Mastopexy—Vertical Approach

Introduction

Commonly, mastopexy is understood to be synonymous with “breast lift.” Among plastic surgeons, a mastopexy has been traditionally understood to mean a skin tightening procedure, certainly for a skin-only mastopexy. However, the goal of a mastopexy is improvement in the shape of the breast, not simply tightening of its elastic envelope. In ptotic breasts, the lower pole is usually reduced (i.e., parenchymal resection) to achieve an aesthetic lower pole and avoid a “mastopexy wrecking bulge.”

Many plastic surgeons use the term vertical scar mastopexy. However, the scar is not always vertical. The scar is frequently modified to a short inverted T. The scar may resemble a Wise pattern scar, but the parenchymal treatment is much different. Accordingly, vertical mastopexy is best labeled “vertical,” referring to the vertical midline parenchymal resection of the lower pole, not the scar.

Indications and Contraindications

For the woman who lifts her breasts by the cups of her hands and says, “This is what I want,” a vertical augmentation/mastopexy is likely to be most satisfactory, in accordance with the minus-plus principle. A patient who says, “I like my size, but just want it up here,” should be advised that such a result is impossible with a mastopexy alone. Breast remodeling is needed—more on top, less on the bottom—and this effect can be accomplished only by simultaneously inserting implants.

Measurements confirm that the inframammary fold (IMF) level moves up after a vertical mammaplasty. Both vertical and inverted-T techniques can elevate the lower pole. However, only the vertical method elevates the IMF. When a Wise pattern and inferior pedicle are used, the IMF remains fixed at the base of the pedicle.

An underappreciated benefit of elevation of the IMF and lower breast pole is the appearance of a longer torso. With the emphasis on fitness in our culture, and the frequent display of the abdomen, this anatomic area takes on greater importance. However, upward mobilization of the superior border of the breast is more challenging. Breast implants are needed to substantially boost breast projection and upper pole projection, ^{, ,} providing the illusion of breast mound elevation. The author inserts breast implants in more than 70% of patients undergoing a mastopexy. A vertical mammaplasty, with a medial, superior, or superomedial pedicle is now used exclusively by a growing number of plastic surgeons.

Although smoking is never advisable, a smoking history is not an absolute contraindication to surgery. The vertical approach is more robust than the inverted-T, inferior pedicle technique because the keel-shaped lower pole parenchymal resection is not accompanied by skin undermining. Nipple–areola perfusion is optimized by preserving medial and deep vascular pedicles. Nevertheless, patients are instructed not to smoke during the perioperative period to reduce the risk of delayed healing, suboptimal scars, and nipple–areola tissue loss.

Preoperative Evaluation and Special Considerations

The mastopexy candidate presents with breast ptosis. The nipple position is evaluated. Patients are informed that implants provide minimal, if any, nipple elevation. Breast implants are not a substitute for a mastopexy. Implants do not adequately “take up the slack.”

The areola size is a consideration. Women with large areolae may wish to have them reduced, making the periareolar scar a favorable trade off. Existing breast asymmetry is the rule, not the exception. Patients are informed of their existing asymmetry and the fact that perfect symmetry is not realistic.

Patients may have had a previous augmentation. This is the time to discuss whether to replace the implants. Considerations include the desired size and the number of years the implants have been in place.

Patients who have had a previous breast lift may be candidates for secondary mastopexy. The original method used does not matter. Obtaining the original operative report is generally unnecessary. The author makes no attempt to replicate the original resection pattern. However, the surgeon must be especially careful regarding blood supply, often including the (de-epithelialized) superior areola hemi-circumference.

Many women who have had a previous Wise pattern mastopexy or reduction already have over-elevated nipples that do not require any additional elevation. Existing nipple overelevation may be improved or corrected by the elevating effect of the vertical lift on the breast mound. The challenge is to site the nipple as low as possible without leaving a scar superior to the nipple–areola.

Simultaneous Breast Implants

Some surgeons think that a mastopexy and breast implant work at cross purposes because a mastopexy tightens the skin envelope whereas a breast implant stretches it. The procedures are in fact synergistic when a vertical method is used. Implants make mastopexy easier to perform. There is less gathering of tissue in the lower pole. An inverted-T modification is less often required because the implant fills out the lower pole.

The mean increase in breast projection after vertical mastopexy is about 1.2 cm ( Fig. 14.1 ). Upper pole projection increases 0.5 cm, on average. These modest increases confirm the clinical impression that mastopexy and reduction cannot duplicate the effect of an implant in creating upper pole fullness.