Introduction
The breast is comprised of parenchyma, which is the inside breast tissue which is made up of glandular tissue and fat. The quality and proportions of these tissues give the breast its characteristic firmness or lack thereof. The parenchyma is covered by skin. So when we are talking about the breast tissues, we mean skin, fat and glandular tissue. The skin and the underlying parenchyma act together to give the breast its shape.
The breast is anchored to the chest onto an oval "footprint." The footprint consists of the lower breast crease, the inner border (cleavage), the outer breast border and the upper breast line. The upper breast line is not usually visible when standing when the breast is freely hanging from the chest wall, but can be easily demonstrated by elevating the breast from the bottom and observing where the upper breast tissue meets the chest wall. In a zero gravity state, the breast would sit on its footprint with the chest, and you would not see any breast tissue falling below the lower breast crease. This is most easily seen from the side view where you can appreciate the lateral edge of the lower breast crease while simultaneously being able to see the lower edge of the breast.
The Problem: Sagging (Ptosis) of the Breast
A breast lift is indicated when there is ptosis (sagging) of the breast. The term "ptosis or sagging" is a very general term, we all have an idea what this means. A "deformity" in aesthetic surgery, and by use of the term "deformity", I do not mean to offend, but rather I use it to describe an anatomical characteristic or set of characteristics that an individual desires to surgically alter.
The best way to think about breast lift surgery is to think of the breast as consisting of two components. The first is the skin "brassiere," and the second is the glandular/fat content. With pregnancy and lactation, the glandular/fat contents enlarge, thereby stretching the skin. After lactation ceases, the glandular and fat contents revert back towards their previous size or smaller, however the skin has been stretched and does not have the same degree of elasticity. In this regard, the skin envelope remains larger than it was previously. Therefore, the skin envelope, if stretched to its natural degree of tension, would have volume that far exceeds that of the glandular/fat tissue inside it.
Furthermore, as the glandular/fat tissue stretches, the very ligaments that support and sustain the shape of the breasts (Cooper's ligaments) are stretched and do not go back to their previous size, thereby causing the glandular/fat content to descend downward. Therefore, there are actually two issues causing breast drooping. The first is the disparity in skin brassiere size versus the actual volume of the glandular/fat contents of the breast. This is seen, for example, in a woman who starts with a B cup breast, and then enlarges to a D cup with lactation, then the glandular/fat tissue of the breasts shrinks back down to a B cup in size, but the skin brassiere may be a C or even a D cup. The second issue is the fact that there is loss of firmness and shape of the glandular/fat contents within the breast.
Categorizing Ptosis: True vs. False Ptosis
Ptosis can be "true" or "false". The reference point for describing a breast as ptotic is the inframammary fold, also known as the lower breast crease. True ptosis refers to the relative position of the nipple with respect to the inframammary fold. False ptosis refers to the relative position of the inside glandular tissue with respect to the inframammary fold. This is also known as "glandular ptosis or psudoptosis." True and false ptosis are very different problems and need to be addressed separately. To make things a little more interesting, true and false ptosis usually coexist to varying degrees.
The below example side view demostrates pseudoptosis (false ptosis, glandular ptosis). The hoizontal line extends from the most lateral aspect of the inframammary fold (or crease) as shown by the red arrow. The purple arrow shows the glandular tissue sagging below this line. This is the ptotic glandular/fatty tissue of the breast. The descent of this tissue is also reflected by the loss of upper breast fullness as shown by the green arrow. The nipple itself is not quite at the level of the inframammary fold, so there is no true ptosis.
It is the responsibility of the surgeon to formulate a plan to correct any existing true and false ptosis. The ultimate goal is to bring the breast into harmony with what is considered the aesthetic ideal for that particular breast. This is not as easy as it seems. The surgeon needs to deal with not only the anatomical issues present in terms of excess skin and sagging tissue, but also needs to take into account the quality of the tissue, as by definition, all ptotic breasts have compromised tissue to some extent. If not, there would be no breast tissue visible from the side of the breast under the lower breast fold.
Ptosis Grade
True Ptosis has been divided into three grades: I, II and III. The grade is assessed by looking at the position of the nipple with respect to the inframammary fold (the lower breast crease). In the below illustrations, the dotted white line represents the inframmary fold.
Grade 1: (Mild ptosis) - The nipple is at the level of the inframammary fold.
Grade 2: (Moderate ptosis) - The nipple is below the level of the inframammary fold but is not at the bottom of the breast. When you look at the breast, you still see some breast skin below the areola.
Grade 3: (Severe ptosis) - The nipple is below the inframammary fold and is at the bottom of the breast. When you look at the breast, you still see no breast skin below the areola. The nipple is essentially pointing downwards.
So What is a Breast Lift?
When the breast is ptotic, or sagging, there is usually a disparate amount of excess skin relative to the amount of underlying breast parenchyma (glandular tissue and fat). This causes the nipple to descend (true ptosis). The underlying parenchyma is also without the support of a strong skin envelope and due to loss of firmness, is now ptotic as well (glandular ptosis). These issues may be caused by a multitude of factors including weight gain/loss, pregnancy/lactation, gravitational effects and genetic predisposition. Whatever the etiology of the ptosis, both true and false, correction is possible by understanding and appreciating the relative contributions of the skin, the glandular tissue and the fat to the problem. There is no "cookie-cutter" approach here. This is where the surgeon's experience, technical expertise and artistic judgment all come into play.
A breast lift is a procedure that is designed to take all the above etiologic factors for true ptosis into consideration and design a plan to remove excess skin, reposition the nipple, and sometimes reduce and/or rearrange the configuration of the underlying glandular and fatty tissue such that when the breast is reassembled, the breast has a more youthful, pleasing, aesthetic appearance. For those with only pseudoptosis, a lift is usually not necessary; rather a submuscular Dual Plane II or Dual Plane III approach works well in these cases. The surgical options for breast lift will be discussed in more details in the following sections.
Who is a Good Candidate for a Breast Lift?
A breast lift is a safe and effective procedure for many women seeking to enhance the appearance of their drooping breasts. There are certain restrictions on eligibility. The ideal candidates for a breast lift are women with:
- Sagging breasts
- Breasts that have lost shape or volume
- Breasts that are flat or elongated
- Nipples or areolas pointing downward
- One breast lower than the other
In summary, anyone who has grade II or III ptosis of the nipple (nipple-areola complex at or below the level of the inframammary fold) may be a candidate for a breast lift procedure. Pseudoptosis (glandular ptosis) may also be corrected at the time of breast lift surgery. It is also very important that breast lift candidates are healthy, do not smoke, maintain a stable weight and have realistic goals and discuss them with their plastic surgeon prior to surgery. Women planning to have children in the near future are advised to postpone surgery. This is because pregnancy and nursing can counteract a breast lift's effects by stretching the skin.
During consultation for a breast lift, I will explore your personal concerns and goals. Next, I will examine and obtain measurements and note the overall shape, size and elasticity of your breasts, as well as the position of the nipple-areola complex. After careful assessmentof all this information, I will be able to make recommendations as to which is the best procedure for you.
SECTIONS - Breast Lift/Mastopexy with Implants
Chapters - Breast Augmentation Guide
- Motiva Breast Implants
- Intro to Breast Augmentation
- Five key decisions you need to make
- One-Day Recovery Breast Augmentation
- Anesthesia – General, Sedation or Local?
- Breast Lift (Mastopexy) with/without Implants or Fat
- What else should I know about breast augmentation?
- Important Things to Consider When You Decide to Move Forward With Breast Augmentation
- Revision of breast augmentation
- ALCL and Breast Implant Illness
