LMSSA(Lond), LRCP(Lond), LRCS(Eng), MS,FRCS
Consultant Oncoplastic Breast Surgeon
Mastopexy (breast uplift)
In the uplift operation the aim is to give the breast a more youthful and pert appearance, usually elevating the nipple to a more ideal position (it should normally sit at the midpoint of the upper arm bone β or 19-22 cm from the collar bone). The scars are placed in inconspicuous positions designed to be hidden when wearing a bra or bikini. The nipple is left attached to breast tissue to preserve its blood supply, and retain its natural appearance. If the areola is too large this will be reduced at surgery. The choice of technique will be discussed at the initial consultation.
When a breast becomes very droopy (ptotic) and at the same time empty (hypoplastic) neither a breast uplift alone (mastopexy), nor a breast augmentation alone will produce a satisfactory result. In these cases both procedures are required and are usually performed at the same time.
Patients who smoke are at greater risk of complications including bleeding and wound infection and are therefore advised to refrain from smoking ideally for two to four weeks prior to surgery and a similar time period post-operatively. Patients should also avoid Aspirin and equivalent anti-inflammatory agents for two weeks prior to surgery as these can increase the risk of bleeding.
It is recommended that patients on the combined oral contraceptive (not HRT or the progesterone only mini pill) should stop taking the pill for four weeks prior to surgery, as the pill is associated with an increased risk of deep vein thrombosis (DVT). During this period alternative forms of contraception should be used.
At the initial consultation after a discussion regarding the specific concerns a full medical and surgical history will be obtained. Details regarding the operation, the aims, the limitations, the recovery, and the risks will be discussed. Before the operation you will usually attend for a pre-operative nurse led assessment. You may require a blood test. Any significant health problems not previously identified may be discussed with Mr Sarakbi or the anaesthetist, and a further assessment may be required to determine suitability for the procedure.
At admission the nurses will again assess you and you will be measured for a pair of compression stockings. These are worn to reduce the risk of thrombosis formation and should be worn for a minimum of two weeks post-operatively. You will be seen by the anaesthetist prior to surgery and will be able to discuss issues pertaining to the anaesthetic and also pain relief in the immediate post-operative period. You will also see Mr Sarakbi who may make some pre-operative markings and will take photographs for the medical records.
The mastopexy is undertaken under general anaesthesia and usually takes approximately 2 to 2ΒΌ hours. The operation is undertaken on the day of admission and patients stay in hospital for 1-2 nights following surgery. Before starting the operation when the patient is asleep the breasts are infiltrated with a dilute solution of local anaesthetic and adrenalin, not only to provide postoperative pain relief but also to reduce bleeding. Skin is removed and the nipple is elevated to a more ideal position. The locations of the incisions will have been discussed before surgery. The wounds are all sutured with self-dissolving stitches and dressings applied. The tissue that is removed is routinely sent for histological analysis.
Our length of stay in hospital is variable and depends on many factors but is usually 1-2 days. Following the mastopexy/augmentation procedure dressings are applied in the operating theatre as follows: butterfly tapes are applied directly to the wound and then an absorbent dressing is placed over this. These dressings are usually left intact for seven days following surgery unless they become messy, in which case they are changed prior to discharge. Patients are invited to re-attend 5-7 days post discharge for a wound check by the nursing staff and a change of dressings. Dressings are then required twice a week for a total of about two to three weeks following surgery. The tapes that are applied directly to the wound should be left longer if possible. From two to four weeks postoperatively (once the tapes have dropped off) the wound should be massaged once or twice a day with Vitamin E containing cream or lotion.
The wound should be kept dry for approximately ten days following surgery and during this period of time patients are advised to wash with a flannel. After this ten day period the patients can get the wound wet provided there are no significant wound problems. Prolonged soaking in a bath should be avoided for three weeks postoperatively.
The breasts will feel tight and firm for two to three weeks and then gradually soften. Some bruising may occur especially if liposuction has been undertaken. Some lumpiness within the breast is common, most will soften with time but the breasts will have a new pattern of lumpiness that should be learnt for breast self-examination purposes. Some numbness around the breast is inevitable and will gradually resolve over many months. Nipple sensation may be altered either down or up β this may be permanent. Hypersensitivity of the nipple may on occasions occur. If this does happen the nipple/areola complex should be massaged and desensitised by gentle tapping.
At discharge a letter will normally be sent from the ward to your General Practitioner informing them of your admission and of the procedure undertaken. Patients are encouraged to keep their GPs informed however should they wish the admission to remain confidential please inform the ward staff and no communications will be sent.
Initially the breasts will not look correct. The mound of the breast will be too high and rounded, and the lower half of the breast will seem flattened and will appear to be squeezing the breast. Some bulging into the armpit is also very common, and the breast may have a boxy appearance. With short scar techniques there may be some wrinkling of the skin under the breast. All of this is normal. Over the first few weeks following surgery the up-down scar under the breast will stretch and the breasts will start to assume a more natural shape. However it will take up to six to nine months to fully normalise.
Mastopexy may be associated with discomfort and pain in the first few days following surgery. It is usually relatively modest in severity. For the first few days following surgery it is advisable to take pain relief on a regular basis to keep on top of any pain or discomfort. After four to five days pain relief is usually taken only as required. Not infrequently patients find that the pain gets worse forty-eight hours following surgery and then may take several days before it resolves again. This is as a result of bruising and swelling. Pain relief should be prescribed prior to discharge.
In the initial 24 - 48 hours patients should avoid Aspirin containing or any other equivalent non-steroidal anti-inflammatory agent (including Brufen, Ibuprofen, Neurofen and Voltarol) as this may increase bruising.
At the end of the operation tape is applied to the wounds on the breast and these are then covered with a light dressing. A further light dressing is placed over the drain sites. At that time the dressings will be inspected and changed if required.
The wound should be covered with a dressing for approximately ten days following surgery and during this time the wounds need to be kept dry. Sterile tape will have been applied to the wound at the end of surgery. Ideally this should be left on as long as possible, though if it has not come off by itself at 3 weeks it should be peeled off.
At three weeks following surgery it may be beneficial to apply some Vitamin E containing cream or ointment to the scar line once or twice day for a few weeks just to minimize the scarring. All of the stitches are self-dissolving and none will need to be removed. Occasionally at the ends of the scar line you may notice a small lump or feel the end of the stitch. This is entirely normal and no action is required as the stitch will dissolve away in due course.
Patients are advised to use a sports bra as soon as possible following surgery. The sports bra should be kept on for a total of six weeks being worn both day and night. The purpose of the sports bra bra is to offer gentle pressure around the breast to help the implant bed in and also to keep it in the right position. After the six week period normal bras can be worn including under-wired ones.
Initially many patients find it too uncomfortable to sleep on their side or on their front. This discomfort will settle after two to three weeks. Patients who sleep on their front may experience difficulty as a result of the presence of their new breasts though lying on them after two or three weeks will not cause any problem.
The scars will inevitably go red, become lumpy and may widen. After two to four weeks when healed, massaging two times a day with Vitamin E containing ointment is advised. This should be continued for at least 2 months following surgery, and longer if the scars are not settling. Full scar maturation may take 6 β 24 months. Ultimately the scars will become pale and flat, however if this process is delayed other treatments including silicone therapy, steroid injections and laser treatment may be required. In rare cases a scar revision procedure may be beneficial, though this will set the clock back in terms of scar maturation.
For the first one to two weeks following surgery patients should rest and convalesce. They should refrain from driving or from undertaking any light housework. After this period light housework and gentle activities can be undertaken, gradually building up to normal over a six to eight week period. Gentle gym activities and jogging can be resumed at 3-4 weeks however heavy lifting or any vigorous sporting activities (aerobics, tennis, and badminton) should be avoided for two to three months following surgery. Most patients refrain from work for 1-2 weeks, however in those with physical jobs or whom recovery is delayed an additional 1-2 weeks may be required.
Sexual activities can resume when patients feel comfortable but usually no earlier than two weeks following surgery.
Despite the extent of the surgery mastopexies are not usually associated with much pain. However regular pain relief is advised for the minimum of at least one week following surgery (usually a combination of anti-inflammatory medication and Paracetamol or Paracetamol / Codeine mixes). These should be prescribed prior to discharge from the hospital. Following the initial week pain relief should be taken as required.
Patients are usually reviewed by the nursing staff for wound check at five to seven days postoperatively and then in the outpatient clinic by Mr Sarakbi at one and six months postoperatively.
No one is perfectly symmetric and in any individual their breasts will frequently have slight differences in size, shape and nipple position. Additionally there may be slight differences in the chest wall muscles and in rib cage shape on either side. These differences will usually be identified at the initial consultation and the effect on the result discussed.
In the first few hours on returning to the ward bleeding may occur and this can accumulate resulting in a haematoma. The breast swells massively and patients need to return to the operating theatre for evacuation of the haematoma. This occurs in about 1:100 cases. There are usually no long-term side effects.
Sensory disturbance to the breast skin and nipple are described above. Some pain and discomfort will occur but usually resolves after a week or two. Some patients do experience a mastitis-like pain for a longer period and occasionally a course of medication is required. Some patients develop painful lumps in the breast. These are usually due to small areas of fat necrosis, and they will usually settle down over 2-3 months.
The commonest complication is wound infection. Occasionally antibiotics are required and dressing may be required for a longer period. In severe infections wounds can breakdown, usually at the bottom of the up/down scar at the T-junction. This is a relatively unusual complication in non-smokers, and patients of normal body weight. Patients who do smoke should refrain for 4 weeks before and at least 4 weeks after surgery. Usually the wounds will heal with simple dressings alone, though occasionally secondary surgery may be required.
In very severe infections the tissues can be damaged and skin loss can occur. Secondary surgery will almost certainly be required; very rarely this involves the use of skin grafts.
All attempts are made to make the breasts the same in terms of size, shape and nipple position however small differences are almost inevitable. If marked then revisional surgery may be required though this is usually deferred for several months as some differences may reduce as all the swelling settles.
The most serious complication following mastopexy surgery is nipple loss. Fortunately this is extremely rare. Should this occur the nipple and areola dies and a scab is formed which will eventually heal up leaving a scarred area. A new nipple can be reconstructed at a later date however these are poor imitations.
Following any surgery there is a risk in developing a deep vein thrombosis (DVT). This is a clot in the calf vein of the leg. In itself it may result in pain and swelling. The risk is that should the clot separate from the vein it can move to the lungs resulting in a pulmonary embolism. This is a potentially life threatening situation. All attempts are made to reduce the risk using compression stockings during and for two weeks after surgery, using pneumatic compression devices on the legs at surgery and in the immediate post-operative period, by encouraging early mobilisation, advising patients to stop the combined oral contraceptive pill four weeks prior to surgery and where it is felt appropriate using injections of blood thinning agents.
When complications do occur all attempts are made not only to remedy the problem in as speedy a manner as possible but also to optimise the final result. As with all cosmetic surgical procedures undertaken by Mr Sarakbi, there is a fixed fee policy which means that no further surgical charges are incurred for complications that occur within one year following the initial surgery. There may however (depending on the local hospital policy), be a charge for the hospital and the anaesthetist for repeat procedures occurring over 30 days from the original operation.
Should there be any concerns then the patient should seek advice. The contact numbers are provided below.
Most patients are delighted with the result of surgery and breast uplifts are associated with very high rates of patient satisfaction. In many it results in a dramatic increase in self-confidence and patients feel not only more proportioned but also more feminine.
In all cases the tissue that has been removed will be sent for routine histological examination. The results usually come back within a fortnight and patients receive a letter confirming the results. Very rarely something untoward is detected and patients will be recalled back for urgent review. Patients over the age of 40 who have not had a mammogram within a year of surgery should consider whether it would be appropriate to have one pre-operatively.
The scarring in the breast may be visible on routine mammography but will not affect the interpretation of the investigation. Breast cancers are not triggered by surgery to the breast.
Before
After