Breast Surgery

Aesthetic Surgery Journal

Continuing Medical Education Article 2018, Vol 38(4) 374–384
© 2018 The American Society for
Aesthetic Plastic Surgery, Inc.
Mastopexy and Mastopexy-Augmentation Reprints and permission:

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[email protected]
DOI: 10.1093/asj/sjx181
www.aestheticsurgeryjournal.com

Ali A. Qureshi, MD; Terence M. Myckatyn, MD, FRCSC, FACS; and

Marissa M. Tenenbaum, MD

Abstract
Mastopexy and mastopexy-augmentation are aesthetic breast surgeries that seek to create youthful, beautiful appearing breasts. Age, hormonal changes,
or weight loss can lead to alterations that require addressing the skin envelope and breast parenchyma. Many surgical approaches have been described
including periareolar, vertical, and Wise pattern techniques, but most modern mastopexies include manipulation of the breast parenchyma to improve
the longevity of breast ptosis correction. Mesh support of the ptotic breast is an extension of this paradigm shift and seeks to restore the lost strength
of the support structures of the breast. Despite initial controversy, single stage mastopexy-augmentation has been demonstrated to be a safe option for
appropriately selected and informed patients who desire both correction of shape and volume. Revisions may still be necessary based on patient and
surgeon goals for correction. Evolving technologies will likely continue to enhance the ability of aesthetic plastic surgeons to provide pleasing, durable
correction of breast ptosis.

Editorial Decision date: August 24, 2017; online publish-ahead-of-print January 20, 2018.

Learning Objectives Aesthetic surgery of the breast encompasses a spectrum

of options from mastopexy to mastopexy-augmentation.
The reader is presumed to have basic knowledge and Reducing the discrepancy between skin envelope and
understanding of breast anatomy and mastopexy and breast parenchyma and can either be addressed from the
mastopexy-augmentation procedures. After reading this “outside-in” with skin redraping, from the “inside-out”
review, the reader should be able to: with parenchymal augmentation, or a combination of the
1. Identify a suitable candidate for mastopexy vs two. Mastopexy aims to create a beautiful breast by pri-
mastopexy-augmentation. marily addressing shape and differs from augmentation
2. Discuss common techniques and potential pitfalls where the primary goal is to alter the size of the breast.
of different mastopexies including the use of mesh The two procedures are, however, not completely discord-
and special circumstances including explantation ant and can actually complement one another as they
mastopexy. address different parts of the breast (skin vs parenchyma).
3. Identify potential risks and benefits of single stage Over the past ten years, there has been a paradigm shift
mastopexy-augmentation.
The American Society for Aesthetic Plastic Surgery (ASAPS)
From the Division of Plastic and Reconstructive Surgery, Department
members and Aesthetic Surgery Journal (ASJ) subscribers of Surgery, Washington University School of Medicine, St. Louis, MO
can complete this Continuing Medical Education (CME)
examination online by logging on to the CME portion of Corresponding Author:
ASJ’s website (http://asjcme.oxfordjournals.org) and then Dr Marissa M. Tenenbaum, Division of Plastic and Reconstructive
Surgery, Department of Surgery, Washington University School of
searching for the examination by subject or publication date. Medicine, 1020 North Mason Rd., Suite 110, Building 3, St. Louis,
Physicians may earn 1 AMA PRA Category 1 Credit by suc- MO 63141, USA.
cessfully completing the examination based on the article. E-mail: [email protected]; Twitter: @drrissy
Qureshi et al375

in our understanding of the results, staging, and safety of measurements as well. Reviewing the imaging with the
mastopexy and mastopexy-augmentation. patient is also a very useful educational tool. Often the
Mastopexies continue to be in the top five surgeries anatomy and asymmetries are more visible to the patient
offered by members of the American Society for Aesthetic in a photo than the mirror.
Plastic Surgery (ASAPS) as of 2016 and have increased in A critical assessment of asymmetries including the size,
number sevenfold when compared to 1997.1 Recent stud- shape, nipple position, and areolar geometry should be
ies of litigation in aesthetic breast surgery have shown rel- performed and reviewed with the patient. Asymmetries
atively low number of litigated cases in mastopexy and may require correction or can persist and be more notice-

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mastopexy-augmentation when compared to augmenta- able after surgery, particularly if augmentation is also
tion and reduction, which are the most commonly litigated being considered.
aesthetic breast procedures. This is a change from prior The location of the breast and its footprint on the chest
when periareolar mastopexy-augmentation was once con- wall should be assessed. As described by Hall-Findlay,
sidered the most litigious procedure. These trends suggest a patient can be “high” or “low” breasted depending on
that mastopexy and mastopexy-augmentation techniques where the breast sits on the chest wall relative to the clav-
have become safer and more acceptable to better-informed icle and humerus.4 Manipulation of the breast footprint
patients.2,3 is limited, but the upper breast border can be altered by
placement of an implant or fat grafting. Chest wall abnor-
malities and asymmetries as well as scoliosis should be
Preoperative Evaluation assessed. Examining the breasts with the patient supine
The preoperative consultation is an opportunity to under- can help assess asymmetries in projection.
stand the patient’s goals and anatomy, and help the patient The location of the nipple relative to the inframammary
navigate a treatment choice that will help them achieve fold as well as gland should be noted as this tradition-
a beautiful appearing breast. Patients should be asked if ally measures the degree of ptosis (Table 1, Figure 1). The
they are bothered by the shape or size of the breasts or density of the breasts and degree of superior pole involu-
both. This can help differentiate between the need for a tion should be examined. An assessment of the soft tissue
mastopexy, augmentation, or mastopexy-augmentation. dynamics including the motion of the skin relative to the
However often the patient’s complaints may not match parenchyma as well as upper pole fullness must be made
their physical exam. Objective assessment by the plastic and is of particular importance in massive weight loss and
surgeon needs to be made in the context of a patient’s postpartum women.5
goals to optimize the outcome that they are seeking. Informed consent is a critical portion of any mastopexy
History should include a summary of previous surgeries, consultation and includes a discussion of risks of the pro-
existing asymmetries, and a breast health evaluation. This cedure including possible need for revisions. When com-
includes past history of breast cancer, abnormal mam- bined with augmentation, a separate discussion of the risks
mograms, and desire for future breast feeding. Patient’s of the devices themselves must be made. If augmentation
weight history should be documented including any major is being performed with fat grafting alone, discussion of fat
changes or surgical weight loss. grafting risks should also be made. Photodocumentation is
Patients being evaluated for secondary mastopexy or imperative and also helps with patient discussions about
mastopexy-augmentation should be asked for previous asymmetries that exist preoperatively.
operative reports, if available. While scars and examina- Specific discussion of scars as well as risk of changes
tion can provide a roadmap, operative notes can provide in sensitivity to the nipples should be addressed. Often,
essential information that may help avoid devastating drawings and photographs of postoperative results can
complications associated with compromised blood sup- help establish realistic expectations of scar placement and
ply to the nipple and incisions. Obtaining these operative visibility.
records can often be challenging if not impossible.
Imaging
Breast Analysis
Routine imaging of the breast with mammography is not
Physical examination should include assessment of body indicated outside the guidelines of the US Preventive
mass index (BMI) as well as breast measurements. These Services Task Force, whose 2016 recommendations were
include base width, sternal notch to nipple distance, based on age over 40 and risk.6 Three-dimensional imag-
nipple to inframammary fold distance, areola diameter ing and simulation in the office can complement routine
and inter-nipple distance. Three-dimensional (3D) imag- 2D photographs for the purposes of preoperative consult-
ing software has emerged as a new way to obtain these ation, though there is little evidence to support its use.
376 Aesthetic Surgery Journal 38(4)

Table 1. Regnault’s Classification of Breast Ptosis

Grade Degree Description

Pseudoptosis - Nipple at the IMF but gland below the IMF

I Mild Nipple at or within 1 cm below the IMF

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II Moderate Nipple below the IMF but above the lowest point of
the breast

III Severe Nipple at the lowest point of the breast

IMF, inframammary fold. Figure 1. Grades of breast ptosis based on nipple and gland
position relative to the inframammary fold (IMF).

Table 2. Different Mastopexy Types: Their Indications, Advantages, and Disadvantages

Mastopexy type Indications Advantages Disadvantages

Periareolar Grade I or II ptosis, nipple Scar hidden at areolar border, can be combined with augmentation Flattening, deprojection of breast, widened
asymmetry scar

Vertical - SPAIR All grades of ptosis Ptosis correction and removal of glandular tissue, little settling Bottoming out, periareolar widening, pleating,
suture spitting

Vertical - Hall-Findlay All grades of ptosis Ptosis correction and removal of glandular tissue, structural support of elevated Final appearance may take months, persistent
nipple with pillar unification, can be combined with augmentation asymmetry

Wise pattern Grade II or III ptosis Greatest control of skin excision relative to parenchyma, easily adapted from Largest scar burden, bottoming out
reduction techniques, can be combined with augmentation

SPAIR, short-scar periareolar inferior-pedicle reduction.

Patients being evaluated for secondary mastopexy or mas- most 2 cm. The markings for mastopexy can be drawn as
topexy-augmentation with a history of implants, rupture, an eccentric oval around the entire circumference of the
or capsular contracture may have imaging including ultra- areola with preferential height difference superiorly to ele-
sound and/or MRI whose review can be helpful. vate the nipple. A skin only donut mastopexy differs from
a Goes or Benelli mastopexy in that the parenchyma is not
manipulated. A crescentic mastopexy is a variation of this
Surgical Approach where a crescent is drawn above the nipple and an incision
Skin only mastopexy has fallen out of favor since the time is not made circumferentially around the areola. Spear
of Benelli who favored parenchymal redistribution in add- et al described rules when designing a periareolar mas-
ition to skin redraping.7 This was a major paradigm shift topexy, seeking to reduce widening of scars and pleating.8
in aesthetic surgery of the breast. Operations that manip- The cited benefit of this technique is hiding the scar at
ulated the skin alone relied on removal of excess skin to the areolar-breast junction. However, the periareolar mas-
buttress and support breast parenchyma. This often lead to topexy removes skin in a concentric pattern and this can
unacceptable scaring, incomplete correction of upper pole lead to flattening and deprojection of the breast when the
hollowing, and recurrent ptosis. Modern aesthetic surgery areola is inset within the new larger, concentric circle of
of the breast recognizes the importance of addressing breast skin. Pleating can occur as the redundancy of the
parenchymal involution from aging or postpartum changes outer circle gathers during the inset. If there is circumfer-
and involves some sort of parenchymal redistribution or ential violation of the dermis to the parenchyma such that
manipulation in addition to skin excision and redraping the nipple relies on a central mound pedicle, there is a risk
(Table 2). of decreased nipple sensitivity with this technique.
Some have advocated the use of a permanent or barbed
Periareolar Mastopexy suture to maintain the areolar diameter with time with the
Periareolar mastopexies can be used in patients with grade thought that increased tension leads to widening of the
I or II ptosis or nipple asymmetry with little skin redun- scar.9 However, periareolar mastopexies have high rates
dancy (Figure 2). It can be used to elevate the nipple at of revision and patient dissatisfaction. In 2001, periareolar
Qureshi et al377

placement.13,14 Suspension sutures are used to tack the

pedicle superiorly to the chest wall with the goal of main-
taining glandular elevation. Skin is then tailor-tacked and
excised with closure in a vertical orientation. Sometimes,
the redundancy of the skin inferiorly may require exci-
sion of the dog ear in a “J” or “T” pattern. There is little
settling involved with the final shape of the breast when
compared to other techniques. However, bottoming out re-

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mains a shortcoming of the technique as it relies on an in-
ferior pedicle. Periareolar widening, pleating, and changes
in nipple sensation are all drawbacks of the technique.15
Placement of an implant is not traditionally performed
with the SPAIR technique.
The Hall-Findlay technique uses a variety of pedicles
but most commonly a superomedial or medial pedicle for
the nipple-areola complex (NAC) and involves suturing of
the medial and lateral pillars of the breast after an inferior
wedge of tissue is removed.16 The markings are made such
Figure 2. Periareolar mastopexy incisions and final scar that the inferior most portion of skin excision is above the
location. native inframammary fold (IMF) as the IMF tends to rise
in this technique and a lower excision can lead to eventual
mastopexy and augmentation was considered the highest scar presence on the abdomen. The unification of pillars is
litigated procedure in plastic surgery, though recent data thought to provide structural support to the elevated NAC
suggest decreased litigation in mastopexy-augmentation and also narrow the breast. The technique is based on the
procedures. Additionally, physician satisfaction has been hypothesis that glandular tissue in the inferior portion of
lowest with this technique.10 the breast creates a downward pull to the breast, leading
This mastopexy can be accompanied by parenchymal to ptosis and bottoming out seen in techniques based on
redistribution as described by Benelli.7 With the Benelli an inferior pedicle. By removing the tissue destined to de-
technique, augmentation is only safe in the submuscular scend and building structure with the lateral and medial
plane because of blood supply disruption with manipula- pillars, this technique seeks to maintain a lifted breast.
tion of the parenchyma. Periareolar mastopexy has been Similar to the SPAIR technique, inferiormost skin redun-
combined with mesh support by Goes in which a wedge dancy can be addressed with a dog ear excision as a “J” or
of superior breast tissue is excised, parenchymal flaps “T” or gathered with boxing stitches. The mastopexy can
united, and mesh placed over the newly shaped breast be complemented with placement of subglandular or sub-
and tacked to the chest wall.11 With the Goes periareolar muscular implant placement without concern for blood
technique, breast augmentation should only be done sec- supply to the nipple which comes from the second or third
ondarily in the submuscular plane if desired. internal mammary perforators. The Hall-Findlay technique
is often considered a circumvertical mastopexy.
Vertical Mastopexy Vertical mastopexies tend to create an almost inverted
Vertical mastopexies have evolved from the described breast shape at the conclusion of the case with exagger-
techniques of Lassus, Peixoto, Arie, Pitanguy, Marchac, ated upper pole fullness and sloped inferior pole. It can
and Lejour for reduction mammaplasty (Figure 3). They take weeks to months for the breast to settle and gain its
incorporate correction of ptosis with removal of glandular final appearance. This requires frequent contact and reas-
tissue for maintenance of correction and include an ex- surance of patients from providers.
tension of the periareolar scar with a vertical component
down the meridian of the breast (Figure 4). All grades of Wise Pattern Mastopexy
breast ptosis have been addressed with vertical mastopex- Wise pattern or inverted-T mastopexy has traditionally
ies. Physician satisfaction has been highest with the short- been used in patients with severe excess of skin relative to
scar periareolar inferior-pedicle reduction (SPAIR) and breast parenchyma in a patient with severe ptosis. It was
Hall-Findlay mastopexy techniques.10 first described by Wise in the 1950s with the development
The SPAIR mastopexy developed by Hammond trans- of templates for making a skin only mastopexy. However,
poses the nipple on an inferior pedicle.12 The technique with developments in reduction mammaplasty techniques,
can incorporate a Gore-Tex periareolar closure as well as the Wise pattern mastopexy was modified with parenchy-
pin-wheel or interlocking pattern of periareolar suture mal alterations and pedicle designs.17,18 Hence, plastic
378 Aesthetic Surgery Journal 38(4)

A B

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C D

Figure 3. (A, C) Preoperative and (B, D) postoperative photographs of a 48-year-old woman taken 1.5 years after bilateral
mastopexy with circumvertical technique.

surgeons familiar with the Wise pattern, inferior pedicle out.10 This is most likely secondary to the inferior pedicle
mammaplasty reduction procedure often feel very com- rather than the skin resection pattern. Additionally, one of
fortable with this mastopexy technique. the problems with the inverted-T mastopexy is healing at
Incisions are made around the areola with extensions the T-junction, especially when an implant is added.
for the vertical limbs as in a vertical mastopexy (Figure 5).
However, the incisions are carried out laterally and medially Explantation Mastopexy
to the borders of the breast and carried down and along the Patients with a previous history of breast augmentation
inframammary fold. Manipulation of the parenchyma com- with an implant may desire explantation without replace-
bined with a Wise pattern scar can take on many variations. ment for a number of reasons including but not limited
Ship et al first described double superior pedicles that were to capsular contracture. When possible, previous operative
“criss-crossed” and also tacked to the pectoralis fascia with a reports can provide information about plane of dissection
skin resection in a Wise pattern. Since then, techniques have and pedicle for NAC blood supply to reduce the risk of
been described by numerous authors with variations in paren- complications explantation-mastopexy.
chymal manipulation under a Wise-pattern skin excision.19-22 Preexplantation level of ptosis has been identified as
This technique has the greatest amount of scar relative an important factor in deciding on mastopexy technique
to the breast vs other techniques. When associated with an either at the time of explantation or in a delayed fashion.23
inferior pedicle, it can also have the bottoming out seen in Explantation-mastopexy has been performed with a verti-
reduction mammaplasty and in a survey of ASAPS mem- cal technique with high levels of satisfaction.24 Smoking,
bers was found to have the greatest frequency of bottoming need for nipple elevation greater than 4 cm, and breast
Qureshi et al379

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Figure 4. Vertical mastopexy incisions and final scar Figure 5. Wise pattern mastopexy incisions and final scar
location. location.

parenchyma thickness less than 4 cm have been identified mastopexy to reduce the outer soft tissue lamella so that
as possible reasons to delay mastopexy after explantation.25 it matches, along with nipple position, the volume of the
Patients with a history of saline augmentation can breast implant. A staged approach can also be considered.
undergo replacement with silicone implants and saline In the first stage, the capsulectomy and explant can be per-
deflation can be useful before implant exchange.26 Wu and formed and a suction drain placed. The skin envelope can
Grotting have recommended waiting 4 weeks after defla- contract, soft tissue healing can occur, and a fresh pocket
tion to allow for “elastic breast recoil” and gland normal- can be dissected months later to match the new implant,
ization before proceeded with secondary mastopexy.27 and centralize the nipple-areola, taking advantage of skin
This may also allow for more accurate surgical planning as retraction to eliminate or limit the need for a skin reduc-
well as more accurate patient education. When consider- ing mastopexy. Little has been published on the topic of
ing replacing an implant the patient has a better sense of mastopexy after explantation for capsular contracture and
their native volume as does the surgeon and this can allow warrants investigation.
for a more accurate choice for a new implant. Techniques
to restore volume including using an inferior dermoglan-
dular flap for autoaugmentation at the time of explanta- Mastopexy in the Massive Weight Loss Patient
tion-mastopexy have been described by Ribiero.28,29 Mastopexy in the massive weight loss (MWL) patient is a
In the authors’ experience, replacement of breast particularly unique and challenging operation as it can be
implants in patients with Baker Grade III and IV capsu- at the far end of the spectrum of excess skin and involuted
lar contractures can be complex. Following capsulectomy, breast parenchyma.31 This is coupled with wound heal-
the soft tissue envelope can be patulous with poor lateral ing considerations and nutrition specific to patients who
support for a fresh breast implant. The breast parenchyma have experienced large fluctuations in weight from diet
can adhere to the contracted capsule, propped up essen- and exercise or surgical weight loss.32 These patients have
tially by the capsule and implant. Simply replacing the distortion of the normal footprint of the breast, often with
device in this new pocket can be problematic. To address a lateral axillary roll, medialization of nipples, deflated
this redundant soft tissue envelope several strategies upper pole, and lax inframammary fold. Techniques to
may be considered. One is to place larger breast implants restore the shape and volume of the breast include mas-
but this, more than likely, will lead to rapid progression topexy (Video 1, available as Supplementary Material
towards device migration and malposition. The use of online at www.aestheticsurgeryjournal.com), mastopexy
acellular dermal matrices in revisionary breast surgery with auto-augmentation, and mastopexy-augmentation
has been well described.30 Alternatively, some capsule can with an implant. A recent study by Coombs et al identified
be retained and used as a capsular flap or capsulorrha- that mastopexy-augmentation in MWL carries high rates
phy to support the lateral pocket or supplemented with of recurrent ptosis within 3 months (16.7%) and implant
a synthetic or biologic mesh. This often combined with a malposition (61.9%).31
380 Aesthetic Surgery Journal 38(4)

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Video 1. Watch now at https://academic.oup.com/asj/ Video 2. Watch now at https://academic.oup.com/asj/
article-lookup/doi/10.1093/asj/sjx181 article-lookup/doi/10.1093/asj/sjx181

Rubin has suggested an algorithm for aesthetic breast success with biocompatible meshes.43 Porcine collagen
surgery in MWL patients based on the severity of ptosis, matrix or FortaPerm (Organogenesis, Canton, MA) has
shape of the breast, and degree of involution.33 He describes been used by Goes in periareolar mastopexy with reported
a technique of dermal suspension autoaugmentation mas- long term maintenance of elevated breast position.44 Most
topexy using the medial and lateral parenchymal flaps to recently, Adams and Moses described their experience
augment the volume of the breast. His technique involves with central mound mastopexy and the use of a poly-4-hy-
anchoring of the new breast mound on the chest wall and droxybutyrate resorbable scaffold for lower pole support
redraping the skin over the autoaugmented breast. The and reported stable results at 1 year without major compli-
technique has the advantage of utilizing the lateral axil- cations.45 No series of mastopexy with mesh have reported
lary fullness to augment the breast mound itself and also interference with mammography or oncologic safety. Only
address the axillary roll. one case report exists of a chronic abscess in patient who
Multiple parenchymal flaps have been described for auto- underwent mastopexy with a polypropylene mesh.46
augmentation. These include the anterior intercostal perfo-
rator flap (ICAP), lateral intercostal perforator flap (LICAP),
the spiral flap, a rotation-advancement flap using a supero- Mastopexy and Fat Grafting
medial pedicle, and lateral breast flap.34-38 When combined Fat has been used in composite breast augmentation and
with implant placement, the lateral breast flap has been as a simultaneous implant exchange with fat for revision
described for inferior pole coverage of the implant.39 breast implant surgery.47,48 It also has been used as an
adjunct in mastopexies following explantation and treat-
Mastopexy With Mesh Support ment of double-bubble deformities.49 Its use in mastopexy
The use of mesh represents another paradigm shift in mas- alone has not been well described in the literature.
topexy, but long term follow up with mesh use demon-
strating its usefulness is still lacking. Mesh seeks to restore Mastopexy-Augmentation
support to a breast that has lost strength in its suspen- Augmentation of the breast can be combined with mas-
sory system and thereby reduce recurrent ptosis and topexy in a single or two-staged fashion using autolo-
prolong the longevity of mastopexy results. Mastopexy gous breast tissue, implants, or fat (Video 2, available as
with mesh support has been described by a number of Supplementary Material online at www.aestheticsurgery-
authors dating back to the 1980s when Marlex Mesh was journal.com). Details of breast augmentation alone are
used to anchor the breast tissue to the second rib.40 More beyond the scope of the present review but augmentation
recently, 3D knitted polyester mesh has been used as an can be performed with an implant in the submuscular or
“internal bra system” with greater than 4.5 year follow up subfascial/subglandular plane (Figure 6). The surgeon
without major complications.41 Histologic and mechanical must be mindful about blood supply to the NAC when per-
studies of explanted mesh have demonstrated induction forming an augmentation in conjunction with mastopexy.
of collagen formation around the mesh, enhancing the Many of the autoaugmentation options are similar to
overall strength of the mesh without resultant palpability those applied for MWL patients, as described above. They
or extreme stiffness.42 Other groups have also reported can also include a superior pedicle dermoglandular flap
Qureshi et al381

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Figure 6. (A, C) Preoperative and (B, D) postoperative photographs of a 36-year-old woman taken 5 years after bilateral
mastopexy-augmentation using Allergan Style 15, 339 cc bilaterally in dual-plane pocket with circumvertical mastopexy.

aimed at restoring central mound projection and narrow- having a 16.9% revision rate most commonly associ-
ing the width of the breast.50 Breast augmentation can also ated with the implant.54-56 Calobrace et al also published
be performed with autologous fat and its techniques are a series of 332 mastopexy-augmentations with a com-
described elsewhere.51 plication rate of 22.9% and revision rate of 23.2%.57
Prosthetic augmentation and mastopexy at a sin- Swanson specifically looked at tissue perfusion in mas-
gle stage has been a largely controversial topic since topexy-augmentation with a vertical technique and
2003 when Spear published “Augmentation/Mastopexy: concluded that simultaneous mastopexy-augmentation
‘Surgeon, Beware” though one of the first publications with an implant does not compromise perfusion to the
on the topic dates to the late 1970s.52 A series of publica- NAC based on a medial pedicle.58 A recent meta-anal-
tions that described the safety and revision rate of such ysis of 23 studies with 4856 cases of single-stage mas-
procedures have stimulated healthy discussion about topexy-augmentation found an overall complication rate
the safety of single-stage mastopexy-augmentation in of 13.1%.59 Pooled complication rates include recurrent
well-selected and informed patients.53 Stevens et al pub- ptosis (5.2%), poor scarring (3.74%), capsular contrac-
lished a series of reports of one-stage mastopexy aug- ture (2.97%), asymmetry (2.94%), seroma (1.42%),
mentation with revision rates between 8.6% to 16.7% hematoma (1.37%), infection (0.93%) with a reopera-
with his largest series of 1192 mastopexy-augmentations tion rate of 10.65%.59
382 Aesthetic Surgery Journal 38(4)

Proponents of single-stage mastopexy-augmentation Obesity was associated with infections in mastopexy,

argue that the revision rate for this procedure is signifi- which had the lowest complication rate of any aesthetic
cantly less than the 100% rate of a second procedure with breast procedure examined. Mastopexy-augmentation
staged mastopexy-augmentation. Ultimately, surgeon com- was found to have a higher incidence of infection; older
fort and appropriate patient selection will dictate whether patients who had mastopexy-augmentation were also
to stage or not. more likely to have a hematoma.61
A survey of physician reported complications after
mastopexy found that suture spitting, excess scarring,
Patient Positioning

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and bottoming out were the most commonly encountered
Patients undergoing mastopexy or mastopexy-augmenta- complications. Of these, suture spitting was reported to be
tion are positioned supine on the operating table with their most common with the SPAIR technique, excess scarring
arms extended on arm boards with appropriate padding. with the periareolar technique, and bottoming out with
The arms and head should be secured in such a way that the the limited inverted-T technique.10 Periareolar mastopexies
patient can be positioned in the upright position for intra- had the highest revision rate at 50%.
operative assessment of symmetry, shape, and position of The risks associated with single stage mastopexy-aug-
the breast and NAC without causing harm. Positioning and mentation have been reviewed above. Risks of procedures
securing the arms on arm boards allows for the arms to be include hematoma, infection, nipple-areola necrosis,
manipulated from an abducted to adducted position; with implant visibility and rippling, asymmetry and malpo-
the patient upright, this can help assess nipple position sition. Capsular contracture can occur as with primary
and allow for intraoperative adjustments as necessary. It is breast augmentation.
also helpful to drape out the upper shoulders to help with Revisions can be performed at the patient and surgeon’s
judgement of symmetry. discretion and often involve bottoming out, recurrent
ptosis, malposition, and scarring.
Postoperative Care
Patients are typically placed in a supportive surgical bra CONCLUSION
at the end of the case to support the newly lifted breast.
Mastopexy and mastopexy-augmentation exist on a spec-
This acts like a splint to offload the effects of gravity as
trum of surgical options to restore a youthful, pleasing
the healing process begins. Drains are not routinely used
shape and volume to a breast that has undergone changes
in mastopexy and mastopexy-augmentation procedures.
associated with aging or postpartum involution. These aes-
There is no clinical evidence for the routine use of postop-
thetic surgeries are offered to breast reconstruction patients
erative antibiotics beyond the consensus statement by the
who undergo contralateral balancing procedures for sym-
American Association for Plastic Surgeons for perioperative
metry as well. Many techniques have been described and
antibiotics for surgical site infections.60 Patients may require
the field has seen major paradigm shift including rear-
narcotic pain medication or muscle relaxants, particularly
rangement of breast parenchyma, use of mesh support,
if an augmentation was also performed in the subpectoral
and increasing evidence demonstrating the safety of single
plane. Typically, if there are incisions in the inframammary
stage mastopexy-augmentation. While once considered a
crease, patients are kept in a surgical or sports bra for about
highly litigated and risky procedure, improved techniques
a month and then weaned to an underwire bra. Physical
and better patient education on the part of aesthetic
activity depending on the nature of the mastopexy and aug-
surgeons has transformed the way mastopexy and mas-
mentation is slowly graduated to full activity typically by 4
topexy-augmentation is currently offered to patients. With
to 6 weeks. Revisions in the authors’ experience are typic-
the rise of noninvasive devices such as radiofrequency and
ally held off until 6 months postprocedure.
ultrasound energy technologies, aesthetic surgery of the
breast is likely to continue to see novel and innovative
Postoperative Complications, Revisions, ways to meet patient goals and expectations.
and Outcomes
Supplementary Material
A recent database study of complications in aesthetic
This article contains supplementary material located online at
breast procedures has revolutionized our ability to assess
www.aestheticsurgeryjournal.com.
complications after these surgeries on a magnitude never
before possible and found a complication rate of 1.15% in
mastopexy and 1.86% in mastopexy-augmentation.61 The Disclosures
complication rate of mastopexy-augmentation was found The authors declared no potential conflicts of interest with
to be significantly higher than that for mastopexy alone. respect to the research, authorship, and publication of this article.
Qureshi et al383

Funding 18. Goulian D. Dermal mastopexy. Clin Plast Surg.

1976;3(2):171-175.
The authors received no financial support for the research,
19. Flowers RS, Smith EM Jr. “Flip-flap” mastopexy. Aesthetic
authorship, and publication of this article.
Plast Surg. 1998;22(6):425-429.
20. Graf R, Biggs TM. In search of better shape in mas-
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