Trading a ptotic breast for a visibly scarred breast with a chance of recurrent ptosis is a poor choice.
Three surgical considerations
Projection
Suspension
Skin excision
Achieving Projection Using glandular flaps to produce coning - Coning is easily produced; however, getting it to last is the biggest problem. Closure of inferior breast pillars is the most secure way to maintain this “compression” over time.
Flowers and Smith – superiorly based parenchymal flap folded onto itself and sutured to the pectoral fascia at the level of the second rib.
Benelli 1990 -
Parenchymal stacking
Pectoralis - Inferiorly based dermoglandular pedicle is passed under a 3cm loop of pectoralis muscle and suspended to the central fascia with tacking sutures (e.g., Graf-Biggs procedure).
controversial from an oncologic point of view whether the pectoralis fascia should be divided, as this will require a more aggressive approach in case of later breast cancer
2cm wide dermal flap pediced on NAC and sutured to pectoralis fascia
glandular suspension
sutures to pectoralis fascia
mesh (Goes)
bipedicled pectoralis sling (Graff-Biggs)
fascial sling
Ritz, Southwick (PRS 2006) – uses bipedicled prepectoral fascia. An inferior based dermoglandular flap is sutured underneath this and the medial and lateral pillars sutured over this.
