Management of ptosis requires analysis of the problem, the patient’s desires and selection of the optimal operation. It is regarded as one of the most problematic procedures in aesthetic breast surgery.
Modern mastopexy operations produce better breast shape, shorter scars, more parenchymal support, and are longer lasting than in the past
Unlike the augmentation patient who has never had an ideal breast or the reduction patient who wants to be smaller even if it requires scars, the mastopexy patient was once satisfied with her breasts and wants them restored to their previous appearance withoutscars.
The risk benefit ratio of the procedure must be discussed with the patient.
Two basic questions must be addressed:
1. Does the breast lift justify the resulting scars?
2. If the insertion of an implant is required, is the additional risk justified?
After correction, the effects of aging and gravity will undo the effects of the procedure. The improvement is not lasting but the patient will be left with scars.
Patients are often unclear on what they want. Not only the droop but the shape and size may not be right.
Upper breast flatness is often a problem and requires the insertion of a prosthesis. This adds a degree of permanence to the procedure but with it comes the problems associated with implants.
THE NORMAL BREAST
The normal breast is located between the 2nd and 6th ribs. In the young girl, the nipple lies at the centre of the gland along the breast meridian opposite the 4th rib. In the mature breast, it lies slightly below the centre of the breast opposite the 5th rib.
CAUSES OF PTOSIS
BreastSkin is present in excess, is often thin and has poor elasticity. Striae reflect tears in the deep dermis.
The Gland is mobile over the chest wall due to attenuation of fascial supports and Cooper’s ligaments. The breast has often fallen down the chest wall resulting in upper pole flattening, (glandular ptosis), in addition to falling over the IMC (true ptosis). The NAC is relatively low, lying below the level of the IMC.
Most patients want slightly bigger breast following mastopexy. Skin tightening will give the perception of smaller breasts. In addition, breast projection is reduced.
Upper pole flatness will usually not be restored with mastopexy an implant is usually necessary to correct it (unless using vertical technique)
Oncologic concerns CLASSIFICATION OF PTOSIS
Type A: Minimal ptosis.
The nipple is located at or just inferior to the IMC.
Type B: Moderate ptosis.
The nipple is approximately 3 cm below the IMC.
Type C: Severe ptosis.
The nipple is more than 3 cm below the IMC.
II REGNAULT (1976)
The relationship between the nipple and the IMC is most important to define whether true ptosis exists and to what degree it is present. In the majority of patients, breasts of satisfactory volume remain aesthetic when the nipple lies above the level of the IMC. According to this relationship, pseudoptosis and 3 degrees of true ptosis can be defined
The inferior pole of the breast droops but the nipple lies above the level of the IMC. The nipple to IMC distance is increased. The breast has fallen through. “Bottoming out”
First degree: Mild ptosis
The nipple lies not more than 1 cm below the IMC.
Second degree: Moderate ptosis
The nipple lies 1-3 cm below the IMC, but remains above the lowermost projecting portion of the breast.
Third degree: Severe ptosis.
The nipple lies > 3 cm below the IMC or at the lower contour of the breast and skin brassier.
1. Glandular ptosis: The breast acts as a unit and the gland, nipple and IMC slide down the chest wall. Nipple to notch, nipple to IMC and notch to IMC are all increased.
2. True ptosis: The IMC remains fixed but the skin (and Cooper’s ligaments) stretch. The breast thus pivots around the fixed base of the IMC. The nipple descends and pivots to face inferiorly. The breast’s rotation is facilitated by some degree of parenchymal maldistribution or lower pole hypoplasia which maintains the IMC in a fairly high position. Nipple to IMC distance is thus relatively short.
3. Parenchymal maldistribution:Parenchymal tissue is located in the lower pole. The upper pole remains empty and flat.
4. Pseudoptosis: Is most common after corrective procedures for glandular ptosis where the fold has descended pre-operatively. The breast pivots around the NAC which points upwards and the IMC descends.