Background
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 Procedure
While descriptions of reduction mammaplasties 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. [1] 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 [2] and used by Lexer. [3] Thorek was credited with the first report of a free nipple graft. Hollander first reported the lateral oblique resection resulting in an L-shaped scar. [4] Schwarzmann described the use of periareolar de-epithelialization to preserve the neurovascular supply of the NAC. [5] 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 advocated preoperative planning using a geometric system and stressed the concept of the skin envelope defining the final breast shape. [6] Wise defined the preoperative geometric marking system most commonly used today. [7] Gonzalez-Ulloa first advocated mastopexy with augmentation for ptosis with hypoplasia or atrophy. [8] Goulian [9] described the use of the dermal mastopexy, and Regnault [10] presented a classification system for breast ptosis and a description of the B mammaplasty.
Johnson, among others, has used Marlex mesh to lift the breast parenchyma. [11] Auclair and Mitz carried on that thought and described the use of an absorbable mesh insertion onto the anterior surface of the gland as internal support for the repair of mammary ptosis in mastopexy. [12] Benelli reported the use of the periareolar round block or purse string mammaplasty. [13]
Procedures to recreate breast fullness using autologous tissue either primarily or after breast prosthesis explantation have been described by Weiss and Ship [14] using the dual pedicle dermoparenchymal mastopexy and the deepithelialized transverse rectus abdominis muscle pedicle, as well as by Flowers. [15] Hall-Findlay [16] used a medial-based pedicle modification of the vertical scar approach first described by Lassus (1970) [17] as superior pedicle and popularized by Lejour (1994) [18] 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. [19]
Hidalgo [20] introduced a further modification of the vertical approach with the use of a Y-scar vertical mammaplasty, an alternative technique meant to reduce further scar burden. [20] Khan described a vertical scar bipedicle technique, a combination employed to produce minimal scarring and robust blood supply to the NAC, as a further option for mastopexies. [21] Loustau et al used the owl technique combined with the inferior pedicle in mastopexies. [22] This technique carries the advantage of the conization effect from the vertical reduction described by Lassus combined with a short L–shaped vertical-horizontal scar, and also uses the inferior pedicle flap described by Ribeiro. [23] Singh et al advocate a Z-mammaplasty technique. [24]
Problem
Mastopexy 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. [25] 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.
Epidemiology
Frequency
While the prevalence of breast ptosis is difficult to estimate, the frequency of mastopexy clearly is increasing. According to the American Society of Plastic Surgeons, 113,188 mastopexies were performed in the United States in 2019, compared with just 52,836 in 2000, a 114% increase. [26]
Etiology
Etiology 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.
Pathophysiology
With 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.
Presentation
A classification system has been suggested by Regnault and modified by numerous authors. The most commonly used system is as follows:
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Grade 1: Mild ptosis - Nipple just below inframammary fold but still above lower pole of breast
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Grade 2: Moderate ptosis - Nipple further below inframammary fold but still with some lower pole tissue below nipple
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Grade 3: Severe ptosis - Nipple well below inframammary fold and no lower pole tissue below nipple; "Snoopy nose" appearance
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Pseudoptosis - Inferior pole ptosis with nipple at or above inframammary fold; usually observed in postpartum breast atrophy
Indications
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 mastopexy is performed to achieve symmetry. [27] 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 Anatomy
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. For more information about the relevant anatomy, see Breast Anatomy.
Contraindications
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.
Smoking, diabetes, and obesity have been associated with an increased incidence of nipple necrosis.
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Breast mastopexy. Preoperative anterior view of a 38-year-old woman with ptosis and postpartum involutional changes who is seeking augmentation in addition to elevation of the breast.
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Breast mastopexy. Preoperative lateral view of a 38-year-old woman with ptosis and postpartum involutional changes who is seeking augmentation in addition to elevation of the breast.
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Breast mastopexy. Postoperative anterior view 3 months following circumareolar mastopexy and placement of 330-mL smooth round implants in a subpectoral pocket in a 38-year-old woman who had ptosis and postpartum involutional changes and sought augmentation in addition to elevation of the breast.
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Breast mastopexy. Postoperative lateral view 3 months following circumareolar mastopexy and placement of 330-mL smooth round implants in a subpectoral pocket in a 38-year-old woman who had ptosis and postpartum involutional changes and sought augmentation in addition to elevation of the breast.
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Breast mastopexy. Preoperative anterior view of 29-year-old woman seeking elevation and minimal reduction of breast.
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Breast mastopexy. Preoperative lateral view of 29-year-old woman seeking elevation and minimal reduction of breast.
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Breast mastopexy. Postoperative anterior view 3 months following reduction mastopexy in a 29-year-old woman who sought elevation and minimal reduction of breast. A medial pedicle was used via the vertical scar technique.
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Breast mastopexy. Postoperative lateral view 3 months following reduction mastopexy in a 29-year-old woman who sought elevation and minimal reduction of breast. A medial pedicle was used via the vertical scar technique.
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Breast mastopexy. Skin excision amount is determined by the looseness of the skin. It may be either concentric or biased to reposition the nipple.
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Breast mastopexy. The skin edge is undermined. Here the scalpel is undermining the skin edge.
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Breast mastopexy. Purse string permanent sutures are placed to prevent skin stretching. Goes and Benelli also use a type of suture or mesh to suspend the gland, although efficacy of this technique is unknown.
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Breast mastopexy. Regnault B-type excision showing new nipple position and skin excision.
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Breast mastopexy. Regnault B-type excision, continued.
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Breast mastopexy. This shows the new nipple position at the inframammary fold after the skin excision.
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Breast mastopexy. The skin edges usually may be approximated without undermining. Excess inferior pole skin is bunched together. This bunching smooths out over time.
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Breast mastopexy. This inverted T (Wise pattern) shows the new nipple position at the inframammary fold and the skin excision.
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Breast mastopexy. AA' to BB' should be no longer than 4.5 cm. This usually creates tension at suture point BB', leading to skin necrosis. Wide undermining also may contribute to this complication.
