A number of factors are likely to be responsible for the development of breast ptosis. Changes in breast volume or composition following pregnancy, weight fluctuations, and menopause are all implicated. Changes in skin elasticity with age will affect the development of ptosis, and smoking is likely to exacerbate these changes. The breast parenchyma is covered by fascia split into two layers. The superficial component passes between the breast and the dermis; the deep component passes between breast and pectoralis major fascia. Cooper’s ligaments are fibrous attachments that pass between these two fascial layers to provide support to the breast. Attenuation of Cooper’s ligaments is also thought to be responsible for breast ptosis, although some authorities disagree with this theory. The appearance of breast ptosis is influenced by the adherence of the lower border of the breast tissue at the inframammary fold (IMF) that secures the lower pole in place and allows the breasts to “fall” or sag over it. Changes at the IMF itself are not responsible for ptosis.1–5
Ptosis derives from the Greek, meaning “falling.” The term is used to describe the descent of the breast parenchyma that traditionally occurs with advancing age and various physiologic changes. Regnault classified breast ptosis in 1976:1 Grade I: Mild ptosis; the NAC lies at the level of the IMF. Grade II: Moderate ptosis; the NAC lies below the IMF but remains above the most dependent part of the breast parenchyma. Grade III: Severe ptosis; the NAC lies well below the IMF and is the most dependent part of the breast on the inferior aspect. Pseudoptosis is also called glandular ptosis and is present when the NAC is above or at the level of the IMF, but the bulk of the breast parenchyma has descended below the level of the fold. This can occur following breast reduction surgery, particularly with inferior pedicle Wise-pattern techniques, and is sometimes described as “bottoming out.” In a normal breast, the NAC and the majority of breast tissue should lie above the IMF (Fig. 52.1).
A normal and well-shaped breast should ideally have the nipple-areola complex (NAC) located above the inframammary fold (IMF) with most of the breast volume also situated above the fold. The ideal breast will have a mildly concave upper pole with a convex lower pole and the nipple pointed 20 degrees superiorly from a horizontal plane. There should be a 45:55 upper pole to lower pole ratio. When patients present to clinic requesting changes to their breast shape, it is important to understand what they do not like about their breasts and how they should wish to change them. There is much media focus on breast shape that can leave patients confused about what shape normal breasts should really be. This case highlights a normal breast and this lady would not require a mastopexy. However, if she dislikes the lack of upper pole fullness and wishes to accept an overall increase in volume, then she may be a candidate for implant surgery. Ptosis refers to breasts becoming droopy, often with increasing age or after weight loss or child birth and breast-feeding. In cases of ptosis, mastopexy may be warranted to uplift and reshape the breast. However, this is not the case in this scenario.1,2
In this case, the nipple height is acceptable, so a standard mastopexy technique is not indicated. The pseudoptosis is caused by bottoming out of the breast with glandular tissue ptosing below the IMF. This may be corrected by performing a transverse wedge excision in the IMF. Rohrich et al1 have described technique selection for breast contouring at the time of breast implant removal that is based on the degree of ptosis and NAC size and location. This can provide a useful guide in managing this patient group. The IMF wedge excision is also effective at managing the high-riding nipple after Wise-pattern breast reduction although it will not physically change the shortened sternal notch-to-nipple distance if the nipple is genuinely high. It is most effective where there is a degree of pseudoptosis as in this case. The other mastopexy options listed are indicated where the nipple position requires elevation. A vertical skin resection may be helpful following inadequate resection within a previous reduction of mastopexy or may be part of a vertical scar uplift. Fig. 52.1 Regnault classification of breast ptosis. A, Pseudoptosis. B, Grade I ptosis. C, Grade II ptosis. D, Grade III ptosis. (Adapted from Kirwan L. Augmentation of the ptotic breast: simultaneous periareolar mastopexy/breast augmentation. Aesthet Surg J 19:34–39, 1999.) A B C D Nipple Inframammary fold Nipple Inframammary fold
32 cm, a large skin excess, and deficient breast volume. She is a nonsmoker, wears an A-cup bra, and wishes to improve both the shape and volume of her breasts. How best might this be managed? After significant weight loss, patients commonly have empty, ptotic breasts that require volume replacement with a prosthesis and mastopexy to reduce skin volume and to raise the NAC. There is debate whether to do this as a single or a multistaged technique because augmentation and mastopexy techniques work against one another. Achieving satisfactory results in a single stage is challenging. Therefore, in this case, a safe, sensible, and reliable approach will be to stage her procedure and uplift the breasts in the first stage, then plan for a second stage 6–12 months later when implants can be inserted. The volume of skin excess in this patient indicates that she would require an inverted-T skin pattern rather than either a periareolar or vertical scar approach.1–3
shows she has breast asymmetry with a notch-to-nipple distance of 28 cm (left) and 24 cm (right). She has adequate breast volume and good quality skin and soft tissues on both sides and prefers the smaller breast. How This woman has mild to moderate ptosis, and this may be treated with a vertical scar technique. She also has a volume difference between the breasts and will therefore need some volume to be removed from the larger breast. In this case a vertical scar approach with low volume reduction is probably her best option to achieve symmetry. She could have a small uplift on the contralateral side as well but the additional scars are probably not worth the benefit she would obtain. A Benelli periareolar technique could potentially be used, but a simple periareolar technique is usually useful only in patients with mild ptosis. A Wise-pattern approach could hopefully be avoided in order to minimize her scar length.1–5
Mastopexy can be described by either the skin pattern design, the pedicle design, or a combination of the two. The skin pattern design is selected based on the amount of skin resection that is required. There will be a trade-off between minimizing scar length and achieving improved breast shape. The crescentic approach to re-siting and uplifting the NAC is ideal in cases where the travel only needs to be small, and where undermining of the breast tissue is ideally avoided. The crescentic approach involves deciding and marking where the NAC should ideally sit and then drawing a crescent in the direction of the travel. The space between the NAC and new position is de-epithelialized and without undermining or with minimal undermining, the NAC is advanced and inset. This approach can work particularly well in combination with an augmentation in patients who have nicely shaped breasts with little ptosis and is safe to perform at the same time as the implant. The addition of an implant begins to take up some of the slack in the soft tissues and this is then further enhanced by the subtle uplift and repositioning. A further benefit is the scars are extremely short and well hidden such that they are unlikely to be noticeable in the longer term. The other skin patterns described are more useful in cases where more involved reshaping and uplifting is required.1–3
Nipple-to-IMF distance is a useful measurement to assess redundancy of the lower pole skin envelope prior to mastopexy. In cases where there is a large excess in a vertical direction, an inverted-T shape scar is indicated. Other key measurements are the notch-to-nipple distances as these provide information on breast ptosis and the need for uplifting and repositioning of the NAC. They also provide information on side-to-side symmetry. The intermammary distance and the breast base width form part of the standard breast measurement series. The base width is worth knowing in cases of reduction, reconstruction, and augmentation. The distance from the clavicle to the IMF is probably most relevant to breast reconstruction cases where a mastectomy has been performed and a soft tissue flap is being designed. This will allow the surgeon to gauge what skin deficiency there is between the mastectomy and contralateral side.1–3
The risks of mastopexy are relatively low in most patients and the main risks are issues relating to wound healing and subsequent poor scarring. Delayed wound healing can occur secondary to fat necrosis where breast parenchyma loses its blood supply during surgery. It can also occur at the T junction part of the scar in a Wise- pattern mastopexy as the blood supply to the skin edges corners may be compromised. Providing good wound care is given and patients do not smoke, wounds generally settle well with time. It is vital to warn patients preoperatively that they may have some slowed or delayed healing and that they must not worry about this self-limiting problem. The other risks such as hematoma and infection are very low providing strict surgical technique is applied and asepsis is maintained. The addition of breast implants changes the dynamic and increase risk of infection in such cases. All patients must be warned about nipple necrosis when undergoing breast reduction or mastopexy; however, this is extremely rare. A high-riding nipple is a surgical planning error and must be avoided. If there is any doubt it is safer to set the NAC slightly too low than too high as it can always be moved up further if required, but moving a nipple lower may necessitate additional visible scars in the upper pole that are prone to poor scar quality and difficult to camouflage.1–3
There are many advantages of using a vertical scar approach to mastopexy. These include avoidance of the horizontal IMF scar and inferior parenchymal pillar closure which provides internal support and reshaping. The technique is therefore quite effective at improving upper pole fullness. However, it does risk skin excess being present at the lower part of the vertical scar leaving a fullness or standing cone there. In many cases it will settle over time, but patients must be warned about it and understand that if it does not settle a short transverse scar will be required in order to remove the excess. The risk of skin pleating around the NAC is most associated with a periareolar approach (because the wider circular resection incision is being forced to tie in with the smaller new nipple diameter) as is flattening of the breast and NAC (although this can occur to some degree in any technique). The risk of T junction breakdown is associated with an inverted-T approach. There is a risk of having an excess of upper pole fullness (not inadequacy) early postoperatively with a vertical scar mastopexy or reduction. In some cases, the breast will look odd at this early stage and again patients should be warned about this. Often at the time of surgery, inverted-T procedures will look better shaped than vertical scar approaches but with time things even out.1–5
alone. It is really important that patients are fully on board with likely outcomes following planned aesthetic surgery such that their expectations match the outcome closely. Patients will come requesting to have implants removed many years after having them implanted. Their reasons may include concerns over distortion of the breast shape, pain or firmness, worries about silicone leak or anaplastic large cell lymphoma (ALCL), or they may just wish to be implant free. Unfortunately, capsulectomy and explantation are procedures that are almost certainly going to result in a poorer cosmetic appearance than before surgery unless the preoperative appearance is especially bad. Therefore, helping patients to understand this is a priority. Removing the volume of the implant as well as reducing the thickness of the soft tissue cover provided by the capsule will only serve to make ptosis worse. It would be absolutely possible to combine the implant removal and mastopexy safely within a single stage and this often works very well for many patients. However, it is still a very reasonable approach to do this in two stages having allowed time for some skin shrinkage. In terms of aesthetics, having the implants replaced would certainly help her volume, but in cases where patients wish to be implant free this is not an option. Her residual breast volume is likely to be less than before her implants were placed as the tissues will have atrophied over time, so it is best for her to expect low volume breasts after this surgery.1
Tuberous breast deformity represents a spectrum of deformity, but typically includes the following features1: • Constricted or narrowed breast base • High inframammary fold (as opposed to absence of a fold) • Breast herniation through the areola, leading to large areolae • Deficiency of breast volume Tuberous breast may also be classified using the von Heimburg system which was described in 1996 and has four subtypes based on the degree of hypoplasia and the size of the skin envelope:2 Type I: Hypoplasia of the lower medial quadrant Type II: Hypoplasia of the lower medial and lateral quadrants with adequate subareolar skin Type III: Hypoplasia of the lower medial and lateral quadrants with deficient subareolar skin Type IV: Severe breast constriction; minimal breast base Grolleau et al proposed another classification system in 1999 reducing the number of subtypes to three based on the degree of hypoplasia of the breast3: Type I: Hypoplasia of the medial quadrant Type II: Hypoplasia of the medial and lateral quadrants Type III: Hypoplasia of all four quadrants These classification systems can be useful to describe the tuberous breast in medical documentation and also to help guide the most suitable treatment option when planning surgery.
Patients with tuberous breast, as in this case, commonly have significant breast asymmetry. Treatment should address both the lower pole skin deficiency and the volume deficiency. It should also lower the IMF, resite the NAC, and reduce the areola diameter as required. This is usually achieved with a combination of techniques including periareolar or vertical scar mastopexy, inferior pole scoring, and tissue expansion followed by augmentation procedures. Given the number of issues that need to be addressed, a staged approach is justified in this case. In the first stage, the lower pole can be expanded by radial release of the constricted tissues, lowering of the IMF, and placement of a breast expander. Once the expansion and volume have been corrected, either a periareolar or vertical scar approach can be used to reduce the size of the NAC and reposition it on the breast mound. Some surgeons may prefer to incorporate the mastopexy into the first procedure; however, options A, B, and E would still be incorrect because neither a permanent implant nor a fat transfer would be adequate without tissue expansion. In some cases, a contralateral reduction is warranted, but in this case the patient is happy with the larger breast so this should be left alone.1–3
inferiorly. The choice of mastopexy technique depends on the degree of ptosis, surgeon’s preference, and patient factors. The Lejour, Lassus, and Hall-Findlay techniques use a vertical scar and approximation of the medial and lateral breast pillars to cone the breast, thereby increasing projection. Differences in the techniques are that wide undermining is performed in both the Lejour and Hall-Findlay techniques, whereas no undermining is performed in the Lassus technique. Lejour and Hall-Findlay may also combine liposuction. Lejour uses a superior pedicle, whereas Hall- Findlay uses a medial pedicle. Hammond’s technique is a short-scar, periareolar, inferior pedicle procedure (rather than lateral pedicle). Benelli described the purse-string suture using a permanent suture and not a long-acting resorbable suture like polydiaxone.1–7
plastic surgeons. A survey of board-certified plastic surgeons found that periareolar techniques had the highest rate of surgeon dissatisfaction and the highest rate of revision.1 Although most popular, the inverted-T group reported a significantly greater frequency of bottoming out (p 0.043) and excess scarring along the inframammary fold (p 0.001) compared with the short scar and periareolar groups. A review of 1700 vertical scar procedures showed that the NAC was 1.3 cm higher at day 5 after surgery and remained 1 cm higher 4 years after surgery compared with preoperative measurements, suggesting that elevation of the nipple is well maintained over time.2 A review of 82 publications on mastopexy and reduction, including the most popular techniques, showed that neither breast projection or upper pole projection were increased significantly.3 Methods to increase upper pole fullness or projection, such as fascial sutures and autoaugmentation, generally did not maintain shape in the long term. Nipple over-elevation was observed in around 40% of patients.
Rubin has classified the severity of the breast deformity following massive weight loss into three grades: Grade I: Ptosis grade I or II or severe macromastia Grade II: Ptosis grade III, moderate volume loss or constricted breast Grade III: Severe lateral roll and/or severe volume loss with loose skin The grading has clinical relevance as it can guide surgical management of these patients. In this grade III case, a Wise-pattern approach with long scars is required to address the skin excess. Implant augmentation is best avoided providing the existing volume can create a reasonable result. In such cases a dermal suspension autoaugmentation procedure can be undertaken. This is based on a Wise-pattern technique and uses de-epithelialized tissue from the lateral roll and inferomedial breast to autoaugment the breast volume by anchoring the flaps to the anterior chest wall around a degloved breast mound. Less severe grades I and II may be effectively managed with either vertical scar or Wise-pattern skin approaches and will often need additional volume from prosthetic implant placement either as single- or two-stage procedures.1,2