Breast Lift and Augmentation (Augmentation Mastopexy):
The 'top half' of many 'mommy makeovers'
Augmentation mastopexy is designed to correct the two most common changes that occur in breast appearance following pregnancy: loss of breast volume, and stretching out of breast skin. While there are some moms who can get an acceptable cosmetic result from augmentation alone or from mastopexy alone, many moms have a combination of breast volume loss and skin excess that requires simultaneous augmentation and mastopexy (breast lift). I frequently perform this surgery in concert with an abdominoplasty (tummy tuck), and this combined breast and tummy rejuvenation surgery is sometimes referred to as a 'mommy makeover'.
Augmentation mastopexy is also commonly performed for major weight loss patients, including those who have had bariatric surgery including gastric banding and gastric bypass. Obesity followed by major weight loss usually produces breast changes that are very similar to those seen after successive pregnancies, and often the effect on breast skin is quite severe. Additionally, as a North Carolina breast implants surgeon, I regularly see patients with significant breast ptosis (the medical term for 'droopiness', pronounced TOE-sis) in young adulthood, without any history of pregnancy or major weight loss. Some breasts are just naturally droopy, and I have performed mastopexy and augmentation mastopexy for patients as young as 21 years.
This surgery is a potentially challenging one which requires thoughtful preoperative evaluation and planning, and careful attention to detail in the operating room. Many surgeons have traditionally performed breast augmentation and mastopexy surgery in stages, usually mastopexy first followed by augmentation at a later date. In the recent past more and more surgeons have adopted a non-staged, single surgery approach to augmentation and mastopexy, and that is what I propose for the vast majority of patients who I see in consultation that need both procedures. I believe that the results of simultaneous augmentation mastopexy are as good or better than a staged approach in most cases, and of course patients quite naturally prefer a single trip to the operating room if at all possible.
Some patients I see in consultation are primarily interested in a breast lift procedure. For those with a significant amount of existing breast tissue, a breast lift alone may produce an aesthetically ideal breast appearance. However, it can difficult to achieve significant fullness in the upper poles of the breasts (the upper aspect of the breasts, above the nipple-areola area) in many patients by means of a breast lift alone. I ask patients who are considering a breast lift procedure how important it is for them to have the appearance of some fullness in the upper part of the breasts, and to thereby achieve a significantly more youthful breast profile. For patients who confirm that this appearance is important to them, and who do not have enough natural upper pole breast tissue to achieve this appearance with a mastopexy alone, I recommend an augmentation mastopexy.
Other patients are primarily interested in increasing their breast volume, but have enough breast ptosis to make the appearance of breast augmentation alone odd and unappealing. Placing implants behind breasts with significant ptosis creates the appearance of breasts hanging off of a pair of implants, which looks distinctly unnatural and aesthetically unappealing. These patients are also best served by augmentation mastopexy, which in addition to increasing breast volume restores the position of the nipple-areola complex to the top of the breast mound, tightens the lower pole and lifts the breast.
Step one: adding volume (breast augmentation)
On the morning of surgery, patients are marked for augmentation mastopexy in the standing position. The markings include the design for skin excision which will serve to tighten the skin envelope of the breasts. In the operating room, the breast augmentation is performed first. For augmentation mastopexy patients with a preoperative A-cup breast volume, an implant volume of up to 325 to 350cc may be required as the implant will make up the majority of the postoperative breast volume.
For patients with a full B or C-cup breast volume, an implant is often added at the time of mastopexy solely for the purpose of creating upper pole breast fullness. Breasts that appear 'deflated' after pregnancy are often most lacking in breast volume in what used to be the upper poles and in such cases mastopexy alone is not capable of creating lasting upper pole fullness. In these patients an implant volume of 150 to 240cc will often be adequate for this purpose.
The upper limit of implant sizes that work well for augmentation mastopexy is, in my opinion, in the range of 325 to 350cc - and that is in patients where the preoperative breast volume is an A-cup. Implant volumes larger than this only serve to stretch out the mastopexy in the weeks and months following surgery, and tend to result in heavy-looking, bottomed-out breasts. Which certainly is not the intended outcome of this surgery.
So a full B or a C-cup breast profile is a reasonable goal to have in mind for an augmentation mastopexy if the starting breast profile is an A or a small B-cup and the majority of the breast volume is going to be provided by a breast implant. Patients starting with a B or C-cup breast profile can reasonably transition to a C or even a small D-cup breast profile following augmentation mastopexy. The important caveat for patients that desire a D-cup breast profile after this surgery is this: the bigger the implant, and the bigger the breast, the more quickly the augmented and lifted breast will become droopy again. If you need an augmentation mastopexy, a 'C' is probably the ideal postoperative breast volume.
Step two: the breast lift (mastopexy)
Once the implants have been placed, the patient is again placed in the upright sitting position and adjustments are made to the preoperative markings for the mastopexy. The mastopexy involves not only removing breast skin, but also creating an internal support for the breast implants so that breast fullness is maintained long-term (and the chances of 'bottoming out' are reduced). Skin is elastic and tends to stretch out over time, no matter how much you tighten it. So mastopexy procedures that only address the excess skin do not produce breasts that remain 'lifted' very long.
Some internal rearrangement of breast tissue is required to support the weight of the breast tissue and the added weight of the implant over time. I also believe that it is important to remove a significant amount of the lower pole breast tissue that hangs below the inframammary fold preoperatively. This droopy lower pole tissue does not contribute anything positive to overall breast aesthetics, and there is no magical way to get it back up above the inframammary fold and keep it there. So it is best to remove it, and in doing so significantly tighten the lower pole of the breast.
The augmentation mastopexy technique that I use involves the removal of a vertically-oriented wedge of breast tissue below the six o'clock position of the areola. The width of the lower pole tissue excision varies with the amount of lower pole tissue excess. The remaining medial and lateral lower pole tissue is pulled together and repaired below the areola, creating a 'sling' of internal scar tissue that serves to support the weight of the lifted and augmented breast. This technique has the added benefit of actually increasing breast projection, rather than flattening the breast as often occurs with traditional mastopexy techniques. That increased projection holds up quite well over time, and most of the augmented and lifted breast remains above the level of the inframammary fold for the long term.
Some patients with limited breast ptosis may be best served by a more limited 'mastopexy' procedure in which skin is removed around the areola only and the areolar diameter is reduced. This is referred to as a 'circumareolar mastopexy'; it is also called a 'Benelli mastopexy', or 'donut mastopexy' - because the pattern of skin removal is donut-shaped. I put the term 'mastopexy' in quotes here as, in my opinion, this is not truly a breast lift procedure. Removing skin around the areola may allow one to move the nipple-areola complex to a slightly higher level, perhaps two to three centimeters or so, but it does not actually 'lift' the breast. To truly lift the breast one must remove some lower pole breast tissue and rearrange breast tissue internally to create an aesthetically appealing, lifted breast in which the result of the lift is lasting.
Overzealous 'circumareolar mastopexy' procedures actually distort the shape of the breast, flattening the projection at the top of the breast mound. In my practice, I use a more limited version of this procedure only as a means to elevate the position of the nipple-areola complex. If the patient actually needs a breast lift then it is much better, in my opinion, to perform the lower pole tissue removal and internal breast tissue rearrangement that produces a vertical scar between the areola and the inframammary fold. In patients who truly need a breast lift, I believe that a perky, youthful and natural-appearing breast profile (with the vertical mastopexy scar) is far preferable to a distorted, flattened and unnatural-appearing breast profile (without the vertical mastopexy scar).
The trade-off: a perky breast at the expense of surgical scars
One goal I have for my augmentation mastopexy patients is giving them the freedom to go without a bra in some kinds of clothing if they so desire. Patients report that this is one of the most liberating and enjoyable benefits of this procedure. The perky breast profile comes at the expense, of course, of the surgical scars required by the mastopexy procedure, so those scars are certainly worth some discussion.
Most mastopexy procedures create a scar around the border of the areola (called a 'circumareolar' scar), a vertical scar from the bottom of the areola to the inframammary fold, and in some cases a curving scar in the inframammary fold. I use a vertical mastopexy technique, so-named because it is designed to create a lifted breast with only the circumareolar and vertical scars. However, the vertical mastopexy has an inherently limited capacity to tighten the lower pole of the breast, and I do not hesitate to add a horizontally-oriented excision of lower pole skin and breast tissue if I think that is required to create an ideal and truly youthful-appearing breast.
With very droopy B and C-cup breasts, the need for that additional lower pole tissue excision and inframammary fold scar is in most cases a certainty, and I tell patients preoperatively that it is part of the surgical plan. With smaller and less droopy breasts, the need for this part of the procedure is variable and I therefore inform patients that the decision will be made intra-operatively. In my opinion, it makes no sense to leave a patient with an overly full lower pole (and thus a less lifted-appearing breast) all for the sake of not having a scar in the inframammary fold - a scar that is almost always the least concerning one for augmentation mastopexy patients.
The color and texture difference between areolar skin and breast skin effectively conceals the circumareolar scar in most patients, and the inframammary fold scar (when present) is hidden in a skin fold and thus is only apparent if you are looking for it. The vertical scar is the least concealed one, and in most fair-skinned patients it, like the other scars, gradually fades to a faint white line that is minimally noticeable. In patients with deeper skin pigmentation, the vertical scar tends to be more noticeable.
In my practice we are very proactive about treating healing surgical incisions in order to reduce the likelihood of a problematic scar. Patients begin using topical silicone gel products, which have been shown to be highly effective in flattening and fading surgical scars, on a daily basis as early as two to three weeks following surgery. We also provide patients with a series of V-beam laser treatments of their healing incision sites. The V-beam is a vascular laser shown to be highly effective at modulating scar development. These treatments are provided at no cost to surgical patients of this practice, and are continued at intervals of three to four weeks for as long as necessary.
The reality is that many patients will have perfectly acceptable augmentation mastopexy scars without any specific postoperative intervention, but there is no way to identify in advance the subset of patients that may develop problem scars. Because mastopexy scars are so cosmetically significant, we treat all patients the same - as if they all are potentially at risk of ultimately having unfavorable scars. In doing so, we see very few patients who ultimately develop unfavorable mastopexy scars, and I do not often have patients who require mastopexy scar revision. I am more than happy to revise unfavorable scars if they develop, and this can be done quite easily in the office under local anesthesia. Fortunately, the need for that procedure in my practice is quite small.