One of the most challenging aesthetic breast surgery operations performed by Plastic Surgeons is augmentation mastopexy. Augmentation fills out redundant or stretches tight breast tissue by adding volume that was not present before. Women appreciate the increase in size and firmness, as well as greater superior fullness. Mastopexy reduces extra skin and breast tissue while raising the nipple level and rotating it more forward or upwards looking.
What happens with a breast that has extra skin, loss of volume, and a low lying nipple? My usual approach is to use an implant on the larger side ( which most women want anyway ) to fill out the breast envelope and recruit skin from below the areola to make the nipple look as if it is higher on the breast mound. Immediately after the operation, the implant sets a bit high and the breast looks as if it is hanging off of the implant. With the assistance of a bandeau ( elastic strap ) providing pressure from above and an underwire bra providing a stable platform to push against, the implant over time descends to the appropriate position. This method usually works well in appropriately selected patients, costs less, has less risk, and avoids additional scarring around the nipple. The patient, however, must accept any baseline asymmetries, a still relatively low nipple position, and the possible need for a mastopexy in the future.
What about when there is breast droop ( ptosis ) as well as relatively large volume ( C cup or greater)? In this case, patients are best served with a lift ( mastopexy ) only. They do not have the advantage of superior fullness or increased size from an implant, but do not have the downsides of an implant either ( increased costs and likely need for further surgery).
In select patients, augmentation mastopexy is the appropriate choice. These patients have sufficient volume loss and extra skin to accommodate an implant and have a nipple in too low a position for an implant only to effectively get to the bottom of the breast envelope. A significant breast asymmetry is another factor favoring the combination operation. What makes the operation particularly difficult is increasing the mass of the breast with an implant while decreasing the skin envelope to hold the implant at the same time. Keys to success are limiting implant size and nipple movement to the amounts needed to accomplish the aesthetic goals. The increased risks include asymmetries, poor nipple position, and potential implant infection / exposure / and loss secondary to the additional incisions. The case of the month presented below represents a relatively large breast for combined operation.
Augmentation mastopexy is a good operation, but has additional costs and risks which must be accepted by the patient, and should only be performed by a Plastic Surgeon with sufficient experience. Sometimes aesthetic goals connot be reached safely or with high enough probalbility to justify the risks of operation. In this case, either augmentation or mastopexy only should be chosen. In rare instances, the operation not initially chosen may be performed secondarily. Usually, this goes augmentation first and mastopexy second, but the converse may also be appropriate for certain patients. A good example of this situation is a woman’s breast with a broad base, high fold, ptosis, and short distance from areola to fold. There is really no additional skin to take for a mastopexy, so augmentation only with possible later mastopexy (if needed ) works best.
