Multi-Level Mammaplasty

Definition

Multi-Level Mammaplasty is a breast reshaping approach in which each anatomical layer of the breast is addressed separately, rather than relying on the skin envelope as the principal means of support. The approach was developed by Amiram Borenstein and described together with Or Friedman in a series of peer-reviewed papers and in the volume Multi-Level Mammaplasty: Anatomical Support and Re-Shaping of the Breast (World Scientific, 2020).

Anatomical rationale

Most reduction and mastopexy techniques rely, to a greater or lesser degree, on the skin to hold the new breast shape. Skin is elastic tissue and behaves accordingly. It stretches under load, and a shape maintained by skin tension tends to descend over time, which is the mechanism behind late bottoming out and loss of upper pole fullness. The multi-level approach treats the operation as a system of layers that act together, each with a defined role in determining shape, projection and long-term support. Support is built at the deeper levels, at the pectoralis fascia and within the glandular pillars, so that the skin is closed over a shape that already exists rather than being asked to create one.

Operative principles

The operation is planned around a periareolar de-epithelialisation pattern with a superior pedicle, and the breast is shaped from the bottom up. After the parenchyma is dissected above the pectoralis fascia, absorbable foundation sutures are placed between the lateral breast tissue and the fascia, medial to the breast meridian and angled upward. These sutures are assessed before being tied, so that their effect on the lateral contour can be judged rather than assumed, and the step is repeated more superficially in larger breasts.

The Borenstein manoeuvre follows. Two thin dermal flaps are raised on either side above the pillars, and horizontal figure-of-eight sutures are placed at the exposed edges of breast tissue, narrowing the base of the breast while adding projection. The step is repeated until the intended contour is reached. Only then is the excess skin excised and the dermal edges approximated without tension, with the patient positioned semi-upright for marking of the new areolar opening and inset of the nipple-areola complex. The sequence matters as much as the individual manoeuvres. A foundation is established first, the shape is built on it, and the skin is fitted to the result.

How it differs from conventional technique

The most visible difference is the scar. Progressive gathering of breast tissue during reconstruction of the mound, together with trimming of the excess skin for a short and tension-free vertical closure, avoids the submammary horizontal scar characteristic of the inverted T pattern. The tradeoff is deliberate. A vertical extension is added in order to keep the periareolar scar a fine line and to prevent the periareolar closure from being loaded by unnecessary tension. The less visible difference is structural. Because support is anchored to the fascia and within the parenchyma, the shape is not dependent on the skin envelope for its durability.

Indications

The approach has been applied to breast reduction, to mastopexy, and to implant explantation combined with mastopexy, where the breast must be reshaped after the volume that was filling it has been removed. It suits patients in whom the objective is a stable shape over years rather than an appearance at the first postoperative visit, and it is particularly relevant where tissue quality is poor and skin cannot reasonably be expected to provide support.

It is not the right operation for every patient. Where the presenting problem is volume alone, or where the breast requires no reshaping, a simpler procedure is preferable. The choice of technique follows from the surgical problem, and part of the consultation is establishing which problem is actually being solved.

Limitations

The approach does not produce a scarless result and does not claim to. In the larger breast the vertical limb may extend towards the chest wall, and this is discussed with patients before surgery rather than presented as an incidental finding afterwards. The vertical scar fades over time and is partly obscured by the breast itself, but it remains a scar. The published evidence is retrospective, drawn from consecutive series rather than from randomised comparison, and it establishes safety and reproducibility rather than superiority over every alternative. Individual anatomy, healing and prior surgery all constrain what any technique can achieve.

Sources

Borenstein A, Friedman O. Multilevel Breast Reduction: A Retrospective Study of 338 Breast Reduction Surgeries. Plast Reconstr Surg Glob Open. 2019;7(8):e2427. doi:10.1097/GOX.0000000000002427
Borenstein A, Friedman O. The Borenstein Maneuver: A Surgical Technique to Narrow the Breast and Add Projection. Plast Reconstr Surg Glob Open. 2020;8(3):e2631. doi:10.1097/GOX.0000000000002631
Borenstein A, Friedman O. Combined Breast Implant Explantation and Multilevel Mastopexy Technique. Plast Reconstr Surg Glob Open. 2019;7(9):e2429. doi:10.1097/GOX.0000000000002429
Borenstein A, Azaria R, Inbar R, Friedman O. The Paper Mache Bra: A Postsurgical Breast Taping Technique. Plast Reconstr Surg Glob Open. 2019;7(9):e2407. doi:10.1097/GOX.0000000000002407
Borenstein A, Friedman O. Multi-Level Mammaplasty: Anatomical Support and Re-Shaping of the Breast. Singapore: World Scientific; 2020. ISBN 978-981-121-912-2.

The complete publication record is available at ORCID. Written and reviewed by Or Friedman, MD. Last reviewed: August 2026.