A breast lift, also known as a mastopexy, is a procedure to raise and reshape sagging breasts.  As a woman ages, skin loses some elasticity which can cause the breasts to lose their natural shape and firmness.  This procedure is designed to elevate the breasts and give them a more youthful appearance.  A breast lift may also be completed in conjunction with breast enlargement surgery (augmentation).

Reasons for Considering a Breast Lift:

• Elevate the breasts due to sagging caused by the effects of aging and gravity.
• Firm the breasts if they have lost substance due to pregnancy and subsequent breast-feeding.
• Re-align your nipples/areolas if they point down or to the side.
• Bring back natural suppleness after weight loss.

General Procedure

The breast lift surgical procedure usually takes one and a half to three hours.  Techniques vary, but the most common procedure involves an anchor-like incision along the underside of the breast.  The incision goes around the area where skin will be removed, thus defining how the nipple will be relocated.  When the excess skin has been removed, the nipple and areola are moved into a higher position.  The skin surrounding the areola is brought down and together to reshape the breast.

Some patients, especially those with relatively small breasts and minimal sagging, may be candidates for modified procedures requiring less extensive incisions.  One such procedure is the "doughnut (or concentric) mastopexy" in which circular incisions are made around the areola and a doughnut-shaped area of skin is removed.  Recent innovations in breast lift techniques include minimal incision techniques and nipple sensation reducing procedures.

If the patient is having an implant inserted along with the breast lift, the implant will be placed in a pocket directly under the breast tissue or under the muscle of the chest wall.

Recovery Process

Generally, post-operative instructions call for plenty rest and limited movement in order to speed up the healing process and recovery time.  Bandages are applied right after surgery to aid the healing process and to minimize movement of the breasts.   Once the bandages are removed, the patient will need to wear a specialized surgical bra for several weeks.  Pain associated with this surgery can be treated with oral medication.  While complications are rare, patients can minimize potential problems by carefully following the post-operative directions given by the surgeon.
 
The following article was written to inform other types of doctors about the breast lift procedure.

      MASTOPEXY

The effects of pregnancy, weight fluctuation, and age commonly result in a lower position of the breasts. This drooping is referred to as “ptosis”, and it can refer to the position of the glandular tissue, the nipples and areolas, or both the glands and the nipple areas.  Ptosis is a natural process, and yet the resultant shape does not conform to our society’s youth-oriented ideal.
We encounter people who desire improvement of breast ptosis. Mastopexy is the term plastic surgeons use for “breast lift”.  This paper will outline some of the treatment considerations related to mastopexy.  I will not address concerns about breast size in this article.
 It is most important for the doctor to listen to and address the patient’s desires and concerns.  However, the patient also needs to understand what can realistically be accomplished.  And the doctor’s knowledge can contribute to the patient’s long-term satisfaction.  The doctor’s artistic skill and attention to detail can add finishing touches to the final result.  But the procedures are based upon measurements and facts, and this article will focus primarily upon these facts.
  A series of breast measurements in centimeters taken as ideal in 1949 is still often used as a general guide to attaining the result that most patients desire.   It should be noted that these are measurements of skin only (not breast volume).  Interestingly, normal skin thickness and elasticity is such that if breasts are designed to be much larger than ideal, (even if the patient is a large person) the weight of the breasts will likely result in recurrent drooping.   A youthful woman with approximately these breast measurements usually would wear a “C” cup sized bra.  Another general guideline is that relating to projection of the breasts from the chest, and this is easiest to do by comparing bustline to the chest circumference just underneath the arms.  (This is done while the woman is upright and wearing a bra.)  If the two measurements differ by one inch, the appropriate bra size would be an A.  If the difference is two inches, a B sized bra is expected (three in., a C; four in., a D; five in., a DD).  The above measurements apply primarily to women of average overall height and weight.  If the patient desires a change in breast volume, the amount of tissue to be removed (or volume of implant necessary) is related to the chest circumference as in established guidelines below:

 Chest Girth      Volume of tissue per bra cup size
     32-34in.          100cc
     36-38in.          200cc 
                                                                                       40-42in.          300cc
                                                                                       44-46in.          400cc

In addition to the above, there are guidelines as to the ideal areolar diameter (38 to 42 millimeters), and other details of breast slope and shape.
My approach begins with listening to the patient’s desires in terms of size and shape.  I then discuss the general of risks and possible complications related to mastopexy.  The patient is then examined and measured. These measurements are compared to the patient’s desired result.  Skin measurements exceeding the ideal measurements (with some adjustment related to height and weight) are usually incompatible with the patient’s desired long-term result, and some excess skin needs to be removed.  If the patient’s skin measurements are compatible with her desired size and shape, then augmentation with implants may give the best results.  As noted above, breast implants large enough to fill a skin envelope that is larger than the “ideal”, will probably result in recurrent ptosis (drooping).  Thus, size is the first issue.  If the current breast volume is reasonably close to the patient’s desires, I exhort the patient to avoid the “issues” related to breast implants, and to focus on shape and scar positions.  If the patient desires augmentation (enlargement), the concerns related to implants (not discussed in this paper) are reviewed in depth.  The next consideration is which method has the best balance of (1) production of the ideal shape vs. (2) minimizing scar length and visibility.  Unfortunately, these two goals are often at odds with each other.
If the areolas are larger than desired, if the positions of the areolas are close to the desired positions, and if there is not very much excess skin, then the excess skin can be removed around the areolas.  This is called a Binelli of “donut” mastopexy (Figure 3).  The resultant scar is around the areola only, and this results in the shortest scar possible for a mastopexy.  (But this scar is still more visible than the scar for breast augmentation.)  The downsides of this procedure are that (1) after surgery, the outer edge of the skin closure is pleated, due to the fact that a longer (outer) skin edge is approximated to a shorter (inner) skin edge.  This pleating smoothes in a few months, but the final scar will not be as narrow as it would be if there had been no pleating.  (The scar can be made more narrow in a subsequent procedure, often under local anesthesia.)  (2) The breast shape will flatten (be less conical) in proportion to the amount of skin removed with this technique.  (3) This technique requires placement of a circumferential “purse string” suture of non-resorbing material just beneath the skin (to prevent excessive stretching of the areola).  The consequence of this necessary suture is that the circumference of the areola cannot change significantly.  After healing, when the patient becomes cold, the areola will flatten, and when the patient becomes warm, the nipple and areola will protrude more.
 If somewhat more skin needs to be removed, or if more elevation of the nipple is desirable, a technique that results in a longer scar will be necessary (see drawing at right).  The advantages of this technique are that a more conical breast shape can be obtained, and it may be possible to avoid using the “purse string” suture.  The disadvantage of this technique is that it results in a vertical scar extending from the areola down to the fold beneath the breast, in addition to a circular scar around the areola.  This method can be combined with the Binelli method above, and/or with breast implants in order to take up more excess skin without resorting to an even longer scar.
 Often, it is necessary to remove more excess skin than can be accomplished with the above techniques.  In this case, the addition of a scar just above the crease beneath the breasts (inframammary fold) may be necessary (see below).                                                                                    The length of the horizontal part of the scar depends largely upon how much additional skin needs to be removed. This is called a “Wise pattern”  (after Dr. Wise, who developed it in consultation with a bra designer).  This method gives the most control over breast shape and nipple/areola placement. Unfortunately, the resultant scar is anchor-shaped, long, and sometimes tender.  This technique is often performed at the same time as removal of excess breast tissue (breast reduction).
 The above presents some basic information related to mastopexy techniques.  Additional methods are available, but each technique has relative indications and contraindications.  A plastic surgeon can inform prospective patients regarding the application of this information in specific cases.
 It should be apparent that the breast lift is a significant surgery, and that general anesthesia is nearly always necessary.  Interestingly, one would expect more postoperative pain than usually actually occurs.  Most patients can go home on the day of the procedure, unless a significant breast reduction or other operation is performed simultaneously.  A supportive, well-fitting, cup-shaped bra without an underwire must be worn during the healing period.  Regular check-ups are necessary to prevent excessive scarring.
 The risks and possible complications associated with mastopexy procedures are several.  Despite the best planning, the desired shape, size and symmetry may not be attained, and a second procedure may be necessary.   The larger and heavier the breasts, the more rapidly sagging will occur again.  Infection or excessive bleeding is possible after any type of surgery.  It is also possible for some of the breast skin or deeper tissue to become necrotic (i.e. dead skin and/or deeper tissue), which can result in an open wound that is slow to heal.  Loss of sensation to the nipple can also occur.  It is possible to lose the ability to nurse.  Slowly dissolving sutures are placed beneath the skin, and these can come to the surface, or even become infected, weeks or months after the surgery.  The above risks are more common with breast reduction, and risks increase in proportion to the amount of tissue removed.
 As with other types of cosmetic surgery, it is evident that there is no magic.  The decision to proceed with surgery, and choosing the best operation, is individual.  The above information should help to provide a basis for realistic and appropriate decision-making.

References:
1. Penn J:  Breast Reduction.  Br J Plast Surg 4:13, 1949
2. Regault P and Daniels RK:  Aesthetic Plastic Surgery.  Principles and Techniques.  Boston, Little Brown1984. Ch 21, pp499-538
3. Wise RJ: A preliminary report on the method of planning the mastopexy.  Plast Reconstr Surg 17:367 1956