Position: Supine, Sitting / Beach Chair, arms extended
Time: 2-4 hours (long)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: No

Blocks: PEC II

Preop Marking – The surgeon will mark the patient in preop while they are sitting or standing upright. Hold any sedation until this has been completed.

Positioning – During the procedure the surgeon will request a high fowler’s position, so make sure the arms have been secured to the armboards (wrapped) and adjust IV tubing and circuit tubing as needed. Watch for hypotension.

Block – A PEC block may be performed prior to emergence or right after induction with great efficacy but are not yet frequently used.

Deep Extubation – If GETT is the approach, perform a deep extubation (where not contraindicated) to avoid bucking or coughing.

Antibiotic – Typically cefazolin.

Beach Chair/sitting position (general considerations): When putting the patient in this position, the staff will typically help lift the patient and exchange the head rest after intubation. Once the headrest is secured, the patient will be lifted to the sitting position. At this junction, make sure the circuit is disconnected and the ETT is free – this could easily extubate the patient if the ETT is still attached when lifting the patient. The degree of hemodynamic changes depends on the angle. If sitting at 45 degrees there will be minimal changes, whereas 90 degrees will reduce cardiac output by 20% (due to venous pooling in the legs). SVR will be 15-20 mm Hg lower at the circle of willis than at the cuff, which may compromise cerebral perfusion. Consider having ready ephedrine and phenylephrine to support blood pressures. For higher risk patients requiring an A-line, it is recommended to place the transducer at the level of the brain (level the transducer at the tragus). Make sure the head is in a neutral position (looking straight ahead and void of flexion/extension).

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

A mastopexy or breast lift is performed to reduce the volume of the skin envelope to match the volume of the breast. Breast ptosis (drooping of the breasts) is either treated with augmentation to increase the breast volume, with skin incision to decrease the skin envelope, or with a combination of the two.

Causes of breast ptosis include pregnancy, weight fluctuations, aging, breast feeding, etc.

Ptosis is caused by the relaxation of Cooper suspensory ligaments (the ligaments that suspend the mammary gland) and dermal laxity. This contributes to descent of the breast tissue and nipple areola complex (NAC).

The surgeon begins by marking the areola with an areola sizer and then incising it. Then, the skin flaps are elevated, excess tissue is removed, and the breast tissue is moved up to the higher position on the chest wall. The skin is then re-draped and closed. The patient will be placed in a high fowler or sitting position to check for symmetry and nipple location.  The nipple-areola complex is then brought into its new position.

Contraindications include aspirin use, tobacco smoking, and diabetes. Smoking, obesity, and diabetes have been associated with increased likelihood of nipple necrosis.