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Breast Lift Choices

Information, Alternatives and Choices Regarding Breast Lifting Techniques

We are providing you the following written information as one part of our patient education process. It is impossible for you to make optimal decisions without information. We ask that you carefully read this information, and make notes and list questions as you read. If you have any questions about any part of this information, if any part is unclear, or if you want or need additional information, we will be happy to provide answers or additional information.

Breast Lift (Mastopexy)

The term mastopexy is used to describe procedures that elevate a sagging or excessively low breast mound in conjunction with repositioning of the nipple-areola complex. Breast shape and the degree of breast sagging can vary tremendously from patient to patient, and the type and extent of breast lifting procedure necessary to improve the appearance of the breast can also vary tremendously. In general, the wider a patient’s breasts, and the greater the degree of sagging, the further the breast and nipple have to be moved upward in order to optimize breast appearance.

Why Breasts Sag, and Why Mastopexy isn’t Permanent

You are consulting a surgeon because your breasts sag, are likely too empty in the upper breast, and you desire improvement. The reason that you may need a breast lift or mastopexy is the same reason that the operation provides only temporary and partial improvement—the characteristics of your tissues have not adequately supported the weight of your breast tissue, allowing skin to stretch and your breasts to sag. As you age, your skin will continue to decline in it’s ability to support weight, your breasts will resag to some degree, and may require additional procedures to keep them looking as good as possible. Surgery cannot control your tissue characteristics, and surgery cannot prevent future stretch, sagging, and emptying of the upper portion of your breasts, despite what you may hear or read from other sources.

The “Best” Type of Breast Lift—Does One Exist?

There is no one best type of breast lift procedure for every patient. Your tissue characteristics, the width of your breast, the distance from your nipple down to the fold under your breast, and the distance upward that your nipple needs to be moved are all important factors in selecting the most appropriate type of breast lifting procedure.

Many surgeons may focus on only one type of lifting procedure, and try to convince patients of the superiority of a single type of breast lift. Some other surgeons may rarely measure all of the important dimensions of the breast, and simply base their decisions on “eyeballing” and “artistic eye” criteria rather than quantifiable measurements. Even great artists and sculptors such as Leonardo da Vinci and Michaelangelo used detailed measurements before applying their artistic eye, and we do the same. We believe that it is difficult or even impossible for us to make optimal decisions about which techniques may be optimal for you without basing our decisions on measurements, and offering you a range of choices, each with different tradeoffs.

Achieving and Maintaining Upper Breast Fullness- Lifting with or without a Breast Implant

Most breast lifting procedures temporarily increase fullness in the upper breast. Regardless of what you might hear or read, we are not aware of any conclusive scientific evidence that any type of surgical procedure or breast implant can maintain upper breast fullness for more than a few months, especially in patients with sagging breasts where the skin has not supported event the weight of the breast tissue. Many gimmicky procedures such as special suturing techniques, tissue pull-through techniques, and internal sling techniques purport to maintain upper fullness. Although you may see pictures in scientific publications supporting those procedures, in our opinion none of them predictably maintain upper fullness, and many add potential compromises or tradeoffs. Our opinion is reinforced by the results of surgeries done using these procedures in “live surgery” symposia where the surgeon advocating the procedure cannot show selected cases or publish selected cases.

Mastopexy or breast lifting may temporarily improve upper breast fullness, but mastopexy with or without a breast implant cannot predictably maintain upper breast fullness. The skin that stretched in the first place to allow the breast to sag will stretch again, especially as it ages, and the more weight in the breast, the more and faster it is likely to restretch and sag. A little common sense here goes a long way.

Adding a breast implant during a mastopexy adds additional weight to the breast at a time when the tissues have been mobilized to reposition the breast. Normal tissue attachments have been detached in certain areas to allow the surgeon to lift the breast. The skin of your breasts didn’t even support the weight of your own breast tissue, or the breasts would not be sagging and need a breast lift. Adding weight to those tissues at any time is questionable judgment and carries significant tradeoffs, but adding that weight at the time of mastopexy when supporting structures are partially detached, is even more questionable judgment. In our opinion, simultaneous mastopexy-augmention is rarely logical or indicated, and only in specific circumstances where nipple repositioning without actual breast lifting is required.

Types of Breast Lifting Procedures

Breast lifting procedures are often categorized by the amount and location of incision (and therefore scar) that accompany each type of procedure. Three basic categories of breast lifting procedures are common;

  1. Periareolar Mastopexy – A procedure in which the only incision is around the edge of the areola.
  2. Vertical Mastopexy – A procedure in which in addition to the incision around the areola a vertical scar in the 6 o’clock position of the areola directly downward to the 6 o’clock position of the fold beneath the breast is made.
  3. Inverted-T Mastopexy – A procedure in which a periareolar incision is accompanied by a vertical incision and also an incision that lies near the fold underneath the breast, with the vertical incision and the incision beneath the breast forming and inverted-T.

The goal in any breast lifting procedure is to improve the appearance of the breast as much as possible within the limitations imposed by each patient’s individual tissue characteristics and breast characteristics and dimensions. Scars are a necessary trade-off of any breast lifting procedure, and the quality and manner of healing of scars varies from patient to patient and is not totally predictable. Patients and surgeons obviously would like to limit the length of these scars as much as possible, and “short scar techniques” such as 1) periareolar mastopexy and 2) vertical mastopexy often seem more appealing than techniques such as 3) inverted-T mastopexy. However, in order to make an informed decision about the specific technique you might prefer, you as a patient must understand the trade-offs of each different technique.

In general, the wider your breast and the longer the distance from your nipple down to the fold under your breast (a measure of “sagginess”), the longer the scars required to lift your breast and leave as smooth scar contours as possible immediately after surgery. If you don’t balance the characteristics of your breasts to the type and extent of incisions required for correction, you are more likely to experience bunching of skin, puckering of skin, less than optimal contours for several months following surgery, and more risk of needing additional procedures for revision in the future.

Each of the techniques listed previously is appropriate and optimal for specific types of breasts. Whether a technique is optimal for your breast depends on the following:

  1. the width of your breast
  2. the distance from your nipple to the fold underneath your breast measured under maximal stretch
  3. the distance your nipple needs to move upward,
  4. the trade-offs and nuisances that you are willing to tolerate that are involved with each of the techniques
  5. your willingness to accept the risks and costs of additional procedures should a revision procedure be necessary.

Periareolar Mastopexy

Periareolar mastopexy, while appealing because of the shorter scar compared to the other two techniques, has unique limitations and trade-offs. When an incision is made only around the areola, the greater the amount of skin that needs to be removed from the breast in order to produce lift, the more that the skin has to be gathered during closure of the incision. This results in pleating and puckering around the areola that can persist for months or longer than a year, and may require additional surgery for scar revision. This type of procedure puts considerable tension on the areola, and excessive widening of the areola can occur. To prevent excessive widening of the areola, a permanent purse string suture is often placed beneath the skin to try to offset the tension that creates excessive widening. You will be able to feel this pursestring suture beneath the edge of your areola as a circular ring beneath the skin. Most surgeons prefer a permanent type suture for the purse string suture, but even a permanent type suture can break or wear out over time, allowing the areola to widen excessively. Because of the additional and variable tension placed on the areola with periareolar mastopexy, differences in shape of the areolas and widening of the areola can occur. In most instances, periareolar mastopexy is optimal for patients who have relatively narrow breasts and who require only a minimal amount of elevation of the breast and nipple areola.

Vertical Mastopexy

The second category of mastopexy procedures, vertical mastopexy, involves an incision around the areola as well as a vertical incision extending downward from the 6 o’clock position of the areola. To avoid the side-to-side scar in the fold under the breast (the inverted T incision), vertical mastopexy gathers skin upward into the lower breast rather than removing it (the scar in the fold allows the surgeon to remove the excess). When the excess skin is distributed upward into the breast to avoid removing it (and hence the scar in the fold), there is often some bunching or bulging of skin at the bottom of the vertical incision, near the fold. This bunching or irregular contour may or may not completely resolve, and may require a revision procedure in order to achieve an optimal, smooth contour. In some cases the vertical scar may need to actually cross the fold and may extend below the fold permanently. When excess skin is distributed up into the vertical incision area instead of removing it, there is a greater chance that in the months following surgery, this excess skin will restretch and allow the implant to shift downward excessively, producing a “bottomed out” appearing breast, with too much fullness in the lower pole, the fold too low, the nipple pointing upward, and an emptier upper breast. Vertical mastopexy is usually a satisfactory option for women with narrow to moderate width breasts who have only mild to moderate sagging and do not require much nipple movement.

Inverted- T Mastopexy

The inverted-T scar mastopexy, while placing more scars on the breast, gives a surgeon maximum flexibility in the design of the operation and maximal ability to correct a wide range of deformities. The inverted-T approach is especially effective in moderate width to wider breasts with greater degrees of sagging where more nipple areola positioning is required. Although the scars are longer, the surgeon using an inverted-T technique has more flexibility in eliminating skin wrinkling and puckering, and scar contours are usually better much sooner following surgery.

Making Definitive Choices and Decisions about Mastopexy

You should not make a definitive choice about what type of mastopexy technique you prefer until your surgeon has had an opportunity to measure your breasts, demonstrate to you the width of your breasts, the distance from the nipple to the fold and how the specific shape, dimensions, and skin characteristics of your breasts affect each of the trade-offs listed above. Trade-offs are not the same for every patient, because breasts are different in every patient. No single technique listed above is best for each patient. Only after measuring your breasts and examining your breasts with respect to individual tissue characteristics can your surgeon provide you with a realistic estimation of the risk of each trade-off listed above.

Tradeoffs, Risks and Possible Complications of Periareolar Mastopexy

A periareolar mastopexy produces a scar that extends completely around the outside of the areola, and the quality of this scar depends largely on your individual healing characteristics and is not totally predictable or controllable by Dr. Tebbetts.

In almost all cases of periareolar mastopexy, there will be puckering, pleating, or bunching with protrusion of the skin around the edge of your areola that may persist for many months, will be somewhat different on the two sides, that may not resolve completely, and that may require scar revision in the future with costs up to $1500.00 of additional surgeon fees as well as additional surgical facility fees and anesthesia fees. If a revision is necessary, Dr. Tebbetts will wait at least a year or more after your initial procedure to perform the revision in order to give the tissues time to optimally heal and the scar to mature.

In order to try to reduce risks of your areola widening excessively after a periareolar mastopexy, Dr. Tebbetts will need to place a “pursestring” suture immediately underneath the skin around the edge of your areola. You will be able to feel a ridge, firm ring, or band beneath the outer border of my areola caused by this pursestring suture that is necessary to try to minimize excessive stretching and widening of the areola.

A “permanent” pursestring suture, placed to minimize areolar widening or distortion, can pull through the tissue and fail, allowing your areola to widen excessively. If this occurs, additional surgery may be necessary for improvement.

Tradeoffs, Risks and Possible Complications of Vertical Mastopexy

Vertical mastopexy results in a scar that extends completely around the outside of the areola and from the bottom of the areola down to or below the level of the fold under your breast, and that the quality of this scar depends largely on your individual healing characteristics and is not totally predictable or controllable by Dr. Tebbetts.

Following vertical mastopexy, you may notice puckering, pleating, or bunching with protrusion of the skin around the edge of your areola or in the lower area of the vertical scar near the fold under your breast that may persist for many months, will be somewhat different on the two sides, that may not resolve completely, and that may require scar revision in the future with costs up to $1500.00 of additional surgeon fees as well as additional surgical facility fees and anesthesia fees. In some cases, it may be necessary for the vertical scar to cross the fold under the breast, or it may be necessary to add a side-to-side scar in the fold in order to achieve optimal scar contour and breast correction. If a revision is necessary, Dr. Tebbetts will wait at least a year or more after your initial procedure to perform the revision in order to give the tissues time to optimally heal and the scar to mature.

If a pursestring suture is necessary, you may be able to feel a ridge, firm ring, or band beneath the outer border of your areola as a tradeoff to try to minimize excessive stretching and widening of the areola.

A “permanent” pursestring suture, placed to minimize areolar widening or distortion, can pull through the tissue and fail, allowing your areola to widen excessively. If this occurs, additional surgery may be necessary for improvement.

Tradeoffs, Risks and Possible Complications of Inverted-T Mastopexy

An inverted-T type of mastopexy procedure results in a scar that extends completely around the outside of the areola, from the bottom of the areola down to or below the level of the fold under your breast, and side-to-side near the fold under your breast. The length of scar depends on your breast dimensions and the amount Dr. Tebbetts needs to lift your breast and nipple. The length and the quality of these scars depend largely on your individual healing characteristics and are not totally predictable or controllable by Dr. Tebbetts.

You may experience puckering, pleating, or bunching with protrusion of the skin in any of your incision areas or other areas, even though the inverted-T incision approach allows Dr. Tebbetts to minimize these occurrences compared to a periareolar or vertical mastopexy. Scar or incision line irregularities in any area may persist for many months, will be somewhat different on the two sides, that may not resolve completely, and that may require scar revision in the future with costs up to $1500.00 of additional surgeon fees as well as additional surgical facility fees and anesthesia fees. If a revision is necessary, Dr. Tebbetts will wait at least a year or more after my initial procedure to perform the revision in order to give the tissues time to optimally heal and the scar to mature.

Tradeoffs, Risks and Possible Complications Common to All Types of Mastopexy

With any breast lifting procedure, it is necessary to separate the skin from the underlying breast tissue and separate the breast tissue from some of its attachments in order to reposition the breast. When skin is separated from breast tissue or breast tissue is separated from other attachments, nerves and blood vessels must be divided or cut and this can produce temporary or permanent loss of sensation in any or all areas of the breast as well as deficiency in blood supply to either skin or internal tissues of the breast that can cause death of the tissues that may require additional surgery and may leave temporary or permanent deformities. If these problems occur, additional operations may be necessary necessary, and you should understand and accept that you are personally responsible for surgeon fees, anesthesia fees, surgical facility fees, and other costs associated with time off from work or time off from normal activities, and be willing to personally assume all of these financial responsibilities.

With any breast lifting procedures, your breasts do not match before surgery, and they will not match after surgery. Specifically, the size of your breasts will not match after surgery, the position of the nipple and areola with respect to each breast mound will not match after surgery, and the size and shape of the areolas will not match on the two sides.

Dr. Tebbetts performs all breast lifting procedures using general anesthesia to provide maximal control and safety during your surgery. You must be aware that it is possible to die during or after any anesthetic, or from administration of any type of drug or medication. Those dire risks are exceedingly small, and we perform our surgery in a fully accredited surgery center where all patient care personnel are certified in essential emergency procedures.

The fact that you may need a mastopexy means that your skin has not supported the weight of your own breast tissue, stretching and allowing your breasts to sag. Following any breast lifting procedure, your skin will continue to restretch. As it restretches in the lower breast, it allows your breast tissue to shift downward, emptying the upper breast to some degree, and resulting in a sagging appearance again. Very little additional stretch in the lower breast will cause significant loss of fill in the upper breast. It is impossible for Dr. Tebbetts or any other surgeon to predict the degree to which your tissue will restretch, or the time required for it to restretch. As a result, Dr. Tebbetts cannot predict how long or how well your breast lifting procedure will last.

John B. Tebbetts, M.D., Dallas Plastic Surgeon

Dallas Plastic SurgeonRead more about Breast Lift vs Breast Augmentation

The Best Breast

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