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Discuss your goals with your surgeon so that you may reach an
understanding with what can realistically be achieved. If you are
planning to still have children it is a good idea to wait to have surgery
until you no longer wish to have any additional children. The skin
may naturally stretch and then sag again after pregnancy, this would
create an even thinner skin envelope.
What Grade Breast
Ptosis (Sag) Do You Have?
The physical examination will include
determining the laxity of the skin and degree of ptosis of the breasts.
Determining your grade of ptosis can be done at home in advance if you are
curious. This can be done by placing a ruler under the breasts at
the natural breast fold, called the infra-mammary fold. The top edge
of the ruler should be at the junction of the breast where it meets the
ribcage.
click graphic for the full
size image
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Grade 1 (Mild Ptosis): The
nipple is at the same level of the mammary fold, or slightly above the top
of the ruler, and is still above the lower pole of the breast.
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Grade 2 (Moderate Ptosis): The
nipple is 1 to 3 cm below the top edge of the ruler and still above the
lower pole of the breast.
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Grade 3 (Severe Ptosis):
The nipple is 3 cm or lower than the top of the ruler, it is a possibility
that you may have Grade 3 ptosis.
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Pseudo-ptosis (Pseudoptosis):
The nipple is still above the top edge of the ruler, but your breasts
appear as if they are sagging due to a prominent, (and sometimes
flattened) breast lobe.
You will also discuss the type of anesthesia that
your surgeon prefers for the breast lift procedure. Most
breast lift procedures are performed under either General or Light Sleep
Sedation. If you do go under General, ascertain that the anesthesiologist is certified
and that you divulge all of the medications that you presently take to
both the surgeon and your anesthesiologist. Please
read the All About Anesthesia Page. The risks regarding anesthesia
should be considered for a fully informed choice.
You may or may
not choose to book a surgery with this surgeon at this time.
If you do, you will more than likely be expected to place down a deposit to hold your surgery date.
You will then usually make an appointment for your pre-operative appointment
and make arrangements for preliminary blood tests and other lab work.
Available Breast Lift Techniques
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The Crescent
Lift (Diagram 1): This
technique involves removing a crescent-shaped piece of tissue above
the areola and resuturing the tissue higher. This creates a minor
lift for patients who have slight ptosis. The areola skin is
thinner than the surrounding tissue, so slight distortion at the top
is possible if proper support is not worn, or with natural sag and
aging. This can cause the areola to appear oval or egg-shaped
as a result.
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The
Benelli Lift (concentric, or peri-areolar, donut or doughnut lift,
Diagram 2)
This technique
is considered less invasive and was designed with the incisions being
made around the areolae (or areolas). With the Benelli, a
doughnut shaped piece of
tissue around the areola border (or includes areolar tissue as well
to reduce its size) is removed and the surrounding
tissue sutured to the areola. The incisions are sometimes closed with
permanent purse string sutures. The Benelli lift results in flatter
projection, yet a rounder
breast shape post-operatively as opposed to a naturally sloped breast.
Having had a Benelli lift, I feel that my breast projection did
decrease, but I do not feel that my overall breast shape was made to
appear more
round. In fact, I wish it had. View more information on the
Benelli (Peri-areolar)
Breast Lift.
The scars are only
around the areola complex and may be darkened with the use of
micropigmentation. My scars
are light, but this does not detract away from the appearance of the
breast. There is also slight puckering present, which would be
solved by the insertion of breast implants.
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The Benelli Lollipop,
or simply Lollipop (or Keyhole, Diagram 3):
This lift is the same as
the above but with the addition of a straight scar from under the areolae to the
mammary fold (crease). This is for those who have medium ptosis,
too much for the Benelli only and too little for a full anchor
incision. Although some surgeons are capable of giving good
results with the peri-areolar lift only for medium ptotic patients.
Puckering at the edge of the areola is possible.
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Full Mastopexy
(anchor, Diagram 4): The
most commonly used technique for those with severe ptosis is with an anchor-shaped incision that
starts at the base of the areola, then vertically to the where the breast
crease meets the rib cage and then along the lower portion of the
breast at the natural crease (or slightly higher).
Nipple re-positioning is sometimes necessary with this technique as
the nipple must be partially removed (see below) and left on a
pedicle of flesh to retain the blood flow. This is
considered one of the major scarring techniques (with the below
being the most scarring) but it sometimes necessary with severely
sagging breasts. With the Standard Mastopexy, the resulting
scar appears as the shape of an anchor at the natural crease of the breast
up to the areola (darker skinned area) and nipple area.
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Full Mastopexy
(anchor) with an areolae reduction or relocation (Diagram 5):
This
is sometimes needed or requested to decrease the size of the areolae
complexes. This includes the anchor lift scars with the scars
around the areola as with the peri-areolar lift.
Resulting Breast lift Scars Depicted In Blue
click graphic for the full
size image
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Areola Reduction: This
is pretty much a Benelli lift, however the only tissue excised is a
doughnut of tissue on the actual areola itself. Some women may be
displeased with the size of their areolae which may be enlarged due to
genetic predisposition, previously having had large breasts then
undergoing tissue loss, stretching of the areola due to implants or other
reasons. The areola reduction surgery is designed to remove the
redundant areola tissue to improve the overall cosmetic appearance of
enlarged areolae. The reduction may result in a slight lift and may
also produce slight irregularities at the incision line if the
reduction was significant. The areola skin is thinner than the
surrounding tissue, so slight distortion is possible if proper
support is not worn.
Diagram depicts the dramatization
of a patient undergoing a Benelli Lift with Areola Reduction and Breast
Implants.
click graphic for the full
size image
Pre-operative Appointment
If you choose to book your surgery, you will schedule a pre-operative
appointment to further discuss your needs, receive your prescriptions, and a
list of what not to take (aspirin-containing medications, vitamin E, ibuprofen,
etc.). View our helpful Medications
Not To Take Before & After Surgery list. You will more than likely
also receive information on how to go about getting your labwork performed.
Lab work normally includes a Complete Blood Count (CBC), an HIV test, a
pregnancy test, and a prothrombin time test (PT) which is a
blood clotting test.
You will also be asked to purchase
post-operative, or surgical bras if your surgeon will not be providing them.
Surgeons usually prefer a certain brand and will give you the information to
obtain 2 garments. Popular brands include Design Veronique and Marena
Comfortwear. I have used both and either is a good option.
Your scheduled surgery date is right around
the corner so do not delay in getting your affairs and supplies in order.
Please see our Preparing
For Plastic Surgery checklist for more information. Remember not to
eat or drink anything the day of your surgery or after midnight if your
surgery is in the morning.
Surgery Day
On your surgery day you will arrive at the instructed time, or earlier.
You will usually fill out more paperwork, discuss and last minute concerns, and
you may be given an oral sedative such as a Xanax with only a very little amount
of fluid. Or you may have been given permission to take one before you
left your house.
Surgical
Markings
You will be marked for surgery. These markings will indicate
where the incisions will be, depict the center of the sternum,
etc. These markings are made with a permanent Sharpie-type
marker. Many surgeons use single
use, individually wrapped surgical pens. Some surgeons draw your
markings in the examination room, some in the O.R. and still others on
the operating room table.
The markings will remain on the skin even after you are scrubbed with Betadine solution
in the O.R..
I.V
Insertion & Monitoring Equipment
You may or may not have already been hooked up to the saline IV drip and
are awaiting the O.R. to be prepared for your surgery. Other
surgeons wheel you into the O.R. and insert your IV then. If you had been given an oral
sedative or valium prior you usually could care less what they are sticking in
you. If you haven't been given a sedative, the initial first few
minutes until you are anesthetized may be stressful.
Having an IV inserted feels sort of like
blood being drawn, but for a shorter period of time. It's the initial placement
of the IV catheter that may sting a bit. Some
patients get it in the crook of
the elbow, some the hand. I dislike the ones in the hand as it's a nasty place for a
bruise to be, at least with the arm you can hide it, it all depends upon your
veins though. So if your veins are not very prominent this can be a problem.
Some patients even have to be catheterized in the leg.
After the needle is injected into the
vein, it is pulled out and a little Teflon coated tube is left in your vein. This
intravenous tube is called a catheter. However many people consider
the whole access system a catheter. Let's call the access system a 'catheter
hub' for simplicity. This hub usually contains the catheter, a needle,
a flashback chamber and tubing connected with a luer lock. The hub
acts as an injection port and is taped to your skin to keep it from
getting knocked
out. Medications can be injected into the body via this port or be
connected the tubing to allow automatic infusion of drugs and intravenous
fluids with a computerized drip system. In short, the
IV is for a saline drip to keep you hydrated and also acts as a vascular doorway
for medications, many times including anesthesia.
You may or may not receive
some medications to help you relax or feel sleepy at this time. This
can help with pre-operative anxiety if you were not given an oral
medication to do so.
Regardless of the order and manner in which they insert your IV, after you
are placed on the operating table they will talk to you for a minute or
two and hook you up to the heart monitoring and oximeter machines, possibly
wrapping your legs with compression cuffs and other final
preparations. Your vital signs will be monitored, including your
blood pressure, body temperature, pulse rate/heart beat, and your
breathing rate, all very important factors to determine if you
are okay while under anesthesia. The O.R. staff will also check your
blood pressure. You have more than likely had your blood pressure
taken before with the use of a cuff which inflates firmly around your
arm. You will also have an oximeter clip (or strip) placed on either
your finger, your earlobe, or possibly on your big toe. The oximeter
machine monitors the oxygen/carbon dioxide saturation in your blood,
this is very important.
You may also
have intermittent pneumatic compression sleeves placed on your legs to
decrease the risk of Deep Venous Thrombosis (DVT) and subsequent pulmonary
thromboembolism. Heavier patients may especially benefit from
this. These devices are inflatable sleeves for your legs which are
either thigh high or knee high that inflate and deflate to keep
circulation optimal. You may also have heat lamps or heated
blankets, depending upon the surgeon, your temperature, etc.
Your vital statistics must be determined as stable before going any
further.
Anesthesia Types
Used In Breast Lift Surgery
If you and your surgeon have
chosen an IV Liquid Sedative, they will
either manually insert medications with a hypodermic into a Y site or injection
port along the length of the silicone tubing connected to your catheter hub/IV
or more than likely your anesthesiologist will attach a bag of
anesthetic or use a computer-controlled drip system. The computer system
automatically infuses a few drops of anesthetic every few seconds into a drip
chamber where it mixes with the saline. The drip crate can also be
controlled via the roller clamp. Flow regulators can also regulate the
flow rate.
When the
anesthesiologist releases the
roller clamp the mixture starts heading towards your body. The effects of the anesthesia are felt
soon after injection or opening the roller clamp, a few seconds in fact.
It
feels like heat going into you veins then creeping up your arm; then it jumps from your shoulder to a metallic-like taste under your
tongue and then you are blissfully anesthetized.
If you have
chosen Gaseous-state anesthesia (Twilight, Gaseous General)
Your
mouth and nose will be covered with a mask and you will usually be told to
count back from 100. You will usually remember getting only to about
96 before falling fast asleep. Then, the anesthesiologist will more
than likely intubate you. Intubation usually involves an
endotracheal tube down your throat to deliver gaseous anesthesia to your
lungs. However, some surgeons give you a little IV sedation and then
intubate you and switch over to gaseous sedation. Both of these
maneuvers eliminate the horrible experience of having a tube shoved down
your throat while you are awake.
Another option
is with the use of a laryngeal mask airway (or LMA). This is a lot
like the older intubation for General but
there is a shorter tube and a little balloon the size of your two thumbs at he
end. The tube holds your tongue down and of the way so it does not obstruct your
breathing and the balloon inflates and bocks fluid from entering your
windpipe either from saliva or stomach acid and makes a seal so the gas can
be delivered to your lungs. It is basically like a diaphragm for your
windpipe. With the
older intubation you have the pleasure of having a tube down your throat but you
don't usually remember it going in. You may wake up with a raw throat with
either but it is usually less so with the LMA.
You may
wake up with an irrigated and dry throat regardless because canned or
cylinder air (scubadiving tanks as well) is d-r-y. There is no moisture in these
tanks. It is your turbinate structure (three little fleshy flaps in your sinuses)
inside your nasal structure that mostly warms and humidifies the air which you breathe.
When you have to humidify your air, your body needs more moisture. The
saline drip will assist in this as well.
Another
option is with silicone tubing which is placed in the nose, however this
is rarely used as surgeons and anesthesiologists prefer that the windpipe
be protected and the tongue held down firmly. Be sure to ask your
surgeon which method he will be using if you are interested.
Regardless of which method, the gaseous anesthetic is mixed with oxygen
and this is how you will breathe during your surgery.
How Breast Lift Surgery Is
Performed
Mastopexy surgery usually takes about
1 1/2
to 3 hours
depending upon the technique, degree of ptosis (sag) and if prosthetic mammary implants
are used to augment the breasts as well, the skill of the surgeon or the amount of correction
needed. Your surgery may take longer if other
procedures are being performed in conjunction with your breast lift such
as reduction or non breast-related procedures.
The O.R. staff will then scrub your torso (and other areas if you are
having other procedures) with a 7.5% Betadine Surgical Scrub. The
O.R. staff will then rinse off the area with sterile gauze soaked in
saline and then paint your surgical area with the 10.% Betadine Solution
which resembles a brownish, iron-colored liquid. This will sterilize
the area by killing surface bacteria, fungi, protozoa, viruses and
yeasts. A common bacteria found on the skin is the naturally occurring
Staphylococcus aureus, or simply Staph) and decrease your risks of
an infection.
The surgeon then makes
the incisions, there are several techniques so your incisions may be
different depending upon your needs. Determine the intended
technique beforehand so there are no surprises.
The actual incisions
will either be smaller or larger than the diagrams depict, depending upon
your indivudual level of
ptosis. After the breast envelope is pulled together and sutured the
incision line is a lot thinner, as depicted above. Although the
scars may stretch due to tension, poor elasticity due to age or illness,
the implantation of very large breast breast prostheses or improper
support during the healing phase. Scar tissue can take up to a year to
mature. Here is a dramatization of an incision for a standard full
(anchor) mastopexy with areola reduction for a patient with medium ptosis, the closure of the breast
envelope/incision, suturing and the resulting scar:
Anchor Mastopexy With Areola
Reduction
click graphic for the full
size image
After the predetermined
incisions are made the excess skin is removed from the breast. The skin
underneath the breast (the incision line) is drawn together and sutured,
lifting the breast to a new higher position. The areolae and nipples are removed (if applicable) to reposition at a higher placement
for the rejuvenated breast. The sutures will remain in this anchor fashion and around the areolae until about 10 days,
depending upon the heaviness of the breast and if implants were utilized
for augmentation.
With the Lollipop (or
keyhole) Mastopexy, the incisions are around the areolae and nipple area
and in a straight line down from underneath the areola to the natural
crease of the breast. It is like the Standard Mastopexy but a little less
tissue (in the shape of a triangle) as well as excess tissue around the
areolae is removed. This is generally for breasts which have a medium
amount of ptosis (sag). The incision edges are drawn together as in
the Standard Mastopexy and sutured together. The nipple and areolae
complex is moved up as well.
Again, if you have minimal
ptosis (sag) you can possibly have the opportunity of having a Concentric
(Benelli, peri-areolar, doughnut) Mastopexy. If you have VERY
minimal sag, the crescent lift may be enough for you. I you have severe
sag usually the anchor lift is the commonly-chosen game plan by most
surgeons. Although some surgeons do perform the Benelli with or
without the addition of permanent sutures and report great results in very
ptotic patients.
Of course, if you are having breast augmentation with prosthetic mammary
implants with your mastopexy please read our
breast
augmentation website, which hyperlinks to our sister site, in its
entirety.
Usually before closure the
operating room staff performs an instrument and sponge check. After
all is accounted for your sutures are fully closed and dressed and you are dressed in
your bra or two or whatever compression/surgical garment your doctor has a
preference for (perhaps wrapped with an ACE bandage as well). You are then
gently woken up.
Coming out of Anesthesia
& The Recovery Room
The
transition period can be very rough for some patients. You may
experience sickness, dizziness, crying, depression, anxiety,
haziness, etc. It is generally like drinking too much alcohol
(if you have ever experienced that) but with even less control over
your body's movements at first. You may also be cold and shaking
and this is usually from the anesthesia and epinephrine, the
possibly cold saline drip, and the cold operating room. This will pass.
Please ask for an extra blanket if desired. Y\Also, your
throat may be sore if you chose to have General anesthesia via intubation.
You will be taken
to the recovery room, which is usually located right off of the
operating room, and placed in a recliner, hospital bed or gurney and
placed somewhat upright to help with swelling and drainage. Your
saline drip will more than likely still be inserted and you will usually be hooked up to the monitors so that your recovery can be properly
tracked. If you do feel sick or are in pain, alert the recovery nurse. He or she will give you a pain reliever and possibly some sickness
relief medication or a few sips of cool water to ease your stomach.
If you chose
Light Sleep Sedation or Local with IV (basically the same thing) you
should be allowed to go home pretty soon (2-3 hours, depending). If
you chose General they will want to keep you around for a bit longer, plus you may get a little sick. They give you medication to remedy this
but it may or may not work for you. You may have to urinate directly
after surgery due to the amount of saline, In fact the surgeon may
insist that you do before releasing you.
You MUST have someone to drive you home and care for you for the first
48 hours. This person will need to
help you to the bathroom, dressing, eating, etc.
Risks,
Complications & Contraindications of The Benelli (Peri-areolar) Breast
Lift
There are great benefits in getting
a mastopexy for those who need it, but everything comes with risks.
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The most severe risks are
attributed to anesthesia. There may be an allergic reaction to the anesthesia
or medications, especially if you have failed to make known your current
medication consumption, or if you have not ceased consumption of alcoholic
beverages or illegal drugs as instructed.
Abide by your surgeon's instructions regarding the consumption of food and
liquids before your surgery as well. Risks of intubation are exacerbated
when the patient is an asthmatic. Please read the All About Anesthesia Section
for more information.
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Other risks include
hematoma (internal bleeding) and/or seroma (fluid build up which may
require aspiration) are possible, leading to additional surgeries.
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Infections, although rare can
happen when bacteria such as Staph, which naturally lives on your skin,
gets into your incision area and multiply or develop. Washing your breasts, neck and torso with an anti-bacterial
soap like Hibiclens or even Dial anti-bacterial soap for several
days up until your surgery can reduce the amount of Staph on your
skin. Infections can also develop intra-operatively from unsterile equipment used by a surgeon or staff of the surgeon. Infections can also
result from the introduction of bacteria post-operatively through improper
dressing changes, bathing or swimming in water which contains infectious
agents.
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Although very rare, another risk is tissue
necrosis. Necrosis can happen when the tissue loses its blood
supply. Your chances of necrosis increase if you smoke and/or you have poor
oxygen-tissue saturation, the surgeon did not use a pedicle
to keep blood flowing to your nipple or other skin sections that were
reattached, or severe post-operative swelling disrupted the blood flow.
Necrosis can also be the result of an infection.
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Numbness and lack of
sensation can be problematic, although usually temporary.
Unfortunately this can be a permanent problem in some cases.
It is a complication we must be aware of before undergoing mastopexy or
mastopexy with breast augmentation.
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Keloidal & hypertrophic scarring is
possible in those who are prone to such. This is when the scar
tissue forms outside of the area of the wound. It can result in
thick, ropey scars.
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Asymmetry,
where one breast or nipple may appear higher, or larger
than the other. Your areola may not be
completely round, edges may appear jagged or the areola may appear oval in
shape.
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You may have incision
line puckering, which may resemble the opening of a drawstring bag.
I do have puckering but it lessened over time.
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The breasts may also have less
projection if you have chosen to have a breast lift without the
insertion of breast implants. My breasts have
slightly less projection as compared to before my procedure. Then
again, I have had several peri-areolar lifts due to
repeat wound opening and I had implants. When you have adequate
breast tissue or breast implants, the puckering is very minimal.
Your chances of any of the above happening can be
significantly decreased when you have a
qualified plastic surgeon to perform your Breast Lift. Following
your surgeon's instructions can further decrease your chances of having a
complication. Please abide by your surgeon's instructions for a
smoother, more pleasant recovery and results.
General
Risks & Complications
First and foremost there could be
an allergic reaction to the anesthetic. General is
considered to be more risky yet any anesthetic could bring on a
negative reaction.
Please
read our anesthesia section for a full disclosure of the inherent
risks of undergoing anesthesia. Negative reactions to
medications may also be an issue so watch for sudden rashes,
difficulty breathing, increased or decreased heart rate, hives,
wheezing, anxiety, fainting, dizziness, nausea, vomiting, etc.
For more information, see our anesthesia
section.
Medications which may
commonly cause an allergic reaction include anticonvulsants, barbiturates,
penicillin or other antibiotics, Novocain, Xylocaine, sulfa drugs,
and some pain medications.
Loss
of Sensitivity or Numbness
Loss of sensitivity is common, although temporary. Nerve
endings are severed during this surgery, so you must be patient
until they regenerate and sensations begin to return. This
can take several months, however permanent sensation loss in the
areola (nipple) area or breasts, in general, can and may
happen.
Scarring
Irregularities
While scars are going to be a reality, there is also a risk of
hypertrophic scar tissue, keloids or inner scar tissue. If you
smoke or have a history of abnormal collagen formation or scarring,
you may have irregular scarring. A
regimen of Steri-Strips directly post-op, switching over to scar gels
and Silicone Gel Sheeting after suture removal.
Wound
Separation
The separation of the wound edges may be an issue in some cases.
If this occurs, keep the area very clean and contact your surgeon
immediately. Revision surgeries are not always necessary but can
be in some cases. Wet bandages can keep wound edges moist and encourage
collagenation and wound binding. If this is not the case, an
additional surgery to either excise the wound edges or score the
edges and resuture the incision is possible. Regardless of the
method needed to close the wounds, the healing process will take
longer for a patient with separation than it would with a patient with
normal wound healing.
Asymmetry
There may be asymmetry. Although your surgeon will attempt to
make your breasts as even in volume and height as possible, the body
is not made of modeling clay. The body also heals differently
from patient to patient. However, this does not in anyway excuse
a surgeon from doing poor, or rushed, work. Please be sure to view as many
before and after photographs as you can during your initial consultation
and ask the opinions of other patients, what they have heard, and
speak to patients who have actually had breast lifts with your
surgeon..
Scar
Treatments
There are many studies which report
that keloid scars were prevented (and lessened in existing cases) with the
use of silicone sheeting and gels. There are several scar therapies
on the market, including the below sheets which are made specifically for
mastopexy procedures made by
www.BioDermis.com
click graphic for the full
size image
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