The small ptotic breast: reposition autoaugmentation mammaplasty

British Journal of Plmfic Surgery (1986) 39.7680 0 1986 The Trustees of British Association of Plastic Surgeons

The small ptotic breast: reposition autoaugmentation mammaplasty L. C. Y. HO Division

of Plastic Surgery,

Concord

Hospital,

Concord,

NS W, Australia

Summary-Autoaugmentation mammaplasty of the small ptotic breast with adjacent pedicled fat and simultaneous correction of ptosis is presented. The operative procedure is described and some representative results are shown.

This paper plasty:

is a follow-up

A Technique

on the paper

of Comprehensive

Mamma-

Correction

of

the Ptotic Breast (Ho and Pelly, 1983) where rereduction mammaplasty, reposition position mammaplasty and reposition augmentation mammaplasty were described. A method of mammaplasty is presented using adjoining pedicled fat to augment the small ptotic breast with simultaneous correction of the ptosis.

are points on the circle at 7 and 5 o’clock. The points AI-C, A2ZC1, Cl-E-B and C-B are joined. The shaded area below and beyond the inframammary fold shows the area to be undermined and dissected for pedicled fat for autoaugmentation mammaplasty. Operative procedure

Pre-operative markings These are carried out with the patient in the erect posture (Fig. 1). The new site of the nipple, point A, is determined first. Point A is marked on the midclavicular line and lies midway between the optimum position of the nipple and the actual position of the nipple. Point B is on the anterior axillary line and lies on the same level. A circle 2 cm in diameter is drawn around A. E is situated on the mid-clavicular line and will be the lowest point of the new infra-mammary fold. The length of A-E is equal to the radius of the reconstructed breast cone as represented by the cup radius of the brassiere of the proposed size and is determined from the chart (Fig. 2). C and Cl are points on the breast skin lateral and medial to E. Their approximation to E determines the tension of skin closure in the vertical limb: A-Al-C and A-A2-Cl equal A-E in length. C is marked by pushing the breast medially as far as possible with point E secured with the tip of the finger and is the most lateral point that will approximate E comfortably. Cl is similarly marked with the breast pushed laterally as far as possible and is the most medial point that will approximate E comfortably. Thus C and Cl are points in the arc centred around A that can be made to approximate to E comfortably. A 1 and A2 76

For this operative procedure the breast should be small and ptotic. The operation begins with a superficial circumcision of the nipple and areolar complex 45 mm in diameter. The area enclosed by C-Al-A3-AZCl-C (Fig. 1) is incised into subcutaneous fat. The skin between these two incisions is de-epithelialised, leaving the dermis substantially intact. Full thickness skin is excised from the area B-C-Cl-E-B. The skin below B-E-Cl is then dissected off the breast tissue and fat beyond the inframammary fold for a distance of 6cm. The fat is incised around the periphery of the dissection down to deep fascia. This fat is then freed from the deep fascia, keeping its attachment to the breast tissue intact and the latter is raised from the chest wall to create an adequate retro-mammary space centred around the new site of the nipple (Fig. 3). Lateral and medial wedges are not excised; all dissected tissue is retained for autoaugmentation mammaplasty. The pedicled fat so dissected is tucked into the retro-mammary space behind the bulk of the breast parenchyma. Haemostasis is secured along the way in the procedure. The new infra-mammary fold (Fig. 4) is secured with four 3/O Prolene mattress sutures, tacking the skin edge along B-E and medial to E to the underlying tissue. These sutures are tied over a piece of Portex tubing. C is then approximated to E. Closure of the vertical limb is performed and proceeds from below up-

THE SMALL

PTOTIC

BREAST:

REPOSITION

AUTOAUGMENTATION

77

MAMMAPLASTY 32

34

36

38

40

42

Fig. 2 Figure ?--The size of the cup radius or distance from centre cup seam to the base for different brassiere sizes. Courtesy of Playtex Pty Ltd.

____________f_____________’

J

I iI I I II

Fig. 3 Figure 3--The nipple is carried on an island of dermis: C-A I -A3-A2-Cl-C. The tissue below and beyond B-C-C1 is breast tissue and adjacent pedicled fat that has been dissected free. This pedicled tissue is tucked into the prepared retro-mammary space centred around the new site of the nipple.

Fig. I Figure I-Pre-operative markings of the breast. The middle horizontal line indicates the optimum position of the nipple which lies I cm below the mid-point between the tip of the acromium and the lateral epicondyle.

wards until Al and a point on the medial vertical skin edge lie comfortably together. The frank excess of skin media1 to the proposed site of the nipple-areolar complex is excised appropriately to create a circular defect. The horizontal limb is next

closed and place. The strips and are advised dissection.

the nipple-areolar complex sutured in suture line is sealed with “f inch” steristerile dressings applied. Suction drains as large raw areas are left behind in the

Post-operative care Two days post-operatively the dressings are taken down and the wounds inspected. The Prolene mat-

78

BRITISH

JOURNAL

OF PLASTIC

SURGERY

tress sutures and drains are removed. Fresh steristrips and dressings are applied. Interrupted sutures are removed at 10 days and subcuticular sutures on the fourteenth day.

Results A small series of 18 patients have been operated on by this technique without any significant complications. Minor necrosis of the rim of the inframammary flap occurred in one patient. Representative results of the procedure are shown in Figs 5, 6 and 7.

Discussion Fig. 4 Figure &The new infra-mammary fold is sutured at the new raised level. Closure of the vertical limb as described leaves a frank excess of skin medial to the proposed site of the nippleareolar complex. Appropriate excision of this excess skin creates a circular defect.

The general pattern of this operation is similar to that described earlier (Ho and Pelly, 1983) but in this technique the breasts are autoaugmented with adjacent pedicled fat. Care and gentleness must be exercised in the dissection of the thin skin flap beyond and below the old infra-mammary fold to

Fig. 5 Figure S-(A

and B): 34A small atrophic

ptotic breast. (C and D): Reposition

autoaugmentation

mammaplasty

to 34B.

Fig. 6 Figure &(A

and B): 32B minus small lax atrophic

breast. (C and D): Reposition

C Figure 7-(A

auioaugmentation

mammaplasty

to 34B

D Fig. 7 and B): 32A minus small ptotic breasts.

(C and D): Reposition

autoaugmentation

mammaplasty

to 32B.

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JOURNAL

OF PLASTIC

SURGERY

prevent trauma and subsequent necrosis of the flap margin. As no silicone mammary prosthesis is used, the complication of capsular contracture is avoided. This procedure is suitable for the patient with small ptotic breasts who would like a reposition augmentation mammaplasty but does not want a silicone implant.

Ho, L. C. Y. and Pelly, A. D. (1983). Mammaplasty: a technique of comprehensive correction of the ptotic breast. Brirish Journal of PlasticSurgery, 36.5 10.

Acknowledgements

The Author

The author would like to thank Mr Roger Hansen, Head of the Department of Medical Illustration. for preparation of photographs and prints, Mr Joachim Meyer. Senior Scientific Officer, Surgical Laboratory. University of Sydney. Department of Surgery at Concord and Franca Rubriu, Medical Artist, for the drawings and illustrations. and the late Dr A. D. Pelly without

Lawrence C. Y. Ho, FRACS, FRCS, Consultant Plastic Surgeon, Division of Piastic Surgery, Concord Hospital, Concord, NSW 2 137. Australia.

whose help and encouragement possible.

this work would not have been

Reference

Requests for reprints to: Lawrence C. Y. Ho, FRACS, 187 Macquarie Street, Sydney 2000. Australia.

FRCS,