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Combined Mastopexy andBreast
https://t.me/medicina_free
Augmentation
AngeloCuzalina,PasqualeG.Tolomeo
andVictoriaA.Mañón
12
12.1 Introduction
Augmentation mastopexy for the correction of both breast
ptosis and gland hypoplasia is a pivotal skill for any cosmetic
surgeon. The simultaneous performance of the mastopexy
and augmentation is one of the most challenging procedures
with less predictable results. The goals of the mastopexy are
nipple repositioning, breast reshaping, and skin laxity reduction, while the goals of the augmentation are breast volume
enlargement and expansion of the skin. These differing goals
create a competitive environment in regard to tissue availability, viable blood supply, and implant position.
According to the ASPS, breast augmentation and mastopexy
were among the top ten cosmetic surgical procedures in 2019,
with breast augmentation being the most common and mastopexy being the seventh most common (Plasticsurgery.org 2020).
The combination of these two procedures are less common in
the cosmetic practice due to the extensive pre- operative planning and clinical expertise to manage multiple variables. There
are multiple factors that cause a patient to develop deation and
ptosis including but not limited to pregnancies, lactations,
weight uctuations, and congenital abnormalities (De Fazio and
Cingozoglu 2020). As the breast changes over time, there is a
disharmonious relationship between the breast and the nippleareola complex (NAC) as the NAC becomes displaced below
the inframammary crease with some deation of the breast
parenchyma. In order to achieve the aesthetic breast, one must
be able to manipulate these parameters: amount of augmentation/lift desired, current breast size/shape/symmetry, NAC size/
position, position of the inframammary fold, and overall chest/
torso anatomy (De Fazio and Cingozoglu 2020; Cuzalina and
McLain 2019). The surgeon who is able to address these parameters while honoring the limitations of the breast itself will be
able to achieve a desirable esthetic result (Fig.12.1).
Supplementary Information The online version contains supplementary
material available at
A. Cuzalina (*)
Tulsa, OK, USA
e-mail: angelo@tulsasurgicalarts.com
P. G. Tolomeo
Exquisite Aesthetics, New York, NY, USA
V. A. Mañón
University of Texas Health Science Center, San Antonio, TX, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_12
https://doi.org/10.1007/978- 981- 99- 3726- 4_12.
165
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Fig. 12.1 Combined
augmentation and mastopexy
A. Cuzalina et al.
12.2 Pertinent Anatomy
12.2.1 Breast
The breast is derived from ectodermal tissue and begins to
develop as early as weeks 4–6 of gestation. At week 6, there
is a proliferation of paired epithelial cells in the thoracic
region extending from the axilla to the groin, with the development of two ridges known as the milk lines or mammary
crests. From weeks 8 to 10, breast growth continues with differentiation of the paired ridges in the area of the fourth intercostal space, while atrophy of the remaining lines ensues.
This process allows for the formation of the primary mammary buds. Failure of the remaining milk lines to atrophy
leads to the presence of accessory mammary glands (polymastia) and nipples (polythelia) (Nahai 2011). As the primary
buds enlarge, indentations become prevalent along the bud.
These indentations contain cells that evaginate into the stroma
and develop into the secondary epithelial buds. The secondary buds extend into the mesenchyme, canalize, and coalesce
to form the secondary mammary buds. These secondary buds
will eventually develop into the lactiferous ducts around
weeks 20–24 of gestation (Hammond 2008). The mammary
pit develops during the third trimester and is the future of the
nipple. The lactiferous ducts drain into terminal ducts, the
retro-areolar ampullae, and converge into epithelial pits. As
the lactiferous ducts drain into the pits, the pits elevate and
form the nipple. Failure of the elevation of the epithelial pits
lead to an inverted nipple; occurring in 2–4% of females
(Nahai 2011; Janis 2017). Near the end of the gestational
period, there is an increase in the vascularity of the breast
stroma due to the hormonal interactions between fetus and
mother. At birth, the breast contains approximately 15–20
lobules with an associated lactiferous duct draining into the
mammary pit (Nahai 2011; Janis 2017; Hammond 2008).
12.2.2 Surface Anatomy
The breast is located on the anterior thoracic wall and overlies the pectoralis major, serratus anterior, external oblique,
and upper rectus muscles (De Fazio and Cingozoglu 2020).
The majority of the breast extends from the second to seventh ribs in the midclavicular line and spans from the sternocostal junction medially to the mid-axillary line laterally. A
portion of the breast gland, known as the axillary Tail of
Spence, extends into the axilla and provides the breast with
its teardrop appearance. The breast is conical in shape with a
base width of 10–12 cm and thickness of 5–7 cm (Nahai
2011). For the esthetic breast, the NAC is situated at the
mound of the breast with the greatest projection. The ideal
NAC is approximately a third of the overall breast diameter
with the nipple being a third of the overall areolar diameter
(Hauben etal. 2003).
12.2.3 Glandular Anatomy
The breast parenchyma is made up of a series of ducts while
the stroma contains the adipose tissue. The functional unit of
the breast is the lobule. The lobule drains approximately
10–100 acini, which ultimately drain into the lactiferous
ducts (Janis 2017). For every lactiferous duct, there are 15–20
breast lobules and for every breast, there are 15–20 lactiferous ducts. Surrounding the lobules is the connective tissue/
stroma that contains the lymphatic system and adipose tissue,
all of which contribute to the size of the breast. Most of the
glandular tissue is found along the central and upper portions
of the breast mound (Nahai 2011; Janis 2017; Hammond
2008; Mugea and Shiffman 2016; Hamdi etal. 2005).
The breast tissue is encased by the supercial and deep
layers of the supercial fascia that is connected to the dermis
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and breast tissue. Between the breast and pectoralis fascia
lies a layer of loose connective tissue called the retromammary space (Hamdi et al. 2005). This space is commonly
used as an ideal plane of dissection in breast reconstruction.
The breast stroma contains multiple ligaments that support
the parenchyma. The deep layer of the supercial fascia
extends into the pectoralis fascia and forms the posterior suspensory ligament. The stroma forms the Cooper’s ligaments
and functions to secure the breast to the dermis and underlying pectoral fascia, as well as divide the secretory lobules of
the breast. The ligamentous system of the breast acts as a
conduit for the nerves and vasculature of the breast and
nipple- areola complex. The horizontal septum originates at
the attachment of the pectoralis muscle to the fth rib and
travels vertically along the medial and lateral aspect of the
breast. The horizontal septum divides the glandular tissue
cranially and caudally creating a distinct separation in the
parenchyma. The cranial parenchyma varies in size depending on the patient’s breast, while the caudal parenchyma
maintains a constant thickness of 2cm (Hamdi etal. 2005).
This separation can assist with achieving symmetry during
breast surgery. Along the vertical limb of the septum, the
medial limb thickens and attaches the sternum to the inframammary crease while the lateral limb attaches the axillary
fascia to the thoracic wall. The medial and lateral limbs of
the horizontal septum function as an internal sling for the
parenchyma and assist with breast elevation. The ligamentum suspensorium mammae runs from the clavicle to the
upper pole of the breast and assists with breast suspension;
this may correlate with a decreased incidence of ptosis in
patients. The inframammary crease ligament functions as a
parenchymal sling and forms the inframammary fold. The
inframammary crease ligament attaches to the fth rib medi-
ally and the fth/sixth rib laterally; this ligament assists with
prevention of bottoming out after augmentation mammaplasty (Nahai 2011; Janis 2017; Hammond 2008; Mugea and
Shiffman 2016; Hamdi etal. 2005, Lteif and Javed 2013).
12.2.4 Vascular Supply oftheBreast
12.2.4.1 Arterial
The breast is perfused by three main arteries: the internal
mammary (internal thoracic artery), the lateral thoracic, and
the intercostal arteries. The majority of the breast, more specically the medial aspect, is supplied by the internal mammary artery (IMA) via anterior and posterior perforating
branches, which accounts for approximately 60% of total
blood ow (Hamdi et al. 2005). The second through fth
branches of the IMA perforate through the intercostal muscles and collateralize with the lateral thoracic, thoracoacromial, and intercostal arteries to supply the breast parenchyma.
More specically, the second and third anterior branches
perfuse a majority of the breast parenchyma (Hamdi etal.
2005). The external mammary artery, or lateral thoracic
artery, is responsible for perfusion of the lateral and upper
outer breast. The inferior aspect of the breast is supplied by
the third to fth intercostal arteries. The skin is perfused by
the subdermal plexus which communicates with the intercostal breast perforators (Hamdi et al. 2005). The nipple
areola complex receives both parenchymal and subdermal
blood supply via the internal and external mammary arteries.
The arteries travel along the subcutaneous plane and converge to provide communicating vessels to the surrounding
areola tissue and nipple (Figs.12.2 and 12.3) (Janis 2017;
Hammond 2008; Hamdi etal. 2005).
Fig. 12.2 Vascular supply to
the SMC pedicle
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Fig. 12.3 The central aspect
of the SMC provides a robust
amount of blood to the
overlying parenchyma
A. Cuzalina et al.
12.2.4.2 Venous
Venous drainage parallels the arterial supply and is divided
into two systems (Hamdi etal. 2005). The supercial system
is situated below the supercial layer of the supercial fascia
and involves the transverse and longitudinal veins. The transverse veins perform a majority of the drainage along the subcutaneous layer and empty into the internal mammary vein
(internal thoracic vein) while the longitudinal veins drain the
breast towards the suprasternal notch and empty into the
supercial veins of the lower neck. The deep venous system
is composed of the perforating branches of the internal mammary vein, the tributaries of the axillary vein and the perforating branches of the posterior intercostal veins. The
perforating branches of the internal mammary vein drain a
majority of the superomedial and inferior poles of the breast
through the third and fourth intercostal spaces, eventually
emptying into the brachiocephalic veins. The perforating
branches of the posterior intercostal veins drain the posterior
aspect of the breast and combine with the vertebral and azygos veins to empty into the superior vena cava (Nahai 2011;
Janis 2017; Hammond 2008; Hamdi etal. 2005).
12.2.4.3 Innervation
Sensory innervation to the breast is based on the dermatomal
distribution of the thoracic intercostal nerve levels T2–T6 via
the anterior and lateral intercostal branches. The superior
and outer pole of the breast is innervated by the supraclavicular nerves from the cervical plexus (C3,C4) (Nahai 2011;
Janis 2017; Hammond 2008; Mugea and Shiffman 2016;
Hamdi etal. 2005).
The anterolateral cutaneous branches travel through the
intercostal muscles and deep fascia to penetrate the breast.
The lateral branch of the second intercostal nerve, the intercostobrachial nerve, supplies the axillary tissue, and upper
medial arm. The third to sixth lateral cutaneous branches, the
lateral mammary branches, travel along the surface of the
serratus anterior and divide into supercial and deep
branches. The deep branches course within the pectoral fascia towards the midclavicular line where it gives off several
branches to the overlying parenchyma. The supercial
branches course through the subcutaneous tissue and innervate the skin of the lateral breast (Nahai 2011; Janis 2017;
Hammond 2008; Mugea and Shiffman 2016; Hamdi etal.
2005).
The anteromedial cutaneous branches innervate the
medial aspect of the breast. The branches travel through the
deep fascia and divide into lateral and medial branches. The
medial branch innervates the area along the lateral border of
the sternum while the lateral branch travels along the inferolateral aspect of the breast and innervates the skin and areolar
region (Nahai 2011; Janis 2017; Hammond 2008; Mugea
and Shiffman 2016; Hamdi etal. 2005).
Many studies have reported various distributions patterns
and courses taken by the nerves innervating the nipple-areola
complex (NAC). Innervation of the NAC is achieved by the
anterior and lateral cutaneous branches of the third to fth
intercostal nerves, with the lateral cutaneous branch of the
fourth intercostal nerve being the most prevalent (93% of
breasts) (Hamdi et al. 2005). In 93% of cases, the nerve
courses below the pectoralis fascia and once at the midclavicular line travels anteriorly through the glandular tissue to the
posterior aspect of the nipple. Innervation of the medial aspect
of the NAC is provided by the anterior cutaneous branches of
the third to fth intercostal nerves, mostly from the third and
fourth branches. These two branches travel along the supercial aspect of the subcutaneous tissue and innervate the medial
areola (Nahai 2011; Janis 2017; Hammond 2008; Mugea and
Shiffman 2016; Hamdi etal. 2005).
ab cde
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12.2.4.4 Lymphatic Drainage
Lymphatic drainage of the breast originates from the breast
lobules, which drain into the intramammary nodes and subsequently into the subareolar plexus, known as Sappey’s
plexus. Lymphatic drainage occurs along the venous tributaries via three routes: axillary, internal mammary, and retromammary. A majority of this lymphatic drainage is performed
by the ipsilateral axillary nodes (Nahai 2011). The axillary
pathway drains the lateral quadrants of the breast and traverse along the inferior border of the pectoralis muscle. The
internal mammary pathway drains the medial and lateral
quadrants of the breast as it passes through the intercostal
spaces and pectoralis muscle, before emptying into the parasternal/internal mammary lymph nodes. The retromammary
pathway originates from deep within the breast tissue and
drains into the subclavicular plexus (Nahai 2011; Janis 2017;
Hammond 2008; Mugea and Shiffman 2016; Hamdi etal.
2005).
Fig. 12.4 Classication of
ptosis (Stevens 2013)
12.3 History
Dr. Paule Regnault was one of the rst surgeons to address
the hypoplastic and ptotic breast with a combined mastopexy
and prosthetic augmentation. Dr. Regnault identied that
treatment of one condition, rather than both, leads to an
unaesthetic result. Over a 5-year period, Dr. Regnault treated
34 patients with the combined operation and concluded that
this procedure was safe and satisfactory results are obtainable (Regnault 1966).
Dr. Regnault developed a grading system to assess breast
ptosis based on the position of the nipple in relation to the
inframammary fold (IMF) and skin envelope (Figs.12.4 and
12.5) (Stevens 2013).
Fig. 12.5 Breast ptosis classication (Stevens 2013). (A) Normal. (B)
First degree. (C) Second degree. (D) Third degree. (E) Glandular
ptosis
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A. Cuzalina et al.
12.4 Patient Selection
Prior to a physical examination, it is very important to obtain
the patient’s medical history and chief complaint. The chief
complaint should be in the patient’s own words and should
be the primary area of discussion. The provider should
review the complete medical history as well as the family
history for cancers, and should assess any previous mammograms, biopsies, or breast scars. Women above the age of 40
or less for those that are high risk should receive a mammogram prior to surgery (Susan G.Komen® 2020).
Upon evaluation of the patient, the key areas to focus on
are the breast volume, skin envelope (laxity and quality),
NAC position, areolar size, degree of ptosis, and asymmetries. It is crucial to factor in the patient’s expectations in
regard to nal shape and presence of scars (Grotting etal.
2006).
Of particular importance, one should understand that not
all patients are ideal candidates for a combined mastopexy
and augmentation. When considering the goal of each procedure, mastopexies aim to reduce the skin envelope while
augmentation increases the breast volume. These two factors
are competing against each other and can lead to poor
esthetic results. The volume increase of the breast may compromise the breast envelope due to restriction of arterial ow
and venous drainage, thus diminishing perfusion to the
NAC.Patients with severe laxity, pedunculated or constricted
breasts and those who desire a signicant augmentation
would obtain an improved result by staging these procedures. These conditions require an extraordinary amount of
tissue reduction as well as rearrangement in order to create
an esthetic breast. Another group of individuals who would
benet from staging are those with medical comorbidities
and prior breast surgery. The goal of staging is to avoid compromise of the breast tissue and NAC due to ischemia and
necrosis (Fig.12.6).
In these cases, a mastopexy would be the rst stage and
allow for proper reduction of the skin envelope and placement of the NAC.This enables the surgeon to have a more
predictable outcome with regard to the size and shape of the
breast. The second stage would involve an augmentation to
achieve the desired volume. For the ideal patient, the combination of the mastopexy and augmentation should work
together by developing a well-positioned breast envelope
with placement of an implant that produces an aesthetic
breast.
Fig. 12.6 The goal of staging is to minimize the risk of ischemia to the
parenchyma and NAC.Patients with large breast with severe ptosis or
those with tubular/constricted breasts are an increased risk of ischemia;
these patients would benet from a mastopexy followed by
augmentation
Mastopexy Incision Design Indications Advantages Disadvantages
with augmentation
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12.5 Mastopexy Incision Design (Figs.12.7
and12.8) (Qureshi etal. 2018)
The goal of the mastopexy is to recreate a breast that is symmetrically shaped, appropriately sized and has long-term stability (Nahai 2011). The combined procedure involves
elevation of the NAC with associated breast/skin excision.
For the simplest of cases, a crescent lift may be appropriate
while larges breasts may require a signicant amount of tissue reduction with an equal amount of skin excision.
12.5.1 Periareolar/Crescent
The periareolar technique is ideal for patients who present
with Grade I/II ptosis or nipple asymmetry with minimal
skin excess. This approach has great purpose in elevating
the position of the NAC within 2cm, but has little benet in
regard to the treatment of redundant tissue or skin. This
procedure assists with balancing out the nipples with minimal effect on the breast parenchyma. The benet of this
technique is the placement of the incision along the areolar-
breast junction that improves the scar appearance. For those
patients who present with tubular or severely constricted
breasts, the periareolar approach proves benecial due to
its ability to atten the breast mound and NAC.In attempts
to reduce the skin envelope, a periareolar defect may
develop and lead to poor wound healing, distortion of the
NAC, and decreased breast projection (Nahai 2011). In
order to minimize periareolar widening, two techniques
may be utilized. First, after determination of the planned
areolar size, maximal stretch should be applied while creating the incision to overcome the effects of the immediate
post-operative stretching. Second, the periareolar incision
should be re-approximated using a permanent purse-string
suture. This allows for stress absorption by the suture and
reduction in tension along the areola. The most common
suture used is a polytetrauoroethylene (PTFE) suture,
Teon, due to its non-resorbable nature and ease of use
(Nahai 2011).
The crescent mastopexy is a variation of the periareolar
technique with resection of the tissue above the areola. The
crescent incision is ideal for an asymmetrical nipple and
allows for elevation of the NAC by 1–2cm.
Periareolar/Crescent
Grade I or II ptosis,
nipple asymmetry
1.NAC elevation
1-2cm
1.Decreased
projection of breast
mound
2. Camouflaged
scar
Vertical/Teardrop
All ptosis grades 1. Correction of
ptosis & resection
of excess tissue
2. Preservation of
2. Scar Widening
1. Possible persistent
asymmetry
2. Decreased lower
pole projection
nipple mound
projection
Vertical-Short Scar Periareolar
Inferior Pedicle Reduction
All ptosis grades 1. Correction of
ptosis
1. Periareolar
widening
(SPAIR)
Wise Pattern/Inverted T
2. Resectionof
excess tissue
Grade II or III ptosis1. Increased
resection of breast
2. Implant bottoming
out
1. Increased scar
presence
parenchyma &
skin
2. Increased suture
spitting
2. Allows for
breast reduction &
lift in conjunction
Fig. 12.7 Mastopexy Incision (Qureshi etal. 2018)
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A. Cuzalina et al.
Fig. 12.8 Mastopexy Incisions
Bennelli described a technique that incorporates a peri-
areolar mastopexy with parenchymal restructuring (Benelli
1990). This technique has been adapted to treat larger breasts
while utilizing the periareolar approach. The inferior breast
parenchyma is incised vertically and repositioned to decrease
the base while simultaneously elevating the breast position.
If a concurrent augmentation is planned, the implant must be
placed sub-pectoralis to avoid vascular compromise to the
overlying parenchyma and NAC (Qureshi etal. 2018).
Based on the authors’ belief and the literature, periareolar
mastopexies have high rates of revision due to undesirable
results such as poor esthetics, inadequate projection, and
high recurrence rates (Cuzalina and McLain 2019; Qureshi
etal. 2018).
12.5.2 Vertical-Teardrop
The vertical mastopexy has evolved from the initial techniques of Lassus, Peixoto, Arie, Pitanguy, Marchac, and
Lejour and have been further modied by Hall-Findlay and
Hammond. The vertical mastopexy allows for NAC repositioning and ptosis correction with excision of glandular tissue, ultimately improving the longevity of the procedure.
This technique involves a periareolar incision in addition to
a vertical component, with the goal to avoid a horizontal
incision.
The Hall-Findlay approach is commonly utilized due to
the versatility in pedicle design, minimal scar presence, and
restoration of projection. This technique is most commonly
performed with a Superomedial-Central (SMC) or a Mediocentral (MC) pedicle due to its signicant arterial supply and
adequate venous drainage. The approach involves a wedge
resection of the inferior breast parenchyma with reapproximation of the medial and lateral parenchyma thus
providing a pillar to support the NAC while both lifting and
narrowing the breast (Hall-Findlay 2002). The placement of
the inferior aspect of the skin incision is pivotal; it must be
placed above the inframammary fold (IMF) due to the tendency of the IMF to raise, hence causing the incision to
overly the abdomen. In regard to augmentation, a subglandular or sub-pectoralis implant placement is possible due to the
adequate perfusion of the NAC by the second/third internal
mammary perforators (Qureshi et al. 2018). Immediately
post-operatively, the breast appears to have signicant upper
pole fullness as well as a sloped inferior pole. It is important
to note that nal breast shape may take several months to
develop.
12.5.3 Vertical-SPAIR
Hammond developed the short-scar periareolar inferior pedicle reduction (SPAIR) to address breast ptosis. The tech-
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nique utilizes an inferior pedicle to provide perfusion to the
NAC while excising the surrounding parenchyma in the
shape of a horseshoe. The inferior pedicle is then suspended
to the chest wall to assist with elevation, while the overlying
skin is excised and re-approximated in a vertical fashion.
The results of this procedure are seen immediately and do
not require additional time for settling. The major disadvantage of this technique is the potential of an implant bottoming out, periareolar widening, altered nipple sensation and
decreased likelihood of simultaneous implant placement
(Hamdi etal. 2005; Qureshi etal. 2018).
12.5.4 Wise Pattern/Inverted T
The Wise Pattern was originally described by Wise in the
1950s to address breast ptosis with only skin mastopexies.
As new techniques were developed, the Wise Pattern mastopexy evolved to include parenchymal and pedicle designs
(Ship etal. 1989). In the USA, the Wise Pattern is one of the
most commonly utilized mastopexy and reduction patterns
due to its versatility to be combined with augmentation. The
mastopexy may employ multiple pedicles, and while the
inferior pedicle was preferred historically, new techniques
allow for the use of superior and medial pedicles (Cuzalina
and McLain 2019). The horizontal component is pivotal in
removing redundant skin tissue as well as controlling the
nipple to inframammary fold distance (N-IMF) in those with
measurements greater than 8cm. The major downside to this
procedure is the signicant scar presence when compared to
other mastopexies. Another concern, more specically with
the inferior pedicle approach, is the increased incidence of
bottoming out due to a weakened pillar of support along the
inferior aspect of the implant (Rohrich et al. 2006). When
combined with an augmentation, there is an increased incidence of incision breakdown along the T-junction due to the
pressure of the overlying implant (Qureshi etal. 2018).
12.6 Pedicle Options
The supero-medial pedicle (SM), in combination with a central pedicle (C), is the most versatile and robust pedicle due
to its unaltered blood supply during mastopexy and augmentation and constitutes the SMC pedicle (Hall-Findlay 2004).
The SM pedicle relies on the internal mammary artery as
well as the second to fourth internal mammary perforators
while the C pedicle is perfused via trans-pectoral perforators
supplied by the internal mammary and medial mammary
branches. The vascular supply of the C pedicle is affected
during the creation of a subglandular breast pocket
(Fig. 12.9). The surgeon should plan accordingly prior to
plane development as well as revision surgery to reduce the
risk of complications. Of note, the minimal base width of the
pedicle is 6–10cm.
There are varying circumstances where the authors would
elect to utilize various pedicles (Fig. 12.10). For patients
who present with pendulous breasts and severe ptosis (SN-N
>30cm, commonly seen with massive weight loss patients),
a Medio-central pedicle (MC) is favored. The MC pedicle
preserves the internal mammary artery and associated arterial perforators while sacricing the surrounding vasculature
to assist with pedicle rotation and minimal tension (Siy etal.
2015). For patients with mild to moderate ptosis with the
displacement of the NAC 2–3cm below the IMF, a Superocentral pedicle (SC) is recommended due to its ability to
improve upper pole fullness and breast shape. The SC pedicle relies on the lateral and internal mammary arteries in
Fig. 12.9 Submammary
pocket development disrupts
the perforators to the central
pedicle
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Fig. 12.10 Breast pedicles
A. Cuzalina et al.
Fig. 12.11 The SMC pedicle is utilized for most mastopexy cases. For patients with a SN-N greater than 30cm, a MC pedicle is preferred due to
its ease of rotation of the NAC with minimal constriction
addition to the axillary artery to maintain perfusion to the
pedicle. This abundant blood supply is particularly benecial
as it may reduce the risk of wound dehiscence (Siy et al.
2015). For patients with a long SN-N with a short N-IMF, an
inferior pedicle is not a viable option for ptosis correction
(Fig.12.11).
The authors almost exclusively use a subpectoral/submuscular plane for implant placement. With the submuscular plane, the blood supply to the overlying parenchyma
and NAC is preserved and the plane allows for a more signicant soft tissue coverage, thus decreasing the incidence
of capsular contracture. It is important for the surgeon to
properly develop the submuscular pocket. If the pocket is
inadequately released, the implant will be situated superior
to the NAC and overlying breast tissue, therefore producing an enlarged upper pole with a downward trajectory of
the NAC (Nahai 2011). In addition to the subpectoral
plane, the authors partially develop a plane below the serratus anterior and external oblique muscles to augment
coverage along the inferior aspect of the implant, as well
as fortify the barrier between the implant and the skin surface (Fig.12.12).
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