Mastopexy or Breast Lifting Procedures
Ptotic, or droopy breasts are a real concern for many women. Weight loss, a severe diet program, pregnancy, and breast-feeding can all contribute to the development of droopy breasts. Women with pendulous or droopy breasts of satisfactory, comfortable size are good candidates for a breast lift. The problem may be that the breasts lack substance or firmness, nipple areolae point downward, and nipple position is below the breast crease. The “pencil test” is a good way to determine eligibility—if a woman places a pen or pencil underneath her breast and the item stays in place without assistance, she would benefit from a breast lift.
The most common patient is one who has had two children and has breast-fed them. After pregnancy and breast-feeding, the top half, or superior aspect, of the breast loses some of its fullness due to involution of breast tissue. Some patients are luckier than others and actually develop fuller breasts after pregnancy, but this is rare. Breast-feeding is extremely important for the baby, and no woman should avoid this important part of the nurturing process just because it might affect the appearance of her breasts.
The most common breast lift operation is the mastopexy/breast lift. It involves repositioning the nipple areolar complex to a location higher on the chest wall. The incisions are located around the nipple areolar complexes. This operation is usually performed with the patient under general anesthesia or heavy IV sedation. It can be done as an outpatient procedure in a hospital operating room or in a physician’s operating room, and it takes approximately three hours.
Some patients will have lost quite a bit of breast fullness and may require the placement of silicon breast implants in addition to the lift. In this case, the lift is performed in the usual way, and the implants are placed most often underneath the muscle.
There are several degrees of ptosis: type 1, the minimal ptosis requiring only a breast implant; type 2, where the nipple areolar complex is approximately two centimeters below the inframammary crease and requires a small circumareolar lift; and type 3, which is depicted by a patient who has a much more ptotic breast and possibly loss of fullness at the same time, and will most likely require a formal lifting procedure either with an implant or by itself; and the patient with significantly ptotic breasts who needs a full breast mastopexy/breast lift incision or an anchor-type incision. Your plastic surgeon may also categorize your breasts in terms of “mild,” “moderate,” or “severe” ptosis, and based on that evaluation, decide what type of operation will be necessary to place your nipple areolar complex in the correct location on each breast.
Occasionally, other types of breast lifts will be recommended, depending on the degree of ptosis. These techniques include the “crescent” mastopexy/breast lift for mild ptosis and the circumareolar technique also for mild ptosis; the vertical scar technique for moderate ptosis; and the vertical technique (anchor incision) for the severe or major ptosis.
Once a procedure is chosen, I describe it in detail to the patient and explain that her incisions will be red and noticeable for up to a year, and sometimes longer. If a patient’s expectations are realistic, she will be satisfied with her results.
WHAT AGE IS APPROPRIATE TO PROCEED WITH A BREAST LIFT?
A breast lift can be performed at any age, but plastic surgeons usually recommend that once breast development has stopped is a perfect time to proceed with a breast lift if it is considered necessary. If patients are interested in having children first, a breast lift can be performed after pregnancy; however, if patients are extremely concerned about ptotic or droopy breasts prior to pregnancy or having children, a breast lift can be performed without impacting breast-feeding. The milk ducts and nipples are left intact, and the breast lift surgery usually does not affect your ability to breast-feed. Details such as this will be discussed with your plastic surgeon prior to your procedure.
Most breast lift surgeries are considered cosmetic surgeries and are not usually covered by the insurance companies. Occasionally, if a patient has a breast reconstruction on one side and the opposite breast is ptotic or quite droopy, a left breast mastopexy/breast lift will be performed to improve the appearance of both sides. This will usually be covered by insurance.
GETTING READY FOR THE SURGERY
Once you’ve consulted with a plastic surgeon, there are some things about mastopexy/breast lift that you need to consider. First and foremost, the procedure that you have discussed with your surgeon will improve the appearance of your breasts, and they will be higher on your chest wall. You may consider breast augmentation to create more fullness and ultimately give a better shape and look to the breast. Your clothes will fit better as the contour of your body reveals the improvement, and this will be especially noticeable in lingerie and swimwear.
It is most important to understand that there will be incisions as depicted and outlined in the figures, as well as in the before-and-after plastic surgery pictures. The majority of patients heal very well following this procedure, but occasionally there may be some incision irregularities, in which case touch-up procedures or scar revisions will have to be done. In some cases, tattooing can improve the appearance of the nipple areolar complex.
If implants are to be used, it’s best if the patient brings in photos with pictures of the size and shape of breasts she wants. This helps the doctor understand precisely what the patient expects.
Once the procedure is chosen, the patient will be scheduled for a preop appointment approximately ten days to two weeks prior to the surgery. At that time, I answer all questions, take pictures, and confirm that the patient is healthy. Smoking is contraindicated. There can be problems with blood supply to the nipple areolar complex, and this can occur when patients smoke or even are near secondhand smoke. Secondhand smoke is responsible for 50 percent of complications in patients who experience problems following surgery.
The actual operation will take place either in a hospital setting, an outpatient surgery center, or the doctor’s personal operating room. The patient will meet with the anesthesiologist, surgeon, and nursing staff prior to the procedure. The surgeon will mark the proper position of the nipple areolar complex and do markings with the patient in a sitting position. This is the position the breasts will ultimately be in when she stands up. Markings done on the patient who is in a lying down (supine) position will give inappropriate position changes for the nipple areolar complex.
Following this, the patient is brought back to the operating room, an IV is started, and anesthesia, either IV sedation or general anesthesia, is administered. The operation continues with the removal of excess skin and lifting of the breast tissue up into the proper location. Saline implants are used most often when this is part of the surgery. They are slipped underneath the muscle through one of the access incisions that was used for the lift. The actual placement of the implants will help lift some of the tissue as well, and this needs to be considered when designing the breast lift prior to the procedure. All of this is followed by the closing of the incision lines in layers. I usually use a subcuticular suture ( a closing which is buried underneath the skin) similar to the type used with a breast reduction. Following the procedure, I may or may not use little tiny drains. If used, the drains are usually removed within the first twenty-four to forty-eight hours. Following this, a sterile dressing is applied.
THE POSTOPERATIVE PERIOD
The dressing is removed, as are any drains, during the postoperative follow-up visit on the first or second day. I see my patients frequently, generally within the first twenty-four to forty-eight hours. The doctor generally checks the nipple areolar complex to make sure that its color is a robust pink, and that it has an excellent blood supply. Occasionally, patients may have problems with the blood supply to the nipple areolar complex, but this is extremely rare. Again, smoking, if an issue, can affect the blood supply to the nipple areolar complex, and we recommend discontinuing smoking at least two to three months prior to the procedure.
With regard to the incisions and breast symmetry following the procedure, there may be slight differences between the two breasts. If so, the plastic surgeon will perform a small touch-up procedure to help reposition the nipple areolar complex as necessary. Minor adjustments can be made at a later time. Permanent loss of sensation in the nipples or breast skin is very rare.
After the operation, expect to be a little uncomfortable for a few days. Your doctor will usually recommend that you wear a bra or have a special dressing in place to provide the support you will need during your recovery. I sometimes ask my patients to wear a supportive Miracle Bra or push-up bra that helps keep everything in place, twenty-four hours a day, for at least four to six weeks. For the first week, you require pain medication. I routinely prescribe antibiotics as well. Your surgeon may have placed drains that need to be removed the second or third day. If implants were placed, you will need to be careful to avoid impact-to-the-chest-type activities, as this may cause rupture of the implant.
Within two to three weeks, all sutures are removed. The size and shape of the breast continues to get better and better as time proceeds. Following the procedure, it is very important to limit activity and maintain a calm environment while at home during recuperation. If patients have small children, I inform them that they are not allowed to do any lifting or reaching with their arms. I suggest that a patient either has her children sit beside her on the sofa, or that she sits on the floor next to her child. Heavy lifting is not permitted for at least four to six weeks following the procedure.
UNDERSTANDING THE RISKS FOLLOWING A BREAST LIFT
Complications following breast lifts are relatively uncommon. The main three are bleeding, infection, and scarring. We have discussed the complications of bleeding and infection at length in other chapters, and what to do preventively: to reiterate, make sure that you are off aspirin-containing products, be sure that your blood pressure is under control, and take antibiotics as necessary.
WILL I EVER NEED A MASTOPEXY/BREAST LIFT AGAIN IN THE FUTURE?
It maybe possible that you’ll require another mastopexy/breast lift. Time moves on. Gravity and the aging process will continue to take their tolls on your body. Sometimes a repeat mastopexy/breast lift will be necessary as a “touch-up” procedure to improve the overall look, but a full-length procedure will usually not be required.