Breast Augmentation for Early Ptosis

Abstract

The treatment of the ptotic breast is a complex process with a variety of techniques utilized to achieve optimal results. When a mastopexy is recommended based on the breast ptosis and nipple position, it can be performed alone or in conjunction with placement of a breast implant. In an ideal world all patients who are candidates for a lift will undergo a lift to optimize their breast aesthetics. However, some patients may wish to forgo the breast lift for a myriad of reasons, most commonly being financial reasons or avoidance of the necessary scars as part of a mastopexy. Patients may also have risk factors that make a mastopexy less desirable, such as a smoking history, keloid scarring or obesity.

One option for some patients with limited ptosis is to utilize only an implant without a formal mastopexy to achieve correction. Today, there are more implants with a variety of unique characteristics that can be used to the surgeon’s advantage when attempting to correct the ptosis without a mastopexy. Silicone implants have allowed lower pole expansion with less long-term overstretching of the lower pole that was seen with saline implants. There are multiple profiles, projections and size choices of silicone implants allowing the surgeon to choose an appropriate implant that fits within the parameters of the patient’s breast anatomy. Optimally filled implants and more cohesive 5th generation gels allow an implant to relax into the base of the pocket with less concern for upper pole volume loss and traction wrinkling. The textured implants provide more support and grip to the breast than a smooth device which has helped improve management of chest wall deformities. The anatomic shaped implants have lower points of maximal projection with more volume distributed in the lower half of the implant providing more lift and expansion of the lower pole.

The pocket selection also has an impact on the final breast aesthetics. The anatomy of the patient’s breast specifically the quality and thickness of the overlying tissue helps guide the pocket choice to provide adequate coverage of the implant. The subglandular and subfascial planes have been very helpful in correcting ptosis but limited soft tissue coverage often obviates their use. The submuscular pocket restricts expansion of the lower pole, however employing the dual plane allows modification of the muscle position with an increasing percentage of the breast tissue over the lower pole of the implant to improve the final position of the breast and nipple.

The success of the operation is multifactorial, but implementing the optimal surgical technique based on patient factors can significantly contribute to the long-term outcomes. In this chapter, the authors focus on a unique patient population in plastic surgery who have mild ptosis or pseudoptosis that undergo lifting of the breast with augmentation only without a concomitant mastopexy. We discuss the perioperative decision making which includes patient selection, implant selection, the preferred pocket for implant placement and use of the dual plane technique. Each of these decisions is based not only on the level of NAC ptosis and degree of vertical excess, but also on many other factors including the soft tissue characteristics, the distribution of the ptotic breast volume, the quality of the parenchyma and skin, and the patient’s expectations and risk factors.