Ptosis and Mastopexy Flashcards by Amita Shah

Define the different grades of breast ptosis

1 = nipple with or above IMF
2 = nipple below IMF
3 = on most dependent portion of the breast
Pseudoptosis = nipple at or above IMF with increased IMF to nipple distance with majority of breast tissue below IMF

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What is the vascular supply to the breast?

Internal mammary, lateral thoracic, thoracoacromial, thoracodorsal, intercostals 3-5.

(medioinferior) Internal mammary-anterior intercostal system
(superolateral) Lateral thoracic and minor contributors including axillary artery
(periareolar) anastomosis between the two systems

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What are classifications of ptosis?

Glandular = breast migrates inferiorly en bloc

Parenchymal = high IMF and inferior hypoplasia (tuberous or constricted breast deformity)

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What is the “three-step principle” when assessing the breast?

skin envelope
Breast conus
Breast footprint

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What measurements do you need to obtain during your assessment of patients for breast surgery?

Notch to nipple, nipple to IMF, base width, degree of ptosis, NAC diameter

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What are risk factors for developing ptosis?

Age, significant weight loss, higher BMI, larger cup size, number of pregnancies, smoking

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Is breast feeding associated with the development of breast ptosis?

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What are the characteristics of a tuberous or constricted breast?

high IMF
narrow base
herniation of breast parenchyma into areola

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What maneuvers need to be performed for treating a tuberous breast deformity?

Lower IMF, increase inferior pole volume, scoring breast parenchyma, NAC repositioning, decreasing areola size

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What are the characteristics of Massive Weight Loss patient breasts?

Grade III ptosis
medialization of the nipple-areola complex
Lateralization of the breast mound
Extension to a lateral axillary fat roll
Lowered inframammary fold
Asymmetrical volume loss
Deflated and flat appearance of the breast (particularly a flat upper pole)
Excess skin laxity

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Three key principles of mastopexy

repositioning the NAC
Parenchymal shaping
Skin resection

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When treating a tuberous breast, what maneuver will decrease the risk of a double-bubble deformity?

Parenchymal scoring. This releases constricting bands. Double bubble occurs when the natural IMF is not adequately obliterated.

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What is the most common complication of a donut (periareolar) mastopexy?

widening of the areola. This is minimized by using a permanent Gore-Tex suture in a Wagon-wheel technique and limiting the skin resection outside the NAC to 2:1

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What is the dominant blood supply for a breast superior pedicle?

Internal thoracic superficial branch from the 2nd interspace

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What is the dominant blood supply for a breast inferior pedicle?

Internal thoracic superficial branch from the 4th interspace

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What is the dominant blood supply for a breast medial pedicle?

Internal thoracic superficial branch from the 3rd interspace

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What is the dominant blood supply for the breast lateral pedicle?

superficial branches of the lateral thoracic artery

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What is the most common medial innervation to the NAC?

3rd and 4th intercostal nerve anterior cutaneous branches

What is the predominant innervation of the NAC?

Lateral cutaneous branches of the 4th intercostal sensory nerve

What is the sensory innervation to the upper pole of the breast?

Supraclavicular nerves from the 3rd and 4th branches of the cervical plexus

What is the sensory innervation to the medial and lateral breast?

anterior and lateral cutaneous branches of the intercostal nerves II through VII

What are indications that a free nipple graft may be needed?

1500g or more reduction2. Nipple transposition >25cm3. Smokers4. Diabetes

How do you determine the bra cup size?

Measure the diameter of the chest under the breast (band size). Measure the breast diameter at the point of most projection.

1 inch difference = A cup

2 inch = B cup

3 inch = C cup

4 inch = D cup

5 inch = DD cup

How do you manage a dusky nipple postoperatively?

Release the sutures holding the NAC
If that doesn’t work, return to OR to check pedicle for kinking
Apply nitro paste to nipple
Convert to Free-nipple graft if needed
HBO

What is the most common planning error with mastopexy and the most difficult to correct post-op?

Placing the nipple too high (star-gazing nipple)

Relaxation of what structure allows for ptosis?

Attenuation of Cooper's ligaments

When should a staged mastopexy/augmenation procedure be considered?

When more than 3cm of nipple elevation is required

When combining augmentation and mastopexy, what are general recommendations for the NAC to sternal notch distance?

* \<225cc implant = NAC at 21cm * 250-325cc implant = NAC at 22cm * \> 350cc implant= NAC at 23 cm

How to do you prevent the crossing the IMF with the vertical limb during a vertical mastopexy?

The lower border of the mosque design should stop 2-6cm above the IMF

Describe the Benelli Round-block technique

Describe the Wagon-wheel suture technique for peri-areolar mastopexy. What type of suture is used?

Gore-Tex Suture in a wagon-wheel pattern as described by Hammond

What are the different types of periareolar mastopexy?

1. Benelli Round-block 2. Spear concentric 3. Hammond interlocking Gore-tex

What are some types of vertical mastopexy?

1. \* Hall-Findlay medial pedicle 2. \* Closure of medial and lateral pedicles 3. \* Hildago Y-scar 4. \* Lassus - superior pedicle 5. \* Lejour - superior pedicle + liposuction

What are principle features of the vertical mastopexy?

* \* The IMF is raised * \* The breast width is decreased * \* The breast will have an inverted shape that settles over time

What are some modified vertical mastopexy techniques?

* \* Marchach - short horizontal scar * \* Chiari - L scar * \* Regnault - B scar

Describe different inverted T mastopexy skin patterns:

Augmentation can only correct _____ ptosis

Mild

Your patient needs a 2-stage aug-mastopexy. Which procedure do you do first?

Mastopexy

Your patient is having a one-stage aug-mastopexy. Which proceudre do you do first?

Augmentation

What risks of mastopexy should you discuss with your patient?

* Nipple loss * Decreased sensation to the nipple * inability to breast feed * asymmetry * scarring * recurrence of ptosis * need for reoperation

What is the advantage of aug-mastopexy versus mastopexy alone?

improvement of upper pole fullness

What is a common complication of mastopexy and breast reduction over time?

Bottoming-out AKA pseudoptosis (increase of NAC to IMF length)

What are increased risks of Aug-mastopexy?

* more rapid recurrence of ptosis (weight of the prosthesis places additional tension at the site of incision) * Nipple malposition * Nipple ischemia (The larger the prosthesis, the greater the adverse effect on vascularity) * Skin flap loss * Prosthesis infection/exposure * “Resultant deformities” * NO increased risk of loss of nipple sensation