A Surgical Procedure for Correctingbreast Ptosis When the Breast Volume Is Satisfactory

MASTOPEXY

INTRODUCTION

A surgical procedure for correctingbreast ptosis when the breast volume is satisfactory.
The aim is to restore a youthful, uplifted look to breasts that have aged and sagged.
Management of ptosis requires analysis of the problem, the patient’s desires and selection of the optimal operation. It is regarded as one of the most problematic procedures in aesthetic breast surgery.
Modernmastopexy operations produce better breast shape,shorter scars, more parenchymal support, and are longer lasting than in the past
Unlike the augmentation patient who has never had an ideal breast or the reduction patient who wants to be smaller even if it requires scars, the mastopexy patient was once satisfied with her breasts and wants them restored to their previous appearance withoutscars.
The risk benefit ratio of the procedure must be discussed with the patient.

Two basic questions must be addressed:

1.Does the breast lift justify the resulting scars?

2.If the insertion of an implant is required, is the additional risk justified?

After correction, the effects of aging and gravity will undo the effects of the procedure. The improvement is not lasting but the patient will be left with scars.

Patients are often unclear on what they want. Not only the droop but the shape and size may not be right.

Upper breast flatness is often a problem and requires the insertion of a prosthesis. This adds a degree of permanence to the procedure but with it comes the problems associated with implants.

THE NORMAL BREAST

The normal breast is located between the 2nd and 6th ribs. In the young girl, the nipple lies at the centre of the gland along the breast meridian opposite the 4th rib. In the mature breast, it lies slightly below the centre of the breast opposite the 5th rib.

CAUSES OF PTOSIS

1.Pregnancy and lactation

2.Mammary hypertrophy

3.Sudden gain and loss of weight

4.Menopausal glandular hormonal regression

5.Dermatochalasis

THE PROBLEM

BreastSkin is present in excess, is often thin and has poor elasticity. Striae reflect tears in the deep dermis.

The Gland is mobile over the chest wall due to attenuation of fascial supports and Cooper’s ligaments. The breast has often fallen down the chest wall resulting in upper pole flattening, (glandular ptosis), in addition to falling over the IMC (true ptosis). The NAC is relatively low, lying below the level of the IMC.

CONCERNS

Size and shape

Most patients want slightly bigger breast following mastopexy. Skin tightening will give the perception of smaller breasts. In addition, breast projection is reduced.

Upper pole flatness will usually not be restored with mastopexy an implant is usually necessary to correct it (unless using vertical technique)

Scars

Implants

Permanence

Symmetry

Oncologic concerns

CLASSIFICATION OF PTOSIS

IMcCarthy

Type A: Minimal ptosis.

The nipple is located at or just inferior to the IMC.

Type B: Moderate ptosis.

The nipple is approximately 3 cm below the IMC.

Type C: Severe ptosis.

The nipple is more than 3 cm below the IMC.

IIREGNAULT (1976)

The relationship between the nipple and the IMC is most important to define whether true ptosis exists and to what degree it is present. In the majority of patients, breasts of satisfactory volume remain aesthetic when the nipple lies above the level of the IMC. According to this relationship, pseudoptosis and 3 degrees of true ptosis can be defined

Pseudoptosis

The inferior pole of the breast droops but the nipple lies above the level of the IMC. The nipple to IMC distance is increased. The breast has fallen through. “Bottoming out”

First degree: Mild ptosis

The nipple lies not more than 1 cm below the IMC.

Second degree: Moderate ptosis

The nipple lies 1-3 cm below the IMC, but remains above the lowermost projecting portion of the breast.

Third degree: Severe ptosis.

The nipple lies > 3 cm below the IMC or at the lower contour of the breast and skin brassier.

III BRINK

1. Glandular ptosis: The breast acts as a unit and the gland, nipple and IMC slide down the chest wall. Nipple to notch, nipple to IMC and notch to IMC are all increased.

2.True ptosis: The IMC remains fixed but the skin (and Cooper’s ligaments) stretch. The breast thus pivots around the fixed base of the IMC. The nipple descends and pivots to face inferiorly. The breast’s rotation is facilitated by some degree of parenchymal maldistribution or lower pole hypoplasia which maintains the IMC in a fairly high position. Nipple to IMC distance is thus relatively short.

3. Parenchymal maldistribution: Parenchymal tissue is located in the lower pole. The upper pole remains empty and flat.

4.Pseudoptosis: Is most common after corrective procedures for glandular ptosis where the fold has descended pre-operatively. The breast pivots around the NAC which points upwards and the IMC descends.

AGlandular ptosis / BTrue ptosis / CParenchymal maldistribution / DPseudoptosis
1.Movement / Straight down descent / Pivots around the IMC / None / Pivots around the nipple
2.Notch to nipple distance / Increased / Increased / Normal / Normal
3.Nipple to IMC distance / Increased / Normal / Normal or short / Increased
4.Nipple position and orientation / Below IMC
Points forward / Below IMC
Points down / Normal but points down / Level with IMC
Points up
5.IMC / Descended / Fixed normal / Normal
Fixed and high / Variable, usually low

SURGICAL PRINCIPLES

reliable nipple-areolar transposition
maximal parenchymal support
minimal scars

Trading a ptotic breast for a visibly scarred breast with a chance of recurrent ptosis is a poor choice.

Three surgical considerations

Projection
Suspension
Skin excision

Achieving Projection

Using glandular flaps to produce coning - Coning is easily produced; however, getting itto last is the biggest problem. Closure of inferior breast pillars is the most secure way to maintain this “compression” over time.
Flowers and Smith – superiorly based parenchymal flap folded onto itself and suturedto the pectoral fascia at the level of the second rib.

Benelli 1990 -

Parenchymal stacking
Pectoralis - Inferiorly based dermoglandular pedicle is passed under a 3cm loop of pectoralis muscle and suspended to the central fascia with tacking sutures (e.g., Graf-Biggs procedure).
controversial from an oncologic point of view whether the pectoralis fascia should be divided, as this will require a more aggressive approach in case of later breast cancer
may lead to breast movement with pectoralis contraction
Mastopexy plus implant.

Glandular Suspension

In an effort to oppose the gravitational effects of ptosis and to reduce thr risk of hypertrophic scarring

dermal suspension
shown to be least effective. Up to 50% risk of hypertrophic scars
dermal cloak
2cm wide dermal flap pediced on NAC and sutured to pectoralis fascia
glandular suspension
sutures to pectoralis fascia
mesh (Goes)
bipedicled pectoralis sling (Graff-Biggs)
fascial sling
Ritz, Southwick (PRS 2006) – uses bipedicled prepectoral fascia. An inferior based dermoglandular flap is sutured underneath this and the medial and lateral pillars sutured over this.
superficial fascial system suspension (Lockwood PRS 1999)
In the chest, the superficial fascial system splits to form the anterior and posterior fascial layers of the breast

SKIN INCISION

The Options are

Augmentation only
Periareolar scar technique
Vertical scar technique
Vertical and short horizontal scar
Vertical and horizontal scar technique (inverted T)
Combinations of above.

Peri-areolar Incision

results in the shortest possible scar pattern
elevation of the nipple-areola complex is limited, so that usually only minor degrees of ptosis are addressed with this approach (1-2cm)
Spear uses this only Grade 1 ptosis
eccentric pattern to maximize elevation of the nipple-areola complex

Closure leads to periareolar wrinkling and pleating. This usually resolves over a period of a few months
Disadvantages: areolar widening and distortion (30-40% initially)
introduction of the purse-string technique with a non-absorbable Gore-Tex suture significantly reduced areolar and scar widening (Benelli round block suture allows the formation of a circular fibrous tissue layer around the nipple-areola complex that prevents spreading of the scar)
to minimize tension and wrinkling, it is important to limit the size of the outer diameter to three times that of the inner diameter (Spears)

Vertical Incision

Lassus, Lejour, and Hammond use a vertical scar mastopexy to correct all grades of ptosis

most useful for mild to moderate ptosis- N-IMC distance < 7-8 cm
Addition of glandular suspension techniques reduces or eliminates the reliance on the skin envelope for suspension, thereby improving long-term results.
The vertical scar techniques provide the most flexibility for augmentation ptosis.

Inverted T

used mainly for correction of severe grade III ptosis.
longer horizontal inframammary scar will allow maximum correction of ptosis.
Wise pattern tends to produce a long horizontal scar. Another option is a modified Strombeck pattern, which uses an oblique instead of a vertical scar so that the scar is rotated laterally

Inverted-T scar technique: (above, left) Strombeck, (above, center) Flowers, (above, right) Nicolle, (below, left) Peixoto, (below, second from left) Pitanguy, (below, third from left) Wise, and (below, right) Marchac.

marked versatility in augmentation and/or mastopexy applications.
Tradeoff is increased scar length.

L Shaped

Best for grade I and II ptosis, results may not be great for severe grade III ptosis.
Eliminates medial portion of an inverted-T scar and shortening the lateral limb.
Regnault - vertical limb of the L originates from the lateral margin of the areola and then extends down to the inframammary fold.

(left) Chiari and (right) Regnault.

Horizontal Incision

For moderate ptosis where the N-IMC distance requires shortening, a horizontal ellipse is added to the vertical. As the degree of ptosis becomes more severe, the horizontal ellipse needs to be made larger.

The Case for Implants (Bostwick)

1. Preserves breast volume in cases where the lower pole of the breast is resected. Maintenance of the ptotic lower pole of the breast is likely to cause ptosis recurrence. A reduction in breast volume will produce a more long-lasting result.

2.Allows augmentation of the smaller breasted woman requesting mastopexy.

3.Best way to achieve upper pole fullness.

4. Allows smaller scars (skin envelope can be filled rather than made smaller).

5.Greater permanence.

6.Predictable and volume can be controlled.

Disadvantage:

High risks of poor scarring, wound separation, nipple and implant malposition, implant extrusion and nipple/skin necrosis

Bostwick favours the use of implants, especially when the upper pole lacks fullness.
Regnault is also a proponent of implants when there is ptosis and hypoplasia (the minus plus mastopexy).
Bostwick advises shaping the breast mound first (excision plus implant) and then, uses a tailor-tack approach (stitch and cut) to define the skin that needs excision
To reduce risk to nipple, some surgeons perform in 2 stages – augment first than mastopexy.
Friedman tips

Place implants in a submuscular position. This reduces the risk of implant exposure, devascularization of the overlying breast tissue (with consequent nipple or skin flap loss), and excessive postoperative implant descent.
Perform augmentation before mastopexy. Preoperative mastopexy markings are simply educated guesses, as the precise amount of skin excess is unknown until after the implants are placed. Tailor-tacking (and any necessary adjustment) of the preoperative markings should be performed with the patient in a semi-upright position on the operating table after implant placement. This prevents underresection of skin with consequent persistent nipple and/or breast ptosis. More importantly, it prevents over-resection of skin with consequent excessive tension on the closure, which leads to widespread scars and skin flap loss.
Do not perform augmentation with a Wise-pattern mastopexy. Periareolar and vertical augmentation/mastopexy patterns generally can be performed without excessive skin flap tension and tissue devascularization. However, an inverted-T closure paired with an augmentation requires significant undermining, which often leads to an unacceptably high rate of complications. In the very small subset of patients requiring a Wise pattern, consideration should be given to staging of the procedures.
Do not be afraid to resect breast tissue. Although the surgery is meant to enlarge the breasts, a small amount of breast tissue may need to be excised to facilitate closure without excessive tension. In particular, resection of parenchyma superior to the nipple-areola complex may be required to enable significant tension-free nipple-areola elevation. Similarly, a vertical mastopexy pattern requires vertical wedge excision of lower-pole parenchyma. This reduces closure tension, the need for undermining, and the risk of persistent lower-pole ptosis.

Algorithm

Grade 1 – subglandular implant if skin thickness>2cm, subpectoral implant otherwise
Grade 2 - subglandular implant if skin thickness>2cm, dual plane implant otherwise
Grade 3 – 2 stage, augmentation first than mastopexy

Horizontal wedge excision

Modified Kiel

Mastopexy following Explantation

goal of explantation is to remove the implant and capsule, if possible, without implant rupture
Reasons for capsule removal:

number of reports of palpable or mammographically detectable masses present in the breast following explantation when the capsule had been left
presence of residual silicone particles within the capsule

dissection of a subpectoral implant is more difficult than that of a subglandular (risk of pneumothorax)
Postoperatively, the breast mound drops inferiorly producing a glandular or pseudoptosis.
Options after explantation

(1)explantation alone

(2)implant exchange

(3)mastopexy with implant

(4)mastopexy alone.

Rohrich Algorithm for mastopexy alone post explantation

OTHER CONSIDERATIONS

Parenchymal Transposition Flaps of lower pole breast tissue to the upper pole to attain fullness above.

IMF is formed by attachment of the dermis to the underlying fascia. To re-position the crease, these attachments need to be divided and re-created with sutures.

Skin Patients with inelastic, striated skin receive minimal lasting support from skin tightening. The skin below the NAC bears the brunt of the force and heals slowly, especially if the patient is a smoker.

Lateral folds will become more prominent post-op and therefore must be dealt with as part of the plan.

COMPLICATIONS

EARLY

1.Haematoma: Uncommon. If large - return to theatre.

2.Infection: Uncommon - associated with poor vascularity - smokers etc.

3.NAC Necrosis: Uncommon - only occasionally seen in heavy smokers.

LATE

1.Asymmetry: May need revision.

2.Recurrent Ptosis The most common problem following mastopexy. Often associated with weight loss. A loss of 5kg will significantly be reflected in breast shape. It is said to occur most predictably with “skin only” mastopexy where the lower pole ptotic breast tissue is not excised at the initial procedure.

3.Upper pole flattening: Should be noted in pre-op assessment. Treated with appropriate sized implants.

4.Implant Related Problems

5.Scar problems

LONG TERM RESULTS

Mastopexy is a temporary procedure - one should expect some recurrence with time.

Patient satisfaction is directly related to pre-operative decisions - the more time spent discussing the options with the patient pre-operatively, the less likely the need to justify the result.

CONCLUSIONS

1.Mastopexy is not a single operation but rather one that must be individualised to fit the patient’s deformity and desires. It bridges the spectrum of aesthetic breast surgery from augmentation to glandular reduction.

2.None of the currently accepted techniques are without problems. None of the solutions are permanent and there is always a trade off to be made - scars +/- implants.

3.As with any aesthetic procedure, careful pre-operative assessment - both physical examination and discussion of aesthetic goals with patient, will minimise the problems post operatively.

4.For the minor ptosis - augmentation +/- NAC elevation appears to give the most satisfactory results.

5.For more severe ptosis, lower pole resection and augmentation to achieve upper pole fullness offer the best and most predictable long term results.

MASTOPEXY

Essentially aesthetic in nature so consideration of scarring is critical

Classification of Ptosis—Regnault

Inipple descends to level of inframammary fold

IInipple below fold but above lowest contour of breast

IIInipple reaches lowest contour of breast

Pseudoptosis—loose, lax breast with nipple above inframammary fold

Majority of gland is below IMF

Ptosis is also a lateralization of the breast

Grabb and Smith pg 744

Nipple—IMF > 7cmptosis that can’t be corrected by implant alone

Benelli Round Block Mastopexy+/- reduction

Best for moderate ptosis and small reductions (<250gm)

+/- reduction or augmentation

reshape gland and redrape without tension (tension flattens breast)

mark midline and breast meridian

sup margin of new nipple point 2cm above IMF

less skin excision laterally than medially

excision appears elliptical when standing and round when lying

de-epithelialise

s/c flaps raised to IMF

elevate sup dermoglandular pedicle and divide inferiorly the remaining breast to create lat

and med glandular flaps

resection for reduction as necessary