Mammaplasty : hypertrophy or ptosis correction

Definition and principles

When breasts are too large or sag or droop too much, a mammaplasty can be performed. This operation aims at sculpting tissues and replacing the areola in its correct position in order to achieve a smooth curve (with or without correcting the size).

The objective of a mammaplasty is either to correct excess volume – in which case we talk of a mammary reduction or mammaplasty for hypertrophy – or to correct drooping – in which case we speak of a mammaplasty for ptosis.

The ptosis is enhanced by age and notably by significant weight changes or pregnancy. Drooping can be treated:

• on its own: the patient simply wants redraping whilst preserving the volume
• associated to a breast increase (the surgeon corrects the tissue, treats the ptosis and puts the breast implants in place in the same session).
• associated to a reduction: mammaplasty of reduction for hypertrophy.

Mammary hypertrophy (excess mammary volume) leads to physical and functional discomfort (back pains, impossibility to play certain sports, difficulties when dressing, etc) and sometimes a negative psychological affect. Apart from if the patient is very young, hypertrophy is associated to a ptosis due to the inevitable drooping of the chest with gravity.

All mammaplasties aim to achieve the prettiest shape possible in keeping with the wishes of the patient whilst limiting potential scarring.

In function of the initial condition of the breasts, the surgeon determines together with the patient the desired shape depending on the patient’s taste and whether this shape is best achieved simply by resculpting, or potentially by also filling a slightly empty breast (in this case a mammary implant will be necessary), or, on the contrary, by associating a volume reduction to this action of redraping. He also determines the position of future scars and their probable development in function of the patients’ skin type.

Scars

Depending on the initial state of the breasts, the scars can be:

• Classic, in a so-called upside down T shape or anchor shape for significant ptoses, most hypertrophies and when the re-curving aspect is preferred. The scar forms a circle around the areola then goes downwards vertically (in a visible areas) between the areola and the crease under the breast, finishing in a horizontal segment hidden in the crease under the breast.

• Vertical, that is to say limited around the areola and at the vertical with no horizontal scar under the breast (lollipop scar). This technique is reserved for treating moderate ptosis and moderate hypertrophies.

• Peri-areolar only for less serious ptoses, but this technique is very rarely recommended since it results in flat, “fried-egg”-like breasts and runs the risk of creases around the scars if the volume to be removed is too great. The peri-areolar technique is most appropriate when a mammary implant is used together with treatment on mild ptosis

Consequences:

A mamma-plasty can be performed once growth stops.

An ulterior pregnancy is clearly possible, as is breastfeeding, but this can have negative affects on the aesthetic result.

The result will be all the more stable if weight remains stable (weight increases must be avoided since they stretch scars in the same way as significant weight loss, leading to secondary drooping.) Thus, you will have to forego the operation if you are planning to go on a diet.

The risk of cancer is not increased by this operation.

Operation

Practical advice prior to the operation

Other than the usual pre-op assessment and anaesthetic consultation, it may be useful to undergo a mammary scan prior to the operation.

Do not arrive too morally or physically tired to the operation. Let us know about any change in your state of physical or mental health and do not forget that there is never any urgency to carry out an aesthetic operation.

Medicines that cause bleeding are prohibited during the days leading up to the operation : Aspirin, Anti-inflammatory medicines, Anticoagulants, Vitamin E….

The operation will be cancelled if you are ill, or for women, if you are pregnant on the day of the operation.

It is imperative that you neither drink nor eat for the 6 hours prior to the operation.

Due to the risk of necrosis it is imperative that a patient stops smoking.

The operation will be cancelled if preoperative advices are not adhered to : assessment, fast, stopping smoking…

When preparing your belongings DO NOT FORGET YOUR MEDICAL FILE.

Where possible, do not bring any valuable jewellery with you (or put it in the safe at the clinic with your other valuables during the operation.)

Have a shower or bath before coming to the clinic and make sure your hair is clean; women should obviously not wear nail varnish or make-up.

Prior to the anaesthetic contact lenses, dentures and hearing aids must imperatively be removed.

Anaesthetic and hospitalisation

The operation is always performed at the clinic and under general anaesthetic. Dr Le Louarn will prepare the markings with you prior to the operation. They are very important to determine the position of future scars. The operation lasts from 1.5 to 2 hours.

Upon waking up, you will find it difficult to lift your arms. You will have drains to limit the risk of haematomas.

As of the day after the operation, you will be asked to get up to reduce the risk of embolisms.

Leaving the hospital

Prepare an outfit that is not put on over the head for when you leave the hospital and that is wide enough around the chest. Avoid any chains or heavy brooches on the chest.

Next steps

For the first few days at home you must relax as much as possible and avoid all over exertion. However, you should walk a little several times a day to prevent the risk of embolisms and should eat enough to enable healing.

Due to traction on the scar, it will be difficult for you to lift your arms. It is not until after the 15 th day that you will be able to drive or pick things up that are high up.

It is important that you do not smoke for 15 days in order to facilitate healing and reduce the risks of necroses.

Note down the telephone number of the surgery, 01 45 53 27 17 from France or 33 1 45 53 27 17 for international call, and the number of the clinic near your home telephone and in your mobile phone. Do not hesitate to call us if you are worried. Call us if you have a temperature, experience weeping, pain or other symptoms that give you cause to worry.

Leave from work: 1 to 2 weeks
Stitches will be absorbable or removed 12 to 17 days after the operation
Bruises 15 to 20 days
Swelling at its height on 3 rd /4 th pre-op day then fades progressively
Scars 6 to 9 months before they whiten
Exercise that leads to tensions on scars is prohibited for 2 months.

Risks

In most cases, operations run smoothly and patients are happy with the result. However, before deciding to go ahead with an operation, you should be aware of the risks and possible complications.

If you also plan a mammary implant, see the breast augmentation fact sheet.

General risks of all surgical operations: infections, haematomas, healing problems and risks from anaesthetics

Infections

General risk of infection is rare when the operation is performed under normal conditions and when pre and post-op care and advice are adhered to. You will notably be asked to initially wash every day to keep the scars clean and to respect the antiseptic and antibiotic prescriptions. In breast surgery, infection can sometimes require surgical draining.

Haematomas

Haematomas are very rare complications, but need to be evacuated rapidly. They tend to occur in the hours following the operation. The risk of haematoma rises considerably when medicines that can cause bleeding are taken pre and post-op. Cases of haematoma have also been reported after aeroplane journeys made too soon after the operation (due to the variations in atmospheric pressure.)

Healing problems

Immediately after the operation a scar may inflame or weep, requiring specific local treatments that can often be long. Respect of advice concerning cleanliness, stopping smoking and attendance of monitoring sessions will be decisive. In the mid-term, a scar can sometimes develop poorly: thicken, expand, form keloids. This principally depends on the type of skin (red or black skins experience more problems) and health behaviour (cigarettes and the contraceptive pill increase this risk.)

Risks from anaesthetics

Anaesthetic techniques and monitoring methods have improved immensely and safety is high when an operation is performed in non-emergency conditions on a person in good health, when the anaesthetist is competent and working in a recognised establishment. However, the effect of anaesthetics on the body can be difficult to predict and treat. Therefore there are still risks and hazards inherent to all anaesthetics before and after the operation. This is why it is imperative that you consult the anaesthetist prior to the operation and fully inform him of the state of your health. In function of your health and the planned operation, he will assess the risks related to anaesthetics and tell you of any potential precautions to take. If the anaesthetist objects to the operation, this decision is final.

(see in chapter ” Before surgery ” section “Check up and anaesthetic consultation“)

Risks during any aesthetic operation: asymmetry, a result judged as insufficient or excessive, need to touch up results, sensitivity issues

The way in which tissues react to an operation is always specific and, to a certain extent, unpredictable. It depends on the patient correctly following the doctor’s recommendations, but luck also plays a role. This is why all risks of asymmetry, unsatisfactory or excessive results and the need to touch up results are evoked prior to any aesthetic operation.

Symmetry:

Breasts are by nature never perfectly symmetrical. After any aesthetic operation, it is usual for the patient to look at themselves and to analyse themselves more, and, since the features that they did not like have been treated, certain patients come not to like a pre-existing asymmetry that they had seen as insignificant prior to the operation. Mammaplasty treats possible pre-existing asymmetries with planned specific action aimed to target them, however sometimes at the price of larger scars.

It is also important to be aware that after the operation, factors concerning healing and reactions specific to each client come into play and can lead to disharmony in terms of volume, size or areolar position. For example, mammary surgery can lead to a change in posture that gives the illusion of asymmetric breasts, even if the breasts are identical, (this risk increases in the case of deformation of the vertebral column.)

Asymmetries can be corrected by further surgery, but it is necessary to wait for 6 to 12 months before doing so.

Problems of inappropriate size

Can arise further to decisions taken without due consideration. This risk can be limited by good prior reflection.

Sensitivity

Notably of the nipples, can occur, but this usually fades after 12 to 18 months.

Need to touch up results

This is unfortunately inherent to all aesthetic surgery. In mammary plasty, this primarily concerns repeat operations under local anaesthetic on the tip of the scar.

Specific mammaplasty complications :

Skin seizure and necroses

Skin or glandular pain can develop into partial or total necrosis of the nipple. This is rare but significant when it does occur. The risk is increased by two factors: smoking and considerable pressing on the extremity of the nipple which implies that the greater the volume to be removed, the higher the necroses risk. In any case of start of cutaneous suffering, the respect of surgeon advices regarding care will be key factor in tissue evolution.

Thrombo-embolic problems

They are the most dreaded complications, even if they remain extremely rare in this type of surgery. The phlebitis can sometimes lead to pulmonary embolisms which can be fatal. This risk increases with long haul flights too soon after the operation, by certain pathologies. This is why anaesthetic prescriptions in this regard must be strictly adhered to : early raising up and if appropriate, the wearing of anti-thrombosis tights and anti-coagulant treatment.

The result

Two to three months after the operation, an initial evaluation of the result can be made. However, scars and tissues can experience an inflammatory peak at that moment. This is why it is often necessary to wait for nine to twelve months to see a final result.

Usually an appreciable aesthetic result is achieved with real psychological benefits and, in the case of hypertrophies, the comfort of the patient is generally also greatly improved.

The final appearance of the scars depends on the reaction specific to each patient and stopping smoking will be a decisive factor in the scar development.

For mammary plasties, the longevity of the result essentially depends on health behaviour. The effect will be longer-lasting if significant weight fluctuations are avoided.

By way of conclusion, we remind you that precise and detailed information, an in-depth analysis of the reasons for the operation, teamwork between the patient and the surgeon during the preparatory phase, the search for surgical excellence coupled with a good analysis of benefits and risks, the respect of pre-op and post-op advice and regular monitoring of the patient are all key elements for aesthetic surgery to be a success.

References:

You can find  information in english regarding the mammaplasty for ptosis and mammaplasty for hypertrophy in sections « Breast lift » and  « Breast reduction » of the ISAPS’website (International Society of Aesthetic plastic Surgery) section : « Info for patients ».
www.isaps.org

You will also find information in french on the page « ptose mammaire » (sagging) and « hypertrophie mammaire » (excessive volume) of the SOFCPRE’s website  (Société Française de  Chirurgie  Plastique Reconstructrice  et Esthétique).
www.plasticiens.org

Specific information delivered on this website is based on Doctor Le Louarn’s practice and on his scientific works :

1 – LE LOUARN S. & LE LOUARN C. : La chirurgie mammaire et l’esthétiquement correct: Le sein et les medias – Mammaplasty and the aesthetically correct: breast and medias
Ann Chir Plast Esthet. 2005 Oct;50(5):378-93.
http://www.ncbi.nlm.nih.gov/pubmed/16165263
http://dx.doi.org/10.1016/j.anplas.2005.07.006

2 – LE LOUARN C. : La technique du sillon latéral dans la plastie mammaire – The lateral fold mammaplasty
Ann Chir Plast Esthet. 2004 Aug;49(4):366-72.
http://www.ncbi.nlm.nih.gov/pubmed/15351460
http://dx.doi.org/10.1016/j.anplas.2004.01.003

3 – LE LOUARN C., LEVET Y., FLAGEUL G. : Proposition pour une  nouvelle technique de plastie mammaire :
notes préliminaires présenté par Mr le Pr Grignon à la Société Français de Chirurgie plastique – Avril 1981

Regarding mammaplasties, the following publications and works can also be listed (this list is obviously not exhaustive and may be amended) :

1 – BOTTI G. : Aesthetic Mammaplasties
Practical Atlas of Plastic Surgery – Edited by SEE – Firenze 2008

2 – COURTISS E.G., GOLDWYN R.M.: Reduction mammaplasty
Chapter 10 in Complications and Problems in Aesthetic Plastic Surgery
Edited by George C. PECK – Gower Medical Publishing 1992 : ISBN 0-397-44613-6

3 – MULLER G.H. : Key-stone mammaplasty. Architectural considerations
Ann Chir Plast Esthet. 1990;35(3):219-24
http://www.ncbi.nlm.nih.gov/pubmed/1702277

4 – BOSTWICK III J. : Aesthetic and reconstructive breast surgery
C.V. Mosby Company 1983 : ISBN 0-8016-0731-0

5 – ASTON S.J. , REES T.D. : Breast reduction and matopexy
Chapter 33 Volume II in Aesthetic Plastic Surgery edited by Thomas D. REES
Saunders 1980 : ISBN 0-7216-7521-2