**6. Pedicle options/implant location options**

When combined with a central component, the superomedial pedicle has the most robust and unaffected blood supply during a combined mastopexy and augmentation procedure [6]. Hence, our pedicle of choice in the majority of mastopexy augmentations is the Superomedial-Central (SMC) pedicle. This majority of blood supply for this pedicle originates from the internal thoracic artery (via the internal mammary artery) that should be preserved using a SMC. The central component houses trans-pectoral perforators from the internal thoracic artery and medial mammary branches (**Figure 4**). This central component vascularization can only be maintained well when placing implants in a subpectoral or submuscular plane and are sacrificed with development of a subglandular pocket (**Figure 5**). This is an

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

 important consideration when selecting implant plane and in revision surgery when implants may have been placed in a subglandular fashion. For the aforementioned reasons, the authors almost universally use subpectoral or submuscular placement during the augmentation phase of the procedure. This is not only beneficial from a blood supply and venous drainage perspective, but also results in more soft tissue coverage of the implant and likely results in a decreased incidence of capsular contracture. An additional advantage is when utilizing a *total submuscular* plane, the elevated fibers of serratus and external oblique with their corresponding fascia are elevated partially to help cover the implant inferiorly and laterally to dissuade bottoming out and as a further barrier to the external environment and potential microbes should even a small wound dehiscence occur postoperatively (**Figure 6**). This is particularly important when capsular contracture exists above muscle and

#### **Figure 6.**

*The SMC pedicle allows for implant placement in a total submuscular location if the incision as shown is made immediately inferior to the central pedicle component that remain attached to the pectoralis major. Total coverage of a new implant gives protection of any incision breakdown and also prevents the implant from "slipping out" of the pocket especially when a submammary implant was simultaneously removed.* 

#### **Figure 7.**

*While the SMC can be used in most ever breast ptosis situation, when the sternal notch to nipple (SN-N) distance becomes greater than 30 cm, a MC pedicle improves the arc of rotation to obtain proper NAC elevation with less kinking of the pedicle. Most of the same blood supply exists between a SMC vs. MC pedicle with the occasion loss of the 2nd intercostal in some medial pedicle situations.* 

#### **Figure 8.**

*The four most common pedicles as discussed and shown here have specific advantages and disadvantages. Regardless, the surgeon must make sure any of the four if used is treated gently and has an adequate base to allow proper drainage to and from the NAC.* 

a complete capsulectomy is performed and a new implant is immediately placed beneath muscle in a new pocket. In this situation, a subpectoral placement only will result in "slipping out" of the implant from the subpectoral position back into the above muscle pocket unless an acellular dermal matrix (ADM) is added to the inferior muscle edge. The total submuscular placement prevents implant slippage and avoids the need for an expensive ADM placement.

Although the SMC pedicle likely offers the most versatility and safety, this can be altered in select situations (**Figure 7**). For instance, a purely Medial-Central (MC) pedicle should be considered in cases of long pedicle length and greater degrees of ptosis (SN-N > 30 cm) such as some massive weight loss patients. This option allows for maintenance of the medial mammary and pectoral arterial branches while allowing an easier or better "arc of rotation" of the pedicle into its final position, without excessive kinking or tension on the pedicle [7]. In cases where the mastopexy component is fairly small and the degree of NAC elevation minor (only 2–3 cm), a purely superior-central (SC) pedicle can often facilitate easier transposition of the NAC into position [8]. A purely SC pedicle will gain some axillary artery contribution as well as some lateral and internal thoracic branches to the pedicle [9]. An inferior pedicle is rarely selected in certain staged procedures where the patient has a very long SN-N along with a relatively short N-IMF distance (**Figure 8**). Because the inferior pedicle bottoms out more than other pedicles, the vertical limbs of an inferior pedicle should be drawn close to 5 cm compared to a 7 cm length of vertical limbs for superior, medial or superomedial pedicles that have very limited stretching comparably.

### **7. Implant selection**

The style and type of implant used is quite variable. This technique performs well regardless of implant style used assuming some common considerations. Saline or silicone implants are well suited for this procedure and their selection should be based on similar criteria one would use for augmentation alone typically. However, given that the implant plane is sub muscular, the incidence of rippling is less than with a subglandular plane. As previously mentioned implant size is critical. Utilizing very large implants can stress the mastopexy closure and lead to ischemia

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

to the NAC. A more conservative approach to implant sizing is preferable and avoidance of excessively high profile implants can help to avoid wound complications. Although textured, anatomically shaped implants have gained popularity, it is the authors' opinion that usually, the smooth round implants perform best in combined mastopexy/augmentation surgery by removing the variable of rotational alignment intraoperatively required with the use of anatomically shaped implants.
