No double bubbles were encountered. Secure approximation of the medial and lateral pillars helps prevent inferior implant displacement. For implant insertion, the author prefers a horizontal incision within the lower pole, above the existing inframammary fold, with a submuscular dissection cephalad to the inframammary ligaments.46
Technical points include (1) a willingness to “T” off the lower end of the mammaplasty when needed; (2) adequate resection of excessive lower pole parenchyma; (3) tightening of the lower pole and coning of the breast; and (4) intraoperative nipple positioning just below the apex of the breast to prevent nipple overelevation. With these adjustments, the need for revisions for persistent ptosis has dropped in half from 10.3% to 5% for the most recent 100 cases. Adequate parenchymal resection of the lower pole avoids a “mastopexy wrecking bulge”47 or a snoopy deformity. Direct excision is used rather than liposuction so as to adequately remove denser breast tissue along with fat from the lower pole and to limit tissue trauma. A 39-mm areola marking ring is preferred because the areola tends to stretch about 1 cm postoperatively.48 Women prefer areola diameters that do not exceed 5 cm.49 There was no correlation between complications and secondary mastopexies, including delayed wound healing. Women who have had previous Wise pattern mammaplasties may be safely treated using the vertical technique,20,50 provided that a wide areola attachment is preserved.
Subpectoral implant placement adds a layer of tissue cover and is preferred by most operators.6–8,10,12–16,20 However, prepectoral placement is a valid alternative, particularly in women with adequate breast tissue, and avoids an animation deformity. There is a general preference for silicone gel implants29 although some surgeons more commonly insert saline implants.6,20 Silicone gel implants have traditionally been favored for a more natural feel characteristic and possibly less rippling.35 However, in a woman who has a moderate breast volume, this difference may be negligible, particular in a subpectoral pocket. The author does not use more cohesive, form-stable implants because they have not been shown to produce a superior outcome51,52 and have disadvantages that include firmness, rotation, expense, and texturing—which is linked to late seromas, double capsules, and anaplastic large cell lymphoma.53,54 Mean implant volumes in other studies vary from 306 to 450 mL.6–8,15,16,55 In this study, the average implant volume was 372 mL, 20 mL less than the average for breast augmentations without mastopexy,18 and similar to the mean volume in the study by Calobrace et al7 (392 mL). Measurements of nipple/areola perfusion25 reveal that implant sizes up to 575 mL may be safely inserted using a vertical method and medial pedicle. It has been suggested that, logically, larger implants should have a higher complication rate.8 However, neither this study nor the study by Calobrace et al7 substantiates this claim. Larger implants correlate with greater patient satisfaction.18,49
Eighty percent of women undergoing reduction mammaplasty report that nipple sensation is important sexually.56 Regardless, sensate body parts are always to be preferred. An inverted-T pedicle sacrifices all superficial innervation to the nipple. The deep innervation is precarious and depends on the extent of the deep dissection. Courtiss and Goldwyn57 reported that 35% of women experience persistent nipple numbness 2 years after an inverted-T, inferior pedicle breast reduction–much higher than the 13.3% rate of persistent nipple numbness in the present study. Although many surgeons favor a superior or superomedial pedicle, Schlenz et al58 found that a superior pedicle compromises nipple sensation by sacrificing the deep innervation. The author prefers to maintain a parenchymal attachment deep to the nipple/areola complex in an effort to preserve deep innervation and a medial pedicle to capture the dominant medially based superficial innervation.21
The mean follow-up time was 9.4 months. Therefore, long-term complications such as implant deflation or capsular contracture are likely to be underrepresented. A specific operation is evaluated—vertical augmentation mastopexy with a medially based pedicle. Certainly, there are many variations in technique from the method described here that may achieve an optimal outcome.
No patient was selected for staged treatment, avoiding selection bias. A large patient population and consecutive patients add to the reliability of the study findings. The consistency of the same surgeon and technique avoids confounding variables. Outcome data provide valuable information from the patient’s perspective.
A simple algorithm may be used to select the treatment of women with breast ptosis and volume deficiency. The combined procedure is safe and widely applicable. Staging is unnecessary. Patient-reported outcome data are favorable, with 94.4% of patients reporting that they would repeat the surgery (Seevideo, Supplemental Digital Content 7, which displays the entire procedure in one clip. This video is available in the “related videos” section of the full-text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A323).
The author thanks Jane Zagorski, PhD, for statistical analyses; Lindsey Kroenke, BSN, Sarah Maxwell, RN, Christina Engel, RT, and Janice Ragain for data collection; and Gwendolyn Godfrey for the illustration.
1. Rohrich RJ, Thornton JF, Jakubietz RG, et al. The limited scar mastopexy: current concepts and approaches to correct breast ptosis. Plast Reconstr Surg. 2004;114:16221630.
2. Georgiade NG, Serafin D, Riefkohl R, et al. Is there a reduction mammaplasty for “all seasons?”. Plast Reconstr Surg. 1979;63:765773.
3. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg. 1999;104:748759discussion 760.
4. Spear SL. Augmentation/mastopexy: “Surgeon, beware.” Plast Reconstr Surg. 2003:112:905906.
5. Spear SL, Dayan JH, Clemens MW. Augmentation mastopexy. Clin Plast Surg. 2009;36:105115, viidiscussion 117.
6. Beale EW, Ramanadham S, Harrison B, et al. Achieving predictability in augmentation mastopexy. Plast Reconstr Surg. 2014;133:284e292e.
7. Calobrace MB, Herdt DR, Cothron KJ. Simultaneous augmentation/mastopexy: a retrospective 5-year review of 332 consecutive cases. Plast Reconstr Surg. 2013;131:145156.
8. Lee MR, Unger JG, Adams WP Jr. The tissue-based triad: a process approach to augmentation mastopexy. Plast Reconstr Surg. 2014;134:215225.
9. Don Parsa F, Brickman M, Parsa AA. Augmentation/mastopexy. Plast Reconstr Surg. 2005;115:14281429.
10. Persoff MM. Vertical mastopexy with expansion augmentation. Aesthetic Plast Surg. 2003;27:1319.
11. Spring MA, Hartmann EC, Stevens WG. Strategies and challenges in simultaneous augmentation mastopexy. Clin Plast Surg. 2015;42:505518.
12. Spear SL, Boehmler JH, Clemens MW. Augmentation/mastopexy: a 3-year review of a single surgeon’s practice. Plast Reconstr Surg. 2006;118(Suppl):136S147S.
13. Cárdenas-Camarena L, Ramírez-Macías R; International Confederation for Plastic Reconstructive and Aesthetic Surgery; International Society of Aesthetic Plastic Surgery; Iberolatinoamerican Plastic Surgery Federation; Mexican Association of Plastic Esthetic and Reconstructive Surgery; Western Mexican Association of Plastic, Esthetic and Reconstructive Surgery; Jalisco College of Plastic Surgeons. Augmentation/mastopexy: how to select and perform the proper technique. Aesthetic Plast Surg. 2006;30:2133.
14. Stevens WG, Stoker DA, Freeman ME, et al. Is one-stage breast augmentation with mastopexy safe and effective? A review of 186 primary cases. Aesthet Surg J. 2006;26:674681.
15. Stevens WG, Freeman ME, Stoker DA, et al. One-stage mastopexy with breast augmentation: a review of 321 patients. Plast Reconstr Surg. 2007;120:16741679.
16. Stevens WG, Macias LH, Spring M, et al. One-stage augmentation mastopexy: a review of 1192 simultaneous breast augmentation and mastopexy procedures in 615 consecutive patients. Aesthet Surg J. 2014;34:723732.
17. Ching S, Thoma A, McCabe RE, et al. Measuring outcomes in aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg. 2003;111:469480discussion 481.
18. Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:11581166discussion 1167–1168.
19. Swanson E. Breast reduction versus breast reduction plus implants: a comparative study with measurements and outcomes. Plast Reconstr Surg Glob Open 2014;2:e281.
20. Swanson E. Prospective comparative clinical evaluation of 784 consecutive cases of breast augmentation and vertical mammaplasty, performed individually and in combination. Plast Reconstr Surg. 2013;132:30e45ediscussion 46e–47e.
21. Schlenz I, Kuzbari R, Gruber H, et al. The sensitivity of the nipple-areola complex: an anatomic study. Plast Reconstr Surg. 2000;105:905909.
22. Swanson E. Doppler ultrasound imaging for detection of deep vein thrombosis in plastic surgery outpatients: a prospective controlled study. Aesthet Surg J. 2015;35:204214.
23. Swanson E. Photometric evaluation of inframammary crease level after cosmetic breast surgery. Aesthet Surg J. 2010;30:832837.
24. Swanson E. Comparison of vertical and inverted-T mammaplasties using photographic measurements. Plast Reconstr Surg Glob Open 2013;1:e89.
25. Swanson E. Safety of vertical augmentation-mastopexy: prospective evaluation of breast perfusion using laser fluorescence imaging. Aesthet Surg J. 2015;35:938949.
26. Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:12821301.
27. Sackett DL, Straus SE, Richardson WS, et al. Therapy. In: Evidence-based Medicine. 2000:2nd ed. Toronto: Churchill Livingstone; 105154.
28. Wong C, Vucovich M, Rohrich R. Mastopexy and reduction mammoplasty pedicles and skin resection patterns. Plast Reconstr Surg Glob Open. 2014;2:e202.
29. Khavanin N, Jordan SW, Rambachan A, et al. A systematic review of single-stage augmentation-mastopexy. Plast Reconstr Surg. 2014;134:922931.
30. Tebbetts JB. A process for quantifying aesthetic and functional breast surgery: II. Applying quantified dimensions of the skin envelope to design and preoperative planning for mastopexy and breast reduction. Plast Reconstr Surg. 2014;133:527542.
31. Parsa AA, Jackowe DJ, Parsa FD. A new algorithm for breast mastopexy/augmentation. Plast Reconstr Surg. 2010;125:75e77e.
32. Tessone A, Millet E, Weissman O, et al. Evading a surgical pitfall: mastopexy–augmentation made simple. Aesthetic Plast Surg. 2011;35:10731078.
33. Rohrich RJ, Gosman AA, Brown SA, et al. Mastopexy preferences: a survey of board-certified plastic surgeons. Plast Reconstr Surg. 2006;118:16311638.
34. Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthetic Plast Surg. 1990;14:93100.
35. Spring MA, Macias LH, Nadeau M, et al. Secondary augmentation-mastopexy: indications, preferred practices, and the treatment of complications. Aesthet Surg J. 2014;34:10181040.
36. Cruz-Korchin N, Korchin L. Vertical versus Wise pattern breast reduction: patient satisfaction, revision rates, and complications. Plast Reconstr Surg. 2003;112:15731578discussion 1579.
37. Hall-Findlay EJ. The three breast dimensions: analysis and effecting change. Plast Reconstr Surg. 2010;125:16321642.
38. Nahai F. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002 (Discussion). Plast Reconstr Surg. 2004;114:17341736.
39. Chen CM, White C, Warren SM, et al. Simplifying the vertical reduction mammaplasty. Plast Reconstr Surg. 2004;113:162172discussion 173.
40. Serra MP, Longhi P, Sinha M. Breast reduction with a superomedial pedicle and a vertical scar (Hall-Findlay’s technique): experience with 210 consecutive patients. Ann Plast Surg. 2010;64:275278.
41. Neaman KC, Armstrong SD, Mendonca SJ, et al. Vertical reduction mammaplasty utilizing the superomedial pedicle: is it really for everyone? Aesthet Surg J. 2012;32:718725.
42. Lista F, Ahmad J. Vertical scar reduction mammaplasty: a 15-year experience including a review of 250 consecutive cases. Plast Reconstr Surg. 2006;117:21522165discussion 2166.
43. Hofmann AK, Wuestner-Hofmann MC, Bassetto F, et al. Breast reduction: modified “Lejour technique” in 500 large breasts. Plast Reconstr Surg. 2007;120:10951104discussion 1105.
44. Amini P, Stasch T, Theodorou P, et al. Vertical reduction mammaplasty combined with a superomedial pedicle in gigantomastia. Ann Plast Surg. 2010;64:279285.
45. Thoma A, Ignacy TA, Duku EK, et al. Randomized controlled trial comparing health-related quality of life in patients undergoing vertical scar versus inverted T-shaped reduction mammaplasty. Plast Reconstr Surg. 2013;132:48e60e.
46. Swanson E. Can we really control the inframammary fold (IMF) in breast augmentation? Aesthet Surg J. 2016;36:NP313NP314.
47. Flowers RS, Smith EM Jr. “Flip-flap” mastopexy. Aesthetic Plast Surg. 1998;22:425429.
48. Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e819e.
49. Swanson E. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg. 2013;66:937949.
50. Lista F, Austin RE, Singh Y, et al. Vertical scar reduction mammaplasty. Plast Reconstr Surg. 2015;136:2325.
51. Hidalgo DA, Spector JA. Breast augmentation. Plast Reconstr Surg. 2014;133:567e583e.
52. Hidalgo DA, Sinno S. Current trends and controversies in breast augmentation. Plast Reconstr Surg. 2016;137:11421150.
53. Hall-Findlay EJ. Breast implant complication review: double capsules and late seromas. Plast Reconstr Surg. 2011;127:5666.
54. Brody GS, Deapen D, Taylor CR, et al. Anaplastic large cell lymphoma occurring in women with breast implants: analysis of 173 cases. Plast Reconstr Surg. 2015;135:695705.
55. Scheer J, Patel A, Blount A, et al. One-stage augmentation and mastopexy: a review of outcomes in a large patient population. Plast Reconstr Surg. 2012;130(Suppl 5S-1):8586.
56. Cerovac S, Ali FS, Blizard R, et al. Psychosexual function in women who have undergone reduction mammaplasty. Plast Reconstr Surg. 2005;116:13061313.
57. Courtiss EH, Goldwyn RM. Breast sensation before and after plastic surgery. Plast Reconstr Surg. 1976;58:113.
58. Schlenz I, Rigel S, Schemper M, et al. Alteration of nipple and areola sensitivity by reduction mammaplasty: a prospective comparison of five techniques. Plast Reconstr Surg. 2005;115:743751discussion 752.