Mastopexy with concurrent breast augmentation

Breast lift (Mastopexy)

A breast lift, or mastopexy is an option for women who are concerned about breast shape changes. They may be unhappy with drooping or the way their nipples and areola point downwards. In many cases this has occurred following breast feeding or following significant weight loss. Tubular breasts may also be lifted.

There are many types of mastopexy and the technique used will depend on how much excess skin needs to be removed, if the areola needs to be narrowed or lifted to a higher position and whether a small implant is also used. The type of scar varies depending on the technique used and Mr Davis would show examples of likely scars for the technique that is most appropriate.

A mastopexy does not change breast volume, although for reasons discussed below, the bra cup size may decrease. If more volume is desired then a breast implant can be added at the same (or a later) procedure.

To learn more about breast lifts and see the gallery of before and after photos visit my website dedicated to breast surgery. www.breast-surgery.co.nz

Frequently asked questions

General questions

The cost of a mastopexy varies depending on the surgical time likely to be needed. This is different for everyone. In some cases implants are also used. Costs can range from around $15,000 under general anaesthetic up to $16,500 if implants are required. Costs are less if areolar repositioning is not required because of the decreased theatre time. Some cases are suitable for local anaesthetic and the costs are then less than half of this. Costs are also less if surgery is combined with other procedures such as an abdominoplasty (tummy tuck) because of the shared costs.

A fixed cost is given after a consultation once the likely theatre time and special consumables are known. We are happy to review photographs before a consultation to give a fairly accurate range of likely costs based on recent cases.  Please either email us or phone us on 0800 268 526.

The quoted cost for surgery covers everything including anaesthetist fees, theatre fees, consumables, staying overnight in hospital after surgery, any additional consultations after the first consultation and all the follow up for dressings and checks in the first year after surgery. This cost includes GST.

If you are sending photos for a cost estimate, please include views from the front, 45 degrees and side on. It is ideal if your arms are by your side.

Examples of Mr Davis’ work can be seen at www.breast-surgery.co.nz. Examples of incisions in the first few weeks after surgery are shown during the consultation. Specific examples of anatomic variations may also be shown during a consultation where appropriate.

Breast ptosis refers to the sag or droop of the breast gland. Surgeons recognise different grades of severity (the Regnault classification).

  1. The nipple has dropped to the level of the inframammary crease
  2. The nipple has dropped below the level of the IMF
  3. The nipple points downwards
  4. Pseudoptosis. The nipple is high but the breast gland in the lower pole has dropped.

Most women have mastopexy to change the shape of their breasts. In addition to shape changes, some women would like to have firmer breasts. Changes in shape are easier to achieve that increasing the firmness of breast tissue. Once the swelling has settled after surgery, the breast tissue will return to its usual density but may feel firmer in some instances if the overlying skin is pulled tighter. However this is not predictable. Breasts may be less likely to fall out of loose fitting bras when leaning forward after a mastopexy.

If your areolae are very wide, they will be reduced during surgery. A standardised width of just over 4 cm is typically used.

If someone has droopy breasts then it is likely they have an underlying loss of elastic recoil of their breast skin and underlying breast tissue that does not hold its shape. A mastopexy cannot change the breast skin quality or elasticity.

A mastopexy works by removing a large amount of the breast skin. Excising redundant skin tightens the breast envelope. It can be thought of as tightening a cone.  However a mastopexy cannot change the breast skin quality or elasticity.

Mastopexy cannot change the firmness of the underlying breast tissue

Mastopexy cannot permanently hold breast tissue high in the upper pole. A small implant can be added to create this fullness if desired.

No matter how lifted a breast is, the remaining skin will relax over time and some future loss of the initial shape is normal and expected.

A combined mastopexy and breast augmentation procedure can be challenging due to the unpredictable nature of breast shape change after the operation and the need to over compensate for these changes.

It is important that patients have realistic expectations about what mastopexy can achieve. A mastopexy will give the breast a more lifted look. It will lift nipple-areolar complex if it has dropped. It can create tighter breast skin, although this will eventually soften somewhat. However a mastopexy cannot create firmer breast tissue. Immediately after surgery, the breast tissue will be quite firm. But once surgical swelling has settled, the tissue will soften to its previous texture, albeit in a more lifted position and with a tighter overlying skin envelope.

The only way to create a firm breast in the presence of “soft” breast tissue is to remove the breast gland and replace it with an implant. This is a hypothetical suggestion except in the case of breast cancer.

After a vertical mastopexy, the upper pole of the breast will usually be relatively full. However it will drop. Even the most experienced breast surgeons have described their frustration at being able to maintain upper pole fullness in the long term by rearranging the breast gland architecture. Sometimes placing a small implant may be appropriate. This will help give upper pole fullness even when not wearing a bra. However this has to be balanced with all the long term considerations of having a breast implant which is discussed elsewhere on this site.

Most breasts have subtle asymmetries however it is also common in my practice to see breasts that are a cup size different in volume between sides, different nipple heights or quite different shapes between sides. Surgery will be adapted to balance any asymmetry and significant improvements in symmetry should be seen. However minor asymmetries are still possible.

Some causes of asymmetry are unable to be changed especially if they related to a twist of the spine, different forward projections of the rib cage or shoulders naturally held at different heights. Breasts are very unlikely to be perfectly symmetric after surgery.

During surgery

There are many different types of mastopexy. After examining your breasts the most appropriate procedure recommended will be discussed with you in detail along with the rationale for this choice.

There are three main techniques used when performing mastopexy:

  1. Vertical gland plication
  2. Wise pattern skin tightening
  3. Peri-areolar tightening.

The vertical gland plication is the main technique that I use. This is a technique that evolved in France and across Europe and more recent modifications have been made in Canada. Some of the more famous surgeons names associated with vertical plication techniques are: Claude Lassus, Madeline Le Jour, Daniel Marchac and Elizabeth Hall-Findlay.

The advantages of the vertical technique is the breast gland tissue itself is modified in shape to produce a cone shape, the breast shape tends to hold itself more securely over time with less “bottoming out than skin tightening techniques and the inframammary crease scar can be minimised or not used at all.

The disadvantages are that the techniques is more complex and there is a learning curve, an inframammary crease scar is still required after massive weight loss cases, and late revision of the skin envelope under local anaesthetic is still needed in about 10% of cases.

The Wise pattern refers to the W-shaped pattern of skin incision that leaves a scar around the nipple and vertically down to the inframammary crease (like the vertical mastopexy) but also leaves a scar running along the inframammary crease. Essentially the skin is cut out and reshaped like a bra. I  use this technique when performing mastopexy for massive weight loss patients who have very poor tissue recoil.

The advantage is that the initial result looks very good but because of the increased likelihood of bottoming out with time I use the vertical gland plication technique in other cases.

A periareolar mastopexy is performed using an incision around the areolar only. This can be a useful technique for minimal drooping. However it is not suitable for large amounts of skin redundancy as the breast tends to be flattened as the suture is tied around the areola, the skin will have more ripples and both the scar and the areolae can widen with time.

The Benelli technique is a common peri-areola technique and a number of modifications have been described with de-epithelialised dermal pedicles to decrease scar stretch. I rarely see cases for which this technique is suitable.

To date I have not used mesh techniques. They involve the use of synthetic or biologic meshes around the breast gland as a cone or as a sling beneath the breast (but under the skin). The Goes technique is one well-known mesh technique. Mesh techniques were devised to maintain breast shape however the mesh could become exposed or infected or suffer other foreign body related complications.

After surgery

After surgery

Some women who tell me they wear an E-cup bra, actually only have a B-C cup of breast tissue. Sometimes none of the breast tissue is over the breast base on the chest wall. When they lift all their breast skin they fill a larger bra than their true cup size.

The excess skin is removed at surgery, but no breast gland tissue is removed. They will then usually fit a smaller cup sized bra. This phenomenon is important when considering whether you are happy with breast volume before surgery and considering whether an implant will be required.

The shape of breasts will continue to change for at least 6 -9 months after a breast lift/ mastopexy. This aspect is not well discussed in the NZAPS information brochure I give my patients to read about breast lift surgery. As the internal swelling settles and scar tissue softens, the breasts will drop.

Regardless of the procedure performed, breasts will drop after surgery. I over-elevate the breast gland in anticipation of some drooping in months after surgery. If the breast shape looks perfect after surgery, then I have not elevated it enough!

People requiring mastopexy tend to have poor elastic recoil of their skin.

6 months after a mastopexy when everything has softened there will be some breast droop. In about 10% of cases there will be more breast droop than is ideal. This is more likely in patients who have had massive weight loss.

If this occurs I can further tighten the breast skin envelope under local anaesthetic, using the same scar. There is no surgical fee for doing this however there is a small charge for the theatre fee and any consumables used.

Temporary breast and nipple sensation change after a mastopexy is common. Very rarely this can be permanent. It can take up to a year or more after surgery for sensation to recover as much as it is going to.

The potential risk of decreased sensation varies with the type of mastopexy technique used and I will discuss this with you depending on the technique selected. The importance of erogenous sensation in the nipple region is different for everyone but if it is very important for you, then it is essential to be clear about the risk of sensory change after surgery. It is rare to have completely numb nipples a year after surgery but this is possible. Usually sensation in the upper part f the breast is back to normal within a few weeks.

I will show you photos of other patients of mine at the consultation to illustrate the typical range of scars and how these change over time.

The location of scars will vary depending on what type of breast lift is required. Most people have a vertical scar running from the lower areola to the inframammary crease beneath the breast. If the areola needs to be lifted into a new position, there will be a scar around the areola. Some people refer to the combination of these 2 scars as the “lollipop scar”. In some cases the scar around the areola is the only scar required.

Because of the vertical mastopexy techniques I use, the transverse horizontal scar along the inframammary crease may not needed, or if it is, it is only a few centimeters long. This is sometimes referred to as the “anchor” scar. However the long horizontal scar is now rare is my practice and is reserved for cases of extreme skin excess for instance after massive weight loss.

It is possible to do a scar only around the areola, a so called “peri-areolar” or Benelli mastopexy. I rarely do this because there is puckering around the areola which stretches over time. Because of the vectors of tension the breast looks flat rather than perky. Ongoing droop over time is more likely than if  vertical scar is used to remove much more lower pole skin.

The risks

The main complications after mastopexy include:

  • Shape change – ongoing over time
  • Scars
  • Sensation change
  • Asymmetry
  • Volume changes
  • Unrealistic expectations.

Despite the potential complications, most patients are very happy that they can walk around home topless (or with a very light bikini top at the beach) and their breasts now sit in a much more youthful position without the help of a bra to keep them in place.