A and Ptosis 3

HYPERMASTIA AND PTOSIS
DR. WAN SYAZLI Plastic Surgery Masters Class
References
1. Mathes SJ. Plastic Sugery, 2nd Edition, Volume VI, 2006.
2.
3.
Adam WP, Reduction Mammoplasty and Mastopexy, Selected Reading in Plastic Surgery, Volume 9, Number 29, 2002.
Grabb & Smiths Plastic Surgery, 6th edition, 2007.
4.
Okoro, Stanley, Barone, Constance, Bohnenblust, Mary, Wang, Howard Breast Reduction Trend among Plastic Surgeons: A National Survey. Plastic & Reconstructive Surgery. 122(5):13121320, November 2008
Spear SL, Howard MA. Evolution of the Vertical Reduction Mammaplasty. Plastic And Reconstructive SurgeryPLASTIC, September 1, 2003.
5.
References
6. Maxwell GP, White DJ. Inferior Pedicle Technique of Breast Reduction. Operative Techniques in Plastic and Reconstructive Surgery, Vol 3, No 3 (August), 1996: pp 170-175. Malata CM,Bostwick J. Breast Reduction with the Superior Parenchymal Pedicle: T-Scar Approach. Operative Techniques in Plastic and Reconstructive Surgery, Vol 6, No 2 (May), 1999: pp 126-135. Hanemann, Michael S. Jr MD *+; Grotting, James C. MD, FACS Evaluation of Preoperative Risk Factors and Complication Rates in Cosmetic Breast Surgery Annals of Plastic Surgery. 64(5):537540, May 2010. Henry, Steven L. M.D.; Crawford, J Lauren M.D.; Puckett, Charles L. M.D. Risk Factors and Complications in Reduction Mammaplasty: Novel Associations and Preoperative Assessment Plastic and Reconstructive Surgery Volume 124(4), October 2009, pp 1040-1046
7.
8.
10.
References
11 Foad Nahai, The Art of Aesthetic Surgery, Quality Medical Publishing 2005 Hall-Findlay, Elizabeth J. M.D., F.R.C.S.(C) A Simplified Vertical Reduction Mammaplasty: Shortening the Learning CurvePlastic & Reconstructive Surgery: September Volume 104 Issue 3 - pp 748-759
12
13 Lejour, Madeleine M.D., Title Vertical Mammaplasty and Liposuction of the Breast. Plastic & Reconstructive Surgery. 94(1):100-114, July 1994
Outline of presentation
Introduction Anatomy History of breast reduction / mastopexy Breast reduction / mastopexy Definition Indication / goal Contraindication Pre-op counselling / evaluation Planning Technique complication
Introduction
The size, shape, and symmetry of a womans breasts can have a profound effect on her wellbeing, both mental and physical. Breast enlargement usually completed by late teen but may continue into early adulthood. Reduction mammaplasty is performed more than 100,000 times per year in the United States
May be associated with:

Hypertrophy Asymmetry ptosis
Hypermastia hypertrophied breast Ptosis sagging breast
Breast Hypertrophy
Breast Hypertrophy
abnormal end-organ response to estrogens. usual number of estrogen receptors begins with the hormonal challenges puberty and pregnancy consists primarily of fibrous tissue and fat The breast stroma: increases but the glandular component: remains fairly low.
Gigantomastia
imassive enlargement of the breast tissue to enormous proportions defined as yielding at least 1800 g of tissue per side during reduction mammaplasty.
Gigantomastia
occurs predominantly in girls 11 to 14 years of age and most often manifests with the first menses
Differential diagnosis
Differential diagnosis of unilateral breast enlargement:
Giant fibroadenoma Cystosarcoma phyllodes Breast harmatoma Virginal hypertrophy Hematoma / trauma Breast cancer
Anatomy
The breast overlies the pectoralis major muscle as well as the uppermost portion of the rectus abdominis The nipple should lie above the inframammary crease and is usually level with the fourth rib and just lateral to the midclavicular line.
Anatomy
Blood supply:
1. Internal mammary perforators
2nd to 5th perforators

Mainly supply medial portion
60% total breast blood supply
2.
Lateral thoracic artery
Supply lateral and upper outer portions 30% of total breast vascularity
3.
posterior intercostal arteries
branches from the 3rd, 4th, and 5th Supply the lower lateral aspect 10% of total breast vascularity
Nerve supply:
Breast innervation: 2nd to 6th intercostal nerves
1.
2.
Lateral: lateral cutaneous branch of 3rd 6th intercostal nerves Medial: anterior cutaneous branches of 2nd 6th intercostal nerves Anterior and lateral cutaneous nerves of 3rd 5th intercostal nerves Most important: lateral cutaneous branch of 4th Intercostal nerve
Nipple/ areolar:
1. Period before 1930

1880 - 1930: period of enlightenment -appeared European literature and debated in surgical forums transition from an ablative (mastectomy) to reconstructive approach to macromastia often failed to produce natural form or contour
1. Period before 1930

concepts fundamental to modern mammaplasty were introduced Morbidity: due to limited understanding of the vascular anatomy of the breast and NAC
6th century AD - Paulus Aeginata: described reduction mammaplasty for gynaecomastia early 19th century Hans Schaller: described breast amputation mammoplasty
1848 Dieffenbach: performed first reduction mammaplasty 1909 Morestin: introduced concept of nipple-areolar complex (NAC) transposition
1922 Thorek: advocated transverse amputation of lower pole of breast with free nipple grafting
1923 Aubert: emphasized the importance of leaving the skin attached to the gland to minimize vascular complications
1925 Passot: described nipple transposition into a button hole incision higher on the breast mound
1928 Biesenberger:
total dissociation of skin from parenchyma and transfer of the nipple on the retained gland inverted T scar
1930 Schwarzman: suggested maintaining the nipple on a superomedial dermal pedicle
2. Pre-modern era (Period 1930-1960)

recognition of the importance of the dermal blood supply to nipple viability marked the transition to this era noted for the widespread popularity of the Beisenberger technique refinements in skin incisions (to place scars in aesthetic sites) and pedicle designs to further preserve vascularity
1948 Barnes: emphasized on pre-operative marking of incisions and proposed resection 1949 Aufricht: commented post-surgical skin brassiere 1956 Wise:
landmark paper measured keyhole pattern of skin resection
3. Modern Era (From 1960 onwards)

Fundamental techniques introduced by, Skoog, McKissock Strombeck, and others in the early 1960s mark the modern era of reduction mammaplasty
1960 Strombeck:
described a horizontal dermal bipedicle flap for NAC transposition that maintained NAC innervation through lateral attachments
Many variations based on different orientations of the dermal pedicles emerged:

1962 Pitanguy/ Weiner: superiorly based pedicle 1963 Skoog: Horizontal unipedicle, inverted T scar 1972 McKissock: Vertical bipedicle 1975 -- Orlando/ Guthrie superomedially based pedicle 1975 -79 -- Ribiero (1975) /Courtiss and Goldwyn (1976) / Georgiade (1979) inferiorly based pedicle
Vertical and short scar techniques:

1964 Lassus: vertical technique with a superior pedicle 1982 Marchac: Vertical technique with short inframammary scar 1990 Lejour: popularized the vertical reduction mammaplasty. Suturing of the gland , with extensive skin undermining inferiorly and gathering of the vertical scar 1998 Hammond: Short Scar Periareolar Inferior Pedicle Reduction (SPAIR) mammaplasty 1999 -- Hall-Findlay: modification of the vertical reduction mammaplasty using superiomedial pedicle
1990-96 Benelli: periareolar reduction Suction lipectomy
Breast Reduction - Definition

Surgical reduction of breast volume to achieve
a smaller, aesthetically shaped breast mound with Relief of potential symptoms of mammary hypertrophy
GOALS OF SURGERY
provide parenchymal support to the breast for longevity of the result discard excess skin while reducing tension on the closure (avoid using the skin to create the breast shape) minimize scars
GOALS OF SURGERY
improve symptomatology decrease the volume of breast tissue while maintainin the vascular and neural integrity of the nipple-areola reposition the nipple-areola complex in its anatomically correct position create a predictable, stable, and better breast shape
Breast Hypertrophy - Indications for surgery

Major indications:
1. 2. 3. 4. Very large breasts Shoulder pain Cervical and upper thoracic backache Severe embarrassment (physically or sexually) 5. submammary maceration and infection
Breast Hypertrophy - Indications for surgery

Minor indications:
1. 2. 3. 4. Inability to exercise due to breast discomfort Difficulty with breathing during exercise Difficulty finding clothing to fit Grooving and hyperpigmentation of shoulder strap areas
Breast Reduction Contraindication

In extreme cases degenerative arthritis of the cervical and thoracic spine has been noted.
Breast Reduction - Contraindication

Absolute contraindications:
1. Current or recent lactation (< 9 months) 2. Unevaluated breast masses or unevaluated mammographic findings
Relative contraindications:
1. Current smoking history 2. Greater than 30% ideal body weight; obesity 3. Inappropriate psychiatric evaluation
Breast Hypertrophy - Evaluation

History:
Presenting symptoms:
Younger patients:
Breast pain Rashes beneath or btw the breasts during summer months Psychological issues: Personal embarrassment, anxiety
Older patients:
Physical symptoms: upper thoracic backache Difficulties in mammograms
Active women:
Inability to exercise without discomfort

Review of breast cancer risk factors (personal or familial) Scarring tendencies Review of history of any bleeding disorders, DM or collagen vascular disease Smoking history Review general medical background Pregnancy and childbearing history Lactation and nursing history Future pregnancy and nursing plans

Physical examination
General body habitus
Height and weight (estimated % of ideal body weight)
Local examination:
to exclude masses axillae and supraclavicular lymphadenopathy striae and scar in breast skin shoulder and bra grooving breast asymmetry nipple-areola complex: size, shape, sensitivity

Specific Investigations:
Mammography:
in all pts with risk factors or > 35 years
Psychological evaluation and counseling
Preoperative counseling
Preoperative counseling should be unhurried, thorough, and should cover the following points: Expected scar appearance Worst case scar appearance Expected immediate and final breast shape Uncertainty with regards to future lactation potential as well as postoperative nipple sensation Chance of partial or complete nipple necrosis
Evaluation of Preoperative Risk Factors and Complication Rates in Cosmetic Breast Surgery
Hanemann, Michael S. Jr MD*; Grotting, James C. MD, FACS
Annals of Plastic Surgery. 64(5):537-540, May 2010. 13,475 consecutive patients between April 1, 2008 and March 31, 2009. Correlations between complication rates and risk factors of body mass index >=30, smoking, and diabetes were analyzed.
Breast Size after Reduction

Patients are measured while sitting with arms by the sideband wearing a bra. depends on the ratio of breast girth to chest girth. If breast girth exceeds chest girth by1 inch, cup size is an A; 2 inches, a B; 3 inches, a C;4 inches, a D; and 5 inches, a DD.
Breast Size after Reduction
Penn:
Determining Nipple Location and Size

Nipple to sternal notch distance: 21cm (19-22cm) Internipple distance Nipple to inframammary fold distance: average 7cm (812cm) Nipple diameter (38 45mm)
Pitanguy points:the level of the

inframammary crease at the midclavicular liine
Pitanguys point:
measure from the level of the inframammary crease at midclavicular line
principles of modern reduction

The fundamental principles of modem reduction mammaplasty:
1. Sculpture of the breast by tailoring both skin and gland. 2. Preservation of nipple blood supply and innervation by transposition of the nippleareolar complex on a parenchymal pedicle. 3. Reliance on predetermined patterns and mechanical aides.
Techniques of Reduction Mammoplasty

Classified by 1. The pattern of skin excision 2. The design of pedicle
Skin resection patterns

Wise / Inverted T skin resection pattern Vertical skin resection pattern Lateral skin resection pattern B technique (Regnault) Circumareolar skin resection pattern Pattern with no vertical scar
Inverted T skin resection pattern

Workhorse approach of breast reduction Usually associated with inferior pedicle Skin brassiere to shape and hold breast
Inverted T skin resection pattern

Best for very large
breasts or for massive weight loss patients who have a large amount of loose inelastic skin
Vertical skin resection pattern

Can be used for a wide variety of breast sizes Up to 2000g and above Cones the breast better than inverted T
Retain shape longer = avoids effect of gravity
Vertical skin resection pattern

For a larger
resection, ,may add a short T or L to remove excess skin Weight of inferior pedicle = bottoming
Small breast reductions The doughnut is sutured to the hole Benelli roundblock technique
Circumareolar skin resection pattern
Circumareolar skin resection pattern

? Separate skin from
the glands to reduce tension on skin closure A permanent suture still required Sampaio Goes absorbable mesh
Lateral skin resection pattern

Skin excision tapered laterally May result in medial displacement of the NAC if used lateral skin and parenchymal resection alone When designed separately from the skin, parenchymal resection can achieve an acceptable result May avoid the medial inframmary scar with inverted T technique
The B technique (Regnault)

A variation on the lateral resection Using superior pedicle but tapered the skin resection laterally, leaving a B-shaped scar Complicated design
Regnault B Technique: superiorly based dermal pedicle, inferior and deep parenchymal resection, and preferential preservation of the lateral tissue for creation of breast mound.
Blood supply to the NAC

One is through a dermal-parenchymal pedicle in which the nipple-areola is left attached to its surrounding dermis and underlying parenchyma to preserve the subdermal plexus that nourishes. The second method is a parenchyma-only pedicle.

Dermal-parenchymal pedicle
Horizontal bipedicle Vertical bipedicle Inferior pedicle Superior pedicle Central pedicle Lateral pedicle Medial pedicle
Parenchymal only pedicle

central mound technique
Dufourmentel-Mouly mammaplasty
Horizontal bipedicle (Strombeck)

Combines laterally based circulation to the areola and medially based circulation Dermal pedicle may be sufficient Caused nipple retraction
Horizontal bipedicle (Strombeck

horizontal and vertical resection of glandular tissue from the lower pole and transposes the nipple to its new location on a horizontal bipedicled flap of dermis fatty breasts or when the nipple was inverted or under traction, divided the lateral pedicle to create a single medial dermal pedicle transposition flap
Horizontal bipedicle (Strombeck)

criticized on the basis of a difficult nipple inset and awkward maneuvering of the pedicle intraoperatively a high incidence of nipple insensitivity postoperatively.
Vertical bipedicle (McKissock)

1972 Good circulation to the nipple the inferior limb, including the nippleareola, contained a dermoparenchymal component. Not difficult to inset
Vertical bipedicle (McKissock)

Maximum pedicle length recommended for this technique is 40 cm The superior flap is thinned of underlying parenchyma and the area above the nipple is left with only dermis Maximum pedicle length recommended for this technique is 40 cm.
Vertical-Bipedicle Techniques
The inferior pedicle base is tapered laterally to recruit blood supply and help preserve sensory innervation to the nipple
McKissock Vertical Bipedicle Technique

The flap was folded on itself at inset Better nipple sensation than Strombeck procedure
Vertical bipedicle folded on itself as key sutures tied
Inferior pedicle
The superior portion or vertical bipedicle was not necessary for circulation to the NAC Inferior pedicle alone may be adequate
Inferior Pedicle Technique

One of the most commonly used in USA Basis: preservation of NAC viability on a inferiorly based dermal-parenchymal pedicle Described with many variations by surgeons such as Ribeiro(1975), Robbins (1977), Courtiss and Goldwyn (1977), Giorgiade (1979)
Inferior-Pedicle Techniques
inferior-pedicle techniques lack parenchymal support and inevitably the breast will bottom out. While shortening the nipple- IMF distance can help counteract this tendency, it must be balanced against excessively tight closure.
3002500 g can be removed safely. The longer the nipple-to-IMF distance, the wider the base of the pedicle should be. Georgiade recommend a 3:1 length-towidth ratio and state maintaining the attachments of the breast to the pectoralis major muscle and thereby to the intercostal perforators. Mandrekas et al - 72% were able to secrete milk
The longer the nipple-to-IMF distance, the wider the base of the pedicle should be very wide pedicle bases may compress small vessels when the skin envelope is closed.
Its advantages:
1. ease of performance and teaching 2. good preservation of the neurovascular supply to the nipple (vascularity and sensation) 3. applicable over a wide range of reduction sizes (Breast volumes of 3002500 g can be removed safely) 4. consistently gives good results that appear to hold their shape over time. 5. a very flexible technique useful on asymmetric breasts Allows varying amounts of resection from flaps and pedicles, and in nipple placement.
Disadvantage:
conventional inferiorpedicle techniques:
lack parenchymal support, the breast will bottom out Shortening the nipple-IMF distance can help counteract this tendency
Superior-Pedicle Techniques
Weiner first described reduction mammaplasty on a superiorly based dermal flap in 1973. inferior-pole parenchymal resection reliable. limited by increased difficulty in moving the nipple longer distances, particularly in patients with significant breast hypertrophy.
Superior Pedicle Technique

Robbins and Hoffman (1992):
Superior dermoglandular pedicle Nipple necrosis 1.4% (193 pts) Nipple sensation appeared good Recommended for resection up to 1200g
Advantage:
reliable and reproducible. avoid the bottoming out of inferior/central mound methods provide satisfactory preservation of nipple sensation.
Limitation: increased difficulty in moving the nipple longer distances in significant breast hypertrophy.
Superior pedicle
Still being used especially in Europe and South America Less ptosis, - removing heavy inferior tissue Not easy to inset Pedicle need to be thinned
Lateral pedicle
Dual circulation through horizontal bipedicle unncessary Not easy to inset without depressing the NAC Overshadowed by successful applicatio of the inferior pedicle
Lateral-Pedicle Techniques
Skoog described an operation in which the nipple-areola was elevated on a lateral dermal pedicle. a modified of Strombeck resection, with most of the reduction in the inferior and medial quadrants
Nicolle104 modified Skoogs procedure by angulating the keyhole resection obliquely toward the lower lateral quadrant of the breast. The nipple is carried on a lateral dermoparenchymal pedicle instead of a purely dermal pedicle as Skoog
Botta and Rifai - refinements of Skoogs lateral-pedicle technique for reduction mammaplasty limit nipple transposition to a maximum of 15 cm to lessen the risk of nipple necrosis. new nipple position is 2023 cm from the suprasternal notch
Medial-Pedicle Techniques
Translocated on a medial dermoglandular pedicle. Nahabedet - Forty-four of 45 breasts were successfully reduced by this technique
The dilemma of how to maximize vascularity of the long pedicle (by keeping it wide) while ensuring adequate tissue resection is pervasive
Medial pedicle
Believed that nipple sensation may be affected mistakenly understood that the only innervation to the nipple came superficially through the lateral forth intercostal nerve
Parenchymal only pedicle

Biesenberger 1931 1960s Climo and Alexander suggested removing the dermal bridge while preserving the attachments of the anterior branches of the 4th through 6th intercostal arteries to the inferior parenchymal tissue NAC to be supported by a central parenchymal pillar
Closure of the lower incision molds the residual gland into a conical shape and tightens the dermal brassiere.
Central Mound Technique

Described by Hester in 1985 Nipple on central glandular pedicle A conical or mound shape all around the central NAC, better shape for new breast Problem: bottoming out
Central pedicle
Modification of the inferior pedicle technique, based the NAC on the central pedicle Same blood supply as the inferior pedicle technique Perforating arteries through the pectoralis muscle
Dufourmentel-Mouly mammaplasty
a lateral wedge mammaplasty that involves lateral excision of skin and parenchyma and nipple transposition on a superomedial parenchymal pedicle The skin over the inferior pole of the gland is undermined lightly to allow rotation, and the nipple is placed in its new position,
Short-Scar Techniques
Technical modifications aim to eliminate or minimize the vertical and horizontal scar limbs In general, it is best suited to young women with modest to moderate hypertrophy and good skin quality. Short-scar techniques categories:
1) vertical mammaplasty; 2) vertical mammaplasty with short horizontal extension 3) L-scar mammaplasty; 4) horizontal mammaplasty 5) periareolar mammaplasty
Vertical Mammaplasty
1964 Claude Lassus by resection en bloc of skin, fat, and gland; transposition of the areola on a superiorly based flap; no undermining; and a vertical scar
Lassus pioneered vertical scar technique in 1964 Principles:

Use of superior derglandular pedicle Inferior pyramidal glandular resection No skin undermining Closure with a vertical scar
1996: results of 710 pts over 30 yrs

No nipple necroses (if nipples not transposed > 9cm vertically) Conical projection well maintained Results stable over long
Vertical breast reducion technique

The vertical limbs are similar to Wise pattern except that they are joined rather then extended laterally and medially Increased projection of nipple New nipple at IMF, lower than inverted T
Vertical incision design

Design of the areolar opening Design of the pedicle Areas to be liposuctioned
Position of the IMF

Placement of tape measure beneath the breasts and marking of the inframammary fold
Determining the new horizontal nipple position

Meridien marking is independent of the current nipple position Marking should be at the chest wall and breast meridien
Determining the new vertical nipple position

Transposition of the IMF to the front of the breast The new nipple must be placed 2cm lower than inverted T procedure To accommodate increased projection Closure of vertical elllipse tend to push the nipple higher
Marking the breast meridian by rotating the breast laterally and medially Breast median
resection pattern marked by rotating the breast upward and outward to join the meridien marked on the upper breast to the one below the IMF
Marking the breast meridian by rotating the breast laterally and medially
Closure should not be under tension
Inferior extent of the skin resection

Vertical lines joined above the IMF In small reduction, lower portion of the U at least 2cm above the IMF In larger resection, 4cm brige margin Larger resctiion, 6cm left
Design of the areola opening

The new nipple position was marked at the level of the IMF Vertical incisions were then joined as a triangle for a later areolar opening design
Design of the areola opening

Mark areolar opening before surgery Lejour mosqueshaped design A circle when closed The symmetry of the areolar design and skin resection pattern is checked
Design of the pedicle

Medial based pedicle Half of the base in the areolar opening and half below vertical opening 1:1 ratio for the base to the full pedicle length Pedicle can be medial or superomedial
Areas to be suctioned
The preaxillary and lateral chest wall areas to be suctioned are marked Liposuction is combined with direct fold excision to elevate the fold
Vertical resection pattern with the medial pedicle

Parenchymal resection extends well beyond the skin resection

Pedicle deepithelized, leaving a margin of skin around areolar Areolar diameter designed about 5cm in diameter with extra cm if skin and tissue

About half of the pedicle base is in the areolar opening and half of the base is on the vertical incision line A significant amount of skin is left intact between the resection and IMF

Pedicle is carried down to the chest wall Pedicle rotated into position Haemostat is pointing to the vascular leash, transected with the resection

Inf border of the medial pedicle becomes the medial pillar and the whole pedicle, including its base, rotates into position Resection beveled medially and laterally down to IMF Less skin than Wise

Parenchyma resected Skin flap thicker further away from the skin edges Care maintain to upper pole fullness

Tissue left on either side of the marked breast meridian

The final resection of the parenchyma should follow the Wise pattern Tissue remains is superior, superomedial and superolateral

The medial pedicle is full thickness down to the meridian of the chest wall Parenchymal resection beveled out laterally Base of areolar sutured

Pillars should be no more than 7cm in length Suturing starts inferiorly at the lower end of the pillars

Liposuction performed before final closure

The areolar is sutured
Vertical Reduction Mammoplasty

Advantages:
1. Elimination of the inframammary scar, important in women prone for scarring. 2. Improve in breast shape with better projection 3. Safe procedure for all sizes of breasts 4. Skin marking adjustable for all patients 5. Skin is not relied on to support the breast 6. Shorter operating time 7. Nipple sensation comparable with other techniques
Vertical Reduction Mammoplasty

Cons:
1. The scar and breast shape are not significantly different with this technique 2. Technique restricted to small breasts only 3. Steeper learning curve
Lejours technique
In 1990s, Lejour modified Lassuss technique with wider acceptance Her modifications:
1. 2. 3. 4. Adjustable skin markings Total breast liposuction for volume reduction Extensive lower lateral breast skin undermining Suture suspension of pedicle to pectoralis major fascia 5. Tumescent fluid infiltration into breast gland 6. A short vertical scar that does not extend below the IMF
Preoperative marking:
In upright position Mark the midline, IMF and future nipple position (typically 22-23 cm from sternal notch) Displace the breast medially and laterally in relation to the vertical axis of the breast marked below the IMF Connect the medial and lateral margins by a gently curving line above the IMF. Make the curvilinear mosque dome periareolar marking 2 cm above the future nipple location.
Intraoperative details:
place the patient symmetrically on the operating room table with arms abducted Infiltrate of lidocaine with epinephrine Liposuction on the breast through the lower pole incision De-epithelialization of superior pedicle Resection of lower pole of the breast Undermine the skin on the inferior portion of breast Plication to Pect major fascia Inset the nipple-areolar complex Gather the undermined skin overlying the mound in the short inframammary scar for final closure.
Pre-op
Post-op: Lejour Technique
Vertical pattern and medially based pedicle
Vertical approach
Vertical approach
Lejours technique
Pros:
1. Stable, conical shape breast with minimal scarring 2. no reliance on the skin envelope to shape the postoperative breast 3. Liposuction with less tissue resection and, therefore, increased preservation of the nerves and vessels
Lejours technique
Cons:
1. up to 6 months may be required to achieve final shape and for vertical scar to smooth and flatten 2. Breast skin excess at the inferior portion of the vertical scar 3. Delayed healing 4. Volume reduction relies heavily on liposuction, not feasible in dense, glandular breasts.
Lassus points out two main differences between his operation and Lejours: Lejour uses undermining and often combines the procedure with liposuction, Lassus does not cautions against marking the nipple too high and reminds us to keep the lowermost aspect of the vertical resection at least 3-4 cm (in smaller, ptotic breasts
Vertical breast reduction technique

Some completely separate the skin resection pattern from the parenchymal resection pattern. Others follow the skin pattern closely Lejour undermined lat and medially to allow more resection inferiorly and to facilitate closure In medially based pedicle = inferior border of the medial pedicle becomes medial pillar and cones the breast
Vertical Mammaplasty and Liposuction of the Breast Lejour, Madeleine M.D., Ph.D.
Plastic & Reconstructive Surgery. 94(1):100-114, July 1994. 100 consecutive patients (192 breasts) operated on from 1990 through 1992 liposuction was attempted as a complementary procedure before the surgical reduction in the 120 few complicationsrelated to the weight of the breasts and not to the patient's obesity or to the liposuction procedure
L-Scar Reduction Mammaplasty

Bozola118 describes a reduction operation similar to the B technique of Regnault that eliminates the medial horizontal limb of the usual inverted-Tclosure creating an L-shaped scar instead.
Periareolar Reduction
to camouflage the scar in the areola-skin junction Areola diameter can be trimmed irregularities created by the skin gatherings disappear with time Include:
Benelli round block technique Goes procedure Hammond procedure: SPAIR
Periareolar Reduction
Advantages:
minimal scarring and shorter operating times.
Cons:
a flat, underprojecting breast, primarily in the nippleareolar area. marked tendency for the areola to widen
Indication:
may be best for small to moderate reductions with limited skin resection and for mastopexy.
Benelli Round Block technique

Described by Benelli in 1990 The excess skin is taken up in a pursestring manner around the areala High degree of patient satisfaction Cons:
Tendency of breast to flatten in AP dimension Tendency of widening of areolae with time
Goes Periareolar Reduction Mammoplasty

Reported by Goes in 1996 in 254 patients Double skin technique Less skin resection to reduce breast flattening Not for resection >500g
Elevation of thin skin flap Breast resection around a central pedicle Skin flap sutured to anterior pect fascia and closed to cone the breast Vicryl mesh cone further support central pedicle
Short-scar Periareolar Inferior Pedicle Reduction (SPAIR ) Mammoplasty

Introduced by Hammond in 1998 Aim: to provide simpler inferior pedicle-based vertical approach Principles:
The nipple is based on a modified inferior dermoglandular pedicle medial, superior, and lateral glandular resection, parenchymal suspension sutures permanent periareolar purse-string suture to prevent areolar dilatation, and inferior pole skin resection (de-epitheliazation)
Short-scar Periareolar Inferior Pedicle Reduction (SPAIR) Mammoplasty

Pros:
Safety and familiarity of inferior pedicle technique No bottoming out Reduce skin wrinkling with combination of pursestring periarealar suture and vertical closure A truly circumvertical method
Cons:
Reported periareolar scar widening (17%) and wrinkling (11%) Reduced nipple sensation (28%)
Free Nipple-Areolar Grafting

The main indications of partial breast amputation with free nipple areolar grafting: 1. Elderly poor risk patients with systemic diseases (shorter anaesthetic time) 2. Younger women with gigantomastia, overweight ptotic breasts 3. Those who have had previous breast surgery that might risk the future viability of the NAC
After the nipple-areola complex is removed as a free graft, it is thinned to become a thin full-thickness graft The inferior pole is amputated, but deepithelialized breast tissue is purposely left on the superior pedicle extending below the 7-cm vertical limb markings
This deepithelialized tissue can be tucked under later to give more central mound projection The lateral and medial pillars of breast tissue are brought together using a suture technique of several layers to maximize central mound projection The vertical limb of the T-pattern is then intentionally closed with a dog-ear at the top to improve nipple projection.
Free Nipple-Areolar Grafting

1. 2. 3. 4.
1. 2.
Pros: can give excellent relief of pre-operative symptoms good and more lasting cosmetic results Shorter surgery time easily learned technique without complicated preoperative skin marking plans Cons: unpredictable/poor return of nipple sensation Nipple depigmentation (esp in black pts)
minimized by thinning the nipple graft in the periphery Tattooing is required.
The simplified vertical reduction mammaplasty : Hall-Findlay technique

In 1999, Hall-Findlay introduced modifications of Lejours procedure. The aims:
to shorten the learning curve For more reliable in large breast reductions
The modifications include

a superomedial pedicle, no skin undermining, targeted liposuction, and no pectoralis fascia sutures.
Particularly effective in small to moderate reductions tends to maintain its conical shape in long term and less tendency to bottom out.
Liposuction assisted Reduction

As adjunct to excision reduction (Teimourian, 1985) or suction alone (Matarasso,1991). Selection criteria:
Elastic skin and predominantly fatty breasts with nipples in normal nonptotic position For pts wishing conservative reduction without extensive scars.
Complications:
Breast oedema Nipple-arealar diameter decreased with time
No evidence of traumatic calcification (Courtiss, Lejour)
Inverted T technique
Mark breast pre-operatively and determine the new nipple position. Key landmarks = breast meridian and IMF
Position of the IMF Transposition of the IMF to the front of the breast to determine the new vertical nipple position Breast meridian to determine the new horizontal nipple position
Breast meridian technique using the Wise pattern Distance of the vertical limbs Design of the areolar opening Pedicle design Areas to be suctioned
Other technique
Distance from the suprasternal notch to the nipple on both sides Distance from the IMF to the nipple on both sides Suprasternal notch to the new nipple position on both sides (should be lower on a larger breast)
Position of the inframammary fold : using the tape measure

Measuring tape placed along the IMF Mark the postion of IMF
Determining the new vertical nipple position

Transposition of the marking anteriorly form the finger placed under the breast in the IMF
Determining the new horizontal nipple position

Vertical breast merridian is marked by dropping a line from the midclavicle to the midbreast or midchest position Line not necessarily go through the nipple Ideal position on the chest wall
Breast meridian markings using the Wise pattern

Wise pattern, transferred onto X-ray film Dotted line showed how the vertical limbs could be positioned differently depending on how much skin to be removed Distance of vertical limbs measured 5cm
Areolar circumference measured 14cm
Distance of the vertical limbs

The superior pedicled designed Distance of the vertical limb was 6cm Angle of separation btwn VL = amount of tissue to be resected
Design of the areolar opening

Design as an inferior pedicle Areolar opening according to the Wise pattern a triangle in which the desiign will be determined intraoperatively after resection
Design of the areolar opening

Skin resection follows a Wise pattern with a keyhole opening for the nipple areolar complex Excision that gives an achor-shaped skin closure Areolar diameter usually btw 3.5 to 4cm
Pedicle design
Pedicle design separate from skin resection pattern
The breast meridian is marked and this line is extended onto the abdominal wall The anterior projection of the inframammary crease (or a maximum of 12 cm above) is marked on this line as the new nipple position If measured, this will usually be between 22 and 26 cm
A second line 2 to 2.5 cm above this is then marked as the new areolar top marking The patient is then asked to remain still while the breast is pushed laterally The meridian point on the abdomen and just lateral to the new nipple point are then connected creating the line of the medial
This is then repeated pushing the breast medially for the lateral pillar line This will give an angle that varies between 45 to 180 degrees in the extremes Importantly, the angle created is ideal to remove the available laxity of that breast without creating excessive tension in
A dome marking is then done for the areolar edge The horizontal markings are then made, which are usually between 5 and 7 cm caudal from where the dome markings meet the vertical lines. The superior horizontal line is usually drawn with a
The inferior line is placed 0.5 to 1 cm above the crease and always kept within the breast This allows a good curve to the inferior incision and similar limb lengths with the superior line. These maneuvers are key to minimize the risk of a boxy breast
If the nipple already lies partly within the keyhole of the new areolar markings then a superior pedicle is usually used. If the nipple lies below this point and so allowing easy rotation of a pedicle, a superomedial pedicle is planned.
Under general anesthesia, the patient is supine with the arms either adducted by their side or abducted out on boards. The pedicle is marked and cut to the depth of a 23 blade
This is usually about 2 to 2.5 cm thick
With the preferred superomedial pedicle the tissue lateral to the pedicle is excised to allow turning of the pedicle
The medial and lateral pillars are then dissected They may be thicker than the nipple pedicle or a similar plane depending upon volume of breast required
Therefore the new breast can be dissected off the main bulk of the breast to be excised It can even be roughly approximated to help assess the new volume and shape . For greater projection, more tissue is left
The inferior excision is then made This is taken down to the relatively avascular plane above the pectoral fascia leaving a layer of loose tissue covering the fascia. Volume checked once again by approximating pillars
If more volume is required, some of the inferior tissue can be preserved. If not, as is usual, this can be connected with the upper dissection creating a single excision
Any trimming of the pedicle and pillar is then performed. Use of additional tissue around the pedicle or tissue preserved centrally (from the tissue normally excised) can be used for additional projection
After thorough hemostasis and wash the closure is performed The areolar is closed and the nipple inset The parenchymal pillars are approximated
Deep dermal sutures are then used to approximate the vertical incision The medial and then lateral ends of the horizontal incision are then closed, working toward the natural resting place of the T-junction
A Comparison of the LeJour and Wise Pattern Methods of Breast Reduction Kreithen, Joshua MD et l Annals of Plastic Surgery Issue: Volume 54(3), March 2005 pre- and postoperative photographs retrospective review comparing operative times, blood loss, complications, and a postoperative patient questionnaire 112 women who had moderate to large reductions (>500 g/breast) between 1999 and 2002 Shands Hospital at the University of Florida
A Comparison of the LeJour and Wise Pattern Methods of Breast Reduction
The Wise pattern patients (n = 70) had a classic reduction pattern with an inferior dermoglandular pedicle The vertical reduction patients (n = 42) had a superior pedicle reduction pa
Ultrasound-assisted lipoplasty (UAL)

treatment of fatty areas with a high fibrous component, and as such it seems to be well suited to the hypertrophied breast.
From Matarraso A. Breast Reduction by Suction Mammoplasty. Operative Techniques in Plastic and Reconstructive Surge~ Vol 6, No 2 (May), 1999: pp 136-140
Selection of Technique
Factors:
1. 2. 3. 4. Breast size Estimated resection volume Breast shape Experience of surgeon
Small to moderate reductions:
150 500g per side Choices: 1. Vertical scar technique
Minimal risk of skin redundancy at IMF
2. Periareolar techniques
E.g. Benelli and Goes procedures
Need careful breast shaping and permanent
purse-string sutures
Major reductions:
500 1500g per side Choices: 1. Short scar vertical scar technique
Such as Lassus-Lejour, Hall-Findlay or SPAIR techniques Results are predictable, complication few Well-mounded breasts with excellent projection Less tendency to buttom out Scar minimal
2. Standard Wise-pattern technique

Such as Inferior or central pedicle technique
Massive reductions:
>1500g per side Same principles described for major reduction apply When resection near 1800 2000g per side, consider breast amputation with free nipple grafting If the IMF to nipple distance < 22cm, a central mound reduction is still reliable and safe.
Introduction Anatomy History of breast reduction / mastopexy Breast reduction Definition Indication / goal Contraindication Pre-op counselling / evaluation Planning Technique complication
Complications of Reduction Mammoplasty

Early
1. Haematoma and seroma

2. Infection 3. Skin Necrosis (T-junction dehiscence) 4. Fat necrosis 5. Infection (cellulitis, abscess)
6. Nipple loss
7. Nipple numbness
Complications of Reduction Mammoplasty

1. 2. 3. 4. 5. 6. 7.
Late Asymmetry Inadequate reduction or overreduction Inability to breast-feed Hypertrophic scars Dog-ears Intramammary scarring Recurrent enlargement
Risk Factors and Complications in Reduction Mammaplasty: Novel Associations and Preoperative Assessment Henry, Steven L. M.D.; Crawford, J Lauren M.D.; Puckett, Charles L. M.D Plastic and Reconstructive Surgery 2009
retrospective chart review of a consecutive series of 485 patients patients who underwent Wisepattern, inferior-pedicle reduction mammaplasty
Current trend
Breast Reduction Trend among Plastic Surgeons: A National Survey. Okoro et al (PRS 2008) - 5112 plastic surgeons surveyed, 2665 (52 percent) responded. 69% - inferior pedicle breast reduction technique procedure
. Age was significantly associated with significant pathologic findings. Increased sampling was associated with significant pathologic findings only in patients 40 years or older the need for thorough sampling of reduction mammaplasty specimens in patients older than 40
Current Trends in Breast Reduction Hidalgo, David A. M.D.; Elliot, L. Franklyn M.D.; Palumbo, Steven M.D.; Casas, Laurie M.D.; Hammond, Dennis M.D
Plastic & Reconstructive Surgery Issue: Volume 104(3), September 1999, pp 806-815 A total of 190 respondents participated in the voting process (74 percent) preferred a traditional central or inferior pedicle inverted-T scar technique
12 percent - Lejour-type vertical-scar method Mild macromastia with normal nipple position
31 percent Lejour approach 15 percent Superior pedicle T-scar methods 43 percent traditional approach with a central/inferior pedicle design.
ptosis grade II or grade III and mild to moderate macromastia

80 percent - the inferior/central pedicle T-scar method less than 10 percent - The Lejour vertical scar technique, the superior pedicle T-scar method, and free nipple grafts
severe macromastia
49 percent - inferior/central pedicle 41 percent - free nipple graft
Endoscopic Reduction Mammaplasty

Faria-Correa - endoscopic reduction mammaplasty/mastopexy in 56 women good skin elasticity without significant excessive skin first- or second-degree ptosis with or without hypertrophy Arthroscopic shaving device from the base of the glandular cone. The shaver works like a punching aspirator.
Endoscopic Reduction Mammaplasty

After appropriate excision, the gland is affixed to its new position with transcutaneous sutures and the patient is fitted with a modulator bra very small reductions in young women who meet the authors criteria of excellent skin elasticity and minimal ptosis.
Reduction Mammaplasty in Adolescents

Young women considering reduction mammaplasty should be counseled thoroughly about potential complications of surgery possibility of ptosis and changes in breast shape after pregnancy. hormone-induced recurrence of hypermastia sensory alterations, difficulties with breast-feeding, interference with mammography
NIPPLE SENSATION
well-known complication of reduction mammaplasty Some reduction techniques are associated with a higher incidence of nipple sensitivity than others.
Gonzalez F et al: Preoperative and postoperative nippleareola sensibility in patients undergoing reduction mammaplasty. Plast Reconstr Surg 92:809, 1993.
Gonzalez et al used pre- and postoperative testing to quantitate nipple-areolar sensation before and after breast reduction surgery either the central parenchymal pedicle technique or a laterally based inferior pedicle technique. 84 breasts (43 patients) Overall, nipple sensitivity was lost in 9.5% of breasts and correlated increasing breast size and amount of resection. <440 g per breast was resected, nipple sensation retained 100% of the time.
Hamdi et al looked at breast sensation after superior pedicle vs inferior pedicle mammaplasty anatomical study in cadavers was designed to quantify the nerve branches preserved more branches in inferior pedicles compared with superior pedicles Anterior and lateral branches of the 2nd through 4th intercostal nerves were found in both groups and became more superficial near the areola.
careful de-epithelialization of the pedicle is important to keep the superficial nerves intact near the areolar border.
Hamdi M, Greuse M, Nemec E, et al: Breast sensation after superior pedicle versus inferior pedicle mammaplasty: anatomical and histological evaluation. Br J Plast Surg 54:43, 2001.
clinical study analyzed breast sensation after superior vs inferior pedicle mammaplasty 18 and 20 patients Decreased nipple sensibility in both groups was documented at 3 months. The breast skin had better sensation after superior pedicle techniques the areola had slightly better sensation after inferior pedicle techniques.
At 6 months the mean values for NAC sensation were comparable between the groups. No patient had a completely insensible NAC at 6 months approximately half of breasts had not regained their preop level of sensation
recovery of sensation is related to preservation of cutaneous nerve branches regeneration of severed cutaneous nerve branches Final may take longer than 6 months.
Hamdi M, Greuse M, DeMey A, Webster MHC: A prospective quantitative comparison of breast sensation after superior and inferior pedicle mammaplasty. Br J Plast Surg 54:39, 2001.
Breast Cancer in Reduction Mammoplasty: Case Reports and a Survey of Plastic Surgeons
Jansen, David A. M.D.; Murphy, Mark B.A.; Kind, Gabriel M. M.D.; Sands, Kenneth M.D. Plastic & Reconstructive Surgery Issue: Volume 101(2), February 1998, pp 361-364 1959, Snyderman and Lizardo - 5008 reduction mammoplasty cases yielded 19 patients with malignancies The total number of breast reduction patients was 2576.
The Impact of Breast Reduction Surgery on Breastfeeding Performance
Souto, Glaucia, MD, MsC, Giugliani, Elsa, MD, PhD, Giugliani, Camila, Schneider, Marcia Journal of Human Lactation. 19(1):43-49, February 2003 49 Brazilian women who had undergone breast reduction surgery
The prevalence of any breastfeeding at 1, 6, and 12 months was 58%, 16%, and 10% for women with mammoplasty, and 94%, 58%, and 42% for controls For women with surgery, the median duration of exclusive and any breastfeeding was 5 days and 2 months, respectively, and 3 months and 6 months for controls.
Breastfeeding After Reduction Mammaplasty: A Comparison of 3 Techniques
Kakagia, Despoina PhD*; Tripsiannis, Gregory PhD; Tsoutsos, Dimosthenis Annals of Plastic Surgery Issue: Volume 55(4), October 2005, pp 343-345 Among 314 women who underwent reduction mammaplasty from February 1996 to August 2001, 178 were operated at fertile age
. A standard questionnaire was sent to them 38 years after surgery requesting data regarding postoperative child bearing and breastfeeding Women were divided into 3 groups
A underwent breast reduction by the superior pedicle technique group B by the inferior pedicle group C by the horizontal bipedicle technique
Breastfeeding was considered successful if it was performed exclusively and with no need of any supplementation for at least 3 weeks
BREAST PTOSIS
Breast ptosis - mastopexy Definition Classification of ptosis Contraindication Pre-op counselling / evaluation Planning Technique complication
Introduction
In the primary or nonaugmented breast, the ideal aesthetic nipple lies 5 - 7 cm above the inframammary fold (IMF). A distance < 5 cm above the IMF with a loss of the obtuse angle between the breast and the abdomen denotes some degree of ptosis.
The breast in young adult females:

The base: from 2nd till 6th intercostal space The nipple: usually slightly lower than the center of breast.
The ptotic breast:

Excess skin Nipple at various positions inferiorly May a/w hypertrophy or varying amount breast tissue and fat atrophy.
Mastopexy
Mastopexy, or breast lift, is a procedure designed to elevate the breast tissue and NAC to correct breast ptosis. It is derived from breast reduction procedure, except that only skin is removed with little or no parenchymal resection. past 9 years, there has been a 506 percent increase in mastopexy procedures alone (Stevens et al.PRS 2007)
In 1992, fewer than 8,000 mastopexies were performed

In 2007 - more than 126,178 mastopexies were performed in the United States alone.
(Statistics
2007 [database online]. New York, NY: American Society of Aesthetic Plastic Surgeons; 2007. Updated 2007)
Patophysiology
With time, relaxation of Cooper ligaments and dermal laxity descent of the breast tissue and NAC. Postpartum involutional changes exacerbate the laxity of the suspensory ligaments and skin envelope. To properly correct
elevating the breast parenchyma the redundant skin envelope must be removed and the NAC must be transposed.
Classification of Ptosis (Regnault)

Regnault defined mammary ptosis according to relative positions of nipple and IMF.
1.
First degree (mild ptosis):

Nipple is within 1cm of level of IMF & Above the lower contour of breast
2.
Second degree (moderate ptosis):

nipple is 1 - 3cm below the level of IMF but Remains above the lower contour of breast. Nipple is > 3cm below the IMF & Below the lower contour of
3.
Third degree (severe ptosis)

4. Pseudoptosis: The nipple is above or at level of IMF with Majority of breast tissue below usually observed in postpartum breast atrophy
Types of Breast Ptosis (Brink)
Causes of Breast Ptosis

1.
2. 3. 4.
Common causes: Breast parenchyma involution after pregnancy Excess residual skin after weight loss Excess skin after explantation of implant Loss of skin elasticity secondary to aging (relaxation of Cooper ligaments and dermal laxity)
Breast ptosis Definition Classification Mastopexy
Pre-op counselling / evaluation Planning Technique complication
Pre-op evaluation
planned future pregnancies lactation and subsequent involution further change the shape of the breast. patients capsular contracture of breast implants contracted, high-riding implants often appear to have severe ptosis even though they do not. high risk of primary or recurrent breast cancer screening more difficult
Breast ptosis - mastopexy Definition Classification of ptosis Pre-op counselling / evaluation Planning Technique complication
History of mastopexy
late 19th century correcting ptosis of the breast History parallels that of breast reduction Morestin and Lexer transposed the nippleareola complex (NAC) as a vascular pedicle
Thorek - free nipple graft Hollander - lateral oblique resection resulting in an Lshaped scar
Schwarzmann - periareolar deepithelialization to preserve the neurovascular supply of the NAC By the 1930s, most of the essential technical elements of the mastopexy had been developed. Aufricht - preoperative planning using a geometric system and stressed the concept of the skin envelope defining the final breast shape
Wise defined - preoperative geometric marking system Gonzalez-Ulloa - mastopexy with augmentation for ptosis with hypoplasia or atrophy. Goulian - use of the dermal mastopexy Regnault - classification system for breast ptosis and a description of the B mammaplasty
Johnson - used Marlex mesh to lift the breast parenchyma Auclair and Mitz - absorbable mesh insertion onto the anterior surface of the gland as internal support for the repair of mammary ptosis in mastopexy. Benelli - periareolar round block or purse string mammaplasty
Lassus, Lejour, Hall-Finlay Graf and Biggs (2002) - modification of the vertical approach that places an autologous tissue flap deep to a strip of pectoralis muscle to improve shape and maximize longevity of the lift. Hidalgo - Y-scar vertical
Goals
to obtain a more youthful appearance, improved projection, and reduced ptosis Minimize scar formation
3 incisional patterns of mastopexy:

1.Inverted T 2.Periareolar 3.Vertical or short scar
Determining Nipple Location and Size
Inverted-T Mastopexy Procedures

In 1956, Wise described skin excision marking for skin mastopexy procedure. In 1971, Goulin described the concept of a dermal mastopexy:
removing excess skin with no undermining The dermis was folded on dermis to reshape the breast
The final scar was an inverted-T Recurrence of ptosis and bottoming out is high
Concentric Mastopexy Procedures

Bartel (1976) described the first attempt of concentric mastopexy.
Complicated by poorly shaped breasts, wide scar and enlarged areola.
Spear (1990) described 3 rules to mark the patients having concentric mastopexy.
Periareolar Round-Block Mastopexy

Benelli mastopexy Multiple flaps within the breast gland are crisscrossed sutured together to form a conical breast shape. Round-block permanent periareolar suture is placed
Indications:
For pts with moderate size breasts with some hypertrophy Tubular breast deformity
Advantages:
Improved ability to shape the gland and recontour the breast Minimizing the scar
The B technique
lateral and inferior resection. periareolar deepithelialization and superior undermining allow elevation of the nipple. breast tissue rotated together to increase central projection and decrease lateral fullness
Goes Technique
A periareolar mastopexy technique described by Goes The glandular elements of breast are supported by wrapping the tissue with mesh and suturing the mesh to the chest wall fascia
The periareolar dermis was placed underneath the mesh
Periareolar mastopexy techniques were limited by amount of tisssue manipulation and nipple/areola movement.
Vertical-Incision Mastopexy
Performed with a periareolar scar and a vertical limb The Lejour and Lassus mastopexy
Nipple on superior pedicle Skin is resected in lower portion of breast The central pedicle of tissue is sutured in an elevated fashion to pectoralis fascia Lejour undermines the skin flaps more than Lassus
Augmentation Mastopexy
Breast ptosis is caused by a relative excess of skin envelope for the amount of breast tissue The increased breast volume with breast augmentation will correct the skin-breast volume disparity. Breast augmentation is frequently combined with mastopexy. Augmentation alone can be used to correct minimal breast ptosis.
The simplest method involves resection of an ellipse (crescent) skin above the areola.
When modest skin tightening or repositioning of NAC is required, the full concentric mastopexy may be required. To elevate the NAC, the outer circle must encompass more skin above than below the nipple.
Vertical-scar Augmentation mastopexy

is usually used to correct moderate degree of breast ptosis and Allows greater ability to move the NAC and remove excess skin
Patient standing Midline and meridian of the newly shaped breast Point A = future superior border of areolar, 2cm above IMF Point B = future inferior border
Point C and D = meidial and lateral limits of the new nipple Equidistant from the meridian Based on anticipated final volume
Operative technique
Desired areolar diameter is marked Periareolar ellipse deepithelized Dissection extended towards IMF in subcut plane Dissection cont to upper quadrant Semicircular glandular incision
Dissection cont to prepectoral space in the avascular central space preserving the periphearal blood supply
Operative technique
Inferior glandular flap then cut vertically beyond the breast meridian upt o fascia Four flaps elevated Sup dermoglandular to support arelar Glandular medial Glandular lateral Detached skin flap
Operative technique
After gland dissection, gland lifted by stiching the superior flap high on the pect fascia To produce exaggerated bulge in sup pole Nipple raised by this maneuver Sup roundness flatten due to gravity
Operative technique
Medial and lateral flaps are folded over one another Medial flap rotated behind areolar Fix distal portion to the pect muscle Lat flap crossover and fix to medial flap Form glandular cone
Operative technique
Plication invagination can be performed to achieve conization and elevation of breast shape
Operative technique
Areolar is fixed to the sup border of the ellipse Areolar to be supported Inverted sutures on the underside of the gland Too tight = glandular necrosis
Operative technique
Skin redraped over the breast Round block circlage stich is passed in deep dermis in pursestring fashion
Operative technique
Diametrical transareolar U suture placed to serve as a barrier and to help prevent areolar protrusion Site dressed with wet compress on areolar and dry compress on detached skin Mammary support bra
Operative technique Goes periareolar techinque with mesh

Expanded the use of periareolar tecnique by using a layer of prosthetic mesh double skin the use of a doughnutshaped, periareolar, deepithelized dermal flap to support the gland under normal skin
Preoperative marking Leave adequate skin to cover the new breast mound Point A level of the top of new areolar Point B distance from the IMF Point C distance from the midline Point D from AAL
Operative technique
Are deepithelized to the nipple Outer border is incised and a skin flap developed superiorly Undermined another 5cm once pect fascia reached Inf flap developed down to the IMF Perforators preserved
Operative technique
After the skin and breat parenchyma separated into components, excess tissue can be resected in a wedge shape at the sup and inf poles Gland shaped by suturing the gland together superiorly and fix to chest wall
Operative technique
Inferior resection sutured together and fix to intrammary connective ligaments and ant pect fascia Deepithelized area then streched out over the new breat mound This creates internal skin lining
Operative technique
Mesh placed over the newly created mound and internal skin lining to function as a brassiere Elevate the breast and provide a stable base for conical shape Mesh affixed to the ant pect fascia at the base
Vertical mastopexy without implants

Patient standing IMF marked then transposed to ant surface of breast Lower pole gathered to simulate the pexy Symmetry and distance from sternal notch checked
Midline of breast marked on ant surface Midpoint of the IMF = where the bottom of the vertical limbs will be centered
Medial pillar marked in line with midline sup and inf Th e mark is joined with the Inf mammary midline with a curvilinear line
The same maneuver in opposite direction defined the lateral pillar The markings are drawn in a parabolic shape inferiorly ending 2 -3cm above the native fold Curve up superiorly
The top of the vertical closure is estimated by pinch technique Closure without tension
From the top of the vertical closure, measures down 5 to 6 Position of the new fold
Segment between medial and lateral pillars and periareolar skin deepithelized Breast elevated off the pect fascia Dissect up to the top of the sup pole = flap can be placed as high as possible
Once breast undermined, flap is placed in subpectoral pocket medial and lateral cuts are made, isolating the breast on its superior blood supply
If no implant is to be used, a subglandular dissection is performed With implants, a subpectoral pocket is used
Flap is then folded underneath into the upper pole Pillars reapproximated beginning at the top, then most inf point then in between Bite of lateral breat parenchyma sutured medially to help cone the breast
The upper pole fill and the improved nipple postition
Opposite breast is shaped the same way and to the same point Dressings support the final shape Nipple should not be compressed by the dressings.
The choice of technique is determined by
1. degree of ptosis and 2. desired size of the breast postoperatively
Mild ptosis:
Periareolar mastopexy with or without augmentation
Moderate ptosis
Vertical scar mastopexy procedures, including the Regnault B technique and Lejour/Lassus techniques.
Severe ptosis
inverted T incisions regardless of the pedicle used.
Pseudoptosis
augmentation and/or skin excision without nipple transposition (excision of lower pole skin) or Benelli periareolar technique.
Complications
General complications:
bleeding, infection, and problems secondary to anesthesia.
Specific complications:
skin necrosis, sensation changes, and asymmetry
One-Stage Mastopexy with Breast Augmentation: A Review of 321 Patients

Stevens, W Grant M.D.; Freeman, Mark E. M.D.; Stoker, David A. M.D.; Quardt, Suzanne M. M.D.; Cohen, Robert M.D.; Hirsch, Elliot M. M.D. Plastic and Reconstructive Surgery Issue: Volume 120(6), November 2007, pp 1674-1679 A retrospective chart review was conducted of 321 consecutive patients who underwent one-stage mastopexy and breast augmentation Data collected included the following: patient characteristics, implant information, operative technique, and postoperative results
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HYPERMASTIA AND PTOSIS

DR. WAN SYAZLI Plastic Surgery Masters Class

May be associated with:

Hypermastia hypertrophied breast Ptosis sagging breast

2nd to 5th perforators

60% total breast blood supply

Lateral thoracic artery

posterior intercostal arteries

1. Period before 1930

1. Period before 1930

1930 Schwarzman: suggested maintaining the nipple on a superomedial dermal pedicle

2. Pre-modern era (Period 1930-1960)

3. Modern Era (From 1960 onwards)

Many variations based on different orientations of the dermal pedicles emerged:

Vertical and short scar techniques:

1990-96 Benelli: periareolar reduction Suction lipectomy

Breast Reduction - Definition

Breast Hypertrophy - Indications for surgery

Breast Hypertrophy - Indications for surgery

Breast Reduction Contraindication

Breast Reduction - Contraindication

Breast Hypertrophy - Evaluation

Breast Hypertrophy - Evaluation

Breast Hypertrophy - Evaluation

Breast Hypertrophy - Evaluation

Psychological evaluation and counseling

Breast Size after Reduction

Breast Size after Reduction

Determining Nipple Location and Size

Pitanguy points:the level of the

principles of modern reduction

Techniques of Reduction Mammoplasty

Skin resection patterns

Inverted T skin resection pattern

Inverted T skin resection pattern

Vertical skin resection pattern

Vertical skin resection pattern

Circumareolar skin resection pattern

Circumareolar skin resection pattern

Lateral skin resection pattern

The B technique (Regnault)

Blood supply to the NAC

Blood supply to the NAC

Parenchymal only pedicle

Blood supply to the NAC

Horizontal bipedicle (Strombeck)

Horizontal bipedicle (Strombeck

Horizontal bipedicle (Strombeck)

Vertical bipedicle (McKissock)

Vertical bipedicle (McKissock)

McKissock Vertical Bipedicle Technique

Vertical bipedicle folded on itself as key sutures tied

Inferior Pedicle Technique

Superior Pedicle Technique

Parenchymal only pedicle

Central Mound Technique

Lassus pioneered vertical scar technique in 1964 Principles:

1996: results of 710 pts over 30 yrs

Vertical breast reducion technique

Vertical incision design

Position of the IMF

Determining the new horizontal nipple position

Determining the new vertical nipple position