Endoscopic Mastopexy

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CHAPTER 22

Endoscopic Reduction Mammoplasty,Mastopexy, and Mastopexy

With Prosthetic Augmentation

W.Johnson

oldwyns objectives modified by Haubinl for the op-mal reduction mammoplasty are: safe; simple;

eedy; sensation preserved; symmetry; suitablyaped and sexy breasts; and sine sanguine (bloodless)eration. There are numerous techniques for reduc-

on mammoplasty; it is obvious that there is no singlest technique.2 The techniques described in this chap-r for my method of reduction mammoplasty combinerts of several procedures or techniques that are al-ady recorded in the literature. However, there hasen no reported combination of the techniques in the

shion that I have combined them to attain reductionammoplasty, mastopexy, and mastopexy with aug-entation. And the necessary adjunctive use of the en-

with my combination of other techniques fur-ers these procedures as truly new and innovative.

he Endoscopic Approach

r many years gynecologists and general surgeonsarned and practiced their skills by making large inci-ons. As general surgery residents, we were taught

at a skin incision heals from side to side, not end tod; therefore -we made incisions as long as necessary.any years before we plastic surgeons could pro-unce the word endoscopically, other surgeons hadready started doing it. They were doing the veryme surgery internally and still healing their patients,t with a much smaller skin incision. The reason forscussing and showing the techniques of doing thepen circumareolar reduction mammoplasties,astopexies, and mastopexies with augmentation, iscause when we do this surgery through the axilla,

e do exactly the same work inside as we have done ine open circumaureolar technique except for two fac-

tors: We do not make an incision around the nippleand we have to use endoscopic assistance to visualizewhere we are going in order to elevate, project, and su-ture the breast properly.

According to Gombrich,s Owen Jones stated a cen-tury ago that the most beautiful proportions are thosethat are the most difficult for the eye to detect.Birkhoffb defined the aesthetic value of any object asthe ratio between order and complexity: pleasure ofperception derives from a high degree of order, har-mony, balance, unity, and contrast when combined

with a lower degree of confusion and complexity. Asthe plastic surgeon it is our job to paint the Mona Lisa,and unlike Leonardo, we cannot throw the canvasaway and start over if we make a mistake or producea bad result. Therefore it is obvious why so manyexcellent surgeons develop their own technique inthe ongoing effort to paint the perfect reductionmammoplasty.

I now add to the long list of techniques devised byother surgeons and leave to it modern day artists to de-termine if my new combination of techniques will

stand the test of time and produce artistic results thatwill add these techniques to the armamentarium of thepresent and future artistic surgeons.

The first thing that should be evaluated is the pri-mary goal of the patient and the surgeon in doing abreast reduction, mastopexy, or mastopexy with aug-mentation. These five goals are:

1.

2.

3.

a breast of ideal size for the patient elevated to an o r m a l p o s i t i o n o n t h e c h ea breast of ideal form or ideal shape for the patient;

a breast with a minimal amount of scarring or visi-ble scarring;

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a breast with normal sensation and erectile functionof the nipple;a breast that can lactate and function normally fornursing, if necessary.

The patient who has such large breasts that the pri-,ary goal is volume reduction for the sake of health ormfort of the patient, and the ultimate cosmetic re-

ults take a distant second place, is not considered in

is chapter. Those patients in whom the goal of goodsmetic results take primary consideration or at least

qual consideration with the health or comfort of theatient are the subjects of these discussions.Any new technique in any branch of surgery must be

ne that can be learned by the average surgeon whon then operate on a patient and produce the averagesult. A technique that is so complicated, requires aore skillful surgeon, or requires the most complicated

nd expensive instruments to reproduce comparablesults is a technique that is not really useful to the ma-

rity of the people in medicine or surgery. As stated byr. Paul McKissock,5 No matter how appealing oroubtful a new operation may seem in print, its truelue ultimately must be measured by its reproducibil-

y in the hands of others. The surgeons quest for theeal method of breast reduction began long beforeere was a specialty of plastic surgery. Many namessociated with the reduction mammoplasties in the

920s included Thorak, Morestin, Joseph, Durfour-entel, and de Quervain. Dr. Biesenbergerb described

n extensive glandular resection with nipple transposi-

on with very wide undermining of the skin with ex-osure of the gland. Certain variations of his techniquee still used today. Some plastic surgeons agree fullyith wide skin undermining and others do not.By the early 195Os, Dr. Robert J. Wise of Houston

ad analyzed and come up with some of the earliesteas, methods, and techniques to accomplish a reduc-

on mammoplasty, to obtain symmetrical results withcellent preservation of the nipple and skin, and toee graft the nipple in large breasts. In 1960, Dr.

reported on his new technique for breast

duction based on the two pedicle procedure. In 1963,r. Skoogg reported on his new technique of breast re-uction by transposition of the nipple on a continuousscular pedicle and by 1967, Dr. Pitanguylo reported

n his technique of treatment of breast hypertrophy ineffort to give a better shape and better results post-

perative. Up to this point in the late 196Os, the twoimary considerations in doing the reduction mam-oplasties were to not have any necrosis of the skin ore nipple and to get an adequate reduction with asod a form as possible. No real consideration was be-

g given to sensation in the nipple nor to the ability ofe nipple to lactate and function should that becomecessary.

G.W. Johnson

Beginning in about 1973, Dr. Ribeiro. began doingreduction mammoplasties using an inferiorly basedpedicle flap. He reported his work in March of 1975which was the first report of a new procedure that hada tremendous influence on the type of reductions thatare done presently. Dr. Ribeiros inferiorly based pedi-cle flap to preserve the nipple was also one of the firstprocedures designed in reduction mammoplasty that

gave an excellent chance for preservation of sensationof the branches of both medial and lateral sensorynerves to the nipple as well as the possibility of lacta-tion. Dr. Ribeiros technique and report were followedby Dr. Robbins report in 1977 of his experiences witha reduction mammoplasty with the areolar-nipplecomplex based on an inferiorly dermal pedicle. Dr.Robbins also, perhaps more so than Dr. Ribeiro, wasaware that this technique meant that nipple sensationwas more often retained than other methods of reduc-tion. The efforts of Dr. Ribeiro and Dr. Robbins in pro-moting the inferior pedicle technique was given atremendous boost in April of 1977, when Dr. Curtisand Dr. Goldwynr3 published their article on reductionmammoplasty by the inferior pedicle technique. Drs.Curtis and Goldwyn likewise found that the resultingbreast sensation in their series of patients was betterthan obtained after other methods of reduction mam-moplasty. They found that the inferior pedicle tech-nique was a, versatile method for reduction for bothlarge and small breasts with comparable results andcomplications similar to other techniques. They felt

that the inferior pedicle technique had the benefit ofpreserving the important cutaneous branches of thefourth, fifth, and third intercostal nerves. They statedthat patients with normal sensation before surgeryusually showed no change after the operation.

By the beginning of the 198Os, the average plasticsurgeon was now able to achieve up to four of the fiveprimary goals:

1. a breast of ideal size for the patient elevated to anormal position;

2. a breast of ideal form or shape for the patient;3. a breast with normal sensation and erectile function

of the nipple;4. a breast that could lactate and function normally in

nursing.

However, there still remained the problem of scarringand no one was yet able to eliminate the excessive scar-ring involved, especially with large reductions.

In the 198Os, plastic surgeons began to turn their at-tention to reaching the fifth goal of the patient and sur-geon, a breast with minimal amount of scarring or

minimal amount of visible scarring. Too many plasticsurgeons for too many years have accepted scarring asan inevitable part of our own profession. We call our-


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6 C.W.Johnson

2 cm used presently. Maintaining the 2 centimetertance was previously advocated by Hester et al.21

hen the upper hemisphere of the glands was then re-sed from the muscle, and detached from the periph-

y (Fig. 22.2), the blood supply came in from the per-ators and medial and lateral vessels from below.casionally there was some compromise that resultedsuperficial loss, and in one case full loss of a nippleone patient. I soon realized, however, the necessitypay attention to the method of dissection in the

wer hemisphere of the breast and not approachser than about 2 cm to the chest wall in the under-ning of the skin away from the breast tissue.was confident from previous reports in the litera-

e that the nipple could and would survive on justglandular circulation itself.**,*3 I also knew from

iew of the anatomy and the literature that when thedial and lateral blood supplies were protected, the

nerve supply to the nipple also was much more likelyto remain intact.

When I began the circumareolar reduction mammo-plasties, mastopexies, and mastopexies with augmen-tations, I initially used Marlex mesh to help gain sup-port just as I had done in the late 1970s with theinferior pedicle technique.*O However, as I have al-ready indicated, because of criticism from peers re-

garding this technique of putting a foreign body in thebreast, I elected to eliminate this portion of the tech-nique.

In this first section, a form of circumareolar masto-pexy will be discussed in detail. I have used the tech-niques and procedures on the gland via an areolar ap-proach for 8 years. These same techniques, tested andproven (and some were tested and discarded), are nowbeing used through an axillary approach with endo-scopic assistance.

Exludes areolar borderof nipple \ Skin from fascia

Endoscopic axillary m& breast tissueMastopexy w/augmentation m Breast from

muscle/fascia

Endoscopic axillarymastopexy only

border but preservesductile system

Endoscopic axillary

Figure 22.2. Area of undermining and dissection.


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2. Axillary Endoscopic Reduction Mammoplasty, Mastopexy, and Mastopexy With Prosthetic Augmentation 207Circumareolar Mastopexy

With Augmentation

With the patient in preanesthesia in the erect positionrior to induction of anesthesia, the marks are made onhe chest with the nipple to fall in the midclavicularne at about X3-20 cm from the suprasternal notch, de-ending upon the height of the particular patient. This

measurement, for location of the nipple, is more a per-unctory maneuver in this procedure because it iseally not that critical to the surgical procedure itself.ontrary to most reduction mammoplasty procedures

where the preoperative marking of the nipple andreast are the most important step in the procedure,

with this procedure preoperative marking actually isot necessary. Remember that the positions of a

womans nipples on her chest wall are different in therect position versus the reclining position (Fig. 22.3).

However, fixed points on the skeleton do not change,hus the choice to use fixed skeletal points such as the

avicle, second rib, and sternal angle (Fig. 22.4). Theatient is placed under general endotracheal anesthe-a and prepped and draped in the routine manner forilateral breast surgery. Antibiotics are given intra-enously and then the breasts are marked for the ap-ropriate location of the pocket that will contain therosthesis later on (Fig. 22.5). The incision is designedround the nipple and the concentric circle is maderound the nipple marking with its circumference

Standing Reclining

/-FL__\/ \! \

igure 22.3. Standing versus reclining positions of the breast

or endoscopic axillary mastopexy or reduction mammoplasty.

Figure 22.4. Endoscopic mastopexy: location of sutures.

made only as large as necessary to gain access to thesurgical site. The concentric circle technique is not inany way used in this procedure to help elevate the nip-ple as in the doughnut mastopexy. After these mark-ings have been made, a stab wound is made at the 6 o-clock position on the nipple, and using the longinfiltration needle that is used for the tumescent tech-nique with liposuction, the subcutaneous areas of thebreast are infiltrated in an area from the nipple to thesternal angle and from the nipple to the midaxillaryarea and up to the clavicle (Fig. 22.6). This is the maxi-mum amount of undermining that we do in themastopexy with an augmentation. After this infiltra-

tion, the incision is made and the skin is deepithelizedin the areas between the nipple markings and the con-centric circle. After the skin has been deepithelized, itis then cut through with the electrocautery. At thispoint, sharp dissection is done using scissors as if asubcutaneous mastectomy were being done, leaving athin skin pedicle because the ability of the skin toshrink and not fold upon itself is basically related tohow much soft tissue is left attached to the skin. Thedissection is carried out subcutaneously until the up-per pole of the breast is reached. At a point which is

not necessarily discreet (Fig. 22.21, but at which onecan tell clinically that the upper margin of breast tissueends and regular soft tissue begins, the dissection is


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C.W. Johnson

Sternal angle

crease i

! %=== Double dashes indicate boundariesof undermining of skin in mastopexywith prosthetic augmentation.

--- Dotted line indicates boundariesof undermining of skin in axillarymastopexy or mammoplasty.

90 angle at the nipple), and bounded by the arc of theclavicle above. After the pocket has been made in thearea that we have planned an appropriate pocket forthe implant, the pocket is then irrigated with antibioticsolution and the implant is slipped over the top of thebreast and slipped down into the pocket (Fig. 22.7).The pocket is made about 50% larger than the implant.With the extra room in the pocket the free upper quad-

rant of the breast is pulled up and attached to the fas-cia in the area above the second rib. Just below theclavicle starting from medially and going laterally it isattached with 2-O Vicryl or Dexon sutures with three tofour sutures along the upper arc of the breast to helprecreate that arc (Fig. 22.7). The upper margin of thebreast is now back to the point that nature had it whenthe breast first developed. The breast is now elevated.

To correct for any discrepancies in preoperative posi-tions of the nipples, make the distance from the nippleto the upper margin of the breast the same on each side

and suture that margin of the breast back into the fasciato elevate the nipple to the exact position on each side.If the distance from the upper pole of the breast to thenipple is the same on each side, you will have the nip-ples positioned properly. The incision is closed with a

ure 22.5. Markings for endoscopic axillary mastopexy with

without prosthetic augmentation and for endoscopic axil-reduction mammoplasty.

arried from the subcutaneous plane through the softsue to the fascia of the pectoralis muscle. At thisint the dissection is continued cephalad staying on Sternal

p of the fascia of the muscle. From this point the dis- I angle\ction is done with the electrocautery staying abovee pectoral fascia and dissecting above the second rib - $ to about 1 cm below the clavicle. This is dissected

ong the arc that forms the classic cleavage of upperlness of the female breast in the exaggerated pushed

position. At this point, the upper pole of the breast Puncture woundlifted and using the electrocautery, dissection is car-ed over the top of the breast tissue and dissectedwnward to make the retromammary pocket. The

ssection of the retromammary pocket can be done us-g the expansion technique with a tissue expanderd it is in fact the technique that I now use with thedoscopic axillary mastopexy. However, in the rou-e circumareolar mastopexy that I have done for thest 8 years, I manually dissect under direct visionth the electrocautery, the entire posterior pocket. Re-

ember at this point the only place that the gland istached from the skin is in the single quadrantrmed by two lines from the nipple tothe second rib Figure 22.6. Endoscopic axillary mastopexy: infiltration of aread from the nipple to the axillary area (which form a to be undermined to reduce bleeding.


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Endoscopic Reduction Mammoplasty, Mastopexy, and Mastopexy With Prosthetic Augmentation 209nelli suture.*9 This suture has also been described by

Robert Ersek.24 Prolene 4-O running suture is used tose the areolar border/skin.

During the first 4 years of using this circumareolarhnique for the reduction mammoplasties, reductionstopexies, and mastopexies with augmentations, Inot use the circumareolar suture. I have used a sin-suture of 2-O white Mersilene to form a purse-string

ure since 1990. The knot is always left at the 6 o-ck position for easy postoperative location if neces-y. The remainder of the incision is closed with sim- 5-O Prolene running sutures and the patient ised with Benzoin and steri-strips. She is placed in am or elastic type bandage to help form the breastd keep it supported and she is put into a bra andd to absolutely not remove the bra in the erect posi-n for any reason for at least 3 weeks. After l-2eks, the elastic or supportive tape is removed, or ifpatient has an allergic reaction to the tape, she is

d to pull it back and trim it away from the reactivea or to remove the tape if necessary, all of which isne with her in the reclining position. The bra is anderwire bra with nonelastic straps kept tight, dayd night for at least 3 weeks, including showering in

bra; after which she can lie down and change the. After the first 3 weeks, she can take a shower with-

Figure 22.8. Effects of aging on suspensory ligaments of

Cooper stretching and lengthening result of breast ptosis.

Elevated breast Unelevated breast

out the bra on, but she still must wear the bra day andnight for another 3 weeks. What is accomplished hereis akin to fixation of a broken bone that can be platedand then cast, but if the cast were removed every day

just to allow for bathing of the extremity, the platewould not hold properly. Once the sutures are put inplace the breast has been restored to its normal posi-tion; but if it is going to heal there, it has to be held in

position for a sufficient period of time (Fig. 22.8).

ures

ure 22.7. Endoscopic axillary mastopexy with augmenta-

.

Mastopexy

In the chapter of this book on the endoscopic augmen-tation mammoplasty, there is a considerable amount ofdiscussion given as to how to determine size and vol-ume of breasts. To perform a mastopexy or a reductionmammoplasty, the determination must be made as towhat volume of breast will remain after the surgeryand subsequent postoperative atrophy, in order to de-

termine if that volume will make the patient the sizeshe would like to have. The amount of postoperativeatrophy can be the most significant factor betweenhaving a happy patient or an unhappy patient. Postop-erative atrophy has been discussed in the literature2U5and is also discussed in this book.

If the patients primary request is for a mastopexy,the procedure is to first determine what is the patientsbreast volume. In the ptotic breast the most simplemethod to estimate volume is usually with the patientwearing a good fitting bra. Before planning a

mastopexy the determination must be made if the pa-tient is happy with the volume she has with her bra on,and would she be unhappy if her breasts were % or %cup smaller after surgery. If she can accept this volume


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0 C.W. Johnson

s, the mastopexy can produce a good result and appy patient. If she cannot accept the volume loss sheeds a mastopexy with volume addition.With mastopexies the estimated final long-term post-erative breast volume is determined during the pre-erative office visit, taking into account the fact therell be a 20-25% loss of volume in the long-term post-erative phase. My estimate assumes the patient will

ndergo no significant weight gain or loss. Theastopexy patient is also marked in preanesthesia fore appropriate location of the nipple in the midclavic-ar line about 18-20 cm from the suprasternal notch,pending on the patients height. Any difference inpple distances would be noted here and this wouldcompensated for as we previously explained in the

astopexy with augmentation. The patient is thenaced under general endotracheal anesthesia, preppedd draped in the standard manner, given IV antibi-cs, and the breasts marked for the margins. The nip-

e is marked for the appropriate size depending uponhat the patient wants or what would be ideal for here and if there is excessive areolar border; it is also

arked for excision with a concentric circle type inci-n, the size of the outside circle being only as large ascessary to remove whatever excessive areolar borderay be there, but at least large enough to gain the ap-opriate length of incision for exposure. The addi-nal markings that are made in the reduction

astopexy versus the mastopexy with augmentation isine marked around the lower hemisphere of the

east, staying about 2 cm up on the breast away frome chest wall, and then as the line comes to about theoclock position, it advances toward the axilla, andom the 3 oclock position it advances toward thernal angle (Fig. 22.5). A stab wound is made in the

wer portion of the areolar border and the subcuta-ous tissue is infiltrated with the same solution usedr liposuction for the tumescent technique and as de-ibed in the mastopexy and augmentation. The infil-tion is accomplished over the entire surface of the

east down to the chest wall including the part of the

marked 2-cm margin of skin (Figs. 22.6, 22.9). Thecision is then made and deepithelialization done aseviously described. Sharp dissection with scissors ised for all dissection that involves undermining toeate a thin skin flap. When the upper pole of theeast is reached, the electrocautery is used to carry thesection down through the soft tissue to the fascia of

e muscle. The dissection is continued over the fasciaove the second rib and to within about 1 cm of thevicle, and, as described in the mastopexy with aug-

entation, the upper pole of the breast is then freed

ay from the fascia only down to the level betweene 3 and 9 oclock position. This results in the uppermisphere of the breast being completely detached.e lower hemisphere of the breast is not detached

Blind underminingof skin from fascia& breast tissue inclu-ding areolar borderbut excluding nipple.

Additionallv, blood&

nerve subpjies arepreserved by leavinga 2 cm margin above theinframammary crease

2 Lrn

Figure 22.9. Endoscopic axillary reduction mastopexy.

from the fascia and the viability and sensation are pre-served via the important medial and lateral blood andnerve supply to the breast and nipple through thegland and 2-cm pedicle of skin that is not detached(Figs. 22.10,22.11).

From about the 12 oclock position, or the northpole of the upper hemisphere, an incision is madestraight through the breast tissue from the anterior toposterior surface to within about l-2 cm of a line verti-cal to the nipple. The upper hemisphere of the breasthas now been divided into two flaps (two quadrants),

upper medial and upper lateral (Fig. 22.12).To effect a conization of the breast, increase projec-tion, and elevation of the breast and nipple, the upperouter quadrant is picked up at the 12 oclock positionand this lateral quadrant is advanced up and mediallyand sutured to the surgically exposed fascia and mus-cle above the second rib and near the clavicle (Fig.22.13). The point of attachment is secured with 2-OVicryl or Dexon. The lateral margin of that upper outerquadrant flap is sutured in two or three more places tohelp secure it to its new position on the chest wall. The

upper inner quadrant flap is picked up at the 12 o-clock position and advanced up and lateral toward theroll of the pectoral muscle. This overlapping of quad-rants results in elevation and conization of the breasts.


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2. Axillary Endoscopic Reduction Mammoplasty, Mastopexy, and Mastopexy With Prosthetic Augmentation 211

ntercostal perforators

Cutaway/ axis

Transverse viewleft breast

- perforators

-ImplantTransverse view

left breast

gure 22.10. Endoscopic axillary mastopexy withaugmenta- Figure 22.11. Endoscopic axillary mastopexy with augmenta-on: blood supply. tion: nerve supply.

ost often some additional treatment is needed on thewer hemisphere because it remains flat. Treat thewer hemisphere like plication of the rectus muscles: atle more release of the 2-cm skin margin in the infra-ammary crease midline, then imagine a line from theeolar to 6 oclock in the inframammary area. Invagi-

ate that line from nipple to crease and suture over ittighten and cone the lower hemisphere of the breast.

With the exposure available through a circumareolarcision, I normally use the 2-O suture. However withe endoscopic approach we find it necessary to use

scial staples (Fig. 22.14). Sometimes there may be toouch fatty tissue in the lower portion to provide ade-

uate strength and tension for the plication. If neces-ry take the liposuction with a flat (or single port) suc-

on tip and suction the fat off the breast enough to getood fibrous tissue that can be sutured to plicate theeast. The pocket is irrigated well and in these cases Ildom, if ever, drain these breasts. If there is any post-

perative fluid collection, simply tap it off with a nee-e. The incision is closed, and dressings, supportivepe, and a bra or a compressive bandage are applied

these patients the same as described in theastopexy with augmentation procedure. Postopera- Figure 22.12. The upper hemisphere of the breast divided intoe instructions are also the same. two quadrants: upper medial and upper lateral.


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G.W. Johnson

proximation of how much volume or weight wouldbe removed from each breast. The lateral quadrant ofthe upper hemisphere is picked up at the 12 oclockpoint and advanced into or toward the sternal angle.V With application of the amount of pull (force) the sur-geon feels is reasonable, an estimate is made of thevolume/weight of the breast tissue in the upper-lat-eral flap that is being displaced (pulled) across a linefrom the midclavicular position to the nipple (Onorth line). The same determination is made with theupper inner quadrant. If the intraoperative estimateof volume or weight as described is equal to orgreater than the volume removal estimated preopera-tive, proceed to excise the appropriate amount of tis-sue from each quadrant (Figs. 22.15, 22.16). If the in-traoperative estimate of volume is less than thepreoperative estimate, carefully undermine the lowerhemisphere and extend the release of the medial andlateral attachments (to perhaps the 4-8 oclock posi-tion). The adjustments of the lower hemisphere at-tachments should allow the surgeon to remove theproper volumes from both quadrants. There remainsno excessive tissue that needs overlapping; therefore

igure 22.13. Endoscopic axillary reduction mammoplasty.

0..duction Mammoplasty

e reduction mammoplasty, through the circumareo- \, Iincision, is technically more difficult than simplyng the mastopexy, but it is not so difficult that the

erage plastic surgeon cannot perform the procedure. *e real problem can occur if the nipple incision isnd to be too small in a very large breast requiring a

or 1500-g reduction from east breast. Making a

ger concentric circle incision will allow more areamanipulation. The reduction mammoplasty patient

marked preop and prepped and draped in the samenner as a mastopexy patient. One minor differencehat in preanesthesia a few extra marks are some-

mes made to do some adjunctive suction on a largereral breast roll or excessive axillary fat pad. Otherrkings in surgery are made the same as described onmastopexy, and the technique is done in the same

nner. The incisions and dissection are also the sameto and including the 12 oclock to nipple division ofsurgically freed upper hemisphere. Figure 22.14. Endoscopic axillary mastopexy. The inframam-he determination must have been made in the pre- mary incision is made to plicate the lower breast (using cervi-cal tenaculum and fascia stapler) for increased projection and

erative evaluation of how much, or at least an ap- conization of the breast.


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Axillary Endoscopic Reduction Mammoplasty, Mastopexy, and Mastopexy With Prosthetic Augmentation 213

ure 22.15. Endoscopic axillary reduction mastopexy: the

ast is reduced by removing a wedged portion of the upper

e then suturing the tissue together.

ture the new 12 oclock positions of each upperadrant to fascia/muscle above the second rib.ree to four 2-O sutures should be used on each flap,d the two flaps should be sutured together. Thewer hemisphere is handled the same way as de-ibed for the mastopexy and the skin closure and

ping and dressings are likewise the same.

ndoscopic Axillary Mastopexy

th Augmentation

chnically the mastopexy with augmentation is theost simple procedure and generally produces veryod results. Preoperative, anesthesia, prep andape, and intraoperative antibiotics are the same asthe circumareolar procedures. The only significantference in the two techniques is that in the circum-eolar technique the arms are on arm boards at

90gle. In the endoscopic axillary approach, an ethereen is used and the forearms and hands are se-

red horizontally, leaving good exposure of the ax-

Figure 22.16. Endoscopic axillary reduction mammoplasty: the

breast tissue is divided then elevated by suturing the lateral

portion first and the overlapping medical portion second.

illa without undue stress on any nerves or joints. Thepatient is then prepped and draped. With both axillaexposed the pocket is designed. The 90 lines fromthe sternal angle to the nipple and from the nipple tothe axilla delineates the upper quadrant of thebreast. These lines are marked and then the infiltra-tion is done. After the infiltration, the incision ismade in the axilla and the dissection is carried up tothe fascia of the pectoralis muscle, and getting abovethe fascia and with the scope for visualization, theendotube is then inserted and passed from the axillaover the pectoral fascia (Fig. 22.17), the same as ifone were going to do an axillary subglandular aug-mentation. The tissue expander is put in (Fig. 22.18)and is inflated over 50% of the size of the implant tobe used. It does not hurt to inflate even more if youlike because what is being done here is dissecting the

posterior pocket (Fig. 22.191, dissecting the fasciaaway from the muscle. The expander is then re-moved. At this point, with blind dissection and ex-ternal palpation, the undermining of the skin is ac-


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4 G.W. Johnson

Figure 22.17. Endoscopic axillary mastopexy. Step 1 for

dissection of the breast tissue by the expander: the endo-tube is inserted and passed from the axilla over the pec-

toral fascia.

mplished in the upper quadrant from the axilla us-g the scissors. This undermining, once again, is theme as if it were being done from a circumareolarcision except it is being approached from the axilla.nce the undermining has been done up to the up-r margin of the breast tissue, the pocket is thennnected from the subcutaneous position. Theeast tissue is then released by cutting the breast tis-

e loose so that there is now a direct communica-on from the subcutaneous pocket around to thestglandular pocket. This is the same method that

as used on the circumareolar, but using a differentproach. The dissection is continued now by elevat-g the soft tissue away from the pectoralis muscled fascia going up above the second rib and just be-w the clavicle. At this point, with the upper breastving been released properly, one can then grip theper fold of the breast with the forceps and pull up-

ard and see how well it lifts the nipple areolar

mplex. At this point, the upper pole of the breast is

then sutured into the fascia (Fig. 22.201, prepectoralfascia, with the suture again going through a goodportion of the breast with the fascia and a bite to themuscle. Usually using at least three to four sutures of2-O Dexon or Vicryl, the first suture is put in the mostmedial portion and then the second, third, andfourth suture finally out at the axillary area. Oncethis elevation has been accomplished, then there is

still an opening from the axilla into the subglandularspace. An implant is rolled up and placed into thispocket (Fig. 22.21) and inflated in the same manneras if one were doing the endoscopic augmentationsimply through an axillary approach. Once this stephas been completed, the incision is closed using onlysubcutaneous sutures of Dexon or Vicryl and rein-forced with steri-strips. The patient is dressed the ex-act way that the mastopexy with augmentationthrough a circumareolar incision would be dressed.They need the same kind of support over the same

period of time to allow this to heal properly.

Figure 22.18. Endoscopic axillary mastopexy. Step 2 for

dissection: the insertion of the expander.


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Axillary Endoscopic Reduction Mammoplasty, Mastopexy, and Mastopexy With Prosthetic Augmentation 215

ure 22.19. Endoscopic axillary mastopexy. Step 3 for dissec-

n: filling the expander.

ure 22.20. Endoscopic mastopexy: elevation of the breast

clining position). The first suture (see 1) is placed in the mostdial portion; the second suture (2) and the third suture (3)

at the axillary area.

Figure 22.21. Endoscopic axillary mastopexy with augmenta-

tion: insertion of implant between breast and pectoral.

Axillary Endoscopic Mastopexy

The next approach is the axillary endoscopic masto-pexy without augmentation. This technique is ap-proached in a similar fashion to the circumareolarmastopexy without augmentation with the exceptionthat there is no circumareolar incision and there is anaxillary incision. If the areolar border is too large in theperson who needs a mastopexy, the areolar border isreduced in size by a purse-string suture that is placedthrough four stab wounds so that there is no incisionmade around the areolar border. Again, the procedureis begun by the patient being marked in preanesthesia.She is placed under general anesthesia, given IV antibi-otics, arms are positioned on the ether screen, and thechest and breasts are marked from the 3 oclock posi-tion at the nipple to the sternal angle; from the 9 o-clock position at the nipple to the axilla; and a lienaround the lower hemisphere staying about 2 cmabove the chest wall up on the breast. Once thesemarkings are made, the stab wound is made in the are-olar and the tumescent technique is used for infiltra-tion of the subcutaneous area all over the breast, in-cluding the lower hemisphere, to help prevent anybleeding. After infiltration, an incision is made about6-8 cm long and dissection is carried up to the pec-toralis muscle. Then using the endotube, a tunnel is


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6 C.W. Johnson

ade above the muscle with the endoscope to verifyosition and location and a tissue expander is put intoace. This tunnel is made generally in the upper posi-

on of the breast because it is not necessary to under-ine the entire pocket (or the lower hemisphere) one mastopexy. After the expander is deflated and re-oved, the subcutaneous undermining is done with

harp dissection (scissors) coming from the axilla in aind fashion, palpating with one hand. The breast isndermined over the entire portion of the areasarked to give us a complete freedom of the skin frome glands (Fig. 22.22). If the areolar border may needbe made smaller, then the entire areolar will be un-

ermined also. The nipple and the ductal system areft intact, but all the areolar border is underminedong with the rest of the skin. After this has been ac-

omplished, the subcutaneous pocket is then con-ected to the retromammary pocket in the upper por-on of the breast by cutting through the soft tissue atis point, and the dissection is continued up above the

cond rib to the clavicle. The upper hemisphere of theeast is divided through from the 12 oclock positionthe nipple (as described in the circumareolar reduc-

on) which can be done either with the right angle pair

of scissors or a very sharply curved pair of scissorsdone blindly or under direct vision with the scope. If itis done blindly, then you probably need the scope tohelp control bleeding. Once this has been divided, thelateral flap is brought up and inward and sutured inplace. The flap is then sutured in two or three addi-tional places. The medial flap is brought up and out-ward and sutured in place with the medial part su-tured first, the part to the lateral flap sutured second,and then the tip of the flap sutured over the muscleheaded toward the axilla. The breast has now been ele-vated and coned for projection as with the circumareo-lar mastopexy. If the lower portion of the breast isfairly firm and does not really need anything done to itas far as projection, we will sometimes do minimal li-posuction superficially at this point to help create somefibrous tissue so that it can adhere back to the skin tohelp form a better shape and, when put in the ban-dage, to help secure the breasts. If however, the breastis too flat and needs more projection, the 2-cm bridge

of skin below the nipple is released down to the infra-mammary crease, just below the nipple, and an inci-sion is made about 1.5-2 cm long. This incision will beobviously below the area that has been underminedbecause we stayed 2 cm away. We then connect fromthe incision up to the undermined area and then usingthe cervical tenaculum and fascial staples as describedearlier, the lower hemisphere is plicated to improvedfirmness and projection of the breasts. One more thingthat may have to be done is to make stab wounds if thepatients areolar border was too large or she wanted to

be smaller; there is already a stab wound at 6 oclock,so we make one at 3,9, and 12 oclock, and then usingthe circumareolar suture on a Keith needle or on a cir-cular needle, we pass it around the nipple and usingthe purse-string suture to pull the nipple down to theappropriate size. Because this entire areolar border hasbeen undermined and a suture has been used to pullthe nipple down to the proper size, when this patient istaped and put into a bra and kept in this bra for 6weeks, she can expect that the nipple will heal back tothe tissue below in the proper position and in the

proper size. She will have a nipple that is the propersize without having the circumareolar incision madearound the nipple. The axillary incision is then closedwith interrupted sutures of Dexon or Vicryl. She isdressed with foam of elastic bandage to support thebreast, placed in a bra, and taken to the recovery room.

Clavicle

2nd rib

Blind undermining

ascia & breast tissue

gure 22.22. Mastopexy with augmentation: blind undermin-

g of skin from fascia and breast tissue.

Axillary EndoscopicReduction Mammoplasty

The next operative technique is the axillary endoscopicreduction mammoplasty. Again, the techniques hereare very similar to those described in the axillary endo-


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Axillary Endoscopic Reduction Mammoplasty, Mastopexy, and Mastopexy With Prosthetic Augmentationopic mastopexy. The markings are made from the 3-9clock position on the breast and 2 cm above the chestall, and then from the 3 oclock position to the sternalgle and from the 9 oclock position to the axilla. The

ab wound is then made in the infra-areolar area ine 6 oclock position and the subcutaneous tissue overe entire breast is infiltrated with the tumescent tech-que to help control any bleeding. The incision is then

ade in the axilla. The approach is made to the pec-ralis fascia, and exposure of the fascia allows the in-oduction of the endotube and the endoscope into thecket above the muscle and below the breast tissue,d the expander is put into place. The expander is ex-nded to create the retromammary pocket. The sharpssection is then done blindly to dissect the skin andbcutaneous tissue free from the breast over the entireeast surface and the areas that have been marked, in-uding the areolar border, but excluding the nipple ande ductal system. The undermining having been accom-shed, the subcutaneous pocket is then connected su-riorly to the retromammary pocket by dividing

rough the tissue. This then creates the upper free flapbreast tissue, and then by dissecting around either

ndly and then controlling bleeding with the scope orssecting with the scope to the 3 oclock position anden to the 9 oclock position, the upper pole of theeast is free. The dissection is carried on up over thectoralis fascia up over the second rib to just belowe clavicle. At this point the division of the breastom the 12 oclock position to the nipple is accom-

shed either under direct vision with electrocauteryd the scope or done blindly with curved or sharp an-ed scissors. This creates the upper hemisphere intoo flaps, the medial quadrant flap and the lateraladrant flap. At this point, the amount of excessivesue that can be ressected is removed from the medialp and from the lateral flap. An easier way to do this,to estimate ahead of time how much wedge younk you can remove, how much needs to be removedreduce to the volume you want to be, and then sim-y remove the wedge of breast tissue (Figs. 22.15,

16) like a piece of pie with the point of the pie beingward the nipple and crust of the pie being in the pe-phery of the breast in the upper quadrant of theeast. Once this has been accomplished and bleedingntrolled once again, the medial portion of the medialp is sutured to the fascia above the second rib. Addi-nal sutures as necessary are put in that portion of flap and then the most medial portion of the me-

al flap is sutured to the 12 oclock position. The me-l portion of the lateral flap is then sutured to the 12lock position. The remainder of the lateral flap is su-

ed around the lateral portion of the chest. Suturesthen put from the 12 oclock position toward the

21 7

nipple to suture the two flaps together. At this point,the attention is then turned to thelower portion of thebreast and the incision has already been made. Somesuction is done as necessary to have enough fat re-moved so there is good fibrous breast tissue present.Then using the tenaculum and the staple gun, this isplicated in the inframammary portion of the breast.Once this is completed, the purse-string suture is

placed around the nipple starting at the 6 oclock posi-tion going around the nipple using the Keith needle orcurved needle and tightening this down. Once again,with the areolar border being undermined, and the pa-tient taped and held this way, this will heal withouthaving to make an incision around the nipple. The axil-lary incision is closed with subcutaneous sutures ofDexon or Vicryl. After the closure of the axillary area,the patient is then placed in the foam tape or the elasti-plast and placed in a bra. Again there is a 6-week re-covery period.

Long-Term Results

Long-term results on the axillary mastopexy consist ofonly about 7 months to date, but have been very good.In one case there was some skin loss on both breasts ina reduction that was a very major reduction. This re-duction was around 1500-mL volume from each sidewith the axillary technique. But even with some skinloss on each side, we did not lose any sensation in the

nipple. The patient has basically normal sensation inboth nipples, so this technique has a lot of merit. Butthe long-term results appear to correlate the axillarysurgery to the circumareolar because both internaltechniques are the same. I have done over 150 proce-dures through this technique. These procedures in-clude reduction mammoplasties, reduction mastopex-ies, and mastopexies with augmentation through thecircumareolar technique that has been described here.We feel that long-term results are excellent and there iscertainly no tendency for descent of the breast or for

bottoming out of the breast that are seen in the inferiorpedicle technique. This is also a technique that recog-nizes all five of the primary goals of the patient and thesurgeon. So, even the circumareolar technique comesclose to fulfilling all these goals, but the axillary tech-nique, especially when it can be used without havingto make an incision around the nipple to make the nip-ple smaller, can really come very close to fulfillingthese goals completely. Figures 22.23-22.29 illustrateour clinical experience with the various techniquespresented in this chapter.

References follow on page 225

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