Mastopexy and augmentation mastopexy

Mastopexy is a parenchymal reshaping that may or may not require a small parenchymal reduction, whereas reduction mammaplasties always require parenchymal reduction.

The difference between mastopexy and reduction mammoplasty is whether the patient truly exhibits symptoms of macromastia.

Typically, the ptotic breast has a paucity of breast parenchyma in relation to a lax, excessive skin envelope, while the cardinal finding of the hypertrophic breasts seen in cases of macromastia and gigantomastia is a predominance of parenchyma without skin excess.

The pathophysiology of breast ptosis is the result of the combination of expansion and aging, or separately as a result of a congenital deformity.

Breast ptosis in its various degrees is defined by its anatomic relationship to the inframammary fold (IMF). In 1976, Regnault described degrees of breast ptosis ( Fig. 18.1 ) .

• Grade I ptosis (mild): the nipple is within 1 cm of the IMF and above the lower pole of the breast.

• Grade II (moderate): the nipple is 1–3 cm below the IMF but still above the lower pole of the breast.

• Grade III (severe): the nipple is more than 3 cm below the IMF and is below the lower breast contour.

• Grade IV (pseudoptosis): the nipple rests above the IMF, but the majority of breast parenchyma is below it, giving the appearance of ptosis.

An additional caveat to the Regnault classification was submitted by Brink, which takes into account other causes of the ptotic breast, such as parenchymal maldistribution, and posits an algorithm by which they can be surgically addressed ( Table 18.1 , Fig. 18.2 ).

One of the most helpful questions that can be posed to a patient is “Can you make your breasts look the way you want them to in a bra?”

• If the answer is yes, then perhaps a mastopexy alone is the best recommendation.

• If the answer is no, and the patient relies on adding volume by stuffing or padding, then adding an implant may be necessary.

The plastic surgeon must take into account the degree of skin laxity, the excess amount of skin in relation to the parenchyma, the position or malposition of the parenchyma, and degree of nipple–areolar complex elevation anticipated.

Measurements are a key component to the diagnosis and treatment of the patient with breast ptosis. These measurements offer guidelines for altering the breast, which must be individualized, based on proportionality, variances in chest wall anatomy, posture, and patient preference. Important measurements and their reported statistical standards ( Fig. 18.3 ) include:

• The sternal notch to nipple distance: 19–21 cm.

• The nipple to IMF distance: 5–7 cm.

• Nipple to midline distance: 9–11 cm.

• The breast base diameter.

• The degree of ptosis: based on Regnault classification.

The majority of patients presenting for mastopexy procedures typically fall into three categories. The analysis of the quality and amount of skin in relation to the mass and anatomic distribution of the breast parenchyma usually dictates which procedure is necessary.

• Patients who indeed would benefit from mastopexy. Normal volume of breast parenchyma and a minimal to moderate excess of skin that is of good quality.

• Patients who need an augmentation with mastopexy. Minimal glandular mass and breast ptosis.

• Patients who need a formal reduction mammaplasty. Overabundance of parenchyma and ptosis.

Any history of breast changes/masses, nipple–areolar changes or discharge, mammography, previous breast surgery, pregnancies and breast-feeding, radiation therapy to the chest or breast, and personal or family history of breast cancer must be explored with the patient in detail.

Most agree that patients over 35 years of age should obtain a recent mammogram, unless a normal one has been documented in the year prior, before proceeding with surgery.

Knowledge of the breast anatomy is critical for optimizing outcomes following mastopexy ( Figs. 18.4–18.11 ) .

The vascular supply to the breast and nipple–areolar complex is rich and redundant and includes contributions from the internal mammary perforator, lateral thoracic perforators, and the intercostal perforators from both the anterolateral and anteromedial origins.

Branches of the lateral division of the fourth intercostal nerve provide the primary innervation of the nipple. Contributions from the third and fifth anterior cutaneous intercostals, as well as the fifth lateral cutaneous intercostals, may also provide some sensation of the nipple.

Cooper ligaments run from the pectoralis muscular fascia, through breast parenchyma, and insert into the dermis ( Fig. 18.12 ) . Parenchymal changes with aging, weight changes in the obese, and pregnancy are accompanied by specific alterations in the integrity of Cooper ligaments, as well as the breast's fascial components and the overlying skin. The breast parenchyma, once held in place on the chest wall by and within these structures, becomes mobile and descends with the constant pull of gravity.

Mastopexy techniques are often described by the scar pattern from the skin reduction: periareolar, vertical, J or L, and inverted-T.

Periareolar techniques are best suited for patients with mild to moderate breast ptosis and in whom the parenchyma is adequate from a volume standpoint. Incisions range from a superior crescent of excised skin to a complete donut.

Patients who present with mild to moderate breast ptosis, but with inadequate parenchymal volume, can be treated with an implant via the periareolar technique.

The greatest advantage of the periareolar technique is that the incision is camouflaged in the aesthetic transition from breast skin to the skin of the nipple–areola.

Disadvantages of periareolar techniques include:

• A limited degree of cephalic nipple–areolar complex movement.

• Possible scar widening.

• Possible decreased breast projection.

Small, mildly ptotic breasts with adequate parenchyma respond best to these techniques.

Excising skin around the nipple–areola at the same operative setting elevates the nipple–areolar complex to a more aesthetic location and completes the periareolar mastopexy. Usually, the amount of lift obtained is limited to 1–2 cm.

In an effort to limit complications associated with periareolar mastopexy techniques, Spear et al. designed a series of rules to follow.

• Rule 1: D _outside ≤ D _original + (D _original − D _inside ). The amount of non-pigmented skin excised should be less than the amount of pigmented skin excised. In doing so, there will be no undue tension on the new areola that could cause subsequent widening. The distance from the edge of the areola to the outer diameter located on the normal breast skin should roughly equal the distance to the inner diameter, which should be located within the areola.

• Rule 2: D _outside < 2 × D _inside . The design of the outside diameter should be no more than two times the inside diameter in order to minimize the discrepancy in circle sizes, thereby reducing tension on the closure.

• Rule 3: D _final = ½(D _outside + D _inside ). This final rule helps predict the final areolar size, which is particularly useful in asymmetry cases, as well as those in whom no round block suture is employed ( Fig. 18.13 ) .

  

As the degree of the breast ptosis increases, so does the total length of the incision necessary to correct it. The logical extension of the periareolar scar is the addition of a vertical component.

Lassus and other vertical mastopexy techniques combine four principles:

• (1) a central wedge resection to reduce the size of the breast, if needed; (2) transposition of the areola on a superiorly-based flap; (3) no undermining of the skin; (4) addition of a vertical scar component.

Vertical mastopexy techniques are best for young women with good skin elasticity; a firm, glandular breast; and breasts that are not excessively large or ptotic.

Advantages of vertical techniques: almost no risk of skin, nipple, or glandular necrosis; preservation of most of the neurovascular supply to the areola; long-lasting results from cicatricial healing; drains are usually not necessary.

Disadvantages of vertical techniques: a visible vertical scar, less than ideal early postoperative breast shape that may take several months to settle, and an “adjust as you go” approach to reshaping.

The advantages and disadvantages of the mastopexy techniques remain the same; however, the added benefits and risks of augmentation mammaplasty must now be considered.

Advantages include improved fill of the skin envelope by virtue of the implant.

Risks include wound problems and dehiscence because of the added weight of the implant, the inherent risks of the implants (malpositioning, leakage, rupture, capsular contracture), potential risk of devascularizing the nipple–areolar complex.

In general, the base diameter and projection of implants chosen for augmentation–mastopexy procedures are smaller than in implants chosen for standard augmentation procedures.

Textured implants may assist in avoiding malposition, especially when the subglandular plane is selected. If the parenchymal volume is deficient in the upper pole (<3-cm pinch thickness), then we prefer a subpectoral placement.

The inverted-T scar technique is reserved for those women with moderate to severe breast ptosis with a large excess of skin and a moderate amount of glandular tissue.

Advantages: ability to excise all excess skin, ability to see the final shape of the breast while the patient is still on the operating table, leading to a decreased chance for revision.

Disadvantages: increased length of the incisions/scars; the breast shape is supported mainly by the skin envelope, which increases the chance of recurrent ptosis during the subsequent months and years.