One of the oldest adages in surgery is that the more solutions there are to a problem, the less likely it is that any one of them is consistently successful in all situations. Each mastopexy procedure aspires to lift, shape, and support the ptotic breast and to maintain that result for a meaningful postoperative period. The ideal procedure should minimize scarring and maximize breast cancer surveillance.

To date, there is no singular approach that can achieve these goals to the exclusion of others. Instead it is generally accepted that the type of mastopexy and its associated risks should be paired with degree and type of the patient’s problem and the surgeon’s facility with the technique. A patient with minimal ptosis and thick breast tissue does not necessarily merit a complex procedure that involves rotation flaps, tissue advancement, fascial or muscle slings, and accessories such as meshes (synthetic and absorbable), dermal grafts, or allogeneic and xenogeneic dermal matrices. However, there is no doubt that there are patients with problems that may require one or more of these options. An understanding of and a comfort with these more aggressive approaches allow each surgeon to customize his or her solution for each patient.

Mastopexy has evolved from skin and tissue resection to parenchymal modification, implants (1,2), local advancement flaps, rotation flaps (3), stacked flaps (4) supported flaps using dermal suspension (5), fascial suspensions (6,7,8), pectoralis muscle suspensions (9), meshes (10,11,12), allografts, and xenografts (13,14). With increased parenchymal rearrangement and internal support, mastopexy techniques have moved away from inverted-T incisions to the smaller scars of a vertical mastopexy (15,16), periareolar mastopexy skin incisions (15,17,18,19,20,21,22), and limited inframammary fold incisions (23). An excellent overview of the history of mastopexy is provided elsewhere in this textbook and has been summarized by many authors (3,4,6,7).

Breast augmentation has been a facile ancillary tool for treating the depleted ptotic breast. As mastopexy procedures have evolved to more complex parenchymal rearrangements, the advisability of pairing the procedure with breast augmentation has been questioned. Arterial and venous insufficiency, nipple necrosis, sensory loss, malposition of the implant, and unpredictable results have been sited as serious risks when combining breast implantation with mastopexy, particularly when implants are placed in a subglandular position (1,2). Without the crutch of implants, mastopexy procedures are often unable to provide upper-pole soft tissue augmentation.