Round bloc technique (11)
Type 1; Mild Ptosis, F-Fp < 15 cm/NJD < 22 cm. Small to normal gland size; Cup A-B.
Areola diameter 3.5-4 cm; 2nd. oval circle, maximum 3 cm higher than original.
De-epithelization of the area between the two circles; Incision of the caudal outer circumference up to the median line. Preparation between gland and subcutis caudally, laterally and medially up to the pectoral fascia. Mobilization of the gland ventrally of the fascia in a 3-finger-wide tunnel upwards and fixation of the gland on the fascia with delayed- or non-resorbable suture. Periareolar purse string sutures (PDS or non-absorbable; 3.0 -4. 0) to diminuish the outer circle. Wound closure by running sutures.
Advantages: Limited scar area; minor surgical trauma
Disadvantages: only suitable for small tightening; widened scars; Recurrent ptosis
Vertical mastopexy with cranial pedicle ("monobloc"; mod. Lassus / Lejour) (13)
Type1: F-Fp <15 cm/ NJD 22- 25 cm; or Type 2: F-Fp >15 cm/ NJD >25 cm/ N-Fp < 8 cm. Moderate ptosis, Average size of the gland, Cup A to C. Moderate skin excess in the lower breast pole.
Areola 3.5-4 cm; “Dome design” as described by M. Lejour. Cranially pedicled skin flap.
De-epithelialization of the MAC- pedicle including an approx. 2 cm zone caudal to the areola.
Mobilization between subcutis and gland caudally, laterally and medially (similar to a virtual, subcutaneous wise pattern figure).
Mobilization of a 3-5 cm -tunnel superior to the pectoralis fascia.
A fixation suture is made between this point and the cranial mid of the gland (non-absorbable or delayed). Shortening of the vertical scar by 2 continuous, deep and superficial intradermal sutures.
Continuous suture for the areola; in case of higher tension, possibly an additional purse string suture is needed.
Mastopexy Lejour postop
Vertical mastopexy with medial pedicle and rotation (Hall-Findlay) (14)
as 2.; often in combination with a breast reduction.
Slightly better projection; occasionally bottoming out.
As 2.; the pedicle is designed from medially.
De-epithelialization of the MAC- pedicle
C-shaped incision around the pedicle transglandular down to the fascia.
Rotation of the gland for 90 degrees cranially; Fixation by pillar sutures between the gland flaps.
Running suture for the vertical scar with a slight shortening; Periareolar suture (absorbable).
In case of malformation (tubular breast): Spreading, Dividing and Unfurling of the mammary gland (15)
Type 4; Breast malformation with hypoplasia of (inferior) parts of the gland and skin deficiency (tubular breast; see chapter Malformation)
If the skin envelope at the lower pole is deficient, only periareolar, as described under 1)
Otherwise with an additional small vertical scar
De-epithelization of the marked periareolar zone and incision semicircular at the inferior circumference. Mobilization between the subcutis and gland to the fascia
Preparation of the entire gland on the surface of the fascia up to the midline behind the nipple.
In case of hyperdense glandular tissue, radial incisions from dorsal (spreading); otherwise cross- incision at the level of the nipple at the backside of the gland and forming of a pocket caudally, which can be spread out down to the planned new inframammary fold by longitudinal incisions.
It is important to fix the lower pole of the gland at the new inframammary fold with resorbable sutures
Wound closure by purse string and separate periareolar suture.
Tuberous breast postop2
T-scar Mastopexy with inferocentral, septum-based pedicle
Type 2: F-Fp >15 cm/ NJD > 25 cm/ N-Fp > 8 cm; Type 3: Loss of elasticity. Advanced skin excess or loss of elasticity; possibly combined with reduction mammaplasty
Wise pattern: 4-4,5 cm NAC; 5-7 cm vertical scar; horizontal part depending to skin excess
De-epithelization of an inferior pedicle which includes the NAC and circular incision of the new position. Vertical skin incision laterally and medially of the pedicle according to the expected skin excess. Mobilization subcutaneously from all sides down to the fascia; the gland gets its blood supply through the fascia and the Wühringer septum. Fixation of the cranial part of the gland to the fascia at the height of the 3rd rib, with medial and lateral plication if necessary.
Caudal stabilisation with turnover-flap
Type 3; loss of elasticity, caudal skin excess >10 cm vertically. Often after implant removal.
T-scar, cranial pedicle (depending to the amount of skin surplus)
Complete deepithelialisation of the whole pedicle supporting the NAC including the caudal area down to the IMF; including the Wise-Pattern area caudally. Removal of the implant, if necessary. Mobilisation of the gland on the pectoral fascia cranially and mastopexy of the gland between the 2nd rib and the retroareolar tissue. The deepithelialized caudal flap is folded 180° and sutured to the pectoralis fascia to support projection and stabilize the lower pole. In case of a longer caudal pedicle, the lateral branches of the wise-pattern-figure can be sutured to the cental part to gain more volume in this area. The skin pedicles are closed over the new breast mound.
Autoaugmentation: implant ex
Autoaugmentation: flap folded
Autoaugmentation : folding the pedicle
Autoaugmentation: closing skin envelope
Auto-augmentation and internal suspension (Rubin) (17)
Type 2/3; massive excess of skin, also towards the axilla, after excessive weight loss; small gland left with the patient`s desire for autologous enlargement
Like Wise Pattern; with medial wing up to the median line and lateral wing up to the middle axillary line, rising upwards at the axilla and including the skin excess.
Incision of 3.5-4 cm areola diameter; caudocentral pedicle.
Complete de-epithelization of the entire remaining incision area.
Preparation subcutaneously down to the fascia; no mobilization of the gland from the pectoral fascia!
The medial and lateral pedicle is mobilized up to the sternal margin or to the anterior axillary line and folded around the gland, so that the dermis flaps finally cover the gland completely like an implant envelope. These flaps are sutured together with delayed resorbable sutures.
Fixation of the border of this sheath with cranialization on the pectoral fascia; the skin flaps are placed over this “anatomical implant” and sutured together.
Rubin side pre
Mastopexy and Augmentation (18)
All types; ptosis and hypomastia; patient`s desire for enlargement.
It should be noted that the combination of mastopexy and implant-supported augmentation is associated with an increased risk of form disorders; the possibility of two-stage surgery should be discussed with the patient.
With a slight ptosis of 1. ° following Regnault`s classification and the desire to enlarge by at least one cup size, the implant will fill up the skin envelope and inframammary incision may be sufficient.
If this does not fit for the skin excess, a periareolar tightening figure should be used (see pt. 1).
In case of Ptosis 2-3°, a vertical figure should always be planned (see point 2).
The expected result can be simulated with test implants and a bustier to demonstrate the form facing a mirror. Depending on the desired breast size, the volume and shape of the implants and the tightening figure are planned:
a) Skin excess expected to be slight:
Inframammary incision; round or anatomical implants.
b) Excess of skin to be expected even after augmentation (tested with staples intraoperatively):
Periareolar deepitheliasation; semicircular incision at the caudal border and preparation between gland and subcutis, if the subcutaneous tissue amount is sufficient. The implant pocket is formed epi- or subpectorally.
c) Moderate to severe excess of skin to be expected:
Deepitheliazation of the vertical figure, fixation of the dermal flap caudally in the IMF after augmentation.
CAVE: When lowering of the inframammary fold is planned, it is important to spread the gland down to the new fold and fix it to avoid “double-bubble”!
Mastopexy and Lipofilling
Type1-4; patient`s desire for moderate enlargement and rejection of foreign body
Sufficient donor areas available
Request for liposuction.
Like mastopexy alone; a slight skin excess is planned.
Marking of the liposuction areas.
Due to the required exposure time of the tumescent solution, the procedure starts with the infiltration of the liposuction areas.
The next step performs de-epithelialization of the NAC- pedicle, mobilization of the subcutaneous tissue and mastopexy of the gland, as well as temporary closure with clips to simulate the shape, regarding the estimated volume excess by fat transfer.
The fatty tissue harvested by liposuction is filtrated or centrifuged and infiltrated with a 2mm cannula in a criss-cross technique without bolus injection in the subcutaneous layer and behind the gland; an intraglandular injection has to be avoided.