The Clinical Problem
Hypoplasia and ptosis of the mammary are frequent occurrences, especially in multiparous women or in women after significant weight loss. Decreased breast volume may induce a negative body image and low self-esteem, affecting a patient’s quality of life. A mastopexy survey of 487 members of the American Society for Aesthetic Plastic Surgery, published in 2006, concluded that the inverted T is the most popular mastopexy approach (46%) despite the varying nature of mammary ptosis and its treatment. Short scar mastopexy techniques were used by 18% of respondents, and the periareolar approach was used by only 6.2% of respondents. Breast augmentation with a simultaneous periareolar mastopexy has remained a challenging and controversial procedure. The aesthetic results may be less predictable than those associated with implant-based augmentation or mastopexy alone.
According to Rohrich et al., the periareolar approach is the preferred breast mastopexy technique for as many as 40% of the most experienced surgeons, who perform more than 26 mastopexies each year. There is a suggested learning curve for achieving acceptable aesthetic results. Breast surgery has constituted 60% of all cosmetic liability claims in the United States in the last decade, and periareolar mastopexy comprised 63% of all mastopexy liability claims.
Planning simultaneous augmentation and periareolar mastopexy with shaped implants helps achieve the desired results, avoids unnecessary scars, and minimizes the frequency of complications in carefully selected cases ( Fig. 28.1 ). Ideal objectives include breast lift, addition of volume, nipple areolar complex (NAC) lift, reduction of the areolar diameter and skin envelope, outcome longevity, and minimal complications.
Synopsis
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Periareolar breast augmentation and mastopexy is a very versatile technique.
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Anatomic implants provide the best possible match in uplifted breasts.
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Careful patient selection and planning are necessary.
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Be conservative in lateral areolar resections.
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Always consider staging.
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Extra attention should be paid with large implants (to avoid bottoming out).
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Always advise the patient about possible revisions.
Case 28.1
Presentation and Outcome
A multiparous 42-year-old woman presented with bilateral hypoplasia and grade 2 breast ptosis. She opted for a simultaneous augmentation and mastopexy ( Fig. 28.2 ).
Fig. 28.3 shows the markings for a periareolar approach on the right breast and an anticipated lollipop approach to the left breast. Fig. 28.4 shows the intraoperative result following simultaneous periareolar augmentation and mastopexy on the right breast. Left breast symmetry was achieved by a periareolar approach of augmentation and mastopexy ( Fig. 28. 5 ). Fig. 28.6 shows the lateral view of the right breast 1 year after simultaneous mastopexy and augmentation.
Critical Decisions in Augmentation and Mastopexy
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Which mastopexy technique should be used?
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Should it be one stage or two?
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One-stage approach—first, the augmentation
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Two-stage approach—first, the mastopexy
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How much should the nipple-areolar complex (NAC) be elevated?
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How much skin should be removed?
Deciding Augmentation or Simultaneous Augmentation and Mastopexy
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Is a mastopexy needed?
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Is an implant needed?
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Is there uncertainty about the blood supply, previous scars, long pedicle, and/or tissue cover of the implant?
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A one-stage approach requires extra attention, but a two-stage approach is generally safer and allows revisions.
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A second stage can always be carried out later.
Tips and Tricks in One-Stage Augmentation and Mastopexy
Always re-evaluate after the augmentation while the patient is positioned upright, after closure of the implant pocket. Tailor-tack over the augmented breast and then perform the mastopexy. Anatomic implants enhance results and NAC positioning. Do not be fixed to an anticipated implant.
Use sizers to assist in implant selection. Carefully consider the nipple inframammary fold (IMF) distance. Check the areolar position on the breast. Check skin coverage and tissue quality.
Considering Breast Ptosis
The Regnault classification is commonly used to assess breast ptosis ( Table 28.1 ). However, essential aspects not evaluated by this classification but vital to consider are breast skin elasticity, striae or scars, breast surface area, breast volume, and internal consistency and tissue support of the breast.
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