Some patients desiring Breast Enhancement have breast tissue that is loose and saggy. The medical term for this condition is Breast Ptosis. This may be a consequence of advancing age, pregnancy, nursing and/ or weight fluctuations. Breasts progressively hang lower on the chest with loss of upper breast projection (perkiness), elongation and flattening. In some cases, the nipples point straight down. These changes are also common in patients with naturally large breasts.
The basic problem with ptotic (saggy) breasts is that there is too much skin for the amount of breast tissue present. Additionally, the nipple may reside too low on the chest wall. With mild stages of breast ptosis, a breast implant may be all that is needed. However, in many women, the breast has fallen too far down the chest to allow an implant to give an aesthetically pleasing result. In these women, some form of breast lift (Mastopexy) is indicated. In this situation, a simple breast augmentation would result in the implant residing in the normal location with the nipple appearing to have slipped off the front of the breast. Some doctors may suggest placing the implant above the muscle to minimize this appearance. It may work. However, all too often what results is a “rock-in-a-sock” appearance. In my opinion, this is totally unacceptable. It is also very difficult to fix and may require multiple operations to improve.
When natural breasts are large, similar changes to the skin and nipple position usually occur. The techniques of Breast Reduction and Mastopexy are similar with the exception that in Reduction, breast tissue is removed to fashion a more pleasing size and shape. Reduction may also relieve symptoms of neck and back pain.
Because of the anatomical changes described above, Mastopexy and Breast Reduction procedures are designed to remove the extra skin (+/- the extra breast tissue) and reposition the nipple. One of the consequences of doing this is a visible and permanent scar on the breast. This is a real compromise (a scar versus a saggy and/ or large breasts). Although many scars will heal with little visibility, if a scar is completely out of the question, you are not a candidate for mastopexy, period. The only exception is in patients that have a small amount of enlargement that can be improved with liposuction alone. As common sense would predict, this usually worsens any ptosis and produces a more saggy and bottomed-out breast.
The classic technique of Mastopexy and Breast Reduction requires a scar that resembles an “anchor.” This scar is located around the areola (pigmented part around the actual nipple), down the front of the breast and along the fold under the breast. Most Plastic Surgeons continue to use this technique because it can give a reliable and safe result. It is still the gold standard for comparison within the Plastic Surgery community and many excellent results have been achieved. With the Anchor Technique, skin is removed so as to create a new “skin brazier” which holds the breast tissue in place. Relying on the skin for the result can be a negative because, after all, what caused the problem in the first place was the stretchy skin. Because of this fact and the resulting large scar, newer methods of “Minimal Scar” Mastopexy evolved that may offer a better option. Not all women are candidates for these techniques, but many are.
In selected cases of women desiring enlargement and mastopexy, the scar can be limited to around the areola. This technique is called a Doughnut or Binelli Mastopexy after Louis Binelli, the French Plastic Surgeon who described it. In essence the procedure is done is by removing a doughnut-like circle of skin from around the areola and leaving the nipple attached. This allows for placement of the implant and can lift the nipple up to 1 inch.
In women who desire to lift their natural breasts into a more youthful position and contour, a third technique, called Lejour Mastopexy (Verticle Mastopexy) after the Belgian Plastic Surgeon Madeline Lejour, may be the best option. This technique differs from the others in that the result is not dependent upon the breast skin. In this technique, the breast tissue itself is molded with sutures into a new natural shape. The scar can usually be limited to around the areola and down the front of the breast (“lollipop”). Also, the result can be more natural and last longer. Because of these factors, the Lejour technique is my preferred method for correcting breast ptosis in those not desiring enlargement and in those women needing moderate amounts of reduction.
Mastopexy is performed as an outpatient and patients can usually return to work in 5 to 10 days.