Breast Mastopexy Treatment & Management

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]