Mastopexy (Breast Lift)

Anatomy and Physiology

Breast ptosis can occur in patients of all ages secondary to various factors. The underlying mechanism of breast ptosis is a change in breast parenchyma volume without the breast suspensory ligaments and skin not appropriately compensating for this change.[1] Common causes of breast ptosis include: 

Aging

• Loss of skin elasticity: As women age, their skin loses collagen and elastin, essential proteins that provide structure and elasticity.
• Gravity: Over time, gravity exerts a downward pull on the breast tissue, leading to laxity in the skin.

Pregnancy and Breastfeeding

• Hormonal changes: Pregnancy causes hormonal fluctuations that can stretch the breast ligaments.
• Weight fluctuations: Breasts often enlarge during pregnancy and shrink after breastfeeding, leading to stretched skin and ligaments.
• Milk production: The engorgement of breasts with milk can stretch the skin and supportive breast ligaments.

Weight Fluctuations

• Weight gain or loss: Significant weight gain can stretch the skin, and subsequent weight loss can leave the skin lax, contributing to ptosis.
• Fat distribution: The breasts consist primarily of fatty tissue, and changes in body weight can alter their shape and firmness.

Genetics

• Inherited traits: Genetic factors can influence skin elasticity, breast density, and ligament strength, making some women more prone to ptosis.

Lifestyle Factors

• Smoking: Smoking reduces blood supply to the skin, accelerating the loss of collagen and elastin, thus hastening sagging.
• Poor diet: Lack of nutrients that support skin health can contribute to loss of skin elasticity.

Breast Size and Shape

• Larger breasts: Heavier breasts are more susceptible to the effects of gravity, making them more likely to sag over time.
• Breast density: Breasts with more fatty tissue (as opposed to glandular tissue) are more prone to sagging.

Hormonal Changes

• Menopause: Decreased estrogen levels during menopause can lead to a reduction in glandular tissue and elasticity, contributing to ptosis.

Physical Activity

• High-impact exercises: Repeated bouncing or impact (eg, running) without proper support can stretch Cooper ligaments, which help maintain breast shape.
• Lack of support: Not wearing a supportive bra, especially during exercise, can contribute to sagging.

Health Conditions

• Breast surgery: Surgical procedures can alter the structure and support of the breast tissue.
• Medical conditions: Certain skin and connective tissue conditions (eg, Ehlers-Danlos syndrome) can increase the risk of ptosis.[2]

Clinicians should assess specific measurements when evaluating a patient with breast ptosis, including Pitanguy point, sternal notch to nipple distance, sternal notch to inframammary fold distance, and nipple to inframammary fold distance. To find the Pitanguy point, the inframammary fold is transposed to the anterior breast at the breast meridian; this is the point where the NAC should be positioned.[3] 

Regnault Classification of Ptosis

The following Regnault classification describes the varying degrees of ptosis:

• Pseudoptosis: The NAC is at or above the level of the inframammary fold, but the majority of the breast parenchyma is below the inframammary fold.
• Grade I ptosis: The NAC is at the level of the inframammary fold.
• Grade II ptosis: The NAC is below the inframammary fold but is not at the lowest point on the breast.
• Grade III ptosis: The NAC is at the breast's lowest or most dependent point.[4]

Any breast asymmetries and any asymmetry with the patient's musculoskeletal system should be evaluated, as deformities, eg, scoliosis, rib flare, pectus deformities, and a patient's natural posture, can affect the appearance of the breasts. 

Indications

Indications for mastopexy include any patient with breast ptosis who does not want a decrease in their breast size or volume but desires their breasts and NAC to have a lifted appearance. Additionally, mastopexy techniques can be used to address differences in areolar size and symmetry.[5] In patients with natural asymmetry, a unilateral mastopexy may be all that is required.

Furthermore, mastopexy may be indicated in a patient undergoing explantation of breast implants to address skin laxity and reposition the nipples.[6] In a patient with a history of unilateral breast cancer, mastopexy of the unaffected breast may be performed in combination with oncoplastic procedures for improved symmetry.[7] In patients undergoing prophylactic nipple-sparing mastectomies, mastopexy may be performed before mastectomy, allowing the surgeon to address excess skin laxity and position the nipple appropriately, allowing the breast to heal before completing the mastectomy.[8] Notably, mastopexy can be performed in patients who desire a breast lift in combination with breast augmentation in an immediate or staged fashion.

Contraindications

Contraindications for performing a mastopexy alone include:

• Active breast cancer
• Active breast infection
• Patients who wish to have a significant decrease in breast size
• Pregnant patients
• Patients who are not medically stable for anesthesia

Clinicians should also assess the patient's motives for requesting this aesthetic surgery and ensure that the underlying reason is not due to external factors, including but not limited to persuasion from a partner or friend, an unstable personal relationship, or body dysmorphia, as patient satisfaction following surgery for these reasons is typically low.[9]

Equipment

Typically, a general plastics and breast tray of instruments can be used for mastopexy, including a 10- and 15-blade scalpel, Adson forceps, army-navy retractors, needle drivers, electrocautery, and suction. Suture choice will vary with surgeon preference. If simultaneous augmentation is performed, larger retractors and a lighted retractor are necessary, along with a long electrocautery tip, breast implant sizers, and permanent implants. Additionally, a Keller funnel and irrigation may be needed based on the surgeon's preferences. Patients will also typically be given preoperative antibiotics. Postoperative pain medication regimens are also surgeon-specific. 

Personnel

Standard operating room staffing is required for mastopexy procedures, including a circulating or operating room nurse, surgical technician, anesthesiologist, and surgeon. This procedure can be performed in a hospital, surgery center, or office-based certified operating room. Assistance with retracting and closure may help improve operative time and efficiency. 

Preparation

Preoperatively, the primary surgeon must ensure the patient is current on any necessary breast imaging, such as screening mammography. Patients with medical comorbidities should have those comorbidities optimized prior to surgery. If the patient plans to lose a significant amount of weight, the procedure should be delayed until they are near their goal weight or at a stable weight; losing weight after surgery can cause recurrent breast ptosis. Similarly, pregnancy can also lead to breast changes, which may require another mastopexy procedure in the future if they wish to have the surgery before they are finished with childbearing. Finally, a thorough breast history, including a personal or family history of breast cancer, must be obtained before the procedure is performed.

Mastopexy is typically performed under general anesthesia with the patient supine and the arms extended. Intraoperative indwelling catheterization is typically not required due to shorter operative times. An antimicrobial solution, typically either betadine or chlorhexidine-based, of the surgeon's choice, is used to cleanse the surgical site from the upper abdomen inferiorly to the neck superiorly, extending to the midaxillary lines bilaterally and encompassing the shoulders and upper arms. The patient is draped in the normal, sterile fashion, and a surgical time-out is performed according to institutional protocol. 

Technique or Treatment

Mastopexy can be performed using various techniques. The method selected is typically based on the amount of lift needed and the degree of breast ptosis present. Mastopexy techniques include the crescent lift mastopexy, circumareolar mastopexy, vertical mastopexy, and wise pattern mastopexy, also called anchor pattern or inverted T. In addition to these options, patients can have an autologous augmentation using their own tissue or an implant-based augmentation. The goals of a mastopexy are to return the NAC to the appropriate position, address areolar size if necessary, restore some of the upper pole fullness lost with ptosis, reshape the breast in cases of higher grade ptosis, and achieve better symmetry to the extent that the patient's anatomy will allow.

Crescent Mastopexy

In crescent mastopexy, a superior crescent of tissue at the NAC margin is excised, and the remaining skin is sutured closed to lift the NAC very slightly. The risk and benefits of the procedure include:

• Advantages: The scar is short and hidden in the areolar border; typically, nipple sensation is unchanged.
• Disadvantages: This procedure can lead to the elongation of or misshapen areolas due to uneven tension only on the superior portion. Crescent mastopexy is only an option for very minimal lifts and scant skin excess.

Circumareolar Mastopexy

A circumareolar mastopexy is recommended for patients who require less than 2 cm of lift. Two concentric circles are made around the areola, with a wider portion excised superiorly, and a small donut-shaped portion of skin is removed. This incision goes around the entire areola and can be used to reduce areolar size and improve symmetry. A purse string or wagon wheel suture is used to cinch the skin, giving the mastopexy effect. The risk and benefits of the procedure include:

• Advantages: The scar is typically hidden at the areolar border.
• Disadvantages: This technique can cause widening of the areola due to tension, decreased projection of the breast, and potential for changes in nipple sensation.[10]

Vertical Mastopexy

A vertical mastopexy or lollipop incision is used when the NAC needs a greater lift length, and the skin envelope needs tightening. Several techniques for performing a vertical mastopexy have been established, most of which include a superior or superomedially based pedicle. A circumareolar incision and a vertical incision inferior to the NAC are made. The NAC is dissected on a superior superomedial breast pedicle. Typically, the vertical skin is tailor-tacked in place temporarily with staples to determine the extent of skin excess that can be removed. A small wedge of inferior pole parenchyma can be excised along with the overlying skin, and the remaining medial and lateral pillars of breast parenchyma are then sutured together typically at the level of the subcutaneous to provide structural support to the breast, which will aid in preventing recurrence of ptosis. If an augmentation is performed with a vertical mastopexy, the dissection is done through this vertical incision.

Usually, at minimum, a 2-layer closure is performed, with interrupted sutures in the deep dermal layer and a running subcuticular suture. There is some variability in the closure of the NAC, with some surgeons choosing all absorbable, buried sutures and others using a deep layer of absorbable sutures and a superficial layer of prolene with either mattress or running sutures that are later removed in the office. The use of monofilament versus braided versus barbed sutures is also a surgeon's preference. The risk and benefits of the procedure include:

• Advantages: This option reduces the areola and tightens the skin envelope while avoiding a long horizontal incision in the inframammary fold. 
• Disadvantages: Because this technique does not have a horizontal component to the incision, this procedure can lead to an increased length of the nipple to inframammary fold distance, which can cause abnormal breast proportions. Another disadvantage of this technique is a more apparent vertical scar in addition to the periareolar scar.[5]

Wise Pattern Mastopexy

The last option is a wise pattern mastopexy, also referred to as anchor pattern or inverted T pattern, which includes a horizontal incision along the inframammary fold, in addition to the vertical and periareolar scars. This option helps to decrease the skin excess vertically and horizontally, as well as lifting the NAC a larger amount. This can also reduce the areola size and aid in symmetry. A wise pattern mastopexy is typically performed in patients with a higher degree of ptosis. This technique is similar to the pattern for a breast reduction, but either none or a small amount of the breast tissue is removed in a mastopexy, unlike the high volume required for a reduction mammaplasty.

Several options for the tissue pedicle may be utilized just as with breast reductions, including inferior pedicle, superior pedicle, and superomedial pedicle, which are the most common choices for surgeons. This pedicle is used to reshape the breast parenchyma and allows the overlying breast skin envelope to be draped over the reshaped and lifted breast. Some surgeons choose to suture the pedicle loosely to the underlying chest wall with absorbable sutures to prevent migration of the pedicle, while others do not. The skin envelope is typically tailor-tacked with staples, just as the vertical mastopexy, to determine the extent of skin resection necessary. Closure is similar to the vertical mastopexy or a standard breast reduction, with all incisions closed in at least 2 layers. Some surgeons prefer to use a barbed suture, while others do not. The NAC closure is also based on surgeon preference, with the same options as vertical mastopexy. The risk and benefits of the procedure include:

• Advantages: The horizontal portion of the incision/scar is usually well hidden in the inframammary fold, and surgeons are typically very familiar with this marking pattern from reduction mammaplasty procedures.
• Disadvantages: A greater extent of scarring occurs, as well as potential healing issues at the T zone of the incisions.[11]

Augmentation

If autologous augmentation is desired, options include using autologous tissue flaps and or fat grafting.[12][13] Autologous augmentation utilizes the breast parenchymal flaps that would otherwise have been excised during a standard mastopexy, which are repositioned and sutured to provide additional volume to the newly reshaped breast. 

If an implant-based augmentation is planned, the surgeon will typically use a sizer to ensure the correct implant size before placing the permanent implant, which will either be saline or silicone, depending on the surgeon's and patient's preference.[14] The dissection depends on the mastopexy incision type being performed for the patient. Usually, the implant is placed before the mastopexy is completed to avoid over-resection of skin. 

A single-stage and 2-stage approach are also used to augment mastopexy, mostly when discussing implant-based augmentation. Patients with mild to moderate ptosis, good skin elasticity, and plans for a small implant are feasible to perform a 1-stage procedure. Patients that have severe ptosis, wish for a large volume implant, have poor skin elasticity, or require a large amount of skin excision will typically fare better with a 2-stage procedure, with the mastopexy being done in the first stage and the patient being brought back for the augmentation at a second procedure.[15] The risk and benefits of the procedure include:

• Advantages: With autologous augmentation, the patient avoids a foreign implant if they so desire and maintains their current breast volume. With implant-based augmentation, the patient can get a notable increase in medial and upper pole fullness, which these patients hope will settle less than with their own tissue.
• Disadvantages: Some patients may not have much breast tissue to auto-augment, and other patients may not wish to have a "foreign" implant placed that requires maintenance.

Postoperative Care

Mastopexy, with or without augmentation, is an outpatient procedure, meaning the patients will be discharged home following surgery. Postoperative care varies by surgeon regarding the degree of activity restriction, when showering is acceptable, and the duration of surgical or support bra use. 

Complications

Complications of this procedure include infection, bleeding, delayed wound healing, nerve injury, spreading or asymmetry of the NAC, sensation changes of the NAC, hypertrophic scar, keloids, breast asymmetry, and recurrent breast ptosis.[16] If an implant is used, there is always a risk of infection and/or implant loss, capsular contracture, need for routine breast/implant imaging, and need for regular implant exchange in the future. If a textured implant is used, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is also a risk; the specific textured implant associated with this cancer has been removed from the market.[17] It is important to discuss the risks and complications of these procedures with patients so they can make an informed decision and provide informed consent. It is also required that any patient receiving a breast augmentation with implants be aware of BIA-ALCL. 

Specific nerves that can be injured during these procedures include the intercostal nerves from T3-5, which innervate the NAC; the intercostobrachial nerve, which gives off the medial brachial cutaneous nerve; and the long thoracic nerve, which innervates the serratus anterior. With the crescent and circumareolar mastopexies, there is no risk to these nerves as there is no dissection into the breast parenchyma. Nerve injury is rare but occurs more with the wise pattern mastopexy and mastopexy with augmentation, as there is a wider field of dissection that can lead to inadvertent nerve injury. This can be a direct injury from electrocautery or scalpel dissection or a traction stretch injury from retractor use. These nerve injuries can lead to hypoesthesia or hyperesthesia and may cause significant distress to patients.[18]

According to a study by Gupta et al, mastopexy alone has the lowest overall incidence of complications at 1.15%, while the augmentation with mastopexy complication rate is higher at 1.86%. The most common complication identified in this study was hematoma for both operations, 0.65% and 1.10%, respectively, and infection was second most common at 0.32% and 0.43%, respectively.[19]

Clinical Significance

Surgeons should be able to identify which patient will benefit from a mastopexy and which specific technique aligns with the patient's desires for an aesthetic outcome postoperatively, along with the patient's anatomy and degree of breast ptosis. If a patient wishes for a significant reduction in breast size, a mastopexy would not be the best procedure for the patient, and a reduction mammaplasty should instead be discussed.

Clinicians should set the patient's expectations for their surgical outcome and discuss that some degree of scarring will occur depending on the approach. Clinicians should ensure that patients understand that returning them to the exact breast size and shape that they had before any pregnancy, weight loss, or insult to the breasts is challenging and likely impossible. The interprofessional team involved with the surgery should know the equipment necessary for such a procedure. 

Enhancing Healthcare Team Outcomes

Mastopexy is a common outpatient aesthetic surgery performed to reposition the breast and NAC, restoring a more youthful appearance. Achieving optimal patient-centered care, safety, and outcomes requires a collaborative, interprofessional approach. Plastic surgeons and advanced practitioners must identify suitable candidates and discuss tailored surgical options based on the patient’s anatomy, degree of ptosis, and scarring preferences.

Physicians play a critical role in coordinating necessary preoperative breast imaging and medical clearances, ensuring patient safety. Intraoperatively, effective communication among plastic surgeons, anesthesiologists, nurses, and scrub technicians is essential to ensure proper equipment availability and adherence to best practices. Postoperatively, nurses and advanced practitioners play a crucial role in patient education, managing wound care, monitoring for complications, and supporting recovery. Pharmacists contribute by guiding pain management, antibiotics, and necessary medications while ensuring patient safety through accurate dosing and interaction review. By fostering a culture of teamwork, open communication, and shared responsibility, the interprofessional team enhances patient outcomes, safety, and satisfaction while optimizing the efficiency of the surgical process.