We read with great interest the extremely informative CME article by Nahabedian1 and would like to discuss some key points in mastopexy, sharing our experience with the double-flap mastopexy technique,2 where the nipple-areola complex is based on the superior pedicle and an inferior dermoglandular flap is used to increase projection and upper pole fullness. The target of this technique is augmenting the upper breast pole, focusing on breast projection and fullness, reshaping the inferior pole of the breast in patients with moderately to severely ptotic breasts.
The superior pedicle is usually chosen for mastopexy and small to medium breast reduction. If the nipple-areola complex has to be lifted up more than 8 cm or in larger reductions, the superomedial pedicle is preferred. The skin pattern resection is usually a Wise pattern with a shorter horizontal scar than the classic inverted-T.
There are two possibilities in shaping the inferior dermoglandular flap: (1) blocking the inferior flap in a flat position to the upper, medial, and lateral part of the pectoralis major muscle, obtaining a homogeneous autologous implant; and (2) modeling the dermoglandular flap in a conic shape, to achieve a better projection. This flap can be tailored as needed; it is not affected by bottoming-out as occurs with the inferior pedicle because it is shorter and less heavy, and it is accurately stitched to the muscle and therefore reliable for a long time. This allows for optimal projection and pleasant upper pole fullness and provides long-lasting results.
In our experience, it is not useful to pass the inferior dermoglandular flap through a strip of pectoralis major muscle or sheath, as suggested by others,3–5 because this yields increased postoperative pain, muscular weakness or atrophy, and partial loss of the projection obtainable from the inferior dermoglandular flap itself. We also believe that it is not safe from an oncologic point of view because we would carry some glandular tissue behind the muscle, therefore making detection of possible malignancies more difficult. On the contrary, the simple overlaying of the two flaps does not hinder eventual detection of breast cancer developing in the inferior dermoglandular flap.
The presence of an inverted-T scar is debatable. Although we are keen on using vertical and any other short scar techniques, breast shaping and modeling are most important to patients. We encourage scar-reducing techniques, but it should not be at the cost of a high rate of wound dehiscence and scar revision. Adding a short inframammary scar permits better control of breast parenchyma and shape, no scar revision, no dog-ears or puckers to be corrected, no down time, but immediate outstanding results. We found that all patients were extremely happy with the aesthetic results and not bothered by a short scar in the inframammary fold.
This technique is particularly suitable for breast ptosis, asymmetry (Fig. 1), post–massive weight loss surgery, and after implant removal for modeling the remaining glandular tissue. It is a safe, speedy, and versatile technique, with high predictability, a low complication rate, excellent results, and high patient satisfaction.
Stefano Bonomi, M.D.
Fernanda Settembrini, M.D.
Andrè Salval, M.D.
Gaetano Musumarra, M.D.
Chiara Gregorelli, M.D.
Department of Plastic Reconstructive Surgery and Burn Unit Center, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, Milan, Italy
The authors have no financial interest to declare in relation to the content of this article.
1. Nahabedian MY. Breast deformities and mastopexy. Plast Reconstr Surg. 2011;127:91e–102e.
2. Foustanos A, Zavrides H. A double-flap technique: An alternative mastopexy approach. Plast Reconstr Surg. 2007;120:55–60.
3. Ritz M, Silfen R, Southwick G. Fascial suspension mastopexy. Plast Reconstr Surg. 2006;117:86–94.
4. Caldeira AM, Lucas A. Pectoralis major muscle flap: A new support approach to mammaplasty, personal technique. Aesthetic Plast Surg. 2000;24:58–70.
5. Graf R, Biggs TM. In search of better shape in mastopexy and reduction mammoplasty. Plast Reconstr Surg. 2002;110:309–317; discussion 318–322.
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