Breast Augmentation–Mastopexy: Standardized Marking Algorithm to Combat Challenges using MAMAS Techniques
- Admin
- Jun 19
- 6 min read
Augmentation–mastopexy remains one of the most technically challenging procedures in aesthetic breast surgery. Combining implant placement with skin and tissue manipulation introduces multiple variables that impact both aesthetic outcomes and revision rates. Despite its popularity, it consistently ranks among the aesthetic procedures with the highest revision rates.
To address these challenges, a novel approach known as the MAMAS (Marking Algorithm for Mastopexy with Augmentation Surgery) technique was developed and evaluated in a prospective cohort of 106 patients. This article outlines the rationale, marking methodology, and early clinical outcomes based on the findings of this published study (Payer, Chalkidis, Polackova, & Patzelt, 2024).
The Rationale for MAMAS: A Need for Preoperative Precision
Traditional mastopexy–augmentation techniques often rely on intraoperative adjustments—particularly regarding nipple–areola complex (NAC) positioning and vertical skin excision. However, once the implant is placed, the breast shape changes due to volume expansion and tissue tension, making real-time adjustments difficult and inconsistent. This reactive approach can result in poor symmetry, malpositioned NACs, and suboptimal upper pole projection.
MAMAS offers a proactive, standardized method to guide preoperative markings, particularly focusing on determining vertical limb length based on the planned implant volume. This allows for more accurate predictions of skin excess, nipple elevation, and final breast contour, reducing intraoperative guesswork and improving consistency.
Key Features of the MAMAS Technique
Preoperative SN–N Planning: NAC positioning is determined using a standardized suprasternal notch-to-nipple (SN–N) distance (typically 19–21 cm).
Vertical Limb Length (L): Defined as the distance from the top of the areola to the convergence point at the inframammary fold (IMF), L is pre-marked based on implant volume:
≥275 cc: 6.5 cm
<275 cc: shorter, though the study did not define exact lengths
No Intraoperative NAC Re-marking: Markings are final once the patient is prepped, eliminating the need for intraoperative adjustments.
Glandular Wedge Excision: For patients with ptosis, a 25–75 g wedge of tissue is excised to promote superior nipple migration and reduce lower pole redundancy.
Dual-Plane Implants: All patients in the study received smooth, round, moderate-profile silicone implants placed in a submuscular (dual-plane) pocket.
Surgical Procedure: MAMAS Technique in Detail
1. Preoperative Marking
Patients were marked in the upright position to identify midline, inframammary folds, and nipple position. A Wise-pattern (inverted-T) design was employed, adjusted per patient anatomy.
Vertical limb length was determined by implant volume:
≥275 cc: 6.5 cm
<275 cc: Shorter, individualized length (not specified)
Vertical limb length was measured from the top of the areola to the inframammary fold convergence point.
No intraoperative NAC repositioning was performed—final nipple position adhered strictly to preoperative markings, demonstrating reproducibility and efficiency of the MAMAS approach.
2. Anesthesia and Positioning
General anesthesia was administered.
Patient was positioned supine, arms abducted to 90°, and chest prepped and draped.
Preoperative markings were referenced throughout the procedure.
3. Incision and Skin Flap Elevation
Incisions followed the Wise-pattern: periareolar and vertical limbs first.
Skin flaps were elevated carefully to preserve vascularity, especially in the inferior pole.
De-epithelialization was performed along the vertical limb and areolar edge, based on the marked excision length.
4. Implant Pocket Creation
A dual-plane pocket was dissected via the vertical limb incision:
Subglandular dissection extended to the pectoralis major muscle.
Subpectoral elevation maintained the integrity of the inferior pectoral border.
Lower pole dissection was limited to maintain implant support and minimize bottoming-out.
A trial sizer was optionally used to guide implant selection and assess breast shape.
5. Implant Placement
Final Mentor silicone implants were inserted into the prepared pocket.
A Keller funnel may be used to reduce implant handling.
The patient was occasionally placed in a semi-upright position intraoperatively to confirm symmetry and projection.
6. Glandular Wedge Resection (If Indicated)
In cases with significant glandular ptosis or lower pole fullness:
A central wedge excision (2–4 cm wide, 25–75 grams) was performed below the areola.
This maneuver:
Elevated the nipple-areolar complex (NAC)
Improved upper pole projection
Reduced risk of bottoming-out
Hemostasis was ensured meticulously.
7. Closure and Contour Refinement
Vertical and inframammary limbs were closed in layers:
Deep dermal and fascial sutures redistributed tension and supported the vertical closure.
Skin closed with subcuticular sutures for optimal cosmetic outcomes.
Dog-ears and T-junction puckering were carefully avoided.
A drain was placed selectively, based on intraoperative judgment.
8. Dressing and Postoperative Care
Steri-strips and light compressive dressings applied.
Patient fitted with a supportive surgical bra.
Postoperative instructions included:
Limited upper body activity
Incision care
Routine follow-up visits
Key Surgical Pearls
Accuracy of Preoperative Markings: Strict adherence eliminates intraoperative nipple repositioning, saving time and improving symmetry.
Selective Glandular Resection: Tailored tissue removal enhances the implant-breast relationship, particularly in heavy or ptotic glands.
Tension Redistribution: Layered closure technique minimizes skin stress and helps maintain long-term breast shape.
What Sets MAMAS Apart
Feature | Traditional Methods | MAMAS Technique |
NAC Placement | Intraoperative, subjective | Preoperative, SN–N based |
Vertical Excess Estimation | Based on judgment | Guided by implant volume and L |
Reliance on Implant Fill | High | Reduced with wedge excision |
Predictability | Inconsistent | Highly reproducible |
Workflow Complexity | Frequent intra-op adjustments | Streamlined pre-op planning |
Unlike traditional techniques, MAMAS does not depend on areola-to-IMF measurements, which often change post-implantation. By focusing on fixed landmarks and standardized limb lengths, it improves predictability, especially in patients with asymmetry or previous surgery.
Clinical Outcomes
The study included 106 patients, all operated on by a single surgeon. A subset of 50 cases underwent detailed retrospective analysis. Key findings included:
Average implant volume: 325.6 cc
Average vertical limb length: 6.5 cm
Revision rate: 4.7%
Complication rate: 15.1% (mostly minor wound healing issues)
High patient satisfaction: 94% satisfaction rate
NAC Symmetry: 87.2% had no visible asymmetry post-op
Upper Pole Projection: Significantly improved in most cases
No major complications: No capsular contracture, seroma, hematoma, or infection
Importantly, all revision cases involved patients who had vertical limb lengths <5.5 cm, suggesting this may be a critical threshold for achieving an effective lift.
Postoperative BREAST-Q scores showed significant improvements across all domains: satisfaction with breasts, psychosocial, physical, and sexual well-being.
Compared to traditional techniques—where revision rates range from 13% to 23%—the MAMAS technique demonstrates a marked reduction in reoperation frequency.
Limitations and Considerations
While promising, the study is limited by its:
Single-surgeon experience
Relatively short follow-up
Uniform use of moderate-profile silicone implants
The generalizability of the MAMAS algorithm to different implant types, profiles, and more complex cases (e.g., post-massive weight loss) remains to be explored.
Patient Selection: Who Benefits Most?
Ideal candidates:
Grade 1–2 ptosis
Moderate to full upper pole volume restoration desired
Good skin quality without significant thinning or radiation exposure
Use caution in:
Post-bariatric patients with excessive laxity
High-risk scarring (e.g., keloid-formers)
Those requiring extreme lifts (>7 cm)
Avoiding Common Pitfalls
Undermarking L (<5.5 cm) → Insufficient lift, NAC malposition
Inadequate wedge excision → Poor upper pole projection
Inconsistent preoperative measurement → Asymmetry, unpredictable results
Final Tips for Surgeons
Use implant volume to guide vertical limb length (L).
Always mark SN–N distance preoperatively.
Incorporate wedge excision for optimal contour and projection.
Avoid vertical lengths <5.5 cm unless anatomy clearly supports it.
Apply layered closure techniques to distribute tension and preserve projection.
Conclusion
The MAMAS technique introduces a structured, reproducible method for performing augmentation–mastopexy with a high degree of aesthetic reliability. By anchoring preoperative planning in objective measurements tied to implant volume, it minimizes intraoperative guesswork and leads to improved outcomes with fewer revisions.
For plastic surgeons seeking greater predictability in this complex procedure, the MAMAS technique represents a practical and effective solution—one that may be particularly useful in challenging or revision cases. Further multi-center studies with longer follow-up are warranted, but early evidence positions MAMAS as a significant advancement in breast surgery planning.
Reference:
Payer, J., Chalkidis, N., Polackova, P., & Patzelt, M. (2024). MAMAS (mastopexy–augmentation made applicable and safer): A standardized template of pre-operative marking and step-by-step surgical procedure. JPRAS Open, 40, 293–304. https://doi.org/10.1016/j.jpra.2024.03.007
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