Mastopexy

Published on 22/05/2015 by admin

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Last modified 22/05/2015

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Chapter 18 Mastopexy

G Patrick Maxwell, Jeremy Waldman, Stephanie Stover

Mastopexy is one of the most demanding operations in breast surgery. Although it may increase the challenge, performing simultaneous breast augmentation can be an effective way of producing an aesthetic breast form. As the breast mound descends on the chest wall patients will display variability in breast shape, tissue laxity, symmetry, parenchymal distribution, and nipple position

Summary

1. The goal of mastopexy is to reshape the breast by tightening the skin envelope with or without adding to the breast volume.
2. Factors contributing to the etiology of the breast ptosis include involution, aging, weight loss and multiple pregnancies.
3. Breast ptosis classifications include classes I-III based on nipple areola position in relation to the inframammary fold and breast mound position.
4. Patient evaluation should include history of breast surgery and tumors related to the patient and the patient’s family.
5. Patients who lack sufficient breast volume may require augmentation as well as mastopexy.
6. Only patients with minor breast ptosis (grade I) may benefit from a periareolar mastopexy.
7. Marking of the patient starts with the patient in a sitting position and the nipple-areola complex is measured from the sternal notch and mid-clavicle area as well as the submammary fold.
8. On patients requiring breast ptosis correction with augmentation, augmentation is done first followed by mastopexy.
9. The complications of breast ptosis correction include hematoma, infection, paresthesia, anesthesia, nipple areola necrosis, and capsular contracture among other rare complications.
10. Postoperative care includes continuation of oral antibiotics for 3 days, particularly if an implant has been used. Vigorous exercise can be resumed in 2-4 weeks depending on the magnitude of the surgery.

Introduction

Mastopexy is one of the most demanding operations in breast surgery. Although it may increase the challenge, performing simultaneous breast augmentation can be an effective way of producing an aesthetic breast form. As the breast mound descends on the chest wall patients will display variability in breast shape, tissue laxity, symmetry, parenchymal distribution, and nipple position. There are several options for restoring a youthful appearing breast, but the common goals are to:

• raise the nipple areola complex;
• decrease the skin envelope;
• achieve symmetry;
• improve the breast shape;
• maintain or increase volume.

The additional challenge is to provide a correction that will endure the test of time.

Indication

• Breast ptosis

Breast ptosis is most often a consequence of aging tissues. Over time, Cooper’s ligaments become attenuated and the breast loses its fascial support, frequently with a concurrent decrease in volume. Age-related changes are often hastened or mimicked by weight loss and involutional changes seen with pregnancy/lactation, and menopause.

Regardless of the etiology, a useful tool for the surgeon is to classify patients by the degree of ptosis present. The classification system used most frequently was first described by Regnault1 and grades the breast based on the position of the nipple relative to the inframammary fold (IMF) (Table 18.1).7 The amount of preoperative ptosis can be used as a guide to selecting the operation necessary to achieve correction.

Table 18.1 Regnault classification.1

Grade I Nipple at the level of the IMF, above the lower contour of the gland
Grade II Nipple below the IMF, above the lower contour of the gland
Grade III Nipple below the IMF and at the lower contour of the gland
Pseudoptosis Normal nipple position with glandular tissue below the IMF

IMF, inframammary fold.

Preoperative History and Considerations

Appropriate and thorough preoperative evaluation will allow the surgeon to select and plan a suitable operation. Choosing the proper technique begins with designing incisions based on scar placement and length. Minimizing scar appearance is fundamental to any operation in plastic surgery. However, scars should not be avoided if they are necessary to provide adequate and durable results. A balance must be accomplished between scar placement and efficacy because the final result will depend on the harmony of the breast shape and scar appearance.

The terms ‘short scar’ or ‘limited scar’ have been used interchangeably and applied to many different techniques. As a result, virtually any procedure that leaves a final scar shorter then the classic inverted-T has been classified as such. Explanation of these terms can be essential when counseling patients who are demanding minimal incision lengths and maximal results.

For each patient, the surgeon should develop a strategy for reshaping and positioning the breast parenchyma and determine the need, if any, for additional soft tissue augmentation with an implant or autologous flap. Breast shaping can be elaborate or simple and may include combinations of suturing, local flaps, muscle slings, or placement of internal mesh support.2–5

Combining augmentation with mastopexy can be accomplished safely for many patients. Clearly, adding an implant to an already complex operation will increase the number of variables that the surgeon must consider. Many women with ptotic breasts focus more on the loss of upper pole volume that has occurred as their breasts have aged, than on the change in nipple position that has accompanied it. An implant can be a very powerful tool in restoring youthful fullness to the upper pole.

Patient assessment

The initial consultation for mastopexy should include a detailed discussion of the patient’s goals and expectations and a careful review of medical and psychiatric histories. As with any breast surgery, a personal and family history of breast disease or cancer should be obtained. The surgeon should specifically note a history of any previous breast surgery or radiation therapy. Preoperative mammography is recommended for any patient who has significant risk factors and those over 35 years of age.

Prior surgical history should include previous augmentation or reduction procedures. When possible, operative notes detailing techniques and implant devices used should be reviewed. Information about past or planned pregnancies and changes in weight and/or brassiere size can also aid in preoperative assessment.

Preoperative planning and dimensional analysis

Management of patient expectations is crucial to ensuring satisfaction. The ideal breast aesthetic may vary greatly between patients and surgeons. Every attempt should be made to understand the patient’s motivations and anticipated results. Patients who are unrealistic or unwilling to accept the necessary scars should be avoided.

Preoperative physical exam should include measurements as well as an assessment of tissue qualities and distribution. Significant asymmetries will be noted in most patients when carefully examined.6 It is important to recognize and point out any pre-existing asymmetries, spinal curvature, or chest wall deformities because these may be difficult to correct and can become noticeable in the postoperative period. Preoperative photographs with multiple views are obtained on all patients and maintained as part of the office record.

Thorough palpation of the breast and axilla should be performed and documented. Any palpable masses or lymph nodes must be evaluated before proceeding with surgery. Measurements of breast width (BW), breast height (BH), intermammary distance, nipple to suprasternal notch (N : SSN), and nipple to inframammary fold (N : IMF) should be made and documented. Measurements can aid in planning the operation, recognizing asymmetries, and tracking postoperative results.

The soft tissue envelope should be characterized and the desired resultant breast form planned (Box 18.1). Once accomplished the surgeon can assimilate the information to select an appropriate implant, if desired, and plan the mastopexy approach. Use of the BioDIMENSIONAL® preoperative planning system (INAMED Corporation) can be used on patients requiring ptosis correction with augmentation.

Box 18.1 Steps in preoperative planning and dimensional analysis

• Careful analysis and measurement of the dimensions and shape of the existing breast
• Analysis of the character and evaluation of the adequacy of the soft tissue envelope
• Development of an anatomically well-defined goal for the breast shape after mastopexy or mastopexy augmentation
• Selection of the implant size, shape, height, width and projection to accomplish the individual patient’s goals
• Selection of the surgical approach (incisions) and implant location

Patient marking

Preoperative markings are made with the patient in an upright position and begin with:

• midline;
• current IMF;
• planned nipple position.

Additional marks, determined by the patient’s tissue characteristics, are then made as guidelines for resection.

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