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Single Stage Augmentation Mastopexy with L-shaped Inferior Pedicle Combined with Dual Plane Implant Placement

Ungarelli, Luís Fernando; Rosique, Marina Junqueira; Coltro, Pedro Soler; Farina Júnior, Jayme Adriano

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Plastic and Reconstructive Surgery - Global Open: January 2017 - Volume 5 - Issue 1 - p e1184
doi: 10.1097/GOX.0000000000001184

Augmentation mastopexy is indicated to project the breast cone, cranially transpose the nipple-areola complex (NAC), and correct volume deficiencies, especially when the upper pole of the breast lacks fullness. Augmentation mastopexy may be a single- or two-stage procedure. The decision to stage surgery involves safety limits for NAC transposition (ranging from 4 cm to 6 cm) and the presence of difficulties such as high degrees of ptosis, poor skin quality, history of massive weight loss, extreme asymmetry, and nipples off midline.1

Although two-stage augmentation mastopexy is an interesting option in complex cases, it is extremely unpopular in our country and we try to avoid it. In the last eight years (2008 to 2016), we performed 85 bilateral augmentation mastopexy surgeries and 9 patients (10.6%) presented special complexities as described earlier.

For these cases, we have devised a single-stage technique in which a modified inferior nipple-areolar pedicle2 is combined with implant placement in a submuscular dual-plane pocket.3 Despite several available variations of the inferior pedicle, we have not found reports of this particular modification or association of techniques in literature.

In this technique, we utilized a modified Wise pattern for skin resection.4 Skin markings and de-epithelialization of the inferior pedicle varied from 6 × 8 cm to 8 × 14 cm (width-to-length), according to desired breast size. Lateral and superior borders of the pedicle were incised down to prepectoral fascia. Inferomedial quadrant of the breast was deskinned as needed and remained attached to the pedicle at the level of fourth and fifth intercostal spaces. Superomedial border of the pedicle was incised obliquely to the fascia at the level of second and third intercostal spaces maintaining a 1.5-cm-thick superomedial dermoglandular flap. The result was an L-shaped inferior pedicle fully attached to prepectoral fascia. This dissection aimed to preserve the maximum number of perforators from the breast septum.5 Identical implants were placed in dual-plane type 1 pockets3 (SDC1). (See video, Supplemental Digital Content 1, which shows the intraoperative details of the inferior L-shaped nipple-areolar pedicle. This video is available in the “Related Videos” section of the Full-Text article on or available at

Video 1.:
See video, Supplemental Digital Content 1, which shows the intraoperative details of the inferior L-shaped nipple-areolar pedicle. This video is available in the “Related Videos” section of the Full-Text article on or available at

In this series, mean age at the time of surgery was 31.6 years (range, 17–48 years) and mean follow-up time was 11.2 months (range, 6–21.7 months). Mean preoperative sternal notch to nipple distance (SNN) was 24.9 cm (range, 21–29.5 cm) and mean postoperative SNN was 20.2 cm (range, 19–22.5 cm). Mean vertical NAC transposition was 4.7 cm (range, 2–8 cm). Round, texturized, cohesive silicone gel implants were used in all cases and mean implant volume was 260 cm3 (range, 205–295 cm3). Figures 1 and 2 demonstrate preoperative and postoperative views, respectively.

Fig. 1.:
Patient with grade 3 ptosis, nipples off midline, inelastic thin skin, constricted inferior breast poles, and asymmetry. She desired both breasts to have a volume similar to the bigger breast. Preoperative frontal view.
Fig. 2.:
Symmetry was achieved with bilateral mastopexy with inferior L-shaped nipple-areolar pedicle, unilateral reduction of the right breast, and inclusion of 295 cm3 high-profile implants (submuscular, dual-plane pockets) in both breasts. Nine months postoperative frontal view.

Dehiscence occurred in 2 patients (22.2%) and 1 patient (11.1%) had bilateral recurrence of ptosis. None of the patients had areolar necrosis or implant-related problems. We believe selection bias and small sample size account for a higher number of dehiscences than previously reported.1

This technique has allowed us to successfully carry out single-stage augmentation mastopexies in complex cases, with a considerably less than 100% reoperation rate required by two-stage procedures.


1. Khavanin N, Jordan SW, Rambachan A, et al. A systematic review of single-stage augmentation-mastopexy.Plast Reconstr Surg2014134922–931
2. Ribeiro L. A new technique for reduction mammaplasty.Plast Reconstr Surg197555330–334
3. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types.Plast Reconstr Surg20011071255–1272
4. Ungarelli LF, Farina JA Jr.. Line-of-nines guide to define points B and C in mastopexy and reduction mammaplasty.Plast Reconstr Surg2015136711e–713e
5. van Deventer PV, Graewe FR. Enhancing pedicle safety in mastopexy and breast reduction procedures: the posteroinferomedial pedicle, retaining the medial vertical ligament of Würinger.Plast Reconstr Surg2010126786–793

Supplemental Digital Content

Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.