Ptotic Breasts Research Articles

A Modified Superior Pedicle Mastopexy Technique With an Inferolateral-Based Auto Augmentation Flap.

Current mastopexy techniques have evolved to decrease scar length and maintain a more consistent upper pole fullness, improving the breast shape. Many different approaches have tried to suspend breast tissues to achieve a more attractive upper pole. Most of the auto-augmentation mastopexy techniques use inferior-based breast parenchymal tissues to fill the upper part. This paper presents a modified approach to fill the breast's upper pole, with an inferolateral-based breast flap. The advantages of changing the inferior-based auto-augmentation technique to the inferolateral comprise improving blood supply and increasing repositioned breast flap's mobility. In our technique, the breast tissue used to auto-augment the upper pole receives its blood supply from pectoral perforators and lateral breast tissue. When surgeons need more flap mobility, they can raise the medial edge of this flap from the pectoral fascia to mobilize this flap higher on the chest wall, depending on the lateral blood supply. One other advantage is that when the inferolateral-based breast tissue is pulled in a superomedial direction to fill the upper part, the lateral ptotic breast tissues come closer to the breast meridian to meet with medial breast parenchyma easily. The tension on the vertical parenchymal suture line is reduced with this approach. Our technique can be used in most mastopexy operations and for all types of ptosis except for cases with insufficient breast volume. It brings safety to the auto-augmentation procedure and is also time-saving. The stability of breast shape and upper pole fullness lasts as long as other auto-augmentation procedures; therefore, it can be an excellent alternative to other techniques. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Internal Mastopexy: A Novel Method of Filling the Upper Poles During Dual-Plane Breast Augmentation Trough Periareolar Incision.

Breast ptosis is a deformity commonly found in patients seeking breast augmentation. Current mastopexy techniques rely on incisions on the breast to correct ptosis; nonetheless, they leave extensive scars. Having to opt for a visibly scarred breast over a ptotic breast can be a difficult choice. We sought an innovative internal suture mastopexy for hypomastia of mild breast ptosis. A procedure that left a tiny scar on the nipple-areolar complex was introduced. This method was safe and efficient when combining mastopexy with augmentation. Overall, 53 patients underwent this operation in the Plastic and Cosmetic Department of Guangdong Second Provincial General Hospital from January 1, 2013, to June 30, 2017, with a mean follow-up of 38 ± 16 months. The pre-operation and post-operation SN-N lines (the distance from the sternal notch to the nipple) were 21.8 ± 1.2 cm and 20.7 ± 1.0 cm, respectively; the difference was statistically significant (P<0.05). The patients and surgeon expressed satisfaction with the procedure. Based on the results of the present study, which included more than 50 patients, we believe that internal suture mastopexy can be used as an effective alternative hypomastia in patients with mild breast ptosis. IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. .

Post-Operative Complications and Nipple Necrosis Rates Between Conventional and Robotic Nipple-Sparing Mastectomy.

PurposeThis study is to directly compare surgical outcomes between conventional nipple-sparing mastectomy (CNSM) and robot-assisted nipple-sparing mastectomy (RNSM).Materials and MethodFor this case–control study, 369 cases of 333 patients who underwent CNSM or RNSM with immediate reconstruction between November 2016 and January 2019 at Severance Hospital in Seoul, Republic of Korea were reviewed. Patients with stage IV breast cancer (n = 1), receiving neoadjuvant chemotherapy (n = 43), or subjected to previous operations (n = 14) or radiotherapy on the breasts were excluded. The main outcomes were comparing rates of post-operative complications, of high-grade post-operative complications as defined by the Clavien-Dindo classification, and nipple necrosis between the CNSM and the RNSM groups.ResultsA total of 311 cases, including 270 CNSMs and 41 RNSMs, were analyzed. The rates of post-operative nipple necrosis (p = 0.026, 2.4 vs. 15.2%) and of high-grade post-operative complications (p = 0.031, 34.8 vs. 17.1%) in the RNSM group were significantly lower than those in the CNSM group.ConclusionRNSM was associated with lower rates of high-grade post-operative complications and nipple necrosis than CNSM for patients with small breast volumes and less ptotic breasts.

Comment on Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction With or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis

Comment on Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction With or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis

Immediate Reconstruction of Large Ptotic Breasts following Vertical Reduction Pattern Nipple-Sparing Mastectomy.

PurposeWomen with large and/or ptotic breasts are generally not considered candidates for nipple-sparing mastectomy because of concerns regarding the high incidence of postoperative complications including ischemic complications. Therefore, we adopted a vertical skin resection technique for nipple-sparing mastectomy, and obtained satisfactory results following immediate autologous breast reconstruction. In this study, we aimed to describe our operative technique and review its outcomes.MethodsBetween January 2010 and March 2017, immediate autologous breast reconstructions were performed in 28 patients with moderate or large ptotic breasts after nipple-sparing mastectomy using the vertical reduction pattern. Grade II ptosis was observed in 12 patients, and 16 patients were classified as having grade III ptosis.ResultsOf the 28 patients, 21 received abdominal free flap reconstruction. In the remaining 7 patients, extended latissimus dorsi flaps were used in conjunction with anatomic implants. The mean weight of the excised breast tissue in the 2 groups was 575 g and 482 g, respectively. Satisfactory esthetic outcomes without major complications were achieved in all patients. Similar vertical reductions or mastopexies in the contralateral breast allowed better postoperative adjustment for symmetry. There was only 1 case of complete nipple necrosis; however, the problem was solved with “skin banking.” No local recurrences or distant metastases were detected at follow-up (mean 18 months, range 4 months to 6 years).ConclusionTo enhance cosmetic outcomes in patients with large and/or ptotic breasts, the vertical skin resection pattern for nipple-sparing mastectomy can be used to achieve better breast shape while preserving the nipple-areola complex. Moreover, it can improve the esthetic outcome without compromising oncologic safety.

Immediate Breast Reconstruction in Large Ptotic Breasts Using the Inferior Based Dermal Flap. Indications and Technique

Immediate Breast Reconstruction in Large Ptotic Breasts Using the Inferior Based Dermal Flap. Indications and Technique

The New Concept of making the Excellent Result in Mastopexy

Background: Breast ptosis is one of the more common issues seen in cosmetic surgeons’ offices, particularly those performing a significant amount of aesthetic breast surgery. Patients with ptosis generally desire the same result – youthful and “perky” breasts. However, due to wide variations in breast volume and tissue quality, ultimate results vary with each patient, and as a result, preoperative management of expectations is critical. There are many surgical options that can be customized to patients’ needs, but these generally address repositioning of the glandular tissue and nipple areolar complex and management of skin excess. Scar patterns include circumareolar, circumvertical (including J or L scar variations), and inverted-T patterns. If author’s new concept can eliminate the remaining skin excess that occur from approximately preoperative markings of traditional mastopexy and can decrease the scar pattern (J or L scar variations and inverted-T patterns), they are interesting to bring an alternative to reduce complications and more satisfactory results. Objective: Author study the new concept of surgical techniques of mastopexy in severe ptotic breasts. The new concept is the changing steps of procedure that performs repositioning and reshaping of the glandular tissue and repositioning of nipple areolar complex before, follow by design and excise the excess skin flaps. Surgical result, main complications and patient satisfaction are evaluated. Methods: The study has performed in 11 patients who have severe ptotic breasts with author’s techniques of mastopexy since July 2017 to march 2018. The techniques including repositioning and reshaping of the glandular tissue and repositioning of nipple areolar complex, skin flaps are designed and excised accurately. Postoperative care makes as standard protocols. Results: Of 11 patients who underwent mastopexy with author’s techniques, all patients have symmetric, only short vertical scar and beautifully shaped breasts and 2 patients have superficial necrosis of skin which at junction of inferior edge of areola and vertical incision, both sides and right side respectively. Three breasts which have superficial skin necrosis, manage include death tissue was removed, dress wet wound every day and make delay primary wound closure in some areas. Nipple sensation is usually normal. Some patients have decrease sensation and fully recover within three months. Conclusion: Author’s surgical techniques change steps of standard mastopexy, as new concept for severe ptotic breast. Repositioning and reshaping of glandular tissue and repositioning of nipple areolar complex firstly, these will help surgeon design and excise the excess skin flaps more accurately. But surgeons do not over excise skin flap to prevent skin necrosis especially junction area. Accordingly, author’s technique can decrease frequent complications of mastopexy including asymmetry, improper of flap excision and undesired J or L, inverted T scar.

Comparison of breast volume change between oncoplastic breast-conserving surgery with radiation therapy and a simultaneous contralateral balancing procedure through the inverted-T scar technique.

BackgroundReduction mammoplasty or mastopexy is performed as an additional balancing procedure in patients with large or ptotic breasts who undergo breast-conserving surgery (BCS). Radiation therapy on breasts that have undergone surgery may result in changes in the volume. This study presents a comparative analysis of patients who received post-BCS balancing procedures to determine whether volume changes were larger in breasts that received radiation therapy than on the contralateral side.MethodsThirty-six participants were selected among patients who received BCS using the inverted-T scar technique between September 2012 and July 2017, were followed up for 2 or more years, and had pre-radiation therapy computed tomography images and post-radiation therapy images taken between 12 and 18 months after completion. The average age of the participants was 53.5 years, their average body mass index was 26.62 kg/m2.ResultsThe pre- and post-radiation therapy volumes of the breasts receiving BCS were 666.08±147.48 mL and 649.33±130.35 mL, respectively. In the contralateral breasts, the volume before radiation therapy was 637.69±145.72 mL, which decreased to 628.14±166.41 mL after therapy. The volume ratio of the affected to the contralateral breasts was 1.05±0.10 before radiation therapy and 1.06±0.12 after radiation therapy.ConclusionsThe ratio of the volume between the two breasts immediately after surgery and at roughly 18 months postoperatively was not significantly different (P=0.98). For these reasons, we recommend a simultaneous single-stage balancing procedure as a reasonable option for patients who require radiation therapy after BCS without concerns regarding volume change.

Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis.

Nipple-sparing mastectomy (NSM) and implant-based immediate breast reconstruction are becoming preferred options with improved outcomes. However, reconstruction in patients with large and ptotic breasts is challenging. When mastectomy and skin reduction are combined in a single-staged procedure, the vasculature of the skin is disturbed leading to increased complication rates. This paper aims to compare complication rates of NSM and immediate implant-based reconstruction with or without reduction to determine the safety of reduction in this patient group. Breast cancer patients that underwent NSM and implant-based immediate breast reconstruction between November 2010 and 2018 were analyzed. All implants were placed submuscularly. Patients with skin reduction and nipple-areolar complex transposition were matched in a 1:1 fashion with patients without reduction. There were 50 patients (72 procedures) in each group. Demographics of the groups were similar as a part of matching process. Mean implant volume in the reduction group was higher (399.93 ± 97.54 vs. 360.21 ± 82.54, p = 0.009). Full thickness skin necrosis rate was higher in the reduction group [12/72 (%17) vs. 2/72 (3%), p = 0.009], and the most common site was over the suture line [6/12 (50%)]. Complications in the reduction group were more common in reconstructions with implant volumes greater than 500cc (p = 0.008). When compared with no reduction, the skin necrosis rate of NSM and immediate implant-based reconstruction with skin reduction is higher. The described technique can only be considered in patients with moderate breast volumes, grade II-III ptosis, and when the planned implant volume is low (< 500cc). IV. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Oncoplastic breast surgery combining partial mastectomy with V-rotation mammoplasty for breast cancer on the upper inner area of the breast.

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique for obtaining symmetry of the breast shape and a level inframammary line and nipple-areola that achieved excellent results. Four Japanese patients with early breast cancer located on the upper inner area of the breast were enrolled into this study. De-epithelialized skin close to the resected area and skin from the epigastric area with subdermal fatty tissue were moved to repair the defect. Oncoplastic breast surgery (OBS) combining partial mastectomy with the V-rotation mammoplasty technique was useful for patients with breast cancer on the upper inner area of minimal ptotic breasts.

"Bifidus pedicle", The Use of Bilobed Superomedial Pedicle for Breast Reshaping Following Upper Outer Quadrantectomy: A New Oncoplastic Breast Surgery Technique.

The aim of this work was to describe our technique, the "Bifidus pedicle", which is a modification of the superomedial pedicle, for managing large breast cancers (BCs) in the upper outer quadrant (UOQ) in patients with medium/large breasts and associated ptosis. Observed complications, cosmetic outcome and oncologic safety were also reported. Thirty patients underwent our modification of the superomedial pedicle combined with a Wise skin resection pattern for large BCs in the UOQ. All patients underwent contralateral Wise pattern breast reduction/mastopexy for symmetry. The average weight of the quadrantectomy specimen was 235 grams (range: 36-400 grams). Mean free tumour margin was 19.4 mm (range: 16-30). Mean operative time was 165 minutes (range: 150-220). Eight (13.2%) breasts had minor complications: two partial NAC necrosis, and six minimal wound dehiscences. Mean follow-up was 22 months (range: 12-30). Overall satisfaction rate was 91%; patients reported to be satisfied the most with the shape (92%) of the breasts, the achieved symmetry (94%), and the volume (85%), focusing on the fullness in the UOQ. Our Bifidus pedicle allowed to fill even wide defects in the UOQ, because we selectively employed it in patients with medium to large ptotic breasts where the lower pole had enough tissue to be displaced. Satisfactory cosmetic and oncologic outcomes were achieved with low complication rate. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Free Nipple Grafting and Nipple Sharing in Autologous Breast Reconstruction after Mastectomy.

Summary:Nipple sparing mastectomy is gaining popularity in recent years, as it provides superior aesthetic results and has a positive impact on the psychological well-being of patients. However, patients with macromastia and high grade ptosis are not good candidates for nipple sparing mastectomy due to a high risk for nipple necrosis; for these patients, the free nipple grafting (FNG) is an excellent option following autologous reconstruction. We herein present our experience with FNG for women with large and ptotic breasts undergoing mastectomy and autologous reconstruction. We also present the option of splitting a single nipple-areolar complex to provide 2 grafts for bilateral nipple reconstruction. This retrospective study is based on data collected between 2014 and 2019 at a single institution. We report on 7 patients (13 grafts): 5 patients underwent FNG (4 bilateral, 1 unilateral) and 2 patients had a single nipple split into 2 parts to create 2 nipple-areolar complexes. Of the 13 grafts, 9 had complete take, 3 had almost complete take, and only 1 graft was lost. Overall patient satisfaction from the procedure was high. The use of FNG is an excellent reconstructive option, as it preserves the patient’s own nipple in terms of color, shape, and texture. The procedure can be executed as part of a direct single-staged reconstruction for patients who are at a high risk for nipple necrosis.

Mastopexy

Mastopexy and mastopexy-augmentation are commonly performed surgeries to lift ptotic breasts while improving breast shape and volume. Factors that cause breast ptosis include aging, hormonal changes, and weight loss. Common surgical approaches for mastopexy utilize the periareolar, vertical, and wise techniques. All of these techniques incorporate parenchymal rearrangement in addition to skin envelope resection in order to achieve the patient’s aesthetic goals. A plastic surgeon should carefully select the appropriate mastopexy technique based on a patient’s preoperative grade of ptosis, breast shape/volume, and aesthetic goals. Many of these mastopexy techniques can be combined with implant augmentation, either as a single or two-stage procedure in appropriate patients with volume concerns. Revisions tend to be more common after implant-augmentations and may be necessary based on patient concerns and surgeon discretion. This review contains 5 figures, 5 tables, and 14 references Keywords: mastopexy, mastopexy-augmentation, breast lift, breast ptosis, vertical mastopexy, periareolar mastopexy, wise pattern mastopexy, breast surgery

Evaluation of the medially pedicled skin-reducing nipple-sparing mastectomy as a standard mastectomy technique for large and ptotic breasts.

Evaluation of the medially pedicled skin-reducing nipple-sparing mastectomy as a standard mastectomy technique for large and ptotic breasts.

Abstract QS13: Goldilocks Procedure With And Without Immediate Implant-based Breast Reconstruction In Obese Patients: The Mayo Clinic Enterprise System Experience

Purpose: Obesity is a risk factor for surgical patients. Thus, implant-based breast reconstruction in obese women may be controversial. We conducted an analysis of obese patients with ptotic breasts who underwent the Goldilocks procedure and compared outcomes between two groups: immediate implant-based reconstruction (IBR) and no IBR. Methods: After Institutional Review Board approval (Study No. 19-008324), we performed a retrospective review of patients treated at the three Mayo Clinic campuses from 2014 - 2019. Patients with BMI ≥ 30kg/m2 and ptotic breasts grade ≥ II who underwent skin-sparing Goldilocks procedure were included. Breasts with prior reduction/augmentation mammoplasty or prior mastectomy were excluded. Demographics, operative characteristics, outcomes and complications were assessed. Two groups were compared: Goldilocks with IBR vs. Goldilocks-only. Patient-reported outcomes using BREAST-Q questionnaire were assessed. Results: One-hundred-sixteen patients (198 breasts) were included. Mean age and BMI were 54.1 ± 10.4years and 37.9 ± 5.8kg/m2. Median follow-up time was 14.9 months (Q1-9.8, Q3-27.7). A total of 100 (50.5%) breasts underwent Goldilocks-only procedure, 92 (46.5%) underwent Goldilocks with two-stage IBR and 6 (3.0%) with one-stage IBR. In the Goldilocks-IBR group, 87 breasts underwent prepectoral and 10 subpectoral implant placement. Multivariate analyses showed increased risk of 6-months major complications (hematoma requiring drainage, unplanned reoperations, infection requiring drainage or IV antibiotics, skin-flap full-necrosis) in the Goldilocks-IBR group (OR 2.8, 1.3 - 6.2). When only severe obese patients (BMI≥35) were analyzed, Goldilocks-IBR was associated with an even higher risk of 6-months major complications (OR 4.8, 2.0-11.7) compared to Goldilocks-only. Median patient satisfaction was statistically higher in the IBR group than Goldilocks-only group (73% vs. 58%, p 0.02). No difference was found in physical, psychological and sexual well-being between groups. Conclusion: Breast reconstruction is an important option for women undergoing mastectomy. Goldilocks procedure is feasible, but when performed with IBR it is associated with higher rates of all complications. Despite these Goldilocks-IBR demonstrate higher satisfaction, in obese and particularly in severely obese women, Goldilocks-IBR is associated with higher rates of all complications; delayed reconstruction and consideration of other surgical reconstructive options should be considered due to the higher complication rate.

Flying brevet: a technique for mastectomy in female-to-male gender reassignment

Background: Several techniques are described for chest wall contouring in female-to-male (FTM) transgender patients, each with specific applications and limitations. Factors to consider are the aesthetic requirements of the male chest, elimination of anatomical female breast features, operative technique, scar minimisation and success of outcome. We describe the ‘flying brevet’ technique, named for the pattern of excised skin that resembles pilot’s wings. This procedure is tailored to FTM patients but can also be used for large gynaecomastia patients. We present a description of the technique with a retrospective review of outcomes and case series of patients who have undergone this procedure.&#x0D; Methodology: This is a retrospective review of a single surgeon experience with 113 consecutive patients who have undergone the flying brevet technique. The approach involves a semicircular areolar incision, with superior skin resection and glandular resection. A planned second stage procedure may be performed for larger breasts if required.&#x0D; Results: Seven per cent incidence of postoperative haematoma, one case of fat necrosis, one case of partial nipple-areolar-complex (NAC) necrosis and one case of full NAC necrosis in the series. There was one postoperative infection and six per cent incidence of hypertrophic scarring.&#x0D; Conclusions: The flying brevet provides a consistent method of mastectomy for FTM chest wall reconstruction. It permits large glandular and skin resection in ptotic breasts with preservation of NAC circulation. The flying brevet is an additional technique that can be added to the current options for mastectomy in FTM chest wall reconstruction.

Therapeutic Mammoplasty and Dermal Flap: A Novel Hybrid Approach for Chest Wall Reconstruction.

A retrospective review was conducted on patients who underwent chest wall resection and reconstruction using therapeutic mammoplasty and dermal flap to provide soft tissue coverage in the period between 2012 and 2018. Patient's demographics, clinicopathological, radiological, operative details, postoperative morbidity, and follow-up data were recorded. Nine patients with chondrosarcoma (7/9) and giant cell tumor (2/9) were managed with a mean age 44.1 years (range 28-73). Complete oncological resection was achieved in all patients followed by rigid/nonrigid skeletal reconstructions. All procedures were completed successfully with no nipple areolar complex (NAC) necrosis or prosthesis failure experienced during the follow-up period (range 12-72 months). Excellent functional and aesthetic outcomes were reported in all patients. The authors' results demonstrate that this technique could be safely planned for soft tissue coverage postchest wall resection with superior aesthetic and durable outcomes.

Single-Stage Immediate Breast Reconstruction Using Anatomical Silicone-Based Implant and The Hammock Technique of Dermal-Muscle Flap in Large and Ptotic breasts: A Multicenter Study.

This study revisits the previously described technique of inverted-T skin-reducing mastectomy and dermal-muscle pocket as a single-stage breast reconstruction using anatomical implants in large and ptotic breasts. Refinements have been added to enhance the quality of implant coverage, improve aesthetic outcome, and augment the implant volume than previously described in the literature. The study was performed in three centers in the UK, Egypt, and Libya. It included patients with large ptotic breasts with a breast cup size of D or larger. The areola-to-inframammary fold distance is of 8cm or more, and a nipple-sternal notch distance is 25cm or more. Modification of the dermal-muscle flap was made through dividing the medial and lateral ends of the de-epithelialized flap at a distance of one inch to create wings that could be sutured to the free edge of pectoralis major muscle to act as a hammock. It included 42 patients, and the mean age of the patients was 44.4years (range 28-62). The mean body mass index was 34.2 (range 24-42). The reconstruction was unilateral in 32 (76.2%) patients and bilateral in ten (23.8%) patients. The average implant volume was 498.5 CC (range 375-650). Seventeen (40.5%) patients had a symmetrizing breast reduction. The average follow-up time was 52weeks. Major complications were noticed in four (7.7%) breasts: Three breasts had major skin necrosis and one breast had hematoma that necessitated surgical evacuation. There were no reported cases of implant extrusion. Minor complications were recorded in six (11.5%) breasts; two had wound infection, and three had minor skin necrosis. The hammock technique of dermal-muscle flap is safe and versatile in large and ptotic breasts. It also creates a natural-looking breast with bigger implants.

Skin-Reducing Mastectomy and Pre-pectoral Breast Reconstruction in Large Ptotic Breasts.

Pre-pectoral breast reconstruction is increasingly offered to breast cancer patients, as the one-stage technique has proved surgical and oncological safety and aesthetic effectiveness. Nevertheless, there are limited data on outcomes after pre-pectoral breast reconstruction in large and ptotic breasts. The aim of the paper is to present the authors' experience in performing Wise pattern mastectomy with pre-pectoral implant and complete acellular dermal matrix (ADM) coverage as a single-stage procedure in patients with large ptotic breasts. A retrospective review of protective collected data from January 2017 to June 2019 of patients who presented with large and ptotic breasts undergoing skin-reducing mastectomy and immediate pre-pectoral breast reconstruction with complete ADM coverage and inferior dermal sling was performed. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through BREAST-Q questionnaire. Nineteen patients met the inclusion criteria. The average patient age was 55.6years, and the mean body mass index was 31.2. Mean follow-up was 23.2months from the initial reconstruction. One patient experienced seroma, and two cases of wound dehiscence at the T junction were observed and treated conservatively with no implant loss. All patients were satisfied with the final reconstruction. The Wise pattern skin-reducing mastectomy and pre-pectoral breast reconstruction could be offered to patients presenting with large and ptotic breasts. Future studies should better define long-term outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Reconstruction of Large Ptotic Breasts After Nipple-Sparing Mastectomy: A Modified Buttonhole Technique.

As nipple-sparing mastectomies continue to gain popularity, the reconstruction of a large ptotic breast remains a challenge. The purpose of this article is to introduce the senior author's modifications of a novel technique previously described for addressing the redundant skin envelope in ptotic breasts during immediate reconstruction after nipple-sparing mastectomy. In this review, 15 patients (29 breasts) were reconstructed using our modified "buttonhole" technique. Postoperative complications included 1 case of nipple necrosis and 1 case of tissue expander loss secondary to infection. All patients eventually underwent full expansion and exchange to permanent implants. Ultimately, this surgical approach offers immediate reconstruction after nipple-sparing mastectomy while concurrently performing a safe and aesthetically pleasing mastopexy with acceptable risk to the nipple-areolar complex.