Background: The author's wide experience with postbariatric body contouring pushed him to find a technique suitable for correcting the two most common defects of the massive weight loss (MWL) breast: hypotrophy and ptosis. For these defects, a technique selection algorithm has been created. According to the algorithm, the "upside-down" technique was developed for those cases with a diagnosis of "minor ptosis" (<6 cm of vertical nipple-areolar complex correction).
Methods: The upside-down technique is performed as follows. (1) Complete subcutaneous undermining of the glandular upper pole to the upper edge of the mammary gland is performed. (2) After rotation around the edge, upside-down retroglandular undermining is performed, with great care taken to leave the inframammary fold and 2 cm of the gland undetached. (3) Topside-bottom implant insertion is performed with a "mailbox posting" action. The inframammary fold and the undetached gland act as a bra to prevent implant ptosis. The upper one-third of the prosthesis can be placed beneath the pectoralis major muscle with the "dual-plane" technique if a round implant is used or left completely retroglandular if an anatomic implant is used. (4) The type of implant needed (round vs anatomic) basically depends on the type of aesthetic defect. Major upper pole defects need round implants, and major lower pole defects need anatomic implants. The patient's preferences are a primary factor in the decision. (5) Breast lifting is performed through strong anchorage to the fascia, muscle, and second rib periosteum. At least three stitches of threaded nonabsorbable 0 or 1 suture are positioned. The whole lower gland pole is left undetached to guarantee blood perfusion (only 1 or 2 cm of periareolar incision are undermined). (6) Periareolar suture is always performed with the "interlocking" technique according to Hammond.
Results: From November 2001 to May 2010, 231 patients underwent surgery using the described technique. The patients all were Caucasian with an average age of 38 years (range, 31-53 years), and all underwent surgery bilaterally. The mean operating time was 150 min (range, 120-180 min), and the mean hospital stay was 3.5 days (range, 2-5 days) after surgery. The ptosis recurrence rate was evaluated. A recurrence is identified when the nipple-areola complex slides more than 2 cm 1 year after surgery. The recurrence rate was 27.6% for other techniques versus 9.1% for the upside-down technique.
Conclusions: Natural shape, stable position, and short scars are the main advantages of the upside-down technique. The typical breast flatness after periareolar access is best corrected by the last-generation dual-cohesiveness anatomic implants, which the author strongly recommends to obtain the best results with this technique. The Body Uneasiness Test (BUT) study showed 100% improvement of patient discomfort.