Aesth Plast Surg
https://doi.org/10.1007/s00266-021-02481-3
ORIGINAL ARTICLE
Mastopexy with an Implant and the Making of a Horizontal Flap
of the Upper Pedicle, Simulating an Internal Bra
Getulio Duarte Junior1 • Fábio Coelho Duarte2 • Andre Cervantes3
Received: 14 April 2021 / Accepted: 11 July 2021
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2021
Abstract
Introduction Mastopexy with an implant is undoubtedly
one of the most challenging surgeries in cosmetic surgery
since it involves two overlapping procedures. The aim of
this study was to demonstrate that by using horizontal
glandular flaps in the sulcus in mastopexy with implants, it
is possible to reduce the number of postoperative
complications.
Methods Sixty-three female breast surgery patients with
some degree of flaccidity who underwent surgery from July
2018 to January 2020 were selected. All surgeries were
performed in one procedure with an initial resection of the
excess skin associated with a horizontal flap of the upper
pedicle that promoted the protection of the implants and
decreased the surgical wound tension.
Results Forty-seven patients were included in the sample,
for a total of 94 breasts. The motivation of the surgery was
esthetic in all cases. Related to complications, we had 1
(1.06%) case of seroma, 1 (1.06%) case suffering from
areola necrosis, 6 (6.3%) cases with scar revisions, 10
(10.6%) cases with complications in the transition from the
‘‘T’’ and no case of hematoma, infection or extrusion of the
implants. The follow-up time was 12 months.
& Getulio Duarte Junior
drgetulioduarte@hotmail.com
1
Serviço de Cirurgia Plástica ‘‘Professor Ronaldo Pontes’’,
Universidade de Marı́lia – São Paulo –Brazil, Hospital
Niterói D’or – RJ, Alameda das Quaresmeiras 30,
condomı́nio Vale do Canaã, Marilia, SP 17525-454, Brazil
2 repair at the hospital level after female breast surgery. The
Serviço de Cirurgia Plástica ‘‘Professor Ronaldo Pontes’’,
Hospital Niterói D’or – RJ, Niterói, Brazil
3 after augmentation surgeries with implants was 1.40%, that
Instituto Thuler & Cervantes, Head of Section of Post-
Bariatric Plastic Surgery - Hospital Alemao Osvaldo Cruz,
Sao Paulo, Brazil
BREAST SURGERY
Conclusion This technique allows the surgeon to perform a
resection of excess skin and place the implants in one
procedure, thereby decreasing the tension in the suture line,
protecting the implants and forming a protective stabilizing
brace in the mammary groove.
Level of Evidence 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.
Keywords Mastopexy with implants
Mastopexy

Mammoplasty
Breast implants
Upper pedicle flap

Bottoming out
Introduction
Mastopexy with the inclusion of implants is a combination
of two routine plastic surgical procedures. Variations
related to mammoplasty techniques [1–4] and the many
different types of implants make this procedure one of the
most challenging in cosmetic surgery.
The esthetic gain with the association of the two tech-
niques is indisputable. On the other hand, there is an
increase in the incidence of complications [5] since two
overlapping surgical procedures need to be performed.
In 2017, Gupta et al. [6] conducted a study on 71,110
patients in a database of an insurance company in the USA
regarding esthetic complications that needed some surgical
rate of complications that required a hospital-level stay
after mastopexy was 1.15% and that after mastopexy with
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Fig. 1 a Marking of the

horizontal flap type in a wing
design, indicated for patients
with the position of the papillary
areola complex 2 cm above the
BC marking. b decortication of
the flaps; c coverage of the
implant with the lateral, central
and medial flaps; d illustrative
drawing

implants was 1.86%, showing a significant increase when
we combined the two surgeries.
The aim of this study was to demonstrate that by using
horizontal glandular flaps in the sulcus in mastopexy with
implants, it is possible to reduce the number of postoper-
ative complications.
The age of the patients varied between 19 years and 68
years (mean 39 years) and 3 patients smoked (6.3%). All
patients signed an informed consent form, medical and
surgical, authorizing the surgery and the publication of the
case.

Patients and Methods
In the present study, 63 consecutive female breast surgery
patients with some degree of flaccidity underwent surgery
from July 2018 to January 2020 at the Hospital Beneficente
de Marı́lia (ABHU)-SP/Brazil. For the inclusion criteria, 47
patients with breast flaccidity and grade I, II or III ptosis
were selected as described by Regnault [7]. The exclusion
criterion was patients with breast hypertrophy. In these
cases, we performed reduction mammoplasty with an
inferior pedicle flap as described by Ribeiro et al. [8]
Operative Technique
The patients were photographed in the pre- and postoper-
ative periods using a standardized technique. Skin resection
marking was performed on the eve of the surgery following
the A, B, C, D, E patterns described by Pitanguy [9], but
we did not perform digital clamping to mark the distance
between points ‘‘B’’ and ‘‘C.’’ We did conduct traction of
the medial and lateral flaps toward the mammary meridian,
as explained below. With the patient in an orthostatic
position, we determined the ‘‘A’’ point, which varied from
17 to 19 cm, with an average of 18 cm as a reference for the
sternal furcula. At this time, we also demarcated the

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Aesth Plast Surg
Fig. 2 a Fixation of the lateral
flap exceeding the median line;
b relaxation incision in the
dermis; C illustrative drawing
mammary groove. Next, we placed the patient in the supine
position; we drew two lines in the shape of an arc, i.e., one
medial and the other lateral between the ‘‘A’’ point and the
mammary meridian in the groove. This drawing was car-
ried out by pulling the breast in the medial and lateral
directions. The marking of the mammary meridian in the
groove varied from 9 to 11 cm, with an average of 10 cm as
a reference from the central, presteronal region. Points ‘‘B’’
and ‘‘C’’ were positioned in this arciform design at a dis-
tance of 9 to 11 cm from point ‘‘A’’, with an average of 10
cm. We always manually pulled the flaps drawn in the
medial and lateral directions until points ‘‘B’’ and ‘‘C’’
reached the mammary meridian in the groove to ensure that
the flaps were tension-free after insertion of the implants. If
points ‘‘B’’ and ‘‘C’’ reached the mammary meridian with
tension in the traction of the flaps, they were repositioned
slightly more centrally or more inferiorly so that the flaps
had a correct positioning and their pillars were centralized
without tension between points ‘‘B’’ and ‘‘C.’’ The length
of the slope varied from 5 to 7 cm with an average of 6 cm.
At the end of the markings, we took a photograph and
checked the symmetry of the markings on the computer
image, correcting any differences between them.
The implant we used was round in shape with a high or
extra high projection and a polyurethane foam coating in
the retroglandular plane in all cases. The volume ranged
from 155 cc to 380 cc, with an average of 235 cc.
The surgery patients were placed under general anes-
thesia in a hospital environment. The patients were in the
supine position with their arms abducted. At certain
moments in the surgery, we placed the patient in a sitting
position to check the positioning and symmetry of the
breasts and implants.
During the surgical procedure, we first performed a
resection of the surplus skin, together with the creation of
the flaps and the space. Next, the implants were placed and
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Fig. 3 a Fixation of the medial

flap over the lateral flap,
exceeding the median line;
b fixation of the two
overlapping flaps as a strap for
protection of the end of the
slope with the remaining central
flap. We observed complete
protection of the implant;
c schematic drawing

Fig. 4 a Marking of the

mastopexy with little skin
flaccidity, showing the complex
of the high papillary areola and
a short distance between points
‘‘B’’ and ‘‘C;’’ b fixation of the
horizontal flap of the upper
pedicle in block without
bipartition in the muscular
fascia

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Aesth Plast Surg
Fig. 5 a and b Observe the marking of the type II horizontal flap,
associated with a small inferior flap in the shape of a ‘‘finger,’’
performed in those cases where the papillary areola complex is less
than 2 cm from the BC marking or below it; c visualization of the 3
flaps already made; d illustrative drawing; e observe the flap in the
protected with the flaps. We will describe below how we
made the flaps.
A horizontal flap in a wing design has two variants to
promote the complete protection of the implants and is
directly linked to the position of the papillary areola
complex in relation to the ‘‘BC’’ marking. When the edge
of the areola was 2 cm from the ‘‘BC’’ marking, we per-
formed a horizontal flap type I, which was made of three
flaps of the upper pedicle: medial, central and lateral
(Fig. 1A–D).
Horizontal flap type I is made after the decortication of
the epidermis between the ‘‘CD’’ and ‘‘BE’’ markings.
Being 2 to 3 cm in length, the width of the flap will depend
on the size of the base of the breasts, with its medial limit
ending at 2 cm from point ‘‘D’’ (the end of the medial
marking) and the lateral limit would be up to the anterior
axillary line or ending at 2 cm from point ‘‘E’’ (the end of
the lateral marking). The vascularization of the flap is
randomized and it has an upper base, the thickness of
which is approximately 3 cm. We split this flap when point
‘‘B’’ was far from point ‘‘C’’ and preserved the central flap
‘‘finger’’ design of the lower pedicle after fixing the horizontal flaps
on the muscular fascia; f illustrative drawing; g positioning the flap in
a ‘‘finger’’ design between the horizontal flaps, protecting the slope
and the implant; and h fixation of the ‘‘finger drawing’’ flap at the
base of the areolar flap
between these points. The position of inclusion of the
implants was retroglandular at the author’s option in all
cases, but retromuscular and subfascial pockets could also
have been used. At the end of the inclusion of the implants,
the horizontal dermoglandular flap was attached to the
muscular fascia with 4.0 nylon thread. First, the lateral flap
must be fixed to the muscular fascia, passing the line of the
breast meridian and moving the breast in the medial
direction, and a relaxation incision in the dermis should be
made at the end of the fixation (Fig. 2A–C).
Next, the medial flap crosses the median line overlap-
ping the lateral flap and is fixed in the muscular fascia. The
ideal is not to leave the flaps with tension in this fixation.
We made a relaxation incision in the dermis after fixing the
flaps (Fig. 3A–C).
In cases where the areola was high, with little tissue
flaccidity and, consequently, a small distance between the
‘‘B’’ and ‘‘C’’ markings, the upper pedicle flap was made
differently, fixed in the muscular fascia en bloc, without
bipartition, as shown in Fig. 4A and B.
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Fig. 6 Photograph of pre- and

postoperative mammoplasty
with polyurethane implants at 6
months (PolitechÒ), volume of
235 cc, high profile (MHS),
bilateral

The other variant of the horizontal flap is type II, which
is indicated when the edge of the areola is close to the
‘‘BC’’ mark, that is, at a distance \2 cm from the ‘‘BC,’’
for which there is a need for superior rotation of the pap-
illary areola complex. In these cases, the lower 1/3 of the
slope has little coverage for the implants after the areola
ascends.
We then associated a small, decorticated flap (in the
shape of a finger), with a 3 cm base and 4 cm height for the
lower base in the position of the breast meridian, to which
it would be positioned on the slope, being able to be free,
fixed on the lateral pillars and medial or fixed at the base of
the areola pedicle. To better accommodate the finger flap in
the ‘‘BC’’ region, we left a small space between the fixation
of the lateral and medial flaps (Fig. 5A–H).
All surgeries were drained in a closed vacuum system
for a period of approximately 24 hours.
Nylon 4.0/5.0/6.0 and PDS 5.0 were used to close the
breast.
Results
Forty-seven patients were included in the sample, for a
total of 94 breasts. The motivation for the surgery was
esthetic in all cases. Of these, 32 (69%) were primary
surgeries and 13 (29%) were secondary surgeries. We

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Fig. 7 Pre- and postoperative
photographs at 8 months after
mammoplasty with
polyurethane implants
(PolitechÒ), volume of 275 cc,
high profile (MHS), bilateral
made upper pedicle flaps associated with a flap in the
‘‘finger’’ design of the lower base in 60 (63.8%) breasts. In
34 (36.1%) breasts, we only made a horizontal flap of the
upper pedicle because the papillary areola complex was in
a high position in relation to the ‘‘BC’’ marking. See below
some pre- and postoperative results in Figs. 6, 7 and 8
In the present study, there was no case of hematoma;
however, 1 (1.06%) breast had early seroma in the first
week after surgery. This was a patient with previous
mammoplasty and capsular contracture associated with late
seroma who was previously biopsied and found to be
negative for markers of giant cell anaplastic lymphoma. In
this specific case, the seroma was treated with block
capsulectomy with implants and closure of the lateral pillar
with adhesion points. The seroma resolved in approxi-
mately 4 weeks after serial punctures directly into the space
and corticosteroid therapy. There was no seroma fis-
tulization through the suture line. The follow-up of this
patient was 12 months with no recurrence of the seroma or
contracture.
We observed a small amount of postsurgical reaction at
the junction of the flaps (‘‘T’’) in 10 (10.6%) breasts, but
without exposure of the implants and with favorable res-
olution of the cases. In this series, there were 3 breasts in
smoking patients, 3 breasts in secondary surgery patients, 2
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Fig. 8 Pre- and postoperative
photograph at 6 months after
secondary mammoplasty with
polyurethane implants
(PolitechÒ), volume of 250 cc,
extra high profile (MXS),
bilateral
breasts in a patient who performed early physical activity
and 2 tuberous breasts where the flaps became tenser.
Figure 9 shows the transition from the ‘‘T’’ to which it
was debrided and the complete protection of this region by
the flap.
Revision of the scar was necessary in 6 breasts (6.3%),
in 2 cases due to hypertrophic scars and in 4 cases due to
unsightly scarring on the slope. One breast (1.06%) had
partial necrosis of the papillary areola complex, which
resolved with pigmentation. See Fig. 10 for a summary of
the indications for the horizontal flap types 1 and 2.
There were no cases of reoperation due to dissatisfaction
with the result, infection or removal of the implants. See
Table 1.
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Aesth Plast Surg
Discussion
Different surgical techniques and tactics have been
described for the protection of breast implants in breast
surgeries in the past 4 decades. In 1980, Tansk [10]
described a work with the title ‘‘A new method for pro-
phylactic mastopexy,’’ which reported the protection of the
implants by using a lower-base dermal flap in a retrog-
landular space. In 1990, Bostwick [11] published the pro-
tection of the implants in a retromuscular space by making
a pocket in the lower-base dermal flap, which was sutured
in the pectoralis major and serratus anterior muscle during
breast reconstructions. Later, in 2002, Hamnond et al. [12]
used the same flap to protect breast expanders and then
performed the surgery in two stages.
Aesth Plast Surg

Dermoglandular flaps with a lower base, based on the

Fig. 9 Postsurgical reaction at the ‘‘T’’ transition with complete
protection of the implant by the horizontal flap of the upper pedicle
Ribeiro [8] technique, were adapted to protect the implants
and published by Mansur and Bozola [13] in 2009, Garcia
et al. [14] in 2010 and Pessoa et al. [15] in 2013, which was
a series of cases with satisfactory and encouraging results
since they presented a decrease in the complication rates.
In 2013, Forcada et al. [16] described making 4 flaps to
protect the implants and performing the surgery in one
procedure. In 2017, Vita et al. [17] published a retrospec-
tive study with 207 patients using a lower-base dermog-
landular flap called the ‘‘Balcony Technique’’; more
recently, in 2020, Mansur et al. [18] demonstrated the
construction of two upper and lower fascioglandular flaps
and making a pocket after suturing between them, thereby
aiming to protect the implants.
The horizontal flap of the upper base described in the
present work, similar to the dermoglandular flaps described
above, aims to provide greater safety while performing the
mastopexy associated with the breast implant. The safety
provided by the horizontal flap of the upper pedicle occurs
by the formation of a barrier in the suture line and in the
mammary groove, protecting the implant from the external

Fig. 10 Summary of the

indications

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Table 1 Complication rates
Complications
Hematoma
Seroma
Scar revision
Necrosis of the areola
Infection
Extrusion of the implant
Postsurgical reaction at the ‘‘T’’ transition
The follow-up time was 12 months.
environment and avoiding fistulas, contamination and
extrusion. The addition of a lower-base flap in a ‘‘finger’’
design helps to protect the implants in the vertical suture
line in those cases where there is a need for upper rotation
of the papillary areola complex.
The present study describes a horizontal dermoglandular
flap that is similar to other glandular flaps in relation to
implant protection. However, the innovation of this tech-
nique is that there is decreased tension on the surgical
wound, as there is a transfer of this force to anchor the flaps
in the deep muscle plane, similar to what happens in
abdominoplasty with adhesion points, as described by
Baroud et al. [19] and Pollock et al. [20]
The fact that the lateral horizontal flap, which pulls the
breast in the medial and inferior directions, makes a real
decrease in the tension in the vertical suture line and in the
mammary fold thereby promotes the stabilization of the
mammary parenchyma. The transposition of the medial
horizontal flap in a jacket over the lateral flap helps to
stabilize the entire breast and seals the region of the
mammary fold in type 1 flaps. At the end of the fixation of
the flaps, we noticed little mobility of the breast tissue due
to its anchoring in the deep tissue. To our understanding,
this would help not only to protect the implants and reduce
tension on the suture line but also help to prevent seromas
and hematomas. Studies demonstrated a decrease tension in
the surgical wound with a low incidence of seroma, using
negative pressure, as published by Ryu et al. [21] and
Galiano et al. [22]
The fixation of the horizontal upper dermoglandular flap
in the muscular fascia would theoretically decrease breast
and implant ptosis since it is a pexy of the breast tissue in
the thoraco-abdominal wall. In addition to anchoring deep
tissues, the flaps form a barrier in the breast groove, similar
to the action of a bra, which would help to prevent ‘‘bot-
toming out.’’
Currently, mastopexy with implants can be performed in
2 surgical procedures or in one procedure. Horizontal flap
type 1 and type 2 allowed us to perform it all in one pro-
cedure with a low incidence of complications, even in
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Aesth Plast Surg
N = 94 Breasts Percentage
0 0%
1 1.06%
6 6.3%
1 1.06%
0 0%
0 0%
10 10.6%
secondary cases. Studies published by Ali et al. [23] and
Colobrace et al. [24] also demonstrated a low incidence of
complications in a single procedure combining mastopexy
with implants. The resection of the excess skin before the
insertion of the implants provides greater precision in the
correction of sagging and symmetrization of the breasts.
The surgery time is shorter when we perform resection of
the excess skin before insertion of the implants. Because
marking is performed before the surgery, we avoid adding
any additional surgical time. We believe that the stabi-
lization of the breast parenchyma with a decrease in tension
in the suture lines is an important factor in the good evo-
lution of these cases.
Regarding the limitations of our study, I would like to
mention the small number of cases studied, the absence of
a control group, the limited size of the implants studied and
the fact that only macrotexture implants were analyzed in a
retroglandular plane.
Despite the lack of analysis of other textures and other
detachment plans, we believe that the horizontal flap, since
it is easy to perform and safe, will be useful in surgeries in
the retromuscular and retrofascial planes and when smooth
implants and different textures are used.
Conclusion
Breast remodeling surgery, due to the effects of gravity and
time on the breasts, has assumed an important role in the
daily routine of plastic surgeons in recent years. Different
techniques and different approaches have been widely
discussed and researched for this surgery.
A one-procedure surgery with initial resection of the
excess skin proved to be safe with the use of a horizontal
flap for the upper base, thereby helping to protect the
implants with a reduction of tension in the suture line and
in the stabilization of the breast tissues and implants and
presenting good esthetic results with a low incidence of
complications.
Aesth Plast Surg
Declarations
Conflict of interest The authors declare that they have no conflicts of
interest.
Ethical Approval All procedures performed in studies involving
human participants were conducted in accordance with the ethical
standards of the institutional and/or national research committee and
with the 1964 Helsinki Declaration and its later amendments or
comparable ethical standards.
Informed Consent All patients provided informed consent.
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