This video will highlight the operative technique for aesthetic mastopexy and auto-augmentation with an inferior flap. Standard preoperative markings are completed with the patient in the upright position and include sternal notch, midline, breast meridians, inframammary fold, upper breast border, and proposed nipple location. In our practice, nipple location is determined based on a combination of Petengi's point, which is transposing the inframammary fold onto the meridian of the breast, and the distance from the upper breast border, generally 8-10 cm inferior to this border. Multiple measurements are taken to ensure symmetric nipple location. The vertical mastopexy markings are then completed with nipple to inframammary fold distance marked at roughly 8 cm. The breast is rotated medially and laterally to determine the width of the vertical component. Approximately 2 cm above the native IMF, a U-shaped mark connects the medial and lateral vertical markings. This completes the vertical mastopexy markings. All tissue within this marking is to be retained. A superior superior medial pedicle is then marked, and an inferior auto-augmentation flap is also marked. Surgery first begins with utilizing a 38-42 mm areola sizer to create a new areolar diameter. The entirety of the vertical markings is deepothelialized. The superior pedicle providing the blood supply to the nipple areolar complex is defined down to the chest wall. The inferior auto-augmentation flap is defined superiorly, medially, and laterally down to chest wall without undermining to ensure that the deep blood supply from the fourth internal mammary artery is maintained. At the inferior aspect of the vertical mastopexy markings, the skin is incised through dermis and elevated off the inferior auto-augmentation flap as far inferiorly as the native inframammary fold for multiple reasons. First, to ensure that the blood supply to the auto-augmentation flap is optimized, dissection straight down to the chest wall at the inferior aspect of the vertical mastopexy markings could compromise the fourth internal mammary artery perforator as it runs through Waringer's septum 1-2 cm above the inframammary fold. Second, is to capture as much flap volume as possible. And finally, to allow for enhanced mobility of the inferior flap supermedially without unwanted upward pull on the new inframammary fold. At the level of the native inframammary fold, the flap can be dissected down to chest wall if needed to assist with mobilization. Dissection then proceeds medially and laterally from the vertical markings to create medial and lateral flaps with care taken to keep at least 2 cm in thickness. If there is notable asymmetry in breast size, parenchyma can be resected either medially, laterally, or superiorly from the deep surface of the superior pedicle and this can be done because the pedicle blood supply runs from the second internal mammary artery perforators that arise from the second inner space and travel within 1-2 cm of the skin. Once volume is symmetric, a subglandular pocket is dissected supermedially above the pectoralis fascia. The inferior flap is then advanced into this pocket and secured to the chest wall with 2-0 Vicryl. In patients with history of massive weight loss or have poor skin or soft tissue quality placing them at risk for recurrent ptosis, an absorbable mesh, in this case P4HB, can be utilized to secure this flap down to the chest wall, again with 2-0 Vicryl. Medial and lateral pillars are then closed over the inferior auto-augmentation flap and secured to the P4HB with 2-0 Vicryl. Tailor tacking of the vertical limb is then performed. The patient is sat upright and the new areolas are marked with a 38-42 mm sizer. Multiple measurements are taken to ensure symmetry. Once the symmetry is confirmed, the patient is laid supine, the areolas are inset, and the vertical limbs are closed with absorbable suture. If after tailor tacking, the nipple areolar complex to inframammary fold distance is longer than 6-7 cm, the skin and breast tissue that remains inferior to this mark must be addressed. In our practice, we address this excess with a horizontal wedge excision, creating an inverted T scar.

aesthetic mastopexy

auto-augmentation

inferior flap

surgical technique

breast symmetry