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The I.D.E.A.L.® Breast Lift forModerately
https://t.me/medicina_free
toSeverely Ptotic Breasts: AStaple-First
Technique That Can BeCombined
withBreast Augmentation
TedS.Eisenberg
13
13.1 Introduction
This chapter introduces a technique to simplify mastopexy
with or without breast augmentation. The challenge is knowing how much skin needs to be excised without causing
necrosis of the skin edge (Regnault 1976
Camarena and Ramirez-Macias 2006) (Fig.13.1).
The technique of invaginating all the tissues by stapling
provides the unique advantage of seeing the nal result
; Cardenas-
before making any incision and allows for cutting the invaginated skin in one piece.
When breast implants are also utilized, some surgeons
choose to do a two-part procedure. They tighten the skin
with the lift initially; after healing is complete, they place
the breast implants. With the I.D.E.A.L. Breast Lift, the
lift and the augmentation can be done more easily at the
same time.
Supplementary Information The online version contains supplementary
material available at
T. S. Eisenberg (*)
Plastic and Reconstructive Surgeon, Philadelphia, PA, USA
e-mail: info@lookingnatural.com
© 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_13
https://doi.org/10.1007/978- 981- 99- 3726- 4_13.
185
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Fig. 13.1 The challenge is determining how much skin needs to be
removed for the mastopexy when an implant is also being placed
13.2 Historical Background
oftheProcedure
Over the past 50years, surgeons have developed various complex patterns (Wise etal. 1963; Kirwan 2007; Regnault 1966)
to solve the puzzle of the one-stage approach: How to tackle
the opposing tissue forces necessary to make ptotic breasts
fuller (by stretching the skin with augmentation), yet rmer (by
tightening the skin with mastopexy) (Speer and Giese 2000).
Each evolution attempted to maximize the amount of skin
to be cut and minimize possible necrosis of the skin edge
(Parsa and Jackowe 2010).
For many years prior to doing my technique, I would do
the following after placing the breast implants:
• draw a Wise pattern,
• deepithelialize or deskin within the Wise pattern,
• and then staple the skin together, which often meant need-
ing to cut additional skin to adjust the symmetry (Whidden
1978).
In the early 2000s, I changed the approach, which allowed
me to staple together the maximum amount of invaginated
tissue rst. This enabled me to see the nal result before any
cutting was done. I then:
• made a line around the staples before removing them, and
• deepithelialized or deskinned the tissue inside of the
markings.
This tissue inside of the lines usually represented a much
larger area to be removed than the older technique did.
This approach is also useful for mastopexy with breast
implants.
I have found that the I.D.E.A.L.Breast Lift can:
• x any degree of ptosis,
• x severe asymmetries,
T. S. Eisenberg
• maximize the tissue needed to be cut without causing
necrosis of the wound edges,
• simplify the new location of the nipple-areola complex
(NAC),
• eliminate the need for internal mesh,
• be easily performed.
13.3 Classications ofBreast Ptosis
Breast ptosis, or sagging, is usually determined by Regnault’s
grades 1 through 4, based upon where the nipples sit relative
to the inframammary crease (IMC):
1. Mild ptosis. The nipple is at the IMC.
2. Moderate ptosis. The nipple is slightly lower than the
IMC.
3. Moderate to extreme ptosis. The NAC is lower than the
IMC, and the nipples are facing anteriorly, or
forward.
4. Extreme ptosis. The NAC is lower than the IMC, and the
nipples are facing inferiorly, or down.
13.4 Examination
The following measurements should be taken at the inperson consultation (Fig.13.2). To evaluate the grade of ptosis, wrap a measuring tape around the patient’s rib cage in
the crease where the bra band would rest. Refer to Regnault’s
classications.
Further evaluation of the degree of sagging breast is done
by measuring from:
1. the top of the sternum to the center of the NAC,
2. each nipple to the IMC,
3. and mid-clavicle to the IMC.
To determine the possible breast implant volume, mea-
sure the breast width diameter (BWD), the distance from the
side of the sternum directly over the breast mound to the lateral aspect of the breast. If the breasts are larger and displaced laterally, have the patient raise her arms to get a truer
BWD measurement.
Evaluate the laxity of the skin; when using an implant
more ccs can be added when the tissues have been stretched
from signicant weight change or the milk that comes in during pregnancy.
Assess breast asymmetry from the sitting or standing
position and then again while the patient is lying down.
Any obvious volume difference between the breasts
caused by rib cage irregularities should also be included.
For example, if the rib cage is more prominent on one
13 The I.D.E.A.L.® Breast Lift for Moderately to Severely Ptotic Breasts: A Staple-First Technique That Can Be Combined…
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Fig. 13.2 Measurements taken during consultation
side, additional ccs might need to be added to the other
side.
Finally, measure the rib cage circumference (where the
bra band would sit). I measure the circumference in inches
(not centimeters) and add 4in. This is consistent with how
UK and US bra manufacturers size their bra bands.
When I ask a patient her desired bra cup size—as a wish,
not a promise—she often says, “a C cup.” I use her bra band
size to make this point: A woman with a petite frame (32-in.
bra band size) might only need a B cup to have a “C look,”
whereas a larger-framed woman (38-in. bra band size) may
need a D cup to have the same “C look.” This helps patients
understand that their post-op bra size will be more of a “cupsize look” than an actual “cup size.”
13.5 Treatment Approach
Your examination, along with evaluating patient goals, will
provide the information you need to determine whether a
breast lift alone or in combination with breast implants will
achieve her goal.
Patients say they want “to be perky.” If the ptosis is moderate to severe (Grades 2, 3, or 4), a mastopexy is required
for “perkiness.” The mastopexy raises the nipples and resects
the stretched tissue.
To determine when a breast implant is needed, I ask:
“When you are standing in front of a mirror with your bra on,
are you happy with the size of your breasts and how you ll
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T. S. Eisenberg
out your bra, or do you wish your breasts were a little
bigger?”
When a woman is satised with her breast size in clothes,
I suggest a lift. If she wants more volume, I suggest a lift and
implants. When a patient says she is too big, then tissue is
removed during the lift.
If ptosis is mild (Grade 1), sometimes just an implant
alone will give the appearance of a lift without the nipple
actually being raised. I show the patient before and after photos of women with measurements and ptosis similar to hers,
so she can see if the illusion of a lift is adequate.
13.6 The I.D.E.A.L.Breast Lift Technique
13.6.1 Preoperative Markings
Blueprint drawings are made on the woman. She should be
upright, sitting, or standing (Figs.13.3 and 13.4). The blueprint drawings are similar to those for the anchor pattern
(Marchac 1990), but I only use these markings as a guideline
for stapling the invaginated tissues and not as an actual
pattern.
1. First, hide the new inframammary markings at least
2–3 cm laterally from the cleavage area. Do the same
2–3cm medially at the lateral aspect of the new inframammary line so that the ends of the new IMC will not be
seen. This line should be mostly covered even if the
patient lifts her arms.
2. Bisect each breast with a long mark. This mark should
only go to the NAC when the NAC is in the middle of the
breast. In other words, the line should be right in the middle of the breast, even if the NAC is located medial or
lateral to this mark: In larger breasts that may extend laterally, the central line can often be more easily determined when the patient’s arms are raised.
3. Mark the new nipple position on this bisecting line as
published by Dr. Ivo Pitanguy. This new nipple position
on the bisecting mark correlates with the new inframammary marking.
4. Then, from this new nipple position draw a point 2 cm
above, which will represent the top of the new NAC.
5. Next, draw a long horizontal line at this apex mark to
designate the upper limit of the new NAC.This will be
useful in nding the top of the new NAC after this area is
invaginated by the stapling.
Fig. 13.3 Pre-op markings
for nipple placement, IMC,
and 9–10cm apex-to-crease
keystone lines
Middle of the IMC incision
(IMC
)
13 The I.D.E.A.L.® Breast Lift for Moderately to Severely Ptotic Breasts: A Staple-First Technique That Can Be Combined…
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Antiseptics that contain alcohol will remove the pre-op
markings, so when prepping the patient I use a Betadine
solution so as not to lose my markings.
I place all breast implants partially subglandularly and
partially submuscularly through an inframammary incision.
Saline implants require an incision of approximately 3–4cm;
silicone gel need 5–6cm. Presuturing of this area (without
tying the suture) is performed with 2-0 absorbable suture so
as not to later puncture the implant at the nal closure. The
subcutaneous layer is closed with 4-0 absorbable suture.
Saline implants that were used averaged 500 cc; silicone
implants averaged 350cc and have been Mentor MemoryGel
(moderate plus prole). Breast asymmetries as large as
225cc were corrected with this approach (Eisenberg 2009).
189
Fig. 13.4 Comparable preoperative markings on the patient
6. From the new top of the NAC, draw 9–10cm lines hugging either side of the areola and angled toward it—
regardless of the nipple position. This angling allows a
nipple that’s located medially, for example, to be moved
more centrally to the new NAC position. The length of
these lines will represent both the distance of the diameter of the new nipple-areola complex (approximately
4 cm) and the distance from the bottom of this new
complex to the new inframammary fold (approximately
5cm).
7. You must check that the endpoints of these 9–10cm lines
can reach the center of the newly drawn IMC.If it does
not, the new nipple location, or Pitanguy point, must be
lowered so that these distal points can reach.
13.6.2 Preparation During Surgery andBreast
Enlargement
Lay the patient on her back with her arms out 90°. Having
the arms extended will minimize the chance of removing too
much deepithelialized tissue. Care must be taken not to
abduct the arms more than 90° as this might cause a brachial
plexus injury.
Before receiving general anesthesia, all of my patients
are placed in lower extremity sequential compression
devices (for anti-DVT protocol). In addition, to lower the
possibility of lung emboli, 5000 units of subcutaneous
heparin are given. Perioperative antibiotics are used (usually cephalosporin, or doxycycline if penicillin allergic)
to minimize the chance of infection. To lower postoperative emesis, anti- nausea medicines are given (Eisenberg
2008).
13.6.3 Mastopexy: Invagination ofTissues
andStapling ofBoth Breasts
Begin the breast lift by placing three wide staples at the top
of the anchor and at either end of the newly drawn inframammary fold (Fig.13.5).
1. Staple the end point of the previously drawn 9–10cm line
(made around the former areola) to the center of the IMC
(M–M1), then (L–L1) (Fig.13.6).
2. With ngers or forceps pull inferomedially to invaginate
the lateral redundant breast tissue. Doing this maneuver
rst creates more projection in the inner cleavage area
(Fig.13.7).
Bisecting Line
Apex Staple of
L
with
the New NAC
L
1M1
Medial
M
(IMC
Medial
Staple
Lateral
Direction of
invagination
and stapling
Lateral
)
Staple
Fig. 13.5 Direction and sequence of tissue invagination and stapling
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T. S. Eisenberg
Fig. 13.8 The new areola position is marked with a cookie cutter
Fig. 13.6 Stapling of the end of the medial 9–10cm line to the center
of the new IMC
Fig. 13.7 Lateral tissue invagination and stapling. This creates medial
fullness
3. Pull and invaginate the medial redundant breast skin and
tissue from the medial staple in an inferolateral direction
and staple it. This maneuver will then create more projection of the breast mound.
4. Infold and staple the two previously drawn 9–10cm lines
toward each other from the apex to the IMC while burying the old NAC.If the apex of the 9–10cm line needs to
be attened or shortened, it can be stapled inferiorly. The
same procedure is then performed on the other breast.
Bisecting Line
Apex
Staple
Lateral
X
Y
Lateral
Staple
Fig. 13.9 Schematic of staple outlining
Horizontal
Line of Apex
of New NAC
Medial
“Cookie Cutter”
for New NAC
X
1
Y
1
Medial
Staple
Infolding of tissues and stapling takes me approximately
4min per breast.
5. Position the inked “cookie cutter” (approximately 4cm)
(Fig. 13.8). Then match the position on the opposite
breast.
6. Mark the outline of the stapled tissue (Figs. 13.9 and
13.10).
13 The I.D.E.A.L.® Breast Lift for Moderately to Severely Ptotic Breasts: A Staple-First Technique That Can Be Combined…
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191
Fig. 13.10 The outside of the staples is marked and additional orienting lines are drawn
7. I recommend making additional marks and labeling them
as seen in these gures to make it easier to orient closure.
8. Remove all the staples from each breast.
(See the I.D.E.A.L.Breast Lift Video 13.1).
13.6.4 Deepithelialization or Deskinning
Complete the deepithelialization of one breast before repeating the following steps on the other breast.
Inltrate the tissues of the breast you are going to resect
rst. (Hold off on inltrating the other side until you are
ready to resect those tissues.) I use 0.5% lidocaine with epinephrine. To lower the chance of causing necrosis of the
original NAC, I do not inltrate around it.
When marking the new NAC, minimally stretch the existing NAC to prevent attening it or making it too small,
because it will want to contract.
Prior to incising the NAC, I also tattoo it with a couple of
points to minimize any torsion of the NAC on closure. Next,
incise around the NAC rst and then inside the markings
made around the staples. Deepithelialize or deskin from the
IMC superiorly to above the NAC.Take care not to deepithelialize the nipple itself.
With the electrocautery, make relaxing incisions through
the dermis medially and laterally from the NAC within a
quarter-inch of the skin edge and extend distally to the
IMC.Then make a relaxing horizontal incision 2cm distal to
the NAC, which connects the medial and lateral relaxing
incisions (Fig.13.11).
Fig. 13.11 Relaxing incisions through the dermis are made with electrocautery and correlate to the dotted lines in Fig.13.12
13.6.5 Sequence ofSkin Closure
Approximate the tissues in alphabetical order from tightest
to loosest with 3-0 absorbable suture. In Fig.13.12, the A to
A1 closure would be the tightest if left to the end; the H–H1
or lateral aspect of the breast is saved until the end because it
represents the least tension for closure (Figs. 13.12 and
13.13).
1. Suture the apex of the nipple-areolar complex with 3-0
Vicryl (Ethicon) (A–A1). All sutures are buried and
interrupted.
2. Sew the inferomedial point (B–B1) of the medial limb to
the center of the IMC and reinforce this stitch with
another next to it.
3. Suture (C–C1), which is the most distal point of the lateral
line.
4. Suture the bottom of the nipple-areolar complex to the
top of the medial and lateral limbs as a “corner stitch”
(D–D1–D2).
5. Sew (E–E1), which represents the approximate 5cm limb
from the bottom of the newly positioned NAC to the center of the new IMC.
6. Alternate the closure between the lower medial limb (F–
F1), the lower lateral limb (H–H1), and the area around the
NAC (G–G1) in an interrupted fashion.
7. Approximate the skin with 5-0 monolament
absorbable suture in a running subcuticular fashion
along each of the following: E–E1, F–F1, H–H1, and
each half of G–G1 (the nipple-areolar complex)
(Fig.13.14).
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T. S. Eisenberg
Relaxing Incisions
Through the Dermis
Lateral
G
1
X
Y
H
Bisecting Line
A
D
GG
E
C
A
1
E
1
D
1
B
C
1
1
B
Medial
G
1
D
2
X
1
Y
1
F
Fig. 13.13 After skin closure
H
1
F
1
Fig. 13.12 The darkened area should be deepithelialized. The dotted
lines represent the relaxing incisions that have been made through the
dermis. Points are to be reapproximated in alphabetical order from
tightest to loosest tissues
Duplicate the entire technique on the other breast, newly
inltrating the tissues to be resected with more local anesthesia containing a vasoconstrictor.
At completion, notice that the nipple is facing down
approximately 5–10° (Figs.13.14 and 13.15). This is normal
and necessary because the segment from the bottom of the
nipple-areolar complex to the center of the inframammary
fold will lengthen up to two to three times its initial distance
of approximately 5cm to 8–15cm. The tightened and superiorly elevated breast tissue—and implants if used—will
drop into and ll out the stretched area, which will cause the
nipple to rise up to a normal forward-facing position.
Fig. 13.14 The nal appearance with all tissues reapproximated
13 The I.D.E.A.L.® Breast Lift for Moderately to Severely Ptotic Breasts: A Staple-First Technique That Can Be Combined…
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The day after surgery, patients may shower—but not
bathe—and can remove their bra to do so.
Patients are told to expect normal mild drainage (dots of
red, yellow, green, and orange) for up to 3weeks. To protect
their bra from this, they’re instructed to apply a thin layer of
ointment directly on top of the Steri-Strips and then to place
gauze pads on top. It’s not uncommon for a stitch to be spit
from the incision for up to 6weeks.
Ice is not recommended for discomfort because it will
cause constriction of blood vessels and increase the chance
of vascular compromise to the skin.
Almost all of my patients inform me that they return to
ofce work within 5days after surgery. Those who use their
Fig. 13.15 The nal closure and dressing with the suture strips
arms a lot return at about 2weeks.
Patients are permitted to do activities like running, aerobics, and lower body weights from the third week on; using
13.6.6 Dressings
upper body weights will be more comfortable at about 5 or
6weeks. They are told not to soak in a bathtub or pool for
Dress the incisions with any latex-free exible wound clo-
6weeks; incisions are fully healed at this time.
sure strips that do not require additional adhesive to stay in
place and do not wash off easily in the shower. I use SteriStrips (1/2 × 4-in. Suture Strip Plus from Derma Science)
13.6.8 The First Post-op Visit
(Fig.13.15).
Place a non-adhering gauze over the Steri-Strips, and then
apply Bacitracin or Bacitracin Polymyxin B ointment on the
non-adhering gauze along the incision lines.
Cover the ointment and non-adhering gauze with a
sterile gauze pad (5 × 9-in.) secured loosely with 3-in.
paper tape. The gauze pads protect the support bra from
the ointment and subsequent mild oozing from the wound
edge.
My surgical time for augmentation mastopexy averages a
little over 3h: approximately 1h for the augmentation and
2h for the lift. Patients are discharged the same day. I do not
use drains and they are not recommended.
Patients are generally seen 5–7days after surgery. At this time,
their Steri-Strips are removed; if they’ve come off sooner it’s
no problem. I recommend that the patient continue applying
the Bacitracin or Polysporin ointment for several weeks and
then change to a gentle moisturizer to promote good healing.
Depending upon how high the pectoral muscle has displaced the implant, I might start the patient on a gentle pull up exercise, which displaces the implant in the opposite
direction to facilitate it connecting to the existing breast tissue. Patients are instructed to pull up from the top of the
breast toward the clavicle and hold it for 1min each time
twice a day for a maximum of 3months (Fig.13.16).
193
13.6.7 Post-op Protocol
In the recovery room, patients are placed in a support bra that
clips in the front; they nd this style easier to put on and take
off. They are told to use the bra throughout the day and night
for 2weeks and then 16h a day for the next month in order
to minimize swelling and support the tissues during this
early healing phase.
Because early ambulation is advisable, patients are told
not to stay in bed, but they are advised to “take it easy” for
1week. That includes refraining from activities like sex that
might raise their blood pressure and promote bleeding.
Mothers can pick up toddlers on the third day after surgery to
transfer them to a high chair, car seat or crib, but should not
carry their child for an extended period of time until 14days
after surgery.
Fig. 13.16 A gentle pull-up exercise toward the clavicle displaces the
implant in the opposite direction and facilitates its connection to the
existing breast tissue
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T. S. Eisenberg
Patients are reassured that it will take 6weeks before their
breast implants even begin to settle and come down, and that
their breasts will be 80% settled, soft and shaped by 3months,
roughly 1% a day and close to 100% at 9–12months. Patients
are informed about all of this at their initial consultation and
also shown pictures of how their breasts will look at 2weeks
post-op.
Patients are told that the pleated edges in the inframammary fold will disappear and smooth out by 3 months
(through contraction), and that any change in nipple sensation (an increase or decrease) takes about 6weeks to normalize on average.
13.7 Complications
A small wound opening may develop where the tissue
approximation is the tightest, corresponding to B–B1 and C–
C
at the inframammary fold (Figs.13.12 and 13.13). I have
1
never needed to restitch this area and found that using an
antibiotic cream like silver sulfadiazine (when the patient is
not allergic to sulfa medications) for 2–3weeks allows the
area to completely heal. At consultation, I advise patients
that if this occurs the scar in this area of the IMC may be a
little wider. This complication, when is occurs, has been
widely accepted by my patients. Decreasing the tension of
closure at the B-C junction by deepithelializing tissues
within the drawings made around the staples—instead of
outside these marks—may minimize the occurrence.
Positioning the patient on the operating table with arms
extended at 90° away from her sides may also help by maximally stretching the skin to minimize over-resection.
I have never seen a keloid develop, but on a rare occasion
the scars may thicken, or hypertrophy. This is commonly
minimized or improved after hypertrophy develops with topical scar creams, silicone gel sheets, or an intralesional injection with a steroid like triamcinolone 10mg/mL.In general,
I prefer to excise the old scar when doing a revision.
Skin or nipple loss is considered a major complication
(Spear 2003). Other more common complications include
NAC asymmetry, recurrent ptosis, capsular contracture, and
implant deation when an augmentation mastopexy is performed (Stevens etal. 2006). The revision rate in one study
involving breast augmentation with a lift was 16.6% and
when a breast lift alone was performed, the revision rate was
8.6% (Stevens etal. 2007).
To date, I have had none of the above-mentioned complications, and patients were satised with the quality of their
scars. I believe that I’ve had no incidents of areola asymmetry because my approach allows for previsualization of the
nal result.
Recurrent ptosis, or “bottoming out,” is another complication. Some surgeons recommend a dermal graft to prevent
this, and they say that removing only skin will cause recurrent ptosis (Karacaoglu 2009). I believe their concerns arise
because their patterns are too conservative and they are worried that tightening the skin too much will compromise the
skin-edge circulation.
I have not found bottoming out to be a problem. With the
I.D.E.A.L.Breast Lift technique, the amount of skin that’s
removed after the invaginating and stapling is greater than
any pattern I’ve ever used. And because I can previsualize
the results, I can safely provide maximum tightening without
affecting skin-edge circulation.
13.8 Pre- andPost-op Pictures
(Figs. 13.17a–f and 13.18a–f)
Pearls of Wisdom
• The I.D.E.A.L Breast Lift technique is useful for both
augmentation mastopexy and a mastopexy without
implants. It allows for the use of a wide variety of implant
sizes and the correction of a wide degree of
asymmetries.
• When doing simultaneous augmentation mastopexy,
always perform the augmentation prior to resecting the
skin for the mastopexy (Speer etal. 2009).
• Creating a pattern around the staples after the implant is
placed eliminates the worry that the pre-drawn pattern
will stretch after placement of the implants and render the
pattern obsolete (Pinsky 2005).
• I prefer subpectoral dual-plane placement of breast
implants. Patients tell me that this placement gives them a
more natural look and their friends and family often can-
not tell that they’ve had breast enlargement surgery. Also,
it has been reported that this placement produces less cap-
sular contracture and makes interpreting mammograms
more reliable than subglandular placement of the
implants. For simultaneous augmentation mastopexy,
subglandular placement might be problematic and needs
to be further studied as this placement may disrupt more
vessels and compromise circulation to the chest skin and
areolar complex.
• In augmentation lift surgery: After the implants are
placed, and the patient is in the supine position, at times it
might appear that she no longer needs a lift. Don’t be
fooled. Continue with the lift because the ptosis will per-
sist when the patient is sitting or standing.
• With the I.D.E.A.L. Breast Lift technique, no compli-
cated measurements are needed to nd the new position
of the nipple. Instead, if you invaginate the original nip-
ple/areolar complex along with all the excess medial and
lateral breast tissue, it will allow for simple, proper
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