Mastopexy With Mesh for Breast Ptosis

The Clinical Problem ( Fig. 27.1 )

Synopsis

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Different classifications of breast ptosis have been put forward by Regnault and Kirwan, depending on the extent of the nipple-areola complex (NAC) descent below the submammary fold.
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The surgically corrected ptotic breast must be supported internally to prevent recurrence.
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Implants can help in marginal ptosis.
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An internal bra mesh system (Breform, Triangle Surgical, Buckinghamshire, England) is indicated for women who are having no more children, with acceptable breast volume, who are not seeking augmentation.

The Aesthetic Problem

Breast ptosis occurs when the supporting structures of the breast fail. Structures that support the breast relative to the chest wall include the ligamentous suspension, described by Wueringer and Tschabitscher, and the supporting ligaments, described by Matousek et al. The ligamenta suspensoria described by Cooper, stretching from the lobules to the skin, are responsible for breast shape but cannot support the breast relative to the chest wall; it was described very accurately in his book. The supportive function of the skin could be questioned because of the frequent recurrence of breast ptosis in techniques relying on the skin for postoperative breast support.

Surgical Preparation and Technique

Treatment Options

It is also important to take the breast volume into account when dealing with breast ptosis. There are basic principles that should be applied when treating breast ptosis.

The hypotrophic breast requires an augmentation. During the procedure, the nipple-areola complex (NAC) may rise to the required level, but, if not, a formal mastopexy must be performed, with excision of the excessive skin and NAC elevation. It is advisable that the augmentation should precede the mastopexy; otherwise, too much skin could be removed at the initial surgery.

Hypertrophic breasts need reduction of the excessive breast mass to reduce the effect of gravity on the supporting system. Any surgical technique can be used, and those reducing the inferior pole have a better chance for maintaining a long-term result.

It has been well documented that renowned plastic surgeons agree that mastopexy procedures generally have a temporary result. Recurrent ptosis or pseudoptosis can occur, regardless of the technique used.

Replacing the supporting structures, which maintain the normal breast position relative to the thoracic wall, with biocompatible nonabsorbable mesh can result in satisfactory long-term results.

Correcting Breast Ptosis: Internal Breast Support Procedure

For this technique, patient selection is important. The amount of breast tissue to be supported must be adequate but not too large. The best results are obtained by supporting breasts with a mass of between 300 and 500 g. If the breast is too large, a breast reduction should be done simultaneously. The breast tissue must be disease-free. A body mass index (BMI) of between 20 and 27 is preferable.

The mesh must be nonabsorbable and biocompatible. The best material is polyester, with an adequate pore size. Commercially preshaped polyester meshes are available but only in four different sizes. Alternatively, a flat mesh cut into a U shape can be used with any sized pedicle, adjusting the size by overlapping the edges by varying degrees ( Fig. 27.2 ).

The key to success entails wide undermining to attach the mesh effectively; knowledge of the blood supply and its anatomic variations in the pattern of supply to the NAC is mandatory. Previous breast surgery must be taken into account to ensure that the blood supply to the NAC is not jeopardized. It is recommended that the posteroinferomedial pedicle with the retained medial vertical ligament be used in the surgical technique ( Fig. 27.3 ).