1. “Upside-Down” Augmentation Mastopexy
“San Martino” Univ. Hosp. Genova - Italy
Franco Migliori
Plastic Surgery Unit

2. TRADITIONAL MASTOPEXY
Approach from the bottom with I.M.F. incision and/or disruption Gland “push-up”
What we usually do in a traditional mastopexy is
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3. Post-pregnancy and post-bariatric breast
Main problems:
Hypotrophy
Ptosis
“Sled” or “rotated” glands with fixed IMF
Flat and empty breasts
Totally inelastic covering tissues
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4. I.M.F. in ptosis IMF is a well defined anatomical stable structure
In fact, performing a simple diagnostic handling, just stretching the breast forward, we can appreciate the IMSC moving up and we can palpate the IMF fixed and stable
IMF is a well defined anatomical stable structure
IMSC is the external coverage
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5. Ptosis PATHOGENESIS IMF-IMSC increasing distance
How does the ptosis develop?
IMF-IMSC increasing distance
Footprint shrinking (gland sliding on the chest wall)
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6. Breast ptosis detection
Based on N.A.C. position (on the emiclavear line) NAC – IMF = Ptosis (in cm.) Ptosis < 6 cm. = Minor ptosis Ptosis > 6 cm. = Major ptosis “Upside-down” technique is indicated in MINOR PTOSIS
How do I detect the ptosis degree?
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7. Breast volume
No good procedure or device to detect breast volume (i.e. water displacement) Decision determined on surgeon’s measurements and patient’s desires
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8. Implant volume
diameter of the implant = emithorax – 1 cm. (inter- mammary crease) – pinch thickness test; height of the implant (L, M or F, related to the diameter of the implant) = patient’s body structure [Del Yerro] – 2 cm. (see technique); projection of the implant = patient’s desires, BUT the extra-projected (x) implants are strongly suggested with the Upside-Down technique; volume is derived by the measures above.
Decreased by
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9. Problems with implants in ptosis
«Bottoming-out» due to IMF disruption; «Double-bubble» due to sub-muscular implant (the implant is fixed, the gland continues to slide down); Breast collapse: inadequate indications (tissues), inadequate implants (non-cohesive gel)
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10. New maMMARY iMPLAnts
The new generation of anatomical mammary implants lets new procedures inapplicable before:
highly aggressive texture (Velcro©-like capsule, implant grips on the chest wall, gland grips on the implant)
highly cohesive, dual-cohesiveness, gel (stable shape and upper edge, good projection, long-lasting position)
Today new mammary implants can be utilized as “stabilizing” or even “suspending” devices
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11. You can see the different behavior between a standard anatomical implant (410) and a dual-cohesiveness last generation implant (510): the first one tilts under gravitational stress, the second one remains fixed and stable
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12. Undermining of the gland upper pole
“Egg” incision
Undermining of the gland upper pole
Upside-down retroglandular undermining
“Mailbox” implant insertion
Gland fixation and ptosis correction
“Interlocking” peri- areolar suture
So, what does this technique provide?
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13. Upside-down Augmentation mastopexy
You can better see from the lateral view: leaving 2 cm. of gland undetached is remarkable
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14.
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15. I.M.S.C. CORRECTION IMF is where it has always been
IMSC is where it was before correction
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16. POST-OP EARLY ASPECT
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17.
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18. These are two old cases, with old round implants and without interlocking suture
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19.
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20.
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21. Results
231 patients ( ) Av. age 38 (range 31/53) All Caucasian All bilateral Mean operating time 150’ (range 120’/180’) Mean hospital stay 3,5 days (range 2/5) Bra is mandatory for 1 m. d/n + 15 d. only n.
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22. Ptosis recurrence rate
Ptosis recurrence = N.A.C. sliding > cm year post-op
Any technique + implant (50 cases) 27,6 %
Upside-down Augmentexy (50 cases) 9,1 %
(all style 510 implants, av. follow-up 16 months)
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23. Conclusions Advantages: Natural shape Stable position Short scars
Disadvantages:
Long learning curve
Medium/long operating time
Medium/long hospital stay
Last generation dual high cohesiveness anatomical implants are strongly suggested
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24. Final considerations Main features of “upside-down” technique are:
highly natural breast profile produced by a different kind of ptosis correction (the gland is pulled and suspended topside-up and not pushed bottomside- up);
long lasting ptosis correction caused by a double process:
periostium anchorage, strongly holding the gland long enough to let the capsule develop and stabilize
implant itself
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25. AESTHETIC PLASTIC SURGERY
Published online
November 2010
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26.
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