Panel Discussion
Treatment of Breast Ptosis
Editor’s Note: My thanks to the moderator, Stephen R.
Colen, MD (board-certified plastic surgeon, New York,
NY); and to panelists Sharon Y. Giese, MD (board-certified
plastic surgeon, New York, NY); Ruth Graf, MD (ASAPS
international member and member of SBCP, Curitiba, Brazil);
and Dennis C. Hammond, MD
(board-certified plastic surgeon
and ASAPS member, Grand
Rapids, MI), for sharing their
opinions and clinical experience.
Dr. Colen: The first patient is a
29-year-old woman who underwent a periareolar subpectoral
augmentation with a round,
smooth saline implant 1 year
ago (Figure 1). Dr. Giese, can
you describe this patient’s
problem and how it might have
been avoided?
Stephen R. Colen, MD
Dr. Giese: In this oblique view,
it appears that the patient has a
double-bubble deformity. In
addition, her breast mound and
Ruth Graf, MD
the implant appear unequal; her
left breast seems higher on the
chest wall than the right.
To avoid the occurrence of a double bubble, I would
not have chosen to obliterate the natural inframammary
fold, if possible. The natural inframammary fold acts as a
very strong sling to keep the implants properly positioned
on the chest wall. Here, the implant has fallen beyond the
natural portion of her breast and into the surgically created inframammary fold pocket. This patient needed an
augmentation mastopexy. I like the periareolar approach
and the subpectoral position with a round, smooth saline
implant, but, again, I would have tried to avoid lowering
or changing her natural inframammary folds. Maybe that
would have meant using a smaller implant. I do not know
what necessitated lowering the folds.
Dr. Colen: Dr. Hammond, what would your initial
A
approach to this patient have been?
Dr. Hammond: If I felt that she needed a mastopexy, I
would have performed a periareolar mastopexy without
hesitation. When I am already in
the periareolar incision, I use
that to gain access to the breast;
it is a very nice approach to the
lower breast apron. The inframammary-fold incision sometimes masks the location of that
fold when the implant is inserted. But from above, through the
periareolar incision, you can
really see that lower apron quite
Sharon Y. Giese, MD
nicely.
Lowering a fold is a maneuver that should be approached
with tremendous care and performed only when absolutely
indicated. You can see where the
original fold was, and the distance from that point up to the
areola and the nipple is certainly
adequate to accommodate an
augmentation of this size. If the
Dennis C. Hammond, MD
folds are inadvertently lowered,
of course, this can result in a
double-bubble situation. I would perform a capsular
manipulation along that fold, incising along the capsule
and using the capsule as an apron to hike the fold up
superiorly to restore the breast to its original fold location.
Revising the fold would reposition the implant in the
breast and improve the double-bubble deformity. I agree
with Dr. Giese that the left nipple still looks low. She may
need a revision of the periareolar lift to raise the nipple.
Dr. Colen: Dr. Graf, how would you correct this problem
if the patient was unhappy with this double bubble and
wanted her contour restored?
Dr. Graf: If the implant was vertically positioned and prob-
lem-free, I would keep it intact. There is excess skin in the
inframammary region that can be diminished or eliminated
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Figure 1. This 29-year-old woman underwent periareolar subpectoral augmentation with a
round, smooth saline implant 1 year ago. She does not like the appearance of her breasts.
with the vertical technique, in which
skin is moved inferiorly. This technique would enable me to correct the
asymmetry of the nipple-areolar complex, elevating the left side.
Dr. Colen: Are you saying that a vertical incision would improve her
lower breast contour?
Dr. Graf: Yes. Through the vertical
incision, I can perform an internal
fixation of the previous inframammary fold, correcting the doublebubble deformity.
Dr. Colen: Dr. Hammond, do you
think a vertical incision would be
helpful?
zontal problem; adding another vector would not help the doublebubble phenomenon.
I believe that Dr. Graf was actually referring to the ptosis of the nipple and the areola. Adding a vertical
component can help tremendously in
shaping the breast and providing a
more cone-shaped appearance. But a
vertical incision is not going to help
that double-bubble deformity along
the inframammary folds.
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Dr. Colen: Dr. Giese, do you think
anatomically-shaped implants would
benefit this patient?
Dr. Giese: No. She has adequate
Dr. Colen: When you look at her tan
line, it appears that the top of her
nipple is quite close to the top of her
tan line. Would you be concerned
about raising her nipple? How
would you perform the periareolar
mastopexy?
Dr. Hammond: I do not think that
the vertical approach would be the
best approach. It is basically a hori-
so I might perform a unilateral
mastopexy. The right side actually
looks okay, except for the doublebubble deformity. If I were to use a
periareolar approach, I would stabilize the opening through which the
mastopexy is performed and then
allow the areola to sit in that opening without tension. I would cut the
areola at a diameter of 50 to 52 mm
— greater than what I ultimately
will need. The outer incision is performed superiorly, as far as necessary, to achieve the desired lift. I use
a Gore-Tex suture (WL Gore &
Associates, Elkton, MD); it is permanent, strong, very slippery, and
slides easily through the dermal cuff
around that areolar opening. You
can control that opening, millimeter
by millimeter, as you cinch the knot
down. I actually cinch it down to an
opening that is less than 52 mm to
about 44 mm. With the patient
upright, I can convert that opening
into a perfect circle by deepithelializing a small additional bit of skin if
needed. Then the nipple and areola
can be raised and will fit into that
opening without tension. That has
been a very effective way to create a
natural-looking nipple and areola
that does not appear plastered
against the apex of the breast.
Dr. Hammond: It looks as if the left
side is slightly lower than the right,
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breast tissue, and a round implant
placed in the subpectoral position
produces essentially the same aesthetic result as an anatomically
shaped implant. Another reason not
to choose an anatomically shaped
implant is the possibility that the
implant will turn and create additional deformity; it would just add
an additional variable without proVolume 23, Number 4
Panel Discussion
viding a clear benefit.
Dr. Colen: Dr. Graf, if this patient
wanted silicone-gel implants instead
of saline, would there be specific
considerations in choosing the size
or the shape of the silicone implant
to replace a saline implant?
Dr. Graf: Silicone gel is often preferred in Brazil because these
implants are felt to produce a better
breast shape. But in this patient, the
size and shape of the saline implants
look good. I would not change the
implant shape to an anatomic one,
because it could worsen the inferior
pole fullness that we are trying to
correct with the vertical scar.
Dr. Colen: But if a patient had a
275-cc saline implant, would you be
able to switch to a 275-cc cohesive
gel, or would you have to adjust the
volume because of the shape of the
silicone implant compared with that
of the saline one?
Dr. Graf: The cohesive gel implant
would have to be smaller, maybe
250 cc.
Dr. Colen: Dr. Giese, do you think
that implants that are high or low
profile are of any advantage in
treating a patient with this degree
of ptosis?
Dr. Giese: I would decide to use a
high- or low-profile implant on the
basis of 3 parameters: base width of
the breast, position of the breast on
the chest wall (high or low), and
desired breast size.
Dr. Colen: The next patient is a 23year-old woman who would like to
improve her breast contour and
attain a larger cup size, going from
34B to 34C (Figure 2). Her right
Treatment of Breast Ptosis
Figure 2. This 23-year old woman would like to improve her breast contour and gain one cup size.
breast is slightly larger than her left.
Dr. Giese, what procedure would
you recommend, and how would
you plan that procedure?
Dr. Colen: Dr. Graf, what would your
approach to this patient be? What
mastopexy design would you use?
Dr. Graf: I would perform a vertical
Dr. Giese: Considering her asymme-
try, I might or might not use
implants of different sizes. I cannot
judge from the photograph how
much larger the right breast is. She
wants to improve her contour, and
she has moderate to severe breast
ptosis, with her entire breast tissue
volume hanging off the pectoralis
major muscles, so she also requires a
mastopexy. My preference would be
to perform a simultaneous augmentation mastopexy, placing the
implant in the subpectoral position.
I would offer the option of a silicone
gel implant. Her ptosis is so severe
that she is going to need at least a
vertical incision and possibly a small
“T” to reposition the nipple-areola
complex.
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mastopexy. I use the chest wall–
based flap, passed under the pectoral
muscle loop to maintain the shape
over time. This flap will increase the
upper pole fullness, creating an
enlarging effect, because it seems she
has enough tissue to work with. If
she wanted an even larger breast, I
would use a round, textured cohesive gel implant, maybe 200 cc, in
the subfascial plane. That would
give the breast shape, and therefore
it would be unnecessary to reshape
the breast tissue.
Dr. Colen: Dr. Hammond, do you
have any suggestions?
Dr. Hammond: This is a difficult case,
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Panel Discussion
periareolar approach alone would
probably suffice.
With a patient such as this one, I
would make sure expectations were
realistic. I think there is a significant
possibility she will need a revision to
achieve the best results, and I would
discuss that with her thoroughly
before surgery.
Dr. Colen: Dr. Graf, do you think
that performing reduction or partial
tissue resection in a patient such as
this one would help?
Dr. Graf: The right breast is a little
Figure 3. This 31-year-old woman has had 3 children and would like her breasts lifted. She
desires to remain as large as possible and does not want implants.
tory. Two factors must be appreciated: first, she is tremendously ptotic
and asymmetric; second, she has a
tuberous breast deformity, particularly on her left breast. The lateral
aspect of the breast is rounded and
the medial aspect is flat, which is a
hallmark of mild constriction of the
inframammary fold. Also, the fold is
positioned high, although we cannot
see it clearly. That combination is
very difficult to deal with because the
inframammary folds are going to be
very problematic. This patient would
qualify for one of our silicone gel
studies because she does have ptosis.
I think that a silicone gel implant is
much more forgiving than saline. My
preference, because of shape, would
be a round, smooth silicone gel
implant.
As far as implant location, I have
some experience with the data Dr.
Graf has recently published regarding
subfascial implant placement. I have
moved, over the past year, into subg282
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landular positioning for most breast
augmentations, and I think that elevating the fascia from the superior
aspect of the pectoralis major has
been a nice adjunct to that technique
because it tends to blunt the superior
pole and prevent any distortion. A
round, smooth silicone gel implant in
the subfascial or subglandular position would be my choice.
The major problem is the kind of
lift to perform. I would start with a
periareolar lift, placing the top portion of the areola no more than 2 cm
above that fold, and I would purposely try to drop the fold a centimeter or
so on each side. That is going to be
difficult in a tuberous breast, and I
would defer the decision to add a vertical component to the mastopexy
until the implants were placed. I
would elevate the patient to a sitting
position at the end of the procedure,
and if a vertical skin excision
improved the breast shape, I would
execute it. But my feeling is that the
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bigger than the left. If the patient
wanted to keep her size, I would
remove some tissue on the right side.
If she wanted a volume increase, I
would use an implant.
Dr. Colen: Dr. Giese, do you think
this patient has a significant risk of
needing a second procedure? Is
recurrence of ptosis likely?
Dr. Giese: Absolutely. Dr. Hammond
covered several good points, especially advising a patient before surgery,
when most of the breast tissue is
hanging off the pectoralis muscle,
that there is a significant chance she
will need a secondary procedure. This
patient has 2 strikes against her: she
wants to be lifted, and she also wants
to be augmented. You are working
against the force of gravity; the
implant will tend to slip down on the
chest wall.
I also prefer to use a gel instead
of a saline implant for a patient such
as this one. I would be cautious
about using an implant of more than
300 to 330 cc.
Dr. Colen: The next patient is a 31-
year-old woman who has had 3 children and would like her breasts lifted.
She desires to retain as much breast
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Panel Discussion
volume as possible but does not want
implants (Figure 3). Dr. Graf, what
would be your surgical approach?
Dr. Graf: She has an extreme breast
ptosis and a very low nipple-areolar
complex with a lot of skin excess.
She has not only a flat upper pole
but also a depression right above the
nipple-areolar complex bilaterally. I
would perform a vertical-scar
mastopexy with a horizontal incision associated with the chest
wall–based flap, as described by
Marchac.1 I would fix the flap superiorly, passing it under a loop of
pectoralis muscle, and remove breast
tissue if necessary. This technique
can correct ptosis and restore upper
pole fullness. I also would decrease
her areolar diameter to balance with
her new breast. She has a lot of skin
excess, so it would be necessary to
leave a horizontal scar in the inframammary crease.
Dr. Colen: Dr. Giese, how would you
treat this patient?
Dr. Giese: I am a great fan of Dr.
Graf’s technique of internal glandular rearrangement with the chest
wall–based flap. I have some second
thoughts, however, when the nippleareolar complex extends so far
down. In this patient, it appears to
be at least 30 cm from the sternal
notch. I get a much more reliable
result using the inferior pedicle and
a Wise pattern for skin removal.
After 3 children, her poor skin tone
(visible on her abdomen and chest)
would not respond as well or as easily, in my hands, to the operation
Dr. Graf described.
Dr. Colen: Dr. Hammond, what are
your thoughts about this patient?
Dr. Hammond: I would perform a
Treatment of Breast Ptosis
short scar periareolar inferior pedicle reduction (SPAIR) mastopexy in
a fairly straightforward fashion. I
have performed this operation in
numerous patients like this one.
He r pre ope rat i ve appe aranc e
demonstrates extreme ptosis. The
“rock in the sock” deformity is so
evident that she even has divots in
her superior pole. She needs not
only a breast lift but also an internal shaping and rearrangement of
the breast tissue. This surgery
should achieve the least possible
scarring and the longest-lasting
result. That is exactly what the
SPAIR accomplishes. The operation
is based on an inferior pedicle; the
pedicle is managed separately from
the flaps so that the nipple and areola can be raised as much as is necessary. Significant elevation would
be required for this patient. The
vertical component will be added
because this patient’s breast base
diameter needs to be narrowed significantly to take up the excess
skin, and that can be achieved with
the SPAIR operation. Tissue is not
removed, other than that associated with the periareolar and vertical
excisions. The patient’s tissue is
directly rearranged and sutured
back into a more anatomic position
to shape the breast. This achieves a
good immediate result without a
settling period in which you must
observe the breast to see whether it
will assume the hoped-for shape.
Therefore this operation yields
increased consistency and reliability. Because the inframammary fold
is not violated, you have a longlasting result that will not “bottom
out.” In a patient such as this one,
whose tissue is already stretched to
the maximum, there is not going to
be much change in skin envelope
over time. Last, the areola is too
big and the periareolar approach
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will decrease nipple size. The end
result is that her breasts can be
safely and reliably lifted and
reshaped, and all that can be
accomplished with a periareolar
and a vertical scar.
Dr. Colen: Dr. Hammond, how
would you increase her upper-pole
fullness?
Dr. Hammond: Part of the SPAIR
operation is, in fact, a breast reshaping. The upper pole tissues are kept
quite thick and then undermined so
that superior sutures elevate the
whole complex. You use the patient’s
own tissues for elevation and suturing into position to restore upper
pole fullness. This concept is being
used in many aesthetic surgery procedures. Instead of resecting facial fat,
we are repositioning it to restore
cheekbones and the malar eminence.
Likewise, with the breast, we are
using the patient’s own tissues to
redistribute and reshape the breast.
Dr. Colen: Dr. Giese, do you have
any suggestions to increase her
upper pole fullness?
Dr. Giese: Another breast lift or
reduction operation I routinely perform when breasts are so ptotic is
the superomedial pedicle with gateway skin excision and vertical closure. I would tell this patient that
she might also have a horizontal
scar, because I am not certain that
this degree of ptosis can be managed
with a vertical skin closure only. I
think this is an excellent way to
maintain superior fullness.
Dr. Colen: Dr.Graf, do you think the
operation that you suggested would
increase the upper pole fullness?
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Panel Discussion
implant in the subpectoral position
and then perform the mastopexy. I
would raise the patient to a sitting
position to see whether I could perform the mastopexy with a concentric technique and position her nipple
with a “tailor tack” maneuver. If
not, I would add the vertical
mastopexy component. I use a blocking suture, and I prefer Gore-Tex.
Dr. Colen: What are your thoughts
about implant size?
Dr. Giese: She looks very thin. She is
Figure 4. This 35-year-old woman has had 2 children and would like to have her breasts lifted
and augmented.
sue must be reshaped to restore and
maintain the upper pole fullness. If
you do not use this flap, the weight
of the breast will cause it to “bottom
out” over time.
Dr. Giese: I enjoy performing Dr.
Graf’s operation, and I think it provides excellent superior pole augmentation and longevity to a
mastopexy. However, when the
breasts are this low, I have a more
difficult time performing it.
Dr. Hammond: This is the kind of
problem that makes me feel very
excited about surgery. It represents a
wonderful opportunity to resculpt
and reshape the breast in a way that
will provide a stable result over time.
Dr. Colen: The last patient is a 35-yearold woman who has had 2 children
and would like to have her breasts lifted and enlarged from a small B-cup to
a full-size C (Figure 4). Dr. Graf, how
would you help this patient?
Dr. Graf: This patient has breast
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hypoplasia and ptosis. I think that to
achieve good volume and shape, a
breast implant would be mandatory.
I would perform an endoscopic
transaxillary breast augmentation or
an inframammary approach and,
after inserting the implant in the
subfascial plane, I would elevate the
nipple-areolar complex and reduce
the diameter of the areola. I would
use a “round block” suture to avoid
areola enlargement. This approach
decreases the incidence of infection
and seroma because it does not go
through the glandular tissue to get
to the implant pocket. If the patient
would not accept a second incision, I
would use the periareolar approach,
trying to avoid sectioning glandular
ducts, and inserting the implant in
the subfascial plane.
Dr. Colen: Dr. Giese, what would be
your approach?
Dr. Giese: I would perform an augmentation mastopexy, starting with a
periareolar approach to place the
implant. I would use a round gel
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at a high risk for a secondary problem of implant displacement, given
her skin tone and extreme breast
ptosis. I would strongly encourage
her to choose the smallest implant
she could tolerate. I do not know
that I would perform an augmentation if she wanted an implant larger
than 300 cc.
Dr. Colen: Dr. Hammond, what do
you think about this patient?
Dr. Hammond: This would be a difficult patient to treat because her
degree of deformity is considerable.
Ptosis is significant, she has a relatively narrow breast base diameter,
and she is extremely thin. All of these
factors can yield a less than satisfactory result. I agree with the other
panelists that the procedure she
requires is an augmentation
mastopexy. I also would use a round,
smooth gel device because it is most
forgiving as far as shape is concerned. Patients who are this thin do
very well with subglandular placement. I prefer not to get involved
with the muscle if I do not have to,
and I have found that the degree of
“step-off” in the upper pole really is
not significant, whether the implant
is placed subglandular or under the
muscle. I would use the subglandular
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Panel Discussion
approach, using the subfascial technique Dr. Graf has described.
In terms of a superior areolar
mastopexy, this patient presents difficulties because a good bit of the
skin of her breast apex is taken up
by areola. Once the areolar diameter
is diagrammed, the outside dimension of the perioareolar incision will
be somewhat wide because of the
wide diameter of the areola. As a
result, the base diameter of the
breast will be diminished and the
patient may not have a breast size as
large as she would like. It is necessary to balance the base diameter of
the implant with the volume. I
would use a high profile round,
smooth silicone gel device. It is not
going to be a very large augmentation, because the larger the implant,
the greater the stress placed on the
periareolar closure. I would make
sure that the patient had a realistic
idea of the degree of augmentation
the surgery will achieve.
Dr. Colen: Do you think you can ele-
vate her nipples sufficiently with just
the periareolar approach, or do you
think you would have to add another incision?
Dr. Hammond: I can elevate the nipples as high as is necessary simply
with a periareolar approach.
Dr. Colen: Dr. Graf, what are your
thoughts on the periareolar
approach on this patient?
Dr. Graf: I can remove the skin with
a periareolar approach in this patient,
and I would not use a large implant. I
would prefer 180- to 235-cc
anatomic textured cohesive gel
implants placed under the fascia. I
would not use large implants
because she has lax skin, which
might favor recurrence of ptosis.
Treatment of Breast Ptosis
Dr. Colen: Dr. Giese, what are your
thoughts on the periareolar
approach with this patient?
Dr. Giese: I agree that she presents
difficulties. The diameter of her nipple-areola complex is relatively wide
for her breast mound. The periareolar excision for a mastopexy can be
eccentric. In other words, you do
not have to excise a perfect circle of
skin around the areola, and in some
cases, perhaps in this patient, some
of the periareolar skin itself may be
excised. For this patient, I would not
want to use the periareolar approach
because I anticipate raising the nipple a great distance. For me, more
than 4 cm is a lot. I would add a
vertical scar component to get the
breast shape that I would like.
Dr. Colen: Dr. Hammond, it sounds
as if you feel quite strongly about the
periareolar approach in this patient.
What maneuvers do you use in closing the periareolar incisions to maintain the nipple in the new position?
Dr. Hammond: The concepts
involved are cutting the areola at
about 52 mm or a diameter that is
greater than what you ultimately
need. When the periareolar opening
is cinched down with a purse-string
suture, it can settle into that opening
without looking artificial. The trick
is managing the outer diameter. I
keep a little dermal “shelf” along the
inside of that entire periareolar
opening. That is the architectural
framework of dermis through which
I can pass the Gore-Tex suture. It
will hold that suture very sturdily
and allow stabilization of that opening with little difficulty. Again, the
Gore-Tex suture plays a role in the
process because it is strong, reliable,
and permanent. But it also slides
very easily through the architectural
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framework of dermis. You can roll it
back and forth in your hand through
that whole opening, and it allows
easy control of the opening. Beyond
that, you should put as little tension
as possible on the periareolar opening. Her large areolar diameter is
somewhat problematic because
when you add an implant along with
that large skin excision, you are
going to have unavoidable tension
on the periareolar closure.
Dr. Graf: I agree that the purse-string
suture is very important to the periareolar stabilization. I think it is
very important to use the “round
block” suture in this patient.
Dr. Colen: What suture material are
you using, Dr. Graf?
Dr. Graf: In Brazil, we do not have
Gore-Tex sutures. Instead, we use
colorless 3-0 nylon.
Dr. Colen: Dr. Giese, what type of
suture do you use for the periareolar
closure?
Dr. Giese: I use 3-0 Gore-Tex on a
straight needle, just as Dr.
Hammond described. I do feel that
adding a vertical limb for reshaping
the breast over the implant is a necessary option — at least in my hands
— in cases such as this, when the
periareolar approach may not suffice.
Reference
1. Marchac D, Olarte G. Reduction mammoplasty and correction of ptosis with a short
scale scar. Plast Reconstr Surg
1982;69:45.
Reprint requests: Dr. Stephen R. Colen, 742
Park Ave, New York, NY 10021.
Copyright © 2003 by The American Society for
Aesthetic Plastic Surgery, Inc.
1090-820X/2003/$30.00 + 0
doi:10.1067/maj.2003.48
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