All about Breast Lift or Mastopexy Cosmetic Surgery, Breast Lift cost, Clinics, Videos, Breast Lift before and after pictures, photos, complications, recovery and Prices.
BREAST LIFT INFORMATION
Mastopexy, or breast lift, is a surgical procedure that can help restore a more youthful and natural shape to sagging (ptotic) breasts. Gravity, pregnancy, nursing, weight gain and aging can all lead to ptosis and a loss of firmness. Breast implants in conjunction with mastopexy can increase breast firmness and their size. The goals of surgery are to create improved projection and a more youthful, uplifted appearance while minimizing visible scarring. In addition to reshaping the breast, mastopexy can also reduce the size of the nipple areola complex (NAC).
Mastopexy can be performed in any size breast; however very large breasts may be more suited to a formal breast reduction procedure. Pregnancy and nursing will usually stretch breasts that have been previously lifted; therefore the best outcomes are seen in patients who are past their childbearing years.
Ideal candidates for mastopexy are healthy, emotionally stable women who are realistic about what the surgery can accomplish. It is important to emphasize that the tradeoff for lifted, youthful breasts are the scars that remain after surgery. Patients with relatively small breasts and minimal ptosis may be candidates for modified procedures requiring less extensive incisions.
The relevant anatomy is discussed in the breast augmentation chapter.
BREAST LIFT INDICATIONS
In most instances mastopexy is performed primarily to improve an unaesthetic appearance of the breasts. However, certain cases, such as postmastectomy reconstruction or ptosis after implant removal, may require a mastopexy to restore symmetry.
BREAST LIFT CONTRAINDICATIONS
There are no absolute contraindications to breast mastopexy. Planned future pregnancy is a relative contraindication because lactation and subsequent involution can change the shape of breast tissue. Capsular contracture after breast augmentation is another relative contraindication to mastopexy. In many of these patients, the breasts appear ptotic when in fact they truly are not. Therefore, removal and
inspection of the implants while in the operating room is paramount prior to committing to mastopexy. Finally, women with a high risk of breast cancer should be evaluated carefully since surgery may alter the architecture of breast tissue making detection and treatment of cancer difficult.
BREAST LIFT PREOPERATIVE CONSIDERATIONS
Judicious care should be taken during patient assessment and selection to clarify expectations and ensure that desired results are obtainable. A complete physical examination should be performed which includes inspection as well as palpation of the breast parenchyma to rule out suspicious masses. All patients 40 years or older should have a baseline mammogram prior to surgery, a follow-up mammogram 6 months after surgery, and then follow the American Cancer Society recommendations for annual screening mammograms.
Determining the degree of breast ptosis is central to planning mastopexy as it will guide which technique is best suited to achieve the optimal aesthetic appearance.
Table – Grades of Ptosis according to the Regnault classification
(Grade I) – Minor Ptosis – Nipple at the level of inframammary fold, above lower above lower contour of gland.
(Grade II) – Moderate Ptosis – Nipple below level of inframammary fold, above lower contour of gland.
(Grade III) – Major Ptosis – Nipple below level of inframammary fold, at lower contour of gland.
Pseudoptosis – Inferior pole ptosis with nipple at or above the inframammary fold.
Glandular Ptosis – Nipple is above the fold but the breast hangs below the fold.
Determining the correct level of the nipple areolar complex (NAC) is critical when planning a mastopexy. The nipple should be placed at or slightly above the inframammary fold taking care to avoid placing the nipple too high on the breast mound, which can be difficult to fix. Breast volume is important to consider when planning a mastopexy, and any parenchyma that falls below the inframammary crease should be reduced or elevated.
Next, the position, length and definition of the inframammary crease should be evaluated. When augmentation is used in conjunction with mastopexy, the implant pocket is used to define and retain the new inframammary crease. Breast mobility is directed by the firmness of glandular attachment to the underlying deep fascia and should be assessed prior to surgery. Skin and tissue quality should be assessed since women with ptosis have an excess of breast skin compared to the amount of underlying parenchymal tissue.
The appearance of striations indicates a weakness in underlying dermis, and this skin usually has poor elasticity that will not support or shape the breast. Recurrence of breast ptosis in these patients is predictable; therefore planning skin removal and incision placement is an important preoperative consideration. These are planned on a continuum from periareolar to circumareolar to vertical scars and finally to horizontal scars. Should ptosis recur, additional breast tissue can be excised through old incisions.
Women with small breasts and upper pole flatness may benefit from simultaneous augmentation.
The addition of an implant can enhance the size and contour while increasing the longevity of the uplifting effects of mastopexy. Simultaneous breast augmentation and mastopexy should be considered carefully since the two have somewhat conflicting goals. The goal of breast augmentation is to enlarge the
breast, which involves stretching the skin and NAC, while mastopexy is designed to reduce the skin that envelopes the parenchymal tissue. Patients should be aware of the increased risk of poor scarring, implant nipple misalignment and implant extrusion.
The best scenario occurs when the implant fills out the excess skin envelope while leaving enough excess skin to reshape the breast. Depending on the complexity of the problem and quality of the skin support, it may be better to perform two separate, staged procedures. Preoperative markings vary with surgical plan and are essential for obtaining optimum results. In most patients the nipple should be at or slightly above the
inframammary fold. Once the proper nipple location has been determined, an indelible marker may be used to mark the remainder of the skin incision.
PROCEDURES AND INTRAOPERATIVE CONSIDERATIONS
Since scars are the greatest drawback to aesthetic breast surgery, it is best to choose techniques that minimize the length of incisions and place them in hidden areas. Intraareolar and periareolar incisions are tolerated best because they are less likely to become hypertrophic provided there is no tension on the incision. A median inferior vertical incision is also tolerated well compared to a horizontal inframammary incision. As a rule, incisions should be kept off of the superior hemisphere of the breast because women often wear clothing that exposes this area. There are several techniques available to correct breast ptosis, and no single technique is considered ideal.
The degree of ptosis varies from patient to patient and treatment should be individualized. The primary focus is on altering breast volume and contour by removing excess skin and repositioning the NAC.
The common surgical options for ptosis correction are:
1. Augmentation with or without mastopexy
2. Periareolar scar technique
3. Circumareolar scar with periareolar purse-string closure (Benelli mastopexy)
5. Vertical mastopexy. Vertical mastopexy can be combined with the horizontal inverted T technique or the short horizontal scar technique.
AUGMENTATION FOR PTOSIS
Patients that are well suited for augmentation alone are those that have pseudoptosis or grade I ptosis. In these patients, minimal elevation of the NAC is required. Their breasts usually have flattened upper poles and are hypoplastic and involuted. It is important to be aware that if the nipple is below the inframammary fold, an implant may actually enhance the deformity giving a more ptotic appearance. Patients who seek a more elevated NAC may require circumareolar incisions with augmentation. When augmentation is used to correct breast ptosis, the implant is placed in either the submuscular position in the upper portion of the breast or in the subglandular position in the lower portion of the breast.
When placing the implant in the submuscular position, it is important to maintain a loose submusculofascial
pocket to avoid the appearance of a double silhouette (double bubble). This occurs when breast parenchyma descends over the implant while the implant remains fixed at the upper pole.
This approach is best utilized in patients with a minor degree of ptosis who require minimal elevation of the NAC. The periareolar technique involves a crescenteric excision and lift of the NAC. It affords the shortest possible scar and is well hidden within the NAC. Patients that require a greater degree of elevation of the NAC should have a different technique performed since the risk of areola deformity is proportional to the amount of skin removed. Skin quality is important to consider for healing purposes as well as for assessing the risks of recurrent ptosis.
CIRUMAREOLAR SCAR (BENELLI) TECHNIQUE
Circumareolar mastopexy alone tightens the breast envelope without raising the NAC and may cause central breast flattening. Patients who have large areola or tubular breasts may benefit from this technique. Two incisions are required:
an inner incision around the areola and a second parallel outer incision demarcating the area for skin excision. The final diameter of the new NAC should be 40-45 mm. A pursestring, nonabsorbable suture is placed around the outer dermal circumference in order to reduce tension on the suture line and limit the risk of scar widening.
This procedure is called a “Benelli or “round block” mastopexy. The round block technique allows control of the diameter of the areola and maintains it in a fixed circular scar thus avoiding protrusion. Limiting the size of the outer diameter to three times that of the inner diameter helps minimize tension as well.
In addition to a pursestring suture, a Benelli mastopexy may also include pexying the retroglandular surface of the breast parenchyma to underlying rib periostium in a crisscross fashion.
VERTICAL SCAR TECHNIQUE
Vertical mastopexy is needed to correct more severe breast ptosis, such as grade II or III, where the nipple is below the level of the inframammary crease. If the distance the nipple needs to be elevated is significant, and there is excess skin requiring excision, then a vertical limb is required. Removing skin in a vertical direction allows the medial and lateral breast skin to be moved toward the center and prevent flattening of the breast apex. The scar is usually minimally visible with time and is located inconspicuously on the lower portion of the breast out of view when low-cut clothing is worn.
The procedure begins by determining the new position of the NAC. With the patient standing or sitting upright, the apex and the width of the new NAC position are marked. An ellipse is drawn starting from the top of the new position of the NAC around the existing NAC and downward to the inframammary crease.
Incisions are made along the lines of the ellipse as well as around the NAC, and skin is deepithelialized within the ellipse. If implants are being used, they are placed into a subpectoral pocket. Patients with upper pole flattening may benefit from a lower pole deepithelialized parenchymal flap turned beneath the NAC into a new position in the upper pole of the breast. Prior to making any further incisions through breast parenchyma, a technique called tailor tacking may be employed to help the surgeon predict the final outcome. This technique is useful for determining the position of the NAC. The deepithelialized areas are invaginated and the skin edges approximated with staples.
The outer edges are marked, the staples are removed and the excess breast tissue is then excised.
WISE-PATTERN BREAST LIFT
Patients with significant ptosis, very full lower breast poles, or those who require a long transposition of the NAC may opt for the Wise-pattern technique. A keyhole incision is made around the NAC with a vertical limb and a horizontal extension resulting in an inverted T type scar after removal of excess tissue. Different pedicles can be used with this approach depending on surgeon preference (if concomitant implants are to be placed, a superior or medial pedicle may be suitable; if significant lift of the NAC is required, an inferior pedicle may be preferable).
Once the skin and pedicles have been incised and dissected, judicious undermining and removal of excess tissue can be performed. The vertical and horizontal limbs are approximated and the NAC is sutured in place with a tension-free subcuticular closure.
BREAST LIFT RECOVERY AND POSTOPERATIVE CONSIDERATIONS
Postoperatively an elastic bandage or surgical bra is worn over gauze dressings. Several days later, a soft support bra can be worn continuously for 3-4 weeks. Lifting objects above the head should be avoided during the immediate postoperative period. Patients should be instructed about potential complications such as numbness and hematoma formation. Breastfeeding should be normal after some types of mastopexy;
however other techniques increase risk of loss of lactation. Many of the same complications seen after breast augmentation apply to mastopexy as well. These include hematoma or seroma formation, infection, nipple sensory loss and implant contracture. There are several other complications worth mention. These are necrosis of the nipple-areolar complex, recurrent ptosis, nipple and breast asymmetry, upper pole flattening and unacceptable scarring.
NIPPLE AREOLAR NECROSIS
Adequate nipple-areolar microcirculation is imperative to the survival of the NAC.
Patients who are heavy smokers or have predisposing vascular diseases such as diabetes or collagen vascular disease are at risk for nipple-areolar necrosis. All patients who smoke should quit smoking prior to and after surgery in order to help decrease nipple necrosis. Placing a subglandular implant or a periareolar pursestring suture may also increase the risk of nipple necrosis because the central parenchyma may be
damaged to a point where the blood supply to the NAC is compromised.
Many surgeons leave large amounts of lower pole breast tissue beneath their skin closure. Subsequently, many women return with lower pole ptosis, termed “bottoming out.” Ptosis may recur when there is asynchrony between breast parenchyma and NAC descent. Correction during a secondary procedure requires removal of the lower pole parenchyma with simultaneous skin revision.
NIPPLE AND BREAST ASYMMETRY
The goal of breast surgery is to obtain perfect symmetry; however, most women have some degree of asymmetry preoperatively. Postoperative asymmetry of the NAC or patient dissatisfaction may be corrected during a follow-up procedure. Discussing this issue prior to surgery may help alleviate anxiety when there is postoperative asymmetry. Periareolar techniques may afford a modest correction of asymmetry; however in cases of significant asymmetry, a complete revision mastopexy may be necessary.
UPPER PLE FLATTENING
Mastopexy alone may not be sufficient to correct breast ptosis. To avoid upper pole flattening the surgeon may place implants, rotate lower breast parenchymal flaps beneath the upper pole, or perform a reverse periareolar pursestring mastopexy.
BREAST LIFT SCARS – POOR SCARRING
Patients with the highest risk of poor scar outcome are cigarette smokers and any patients with comorbidities that predispose them to microvascular disease. Closing wounds in a tension free manner offers the best chance for optimal scar outcome. If the surgeon anticipates a tight skin closure below the NAC, then extrapigmented skin may be left inferiorly and excised at a later time. Horizontal incisions commonly
heal with hypertrophy due to the amount of tension on these wounds.
Efforts to minimize incision length combined with proper wound taping may help limit hypertrophic scarring. If hypertrophic scarring does occur, silicone gel therapy or steroid injections should be attempted prior to scar revision.
PEARLS AND PITFALLS
Choosing a periareolar technique for significant ptosis will result in poor scarring, deformity of the nipple and recurrence. The vertical mastopexy approach may allow a sufficient lift; however, the use of a variable length of horizontal incision in conjunction with this may allow for the necessary removal of excess skin. A modification of the vertical mammaplasty is the use of a curvilinear J-type incision.
This may obviate the need for a short horizontal scar for more moderate forms of ptosis. An adjunctive internal suspension of the breast parenchyma may be necessary with these approaches depending on the quality of skin and its ability to be an active element in shaping and holding form. With the Benelli approach, care must be taken with preoperative counseling about the scar and the relatively long process of smoothening of contours. While concomitant implant placement may improve not only ptosis but also the overall aesthetic result, it is critical to judiciously evaluate the timing of implant placement in light of patient expectation and anatomy. In some instances it may be more prudent to stage the augmentation and mastopexy.
HOW MUCH DOES BREAST LIFT COST
The average cost of breast lift or mastopexy is $3,000 and $4,500 and this price normally does not include pre and post operative care and medication.
BREAST LIFT BEFORE AND AFTER PICS, PHOTOS AND VIDEO