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Page 6 of 11 Nicholson et al. Plast Aesthet Res 2018;5:34 I http://dx.doi.org/10.20517/2347-9264.2018.30

Figure 5. Creation of a conical breast mound and hitching the gland to an elevated position on the chest wall by suturing dermal wings to
rib periosteum in a superior direction

The essential dermoglandular suspension consists of a 2-0 prolene suture from the chest wall - either rib
periosteum or the pectoralis fascia at the upper aspect of the undermined skin flap - to the superior aspect of
the central mound, roughly half way from the base to the superior edge of the de-epithelialised vertical strip.
It is tied loosely to avoid tissue ischaemia. With the same suture, a further bite is taken at the superior part
of the de-epithelialised dermal strip and tied just tight enough to elevate the nipple to its new height. Thus
the mound is sutured to a new higher position on the chest wall. Again, this is not tied tightly so as to avoid
restricting the plication of the inferior part of the dermal strip later.

The dermal wings are sutured to the chest wall in a superior direction, wrapping partly around the central
mound with 2-0 prolene [Figure 5]. If sutured at an adequate height on the chest, the IMF is lifted slightly,
and the overall effect of wrapping the dermal wings around the gland is to create a youthful cone-shaped
breast mound for the skin envelope to be re-draped over.

To enhance this cone shape, the supero-medial aspect of the medial and lateral dermal wings are sutured to
the sides of the NAC, and the infero-lateral aspect of the wings are sutured to the chest wall.

The nipple is then partially inset using 3-0 vicryl, with a suture superiorly, inferiorly, then medially and
laterally.

The necessary plication of the inferior dermal strip is performed using 3-0 Polydioxanone [Figure 6]. The
distance from the nipple to IMF along the dermal strip is reduced to a length that corresponds to the vertical
edge of the skin envelope and the desired nipple-to-IMF distance.

If required, the IMF ligament is reinforced or reconstructed by suturing the dermis at the IMF, particularly
at the corner of the vertical dermal strip, to the chest wall using 2-0 ethibond. Latterly we have used
additional de-epithelialised dermal flaps based inferiorly at the IMF incision as anchors for strength of the
sutures between the IMF and chest wall. Suturing between dermis and periosteum or pectoralis fascia is
more robust than suturing into the fibrofatty tissue around the IMF.