Breast Lift or Mastopexy
Many patients who initially present requesting breast enlargement are in fact more troubled by the shape of the breasts than the size. The two qualities of shape and size are linked, as is clear when we consider that the skin that contains the breast is simply a bag that can be full (and pert) or empty (and droopy). For this reason small amounts of droop can be managed by augmentation with implant: filling the "skin bag" of the breast. However any significant amount of droop will be accompanied by displacement of the nipple and areola downwards. This is known as ptosis (pr: "tow-sis") and several systems exist to grade the degree of ptosis. As a general rule the youthful young-adult position for the nipple is level with or just above the crease beneath the breast ("inframammary fold").
To correct ptosis or droop it is therefore necessary to either fill the skin bag or reduce it's size to tighten it around breast tissue, at the same time repositioning the nipple at a correct height level of nearly level with the inframammary fold. It is helpful therefore to consider three grades of ptosis and their treatment before we also consider combining correction of droop with augmentation (enlargement).
Minor degree of ptosis (droop)
Minor degree of ptosis with minimal displacement of the nipple may require no treatment. If improvement in shape is requested it may be wise to consider augmentation by breast implants since this method of "filling out the skin bag" of the breast leaves little scarring, improves shape and of course size. Most patients I see will not accept the scars of a mastopexy, or breast lift, for only a small degree of correction.
Intermediate degree of ptosis (droop)
Intermediate degree of ptosis poses a dilemma. The benefit of a mastopexy has to be weighed against the disadvantage of scarring, and this can be a fine judgment. Some patients opt to have substantial breast enlargement with accompanying lesser scarring, but often the degree of enlargement needed to restore a full feel and appearance to the breast is unaesthetic, and the nipple position may still be too low. An alternative to either of these extremes is to undertake "circumareolar mastopexy" in which a rim of skin is removed from around the nipple areolar and the resulting wound closed by bunching up the skin and leaving a circular scar around the areola (where scars are often well concealed as the quality of skin is in transition anyway). By making the width of the rim of skin excised greater above than below the nipple, the nipple can be repositioned upwards. At the same time the scar may be used to place implants behind the breast allowing a mixture of mastopexy and augmentation but avoiding the worst scars of the former. Whilst attractive in principle circumareolar mastopexy has disadvantages in terms of quality of scar (which is unpredictable,see scars and keloids ) and difficulty in obtaining a good youthful breast shape. There are also caveats about combining augmentation and lift in one procedure,
Significant degrees of ptosis
Significant degrees of ptosis can only be corrected by true mastopexy. Because this involves the reduction in the skin envelope around the breast and repositioning of the nipple at a higher level, scars are necessarily more extensive. Although there is a variety of techniques, in that most commonly employed, scars pass around the nipple, vertically down to the inframammary fold and horizontally in that fold. These are very similar in disposition to those following breast reduction(see Breast Reduction) and are usually good in quality but can be red or lumpy for some time.
Breast reduction and mastopexy principles
In both reduction and lifting of the breast skin must be removed. New techniques for doing this are beginning to appear for mild deformity (or droop) but the commonest pattern of removal of skin is shown here (and removal of tissue if reducing the breast) and the resulting scar pattern is also shown.
Mastopexy can be combined with breast augmentation
Mastopexy can be combined with breast augmentation but because this procedure involves surgery behind the breast as well as in front of it it reduces the blood supply to the breast temporarily, and should therefore be conducted with caution. For these reasons, to avoid problems arising from poor blood supply, I rarely undertake both procedures atone operation unless the patient is young, a non-smoker and requires modest lift or augmentation.
Unexpected complications following mastopexy
Unexpected complications following mastopexy are similar to those that can arise following breast reduction, and include of course bleeding, infection and adverse scarring. Luckily these are rare and can usually be managed very simply. A problem less commonly seen than with reduction is some slight delay in wound healing either below the nipple or at the point in the fold beneath the breast where the vertical and horizontal scars meet. This problem is exacerbated by smoking and it is therefore imperative that patients do not smoke for 2 weeks either side of surgery. Very rarely the problem is severe enough to need further surgery or to threaten the health and survival of the nipple itself. Alteration in, or loss of, nipple feeling is also rare and so are dissatisfaction with final shape or appearance. The shape of the lifted breast is different from the shape of the original, and the aim is to create as natural a form as possible. However the shape you first see after surgery will not be the final shape since in the first few months a lot of settling and natural adjusting of the breast contour occurs. It is impossible to predict this process (which is highly individual) precisely, and so it is equally impossible to guarantee a particular shape.
All the possible consequences of general anaesthesia can also occur but again serious complication is very unusual . General health problems following aesthetic (cosmetic) surgery are uncommon. The most serious of these is venous thromboembolism. Here clots of blood form in the legs and break loose to travel through the blood stream to lodge in the lungs where they can do serious, even fatal, damage. The risk of such a complication is increased in smokers, those on the pill, those in whom pelvic surgery is undertaken, or in whom post operative immobility increases the risk. Preventative measures can be taken and these include special pneumatic calf compressor devices during and after surgery, specialised supporting stockings during periods of enforced rest, and some pharmacological treatments to reduce the tendency of blood to clot. The latter treatments will be discussed with you prior to surgery but have the potential side effect of slightly increasing bleeding during and immediately after surgery.
The operation is usually scheduled for the same day as admission, and after surgery your new breasts will be lightly bandaged or dressed. Pain of any severity is unusual, but adequate pain relief is always available. Stopping smoking is essential prior to surgery, and usually patients will be advised to stop the oral contraceptive. Usually patients are fit for discharge to home after 24 hours, and return at one week for wound inspection. In my own practice I generally use absorbable sutures that need not be removed, but some surgeons may prefer to remove sutures and will make appropriate arrangements.
Scarring following Breast Lift (mastopexy) or breast reduction
The illustrations show the disposition of scars following breast reduction or the “Wise” pattern of mastopexy (breast lift),
Other techniques of reduction or lift may leave less scarring but are not suitable for all cases.
Mastopexy is a very rewarding operation in the appropriate patient, regardless of age, but no one should proceed without being fully informed. This outline of the process is not meant to replace proper consultation with your surgeon but may serve as an additional source of material to discuss with your primary care physician (G. P.) or surgeon at the next consultation. It is always a good idea to write the questions you may have so that they do not slip your mind during that consultation.
Professor Simon Kay, Consultant Plastic Surgeon