Breast lift and mastopexy address sagging (the medical term is ptosis) of the breasts, which is a common problem. The basic principles of mastopexy amd breast lift are derived from the causes of breast sagging. In his 1931 book “Deformities and Cosmetic Operations of the Female Breast” – the first and for a long time arguably the finest textbook/atlas of cosmetic breast surgery – the Austrian surgeon Hermann Biesenberger very clearly described why breasts sag and what breast lift and mastopexy as operative procedures have to do to create a more uplifted and youthful breast. In youth, a connective tissue “suspensory apparatus” holds the breasts in an uplifted, youthful position. It may be best thought of as a lacy, three dimensional network. Weakness of the connective tissues and thus the “suspensory apparatus” results in sagging. Gravity, age, weight of the breasts, hormonal influences and a shift in the ratio of fatty to breast tissue (youthful breast are generally firm and contain less fat and more breast tissue) in combination or isolation eventually overwhelm the “suspensory apparatus”. This simple, clear and mechanistic explanation allows operative procedures for mastopexy and breast lift to be designed to solve the problems of the sagging breasts.
For a long time classification systems focused on the position of the nipple areola complex, but it is really the position of the breast volume in relation to the inframammary fold and the position of the nipple areola complex in relation to the most projecting part of the breast volume which together give a classification system meaningful enough to design operative strategies for mastopexy and breast lift.
In our plastic surgery practice in Mississippi, USA, we follow the paradigm that structure is beauty. Structure has to be created first. The skin is a secondary phenomenon. We just drape it over the newly created structure. Thus foremost during mastopexy and breast lift we strive to create a conical, youthful breast mound above the inframammary fold. Excess weight if present has to be taken off by small reductions at the lower and outer aspect and the remaining breast tissue has to be shifted into a more uplifted position and shaped into an ideal, youthful conical contour. The nipple areola complex needs then to be moved to the most projecting part of the ideal breast. Lastly, the redundant skin has to be reduced with minimal scarring. Longterm maintenance of results of mastopexy and breast lifting by means of skin reduction alone is not possible. Internal scars resulting from shaping maneuvers and breast tissue rearrangements together with long lasting sutures reinforce the “suspensory apparatus”.
This philosophy is reflected in most contemporary breast lift and mastopexy procedures such as SPAIR (Hammond), round block (Benelli) or vertical (Lejour/Lassus) procedures.
Of note, only in the rare exception (e. g. isolated mild nipple areola complex malposition in relation to the inframammary fold) can one aspire to correct sagging breasts by placing an implant alone. As the breast volume is usually saggy in relation to the inframammry fold the implant cannot be placed correctly without adding another deformity (double bubble or excessively low fold).
Breast lifting (mastopexy) and augmentation with silicone or saline breast implants are really separate procedures and in fact work against each other with the lift trying to move the breast tissue “up and in”, the implant displacing it “down and out”. Striking a balance between these two antithetic concepts is a delicate undertaking as evidenced by the considerable number of reoperations after “augmentation mastopexy” (breast lift with simultaneous placement of a silicone or saline breast implant).
If there is some excess of breast tissue in the lower aspects of the breast we may move it to the central and upper aspects of the breast above the fold to provide more projection and upper pole fullness if desired by the patient. This “autoaugmentation” with the patient’s own tissue (autologous breast augmentation) avoids the placement of an implant.