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Breast Aesthetics
Mastopexy,
Mastopexy-Augmentation Mammoplasty
By:
Dr.Akasha Amber
Mastopexy
• Lay public; breast lift
• Ptosis (Greek; falling)
• Confusion; reduction or mastopexy?
• Reshaping the breast ...
Anatomy
How does a ptotic breast appear???
• Parenchymal sagging, ptotic skin envelope and
upper pole emptiness
Pathophysiology
Ptosis
Skin
stretched,
thinned out,
excess
Inadequate
parenchyma,
maldistribution
Loss of
integrity of
Coo...
Etiological Factors
• Aging
• Breast implant
• Gravity effects
• Hormonal effects on parenchyma during
pregnancy, lactatio...
Grades Of Breast Ptosis
Regnault’s classification
Grades Of Breast Ptosis
Regnault’s classification
Goals
• Restoring youthful firm breast
• Correction of ptosis
• Minimize scarring
• Slow down recurrence/longevity of proc...
History
• Dartiques: minimizing cutaneous incision
• Lösch: circumareolar incision to vertical scar
• Claude Lassus: class...
Tuberous breast deformity
• Tubular/constricted
• High IMF, hypoplastic lower
pole, NAC inferior most
aspect
• Herniation ...
Patient evaluation/selection
• Patient education
• Predetermined notions and patient’s expectation with
regard to the fina...
Points not to be missed in history and
examination
• Age
• Cardiopulmonary status
• Already taking medications or change o...
AGAIN, very important !!!
• Expectations of patient regarding:
– shape, scar pattern and length
– Amount of skin excised
–...
Points not to be missed in history and
examination
• Breast History:
• Any recent breast, nipple changes, any discharge
• ...
Points not to be missed in history and
examination
• Breast size, volume and shape
• Quality and excess of skin envelope
•...
Measurements
• Distance from suprasternal notch to nipple
• Nipple to IMF distance
• Breast base width/diameter( on chest ...
ALGORITHM for choosing right procedure
W.Grant Stevens’
Algorithm
Pseudoptosis
For large: biplanar
augmentation
For same: ...
TECHNIQUES
Scar based:
– Periareolar
• Crescent
• circumareolar
– Vertical
– L or J
– Inverted T
1.Periareolar technique
• Donut skin excision or superior crescent
• Mild to moderate ptosis with adequate breast
parenchy...
Concentric mastopexy without
parenchymal reshaping
• Only periareolar incision given, donut skin
excision done
• Purse-str...
Periareolar Benelli mastopexy
• Mastopexy with reduction
• Skin and gland both treated
• Simple gland folding and plicatio...
A
B
C
S
D
Markings for Benelli mastopexy.
(A) Future superior point of the nipple;
(B) future inferior point of the nipple...
Four flaps of the Benelli mastopexy:
Superior dermoglandular flap
supporting nipple, medial and
lateral flaps, and detache...
Benelli mastopexy. Superior flap attached
to the chest wall demonstrating areolar
elevation and exaggerated convexity of
s...
Plication invagination of the gland to form a conical shape.
Fixation of areola to the superior border of the ellipse.
rou...
Góes periareolar technique with
mesh support
• “double skin” technique
• Pectoral fascia, intramammary connective tissue l...
Four cardinal points of Góes mammoplasty
A is top of new areola,
B is from IMF to new areola bottom (average 7cm)
C is dis...
Lines of resection from the superior
and inferior hemispheres to narrow the
base. In mastopexy alone, these
regions can si...
(A) The breast projects anteriorly and superiorly after
formation of the cone and reinforcement of the breast
with mesh.
(...
2.Vertical/short scar technique
• Lassus vertical scar technique
• reduction and mastopexy
• 4 principals:
– central wedge...
Vertical/short scar technique
• Lejour vertical scar technique:
• Lejour’s modifications of lassus
• Shortening scar, usin...
• Hall-Findlay’s vertical technique:
– Wise pattern vertical technique without lateral
and medial extensions
• Hammond SPA...
Grotting sculpted vertical pillar
mastopexy
Notch to new areolar distance is approximately 20-23cm.
From top of vertical closure,5-6 cm down a point is marked for fut...
• the bottom of the incision line coming to a V approximately 2 cm above the inframammary
fold (point B). The hatched line...
Rounded superior pole, flat lower pole, and
slightly downward pointing nipple.(upside down breast
shape)
lower pole of the...
Final closure and tegaderm dressing(2 weeks) then advise a bra day and night for 6-8 weeks
Augmentation mastopexy
(Kent K. Higdon and James C. Grotting)
• Indications:
– Glandular deficiency irrespective of skin e...
Inverted T scar technique
• Indication:
– moderate to severe breast ptosis with a large excess of
skin and a moderate amou...
Postoperative care
• Prophylactic antibiotic (1st gen. cephalosporin;
cefazolin)
• Analgesics
• Antiemetics
• Tegaderm dre...
Complications
• Nipple loss
• Sensory loss
• Flap necrosis
• Scar widening
• Nipple malposition
• Cosmetic disappointments...
Mastopexy
Mastopexy
Mastopexy
Mastopexy
Mastopexy
Mastopexy
Mastopexy
Mastopexy
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Mastopexy

  1. 1. Breast Aesthetics Mastopexy, Mastopexy-Augmentation Mammoplasty By: Dr.Akasha Amber
  2. 2. Mastopexy • Lay public; breast lift • Ptosis (Greek; falling) • Confusion; reduction or mastopexy? • Reshaping the breast with or without parenchymal reduction(Peter C.Neligan) • Lifting and reshaping breast by redistributing tissue without reducing volume (Grabb & Smith’s)
  3. 3. Anatomy
  4. 4. How does a ptotic breast appear??? • Parenchymal sagging, ptotic skin envelope and upper pole emptiness
  5. 5. Pathophysiology Ptosis Skin stretched, thinned out, excess Inadequate parenchyma, maldistribution Loss of integrity of Cooper’s ligament Inelastic facial support Involutional atrophy of parenchyma over time Effect of gravity
  6. 6. Etiological Factors • Aging • Breast implant • Gravity effects • Hormonal effects on parenchyma during pregnancy, lactation & menopause • Weight fluctuations in obese • Congenital deformity ( tubular breast) • Asymmetry of contralateral breast in post- ablative breast reconstruction
  7. 7. Grades Of Breast Ptosis Regnault’s classification
  8. 8. Grades Of Breast Ptosis Regnault’s classification
  9. 9. Goals • Restoring youthful firm breast • Correction of ptosis • Minimize scarring • Slow down recurrence/longevity of procedure • Reshaping/redistributing parenchyma • Tightening ptotic skin envelope • Maintaining nipple areola vascularity
  10. 10. History • Dartiques: minimizing cutaneous incision • Lösch: circumareolar incision to vertical scar • Claude Lassus: classic vertical scar technique • Lejour: adjunctive suction assisted lipectomy • Hall-Findlay: medial NAC pedicle, no SAL, no undermining of flaps, Laterally based pedicle • Wise: wise pattern reduction mammoplasty, inverted T scar with periareolar incision • Góes: use of mesh • Graf and Biggs: adding autologous tissue flap in loop of pectoralis major muscle
  11. 11. Tuberous breast deformity • Tubular/constricted • High IMF, hypoplastic lower pole, NAC inferior most aspect • Herniation of NAC • Unilateral or bilateral(same or varying degrees) • Classification by Grolleau & Von Heimburg
  12. 12. Patient evaluation/selection • Patient education • Predetermined notions and patient’s expectation with regard to the final results, and misunderstandings resolved • Techniques with their rationale explained – Special discussion about incision pattern and expected scars, weighing risks over benefits • Informed consent (including risks, benefits and alternative to proposed technique) • Preop. planning/measurements • Preop. imaging (digital photography, 3D imaging, computerized image-enhancing softwares)
  13. 13. Points not to be missed in history and examination • Age • Cardiopulmonary status • Already taking medications or change of medication • Previous stroke • Renal or hepatic insufficiency • Coagulation profile • Previous surgery (chest wall or breast) • Any weight loss • Possibility of pregnancy
  14. 14. AGAIN, very important !!! • Expectations of patient regarding: – shape, scar pattern and length – Amount of skin excised – Modification of breast size
  15. 15. Points not to be missed in history and examination • Breast History: • Any recent breast, nipple changes, any discharge • Previous mass or previous surgery • Previous scars • Previous biopsy or mammography • Radiation therapy • Family history of breast cancer • Recommend “mammography” in all above 35 years of age
  16. 16. Points not to be missed in history and examination • Breast size, volume and shape • Quality and excess of skin envelope • Nipple position • Areola size • Asymmetry – (notch to nipple distance and sternum to nipple distance) • Degree of ptosis • General physical and systemic examination
  17. 17. Measurements • Distance from suprasternal notch to nipple • Nipple to IMF distance • Breast base width/diameter( on chest wall) • IMF length
  18. 18. ALGORITHM for choosing right procedure W.Grant Stevens’ Algorithm Pseudoptosis For large: biplanar augmentation For same: Small resection and biplanar augmentation For small: inframammary wedge excision Grade I Ptosis : need upto 2cm nipple elevation Larger: biplanar augmentation with circumareolar mastopexy Same: circumareolar mastopexy Small: small reduction Grade II Ptosis: 3-4cm nipple elevation Large: augmentation with mastopexy(circumvertical with horizontal wedge excision) Same: vertical or wise pattern mastopexy Small: small reduction Grade III Ptosis: >4cm nipple elevation Large: wise pattern mastopexy and augmentation (one stage) Same: wise pattern mastopexy Small: wise pattern reduction0 Based on woman’s desired breast volume and nipple elevation
  19. 19. TECHNIQUES Scar based: – Periareolar • Crescent • circumareolar – Vertical – L or J – Inverted T
  20. 20. 1.Periareolar technique • Donut skin excision or superior crescent • Mild to moderate ptosis with adequate breast parenchyma(volume) • If volume inadequate --- implant • Lift: 1-2 cm • Spear Rules: – Nonpigmented skin excised < pigmented skin excised – Outside diameter not more 2 times the inside diameter – Final diameter= ½ ( outer diameter + inner diameter) • Advantages: camouflage of incision • Disadvantages: limited cephalic NAC movement, widened areolar scar, decreased breast projection
  21. 21. Concentric mastopexy without parenchymal reshaping • Only periareolar incision given, donut skin excision done • Purse-string suturing done
  22. 22. Periareolar Benelli mastopexy • Mastopexy with reduction • Skin and gland both treated • Simple gland folding and plication or creating Superior , medial, lateral dermoglandular flaps • inverted T type of incision through the gland • Cerclage stitch as in donut mastopexy • Minimum glandular tissue-- implant • AIM: Reducing the breast width, tightening the lower pole, and coning the breast construct by crisscrossing the medial and lateral dermoglandular flaps • Useful in very large breast and high degree of ptosis with minimum scarring • not recommended for breasts ,mainly fat or have a large amount of skin excess(poor quality) • Advantages: minimize scar and recontour and reshape the gland • Disadvantage: widened scar, flattened breast
  23. 23. A B C S D Markings for Benelli mastopexy. (A) Future superior point of the nipple; (B) future inferior point of the nipple; (C) medial limit of the nipple; (D) lateral limit of the nipple. Point C averages 8–12 cm from the midline. S is the point where the breast meridian intersects the inframammary fold Dissection of breast during Benelli mastopexy. Incision of dermis from 2-o’clock to the 10-o’clock position with dissection to the inframammary fold subcutaneously
  24. 24. Four flaps of the Benelli mastopexy: Superior dermoglandular flap supporting nipple, medial and lateral flaps, and detached skin flap Keel-like resection Medial flap Lateral flap Superior flap Benelli mastopexy. Attachment of the superior flap to the chest wall by the pectoralis fascia.
  25. 25. Benelli mastopexy. Superior flap attached to the chest wall demonstrating areolar elevation and exaggerated convexity of superior pole. Medial glandular flap affixed to the underlying pectoralis muscle Lateral flap is affixed to the medial flap
  26. 26. Plication invagination of the gland to form a conical shape. Fixation of areola to the superior border of the ellipse. round block suture U stitch: prevents areolar herniation, gives circular shape
  27. 27. Góes periareolar technique with mesh support • “double skin” technique • Pectoral fascia, intramammary connective tissue ligaments, periareolar dermal flap (used as internal skin lining), an absorbable mixed mesh, and the external skin lining • mesh causes a fibrotic reaction that serves to support the breast for a longer time during the healing and cicatrization process • Mesh: – absorbable(mixed mesh; polyglactin mesh with Dacron filaments or woven mesh; polyglactin/polypropylene) – integrated(biological) • Disadvantages: • technical difficulty • mesh-related complications, such as infection, palpability, retraction, skin necrosis, or extrusion
  28. 28. Four cardinal points of Góes mammoplasty A is top of new areola, B is from IMF to new areola bottom (average 7cm) C is distance from medial breast border to medial aspect of new areola at nipple level (avg 9 cm) D is distance from the anterior axillary line to the lateral aspect of the new areola at the level of the nipple (average 12 cm) Dissection of the gland to separate it from the skin along with lines of excision of gland. Note the formation of the internal skin lining Wedge of hemisphere to be resected Internal skin lining Pectoralis fascia Pectoralis major muscle
  29. 29. Lines of resection from the superior and inferior hemispheres to narrow the base. In mastopexy alone, these regions can simply be imbricated rather than resected
  30. 30. (A) The breast projects anteriorly and superiorly after formation of the cone and reinforcement of the breast with mesh. (B) Schematic for placement of mesh. The polyglactin- Dacron composite mesh of Goes’ (Vicryl-Prolene composite) A B
  31. 31. 2.Vertical/short scar technique • Lassus vertical scar technique • reduction and mastopexy • 4 principals: – central wedge resection – transposition of the areola on a superiorly-based flap – no undermining of the skin – addition of a vertical scar component • Indications: • Firm gland, good skin quality, young patients, not very large or ptotic breasts • If NAC elevation >10 cm needed; medial or lateral flap by Skoog • Advantages: • Central wedge excision; avoids injury to vascular supply • No undermining of skin from gland or gland from muscle; no glandular or skin necrosis • Avoids necrosis of nipple areola or loss of their sensation • Disadvantage: • Visible vertical scar • Final result and shape takes months(2- 2.5months) • Technical difficulty
  32. 32. Vertical/short scar technique • Lejour vertical scar technique: • Lejour’s modifications of lassus • Shortening scar, using superior pedicle following three principles: – wide lower pole skin undermining – Overcorrection of the deformity – Liposuction • used either as a reduction technique or as a mastopexy • Advantages: • Postoperative stability • No scar widening • Preservation of nipple sensitivity • Liposuction reduces volume and recontours the shape as needed without damaging important structures • Disadvantage: • Late results • some skin redundancy remains (necessitates excision)
  33. 33. • Hall-Findlay’s vertical technique: – Wise pattern vertical technique without lateral and medial extensions • Hammond SPAIR technique: – Short scar periareolar inferior pedicle reduction mammoplasty – Inferiorly based pedicle
  34. 34. Grotting sculpted vertical pillar mastopexy
  35. 35. Notch to new areolar distance is approximately 20-23cm. From top of vertical closure,5-6 cm down a point is marked for future IMF. Preaxillary fullness and lateral chest rolls: liposuction for the contour
  36. 36. • the bottom of the incision line coming to a V approximately 2 cm above the inframammary fold (point B). The hatched lines show the location of the glandular resection at the bases of the medial and lateral pillars. • A superiorly-based flap can be created from the tissues between the marked medial and lateral pillars, rotated retro-areolarly, and then sutured to the pectoralis fascia to improve upper pole fill.
  37. 37. Rounded superior pole, flat lower pole, and slightly downward pointing nipple.(upside down breast shape) lower pole of the breast detached. The resulting flap transposed into the retro-areolar location to augment the upper pole or resected in cases such as a small reduction or when an implant is to be added (addition-subtraction concept)
  38. 38. Final closure and tegaderm dressing(2 weeks) then advise a bra day and night for 6-8 weeks
  39. 39. Augmentation mastopexy (Kent K. Higdon and James C. Grotting) • Indications: – Glandular deficiency irrespective of skin envelope – After explantation with inadequate residual parenchyma – Asymmetry (one breast is hypoplastic & other is ptotic) • Advantages: – Improved fill in superior and superomedial aspect • Disadvantages: – wound problems and dehiscence because of added weight of the implant – inherent risks of the implants (malpositioning, leakage, rupture, capsular contracture) • Addition subtraction principal • implant ; subglandular or subpectoral position – available parenchyma as determined by skin pinch thickness of >3 cm • Autologous fat grafts in the upper pole (if not wanting an implant)
  40. 40. Inverted T scar technique • Indication: – moderate to severe breast ptosis with a large excess of skin and a moderate amount of glandular tissue. • Advantages: – ability to excise all excess skin – Allows for final adjustments – decreases the chance of subsequent revision • Disadvantage: – increased length of the incisions & scars – high chances of recurrent ptosis • (new breast mound has only skin envelope, no pillars or interglandular sutures) • MARKINGS; – same as wise pattern vertical scar with horizontal component
  41. 41. Postoperative care • Prophylactic antibiotic (1st gen. cephalosporin; cefazolin) • Analgesics • Antiemetics • Tegaderm dressing with areolar window(@ weeks) • Postoperative brassier (6-8 weeks) • Drains; not necessary • Mild activities; 2 weeks later • Full exercise; 8 weeks later
  42. 42. Complications • Nipple loss • Sensory loss • Flap necrosis • Scar widening • Nipple malposition • Cosmetic disappointments • Wound related complication • Implant related complication
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