Techniques in Cosmetic Surgery The Limited Scar Mastopexy: Current Concepts and Approaches to Correct Breast Ptosis

Rod J. Rohrich, M.D., James F. Thornton, M.D., Rafael G. Jakubietz, M.D., Michael G. Jakubietz, M.D., and Jrg G. Grnert, M.D.
Dallas, Texas; and Erlangen, Germany

The literature on short scar mastopexy was reviewed, with a focus on the different techniques. Currently four techniques have been described: the periareolar, the vertical, the inverted-T, and the L-shaped scar. The different techniques were evaluated with regard to patient selection, operative techniques, scar length, and complications. A large number of techniques have been published for minimal ptosis, whereas for significant ptosis, the number of surgical options is limited. It is evident that limited scar techniques can be applied to all grades of ptosis, but there is no one technique that can satisfactorily correct all degrees of ptosis. Plastic surgeons should weigh the advantages and limitations of each technique to correctly address breast ptosis. This article reviews an algorithmic approach to correct all degrees of ptosis with mastopexy. (Plast. Reconstr. Surg. 114: 1622, 2004.)

Mastopexy remains one of the more challenging operations in plastic surgery. Since the surgeon is usually faced with lax and ptotic breast tissue that requires a well-planned and careful approach, many believe that perfection is hard to achieve. The fact that many different options exist does not necessarily make this problem any easier. The goal of the mastopexy is to provide long-lasting correction of breast ptosis by elevating the nipple-areola complex and tightening the skin brassiere. Ptosis is usually graded according to a system introduced by Regnault.1 Ptosis occurs when both the breast mound and the nipple-areola complex descend on the chest wall due to diminished elasticity of tissues when the patient ages1 (Ta-

ble I and Fig. 1). Mastopexy is also an operative procedure that every plastic surgeon performing breast augmentations should be able to offer his or her patients after explantation.2 Contrary to the case with reduction mammaplasties, tissue is not removed but redistributed, in an attempt to restore a firm and youthful look to the breast. Currently, this is not possible without placing incisions on the breast. Depending on the location, they might be more or less visible. In some cases, hypertrophic scarring may also jeopardize the final appearance. Minimizing the extent of scarring remains a key point when modifying existing techniques and introducing new innovative procedures. The so-called short scar or limited scar mastopexy has evolved out of the necessity to reduce the length of the incisions, as mastopexy patients, more than mammaplasty patients, are highly concerned with the aesthetic outcome and often request the shortest scar possible. Trading a ptotic breast for a visibly scarred breast with a chance of recurrent ptosis is a poor choice. The term short scar mastopexy is not limited to one specific technique but is used to describe techniques that minimize the extent of scarring. There is also no defined incision length that would allow a differentiation between a short scar and a scar of normal length. Short is therefore a rather per-

From the University of Texas Southwestern Medical Center, and Friedrich-Alexander University, Erlangen-Nrnberg. Received for publication August 7, 2002; revised July 2, 2003. DOI: 10.1097/01.PRS.0000139062.20141.8C

1622

Vol. 114, No. 6 /

SHORT SCAR MASTOPEXY: CURRENT CONCEPTS

1623

TABLE I Grades of Ptosis: Regnault Classification

Grade I, minor ptosis Grade II, moderate ptosis Grade III, major ptosis Nipple at level of inframammary fold, above lower contour of gland Nipple below level of inframammary fold, above lower contour of gland Nipple below level of inframammary fold, at lower contour of gland

pattern. We evaluated the most popular patterns for each technique. Many of these techniques can be combined to address breast ptosis, but because ptosis is such a complex and variable phenomenon, no technique can successfully correct all types of ptosis. To maximize the outcome and benefit for every patient, the plastic surgeon has to master more than one technique. Sound options also seem to decrease as the degree of ptosis increases. For minor degrees of ptosis, there are many different options that can all produce excellent results. In severe cases of breast ptosis, the reasonable options result in an inverted-T scar resembling the incisions of a Wise pattern or Biesenberger pattern breast reduction.6,7
TECHNIQUES

FIG. 1. Periareolar technique: donut.

Periareolar Technique

sonal description for a scar length that might vary according to different breast sizes and different techniques. In reviewing the recent literature, we found that techniques leading to a scar shorter than the inverted-T scar could be classified as short scar techniques. One should keep in mind, though, that the shortest scar technically possible might not always be the best one, as patient satisfaction is not based solely on the length of an incision. Reducing the length of a scar, but sacrificing shape, position, or longevity, is a poor tradeoff. Breast scarring can be troublesome for both the patient and the surgeon. The aesthetic outcome is greatly influenced by the placement of the incisions on the breast. The medial and lateral portions of the chest wall may produce unsightly hypertrophic scars. Other areas that might initially look intimidating because of easy visibility, such as the breast mound, tend to produce very good scars that fade considerably over time. On the other hand, a short scar that has widened significantly is also undesirable. Therefore, reducing not only the length of the incision but also the tension on the wound will lead to a better result. The introduction of permanent purse-string sutures has greatly added to the options for reducing the amount of scarring.3,4 Recent innovations, such as superficial fascial system suspension, might enable the surgeon to reduce the amount of scarring even further.5 There are four different scarring patterns, with some variations to each one. Usually, a number of different techniques exist for each

The periareolar approach results in the shortest possible scar pattern. Placing the scar at the border of unpigmented breast skin and the pigmented areolar skin provides significant scar camouflage. In periareolar techniques, elevation of the nipple-areola complex is limited, so that usually only minor degrees of ptosis are addressed with this approach. Erol and Spira8 and Gruber9 use their techniques only in mild degrees of ptosis. Spear10,11 would not use his technique in patients with grade II or higher ptosis. Puckett12 limits crescent mastopexy to patients with grade I ptosis. Goes 13 and Benelli3,4 also limit their technique to moderate degrees of ptosis. Incision patterns that lead to this type of scar vary. It can be planned as a concentric incision8 11,14 or an eccentric incision, such as a crescent incision.12 Spear mentions that periareolar mastopexy today rarely has a concentric incision pattern. In most cases, an eccentric pattern is designed to maximize elevation of the nipple-areola complex.11 The pattern does not necessarily need to be a perfect oval or circle. Most often, four key points are connected to form a circular incision pattern. The superior and inferior points can be derived from generally accepted marking patterns, as they represent the nippleto-sternal notch and the nipple-to-inframammary fold distance. The lateral and medial points vary, since they are determined by the intended skin resection. Goes uses fixed measurements as well, while others may rely on individual markings on the patient3 (Table II and Fig. 2). Periareolar techniques have in

1624

PLASTIC AND RECONSTRUCTIVE SURGERY,

November 2004

TABLE II Periareolar Techniques: A Comparison

Author (ref.)

Ptosis Grade

Skin Incision

Skin Technique

Parenchyma Technique

Erol and Spira8 Spear10,11 Goes13 Benelli3,4 Puckett12 Gruber9

I, II I II I

Circumareolar only Circumareolar, eccentric Circumareolar, eccentric Circumareolar Circumareolar, concentric Circumareolar, concentric

Without skin resection Excess skin deepithelialized Excess skin deepithelialized (dermal flap) Excess skin deepithelialized Excess skin deepithelialized Excess skin deepithelialized

Medial/lateral pillars None Reshaped with or without mesh Plication/invagination None None

FIG. 2. Periareolar technique: periareolar.

common that both unpigmented breast skin and pigmented areola skin are resected, thus resulting in an outer wound edge with a much larger diameter and circumference than the inner wound edge. Adjusting the redundant skin of the outer wound edge to the areola will at least temporarily lead to periareolar wrinkling and pleating. This usually resolves over a period of a few months.19 Closing these defects under tension was the main reason for the drawbacks experienced with this periareolar technique, such as the areolar widening and distortion. Initially described by Bartels et al.14 as a skin resection only, it became clear that relying solely on the skin brassiere to reshape the breast leads to recurrence of ptosis. Today, reshaping of the gland is also included in the initial operation. As mentioned earlier, fixation of the glandular tissue should lift the nipple-areola complex and increase projection. This can be achieved using different techniques that aim to increase upper-pole fullness and decrease the diameter of the base of the breast, thereby increasing projection. Erol and Spira8 describe a rotation-invagination technique that decreases the base of the breast while increasing projection. Benelli3,4 describes two options to reshape the gland: in patients with glandular tissue of poor quality, he uses a plication-invagination technique. In patients with good tissue, a criss-cross mastopexy with

transposition of two superiorly based flaps decreases the breast base and increases projection. Goes13 uses a mesh support to induce formation of fibrous tissue to support the breast as an internal brassiere. Benelli3,4 tries to accomplish this with multiple glandular sutures he calls breast lacing. Glandular reshaping should be stable over time so that the skin brassiere will not be solely responsible for longevity and shape. In periareolar techniques, sensation and blood supply of the nipple-areola complex are well preserved, since the subdermal plexus is preserved by deepithelializing periareolar skin. Erol and Spira8 rely on the glandular perforators to the nipple-areola complex as they make full-thickness incisions around the areola. Other authors also did not report nipple necrosis or loss of sensitivity as common complications. Since no glandular resection is performed, sensation and blood supply through the perforating vessels and nerves are preserved as well. The problems reported in early publications of periareolar techniques were mainly distortion of the areola, scar widening, a flat, globular breast, and hypertrophic scarring.12 Puckett12 and Gruber9 reported scar widening in 46 to 50 percent of their patients. The introduction of the purse-string technique with a non-absorbable Gore-Tex suture significantly reduced areolar and scar widening. This suture, placed around the outer circumference, enables the surgeon to perform a tension-free skin closure that prevents widening of the areola and scar. Spear11 uses a nonabsorbable Gore-Tex suture. Benelli applies a similar concept. His so-called round block suture allows the formation of a circular fibrous tissue layer around the nipple-areola complex that prevents spreading of the scar.3,4 Goes13 uses a similar principle. Periareolar wrinkling usually does not worsen the aesthetic outcome, since the wrinkles tend to flatten out within 6 months.15

Vol. 114, No. 6 /

SHORT SCAR MASTOPEXY: CURRENT CONCEPTS

1625

Spear11 reports that to minimize tension and wrinkling, it is important to limit the size of the outer diameter to three times that of the inner diameter. It is possible to combine this mastopexy with an augmentation to increase volume. In his guidelines for augmentation combined with mastopexy, Spear11 points out that an increase in volume will decrease the required amount of skin resection. To prevent dilation of the areola and widening of the scars, the exact amount of skin resection should be reevaluated in the operating room after augmentation. Periareolar techniques can also be used to enhance the appearance of the breast after the explantation of implants. Rohrich et al.2 describe using a periareolar mastopexy for breast contouring in patients with mild ptosis who do not desire a new implant after explantation. The key element is that the periareolar mastopexy results and scars are better in explantation and mastopexy, with relief of underlying skin tension by implant removal as in explantation. The periareolar techniques can be utilized with a concentric or an eccentric incision pattern, with or without gland plication. These techniques can provide superior aesthetic results, but they are reliably applicable to limited ptosis correction only.
Vertical Scar Technique

A vertical scar technique adds a vertical or oblique limb to the periareolar scar. Although the vertical component adds overall length to the scar, it is usually well tolerated by patients, as it does not create any scars on the upper medial quadrants, which are most frequently exposed when the patient wears low-cut clothing. Lejour reports that, despite its placement on the most prominent part of the breast, the scar itself is usually hardly visible because it fades substantially over time and only rarely becomes hypertrophic.16,17 Lassus, Lejour, and Hammond use a vertical scar mastopexy to correct all grades of ptosis.1519 The vertical component can be included in the initial plan-

ning process, such as in the oval-shaped pattern by Lassus or the dome-shaped incision pattern by Lejour.16 19 The Kiel and teardrop patterns by Hagerty20 are similar. Hammond adds the vertical component intraoperatively in his short scar periareolar inferior pedicle reduction mammaplasty/mastopexy, initially using a periareolar incision and then working redundant skin to the lower portion of the areola where it can be excised in a vertical fashion.15 Marconi21 uses the Marchac-marking pattern for an inverted-T scar mastopexy, but gathers the redundant skin along the inframammary fold with a purse-string suture to avoid a horizontal scar in the fold (Table III and Fig. 3). Redistribution and reshaping of glandular tissue can be achieved using techniques similar to those described earlier. Lassus19 describes a superiorly based inferior flap of the central lower tissue that is mobilized and transposed through a retroglandular dissection to a superior position, where it is sutured to the pectoralis fascia to increase upper-pole fullness. Lejour basically applies the same principle without incisions on the flap.16,17 After the breast tissue is folded and the lower pole is attached to the pectoralis fascia, the two lateral pillars created by this maneuver can then be sutured together to reshape the breast mound while increasing projection of the nippleareola complex. As these pillars include less ptotic tissue from the medial and lateral portions, recreating the breast mound with this tissue can contribute to the longevity of the result.16,17 Graf and Biggs22 describe an interesting concept to increase longevity and especially enhance upper-pole fullness; they use an inferiorly based flap passed under a pectoralis muscle loop and secured to the chest wall. This glandular redistribution can be combined with incision patterns, leading to a short oblique scar, an L-shaped scar, or an inverted-T scar. It is controversial from an oncologic point of view whether the pectoralis fascia should be divided, as this will require a more aggressive approach in case of later breast cancer.23

TABLE III Vertical Scar Techniques

Author

Ptosis

Skin Incision

Skin Technique

Parenchyma Technique

Lassus17,18 Lejour15,16 Hammond19

IIII IIII

Oval Mosque dome Circumareolar with vertical scar

Deepithelialized Undermined, deepithelialized Deepithelialized

Flap developments, plication, fixation Flap developments, plication, fixation Flap developments, plication, fixation

1626

PLASTIC AND RECONSTRUCTIVE SURGERY,

November 2004

FIG. 3. Vertical scar technique: (left) Lassus, (center) Lejour, and (right) Hammond.

Blood supply to the nipple-areola complex is preserved, as the periareolar skin is deepithelialized, keeping the subdermal plexus intact. Since no glandular resection is performed and retroglandular resection is only performed in the central area, the perforating vessels to the gland are preserved, so no necrosis of the nipple-areola complex should occur. Sensation is also well preserved, since the lateral portions of the gland are not undermined. Marconi21 tries to stabilize breast tissue by creating an internal support in the fashion of a brassiere by using a central dermal flap sutured to the chest wall. Fayman24 describes a technique using either a superior or an inferior dermoglandular flap to enhance upper-pole fullness and elevation of the nipple-areola complex. Lassus19 reports that limited undermining of the skin reliably preserves nipple sensation. In contrast, Lejour17 performs extensive skin undermining of the lower hemispheres to enhance skin retraction. To prevent scar widening, measures described by Lockwood5 can be considered. It is generally accepted that the vertical component of the scar should not cross the inframammary fold, since scars on the chest wall are visible when the patient wears a sports brassiere, for example, and are, as scars on the chest wall are in general, prone to hypertrophy and unpredictable scarring.15,17,19 Lassus19 and Lejour17 prefer overcorrection at the time of surgery. Over a period of 2 to 3 months, the breast will settle into its final position. It is understandable that such a long waiting period might be troublesome for both the surgeon and the patient, and it might be one of the reasons why this technique is not very popular in the United States. Vertical scar techniques can be combined with augmentation as well. Both Lassus19 and Lejour17 describe augmentation with the vertical scar mastopexy to increase volume. In im-

plant removal, vertical scar mastopexy can also be used to contour the breast. Rohrich et al.2 list a Kiel-pattern mastopexy as an option to correct grade I ptosis after explantation. The vertical scar techniques are most useful for mild to moderate ptosis. The addition of glandular suspension techniques reduces or eliminates the reliance on the skin envelope for suspension, thereby improving long-term results. The vertical scar techniques also provide the most flexibility for augmentation ptosis.
Inverted-T Scar Technique

The inverted-T scar consists of a periareolar component, a vertical component, and a horizontal component, which is usually located in the inframammary fold. This type of scarring pattern is very common for breast reductions, but it is also useful in mastopexy. Because of scarring problems with the horizontal part of the scar, as mentioned earlier, multiple attempts have been made in the past to shorten this part of the scar or even to eliminate it altogether. Taking its origin from breast reduction, the inverted-T scar is used mainly for correction of severe grade III ptosis. A longer horizontal inframammary scar will allow maximum correction of ptosis. Several incision patterns result in an inverted-T scar. The Wise pattern with a horizontal and vertical excision tends to produce a long horizontal scar.6 Another option is a modified Strombeck pattern, which uses an oblique instead of a vertical scar so that the scar is rotated laterally.25 Keeping the horizontal scar short can be achieved with a combination of a vertical ellipse and a short horizontal ellipse. Another incision is the vertical wedge excision of Marchac and de Olarte.26,27 Peixoto28 also describes a technique for ptosis in combination with small hypertrophy. He uses an incision with an elliptical

Vol. 114, No. 6 /

SHORT SCAR MASTOPEXY: CURRENT CONCEPTS

1627

shape around the nipple-areola complex combined with a rectangular part on the bottom of the ellipse (Table IV and Fig. 4). Once again, there are several techniques to reshape the gland.29 Pitanguy30 uses a lozengeshaped glandular resection (Arie-Pitanguy), and a keel resection for severe ptosis.30 For glandular reshaping, Nicolle and Chir31 dissect medially and superiorly and then dissect the breast from the pectoralis muscle. This laterally based pedicle is rotated in an upward and medial direction. The two pillars are positioned one over the other and sutured together, with the lateral being placed on top of the medial pillar. Peixoto28 excises the base and inferior pole of the breast, leaving a cone that is cut obliquely. This will lead to a smaller breast size while using no suspensions. The triple-flap interposition technique uses three glandular

flaps central, lateral, and medialto achieve a conical shape.32 The distal part of the central flap is attached to the pectoralis fascia and provides projection. The medial and lateral flaps are rotated toward the hemiclavicular line and transposed one over the other. The flaps provide the shape of the lower hemisphere and define the new inframammary fold, while narrowing the base of the breast. Other techniques for reshaping the gland have been described by Flowers and Smith,29 who use a modified McKissock vertical bipedicle design called the flip-flap mastopexy to increase the longevity of the procedure. Sensation is preserved by conservation of the upper and lateral connections of the areola to the superficial nerves with the Marchac technique.26,27 This will secure blood supply by avoiding extensive skin undermining and us-

TABLE IV Inverted-T Scar Techniques

Author

Ptosis

Skin Incision

Skin Technique

Parenchyma Technique

Strombeck25 Flowers and Smith Pitanguy30 Wise6 Marchac and de Olarte Peixoto28 Nicolle and Chir

IIII IIII IIII IIII IIII IIII IIII

Inverted horseshoe Modified wise Inverted-T incision Prepatterned curvilinear Arched gateway Ellipse/rectangle Modified Wise

Deepithelialized Resected, deepithelialized Utilized to reshape gland Resected Deepithelialized Resected Deepithelialized, undermined

Resection Pillar developments with plication Resection/plication, Keel technique Flap development with flap plication Resection, plication Resection, no plication

FIG. 4. Inverted-T scar technique: (above, left) Strombeck, (above, center) Flowers, (above, right) Nicolle, (below, left) Peixoto, (below, second from left) Pitanguy, (below, third from left) Wise, and (below, right) Marchac.

1628

PLASTIC AND RECONSTRUCTIVE SURGERY,

November 2004

ing a broad upper pedicle. Therefore, the risk of skin and areola loss is small. Peixoto28 and Nicolle and Chir31 also preserve sensation by not resecting the upper pole and thus not injuring the adipose capsule through which the sensory nerves pass. The horizontal scar in the inframammary fold is the most obvious aesthetic problem with these techniques. The periareolar and vertical scars are usually of good quality and become less visible over time. A horizontal incision, especially from the medial sternum out to the lateral axillary line, can scar poorly. The medial component has the tendency to become hypertrophic, while the lateral component is likely to widen over time. Marchac and Peixoto effectively reduce the length of the horizontal scar.26 28 This scar should be above the inframammary fold so that the scar is not visible when the patient is standing. A further advantage, as Marchac states, is an inframammary fold that is completely free of scars so that the patient can wear a bikini.26,27 A widening of the scar usually does not occur as long as the skin is sutured under limited tension. The risk of skin and areolar necrosis is small because no extensive skin undermining is performed. Peixoto also uses a small horizontal scar located in the inframammary fold.28 In the rotated anchor-shaped scar, the oblique scar will produce higher-quality scars than the vertical scar. Complications are rare with the vertical and periareolar scars. Distortion of the nipple-areola complex can be reduced using a purse-string suture. Since pseudoptosis can occur when reshaping of the gland relies on skin only, most surgeons use some type of suspension of the gland to the pectoralis fascia. The inverted-T scar techniques are applicable in the moderate to most severe examples of breast ptosis and are especially versatile in cases of grade III ptosis, where predictable results can be achieved.6,7,11 These techniques also provide marked versatility in augmentation and/or mastopexy applications. Obviously, the tradeoff is increased scar length.

L-Shaped Short Scar Mastopexy

The L-shaped scar mastopexy reduces the length of the incision by eliminating the medial portion of an inverted-T scar and shortening the lateral limb. The lateral incision is placed in the inframammary fold or slightly above it, where it is less visible. This scar might be visible if it has a long lateral extension or is located on the chest wall. These scars have the tendency to become hypertrophic. Seidel and Chiari33,34 successfully apply L-scar mastopexy in lower grade I to II ptosis. In patients with higher degrees of ptosis, the results may not be as pleasing. The Regnault B-mastopexy is indicated in grade I to II ptosis as well.35 This technique is based on an incision pattern resembling the letter B leading to an L-shaped scar similar to that in other techniques, except that the vertical limb of the L originates from the lateral margin of the areola and then extends down to the inframammary fold. Similar to other techniques, the L-scar can be achieved using different incision patterns. A popular pattern designed by Chiari includes geometric planning with certain key measurements.33,34 The pattern resembles a triangle based slightly above the inframammary fold with a lower lateral extension. The lateral flap is rotated medially and inferiorly to meet the lower and medial borders. Regnault derives his L-scar from an incision pattern resembling a B facing the midline.35 The curved lateral extension should be positioned along the inframammary fold. An L-shaped scar can also be created in a vertical mammaplasty when redundant skin has to be resected so that the vertical scar does not extend below the inframammary fold. Hammond15 sometimes curves out the scar laterally to avoid crossing the inframammary fold inferiorly (Table V and Fig. 5). Reshaping of the gland is achieved mostly in ways similar to those in other mastopexy techniques. Since the periareolar region is deepithelialized to preserve the subdermal plexus and the undermining for the flap transposition is only done in a central segment, blood supply

TABLE V L-Shaped Scar Techniques

Author

Ptosis

Skin Incision

Skin Technique

Parenchyma Technique

Chiari34 Regnault35

IIII IIII

Standardized geometric pattern B-shaped

Deepithelialized Resected, deepithelialized

Lateral/medial pillar developments, plication Pillar developments, plication

Vol. 114, No. 6 /

SHORT SCAR MASTOPEXY: CURRENT CONCEPTS

1629 CONCLUSIONS

FIG. 5. L-shaped scar technique: (left) Chiari and (right) Regnault.

to the nipple-areola complex is not jeopardized. Sensation is generally also preserved, since the lateral portions of the gland are not undermined. Seidel and Chiari33 report excellent nipple-areola sensation. Regnault35 also describes no loss of nipple sensation. The lateral extension can sometimes be visible if it is located on the chest wall below the inframammary fold. A new approach to further reduce scarring has been described by Lockwood.5 Using a superficial fascial system suspension for skin closure enables him to reduce hypertrophic scarring. Although it has only been described in vertical and short inverted-T scar mastopexy, we think it could be applied to the L-scar mastopexy as well. The L-scar mastopexy is applicable to most grades of ptosis. The technique eliminates the undesirable medial scar extension of the inverted-T scar extension.

Mastopexy patients are highly concerned with an aesthetically pleasing outcome, making the procedure a challenging one. Besides recreating a youthful, firm breast, reducing the extent of scarring is one of the major concerns. Over the last decades a number of short scar techniques have evolved. On the basis of the incision pattern, they can be classified into four different groups. Since ptosis includes an enormous spectrum of different shapes and volumes, it is not practical to correct all the different aspects with a single approach. To be able to offer an optimal solution for all mastopexy candidates, the plastic surgeon has to master more than one technique. Techniques that offer a result that is both safe and reproducible with the lowest rate of revision should be the first choice. Reducing the length of a scar is only one component to improving results (Table VI). Limiting postoperative spreading of the scars with techniques that include reducing tension at closure using a permanent purse-string suture in periareolar scars or superficial fascial system suspension in straight scars will also enhance patient satisfaction.4 Besides making the scar less visible, techniques should also improve shape and breast contour to withstand the test of time. The formation of fibrous tissue by an internal mesh support can also be used to achieve a more stable result, as shown by Goes.13 Using permanent mesh grafts in an organ prone to cancer and therefore requiring

TABLE VI Morbidity

Author

Technique

No. of Patients

Morbidity

Pitanguy30 Wise6 Nicolle and Chir31 Peixoto28 Flowers and Smith29 Strombeck25 Marchac and de Olarte26 Lassus17,18 Lejour15,16 Hammond19 Marconi21 Seidel and Chiari33 Regnault35 Erol and Spira8 Spear10,11 Goes13 Benelli3,4 Bartels et al.14 Puckett12 Gruber9

Inverted-T scar Inverted-T scar Inverted-T scar Inverted-T scar Inverted-T scar Inverted-T scar Inverted-T scar Vertical scar Vertical scar Vertical scar Vertical scar L-scar L-scar Periareolar scar Periareolar scar Periareolar scar Periareolar scar Periareolar scar Periareolar scar Periareolar scar

317 Not reported Over 400 Not reported 124 37 77 433 Not reported Not reported 5 Not reported Not reported 6 Not reported 254 73, 69 with augmentation Not reported 26 Not reported

Ptosis None reported Scar widening, hypertrophic lateral scar Scar too long with incorrect measurements Localized tissue necrosis Hematoma, widening of scars, ptosis, skin necrosis Hematoma Scar hypertrophy Not reported Partial areolar necrosis, fat necrosis, delayed wound healing, purse-string rupture, exposed purse-string suture Not reported Flat shape, enlarged nipple-areola complex Partial loss of areola Delayed wound healing Seroma, foreign-body reaction, decreased nipple sensation Hematoma, seroma, fat necrosis, decreased nipple sensation Hematoma, cystosteatonecrosis Stretching, flattening of areola Scar widening, globular breast shape, enlargement of areola Not reported

1630

PLASTIC AND RECONSTRUCTIVE SURGERY,

November 2004

regular examination is problematic. Suspending breast tissue by means of a muscle loop has also been described.22 This might prove useful in creating lasting upper-pole fullness. The limited scar mastopexy is definitely a valuable procedure requiring experience, good judgment, careful planning, and careful patient selection as described, to optimize patient results. The journey continues in the search for the ideal mastopexy for all seasons and all reasons. Rod J. Rohrich, M.D. Department of Plastic Surgery University of Texas Southwestern Medical Center 5323 Harry Hines Boulevard, HX1.636 Dallas, Texas 75390-8820 rod.rohrich@utsouthwestern.edu
REFERENCES 1. Regnault, B. Breast ptosis: Definition and treatment. Clin. Plast. Surg. 3: 193, 1976. 2. Rohrich, R. J., Beran, S. J., Restifo, R. J., and Copit, S. E. Aesthetic management of the breast following explantation: Evaluation and mastopexy options. Plast. Reconstr. Surg. 101: 827, 1998. 3. Benelli, L. A new periareolar mammaplasty: Round block technique. Aesthetic Plast. Surg. 14: 99, 1990. 4. Benelli, L. Periareolar mastopexy and reduction. In S. L. Spear (Ed.), Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven, 1998. 5. Lockwood, T. Reduction mammaplasty and mastopexy with superficial fascial system suspension. Plast. Reconstr. Surg. 103: 1411, 1999. 6. Wise, R. J. A preliminary report on a method planning the mammaplasty. Plast. Reconstr. Surg. 17: 367, 1956. 7. Biesenberger, H. Eine neue Methode der Mammaplastik. Zentralbl. Chir. 55: 2382, 1928. 8. Erol, O., and Spira, M. Mastopexy technique for mild to moderate ptosis. Plast. Reconstr. Surg. 65: 603, 1980. 9. Gruber, R. P. The donut mastopexy: Indications and complications. Plast. Reconstr. Surg. 65: 34, 1980. 10. Spear, S. L. Guidelines in concentric mastopexy. Plast. Reconstr. Surg. 85: 961, 1990. 11. Spear, S. L. Concentric mastopexy revisited. Plast. Reconstr. Surg. 107: 1294, 2000. 12. Puckett, C. Crescent mastopexy and augmentation. Plast. Reconstr. Surg. 75: 533, 1985. 13. Goes, J. C. S. Periareolar mammaplasty: Double skin technique with application of polyglactin or mixed mesh. Plast. Reconstr. Surg. 97: 959, 1996. 14. Bartels, R. J., Strickland, D. M., and Douglas, W. M. A new mastopexy operation for mild or moderate breast ptosis. Plast. Reconstr. Surg. 57: 687, 1976. 15. Hammond, D. Short scar periareolar inferior pedicle reduction (SPAIR) mammaplasty. Plast. Reconstr. Surg. 103: 890, 1999.

16. Lejour, M., and Abboud, M. Vertical mammaplasty without inframammary scar with breast liposuction. Perspect. Plast. Surg. 4: 67, 1990. 17. Lejour, M. Vertical mammaplasty for breast reduction and mastopexy. In S. L. Spear (Ed.), Surgery of the Breast: Principles and Art. Philadelphia: LippincottRaven, 1998. 18. Lassus, C. Breast reduction: Evolution of a techniqueA single vertical scar. Aesthetic Plast. Surg. 11: 107, 1987. 19. Lassus, C. Vertical scar breast reduction and mastopexy without undermining. In S. L. Spear (Ed.), Surgery of the Breast: Principles and Art. Philadelphia: LippincottRaven, 1998. 20. Hagerty, R. External mastopexy with imbrication following explantation. Plast. Reconstr. Surg. 103: 976, 1999. 21. Marconi, F. The dermal purse-string suture: A new technique for a short inframammary scar in reduction mammaplasty and dermal mastopexy. Ann. Plast. Surg. 22: 484, 1989. 22. Graf, R., and Biggs, T. M. In search of better shape in mastopexy and reduction mammaplasty. Plast. Reconstr. Surg. 110: 309, 2002. 23. Adams, W. P. In search of better shape in mastopexy and reduction mammaplasty (Discussion). Plast. Reconstr. Surg. 110: 321, 2002. 24. Fayman, M. S. Short scar mastopexy with flap transposition. Aesthetic Plast. Surg. 22: 135, 1998. 25. Strombeck, J. O. Mammaplasty: Report of a new technique based on the two-pedicle procedure. Br. J. Plast. Surg. 13: 79, 1960. 26. Marchac, D., and de Olarte, G. Reduction mammaplasty and correction of ptosis with a short inframammary scar. Plast. Reconstr. Surg. 69: 45, 1982. 27. Marchac, D. Vertical mammaplasty with a short horizontal scar. In S. L. Spear (Ed.), Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven, 1998. 28. Peixoto, G. Reduction mammaplasty: A personal technique. Plast. Reconstr. Surg. 65: 217, 1980. 29. Flowers, R. S., and Smith, E.M. Flip-flap mastopexy. Aesthetic Plast. Surg. 22: 425, 1998. 30. Pitanguy, I. Surgical treatment of breast hypertrophy. Br. J. Plast. Surg. 20: 78, 1967. 31. Nicolle, F., and Chir, M. Improved standards in reduction mammaplasty and mastopexy. Plast. Reconstr. Surg. 69: 453, 1982. 32. Caldeira, A. M., Lucas, A., and Grigalek, G. Mastoplasty: The triple flap interposition technique. Aesthetic Plast. Surg. 23: 51, 1999. 33. Seidel, S. P., and Chiari, A., Jr. The L short scar mammaplasty. In S. L. Spear (Ed.), Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven, 1998. 34. Chiari, A., Jr. The L-short scar mammaplasty: A new approach. Plast. Reconstr. Surg. 90: 233, 1992. 35. Regnault, P. Breast reduction: B technique. Plast. Reconstr. Surg. 65: 840, 1980.