Breast lift
Encyclopedia
Mastopexy is the mammoplasty
procedure for correcting the size, contour, and elevation of sagging breasts upon the chest. In a breast lift surgery to re-establish an aesthetically proportionate bust
for the woman, the critical corrective consideration is the (histologic) tissue viability
of the nipple-areola complex
(NAC) to ensure the functional sensitivity of the breasts for lactation
and breast-feeding. The indications for mastopexic correction of breast ptosis
are three-fold — physical, aesthetic, and psychological — the restoration of the bust, of the woman’s self-image, and of her mental health
. In corrective surgical praxis, mastopexy can be performed as a discrete breast lift procedure, and as a sub-ordinate surgery within a combined mastopexy–breast augmentation procedure; moreover, mastopexy surgery techniques also are applied to reduction mammoplasty
, the correction of over-sized breasts.
and of the breast skin envelope (mild, moderate, severe, and pseudo ptosis) — determine the applicable surgical approach for lifting the breasts; for example, mild ptosis can be corrected solely with breast augmentation
. Moreover, the usual breast-lift techniques, featuring circumvertical and horizontal surgical incisions, such as the periareolar incision mastopexies — the Anchor pattern, the inverted-T incision, the lollipop pattern — each produce a scar at the periphery (edge) of the nipple-areola complex (NAC), and a descending vertical scar from the inferior margin of the NAC to the horizontal scar in the inframammary fold (IMF) where the breast hemisphere meets the chest; thus, surgical scars upon the breast hemisphere are the aesthetically disadvantageous outcome of mastopexy correction.
The law of gravity
of the Earth is the factor most common to the incidence of breast ptosis
, the prolapsation
— falling forward and sagging of the mammary gland tissues (glandular
, adipose, skin
) from the chest. In the young woman with large breasts
the sagging occurs because of the volume and weight of a bodily disproportionate bust, and the elasticity of the thin, young skin envelope of each breast. In the middle-aged woman, breast ptosis usually is a consequence of postpartum hormonal
changes to the maternal body after the depleted milk glands
atrophy, and of the inelasticity of the skin envelope, which was over-stretched by the engorgement of lactation
. In the post-menopausal
woman, besides Earthly gravity, such breast atrophy is aggravated by the inelasticity of over-stretched, aged skin.
Pathophysiology and presentation
In the course of a woman’s life, her breasts change as the skin envelope becomes inelastic, and the suspensory ligaments
— which suspend the mammary gland
against the chest — become loose, and so cause the prolapsation
, the falling forward and sagging, of the breast and the nipple-areola complex (NAC). Moreover, postpartum involution (diminishment) of the voluminous milk glands
in the breast aggravates the looseness of the suspensory ligaments and of the inelastic skin envelope. The breast lift procedure surgically corrects said physical changes by elevating the parenchymal tissue
, cutting and re-sizing the skin envelope, and transposing the nipple-areola complex higher upon the breast hemisphere.
The degree of mammary gland
prolapse (breast ptosis) is determined with the modified Regnault ptosis grade scale:
The breast lift correction of a sagging bust (breast ptosis
) cuts excess tissues (glandular
, adipose, skin
), over-stretched suspensory ligaments
, excess skin from the skin envelope, and transposes the nipple-areola complex (NAC) higher upon the breast hemisphere.
Composition
Surgically, the breast is an apocrine gland
overlaying the chest — attached at the nipple and suspended with ligaments from the chest — which is integral to the skin, the body integument
of the woman. The dimensions and weight of the breasts vary with her age and habitus (body build and physical constitution); hence small-to-medium-sized breasts weigh approximately 500 gm or less, and large breasts weigh approximately 750–1,000 gm. Anatomically, the breast topography
and the hemispheric locale of the nipple-areola complex (NAC) are particular to each woman; thus, the desirable, average measurements are a 21–23 cm sternal distance (nipple to sternum-bone notch), and a 5–7 cm inferior-limb distance (NAC to IMF).
Blood supply and innervation
The arterial blood
supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery
(from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries
. Drainage of venous blood
from the breast is by the superficial vein system under the dermis
, and by the deep vein system parallel to the artery system. The primary lymph
drainage system is the retromammary lymph plexus in the pectoral fascia
. Sensation in the breast is established by the peripheral nervous system innervation
of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerve
s, and thoracic spinal nerve 4
(T4 nerve) innervates and supplies sensation to the nipple-areola complex.
Mechanical structures of the breast
In realizing the breast lift, the mastopexic correction takes anatomic and histologic account of the biomechanical, load-bearing properties of the three (3) tissue types (glandular
, adipose, skin
) that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility (Poisson’s ratio of ∼0.5).
The surgeon–physician evaluates the woman requesting a breast-lift operation, to ascertain that she understands the health risks and benefits of the mastopexy; and that her ideal body image
(aesthetic goal) corresponds to what can be realistically achieved with the surgical correction of breast ptosis:
I. — Mastopexy of the sagging breast
The following descriptions of the full breast-lift and of the modified breast-lift techniques are limited to the surgical incisions used to address the skin envelope of the breast, not the internal parenchyma
, the substance of the breast.
A. — Full breast lift
The sagging bust is lifted using the circumvertical- and horizontal-incision plan of the Anchor mastopexy (also Lexer pattern, inverted-T incision, Wise pattern, inferior pedicle), which features three incisons:
In cutting the folds of excess skin from the sagging, inelastic skin-envelope of the breast (and occasionally reducing the NAC diameter), the three-incision technique of the Anchor mastopexy allows maximal corrections to the breasts, thereby producing an elevated bust with breasts of natural size, look, and feel. Moreover, each of the three scars to the breast hemisphere produced by the Anchor-pattern mastopexy has a characteristic healing pattern:
Post-surgically, of these three breast-lift surgery scars, the scar to the inframammary fold exhibits the greatest tendency to hypertrophy, to thickness and large size. Although the coloration of mastopexy scars fades with the full maturation of the tissues, they do remain visible.
B. — Modified breast lift
The incision plans of the techniques for modified breast lift feature fewer cuts and fewer scars, but limit the plastic surgeon by allowing fewer changes to the skin envelope of the breast. In surgical praxis
, the modified breast lift often is a sub-ordinate surgery within a mastopexy–breast augmentation procedure, the simultaneous lifting and enlarging the bust. Moreover, these incisions are applied to correct the ptosis discussed above; some technical variants of the modified breast lift are:
II. — Mastopexy of the augmented breast
Women who have undergone breast augmentation
also are susceptible to breast ptosis; which incidence might be induced by the physical and mechanical stresses exerted by the breast implants upon the internal tissues and the skin envelope; such over-stretching thins the skin and atrophies its elastic qualities. Statistically, breast augmentation and mastopexy are plastic surgery operations with low incidence rates of medical complications; yet, when performed as a combined breast-repair procedure (mastopexy–augmentation), the physiologic stresses upon the health of the woman increase the risks of incision-wound infection, breast-implant exposure, damage to the breast and nipple nerves, malposition of the nipple-areola complex, and malposition of the breast implant in the implant pocket. Therefore, a mastopexy–augmentation procedure features increased surgical complication rates, when compared to the lesser complication rates of breast augmentation
and mastopexy as discrete surgical operations; likewise, the individual incidence rates of surgical revision and complications, when compared to the revision and complication rates for the combined mastopexy–augmentation procedure. Recent studies of a newer technique for simultaneous augmentation mastopexy (SAM) indicate that it is a safe surgical procedure with minimal medical complications. The SAM technique involves invaginating and tacking the tissues first, in order to previsualize the final result, before making any surgical incisions to the breast.
Contraindications
The contraindications for mastopexy are few: aspirin
use, tobacco smoking
, diabetes, and obesity
are medical and health conditions associated with increased incidences of nipple necrosis
. In resolving the perceived ptosis of a woman with encapsulated
breast implants, the surgeon determines her suitability for a breast lift procedure after explantation, which facilitates assessment of the true degree of ptosis present in the explanted breasts; likewise the assessment of the effects of a combined breast-lift and revision-augmentation procedure, featuring the removal and the replacement of breast implants. For the woman who is at high risk for developing breast cancer
(primary or recurrent), the mastopexy might alter the histologic
architecture of the breasts, which tissue change might interfere with the accurate MRI detection and subsequent treatment of cancer; the risks and benefits will be discussed in that setting.
s after excising (cutting) excess folds of skin from the skin-envelope, when either replacing or rearranging or augmenting
the internal breast tissues (parenchyma
l and adipose). Breast lift techniques are known according to the number of scars produced, which is related to the achievable degree of breast-lift. Pre-operatively, the patient and the surgeon decide upon the appropriate surgical technique (superior, medial, or inferior pedicle) that will achieve the best degree of breast lift. Generally, breast ptosis
(sagging) is determined by the locale of the nipple-areola complex (NAC) upon the breast; the lower the NAC, the greater the degree of breast prolapsation (ptosis). Nonetheless, in breast-lift surgery, the primary consideration is the tissue viability
of the nipple-areola complex, so that the outcome is a functionally sensate breast of natural size, contour, and feel.
A. The surgical management of breast ptosis is by degree of severity
B. Pseudoptosis — false breast prolapse can be addressed two ways
Mastopexy procedure
Pre-operative matters
The plastic surgeon delineates the mastopexy incision-plan upon the patient’s breasts and torso; the principal corrective consideration is the correct level of the nipple-areola complex (NAC) upon the breast hemisphere. In most women, the nipple should be located at, or slightly above, the inframammary fold (IMF), because emplacing it too high might later lead to a difficult revision surgery. The proper topographic locale for the nipple is determined by transposing the semicircular line of the inframammary fold to the face of the breast (anterior aspect), thereby configuring a circle, wherein the NAC is centred. After determining the nipple locale, the surgeon delineates the remaining skin incisions of the correction, while maintaining the inferior limit of the vertical-incision at a distance above the pre-operative IMF, which precaution avoids extending the surgical scar to the chest wall after the lifting of the breast and the inframammary fold.
Intra-operative matters
Pedicles — superior, inferior, and medial
Although the aforementioned descriptions are of the incisions used to address the breast skin envelope, the surgical management of the breast tissue (parenchyma) is a separate consideration, including maintenance of the neurovascular integrity of the nipple-areola complex (NAC). The degree of hemispheric elevation of the NAC determines the type of pedicle (superior, inferior, medial) that will provide the best venous
and arterial
vascular supply to the NAC. Therefore, the application of the superior pedicle approach affords the surgeon greater procedural flexibility in determining the incision site for emplacing the breast implant, but it limits the possible degree of elevation of the nipple. Application of the inferior pedicle approach affords a greater degree of NAC elevation, but makes difficult emplacing the breast implant, and the subsequent contouring of the breast. Application of the medial pedicle approach preserves breast sensation with a reliable venous and arterial vascular supply, and avoids the technical and procedural limitations of the superior pedicle and the inferior pedicle approaches.
Post-operative matters
Complications
General medical complications of mastopexy include bleeding
, infection
, and the secondary effects of the anaesthesia. Specific complications include skin necrosis
, and dysesthesia
, abnormal changes in sensation (numbness and tingling). Serious medical complications include occurrences of seroma
, a pocket of locally accumulated serous fluid
, and occurrences of hematoma
, a local accumulation of blood outside the vascular system. Necrosis of the nipple and necrosis of the skin flap (or both), when it occurs, can either be partial, and heal imperceptibly with wound care, or can be complete, and necessitate reconstruction. A complication of the Anchor mastopexy is the tension-caused wound breakdown at the junction of the three limbs of the incision, yet the scars usually heal without undergoing hypertrophy. Asymmetry of the bust is usually present pre-operatively, and the breast-lift surgery usually does not definitively eliminate it, regardless of the applied mastopexy technique or of the plastic surgeon’s operative expertise. Moreover, a combined mastopexy–breast augmentation procedure can make the surgical revision of breast asymmetry more difficult because of the over-stretched tissues of nipple-areola complex. Moreover, a possible, undesirable outcome of the periareolar mastopexy (circumareolar incision) is the under-projection of the corrected breast from the chest wall.
To realize a breast lift using the medial pedicle technique, the surgeon delineates the incision plan upon the breasts, chest, and torso of the woman:
Operative technique
Incision plan — After delineating the surgical incision-plan that establishes a technically reliable central axis of the front torso, and before cutting into the breast(s), the plastic surgeon confirms the topographic
accuracy of the delineated incision plan, by triangulating the measures at the upper sternum and at the umbilicus, and modifying the incisional lines, if required. Afterwards, the surgical incision lines are infiltrated to the breast skin with a local anaesthetic mixture (lidocaine
1.0% and epinephrine
1:100,000) that constricts the pertinent vascular system to limit bleeding.
Pedicle skin-flap — After establishing the dimensions of the new nipple-areola complex (NAC), the surgeon de-epithelializes the medial pedicle skin-flap that provides the venous-arterial vascular system for the NAC. The first incisions are through the parenchymal tissue, and separate the medial pedicle. The incision is effected to avoid undercutting the skin pedicle and so preserve the NAC blood-supply vessels. Hence, the tissue volume of the pedicle flap is essential for establishing the adequate projection of the upper pole of the breast, where the breast originates from the chest. The surgeon resects (cuts and removes) an almost-triangular segment of tissue below the medial pedicle. Finally, for emplacing the NAC, the incisions are completed by cutting the ellipse and the tissue adjacent to the medial pedicle.
If the incisions to the breast are satisfactory, the patient’s homeostasis
is feasible at that juncture of the mastopexy operation. The surgeon then evaluates the tissue-thickness of the medial pedicle flap, and its physical capability for rotating in a superomedial direction (above and to the center) with no resultant torsion tension to the tissue of the inferior portion of the pedicle; afterwards, the surgeon reduces the tissue thickness of the skin pedicle. Once positioned superiorly, the pedicle tissue thickness is reviewed to ascertain that it fits into the new position, without undue pressure or constriction; thus are assured the tissue viability
of the medial pedicle and of the nipple-areola complex.
Symmetry — The critical procedural step in forming the new breast is the collecting and the joining of the three folds of breast tissue (the medial pillar and the two lateral pillars) of the lower pole of the breast, where it meets the chest. The suturing is critical to supporting and shaping the flaccid breast tissues into a hemispheric breast-mound that well projects from the chest wall — a lifted breast. The supine patient then is elevated to a sitting position so that the breasts drape naturally, and the surgeon then delineates upon them the incision plan for the resection (cutting and removing) of the excess folds of skin from the lower sides (inferolateral) and the lower midline (inferomedial) of the new breast. Afterwards, the patient is laid supine, and the excess breast skin is cut; to avoid a scar
at the inframammary fold, a purse-string closure gathers the excess folds of skin at the lower pole of the breast; in due course, the three joined pillars of skin will integrate to the inframammary fold. Again, the supine patient is elevated to a sitting position so that the surgeon can ascertain the size, shape, and symmetry, or asymmetry, of the corrected breasts. If the degree of breast-lift is satisfactory, the patient is re-laid to the operating table, and the plastic surgeon sutures the incision wounds.
Post-operative matters
Complications
The B mastopexy (breast lift) is a variation of the circumvertical approach that features an inverted, upper-case letter-B incision, which, when performed with simultaneous breast augmentation
via submuscular or subglandular implantation of the breast prosthesis, restores the natural contour and appearance of the breasts. Moreover, the B mastopexy technique can procedurally include the simultaneous microliposuction to reduce the lateral parenchyma
l and adipose tissues in order to achieve the correct size, volume, and contour of the corrected breasts. The B mastopexy can correct several types of breast deformity, every form of breast ptosis
, and breast hypertrophy
; it usually has low incidence rates of hypertrophic scar
ring, and of loss of sensation in the nipple-areola complex; furthermore, the B mastopexy technique also applies to reduction mammoplasty, the correction of over-sized breasts.
The technical and procedural efficacy of the B-technique mastopexy was established in Clinical Techniques: B Mastopexy: Versatility and 5-Year Experience (2007), a retrospective study of a 40-woman mammoplasty
cohort upon whom were performed 13 breast-lift procedures without breast augmentation, and 27 procedures with simultaneous breast augmentation
, using a medium-sized breast implant. The cohort reported no medical complications, only one (1) woman underwent scar-revision surgery; and each of the 40 women was satisfied with her mastopexy outcome.
Surgical consultation — The plastic surgeon explains the technical and aesthetic considerations of the breast lift operation to the woman. That the B technique mastopexy yields improved aesthetic results with a breast-skin pedicle created with a curvilinear incision (an inverted, upper-case letter-B). That said curvilinear incision technique eliminates the medial vertical incision of the Anchor mastopexy, and so creates a lifted bust with breasts of natural size, appearance, and contour, and few surgical scars. The consultation includes detailed, pre-operative, post-operative, and healing-stage photographs that illustrate the nature and extent of the mastopexy incisions and the resultant scars. That the full healing (scar maturation) might require approximately one (1) year to establish the final contour of the lifted breasts, after the suspensory ligaments
and the parenchymal tissue
have settled into and upon the chest as an aesthetically satisfactory bust of natural size, appearance, and contour.
Pre-operative matters
To the standing patient, the plastic surgeon delineates the mastopexy incision-plan to the chest, breasts, and torso of the woman. The distance from the suprasternal notch (atop the sternum) to the nipple is measured and recorded to the medical record; the level of the inframammary fold is identified and delineated to the front of the breast (anterior aspect), which indicates the elevated locale to which the nipple-areola complex will be transposed. The medial aspect of the new NAC locale is marked approximately 10–11 cm from the midline, along the mid-breast; and a semicircle with a 38-mm-diameter is delineated around the nipple; the distance of the semicircle from the ptotic NAC indicates the new locale of the nipple-areola complex upon the breast hemisphere.
Operative technique
Incision plan — With the patient laid supine upon the operating table, the surgeon performs a free-hand, curvilinear delineation of an inverted, upper-case letter-B pattern to the breast. Then, per the landmarks of the initial incision-plan, a semicircular pattern is delineated around the nipple-areola complex. The vertical and horizontal component-incisions of the B mastopexy are created with a tapering, curvilinear incision that begins from the lower margin of the areola to the lateral crease of the breast. The B-pattern incision results in a vertical closure 5–7 cm long, from the bottom margin of the nipple-areola complex to the inframammary fold.
Wound closure — The surgeon tests the closure tension of the wound sutures by in-folding the breast over the index finger, and towards the transposed NAC, to observe if the skin blanches (whitens) or over-stretches, afterwards, the NAC-area dermis is de-epithelialized. In the combined mastopexy–augmentation procedure, wherein the breast prosthesis is emplaced to a submuscular implant pocket, an anaesthetic tumescent solution is injected along the marked incision line. When the breast implant will be emplaced to a subglandular implant pocket, the hypodermic needle penetrates un-resisted into the anatomic plane above the pectoralis major muscle; the tumescent solution anaesthesia allows blunt dissection. After establishing anaesthesia, the surgeon de-epithelializes each edge of skin by undermining it 3–4 mm, with a razor scalpel, thereby facilitating the closing of the surgical wound without tight sutures. In a mastopexy–augmentation, the breast-implant pocket (locale) determines when the surgeon performs the de-epithelialization of the B pedicle; for submuscular implantation, the skin pedicle de-epithelialization is performed after the emplacement; for subglandular implantation, the skin pedicle de-epithelialization is performed before the emplacement.
If the mastopexy includes simultaneous breast augmentation with submuscular emplacement, the surgeon observes that the pectoralis major muscle
is divided from the sternum and the ribs. After cutting the implant pocket, the surgeon then de-epithelializes the B-pedicle. To facilitate the dermal closure (joining the wound edges) with minimal tension to the sutures, the breast implant either is displaced up, into the implant pocket, or is partially deflated. For the subglandular emplacement of breast implants, the technique is different; the de-epithelialization of the pedicle dermis is performed initially, after which an incision is made through the de-epithelialized dermis, at the base of the vertical limb of the mastopexy, and then, by means of blunt dissection, an implant pocket is cut above the pectoralis major muscle.
Symmetry — During the dermal closure, the nipple-areola complex (NAC) is transposed to its new locale, as determined by the skin pedicle. To create the curvilinear scar, the deep dermal closure is accomplished by rotating the lateral flap down and then medially. The deep dermis is approximated (joined) with sutures, in a simple, interrupted fashion. The key suture is emplaced at the junction where the apex of the vertical incision meets the NAC — because it is the skin area of the breast subject to the greatest tension(s). The subcutaneous dermal closure is effected with interrupted sutures. As required, the final adjustments before suturing the skin closed, might include either micro-liposuction or additional de-epithelialization. After the dermal closure, a suture is emplaced to achieve the continuous approximation of the nipple-areola complex to the adjacent skin edge, and to the lower skin incisions.
Post-operative matters
Convalescence — Post-operative care is minimal after a mastopexy procedure; the lifted breasts are supported with a porous, soft elastic tape, which is removed at 7–10 days post-operative, and then is reapplied to the mastopexy incisions for an additional 1–2 weeks during convalescence. For comfortable healing of the wounds, the woman wears a surgical brassière, and avoids wearing an underwire brassière until the breast implants have settled into position. The mastopexy outcome is photographed at 2–3 months post-operative.
Mastopexy technique observations
Mastopexic correction results in surgical scars on the lifted breasts; the periareolar mastopexy outcome often is a breast of bottom-heavy appearance, with puckered surgical scars; and the Anchor mastopexy outcome is an aesthetic breast of natural size, look, and feel, but with many scars. Whereas, advocates of the mechanical principle of the B technique mastopexy propose that the creation of a rotational pedicle (with an elevated epidermal flap that rotates around the NAC), lifts the breasts with an incision plan with vertical and horizontal incisions that eliminate the medial incision (and its vertical scar), whilst providing good projection of the corrected bust from the chest, and a viable nipple-areola complex. Furthermore, advocates of the B technique mastopexy report that it usually does not require secondary correction, because it allows for the better transposition of excess lateral tissues of the breasts by means of curvilinear incision (inverted, upper-case, letter-B) to the skin envelope.
Mammoplasty
Mammoplasty or mammaplasty can refer to the surgical procedure to insert cheek implants or augmentation mammoplasty, an enlarging of the breasts via implants...
procedure for correcting the size, contour, and elevation of sagging breasts upon the chest. In a breast lift surgery to re-establish an aesthetically proportionate bust
Cleavage (breasts)
Cleavage, anatomically known as the intramammary cleft, is the space between a woman's breasts lying over the sternum. Cleavage is exposed by a garment with a low neckline, such as ball gowns, evening gowns, swimwear, casual tops and other garments....
for the woman, the critical corrective consideration is the (histologic) tissue viability
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
of the nipple-areola complex
Areola
This article is about the breast tissue. For the entomology term, see the glossary of Lepidopteran terms. For an artistic cloud motif, see aureola. For the cactus feature, see Areole....
(NAC) to ensure the functional sensitivity of the breasts for lactation
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
and breast-feeding. The indications for mastopexic correction of breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
are three-fold — physical, aesthetic, and psychological — the restoration of the bust, of the woman’s self-image, and of her mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
. In corrective surgical praxis, mastopexy can be performed as a discrete breast lift procedure, and as a sub-ordinate surgery within a combined mastopexy–breast augmentation procedure; moreover, mastopexy surgery techniques also are applied to reduction mammoplasty
Breast reduction
Reduction mammoplasty is the plastic surgery procedure for correcting over-sized breasts...
, the correction of over-sized breasts.
The patient
The mastopexy patient usually is a woman who requires the restoration of her bust (elevation, size, and contour) after the postpartum loss of tissue volume, and the occurrence of breast ptosis; her clinical indications — the degree of laxness of the suspensory Cooper’s ligamentsCooper's ligaments
Cooper's ligaments are connective tissue in the breast that help maintain structural integrity.Transmission diffraction tomography can reveal the anatomy....
and of the breast skin envelope (mild, moderate, severe, and pseudo ptosis) — determine the applicable surgical approach for lifting the breasts; for example, mild ptosis can be corrected solely with breast augmentation
Breast augmentation
Breast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
. Moreover, the usual breast-lift techniques, featuring circumvertical and horizontal surgical incisions, such as the periareolar incision mastopexies — the Anchor pattern, the inverted-T incision, the lollipop pattern — each produce a scar at the periphery (edge) of the nipple-areola complex (NAC), and a descending vertical scar from the inferior margin of the NAC to the horizontal scar in the inframammary fold (IMF) where the breast hemisphere meets the chest; thus, surgical scars upon the breast hemisphere are the aesthetically disadvantageous outcome of mastopexy correction.
Breast ptosis
EtiologyThe law of gravity
Gravitation
Gravitation, or gravity, is a natural phenomenon by which physical bodies attract with a force proportional to their mass. Gravitation is most familiar as the agent that gives weight to objects with mass and causes them to fall to the ground when dropped...
of the Earth is the factor most common to the incidence of breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
, the prolapsation
Prolapse
Prolapse literally means "to fall out of place", from the Latin prolabi meaning "to fall out". In medicine, prolapse is a condition where organs, such as the uterus, fall down or slip out of place. It is used for organs protruding through the vagina or the rectum or for the misalignment of the...
— falling forward and sagging of the mammary gland tissues (glandular
Mammary gland
A mammary gland is an organ in mammals that produces milk to feed young offspring. Mammals get their name from the word "mammary". In ruminants such as cows, goats, and deer, the mammary glands are contained in their udders...
, adipose, skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
) from the chest. In the young woman with large breasts
Cleavage (breasts)
Cleavage, anatomically known as the intramammary cleft, is the space between a woman's breasts lying over the sternum. Cleavage is exposed by a garment with a low neckline, such as ball gowns, evening gowns, swimwear, casual tops and other garments....
the sagging occurs because of the volume and weight of a bodily disproportionate bust, and the elasticity of the thin, young skin envelope of each breast. In the middle-aged woman, breast ptosis usually is a consequence of postpartum hormonal
Hormone
A hormone is a chemical released by a cell or a gland in one part of the body that sends out messages that affect cells in other parts of the organism. Only a small amount of hormone is required to alter cell metabolism. In essence, it is a chemical messenger that transports a signal from one...
changes to the maternal body after the depleted milk glands
Lactiferous duct
Lactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
atrophy, and of the inelasticity of the skin envelope, which was over-stretched by the engorgement of lactation
Lactation
Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process occurs in all female mammals, however it predates mammals. In humans the process of feeding milk is called breastfeeding or nursing...
. In the post-menopausal
Menopause
Menopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...
woman, besides Earthly gravity, such breast atrophy is aggravated by the inelasticity of over-stretched, aged skin.
Pathophysiology and presentation
In the course of a woman’s life, her breasts change as the skin envelope becomes inelastic, and the suspensory ligaments
Cooper's ligaments
Cooper's ligaments are connective tissue in the breast that help maintain structural integrity.Transmission diffraction tomography can reveal the anatomy....
— which suspend the mammary gland
Mammary gland
A mammary gland is an organ in mammals that produces milk to feed young offspring. Mammals get their name from the word "mammary". In ruminants such as cows, goats, and deer, the mammary glands are contained in their udders...
against the chest — become loose, and so cause the prolapsation
Prolapse
Prolapse literally means "to fall out of place", from the Latin prolabi meaning "to fall out". In medicine, prolapse is a condition where organs, such as the uterus, fall down or slip out of place. It is used for organs protruding through the vagina or the rectum or for the misalignment of the...
, the falling forward and sagging, of the breast and the nipple-areola complex (NAC). Moreover, postpartum involution (diminishment) of the voluminous milk glands
Lactiferous duct
Lactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
in the breast aggravates the looseness of the suspensory ligaments and of the inelastic skin envelope. The breast lift procedure surgically corrects said physical changes by elevating the parenchymal tissue
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
, cutting and re-sizing the skin envelope, and transposing the nipple-areola complex higher upon the breast hemisphere.
The degree of mammary gland
Mammary gland
A mammary gland is an organ in mammals that produces milk to feed young offspring. Mammals get their name from the word "mammary". In ruminants such as cows, goats, and deer, the mammary glands are contained in their udders...
prolapse (breast ptosis) is determined with the modified Regnault ptosis grade scale:
- Pseudoptosis — Sagging of the lower half (inferior pole) of the breast, with the nipple located either at or above the inframammary fold (IMF); false ptosis is usual to postpartum milk-gland atrophy.
- Grade I: Mild ptosis — The nipple is located below the IMF, but remains located above the lower pole of the breast.
- Grade II: Moderate ptosis — The nipple is located below the IMF; yet some lower-pole breast tissue hangs lower than the nipple.
- Grade III: Severe ptosis — The nipple is far below the inframammary fold, and there is no lower-pole breast tissue below the nipple.
Surgical anatomy of the breast
The procedureThe breast lift correction of a sagging bust (breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
) cuts excess tissues (glandular
Lactiferous duct
Lactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
, adipose, skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
), over-stretched suspensory ligaments
Cooper's ligaments
Cooper's ligaments are connective tissue in the breast that help maintain structural integrity.Transmission diffraction tomography can reveal the anatomy....
, excess skin from the skin envelope, and transposes the nipple-areola complex (NAC) higher upon the breast hemisphere.
Composition
Surgically, the breast is an apocrine gland
Apocrine
Apocrine is a term used to classify exocrine glands in the study of histology. Cells which are classified as apocrine bud their secretions off through the plasma membrane producing membrane-bound vesicles in the lumen. This method is also called decapitation secretion...
overlaying the chest — attached at the nipple and suspended with ligaments from the chest — which is integral to the skin, the body integument
Integumentary system
The integumentary system is the organ system that protects the body from damage, comprising the skin and its appendages...
of the woman. The dimensions and weight of the breasts vary with her age and habitus (body build and physical constitution); hence small-to-medium-sized breasts weigh approximately 500 gm or less, and large breasts weigh approximately 750–1,000 gm. Anatomically, the breast topography
Superficial anatomy
Superficial anatomy is a descriptive science dealing with anatomical features that can be studied by sight, without dissecting an organism...
and the hemispheric locale of the nipple-areola complex (NAC) are particular to each woman; thus, the desirable, average measurements are a 21–23 cm sternal distance (nipple to sternum-bone notch), and a 5–7 cm inferior-limb distance (NAC to IMF).
The arterial blood
Arterial blood
Arterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...
supply of the breast has medial and lateral vascular components; it is supplied with blood by the internal mammary artery
Internal thoracic artery
In human anatomy, the internal thoracic artery , previously known as the internal mammary artery , is an artery that supplies the anterior chest wall and the breasts...
(from the medial aspect), the lateral thoracic artery (from the lateral aspect), and the 3rd, 4th, 5th, 6th, and 7th intercostal perforating arteries
Intercostal arteries
The intercostal arteries are a group of arteries that supply the area between the ribs , called the intercostal space.* Highest intercostal artery - first and second intercostal spaces...
. Drainage of venous blood
Venous blood
Venous blood is deoxygenated blood in the circulatory system. It runs in the systemic veins from the organs to the heart. Deoxygenated blood is then pumped by the heart to lungs via the pulmonary arteries, one of the few arteries in the body that carries deoxygenated blood .Venous blood is...
from the breast is by the superficial vein system under the dermis
Dermis
The dermis is a layer of skin between the epidermis and subcutaneous tissues, and is composed of two layers, the papillary and reticular dermis...
, and by the deep vein system parallel to the artery system. The primary lymph
Lymphatic system
The lymphoid system is the part of the immune system comprising a network of conduits called lymphatic vessels that carry a clear fluid called lymph unidirectionally toward the heart. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated...
drainage system is the retromammary lymph plexus in the pectoral fascia
Pectoral fascia
The pectoral fascia is a thin lamina, covering the surface of the Pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and below it is continuous with the fascia of the...
. Sensation in the breast is established by the peripheral nervous system innervation
Peripheral nervous system
The peripheral nervous system consists of the nerves and ganglia outside of the brain and spinal cord. The main function of the PNS is to connect the central nervous system to the limbs and organs. Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the blood–brain...
of the anterior and lateral cutaneous branches of the 4th, 5th, and 6th intercostal nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...
s, and thoracic spinal nerve 4
Thoracic spinal nerve 4
The thoracic spinal nerve 4 is a spinal nerve of the thoracic segment..It originates from the spinal column from below the thoracic vertebra 4 ....
(T4 nerve) innervates and supplies sensation to the nipple-areola complex.
Mechanical structures of the breast
In realizing the breast lift, the mastopexic correction takes anatomic and histologic account of the biomechanical, load-bearing properties of the three (3) tissue types (glandular
Mammary gland
A mammary gland is an organ in mammals that produces milk to feed young offspring. Mammals get their name from the word "mammary". In ruminants such as cows, goats, and deer, the mammary glands are contained in their udders...
, adipose, skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
) that compose and support the breast; among the properties of the soft tissues of the breast is near-incompressibility (Poisson’s ratio of ∼0.5).
- Rib cage. The 2nd, 3rd, 4th, 5th, and 6th ribs of the thoracic cage are the structural supports for the mammary glands.
- Chest muscles. The breasts lay upon the pectoralis major musclePectoralis major muscleThe pectoralis major is a thick, fan-shaped muscle, situated at the chest of the body. It makes up the bulk of the chest muscles in the male and lies under the breast in the female...
, the pectoralis minor musclePectoralis minor muscleThe pectoralis minor is a thin, triangular muscle, situated at the upper part of the chest, beneath the pectoralis major.-Origin and insertion:...
, and the intercostal muscles (between the ribs), and can extend to and cover a portion of the (front) anterior serratus muscle (attached to the ribs, the rib muscles, and the shoulder blade), and to the rectus abdominis muscle (a long, flat muscle extending up the torso, from pubic bone to rib cage). The body posture of the woman exerts physical stresses upon the pectoralis major muscles and the pectoralis minor muscles, which cause the weight of the breasts to induce static and dynamic shear forces (when standing and when walking), compression forces (when lying supine), and tension forces (when kneeling on four limbs). - Pectoralis fascia. The pectoralis major muscle is covered with a thin superficial membrane, the pectoral fasciaPectoral fasciaThe pectoral fascia is a thin lamina, covering the surface of the Pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and below it is continuous with the fascia of the...
, which has many prolongations intercalated among its fasciculi (fascicles); at the midline, it is attached to the front of the sternumSternumThe sternum or breastbone is a long flat bony plate shaped like a capital "T" located anteriorly to the heart in the center of the thorax...
, above it is attached to the clavicleClavicleIn human anatomy, the clavicle or collar bone is a long bone of short length that serves as a strut between the scapula and the sternum. It is the only long bone in body that lies horizontally...
(collar bone), while laterally and below, it is continuous with the fascia. - Suspensory ligaments. The subcutaneous layer of adipose tissueAdipose tissueIn histology, adipose tissue or body fat or fat depot or just fat is loose connective tissue composed of adipocytes. It is technically composed of roughly only 80% fat; fat in its solitary state exists in the liver and muscles. Adipose tissue is derived from lipoblasts...
in the breast is traversed with thin suspensory ligaments (Cooper's ligamentsCooper's ligamentsCooper's ligaments are connective tissue in the breast that help maintain structural integrity.Transmission diffraction tomography can reveal the anatomy....
) that extend obliquely to the skin surface, and from the skin to the deep pectoral fasciaPectoral fasciaThe pectoral fascia is a thin lamina, covering the surface of the Pectoralis major, and sending numerous prolongations between its fasciculi: it is attached, in the middle line, to the front of the sternum; above, to the clavicle; laterally and below it is continuous with the fascia of the...
. The structural stability provided by the Cooper’s ligaments derives from its closely packed bundles of collagenCollagenCollagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
fibers oriented in parallel; the principal, ligament-component cell is the fibroblastFibroblastA fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework for animal tissues, and plays a critical role in wound healing...
, interspersed throughout the parallel collagen-fiber bundles of the shoulder, axilla, and thoraxThoraxThe thorax is a division of an animal's body that lies between the head and the abdomen.-In tetrapods:...
ligaments. - Glandular tissue. As a mammary gland, the breast comprises lobules (milk glands at each lobe-tip) and the lactiferous ductLactiferous ductLactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
s (milk passages), which widen to form an ampulla (sac) at the nipple. - Adipose tissue. The fat tissue of the breast is composed of lipidic fluidLipidLipids constitute a broad group of naturally occurring molecules that include fats, waxes, sterols, fat-soluble vitamins , monoglycerides, diglycerides, triglycerides, phospholipids, and others...
(60–85% weight) that is 90–99 per cent triglycerides, free fatty acids, diglycerides, cholesterol phospholipids, and minute quantities of cholesterolCholesterolCholesterol is a complex isoprenoid. Specifically, it is a waxy steroid of fat that is produced in the liver or intestines. It is used to produce hormones and cell membranes and is transported in the blood plasma of all mammals. It is an essential structural component of mammalian cell membranes...
esterEsterEsters are chemical compounds derived by reacting an oxoacid with a hydroxyl compound such as an alcohol or phenol. Esters are usually derived from an inorganic acid or organic acid in which at least one -OH group is replaced by an -O-alkyl group, and most commonly from carboxylic acids and...
s, and monoglycerides; the other components are water (5–30% weight) and protein (2–3% weight). - The skin envelope. The breast skin is in three (3) layers: (i) the epidermis, (ii) the dermisDermisThe dermis is a layer of skin between the epidermis and subcutaneous tissues, and is composed of two layers, the papillary and reticular dermis...
, and (iii) the hypodermisHypodermisThe hypodermis, also called the hypoderm, subcutaneous tissue, or superficial fascia is the lowermost layer of the integumentary system in vertebrates. Types of cells that are found in the hypodermis are fibroblasts, adipose cells, and macrophages...
. The epidermis is 50–100 µm thick, and is composed of a stratum corneumStratum corneumThe stratum corneum is the outermost layer of the epidermis, consisting of dead cells that lack nuclei and organelles. The purpose of the stratum corneum is to form a barrier to protect underlying tissue from infection, dehydration, chemicals and mechanical stress...
of flat keratinKeratinKeratin refers to a family of fibrous structural proteins. Keratin is the key of structural material making up the outer layer of human skin. It is also the key structural component of hair and nails...
cells, that is 10–20 µm thick; it protects the underlying viable epidermis, which is composed of keratinizing epithelial cellsEpitheliumEpithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands. Functions of epithelial cells include secretion, selective...
. The dermis is mostly collagenCollagenCollagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
and elastinElastinElastin is a protein in connective tissue that is elastic and allows many tissues in the body to resume their shape after stretching or contracting. Elastin helps skin to return to its original position when it is poked or pinched. Elastin is also an important load-bearing tissue in the bodies of...
fibers embedded to a viscous water and glycoproteinGlycoproteinGlycoproteins are proteins that contain oligosaccharide chains covalently attached to polypeptide side-chains. The carbohydrate is attached to the protein in a cotranslational or posttranslational modification. This process is known as glycosylation. In proteins that have segments extending...
medium. The fibers of the upper dermis (“papillary dermis”) are thinner than the fibers of the deep dermis, thus the skin envelope is 1–3 mm thick. The thickness of the hypodermis (adipocyte cells) varies from woman to woman, and body part.
Surgical procedures
IndicationsThe surgeon–physician evaluates the woman requesting a breast-lift operation, to ascertain that she understands the health risks and benefits of the mastopexy; and that her ideal body image
Body image
Body image refers to a person's perception of the aesthetics and sexual attractiveness of their own body. The phrase body image was first coined by the Austrian neurologist and psychoanalyst Paul Schilder in his masterpiece The Image and Appearance of the Human Body...
(aesthetic goal) corresponds to what can be realistically achieved with the surgical correction of breast ptosis:
- The correction of sagging breasts, which prolapsed (fell forward) consequent to postpartum milk glandLactiferous ductLactiferous ducts lead from the lobules of the mammary gland to the tip of the nipple. They are also referred to as galactophores, galactophorous ducts, mammary ducts, mamillary ducts and milk ducts...
diminishment, menopauseMenopauseMenopause is a term used to describe the permanent cessation of the primary functions of the human ovaries: the ripening and release of ova and the release of hormones that cause both the creation of the uterine lining and the subsequent shedding of the uterine lining...
, gross weight-loss, et cetera. - The correction of post-explantation ptosis, the sagging of the inelastic skin envelopes, once emptied of the breast implants.
- The treatment of congenital ptosis and pseudoptosis, as observed in conditions such as tuberous breast deformityTuberous breast deformityTuberous breasts are a result of a congenital breast deformity or abnormality which can occur in both men and women . During puberty breast development is stymied and the breasts fail to develop normally and fully. The exact cause of this is as yet unclear...
(constricted breast). - The management of acquired or relative ptosis, as seen in the post-mastectomyMastectomyMastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. Mastectomy is usually done to treat breast cancer; in some cases, women and some men believed to be at high risk of breast cancer have the operation prophylactically, that is, to prevent cancer...
breast reconstructionBreast reconstructionBreast reconstruction is the rebuilding of a breast, usually in women. It involves using autologous tissue or prosthetic material to construct a natural-looking breast. Often this includes the reformation of a natural-looking areola and nipple...
of a bustCleavage (breasts)Cleavage, anatomically known as the intramammary cleft, is the space between a woman's breasts lying over the sternum. Cleavage is exposed by a garment with a low neckline, such as ball gowns, evening gowns, swimwear, casual tops and other garments....
that is of natural and proportionate size, look, and feel.
I. — Mastopexy of the sagging breast
The following descriptions of the full breast-lift and of the modified breast-lift techniques are limited to the surgical incisions used to address the skin envelope of the breast, not the internal parenchyma
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
, the substance of the breast.
A. — Full breast lift
The sagging bust is lifted using the circumvertical- and horizontal-incision plan of the Anchor mastopexy (also Lexer pattern, inverted-T incision, Wise pattern, inferior pedicle), which features three incisons:
- the Anchor ring: a circular incision at the upper-edge of the periphery of the nipple-areola complexAreolaThis article is about the breast tissue. For the entomology term, see the glossary of Lepidopteran terms. For an artistic cloud motif, see aureola. For the cactus feature, see Areole....
(NAC). - the Anchor shank: a vertical incision from the lower edge of the NAC to the inframammary-fold incision (IMF).
- the Anchor stock: a horizontal incision along the IMF (inframammary fold), where the breast joins the chest.
In cutting the folds of excess skin from the sagging, inelastic skin-envelope of the breast (and occasionally reducing the NAC diameter), the three-incision technique of the Anchor mastopexy allows maximal corrections to the breasts, thereby producing an elevated bust with breasts of natural size, look, and feel. Moreover, each of the three scars to the breast hemisphere produced by the Anchor-pattern mastopexy has a characteristic healing pattern:
- at the periareolarAreolaThis article is about the breast tissue. For the entomology term, see the glossary of Lepidopteran terms. For an artistic cloud motif, see aureola. For the cactus feature, see Areole....
area — the edge of the NAC — the surgical scar is concealed by the light-to-dark skin color at the pigmentPigmentA pigment is a material that changes the color of reflected or transmitted light as the result of wavelength-selective absorption. This physical process differs from fluorescence, phosphorescence, and other forms of luminescence, in which a material emits light.Many materials selectively absorb...
transition, where the light-color breast skin becomes the dark-color areola skin (the ring of the Anchor pattern) - the medial vertical scar (the shank of the Anchor pattern) extends from the lower edge of the nipple-areola complex to the inframammary fold; the shadow of the breast hemisphere hides it
- the horizontal scar (the stock of the Anchor pattern), which follows, and is hidden in, the inframammary fold.
Post-surgically, of these three breast-lift surgery scars, the scar to the inframammary fold exhibits the greatest tendency to hypertrophy, to thickness and large size. Although the coloration of mastopexy scars fades with the full maturation of the tissues, they do remain visible.
B. — Modified breast lift
The incision plans of the techniques for modified breast lift feature fewer cuts and fewer scars, but limit the plastic surgeon by allowing fewer changes to the skin envelope of the breast. In surgical praxis
Praxis
Praxis is the putting of theory into practice. The term may refer to:* Christian theological praxis* Praxis , the practice of faith, especially worship* The Praxis School, a school of Marxist philosophy...
, the modified breast lift often is a sub-ordinate surgery within a mastopexy–breast augmentation procedure, the simultaneous lifting and enlarging the bust. Moreover, these incisions are applied to correct the ptosis discussed above; some technical variants of the modified breast lift are:
- the periareolar lift (crescent lift), featuring a crescent-shaped incision, above and at a variable portion of the NAC perimeter, allows the cutting and removal of a crescent of flesh, thereby facilitates the elevation (transposition) of the nipple-areola complex to its higher (new) locale upon the breast hemisphere.
- the circumareolar lift (Benelli breast lift, donut lift), featuring the cutting out of a concentric ring of flesh from around the nipple-areola complex, limits the size and diameter of the circular scar.
- the circumvertical lift (lollipop lift, vertical scar), featuring a circumareolar incision, around the circumference of the nipple-areola complex, and a vertical incision from the lower edge of the NAC periphery to the inframammary fold.
II. — Mastopexy of the augmented breast
Women who have undergone breast augmentation
Breast augmentation
Breast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
also are susceptible to breast ptosis; which incidence might be induced by the physical and mechanical stresses exerted by the breast implants upon the internal tissues and the skin envelope; such over-stretching thins the skin and atrophies its elastic qualities. Statistically, breast augmentation and mastopexy are plastic surgery operations with low incidence rates of medical complications; yet, when performed as a combined breast-repair procedure (mastopexy–augmentation), the physiologic stresses upon the health of the woman increase the risks of incision-wound infection, breast-implant exposure, damage to the breast and nipple nerves, malposition of the nipple-areola complex, and malposition of the breast implant in the implant pocket. Therefore, a mastopexy–augmentation procedure features increased surgical complication rates, when compared to the lesser complication rates of breast augmentation
Breast augmentation
Breast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
and mastopexy as discrete surgical operations; likewise, the individual incidence rates of surgical revision and complications, when compared to the revision and complication rates for the combined mastopexy–augmentation procedure. Recent studies of a newer technique for simultaneous augmentation mastopexy (SAM) indicate that it is a safe surgical procedure with minimal medical complications. The SAM technique involves invaginating and tacking the tissues first, in order to previsualize the final result, before making any surgical incisions to the breast.
Contraindications
The contraindications for mastopexy are few: aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
use, tobacco smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...
, diabetes, and obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
are medical and health conditions associated with increased incidences of nipple necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
. In resolving the perceived ptosis of a woman with encapsulated
Capsular contracture
Capsular contracture is an abnormal response of the immune system to foreign materials in the human body. Medically, it occurs mostly in context of the complications from breast implants and artificial joint prosthetics....
breast implants, the surgeon determines her suitability for a breast lift procedure after explantation, which facilitates assessment of the true degree of ptosis present in the explanted breasts; likewise the assessment of the effects of a combined breast-lift and revision-augmentation procedure, featuring the removal and the replacement of breast implants. For the woman who is at high risk for developing breast cancer
Breast cancer
Breast cancer is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas...
(primary or recurrent), the mastopexy might alter the histologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
architecture of the breasts, which tissue change might interfere with the accurate MRI detection and subsequent treatment of cancer; the risks and benefits will be discussed in that setting.
General
In realizing a breast lift, a conservative surgical technique produces the fewest, least visible scarScar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
s after excising (cutting) excess folds of skin from the skin-envelope, when either replacing or rearranging or augmenting
Breast augmentation
Breast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
the internal breast tissues (parenchyma
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
l and adipose). Breast lift techniques are known according to the number of scars produced, which is related to the achievable degree of breast-lift. Pre-operatively, the patient and the surgeon decide upon the appropriate surgical technique (superior, medial, or inferior pedicle) that will achieve the best degree of breast lift. Generally, breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
(sagging) is determined by the locale of the nipple-areola complex (NAC) upon the breast; the lower the NAC, the greater the degree of breast prolapsation (ptosis). Nonetheless, in breast-lift surgery, the primary consideration is the tissue viability
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
of the nipple-areola complex, so that the outcome is a functionally sensate breast of natural size, contour, and feel.
A. The surgical management of breast ptosis is by degree of severity
- Grade I: Mild breast ptosis, which can be corrected with breast implant augmentationBreast augmentationBreast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
, or with a periareolar skin resection (crescent lift), with or without breast augmentation.
- Grade II: Moderate ptosis, which can be corrected with a circumareolar donut mastopexy technique featuring Benelli cerclage suturing; and with circumvertical-incision (lollipop mastopexy) techniques such as the Regnault B Mastopexy and the Lejour–Lassus breast reduction.
- Grade III: Severe ptosis, which usually can be corrected with the circumvertical and horizontal incisions of the Anchor mastopexy (inverted-T incision), regardless of the type of pedicle used (inferior or superior).
B. Pseudoptosis — false breast prolapse can be addressed two ways
- With a breast augmentation, or with a skin excision, or with both procedures; and without transposing the nipple-areola complex, which requires cutting the skin of the lower pole of the breast.
- With the circumareolar suturing that encircles the nipple-areola complex. To achieve the desired degree of breast lift in accordance with the woman’s anatomy, the circumareolar mastopexy technique (circumvertical lift) can be modified with an additional vertical incision. The extra skin-envelope tissue remaining after a vertical-incision technique can either be gathered in a series of pleats, along the vertical limb of the incision, or can be resected, cut and removed, at the inframammary fold, thereby producing a horizontal incision of varying length, as in the circumvertical and horizontal breast lift.
Mastopexy procedure
Pre-operative matters
The plastic surgeon delineates the mastopexy incision-plan upon the patient’s breasts and torso; the principal corrective consideration is the correct level of the nipple-areola complex (NAC) upon the breast hemisphere. In most women, the nipple should be located at, or slightly above, the inframammary fold (IMF), because emplacing it too high might later lead to a difficult revision surgery. The proper topographic locale for the nipple is determined by transposing the semicircular line of the inframammary fold to the face of the breast (anterior aspect), thereby configuring a circle, wherein the NAC is centred. After determining the nipple locale, the surgeon delineates the remaining skin incisions of the correction, while maintaining the inferior limit of the vertical-incision at a distance above the pre-operative IMF, which precaution avoids extending the surgical scar to the chest wall after the lifting of the breast and the inframammary fold.
Intra-operative matters
- The sole application of breast augmentationBreast augmentationBreast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
mammoplasty to correct minimal breast ptosis (Grade I) usually is effected with a breast implant prosthesis. The dual application of mastopexy and of breast augmentation surgeries — as one surgical procedure — requires thorough planning, because of the required resections of the parenchymal tissuesParenchymaParenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
. The periareolar incision lends itself to breast prosthesis implantation and to NAC transposition, whilst maintaining the tissue viabilityHistologyHistology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
of the nipple-areola complex.
- Mastopexy by internal surgical approach applies to the woman who has undergone explantation of breast prostheses. In operative praxis, the plastic surgeon elevates the flaps of the cut breast-implant capsulesCapsular contractureCapsular contracture is an abnormal response of the immune system to foreign materials in the human body. Medically, it occurs mostly in context of the complications from breast implants and artificial joint prosthetics....
, and folds them in order to increase the volume of the internal mass of the breasts — thereby increasing the projection of the bust from the chest surface. The nipple-areola complex is elevated with plication sutures, and requires no skin resection when there is no excess skin.
Pedicles — superior, inferior, and medial
Although the aforementioned descriptions are of the incisions used to address the breast skin envelope, the surgical management of the breast tissue (parenchyma) is a separate consideration, including maintenance of the neurovascular integrity of the nipple-areola complex (NAC). The degree of hemispheric elevation of the NAC determines the type of pedicle (superior, inferior, medial) that will provide the best venous
Venous blood
Venous blood is deoxygenated blood in the circulatory system. It runs in the systemic veins from the organs to the heart. Deoxygenated blood is then pumped by the heart to lungs via the pulmonary arteries, one of the few arteries in the body that carries deoxygenated blood .Venous blood is...
and arterial
Arterial blood
Arterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...
vascular supply to the NAC. Therefore, the application of the superior pedicle approach affords the surgeon greater procedural flexibility in determining the incision site for emplacing the breast implant, but it limits the possible degree of elevation of the nipple. Application of the inferior pedicle approach affords a greater degree of NAC elevation, but makes difficult emplacing the breast implant, and the subsequent contouring of the breast. Application of the medial pedicle approach preserves breast sensation with a reliable venous and arterial vascular supply, and avoids the technical and procedural limitations of the superior pedicle and the inferior pedicle approaches.
Post-operative matters
- After the breast-lift surgery, wound care is minimal when the sutured closure is subcuticular (under the epidermis), and reinforced with strips of absorbable adhesive tape (butterfly stitches) applied to maintain the wound closed.
- Post-operative surgery scars upon the breast hemisphere can alter the way that the woman conducts her breast self-examination for cancerous changes to the tissues; thus exists the possibility that masses of necroticNecrosisNecrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
fat might be mistakenly palpated as neoplasm lumps; or might be detected as such in the woman’s scheduled mammogramMammographyMammography is the process of using low-energy-X-rays to examine the human breast and is used as a diagnostic and a screening tool....
examinations; nonetheless, such benign histologicHistologyHistology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
changes usually are distinguishable from malignant neoplasms.
Complications
General medical complications of mastopexy include bleeding
Bleeding
Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system...
, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
, and the secondary effects of the anaesthesia. Specific complications include skin necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
, and dysesthesia
Dysesthesia
Dysesthesia comes from the Greek word "dys", meaning "not-normal" and "aesthesis", which means "sensation" . It is defined as an unpleasant, abnormal sense of touch, and it may be, or not be, considered as a kind of pain...
, abnormal changes in sensation (numbness and tingling). Serious medical complications include occurrences of seroma
Seroma
A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....
, a pocket of locally accumulated serous fluid
Serous fluid
In physiology, the term serous fluid is used for various bodily fluids that are typically pale yellow and transparent, and of a benign nature, that fill the inside of body cavities. Serous fluid originates from serous glands, with secretions enriched with proteins and water. Serous fluid may also...
, and occurrences of hematoma
Hematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
, a local accumulation of blood outside the vascular system. Necrosis of the nipple and necrosis of the skin flap (or both), when it occurs, can either be partial, and heal imperceptibly with wound care, or can be complete, and necessitate reconstruction. A complication of the Anchor mastopexy is the tension-caused wound breakdown at the junction of the three limbs of the incision, yet the scars usually heal without undergoing hypertrophy. Asymmetry of the bust is usually present pre-operatively, and the breast-lift surgery usually does not definitively eliminate it, regardless of the applied mastopexy technique or of the plastic surgeon’s operative expertise. Moreover, a combined mastopexy–breast augmentation procedure can make the surgical revision of breast asymmetry more difficult because of the over-stretched tissues of nipple-areola complex. Moreover, a possible, undesirable outcome of the periareolar mastopexy (circumareolar incision) is the under-projection of the corrected breast from the chest wall.
Mastopexy with medial pedicle flap
Pre-operative mattersTo realize a breast lift using the medial pedicle technique, the surgeon delineates the incision plan upon the breasts, chest, and torso of the woman:
- The breast meridian for the length of the sternum bone (from the sternal notch at the lower-throat) to the xiphoid process (at the lower tip).
- An ellipse, centered upon and bisecting, the breast meridian line on the sternum.
- The form and dimensions of the medial pedicle skin-flap, the base of which is above the midline of the ellipse. A 6-cm-long pedicle-base will provide an adequate vascular supply of venousVenous bloodVenous blood is deoxygenated blood in the circulatory system. It runs in the systemic veins from the organs to the heart. Deoxygenated blood is then pumped by the heart to lungs via the pulmonary arteries, one of the few arteries in the body that carries deoxygenated blood .Venous blood is...
and arterialArterial bloodArterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...
blood to ensure the tissue viabilityHistologyHistology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
of the nipple-areola complex (NAC). - A semicircle at the superior face of the ellipsis — either a hemisphere (1/2 circle) or a crescent (3/4 circle) — to indicate the transposed locale of the NAC. The top of the semicircle is marked at 21-cm from the superior margin of the sternal notch. In surgical praxis, the incision plan is modified to the woman’s anatomy (height, weight, degree of ptosis), and the treatment of the parenchymal tissue.
Operative technique
Incision plan — After delineating the surgical incision-plan that establishes a technically reliable central axis of the front torso, and before cutting into the breast(s), the plastic surgeon confirms the topographic
Superficial anatomy
Superficial anatomy is a descriptive science dealing with anatomical features that can be studied by sight, without dissecting an organism...
accuracy of the delineated incision plan, by triangulating the measures at the upper sternum and at the umbilicus, and modifying the incisional lines, if required. Afterwards, the surgical incision lines are infiltrated to the breast skin with a local anaesthetic mixture (lidocaine
Lidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...
1.0% and epinephrine
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...
1:100,000) that constricts the pertinent vascular system to limit bleeding.
Pedicle skin-flap — After establishing the dimensions of the new nipple-areola complex (NAC), the surgeon de-epithelializes the medial pedicle skin-flap that provides the venous-arterial vascular system for the NAC. The first incisions are through the parenchymal tissue, and separate the medial pedicle. The incision is effected to avoid undercutting the skin pedicle and so preserve the NAC blood-supply vessels. Hence, the tissue volume of the pedicle flap is essential for establishing the adequate projection of the upper pole of the breast, where the breast originates from the chest. The surgeon resects (cuts and removes) an almost-triangular segment of tissue below the medial pedicle. Finally, for emplacing the NAC, the incisions are completed by cutting the ellipse and the tissue adjacent to the medial pedicle.
If the incisions to the breast are satisfactory, the patient’s homeostasis
Homeostasis
Homeostasis is the property of a system that regulates its internal environment and tends to maintain a stable, constant condition of properties like temperature or pH...
is feasible at that juncture of the mastopexy operation. The surgeon then evaluates the tissue-thickness of the medial pedicle flap, and its physical capability for rotating in a superomedial direction (above and to the center) with no resultant torsion tension to the tissue of the inferior portion of the pedicle; afterwards, the surgeon reduces the tissue thickness of the skin pedicle. Once positioned superiorly, the pedicle tissue thickness is reviewed to ascertain that it fits into the new position, without undue pressure or constriction; thus are assured the tissue viability
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...
of the medial pedicle and of the nipple-areola complex.
Symmetry — The critical procedural step in forming the new breast is the collecting and the joining of the three folds of breast tissue (the medial pillar and the two lateral pillars) of the lower pole of the breast, where it meets the chest. The suturing is critical to supporting and shaping the flaccid breast tissues into a hemispheric breast-mound that well projects from the chest wall — a lifted breast. The supine patient then is elevated to a sitting position so that the breasts drape naturally, and the surgeon then delineates upon them the incision plan for the resection (cutting and removing) of the excess folds of skin from the lower sides (inferolateral) and the lower midline (inferomedial) of the new breast. Afterwards, the patient is laid supine, and the excess breast skin is cut; to avoid a scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
at the inframammary fold, a purse-string closure gathers the excess folds of skin at the lower pole of the breast; in due course, the three joined pillars of skin will integrate to the inframammary fold. Again, the supine patient is elevated to a sitting position so that the surgeon can ascertain the size, shape, and symmetry, or asymmetry, of the corrected breasts. If the degree of breast-lift is satisfactory, the patient is re-laid to the operating table, and the plastic surgeon sutures the incision wounds.
Post-operative matters
- During the initial post-operative period, the plastic surgeon examines the patient for occurrences of hematomaHematomaA hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
, and to evaluate the histologic viability of the breast-pedicle skin flaps and of the nipple-areola complex.
- During the first three (3) weeks of post-operative convalescence, the surgeon monitors the healing of the mastopexy wounds during weekly consultations with the patient. Depending upon the wound-healing progress of the woman, more or fewer follow-up examinations shall follow.
Complications
- Tissue necrosisNecrosisNecrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...
of the nipple-areola complex is the principal mastopexy medical complication. To prevent NAC necrosis, the surgeon monitors and evaluates the viability of the transposed tissue; by the presence of oxygenated, bright red arterial bloodArterial bloodArterial blood is the oxygenated blood in the circulatory system found in the lungs, the left chambers of the heart, and in the arteries. It is bright red in color, while venous blood is dark red in color...
demonstrates the proper functioning of the NAC vascular system. A more common post-operative NAC complication is dysesthesiaDysesthesiaDysesthesia comes from the Greek word "dys", meaning "not-normal" and "aesthesis", which means "sensation" . It is defined as an unpleasant, abnormal sense of touch, and it may be, or not be, considered as a kind of pain...
, manifest as an abnormal sensation of numbness, and as a sensation of tingling, that perdures for the wound-healing period, yet it diminishes as the full functioning of the breast’s innervation resumes the full sensitivity to the nipple-areola complex; nonetheless, permanent numbness of the NAC is rare.
- Tissue necrosis of the medial pedicle flap is a potential, but rare, complication of mastopexy procedures. Moreover, the occurrence of hematomaHematomaA hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
also is possible; in post-operative praxis, a large hematoma is drained immediately, whereas a small hematoma can be observed for self-resolution, before draining.
- Wound dehiscenceWound dehiscenceWound dehiscence is a surgical complication in which a wound breaks open along surgical suture. Risk factors are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery.-Symptoms:...
, the bursting of a surgical woundWoundA wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...
at the line of closure sutures, is a medical complication resulting from the poor healing of the wound. Unless wound dehiscence aesthetically compromises the breast-lift outcome, it is managed conservatively.
- Breast contour irregularities occurred when the tissues of the inferior part of the incision are gathered to avoid forming a scar at the inframammary fold. If the complications do not self-resolve, if the tissues do not flatten, or become smooth, they are revised with additional surgery.
Mastopexy with B-pedicle
B mastopexy, B technique mastopexy, Regnault mastopexy techniqueThe B mastopexy (breast lift) is a variation of the circumvertical approach that features an inverted, upper-case letter-B incision, which, when performed with simultaneous breast augmentation
Breast augmentation
Breast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
via submuscular or subglandular implantation of the breast prosthesis, restores the natural contour and appearance of the breasts. Moreover, the B mastopexy technique can procedurally include the simultaneous microliposuction to reduce the lateral parenchyma
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
l and adipose tissues in order to achieve the correct size, volume, and contour of the corrected breasts. The B mastopexy can correct several types of breast deformity, every form of breast ptosis
Ptosis (breasts)
Ptosis of the breast refers to drooping or sagging of the breast. Breast ptosis is related to the laxity of the superficial fascia, suspensory ligaments and skin....
, and breast hypertrophy
Hypertrophy of breast
Hypertrophy of the breast is a rare disease of the breast connective tissues; the indication is a breast weight increase that exceeds , which enlargement causes muscular discomfort and over-stretching of the skin envelope, leading to ulceration...
; it usually has low incidence rates of hypertrophic scar
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...
ring, and of loss of sensation in the nipple-areola complex; furthermore, the B mastopexy technique also applies to reduction mammoplasty, the correction of over-sized breasts.
The technical and procedural efficacy of the B-technique mastopexy was established in Clinical Techniques: B Mastopexy: Versatility and 5-Year Experience (2007), a retrospective study of a 40-woman mammoplasty
Mammoplasty
Mammoplasty or mammaplasty can refer to the surgical procedure to insert cheek implants or augmentation mammoplasty, an enlarging of the breasts via implants...
cohort upon whom were performed 13 breast-lift procedures without breast augmentation, and 27 procedures with simultaneous breast augmentation
Breast augmentation
Breast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
, using a medium-sized breast implant. The cohort reported no medical complications, only one (1) woman underwent scar-revision surgery; and each of the 40 women was satisfied with her mastopexy outcome.
Surgical consultation — The plastic surgeon explains the technical and aesthetic considerations of the breast lift operation to the woman. That the B technique mastopexy yields improved aesthetic results with a breast-skin pedicle created with a curvilinear incision (an inverted, upper-case letter-B). That said curvilinear incision technique eliminates the medial vertical incision of the Anchor mastopexy, and so creates a lifted bust with breasts of natural size, appearance, and contour, and few surgical scars. The consultation includes detailed, pre-operative, post-operative, and healing-stage photographs that illustrate the nature and extent of the mastopexy incisions and the resultant scars. That the full healing (scar maturation) might require approximately one (1) year to establish the final contour of the lifted breasts, after the suspensory ligaments
Cooper's ligaments
Cooper's ligaments are connective tissue in the breast that help maintain structural integrity.Transmission diffraction tomography can reveal the anatomy....
and the parenchymal tissue
Parenchyma
Parenchyma is a term used to describe a bulk of a substance. It is used in different ways in animals and in plants.The term is New Latin, f. Greek παρέγχυμα - parenkhuma, "visceral flesh", f. παρεγχεῖν - parenkhein, "to pour in" f. para-, "beside" + en-, "in" + khein, "to pour"...
have settled into and upon the chest as an aesthetically satisfactory bust of natural size, appearance, and contour.
Pre-operative matters
To the standing patient, the plastic surgeon delineates the mastopexy incision-plan to the chest, breasts, and torso of the woman. The distance from the suprasternal notch (atop the sternum) to the nipple is measured and recorded to the medical record; the level of the inframammary fold is identified and delineated to the front of the breast (anterior aspect), which indicates the elevated locale to which the nipple-areola complex will be transposed. The medial aspect of the new NAC locale is marked approximately 10–11 cm from the midline, along the mid-breast; and a semicircle with a 38-mm-diameter is delineated around the nipple; the distance of the semicircle from the ptotic NAC indicates the new locale of the nipple-areola complex upon the breast hemisphere.
Operative technique
Incision plan — With the patient laid supine upon the operating table, the surgeon performs a free-hand, curvilinear delineation of an inverted, upper-case letter-B pattern to the breast. Then, per the landmarks of the initial incision-plan, a semicircular pattern is delineated around the nipple-areola complex. The vertical and horizontal component-incisions of the B mastopexy are created with a tapering, curvilinear incision that begins from the lower margin of the areola to the lateral crease of the breast. The B-pattern incision results in a vertical closure 5–7 cm long, from the bottom margin of the nipple-areola complex to the inframammary fold.
Wound closure — The surgeon tests the closure tension of the wound sutures by in-folding the breast over the index finger, and towards the transposed NAC, to observe if the skin blanches (whitens) or over-stretches, afterwards, the NAC-area dermis is de-epithelialized. In the combined mastopexy–augmentation procedure, wherein the breast prosthesis is emplaced to a submuscular implant pocket, an anaesthetic tumescent solution is injected along the marked incision line. When the breast implant will be emplaced to a subglandular implant pocket, the hypodermic needle penetrates un-resisted into the anatomic plane above the pectoralis major muscle; the tumescent solution anaesthesia allows blunt dissection. After establishing anaesthesia, the surgeon de-epithelializes each edge of skin by undermining it 3–4 mm, with a razor scalpel, thereby facilitating the closing of the surgical wound without tight sutures. In a mastopexy–augmentation, the breast-implant pocket (locale) determines when the surgeon performs the de-epithelialization of the B pedicle; for submuscular implantation, the skin pedicle de-epithelialization is performed after the emplacement; for subglandular implantation, the skin pedicle de-epithelialization is performed before the emplacement.
If the mastopexy includes simultaneous breast augmentation with submuscular emplacement, the surgeon observes that the pectoralis major muscle
Pectoralis major muscle
The pectoralis major is a thick, fan-shaped muscle, situated at the chest of the body. It makes up the bulk of the chest muscles in the male and lies under the breast in the female...
is divided from the sternum and the ribs. After cutting the implant pocket, the surgeon then de-epithelializes the B-pedicle. To facilitate the dermal closure (joining the wound edges) with minimal tension to the sutures, the breast implant either is displaced up, into the implant pocket, or is partially deflated. For the subglandular emplacement of breast implants, the technique is different; the de-epithelialization of the pedicle dermis is performed initially, after which an incision is made through the de-epithelialized dermis, at the base of the vertical limb of the mastopexy, and then, by means of blunt dissection, an implant pocket is cut above the pectoralis major muscle.
Symmetry — During the dermal closure, the nipple-areola complex (NAC) is transposed to its new locale, as determined by the skin pedicle. To create the curvilinear scar, the deep dermal closure is accomplished by rotating the lateral flap down and then medially. The deep dermis is approximated (joined) with sutures, in a simple, interrupted fashion. The key suture is emplaced at the junction where the apex of the vertical incision meets the NAC — because it is the skin area of the breast subject to the greatest tension(s). The subcutaneous dermal closure is effected with interrupted sutures. As required, the final adjustments before suturing the skin closed, might include either micro-liposuction or additional de-epithelialization. After the dermal closure, a suture is emplaced to achieve the continuous approximation of the nipple-areola complex to the adjacent skin edge, and to the lower skin incisions.
Post-operative matters
Convalescence — Post-operative care is minimal after a mastopexy procedure; the lifted breasts are supported with a porous, soft elastic tape, which is removed at 7–10 days post-operative, and then is reapplied to the mastopexy incisions for an additional 1–2 weeks during convalescence. For comfortable healing of the wounds, the woman wears a surgical brassière, and avoids wearing an underwire brassière until the breast implants have settled into position. The mastopexy outcome is photographed at 2–3 months post-operative.
Mastopexy technique observations
Mastopexic correction results in surgical scars on the lifted breasts; the periareolar mastopexy outcome often is a breast of bottom-heavy appearance, with puckered surgical scars; and the Anchor mastopexy outcome is an aesthetic breast of natural size, look, and feel, but with many scars. Whereas, advocates of the mechanical principle of the B technique mastopexy propose that the creation of a rotational pedicle (with an elevated epidermal flap that rotates around the NAC), lifts the breasts with an incision plan with vertical and horizontal incisions that eliminate the medial incision (and its vertical scar), whilst providing good projection of the corrected bust from the chest, and a viable nipple-areola complex. Furthermore, advocates of the B technique mastopexy report that it usually does not require secondary correction, because it allows for the better transposition of excess lateral tissues of the breasts by means of curvilinear incision (inverted, upper-case, letter-B) to the skin envelope.
See also
- BreastBreastThe breast is the upper ventral region of the torso of a primate, in left and right sides, which in a female contains the mammary gland that secretes milk used to feed infants.Both men and women develop breasts from the same embryological tissues...
- Breast augmentationBreast augmentationBreast augmentation denotes the breast implant and fat-graft mammoplasty procedures for correcting the defects, and for enhancing the size, form, and feel of a woman’s breasts...
(augmentation mammoplasty) - Breast implant
- Breast reductionBreast reductionReduction mammoplasty is the plastic surgery procedure for correcting over-sized breasts...
(reduction mammoplasty) - MammoplastyMammoplastyMammoplasty or mammaplasty can refer to the surgical procedure to insert cheek implants or augmentation mammoplasty, an enlarging of the breasts via implants...
- Plastic surgeryPlastic surgeryPlastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...