Mastopexy - Breast Ptosis

Breast Ptosis

Etiology

The gravity of the Earth is the most common cause of breast ptosis, the prolapsation — the falling forward and the sagging — of the breast tissues (glandular, adipose, skin) from the woman’s chest, relative to her habitus, her body build and physical constitution.

• In the young woman with large breasts the sagging occurs because of the volume and weight of a bust that is disproportionate to the woman’s body type, and because of the great elasticity of the thin, young skin envelope of each breast.

• In the middle-aged woman, breast ptosis usually is caused by the postpartum hormonal changes to the maternal body, which depleted the quantity of adipose fat tissue and atrophied the milk glands, and because of the inelasticity of the skin envelope, which was overstretched by the engorgement of lactation.

• In the post-menopausal woman, besides gravity, such breast ptosis atrophy is aggravated by the inelasticity of overstretched, aged skin.

Pathophysiology and presentation

In the course of a woman’s life, her breasts change in size and volume as the skin envelope becomes inelastic, and the Cooper’s suspensory ligaments — which suspend the mammary gland high against the chest — become loose, and so cause the falling forward and the sagging of the breast and the nipple-areola complex (NAC). Moreover, additional to tissue prolapse, postpartum diminishment (involution) of the voluminous milk glands in the breast aggravates the looseness of the suspensory ligaments, and of the inelastic, overstretched skin envelope. Mastopexy corrects said degenerative physical changes, by elevating the (internal) parenchymal tissues, cutting and re-sizing the skin envelope, and transposing the nipple-areola complex higher upon the breast hemisphere. The degree of breast ptosis of each breast is determined by the position of the nipple-areola complex (NAC) upon the breast hemisphere; ptosis of the breast is measured with the modified Regnault ptosis grade scale.

The Regnault ptosis grade scale

• Grade I: Mild ptosis — The nipple is located below the inframammary fold (IMF), but remains located above the lower pole of the breast.

• Grade II: Moderate ptosis — The nipple is located below the IMF; yet some lower-pole breast tissue hangs lower than the nipple.

• Grade III: Advanced ptosis — The nipple is located below the IMF, and is at the maximum projection of the breast from the chest.

• Grade IV: Severe ptosis — The nipple is far below the inframammary fold, and there is no lower-pole breast tissue below the nipple.

Additional mastopexy considerations

Pseudoptosis — The indication is the sagging of the skin of the lower half (inferior pole) of the breast, featuring the nipple located either at or above the inframammary fold (IMF); as such, pseudoptosis is a usual consequence of postpartum milk-gland atrophy. The nipple is located either at or above the IMF, while the lower half of the breast sags below the IMF. Pseudoptosis usually occurs when the woman ceases nursing, because the milk glands have atrophied, and so reduced the volume of the breast, thus the sagging of the breast-envelope skin.

Parenchymal maldistribution — The lower breast lacks fullness, the inframammary fold is very high under the breast hemisphere, and the nipple-areola complex is close to the IMF. Such indications of the maldistribution of parenchymal tissues indicate a developmental deformity.