**8. Preferred technique**

 Operative sequence for the authors preferred technique differs from others in that the mastopexy is performed first and implant placement is performed prior to closure. Although, theoretically this could increase the risk of over resection of skin, this has not often been encountered with thoughtful skin marking/resection and implant selection. The primary advantage gained is the ability to place the implant in a total submuscular plane and more fully manipulate the skin and glandular elements of the procedure. It also can be challenging to estimate ideal implant position prior to the mastopexy when there is significant ptosis or asymmetry combined with the typical alteration of the inframammary crease that can occur during mastopexy. It is for these reasons that the mastopexy is initiated first followed by implant placement, then glandular manipulation as required and finally skin closure.

### **8.1 Marking**

 Mastopexy marking is performed with an indelible marker with the patient in upright or standing position for obvious reasons. A mastopexy template is beneficial and can facilitate symmetry. Either a Wise pattern or vertical pattern is marked with emphasis on positioning the NAC at or slightly above the inframammary crease. In cases where you may be unsure if a horizontal skin excision will be required it is advisable to mark the patient with a vertical excision plan (**Figure 9**). Minor horizontal excision can be done accurately and easily intraoperatively. However, most cases requiring any significant degree of skin resection or NAC elevation, are best served by Wise pattern excision which controls the nipple to fold

#### **Figure 9.**

*Marking for a simultaneous lift/augmentation is always performed with the patients standing and arms to the side. As shown for limited ptosis case, the vertical mastopexy marks are along the nature breast axis after lateral and medial displacement of the parenchyma. The base of the vertical must stop 1–2 cm above the IMF to prevent scarring below the fold after closure.* 

#### **Figure 10.**

*Marking a planned inverted T incision for a lift/augmentation on a larger breast is similar to marking a vertical mastopexy until vertical limbs are complete. Next, the horizontal incision is typically placed approximately 1 cm above the planned IMF and horizontal limbs kept as short as possible to match the residual skin on each side of the breast axis line as shown (X, Y).* 

 distance to a greater degree (**Figure 10**). When marking the vertical and horizontal limbs of the pattern, it is advisable to err on the side of more conservative resection, given that volume will be added by the implant. Some flexibility in the surgery is added by using implant sizers during the procedure and having multiple implant sizes available intraoperatively. Occasionally, it may be beneficial to use either a larger or smaller implant than initially planned for.
