Breast ptosis is commonly associated with aging, macromastia, weight loss, pregnancy, and hormonal changes, although it can present in patients of all ages and breast sizes. The natural history of breast ptosis begins with the skin envelope stretch, ductal structures, and supporting ligaments. The breast parenchymal volume enlarges, rendering the supporting structures ineffective and causing skin redundancy. Ptosis also occurs when parenchymal volume decreases and skin redundancy ensues. The ptosis grading is based on the degree of inferior breast displacement, and various corrective techniques can be chosen according to the different types of ptosis.
Anatomy and Physiology
The nipple-areolar complex (NAC) has robust and overlapping vascularity from different arterial sources. The internal mammary artery (IMA) perforators are the dominant blood supply to the nipple, especially the second, third, and fourth perforators used in superomedial pedicle based mastopexies. The lateral thoracic and thoracoacromial arteries supply the breast and the nipple's superolateral aspect, and the intercostal arteries supply the anteromedial and anterolateral aspect of the breast.
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 or mild ptosis is when the nipple is at the level of the fold. Grade 2 or moderate ptosis is when the nipple is below the level of the fold, but it is not at the most dependent part of the breast. Grade 3 or severe ptosis is when the nipple is below the fold and is the most dependent part of the breast. Pseudoptosis is when the nipple is above or at the level of the fold, most of the breast is well below the fold, and the nipple to IMF distance is usually more than 6cm.
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, volume, or both. The overall goals are having a pleasing breast contour, a well-positioned nipple, breast symmetry, upper pole fullness, and a non-redundant skin envelope.
All surgical approaches have advantages and disadvantages, and different degrees of scar burden, which is a frequent source of litigation. The probability of a lawsuit can be decreased by adequately managing the patient’s expectations, establishing open communication and good rapport with the patient, and having well-documented consent.
Individual indications for each technique are described below (see Technique).
The initial preoperative evaluation should be focused on determining the patient's goals, identifying significant medical and surgical history, and assessing breast anatomy. All these factors will help the patient and surgeon to 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 whenever they are present. So clinical photography is imperative, as it can make the patient aware of them.
The next step is to thoroughly evaluate the patient's medical, surgical, and smoking history, medications, and any other pertinent information. 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 US Preventive Services Task Force guidelines and the patient’s breast cancer risk. Furthermore, breast ultrasound and/or MRI are sometimes included during the preoperative evaluation when the patient has a history of implant-related complications. Previous breast surgery can change the robust vascularity of the nipple and the breast, so it is essential to obtain as much information, including operative notes, to drastically change the surgical approach.
The physical examination begins with an assessment of the breast’s skin and parenchymal quality and the measurement of various distances between both breasts and the neighboring landmarks to objectively identify asymmetries and allow comparison of pre and postoperative changes. Furthermore, it is essential to know how each technique modifies the different breast measurements when deciding each patient's most suitable approach.
The nipple to IMF (N-IMF) distance determines the lower pole’s skin redundancy and decreases after the vertical and inverted-T mastopexies. The suprasternal notch to nipple (SSN-N) distance identifies any asymmetry between the two nipples; it remains unchanged after a vertical mastopexy, but it 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 could lengthen the SSN to IMF distance, especially when the implant is placed in the subpectoral plane. The breast width suggests the appropriate implant’s width, achieving a more natural look and fewer complications when not oversized.
The differentiation of low versus high breasted patients is based on the relative position of the breast footprint to the clavicle and humerus. The correct identification of low breasted patients is essential; otherwise, these patients could erroneously be perceived as having ptotic breasts. Low breasted patients do not have true breast ptosis, so instead of a mastopexy, improving the upper pole with breast augmentation or fat grafting is more suitable.
Mastopexy is indicated for patients with ptosis, who desire only to change the breast shape but not the volume and gain upper pole fullness and a youthful, lifted appearance. It is contraindicated in active smokers or patients wanting volume change as well. There are different types of mastopexies, which are used based on the degree of ptosis and tissue quality.
Periareolar mastopexy is indicated for patients with mild or moderate ptosis, or nipple asymmetry, with little lower pole skin redundancy, who possess reasonable skin and parenchyma quality. This technique is mainly used to reposition the nipple, at most 2 cm.
The traditional mastopexy technique re-drapes 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 to hide the scar at the areolar border, it also has a high rate of patient dissatisfaction and revision, secondary to loss of breast projection, nipple widening, and flattening by seeking to reduce postoperative scar and nipple widening, some advocate for a superior crescent-shaped marking instead of the traditional circumareolar oval, as well as the use of barbed or permanent suture purse-string closure, with various degrees of success.
The Benelli periareolar mastopexy has gained popularity over the traditional technique because it also 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. By doing so, the breast shape gains projection and a narrower width. An important consideration is that after the parenchyma is incised, the normal blood supply to the nipple is disrupted, and it becomes dependent on the superomedial vessels. So in patients undergoing augmentation/mastopexy (see below), an implant placed in the submuscular plane would be safer.
Vertical Mastopexy is indicated for any degree of ptosis. In general, all vertical mastopexies combine small amounts of parenchymal excision and skin envelope redraping, so they all have the potential to reduce the breast size modestly. The traditional vertical mastopexy with and without undermining (Lejour and Lassus techniques, respectively) has evolved into the current techniques, namely the SPAIR mammaplasty by Hammond and the Hall-Findlay Mastopexy.
The Short-scar Periareolar Inferior Pedicle Reduction Mammaplasty (SPAIR) was developed by Dennis C. Hammond and is performed via a circumareolar elliptical incision. 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 so that the nipple can maintain its new 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 are changes in the nipple sensation and periareolar pleating, as well as periareolar widening, despite the use of a pin-wheel 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.
The Hall-Findlay vertical mastopexy uses a medial or superomedial based pedicle. 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 down. Theoretically, the breast is constantly being pulled downward by its own lower pole’s weight. So, by excising parts 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), so a subglandular or submuscular augmentation/mastopexy is possible, as the implant does not exert pressure on the pedicle.
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 is indicated for patients with severe ptosis because these patients have an excessive skin envelope to parenchyma ratio. Another indication is any grade ptosis patient with fatty parenchyma or poor skin quality. Similar to the vertical mastopexy, the inverted-T mastopexy has periareolar and vertical incisions, but it also has an added horizontal incision within the inframammary fold itself.
The most popular skin incision approach has been the traditional Wise-pattern, as plastic surgeons widely use it for reduction mammaplasty. Other skin excision patterns with various degrees of favor seeking to reduce the horizontal scar burden. Regardless of the incision pattern used to excise the redundant skin, the parenchyma is then trimmed and redistributed. Commonly, the inferior crossing of the lateral and medial parenchymal edges lends longevity to the mastopexy. To improve upper pole fullness, the lower pole parenchyma can be suspended from the pectoralis fascia. Different pedicle types and parenchymal manipulations can be used with vertical mastopexies depending on the surgeon’s preference. 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 the predictable results and the surgeon's familiarity with it.
Breast augmentation can be obtained using autologous breast tissue, fat, or, more commonly, implants. It increases the size of the breast, stretches the skin envelope, and exerts pressure on the lower pole’s parenchyma. On the other hand, mastopexy aims to reposition the nipple and reshape the breast by excising redundant skin and redistributing the parenchyma to reinforce the lower pole. So by definition, the two procedures have forces working against each other.
Augmentation alone is adequate in patients with hypomastia without ptosis or with minimal ptosis (N-IMF distance less than 10cm, or skin stretch less than 4 cm). In these 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 by reducing the surface area, augmentation/mastopexy (combined augmentation and mastopexy) is only indicated whenever the volume deficit and the 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 fold 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 with a higher revision rate, which translated 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.
Eric Swanson demonstrated that tissue perfusion is not affected when vertical mastopexy and implant augmentation are performed at the same time, specifically when the nipple is based on a medial pedicle. A recent meta-analysis included 4856 cases of single-stage augmentation/mastopexy. 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 (less than 2% each). The reoperation rate was 10.7%, which is comparable to the mastopexy-only reoperation rate of 10.2%. 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 in terms of mastopexy and augmentation techniques, outcome definition, and follow-up duration. So further clinical trials are needed before reaching a uniform consensus.
Ultimately, appropriate patient selection will dictate the type of approach. The ideal candidate for a single-stage procedure would have mild or moderate ptosis, a flaccid and soft breast with good skin elasticity, not need large parenchymal or skin resection, and only wish for a moderate augmentation (<360cc). In contrast, patients with severe ptosis, a vertical excess greater than 6cm, attenuated nipple vascularity, or desire a marked augmentation would benefit from a two-stage approach.
Drains are rarely used. Adequate pain control is usually achieved with oral narcotics; muscle relaxants are added to patients with subpectoral implant placement. There is 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 week 4 to 6.
The incidence of major complications is 1.15% after mastopexy, 1.40% after augmentation, and 1.86% after augmentation/mastopexy. Hematoma and infection are the most frequent, 1% and 0.25%, respectively. Small hematomas can be observed, but large and tight hematomas need urgent evacuation, hemostasis, and closure. Furthermore, a BMI greater than 30 is an independent risk factor for postoperative infection and hematoma formation. Patient age over 60 years is noticed to be an independent risk factor only for hematoma formation.
The most common non-major complications after mastopexy alone are suture spitting, bottoming out, and excess scarring. 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 usually held off until the breast tissue settles down and acquires the final shape and projection, 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 rate. Periareolar mastopexy had the lowest satisfaction rate among surgeons and had the highest revision rate (50%) compared to inverted-T and vertical mastopexy (21% and 29.9%, respectively). Most revisions were secondary to recurrent ptosis, bottoming out, excess scarring, and malposition.
Enhancing Healthcare Team Outcomes
Breast ptosis treatment requires close cooperation between all interprofessional healthcare team members to achieve good outcomes. It begins with the primary care physician and nurse practitioner, who identify those patients with breast ptosis and assess their pertinent medical history, including breast cancer risk factors and the need for further breast cancer screening.
Since the surgery is elective, all the medical health 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 surgery. In the postoperative period, the patient will require vigilant monitoring from the entire interprofessional team, with nursing playing a significant role in monitoring, and coordination with pharmacy if there is needed post-operative pain control. A physical therapist may guide the patient in a slow and progressive return to intense physical activity in 4 to 6 weeks. 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. [Level 5]