PRISMA (Pectoralis–Rib Implant Support and Muscle Adjustment): An Innovative Technique for Secondary Mastopexy

Abstract

Background:

Secondary mastopexy following breast augmentation is technically challenging due to altered anatomy, compromised soft tissues, and increased complication risk. This study aims to describe a novel technique (PRISMA [pectoralis–rib implant support and muscle adjustment]) incorporating dual-plane implant placement with muscular support and to evaluate its safety and aesthetic outcomes in revisionary cases.

Methods:

A prospective observational cohort study was conducted on 74 female patients undergoing secondary mastopexy between January 2023 and January 2026. All patients had prior breast augmentation and underwent surgery using a modified dual-plane technique with muscular fixation. Standardized anthropometric breast measurements were obtained preoperatively, immediately postoperatively, and at 12 months. Descriptive statistics and paired t tests were used for analysis.

Results:

Mean age was 44 years, and all patients underwent dual-plane implant placement. Correction of ptosis was achieved in all cases. Improvements were observed in anthropometric parameters, including clavicle-to-nipple distance (mean reduction of ~ 5.3 cm bilaterally; P < 0.001) and clavicle-to-upper implant border distance (P < 0.001), indicating improved nipple position and upper pole fullness. Inferior pole measurements demonstrated controlled expansion without bottoming out. Outcomes remained stable at 12 months. The overall complication rate was 6.76%, with no cases of infection, hematoma, or total nipple–areola complex necrosis.

Conclusions:

The PRISMA technique demonstrated effective and durable correction of ptosis with stable anatomical repositioning and low complication rates. Objective anthropometric analysis supports its reproducibility and structural reliability in secondary mastopexy. Despite limitations, this approach represents a safe and effective option for complex revision breast surgery.

Takeaways

Question: Can a mastopexy technique with rib-anchored muscle support optimize outcomes in secondary breast surgery?

Findings: The PRISMA (pectoralis–rib implant support and muscle adjustment) technique was applied in 74 patients with prior breast augmentation. It resulted in consistent nipple–areola complex elevation (average 5.3 cm), improved upper pole projection, and low complication rates (4.05%) during 6 months of follow-up.

Meaning: PRISMA is a reproducible and safe approach for secondary mastopexy, offering quantifiable improvement in aesthetics and structural implant support through pectoral–rib anchoring and muscle adjustment.

INTRODUCTION

The increasing global prevalence of primary breast augmentation, combined with the aging of the original implant population, has led to a notable surge in demand for secondary breast procedures, particularly revisionary mastopexies with or without implant exchange.¹ Unlike primary mastopexy or augmentation-mastopexy, secondary mastopexy presents unique anatomical, technical, and aesthetic challenges due to altered tissue planes, scarred capsules, preexisting asymmetries, compromised vascularity, and patient expectations shaped by prior surgery.^2,3 Consequently, the secondary mastopexy has emerged as one of the most complex procedures in aesthetic breast surgery, requiring a comprehensive understanding of surgical history and a highly individualized, safety-oriented approach.^4,5

Historically, the combination of breast augmentation with mastopexy was viewed as a “recipe for disaster” due to the competing mechanical goals of increasing breast volume while simultaneously tightening the skin envelope.³ These 2 forces (expansion and reduction) are intrinsically antagonistic, and when superimposed on tissue that has already undergone surgical manipulation, the risk of complications such as wound dehiscence, implant malposition, bottoming out, and nipple–areola complex (NAC) necrosis increases exponentially.^4,6 Secondary augmentation-mastopexies are not only technically demanding but also highly litigated, with studies reporting revision rates of 8%–20% and dissatisfaction often arising from unmet expectations and unpredictable soft-tissue response.^4,7

One of the principal limitations in secondary mastopexy is the compromised quality of the soft-tissue envelope, particularly in patients who have experienced postoperative atrophy, weight loss, radiation, or capsular contracture.^2,8 The vascular anatomy is of critical concern, especially when performing full-thickness resections or repositioning the NAC, as the blood supply may have been altered by prior surgery. Several authors have emphasized the need for careful intraoperative planning and minimal undermining to preserve perfusion, particularly when using periareolar or vertical techniques.^5,6,9

In response to these challenges, multiple strategies have been proposed in the literature. Spring et al³ advocated for a standardized classification of surgical options and complication management in secondary augmentation-mastopexy, underscoring the importance of individualized planning and avoiding a one-size-fits-all approach. Abdelkader et al¹⁰ proposed a 5-step algorithmic strategy to evaluate patients and guide decision-making regarding implant position, skin excess management, and soft-tissue adaptation. Salibian et al² reported favorable long-term outcomes using a Wise-pattern secondary mastopexy in patients who had undergone 2-stage subcutaneous implant reconstruction after nipple-sparing mastectomy, highlighting the importance of delayed intervention for better symmetry and aesthetic improvement.

Techniques involving plane change, particularly conversion from subglandular-to-subpectoral placement, have also gained traction in revision cases. Ono and Karner¹ presented a 4-step subglandular-to-subpectoral conversion technique that offers inferolateral muscular support and reduces implant mobility, with low complication rates and high patient satisfaction. Similarly, other authors have introduced the concept of triple-plane augmentation-mastopexy to manage severe ptosis, particularly in cases of massive weight loss or glandular deflation, by combining subfascial, subglandular, and subpectoral dissection.⁷ These innovations reflect the evolving surgical paradigm in which safety, longevity, and structural support are prioritized over mere aesthetic enhancement.

The complexity of secondary mastopexy is further heightened by the variability in ptosis patterns and tissue elasticity. The Regnault classification remains a useful tool for grading ptosis; however, it must be interpreted in the context of previous incisions, implant type, and capsule behavior.^4,6 Physical examination should be complemented by a thorough review of operative history, patient expectations, and photographic documentation of previous procedures. In patients with limited skin redundancy or high-positioned inframammary folds (IMFs), periareolar techniques may be effective for correcting mild ptosis with minimal scarring.⁵ However, in more severe cases or those requiring greater NAC transposition, Wise-pattern or vertical approaches are often necessary, despite the increased risk of wound complications.^2,9

Despite its technical demands, secondary mastopexy can achieve excellent outcomes when performed with rigorous surgical planning, anatomical precision, and appropriate technique selection. Emerging data suggest that patient satisfaction remains high when goals are aligned with surgical feasibility, and complications are proactively mitigated through algorithmic intraoperative strategies.^1,10 Furthermore, innovations such as implant pocket conversion, structural reinforcement with muscular slings, and delayed NAC transposition have redefined the landscape of revisionary breast surgery.

In this context, we introduce a novel technique for secondary mastopexy that addresses the limitations of current approaches. This article aims to describe the surgical technique, analyze its safety and aesthetic outcomes, and position it within the evolving body of evidence surrounding complex breast revision procedures.

METHODS

Study Design

A prospective observational cohort study was conducted using data from the medical records of patients operated on by Dr. Zamir Paez in Medellín, Colombia. The study covered the period from January 2023 to January 2026.

Subjects

The study population consisted of 74 female patients who underwent secondary mastopexy with dual-plane implant placement, either as a standalone breast procedure or in combination with other body-contouring procedures such as abdominoplasty or liposuction. All patients had previously undergone breast augmentation with implants. Preoperative evaluations were carried out to ensure surgical eligibility and included clinical and photographic documentation of mammary ptosis. Patients with connective tissue disorders, active smoking habits, or significant comorbidities contraindicating surgery were excluded from the study.

Materials and Variables

The study database included the variables summarized in Table 1.

Table 1.

Study Database Variables

Type of Variable	Variable
Sociodemographic information	Age
	Height
	Weight
	BMI
	Ethnicity
Clinical information	Personal medical history
	Previous surgical procedures
	Surgical time
	Type of simultaneous surgical procedures (if applicable)
	Implant volume (removed and placed)
	Indication for revision
Anthropometric breast measurements (preoperatively and postoperatively)	Clavicle-to-nipple
	Clavicle-to-upper pole of implant
	Nipple-to-IMF
	IMF-to-costal margin
	Clavicle-to-costal margin distances
Outcomes	Improvement in ptosis
	Surgical complications
	Stability of anatomical repositioning at 12 mo

BMI, body mass index.

Anthropometric Measurements

Anthropometric measurements of the breasts were performed in a standardized manner with the patient in an upright position and arms at rest, using a flexible measuring tape and marking key reference points along the midclavicular line. Measurements included clavicle-to-nipple distance, clavicle-to-upper edge of the implant (palpable or visible transition), nipple-to-costal margin, inferior pole-to-costal margin, and clavicle-to-costal margin. These were recorded preoperatively, immediately postoperatively, and at 6-month follow-up. All measurements were performed by the surgical team to ensure consistency.

Surgical Procedure

The PRISMA (pectoralis–rib implant support and muscle adjustment) technique is indicated for secondary mastopexy cases requiring pocket adjustment due to implant lateralization and/or caudal displacement in patients with prior dual-plane or retromuscular breast augmentation. (See Video 1 [online], which displays the initial surgical stages, focusing on safe explantation and capsular evaluation. Key steps include precise dissection along the pectoralis major, assessment of tissue integrity, and preservation of vascularized planes to optimize implant coverage.) (See Video 2 [online], which highlights the innovative core step of the PRISMA technique—the lateral border of the pectoralis muscle is released, and a personalized pocket is designed based on the implant size.) (See Video 3 [online], which demonstrates how to collocate and cover the implant.)

Video 1. Retirement of previous implant. This video demonstrates the initial surgical stages, focusing on safe explantation, capsular evaluation. Key steps include precise dissection along the pectoralis major, assessment of tissue integrity, and preservation of vascularized planes to optimize implant coverage.

Download video file ^{(5MB, mp4)}

Video 2. Design of personalized pocket. This segment highlights the innovative core step of the PRISMA technique—first the lateral border of the pectoralis muscle is released, a personalized pocked is designed based in the implant size.

Download video file ^{(10.6MB, mp4)}

Video 3. Implant colocation and layered closure in the PRISMA mastopexy. This clip demonstrates how to collocate and cover the implant.

Download video file ^{(8.1MB, mp4)}

Preoperative Marking

The new areolar position is marked at 16–18 cm from the sternal notch, measured along the breast meridian. This distance is individualized according to the planned implant dimensions, thoracic proportions, and tissue compliance. The selected point must align with the midclavicular line, which generally corresponds to approximately 10% of the patient’s body height, ensuring anatomical proportionality.

The vertical limb length is determined by measuring the distance from the point of maximal projection of the selected implant to the inferior implant border, subtracting 2 cm, while accounting for a standard areolar diameter of 4 cm. The medial and lateral extent of the horizontal resection component is defined using a pinch test to avoid excessive tension and minimize the risk of dog-ear formation.

Surgical Technique

Initial Dissection

Following preoperative marking, the procedure begins with an incision at the IMF. A supracapsular dissection is then performed in a cephalad direction, elevating a supracapsular breast flap until the pectoralis major muscle is identified. The dissection continues in a suprafascial plane, fully exposing the lateral and superior borders of the pectoralis major muscle and extending approximately 3 cm inferior to the clavicle.

Capsular Management (Baker Grades I and II)

A capsulotomy is performed to remove the previous implant. The lateral border of the pectoralis major muscle is identified within the pocket, and a directed capsulotomy is carried out to release the muscular edge. Electrocautery may assist in the precise identification of the muscle fibers. A critical step is performing a cephalic capsulotomy at the superior portion of the pocket. This maneuver allows controlled caudal advancement of the pectoralis major muscle and facilitates the creation of a new implant pocket in a more cephalic position.

Creation of the New Pocket

After completing the superior capsulotomy, a customized pocket is designed according to the dimensions of the selected implant. A sterile implant sizer is temporarily positioned over the rib cage to assess projection, symmetry, and ideal implant boundaries. If a sizer is not available, the definitive implant dimensions are directly marked on the chest wall to guide pocket dissection.

Muscular Fixation and Structural Support (PRISMA Concept)

Personalized fixation of the pectoralis major muscle is performed using #0 polydioxanone sutures. The inferior limit of fixation corresponds to the anterior border of the sixth rib, whereas the lateral fixation is determined by the base width of the planned implant. An inferolateral pectoral muscular sling is reconstructed through controlled myotomies, allowing adequate caudal advancement of the muscle. The pectoralis major is then anchored to the rib cage, and the IMF is reinforced and fixed to the sixth rib using #0 polydioxanone suture.

Capsular Management (Baker Grades III and IV)

In cases of Baker grade III or IV capsular contracture, a total capsulectomy is performed. The pectoralis major muscle is then released laterally and reanchored to the rib cage according to the dimensions of the selected implant to recreate a type I dual-plane configuration, complemented by a lateral pectoral muscular sling, thereby optimizing upper pole projection.

Tissue Coverage and Closure

A superomedial glandular flap is designed to ensure complete implant coverage and reinforce soft-tissue support. Controlled thinning of the breast flaps and glandular tissue is performed, leaving a final thickness of approximately 2–3 cm to preserve vascularity while optimizing contour. Breast conification is then carried out, followed by layered closure of the incisions.

Ethical Considerations

All patients signed an informed consent form before surgery that included authorization for the surgical procedure, photographic documentation, and use of anonymized data for academic research purposes. Participation was voluntary, and patients retained the right to withdraw consent at any time. This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the local ethics committee.

Statistical Analysis

Descriptive statistics were used to summarize patient demographics and surgical characteristics. Paired t tests were used to compare preoperative, immediate postoperative, and 12-month anthropometric measurements. A P value of less than 0.05 was considered statistically significant. Analyses were conducted using Jamovi statistical software (The jamovi project, version 2.5; https://www.jamovi.org).

RESULTS

A total of 74 female patients were included in the study. The mean age was 44 years (SD 6.8 y), average height was 1.61 m (SD 0.048 m), mean weight was 64.8 kg (SD 6.77 kg), and the average body mass index was 25.1 kg/m² (SD 2.56 kg/m²). Regarding ethnicity, most patients were Latina (n = 62), and the remaining were White (n = 12) (Table 2).

Table 2.

Demographic Characteristics

Variable	Measure of Central Tendency, n (%)	Dispersion Measurement
Age, y	Mean: 44	SD: 6.8
Weight, kg	Mean: 64.8	SD: 6.77
Height, m	Mean: 1.61	SD: 0.048
Ethnicity	Total: 86	NA
Latino	62 (83.7)
White	12 (16.2)

Among the patients, 24 reported having at least 1 medical condition, accounting for a total of 34 diagnoses. The most frequent conditions were hypertension (n = 12), dyslipidemia (n = 8), and asthma (n = 8). All patients had previously undergone breast augmentation surgery. In terms of prior procedures, 22 had undergone liposuction, 12 abdominoplasty, and 6 rhinoplasty (Table 3).

Table 3.

Medical History Characteristics

Variable	Measure of Central Tendency, n (%)	Dispersion Measurement
Medical history	Total: 34 diagnoses	NA
None	40 (54.05)
High blood pressure	12 (16.21)
Dyslipidemia	8 (10.81)
Asthma	8 (10.81)
Hypothyroidism	4 (5.40)
Rheumatoid arthritis	1 (1.35)
Sleep apnea	1 (1.35)

The mean operative time was 328 minutes (SD 122 min). Most patients (n = 58) underwent multiple procedures in addition to the breast surgery, with abdominoplasty (n = 42) and liposuction (n = 16) being the most common. The main indication for breast surgery was mammary ptosis (n = 66), followed by implant exchange (n = 8). All breast implants were placed in a dual-plane position. The mean volume of the removed implants was 380 cm³ (SD 100 cm³), whereas the mean volume of the newly inserted implants was 360 cm³ (SD 80 cm³).

Surgical outcomes were aesthetically favorable, achieving complete correction of the presenting ptosis in all cases. The anthropometric changes for the right breast showed significant improvements across the principal vertical anthropometric measurements: the clavicle-to-nipple distance demonstrated a marked reduction immediately after surgery, with sustained elevation at 12 months, reflecting stable repositioning of the nipple–areolar complex (mean reduction of 5.29 cm; P = 0.009); similarly, the clavicle-to-upper implant border distance decreased significantly (mean reduction of 3.63 cm; P < 0.001), indicating improved upper pole positioning and enhanced superior fullness; measurements related to the inferior pole showed favorable remodeling. Although the nipple-to-costal margin distance did not demonstrate statistically significant long-term variation (P = 0.692), nor did the clavicle-to-costal margin distance (mean difference 1.25 cm; P = 0.773), the lower pole-to-costal margin distance increased significantly postoperatively and remained stable at 12 months (P < 0.001), supporting controlled inferior pole expansion without evidence of bottoming out (Table 4).

Table 4.

Right Breast Anthropometric Changes After Surgery

Right Breast	Preoperative (n = 74)	Postoperative (n = 74)	T Test, MD, CI, and P
Clavicle-to-nipple distance	Mean: 21.4 ± 3.09	Mean P: 15.3 ± 1.36	T = 11.76; MD = 6.08; CI = 5.03–7.01; P < 0.001**
		Mean Y: 16.1 ± 0.99	T = 9.65; MD = 5.29; CI = 4.18–6.41; P < 0.001**
Clavicle-to-upper implant border	Mean: 9.78 ± 2.28	Mean P: 5.89 ± 1.74	T = 7.51; MD = 3.89; CI = 2.84–4.94; P < 0.001**
		Mean Y: 6.1 ± 0.97	T = 9.00; MD = 3.62; CI = 2.80–4.44; P < 0.001**
Nipple-to-costal margin	Mean: 11.9 ± 2.37	Mean P: 13.0 ± 1.35	T = −2.36; MD = −1.06; CI = −1.98 to −0.15; P = 0.023**
		Mean Y: 12.1 ± 1.89	T = −0.39; MD = −0.18; CI = −1.15 to 0.73; P = 0.692
Lower pole-to-costal margin	Mean: 5.03 ± 1.93	Mean P: 6.97 ± 1.47	T = −5.52; MD = −1.79; CI = −2.45 to −1.13; P < 0.001**
		Mean Y: 6.82 ± 1.49	T = −4.64; MD = −1.94; CI = −2.79 to −1.09; P < 0.001**
Clavicle-to-costal margin	Mean: 31.2 ± 4.75	Mean P: 28.3 ± 1.55	T = 3.55; MD = 2.90; CI = 1.25–2.46; P < 0.001**
		Mean Y: 30.0 ± 1.76	T = 0.99; MD = 1.25; CI = 2.05 to −0.53; P = 0.773

**Statistical significance.

CI, 95% confidence interval; mean P, mean immediately postoperative; mean Y, mean at 1-year follow-up; MD, mean difference; NA, not applicable.

The left breast demonstrated comparable and consistent improvements across all principal vertical measurements. The clavicle-to-nipple distance showed a significant reduction immediately after surgery, with stable positioning maintained at 12 months, confirming durable elevation of the nipple–areolar complex (mean reduction 5.35 cm; P < 0.001). Similarly, the clavicle-to-upper implant border distance decreased significantly (P < 0.001), indicating improved upper pole positioning and structural support. Inferior pole measurements also reflected favorable remodeling. The nipple-to-costal margin distance increased significantly and remained stable at 1 year (P < 0.001), suggesting controlled lower pole expansion without evidence of bottoming out. The lower pole-to-costal margin distance also demonstrated significant postoperative improvement (P = 0.003). In contrast, the overall clavicle-to-costal margin height did not demonstrate a statistically significant change over time (P = 0.651; Table 5).

Table 5.

Left Breast Anthropometric Changes After Surgery

Left Breast	Preoperative (n = 74)	Postoperative (n = 74)	T Test, MD, CI, and P
Clavicle-to-nipple distance	Mean: 21.6 ± 2.33	Mean P: 16.0 ± 1.50	T = 15.48; MD = 5.65; CI = 4.91–6.39; P < 0.001**
		Mean Y: 16.2 ± 1.3	T = 12.29; MD = 5.35; CI = 4.46–6.23; P < 0.001**
Clavicle-to-upper implant border	Mean: 10.27 ± 2.1	Mean P: 5.85 ± 1.84	T = 8.87; MD = 4.41; CI = 3.41–5.42; P < 0.001**
		Mean Y: 6.58 ± 1.46	T = 7.89; MD = 3.68; CI = 2.74–4.63; P < 0.001**
Nipple-to-costal margin	Mean: 10.8 ± 3.01	Mean P: 13.0 ± 1.23	T = −4.14; MD = −2.21; CI = −3.30 to −1.32; P < 0.001**
		Mean Y: 12.9 ± 1.77	T = −3.86; MD = −2.13; CI = −3.25 to 1.01; P < 0.001**
Lower pole-to-costal margin	Mean: 5.34 ± 1.72	Mean P: 6.82 ± 1.43	T = −5.22; MD = −1.48; CI = −2.06 to −0.91; P < 0.001**
		Mean Y: 6.58 ± 1.43	T = −3.18; MD = −1.18; CI = −1.93 to −0.42; P = 0.003**
Clavicle-to-costal margin	Mean: 30.4 ± 3.39	Mean P: 28.9 ± 1.55	T = 2.61; MD = 1.50; CI = 1.25–2.46; P = 0.013**
		Mean Y: 30.7 ± 2.05	T = −0.45; MD = −0.28; CI = −1.53 to 0.96; P = 0.651

**Statistical significance.

CI, 95% confidence interval; mean P, mean immediately postoperative; mean Y; mean at 1-year follow-up; MD, mean difference; NA, not applicable.

The overall complication rate of this procedure was 6.76%, including 2 cases of suture dehiscence, 1 case of keloid scar formation, and 2 cases of partial NAC necrosis. No cases of infection, hematoma, or total NAC necrosis were observed.

DISCUSSION

This study presents the outcomes of a standardized secondary mastopexy technique in patients with previous breast augmentation, combining dual-plane implant placement with soft-tissue reshaping. Our findings demonstrate that the proposed method effectively corrected mammary ptosis while achieving durable upper pole fullness and inframammary definition, as evidenced by significant changes in anthropometric parameters at 12-month follow-up (Figs. 1–3).

Fig. 1.

Preoperative and 12-month postoperative results of patient 1, a female patient in her early 30s. A and B, Preoperative frontal and lateral views demonstrating bilateral breast bottoming out. Reduced upper pole fullness and inferior pole elongation were noted; previous implant volume was 230 cm³. C and D, Twelve-month postoperative frontal and lateral views showing correction of bottoming out with elevation and centralization of the NACs, restoration of upper pole projection, improved breast symmetry, and well-matured scars. Actual implant volume was 300 cm³.

Fig. 3.

Preoperative and 2-month postoperative results of patient 3, a female patient in her mid-30s. A and B, Preoperative frontal and lateral views demonstrating bilateral breast waterfall deformity, characterized by marked inferior displacement of the NACs with significant lower pole redundancy and reduced structural support; previous implant volume was 330 cm³. C and D, Two-month postoperative frontal and lateral views showing substantial elevation of the NACs, improved breast projection and contour definition, and stable long-term aesthetic outcome with mature scars. Actual implant volume was 425 cm³.

Fig. 2.

Preoperative and 12-month postoperative results of patient 2, a female patient in her late 20s. A and B, Preoperative frontal and lateral views demonstrating bilateral bottoming out and decreased upper pole fullness. Mild asymmetry in breast volume was observed; previous implant volume was 275 cm³. C and D, Twelve-month postoperative frontal and lateral views demonstrating correction of bottoming out, improved projection and upper pole fullness, appropriate nipple–areola positioning, and favorable scar maturation. Actual implant volume was 325 cm³.

Anthropometric analysis showed consistent improvement in all key vertical measurements, particularly in nipple position (clavicle-to-nipple distance), which improved by an average of 5.3 cm bilaterally. This confirms effective elevation of the NAC with sustained results over time.^11,12 Additionally, the clavicle-to-implant upper pole distance decreased significantly, indicating a favorable redistribution of volume superiorly, which is a frequent aesthetic concern in revisionary cases.^1,3 Notably, the IMF-to-nipple distance increased postoperatively, particularly on the left side, supporting the hypothesis that controlled inferior pole expansion contributes to natural projection without bottoming out. Interestingly, although the total clavicle-to-IMF height decreased in both breasts at 6 months, this change likely reflects postoperative tissue remodeling and upward retraction of the skin envelope, rather than recurrence of ptosis, as nipple position remained stable.^7,8

Our findings are consistent with previous literature emphasizing the complexity of secondary augmentation-mastopexy. Sarosiek et al⁴ described the inherent biomechanical contradiction in combining volume expansion with skin tightening, noting increased reoperation rates in revisionary settings. In our series, however, the absence of ptosis recurrence and the low revision rate (not reported in the present segment but worth highlighting if applicable) suggest that our surgical technique overcomes these biomechanical tensions effectively.⁴ Ono and Karner¹ demonstrated that subglandular-to-subpectoral conversion with muscular sling support reduces implant displacement and improves aesthetic outcomes in revisionary mastopexies. Similarly, our use of the modified dual-plane approach likely contributed to implant stability and maintained upper pole projection without compromising NAC vascularity.

Compared with the Wise-pattern secondary mastopexy described by Salibian et al² in reconstructive patients, our technique, applied in aesthetic revision cases, achieved comparable anthropometric outcomes with limited scarring and high reproducibility. Furthermore, our data align with the standardized approach proposed by Abdelkader et al,¹⁰ who emphasized patient-tailored strategies and soft-tissue measurements to guide decision-making in complex cases.

The complication rate of this mastopexy procedure was comparable to that reported in the literature (6.76% versus 6.2%).¹³ The occurrence of postoperative complications depends on several factors beyond the surgical technique itself. In our series, various postoperative strategies were implemented, including antibiotic and prophylactic measures,^14,15 which likely contributed to the absence of infectious complications. The routine use of hyperbaric oxygen therapy in the postoperative period has been a contributing factor to the overall low complication rate.¹⁶ Furthermore, an adequate recovery period and structured follow-up before return air travel have been key components in ensuring favorable outcomes.¹⁷

The present results highlight the clinical utility of objective anthropometric measurements for evaluating mastopexy outcomes beyond photographic or subjective assessment. By quantifying variables such as clavicle-to-nipple distance and implant pole height, surgeons can objectively monitor long-term stability and symmetry. Moreover, the statistical significance and narrow confidence intervals in key measurements support the reproducibility of our technique in secondary settings.

A key strength of this study is the use of bilateral, standardized anthropometric points across 3 timeframes (preoperative, immediate postoperative, and 12-mo follow-up), allowing for dynamic tracking of surgical outcomes. Additionally, all implants were placed using the modified dual-plane technique by the same surgical team, minimizing variability. However, the study has some limitations; first, the absence of a control group precludes direct comparison of outcomes; second, the follow-up period, although sufficient to capture early tissue settling, may not reflect long-term durability or late complications such as capsular contracture or recurrent ptosis; third, there was missing information related to the surface texture of the previous implants that may be linked to the contracture and ptosis occurrence.

Future research should focus on prospective, multicenter comparisons of different revision mastopexy strategies using standardized outcome measures. Moreover, the incorporation of 3-dimensional imaging or automated anthropometric analysis could further validate objective outcomes. Finally, studies including patient-reported outcome measures would strengthen the understanding of aesthetic success from the patient’s perspective.

CONCLUSIONS

This study demonstrates that secondary mastopexy with modified dual-plane implant placement is a safe and effective technique for correcting breast ptosis in previously augmented patients. Through objective anthropometric analysis, we confirmed significant and sustained improvements in nipple position and upper pole projection, with stable outcomes at 6-month follow-up. The technique provided reliable aesthetic enhancement without evidence of recurrent ptosis or bottoming out, even in cases requiring implant exchange or concurrent body-contouring procedures. These findings support the reproducibility and durability of our approach and highlight the value of quantitative breast measurements for evaluating surgical success in complex revision cases.

DISCLOSURE

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

PATIENT CONSENT

Patients provided written consent for the use of their images.