When Breast Augmentation Is Not Enough: Mastopexy Augmentation

Key points

•
Pseudoptosis and grade 1 ptosis can be managed in multiple ways.
•
Patient goals and anatomy will dictate the best choice for her.
•
Subpectoral augmentation with superior pedicle mastopexy can maximize aesthetics and longevity.

Abbreviation

IMF	inframammary fold
NAC	nipple areola complex

Video content accompanies this article at http://www.plasticsurgery.theclinics.com .

Introduction

In a textbook about breast augmentation, we need to discuss the tipping point. When is breast augmentation NOT enough? The primary goal of breast augmentation with a breast implant is to elevate the upper breast border significantly, maintain that upper pole fullness, and increase breast volume. Breast augmentation alone will make the patient’s existing breast larger in every dimension, including the upper breast border, but cannot address any other issues that the patient may want to change such as nipple position, gland envelope shape, asymmetries, or enlarged areolae. We can all agree that patients with grade 2 or 3 ptosis who want an elevated upper breast border will also need a mastopexy with their augmentation. That is not the subject of this article. The real question is how to address the “borderline” patient with pseudoptosis or grade 1 ptosis. These patients are not straightforward, and their surgical options will vary based on patient goals and anatomy. This article will encompass my thoughts and approach to borderline patients with pseudoptosis, grade 1 ptosis, and grade 2 ptosis.

With the recognition of breast implant-associated anaplastic large cell lymphoma and the voluntary recall of Biocell implants in 2019, textured breast implants are essentially not used for cosmetic purposes in the United States any longer. Shaped, textured breast implants were more forgiving in all augmentation planes and could even disguise a low upper breast border without widening the breast too much due to different heights and their ability to velcro in place. Patients would do reasonably well even with a pinch thickness of 1.5–2 cm in a subglandular plane. The lower pole of an anatomic implant can preferentially fill the inferior pole of a breast envelope that is somewhat lax. These devices could help a borderline patient with pseudoptosis or Grade 1 ptosis achieve an acceptable result with augmentation alone, for a longer period of time before revision. Now this tool has effectively been removed from our toolbox.

Dual plane breast augmentation, as described by Tebbetts in 2001, is the most common approach to breast augmentation in the United States. In this canon article, 91% of the breast implants placed were Biocell anatomic devices. 7.3% of the implants were textured, but round. Only 1.7% of patients in this study had smooth devices placed. The piston effect of the contracting, window-shaded pectoralis major muscle over a smooth device will displace the implant inferolaterally over time, far worse than with a textured implant. The question is how long the result will be acceptable, and that is hard to gauge because tissue quality, implant volume and projection, and weight changes certainly play a role in the longevity of the result. While I have always used smooth breast implants for cosmetic cases since 2001, I had to learn the hard lesson that smooth devices do not hold up well in challenged breast tissue in any plane, and thus have modified my approach to dual plane augmentation for better longevity with smooth implants, and became adept at single-stage mastopexy augmentation. Both approaches are reasonable surgical offerings for borderline patients, and the patient’s goals, anatomy, and quality of tissue will dictate which approach is best.

Patient evaluation

Patient satisfaction is our ultimate objective, and to achieve that, the surgeon must fully understand the patient’s idea of a great result for herself. I find that having the patient bring “goal pictures” from our website of before and after results of similarly built women helps to flesh out if the patient has realistic goals of what augmentation alone can achieve, or even an accurate understanding of her own anatomy. In addition, 3-dimensional imaging is very helpful in simulating realistic results of augmentation. I do not find the simulation of mastopexy augmentation to mimic my results and do not use this tool to portray their anticipated results. Instead, we look at before-and-after pictures of mastopexy augmentation results from our website, directing the patient to women with similar frames. Probably even more important than the augmentation simulation, 3-dimensional imaging is an educational tool to point out both skeletal and gland asymmetry that will impact surgery, and thus, the results of breast augmentation alone. When the patient is dissatisfied with realistic, simulated results of augmentation alone, they better understand why mastopexy augmentation is the path to achieve not only the size, but also the chest wall position, nipple position, and shape they desire.

After taking standard breast measurements, the most vital being her breast diameter, I have the patient look in the mirror and displace her breast tissue upward to where she would like the upper breast border to be. This maneuver will help to determine if the borderline patient will be pleased with augmentation alone or will require mastopexy augmentation.

In Fig. 1 A–D , this 32 year old G1P1 woman desired breast augmentation to increase her cup size. I consider her borderline as her right breast is pseudoptotic, and her left breast has grade 1 ptosis. Her nipples are both outward-facing, although asymmetrical. She felt she would be happy with augmentation alone, filling her breast envelope. She was very concerned about scarring and nipple sensitivity. She expressed understanding that she would be dual planed, that the longevity of her result would be unknown, and the nipple asymmetry and position would not be addressed. She remained content for 12 years before asking for improved upper pole fullness and smaller areolae.

A set of photographs shows a woman before and after multiple breast surgeries in front and side views. — Fig. 1

Fig. 2 A–C shows a 29 year old G2P2 woman who desired augmentation with her elevated upper breast border at the preaxillary crease. She has grade 1 ptosis with acceptable nipple position. She chose subpectoral mastopexy augmentation to achieve the upper pole she desired, with maintenance of results for 14 years.

A set of photographs shows a woman before and after breast augmentation and mastopexy in front and side views. — Fig. 2

Both patients were given the option to undergo augmentation alone or mastopexy augmentation. Different surgeons may not even offer mastopexy augmentation since their nipple areola complex (NAC) is in an acceptable position and outward facing. Truthfully, sometimes finances are a factor for the patient, and the additional cost of mastopexy is not reasonable for them. Nicotine use is another issue that can influence a patient’s choice. I do not perform mastopexy augmentation in smokers, and the patient in Fig. 3 A–D chose augmentation alone due to her inability to quit nicotine. While I personally felt that she would do better with mastopexy augmentation, she remained happy for 18 years and did a simple exchange in the same plane when she had a partial deflation. The tipping point of mastopexy augmentation over augmentation alone is a gray area that the patient must decide after being educated on what is attainable with each approach, the risks and benefits, and potential longevity of each.

A set of photographs shows a woman before and after breast augmentation and subsequent revision surgeries in front and side views. — Fig. 3

So, when should a surgeon offer mastopexy with breast augmentation?

1.
She has glandular or nipple ptosis.
2.
She has a low breast footprint.
3.
She does not like her current gland shape.
4.
She has significant gland envelope or nipple asymmetry.

Breast ptosis

Using Regnault’s classification of ptosis, Fig. 4 , some surgeons and patients would choose to treat pseudoptosis and Grade 1 ptosis with breast augmentation alone and avoid mastopexy scars if her tissue quality is reasonable and she has nipple symmetry. Tissue quality is often the critical determinant of augmentation versus mastopexy augmentation, and this knowledge comes with experience—usually bad—of only offering augmentation in a woman with lax gland, particularly weight loss patients. Fig. 5 A, B shows a patient with pseudoptosis, poor tissue quality, and enlarged areola. Breast augmentation alone would further enlarge the areolae, and the longevity of the result would likely be shorter due to her already challenged gland. She chose mastopexy augmentation to have a more youthful appearance and smaller areolae.

A set of four photographs shows a breast augmentation. The top row is the preoperative view showing pseudoptosis, and the bottom row is the nine year postoperative result. — Fig. 5

Of course, gland and or nipple ptosis and asymmetry can be treated with a mastopexy alone; however, there will be no elevation of the upper breast border, nor an increase in volume of the breast. Even with auto-augmentation using an inferiorly based flap, as described by Ribero and Graf, the upper breast border will only elevate at most by 1 cm, and there will be no increase in breast volume. For those women who want increased volume, subpectoral augmentation with a mastopexy can elevate the upper breast border by 2.5 cm and address gland and nipple ptosis and asymmetries. I prefer superiorly based mastopexy pedicles due to their robust blood supply, ability to remove the most ptotic gland and elevate the inframammary fold (IMF) if needed. I do not offer crescent or Benelli mastopexy to anyone.

Fig. 6 A–C depicts a 32 year old G2P2 woman with grade 1 ptosis. She specifically wanted “all of her breast higher.” Subpectoral augmentation with 371 cc moderate profile gels and superior pedicle mastopexy achieved her goals with satisfaction 4 years later.

A set of photographs shows a woman before and after breast augmentation with mastopexy in front and side views. — Fig. 6

I hope all plastic surgeons would offer mastopexy augmentation to someone with grade 2 ptosis ( Fig. 7 A–D ). This 30 year old G1P1 woman desired fuller volume and position. With the laxity of her gland, a superior pedicle is still possible despite how caudal her NAC is positioned. I performed a subpectoral augmentation with moderate profile 330 cc gels and superior pedicle mastopexy, removing 81 g from the right, 60 g from the left. She has maintained her result 7 years later despite a 23 pound weight gain. When the lower pole excess gland is removed, weight changes cause less waterfall than augmentation alone.