New plastic surgery statistics released on March 31, 2014 by the American Society of Plastic Surgeons (ASPS) show that breast lift procedures are growing at twice the rate of breast implant surgeries. Since the year 2000, breast lifts have grown 70%, from 53,000 in 2000 to 90,000 in 2013 vs. 2013, just a 37% increase in breast augmentation surgery over the same time period. Breast implants remain by far the most performed cosmetic surgery on women, but lifts are steadily winning. In 2013, 70% of these women were between the ages of 30 and 54.
At a young age, the skin of the breast is tight and elastic, and the ligaments that attach the breast tissue to the chest wall are short and taut. With aging, exposure to gravity, weight changes, and pregnancy, the ligaments and skin stretch and tear, eventually leading to sagging breasts, especially after breast involution after surgery. pregnancy and lactation. Surgery to correct this sagging is called a mastopexy or breast lift and involves surgery on the skin of the breast and/or deeper breast tissue. The pencil test is a simple way for a woman to assess whether breast lift surgery might be beneficial. A pencil is placed under the breast. If the breast tissue is holding the pencil in place against the chest, it implies that the breast has a pendulous nature that can be improved by a lift. When evaluating these patients, the surgeon should be aware of the history of breast size with weight changes or pregnancy, breast measurements (breast volume, amount of filler in the breast skin envelope, position of the nipple on the chest, distribution of breast tissue, quantity and quality of skin, areola size, amount of skin showing under the nipple when standing up, and asymmetry/symmetry).
These patients want fuller upper breast poles with breast tissue completely above the breast crease and no skin scarring. Many also do not want breast implants. Clearly this is not possible, but a variety of options with variable offsets are available. Historically, breast lifts were performed by removing only excess skin from the breast. This was associated with a high recurrence rate as the skin and scars stretched over time. In the 1990s, Brazilian surgeons began to contour the breast tissue under the skin at the time of surgery to decrease these recurrence rates.
When designing the skin removal pattern, one of the surgeon’s goals is to leave the patient with a round areola and no loose skin outside the confines of that round areola. The areola can be distorted with tight sutures after excess skin is removed. Another goal is to increase the visible skin between the breast crease and the nipple when one is standing. This is particularly important in breast augmentation because just placing breast implants in someone without this skin visible when standing is not going to result in a good appearance.
Breast lifts or mastopexies are often performed in conjunction with other breast procedures, such as reconstruction after cancer surgery, breast augmentation, and breast reduction with the removal of widely varying amounts of breast tissue. To improve symmetry, different approaches are often used for each breast.
SURGICAL OPTIONS
- Crescent mastopexy
Crescent mastopexy is the removal of a crescent or crescent of skin anywhere along the edge of the areola on a portion of its circumference. The crescent may be just skin and/or may involve deeper tissues. The skin-only type is mainly used to adjust the position of the nipple at the time of breast augmentation to improve the symmetry of the breast. The crescent can be placed anywhere around the edge of the nipple complex so that the nipple can be moved in any direction. If a breast implant is placed without doing so, this asymmetry can increase leading to an unhappy patient after surgery. Deeper tissue crescent removal is used to reshape the breast, to make a tuberous breast rounder. Deeper tissue removal can also be performed with various skin removal patterns to achieve the best result.
The main limitation of the procedure is distortion of the areola if the width of the skin crescent is too great. In most cases, this limit is 1 cm wide.
- Circumareolar Mastopexy
This procedure involves the removal of a donut of skin around the areola, which is why it is also called a donut mastopexy or Benelli mastopexy.
A few years ago these were made by cutting large donuts and releasing the skin down to the crease of the breast and down to the clavicle. Patients liked this approach because they felt a scar around the areola would be less visible, but these aggressive circumferential mastopexies were associated with multiple problems. The limitation of the procedure is that the outer edge of the donut cannot be more than 1.5 to 2 times the circumference of the inner donut. If it exceeds these dimensions, the breast mound flattens, the areola stretches over time to an abnormal size, the scar thickens and widens to be more noticeable, and the skin on the outer edge may bunch up creating a cardboard appearance. corrugated or pleated.
To maintain the shape of the areola over time, many surgeons place a round purse-string suture on the surrounding edge of the skin. This suture can break through the tissue, break or puncture the skin, and lose its ability to hold the shape of the areola. In case revisions, this type of lift is associated with the highest rate of revision surgery.
- Vertical Mastopexy
Vertical mastopexy elevates or elevates the nipple by removing an inverted triangle of skin between the nipple complex and the breast crease. When the triangle is closed, the teat is pushed up.
The size of the triangle is limited by the tendency 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 most of the excess skin is in the horizontal plane, a horizontal crescent combined with a vertical ellipse skin removal results in a vertical Y-scar mastopexy.
The primary use of this lift is to minimize scarring on the skin’s surface and to avoid a horizontal scar in the breast crease. However, this lift 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 most often used in conjunction with breast augmentation for patients who do not have visible skin between the nipple complex and the breast crease when standing. The lollipop lift removes an eccentric oval of skin around the nipple complex and the vertical branch of the paddle ends somewhere between the nipple complex and the crease or in the crease itself, depending on how much nipple lift is required. . Excision around the nipple complex is subject to the same limitations as circumareolar mastopexy. The nipple cannot be lifted more than about 2 cm with this approach, as the breast mound begins to distort with further lift.
- Inverted T mastopexy
The inverted T mastopexy has been the workhorse of breast lifts and breast reduction surgery for decades.
This pattern of skin removal allows for the removal of the greatest amount of skin with the greatest amount of nipple lift and gives the surgeon the greatest exposure to maneuver into the deeper breast tissue. The tradeoff is that it has the most skin scarring of all breast lift procedures.
This is the method of choice for breast lift surgery after major weight loss, whether it is related to diet or weight loss surgery and whether or not a breast implant is placed. Massive weight loss patients have severely sagging breast tissue and a lot of excess skin. This approach allows the removal of excess skin up the sides of the torso.
This type of elevator has the highest rate of “bottoming out” compared to other types of elevators. Its occurrence is minimized by making the vertical branch of the T only 5 cm.
There are variations of this that result in L-shaped skin closures/scars. They fall between inverted-T and upright designs. Some surgeons like them, but I have not found them to be useful in most cases due to the asymmetrical removal of the skin in relation to the mid-axis of the breast.
- Techniques of fixation, redistribution and autoaugmentation of the parenchyma
As mentioned above, recurrence rates due to skin and scar stretching and inadequate filling of the upper half of the breasts associated with skin-only procedures have led surgeons to tissue-manipulative lift procedures. deep mammary to the skin. These include suture fixation of the breast tissue to the chest muscles, cutting and redistributing the breast tissue, inserting absorbable or non-absorbable prosthetic meshes to support and shape the breast tissue, injecting fat from other areas of the body, and creating skin slings. Denuded from the excess that would otherwise be removed is sutured deep into the breast to support and lift the tissue (laser bra lift). There have been no controlled studies demonstrating the superiority of these techniques over procedures that only affect the skin. Many of these originated from Brazil and I saw them when I was training there, but left them after a short trial in the US. The points between the breast tissue and the pectoral muscle ultimately extract the fat. Tongues of breast tissue that are dissected and passed under the breast mound can die and thus only result in a smaller breast. Absorbable meshes dissolve and the usefulness they provided disappears after a short time.
Recognizing this problem with breast fat sutures, some surgeons have advocated drilling a hole in the muscle and passing a tongue of breast tissue from below and behind the muscle to the top of the muscle. This is supposed to avoid the problem of sutures pulling out of the breast fat, but presents the possibility of breast distortion when the muscle is activated.
There are many different ways to perform a breast lift and even minor variations on those ways. What is effective in one patient will not be as effective in another. If you see 10 different plastic surgeons, you’ll get 10 different answers about what type of breast lift should be done. It is even more complicated if you place breast implants for augmentation at the same time. This is because the skin markings for surgery are made before the implants are placed and it can be very difficult to plan the surgery taking into account the stretching of the skin after the implants are placed. Therefore, these combination procedure patients have a high rate of reoperation or revision surgery, even in the best surgical hands.
My preferred lift procedures are crescent, circumareolar, lollipop, and inverted T, depending on the individual needs of each patient. I have not found the others to be beneficial in my patient population.
