Saturday, November 17, 2007

Mastopexy

Mastopexy, or breast lift, is a procedure designed to improve the appearance of sagging or ptotic breasts (pick them back up). The goal of surgery is to improve the shape of the breast while minimizing visible scars. Many procedures and many modifications of the mastopexy have been suggested to try to achieve this end result.

The classification system (suggested by Regnault and modified by numerous authors) 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

There are no medical treatments of breast ptosis. It takes surgical removal of skin and/or adding an implant to fill up the excess skin envelope. There are no absolute contraindications for breast lift surgery. However, if you plan future pregnancies, because lactation and subsequent involution will further change the shape of the breast, it is best to delay the mastopexy surgery until after those future pregnancies. In patients who are at high risk of primary or recurrent breast cancer, consideration of whether a mastopexy will alter the breast architecture and add scar tissue within the breast tissue needs to be considered, as this may make detection or treatment of cancer more difficult. It is best to be a non-smoker.

Some guidelines for surgical correction:

Minimal or minor breast ptosis

  • can be corrected with breast implant augmentation.
  • can be corrected with periareolar skin resection (around the nipple complexwith or without augmentation. (photo credit)

Grade 2 ptosis

  • Minor grade 2 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. (photo credit)

Severe grade 2 ptosis and grade 3 ptosis

  • This degree of ptosis usually requires inverted T incisions regardless of the pedicle used. (photo credit)

Pseudoptosis

  • can be addressed with augmentation and/or skin excision without nipple transposition (excision of lower pole skin) or with the circumareolar cerclage technique.

Complications:

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 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.

The periareolar approach can result in under projection 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. Augmentation brings its own complication/risk list (capsule formation, deflation, etc).

Something to think about:

The lift done alone does not tend to change your breast size (volume). An exception to this is extreme Grade 3 ptosis where the amount of skin removed may be large enough to make a perceptible change in volume.

So when thinking about having a breast lift with or without an augmentation, give some thought to whether you want breasts the same size or larger when healed. If you want to be the same size, only "picked up" then the scars needed will be worth it. If you want to be larger, then you will have to be willing to have breast implants added into the picture. Go into this informed and don't let your surgeon tell you that you need an implant if you don't want to be larger breasted. I say this because I have removed implants for a couple of women this year who only wanted to be lifted (and are okay with their scars) and did not want to be larger in the first place. Their first surgeon "talked" them into the implants (smaller scars) which they then had removed--both within less than two years after the first procedure (augmentation procedure).

References

Breast Mastopexy by Jorge I de la Torre, MD--eMedicine Article

Breast Lift Mastopexy Videos and Movies Before and After Surgery Gallery--Michael Bermant, MD

Breast Lift (Mastopexy)--American Society of Plastic Surgeons

Photo of Grade 3 Ptosis, before and after correction, no implant--Dr R. V. Dowden

Surgery of the Breast: Principles and Art By Scott L. Spear--Google eBook (or purchase through Amazon.com)

6 comments:

Femail doc said...

Grade 3 ptosis sounds a lot more elegant than what most of my aging lady patients call it! Very interesting...as always.

rlbates said...

Thanks. I guess compared to the usual descriptions, "Grade 3 ptosis" does sound elegant.

make mine trauma said...

What are your thoughts on well developed pecs? Do you think that muscle tone alone is enough to lift the breasts in someone with more than grade 1 ptosis? And would gravity eventually win regardless?

rlbates said...

MMT--I don't think the tone of the pecs have anything to do with breast ptosis or size. They do affect our posture and can help there. Gravity and aging will usually win out. That's not always a bad thing.

Support your breast when jogging, aerobic dancing, or riding horses, etc. Be kind to your skin.

Lauren said...

I have grade 1 ptosis. Developing my pecs(or athletic,not aesthetic reasons) has made the overall look much much worse- not better. The muscle developement is much higher(armpit level) and glands are middleish of arm leaving a significant valley between the two.
Ive heard so many girls work their pecs for a lift affect. But unless you have no ptosis then I can't see it working.

Roy Kim MD said...

A very interesting blog.

Check out my blog for information about breast lift and other plastic surgical procedures:

www.drkim.com/blog