Aesth Plast Surg (2009) 33:302–307

DOI 10.1007/s00266-009-9310-7

ORIGINAL ARTICLE

Autoaugmentation Mastopexy with an Inferior-Based Pedicle

Johannes Franz Hönig Æ Hans Peter Frey Æ
Frank Michael Hasse Æ Jens Hasselberg

Received: 21 June 2008 / Accepted: 22 September 2008 / Published online: 19 February 2009
Ó Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2009

Abstract Mammaplasty for breast enhancement and procedure corrects ptosis while increasing the projection
correction of ptosis augmentation is described. Between and apparent volume of the breast when mastopexy is used.
2002 and 2007, autoaugmentation mammaplasty was per- The goal of autoaugmentation mammaplasty is to give
formed for 27 patients (age, 48 ± 7.3 years) using an the breast volume. Using the inferior pedicle described by
inferior-based flap of deepithelialized dermoglandular tis- Ribeiro et al. [3, 4] in 1971 or the vertical pedicle described
sue inserted beneath the breast parenchyma of a superior- by McKissoc [9], volumetric transfer of the back of the
based nipple-areolar complex pedicle. The results con- central pedicle augments the breast projection. At follow-
firmed that autoaugmentation mammaplasty corrects ptosis up evaluation, autoaugmentation mammaplasty is assessed,
while increasing the projection and apparent volume of the with special attention paid to the long-term results in terms
breast. The degree of inframammary fold (IMF) descent of breast shape.
6 months after surgery generally paralleled that of the
nipple. The mean level of the IMF was below the mean
level of the nipple. Postoperatively, the optimum distance
had been largely achieved. The advantage of the technique
is that it optimizes the shape and volume of the breast
without the use of an implant.

Keywords Autoaugmentation mammaplasty

Breast ptosis
Mastopexy

Autoaugmentation mammaplasty is an alternative for

patients with small breasts who desire improvement in their
breast shape without the use of an implant [1–12]. This

J. F. Hönig
F. M. Hasse
J. Hasselberg

Paracelsus Clinic Hannover, Hannover, Germany

J. F. Hönig (&)
Department Plastic Surgery, University Hospital and Medical
School of Goettingen, Robert-Koch-Street 40, 37075 Goettingen,
Germany
e-mail: info@professor-hoenig.de

H. P. Frey Fig. 1 Preoperative view showing the preoperative markings for a

Clinic im Loewen-Center Luzern, Luzern, Switzerland patient undergoing autoaugmentation mammaplasty

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Table 1 Pre- and postoperative evaluation of the NAC positioning Indications

(n = 27)
Distance Preoperative After 6 months After 12 months Autoaugmentation mammaplasty is suitable for patients
(cm) (cm) (cm) with small or ptotic breasts who desire repositioning of
their breasts but do not wish to undergo a breast implant.
N-SN 25.2 ± 0.9 20.2 ± 0.7 21.3 ± 0.6
N-IMF 9.3 ± 0.8 7.1 ± 0.7 7.3 ± 0.3
IMD 3.4 ± 0.1 2.8 ± 0.9 3.2 ± 0.7 Patients and Methods
N-SN distance between the nipple and the sternal notch, N-IMF dis-
tance between the nipple and the inframammary fold, IMD Between 2002 and 2007, autoaugmentation mammaplasty
intermammary distance was performed for 27 patients (age, 48 ± 7.3 years). All

Fig. 2 a Frontal intraoperative view of a patient undergoing auto- on top. c Frontal intraoperative view a patient undergoing autoaug-
augmentation mammaplasty using an inferior-based flap of mentation mammaplasty with a superior pedicle mastopexy technique
deepithelialized skin and subcutaneous breast tissue modulated to using a deepithelialized inferior-based flap. The flap has been sutured
its pedicle inserted beneath a superior pedicle to correct ptosis and to to the pectoralis major fascia. Note the volume of the modulated flap.
increase the projection and apparent volume of the breast. b Lateral d Oblique intraoperative view of a patient undergoing autoaugmen-
intraoperative view of a patient undergoing autoaugmentation mam- tation mammaplasty with a superior pedicle mastopexy technique
maplasty with a superior pedicle mastopexy technique using a using a deepithelialized inferior-based flap. The skin has been draped
deepithelialized inferior-based flap of subcutaneous and breast tissue over the flap
as a foundation with the superior nipple-areola complex (NAC) seated

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Table 2 Pre- and postoperative evaluation of nipple (N) and inframammary fold (IMF) positioning (n = 27)a
Level Preoperative (cm) After 6 months (cm) After 12 months (cm)

N to Y 4.2 ± 3.2 1.2 ± 2.1 1.4 ± 1.8

IMF to Y 5.8 ± 2.2 4.3 ± 1.8 4.8 ± 1.7
a
Level of nipple (N) and level of the inframammary fold (IMF) to Y. Pre- and postoperative lateral views in a series of autoaugmentation
mammaplasties. Y is the midpoint between the tip of the acromion and the lateral epicondyle minus 1 cm

Table 3 Pre- and postoperative evaluation of nipple projection (n = 27)a

Distance Preoperative (cm) After 6 months (cm) After 12 months (cm)

Npr to Ch = Z 4.6 ± 1.2 5.6 ± 1.1 4.9 ± 1.2

a
Projection of the nipple (Npr) to a perpendicular line of the chest (Ch) wall in patients standing erect in a series of autoaugmentation
mammaplasties before and after surgery. Z = distance from nipple to chest wall

the patients underwent a thorough, individualized preop- pedicle was fixed to the pectoralis major fascia without any
erative evaluation to establish a correct diagnosis, exclude restriction behind the NAC (Fig. 2c).
malignancies, and determine the level of the new nipple After the flap was tacked to the chest wall with 3 9 0
position. polydioxanon sutures, closure of the medial and lateral
For all the patients, the distance between the nipple and pillars over the flap optimized upper pole fullness. Closure
the sternal notch, the distance between the nipple and the of the periareloar incision was performed via a round block
inframammary fold, and the intermammary distance were technique using a purse-string suture as described by
measured preoperatively then 6 and 12 months after sur- Hammond et al. [2].
gery (Fig. 1, Table 1).

Surgical Techniques

With the patient under general anesthesia, autoaugmenta-

tion mammaplasty was routinely performed. Markings
were performed preoperatively with the patient in a
standing position (Fig. 1). Establishment of the new nipple
position was the most important step. The best way to
estimate nipple position is by measuring the proposed new
nipple from the fixed point of the suprasternal notch. The
final nipple position was established with the patient sitting
up at 908 on the operating table.
The breast tissue was reconfigured to produce the best
possible shape by narrowing the base dimension and
position of the breast, which usually entailed central
transposition of tissue. This was achieved with a superior
pedicle mastopexy technique using a deepithelialized
inferior-based flap of subcutaneous and breast tissue as a
foundation with the superior nipple-areola complex (NAC)
seated on top (Fig. 2a–d).
The inferior pedicle was drawn with a width of 5 to
6 cm, a length 2 cm below the NAC, and a thickness not
less than 2 cm. After deepithelialization of the periareoalar
and pedicle area, the marked flap was incised. After the Fig. 3 Schematic drawing of the pre- and postoperative measure-
parenchyma had been undermined toward the upper pole, ments of the nipple and inframammary fold (IMF) position. The level
the inferior deepithelialized pedicle was raised and both the of the nipple (N) and the level of the inframammary fold (IMF) to Y
subcutaneous tissues and the breast parenchyma of the are measured in the lateral view in a series of autoaugmentation
mammaplasties pre- and postoperatively. Y is the midpoint (B)
central lower breast were folded beneath the nipple and between the tip of the acromion and the lateral epicondyle minus
areola to maximize upper breast volume (Fig. 2a–d). The 1 cm. X is the level of the IMF measured to Y

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Results The degree of inframammary fold (IMF) descent

6 months postoperatively generally paralleled that of the
The median follow-up period was 18 ± 2.1 months. nipple (Tables 1 and 2). The mean level of the infra-
Immediate healing was achieved without complications, mammary fold was below the mean level of the nipple.
adverse reactions, or side effects. All patients healed Postoperatively, the optimum distance had been largely
uneventfully without any postoperative problems. No achieved. There was a descent of the inframammary fold
swelling or seromatous fluid collection necessitated a sec- and that of the nipple projection as a result of whole breast
ond procedure or a prolonged drainage. No partial or total ptosis (Table 3).
necrosis of the nipple or hypertrophic scarring was detected.
The surgical outcome was evaluated according to anal-
yses performed before and after surgery based on pre- and Discussion
postoperative measurements (Fig. 3). The aesthetic results
were considered good to excellent in all cases, and the Autoaugmentation mammaplasty dates back to Ribeiro’s
contour results were stable in the long-term follow-up [3, 4] report in 1971. This procedure removes breast tissue
evaluation (Figs. 4 and 5). from the area with more tissue and places it in an area with

Fig. 4 a Preoperative frontal view of a patient undergoing autoaug- c Preoperative right oblique view. d Postoperative right oblique view.
mentation mammaplasty using an inferior-based deepithelialized flap Note the projection of the nipple-areola complex (NAC). e Preoper-
in combination with a vertical mastopexy technique for breast ative lateral view. f Later view 12 months after surgery
enhancement. b Postoperative frontal view 12 months after surgery.

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Fig. 5 a Preoperative frontal

view of a patient undergoing
autoaugmentation
mammaplasty using an inferior-
based deepithelialized flap in
combination with a vertical
Lejour reduction/mastopexy
technique. b Postoperative
frontal view 12 months after
surgery. c Preoperative left
oblique view. Note the ptosis
and flatness of the breast.
d Postoperative oblique view
after autoaugmentation
mammaplasty. The nipple-
areola complex (NAC) has an
improved projection without the
use of an implant

a deficit. This tissue works as a natural prosthesis and autoaugmentation mammaplasty is performed. Therefore,
provides good vascularization for the lower portion of the the volume of the inferior pedicle depends on the distance
breast. The inferior pedicle allows shifting of the pedicle between the areola and the inframammary fold. Its upper
under the central parenchyma of the breast behind the NAC limit is located 1 cm below the inferior edge of the areola.
to the area that usually is loose and empty. The technique The distance between the lateral and medial borders of the
also has a conization effect from vertical reduction using breast pillars and the base of the pedicle extending to the
the method described by Lassus [10], Lejour [11] and inframammary crease defines the width of the flap, which is
Marchac [13]. The inferior pedicle preserves the bottoming approximately 6 to 8 cm, with a thickness of 4 cm.
out because the flap is attached to the pectoralis major Compared with a superior pedicle flap or a McKissock
fascia, thereby reducing the weight of the remaining breast. [9] flap, which is folded on itself, the inferior pedicle has
This allows elevation of the inframammary fold and the disadvantage that in cases of a short pedicle, it can not
reduction of the base, as confirmed by our results. How- be folded on itself. Therefore, the milk ducts will not
ever, fixation of the flap to the pectoralis major is critical recanalize because the deepithelialized dermoglandular
[14–20]. It is imperative that a predictable and strong fix- surface is in contact with the sub areola area. Compared
ation to the pectoralis major fascia be obtained because the with the lateral pedicle advocated in some reduction
muscle fibers alone are prone to rupture. mammaplasty procedures for autoaugmentation, which
To achieve aesthetically pleasant pole fullness, a long offers limited recruitment of tissue [12], the inferior pedi-
volumetric pedicle usually is needed when cle is designed to give a better breast shape, with upper

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fullness and more volume, which is imperative in auto- 2. Hammond DC, Khuthaila DK, Kim J (2007) The interlocking
augmention. Ribeiro’s [3, 4] technique, involving rotation Gore-Tex suture for control of areolar diameter and shape. Plast
Reconstr Surg 119:804–809
of an inferior pedicle flap in the upper pole, provides 3. Ribeiro L, Accorsi A Jr, Buss A, Marcal-Pessoa M (2002) Cre-
autoaugmentation mammaplasty improvement of upper ation and evolution of 30 years of the inferior pedicle in
breast fullness, as our results confirmed. reduction mammaplasties. Plast Reconstr Surg 110:960–970
To stabilize the shape and the size of the areola, which is 4. Ribeiro L (1975) A new technique for reduction mammaplasty.
Plast Reconstr Surg 55:330–334
mandatory, we use a round block suture as described by 5. Graf R, Biggs TM, Steely RL (2000) Breast shape: A technique
Hammond et al. [2]. In combination with the pedicle, this for better upper pole fullness. Aesth Plast Surg 24:348–352
provides a conical shape of the breasts with good projec- 6. Graf R, Biggs TM (2002) In search of better shape in mastopexy
tion and gives good long-term results. and reduction mammoplasty. Plast Reconstr Surg 110:309–317
7. Graf R, Biggs TM (2006) Mastopexy with a pectoralis loop. In:
We believe that the autoaugmentation mammaplasty Spear S (ed) Surgery of the breast, 2nd edn. Lippioncott Williams
procedure is suitable for patients with small ptotic breasts & Wilkins, Philadelphia, pp 1008–10039
who desire repositioning of their breasts with autogenous 8. Ramirez OM (2002) Reduction mammaplasty with the ‘‘owl’’
tissue, thereby avoiding insertion of another implant. The incision and no undermining. Plast Reconstr Surg 109:512–522
9. McKissock PK (1972) Reduction mammaplasty with a vertical
described technique can be used with standard inverted dermal flap. Plast Reconstr Surg 49:245–252
T-incisions, vertical incisions with short incision compo- 10. Lassus C (1987) Breast reduction: Evolution of a technique—a
nents, and pure vertical incisions. Depending of the patient’s single vertical scar. Aesth Plast Surg 11:107–112
wishes and the volume of the breast, a bipedicle flap also can 11. Lejour M (1993) Vertical mammaplasty. Plast Reconstr Surg
92:985–986
be used for re-autoaugmentation in certain cases. 12. Hall-Findlay EJ (2002) Pedicles in vertical breast reduction and
mastopexy. Clin Plast Surg 29:379–391
13. Marchac D, de Olarte G (1982) Reduction mammaplasty and
Conclusion correction of ptosis with a short inframammary scar. Plast Rec-
onstr Surg 69:45–55
14. Mottura AA (2003) Circumvertical reduction mastoplasty: New
Autoaugmentation mammaplasty is an alternative for considerations. Aesth Plast Surg 27:85–93
patients with small breasts who desire improvement of 15. Loustau HD, Mayer HF, Sarrabayrouse M (2008) The owl
their breast shape without the use of an implant. It corrects technique combined with the inferior pedicle in mastopexy. Aesth
Plast Surg 32:11–15
ptosis while increasing the projection and apparent volume 16. Widgerow AD (2005) Breast reduction with inferior pedicle
of the breast. The advantage of the technique is that it both fascial suspension. Aesth Plast Surg 29:532–537
minimizes the skin scar and optimizes the shape of the 17. Rohrich RJ, Gosman AA, Brown SA, Reisch J (2006) Mastopexy
breast due to suture fixation of the pillars of the breast preferences: a survey of board-certified plastic surgeons. Plast
Reconstr Surg 118:1631–1638
parenchyma. 18. Pennington DG (2006) Improving the results of inferior pedicle
breast reduction using pedicle suspension and plication. Aesth
Plast Surg 30:390–394
19. Daniel MJ (1994) Mamoplastia com retahlo de musculo peitoral.
References Arch Catarinense Med 23(Suppl 1):119
20. de Araujo Cerqueira A (1998) Mammoplasty: breast fixation with
dermoglandular mono upper pedicle flap under the pectoralis
1. Ramirez OM (2008) The owl technique combined with the muscle. Aesth Plast Surg 22:276–283
inferior pedicle in mastopexy. Aesth Plast Surg 32:16–17

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