**8.3 Technique**

The surgery is initiated by placing an areolar imprint with an appropriately sized areolar marker centered over the nipple itself. Then, partial thickness incisions are made, followed by de-epithelialization within the planned incisions. Caution is a must so not to undermine the new NAC. While removal of excess fat and gland helps improve shape and longevity, care must be used to leave adequate tissue below the NAC (central pedicle) as well as adequate tissue below each vertical limb. This is followed by development of the pedicle, and en bloc resection of excess or ptotic glandular tissue (**Figure 11**). Typically resecting portions of the inferior, lateral and superolateral area of the keyhole are common for the SMC pedicle. More is removed from the inferior glandular tissues versus less resection superiorly. However sufficient tissue must be removed from the keyhole area to allow inset of the NAC and pedicle without compression or congestion. The inferior excision is completed

*Simultaneous Mastopexy with Augmentation DOI: http://dx.doi.org/10.5772/intechopen.84967* 

#### **Figure 11.**

*Excision of redundant skin as well as fat and parenchyma is critical for long term maintenance of the lift. But, as shown, care must be used to not remove too much tissue below the NAC and avoid thinning the flaps below the vertical limbs.* 

#### **Figure 12.**

*Three separate patients are shown who lost over 100 lbs. by gastric bypass prior to having simultaneous mastopexy and augmentation. The key for this subset of patients is to remove as much of the excess poor quality mammary tissue and fat as well as skin. This is especially helpful when the breast shape is constricted or conical.* 

 down to the level of the pectoral fascia, but without insult or injury. Excision of tissue is especially important in massive weight loss patients whose residual excess tissue will sag later if not removed (**Figure 12**). Excising as much as possible safely on this subset of patients and allowing a larger implant will produce better longevity and appearance compared to excising little tissue and use of a smaller implant (**Figure 13**). After excision, attention is taken to expose only the inferolateral aspect of the pectoral border for a few centimeters medially. This will allow myotomy paralleling the fibers of the pectoralis major into the postpectoral space while not injuring the central deep component of the glandular pedicle. Once in the postpectoral space, circumferential blunt dissection is initiated with a finger. Inferolaterally, using a sweeping maneuver with the forefinger it is typically easy to lift fibers of the anterior serratus and external oblique muscles (**Figure 14**). Occasionally it may be necessary to utilize limited cutting cautery to aid in pocket development. Once the total submuscular pocket is developed, a lighted retractor will aid in minor sub

#### **Figure 13.**

*Massive weight loss patients who desire to be the "same size" but "round and perky" typically will not be happy with a mastopexy alone because of the poor quality of residual tissue. Reduction and augmentation is required as shown to obtain the results most patients will find pleasing.* 

#### **Figure 14.**

*Elevation of a "total" submuscular coverage pocket is shown during initial finger sweeping. Slow, cautious elevation inferomedially prevents perforation of the flap that is thinner in that location. Lighted retractors are used past initial finger dissection for residual elevation as required and hemostasis.* 

 muscular release if needed for inferior pole expansion and with hemostasis within the pocket. Hemostasis must be performed and verified at multiple points throughout the surgery. After verifying the pedicle and NAC transpose easily into position, the superior trifurcation is closed at the deep dermal level and the NAC pexied into position. Preventing excessive tension at this point greatly improves final scar formation (**Figure 15**). Total submuscular coverage also takes some pressure off the incision line and aids in longevity (**Figure 16**). A sizer can then be placed into the sub muscular pocket and inflated to the desired size. This maneuver can help with assessing implant pocket dimensions and expected tension on the NAC and superior trifurcation closure. The sizer can then be replaced with the corresponding implant and the remaining incisions can then be closed in standard layered fashion with care to carefully align the skin edges and evenly distribute pleating throughout the mastopexy incisions. Glandular pillars may be reapproximated gently with 1–2 resorbable

#### **Figure 15.**

*The vertical limb of the mastopexy greatly improves the scar appearance around the areolas by decreasing radially pressure away from the center. As the patient examples demonstrate, the vertical incision is often required to decrease the diameter of the NAC or at least prevent widening that can often be seen from a donut mastopexy.* 

#### **Figure 16.**

*Demonstration of the longevity benefits from excision of excess glandular tissue as well as total submuscular coverage of the implant as shown. Recurrent ptosis is it occurs is typically from patient weight gain and enlargement of tissue above the implant.* 

sutures as required to improve shape and projection. Over plication must be avoided. Occasionally, it may be beneficial to perform minor liposuction to the lateral breast if excess fat or fullness at the lateral pole of the incision is present.
