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Khan. Plast Aesthet Res 2018;5:45 I http://dx.doi.org/10.20517/2347-9264.2018.58 Page 3 of 14

A B

Figure 1. Intraoperative picture and illustration of patient showing incision at the lower end of vertical scar single staged mastopexy with
augmentation (A, B)

Markings and technique
After taking careful history and examination, patient’s breast measurements are taken. Markings for masto-
pexy are selected on the basis of NAC and IMC measurements. Selection of size of the implants is made for
each patient according to the selected markings and patient’s requirements where possible. Limitation of in-
crease in breast cup size is explained to the patient. When vertical or Wise pattern scar is selected, no more
than two cup sizes are promised. Patients presenting with breast asymmetry and chosen for vertical or Wise
pattern scars, have more tissue excised from larger breast with similar size breast implants placed on both
sides. Patients presenting with breast asymmetry and selected for periareolar scars, are managed with differ-
ent size implants.

All patients are marked in standing position with medially based flap and 4.2 cm NAC. IMC is taken as a
reference for neo-NAC repositioning. Patients with NAC to IMC measurements of less than 5 cm and with
a lack of skin envelope are selected for Benelli periareolar markings. Patients with measurements between
5 cm to 8 cm are selected for vertical scar and patients with NAC to IMC measurement of more than 8 cm
are best suited for Wise pattern scar. Patients with pseudoptosis and wishing for an increment of at least
three breast cup sizes are considered for periareolar mastopexy with implants, even if they present with
more than 5 cm NAC to IMC distance.

Single-staged mastopexy with augmentation is performed as a day case under full general anaesthetic with
full muscle relaxation. A single intravenous dose of Cephalosporin is given followed later by an oral course
of antibiotics for five days. No drains are used for this procedure. Existing IMC is marked along with new
position of the nipple, usually 1.5 cm higher than IMC. In vertical and Wise pattern scars mastopexy,
Keyhole for neo NAC is marked with upper margin of the neo-NAC, 2.5 cm higher than the marked neo-
nipple position. Medial and lateral margins of the neo-NAC are marked at 3.5 cm from the centre of the
keyhole. From this point two lines, 2.5-3 cm long each, are dropped, gently curving down centrally to leave 5-6
cm as the neck of the keyhole. From the neck of keyhole, 5-7 cm long gently curvilinear lines are dropped
down and generally 6-8 cm apart at its widest. In vertical scar markings, the lines are extended inferiorly
toward the central line drawn between the mid-clavicular points to a mid-point on IMC, generally 8.5-9 cm
from body midline. These vertical markings end 2 cm higher than the existing inframammary crease and
a cat’s tail extension is drawn laterally for the prevention of dog-ear. In Wise pattern markings, 5-7 cm long
medial and lateral markings are extended to the medial and lateral extent of the marked IMC crease. This
transverse wedge or ellipse of skin helps to raise the existing IMC, control and reduce postoperative NAC
and IMC measurements and limits available skin envelop to prevent future bottoming out. Implant pocket
is accessed through an incision made at the lower end of the Cat’s tail marking or middle of the transverse
crease, which is about 5 cm wide [Figure 1A and B]. After initial subglandular pocket in lower and outer