CHAPTER
35

Mastopexy is a good procedure, and the demand for it continues to increase. Breast reshaping with nipple–areola repositioning with or without some element of breast tissue excision and with incisions placed in favorable locations can often lead to a gratifying result for both the patient and the surgeon. The length of scars and overall “scar burden” has decreased with the introduction of short-scar procedures including vertical techniques, modified periareolar techniques, and modified inverted-T or Wise pattern approaches1 marked by shorter inframammary incisions.

For more than 2 decades there has been more of a focus on parenchymal reshaping and fixation, which is often used as an adjunct in the shorter scar procedures. Incorporated with many of these short-scar procedures is a new emphasis on parenchymal shaping. These innovations have improved plastic surgeons’ ability to achieve better results in many settings. As noted previously, despite these improvements in breast appearance some element of breast ptosis does recur over time in most patients. Therefore patients requesting this procedure must be aware of this and accepting of it.

Patients who desire a significant increase in upper pole fullness typically require an implant as an adjunct to the mastopexy procedure. Although implant technology has continued to improve and the safety of implants has been established, implants too change over time. In addition to capsular contracture, the inherent risks of implant placement include stretching or attenuation of overlying tissue and the periprosthetic capsule space in which the implant resides, producing problems such as lower pole stretch, implant malposition, and some element of nipple–areola malposition. These sequelae are not uncommon. Capsular contracture is still the most common adverse effect of implant placement. Despite this risk, the popularity of single-stage augmentation mastopexy (both procedures done simultaneously) continues to increase.

The patient is examined in the upright and supine positions. In the former position the surgeon must evaluate the general shape of the breasts; the breast volume, weight, and density; the presence of any asymmetries; and nipple position relative to both the breast volume and inframammary fold (IMF). The relationship of the nipple position to the IMF is a very important guideline for the selection of technique. This was first pointed out and published by Regnault in the 1970s.2 This relationship allows the plastic surgeon to classify the ptosis (Fig. 35.1), and this serves as a guideline for procedure selection^2,3 (Table 35.1). Although there are other important determinants for the optimal procedure, including the elasticity of the breast skin and parenchyma and the amount of tissue that overhangs the IMF, the nipple–breast gland–IMF relationship has stood the test of time.²

It is routine in my practice to quantitate important breast dimensions using a tape measure to analyze and record topographic features of the breast, which are measured from fixed landmarks. These include the base width of the breasts, the distance from the suprasternal notch to the nipple, and the distance from the IMF to the nipple without stretching the tissues and with the breast tissue placed under stretch. These are recorded on a data sheet in each patient’s chart³ (Fig. 35.2).

Fig. 35.1 The conditions of glandular ptosis. (a) No ptosis. (b) Pseudoptosis. (c) First degree (mild). (d) Second degree (moderate). (e) Third degree (severe). (Reproduced from Jones GE. Bostwick’s Plastic and Reconstructive Breast Surgery. 3rd ed. New York: Thieme Medical Publishers; 2010.)

Table 35.1 Classification of ptosis by Regnault

Fig. 35.2 The important aesthetic breast dimensions for patients interested in mastopexy. (Modified from Jones GE. Bostwick’s Plastic and Reconstructive Breast Surgery. 3rd ed. New York: Thieme Medical Publishers; 2010.)

Fig. 35.3 Digital compression of the lower pole of the breast in a patient with good parenchymal elasticity produces fullness in the upper pole of the breast, as seen in this photograph.

Parenchymal elasticity and skin elasticity are difficult to precisely define, but they determine the ability to which the breast can be reshaped and the propensity of the reshaped breast tissue to maintain the new shape. A very important maneuver to help define this is one in which the surgeon gently compresses the lower pole of the breast to move tissue to the upper pole (Fig. 35.3). The ability to transpose tissue from the inferior portion of the breast in the area of the lower pole to the upper portion of the breast by gently compressing the lower portion helps define the parenchymal elasticity and aids in procedure selection. For example, if the maneuver illustrated in Fig. 35.3 produces a nice bulge or roundness in the upper pole, the patient is most likely an excellent candidate for a vertical glandular reshaping and a vertical mastopexy. If this maneuver fails to produce an easily discernible bulge, then additional support measures using deepithelialized skin segments for anchoring breast tissue, parenchymal flaps, or parenchymal suturing may be necessary in placing an implant to add fullness to the upper pole.

Careful evaluation of volume loss in the upper outer aspect of the breast and the presence or absence of striae, along with the general condition of the skin, gives the surgeon an estimate of the breast skin elasticity and provides valuable information about the degree of skin tightening necessary in both the vertical and horizontal planes to achieve shape change. This also helps with skin incision pattern selection. The breast evaluation is completed with the patient in the supine position carefully palpating for any masses or thickening in either breast or the axilla.

Fig. 35.4 Mastopexy. (a,b) Preoperatively, this patient had second degree breast ptosis. (c,d) Result 24 months after bilateral vertical mastopexy using superior dermal glandular pedicle mastopexy.

The evaluation allows the plastic surgeon to formulate a surgical plan that is guided by the patient’s goals. A patient who does not desire significant increase in surgical volume and has good breast tissue elasticity, as confirmed with the maneuver illustrated Fig. 35.3, is most likely a good candidate for a mastopexy alone, and often this can be carried out using a short-scar technique. For example, the patient shown in Fig. 35.4 underwent a vertical scar procedure using the Lassuss approach without pillar undermining using a superior dermal glandular pedicle. The undersurface of the pedicle was imbricated into the upper pole and was fixed to the pectoralis muscle fascia by multiple “pexy” sutures of 2–0 coated Polyglycolic acid.

Conversely, a patient with obvious significant loss of upper pole volume and compromised breast parenchymal and skin elasticity who desires a significant increase in upper pole fullness is likely better served by the placement of an implant at the time of her mastopexy.^2,4–7 The breast dimensions in terms of base width and height and the patient’s goal for postoperative size will provide the best guide to implant selection. The planned skin incisions for a mastopexy are determined by the amount and excess of skin and the dimensions in which the skin excess exists. The patient in Fig. 35.5 had an augmentation mastopexy procedure and maintained a good aesthetic outcome after 2 years.

Doctor–patient communication is important in every elective plastic surgery procedure and ideally forms the foundation of a solid surgeon–patient relationship. Such a relationship is important in all areas of surgery and has many benefits such as sustaining confidence at times when complications or untoward results follow a procedure. It has been a key component of my practice over the past 3 decades.

Therefore to minimize complications and patient dissatisfaction, it is incumbent upon the breast plastic surgeon to ensure that the following conditions exist in the consultation and treatment of every mastopexy patient:

Fig. 35.5 Augmentation mastopexy. (a,b) Preoperatively this patient had second degree breast ptosis. (c,d) Results 24 months after bilateral vertical augmentation mastopexy using superior dermal glandular pedicle mastopexy.

An evaluation of breast parenchymal volume and degree of ptosis is important. This includes an evaluation of glandular elasticity as illustrated in Fig. 35.3. In envelope elasticity is also important to note. The surgeon must look at the position of previous scars and the scar quality. The evaluation includes areas of previous skin loss. The position of the nipple relative to the breast gland is a key aesthetic component of a youthful breast. It must be evaluated in patients seeking both primary mastopexy and revision mastopexy. The position of the nipple relative to the IMF and the inferior breast gland including how much tissue overhangs the fold is important. As previously noted, a thorough breast examination and evaluation of the patient’s most recent mammogram results and their official interpretation by a radiologist is important.

The patient in Fig. 35.6 demonstrates a number of errors I committed during a primary procedure that led to revision mastopexy. The 36-year-old nulliparous woman presented for a breast uplift. She had profound third-degree mammary ptosis. She was athletic and exercised regularly, and her weight was stable. She stated that the appearance of her breast was a hereditary characteristic and she did not desire an implant. She had slightly compromised skin elasticity but good breast glandular elasticity. The plan and procedure in cluded a superior dermal glandular mastopexy performed using a vertical technique^8–13 (see Fig. 35.6c).

The patient appeared to have satisfactory transposition of her breast gland on the operating table (see Fig. 35.6d), but the procedure was complicated by skin loss in both the periareolar and vertical incisions and by progressive spreading of the areola and loss of upper pole fullness. The patient developed widened scars that were hypopigmented and a loss of correction with recurrent ptosis at 1 year (see Fig. 35.6e,f).

At 18 months postoperatively I planned a revision of her mastopexy that included a revision vertical mastopexy with resuspension of the gland to the pectoralis major muscle fascia using multiple sutures between the deep surface of her breast parenchyma and the anterior surface of the pectoralis major muscle (see Fig. 35.6g,h). I was able to achieve resuspension of her parenchyma and downsizing of her nipple–areola complex using a permanent Gore-Tex suture.

Fig. 35.6 (a,b) Preoperatively this patient had third degree breast ptosis. (c) Preoperative markings for superior dermal glandular pedicle mastopexy. (d) Right breast reshaping with mastopexy, including pexy sutures from the posterior surface of the breast to the pectoralis major muscle. (e,f) At 12 months postoperatively she had recurrent ptosis, areola widening, and wide scars after skin loss along the vertical incision. (g,h) Revision circumvertical mastopexy at 18 months postoperatively with multiple pexy sutures in the upper pole for superior breast imbrication. Pexy sutures were used to attach the posterior surface of the breast to the pectoralis major muscle. (i,j) Results at 7 years postoperatively.

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