Mastopexy

Published on 22/05/2015 by admin

Filed under Plastic Reconstructive Surgery

Last modified 22/05/2015

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Chapter 18 Mastopexy

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

Indication

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.25

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.

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.