The severely sagging breast usually requires a combined breast lift with an implant, known as a mastopexy with augmentation in plastic surgery terms. This combined procedure lifts and repositions the nipple to a more central mound position, tightens and reshapes the breast mound into more of a conical form, and adds volume to create a fuller mound. In many ways, the different goals of this procedure work against each other….tightening the breast but making it bigger at the same time. This may seem like a trivial consideration, but it is these opposing forces which make a breast lift with an implant a difficult operation. It is difficult to do well and even more difficult to get both breasts as symmetrical as possible.
An extended or full breast lift is needed in the extreme weight loss patient. A large amount of skin must be removed in a ‘keyhole’ or wedge-like pattern. While this skin excision is marked before surgery with a tape measure and the planned incisions made visually symmetric, few breasts are exactly the same to start with. This inherently makes even the most well marked and planned breast lift exposed to risks of asymmetry. In a breast lift, skin is removed but breast tissue (and the nipple) are not. The cutting and redraping of the breast skin provides a more uplifted and better shaped containment sac for the breast tissue. This results in a classic anchor or inverted-T scar pattern on the lower pole of the breast.
During the breast lift, there is ample opportunity and access to introduce and place a breast implant. Because of the blood supply that goes to the nipple through the breast tissue, it is prudent to place an implant under the pectoralis muscle rather than above it. Placing a breast implant above the muscle into the breast tissue may injure or disrupt the nipple’s blood supply, increasing the risk of losing the nipple after surgery due to necrosis. (turns black and dies) What size implant to use will vary greatly. You want to fill out the overlying breast tissue and make a nice round mound but you still want to be able to close the breast lift skin over it. Therein lies the art and skill of the procedure. It is a delicate balance between choosing the right breast size (expansion) that still allows closing and tightening the breast skin (contraction)without too much tension. Too much tension of the breast lift skin closure will result in wide scars at the least and the possibility of suture line opening or breakdown after surgery.
Because of the complexities of making an improved breast shape through lifting and an implant, every patient undergoing this procedure should be aware of and accept that the need for revisional surgery is likely. Whether it be asymmetry of the nipples, positioning of the implants, and poor scarring from the lift, revisional surgery for this operation is not rare.
Dr. Barry Eppley
Indianapolis, Indiana