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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. 13.17 (a, b) Preoperative photos of 43-year-old patient, 5ft 4in.
tall, 141 lb. Starting size: 36C. (c, d) Two-weeks post-op following
simultaneous augmentation mastopexy awith the I.D.E.AL.Breast Lift
technique. Implants are pressed at and high by the pectoral muscle and
the nipples are slightly downward. Implants begin to settle at 6weeks
and are 80% softened, shaped, and settled at 3 months. (e, f) Nine
months post-op when the settling and shaping process is complete. The
patient received 275cc saline implants
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T. S. Eisenberg
c
d
Fig. 13.18 (a, b) Preoperative photos of 39-year-old patient, 5ft 7in.
tall, 120lb. Starting size: 33B.BWD: 19cm. Nipple to IMC distance:
9cm. (c, d) Three-month post-op following simultaneous augmentation
mastopexy with the I.D.E.AL.Breast Lift technique. Patient received
425cc saline implants (80% settled). (e, f) Nine months post-op (100%
settled)
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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197
previsualization of the new nipple position and for a
round aesthetic areola.
• By rst bilaterally invaginating and stapling the excess
tissue, the surgeon has the opportunity to visualize the
nal result and symmetry before an incision is made.
• The marking around the staples provides a more complete
area to be resected en bloc, which saves time from backand- forth trimming.
• The maximum tightening of the invaginated tissue by stapling without tension of the skin edges minimizes the
possibility of tissue necrosis.
This I.D.E.A.L.Breast Lift approach has simplied this
complex procedure for me, especially when combined with
breast augmentation. I am condent that the surgeon will
nd this technique reproducible and efcient and that it will
provide their patients with a satisfactory cosmetic result.
References
Cardenas-Camarena L, Ramirez-Macias R.Augmentation/mastopexy:
how to select and perform the proper technique. Aesthetic Plast
Surg. 2006;30:21–33.
Eisenberg TS. Breast augmentation: minimizing postoperative nau-
sea and vomiting (PONV), maximizing patient satisfaction. Am J
Cosmet Surg. 2008;25:264–8.
Eisenberg TS.Silicone gel implants are back—so what? Am J Cosmet
Surg. 2009;26:5–7.
Karacaoglu E.Single stage augmentation mastopexy: a novel technique
using autologous dermal graft. Ann Plast Surg. 2009;63(6):600–4.
Kirwan L.Breast autoaugmentation. Can J Plast Surg. 2007;15:73–6.
Marchac D. Reduction mammoplasty with a short horizontal scar.
In: Goldwyn R, editor. Reduction mammaplasty. Boston: Little,
Brown; 1990. p.317–36.
Parsa AA, Jackowe DJ.A new algorithm for breast mastopexy/augmen-
tation. Plast Reconstr Surg. 2010;125(2):75e–7e.
Pinsky MA. Radial plication in concentric mastopexy. Aesthet Plast
Surg. 2005;29:391–9.
Regnault P.The hypoplastic and ptotic breast: a combined generation
with prosthetic augmentation. Plast Reconstr Surg. 1966;37:31–7.
Regnault P. Breast ptosis. Denition and treatment. Clin Plast Surg.
1976;3:193.
Spear S.Augmentation/mastopexy: “surgeon, beware”. Plast Reconstr
Surg. 2003;112:905–6.
Speer SL, Giese SY.Simultaneous breast augmentation and mastopexy.
Aesthetic Surg. 2000;20:155–64.
Speer SL, Dayan JH, Clemens MW. Augmentation mastopexy. Clin
Plastic Surg. 2009;36:105–15.
Stevens WG, Stokes DA, Freeman ME, Quardt SM, Hirsch EM,
Cohen R. Is one-stage breast augmentation with mastopexy safe
and effective? A review of 186 primary cases. Aesthet Surg J.
2006;26:674–81.
Stevens WG, Freeman ME, Stoker EA, etal. One-stage mastopexy with
breast augmentation: a review of 321 patients. Plast Reconstr Surg.
2007;120(6):1674–9.
Whidden PG. The tailor-tack mastopexy. Plast Reconstr Surg.
1978;62:347–54.
Wise RJ, Ganon JP, Hill JR.Further experience with reduction mam-
moplasty. Plast Reconstr Surg. 1963;32:12.
Ted S.Eisenberg, DO, FACOS, DFACOS, FAACS, director of the
East Coast Center for Cosmetic Breast Surgery in Philadelphia, PA,
has over 30years of experience as a plastic surgeon. Since 1998, he
has evolved his practice to focus exclusively on cosmetic breast
surgery.
In 2003, Dr. Eisenberg created the I.D.E.A.L.
dure for simultaneous augmentation/lift surgery that maximizes the lift
and minimizes the scar. Much of his earlier work involved the use of
tissue expander implants for breast, scalp, eye and pioneering nose
reconstruction.
He has lectured at conferences and universities nationally and internationally, including in Dubai and Nairobi. A frequent contributor to
academic journals, Dr. Eisenberg’s technique for augmentation mastopexy was published in Aesthetic Plastic Surgery in 2011. He has published articles on topics including the management of PONV in breast
augmentation patients, repairing Tuberous Breast Deformity, the use of
acellular dermal matrix in breast implant exposure, and lowering deation rates of saline implants.
With his wife, Joyce, he is the author of The Scoop on Breasts: A
Plastic Surgeon Busts the Myths (Incompra Press 2012).
Dr. Eisenberg is board-certied in both General Surgery and Plastic
and Reconstructive Surgery by the American Osteopathic Board of
Surgery. He is an Associate Professor of Surgery in the Division of
Plastic Surgery at Philadelphia College of Osteopathic Medicine.
Dr. Eisenberg was the National Chairman of the Plastic and
Reconstructive Surgery Division of the American College of
Osteopathic Surgeons. He also served on the certifying board of the
AOBS and the residency evaluating committee of the ACOS.
He was a corporate sponsor of the Linda Creed Breast Cancer
Foundation, whose core program is to provide free mammograms for
women with little or no medical insurance.
®
Breast Lift, a proce-
The Superomedial Pedicle Breast
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Reduction Technique: ASimple
andEffective Approach toanEsthetic
Breast Reduction
SoaSantareno
14
14.1 Introduction
Breast hypertrophy is an abnormal enlargement of the breast
caused by gland hypertrophy, excessive fatty tissue, or both.
It may be graded as mild (<300g), moderate (300–800g), or
severe (>800 g) (Michala et al. 2015). This is one of the
pathologies with the most impact in the quality of life of the
female patients, regarding both physical and psychological
aspects. Back and neck pain, bent posture, kyphosis and neuropathies, obesity due to the lack of comfort to perform
physical exercise, intertriginous rashes, and difculty in
nding the right bra or clothes, leading to depression and low
self-condence, are among the symptoms (Rogliani et al.
2009; Boschert etal. 1996; Gonzalez etal. 1993; Setälä etal.
2009). In juvenile breast hypertrophy, phenomenon of bully-
ing may also contribute to depression and low self-esteem.
Breast reduction mammoplasty is the only option for these
patients with signicant improvement in self-condence,
anxiety, depression, level of exercise/physical activity, and
eating behaviors (Mello et al. 2010; Romeo et al. 2010;
Saariniemi et al. 2009; Iwuagwu et al. 2006; Singh and
Losken 2012). Charoudi et al. reported improvements in
physical, social, and sexual life in 95%, 55.5%, and 75% of
patients, respectively (Chahraoui etal. 2006; DeFazio etal.
2012). This surgery is among the ten most commonly per-
formed cosmetic procedures worldwide. According to the
American Society of Plastic Surgeons, 129,937 breast reductions were performed in 2017, with a decrease to 33,574 over
2020, possibly due to the COVID-19 pandemic crisis (2020
Plastic Surgery Statistics Report n.d.).
The main objectives in reduction mammoplasty are the
reconstruction of the natural breast shape through the reduction of glandular, fat, and skin components, and the reloca-
tion of the nipple–areola complex (NAC) while maintaining
its vascularization and innervation, with reduced scar length
(Hall-Findlay 2002; Hall-Findlay and Shestak 2015).
Different skin patterns and NAC pedicles [superior
(Zavrides 2017), inferior (Hammond et al. 2015), central
(Kim etal. 2017), superolateral (Cárdenas-Camarena 2009),
medial (Pu 2014), superomedial (Lugo etal. 2013; Davison
etal. 2007), Lejour technique (Lejour 1999), Hall-Findlay
superomedial pedicle (Hall-Findlay 1999)] are possible.
Until today there are no long-term studies based on both
quantitative and qualitative measurements that offer scientic evidence about the superiority of one or another
technique.
The superomedial pedicle (SMP) seams to offer several
advantages among the other techniques: it is simple, fast to
undertake, relatively bloodless, with no increased risk of
NAC necrosis and with greater possibility of an intact sensation (Sapino etal. 2021; Hauben 1984). Although older studies referred to the absence of consistently good long-term
outcomes, more recently it has been reported that it gives
great cosmetic outcome which is maintained over a period of
time, with less “bottoming-out” and more medial breast fullness, resulting in higher patient satisfaction (Lugo et al.
2013; Davison etal. 2007; Aquinati et al. 2019; Brownlee
etal. 2017).
My personal approach of breast reduction is what I call
the superomedial pedicle technique: an inverted T skin exci-
sion pattern with a SMP (superomedial pedicle) and a lower
Santareno inner bra ap that holds and reinforces the lateral
pillar and the lower pole of the breast. The golden number
here is 7.
Adequate preoperative markings and some key simple
surgical strategies may be adopted in order to obtain an
esthetically pleasant breast with satisfactory results.
Supplementary Information The online version contains supplementary
material available at
S. Santareno (*)
Plastic Surgeon, The Dr Pure Clinic, Lisbon, Portugal
© 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_14
https://doi.org/10.1007/978- 981- 99- 3726- 4_14.
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S. Santareno
14.2 Part 1: Preoperative Markings
The patient is marked in a standing position (Figs.14.1, 14.2,
14.3, 14.4, 14.5, and 14.6); one should take advantage of this
moment to rediscuss the expected scars. The patient may
help holding the tape, as she will feel part of this creative
process. The patient is photographed before and after the
markings.
First, the medial line is outlined, extending from the sternal notch to the umbilicus (Fig.14.1a). Then the inframammary fold (IMF) is marked bilaterally, and its projection over
the medial line (Fig.14.1b). From here, 3.5cm are measured
superiorly—this will be the expected new nipple position
(Fig.14.2a).
Then the breast meridian is marked; the lower point is
expected at a 9cm distance from the medial line, which is
marked over the IMF and abdomen. The tape around the
patient’s neck as it falls and overlies over the lower portion
of the previously marked breast meridian may help. Usually
the upper border will be about 7cm from the furcula (sternal
notch or SN), over each clavicle. From this point, the breast
meridian is marked until the lower part over the abdomen.
The breast meridian should be outlined following the ideal
position of the NAC on the breast mound, independently of
the actual nipple location (Fig. 14.2b). Symmetry must
always be conrmed.
Then the new nipple position is marked, transposing to
the breast meridian the previous mark outlined in the medial
body line (Fig.14.2c). A new NAC of 38–40mm is ideal, so
the upper border of the areola is marked 2 cm above the
expected new NAC position (Fig.14.2d).
The distance from the sternal-notch/SN to the actual nipple is conrmed; if it measures up to 28cm I prefer my personal approach; if sternal-notch to nipple (SN-N) distance
>28 cm, the new nipple position may be marked at the
Pitanguy point, the SMP base should be larger (8–10cm),
the pedicle should not be undermined so it conserves the
chest perforators. All skin closure should be tensionless and
drains should be larger and kept for longer time under antibiotic prophylaxis (Roei etal. 2021).
The mosque-dome pattern is drawn by freehand. We may
take advantage of some guiding lines, like an “assistant rectangle box” of 6 × 3 cm, inspired by Guridi (Guridi and
Rodriguez 2019), extending 3cm from the breast meridian at
both sides (6cm total horizontal line), and then its vertical
limbs of 3cm as well (Fig.14.3a). The process is repeated at
the contralateral breast mound, always conrming the symmetry. These measurements may go up to 7cm as horizontal
line and 3.5cm as vertical limb in large breasts.
The lateral and medial limb of the vertical scar are marked
using the Aufricht maneuver—a line connecting the lower
point of the vertical limbs of the rectangle box to the breast
meridian marked over the abdomen is drawn and is reproduced onto the contralateral breast as well, always conrming the symmetry and distance toward the medial body line.
The same maneuver is repeated, connecting the lower point
of the lateral vertical limb of rectangle box to the breast
meridian. During these maneuvers, the patient must stand
still and avoid rotation. Corrections if any should be performed at this point (Fig.14.3b–d).
Conrmation of the distance from the SN to the new
nipple position and its symmetry is measured and
a b
Fig. 14.1 (a) Marking of the midline. (b) Projection of inframammary fold on the midline
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Fig. 14.2 (a) Marking the level of the future nipple (3.5cm superior to
the IMF line) marked by a red arrow. (b) Marking the breast meridian.
(c) Transposing of the new nipple point on the breast meridian bilater-
recorded. If the breasts are very asymmetric, the lateral
skin markings may differ between sides, so the degree of
lateral parenchymal excision is adjusted to achieve better
symmetry.
The mosque-dome pattern is now drawn freehand; the
new NAC position should be outlined as large as possible
inside the assistant rectangle box; the lower portion of this
new NAC position stops about 1–1.5 cm below the lateral
limbs of the assistant rectangle box (Fig.14.4a). We pinch
and conrm it will close nicely; then connection to the vertical limbs of the markings is made (Fig.14.4b, c).
The superomedial pedicle of the NAC (green markings) is
outlined, starting at the superomedial vertex of the assistant
rectangle box, descending in an oblique direction, around the
NAC (about 3cm distance from the nipple), and it ends at the
ally. (d) Marking the upper border of the areola on the breast meridian
(2 cm above the expected new nipple position)
mid-third of the medial vertical marking, with a base width
of 7cm (Guridi and Rodriguez 2019) (Fig.14.5a–c). These
markings are reproduced onto the other breast. Although
achieving symmetry is important, the base of the pedicle
with this technique is 7 cm, even if the pedicle is longer.
Then adjustments on the nal breast volume are made over
the lateral pillar. The length of the lateral and medial limbs or
pillars is also 7cm (red markings, Fig.14.5d).
Finally, a Santareno inner bra ap of 7×7cm starting at
the IMF and extending upwards is outlined (Fig.14.6) if the
patient desires a breast reduction, this ap will be deepithelized and utilized as a breast hammock and as a tension
mini-inverted abdominoplasty; otherwise, if the patient
requests a mastopexy, it can be suspended as an inner
brasserie.
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S. Santareno
Fig. 14.3 (a) Marking of the “assistant rectangle box” (3 cm per limb). (b) The “Aufricht maneuver” marking the medial vertical limb. (c)
Marking the lateral vertical limb. (d) Completing the marking on the opposite side for symmetry
ab c
Fig. 14.4 (a) Drawing a mosque pattern within the rectangle box. (b) Pinch test in the center to conrm the nal closure without tension. (c)
Completing the markings onto the medial and lateral vertical limbs
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Fig. 14.5 (a) Marking the superomedial vascular base of the NAC. (b)
The ap is marked with a base width of 7cm (or up to 10 cm in a modied technique if furcula to SN distance is above 28cm). (c) The com-
pleted marking on both sides. (d) Marking the length of the vertical
edges and keeping it at 7cm
14.3 Part 2: Surgical Technique
The surgery is performed under general anesthesia, cefazolin 1g (clindamycin 600mg if allergic), elastic stockings for
deep venous thrombosis prophylaxis, with the patient at
dorsal decubitus and arms at her sides abducted to less than
90° (ideally 45º). All bony prominences are padded and
sequential compressive devices are placed to each lower
extremity. Disinfection is performed preferentially with
Povidone-Iodine and sterile drapes are used. Local inltration of the incision lines is performed (except for the base of
the superomedial pedicle) with local anesthesia (lidocaine
Fig. 14.6 The Santareno inner bra ap, is marked which has a
7cm×7cm dimension centered on the breast meridian
1% with 1:100000 epinephrine). The lines of the pillars and
SMP (superomedial pedicle) are also inltrated with the
local anesthetic mixed with NaCl 0.9% at a ratio of 50:50. A
cookie-cutter of 38mm is used to outline the NAC.
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S. Santareno
14.3.1 Skin Incision andDe-epithelization
The skin is incised until the dermis with a 15 blade; the
superomedial pedicle and the Santareno inner bra ap are
de- epidermized (Fig.14.7a, b).
14.3.2 Design oftheSuperomedial Pedicle,
Breast Pillars, andSeven-
SantarenoInner Bra Flap
The superomedial pedicle is designed with a 24 cold blade
(or monopolar on coagulation, spray mode, 25 potency) until
a b
the pectoralis major fascia is reached. A C-shaped (lateral
convexity) parenchymal excision is performed in one-block
(Fig.14.8a, b). Extreme care is taken not to undermine the
pedicle to avoid devascularization. In this method, the blood
supply to the NAC originates from the internal mammary
artery perforators as well as the underlying breast parenchyma which is supplied by the intercostal perforators and
thoracoacromial artery (Bauermeister etal. 2019).
The height of 7cm of the medial and lateral pillars is conrmed and Gillies hooks are used to suspend the dermis of
the pillars, so that the 7cm length is transposed to the breast
gland in order to clearly dene the pillars. This will help to
design the breast base. The medial pillar is left as full thick-
Fig. 14.7 (a) The skin marked within the green area is de-epithelized taking care that the NAC is not undermined. A cookie cutter is used to mark
the NAC in a stretched position. (b) The 7cm×7cm ap in the inferior quadrant of the breast is also de-epithelized
Fig. 14.8 (a) The incision is completed and the tissue to be removed is excised using a monopolar cautery. (b) The C-shaped tissue to be excised
is removed
14 The Superomedial Pedicle Breast Reduction Technique: ASimple andEective Approach toanEsthetic Breast Reduction
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ness; the thickness of the lateral pillar should be a minimum
of 2cm thickness and may be used to manage the symmetry
between both breasts. All the breast tissue below 7cm length
is removed when a breast reduction is performed. Gillies
hooks are used to suspend the markings of the Santareno
inner bra ap, which is then defated becoming an adipocutaneous ap with 5mm thickness; this ap may be thicker and
suspended (preferencial with nylon 3/0) in case of an autoaugmentation mastopexy, as proposed by Ribeiro (Ribeiro
2013). The lateral pillar usually looks thick at this point.
14.3.3 3D Prole oftheBreast andDesign
ofLateral Border
The NAC can be rotated around by 90°. No back-cut of the
pedicle to facilitate mobilization is required in these cases;
instead, a dermal platform may be used to support the areola.
Two nylon 3-0 sutures are placed between the new areolar
opening and the areola (at 12 and 6 o’clock) and suspended by
the assistant with mosquito forceps (Fig.14.9). This will help
to have a 3D preview of the new breast, estimate the lateral
border of the breast mound (in continuity with the anterior
axillary fold), which is marked with a dermal pen and transposed to the parenchyma. If the lateral ap behind this marking is too thick, Allis clamps may be used to suspend its inner
surface and defat until it becomes a thin dermal ap; two nylon
3-0 stitches are placed so as to dene the lateral border of the
breast (this step may be performed after the pedicle suspension). In large reductions, liposuction of the lateral breast may
also help at the end of the surgery once the breast has been
reshaped.
14.3.4 Pedicle Suspension andNerve Block
The SMP is suspended to the pectoral fascia at the superior
border of the dissected breast footprint, (Fig.14.10) under no
tension, with 2 stitches of nylon 3-0 to the pectoralis major
fascia. A Pectoralis and Serratus Plane fascial compartments
Nerve Block (PECS II) (Bashandy and Abbas 2015) with
10ml of ropivacaíne 7.5mg is performed this is part of the
RUR (Recuperação Ultra-rápida) or UFR (Ultra-fast recovery) protocol designed by the authors.
14.3.5 NAC Fixation Before Pillars Closure
One of the tricks to avoid the distortion of the NAC is to
place 4 key sutures with monocryl 3-0 (12, 3, 6, and 9
o’clock) at the new areolar opening. As a guide point a meets
c, point b meets d. This step should be performed before closure of the pillars (Fig.14.11A, B). Take in consideration the
sutures over the base os the pedicle (e) should be supercial,
so they don’t compromise the base of the pedicle.
Fig. 14.9 The NAC is sutured at the 12 o clock and 6 o clock position
to the new NAC position skin edges and pulled superiorly by the assistant to check for the 3-dimensional shape of the breast
14.3.6 Intersection Suture, Santareno Inner
Bra Flap Suspension, andClosure
ofthePillars
One nylon 3-0 suture is placed at the upper border of the
Seven-Santareno ap and suspended with a mosquito for-
Fig. 14.10 Suturing of the superior border of the pedicle to the pectoralis fascia with nylon 3/0
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