Mastopexy / Breast Lifting

Breast tissue continues to descend throughout a woman’s life as gravity and other factors affect it. At some point, a breast lift may be needed or desired to improve the overall shape, fullness, and perkiness of the breast. Usually, this can provide a tremendous improvement.

(Fig 29) This is a graphic of the breast which helps one in understanding the process or evolution of drooping. One of the most important anatomic structures of the breast is the fold underneath the breast called the inframammary fold. Early on in life, the nipple is typically located above the level of the fold. As many variables influence the breast over time, the breast tissue sags, becomes more deflated, and the nipple descends lower and lower. Initially and ideally, the nipple is located at a point above the level of the fold. At some point the nipple descends to a level approximately equal to the inframammary fold, which is termed grade 1 drooping. Next, the nipple descends to a level below the inframammary fold, which is grade 2 drooping. Finally, the nipple will descend to a level well below the inframammary fold, which is classified as grade 3 drooping. Many variables affect the degree and rate of drooping, which is unique to each individual patient. Some of these include age of the patient, their genetics, unique and different tissue elasticity qualities, fluctuations of weight, contributing weight from the presence of breast implants, and effects from pregnancies and breast-feeding. Women usually start at the ideal position and frequently eventually end up at grade 3 drooping. Some women get there sooner than others. When the nipple falls below the level of the inframammary fold (as in grades 2 and 3), technically, a patient would benefit from a breast lift or mastopexy. The obvious trade off with the breast lift is the scars, which vary, based on different techniques. Another uncertainty is how long the breast lift will last since the individual’s breast tissue has already exhibited poor tissue qualities and has drooped over time.

Fig-29

Immediately after a lift, your breast will continue a gradual descent downward as gravity continues to exert its constant influence. Often, breast implants along with the lift can provide more fullness and really enhance the effects of the lift. However, the extra weight of the implant can also speed up the ultimate drooping of the breast. There are numerous techniques of combined lifting and augmentation which can variably influence their ultimate effect on the breast lift. It is important to discuss these differences and issues with your surgeon. Chances are he is more experienced and comfortable with some more than others.

Techniques

(Fig 30) Basically, there are four types of breast lifts, each with different scarring patterns as shown here. The Crescent lift (A), the Benelli or Doughnut lift (B), the lollipop lift (C), and the Anchor lift (D).

Fig-30

(Fig 31) With a crescent lift, skin is excised from above the areola and the nipple areola complex is pulled higher on the breast mound. This type of lift leaves the least amount of scarring of all the lifts, but is also the least effective.

Fig-31

The nipple cannot be moved very far or the areola will become stretched out in an unusual shape with usually a much more noticeable scar. This type of lift should usually be reserved for those with very minimal drooping.

The doughnut and Benelli lift mastopexy is very useful for those women with uniquely prominent and tubular shaped nipple areolas as shown in this illustration (Fig 32). This type of lift is often also effective in tightening the breast tissue, providing some elevation of the breast and nipple, and making large areolas smaller.

Fig-32

(Fig 33) Skin is excised completely around the areola and a permanent purse-string suture is placed to cinch down the skin around the nipple areola. The resulting scar goes completely around the areola and the procedure causes the nipple and breast to be tighter and have a profile closer to the chest wall.

Fig-33

In my opinion, this lifting technique is limited in the ability to actually lift the nipple areola to a higher point without adversely compromising the scar and overall shape of the areola and breast.

This technique should be used with great caution in the most carefully selected patients. If used on the wrong patients, it can cause deforming flattening of the breasts, very noticeable scarring, and an inability to correctly perform another breast lift in the future. Usually, the feathered and uneven edges of the natural areola are lost, and the nipple areola becomes very circular and distinct, looking sometimes like a paste on nipple. All that being said, it is a valuable and effective alternative procedure for carefully selected patients with breast drooping, large areolas, and protuberant nipple areolas.

(Fig 34) For patients needing an intermediate lift, a lollipop type mastopexy can be useful. An ellipse of skin is excised from around the nipple and down to the inframammary fold to allow movement of the nipple upwards. The resulting scar goes completely around the nipple and vertically straight down to the inframammary fold. This lift is effective in patients with only very unique measurements of the breast. Your surgeon will tell you if you are a candidate. (Fig 35)Occasionally, this technique can cause a noticeable flattening just under the nipple areola which usually corrects itself over time.

Fig-34	Fig-35

(Fig 36) The anchor lift is the most effective breast lift; however, it usually results in the most scarring. Skin is excised in a geometric pattern that leaves a scar completely around the nipple areola, vertically down to the inframammary fold, and within the inframammary fold to an extent dependent on the amount of skin removed. As you can see in this graphic, point A is the site of the new nipple location, and points b, c, and d are then brought together at the bottom of the breast.

Fig-36

The resultant scar is thus in the shape of an anchor. Unfortunately, the excision of skin and resulting scar in the inframammary fold is often very critical in breast lift patients. Attempts to lift the nipple without it often results in a compromise of a nice breast shape.

(Fig 37) Here is an example of a patient who has had an anchor type mastopexy performed along with placement of a small implant. This intraoperative photo really shows the power of this procedure and the ability to improve the height and shape of the breast as well as the position and shape of the areola.

Fig-37

(Fig 38 a, b, c) These are before and after photos of a sample patient who had a breast lift, or what is commonly called mastopexy performed. She additionally had large implants removed and replaced with smaller ones to maintain an added element of fullness to compliment the lift. The postoperative photos were taken two years after the procedure. The anchor scars seem to be a good tradeoff for the improvement in shape and more perky appearance.

Fig-38a	Fig-38b
Fig-38c

(Fig 39 a, b, c) This patient had an anchor mastopexy performed alone without implants. The after pictures were taken 5 years after her surgery and she has maintained a nice shape during that time

Fig-39a	Fig-39b
Fig-39c

(Fig 40 a,b,c) These are photos of a patient who had much too large of an implant placed on top of the muscle, under very thin skin, and she developed severe capsular contracture. These were done by another surgeon and she came to me for reconstruction. A nice improvement was obtained by using a much smaller implant placed partially under the muscle. Additionally, she needed an anchor type breast lift to take up the extra skin. The photos were taken several months after her surgery so the scars are still fresh. She also has retained pigment in the vertical scar between the nipple and inframammary fold because of her very large areolas. This can easily be removed later with a much smaller procedure.

Fig-40a	Fig-40b
Fig-40c

Again, the tradeoff with breast lifting is usually the scars. These heal very well or very poorly based on many variables, which should be discussed with your physician. It is very valuable if your stable partner or spouse can accompany you to the consult. Their knowledge and understanding of the procedure, and support for you is very helpful. The time in your life that you choose to have a lift performed is based on your needs, desires, and ability to accept the tradeoffs. At some point, the benefit of higher, perkier breasts will outweigh the risks and scars. You really should see other patients with these scars to help you decide if this is an option for you. If you cannot accept the scarring, don’t do the procedure. Often however, the scars are very acceptable, not a bedroom issue, and patients are very happy they had the breast lift performed.

Placing a small implant at the time of surgery can really enhance the effects of a breast lift in many patients. It provides more fullness in the upper breast and a better overall shape. Implants also however, bring with them the added separate risk of the implants.

(Fig 41) These are pictures taken in the operating room after one side has been lifted. The first picture is of a patient who had a breast lift on her right breast, however no implant was placed. Obviously, these pictures were taken prior to the other side being lifted.

Fig-41

Possible Complications of Breast Lift (Mastopexy)

Alternatives

If you are considering having this surgery, you may have already considered the alternatives to having a breast lift and or breast implants. These may include changing your present diet or beginning a new diet program, changing your exercise routines, or possibly addressing a current medical problem if applicable. Different supportive bras or fillers can be worn to make the breasts appear more full. Different clothes can be worn as well to possibly conceal the breasts. Nonsurgical options may not be as definitive. Breast lift surgery is elective surgery and if you choose not to have it, you will avoid the risks associated with the procedure. You should consult with your doctor regarding different types of breast lifts as well as available alternatives other than surgery.

PLEASE NOTE: If breast implants are also placed during the procedure, those risks have to be included as well. Please also review that risk section in the communication regarding breast augmentation.

Asymmetry: Asymmetry is really not a complication. Your surgeon cannot make your breasts look exactly the same. Good results are anticipated but perfect symmetry is not obtainable.

Undesired Bra Sizing: A bra size cannot be guaranteed either since bra sizing itself is an inconsistent communication tool. You should communicate as clear as possible with your surgeon the size breasts you want. Many intraoperative factors however play a role in ultimate size of your breasts. Your surgeon has to place a priority on safety of the procedure and other concerns ultimately over your choice in size. Sometimes patients will feel postoperatively that their breasts are too big, or too small.

Scarring: Incisions heal unpredictably depending on many factors. Some of these include the location of the incision, surgical technique utilized, unique healing characteristics of the patient and their genetics, and how compliant they are with postoperative orders, among others. All scars are permanent and can be seen when examined, however some heal better than others. The degree of scarring ranges from excellent scarring to very poor, with most scarring somewhere in between. Revisions are sometimes needed to improve the appearance. If poor scarring occurs, usually it is under the fold of the breast instead of around the nipple or down the front of the breast.

For some cases of keloid scar formation, post operative x-ray treatment during healing improves the chances of scars healing better in many cases. Sometimes these scars and other deformities are permanent however, and cannot be corrected. It is wise to see a representative patient with good scars and poor scars to decide if you are willing to accept these risks.

Retained Pigment: One type of unique scarring issue which is noticeable and might require revisional surgery is called “retained pigment”. The location of skin excised and the method of closure in some techniques will sometimes result in the incorporation of the pigmented areola skin along a scar. (Fig 42) If this occurs, the pigment is usually along the vertical scar from the nipple to the inframammary fold as shown here. This pigment can usually be excised in one or multiple very small procedures at a later date. This problem is most often seen in those patients with remarkably large areolas, especially when the nipple is not raised much higher than its present position.

Fig-42

Pain: It is possible after your surgery that your symptoms of neck, back or breast pain are not improved as much as you had wanted. Even more unlikely but possible is that you may have pain in your breasts or along your scars following the surgery.

Healing Problems: Sometimes there are areas along the incision that may not heal well from infection, tension, poor blood flow or other reasons. The inverted “T” intersection at the bottom of the breast is a common site for this to happen because of the tension in this area. When this happens, delayed healing or separation of the wound may occur, requiring prolonged medical attention to the area with dressing changes and sometimes antibiotics.

Necrosis of tissue: The worst-case scenario may be if tissue actually dies from compromise of the circulation. Although infrequent, the patients at highest risk for this problem include smokers and patients with tremendously large breasts seeking reduction. (Fig 43) The area most frequently involved is the nipple areola complex as seen in this photograph. Some skin might die requiring placement of a skin graft at a later time or other surgical revisions. These areas may heal a different color than the surrounding areola and may require medical tattooing to blend in. If the breasts are uniquely large as described, sometimes the surgeon will decide to take the nipple off during surgery and apply it in a controlled fashion as a skin graft. These points should be discussed with your surgeon.

Fig-43

Bottoming Out: A common occurrence after breast reduction or breast lifting surgery is bottoming out or further drooping. These surgical procedures will not arrest the process of aging, and your breasts will continue to droop over time. In some patients this can be accelerated within the first two years. Although it is unlikely that significant breast tissue enlargement will reoccur, patients often see a bottoming out of the lower pole of the breast. (Fig 44) This can be treated and improved with an additional much smaller excision of skin on the bottom of the breasts at a later date if needed.

Fig-44

(Fig 45) These are pictures of a patient which demonstrate bottoming out which can occur with breast reductions, lifts, or augmentation. This particular patient had an anchor type breast lift along with placement of implants and the after pictures were taken a year after her surgery. You can see in the before photo that the patients breasts are obviously droopy and the nipple is below the level of the inframammary fold or fold under the breast. Although she has had substantial improvement from this surgery, her breasts have settled and dropped more since that surgery. (Fig 46) This is a picture taken in the operating room at the time of the surgery. You can see that the lifted breast is very high, and in fact the bottom part of the breast (arrow) is not laying on or touching the chest wall. This area of the breast will almost always relax after surgery with the effects of gravity. You cannot expect the breast tissue to stay as tight and high as the day of surgery.

Fig-45a	Fig-45b
Fig-45c	Fig-46

(Fig 47) This picture was taken one year after her lift surgery. The pen is inserted at the level of the inframammary fold and shows how the bottom part of the breast has bottomed out or stretched over time and is now in fact touching the chest wall. Although clearly improved from preoperatively, this is something that can commonly occur after this type of surgery. The degree is variable.

Hematoma: Sometimes the breast can develop a collection of fluid or blood within the dissection area from continued postoperative oozing. Most studies show this occurring approximately 5% of the time. Another smaller surgery to drain this excess fluid from the surgical area may be required. The placement of drains often helps prevent these complications.

Loss of Sensation: Although there is a reasonable chance to maintain nipple sensation following breast reduction or breast lift surgery, a patient must be prepared to lose sensation in their nipple or other areas of the breast.. Usually, the larger the amount of reduction, the higher the risk of losing sensation. Unfortunately, this change in or loss of sensation may be permanent.

Breast Feeding: Likewise, a patient may not be able to breast feed after breast reduction or breast lift surgery. Although the chance remains that breast feeding is possible, it is best to prepare for this possible permanent loss as the result of surgery. Because of the growth and distortion of the breasts during pregnancy, it is probably wise to delay this surgery if pregnancy is planned or desired in the near future.

Calcium Deposits: Breast surgery does NOT increase your risk of breast cancer. The surgical dissection of the breasts however, leads to scarring inside the breasts. Occasionally calcium deposits can form within this scar tissue which can mimic the appearance of breast cancer on future mammograms. This can lead to confusion when later trying to evaluate the presence of breast cancer. Mammograms before and after surgery can help to resolve some of this confusion and establish a baseline for other mammograms to be compared to. It is important to have the breast tissue, which was discarded from your breasts sent to pathology for postoperative evaluation. Often, breast reduction patients have breasts so large; they can not be effectively examined with mammography. Reducing their size often is helpful in evaluating the breasts for cancer with these tests.

Other: Other complications can result from any surgery including permanent deformities, need for expensive revisional surgery, hospitalization, and even death. There are certainly other risks that could occur, and the rate and severity vary with different surgeons and their experience. A more accurate and detailed list can be provided by your surgeon based on the uniqueness of your exam and medical history. Related financial obligations should also be discussed prior to surgery with your doctor.