**2. Options**

 Of course the basics of this procedure are some combination of augmentation with elevation of the NAC with varying degrees of skin/glandular excision. The simplest form would be a basic augmentation with a crescent lift of one or both areolae, while the more challenging case can require a large reduction/lift using an inverted T incision along with augmentation (**Figure 2**). In either case, the goal is to augment the breast volume and reposition the NAC into a more harmonious relationship with the breast implant while successfully managing the soft tissue envelope and glandular area. In our opinion, the mastopexy portion of the procedure allows one to manipulate and idealize the breast tissues, in other words *match,* the breast tissues around

#### **Figure 2.**

*Many incisional options exist for mastopexy but all breasts are different along with patient desires. The basic four options shown above are the crescent, concentric, vertical and inverted T. The vertical and inverted T mastopexies are the most efficient choices for the majority of breast ptosis situations.* 

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

#### **Figure 3.**

*The primary aim of staging is to avoid the devastating complication of ischemia and necrosis to the NAC. Extremely large breast with major ptosis as well as large tubular or constricted breast as shown are ideal for staging when a patient desires both mastopexy/reduction plus implants for a more "rounded" or "perky" appearance.* 

a well-placed and selected implant. However, one must consider limitations to both of the components of the surgery, which are stricter in combination than either in isolation. For example, a breast augmentation alone may allow use of larger implants, but when combined with a mastopexy, the volume of implant must often be limited to avoid undue stress on the resultant breast envelope as well as the arterial perfusion and venous drainage of the NAC. Despite using a smaller implant in certain situations to decrease vascular compromise, the breast implant dimensions should still come close to the base width of the breast. This may often require avoiding a higher profile implant in favor of a more moderate profile and smaller implant that still has the desired base width, particularly when more extensive mastopexy is required.

At this point it is worth noting that not all patients are good candidates for this procedure. If there is extreme laxity, desire for extremely large breasts, or large pedunculated or constricted breasts requiring major reduction and tissue rearrangement staging may be the better option. The primary aim of staging is to avoid the devastating complication of ischemia and necrosis to the NAC which is most at risk (**Figure 3**). Medical co-morbidities and prior surgery may also lead one to recommend staging in select cases as well, but for the majority of patients requiring increased breast volume and repositioning of the NAC and reduction of excess skin are better served by combining these procedures. This often allows a type of synergism from matching the breast envelope to a well-positioned and selected implant that can yield a dramatic and pleasing result while minimizing financial burden, as well as anesthesia and recovery times for the patient.

#### **3. Pertinent anatomy**

 The mammary gland begins as an invagination ectoderm that forms a primary bud which results in the development of multiple secondary buds, usually 15–25. Approximately halfway through gestation the buds have lengthened and formed epithelial chords that extend into the chest wall and then begin to form the lactiferous ducts through lumenization. At birth the lactiferous ducts open into the mammary pits that elevate and form the nipple. Failure to do so results in an inverted nipple (2–4% of females). No further development occurs until puberty when hormonal stimulation triggers proliferation and enlargement of the glandular tissues as well as deposition of fat.

## **3.1 Surface anatomy**

 The variation in size and shape of the female breast is considerable. Typically, the breast extends from the 2nd or 3rd rib superiorly to the 5th or 6th rib inferiorly where the inframammary crease lies. Medially the breast starts from the sterna-costal junction laterally to the anterior axially spine and may extend to the middle axillary line with the axillary tail extending supero-laterally into the axilla proper [1]. Ideally, the breast should form a rounded and conical shape with the NAC situated at the apex. The NAC may be of varying size and pigmentation, but ideally the NAC should be roughly 1/3rd of the overall breast diameter and the nipple itself 1/3rd of the overall areolar diameter [2].

## **3.2 Glandular anatomy**

 15–25 Lactiferous ductules extend from the deep glandular regions toward the NAC, terminating as openings. Each ductule drains 15–20 lobules which is the functional unit of the breast gland where lactation occurs. The breast gland has no discrete fascia but does have fibrous thickenings scattered throughout the gland which extend from the muscular fascia toward the skin. These Cooper's ligaments provide scaffolding support to the glandular breast. The integrity of these ligaments can be compromised with aging, fluctuations in weight and breast size and pregnancy which may eventually contribute to breast ptosis. Recent anatomic studies have elucidated additional internal supporting structures. The inframammary crease ligament has been identified through cadaver dissection and contributes to a well-defined inframammary crease. It typically extends from the medial aspect of the 5th rib and laterally to the fascia of the 5th and 6th ribs [3]. The ligamentum suspensorium mammae extends from the clavicle down to the upper border of the breast and retromammary space and may explain the propensity of some females to develop ptosis while other do not, as it is well defined in some patients but indistinct in others [4, 5].
