Many patients presenting with ptosis at the time of mastectomy and immediate reconstruction require skin redraping. A technique has been developed that achieves this skin redistribution in conjunction with a mastectomy scar confined to the inframammary crease. The three components of this technique are as follows:
- A superiorly based single mastectomy skin flap whose inferior margin is a line extending from the medial inframammary crease to the lateral extent of the inframammary crease with its midpoint at the level of the superior border of the areola.
- An inferiorly based dermal flap created by deepithelialization of the inferior breast skin that is sutured to the inferolateral border of the released pectoralis major muscle covering a tissue expander.
- Nonabsorbable suture fixation of the inframammary crease to the underlying rib periosteum and fascia at its natural level.
This technique has allowed for expansion of the resulting muscle/dermal flap/skin flap overlying the expander while maintaining the scar in the inframammary crease in patients with recognized ptosis. Patients are initially marked in the upright position to define the inframammary crease from the (point A) medial to (point B) lateral extent (Fig. 1). The lowest point on the inframammary crease should be marked at the midline for later reference at the time of anchorage. The breast is then pulled inferiorly and a line drawn between these same two points with its midpoint at the superior border of the areola. When the patient is recumbent under anesthesia, point A will move laterally and should then be marked at its new position. The proposed inferiorly based dermal flap is then marked at its superior border from point A to point B, maintaining the flap height of 6 to 8 cm from the inframammary crease. The superior edge of this flap joins A–B at C–D (Fig. 1).
At the beginning of the mastectomy procedure, the proposed inferiorly based dermal flap is first deepithelialized under tension. The mastectomy then proceeds with creation of a superiorly based skin flap and similar dissection deep to the dermal flap inferiorly. The skin and nipple-areola is resected between points C and D. At the termination of the mastectomy, the pectoralis major muscle is elevated from the ribs and lower sternum to create the superior portion of a pocket for a tissue expander.
Using running or interrupted nonabsorbable suture, the deep dermis of the inframammary crease is anchored at its natural level according to the marked reference point. These anchor sutures must be into the rib periosteum centrally to prevent upward migration of the inframammary crease during expansion.
A dual-staged tissue expander (650, 850, or 1000 cc; PMT Corp., Chanhassen, Minn.) is then placed in the pocket with its inferior extent at the inframammary crease. The superior edge of the dermal flap is then sutured to the free edge of the released pectoralis major with running absorbable suture.
After drain placement, the superiorly based mastectomy skin flap is sutured to the inframammary crease with absorbable stitches. A dressing of topical skin adhesive and transparent film is then applied, and no attempt to inflate the expander is usually made at this time. If the perfusion of the skin flap appears compromised, a thin film of nitropaste is placed under the film dressing and reapplied in 12 hours if necessary.
Tissue expansion is begun at the time of drain removal and continued until maximum expansion has been attained. The dual-stage PMT device provides maximum inferior pole expansion. Expansion beyond the final implant volume is advised.
The second stage is performed through an incision in the lateral inframammary crease scar. Undermining superiorly is then performed and the dermal flap/capsule layer is opened vertically. Scar revision along the inframammary crease can be considered if secondary healing has resulted in an unacceptable scar.
Nipple-areola reconstruction1,2 is performed at the time of alternate breast-balancing procedures in unilateral reconstructions. This simple technique maintains the resultant mastectomy scar in the inframammary crease for patients with ptosis undergoing mastectomy (Fig. 2).
The author acknowledges the patience and support of Drs. C. Hardin, L. Farinas, H. Sohn, H. D. Lin, F. Orr, and P. Dickinson and Virginia Purchase in the preparation of this article.
The author has no financial interest in any of the products or devices mentioned in this article.
Michael J. Halls, M.D.
Alvarado Institute of Plastic and Reconstructive Surgery
6386 Alvarado Court, Suite 330
San Diego, Calif. 92120
1. Halls MJ. Nipple-areola reconstruction: Technical improvements. Plast Reconstr Surg.. 2008;121:342
2. Halls MJ. Nipple-areola reconstruction: Technical improvements. Plast Reconstr Surg.. 2008;121:704