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INTRODUCTION

Mastopexy is a cosmetic surgical procedure designed to improve the appearance of ptotic, or “sagging” breasts. Although a wide variety of techniques are available, the choice of which one to use depends primarily on the severity of ptosis. In essence, a mastopexy is a reduction of the excessive breast skin envelope without significant parenchymal resection. As such, approaches to mastopexy have often mirrored those of reduction mammoplasty. Similar to breast reduction, current approaches to mastopexy emphasize smaller incisions that result in less scarring.

In properly selected patients, mastopexy can produce aesthetically excellent results with a high degree of patient satisfaction.

ANATOMY

The female breast lies along the anterior chest wall extending from the second through the seventh ribs and from the sternal edge to the mid axillary line. It derives its blood supply from multiple sources: internal mammary artery perforators, the lateral thoracic artery (originating from the axillary artery), the thoracodorsal and thoracoacromial arteries, as well as perforators from the third through fifth intercostal arteries. These arteries form a rich collateral circulation that supplies the breast parenchyma, overlying skin, and the nipple areola complex (NAC). Venous drainage follows the arterial supply, namely via the axillary vein, internal mammary vein, and the intercostal veins. Lymphatic drainage of the breast is mainly via an extensive axillary lymph node basin and, to a lesser extent, via the internal mammary lymph nodes located along the course of the internal mammary vessels.

Sensory innervation to the breast comes from the second through the seventh intercostal nerves as well as the cervical plexus. The medial breast and overlying skin is supplied by the anterior cutaneous branches of the second through the seventh intercostal nerves, while the lateral breast and overlying skin receives innervation from the lateral cutaneous branches of the second through the seventh intercostal nerves. Innervation of the nipple is thought to be largely via the lateral cutaneous branch of the fourth intercostal nerve, with lesser contributions from proximate intercostals branches.

Within an individual’s lifetime, the size, shape, and contour of the breast changes with age, weight gain or loss, and after pregnancy. In the middle of the last century, Penn attempted to define the dimensions of the “aesthetically perfect” breast by recording measurements of 150 women. Penn found that the sternal notch to nipple distance averaged 21 cm, while the average nipple to inframammary fold (IMF) distance was 6.9 cm. This study, however, suffered from an extremely limited and homogenous sample size. Although often cited, this study is mostly of historic interest, since the breast metrics described in that study are not commonly seen in the contemporary population. Ultimately, the ‘desired’ size of the breast depends on an individual’s size and body habitus. Most plastic surgeons agree that a NAC diameter of 4 cm is aesthetically pleasing while the appropriately positioned nipple lies anterior to the level of the IMF.

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