Introduction

Breast augmentation and mastopexy are two distinctly different surgical procedures, performed for distinctly different reasons. The objectives or goals of mastopexy and breast augmentation are quite different. Nipple-areola repositioning or reshaping that repositions the nipple areola 2 cm or less is not a mastopexy. A true mastopexy that removes significant skin is an illogical procedure to perform simultaneously with a breast augmentation. Surgeons and patients sometimes choose to combine these two operations at a single surgical setting termed augmentation mastopexy or mastopexy augmentation. For practical purposes, surgeons use the terms augmentation mastopexy and mastopexy augmentation interchangeably to describe a single stage combination of the two procedures.

The challenges of the decision making process and surgical execution of augmentation mastopexy are evidenced by the fact that this combination of operations at a single stage has resulted in the highest rate of medical malpractice claims of any operation in aesthetic surgery. Despite large numbers of peer reviewed and published articles, and countless presentations in surgeon education venues over the past three decades, predictable and optimal outcomes and valid scientific data that prove the safety and efficacy of augmentation mastopexy remain elusive. Anecdotal studies of series of augmentation mastopexy that report good results with minimal complications all suffer from the same deficiency. No peer reviewed and published study currently exists that (1) quantifies the preoperative parameters that define indications for surgery, and (2) define quantified parameters that distinguish a true mastopexy or breast lift from a plethora of minor skin excisions or areola manipulations that surgeons also term “mastopexy”. Without these quantified definitions, scientific analysis and definition of decision processes to optimize outcomes and minimize disasters cannot occur.

Persistent challenges require fresh approaches to critically and logically examine the processes and decisions that produce current results. The track record of single stage mastopexy augmentation is clear—three decades of high complication rates, suboptimal patient outcomes, and high rates of malpractice claims. This track record strongly suggests that if patient safety and optimal outcomes are priorities, surgeons and surgeon professional organizations that control surgeon education should critically reexamine the logic, decision processes, and surgical techniques of single stage mastopexy augmentation. Despite isolated anecdotal series published in peer reviewed literature, complication rates with simultaneous mastopexy-augmentation are well known to most experienced surgeons.

Breast Ptosis—Causes and Classifications

Breast ptosis occurs when the parenchymal mass of the breast exerts stretch forces on the breast soft tissue envelope, causing stretch of breast skin that allows descent of the parenchymal mass and changes in the shape and position of the nipple-areola complex. The weight of the parenchymal mass, genetic and hormonal factors, and a patient’s pregnancy and nursing history determine the occurrence and degree of ptosis in individual patients.

Patients seek surgical improvement for a wide range of ptosis related complaints, ranging from minor degrees of stretch or breast shape change to major displacement and distortion of the breast. When any patient presents with significant ptosis, the skin of the breast, by definition, failed to support the weight of the parenchymal mass. This fact is true regardless of the underlying causes of the ptosis. Performing any type of surgical procedure does not positively improve or alter the tissue characteristics that allowed the deformity to occur.

In 1976, Paula Regnault published a classification of breast ptosis that continues to be a predominant, common of classifying ptosis three decades later.^1,2 Although variations of this classification exist, key elements from Regnault’s classification predominate when surgeons discuss and describe degrees of breast ptosis:

This classification and virtually all classifications of breast ptosis in common use today are based on a surgeon’s subjective, visual assessment of the breast in lateral view. The degree of subjectivity and variability with this classification is enormous, and no scientific study has ever documented reproducibility with single surgeon or multiple surgeon use of this classification.

Lack of an objective, quantifiable classification for breast ptosis is a major contributor to persisting problems with mastopexy and mastopexy augmentation. When problems or suboptimal outcomes occur postoperatively, absent objective data, surgeons cannot objectively and scientifically assess and define the root causes of the problem. Was the assessment suboptimal? Was the decision process flawed? Was the surgical technique less than appropriate? Decision processes based on subjective impressions are often flawed when compared to the same processes based on objective, reproducible, scientifically verified data.

Outcomes and complications with mastopexy augmentation relate directly to the preoperative condition of the patient’s tissues, the extent of the preoperative deformities, and the decision processes for surgical technique and implant. Absent objective, quantifiable, scientifically verified criteria for surgical indications to perform mastopexy or mastopexy augmentation, surgeons rely on subjective opinion and personal preferences in the decision process to perform the surgery and select the surgical technique and implant. The wide range of variations in indications and techniques for mastopexy augmentation, and the track record of high complication and reoperation rates suggest that subjectivity has not produced predictably optimal outcomes for patients. Objectivity and science based methodologies are needed.

Defining Mastopexy

The Medline Plus® Medical Dictionary defines mastopexy as “breast lift: plastic surgery to elevate and often reshape a sagging breast”.² Other definitions in the medical literature include the following in the definition of mastopexy:

Current definitions of mastopexy are unscientifically broad and misleading for patients and surgeons. Excision of an ellipse of skin less than 1 cm wide around the areola is currently termed a “crescent mastopexy”. Circumferentially extended around the areola, a 1 mm skin excision can be termed a “concentric or doughnut mastopexy”. A “periareolar mastopexy” can be anything from excision of 1 mm of skin around the areola to a very large periareolar skin excision with extensive breast parenchyma modifications. Current terminology for “mastopexy” is subjective, poorly defined, and often misleading. Minor skin excisions for nipple-areola modification are orders of magnitude less risky and unpredictable for patients compared to major excisions of lower pole skin and major repositioning of the parenchymal mass and nipple-areola complex. Current terminology for mastopexy does not objectively distinguish amounts of skin excision, modifications and movement of breast parenchyma, and degree of nipple-areola repositioning.

Until surgeons more precisely define quantitative parameters that in turn define the degree of each of the five surgical areas of mastopexy listed in the previous paragraph, confusion will continue. When is a mastopexy really a mastopexy, and when is a so-called mastopexy nothing more than a minor areolar reshaping or minor nipple repositioning? At present, the term mastopexy applies to both, but the degree of technical difficulty, degree of potential devascularization and denervation, and the potential for wound healing problems and permanent, often uncorrectable tissue compromises are dramatically different. A breast augmentation combined with minor nipple repositioning or nipple-areola repositioning in a narrow breast in a young patient is distinctly less risky and unpredictable compared to an augmentation in an older patient that involves greater degrees of skin excision, skin undermining, parenchymal modification, and greater implant size.

When does a mastopexy become a mastopexy? For the past decade, the author has used the following criteria to define a mastopexy and distinguish mastopexy from much more minor nipple repositioning or minor skin excisions in the breast:

Quantifying Critical Parameters in Mastopexy and Mastopexy Augmentation

Currently, no objective, quantifiable criteria exist to provide objective data for scientific assessment of augmentation mastopexy. As a result, scientifically valid outcomes studies for mastopexy augmentation that identify risk factors are non-existent and will remain scientifically invalid until surgeons quantify key parameters that are now totally subjective. Objective, quantifiable tissue parameters that optimize outcomes and minimize reoperation rates dramatically for breast augmentation patients have been peer reviewed and published in the most respected journal in plastic surgery for more than 5 years.^3–11 The same simple, easy to perform measurements from these studies^4,5 generate quantified information and prioritized, defined decision processes that can provide surgeons the tools to improve outcomes in mastopexy augmentation just as they have done for breast augmentation patients.

The following basic parameters should be measured and documented preoperatively for every mastopexy augmentation patient. Detailed descriptions for the first five measurements are included in Chapter 7.^4,5

These basic measurements and calculations provide quantified data which surgeons can use for scientifically valid study design in augmentation mastopexy. Comparing these and other variables pre- and postoperatively enables valid scientific outcomes data to define best practices and proved processes to optimize patient outcomes. If quantified data are available, surgeons can define and prioritize scientifically valid decision processes that can dramatically change the current track record of mastopexy augmentation. Objectivity and science are required to substantively improve the dismal track record of subjectivity and opinion in mastopexy augmentation.

Patients and Patient Requests—Implant Only or Mastopexy Augmentation?

Many patients schedule a consultation for breast augmentation, and on examination, their skin is stretched to an extent that, combined with breast width, requires an exceedingly large implant (>400 cc) to adequately fill the envelope for optimal results. Some of these patients like the idea of a large implant, until they understand that regardless of implant size, absent a mastopexy, their result will be a much larger breast that continues to appear low on the torso. Educating patients to this fact changes some patients’ minds, and they elect a mastopexy or mastopexy augmentation instead, because they do not want a very large breast that hangs low on the torso.

In the same wide, ptotic breast patient group, some patients will simply ask the surgeon to place a specific, smaller than ideal size implant in the ptotic breast to avoid excessive size. With a wide (<13 cm base width breast) with substantial skin stretch (N:IMF > 10.0 cm and/or APSS > 3.5), placing an implant volume that is inadequate to completely fill the envelope will result in a full, larger lower breast with a still empty upper breast that creates a “rock in a sock” appearance. When patients hear the term “rock in a sock” and “empty upper breast”, virtually no patient wants either of these aesthetic outcomes.

A basic principle that every patient must understand during the education process is that an optimal aesthetic result requires that the surgeon place adequate volume in the breast. The wider the breast, the greater the skin stretch, and the longer the nipple to inframammary fold distance under maximal stretch, the greater the volume required to fill the envelope. Inadequate fill produces a full lower or middle breast, but leaves an empty upper breast. Once the ideal volume is in place, additional volume produces a more bulging upper pole, often with a stepoff. Every patient with a ptotic breast should clearly understand and acknowledge that despite any amount of implant volume a surgeon places in order to create upper breast fullness, additional lower pole stretch over time will result in loss of upper breast fullness. Hence the premise that placing any implant in conjunction with a mastopexy will maintain upper breast fullness is patently false, unless the patient develops a capsular contracture.

Understanding these principles, patients with significant ptosis and wide breasts have two realistic choices: (1) place adequate volume to fill the wide, stretched, ptotic envelope and live with the consequences of the appearance and adding significant additional weight in a breast that has already proved it stretches and doesn’t support weight well, or (2) reduce the skin envelope to allow less volume to provide optimal fill (mastopexy).

Mastopexy Without or with an Implant—Patient Requests and Surgeon Responsibilities

Mastopexy can significantly improve the relationships between the inframammary fold, breast parenchymal mass, and nipple-areola complex. No current mastopexy or mastopexy augmentation surgical technique can predictably and consistently maintain upper fill in the post mastopexy breast. Despite publication of numerous techniques that purport to maintain upper fill in the breast, if surgeons examine the publications carefully, they will find that most publications contain the following: short-term results; pictured results rarely show five views of the breast; many of the best results are clearly in younger patients under the age of 40; no independently monitored, consecutive series of patients with long-term mastopexy or mastopexy augmentation results exists in the medical literature; and regardless of surgical technique, the quality of moderate to long-term (3–5 year) results relates more to the age and tissue qualities of the patient compared to one surgical technique or another.

The prevalence of mastopexy augmentation is due in part to the inability of mastopexy to maintain fill in the upper breast, and the misconception among surgeons and patients that a breast implant can predictably create and maintain upper fill. Recognizing that patients want upper fill and that mastopexy, regardless of technique, does not predictably deliver it, for decades surgeons have advised patients that a breast implant is necessary to produce upper fill with a mastopexy. In addition, a subset of patients wants their breasts both lifted and larger.

Patient desires generate powerful economic incentives for aesthetic surgeons to perform medically unnecessary procedures. The degree to which those procedures are logically justified depends on many factors, the most important of which is the safety of the patient and the safety of the patient’s tissues long-term. Few patients consider the long-term implications of mastopexy augmentation before consulting a surgeon; hence the surgeon is responsible for assuring that patients are accurately and comprehensively informed of all potential short- and long-term consequences of performing the surgery.

The FDA and breast implant manufacturers also introduced significant financial incentives to surgeons. During the multi-year adjunct study of older generation silicone gel implants, surgeons were able to provide silicone gel implants to patients who needed or had a concurrent “mastopexy”. By performing a minor periareolar skin ellipse excision or similar minor procedure and terming it a “mastopexy”, surgeons who were willing to “stretch” the system could offer silicone gel implants to patients who requested them long before the implants were approved for the general public. This topic is seldom discussed in surgeon venues, and breast implant manufacturers and the FDA have never released segmented data on mastopexy augmentation patients from any FDA study. Whether these economic factors have affected the popularity of mastopexy augmentation remains a mystery from a scientific data perspective.

The quality of patient education and informed consent documentation determines the patient’s knowledge base and the validity of her decisions that define informed consent. The demands on the surgeon to deliver the required information regarding mastopexy augmentation are immense, and the track record of malpractice claim rates with this operation suggests that deficiencies exist in patient education and informed consent for mastopexy augmentation.

Every mastopexy or mastopexy augmentation patient should learn and acknowledge the following in signed informed consent documents:

Factors that Determine Outcomes in Mastopexy Augmentation

Outcomes and consequences of mastopexy and augmentation relate directly to patient knowledge base, preoperative tissue parameters, the decision processes preceding the surgery, the level of technical execution during surgery, and the characteristics of any prosthetic device implanted during the surgery. Decision processes derive directly from the level of education and knowledge base of the patient and the surgeon.

Preoperative decisions based on subjective assessment have not established an optimal track record of patient outcomes in mastopexy augmentation. Patient and surgeon education determine the content of the patient and surgeon knowledge base used to make decisions. Decisions determine outcomes before any surgical technique occurs. Few, if any, surgical techniques can compensate for suboptimal preoperative assessment and decisions.

Mastopexy augmentation outcomes continue to be challenged by the following:

Reexamining the Challenges of Mastopexy Augmentation from new Perspectives

Improving the unenviable track record of mastopexy augmentation requires that surgeons reexamine the most basic factors and logic that impact patient outcomes. Defining surgeons’ area of focus is straightforward by examining any program from any surgeon education venue. Mastopexy augmentation presentations and discussions routinely focus on scar length and surgical techniques, and rarely focus on the level of objectivity in decision making or the basic, underlying factors that determine the level of patient outcome and the track record.

This chapter is not about techniques for breast augmentation or mastopexy. Instead, this chapter focuses on two levels of reexamining the logic and processes that ultimately define decisions that determine outcomes. The first level is a simple comparison of the goals of mastopexy and augmentation as separate operations to identify areas where each operation’s goals contradict the other operation’s goals. The second level is a detailed reexamination of the factors that affect outcomes using methodologies from business reliability engineering and process engineering to identify factors that cause untoward events, and to use these analyses to define improved processes. Each of these approaches provides a different perspective of the factors and processes that define outcomes in mastopexy augmentation.

Contradictory Objectives in Mastopexy Augmentation

A fundamental problem with mastopexy augmentation is that the goals and objectives of each operation contradict the goals and objectives of the other. Regardless of surgical specialty or procedure, surgeons rarely combine operations with contradictory goals and objectives. Even when medical necessity dictates combining surgical procedures with potentially conflicting goals, surgeons are usually exceedingly cautious and concerned about their ability to deliver optimal outcomes with minimal tradeoffs and complications. For some reason, in the author’s 30 year clinical experience, augmentation mastopexy, a medically unnecessary operation, somehow continues to defy logic in the decision processes of performing both operations in a single stage.

Table 20-1A lists the goals of mastopexy, and for each goal, the corresponding, contradictory effect of placing a breast implant in the breast. Table 20-1B lists the goals of breast augmentation, and for each goal, the corresponding, contradictory objective of mastopexy.

Table 20-1 A Goals of mastopexy and contradictory effects of breast augmentation

* Risks or untoward occurrence factors that can be substantially reduced or eliminated by performing a mastopexy and staging the breast augmentation 6 months later

Table 20-1 B Goals of mastopexy and contradictory effects of breast augmentation

* Risks or untoward occurrence factors that can be substantially reduced or eliminated by performing a mastopexy and staging the breast augmentation 6 months later

Even the most cursory review of Tables 20-1A and 20-1B leaves any objective observer questioning the logic of combining mastopexy and breast augmentation at a single surgical setting. Of the total 16 contradictory objectives of mastopexy augmentation, 10 of the 16 factors (62%) can be substantially reduced or eliminated by performing a mastopexy and staging the breast augmentation 6 months later. Patients should consider a potential 62% reduction in risk factors when considering economic factors of a one versus a two stage mastopexy augmentation. While surgeons could legitimately argue that this number is not supported by peer reviewed and published, valid scientific data, few surgeons could legitimately dispute the simple logic presented in Tables 20-1A and 20-1B.

The potentially negative impacts of performing a breast augmentation simultaneously with a mastopexy depend on a myriad of factors that are more clearly defined later in this chapter. A minor nipple-areola repositioning that does not require skin undermining or parenchymal repositioning certainly involves fewer risks compared to a major skin excision, parenchymal shape modification and repositioning, and extensive skin undermining. Until quantified parameters exist to distinguish the level of tissue manipulation at which patient risks increase, to optimize outcomes surgeons must analyze the combined operation from the perspective of a legitimate mastopexy augmentation instead of a minor areolar or skin excision.

Mastopexy and Augmentation Risks—More than Additive

Table 20-2 lists recognized risks for mastopexy and breast augmentation when surgeons perform the operations separately.

Table 20-2 Risks and costs of mastopexy and breast augmentation

When surgeons perform mastopexy or breast augmentation separately, patients incur risks 1–8 with either operation. However, when surgeons combine the operations at one stage, augmentation separately increases the inherent risks of mastopexy by increasing risks when adding augmentation risks 3, 4, 5, 6, 8, 10, 11, 12, 13, 14, and 15 in the right column of Table 20-2. Placement of any breast implant inevitably increases the risk of delayed wound healing, skin or fat necrosis, scar widening or poor quality scars, nipple-areola loss or asymmetry, and by increasing those risks, also increases the risk of the patient perceiving an unsatisfactory cosmetic result.

Breast augmentation at the time of mastopexy not only increases the risks already inherent to mastopexy (risks 1–8 in Table 20-2), but adds significant risks and costs: additional weight that increases risk of recurrent deformity after mastopexy, additional pressure that risks skin, subcutaneous tissue and parenchymal atrophy or thinning, capsular contracture risk, increased reoperation risk due to implant device failure, interference with breast imaging, and the additional costs of the breast augmentation portion of the procedure. One perspective could argue that breast augmentation only adds risks 9–15 in Table 20-2, but even that perspective means that patients could avoid seven additional risks and cost by not adding augmentation to mastopexy.