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DR MARK EDINBURG MBBCH, FRACS.| MEDICAL DIRECTOR
Ever wondered what a Plastic Surgeon discusses with your patient at her consultation?

The following “imaginary consultation” with a patient requesting a mastopexy(breast lift) compiled by Dr Mark Edinburg one of Australia’s leading aesthetic surgeons will provide you with a fascinating insight.

So I hear you saying that you wish that you could have your physical attributes back again now that you’re in your thirties or forties and having had the two or three kids whom were generously breast fed for six months to a year and occasionally longer. I often hear the distress that “my breasts are halfway down my tummy and I can’t see my nipples and I am so flat at the top.” Most of my patients diplomatically present this scenario: others will be much more direct and say it like it is – which is not for publication in this article. So you see, you are not alone and you are not unique – there are many women out there who like you, seek advice and perhaps will come to surgery and achieve a happier physique along with improved esteem and confidence as well as being able to dress according to desires without stressing about “how do I look”.

There are many reasons why a patient will seek consultation for droopy breasts. Mostly though, it is for breasts that are sitting low with the nipple at or below the fold under the breast, (what we surgeons call ptosis and for which we grade them, depending on the exact position of the nipple relative to the fold), the volume of the breast – mostly empty and especially in the upper part of the breast (upper pole), for enlarged nipple areola complexes, and for loose skin, sometimes wrinkled and for loss of firmness (perhaps I should have put this one first but it doesn’t matter). Some patients are satisfied with size if their breasts and simply want a lift. Some patients add that they want the least amount of scarring and some patients say I saw this or I heard that and why can’t you do it? Damn these TV shows.

The Purpose of a Breast Lift

If I can summarise then, the purpose of a breast lift (mastopexy)

• To raise the level of the nipple and areola
• To improve the firmness of the breast by removing excess skin
• To improve the shape and contour of the breast
• To increase the volume of the breast by inserting an implant which is easier said than done but I will come onto that a little later.

Now that you have nervously confided these closely kept secrets with your Plastic Surgeon, you will be asked more about yourself particularly relating to your current medical status, the tablets that you take – all of them including herbs and what-have-you, because they are all important and may affect the outcome of your surgery. Whether you go to the gym and what exercise you do as this may affect the pocket and placement of the implant. Lastly and very importantly, I ask my patients, who are so very often well informed, what is ideal for them and what they would like to achieve. This is a good avenue for realistic discussion as it deals with expectations early on and what can or cannot be achieved.

The next stage is an examination usually carried out in the office with a nurse in attendance to look after you and me and to take dictation of the findings. A complete chest and breast examination is carried out. Distances are measured, the diameter of the breast base, the distance of the nipple to the breast fold, the symmetry of the breasts and the chest wall as well as the nipple and areola. The position of the nipple in relation to the fold under the breast is very important and plays a crucial role in decision making. Breast lumps and bumps are excluded. Checks are made for nipple inversion or discharge.

This examination will provide me all the information that I would need to make a decision about what operation to offer you and there are many such operations that are available. I would discuss with you what the operative procedure is, where it is done, how long it takes and how long you will remain in hospital. We will also discuss the recovery time as well as the potential complications of the surgery.

The Trade Offs

If you are having an Augmentaion at the same time, you will receive information regarding the various types of implants available, where they would be positioned, in front of or behind the muscle; you will be sized and helped in choosing the right sized implant and you will be able to try out and see what you look like in front of a mirror.

Augmentation – Mastopexy(lift) is often regarded by Plastic Surgeons as one of the more challenging of all the aesthetic procedures performed on the breast. This is because the surgeon has to take care of multiple surgical variables at the same time and therefore the operation involves trade-offs. Patients will need to understand the limitations of their surgery and especially if upper pole fullness is required. Patients are aware and unhappy that their breasts are droopy and at the same time they are flat above (loss of upper pole fullness). A lift alone (mastopexy) may improve the breast shape but may not achieve upper pole fullness that the patient desires, so you are left lifted but relatively empty on top. This is where an implant (augmentation) will be suggested at the same time as a mastopexy to provide a more youthful looking breast with upper pole fullness. But the trade off for this is scars around the nipple areola complex, or scars around the nipple areola complex and down to the chest wall as in a lollipop scar. Sometimes in severe droopy breasts the scars may extend under the breast on one or both sides like an inverted T type scar. You may ask why the difficulty and why so many options. Well simply what the surgeon is doing is to increase the volume of the breast (implant) and at the same time to remove or reduce excess skin and put the nipple areola complex in the appropriate position. As you can see, these actions can compete against each other. The skill of the surgeon is to marry the competing factors by augmenting the breast volume to the required amount and to reduce the remaining excess skin to match the new breast volume in order to create an aesthetic breast shape and size that our patient will be happy with.

I spend a lot of time explaining to my patients these difficult concepts because often my patient is confused about what they present with, what the solution is, and the outcome that will require scars on the breast. Often patients will tell me that they do not want scars on the breast and therein lies the need for trade-off and perhaps results that are not always desired. I find it very important to educate my patients with diagrams and photographs so that they understand well what decisions are made and how they will look after surgery. Often, if expectations cannot be met, then surgery will not be carried out. So, what needs to be taken into consideration are the following:

• Does the mastopexy (lift) justify the scars on the breast?
• Will an implant be appropriate to add and achieve the patient’s desires?
• Will the implant give appropriate fullness to the upper pole and if so will it look natural?
• Will the patient accept that there may be a need for revisional surgery?
• Will the patient be patient enough to allow the breast to settle for some months after the operation?
• Not to mention in addition, required breast size, breast position and contour, the various types of implants (round, teardrop, rough, smooth, furry, saline or silicone) and oncologic (cancer) concerns with breast screening. Let’s have a quick cuppa coffee!

So you can see that there are many issues to consider in an augment/mastopexy procedure and these are tough questions requiring a lot of information and thought!!

Because of all these factors, some surgeons may prefer to stage the operation i.e to do the augmentation first and at a later date come back and perform the mastopexy (lift). My preference is to perform the operation in one stage

What are the various types of operation?

Now what are the various types of operations that I can offer you? As you will no doubt be aware of by now that this will depend on what you present with. The space in this article will not permit me to go into much detail of each of the indications for a specific procedure and that you would need to discuss with your surgeon.

Permit me to get a bit technical now in describing briefly the operations available for a Mastopexy and Augment procedure.

Vertical scar technique with lower parenchymal flap for upper breast fullness. This means that some tissue is taken from the lower pole of the breast and moved to the central and upper breast region. The improvement is not as good as that achieved with an augmentation but it is indicated in patients who do not wish to have breast implants. The scars resemble a lollipop.

Vertical scar technique with upper parenchymal flap for upper breast fullness. Here the tissue attached below the nipple areola complex is folded in on itself and hitched to the upper chest wall. The indications are the same as the above and results are similar.

Vertical mastopexy-augmentation. In this operation skin excess is removed through vertical incisions around the nipple areola complex and below the complex. An implant is then inserted either in a subglandular position (under the breast tissue in front of the muscle) or below the pectoralis muscle (sub-muscular). The implant provides breast fullness centrally and in the upper pole of the breast.

Vertical scar technique with implant exchange. Some patients who have had implants in the past develop droopy breasts and the breasts now fall lower off the implants. This operation allows for lifting the breast tissue while at the same time an implant exchange can take place if indicated.

Vertical scar technique and short horizontal incision. This short horizontal incision takes care of a moderate amount of excess skin that develops after closure of the vertical mastopexy and sits in the crease line under the breast for a short distance horizontally.

Vertical scar technique with horizontal scars. When there is a lot of excess skin as in very droopy breasts it may be necessary to remove the excess skin horizontally under the breasts resulting in an inverted T type scar.

I know that this is difficult stuff to take in but that is state of the art and the results can be beautiful and very satisfying both for you, the patient, and for me the surgeon.

I hope you found this article informative and that you enjoyed reading it.