Breast Lift (Mastopexy)

Age, pregnancies, lactation, hormonal factors cause the breast tissue to become fatty, i.e., brittle or friable, and loose volume while the skin looses its elasticity. The consequence is stretching and sagging of the breast, which can be corrected by a breast lift.

This pamphlet is written to clarify concepts about the breast lift. Two main questions that all women ask are about size and scars.

"Will the lift make my breast smaller?" No. By definition the lift repositions and reshapes the breast. Thus, the breasts will go back where it should be and regain a nicer shape. The lift is not a reduction. To the contrary, when the breast is repositioned and reshaped, it is no longer hanging down: it gives the impression to look larger.

The first and foremost question pertains to the scars. It covers over 90 years of surgical evolution. In 1910, Girard, a French surgeon published the first technique. Multiple techniques were devised since then. Today the scars remain the patients' major concern.

Removing the excess of skin to reposition and reshape the gland is the oldest technique and can still be used. This technique follows 3 patterns:

The anchor pattern; the most common one used in the United States. Reliable and not that difficult technically, it is a good procedure. The major drawback is the extensive scar.
The lollipop pattern, rather new in the United States, has the advantage to leave less of a scar than the anchor pattern. The technique was created in the late 1950's by another French surgeon, Claude Lassus.
In 1987, Dr Louis Benelli in Paris designed the doughnut pattern leaving the scar only around the areola. This last technique is more difficult but it eliminates any scar on the breast itself.

All of these techniques involving the skin only can obtain a good lift only on breasts that were small with a good elastic skin. However, these 2 conditions are lacking in most saggy breasts, which gave poor breast tissue and skin. Stretching and sagging will usually recur.

The limitations of the skin lift led to another generation of lift, achieving durable results in virtually all saggy breasts.

This new generation of breast lift is based no longer on the skin but on the gland.

They allow a good durable lift in all kinds of saggy breasts, because the breast tissue is tailored and reattached to the chest wall. We don't just rely on the skin anymore. Everything is done on the gland while the skin covers the gland without supporting it.

Thereby, the result is much more durable and predictable though with time if the quality of the breast tissue is poor some sagging will recur but usually much less than the skin technique.

That new concept had started already with Claude Lassus' lollipop pattern, using part of the gland to secure the whole breast on the chest wall.

In 1986, Serge Krupp, (Switzerland) devised another technique more versatile than the Lassus. These authors were not published in the English until Madeleine Lejour (Belgium), in 1994 published a book and video tapes in English, that popularized these procedures in the U.S.

In 1995, Dr. Benelli published 2 glandular techniques through his doughnut pattern. His results speak for themselves but his technique is difficult. After seeing him in meetings, reading his articles and watching his video tapes, I went to Paris to spend a week with him. I then started doing the "Benelli's". He is now well known in the U.S., though less than 15% of the U.S. surgeons use his technique. They don't feel comfortable with it and prefer the anchor pattern. In Europe and South America the "Benelli" procedures became the standard. By now, several surgeons have modified his original techniques.

In 1996, Sampaido Goes (Brazil) innovated an internal brassiere. Through a doughnut pattern he does a complete undermining of the skin and then places a nylon mesh around the breast. The mesh in turn secured to the chest wall. His results are excellent but it is very extensive surgery and the risk of infection with the mesh the major objection. For this reason, it has not gained popularity in the U.S. nor in Europe.

In 2001, Ruth Graf (Brazil) found another good technique which is quite reliable but implies a lollipop pattern versus a doughnut pattern. Some U.S. surgeons use it. All of these glandular lifts give good durable results and usually far superior to the skin lifts.

The lift combined with breast augmentation

In Europe, Breast Augmentation is unpopular. More reduction and lifts are done than breast augmentations. If an augmentation is done it is generally with small implants. For that reason, surgeons are rarely asked to combine a lift and augmentation. When they are, the implants they use are too small to have any significant adverse effects on the breast lift.

The situation is quite different in the United States. Rarely does a woman want just a lift. They almost always want an augmentation as well, in order to regain the size they were before pregnancies or just because they desire larger breasts. In the U.S., women want implants rather large if not large. The techniques presently used to achieve lift and augmentation depend on the degree of breast sagging and the degree of enlargement desired by the patient.

The degree of sagging:

If minimal, usually the augmentation itself will correct the sagging without a lift, placing the implant under the muscle.
If in some rare cases significant sagging occurs with a dense breast tissue covered by good skin. In this situation, an implant large enough can correct the sagging without a lift, if the implant is placed under the gland. The disadvantage, of course is that the implant is not under the muscle. In these rare cases where the tissue is very good and the implant not large, a sub-glandular approach is acceptable.
In most cases, the sagging is pronounced and women request rather large or large implants. A lift is required to obtain a good result. The enlargement of the breast is done under the muscle for a good stable, durable augmentation, whereas the breast gland itself is moved up and secured to the muscle at the right level. In other words, the sub-muscular implant works as a scaffold upon which the breast gland is lifted.

Several techniques have been devised to combine augmentation and left. Practically all of these techniques place the implants under the muscle for the reason explained above. They differ in the work done on the gland to move it up and reattach it higher on the chest wall where it used to be. They also differ in the type of skin pattern using an anchor, lollipop or doughnut pattern. A lot of combinations are possible between muscle, gland and skin but the basic principles are the same as well as... the problems.

The One Stage Approach

This approach is a source of problems. I believe the most common problem encountered in a lift/augmentation done in one stage is due to the effect of the implant on the tissue. Indeed, the muscle is dissected, so is the gland as well as the skin. Once all of these tissues have been cut on, and implant is then added for the augmentation or vice versa. A good result can be and is achieved in most cases. But in cases where the muscle is thin the breast tissue more fatty than glandular, that is to say friable and covered by a skin already thin and stretched, the implant had some adverse effect on these 3 tissues. They will further stretch, thin-up and deform by sheer pressure of the implant. A good result can be expected only when the tissues are very good. We rarely can know that pre-operatively for sure. We never can predict how the tissues will tolerate and support the implant. This is the real problem.

I routinely used the doughnut pattern since 1991 till a few years ago. In case the tissue would stretch in the lower pole of the breast, I would convert it into a lollipop pattern to reinforce the padding and the support.

Between the conversion from doughnut and lollipop pattern as well as secondary reduction of the diameter of the areola or scar revision, the rate of touch-up or secondary procedure was beyond 30% in the one stage augmentation/lift. Hence, actually one-third of the patients ended up having some sort of second stage. Besides, the incidence of complications with one stage was significant. This is due to a basic surgical principal: The more the dissection at a time, the more the complications. That's why the 2 stage approach is far more reliable and became the standard nationwide at the 2001 ASAPS Meeting in New Orleans.

The Two Stage Approach

I started realizing this concept in 1990. This was the year of the "silicone crisis". The silicone gel implants were replaced by saline implants. It took a few years for the plastic surgeons to agree that the saline implants had to go under the muscle and not under the gland as we used to do with silicone implants in most cases. The saline implant is more traumatic to the tissues than the silicone gel and in order to get a better support and cover of the saline implant, under the muscle became a must. To me, I didn't have to change my approach since I was already going under the muscle routinely since 1980 with silicone implants.

I saw patients done elsewhere, coming to me with saline implants placed under the gland. They had developed rippling or this spots with some degree of sagging. The standard to remedy the problem is to replace the implant from under the gland to under the muscle. I was familiar with the technique since I've been using it in case of capsule formation for implants under the gland since the late 1970's. In addition, in cases of sagging I started reattaching the gland higher on the muscle, i.e. doing a breast lift.

After doing a good number of these conversions from under the gland to under the muscle, with lift of the gland, I noticed:

Usually complete correction of the rippling
The need for a larger implant usually between 10% to 30% to get a good fit between the existing thinned up sub-glandular pocket and the newly created sub-muscular one.
And.. .at the same time a dramatic improvement of the sagging. Indeed, the saline implant with time had not only thinned up the gland causing the rippling but also stretched it causing the sagging. The reattachment of the gland higher on the muscle was rather easy and achieved a good durable lift.

After doing enough of these cases, I understood. The implants placed under the gland induces the formation of a plaque of scar tissue on the inner aspect of the breast gland and on the top of the muscle, that is to say all around the sub-glandular pocket. After replacing the implant under the muscle, the implant can no longer damage the tissue that is protected by 2 plaques of scar tissue. The 2 layer of that scar tissue on top of the muscle and on the inner surface of the gland constitute a strong protective shell for the implant. In turn, when the breast tissue is attached higher on the chest wall, i.e. on the muscle, in order to lift the breast, the stitches are between these 2 plaques of scar tissue, breast and muscle. This attachment is solid since we are not stitching muscle to friable breast tissue to scar tissue that contains collagen.

This mechanism understood, I then thought of reproducing the same condition for patients requesting augmentation and lift. The only problem was 2 stages. Women were reluctant to the idea of 2 stages.

I had to explain the advantage of the 2 stages. There is a much higher chance of good results and less scar. Besides, it minimizes the tissue damage and the complications. Furthermore, at the time of the second stage, adjustments can be performed to improve the shape, size, level and symmetry between the two breasts.

Also, a certain number of women are happy after the breast augmentation and feel they don't need or want aTift. With the one stage approach, the lift would have been done needlessly. Thus, I recommend to have a breast augmentation first and decide about a lift after. A lift can always be done later if they are not sure.

The first stage consists of placing the implants under the gland. 2 months later the second stage is performed.

The scar tissue has formed around the implant. We are ready for a stable, more predictable breast lift. With this technique, there is no need to use a doughnut pattern as I had learned form Benelli. The doughnut pattern was a major breakthrough over the anchor and lollipop pattern but is still leaves a scar all around the areola. Due to the pressure of the implant, the scar and the diameter of the areola can widen. It leaves a conspicuous scar and/or an enlarged areola.

A "nipple" incision is sufficient to reposition the implant from sub-glandular to sub-muscular and lift the breast on the muscle. Using a supra-areolar vs. infra-areolar incision facilitates the procedure and allows a good lift of the breast and position of the nipple/areola. The breast lifted at the right level, it is secured to the muscle, achieving a strong and stable lift, since it is stitching scar tissue to scar tissue. The first problem of this technique was the need to make 2 pockets sub-glandular and sub-muscular with more dissection. The second was the time it takes for the breast shape to look normal, usually 2 to 3 months. These 2 drawbacks slowly led me to devise a better alternative.

The Alternative

It consists of another 2 stages surgery but the first stage is a submuscular augmentation vs. a subglandular augmentation. The submuscular implant is used as a scaffold for the second stage. Eight weeks later when the scaffold is stable a small crescent of supra-aerolar skin and breast tissue is excised. This small wedge excision shortens the upper pole and allows an upward rotation of the sagging lower pole of the breast. Stitches secure the upward rotation of the lower pole high on the muscle before re-approximating the breast tissue of the 2 poles. This combination of shortening and rotation achieves the breast lift. The rotation of the lower pole can be reinforced by passing 2 U-stitches in the infraerolar breast tissue, that are anchored to the breast tissue of the upper pole, 4 to 5 centimeters above the areola.

In cases where the lower pole needs shortening vs. the upper pole, the wedge excision can be performed in the infra-areolar area. If in doubt about which pole to shorten, upper or lower, the direction of the nipple is a reliable guide. The nipple pointing down, the most common case, usually indicates the need to shorten the upper pole. The nipple pointing up, usually requires a shortening of the lower pole. Examining the patient in the upright and supine position helps determine the direction of the nipple and the length of the lower and upper pole of the breast. It is most important to recognize which pole has to be shortened to obtain a good shape of the breast and position of the nipple. Doing a supra-areolar wedge excision with the nipple pointing up would place the nipple too high with an upper pole too short. Vica versa, an infra-areolar wedge excision with a nipple pointing down would worsen the deformity dragging the nipple too low.

This technique is less complicated and offers 2 advantages over the 1st one: The reshaping of the breast is achieved intra-operatively without waiting 2 to 3 months for re-modeling.

Only a sub-muscular pocket is used without a sub-glandular pocket, minimizing the risk of complications.

Like for the first procedure described, an augmentation-lift is achieved with practically no scar. I use it routinely for 2 years. It is versatile, with very few complications.

Summary:

I have been doing that technique for the past 3 years. The patients are very pleased. Good, stable, durable augmentations and lifts are achieved. The 2 stages eliminated stretching and thinning are encountered with the 1 stage technique. As for the scar, this approach, using the "nipple incision" only, eliminates the conventional anchor, lollipop and doughnut scar patterns. In 1976,1 started performing breast lifts and augmentations. For almost 25 years I have seen scars and results that wouldn't please me. My frustrations led me to this technique that gives me good results consistently with practically no scars.