Measurements confirm that the inframammary crease level moves up after a vertical mammaplasty [7]. Both vertical and inverted-T techniques can elevate the lower pole [10]. An underappreciated benefit of elevation of the lower breast pole is the appearance of a longer torso [9]. With the emphasis on fitness in our culture, and the frequent display of the midriff, this anatomic area takes on greater importance. However, upward mobilization of the superior border of the breast is more challenging [11]. “Autoaugmentation ” has not lived up to its billing (see Chap. 5) [10]. Breast implants are needed to substantially boost breast projection and upper pole projection [6, 12–14], providing the appealing illusion of breast mound elevation.

The word mastopexy is derived from the Greek “mastos”, for breast, and “pexy,” for fixation. Commonly, mastopexy is understood to be synonymous with “breast lift.” Among plastic surgeons, a mastopexy has been traditionally understood to mean a skin tightening procedure [15], certainly for a “skin-only mastopexy .” However, the goal of a mastopexy is improvement in the shape of the breast, not simply tightening of its (elastic) envelope. In ptotic breasts, the lower pole needs to be reduced (i.e., parenchymal resection) to provide an aesthetic lower pole [6, 9, 16, 17] and avoid a “mastopexy wrecking bulge” [18].

No one denies that a breast reduction is also a mastopexy [10]. However, the reverse is true too. Measurements show that an effective mastopexy is also at least a small breast reduction [6]. Therefore, any distinction between mastopexy and breast reduction is arbitrary [10]. Indeed, mastopexy techniques evolved directly from reduction procedures [15]. We recognize the goals in optimizing breast shape are the same. Many authors acknowledge this false dichotomy and use the more inclusive term “mammaplasty.” [10] These procedures treat the same problem – breast sagging – with the only variable being the resection weight [10]. Therefore, mastopexy and breast reduction may be considered together.

The concept of using sutures [19, 20] in an attempt to suspend the breast on the pectoralis fascia and prevent descent is not new. Maliniac [21] used dermal strips. Almost half (42%) of the publications on the topic of mammaplasty advocate fascial sutures [10]. However, their efficacy has never been established and several surgeons recommend against their use [10, 22–25]. McKissock, in 1980 [25], observed: “The thought that suturing the inferior pedicle to the chest wall will suspend the breast for a prolonged period of time is naïve. It is a continuously recurring concept perpetuated by wishful thinking rather than unbiased observation.” Fascial sutures offer no advantage in breast projection or upper pole projection [10].

One approach that has received renewed attention is the Góes procedure [26], a deepithelialized central mound dissection with an onlay of a mixed permanent/absorbable mesh. This technique does not produce an increase in breast projection or upper pole projection [10]. This method has been popularized recently with the introduction of longer-lasting absorbable mesh [27].

The shortcomings of skin-only mastopexies are well-recognized [15, 28, 29]. Reports of “skin-only” periareolar mastopexies, including the “crescent mastopexy” [30], typically include patients treated simultaneously with implants [10]. Such patients are likely to benefit from the augmentation alone, making the benefit of the periareolar mastopexy questionable. The areola is often distorted [10]. A survey among board-certified plastic surgeons found periareolar techniques had the highest rate of surgeon dissatisfaction [5]. Furthermore, the periareolar operation has been disproportionately represented in malpractice lawsuits [31], accounting for 62% of mastopexy claims [32], despite being used as a single technique by only 6% of surgeons surveyed [5]. Measurements confirm that women treated with the periareolar technique have no significant benefit in breast projection, upper pole projection, lower pole elevation, breast convexity, or breast parenchymal ratio [10]. A conceptual problem with the periareolar technique is that it is usually a skin-only resection [33]. There is no glandular resection. Parenchymal resection is needed for lasting improvement in shape [10]. Not only is the wrong tissue being removed in a periareolar mastopexy, but it is also being removed from the wrong place – around the areola rather than from the lower pole.

The appeal of a periareolar or “donut” mastopexy is avoidance of a vertical scar. Generally, plastic surgeons prefer to avoid vertical scars on the face and body because vertical scars run against natural creases and are not concealed by them. The “no vertical scar” mammaplasty makes use of horizontal elliptical resection, similar to the Wise pattern, and a buttonhole for the new nipple/areola site [34, 35]. The Wise pattern produces a wide lower pole [10, 36]. This effect is exaggerated when no keyhole resection is used, producing a boxy breast shape (Fig. 6.1) [10, 36].

It has been suggested that Brazilian and European surgeons, using “novel concepts,” perform better mastopexies and reductions than their North American colleagues [37, 38]. Indeed, mastopexy is a subject of particular interest in Latin America, particularly Brazil, and notable advances have come from Brazilian plastic surgeons [39, 40]. Pioneering European surgeons, particularly from France, Belgium, and Germany, are responsible for many of the innovations still in use today [16, 41–48]. However, in comparing results in terms of the measured variables, there appears to be no geographical advantage [10].

Significant regional differences in technique include [10]:

Despite the authors’ claims , evaluation of 82 mastopexy and reduction articles reveals no significant increase in breast projection for any method (Fig. 6.2) [10]. On the contrary, nonvertical mammoplasties reduce breast projection. The mean change in breast projection for all procedures is a 0.7 cm decrease [10].

Similarly, no published mastopexy/reduction technique significantly increases upper pole projection (Fig. 6.3). The Wise pattern with a superior or medial pedicle decreases upper pole projection by 0.8 cm, on average.

Although the differences did not reach significance in the author’s study of combined results from numerous surgeons, several individual studies did achieve a boost in breast projection and upper pole projection [17, 49–51]. All used the vertical technique.

The breast parenchymal ratio (upper pole area/lower pole area) increases significantly for Wise pattern, superior or medial pedicle mammaplasties, and for vertical mammaplasties. This ratio is not increased significantly by inverted-T, central pedicle, and periareolar mammaplasties (Fig. 6.4) [10].

All mammaplasty methods, with the exception of the periareolar and inverted-T, central mound dissections, significantly elevate the lower pole (the lowest point on the breast) and nipple (Figs. 6.5 and 6.6). Nipple overelevation was found in 42% of publications, with no significant difference between open and closed nipple siting techniques. None of the photographs showed a patient with a postoperative nipple level below the level of maximum postoperative breast projection [10].

The vertical technique lengthens the lower pole distance (the length along the lateral curve from the plane of maximum postoperative breast projection to the posterior breast margin [52]), a measure of breast constriction [8], by converting an elliptical defect to a vertical straight-line closure (Fig. 6.7) [6, 9, 10, 22, 40, 53]. The lower pole is elevated and the length dividend increases projection [6, 8, 9]. By comparison, constriction of the lower pole, reduced breast projection, and increasing frontal boxiness, consequences of the inverted-T technique, are aesthetic problems that do not resolve [6, 8, 10].

The surgical approach for a mastopexy or breast reduction is the same as for an augmentation mastopexy or breast reduction plus implants, without the implant insertion. A vertical mammaplasty is performed using a medially based pedicle [24] and intraoperative nipple siting [6, 8, 9]. A mosque-dome or keyhole preoperative pattern is not used. A vertical resection is performed. The nipple/areola site is determined after creation of the new breast mound. An inverted-T modification is used in patients in whom the vertical scar extends below the level of the new (elevated) inframammary crease. Videos demonstrating a vertical breast reduction in combination with implant insertion are available at the Plastic and Reconstructive Surgery Global Open website: http://​journals.​lww.​com/​prsgo/​Pages/​videogallery.​aspx?​videoId=​23&​autoPlay=​true. The videos include preoperative marking, details of the surgery and anesthesia, and follow-up 24 h after surgery.

The author performs surgery on outpatients in a state-licensed ambulatory surgery center using total “SAFE” (spontaneous breathing, avoid gas, face up, extremities mobile) intravenous anesthesia [54]. No muscle relaxation is used so as to preserve the calf muscle pump [55]. Patients are also monitored for venous thromboembolism using ultrasound surveillance as part of a clinical trial in progress [56]. The mean operating time for a vertical mastopexy is 106 min, versus 121 min for a breast reduction [9]. The videos include preoperative marking, details of the surgery and anesthesia, and follow-up 24 h after surgery.

Measurements of results in published studies [10] have been discussed earlier in this chapter. The author sought to evaluate his own patients using the same measurement system [52].

Surprisingly, in women with ptotic breasts who undergo mastopexy, augmentation mastopexy, or reduction procedures, the overall mean preoperative nipple displacement (the vertical distance between the nipple and the level of maximum breast projection [52]) is <1 cm on both sides [6]. In 75% of breasts the right nipple is positioned within 1 cm or above the level of maximum preoperative breast projection (Fig. 6.8), and in 60% of women with ptotic breasts both nipples are located at or above the breast apex before surgery [6]. These findings suggest that with breast hypertrophy and ptosis the nipple slides with the breast in most cases rather than on it. The nipple goes along for the ride, so to speak. It is, after all, an ectodermal appendage with the same embryonic origin as the rest of the breast [57]. The pathology is thought to be a weakening of the fascial ligamentous support system of the breast [51], with descent of the parenchyma in an elastic skin envelope, not a skin “brassiere” at all [6].

Vertical mastopexy and reduction reduce breast areas approximately 12.5% and 25% respectively (Fig. 6.9). Vertical breast reduction increases the upper pole area 15% and decreases the lower pole area 50%, on average. Volume varies as the square of area. Therefore, breast reduction reduces volume 44% on average. Vertical breast reduction effectively inverts the breast parenchymal ratio (upper pole area/lower pole area). Most of the gain in breast parenchymal ratio derives from lower pole reduction as opposed to upper pole filling [6].

The mean increase in breast projection after vertical mastopexy is about 1.2 cm (Fig. 6.10). Upper pole projection increases about 0.5 cm. The increment in breast projection is about half as much after breast reduction – 0.6 cm on both sides, likely because of the greater reduction in volume (Fig. 6.11). Upper pole projection increases are similar to mastopexy (<1 cm). These modest increases confirm the clinical impression that mastopexy and reduction cannot duplicate the effect of an implant in creating upper pole fullness [12, 13].

The lower pole ratio (lower pole width divided by length) is a measure of the boxiness of the lower poles, with values much over 2.0 appearing boxy [52]. The mean postoperative lower pole ratio after vertical mammaplasty (combining mastopexy and reduction) is slightly under 2.0, measuring 1.97 on the right and 1.95 on the left [6].

Breast reduction patients tend to have large areolae, averaging 7.1 cm in diameter [6]. The areolar diameter decreases approximately 1.0 cm after mastopexy and 2.4 cm after breast reduction [6]. At least one nipple was overelevated in 30% of the author’s patients. Patients do not favor wide areolae [6]. Despite using a 39 mm areola marking ring and an intraoperative positioning technique that theoretically reduces skin tension around the areola [10], areola diameters for the combined group of vertical mastopexies and reductions averaged approximately 5 cm after surgery, at the outside margin of the range deemed “okay” by patients [6]. For this reason, an areola marking device with a diameter ≤39 mm is recommended, allowing for a 1 cm stretch after surgery [6].

Both vertical mastopexy and reduction significantly elevate the lower pole level, about 3 cm after mastopexy and 5 cm after breast reduction [6]. Vertical mammaplasty effectively elevates the breast mound (level of maximum breast projection), about 4.7 cm after mastopexy and 5.6 cm after reduction [6]. The nipple moves up on average 5.8 cm after mastopexy and 7.5 cm after breast reduction. These measurements suggest that 80% of the upward nipple movement derives from breast mound elevation; 20% is from nipple repositioning on the breast mound (Fig. 6.12) [6]. This figure is calculated by dividing breast mound elevation by nipple elevation.

The author’s study of published mammaplasties revealed shape deficiencies of the Wise pattern, regardless of pedicle orientation [10]. However, this study combined results from many different surgeons. It also evaluated only published photographs, which are likely to represent favorable results.

In order to compare these methods in the absence of confounders, the author undertook a comparative study of his own breast reduction patients [8]. The author performed all mammaplasties using the inverted-T, inferior pedicle method before 2002, and all subsequent mammaplasties with the vertical method, making possible a Level 3 study comparing a historical cohort with a prospective cohort. This study design avoided selection bias based on breast size or other considerations. An inclusion criterion was at least 3 months’ follow-up. Longer follow-up times are preferred. However, they come at the cost of lower inclusion rates [8]. At 3 months, swelling has sufficiently resolved so as not to represent an important confounding factor [6]. Subsequent shape changes are usually minimal [58].

In order to select most representative patients, those patients from each group with the lowest z-scores were chosen for publication (Figs. 6.13 and 6.14). These patients had, overall, the most average measurements among the patients in each study group. Figures 6.15 and 6.16 compare mean shape values depicted in mammographs for the two methods [8].