Patient selection

The initial consultation for mastopexy should include a detailed discussion of the patient’s goals and expectations and a careful review of medical and psychiatric histories. As with any breast surgery, a personal and family history of breast disease or cancer should be obtained. The surgeon should specifically note a history of any previous breast surgery or radiation therapy. Pre-operative mammography is recommended for any patient with significant risk factors and patients over 35 years of age.

Prior surgical history should include previous augmentation or reduction procedures. When possible, operative notes detailing techniques and implant devices used should be reviewed. Information about past or planned pregnancies and changes in weight and/or brassiere size can also aid in pre-operative assessment. Management of patient expectations is crucial to ensuring satisfaction. The ideal breast aesthetic may vary greatly between patients and surgeons. Every attempt should be made to understand the patient’s motivations and anticipated results. Patients who are unrealistic or unwilling to accept the necessary scars should be avoided.

The pre-operative physical examination should include measurements as well as an assessment of tissue qualities and distribution. Significant asymmetries will exist in the majority of patients when carefully examined. It is important to recognize and point out any preexisting asymmetries, spinal curvature, or chest wall deformities as these may be difficult to correct and can become noticeable in the postoperative period. Preoperative photographs with multiple views are obtained on all patients and maintained as part of the office record.

Thorough palpation of the breast and axilla should be performed and documented. Any palpable masses or lymph nodes must be evaluated before proceeding with surgery. Measurements of breast width (BW), breast height (BH), intermammary distance, nipple to suprasternal notch (NSSN), and nipple to inframammary fold (NIMF) should be made and documented. Measurements can aid in planning the operation, recognizing asymmetries, and tracking post-operative results.

The formerly Inamed Corporation has developed the BioDimensional ^® pre-operative planning system to facilitate planning in augmentation mammoplasty ( Table 11.1 ). The same principles can be applied when preparing for mastopexy or mastopexy augmentation. Essentially, the approach should be to first analyze the existing chest and breast form as described. Following that one should characterize the soft tissue envelope and plan the desired resultant breast form. Once accomplished the surgeon can assimilate the information to select an appropriate implant, if desired, and plan the mastopexy approach.

Indications

Breast ptosis is most often a consequence of aging tissues. Over time, Cooper’s ligaments become attenuated and the breast loses its fascial support, frequently with a concurrent decrease in volume. Age-related changes are often hastened or mimicked by weight loss and involutional changes seen with pregnancy/lactation and menopause. Regardless of the etiology, a useful tool for the surgeon is to classify patients by the degree of ptosis present. The classification system used most frequently was first described by Regnault and grades the breast based on the position of the nipple relative to the inframammary fold (IMF) ( Table 11.2 ). The amount of pre-operative ptosis can be used as a guide to selecting the operation necessary to achieve correction.

Patient marking

Pre-operative markings are made with the patient in an upright position and begin with midline, current IMF, and planned nipple position. Additional marks, determined by the patient’s tissue characteristics, are then made as guidelines for resection. Nipple position is established using the current IMF as a guide, by making the mark along the breast meridian while manually palpating the fold. The location of this point is confirmed by checking its distance from the suprasternal notch and mid-clavicle bilaterally. This is usually 20 ± 3 cm from the suprasternal notch. At this point, the surgeon should determine the planned excision pattern and proceed with the appropriate marks. The degree of mastopexy will vary from a periareolar approach to a full inverted-T scar based on the amount of ptosis present. Variations in incision patterns are the same for augmentation mastopexy and mastopexy alone and are gradually increased to accommodate increasing amounts of breast tissue and ptosis.

Minor ptosis is usually addressed with a periareo-lar approach either concentrically or eccentrically designed. This pattern places the scar at the border of the pigmented areola and the breast skin. A point is first made just superior to the planned nipple position and represents the planned position of the upper areolar border. This should be no more than 3 cm above the transposed inframammary fold mark. The areola to be preserved is outlined using a standard nipple marker at 38–42 mm. The distance from the nipple to the planned position of the upper areolar border can be used as the radius for designing a concentric pattern. Often it is necessary to adjust this to a more oval shaped or eccentric configuration to correct for asymmetries and variations in tissue distribution.

When addressing moderate ptosis, a vertical excision is marked. This is done by first repeating the initial steps above to determine the position of the new nipple and upper areolar border. The distance from the center of the nipple to the new upper areolar border is then used to set the width of the planned vertical excision. The vertical limbs are drawn connecting to a point 1–2 cm above the IMF. Adjusting the distance between the vertical limbs will accommodate individual tissue characteristics and asymmetries. This is often done when tailor-tacking as described below.

Patients with more severe ptosis usually require greater nipple elevation and a horizontal excision to achieve adequate correction. The horizontal component will vary from a traditional Wise pattern marking to a shorter version that is adapted into the vertical pattern described above. Marking this pattern begins as described as above and places the horizontal scar along the IMF with the T-junction designed to rest along the breast meridian. When planning simultaneous augmentation, these marks are made conservatively to allow for the excess tension that will be created when an implant is placed. This helps to avoid problems with healing at the T-junction. Regardless of the pattern chosen, all marks are customized to the individual patient, carefully measured, and confirmed with tailor-tacking in the operating room before proceeding with excision.