Breast Lifts (Mastopexy) & Breast Augmentation with Breast Implants

Sagging breasts, medically known as breast ptosis, is a bothersome condition to many women. The most common reasons for desiring correction include breast sagging which is a sign of aging and inability to go "braless". Essentially breast ptosis indicates that the breast is falling on the chest as well as rotating downward (see pre-operative example to the right). Plastic surgeons usually divide ptosis into degrees to describe various amounts of the descent of the breast.

The basic criteria for ptosis frequently accepted by most plastic surgeons looks at the relative position of the nipple areolar complex (NAC) and the fold under the breast known as the inframammary fold (IMF). Remember that the fold is essentially stationary as the breast is falling. Therefore, if the nipple areolar complex is above the level of the IMF there is no sag. When the NAC is at the same level or slightly lower than the IMF this is known as first degree ptosis. If the NAC is 2-3 cm below the fold this is second degree ptosis and if the NAC is lower and pointing toward the floor (rotated 90o) this is third degree ptosis. Other important relative measurements include the distance from the notch in the top of the sternum (breast bone) to the nipple and the distance from the areola to the IMF.

There are 2 other conditions that need to be mentioned and distinguished from ptosis. The first is an empty sac syndrome. Here there is a loss of volume of the breast while the skin envelope remains the same size. The breast appears empty and is often confused with ptosis, but the NAC and IMF are in the correct relationship. The procedure to correct an empty sac syndrome is to fill the breast with an implant. The second condition is called pseudoptosis. Here a large percentage of the breast volume is at or below the level of the NAC creating a hollow in the upper part of the breast. In this condition the relationship of the NAC to the IMF is acceptable and again the usual solution is an implant to acquire some volume in the part of the breast above the NAC. One important thought involves the common misconception that the placement of an implant will alleviate sag (the larger the implant the more sag that will be removed). Such is not the case.

The procedure used to correct breast ptosis is called mastopexy (breast lift). There are options for breast lifts, mastopexies. In general the operations will require that the NAC is relocated into the proper position and the extra skin is removed.

In the classic operation the NAC is lifted in the appropriate position by leaving it attached to the surrounding breast tissue with the outer layer of skin removed known as a pedicle. The pedicle is a bridge of tissue left intact for the purposes of maintaining blood supply. Removal of the excess skin either vertically and/ or horizontalinvolves excision of "darts" of skin. This process will result in a scar completely around the nipple, vertically from the nipple to the IMF and along the IMF. The scar will resemble the configuration of an anchor. This is called the inverted "T". This operation permits for a large amount of adjustability and can handle the most significant amount of ptosis. Obviously one of the major drawbacks to this procedure is the amount of scar present on the breast. The appearance of all scars is an individual characteristic related to your genetic makeup. There are variations of the inverted "T", for example, it is possible in situations with less vertical amount of skin to limit the scar to around the nipple and vertically from the NAC to the IMF thus resembling a lollipop.

The other major category of operations is known as a periareolar mastopexy because the scar is located only around the entire NAC. Essentially a ring of skin around the NAC is removed and gathered together similar to a purse string pocketbook. This procedure is somewhat limited in that it cannot be used with larger amounts ptosis, or excess skin. Also if the permanent suture breaks at any time and skin pulls back to the larger circle creating a giant areola necessitating the surgical placement of another "purse string" suture. Like the purse string pocketbook when you pull on the strings the pocketbook closes but the skin puckers as it gathers. This puckering can be permanent. Finally this procedure results in flattening of the cone of the breast as the pressure is applied to the NAC.

In cases where the NAC is a little low and there is minimal to no excess skin a crescent of skin can be removed from above the nipple. When approximating the edges of the crescent the NAC is positioned slightly more superiorly.

Remember that no mastopexy yields a permanent result. Similar to a facelift, a breast lift will eventually sag again. On the other hand the recurrent sag may take a long time to occur. If there is a desire to have a larger breast then an implant can be added to the surgery and performed at the same time as the lift. However, as noted above a mastopexy and augmentation are not interchangeable operations.

Many thanks to Gary M. Brownstein, M.D. of Cherry Hill, NJ for contributing this article.