Continuing Education Activity

Breast ptosis is characterized by an inferior descent of the nipple relative to the breast fold and lower pole skin redundancy. Initial patient evaluation focuses on determining their expectations, identifying risk factors for surgical correction, and assessing breast anatomy. Various surgical approaches can be used to correct breast ptosis, with specific indications and nuances accompanying each technique. Assessing breast ptosis severity and selecting appropriate mastopexy techniques are essential to achieving excellent surgical results and high patient satisfaction. This activity reviews the evaluation and treatment of breast ptosis and highlights the role of the interprofessional team during the initial assessment, treatment, and postoperative recovery of patients.

Objectives:

• Differentiate between various degrees of breast ptosis and understand the anatomical factors contributing to each stage.

• Implement appropriate treatment plans based on the degree of breast ptosis and patient preferences.

• Identify potential complications and risks associated with breast ptosis surgeries.

• Coordinate preoperative assessments, surgical management, and postoperative follow-up care with the interprofessional team to optimize care for patients undergoing breast ptosis surgery.

Introduction

Although breast ptosis can present in patients of all ages and breast sizes, it is commonly associated with aging, macromastia, weight loss, pregnancy, and hormonal changes. This condition affects physical appearance and can significantly impact patients' emotional well-being.

The natural history of breast ptosis begins with skin envelope stretch and laxity developing in the ductal structures and supporting ligaments. Subsequently, the breast parenchymal volume increases, rendering the supporting structures ineffective and causing skin redundancy. Ptosis can also occur when parenchymal volume decreases (eg, after significant weight loss) and relative skin redundancy ensues.

The ptosis classification system is based on the degree of inferior breast displacement, for which various corrective techniques can be used (depending on the type of ptosis). Addressing breast ptosis involves clinical assessment, surgical expertise, and patient-centered communication, all of which contribute to achieving desired aesthetic outcomes and enhancing the overall quality of life for individuals seeking intervention.[1]

Anatomy and Physiology

The nipple-areolar complex (NAC) has robust and overlapping vascularity from different arterial sources. The dominant blood supply to the nipple is provided by the internal mammary artery (IMA) perforators, especially the second, third, and fourth perforators (used in superomedial pedicle–based mastopexies). The lateral thoracic and thoracoacromial arteries supply the superolateral aspect of the breast and nipple; the intercostal arteries supply the anteromedial and anterolateral aspects of the breast.[2]

The degree of ptosis can be categorized by the Regnault classification, which assesses the breast according to the relative position of the nipple to the inframammary fold (IMF):

• Grade 1: Mild ptosis — The nipple is at the level of the IMF.
• Grade 2: Moderate ptosis — The nipple is below the level of the IMF but is not the most dependent part of the breast.
• Grade 3: Severe ptosis — The nipple is below the IMF and is the most dependent part of the breast.

Pseudoptosis designates a breast configuration in which the nipple is located above or at the level of the IMF, most of the breast is well below the IMF, and the nipple-to-IMF distance is often greater than 6 cm.[3]

Indications

The correction of breast ptosis is achieved via various surgical approaches. The type of surgery is selected according to the degree of ptosis and whether the patient wishes to correct breast shape, breast volume, or both. The overall goals are a pleasing breast contour, a well-positioned nipple, breast symmetry, upper pole fullness, and a nonredundant skin envelope.[2]

All surgical approaches have advantages and disadvantages and different degrees of scar burden, which is a frequent source of litigation.[4] The probability of patient dissatisfaction and resultant litigation can be decreased by adequately managing the patient’s expectations, establishing open communication and good rapport with the patient, and having well-documented consent.

Contraindications

Breast ptosis surgery, although beneficial for many individuals seeking aesthetic or functional improvements, has certain contraindications that need careful consideration. Untreated breast cancer is an absolute contraindication to elective cosmetic breast surgery. Patients with uncontrolled medical conditions such as diabetes, cardiovascular diseases, immune disorders, or coagulopathies may be at higher risk for surgical complications and delayed healing, making surgery less advisable. Active infections or a history of poor wound healing could also increase the risk of postoperative complications. Pregnant or breastfeeding women should postpone breast ptosis surgery, as hormonal changes during these periods can affect surgical outcomes. Moreover, smokers, patients with unrealistic expectations, or those unable to comply with postoperative care regimens may not be suitable candidates. A thorough assessment by a qualified surgeon is essential to ensure that patients are appropriately evaluated and informed about their candidacy for this complex surgery.

Equipment

A standard breast or plastic surgery instrument set is required for safe, effective procedures. Mastopexy retractors, such as Tebbetts Retractors, are available with fiber-optic lights that greatly facilitate exposure and dissection. Suction devices and electrocautery units are crucial for maintaining a clear surgical field and controlling bleeding. Breast implants and appropriate suture materials also ensure optimal results if augmentation is involved.

Personnel

Breast ptosis surgery typically requires a multidisciplinary team comprising a board-certified plastic surgeon with expertise in breast procedures and a surgical assistant. An anesthesiologist ensures patient safety during surgery by administering anesthesia and monitoring vital signs. Additionally, skilled circulator/scout and scrub nurses are also required. The surgical scrub nurse assists the surgeon and maintains sterile conditions throughout the procedure, contributing to a successful surgical outcome.

Preparation

The initial preoperative evaluation should focus on determining the patient's goals, identifying significant medical and surgical history, and assessing breast anatomy. These factors will help the patient and surgeon navigate the various surgical options. The patient's expectations and goals translate into what the patient wishes to change, namely, breast shape, size, or both. However, patients are commonly unaware of their own breast asymmetries and chest wall abnormalities when present. Clinical photography is imperative, as it can make the patient aware of pre-existing irregularities and provide documentation of preoperative and postoperative appearances. This creates a robust medical record. 

A thorough evaluation of the patient's medical, surgical, and smoking history, current medications, and other pertinent information is performed. It is important to pay close attention to the breast history, including size changes during pregnancy, weight changes, personal or family history of breast tumors, recent mammograms, and the desire to breastfeed in the future. The screening mammogram is only recommended based on the U.S. Preventive Services Task Force guidelines and the patient's breast cancer risk.[2][3] Furthermore, breast ultrasound and/or magnetic resonance imaging are sometimes included during the preoperative evaluation when the patient has a history of implant-related complications. Previous breast surgery can change the normally rich vascularity of the nipple and breast; therefore, obtaining as much information as possible, including prior operative notes, is essential, as these details may drastically change the surgical approach or appropriate subsequent surgical options.  

The physical examination begins with assessing the breast skin and parenchymal quality and measuring various distances between both breasts and the neighboring landmarks to objectively identify asymmetries and to allow comparison of pre- and postoperative changes.[5] Furthermore, knowing how each technique modifies the different breast measurements is essential when deciding the most suitable approach for each patient.  

The nipple-to-IMF (N-IMF) distance determines the lower pole's skin redundancy and decreases after vertical and inverted-T mastopexies. The suprasternal notch-to-nipple (SSN-N) distance identifies asymmetry between the 2 nipples; it remains unchanged after a vertical mastopexy but lengthens with a combined augmentation/mastopexy. The SSN-to-IMF distance is measured as a vertical line between the SSN and the breast fold level; it remains unchanged after most mastopexies, except for the Hall-Findlay mastopexy, which shortens the distance. Augmentation/mastopexy may lengthen the SSN-to-IMF distance, especially when an implant is placed in the subpectoral plane.[6] The breast width suggests the appropriate implant width; when it is not oversized, a more natural look and fewer complications are achieved.  

The differentiation of low- versus high-breasted patients is based on the relative position of the breast footprint to the clavicle and humerus. Correctly identifying low-breasted patients is essential; otherwise, these patients could erroneously be perceived as having ptotic breasts. Because low-breasted patients do not have true breast ptosis, improving the upper pole with breast augmentation or fat grafting is more appropriate than a mastopexy.[3][7]

Technique or Treatment

Mastopexy

Mastopexy is indicated for patients with ptosis who desire to change their breast shape and gain upper pole fullness and a more youthful, lifted appearance. It is contraindicated in active smokers or patients wanting to change their breast volume. There are different types of mastopexies, the choice of which is based on the degree of ptosis and tissue quality. 

Periareolar mastopexy

Periareolar mastopexy is indicated for patients with mild or moderate ptosis or nipple asymmetry with minimal lower pole skin redundancy who possess reasonable skin and parenchyma quality. This technique is mainly used to reposition the nipple, at most by 2 cm.  

The traditional mastopexy technique redrapes the circumareolar skin to buttress the parenchyma. An eccentric oval is drawn around the areola, including more skin superiorly to elevate the nipple. The skin in between the nipple edge and the outline is de-epithelialized, and the incision is then closed around the nipple. Although this technique has the advantage of hiding the scar at the areolar border, it has a high rate of patient dissatisfaction and revision, secondary to loss of breast projection, nipple widening, and breast flattening. Some surgeons advocate for a superior crescent-shaped marking instead of the traditional circumareolar oval and a barbed or permanent suture purse-string closure with various degrees of success.[8]

The Benelli periareolar mastopexy has gained popularity over the traditional technique because it redistributes the parenchyma to buttress the breast. In this technique, a slightly larger ellipse is drawn, the parenchyma is then incised inferiorly, and the resulting medial and lateral edges are crossed or invaginated in the midline. Consequently, breast projection is increased while breast width is narrowed. An important consideration is that after the parenchyma is incised, the normal blood supply to the nipple is disrupted and becomes dependent on the superomedial vessels. As a result, in patients undergoing augmentation/mastopexy (see below), an implant placed in the submuscular plane would be a safer option.[3]

Vertical mastopexy

Vertical mastopexy is indicated for any degree of ptosis. In general, all vertical mastopexies combine small amounts of parenchymal excision and skin envelope redraping; therefore, they all have the potential to modestly reduce breast size. The traditional vertical mastopexy, with and without undermining (Lejour and Lassus techniques, respectively), has evolved into the current techniques, namely the short-scar periareolar inferior pedicle reduction (SPAIR) mammaplasty and the Hall-Findlay mastopexy.

SPAIR mammaplasty

The SPAIR mammaplasty was developed by Dennis Hammond and is performed via a circumareolar elliptical incision.[9] The nipple is left on an inferior pedicle with the parenchyma trimmed and redistributed superiorly. The pedicle is then tacked to the superior chest wall by suspension sutures to maintain the new nipple position. Subsequently, the lower pole redundancy is tailor tacked and excised vertically, sometimes in a slight lateral J-pattern to avoid dog ears. The drawbacks of this technique include changes in nipple sensation, periareolar pleating, and periareolar widening despite the use of a pinwheel or interlocking periareolar closure pattern. One caveat is that the nipple will depend on an inferior pedicle, which is considered to increase the risk of bottoming out despite the use of suspension sutures. An inferior pedicle-based technique also dissuades surgeons from using this technique when combining augmentation and mastopexy, as the implant weight over the pedicle could attenuate the blood supply to the nipple.[10]

Hall-Findlay mastopexy

The Hall-Findlay vertical mastopexy uses a medial or superomedial-based pedicle.[11] It is also performed via a circumareolar elliptical incision, but the parenchyma is trimmed and redistributed inferolaterally instead of superiorly. The lower pole skin redundancy is tailor tacked and excised vertically, just as it would be carried out with the SPAIR technique. One caveat is that the native inframammary fold tends to rise with this technique, so the most inferior portion of the incision must end above the native fold to avoid potentially extending the scar onto the abdomen as the breast settles postoperatively. Theoretically, the breast is constantly pulled downward by its lower pole's weight. By excising portions of the lower pole parenchyma, adjoining the medial and lateral edges inferiorly, and narrowing the breast, this technique provides structural support, counteracts the downward forces, and decreases ptosis recurrence. The superomedial pedicle used in this approach is based on the main arterial supply to the nipple (second or third IMA perforator). Hence, a subglandular or submuscular augmentation/mastopexy is possible, as the implant does not exert direct pressure on the nipple pedicle.[3]

Immediately after all vertical mastopexies, the breast has a characteristic inverted shape, with a sloped lower pole and an exaggerated upper pole fullness. It takes months for the final shape to be appreciated by the patient as the breast tissue slowly settles and the lower pole regains its fullness. Hence, reassurance is essential during the immediate postoperative period.  

Inverted-T mastopexy

Inverted-T mastopexy is indicated for patients with severe ptosis, as they have an excessive skin envelope–to-parenchyma ratio. Another important indication for this technique is any grade of ptosis but with fatty parenchyma or poor skin quality. Like the vertical mastopexy, the inverted-T mastopexy has periareolar and vertical incisions, but it also has an added horizontal incision within the inframammary fold.  

The most popular skin incision approach has been the traditional Wise Pattern. Other skin excision patterns that seek to reduce the horizontal scar burden have been described with various degrees of favor.[12] The parenchyma is trimmed and redistributed regardless of the incision pattern used to excise the redundant skin. Commonly, the inferior crossing of the lateral and medial parenchymal edges lends longevity to the mastopexy. The lower pole parenchyma can be suspended from the pectoralis fascia to improve upper pole fullness. Depending on the surgeon's preference, different pedicle types and parenchymal manipulations can be used with vertical mastopexies. The only caveat is that inferior pedicles are associated with bottoming out (see SPAIR mammaplasty). Although inverted-T mastopexy has a considerable scar burden, it is widely used because of reliable and predictable results and surgeons' near-universal familiarity with this technique.[1]

Augmentation/mastopexy 

Breast augmentation can be performed using autologous breast tissue, fat, or alloplastic implants. Augmentation increases the size of the breast, stretches the skin envelope, and exerts pressure on the lower pole's parenchyma. Conversely, the goals of mastopexy are to reposition the nipple and reshape the breast by excising redundant skin and redistributing the parenchyma to reinforce the lower pole. Therefore, by definition, these 2 procedures may have counteracting forces and goals.  

Augmentation alone is adequate in patients with hypomastia without ptosis or with minimal ptosis (N-IMF distance <10 cm or skin stretch <4 cm).[13] In such patients, augmentation can project the nipple and correct the relative skin redundancy. Since mastopexy alone is adequate in patients with ptosis and minimal hypomastia by correcting the relative volume deficiency and by reducing the surface area, augmentation/mastopexy (combined augmentation and mastopexy) is only indicated when the volume deficit and ptosis are severe enough for neither procedure to suffice alone.   

The type of mastopexy combined with augmentation depends on the degree of ptosis. Periareolar mastopexy is used for patients with nipples less than 2 cm below the IMF and not pointing inferiorly. Vertical or inverted-T mastopexies are used for more severe ptosis. 

The most disputed aspect of this approach is when to do a single-stage versus a two-stage approach. Traditionally, the single-stage approach has been considered more unpredictable and has a higher revision rate, which translates into being one of the most frequent sources of malpractice claims. After the publication of the editorial "Augmentation/Mastopexy: 'Surgeon, Beware" by Spear in 2003, the topic became even more controversial, generating more and more literature about the safety and revision rate of the single-stage approach.[14]

Swanson demonstrated that tissue perfusion is unaffected when vertical mastopexy and implant augmentation are performed simultaneously, specifically when the nipple is based on a medial pedicle.[15] A recent meta-analysis included 4856 cases of single-stage augmentation/mastopexy.[16] The study reported a pooled complication rate of 13.1%, namely ptosis recurrence (5.2%), unfavorable scarring (3.7%), capsular contracture (3.0%), tissue-related asymmetry (2.9%), seroma, hematoma, and infection (<2% each). The reoperation rate was 10.7%, comparable to the mastopexy-only reoperation rate of 10.2%.[16][17] Proponents of the single-stage approach argue that a 10.7% reoperation rate is significantly less than the 100% rate in the two-stage approach. Although this study shed some light on the topic, it was highly heterogeneous regarding mastopexy and augmentation techniques, outcome definition, and follow-up duration.[16] Further clinical trials are necessary before reaching a uniform consensus. 

Ultimately, appropriate patient selection will dictate the type of approach. The ideal candidate for a single-stage procedure is a patient with mild or moderate ptosis, a flaccid and soft breast with good skin elasticity, who does not need large parenchymal or skin resection and only wishes for a moderate augmentation (<360 cc). In contrast, patients with severe ptosis, a vertical excess greater than 6 cm, attenuated nipple vascularity, or a desire for a marked augmentation would benefit from a two-stage approach.[13][17][18]

Postoperative Care

Drains are rarely used, though this is a matter of surgeon preference. Adequate pain control is usually achieved with oral narcotics; muscle relaxants are added for patients with subpectoral implant placement. There are no data supporting oral antibiotics beyond the standard perioperative period. A supportive bra is placed at the end of the case, used for the next 4 to 6 weeks, and then switched to an underwire bra. It offers mechanical support while the breast tissue regains tensile strength. Scar treatment routinely begins after 3 weeks. Intense physical activity can be resumed by postoperative Weeks 4 to 6.[2][3]

Complications

The incidence of major complications is 1.15% after mastopexy, 1.40% after augmentation, and 1.86% after augmentation/mastopexy, with hematomas and infection being the most frequent (1% and 0.25%, respectively). Small hematomas can be observed, but large and tight (or expanding) hematomas require urgent evacuation, hemostasis, and reclosure. A body mass index greater than 30 is an independent risk factor for postoperative infection and hematoma formation, among other complications. Patient age older than 60 years is also an independent risk factor for hematoma formation.[19] 

The most common nonmajor complications after mastopexy alone are suture spitting, bottoming out, and excess scarring. Bottoming out is a complication of breast implant surgery that consists of the descent of the IMF with inferior displacement of the implant, causing breast asymmetry. Suture spitting is more common in the SPAIR technique, bottoming out in inferior pedicle-based and inverted-T mastopexies, and excess scarring in periareolar mastopexies. Other tissue-related complications are nipple necrosis, malposition, deformity, and ptosis recurrence. Implant-related complications after augmentation/mastopexy are implant malposition and asymmetry, capsular contracture, and skin rippling. 

Reoperations are typically delayed until the breast tissue has fully settled and the final shape and projection have been acquired, which can take 6 to 12 months. A survey completed by 487 board-certified plastic surgeons in 2002 elucidated the following findings: the most popular approach was the inverted-T mastopexy, but the modified vertical mastopexies (Hall-Findlay and SPAIR techniques) were becoming more popular and had the highest satisfaction rates. Periareolar mastopexy had the lowest satisfaction rate among surgeons and had the highest revision rate (50%) compared with inverted-T and vertical mastopexy (21% and 29.9%, respectively). Most revisions were secondary to recurrent ptosis, bottoming out, excess scarring, and malposition.[20]

Clinical Significance

Understanding the different factors influencing breast ptosis to tailor corrective techniques to patients' needs is essential, thereby increasing patient and surgeon satisfaction. 

• Periareolar mastopexy: Indicated for mild or moderate ptosis, with little lower pole skin redundancy and reasonable skin and parenchyma quality 
• Vertical mastopexy: Indicated for any degree of ptosis; usually combined with small amounts of parenchymal excision and skin envelope redraping; has the potential to reduce breast size modestly 
• Inverted-T mastopexy: Indicated for severe ptosis (because of the excessive skin envelope–to-parenchyma ratio) and breasts with fatty parenchyma or poor skin quality
• Combined augmentation and mastopexy: Indicated only when the volume deficit and ptosis are severe enough for neither procedure to suffice alone

Enhancing Healthcare Team Outcomes

Breast ptosis treatment requires close cooperation between all interprofessional healthcare team members to achieve optimal outcomes. This begins with the primary care physician and nurse practitioner identifying patients with breast ptosis and assessing their pertinent medical history, including breast cancer risk factors and the need for further breast cancer screening.[3] 

Given the surgery is elective, all the medical problems and risk factors should be identified and minimized, including encouraging the patient to stop smoking. The specialist surgeon will navigate the various surgical options with the patient and subsequently perform the most suitable procedure. In the postoperative period, the patient will require vigilant monitoring from the entire interprofessional team, with nursing playing a significant role in patient monitoring and coordination with the pharmacy for postoperative pain control. A physical therapist may guide the patient in a slow and progressive return to more intense physical activity in 4 to 6 weeks postoperatively.[2] At the same time, the surgeon and nurse supervise the recovery of the patient. Open communication among the entire interprofessional team is essential for the patient to obtain the best possible outcome.