The Fujiyama Procedure: A Triangular Skin Paddle Design for Restoring Natural Ptosis in Implant-to-autologous Breast Reconstruction.

The Fujiyama procedure is a surgical technique designed for patients undergoing conversion from implant-based breast reconstruction to autologous tissue reconstruction. Conventional implant-to-flap conversion often fails to reproduce natural breast ptosis and lower pole projection because of biomechanical differences between implants and autologous tissue and an insufficient lower pole skin envelope after long-term implant placement. This technique applies the inverted-T mastopexy concept in reverse and introduces a geometric redesign strategy, in which a triangular skin paddle is intentionally exposed at the lower pole. This design allows redistribution of the skin envelope while providing adequate lower pole volume and skin supply, both of which are essential for restoring a natural ptotic contour. Following implant and capsule removal, the pectoralis major muscle is repositioned to the chest wall, and a prepectoral pocket is created to optimize softness and contour. The transferred flap is inserted into this plane, and the exposed skin paddle forms the "Fujiyama-shaped" lower pole. Intraoperative assessment in sitting position under negative pressure enables contour adjustment. When necessary, the inframammary fold is reinforced using multiple tacking sutures. Seven patients (9 breasts) underwent reconstruction using pedicled or free abdominal flaps and profunda artery perforator flaps. Complete flap survival without major or minor complications was achieved in all cases. Stable inframammary fold reconstruction, natural breast ptosis, and lower pole projection were achieved without secondary revisions. The Fujiyama design represents a structural lower pole redesign rather than simple implant replacement and offers an option for restoring natural breast morphology in secondary autologous reconstruction.