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.

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. A fixed cost is given after a consultation once the likely theatre time and special consumables are known. We would be happy to advise of the 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.

Examples of Mr Davis’ work can be seen at www.breast-surgery.co.nz. 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 the areolae are very wide, they will be reduced during surgery.

Mastopexy cannot change the breast skin quality or elasticity. Excising redundant skin can tighten the breast envelope. This creates a scar but does not change the quality of the remaining skin.

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.

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 critical that patients have realistic expectations about what mastopexy can achieve. It will give the breast a more lifted look. It will lift nipple-areolar complexes that have 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.

After vertical mastopexy, the upper pole of the breast will be relatively full. However it will drop. Even the most experienced breast surgeons have described their frustration at not being able to maintain upper pole fullness in the long term by rearranging the breast gland architecture. Most surgeons suggest a small implant to give upper pole fullness without wearing a bra if this is essential for patient satisfaction.

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. 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 a skin ripple can be left beneath the breast that in about 10-20% of cases may need to be removed under local anaesthetic three months later if it does not completely flatten. This is no additional charge for my patients when this is required.

I now only use this technique when performing mastopexy for massive weight loss patients who have very poor tissue recoil.

The Wise pattern is a 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 long scar running along the inframammary crease. Essentially the skin is cut out and reshaped like a bra.

The advantage is that the initial result looks very good but the disadvantages are the increased likelihood of bottoming out with time and the long inframammary crease scar.

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 Bunelli technique is a common peri-areola technique and a number of modifications have been described with de-epithelialised dermal pedicles to decrease scar stretch.

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 have an E-cup bra, actually only have a C cup of breast tissue. Sometimes most of the breast tissue has dropped below the breast base (the normal area of attachment) on the chest wall. When they lift their breast skin they fill a larger bra than their true cup size. The excess skin is removed at surgery, but no breast 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.

This complication is not adequately discussed in the NZAPS brochure I give my patients to read about mastopexy surgery.  Regardless of the procedure performed, the breasts will drop after surgery.

I over-elevate the breast gland in anticipation of some drooping in the first six months after surgery. The breast does not contain muscle, bone or other tissue that will resist gravitational forces. Once the vertical scar beneath the breast has softened, the over-elevated breast gland will drop. If the breast shape looks perfect after surgery, then I have not elevated it enough!

In about 10% of cases after mastopexy, there will be more breast droop at six months than is ideal. If this occurs I further tighten the breast skin envelope under local anaesthetic, using the same scar. There is no charge to my patients for doing this.

Incisions within the breast tissue or around the skin of the areola can affect nipple sensation. The potential risk of decreased sensation varies with the type of mastopexy technique used and I will discuss this with patients depending on the technique selected. Disrupted sensation may take a year or more to recover. 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 very unusual to have completely numb nipples a year after surgery but this is possible.

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 this. Some people refer to the combination of these two 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 is often 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 in my practice and is reserved for cases of extreme skin excess for instance after massive weight loss.

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

The risks

The main complications after mastopexy include:

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