Breast lift (mastopexy)

Sagging of the mammary glands is a natural process that a woman's breasts are subject to throughout her life. The presence of mammary gland ptosis is usually spoken of in cases where the level of the nipple drops below the level of the inframammary fold.

In this case, with normal or slightly reduced breast volume, mastopexy - a breast lift - can be performed.

Large sagging breasts require reduction rather than just mastopexy.

Elimination of breast ptosis requires in each specific case a thorough analysis and a clear understanding of what the patient wants to get from the operation.

Story

The development of breast lift methods is associated with the development and implementation of numerous surgical interventions and techniques.

G. Letterman and MShurter (1978) divided all proposed operations into four groups [11]:

• interventions on the skin only (excision of excess skin);
• fixation of glandular tissue to the anterior chest wall;
• correction of shape by placing sutures on glandular tissue;
• elimination of ptosis by increasing the gland using endoprostheses.

Among the numerous proposals and methods, it is advisable to highlight the following surgical techniques, which form the basis of modern mastopexy methods.

• Fixation of the upwardly displaced gland tissue with a strong suture to the dense tissues of the chest was introduced by C. Girard (1910) as a mandatory element of the mastopexy operation.
• Excision of excess skin in the lower sector of the gland with movement of the nipple and areola upward was proposed by F. Lotsch in 1923.
• Improving the shape of the mammary gland by moving upward a flap from the tissue of the lower sector of the gland and its retromammary fixation to the anterior chest wall. This technique was first used by H. Gillies and H. Marino (1958), which allowed, in addition to creating a more filled upper pole of the gland, to maintain the result of the operation for a longer period.
• Use of approaches that exclude the formation of a scar in the area between the gland and the sternum. These variants of the operation were developed by L. Dufourmentel and R. Mouly (1961), as well as P. Regnault (1974).
• The elimination of slight ptosis of the mammary glands by implantation of endoprostheses was promoted by P. Regnault (1966).
• Excision of excess breast skin around the areola and improvement of its shape, using only the periareolar approach.

Pathogenesis and classification of mammary gland ptosis

The main causes of breast sagging include:

• influence of gravity;
• hormonal effects on glandular tissue, which can lead to both an increase and a decrease in its volume;
• fluctuations in the patient's body weight;
• loss of elasticity of the skin and ligamentous apparatus of the gland.

Normally, the nipple is located above the submammary fold and is at the level of the middle of the shoulder at any height of the woman. The severity of ptosis of the mammary gland is determined by the ratio of the nipple to the level of the submammary fold and the following variants are distinguished:

• ptosis of the first degree - the nipple is at the level of the submammary fold;
• ptosis of the second degree - the nipple is located below the level of the submammary fold, but above the lower contour of the gland;
• ptosis of the third degree - the nipple is located on the lower contour of the gland and is directed downwards;
• pseudoptosis - the nipple is located above the submammary fold, the mammary gland is hypoplastic, and its lower part is lowered;
• glandular ptosis - the nipple is located above the projection of the submammary fold, the gland has a normal volume, and its lower part.

Indications, contraindications and planning of surgery

In order to determine the main cause of ptosis of the mammary glands, the surgeon finds out their condition before and after pregnancy, fluctuations in the patient's body weight. As a rule, women's requirements for the results of mastopexy are far from the same and most often come down to the desire to have the size and shape of the breasts as before pregnancy.

In practice, a surgeon faces three main clinical situations that determine the tactics of surgical treatment: 1) the skin of the gland is slightly changed and sufficiently elastic, but the gland is lowered with insufficient or normal volume; 2) the skin of the gland is stretched and inelastic, but the volume of the gland is normal and 3) the skin of the gland is excessively stretched, the breast has insufficient or small volume. Each of the named clinical situations is accompanied by ptosis of the mammary glands of varying severity. Ideal candidates for a breast lift are women with normal volume and mild ptosis of the gland. With insufficient gland volume and its ptosis of grade I or pseudoptosis, implantation of endoprostheses is indicated. A combination of endoprosthetics and breast lift may also be advisable in patients with severe involution of the glands, combined with ptosis of grades II-III. In case of glandular ptosis of the mammary glands, it is necessary to remove excess tissue in the lower sector of the gland with mandatory retromammary fixation of the gland to the fascia of the pectoral muscles.

In the presence of excess volume of mammary glands, reduction mammoplasty is indicated.

Contraindications to mastopexy may include multiple scars on the mammary glands, as well as severe fibrocystic diseases of the mammary glands. Common problems that limit the performance of the operation include systemic diseases and mental disorders.

Breast lift surgeries

Vertical breast lift gives good results in cases of grades I and II mammary gland ptosis. Preoperative marking and surgical technique are in many ways similar to those in reduction vertical mammoplasty. However, there are some differences. Deepidermization is performed in the area of the entire marking up to its lower border. The detachment of the skin and fat flaps of the gland is done in the same way as in reduction mammoplasty. However, the lowered tissues of the gland, located in its lower sections, are then moved upward, tucked under the detached gland and the lower edge of the de-epidermized flap is sutured to the fascia of the pectoralis major muscle at the level of the II-III rib (Fig. 37.4.2). Then the edges of the skin are brought together and, if necessary, the shape of the gland is "adjusted", just as in reduction mammoplasty.

Postoperative management is similar to that described for breast reduction surgery.

B-technique (according to P. Regnault, 1974). Breast lift proposed by P. Regnault was called "B-technique" due to the similarity of the preoperative markings with the capital letter B. This method gives good results in cases of grades II and III mammary gland ptosis and allows to avoid scars extending from the gland to the sternum.

Marking. With the patient standing, a line is drawn from the jugular notch through the nipple and point B is marked on this line, located at a distance of 16 to 24 cm from point A, but not higher than 3 cm from the level of the projection of the inframammary fold. Below point B is the new location of the areola.

Next, the marking is done with the patient in a lying position. Point M is drawn, which is located at a distance of 8-12 cm from the midline. In this case, the latter distance should be half the distance between points A and B. A circle of the new areola with a diameter of 4.5 cm is marked. A submammary incision line (P-P') is drawn, which is located 1 cm above the submammary fold. Neither MK is drawn perpendicular to line AB, which divides the latter in half. Then, points MVK are connected with an elliptical line. Points T and T form a line parallel to the MK line (in accordance with the location of the new boundaries of the areola). Line TT' is drawn through the nipple. This line adds a rectangle to the ellipse. Next, a line is lowered perpendicularly from point M to the submammary fold and an arcuate line T'P is drawn tangent to it. On average, its length is 5 cm.

The surgeon uses his fingers to create a fold of skin, which allows the C and C points to be marked, which can be brought together after the excess skin has been removed. The TCP line is then applied.

Technique of the operation. After infiltration of the skin with a solution of lidocaine with adrenaline, its shaded area is de-epidermized and a flap of at least 7.5 cm in width is formed within it. After detachment of the gland tissue from the chest, this flap is displaced upward and retromammary fixed to the fascia of the pectoralis major muscle at the level of the 2nd or 3rd rib. Thus, the displaced tissues allow for the creation of a more filled upper pole of the gland.

Next, a lower skin-fat flap is formed from the lower lateral quadrant of the gland. To do this, points T-T' and C-C are aligned and excess skin is excised. The wound is closed starting with the application of four sutures to the areola at the 6, 12, 3 and 9 o'clock positions on a conventional clock face, avoiding rotational displacement of tissues. The edges of the wound are aligned with an intradermal interrupted suture of No. 5/0 Vicryl. To prevent stretching of the periareolar postoperative scar, a non-removable purse-string suture of No. 4/0 Prolene is applied in the deep layer of the dermis. Then the remaining wound is sutured layer by layer with No. 3/0 Vicryl and a continuous intradermal removable suture of No. 4/0 Prolene. The wound is drained using an active drainage system.

Postoperative management. Drains are removed on the 1st-2nd day after the operation, the continuous suture is removed 12 days after the operation. The final shape of the iron is achieved in 2-3 months. A bra is not worn during this period.

Complications. Postoperative complications are basically the same as after reduction mammoplasty. Of particular interest to practicing surgeons are late postoperative complications, and in particular secondary ptosis of the mammary glands, which may include glandular ptosis of the mammary glands, complete ptosis of the mammary glands, and complete ptosis with loss of volume of the mammary glands.

In most cases, the main reason for repeated ptosis of the mammary glands is a significant decrease in the patient's body weight. Thus, losing 5 kg can significantly affect the shape of a woman's breasts. She should be warned about this before the operation. Other reasons for secondary ptosis may be technical errors during the operation: 1) leaving excess stretched skin in the lower sector of the gland and 2) lack of fixation of the displaced mammary gland tissues to the chest tissues.

In complete secondary ptosis of the mammary glands, ptosis of the entire gland is observed when the nipple-areola complex is located below the projection of the inframammary fold. In this case, it is necessary to re-move the nipple and areola to a new position with the implementation of all the principles of lifting the mammary glands.

In case of complete secondary ptosis of the mammary glands, which occurs as a result of a decrease in their volume, it is enough to place prostheses under the glands to eliminate their sagging.

Sagging of the lower part of the mammary glands only is eliminated by simply excising excess skin in the lower sector of the gland or by deepidermization of excess skin with its folding and fixation under the gland with non-absorbable material. The resulting fold additionally prevents the gland from sagging.

In general, the number of complications after mastopexy is significantly lower than with reduction mammoplasty. The change in the shape and position of the mammary glands is generally completed within the first year after the operation.