Inverted-T Mastopexy With Glandular Treatment and Breast Augmentation: Outcomes and Stabilization Approach

Summary:

Long-term stability in mastopexy and augmentation-mastopexy remains challenging, particularly in patients with dense or ptotic glandular tissue, where skin-based reshaping alone may result in recurrent ptosis or contour distortion. We evaluated a glandular tissue–specific constraining element release technique designed to improve breast shape durability and nipple–areola complex (NAC) elevation. A multicenter retrospective analysis was performed in Venezuela, Mexico, and Peru, including 417 consecutive patients who underwent mastopexy or augmentation-mastopexy between January 2017 and December 2021. The technique consisted of selective release of glandular and aponeurotic restrictive elements while preserving key vascular pedicles, with implant placement when indicated. Outcomes assessed included NAC elevation, postoperative complications, and patient satisfaction at 1-year follow-up. Patients ranged from 17 to 64 years; 67.63% presented glandular hypertrophy with ptosis, and 32.37% had ptosis or hypotrophy. Mean NAC elevation was 7.5 cm (range, 5–9 cm). Complications included 3 cases of total NAC necrosis (all secondary procedures), 13 cases of partial NAC compromise, 10 hematomas, 11 partial wound dehiscences, 3 seromas, and 5 reoperations for shape-related issues. At 1 year, 78% of patients were very satisfied, 18% were satisfied, and 4% were dissatisfied. Selective glandular release with preservation of vascular pedicles provides reliable NAC elevation and stable breast shaping, with complication rates comparable to established techniques.

Takeaways

Question: How can a long-lasting and aesthetically satisfactory breast shape be achieved in mastopexy with implants, despite the challenges of glandular tissue memory and postoperative relapse?

Findings: Long-lasting and stable breast shape in augmentation-mastopexy can be achieved by selective release of glandular and aponeurotic constraining elements while preserving vascular pedicles, allowing effective nipple–areola complex elevation and reduced postoperative relapse.

Meaning: This technique offers a reproducible and durable solution for mastopexy, addressing glandular memory and enhancing long-term outcomes while maintaining a low complication profile.

INTRODUCTION

Breast ptosis reflects a mismatch between the skin envelope and glandular content, making inverted-T mastopexy challenging due to scarring, shape control, and long-term stability.¹ Traditional techniques—especially with implants—often yield persistent width, inadequate rounding, and recurrent ptosis. These limitations motivated the development of a technique that achieves a more stable and predictable shape. By selectively releasing glandular constricting elements, it allows an average 7-cm nipple–areola complex (NAC) elevation, improves tissue mobility, and enhances long-term contour stability.^2–5

MATERIALS AND METHODS

This multicenter study adhered to the Declaration of Helsinki and received institutional ethics approval at all participating clinics. Trained plastic surgeons in Venezuela, Mexico, and Peru applied the glandular tissue–specific constraining element release technique described by the principal author.

A total of 417 consecutive patients underwent surgery between January 2017 and December 2021. Ages ranged from 17 to 64 years. Of these, 282 (67.63%) patients presented with glandular hypertrophy and ptosis, and 135 (32.37%) had ptosis or glandular hypotrophy alone. The technique achieved NAC elevation ranging from 5 to 9 cm, with an average lift of approximately 7.5 cm in breasts with standard glandular density.

SURGICAL TECHNIQUE

Preoperative Marking

With the patient standing, the NAC position, breast base width, and lower pole ptosis are assessed. Clamp testing defines the new inframammary fold, and incision points are verified in a slight recline. Adrenaline (1:300,000) is infiltrated along the markings.

Incisions and Dissection

After de-epithelialization, horizontal IMF incisions allow access to the glandular plane while preserving the prepectoral aponeurosis. Dissection extends to the third intercostal space, maintaining medial and lateral limits and preserving key perforators.

Glandular Reshaping

Lower pole resection is performed, and 2 vertical incisions create a superiorly based central flap supplied by the second internal thoracic perforator. These controlled releases reduce tension, allow reliable flap ascent, and preserve vascularity while generating medial and lateral flaps supported by internal thoracic and lateral thoracic/acromial branches.^6,7 (See Video [online], which displays the general view of glandular reshaping.)

Video 1. This video displays the general view of glandular reshaping.

Download video file ^{(6.9MB, mp4)}

Implant Placement

Subpectoral access is obtained through a 4-cm oblique incision at the fourth intercostal space. Selective myotomies of the deep pectoralis major fibers are performed between the 4- and 9-o’clock positions, extending toward the sixth rib as needed. The inferior muscle sheath and prepectoral aponeurosis are preserved.

Closure and Shaping

After implant insertion, the muscle is closed, key sutures are placed at the inverted-T junction, and glandular coning is achieved with 3 base-to-apex sutures. Excess central flap tissue is trimmed, the PDA is repositioned, and areolar symmetry is refined with a low-tension 3-0 Prolene suture.

Postoperative Care

Drains are kept for 48 hours, followed by nonadherent antibacterial dressings with changes at day 5. Patients are reviewed every 3 days for 21 days, then monthly until month 5, and again at 1 year.

Satisfaction Survey

At 1 year, patients completed an online aesthetic satisfaction survey, which was analyzed with SPSS. Statistical analysis was performed in SPSS software (See table, Supplemental Digital Content 1, which displays the the postoperative satisfaction survey, https://links.lww.com/PRSGO/E757. See table, Supplemental Digital Content 2, which displays postoperative satisfaction with aesthetic outcomes, https://links.lww.com/PRSGO/E758.)

RESULTS

A total of 417 female patients without comorbidities underwent surgery. Patient age ranged from 17 to 64 years (mean, 34.3 y). Mean weight was 61.8 kg, height 1.62 m, and body mass index was 24.6 kg/m² (Table 1). Breast hypertrophy with glandular ptosis was present in 67.63% of cases, whereas 32.37% presented with ptosis or hypotrophy. Of all procedures, 146 were primary and 271 were secondary (previous reduction or mastopexy).

Table 1.

Results of Satisfaction Survey

Level	n	%
Very satisfactory and satisfactory	400	96.00
Indifferent	0	0.00
Unsatisfactory	17	4.00
Total	417	100.00

Rounded implants were used in all patients, most commonly 330 and 285 mL (range, 180–485 mL). The mean glandular resection volume was 230 g (range, 92–530 g). NAC elevation ranged from 4.5 to 8 cm (Fig. 1). Mean operative time was 4 hours (range, 3–6 h).

Fig. 1.

Clinical photographs of a patient with moderate breast ptosis. A, Preoperative view. B, Postoperative view after structural breast mastopexy with implants using an inverted-T (Krulig) technique.

Complications included 3 cases of total NAC necrosis, all in patients with a history of breast reduction. Thirteen patients developed partial-thickness NAC compromise (<50%), attributed to venous congestion. Notably, 3 of these patients had a recent COVID-19 infection, and venous microthrombosis in the Haller circle was observed 2 weeks postoperatively; although temporally associated, causation could not be confirmed.

Additional complications included 3 early seromas requiring ultrasound-guided drainage, 11 partial midline dehiscences (all in secondary cases), 10 hematomas (3 submuscular and 7 glandular), 3 infections associated with hematoma and fat necrosis, and 5 reoperations for recurrent breast shape deformity.

At 1-year follow-up, 78% of patients reported being very satisfied, 18% satisfied, and 4% dissatisfied. Dissatisfaction was primarily related to recurrent ptosis, regression toward the preoperative breast shape, and hypertrophic scarring.

DISCUSSION

Despite the wide range of mastopexy techniques described, achieving long-term breast shape stability—especially in patients with dense or ptotic glandular tissue—remains difficult. Previous studies have shown that skin-based shaping is limited, as the intrinsic “memory” of the glandular tissue often leads to recurrent ptosis or lateral displacement even when resections are technically adequate.^2–5,8

This technique addresses these limitations by selectively releasing glandular and aponeurotic constricting elements that define breast shape. By treating the gland as the primary structural framework and the skin as a tension-free envelope, it minimizes reliance on dermal support—aligning with prior glandular-based reshaping methods that enhance projection and improve long-term contour stability.⁹

Our findings show that controlled glandular release, together with preservation of key vascular pedicles, enables stable breast coning and consistent NAC elevation averaging 7.5 cm in standard glandular density. The complication profile was comparable to other mastopexy-augmentation series, with vascular-related issues more common in secondary cases or those requiring more extensive elevation. This highlights the need for careful preoperative tissue assessment and meticulous intraoperative protection of vascular supply.^10–12

Precise knowledge of pedicle vascularity is essential for flap viability and minimizing NAC complications. When indications and technique are appropriately followed, complications remain uncommon. Most events related to tension or vascular compromise occurred in secondary cases or when NAC elevation exceeded 7 cm.

CONCLUSIONS

The technique described provides more consistent and durable outcomes, offering versatility for managing diverse presentations of breast ptosis. Overall, this method is a useful option for patients with complex glandular anatomy or a risk of recurrent shape change, although longer term follow-up and comparative studies are needed to clarify its advantages over traditional mastopexy approaches.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.