Breast Mastopexy

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.

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]

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.

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 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.

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.

A classification system has been suggested by Regnault and modified by numerous authors. The most commonly used system is as follows:

• Grade 1: Mild ptosis - Nipple just below inframammary fold but still above lower pole of breast

• Grade 2: Moderate ptosis - Nipple further below inframammary fold but still with some lower pole tissue below nipple

• Grade 3: Severe ptosis - Nipple well below inframammary fold and no lower pole tissue below nipple; "Snoopy nose" appearance

• Pseudoptosis - Inferior pole ptosis with nipple at or above inframammary fold; usually observed in postpartum breast atrophy

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.

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.

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.

Only routine preoperative laboratory studies are required as mandated by the age and health of the patient.

Mammograms are the main imaging studies required, especially in middle-aged patients. As a general guideline, all patients aged 40 years or older should undergo baseline mammograms prior to surgery, a postoperative new baseline mammogram, and yearly postoperative mammograms.

The 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 the images below.

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 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.

Augmentation 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 nipple-areola complex (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 at the edges of the periareolar skin incision to decrease the diameter of the window to match the NAC (shown in the images below). This technique can be combined with implant placement as described by De Benito and Sanza.[28]

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 (shown below).

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 (shown below).

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 (shown in the images below).

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.

Wound 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-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.

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 nipple-areola complex (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.

A literature review by Lorentzen et al indicated that when reduction mammoplasty or mastopexy is performed, the complication rate is significantly higher in irradiated breasts than in non-irradiated ones. The rate was 54% in breasts that underwent reduction mammoplasty or mastopexy following lumpectomy and radiation therapy, compared with an 8% complication rate in non-irradiated breasts.[29]

Controversy currently exists with the use of mesh and with the use of liposuction in breast-lifting procedures.[30] Liposuction has been recommended to provide a minimally invasive procedure, which can reduce some of the breast fullness and allow elevation of the nipple-areola complex (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.[31] 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.

Mastopexy in patients with massive weight loss

Plastic surgery has an increasing need for body contouring procedures, including mastopexy in patients who undergo massive weight loss. These patients can be technically challenging because of breast deformities including breast asymmetry, a redundant and inelastic skin envelope, nipple ptosis, disposition of the NAC, and prominent skin rolls.[32] Different techniques, including reduction mammaplasty, breast augmentation, and mastopexy, have been described in the literature.[19, 33]

Losken and Holtz described, based on the concepts and principles by Lejour and Hall-Findlay, the use of a superomedial pedicle technique, which allows glandular placation of the lower pole and auto-augmentation of the upper pole after rotation, leading to an improvement of the breast shape.[34] A medial thigh lift with a transverse gracilis myocutaneous free flap technique for autologous breast augmentation was published by Schoeller et al.[35] Graf et al describe the use of an extended thoracic wall flap with a loop of the pectoralis muscle to achieve better upper pole fullness, better shape, absence of the lateral skin roll, and minimal bottoming out.

Several authors describe the use of an intercostal artery perforator (ICAP) flap in patients with massive weight loss. Van Landuyt et al published one case of autologous augmentation using lateral thoracic tissue based on intercostal perforators.[36] Kwei et al described 5 cases of Wise-pattern mastopexy with a pedicled fasciocutaneus flap supplied by intercostal artery perforators.[37] Rubin et al used lateral chest wall tissue in conjunction with a Wise pattern mastopexy.[38]

Hurwitz and Agha-Mohammadi advocate the breast reshaping with the spiral flap, based on intercostal perforators, as integration to an upper body lift as a comprehensive, effective, and safe method for breast and upper torso contouring after massive weight loss.[39] Rubin and Hurwitz did not specifically identify the perforator vessels or dissect them. Kwei et al differ from that method by specifically identifying the perforator vessels using Doppler technique.[37]

Based on Van Landuyt’s presentation, Hamdi et al published an expanded series of 12 pedicled lateral ICAP (LICAP) flaps using lateral skin-fat excess for breast augmentation.[40] In this series, the perforator vessels were not only identified using Doppler technique but also dissected in meticulous fashion. Additionally, the authors recommend the simultaneous use of a superior pedicle, vertical mastopexy for better contour and shape. Rubin and Khachi published a technique based on principles of dermal suspension and parenchymal reshaping that allows for selective auto-augmentation of the breast with lateral chest wall tissue.[41]

Mastopexy in the augmented breast

Patients who undergo breast augmentation can develop breast ptosis. Additionally, breast implants themselves can cause thinning, atrophy, and tissue stretching, as well as worsening of the ptosis.[42] These changes can lead patients to request reoperation.

Breast augmentation and mastopexy themselves are usually straightforward operations with low complication rates.[43] Spear advised, however, that this may not be the case when breast augmentation and mastopexy are performed at the same time.[44] He suggested increased risk of infection, implant exposure, loss of nipple sensation, malposition of the nipple, and malposition of the implant.[44] He found that primary augmentation plus mastopexy has significantly higher complication rates than primary augmentation alone, and that secondary augmentation plus mastopexy has higher revision and complication rates compared to primary augmentation plus mastopexy procedures.[44]

However, a retrospective study by Stevens et al of 615 patients who underwent combined augmentation mastopexy (1192 procedures) indicated that this surgery can be safe and effective if performed by skilled surgeons on properly selected patients. The investigators concluded that the revision rate for the combined surgery (16.9%) compared well with revision rates reported for patients who have undergone only breast augmentation or mastopexy, with 104 revisions in the study performed for tissue- or implant-related complications (50 and 54 revisions, respectively). Poor scarring was the most frequent complication (5.7%), with wound-healing problems (2.9%) and saline-implant deflation (2.4%) being the next most common.[45]

A study by Swanson indicated that breast implant insertion can be combined with mastopexy, rather than performed separately, without causing a significant decrease in perfusion to the NAC. The study included 25 women, in whom bilateral vertical augmentation-mastopexy was performed using a medial pedicle.[46, 47]

A study by Ross also found that one-stage augmentation mastopexy can be safely and effectively performed, in this case with autologous reinforcement of the inferior pole using a superiorly based dermal flap. This study included 21 patients (40 procedures).[48]

Handel states that secondary mastopexy in the previously augmented breast carries increased risks because of the adverse effects of implants on breast anatomy and physiology.[42] However, with proper planning and attention to detail, most patients achieve good outcomes.

A study by Kalaaji et al indicated that women who undergo breast enlargement with implants are happier with the outcome than are those who undergo augmentation mastopexy. The study, in which women who underwent one or the other procedure were surveyed at a mean 2.8 years postsurgery, found that 93.4% of women who underwent implantation were satisfied with the overall cosmetic result, compared with 69.4% in the augmentation mastopexy group. The rates of satisfaction with shape, scar, and symmetry were 90.1%, 70.6%, and 83.6%, respectively, in the patients who received breast implants, versus 63.9%, 40.5%, and 54.0%, respectively, in those who underwent augmentation mastopexy.[49]

Use of acellular cadaveric dermis in mastopexy

The use of prosthetic mesh has been well-described by Goes for shaping the breast mound. While this technique has been shown to be safe and successful, concerns regarding the reaction of prosthetic mesh in the breast have limited its use. Alternatively, decellularized dermis has been reported as an effective method to cover implants in immediate breast reconstruction.[50, 51] The future of decellularized dermis to shape the breast mound in aesthetic mastopexy procedures merits further investigation.

Contralateral mastoplexy with oncoplastic surgery

A retrospective study by Deigni et al indicated that in carefully selected patients who undergo oncoplastic breast-conserving surgery, immediate symmetry-maintaining contralateral mastopexy/breast reduction can be performed without increasing the complication risk. The overall complication rate among patients who underwent immediate contralateral mastopexy was 25.4%, compared with 26.9% in those in whom contralateral mastopexy was delayed, with the major complication rates being 10.6% and 6.2%, respectively. Moreover, there was no increased risk of delay to adjuvant radiation therapy in the immediate-mastopexy group.[52]