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12 Combined Mastopexy andBreast Augmentation
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Fig. 12.12 Use of the SMC
pedicle allows for the
development of a total
submuscular pocket. The
submuscular pocket allows
for complete coverage of the
implant; this protects the
implant as well as reduces the
risk of bottoming out
175
12.7 Implant Selection
When evaluating implants for use in augmentation/mastopexy cases, there are various styles and types that are available. In regard to ll, both saline and silicone are viable
options for augmentation, and selection criteria is based on
those similar to breast augmentation. With the use of a submuscular plane, the incidence of rippling is signicantly
less when compared to placement in the subglandular
plane. A round, smooth implant is preferred over an anatomic breast implant for the reason being that a round
implant may tolerate movement without risk of breast distortion (Nahai 2011). The surgeon must thoroughly analyze
the current breast volume and factor it into implant size
selection; it is recommended to select a smaller implant
size for augmentation/mastopexy cases in order to achieve
an aesthetic result.
12.8 Surgeon’s Technique
According to the literature, the most conservative approach
to augmentation/mastopexy is for the implant to be inserted
rst, followed by a mastopexy to ensure adequate parenchyma and skin removal. The authors’ selected technique is
reverse, as implant placement is preceded by the mastopexy.
In order to reduce the risk of excess tissue/skin removal,
great detail is involved with the planned resection margins
and implant selection in the pre-operative evaluation. With
this approach, the authors are able to develop a total submuscular plane for implant placement and manipulate the breast
parenchyma to achieve the desired shape and size while
ensuring maximum implant projection. For patients with
severe ptosis or asymmetry, identifying the ideal implant
position prior to a mastopexy is extremely problematic due
to the distortion of the normal breast footprint and concerns
for alteration of the implant following the mastopexy.
12.8.1 Marking
In preparation for surgery, the mastopexy markings are performed in the upright position with the use of a permanent
marker. The pivotal marking is the placement of the superior
most aspect of the areola. The position is determined by creating an imaginary line from the mid-humeral point to the
midpoint of the breast; the ideal location of the nipple.
Additional markings should include positioning of the NAC
at or slightly above the planned IMF.If there is a possible
need for a horizontal excision, the surgeon should make for a
horizontal segment along the proposed IMF (Fig.12.13).
The authors elect to utilize a mastopexy template to
ensure symmetry. The selection of a Vertical or Wise Pattern
is determined by the need for horizontal skin excision. For
cases with a moderate amount of skin resection or NAC elevation, a Wise Pattern is recommended in order to preserve
the N-IMF distance (Fig.12.14). The vertical segment marking is established by lifting the NAC to the ideal location and
reducing the skin of the lower pole vertically down to the
planned IMF.This marking represents the skin resection to
allow for an aesthetic shape. The horizontal segment marking is along the IMF and its medial/lateral extent is dependent on the skin quality/excess, as well as the amount of
inferior pole parenchyma.
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Fig. 12.13 Surgical markings are performed while the patient is standing upright with arms to the side. In mild ptosis cases, a vertical incision
is incorporated into the surgical design, these lines are demarcated
Fig. 12.14 Wise pattern
mastopexy utilizes similar
markings to a vertical
mastopexy in addition to a
horizontal component. The
horizontal incision should be
placed approximately 1cm
above the desired
IMF.Liposuction (areas
marked in red) is an
adjunctive treatment to assist
with breast contouring upon
completion of the mastopexy/
augmentation
12.8.2 Anesthesia
while displacing the parenchyma laterally and medially. The incision is
placed along the breast axis and extends 1–2cm above the IMF
12.8.3 Operative Technique
For all patients undergoing augmentation mastopexy, general anesthesia is required to ensure the safety of the patient
and the surgical team. Tumescent anesthesia, more specically a tumescent solution containing 40cc of 1% lidocaine
with 11mg of epinephrine, is inltrated along the planned
incision lines, subdermal in the areas of planned deepithelization and into the subpectoral plane.
The patient is prepped with sterile antiseptic solution
(ChloraPrep: 2% Chlorhexidine gluconate in 70% Isopropyl
alcohol) and draped in the standard sterile fashion. Surgery
commences with areolar size determination using an
appropriately- sized areolar marker with the nipple centered
under the marker. A #10 blade is utilized to create an incision
through the epidermis down to the dermis along the demar-
12 Combined Mastopexy andBreast Augmentation
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177
cated areas. Attention is then turned to the area within the
planned incision, and is de-epithelialized inferiorly to the
horizontal incision. The surgeon must maintain a supradermal plane and avoid incising into the breast parenchyma
or undermining the NAC. Once the area is adequately prepared, the horizontal and vertical (lateral aspect) incisions
are developed further down to the parenchyma and the ptotic
tissue along the inferior and lateral aspect is excised. The
inferior incision is carried down to the pectoralis fascia,
while taking care to remain above this plane. The pectoralis
fascia is to only be exposed along the inferolateral aspect up
to a few centimeters medially. The dissection is continued
superiorly above the pectoralis fascia to the planned placement of the NAC, which corresponds with the proposed
insertion site of the implant. Enbloc resection of the excess
glandular tissue is performed and additional tissue is removed
along the keyhole area to allow for mobility of the NAC and
pedicle (Fig. 12.15). When treating massive weight loss
patients, it is important to excise excess parenchyma due to
an increase incidence of ptosis relapse (Fig.12.16). In order
to improve the longevity of the procedure, it is recommended
to remove additional breast tissue when possible and place a
larger implant (Fig.12.17).
An incision is made along the pectoralis muscle ensuring
that the incision is parallel to the muscle bers. The muscle
is suspended gently outwards to allow for entrance into the
subpectoral space and to avoid entering into the chest wall.
Once in the subpectoral space, digital blunt dissection is per-
formed in a circumferential matter to create the implant
pocket; dissection is performed with a sweeping motion.
Upon dissection along the infero-lateral aspect of the breast,
the bers of the anterior serratus and external oblique muscles are elevated to assist with implant coverage (Fig.12.18).
It is important to minimize over dissection along the medial,
inferomedial, and inferior aspects to avoid symmastia, boxy
appearance of the medial breast and low implant descent,
respectively (Nahai 2011).
Once the subpectoral plane has been developed, attention
is turned to the medial pectoralis major bers. A lighted
retractor is placed, and from a 3–6 o’clock position (right
breast) to 6–9 o’clock position (left breast), the muscle bers
are incised with the use of cautery several centimeters above
the attachment of the pectoralis major to the sternum, and
carried to the pre-pectoral fascia. This incision allows for
expansion of the breast pocket medially and anteriorly. Once
adequate expansion is achieved, the pocket must be hemostatic and is done so with the use of the electrocautery.
An additional verication is performed to ensure that the
pedicle and NAC are able to be repositioned to the superiorly
placed mark without constrictions. Once the NAC is in position, the superior trifurcation at the NAC/Vertical incision
point is re-approximated along the deep dermal plane and the
NAC is xated into position. Minimizing tension along this
line improves scar formation (Fig.12.19).
An implant sizer is then inserted into the subpectoral
plane and inated to obtain the desired size as well as assist
Fig. 12.15 To ensure the longevity of the mastopexy, it is pivotal to excise the inferior parenchyma. The surgeon must be attentive when debulking
the parenchyma below the NAC and vertical limbs; excess removal can compromise the tissue aps
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Fig. 12.16 These massive weight loss patients have lost over 100lb following bariatric surgery. Removal of excess mammary tissue, fat, and skin
allows for improved breast contour and improved longevity
Fig. 12.17 Massive weight loss patients who desire “perky” breasts
typically require augmentation post mastopexy. Due to the presence of
poor-quality parenchyma, additional tissue must be excised to achieve
an excellent result. Removal of this excess tissue decreases the overall
breast size and an implant assists with increasing the volume and
obtaining a rounded contour
12 Combined Mastopexy andBreast Augmentation
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Fig. 12.18 Digital dissection
allows for development of a
total submuscular ap. The
surgeon must take caution
during the dissection to avoid
perforation of the ap, most
specically along the inferior
aspect
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Fig. 12.19 The vertical component of the mastopexy assists with decreasing the circumferential pull on the areola. Without the vertical component, the diameter of the NAC tends to widen over time
with pocket expansion and evaluation of the overlying tissue.
Once the desirable size is determined, the pocket is irrigated
with solution containing saline, Ancef, Gentamicin, and
dilute Betadine. The implant is then placed in a Keller funnel
containing the above solution and inserted into the pocket.
Placing the implant in a total submuscular plane assist with
reducing pressure along the incision line and improves longevity (Fig.12.20).
Once in place, the patient is placed in a seated position to
conrm aesthetics and symmetry. Upon conrmation, the
patient is placed back into a supine position and the remaining incisions are re-approximated in a layered closure. Prior
to closure, a parenchymal suture is utilized to approximate
the medial and lateral parenchyma pillars and suspend them
to the parenchyma along the IMF. This suture assists with
additional implant coverage as well as inferior displacement
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Fig. 12.20 Total
submuscular pockets in
addition to excision of excess
parenchyma demonstrates the
longevity of the combined
procedures. Recurrence of
ptosis is secondary to weight
gain and enlargement of the
overlying breast tissue
A. Cuzalina et al.
of the IMF.Once complete closure has been performed, the
breasts are re-evaluated and nal shaping may be performed
with lateral liposuctioning.
12.9 Revision Mastopexy/Augmentation
As previously noted, combined augmentation/mastopexy
is a technical procedure with unpredictable results. A surgeon must be prepared to deal with one’s own complications as well as those of colleagues. When dealing with a
revision, the surgeon must establish a denitive plan and
inform the patient of potential complications. It is prudent
for the surgeon to obtain previous operative reports to
ascertain the planes of dissection as well as the selected
pedicle. This information may reduce the risk of further
complications, including but not limited to, NAC ischemia. In cases where the selected pedicle is unknown, it is
prudent to utilize multiple pedicles to reduce the risk of
ischemia (Fig.12.21).
The surgical blueprint should include two-staged mastopexy and augmentation and avoidance of wide excision patterns and signicant undermining. For the patients who
develop capsular contracture, the risk of complications is
even greater. These patients will require explantation with
capsulectomy followed by a revision mastopexy/augmentation (Fig.12.22). The patient should be informed that there is
a signicant risk of skin/nipple necrosis and the need for
possible staging to minimize surgical complications and
improve aesthetic results.
12 Combined Mastopexy andBreast Augmentation
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Fig. 12.21 This patient
previously underwent a
mastopexy/augmentation.
Upon evaluation, the origin of
the pedicle was unknown and
it was determined that the
patient would benet from a
combination of pedicles. The
surgeon must avoid over
dissection of the breast
parenchyma due to an
increased risk of NAC
compromise
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Fig. 12.22 Patients with capsular contraction who desire a breast lift with augmentation must be informed of the high revision rate and risk of
complications
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12.10 Complications
The single stage augmentation and mastopexy has been a
controversial topic since 2003 and was initially addressed by
Spear (2003). Stevens etal. published several case reports
focusing on one-step augmentation/mastopexy. The rst
study documented an overall revision rate of 16.7%,
comparable to the rate for breast augmentation alone, which
is below the 100% re-operation requirement for a two-staged
procedure (Stevens etal. 2006). Another study by Stevens
evaluated 1192 single stage augmentation/mastopexy procedures that demonstrated a 16.9% revision rate, with 52% of
causes associated with implant-related complications
(Stevens etal. 2014). Calobrace etal. evaluated 332 augmentation/mastopexy cases and noted a 22.9% complication rate
with a revision rate of 23.2% (Calobrace etal. 2013). Another
study aimed to focus on the tissue perfusion following augmentation/mastopexy based on a vertical approach and concluded that augmentation in conjunction with a vertical
mastopexy and medial pedicle demonstrates no signicant
reduction in NAC perfusion (Swanson 2015). A meta- analysis
that included 4856 cases of single staged augmentation/mastopexy demonstrated a pooled complication rate of 13.1%
and reoperation rate of 10.7% (based on 13 studies). The
documented complications included recurrent ptosis (5.2%),
poor scarring (3.7%), capsular contracture (2.97%), asymmetry (2.94%), and hematoma, infection and seroma (<2%)
(Khavanin etal. 2014).
A common surgical outcome that requires minor revision
is scarring. Over time, the constricting forces of the skin
excision and expansile forces of the breast augmentation
may cause a widening of the surgical incision with poor scar
formation. Once the scar is permitted to mature, a scar revision is able to rectify the appearance with a high rate of success. Irregularities of the NAC in respect to position or
symmetry are commonly associated with isolated periareolar
lifts. When combined with augmentation, the areolar tends to
expand regardless of type of closure performed. To address
these changes, a periareolar approach with a vertical component will decrease tension along the new areolar incision and
establish a more aesthetic breast result. As stated previously,
this is known as a Benelli lift (Fig.12.23).
Another complication is implant malposition, seen in
both primary augmentation and combined augmentation/
mastopexy. The implant is commonly displaced inferiorly
and laterally, and can be addressed with pocket modications including capsulorraphies/capsulectomies. For those
patients with compromised soft tissue coverage, an acellular
dermis and bio-resorbable scaffolds have shown to be effective in tissue regeneration for reconstruction cases, as well a
revision breast cases (Fig.12.24) (Spear etal. 2006). In addition to allograft material, localized muscle aps are a viable
option for additional implant coverage and tissue defects
(Fig.12.25).
As stated previously, ischemia to the NAC is of utmost
concern when performing an augmentation/mastopexy. If
poor perfusion is identied intra-operatively, the NAC must
be evaluated for an underlying periareolar hematoma and
hemostasis must be obtained. If the NAC appears dusky
postoperatively, nitroglycerin paste should be applied to the
area to relieve venous congestions. In the event of a severe
ischemia, sutures should be removed to allow for decompression of the parenchyma and the possibility of implant
removal should be considered. A nal treatment modality in
treatment of severe ischemia is hyperbaric oxygen therapy
which has proven to be benecial in the early postoperative
period (Copeland-Halperin etal. 2016).
Based on this information, the revision rate of singlestaged augmentation/mastopexy is signicantly less than the
guaranteed 100% reoperation rate for a two-staged approach.
Fig. 12.23 Following a
periareolar mastopexy, it is
common for the areolar
incision to widen. The above
desired rounded and perky
breasts and underwent a
vertical mastopexy with
submuscular implant
placement
12 Combined Mastopexy andBreast Augmentation
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183
Fig. 12.24 The above patient underwent a total of ve breast surgeries
(augmentation, mastopexy, and treatment of capsular contractures).
Upon evaluation, the overlying muscle sustained signicant damage.
Fig. 12.25 The above patient
had undergone several breast
augmentations with the nal
augmentation complicated by
symmastia. The overlying
muscle was signicantly
damaged and an inferolateral
submuscular ap (serratus
and external oblique muscles)
was developed to obtain
coverage over the new
implant
Pitfalls and Pearls
1. No single method is superior in treatment of all types of
breast ptosis.
2. The patient must be involved in the selection of the surgical technique.
3. The surgeon must determine which mastopexy technique works best in his/her hands; becoming efcient in
An acellular dermal matrix was xated to the sixth rib and connected
the remaining pectoralis muscle to the new IMF
the selected technique will allow for more consistent and
improved outcomes.
4. Inadequate removal of breast tissue opposite that of the
vascular pedicle is a leading cause of relapse/revision.
5. Kinking of the vascular pedicle due to poor design and
improper subdermal release results in venous
congestion.
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6. A superior-medial-central pedicle is utilized for breasts
with a sternal notch to nipple distance of up to 30cm.
7. A medial-central pedicle is best for breasts with a sternal
notch to nipple measurement of greater than 30 cm,
especially 35–45cm. This allows for an improved arc of
rotation of the nipple.
8. Staging the procedure is ALWAYS an option, particularly for extremely large breasts, heavy BMI, active
smokers, previously operated breasts, radiation history
or extreme ptosis patients.
9. Massive weight loss patients typically require reduction
of a majority of the poorly elastic breast tissue to avoid
relapse or a “snoopy” deformity.
10. Caution all patients of the challenging nature of the
combined surgery and the higher rates of revision compared to a standard augmentation.
12.11 Conclusion
Simultaneous augmentation and mastopexy allows the surgeon to reverse the effects of aging and restore the breast to
its aesthetic form. Many new techniques have been developed to improve the outcome of surgery while ensuring its
longevity. The patient must have a clear understanding of the
limitations of each procedure and how outside variables may
affect the overall outcome. The risks of the augmentation/
mastopexy is great, but when properly performed, the reward
is even greater.
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