Multiplane L Scar Augmentation Mastopexy An.9

COSMETIC
Multiplane L-Scar Augmentation Mastopexy:

An Individualized Approach to Muscle,
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Glandular Tissue, and Skin

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Adel A. Bark, Jr., MD1

Background: Augmentation mastopexy focuses on restoring the youthful
Guilherme C. Minikowski, appearance of the female breast. Despite those benefits, there is large scar-
MSc, MD2 ring to be considered, and the reduction of this side effect is the main goal
Isaac B. U. Mujahed3 to enhance the aesthetic result. This article aims to describe a variation of the
Curitiba, Paraná, and São Paulo, L-shaped mastopexy technique without complex marking and performed in
São Paulo, Brazil planes, which improves long-term results for patients undergoing this approach.
Methods: This is a retrospective, observational study, based on a series of cases
conducted by the author. The preoperative appointment and the surgical tech-
nique are described and divided into steps according to their components:
cutaneous, glandular tissue, and muscular.
Results: Between January of 2016 and July of 2021, 632 women underwent sur-
gery. The mean age was 38 years (range, 18 to 71 years). The mean volume of
implants was 285 cc (range, 175 to 550 cc). All the implants used were round with
a nanotextured surface. The mean amount of tissue resected from each breast was
117 g (range, 5 to 550 g). Follow-ups ranged from 12 to 84 months, and photo-
graphic documentation was performed from 30 days after surgery. Complications
totaled 19.30% and were divided into minor [treated with expectant treatment,
noninvasive, or with the possibility of correction with local anesthesia (10.44%)]
and major [in which it was necessary to return to the operating room (8.86%)].
Conclusions: Multiplane L-scar mastopexy is a versatile and safe technique with
predictable results, which allows the systematic treatment of the most diverse
breast types, with complications similar to other already described and solidi-
fied techniques. (Plast. Reconstr. Surg. 153: 801, 2024.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
T
he breast plays an important role in a with a new shape and volume, in addition to a last-
woman’s femininity.1 According to 2020 ing result.3 Such benefits provided by this proce-
International Society of Aesthetic Plastic dure are associated with considerable scarring on
Surgery data, mastopexy accounted for 5.9% of the breast; reduction of this side effect is the main
all aesthetic operations performed in the world.2 target to enhance the surgical aesthetic result.4
The objective of these breast operations is to Currently, the most used technique is the
restore the youthful aspect of the female breast, inverted T-scar mastopexy, which has gained pop-
ularity because of its relatively easy replicability,
From 1private practice; 2Escola Paulista de Medicina, usually with good results.5–7 However, the medial
Universidade Federal de São Paulo; and 3Universidade aspect of the horizontal scar in the inframammary
Federal do Paraná. fold is often unsightly8 and typically the subject of
Received for publication June 22, 2022; accepted March 30, patient complaints,1,7 as it is easily seen when the
2023.
Presented at the Inova Plástica, held virtually, November
22, 2021; South American Plastic Surgery Meeting, in Disclosure statements are at the end of this article,
Cartagena, Colombia, May 12 through 14, 2022; 26th
following the correspondence information.
World Congress of the International Society of Aesthetic
Plastic Surgery, in Istanbul, Turkey, September 20 through
24, 2022; and Worldwide Live Surgery, in São Paulo,
Brazil, October 20 through 22, 2022. Related digital media are available in the full-text
Copyright © 2023 by the American Society of Plastic Surgeons version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000010850
www.PRSJournal.com 801
Copyright © 2023 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • April 2024
patient wears a bikini or shows her cleavage. This breast, usually 9 to 11 cm from the superior
limits the range of clothing for these women, and limit of the upper pole.
it may cause a decline in some women undergo- 6. Complementary liposuction areas.
ing mastopexy.
Since the beginning of the twentieth century, With the patient in the supine position, the L
several authors have published techniques with an angle is marked, which corresponds to the mea-
L-shaped scar or contributions to the techniques surement of one-fourth of the thoracic diameter,
already described.9–13 However, none of them usually between 7 and 9 cm from the midline.
became popular among plastic surgeons, mainly
because of the complex preoperative mark- Surgical Technique
ings and difficult replicability. In this article, the Multiplane is a different way to perform a
authors aim to describe a variation of the L-shaped mastopexy. It treats the breast components—skin,
mastopexy technique without complex markings parenchyma, and muscle—independently. Thus,
and performed in planes that allow great stability. separating these structures is fundamental, con-
sidering that the final L scar is asymmetric and
the parenchyma is symmetrically treated, avoiding
PATIENTS AND METHODS the redundant parenchyma seen medially on tra-
Study Design and Informed Consent ditional L-scar techniques.
Under general anesthesia, the preopera-
This is a retrospective, observational study, tive marking is reinforced with the patient
based on a series of cases conducted by the author, in the supine position. The cutaneous com-
performing multiplane L-scar mastopexy. This ponent is treated in two steps. The initial step
study was conducted following the ethical stan- allows wide access to the breast parenchyma
dards of the Declaration of Helsinki. All patients and the muscular plane. The final step involves
signed the consent form. the resection of excess skin and adjustments
Inclusion criteria were female patients, aged to the L-shaped scar.
older than 18 years, with grade 1 to 3 breast ptosis
(of the Regnault classification)14 and body mass Cutaneous Component
index below 30 kg/m2. Excluded were patients
Initially, periareolar deepithelialization is per-
who did not want implants included or presented
formed for the construction of the upper pedicle,
breast asymmetry in which one breast did not
respecting a safety margin of 2 cm below point A,
require mastopexy, patients who smoked, and
which will be determined and confirmed in the
patients with a body mass index greater than or
second stage of the cutaneous component. Then,
equal to 30 kg/m2.
an L-shaped incision is performed, starting from
the marking of the L-angle line 2 cm above the
Preoperative Appointment inframammary fold, in a vertical and superior
Simplified preoperative marking only involves direction. When this line does not meet the are-
highlighting a few important points and anatomi- ola, the incision is shifted to the medial edge of
cal landmarks, with no need to mark the amount the areola. Then, a thin dermofat detachment is
of skin to be resected. With the patient standing performed in a medial and lateral direction of
in front of the surgeon, the following are marked: approximately 4 cm (Figs. 1 and 2). [See Video 2
[See Video 1 (online), which demonstrates the (online), which demonstrates the initial surgical
fast and simple preoperative marking step.] incision stage, which has unique and important
characteristics for the final surgical result. See
1. Midsternal line. Video 3 (online), which demonstrates how an arti-
2. Breast meridian: line joining the midcla- ficial plane is created by incising the breast tissue,
vicular point to the center of the ipsilateral forming a dermofat flap separated from the glan-
breast. dular tissue. This is an important step to treat the
3. Inframammary fold. compartments separately and avoid skin necrosis
4. Upper pole of the breast: upper limit of the because of the composite flap.]
projection of the breast to the bimanual
compression maneuver of the lower pole. Glandular Component
5. Point A: projection of the ideal point of The treatment of the glandular component
the nipple-areola complex (NAC), which starts with an inverted-T incision [the vertical
should be positioned at the center of the component corresponding to the center of the
802
Volume 153, Number 4 • Multiplane L-Scar Augmentation Mastopexy
Fig. 1. Undermining of the skin of the gland with a thin dermofat flap, pre-
serving the vascularization of the subdermal plexus. This detachment allows
complete access to the breast parenchyma. The author recommends using
electrocautery with low power to avoid thermal damage.
Fig 2. Complete access to the breast parenchyma after the dissection of the
dermofat flap. Then, we started the treatment of the glandular component,
separating it from the muscle, which allows independent treatment of the
cutaneous and muscular components, giving more lateral, medial, and infe-
rior support, decreasing the chance of any implant displacement.
803
Fig. 3. Modified dual-plane mastopexy, with the preservation of the lateral

and medial sling muscle.
breast and the horizontal component following by Tebbetts, a modified submuscular pocket
the inframammary fold (IMF)] until the iden- is made in a minimally traumatic manner and
tification of the pectoral muscle, followed by a with prospective hemostasis, preserving the lat-
wide detachment of the mammary gland, disso- eral and medial muscle bands. The pocket is
ciating the glandular component (medially, the washed with Adam solution,15 followed by the
same as a subglandular breast implant pocket; placement of the implant using an insertion
superiorly, up to the upper pole preoperative funnel (Fig. 3).
marking; and laterally, until the anterior axillary The breast parenchyma is fixed to the pec-
line) from the muscular component. The entire toral muscle in a customized way, ascending
breast parenchyma is then resected, preserving the central parenchyma—superior to the NAC,
a homogeneous layer 2 to 3 cm thick up to the and with descending traction of the medial
upper pole, reducing its volume and preventing and lateral parenchyma, simulating the “water-
Snoopy and/or waterfall deformity. [See Video fall effect,” and reducing the dead space. The
4 (online), which demonstrates the step in which horizontal and vertical excess of the columns is
the breast tissue is incised uniformly in a dome resected, followed by the suturing of the medial
shape, leaving a 2- to 3-cm surface layer and and lateral pillars. This step allows the symmet-
removing the deep excess. This makes it easy to ric treatment of the parenchyma, despite the
symmetrize the breasts.] asymmetric final scar. The new IMF16 is fixed
with Stratafix 1 barbed suture. [See Video 5
Muscle Component (online), which demonstrates the last stage of
The next step involves treating the muscular the glandular tissue molding, where resections
component. Following the principles published of the medial and lateral pillars are performed,
804
first in the inferior horizontal direction and Table 1. Incidence of Postoperative Complications,
later in the medial vertical direction. On the Separated into Major and Minor
vertical resection, it is important to make a Complication No. (%)
horizontal incision in the breast tissue proxi- Major
mal to the areola, avoiding excess tissue at that Breast asymmetry 8 (1.27)
location.] Lateral displacement of the implant 9 (1.42)
Waterfall deformity 6 (0.95)

Bottoming-out 9 (1.42)
Cutaneous Component
Capsular contracture 9 (1.42)
The last step involves the treatment of Poor positioning of the implant 12 (1.90)
excess skin, and this is done regardless of pre- Symmetrization of the inframammary fold 1 (0.16)
vious gland resection. The medial and lateral Hematoma 2 (0.32)
skin flaps are also detached and are crossed Minor
with a smooth traction; the medial flap is pulled NAC repositioning 14 (2.22)
laterally and the lateral flap medially. The Excess skin 38 (6.01)
excess skin is marked, resected, and sutured. NAC enlargement 9 (1.42)
This maneuver creates an inferior dog-ear. The Medial excess skin 1 (0.16)
NAC position is defined as the point of great- Partial NAC necrosis 1 (0.16)
est projection of the breast, generally respect- Dehiscence 3 (0.47)
Seroma 0 (0.00)
ing the initial marking of 9 to 11 cm from the
Total 122 (19.30)
upper pole of the breast. At this stage, the 2 cm
left as a safety margin can help to reposition
the NAC more caudally, if necessary. The infe-
rior dog-ear is marked and resected laterally, silicone implants were used on both sides,
resulting in the final L-shaped scar. Finally, except for 10 patients who had more significant
refinements are made according to the needs breast asymmetries. All the implants used were
of each patient, which involves complementary round with a nanotextured surface. The mean
liposuction of the armpits and lateral regions tissue resected was 117.45 g from each breast
of the breasts, fat grafting, correction of excess (range, 5 to 530 g). Postoperative follow-up
skin, and contralateral symmetrization. [See ranged from 12 to 60 months, and photographic
Video 6 (online), which demonstrates that documentation of each patient was performed
the first two stitches of the subdermal suture from 30 days after surgery.
are the most important. First, we position the The complications observed totaled 19.30%
vertical incision where the scar should be; the of all the cases and were divided into minor com-
first stitch will form the L angle and the sec- plications (ie, adjustments of the areola-papillary
ond stitch over the vertical incision without complex, lateral excess skin, medial excess skin,
performing skin compensation. From the sec- partial damage to the NAC, dehiscence, and
ond stitch, we can start the compensations. seroma), which could be treated as noninvasive,
See Video 7 (online), which demonstrates with the possibility of correction with local anes-
that before suturing the skin, it is necessary thesia or expectant treatment (10.44%); and
to resect the excess skin and trim the edges major complications (ie, breast asymmetries, lat-
of the incision to even out them. See Video 8 eral displacement of the implant, poor superior
(online), which demonstrates that excess skin positioning of the implant, waterfall deformity,
forms a dog-ear at the base of the breast, which bottoming-out, capsular contracture, symmetri-
will be resected, resulting in the horizontal zation of the inframammary fold, hematoma),
component of the L-shaped scar.] which were necessary to return to the operating
room (8.86%). All the complications are summa-
rized in Table 1.
RESULTS
Between January of 2016 and July of 2021,
632 patients underwent surgery performed by DISCUSSION
the senior surgeon, totaling 1264 breasts. All For over 30 years, the association of the best
the patients were women aged between 18 and aesthetic result with the smallest possible scar has
71 years, with a mean age of 38 years. The mean been considered the standard in breast surgery.7,11
volume of implants used was 285.82 cc (range, The absence of an apparent scar in the cleavage
175 to 550 cc). In all the cases, identical round lines is the desire of every patient, especially the
805
younger ones and those with more pigmented ptosis and constricted lower pole; and helps to
skin.7 The technique discussed belongs to the prevent serious deformities during movements
group “short-scar technique.”14 As described in related to the total submuscular plane.17,18 The
its essence, it is based on the reshaping of the authors agree with the idea presented by Xue
breast parenchyma and redraping of the skin et al.,19 in which it is stated that large implants
envelope.5 In addition to this concept, the author (ie, >300 cc) have higher rates of ptosis recur-
recommends the understanding and treatment rence, among other complications, such as
of the muscular component separately, and that greater alteration in the blood supply of the
is why this technique is called multiplane L-scar NAC, and high tension leading to pathologic
mastopexy. scarring and alteration of the IMF, leading to
One of the most important aspects of this bottoming-out. The largest implants performed
technique is based on the remodeling of the by the author were used in the first 2 years of
breast parenchyma and consequent reduction the present study and had the highest number
of its base, which favors its projection. Most tech- of complications.
niques with inverted-T scars do not change their As discussed by Beale et al., augmentation
base, often leading to a more square appearance mastopexy with implants has high rates of com-
and little projection.5,7 plications and reoperations because its nature
Although they seem to be a great idea, involves diametrically opposed forces.20 The inci-
L-shaped techniques are not widely accepted dence of postoperative complications presented
among surgeons. This occurs mainly because of by this study is in line with the one published
the difficulty imposed by the complex preopera- by Khavanin et al., who carried out a systematic
tive marking7 and the nonseparation and indi- review and meta-analysis of the literature on
vidualization by planes, which makes it difficult to mastopexy with implants.21 Twenty-three articles
adapt to different types of breasts, leading to low were included, with 4856 treated patients, and an
replicability among surgeons. average of 13.12% postoperative complications
The simplified marking, with just a few ana- (range, 6.7% to 21.3% postoperative complica-
tomical points, is one of the greatest advantages tions) in general.
of the multiplane L-scar mastopexy, different Although some studies show capsular con-
from previously described techniques, because tracture as the main cause of complications and
it reduces the time in the preoperative process, reoperations,21,22 approximately 3%, in this study
is easier to replicate, provides customization we present a rate of 1.32%. This can be explained
for each case, and has a faster learning curve. by the fact that most of our patients still have a
Another essential aspect of the technique is the short-term follow-up, in addition to mainly hav-
treatment of each plane independently, which ing used submuscular and nanotextured surface
makes the method replicable for the most var- implants.22–24
ied forms and volumes of breasts because the Moreover, the reoperation rate presented
surgical procedure remains the same for all of by the meta-analysis was 10.65% (range, 6.7% to
them. 15.4%), higher than the 4.18% presented in this
As shown in Figures 4 and 5, a long-lasting study, which, according to the authors, results
result with good breast projection is possible.5 (See from the systematization of the technique, treat-
Figure, Supplemental Digital Content 1, which ing each component separately, with greater
shows additional photographs of the patient in predictability of results. Finally, as in this study,
Fig. 5; preoperative oblique anteroposterior views. there was a higher incidence of complications
The resected tissue of the left and right breasts related to breast tissue than those related to
was, respectively, 295 g and 175 g. The implants implants.
used were 275 cc on both sides, http://links.lww. The nanotextured breast implant was used in
com/PRS/G552.) all the operations performed in this study, which
The choice of the dual plane, following the had an excellent degree of safety and low rates of
principles described by Tebbetts,17 associates early and late complications. The nanotexture of
the lateral18 and medial muscular sling; not the implant is characterized by having a surface
only keeps the implant more stable, but also that optimizes biocompatibility, presenting a uni-
increases surgical versatility; improves the rela- form topography. Because of these characteristics,
tionship between the implant and soft tissues; the nanotexture has a significantly lower risk of
promotes more predictable results regarding complications when compared with the microtex-
large parenchymal mobilities; avoids glandular tured implant.25
806
Fig. 4. Preoperative and postoperative images (obtained at 1 year 3 months) of a 26-year-old woman; anteroposte-
rior, oblique anteroposterior, and lateral views. The resected tissue of the left and right breasts was, respectively, 180
and 210 g. The implants used were 275 cc on both sides.
Mastopexy with implants is still one of the CONCLUSIONS

most challenging plastic surgical operations. Multiplane L-scar mastopexy is a versatile, safe
Over the years, several authors have defended technique with predictable results, which makes
the idea that there would be an ideal technique it possible to systematically treat the most diverse
for each type of breast and degree of ptosis.14 In types and degrees of ptosis and breast deformity,
our view, the technique described here, by disso- without the need for complex markings and with
ciating the planes, redistributing the tissues, and reduced scars and a consistent number of com-
systematizing the surgical steps, can treat all types plications compared with other already described
of breasts, presenting a pattern of stable results. and solidified techniques.
807
Fig. 5. Preoperative and 5-year postoperative images of a 45-year-old woman; anteroposterior, oblique
anteroposterior, and lateral views. The resected tissue of the left and right breasts was, respectively, 295 g and
175 g. The implants used were 275 cc on both sides.
808
Adel A. Bark, Jr., MD 10. Bozola AR. Breast reduction with short L scar. Plast Reconstr
1183, Prefeito Angelo Lopes Street Surg. 1990;85:728–738.
Curitiba, Paraná, Brazil 11. Chaves L, Cerceau M, Magalhães H. Mastoplastia em “L”: um
adelbarkjr@hotmail.com novo desenho. Rev Soc Bras Cir Plast. 1988;3:40–48.
@dradelbarkjr 12. Chiari A Jr. The L short-scar mammaplasty: a new approach.
Plast Reconst Surg. 1992;90:233–246.

13. Chiari A Jr. The L short-scar mammaplasty 12 years later.
DISCLOSURE Plast Reconstr Surg. 2001;108:489–495.

The authors have no financial interest to declare 14. Regnault P. Breast ptosis definition and treatment. Clin Plast
Surg. 1976;3:193–203.
concerning the content of this article. 15. Adams WP, Rios JL, Smith SJ. Enhancing patient outcomes
in aesthetic and reconstructive breast surgery using triple
PATIENT CONSENT antibiotic breast irrigation: six-year prospective clinical
study. Plast Reconstr Surg. 2006;117:30–36.
Patients provided written informed consent for the 16. Montemurro P, Avvedimento S, Hedén P, Quattrini Li A. A
use of their images. four-layer wound closure technique with barbed sutures for
stable reset of the inframammary fold in breast augmenta-
tion. Aesthet Surg J. 2016;36:966–971.
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