Introduction
Breasts sag due to factors such as pregnancy, female hormones, breast feeding, weight change, breast size change, gravity, ageing, genetic factors, and tissue stretch, and the presence of breast implants. As the skin loses its elasticity, the breasts often lose their shape and begin to sag. The best candidates for a breast uplift procedure (the medical term for a breast uplift is a ‘mastopexy’) are healthy, emotionally stable women who have realistic expectations about what this type of surgery can accomplish. Breasts of any size can be lifted, but the results may not last as long in women with heavy, large breasts.
Breast sag occurs in most women to some degree as they get older. It can affect both breasts differently and can cause the two sides to look more different with time. In some cases these differences can be quite extreme and troubling. In other women the sag occurs quite evenly. Most women who have had children will report that the breasts became very firm and larger during a pregnancy and then the volume went afterwards leaving the breasts with a deflated, empty look. Women who haven’t had children may get sag if they have been over weight and lost this weight again. The skin excess from the previous stretching causes the breast to then hang lower, the nipple to be relatively lower on the breast, to point downwards, and often for the breast to have dropped below the level of the skin crease under the breast.
When the nipple has descended to the level of the skin crease or below, the breast is described as being ptotic. Many women wonder if just having breast implants can correct this, and although it can help to fill the empty envelope, implants alone are usually insufficient to reduce the tissue sag beyond the crease, and will not lift the breasts higher on the chest. When surgeons try to correct sag that has gone too far by using implants alone, women will often find their breasts feel bigger, but are saggier and heavier than before and the nipples look too low. In addition, because their skin is stretched, the breasts tend to drop further.
Mastopexy is the medical term for a breast uplift. It is a broad term and does not define just one operation but rather a collection of procedures designed to tighten the envelope of skin that covers the breast or alter the nipple position. It involves making cuts in the skin of the breast and therefore creates permanent and more visible scars. Breasts are smaller than your current size after mastopexy when done as a stand alone procedure.
Alternative treatments to mastopexy: Mastopexy is an elective surgical operation. Alternative treatment would consist of not undergoing the surgical procedure. Wearing supportive under-garments to lift sagging breasts and keeping your weight stable to try not to aggravate it further are alos important. You can consider help from a clinical psychologist to help you better accept your current appearance if it is constantly on your mind. We have a very good private psychologist at Spire Hospital Leeds that we can put you in touch with.
How do I know if I have breast sag?
If you are not sure, stand in front of a mirror without a bra and lift the breast up one at a time to see the crease underneath the breast (this is the infra-mammary fold). Mark a line horizontally from one crease across to the crease under your other breast with a felt tip pen. Now let the breasts go so they are hanging down naturally again. Observe how much breast tissue falls below the crease line that you drew. If you measure more than a few millimetres then you have some breast sag. If you have several centimetres then this is significant sag. Now look to see where the nipple position is in relation to the crease under your breast. If it lies level with or below the crease then you have significant sag and a nipple position that is too low for correction just with a breast enlargement. If the nipple position is just above the crease, then you still have sag but sometimes an implant can push it up a bit more and you might decide to compromise on your results and decide to have breast implants and not to have an uplift- but be aware your nipple position and breasts can still look too low. See images of grading of ptosis here.
Do I need to have implants (breast augmentation) when I have an uplift (mastopexy)?
- Mastopexy without implants. Many patients with significant sag and whose breasts are of a good volume in their bra, can have a mastopexy without needing breast implants. I would also say that this is in general preferable to the vast majority of patients I see. A full mastopexy using an anchor shaped scar (also called a wise-pattern mastopexy) will elevate the nipple, reduce the diameter of a broad areola, and remove the excess skin. It can also reshape the breast bringing the sagged tissue back up to the centre of the breast. A tighter skin envelope surrounding the relocated breast tissue with a nipple in the right place again looks fantastic. But you must remember that it rarely restores or keeps the fullness to the very upper part of the breast. Although this area often looks great at 2-weeks, as swelling subsides from the very upper part, you tend to be relatively empty in that area after settling. If it is the case that you desire that very upper part to be improved further then you need to consider an implant. This can of course be done at a later date.
- One-Stage Mastopexy-Augmentation: If you feel that your breasts are smaller than you would like, emptier than you would like and you have sag that is not too extreme- ie the nipples are relatively low but still close to the crease under your breast – then to get fullness to the upper and central part of the breast then you will almost certainly need to have a combined one-stage breast uplift with breast implants. When this is done at the same operation it is referred to as ‘mastopexy-augmentation’. It carries greater surgical complexity to do a mastopexy at the same time as placing implants. A modification of technique is required and overall the complication rates are higher than with other surgery. You need take your surgeon’s advise on balancing your desire for larger implants against his concerns on the effect this might have on compromising wound healing around the mastopexy incisions. Too much strain would result from implants that are too big causes early wound problems, infection, and poor scars. It can even lead to having the implants removed straightaway if there are serious complications. The thought of having mastopexy scars on the breasts can lead some patients to decide to just have larger volume implants and to avoid the mastopexy altogether. But you need to be very cautious in taking this approach as large implants often produce unsatisfactory results- bigger but lower breasts, and often an unnaturally low looking nipple position. You are often still likely to find their is emptiness in the upper chest area, and rely on your bra to push the implants up. Therefore if you have sag you must ask about mastopexy and remember that if it is needed, but you opt not to have it, there are always limitations as to how augmentation will improve your breasts, that your breasts could look worse and you might not get the look you want.
- Two-Stage Mastopexy- Augmentation: If you have a lot of breast tissue that has sagged, with nipples that are obviously very low, combined with having breasts that are smaller than you want, you will need to have a full uplift first, then after a minimum period of 4-months, to have the breast augmentation. In other words, it should not be done at the same time, but done as a ‘two-stage’ approach. The first stage involving the mastopexy should correct the sag and give you a greatly improved nipple position. Wounds heal better without being under excess stretch from the implant. Minor problems with healing are unlikely to snow-ball into major complications. After good wound healing the second operation is then done to place the implants, and we make use of part of the old scar in the crease under your breast to do this. This approach gives you the benefit of the very best mastopexy tightening possible, and then much greater flexibility with the choice of implants, and generally results in safer surgery. There are lower risks of complications with a two stage approach, but it costs more money overall.
- Mastopexy Performed at the Time of Breast Implant Exchange: Patients who have had breast implants for years sometimes develop breast sag- the breast tissue might gradually fall in front of an implant and give a snoopy appearance to the breast, or you might get ‘bottoming out’ of the implants with excessive descent of the lower part of the breast leaving the upper part empty. Others develop capsular contraction around the implants which can become rock hard. In all of these situations, simple implant exchange is not likely to give complete improvement to the cosmetic issues. Mastopexy can be employed to help in this situation and can improve the results. However, it does carry greater surgical complexity and the mastopexy technique is limited to adjusting the nipple position and removing excess skin (dermo-cutaneous mastopexy). The complication rates are higher than with other surgery, and the surgeon must carefully balance the size of the replacement implants against the degree of strain on the wound edges and blood supply to the nipple. The implants would have to be removed if there are serious complications.
- Mastopexy Performed at the Time of Breast Implant Removal Surgery: Patients who have had breast implants for years sometimes request their permanent removal (we call this ‘explantation’). If there is likely to be a lot of skin and nipple sag as a result of this, then it can be beneficial to opt for a mastopexy at the same time. This simultaneous removal of breast implants and the surrounding hard capsules if capsular contraction is also present combined with a breast lift (Mastopexy) can leave the breast with a much better shape, even though it can never compensate for the loss of volume. However, it is a more complex operation, and there is some increased risk of necrosis of skin or of the nipples due to decreased blood supply. With careful surgery, from an experienced surgeon who has good judgement your risk should be around 1%. During wound healing it is common to get seroma fluid (like plasma) form in the space where the implant used to be. This can be a good thing when it is mild and was may leave the breast looking better. It does usually get reabsorbed though. Patients with very empty breasts after explanation might consider lipomodelling at a later date to help put some fat back in the breast. This technique needs repeating several times with 4-month gaps between each procedure and only produces a small volume increase each time.
- Please remember that cosmetic breast surgery is very expensive. Each operation comes at a cost and produces a scar. Combining operations, sequencing operations and future revision consultations, are all more common after breast augmentation.
RISKS OF MASTOPEXY SURGERY
Every surgical procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your surgeon to make sure you understand all possible consequences of mastopexy (breast lift).
Bleeding (Haematoma): It is possible, though unusual, to experience a bleeding episode after surgery. The risk is about 2%. This is called a post-operative haematoma. It is usually caused by little vessels in the deeper breast tissue where cuts were made starting to ooze as your blood pressure returns to normal, or when you begin moving around in your bed. You would not be aware it is happening as it is usually gradual in the first few hours after surgery when you are back on the ward under observation. A haematoma is usually very obvious to the staff looking after you. It can be quite uncomfortable and may make you feel light-headed. It can affect the blood supply to the nipple. You would therefore be taken back to the operating theatre to have a haematoma washed out (evacuated). It would mean that you end up staying an extra night in hospital too.
Can I reduce my risk of it happening? Yes- we prefer that you do not take any aspirin, clopidogrel, or anti-inflammatory medications for ten days before surgery, as this may increase the risk of bleeding/haematoma. Non-prescription “herbs” and dietary supplements can increase the risk of surgical bleeding too. Please ensure you inform Mr Turton about all medications and herbal supplements. If you have a higher than normal risk of deep vein thrombosis (eg if you have had one before, if it runs in your family, or if you are obese) we may want to given you heparin medication to prevent blood clots in veins; an unwanted effect of doing this is that it can produce bleeding.
A haematoma can also occur in the first few weeks after surgery when you are back at home and feel that you are well healed. But this is much less common (<1% risk). To reduce your risk it is better not to reach, stretch or strain – for example, slamming a car door shut could cause a haematoma to suddenly form. It is rare to lose much blood from a haematoma, but transfusions are almost never required. However, if you were to need a transfusion we warn you that there is very small risk of blood-related infections such as hepatitis and HIV (AIDS), although these are screened for in UK donors.
Infection: When operating on a patient, surgeons take hefty precautions to prevent infection. Severe infection is very unusual after this surgery. More minor wound infection may occur in around 2% of patients. Should an infection occur, additional treatment including antibiotics, visits for dressing changes and check-ups, hospitalization, or rarely additional surgery may be necessary. Individuals with an active infection in their body or weakened immune system (eg if taking steroids recently) should not undergo mastopexy. Minor problems with wounds are more common and usually easy to manage – stitches can become infected causing redness and swelling under the scar- sometimes sutures need to be removed if this occurs, and a course of antibiotics would normally settle it. Little pockets of fluid under the skin can become infected leading to shallow or deeper abscesses. Bigger problems can occur if you have a breast implant as if this becomes infected it would need to be removed for approximately six months. This would mean there would be a dramatic difference in the size of your breasts for that period of time.
Seroma: Infrequently, fluid may accumulate between the skin and the underlying tissues following surgery, trauma or vigorous exercise. Should this problem occur, it may require additional procedures for drainage of fluid. Seroma fluid can become infected by these procedures and if is is minor it is best left to be reabsorbed by your own body, which usually happens over a 6-week period.
Change in Nipple and Skin Sensation: You are likely to experience a diminished (or loss) of sensitivity of the nipples and the skin of your breast, particularly around the scars. Partial or permanent loss of nipple and skin sensation can occur after a mastopexy in one or both nipples. Changes in sensation may affect sexual response or the ability to breast feed a baby.
Skin Contour Irregularities and asymmetries: Contour and shape irregularities may occur after mastopexy. Visible and palpable wrinkling may occur especially if you have had very loose and stretched skin. One breast may be smaller than the other usually because you have a size mismatch before surgery. Nipple position and shape will not be identical one side compared to the other although a close match is always planned. Residual skin irregularities at the ends of the incisions (often termed “dog ears”) are always a possibility when there is excessive redundant (saggy) skin beyond where the incision stops in the breast crease- we can’t take the incision on your breast all the way around your back. This may improve with time, or it can be surgically corrected at a later date.
Sutures: Most surgical techniques use deep sutures in the dermis (the layer just under the top layer of skin) as well as sub-cuticular sutures (the suture within the top layer of skin but under the surface). You may notice these sutures after your surgery until they fully dissolve. Sometimes one or two of the many sutures inside can cause irritation by sticking into the under-surface of the skin and then working their way to the surface. The suture end may then poke through the skin (usually by less than 1mm) and it may feel like a little bristle, or produce irritation that requires suture removal. It can take 12-months for sutures to fully reabsorb and then for the scar line to soften and mature.
Skin Discoloration/Swelling: Some bruising and swelling normally occurs following a mastopexy. The skin in or near the surgical site can appear either lighter or darker than the surrounding skin. Although uncommon, slight swelling and slight skin discoloration may persist for long periods of time and, in rare situations, may be permanent- the pigment in blood is called haemosiderin and it can leave a very faintly darker patch at sites where you have had deep bruising, although this is very rare.
Skin Sensitivity: Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after surgery. Usually this resolves during healing, but in rare situations it may be chronic.
Scarring: All surgery leaves scars, some more visible than others. The mastopexy with augmentation creates noticeable scars. Often a permanent scar is visible around the areola, from the areola to the base of the breast, and across the crease under the breast. It is also sometimes possible to just get the doughnut mastopexy procedure with implants, which creates a circular scar around the nipple, but this is usually just to lift the areola position a little on the breast and doesn’t tighten the skin much. Scars will diminish with time; however, scarring is definitely something to consider before undergoing the surgery.
Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Scars may be unattractive and of different color than the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be asymmetrical (appear different on the right and left side of the body). There is the possibility of visible marks in the skin from sutures. Hypertrophic scars are where your body forms a thick raised scar and this affects around 5% of patients. They can be uncomfortable and although scars usually mature there is no guarantee a hypertrophic scar will go. In some cases hypertrophic scars may require surgical revision or treatment but they may return again. Scars can feel thick or raised and look red before fading after several years.
Fat Necrosis: Localised areas of fatty tissue found deep to the skin might turn hard when it doesn’t have a good enough blood supply (<5% risk). This may produce a breast lump and a scan or biopsy might be required to evaluate it. Additional surgery to remove areas of fat necrosis may be necessary but this is extremely uncommon. There is the possibility of contour irregularities in the skin that may result from significant fat necrosis.
Nipple necrosis: Loss of the blood supply to the nipple and areola causes it to ulcerate and then scab and leaves a flat scar where the nipple once was, after wound healing. It is a very rare complication with a risk of about 1 in 500.
Pain: You will experience some pain after your surgery. This is usual during wound healing from the inflammation and it is usually easily controlled with Paracetamol and Ibuprofen. Pain of a higher intensity and duration may occur and persist after mastopexy, though it is very unusual. Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue or due to tissue stretching.
Recurrent sag: The first few weeks after mastopexy tissue is quite tight and there is some swelling to the tissue under the skin. This is an artificial period where the breasts will feel perkier than they will be after a few months. As the months pass, the tissue stretches slightly and swelling goes, and you may perceive this as small amount of return of tissue loosening or that they have dropped. This is normal, and it is not something that you can stop, as it is hum flesh that you are dealing with (as opposed to wood or metal!). The breasts do not drop back down to where they were before though, and the settling is a small amount overall.
Breast Augmentation and Simultaneous Mastopexy.
The added benefit of the combination of a lift with implants is that the results of the lift are more prolonged with the placement of the implants. Breasts generally remain full and perky for a longer time.
Risks associated with the implant are covered in a separate informed-consent document on breast augmentation, according to the type of implant selected (please read this document too). In general risks of complications are all higher with combined mastopexy and augmentation- eg capsular contraction, wound infection, loss of the implant, hypertrophic scars, delayed wound healing, asymmetry, nipple or skin necrosis. Excessive firmness of the breast can occur after surgery due to internal scarring (fat necrosis) or scarring around the breast implant. The occurrence of capsular contraction is not predictable except that it affects 1-2% of patients per year. It can turn a soft implant into a hard round ball years after surgery. Additional treatment including surgery may be necessary.
Delayed Healing: Wound disruption or delayed wound healing is possible with simple mastopexy but is a greater risk if combining mastopexy with implants (2% risk). Some areas of the breast skin or nipple region may not heal normally and may take a long time to heal. Areas of skin or nipple tissue may die (necrosis), leaving scar tissue. This may require frequent dressing changes or further surgery to remove the non-healed tissue. Individuals who have decreased blood supply to breast tissue from past surgery or radiation therapy are at increased risk for wound healing problems and poor surgical outcome. Smokers or users of nicotine products (including Vape) have a far greater risk of skin loss and wound healing complications and should not undergo this surgery. It would likely lead to removal of the implant for 6-months.
Asymmetry: Some breast asymmetry naturally occurs in most women. Differences in terms of breast and nipple shape, size, or symmetry also occur after surgery. Additional surgery may be necessary to attempt improvement of asymmetry after a mastopexy. The shape of the areola is stretched slightly differently on each side and the areola usually looks a little different.
General disappointment: You may be disappointed with the results of surgery. In general, your starting point prior to surgery presents the surgeon with a complex array of issues that are not always predictable and tissue can respond differently from one patient to the next. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. Infrequently, it is necessary to perform additional surgery to improve your results, though this would be at your additional cost. For example, you may not be able to achieve adequate fullness (breast size may be incorrect for you) that you desire in your breasts without needing to wear support garments and so decide to have breast augmentation surgery or other types of surgery like lipomodelling. You may be disappointed with the results of mastopexy surgery alone despite best intentions to help you.
Asymmetry in nipple location, unanticipated breast shape and size, loss of function, wound disruption, poor healing, and loss of sensation may occur after surgery and cause disappointment. Unsatisfactory surgical scar location or appearance may occur. It may be necessary to perform additional surgery to improve your results.
Allergic Reactions: The commonest allergies are to dressings, and cause redness to the skin and intense itching. In rare cases reactions (<1% risk) to drugs used during surgery, from prescription medicines, blood products or injected agents have been reported that can cause serious systemic reactions including shock (anaphylaxis (rare risk <0.1%). Allergic reactions may require additional treatment.
Damage to Deeper Structures: There is the potential for injury to deeper structures including, nerves, blood vessels, muscles, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according to the type of procedure being performed. Injury to deeper structures may be temporary or permanent. (It is extremely uncommon < 0.1%)
Extremely rare risks:
Cardiac and Pulmonary Complications: Pulmonary complications may occur secondarily to both blood clots (pulmonary emboli), fat deposits (fat emboli) or partial collapse of the lungs after general anesthesia. Pulmonary emboli can be life-threatening or fatal in some circumstances. Inactivity and other conditions may increase the incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is important to discuss with your physician any past history of swelling in your legs or blood clots that may contribute to this condition. Cardiac complications are a risk with any surgery and anesthesia, even in patients without symptoms. If you experience shortness of breath, chest pain, or unusual heart beats, seek medical attention immediately. Should any of these complications occur, you may require hospitalization and additional treatment.
Surgical Anesthesia: Both local and general anesthesia involve some risk. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation.
Additional notes about Mastopexy Surgery
Medications: There are potential adverse reactions that occur as the result of taking over-the-counter, herbal, and/or prescription medications. Be sure to check with your surgeons or GP about any drug interactions that may exist with medications, which you are already taking. If you have an adverse reaction, stop the drugs immediately and call your hospital for further instructions. If the reaction is severe, go immediately to the nearest Accident and Emergency. When taking the prescribed pain medications after surgery, realize that they can affect your thought process and coordination. Do not drive, do not operate complex equipment, do not make any important decisions and do not drink any alcohol while taking these medications. Be sure to take your prescribed medication only as directed.
Breast Disease: Breast disease and breast cancer can occur independently of breast lift surgery. Breast lift surgery does not increase your risk of breast cancer. Individuals with a personal history or family history of breast cancer may be at a higher risk of developing breast cancer than a woman with no family history of this disease. It is recommended that all women perform periodic self-examination of their breasts, have mammography according to guidelines, and seek professional care should a breast lump or thickening or swelling around the breast be detected. If you are over 40 you should consider having a screening mammogram before having your surgery.
Breast and Nipple Piercing Procedures: Individuals who currently wear body-piercing jewelry in the breast region are advised that a breast infection could develop from this activity.
Contraceptive use: It is important to inform your surgeon if you use the contraceptive pill, estrogen replacement, or if you suspect you may be pregnant. Many medications including antibiotics may neutralize the preventive effect of the contraceptive (birth control pill), allowing for conception and pregnancy.
Intimate Relations: After Surgery: Surgery involves coagulating of blood vessels and increased activity of any kind may open these vessels leading to a bleed, or hematoma. Activity that increases your pulse or heart rate may cause additional bruising, swelling, and the need for return to surgery and control bleeding. It is wise to refrain from intimate physical activities until your surgeon states it is safe, and this is usually a minimum of 3-weeks.
Future Pregnancy and Breast Feeding: Mastopexy is not known to interfere with pregnancy. If you are planning a pregnancy, your breast skin may stretch and offset the results of mastopexy. You may have more difficulty breast feeding after this operation. Your breasts may sag again significantly after pregnancy.
Smoking: Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray): Patients who are currently smoking, use tobacco products, or nicotine products (patch, gum, or nasal spray) are at a greater risk for significant surgical complications of skin dying and delayed healing and additional scarring. Individuals exposed to second-hand smoke are also at potential risk for similar complications attributable to nicotine exposure. Additionally, smoking may have a significant negative effect on anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals who are not exposed to tobacco smoke or nicotine-containing products have a significantly lower risk of this type of complication.
Patient compliance: Follow all surgery instructions carefully; this is essential for the success of your outcome. It is important that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the time of healing. Personal and vocational activity needs to be restricted. Protective dressings and drains should not be removed unless instructed by your surgeon. Successful post-operative function depends on both surgery and subsequent care. Physical activity that increases your pulse or heart rate may cause bruising, swelling, fluid accumulations and healing problems.
Mental Health: Disorders and Elective Surgery: It is important that all patients seeking to undergo elective surgery have realistic expectations that focus on improvement rather than perfection. Complications or less than satisfactory results are sometimes unavoidable, may require additional surgery and often are stressful. Please openly discuss with your surgeon, prior to surgery, any history that you may have of significant emotional depression or mental health disorders, or body dysmorphia. Although many individuals may benefit psychologically from the results of elective surgery, effects on mental health cannot be accurately predicted.
Additional Surgery may be necessary (re-operations): There are many variable conditions that may influence the long-term result of mastopexy surgery. It is unknown how your breast tissue may respond or how wound healing will occur after surgery. Secondary surgery may be necessary to perform additional tightening or repositioning of the breasts. Should complications occur, additional surgery or other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited are particularly associated with mastopexy surgery. Other complications and risks can occur but are even more uncommon. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. In some situations, it may not be possible to achieve optimal results with a single surgical procedure.
Long-Term Results: Subsequent alterations in the breast shape may occur as the result of aging, sun exposure, weight loss, weight gain, pregnancy, menopause, or other circumstances not related to your surgery. Breast sagginess may re-occur.