits
• Informed consent (including risks, benefits and
alternative to proposed technique)
• Preop. planning/measurements
• Preop. imaging (digital photography, 3D imaging,
computerized image-enhancing softwares)

15. Points not to be missed in history and
examination
• Age
• Cardiopulmonary status
• Already taking medications or change of
medication
• Previous stroke
• Renal or hepatic insufficiency
• Coagulation profile
• Previous surgery (chest wall or breast)
• Any weight loss
• Possibility of pregnancy

16. AGAIN, very important !!!
• Expectations of patient regarding:
– shape, scar pattern and length
– Amount of skin excised
– Modification of breast size

17. Points not to be missed in history and
examination
• Breast History:
• Any recent breast, nipple changes, any discharge
• Previous mass or previous surgery
• Previous scars
• Previous biopsy or mammography
• Radiation therapy
• Family history of breast cancer
• Recommend “mammography” in all above 35
years of age

18. Points not to be missed in history and
examination
• Breast size, volume and shape
• Quality and excess of skin envelope
• Nipple position
• Areola size
• Asymmetry
– (notch to nipple distance and sternum to nipple distance)
• Degree of ptosis
• General physical and systemic examination

19. Measurements
• Distance from suprasternal notch to nipple
• Nipple to IMF distance
• Breast base width/diameter( on chest wall)
• IMF length

20. ALGORITHM for choosing right procedure
W.Grant Stevens’
Algorithm
Pseudoptosis
For large: biplanar
augmentation
For same: Small resection
and biplanar
augmentation
For small: inframammary
wedge excision
Grade I Ptosis :
need upto 2cm nipple
elevation
Larger: biplanar
augmentation with
circumareolar mastopexy
Same: circumareolar
mastopexy
Small: small reduction
Grade II Ptosis:
3-4cm nipple elevation
Large: augmentation with
mastopexy(circumvertical
with horizontal wedge
excision)
Same: vertical or wise
pattern mastopexy
Small: small reduction
Grade III Ptosis:
>4cm nipple elevation
Large: wise pattern
mastopexy and
augmentation (one stage)
Same: wise pattern
mastopexy
Small: wise pattern
reduction0
Based on woman’s
desired breast volume
and nipple elevation

21. TECHNIQUES
Scar based:
– Periareolar
• Crescent
• circumareolar
– Vertical
– L or J
– Inverted T

22. 1.Periareolar technique
• Donut skin excision or superior crescent
• Mild to moderate ptosis with adequate breast
parenchyma(volume)
• If volume inadequate --- implant
• Lift: 1-2 cm
• Spear Rules:
– Nonpigmented skin excised < pigmented skin excised
– Outside diameter not more 2 times the inside diameter
– Final diameter= ½ ( outer diameter + inner diameter)
• Advantages: camouflage of incision
• Disadvantages: limited cephalic NAC movement, widened
areolar scar, decreased breast projection

23. Concentric mastopexy without
parenchymal reshaping
• Only periareolar incision given, donut skin
excision done
• Purse-string suturing done

24. Periareolar Benelli mastopexy
• Mastopexy with reduction
• Skin and gland both treated
• Simple gland folding and plication or creating Superior , medial, lateral
dermoglandular flaps
• inverted T type of incision through the gland
• Cerclage stitch as in donut mastopexy
• Minimum glandular tissue-- implant
• AIM: Reducing the breast width, tightening the lower pole, and
coning the breast construct by crisscrossing the medial and lateral
dermoglandular flaps
• Useful in very large breast and high degree of ptosis with minimum
scarring
• not recommended for breasts ,mainly fat or have a large amount of
skin excess(poor quality)
• Advantages: minimize scar and recontour and reshape the gland
• Disadvantage: widened scar, flattened breast

25. A
B
C
S
D
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
Dissection of breast during Benelli
mastopexy. Incision of dermis from
2-o’clock to the 10-o’clock position
with dissection to the inframammary
fold subcutaneously

26. Four flaps of the Benelli mastopexy:
Superior dermoglandular flap
supporting nipple, medial and
lateral flaps, and detached skin flap
Keel-like resection
Medial flap
Lateral flap
Superior flap
Benelli mastopexy. Attachment
of the superior flap to the chest
wall by the pectoralis fascia.

27. Benelli mastopexy. Superior flap attached
to the chest wall demonstrating areolar
elevation and exaggerated convexity of
superior pole.
Medial glandular flap affixed
to the underlying
pectoralis muscle
Lateral flap is affixed to the medial flap

28. Plication invagination of the gland to form a conical shape.
Fixation of areola to the superior border of the ellipse.
round block
suture
U stitch: prevents areolar herniation, gives circular shape

29. Góes periareolar technique with
mesh support
• “double skin” technique
• Pectoral fascia, intramammary connective tissue ligaments, periareolar
dermal flap (used as internal skin lining), an absorbable mixed mesh, and
the external skin lining
• mesh causes a fibrotic reaction that serves to support the breast for a
longer time during the healing and cicatrization process
• Mesh:
– absorbable(mixed mesh; polyglactin mesh with Dacron filaments or woven
mesh; polyglactin/polypropylene)
– integrated(biological)
• Disadvantages:
• technical difficulty
• mesh-related complications, such as infection, palpability, retraction, skin
necrosis, or extrusion

30. Four cardinal points of Góes mammoplasty
A is top of new areola,
B is from IMF to new areola bottom (average 7cm)
C is distance from medial breast border to medial aspect
of new areola at nipple level (avg 9 cm)
D is distance from the anterior axillary line to the lateral
aspect of the new areola at the level of the nipple
(average 12 cm)
Dissection of the gland to separate it from the skin along
with lines of excision of gland.
Note the formation of the internal skin lining
Wedge of
hemisphere to
be resected
Internal
skin lining
Pectoralis
fascia
Pectoralis
major muscle

31. Lines of resection from the superior
and inferior hemispheres to narrow the
base. In mastopexy alone, these
regions can simply be imbricated rather
than resected

32. (A) The breast projects anteriorly and superiorly after
formation of the cone and reinforcement of the breast
with mesh.
(B) Schematic for placement of mesh. The polyglactin-
Dacron composite mesh of Goes’ (Vicryl-Prolene composite)
A
B

33. 2.Vertical/short scar technique
• Lassus vertical scar technique
• reduction and mastopexy
• 4 principals:
– central wedge resection
– transposition of the areola on a superiorly-based flap
– no undermining of the skin
– addition of a vertical scar component
• Indications:
• Firm gland, good skin quality, young patients, not very large or ptotic breasts
• If NAC elevation >10 cm needed; medial or lateral flap by Skoog
• Advantages:
• Central wedge excision; avoids injury to vascular supply
• No undermining of skin from gland or gland from muscle; no glandular or skin necrosis
• Avoids necrosis of nipple areola or loss of their sensation
• Disadvantage:
• Visible vertical scar
• Final result and shape takes months(2- 2.5months)
• Technical difficulty

34. Vertical/short scar technique
• Lejour vertical scar technique:
• Lejour’s modifications of lassus
• Shortening scar, using superior pedicle following three principles:
– wide lower pole skin undermining
– Overcorrection of the deformity
– Liposuction
• used either as a reduction technique or as a mastopexy
• Advantages:
• Postoperative stability
• No scar widening
• Preservation of nipple sensitivity
• Liposuction reduces volume and recontours the shape as needed without
damaging important structures
• Disadvantage:
• Late results
• some skin redundancy remains (necessitates excision)

35. • Hall-Findlay’s vertical technique:
– Wise pattern vertical technique without lateral
and medial extensions
• Hammond SPAIR technique:
– Short scar periareolar inferior pedicle reduction
mammoplasty
– Inferiorly based pedicle

36. Grotting sculpted vertical pillar
mastopexy

37. Notch to new areolar distance is approximately 20-23cm.
From top of vertical closure,5-6 cm down a point is marked for future IMF.
Preaxillary fullness and lateral chest rolls: liposuction for the contour

38. • the bottom of the incision line coming to a V approximately 2 cm above the inframammary
fold (point B). The hatched lines show the location of the glandular resection at the bases of
the medial and lateral pillars.
• A superiorly-based flap can be created from the tissues between the marked medial and
lateral pillars, rotated retro-areolarly, and then sutured to the pectoralis fascia to improve
upper pole fill.

40. Rounded superior pole, flat lower pole, and
slightly downward pointing nipple.(upside down breast
shape)
lower pole of the breast detached.
The resulting flap transposed into the retro-areolar
location to augment the upper pole or resected
in cases such as a small reduction or when an implant is
to be added (addition-subtraction concept)

41. Final closure and tegaderm dressing(2 weeks) then advise a bra day and night for 6-8 weeks

42. Augmentation mastopexy
(Kent K. Higdon and James C. Grotting)
• Indications:
– Glandular deficiency irrespective of skin envelope
– After explantation with inadequate residual parenchyma
– Asymmetry (one breast is hypoplastic & other is ptotic)
• Advantages:
– Improved fill in superior and superomedial aspect
• Disadvantages:
– wound problems and dehiscence because of added weight of the
implant
– inherent risks of the implants (malpositioning, leakage, rupture,
capsular contracture)
• Addition subtraction principal
• implant ; subglandular or subpectoral position
– available parenchyma as determined by skin pinch thickness of >3 cm
• Autologous fat grafts in the upper pole (if not wanting an implant)

44. Inverted T scar technique
• Indication:
– moderate to severe breast ptosis with a large excess of
skin and a moderate amount of glandular tissue.
• Advantages:
– ability to excise all excess skin
– Allows for final adjustments
– decreases the chance of subsequent revision
• Disadvantage:
– increased length of the incisions & scars
– high chances of recurrent ptosis
• (new breast mound has only skin envelope, no pillars or
interglandular sutures)
• MARKINGS;
– same as wise pattern vertical scar with horizontal
component

47. Postoperative care
• Prophylactic antibiotic (1st gen. cephalosporin;
cefazolin)
• Analgesics
• Antiemetics
• Tegaderm dressing with areolar window(@
weeks)
• Postoperative brassier (6-8 weeks)
• Drains; not necessary
• Mild activities; 2 weeks later
• Full exercise; 8 weeks later

48. Complications
• Nipple loss
• Sensory loss
• Flap necrosis
• Scar widening
• Nipple malposition
• Cosmetic disappointments
• Wound related complication
• Implant related complication