The word “ptosis” is derived from the Greek vernacular and is translated as “falling” (1). “Falling” of the breast, or breast ptosis, refers to the position of the nipple relative to the inframammary crease. An aesthetically pleasing breast should have the nipple located above this crease at the most projecting part of the breast mound. The degree to which the nipple descends below the level of the crease determines the severity of the ptosis. Probably the oldest and most commonly used classification is Regnault’s (2). According to Regnault, grade I ptosis is diagnosed when the nipple is at or up to 1 cm below the inframammary crease. Grade II ptosis describes the nipple at a level 1 to 3 cm below the crease but not yet at the lowest contour of the breast. Grade III ptosis describes a nipple more than 3 cm below the crease or at the lowest contour of the breast gland. A condition called pseudoptosis occurs when the lower pole of the breast falls below the inframammary crease but the nipple itself is at or above the level of the crease. It is important to recognize this entity so that the corrective plan does not result in positioning the nipple too high.

The surgical correction of breast ptosis is termed mastopexy. Any procedure designed to accomplish elevation of the breasts must take into account four essential elements (3): (a) elevating the nipple-areola complex (NAC) and preserving its blood supply, (b) removing redundant parenchyma if necessary, (c) removing excess skin, and (d) shaping the breast.

The preservation of the blood supply to the NAC is a top priority in any mastopexy procedure. Almost any pedicle can be fashioned to maintain the viability of the NAC. Common variations include the superior pedicle, inferior pedicle, lateral pedicle, medial pedicle, central pedicle, horizontal bipedicle, and vertical bipedicle.

The removal of excess parenchyma is more of an issue in reduction mammaplasty, but it is sometimes necessary in mastopexies to achieve the desired shape and size. The location of the pedicle will dictate the area of the breast that can be removed and in this way influence the final shape of the breast. For instance, inferior pedicle techniques imply resection of tissue parenchyma in the superior pole. This leaves a breast with lack of upper pole fullness and a potential for “bottoming out” due to the weight of the pedicle in the lower pole. Superior pedicle techniques, on the other hand, resect excess parenchyma from the central and lower pole, avoiding the bottoming-out phenomenon and leaving superior tissue for upper pole fullness.

Excess skin can be resected in different ways. The skin resection design dictates the final scar left on the breast. The most common skin resection patterns are circumareolar, vertical, lateral, and inverted T (Wise). Skin resection patterns are sometimes assumed to automatically refer to a specific type of pedicle or parenchymal resection. The inverted-T or Wise design is often associated with the use of an inferior pedicle when it can be applied with a combination of different pedicle and parenchymal resections. The same applies to the circumareolar, vertical, or lateral mammaplasty techniques. The most common vertical mammaplasty technique incorporates a superior pedicle with a central wedge resection of parenchyma. However, different combinations of pedicles (superior, inferior, lateral, medial) and glandular resection patterns have been described for vertical mastopexies (4,5,6,7,8).

Second only to the blood supply to the nipple-areola complex, the final shape of the breast is the most important objective in a mastopexy procedure. The surgeon cannot sacrifice shape in favor of scar length or location. Therefore, although the circumareolar technique achieves the most desirable scar, it can only be applied in small, mildly ptotic breasts with adequate breast parenchyma. Any nipple-areola elevation above 2 to 3 cm will lead to poor results with this technique (9). One of the factors that have led to the recent popularity of the vertical mammaplasty technique is that it leaves less of a scar than the Wise pattern with a better breast shape.

Vertical mastopexy is therefore a surgical procedure to correct ptosis of the breasts with a vertical skin resection pattern, leaving only a vertical scar. Even though the superior pedicle with central parenchymal resection is most common with this technique, any combination of pedicle design and parenchymal resection can be applied with a vertical scar.

Mastopexy by vertical mammaplasty was described as early as 1925 by Dartigues, but it remained nearly unknown until Arie in 1957 and then Lassus in 1969 revived the technique (4,5,10,11,12). In the early 1990s, Lejour introduced her vertical mammaplasty technique, which was derived from that of Lassus (4). Both Lassus and Lejour have contributed enormously to the evolution and popularization of this procedure.

Claude Lassus is considered one of the pioneers of vertical mammaplasty. In 1964, he performed a breast reduction on a patient with unilateral breast hypertrophy, and in 1969 he published this technique, which combined four principles (5,10): (a) a central vertical wedge resection to reduce the size of the breast, (b) transposition of the areola on a superiorly based pedicle, (c) no undermining, and (d) a vertical scar to finish off.

His vertical mammaplasty technique for mastopexy is similar, except that there is no removal of breast tissue (10). The central wedge of tissue, instead of being removed, is left as a superiorly based flap and is then folded back on itself and anchored to the pectoralis fascia in the upper part of the breast. This flap produces upper pole fullness and retroareolar projection. With the closing of the medial and lateral pillars, this technique achieves narrowing of the base diameter and coning of the breast.
Reapproximating the pillars in several layers extending from the chest wall anteriorly also reinforces a central column that will maintain tissue support and long-term breast shape.

The superiorly based pedicle may be a limiting feature of his operation. Superior translocation of the NAC requires folding of the pedicle and potential collapse of the venous plexus compromising the NAC. When the NAC has to be advanced more than 9 cm the risk of necrosis is high, and a medial or lateral pedicle is preferable (10). In such cases we prefer a vertical bipedicle (superior and central mound) (9). According to Lassus, since he stopped advancing the NAC more than 9 cm on a superior pedicle he has had no cases of areolar necrosis. Before that, he reported 2 cases of total areolar necrosis and 17 partial losses (10).

Lassus avoids subcutaneous or subglandular undermining, so there is less dead space and therefore less chance of hematoma or seroma. Finally, Lassus uses a vertical scar to finish off. In his original description, the postoperative vertical scar often extended vertically below the fold in large reductions and mastopexies. To avoid this, Lassus added a short horizontal incision at the crease. However, he later reverted to a vertical scar only by limiting the inferior extent of skin resection and gathering the vertical closure (8).

In 1994, Lejour introduced her vertical mammaplasty technique. It was derived from that of Lassus. It benefits from three innovative principles: (a) wider lower skin undermining to promote skin retraction and reduce the amount of scarring, (b) overcorrection of deformities to produce better late results, and (c) use of liposuction to facilitate molding of the breast and to remove unnecessary tissue prone to absorption when the patient loses weight. Lejour’s vertical mastopexy also includes the elevation of the lower central portion, which is then sutured to the upper level of the retromammary dissection (4).

An anatomic study of Corduff and Taylor (13) demonstrated that the major blood supply enters the NAC at a superficial level. One branch from the internal mammary artery from the second or third intercostal space supplies the NAC based on a superior pedicle. This artery passes through the subcutaneous tissue into the breast, angles obliquely downward toward the nipple, and then descends into the parenchyma. It is present at the breast meridian about 1 cm deep to the skin. This is why superiorly based pedicles can be safely thinned out up to 1 cm below the areola (5,6,10). Most arteries to the breast do not have an accompanying vein. The venous plexus is superficial and concentrated around the areola; therefore a bridge of dermis with adequate width should always be left around the NAC. Any design that necessitates folding of a long pedicle is likely to collapse the venous plexus and compromise venous return. Arterial inflow might be strong enough to overcome folding, but venous return is likely to suffer. Nipple-areola sensory innervation is provided primarily by the fourth anterolateral and anteromedial intercostal nerves; however, the third and fifth intercostal nerves, as well as nerves from the cervical plexus, also contribute to nipple-areola sensibility. This overlapping of sensory zones of the areola by multiple nerves is probably the reason most patients maintain sensory input after vertical mammaplasty (14,15).

The concept of breast skin excision is three dimensional: unidimensional refers to perioareolar skin removal; bidimensional includes a periareolar and a vertical component; and tridimensional includes a periareolar, a vertical, and a horizontal component of skin removal. The horizontal component may include a short T, a J or L, or the long horizontal T (16).

Periareolar techniques are only indicated in small, mildly ptotic breasts where the NAC needs to be elevated less than 2 to 3 cm. Tempting as it is to confine the incision to the areola, the method leads to poor results if applied to the wrong patients. For more advanced cases of ptosis, vertical or inverted-T techniques are most commonly used. In moderate or severe ptosis, mastopexy with inverted-T skin resection is still one of the most common techniques. However, the vertical approach is becoming more and more popular as plastic surgeons are becoming aware of the advantages and pitfalls of both techniques.

The first and most obvious difference is the shorter scar, with the elimination of the inframammary scar. A survey mailed out to 94 patients who had undergone breast reduction concluded that 65% of them were dissatisfied with their scars; of these, 65% indicated that the horizontal component bothered them the most (17). The vertical scar is barely visible over the years, and it rarely becomes hypertrophic even in women with darker skin. In his 40 years of experience and 1,350 cases of vertical mammaplasty (439 mastopexies and 911 reductions) Lassus reported only 4 cases of severe hypertrophy of the vertical scar that led to a terrible result (10).

With the inverted-T technique, a horizontal ellipse of skin is resected and pulled inferiorly. The vertical arms of the T design are usually short (5 to 6 cm). These two factors limit projection and contribute to a flat breast. On the other hand, with a vertical skin pattern, the long vertical closure allows for adequate projection and coning of the breast.

Inverted-T techniques with central mound or inferior pedicles usually depend on the skin to maintain breast shape. Because skin is elastic, with time the weight of the lower pedicle or central mound parenchyma will cause the skin to stretch, and the breast tissue will migrate to the lower pole. This bottoming-out phenomenon is much less likely with vertical mammaplasty techniques because the shape of the breast does not depend on a skin brassier. The final shape of the breast is accomplished by manipulation of the breast parenchyma, and the skin is simply sutured over and allowed to adapt to this new shape. The long-lasting stable result achieved with this technique is for many its main advantage. Lassus demonstrated maintenance of shape up to 20 years following the initial procedure (5). The vertical mammaplasty leaves shorter scars, improves breast projection, narrows the wide breast, offers better long-term shape. and reduces the bottoming-out phenomenon when compared with inverted-T techniques. The vertical technique reduces breast width, while the Wise pattern maintains breast width. The vertical technique pushes up the NAC, while the Wise pattern pulls it down.

Not all patients are suited for vertical mastopexy or the superior pedicle. In achieving excellent aesthetic results, proper
patient selection is essential. It is best to start with younger patients, with mild to moderate hypertrophy, mild to moderate cases of breast ptosis, and normal-quality, elastic skin (5,10,18,19) (Table 87.1). The technique is not suitable for women with very large breasts and/or severe ptosis. In these cases a horizontal or lateral scar will be necessary to compensate for the extra skin. The relationship between the incidence of complications and body mass index and breasts size is well demonstrated (4). The patient should be willing to accept the fact that the immediate postoperative result in breast shape and scar appearance is not aesthetically pleasing and understand that the final result may not be seen for up to 3 months (4,5,11,20,21,22).