Dr. Cuzalina of Tulsa Surgical Arts, has written many articles on cosmetic surgery. He is also frequently asked to speak at national cosmetic surgery meetings on the topic of simultaneous Breast Lift and Augmentation.  What this means for the patient is one less surgery, one less anesthesia fee, and less overall downtime. This blog includes his latest article in Surge Magazine, a quarterly magazine distributed to members of the American Academy of Cosmetic Surgery.

Challenging Cosmetic Surgery
‘Simultaneous Mastopexy and Augmentation’

Angelo Cuzalina, MD, DDS

Cosmetic surgery of the breast often involves treatment of both breast hypoplasia as well as ptosis. Many women have a combination of breast problems and desire simultaneous breast lift and augmentation. An isolated mastopexy or basic augmentation with implants can be relatively straight forward in select patients; however, combining mastopexy with implants during the same surgery can be a daunting and risky task for even the most experienced surgeon.

Regnault Classification of Breast Ptosis

• Pseudoptosis: Nipple is above the fold & loose breast parenchyma hangs below the IMF
• Grade 1 Ptosis: Nipple is at the fold
• Grade2 Ptosis: Nipple is 1-3 cm below the fold, but above the lowest contour of the breast
• Grade 3 Ptosis: Nipple is located at the lowest contour of the breast >3 cm below the fold

The Regnault breast ptosis classification system was developed in 1976 to demonstrate various breast shapes that help guide a surgeons’ decision making process with regard to augmentation and mastopexy. Unfortunately, the grade of ptosis is only one small aspect for determining the ideal procedure for each patient.

Other Parameters as Important as Ptosis Grade for Treatment Planning

• Current breast volume: The current cup size the patient believes she has
• Firmness of breast tissue: Chiefly at the inframammary fold to avoid a ‘double bubble’ deformity
• The patient’s vision of the ideal breast: especially related to roundness or natural contours
• The amount of size change required: Ideal cup size
• Areolar diameter: desired areolar width
• Breast dimensions: especially nipple to fold distance and base width

No easy or dogmatic method for simultaneous mastopexy and augmentation exists. This is why cosmetic surgery is artistic. Yet, a few rules (or suggestions) can help one avoid problems. First rule, significant ptosis with a nipple to fold distance greater than 10 cm will be difficult to treat without a horizontal incision such as with an inverted T mastopexy unless the surgeon is extremely experienced in a Lejour mastopexy or using a very large implant. Personally, adding a short horizontal incision or lateral curve at the base of a borderline vertical mastopexy case can make the result turn out better with only a small extra scar in the crease. Second rule, a periareolar mastopexy cannot produce major lifting particularly on heavy, dense breast, must less a smaller areolar diameter when simultaneously placing an implant (eventually the smaller circle created will stretch). If the patient has large areolas and wants a smaller diameter at the same time as augmentation, adding a vertical component (scar) will actually improve the areolar scar and can lend to smaller areolas by placing suture tension inferiorly and not around the areolas.

The tendency early in one’s cosmetic breast surgery career is at times to be too conservation with the incision choice and the amount of breast parenchyma and fat excision during simultaneous mastopexy and augmentation. This can be especially true for the type 2 or 3 ptosis patient who is already a C or D cup and desires to be a ‘full C’ with more ‘rounded or upper pole fullness. These are particularly difficult because often a reduction of significant breast tissue and placement of a larger implant is needed to increase the ratio of implant volume to breast volume to achieve the look the patient hopes for. Basically, the more percentage of natural breast tissue, the more natural the breast. And, often more ptotic relapse will occur in women with naturally large, dense breast than one with large breasts due to implants (i.e. reducing natural breast tissue weight in exchange for implant volume will improve long term results).

Another surgical pearl to remember is that you can always remove more skin if needed during the procedure but it is hard to put it back if you remove too much. Having said this, a more conservation incision such as a periareolar or ‘donut only’ type incision for the heavy breast or type 2 or 3 ptosis very often leads to less than ideal results. An inverted T or vertical (Lejour type) mastopexy may be a much better choice for this breast type particularly if the patient wants significant parenchymal elevation. These larger incisions do have the potential for minor wound dehiscence at the trifurcations. So, another nice technique that two of our past presidents (Dr. Bob Jackson and Dr. Claude Crockett) have employed routinely for years is to place the implants in a ‘total submuscular’ position (diagram). The coverage of the lower half of the implant gives added protection particularly if the incision breaks down at little or a lot. Ultimately, the simultaneous mastopexy and breast augmentation can be very rewarding to the patient and surgeon, but will always remain a challenge.