Breast lift (mastopexy)

The omission of the mammary glands is a natural process that affects a woman's breasts throughout her life. About the presence of ptosis of the mammary gland it is customary to speak in those cases when the level of its nipple falls below the level of the pectoral fold.

In this case, with a normal or slightly reduced volume of the breast, mastopexy can be performed - a tightening of the mammary glands.

The omitted mammary glands of a large size should rather be reduced than simply performing mastopexy.

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

History

The development of methods of tightening the mammary glands 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]:

• interference only on the skin (excision of excess skin);
• fixation of the gland tissues to the anterior thoracic wall;
• correction of shape due to suturing of glandular tissue;
• elimination of ptosis by enlarging the gland with endoprostheses.

Among the numerous proposals and techniques, it is expedient to single out the following surgical techniques, which formed the basis of modern methods of mastopexy.

• Fixation of the upwardly transferred gland tissue by a strong suture to the dense tissues of the chest was introduced by C. Girard (1910) as an indispensable element of the operation of mastopexy.
• The excision of excess skin in the lower gland with the movement of the nipple and areola to the top was suggested by F. Lotsch in 1923.
• Improving the shape of the breast by moving up to the top of the tissue from the lower sector of the gland and its retromammary fixation to the anterior wall of the chest. This method was first used by H.Gillies and H.Marino (1958), which allowed, in addition to creating a more full upper gland pole, to keep the result of the operation for a longer period.
• Use of accesses that exclude scar formation in the area between the gland and the breastbone. These variants of the operation were developed by L.Dufourmentel and R.Mouly (1961), as well as P.Regnault (1974).
• Removal of a small ptosis of the mammary glands by implantation of endoprostheses was advocated by P. Regnault (1966).
• Excision of excess mammary gland around the areola and improvement of its shape, using only periareolar access.

Pathogenesis and classification of mammary ptosis

The main reasons for the omission of the mammary glands are:

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

Normally, the nipple is located above the submammary fold and is at the mid-shoulder level for any woman's growth. The severity of ptosis of the mammary gland is determined by the ratio of the nipple to the level of the pectoral 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 II degree of the nipple is lower, the level of the submammary fold, but higher, the lower contour of the gland;
• ptosis III degree - the nipple is located on the lower contour of the gland directed downward;
• 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 surgery planning

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

In practice, the surgeon faces three main clinical situations that determine the tactics of surgical treatment: 1) the skin of the gland is little changed and elastic enough, but the gland is lowered in case of 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 these clinical situations is accompanied by ptosis of mammary glands of different severity. Ideal candidates for a breast lift are women with normal volume and unexpressed ptosis of the gland. With insufficient volume of the gland and its grade I ptosis or pseudoptosis, implantation of endoprostheses is indicated. The combination of endoprosthesis and breast tightening can also be useful in patients with a pronounced gland involution, combined with ptosis II-III degree. When glandular ptosis of the mammary glands, it is necessary to remove excess tissue in the lower gland with mandatory retromammary fixation of the gland behind the fascia of the pectoral muscles.

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

Contraindications to mastopexy can be multiple scars on the mammary glands, as well as severe fibrocystic breast disease. General problems limiting the performance of the operation include systemic diseases and mental disorders.

Breast lift surgery

Vertical lifting of mammary glands gives good results in ptosis of mammary glands of I and II degrees. Preoperative marking and surgery techniques are similar in many respects to vertical reduction mammoplasty. However, there are some differences. Deepidermisation is carried out in the zone of all markings up to its lower limit. The detachment of skin-fat flaps of the gland is done in the same way as in reduction mammoplasty. However, then the lowered tissues of the gland located in its lower parts are moved upwards, turning under the peeled gland and lacing the lower edge of the deepidermis flap to the fascia of the large pectoral muscle at the level of the II-III rib (Figure 37.4.2). Then, the edges of the skin are brought together and, if necessary, the shape of the gland is "adjusted", as is the case with reduction mammoplasty.

Postoperative management is similar to that described with reducing mammary gland plastic.

B-technique (according to P.Regnault, 1974). The lifting of the mammary glands proposed by P.Regnault was called "B-technique" by the similarity of the preoperative marking pattern with the capital letter B. This technique gives good results in ptosis of mammary glands of II and III degree and allows to avoid scars coming from the gland to the sternum.

Markup. In the position of the patient standing, a line is drawn from the jugular notch through the nipple and on this line there is a point B, located at a distance of 16 to 24 cm from point A, but not more than 3 cm from the level of the projection of the pectoral fold. Below point B there is a new place of areola.

Further marking is performed when the patient is lying down. Apply a point M, which is located at a distance of 8-12 cm from the median line. The last distance should be half the distance between points A and B. A circle of a new areola with a diameter of 4.5 cm is marked. A line of the submammary incision (P-P ') is placed, which is located 1 cm above the submammary fold. Whether or not the MC is perpendicular to the AB line, which divides the latter in half. Then connect the ellipsoidal line of the MVC point. The points T and T form a line parallel to the MC line (in accordance with the arrangement of the new areola boundaries). Line TT 'is carried through the nipple. This line adds a rectangle to the ellipse. Further, from the point M to the submammarial fold, the line is perpendicularly perpendicular and an arc-shaped line T'P is drawn along its tangent line. On the average, its length is 5 cm.

The surgeon creates a fold of the skin with his fingers, which allows you to mark points C and C, which can be brought together after removing excess skin. After this, the TCP line is applied.

Operation technique. After infiltration of the skin with a solution of lidocaine with adrenaline, its shaded area is deepidermosed and a flap width of at least 7.5 cm is formed within it. After separation of the gland tissues from the chest, this flap is shifted upwards and retro-memorably fixed to the fascia of the large pectoral muscle at the level of II or III ribs . Thus, the displaced tissues make it possible to create a more filled upper pole of the gland.

Further from the lower gland quadrant of the gland form the lower cutaneous fat flap. To do this, combine points T-T 'and C-C and excise excess skin. The wound is closed beginning with the application of four sutures to the areola at the 6, 12, 3 and 9 o'clock positions on the conventional dial, avoiding the rotational displacement of the tissues. The edges of the wound are compared with an intradermal nodal suture in the vikril No. 5/0. To prevent the stretching of the peri-lateral postoperative scar, an undeletable suture stitch is inserted with a No. 4/0 strain in the deep layer of the dermis. Then, the rest of the wound is sutured to the rest of the wound with Vicril No. 3/0 and a continuous intradermal suture removed by strain 4/0. The wound is drained using an active drainage system.

Postoperative management. Drainage is removed on the 1-2 day after the operation, a continuous suture is removed 12 days after the operation. The final form of iron takes 2-3 months. The bra during this period is not worn.

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

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

With complete secondary omission of the mammary glands, ptosis of the entire gland is observed, when the nipple-areola complex is below the projection of the pectoral fold. In this case, it is necessary to re-move the nipple and areola to a new position with the realization of all the principles of breast-lift.

With complete secondary ptosis of the mammary glands, resulting from a decrease in their volume, it is enough to place the prosthesis under the glands, so that their omission is eliminated.

The sagging of only the lower part of the mammary glands is eliminated by simple excision of excess skin in the lower sector of the gland or by de-epidermisation of excess skin with its tucking and fixation under the gland by a non-absorbable material. The formed fold further holds the gland from sagging.

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