Understanding Breast Uplift – Mastopexy

One of the commonest reasons for women to be disappointed with their breasts is due to breast tissue stretch, a low nipple position and loss of fullness. The low nipple position and loss of shape of the breasts does cause loss of confidence in one’s appearance. When there has been excessive stretch to the skin of the breast with descent of the nipple position, breast implants no longer provide the solution to improve shape. This is because they do not ‘undo’ the excess skin that is present, nor will they makle the nipples sit centrally on the front of the breasts facing forwards as opposed to downwards. This can only be achieved by cutting away the excess skin and repositoning the nipple (we do not need to cut the nipple off to do this, but rather we keep it attached internally and cut around it) on the breast mound.

Breast tissue tends to sag with increasing age- why?

• More common after child birth and breast feeding as the breast volume increases, the ligaments inside the breast stretch and the outer envelope of skin is stretched. Hormonal changes associated with pregnancy contribute to this process. After pregnancy and discontinuing any breast feeding the glandular tissue inside the breast shrinks (atrophy), usually to a lesser amount than before and the volume of the thicker glandular structures in your breasts therefore decreases. The ‘bag’ of skin that surrounds the breast tissue is now more flaccid and relatively under-filled. Under the influence of gravity the breast and the nipple position assumes a lower position. The degree to which this occurs is different in each individual. The consequences on your cosmetic appearance are therefore also different.
• Hormonal influences occur throughout your life, from a monthly menstrual cycle, to changes from the pill, and subsequent hormonal decline with the menopause, or the effect of surgery or some prescribed medication.
• Gravity has a constant effect. When running or exercising the forces on the breast tissue are magnified and you should always well a high impact bra. If you have large breasts you should also wear support at night.
• The internal breast ligaments (Cooper’s ligaments) stretch. These tiny ligaments are not visible to the naked eye but they run through the breast tissue. They stretch when your breasts enlarge and do not return to normal afterwards.
• The skin stretches with time. This is an ageing effect and due to hormones and volume changes in your breasts. The stretched skin causes the breast tissue to be less well distributed in the breast skin envelope. When it falls more into the lower part of the breast, the bottom of the breast becomes more redundant and sinks further below the level of the infra-mammary crease (this is the skin line directly under the edge of your breast where the cup of your bra rests). Because the nipple and areola are on the skin surface, they may become stretched (and get broader. They may descend further down the front of your chest as the breast descends such that they point more towards your feet and come to lie below the level of the infra-mammary crease.
• The medical term for breast sag is “ptosis”

What does a Mastopexy Involve?

• Mastopexy is an operation performed under general anesthetic. Incisions are made on the breast skin and cuts are made into the breast tissue and around the nipple areola structure. Depending on the type of mastopexy, surgery may be more or less extensive but it generally takes a few hours.
• Reshaping and lifting the breasts to produce a fuller, firmer bust where there is sufficient breast tissue to enable this.
• If you have relatively little breast tissue, the mastopexy will be predominantly removing loose skin only (dermo-cutaneous mastopexy) and will elevate the nipple position but there will not be a breast mound if there is insufficient tissue to create one- this is where some patients desire breast implants to be placed.
• Reduction in the areola size if needed
• Raising the height of the nipple so that it is optimized on the breast, facing forwards rather than downwards.

Mastopexy Options

Depending on the severity of breast sag, different techniques are used:

• Donut lift. This is also called a Benelli mastopexy or cirum-areola mastopexy. It produces a scar around the areola. It is generally suitable for minor sag only and allows only a little adjustment. I sometimes do this with breast augmentation where just a small elevation in nipple height on the breast is required. The scar around the areola may be more prominent. Sometimes the areola can stretch again and become broader but that is not common. You may feel the ridge from the suture material that is under the edge of the areola.
• Key hole lift or vertical scar mastopexy: Combines the donut incision with removal of a wedge of skin from between nipple and fold under breast. This is a reasonable option for minor sag but does not allow the full uplift achievable with the wise-pattern mastopexy technique.
• Wise pattern lift: For grade 1-3 sag. Anchor shaped scar (similar to the conventional breast reduction scar pattern) that goes around the areola (as for the Benelli), vertically down the front of the breast and fully across the breast crease under the breast. This gives the surgeon maximal control of symmetry, skin adjustment, reshaping and is optimal for patients with significant sag.
• Wise pattern mastopexy combined with Bra Lift. This is a simple technique that was described by a colleague and it involves a small additional procedure to create additional internal lift and it may reduce recurrent ptosis

• Uplift with implants
  • One needs to be more cautious about combining an uplift and implant placement at the same time. You need very careful assessment by Mr Turton. If the degree of sag is excessive, it is better to do an uplift first, wait 3-6 months, then present your self again for breast enlargement. Mr Turton finds he can produce a much better uplift if the surgery is staged in this way. Minor sag can be treated with uplift and implant surgery at the same time, but be aware the risks of complications are higher.
  • More information on this is in my FAQ page on Uplift.
• Implants alone- only suitable for filling out very minor sag. In all cases the nipples must be above the level of the infra-mammary crease otherwise the breast appearance is not good if a mastopexy is not done as well.
  • breast lift of 1-2cm might be achieved with full projecting implants
  • It won’t prevent recurrent sag
  • Sometimes the areola look bigger.
  • Sometimes the larger breast drop further.

How is breast sag measured?

Mr Turton carries out a detailed assessment of your breasts including specific reference measurements from your collar bones, and breast bone to the nipple, and from the nipple to the crease under the breast. We measure across the breasts and the position and orientation of the nipples. The level of the nipples in relation the crease are determined. The distribution of the breast tissue is assessed and the descent of the lower edge of the breast (the inferior pole) in relation to the crease is measured. The degree of tissue stretch is also checked.

How is it graded?

There are three grades of increasing severity:

Grade 1 Nipple level with the crease

Grade 2: nipple < 3cm below crease

Grade 3: nipple > 3cm below crease

Is it Safe?

• Breast Mastopexy takes between 1-3hrs depending on which method is used
• Complications are not common but as for breast reduction may include:
  • Minor delays in healing
  • With the key -hole lift it can take a while for the vertical scar to flatten
  • Very rare: <1 in 1000: the nipple blood supply can be compromised causing tissue loss
  • Please review the FAQ page on mastopexy for a more comprehensive discussion

Can it be combined with breast implants?

• Yes, but there are additional risk if this is done at the time of the mastopexy. See the FAQ page on mastopexy for a more comprehensive discussion
• It is preferable to wait 3-6 months
• If you are a smoker it is very important to completely abstain until properly healed.