Breast Changes: Multifactorial

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  The amount of breast parenchyma changes with age, body weight, pregnancy, and hormonal changes.

  
  
  
  
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    The skin envelope is stretched when the parenchyma enlarges.

    
    
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    Supporting ligaments and ductal structures are also stretched.

    
    
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    Ptosis results when the parenchymal volume decreases, and the skin envelope and supporting structures do not retract.

    
    
    
    
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      As a consequence, the breast assumes a lower position on the chest wall, and the youthful breast contour is lost.

Regnault Classification

¹

(fig. 53-1)

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  Describes ptosis by the relative position of the nipple-areola complex (NAC) and the inframammary fold

  
  
  
  
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    Grade I ptosis (mild ptosis)

    
    
    
    
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      NAC is at the level of the inframammary fold.

    
    
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    Grade II ptosis (moderate ptosis)

    
    
    
    
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      NAC lies below the level of the inframammary fold, but remains above the most dependent part of the breast parenchyma.

    
    
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    Grade III ptosis (severe ptosis)

    
    
    
    
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      NAC lies well below the inframammary fold and at the most dependent part of the breast parenchyma along the inferior contour of the breast.

    
    
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    Pseudoptosis or glandular ptosis

    
    
    
    
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      NAC is above or at the level of the inframammary fold, but most of the breast parenchyma has descended below the level of the fold.

      
      
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      Nipple-to-inframammary fold distance has increased.

Indications

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  Women who desire an improvement in breast contour without a change in volume

  
  
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  Women who seek a more lifted, “perky,” youthful breast appearance and aim to correct upper pole deflation, ptosis of the areolar complex and breast tissue, and laxity of skin envelope

Contraindications

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  Active smoking

  
  
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  Women who desire volume change

History

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  Age: Involution of breast after menopause

  
  
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  Breast history: Lactation, pregnancy changes, size changes with weight loss/gain, tumors, previous procedures, family history of breast cancer, recent mammogram

  
  
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  Patient goals

  
  
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  Medications, including psychotropic, oral contraceptive, and hormone replacement ⁶

Measurements

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  Sternal notch-to-nipple distance: Allows detection of asymmetry in nipple position

  
  
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  Nipple-to-inframammary fold distance: A measurement of the redundancy of the lower pole skin envelope

  
  
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  Classification of ptosis severity (see Fig. 53-1)

Other Considerations

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  Breast position on chest wall: Patients with low breast position without significant ptosis will not benefit from mastopexy. ⁷

  
  
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  Skin quality and amount: Presence of striae reflects the inelastic quality of affected skin; degree of skin laxity

  
  
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  Parenchymal quality: Fatty, fibrous, or glandular parenchyma and overall volume

  
  
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  Areolar shape and size: Areola are often stretched and large with asymmetries.

Photographs

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  AP, lateral, and oblique photographs should be obtained (see Chapter 3).

Patient Expectations

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  Breast size

  
  
  
  
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    Mastopexy techniques combine small amounts of parenchymal resection (<300 g traditionally in literature ³ ) and redistribution with reduction of the skin envelope — this can result in a reduction in breast size.

    
    
    
    
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      Average decrease of one cup size postoperatively: Important in patient counseling. ³

    
    
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    Many patients desire restoration of upper pole fullness, which may necessitate the placement of an implant simultaneously.

    
    
    
    
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      Mastopexy, augmentation-mastopexy, and reduction all increased breast and upper pole projection with significantly greater boost when implants were combined with mastopexy. ⁸

    
    
  • 
    

    Volume-deficient patients may often require augmentation-mastopexy as well ⁷ (see Chapter 54).

  
  
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  Scar position

  
  
  
  
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    Mastopexy procedures trade scars for improved contour.

    
    
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    Patients should be informed in detail preoperatively about scar placement and scar quality.

  
  
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  Other considerations

  
  
  
  
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    Thorough patient education regarding procedural complications, use of drains, and recurrence of ptosis are essential components of preoperative preparation.

General

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  Incisions are made and closed around the areola.

  
  
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  Scars are therefore camouflaged at the areolar-skin junction.

Patient Selection

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  Useful with mild and moderate ptosis

  
  
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  Skin quality should be reasonable without striae, and parenchyma should be fibrous or glandular.

Techniques

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  Simple periareolar deepithelialization and closure

  
  
  
  
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    Breast parenchyma is not repositioned; therefore only useful with mild ptosis

    
    
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    Permits nipple repositioning

    
    
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    Limited ellipitical techniques can elevate the NAC approximately 1-2 cm. ²

  
  
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  Benelli technique ⁹ (Fig. 53-2)

  
  
  
  
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    A periareolar technique that can be applied to patients with larger degrees of breast ptosis

    
    
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    Allows parenchymal repositioning

    
    
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    Areolar sizers are used to mark the new areolar diameter, and a wider ellipse is marked to reposition the NAC and resect redundant skin envelope.

    
    
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    Undermining separates the breast gland from the overlying skin.

    
    
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    The breast parenchyma is then incised leaving the NAC on a superior pedicle.

    
    
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    Medial and lateral parenchymal flaps are mobilized and crossed or invaginated in the midline, narrowing the breast width and coning the breast shape.

    
    
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    The periareolar incision is closed in a purse-string fashion with permanent suture.

  
  
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  Other periareolar techniques

  
  
  
  
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    Variations on the technique discussed above include use of mesh to support the parenchyma ¹⁰ or routine use of breast implants to reduce the amount of skin resection required. ^{11 , 12}

Advantages

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  Short scar

  
  
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  Scar position camouflaged at border of pigmented areola and nonpigmented skin

Disadvantages

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  Scar and areolar widening occur frequently.

  
  
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  Breast projection can be flattened.

  
  
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  Purse-string closure results in skin pleating that takes several months to resolve.

Related posts:

52. Breast Augmentation 56. Gynecomastia 54. Augmentation-Mastopexy 51. Breast Anatomy 55. Breast Reduction 5. Basics of Anesthesia for the Aesthetic Surgery Patient

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