You are in: eMedicine Specialties > Plastic Surgery > BREAST Breast MastopexyArticle Last Updated: Jul 26, 2005AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Jorge I de la Torre, MD, FACS, Associate Professor of Surgery and Physical Medicine & Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Jorge I de la Torre is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society of Reconstructive Microsurgery, Association for Academic Surgery, and Medical Association of the State of Alabama Coauthor(s): Luis O Vasconez, MD, FACS, Chief, Professor, Division of Plastic Surgery, University of Alabama at Birmingham Editors: Christian Paletta, MD, FACS, Professor, Division Chief and Program Director, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Saleh M Shenaq, MD, Director and Founder, The International Brachial Plexus Institute; Chief, Section of Plastic Surgery, Methodist Hospital, Houston; Nick Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center; Michael J Miller, MD, Professor of Surgery, Chief, Division of Plastic Surgery, Ohio State University College of Medicine Author and Editor Disclosure Synonyms and related keywords: breast lift, mammoplasty, augmentation mastopexy, mammaplasty INTRODUCTIONSection 2 of 11
  Mastopexy, or breast lift, is a procedure designed to improve the appearance of sagging or ptotic breasts. The goal of surgery is to improve the shape of the breast while minimizing visible scars. To achieve this end result, multiple procedures and countless modifications of the mastopexy have been suggested. History of the ProcedureWhile descriptions of reduction mammoplasties can be seen as early as Paulus of Aegina (625-690 AD), not until the late 19th century was emphasis placed on correcting ptosis of the breast. Much of the history of mastopexy parallels that of breast reduction, since both attempt to alter the shape of the breast and the skin envelope. Most of these procedures involved elevation of the breast mound using suspension techniques. Techniques that transposed the nipple-areola complex (NAC) as a vascular pedicle were described by Morestin (1907) and used by Lexer (1912). Thorek (1921) was credited with the first report of a free nipple graft. Hollander (1924) first reported the lateral oblique resection resulting in an L-shaped scar. Schwarzmann (1937) described the use of periareolar de-epithelialization to preserve the neurovascular supply of the NAC. By the 1930s, most of the essential technical elements of the mastopexy had been developed. Further evolution in the mastopexy resulted in refinement of technique and analysis. Aufricht (1949) advocated preoperative planning using a geometric system and stressed the concept of the skin envelope defining the final breast shape. Wise (1956) defined the preoperative geometric marking system most commonly used today. Gonzalez-Ulloa (1960) first advocated mastopexy with augmentation for ptosis with hypoplasia or atrophy. Goulian (1971) described the use of the dermal mastopexy, and Regnault (1976) presented a classification system for breast ptosis and a description of the B mammoplasty. Johnson (1981), among others, has used Marlex mesh to lift the breast parenchyma. Benelli (1990) reported the use of the periareolar round block or purse string mammoplasty. Procedures to recreate breast fullness using autologous tissue either primarily or after breast prosthesis explantation have been described by Weiss and Ship (1995) and Flowers (1998). Hall-Findley (1999) used a medial-based pedicle modification of the vertical scar approach first described by Lassus (1970) as superior pedicle and popularized by Lejour (1994) with the use of breast liposuction. In 2002, Graf and Biggs described a modification of the vertical approach that places an autologous tissue flap deep to a strip of pectoralis muscle to improve shape and maximize longevity of the lift. ProblemMastopexy presents one of the greatest challenges to the breast surgeon. Numerous techniques provide improvement in the shape of the breast. The aesthetic goals are to obtain a more youthful appearance, improved projection, and reduced ptosis. Unfortunately, aesthetic improvement comes at the cost of scars. In addition, although breast implants can provide the upper pole projection patients often desire, they present specific risks and complications. FrequencyWhile the prevalence of breast ptosis is difficult to estimate, the frequency of mastopexy clearly is increasing. In 1992, the American Society of Plastic Surgeons reported that fewer than 8000 mastopexies were performed. The 2004 report indicates that more than 98,000 mastopexies were performed in the United States alone. EtiologyEtiology is varied and can be due to several components but gravity seems to be a common factor. Younger patients are more prone to ptosis because of excessive breast size or thin skin, thus the intertwining of breast reduction and mastopexy procedures. Ptosis in middle-aged patients usually is due to postpartum changes; the breast skin is stretched during lactation or engorgement, and afterward the breast gland atrophies, leaving loosened skin. Finally, in postmenopausal patients, further atrophy, gravity, loss of skin elasticity due to age, and weight gain are factors in creating breast ptosis. PathophysiologyWith time, relaxation of Cooper ligaments and dermal laxity cause descent of the breast tissue and NAC. Postpartum involutional changes exacerbate the laxity of the suspensory ligaments and skin envelope. To properly correct these changes, elevating the breast parenchyma is necessary. In addition, the redundant skin envelope must be removed and the NAC must be transposed. ClinicalA classification system has been suggested by Regnault and modified by numerous authors. The most commonly used system is as follows:
INDICATIONSSection 3 of 11
In most instances, breast mastopexy has no true medical indications and is performed primarily for aesthetic reasons. The main exception to this is in postmastectomy reconstruction, when performing a mastopexy often is essential to achieving symmetry. Another indication is following implant removal, which can result in breast ptosis and lax skin. However, one must be careful in assessing the amount of ptosis in patients with breast implants that are contracted and high riding. All patients considering mastopexy should be evaluated to ensure that they have realistic goals and a thorough understanding of the risks and benefits. RELEVANT ANATOMYSection 4 of 11
The breast is a modified skin gland; therefore, it should be considered not as an underlying structure but as an actual part of the integument. The dimensions of the breast vary depending on the patient's body habitus and age. While nipple location should be tailored to the individual, a sternal notch-to-nipple distance of 21-23 cm and an inferior limb distance of 5-7 cm have been considered average or desirable measurements. The arterial supply has medial and lateral components. The breast is supplied by the internal mammary artery from the medial aspect, the lateral thoracic artery from the lateral aspect, and the third through seventh intercostal perforating arteries. Venous drainage is via the superficial system just under the dermis and from the deep system that accompanies the arterial supply. Lymph drainage system is primarily the retromammary lymph plexus located in the pectoral fascia. Sensory innervation of the breast is provided by the intercostals and brachial plexus. Nipple sensation is provided by the third through fifth anterior cutaneous nerves and the fourth and fifth lateral cutaneous nerves. Of these, the fourth anterior cutaneous nerve is regarded by most authors as most important. CONTRAINDICATIONSSection 5 of 11
No absolute contraindications exist for breast lift surgery. However, one relative contraindication is planned future pregnancies, since lactation and subsequent involution further change the shape of the breast. Another relative contraindication concerns patients with capsular contracture of breast implants. Patients with contracted, high-riding implants often appear to have severe ptosis even though they do not. First removing the implants and then assessing the degree of ptosis on the operating room table is important prior to committing to a mastopexy. In patients who are at high risk of primary or recurrent breast cancer, consider whether a mastopexy will alter the breast architecture, making detection or treatment of cancer more difficult. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
TREATMENTSection 7 of 11
Surgical therapyThe goals of surgical therapy are to restore normal contour and size and to do so with a minimal amount of visible scars. The strategies needed to achieve this goal are (1) remove the excess skin and/or (2) replace or augment the atrophied volume. The types of mastopexy are classified by the amount of scars produced, which often are related directly to the amount of lift achieved. The choice of technique is determined by the degree of ptosis and the desired size of the breast postoperatively (see Images 1-8). Minimal breast ptosis can be corrected with breast implant augmentation. Minor ptosis can be corrected with periareolar skin resection with or without augmentation. Grade 2 ptosis can be corrected using a circumareolar donut mastopexy including the cerclage techniques as described by Benelli. Moderate grade 2 ptosis can be addressed using the vertical scar mastopexy procedures, including the Regnault B technique and Lejour/Lassus techniques. Severe grade 2 ptosis and grade 3 ptosis usually require inverted T incisions regardless of the pedicle used. Pseudoptosis can be addressed with augmentation and/or skin excision without nipple transposition (excision of lower pole skin) or with the circumareolar cerclage technique. These guidelines can be modified for individual patients. In some patients, a circumareolar mastopexy can be modified by adding a small vertical component to achieve the desired result. Likewise, extra remaining skin following a vertical scar technique may require excision with addition of an inframammary fold scar. Preoperative detailsPreoperative marking of the patient is essential for obtaining optimum results. The key to any plan for mastopexy is determining the correct level of the nipple. In most patients, the nipple should be at or slightly above the inframammary fold. Importantly, avoid placing the nipple too high, since this is a serious problem that can be difficult to fix. Proper nipple location can be determined by digital transposition of the inframammary fold to the anterior aspect of the breast. Once the proper nipple location has been ascertained, draw the remainder of the skin incision using the appropriate technique. Keep the inferior limit of the vertical incision 3-5 cm above the preoperative inframammary fold to avoid extension of the scar onto the chest wall after elevation of the breast and inframammary fold. Intraoperative detailsAugmentation alone can be used to correct minimal breast ptosis. Placing the implant in the subglandular area has been recommended as the most effective approach. Proper planning is required when implant placement is used in conjunction with parenchymal modifications. The periareolar incision lends itself to implant placement and nipple elevation while maintaining the viability of the NAC. The internal approach mastopexy can be used following the removal of breast implants. Elevate flaps from the implant capsules and fold them over to increase projection. Use plication sutures to elevate the NAC. No skin resection is performed. Augmentation also can be performed using autologous tissue. With a superiorly based NAC flap, an inferiorly based parenchymal flap provides central breast projection. De-epithelialize the inferior flap and place it behind the superior flap. Suspension sutures support the inferior flap and prevent recurrence of the ptosis. The periareolar technique employs an egg-shaped incision around the NAC. Mark the NAC and de-epithelialize the remainder. Split the parenchyma vertically and then overlap it to create a sling. Finally, a purse string suture is placed and the edges of the periareolar skin incision to decrease the diameter of the window to match the NAC (see Images 9-11). This technique can be combined with implant placement as described by De Binito and Sauza (1993). The B technique by Regnault uses a lateral and inferior resection. Periareolar de-epithelialization and superior undermining allow elevation of the nipple. The remaining breast tissue is rotated together to increase central projection and decrease lateral fullness. The resultant scar has a short inframammary segment lateral to the inferior limb (see Images 12-13). The vertical incision mastopexy uses either a superior or medial-based pedicle. The resection is inferior and lateral with lateral undermining. The inferior breast pillars are approximated with permanent sutures to elevate the breast and provide projection. Lejour includes liposuction of the breast laterally. Lassus advocates the use of a small inframammary incision (see Images 14-15). In some patients with dramatic ptosis or large breasts, inframammary incisions are necessary. The inverted T incision allows excellent access and can be used with any type of pedicle. In addition, it provides modification of the skin envelope in both the vertical and horizontal directions (see Images 16-17). Choosing the pedicle to supply the NAC depends on the degree of nipple elevation. The superior pedicle offers a great deal of flexibility with regard to incision location and access for placement of a breast prosthesis but it does not allow for a great deal of nipple elevation. The inferior pedicle allows a great deal of elevation of the nipple but can make implant placement and breast contouring more difficult. Medial pedicle techniques offer flexibility in technique and preserve sensation with a reliable vascular pedicle. Postoperative detailsWound care is minimal because subcuticular skin closure is used and Steri-Strips are left in place until they come off by themselves. Reinforcement is achieved with the use of Medipore tape to support the breast. The tape can be left in place for 2-3 weeks. Three weeks of some type of postoperative mammary support is recommended. Commercial surgical bras can be purchased from various plastic surgery supply houses, but soft sports bras are available from a variety of department stores. These garments are usually less expensive and are comfortable and easy to launder. Follow-upFollow-up care is minimal. Scarring can occur in the breast postoperatively and can change the patient's breast self-examination. Helping the patient establish a new baseline examination is important. In addition, fatty necrosis may demonstrate as palpable masses or mammographic changes. While these changes are usually discernible from malignant changes, offering prolonged follow-up care if any question should arise is important. COMPLICATIONSSection 8 of 11
General complications can include bleeding, infection, and problems secondary to anesthesia. Specific complications include skin necrosis, sensation changes, and asymmetry. Seromas and hematomas, although relatively uncommon, can pose significant problems when they occur. Nipple necrosis can occur due to tension, torsion, or pedicle compression. Overaggressive undermining can lead to necrosis of the skin flaps or NAC. Neither necrosis of the nipple nor skin flap loss occurs frequently. The inverted T incision increases wound breakdown at the junction of the 3 limbs. Scars usually heal without hypertrophy problems. Asymmetry is almost always present preoperatively, and it is unlikely to be eliminated completely regardless of the technique employed or the experience of the surgeon. Augmentation performed in conjunction with mastopexy can make correction of asymmetry even more difficult. Reviewing this with the patient before surgery is essential. The periareolar approach can result in underprojection of the central portion of the breast, in addition to stretching of the areola. When augmentation is performed with mastopexy, risk of postoperative asymmetry is increased. FUTURE AND CONTROVERSIESSection 9 of 11
Controversy currently exists with the use of mesh and with the use of liposuction in breast-lifting procedures. Liposuction has been recommended to provide a minimally invasive procedure, which can reduce some of the breast fullness and allow elevation of the NAC. Since breast tissue is removed but not examined histologically, and since breast tissue architecture is altered, critics question the safety of this technique. In contrast, proponents indicate that liposuction is safe, that the risk of finding a malignancy in a patient with a negative examination and history is small, and that if needed, the aspirate can be evaluated histologically. Permanent mesh has been advocated for long-term support of the breast parenchyma. This leaves a foreign body in the breast tissue, which can be reactive and is more prone to infection. In addition, an oncologic procedure required in the future may be complicated by the foreign material and tissue plane distortion. This technique has been used with great success outside of the United States, particularly in Brazil. The future of mastopexy surgery lies in the ability to obtain lasting results using a minimally invasive technique. Endoscopic procedures that suspend the breast tissue and minimize apparent scarring have been developed but they have limited indications. Alternatively, development in scar reduction, either through closure techniques or with postoperative treatments (ie, laser treatments), offers patients the opportunity to undergo an ideal procedure for their body shape while minimizing visible scarring. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Article Last Updated: Jul 26, 2005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
