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Fig. 11.2 (a) It occupies the entire space between the anterior axillary line and the mid-sternal line. (b) It occupies an intermediate space between
the anterior axillary line and the mid-sternal line. (c) It occupies a smaller space between the anterior axillary line and the mid-sternal line
Fig. 11.3 (a) Congenital asymmetry. (b) Acquired asymmetry
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Fig. 11.4 Small volume breasts divided into Amazia (a), Moderate breast hypovolemia (b) and Mild breast hypovolemia (c)
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e
Fig. 11.5 Large volume breasts divided into normal to Gigantomastia (a–e)
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Fig. 11.6 (a–f) Breasts have been differentiated based on their morphological characteristics
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11.2 Examination oftheBreasts
1. Inspection: The breast is examined for obvious asymmetries as discussed above. They are also inspected for presence of any scars, obvious nodules as well as ptosis. A
meticulous examination of the breast along with examination of the axilla is a must to rule out any lumps.
Breast hypertrophy is assessed which can be mild,
moderate, and severe.
2. Palpation: The breast is now palpated systematically to
detect nodules and broids from one quadrant of the
breast to the other and ending at the nipple areola complex (NAC). The axilla is also palpated for any nodules
and signs of folliculitis.
3. Measurements (Fig.11.7a, b)
In Latina patients with a height of less than 1m 65cm
the Clavicular midline to NAC distance is: 15–20cm.
NAC to breast groove (Infra mammary crease):
4–8cm.
Diameter of Areola: 3–5cm
Fig. 11.7 (a, b) Approximate anthropological measures of the breast
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11.3 Breast Ptosis: Angle ofAection
Based on the angle of affection, the ptosis of the breasts can
be divided into normal, moderate ptosis or severe Ptosis
(Fig.11.8a–c).
11.3.1 Point A
Point A reects the inframammary crease on the breast
meridian and is the single most important marking to be carried out before a breast lift or mastopexy.
Importance of point A (Fig. 11.9)—This is the point
where the upper end of the future NAC lies. If the NAC is
placed higher than this mark, then it may be visible about the
upper end of the bra.
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Fig. 11.9 Marking point A, the future position of NAC
Fig. 11.8 (a) Normal. (b) Moderate ptosis. (c) Severe ptosis
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11.4 Peri-Areolar Mastopexy
11.4.1 Surgical Techniques
Indications of this technique include:
– Small breast hypertrophy
– Moderate breast hypertrophy
– Breast ptosis
– Tubular breasts
– Breast tumors
– Breast pexias with prosthesis
– Partial or total mastectomy
– Use on narrow and medium-based breasts.
Objectives of the procedure include: (Fig11.10a–c)
(a) Identication of Cooper’s ligaments (Anchor points),
(b) Coning of the breast tissue and rotation with
mastopexy,
(c) Replacement of ligaments.
The anchor points reduce the possibility of post-operative
enlargement of the areola thus improving the quality of the
scar, producing adhesion in the empty spaces, better coning
and rotation of the breast and reduced scar tension (Spanish
Association of Aesthetic Plastic Surgery 2008).
The superior pole, the central pole, and the medial pole
are the main areas that provide vascularity to the breast, so
we must especially be careful while dissecting the internal
mammary pole as the breast vascularity medially is through
the internal mammary artery (Fig.11.11).
The surgical technique for breast reduction, ptosis correction or augmentation with fat transfer or simply mastopexy,
consists of making a peri-areolar incision and creating a circular fascia-cutaneous ap of the breast 2–3 cm thick.
Recognize and mark Cooper’s ligaments which will be made
as anchor points when suturing.
Fig. 11.11 Vascularity of the breast as seen in close proximity to the
anchor points. (Source: Plastic Surgery, magazine of the Spanish
Association of Aesthetic Plastic Surgery, number 7, January 2008, page
9 to 13 Topic: Peri-areolar mammoplasty, Anchor Points, Cooper’s
Ligaments)
Fig. 11.10 (a) Identify Cooper’s ligaments (b) Coning, rotation and Mastopexy (c) Cooper’s ligament replacement
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11.4.1.1 Step 1: Marking Points A, B, C, andD
fortheCircular Skin Fascia Flap
andtheAnchor Points (Fig.11.12)
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Fig. 11.12 (a–h) Maneuvers to shape the breast so as to leave 200–
350cc of breast volume-a (new location of NAC): 15–20cm from the
xiphisternum. (ab= ac to be 5–10cm) sufcient quantity to leave the
breasts volume 250–350cc. (d) It is the distance from the sulcus to the
areola (5–10cm), and the southern part of the periareolar marking
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Fig. 11.12 (continued)
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11.4.1.2 Step 2: Incision andUndertaking
theSchwartzman Maneuver
(Fig.11.13a–c)
We do the Schwartzman maneuver, leaving the diameter of
the areola at 5 cm, then a skin hook is placed at point A
(Fig. 11.13b) as the de-epithelization of the skin is
completed.
11.4.1.3 Step 3A: Marking oftheDermis Flap
forNAC (Fig.11.14)
Using methylene blue or a sterile marking pen mark the incision line to separate the NAC from the skin subcut ap. It is
marked in such a way that a segment of the dermis is left
intact connecting the NAC to the skin ap. It is important to
leave 3–4mm of dermal tissue on the skin ap. The NAC is
based on a medial or supero-medial ap and care should be
taken to not incise the dermis in that area as seen in
photographs.
11.4.1.4 Step 3B: Dissection andRaising
oftheMedial Base Flap
Containing NAC
We incise and dissect the skin and subcutaneous ap leaving
2–3cm thick of the cutaneous fascia ap, avoiding touching
the mammary gland that is released to the pectoralis major
muscle aponeurosis where we then dissect towards the upper
pole, we also identify and mark the Cooper’s ligaments as we
incise them and raise the ap.
When dissecting the mammary gland, a skin ap should
be created circumferentially except in the area marked as a
pedicle for the NAC with a subcutaneous cell layer thickness
of 2–3cm so that irregularities do not form in it which will
happen if the skin ap is very thin (Fig.11.15). We dissect,
leaving the skin ap 2–3cm thick, and mark Cooper’s ligaments with methylene blue.
11.4.1.5 Step 4: Coning theBreast Pyramid by
Suturing theMedial andLateral Pillars
Once the skin ap has been dissected off the breast tissue, we
leave the superior pole, the medial and the central pole that
vascularizes the breast and the areola-nipple complex and
also provides innervation to NAC intact.
We dissect the breasts inferiorly with the upper pole
retracted for 3–5cm, we mark with methylene blue a triangle
of the glandular area to be removed or plicated inward to
give volume to the upper pole. This is marked by in rolling
the glandular tissue inferiorly in the midline and checking
for the fullness in the upper pole of the breast. Adequacy of
the medial movement of the lateral breast tissue is also
checked and marked. With a cautery the area marked with
blue is divided in the middle and we suture the two pillars
together, making the external pillar roll in towards the center,
to move the ap on the axillary side inwards. After bringing
it internally we centralize the gland and do pexy on the pectoral aponeurosis and form the cone of the breast which
should be at least 8cm in height (Fig.11.16).
The next step of Coning of the breast is one of the most
important steps of this procedure. The medial and lateral pillars created as above are brought in the midline inferiorly to
be sutured in such a way that they create fullness in the upper
pole, narrow the breast, increase the projection of the breast
as well as draws the lateral pole of the breast inwards. The
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Fig. 11.13 (a–c) Undertaking the Schwartzman maneuver and de-epithelizing the excess areola and skin
height of the new breast cone should be targeted to be more
than 8cm for a good breast projection. This may be possible
by rolling the lateral pillar medially (Fig.11.17). Rotation of
the external lateral pole and lling of the lower pole, stretching the axillary area to create the pexy and coning so that the
greater diameter at the base is utilized to create height of the
of the breast cone which can be increased from 4 to 8cm, so
the breast will have a beautiful shape. If tissue is decient at
the base of the breast, then we can rotate the external lateral
11.4.1.6 Step 5: Resuturing theCooper
Ligaments andClosure oftheDead
Space
Once coning of the breasts along with pexy is completed, we
reposition and recreate the 10–20 marked Cooper ligaments
in the upper, medial, and lateral poles of the breast. This not
only re-suspends the breast tissue to its normal structure but
also reduces the dead-space in the area helping it heal faster
(Fig.11.18).
pole and leave drains when closing.
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