New plastic surgery statistics released 3/31/14 by the American Society of Plastic Surgeons (ASPS) show that breast lift procedures are growing at twice the rate of breast implant surgeries. Since 2000, breast lifts have grown by 70 percent, increasing from 53,000 in 2000 to 90,000 in 2013 vs. only a 37% increase in breast augmentation surgery over the same time period. Breast implants are still by far the most performed cosmetic surgery in women, but lifts are steadily gaining. In 2013, 70% of these women were between the ages of 30 and 54.
At a young age the breast skin is taut and elastic and the ligaments holding the breast tissue to the chest wall are short and tight. With aging, exposure to gravity, weight changes and pregnancy the ligaments and skin are stretched and disrupted leading eventually to drooping sagging breasts, especially after breast evolution following pregnancy and breastfeeding feeding. Surgery to correct this drooping is termed a mastopexy or breast lift and involves surgery on the breast skin and / or deeper breast tissue. The pencil test is a simple way for a woman to assess if breast lift surgery could be beneficial. A pencil is placed under the breast. If the breast tissue holds the pencil in place against the chest that implies that there's a hanging nature to the breast that may be improved with a lift. In assessing these patients the surgeon needs to know the history of breast sizes with changes in weight or pregnancy, breast measurements (breast volume, amount of breast skin envelope filling, nipple position on the chest, distribution of breast tissue, skin quality and amount, areola size, amount of skin show below the nipple on standing and asymmetry / symmetry).
These patients want fuller upper breastoles with breast tissue completely above the breast crease and no skin scars. Many also do not want breast implants. This is clearly not possible but a variety of options with variable tradeoffs are available. Historically breast lifts were performed by only removing excess breast skin. This was associated with a high recurrence rate as the skin and scars stretched over time. In the 1990s Brazilian surgeons began to shape the breast tissue under the skin at the time of surgery in order to decrease these recurrence rates.
When designing the pattern of skin removal one of the surgeon's goals is to leave the patient with a round areola and no stray areola skin outside the confines of that round areola. The areola can be identified by tight suture closures after removal of the skin excess. Another goal is to increase the visible skin between breast fold and nipple when one is standing upright. This is particularly important in breast augmentation because only putting breastfeeding breast implants into someone without this skin show on standing will not result in a good appearance.
Breast lifts or mastopexies are frequently performed in conjunction with other breast procedures such as reconstruction after cancer surgery, breast augmentation and breast reduction with the removal of highly variable amounts of breast tissue. To improve symmetry different approaches are often employed for each breast.
Crescent Mastopexy is the removal of a crescent or half moon of skin anywhere along the edge of the areola on a portion of its circumference. The crescent can be only skin and / or can involve deeper tissues. The skin only type is mostly used to adjust nipple position at the time breast enhancement in order to improve breast symmetry. The crescent can be placed anywhere around the edge of the nipple complex so the nipple can be moved in any direction. If you place a breast implant without doing this asymmetry can be increased leading to an unhappy patient after surgery. The deeper tissue crescent removal is used to change the shape of the breast, to make a tuberous breast rounder. The deeper tissue removal can also be done with various patterns of skin removal to achieve the best result.
The main limitation to the procedure is areola distortion if the skin crescent width is too large. In most cases this limit is 1cm in width.
This procedure involves the removal of a donut of skin around the areola so it is also called a donut mastopexy or Benelli mastopexy.
Some years ago these were done cutting out large donuts and freeing up the skin down to the breast crease and up to the collar bone. Patients liked this approach because they felt a scar around the areola would be less visible but these aggressive circumferential metopexies were associated with multiple problems. The limit of the procedure is the outer edge of the donut can not be more than 1.5 to 2 times the circumference of the inner donut. If you exceed these dimensions the breast mound is flattened, the areola is stretched over time to an abnormal size, the scar thickens and widens so it is more noticeable and the outer edge skin can bundle up creating a corrugated cardboard or pleated appearance.
To maintain areola shape over time many surgeons place a round purse string suture in the surrounding edge of skin. This suture can pull through the tissue, break or poke through the skin losing its ability to maintain the areola shape. In case reviews this type of lift is associated with the highest rate of revision surgery.
Vertical mastopexy raises or lifts the nipple by removing an inverted triangle of skin between the nipple complex and the breast fold. When the triangle is closed the nipple is pushed upward.
The size of the triangle is limited by the tension of this lift to flatten the lower half of the breast with larger triangles.
- Y-scar Vertical Mastopexy
If the nipple is in a good position and the majority of the excess skin is in the horizontal plane a horizontal crescent combined with a vertical ellipse removal of skin results in a Y-scar vertical mastopexy.
The main use of this lift is to minimize skin surface scarring and avoid a horizontal scar in the breast fold. This lift however will not fill the upper half of the breast and the amount of skin that can be removed is very limited.
- Circumvertical Mastopexy – Lollipop Mastopexy
This approach combines a circumareolar with a vertical lift.
This is used most frequently in conjuction with breast enlargement in patients who do not have visible skin between the nipple complex and breast crease when standing. The lollipop lift removes an eccentric oval of skin around the nipple complex and the vertical limb of the lollipop ends somewhere between the nipple complex and the crease or in the crease itself, depending on the amount of nipple lifting required. The excursion around the nipple complex is subject to the same limitations as the circumareolar mastopexy. The nipple can not be lifted more than about 2 cm with this approach as the breast mound begins to distort with greater lifting.
The inverted T-mastopexy has been the work horse of breast lifts and breast reduction surgery for decades.
This skin removal pattern allows the removal of the greatest amount of skin with great amount of nipple lifting and gives the surgeon the greatest exposure to perform maneuvers on deeper breast tissue. The tradeoff is that it has the highest skin scar load of all the breast lift procedures.
This is the indicated method for breast lift surgery after large weight loss whether it is diet or weight loss surgery related and whether or not a breast implant is placed. Massive weight loss patients have severe breast tissue drooping and a lot of excess skin. This approach allows the removal of excess skin all the way to the sides of the torso.
This type of lift has the highest “bottoming out” rate compared to other types of lifts. Its occurrence is minimized by making the vertical limb of the T only 5 cm.
There are variations of this which result in L shaped skin closures / scars.They fall between inverted-T and vertical designs. Some surgeons like them but I have not found them to be useful in most cases due to the asymmetric removal of skin relative to the mid-breast axis.
- Parenchymal Fixation, Redistribution, and Autouation Techniques
As mentioned above the recurrence rates due to skin and scar stretching and incomplete filling of the upper half of the breasts associated with skin only procedures has lead surgeons to lifting procedures with manipulation of the breast tissue deep to the skin. These include suture fixation of the breast tissue to chest muscles, cutting into and redistributing breast tissue, inserting prosthetic absorbable or non-absorbable meshes to hold and shape the breast tissue, injecting fat from other areas of the body and creating slings of denuded skin from the excess that is otherwise removed that are sutured deep in the breast to hold and lift the tissue (laser bra lift). There have been no controlled studies that prove the superiority of these techniques over skin only procedures. Many of these originated in Brazil and I saw them when I was training there but gave them up after a short trial in the US as I felt that long term they did not do anything other than add to operating room time and the expense of the surgery . Stitches between breast tissue and chest muscle unexpectedly pull through the fat. Tongues of breast tissue that are dissected out and passed under the breast mound can die and therefore only result in a smaller breast. Absorbable meshes dissolve and any utility they provided disappoints shortly thereafter.
Recognizing this problem with breast fat sutures some surgeons have advocated punching a hole in the muscle and passing a tongue of breast tissue from under and behind the muscle to on top of the muscle. This is supposed to circumvent the problem of sutures pulling out of the breast fat but introduces the possibility of breast distortion when the muscle is activated.
There are many different ways to perform a breastfeeding lift and even more minor variations of those ways. What is effective in one patient will not be so effective in another. If you see 10 different plastic surgeons you will get 10 different answers as to what type of breast lift should be performed. It is even more complicated if you place breast implants for enhancement at the same time. That is because the marks on the skin for surgery are made before the implants are placed and it can be very difficult to plan surgery accounting for skin stretch after the implants are in place. These combined procedure patients therefore have a high rate of redo or revision surgery even in the best of surgical hands.
My preferred lift procedures are crescent, circumareolar, lollipop and inverted T depending on an individual patient's needs. I have not found the others to be beneficial in my patient population.