``Flip-Flap' Mastopexy

The ``flip-flap' mastopexy modifies the McKissock vertical bipedicle design by creating a wide superiorly based flap of breast tissue deep to the vertical bipedicle. Transposition of this flap up and beneath the upper breast, with suture anchoring to the pectoralis fascia at the level of the second rib, restores upper breast fullness, decreases mastopexy-wrecking lower breast bulk, and provides a pleasant forward thrust of the nipple–areolar complex. The ``flip-flap' is effective for improving the long-term aesthetic outcome for both reduction mammaplasty and mastopexies of moderate- to full-sized breasts.     

Unsatisfactory results of periareolar mastopexy with or without augmentation and reduction mammoplasty: enlarged areola with flattened nipple

A method of repair is described for correction of abnormally enlarged nipple–areola complex following both periareolar mastopexy and pregnancy. Although during periolar mastopexy or reduction mammoplasty regular subcuticular dermal sutures may control the enlargement of nipple–areola complexes initially, the periareolar scar becomes hypertrophic and areolar spreading occurs to some extent. Periareolar mastopexy techniques are indeed advisable only for minimal hypertrophies or ptosis of the breast, especially for areolar asymmetry, if an acceptable, normal-size areola is expected. The authors believe that in periolar mastopexy or reduction mammoplasty cases resulting in enlarged nipple–areola complexes, the size of the areola can also be corrected by reduction mammoplasty or mastopexy using vertical bipedicle techniques. Although surgery results in an inverted T incision, the shape of the breast is more acceptable and the size of the areola does not enlarge with time.     

Periareolar reduction mammaplasty utilizing the inferior dermal pedicle

The critical points which should not be overlooked when performing reduction mammaplasty are to minimize scar on the breast and to ensure a sufficient blood supply for the viability of the nipple–areolar complex. Periareolar reduction mammaplasty has been widely used because it left only one scar around the areola. However, with the typical periareolar reduction mammaplasty technique, it is difficult to remove a large amount of breast tissue and mobilize the remaining breast tissue. It may result in necrosis of the nipple–areolar complex in some cases. To overcome these limitations we combined the periareolar incision with the inferior dermal pedicle, which has a relatively good blood supply. This new technique was employed in 22 consecutive women (44 breasts) with hypertrophy and a varying degree of ptosis. Infiltration of a tumescent solution and liposuction were performed in all cases. After periareolar incision, dissection of the skin was performed, and the breast was elevated from the fascia of the pectoralis major muscle, leaving the inferior dermal pyramidal pedicle. An adequate amount of tissue was resected in the superior, medial, and lateral areas. After mastopexy, closure was done with a purse-string suture. The amount of tissue resected ranged from 180 to 1510 g per breast, and the mean was 466.1 g. The mean length of elevation of the nipple was 10.6 cm along the meridian of the breast. There were a few complications which needed revision operation: hematoma collection in one breast (2.3%), wound dehiscence in one breast (2.3%), and fat necrosis in one breast (2.3%). There was no necrosis of the nipple–areolar complex. With this new technique of periareolar reduction mammaplasty utilizing the inferior dermal pedicle, we were able to minimize the scar, preserve the nipple–areolar complex, and improve the motility of the breast tissue. But we also observed a flat or square appearance in the case of a large amount of resection in the patients with poor skin elasticity. This technique is safe and versatile and produces aesthetically acceptable results in selected patients.     

Combination of the vertical and periareolar mammaplasty

Vertical mammaplasty has been perfected and popularized by Madeline Lejour; this technique is one of the most versatile methods of manunaplasty today. The vertical scar from the nipple areola to the submammary line is often much longer and distorted than the conventional mammaplastys. The length of the vertical scar can be reduced by 2–3 cm by combining the skin pattern of the periareolar and vertical mammaplasty. The aesthetic result can be improved by shortening the vertical scar.     

A New Personal Surgical Procedure for Breast Reduction and Lifting

A series of 40 patients operated from 1995 through 1997 is reviewed. The women ranged in age from 18 to 40 and were seen in either a university- or a private-hospital setting. Thirty-eight of the patients underwent reduction mammaplasty, which was performed using an inferior pedicle technique with a straight-line incision; two patients underwent mastopexy only. The reduction procedure depends on the formation of a cap from medial, lateral, and superior flaps. Following resection of breast tissue the cap is joined to a cone—the nipple–areola complex carried on a subcutaneous inferior pedicle. The cone is fixed to the chest wall with simple vertical stitches, minimizing the recurrence of ptosis. This technique is safe and versatile, avoids a submammary scar, and offers an aesthetic and long-lasting result.     

Combined superior crescentic total glandular augmentation mastopexy: report of 37 cases

Methods of periareolar, donut, or crescentic patterns for augmentation mastopexy in mild to moderate ptosis cases are minimally invasive (short scar) options. In this article, we report a modified version of the classical crescentic technique of augmentation mastopexy, namely, “superior crescentic total glandular augmentation mastopexy”. Thirty-seven patients with (a) breasts having mild to moderate ptosis (Regnault grades I–II), (b) breasts requiring less than 3 cm of nipple–areola elevation, and (c) mild skin elasticity were included in the study. During surgery, the mean size of 290 cc of silicon gel-filled implants were placed. The mean follow-up was 39 months ranging from 6 and 58 months. None of the patients had disastrous complications such as skin or nipple–areola necrosis. Poor scar healing and areolar asymmetry were the main problems encountered during follow-up. Ptosis recurrence (n = 1), and capsular contracture (n = 1) were the main reasons for revision surgery (5.4%). Five patients were re-operated on due to complications and implant change requirements (13.5% , total revisions). Mean suprasternal notch–nipple distance was recorded as 20.8 cm (19.3–22.4 cm) postoperatively. After an average time of 39 months, this distance was found to be 21.2 cm (20.1–23.2 cm) (the case with the recurrent ptosis was excluded). Superior crescentic total glandular augmentation mastopexy has yielded satisfactory results in patients with mild to moderate breast ptosis; therefore, it seems to be a valuable option in terms of minimally invasive augmentation mastopexy techniques.     

Multiplane technique for simultaneous submuscular breast augmentation and internal glandulopexy using inframammary crease incision in selected patients with early ptosis

Augmentation mammoplasty is a procedure with a high satisfaction rate. On the other hand, augmentation in a ptotic breast requires conventional mastopexy which has a high surgical morbidity. In selected cases, the multiplane technique, a simultaneous submuscular augmentation with internal glandulopexy, is a procedure which avoids the external scarring of mastopexy. Between June 2005 and October 2008, the author operated on 44 patients (12 unilateral for nipple level asymmetry not exceeding 1.5 cm and 32 bilateral procedures in patients with nipple-areolar complexes (NAC) below the inframammary crease (IMC) but not exceeding 1.5 cm). The procedure is performed under general anesthesia through an IMC incision. The average age of the patient was 33.5 years (range 19–50), and in all but one patient, a round, high-profile cohesive gel silicone implants with an average size of 354 cm³ (range 260–440) in bilateral and 350 cm³ (range 300–440) in unilateral procedures, were used. The average preoperative suprasternal notch to NAC measurement in unilateral (n = 12) and bilateral (n = 32) procedures was 22.2 cm (range19–24) and 23.2 cm (range 20–26) respectively. The preoperative average NAC distance to IMC distance in bilateral and unilateral cases was 8.03 cm (range 6–12) and 7.2 (range 4–9) cm respectively. The measured postoperative supra-sternal notch to NAC distance, 22.0 cm (range 19.5–23) in unilateral (n = 12) and 22.4 cm (range 20–26) in bilateral procedures (n = 32) respectively, shows the reduction in suprasternal notch to NAC distance. Postoperative NAC to IMC distance in bilateral and unilateral breasts was 9.3 cm (range 7–11) and 9.1 cm (range 7–10) respectively. When a unilateral procedure is performed, the contra lateral breast is used as a control to compare the results. One patient had an infection and of the 12 unilateral and 32 bilateral procedures, nipple sensation was present in 8 unilateral and 28 bilateral cases. Only one patient with bilateral procedure reported a bilateral loss of nipple sensation in the early part of her recovery. Two patients did have residual ptosis and one requested a bilateral vertical scar mastopexy. The multiplane procedure for submuscular augmentation with internal subglandular mastopexy is an option in selected patients with early ptosis or patients presenting with minor NAC asymmetry in the vertical axis. If necessary, conventional external mastopexy remains a possibility in patients with inadequate results.     

Short Scar Mastopexy with Flap Transposition

A personalized technique using a vertical scar mastopexy is described. The breast tissue is utilized as a transposition flap behind the nipple–areolar complex to increase its projection. The inferior pole of the breast can be developed either as a superiorly pedicled or inferiorly pedicled flap for that purpose and the indication for each version is described. The technique has been successfully utilized in 80 patients with pleasing results. Illustrative cases are presented.     

Radial Plication in Concentric Mastopexy

Concentric mastopexy presents many challenges to the plastic surgeon, especially when breast augmentation is part of the treatment plan. Radial plication is a reproducible and accurate technique for elevating the nipple–areolar complex and shaping the breast mound. Patient selection is important to the success of the radial plication procedure and concentric mastopexy in general. Although most surgeons agree that patients with smaller degrees of nipple ptosis and smaller breasts have better results than patients with greater degrees of nipple ptosis and larger breasts, there has never been an algorithm for patient selection. Regnault’s classification of breast ptosis addresses the degree of nipple ptosis, but no consideration is given to breast volume. Radial placation proved to be a valuable tool in the treatment of 87 patients undergoing concentric mastopexy in the author’s practice over the past 30 months. An algorithm addressing degrees of breast ptosis and breast volume is provided. The plastic surgeon can anticipate gratifying results if the algorithm provided is incorporated into his or her patient selection for concentric mastopexy. The concentric mastopexy technique is similar to the tailor tack procedure for standard mastopexy, allowing the plastic surgeon to mold and shape the breast before making a critical incision.     

Dermafascial Fixation Suture: A Technique for a More Durable Projection with Short-Scar (Vertical) Reduction Mammaplasty

Background Short-scar reduction mammaplasty has several advantages over the traditional technique, mainly reduced scarring and superior long-term breast shape. Multiple modifications of the short scar reduction mammaplasty technique have been made in an effort to decrease the learning curve while improving the results. The authors present another modification of the short-scar technique for a more durable projection without reliance on a skin envelope. Methods The perimeters of the medial pedicle and the nipple–areola complex are marked, and the medial pedicle is deepithelialized. A 2 × 5-cm skin area at the inferior border of the pedicle is further deepithelialized, then pexied to the pectoralis fascia in a superomedial direction using a nonabsorbable monofilamanet suture with a horizontal mattress suturing technique. Results Taking the suture bites from the dermis rather than the breast parenchyma for the pexy aims to spare the pedicle’s circulation. This durable internal rearrangement of the breast parenchyma with dermafascial pexy further decreases the tension at the nipple–areola complex because the final breast shape no longer relies on the skin closure. Suture spitting at the nipple–areola complex also is prevented with elimination of the purse-string suture because there is no need for a further decrease in the tension with the purse-string suture after the dermafascial pexy. Conclusions The authors believe that the dermafascial pexy is a concept more than a technique. It incorporates the two strongest structures, the dermis and the fascia, to achieve more durable results not only with reduction mammaplasty, but also with any aesthetic breast surgery that uses the pedicles.     

Y-Scar Vertical Mammaplasty for Treatment of Mild Macromastia with Pseudoptosis

Y-scar vertical mammaplasty is a technical modification of vertical scar breast reduction, which avoids superior areolar scarring. It has been previously shown to be particularly useful in young patients with mild macromastia and minimal or no ptosis. This case report presents a new indication for which to apply this technical approach. A 58-year-old patient presented with mild macromastia of mainly the inferior pole and pseudoptosis. Since there was no need to transpose the nipple, a Y-scar vertical mammaplasty was performed, removing tissue from the lower pole and preserving upper-pole fullness. Furthermore, superior areolar scarring was avoided. In conclusion, Y-scar vertical mammaplasty may find its use in other less commonly seen patient profiles such as this presented case of an older patient with slightly enlarged breasts and pseudoptosis.     

Evolution of the Vertical Reduction Mammaplasty: The S Approach

The vertical reduction mammaplasty has been popularized over recent years. It always produces marked puckering of the excess skin and requires revision surgery for the persistent dog-ears that develop. Minor complications are often common. As a result, the evolution with S approach is developed. A series of 36 consecutive patients who underwent the S approach reduction mammaplasty is presented. The S approach can be described as having 1) superior dermoglandular pedicle, 2) simple and safe S-shaped skin marking, 3) suspension of the residual glandular tissues transversely to the periosteum of the 5th rib, and 4) short-scar closure. The surgical techniques are described in a step-by-step fashion. An analysis is made of the results obtained from these patients. The mean follow-up period of this study is 21 months. As a result of surgical operation, the symptoms of breast hypertrophy were markedly improved. According to patient assessment, neck, back, or chest pain decreased from 64% to 25%, shoulder grooving improved from 56% to 25%, stooped posture decreased from 42% to 14%, intetrigo improved from 36% to 8%, psychological embarassment decreased from 33% to 8%. The postoperative complications included minimal areolar epidermolysis (11%), hypertrophic scar (8%), etc. All mammograms revealed hypertrophic patterns of the breast. The glandular tissues removed had a mean of 480 g from each breast. Two breasts (3%) had fibroadenomas. The sternal notch–nipple distance changed from a mean of 30.5 cm preoperatively to 20.5 cm, the length of infraareolar scar was 9 cm in average. Eighty-one percent of patients had minimal postoperative ptosis, and the sensitivity of nipple–areola complex was unchanged in 75% of patients. Nine patients (24%) retained the ability to lactate for more than 1 month postoperatively. Twenty-two patients (61%) were very satisfied with their operation, and eight (22%) were adequately satisfied. The technique presented is a simple and safe procedure that provides satisfactory results for patients with breast hypertrophy.     

The dermal overlap subareolar mastopexy: A preliminary report

Background: The major disadvantage of the circumareolar mastopexy is the risk of hypertrophic scarring and relapse or widening of the areola. Objective: The author describes a new technique that gives added support to the scar by means of a dermal overlap flap that is buried under the areola. Methods: A doughnut incision is made, with the size of the outer circle dependent on the amount of ptosis to be corrected. The areolar flap is elevated close to the nipple pedicle, a circumferential incision is made through the dermis between the pedicle and the outer incision, and the dermal edge is elevated. After the mastopexy, closure is performed with nonabsorbable purse-string sutures. Results: Initial results in a series of 34 cases have been encouraging, with no loss of nipple sensation and with less scarring and more natural nipple projection than occurs in conventional doughnut mastopexy procedures. Conclusions: This technique can be used to reduce scarring in procedures such as mastopexy, breast reduction, and tubular breast correction. (Aesthetic Surg J 2001;21:423-427.)     

Wineglass Pattern for Vertical Mammaplasty

The ideal reduction mammaplasty technique should create a pleasing breast shape with minimal scarring. The long and conspicuous scar associated with the classic inverted ``T' pattern mammaplasty techniques are not acceptable for many patients. Periareolar mammaplasty techniques cause less scarring, but they have major disadvantages such as scar widening, areolar distortion, and insufficient breast projection. We used a new pattern for vertical mammaplasty to overcome the insufficient breast projection caused by the round block technique and applied it to 51 patients during the last 3 years. This method results in a single vertical scar and a periareolar scar, allows sufficient volume reduction, and provides good breast shape and projection; the results are durable. This procedure is safe, causes few complications, and is easy to learn and perform.     

Lejour法乳房肥大缩小术的临床体会

目的:探讨LEJOUR方法乳房肥大缩小手术的临床效果。方法:按照LEJOUR方法的设计,切除乳房多余腺体后将其固定于第二肋间胸肌筋膜上,并将剩下的腺体重新塑形;将乳房下极的皮瓣修薄。结果:共24例乳房肥大病人,手术后除1例出现单侧乳头感觉缺失外没有其他并发症,乳房外形满意。结论:LEJOUR方法是一种比较好的乳房肥大缩小手术方法。     

Reconstruction of a burned breast with vertical mammaplasty: a case report

The right upper extremity, axilla, and right anterior hemithorax of a 25-year-old female had been burned with milk when she was 4. Breast tissue developed in a flattened form because of the burn to the entire anterior hemithorax; the nipple–areolar complex was far lower than it should have been; no inframammary fold had developed and the appearance was highly asymmetrical. A vertical mammaplasty was used to restore the nipple–areolar complex to its normal position, and a full-thickness skin graft taken from the groin was used to form an inframammary fold. In this way, the two asymmetrical breasts were given an acceptable symmetry.     

A Solution to the High-Riding Nipple–Areola Complex

There are limited techniques described in the literature on how to lower the nipple–areola complex following surgery to the breast. We present a case of successful correction of a high-riding nipple using a Z-plasty technique with an 8-year follow-up in a breast reconstruction patient. The technique described may also be applicable to cases of high-riding nipples following aesthetic breast surgery such as reduction mammaplasty.     

Nummular Nipple Hypertrophy and Repair as Part of an Aesthetic Nipple-Areola Unit

The author suggests that an aesthetically pleasing ratio between nipple and areola diameter exists which should always be taken in consideration during nipple and areola reconstruction. In a study of 40 nipple–areola complexes of 20 healthy, nulliparous, Caucasian female volunteers with a mean age of 25.5 years, the average nipple diameter measured 28% of the areola diameter, that is, a ratio of 1:3.6. A hitherto undescribed form of macrothelia is presented in which the nipple width rather than the projection (length) is increased. A successful technique for reconstruction is described, based on the new method of assessing the aesthetic relations within the nipple–areola complex and known anatomy.     

Vertical Mammaplasty Marking Using the Key Hole Pattern

Many modifications of the vertical mammaplasty procedure used to shorten the learning curve have been described. The authors advocate marking the breasts for the vertical mammaplasty operation according to the key hole pattern. They have used inverted T techniques on the upper breast and Lejour’s vertical mammaplasty on the lower breast. A total of 14 patients who had breast hypertrophy and ptosis underwent operations with this marking modification. The amount of removed breast ranged from 285 to 875 g per breast. Hematoma, skin necrosis, skin dehiscence, loss of nipple–areola sensitivity, and distortion were not observed in these cases.     

A Superior Vertical Dermal Pedicle for the Nipple–Areola: An Alternative for Severe Breast Hypertrophy and Ptosis

Background  

Nipple–areola nourishment and sensation have been the main concern in reduction mammaplasty for severe breast hypertrophy and ptosis. Free grafting for the nipple–areola can cause flatness and loss of sensation. These complications can be improved by pedicle techniques for the nipple–areola, no matter the pedicle orientation. The aesthetic outcomes and complications are similar for the inferior and superior pedicle techniques. The pedicle length has been crucial to nipple–areola viability and sensation.