Egypt, J. Plast. Reconstr. Surg., Vol. 31, No. 1, January: 57-61, 2007 Restoring Upper Pole Fullness in Reduction Mammaplasty and Mastopexy IKRAM SAFE, M.D.; AHMED ELSHAHAT, M.D. and HEBA HUSSEIN, M.D. The Department of Plastic Surgery, Faculty of Medicine, Ain Shams University. ABSTRACT Advances in techniques of reduction mammaplasty and mastopexy lead to the adoption of the concept of vertical techniques. This concept is based on parenchymal resection and reshaping rather than skin excision and re-draping. Vertical techniques controlled the bottoming out sequence of other techniques but left the upper pole deficient. The aim of this work was an attempt to increase the success of the vertical principle by restoring the upper pole fullness in reduction mammaplasty and mastopexy. Two steps were needed to achieve this goal. First, the ptotic upper breast was freed from the deep (pectoral) fascia. Then, it was re-fixed to the same fascia at a higher position using a superiorly based infraareolar dermofas- cial flap. Forty patients were operated upon using this technique in the period between January 2004 and January 2006. Seating Owl-shaped markings of Oscar Ramirez were used. Upper pole fullness was achieved on the operating table. Follow up for at least six months showed maintenance of the results. We con- cluded that both undermining of the ptotic breast from deep fascia and re-suspension at a higher level were essential to restore the upper pole fullness. This procedure had no adverse effect on the blood supply or sensation of the breast. INTRODUCTION The dominant supply to the integument of the anterior chest is from the following sources: The internal thoracic artery medially, especially from the 2 nd and 3 rd interspaces; the lateral thoracic artery laterally; the anterior intercostals arteries inferiorly, especially from the 4 th and 5 th intercos- tals spaces and from the acromiothoracic perforator superiorly. These vessels anastomose in the vicinity of the nipple-areola complex [1]. Corduff and Taylor [1] imagine the developing breast as a tissue expander which is fixed to the skin at the nipple. Expansion results in elongation of the supplying vessels and their compression towards the periphery of the gland forming a vas- cular hood. Ricbourg [2] termed this vascular hood “cutaneo-glandular plexus”. Within the boundary of this vascular perimeter is a relatively avascular plane between the under- surface of the breast and the deep (pectoral) facia. 57 The breast is supplied by vessels that penetrate the gland from the vascular hood following the con- nective tissue framework between the breast lobules [1]. Therefore the glandular tissue is supplied by retrograde flow from the cutaneo-glandular plexus. The breast being a skin appendage (a modified sweat gland) is enclosed within superficial fascia [3]. Part of this fascia is anterior to the breast and the other part is posterior. The anterior layer of the superficial fascia is an indistinct fibrous fatty layer that is connected to but is separate from dermis and from breast tissue [4,5]. The posterior layer of the superficial fascia has fascial extensions to the underlying deep (pectoral) fascia. These extensions fix the breast to the pectoral fascia. As breast size increases, these connections become looser as a result of gravitational forces and the so called retro- mammary (retro-glandular) space is formed [5]. Therefore enlarged breasts are usually ptotic and have deficient upper pole. Correction of this ptosis and restoration of upper pole fullness during breast reduction or mastopexy necessitates under- mining of the breast from the deep (pectoral) fascia and restoring the anchor points between the breast and the deep (pectoral) fascia to their original superior position. To achieve this goal Marchac and deOlarte [6] introduced the concept of upper glandular plication and suspension to the pectoralis fascia. Lejour [7,8] adopted the same concept. Dermofascial suspension using the anterior layer of superficial fascia and the overlying dermis to fix the breast high up to the deep (pectoral) fascia was described by Grotting et al. [9] for mastopexy and Awad et al. [10] for reduction mammaplasty. Other techniques introduced a chest wall based flap into the upper pole to hold the upper gland up and provide upper pole fullness [11-17].