Purpose:  This study was designed to determine when a primary submuscular breast augmentation would adequately correct Grade 2 or 3 ptosis without a mastopexy.

Materials And Methods:  Between Jan. 1, 1997 and Dec. 31, 2001, 276 patients (552 breasts) underwent primary bilateral subpectoral breast augmentation using saline-filled breast implants.  Of this group, 106 patients (208 breasts) had Grade 2 or 3 ptosis prior to augmentation (189 Grade 2 and 19 Grade 3). Ptosis was graded using the Renault classification. Patients with ptosis were offered the option of proceeding directly to an augmentation mastopexy with the resultant scarring or having an augmentation only followed by a later secondary mastopexy if the ptosis was inadequately corrected with implants. When mastopexy was chosen by patients, either concentric circle or Wise pattern procedures were done. In the last year, however, the vertical short-scar mastopexy has become the preferred technique.

Results:  Results are shown in Table 1 according to implant size and whether ptosis was improved. In general, augmentation alone was successful in correcting ptosis by at least one grade in approximately 50% of breasts using this treatment algorithm. In general, the size of implant used did not matter to any significant degree, with the exception of implants smaller than 300 cc or larger than 600 cc. Concentric circle mastopexy at the time of augmentation was not successful in the majority of cases; only 3 of 10 breasts were improved by at least one grade. Eight breasts underwent a Wise-pattern mastopexy, and all improved. Despite incomplete correction of ptosis, only three patients (4 breasts) have thus far proceeded to secondary mastopexy because of reluctance to accept the resulting scarring, added expense and additional time off work. We were unable to identify objective parameters that could discriminate between patients who would benefit from an implant alone and those better served by primary augmentation mastopexy. Therefore, patients with Grade 2 or 3 ptosis are currently encouraged to preoperatively consent to the option of augmentation plus short-scar vertical mastopexy if it becomes apparent that ptosis has not been satisfactorily corrected by augmentation alone.

Table 1.

	200-299 cc (n=3)	300-399 cc (n=35)	400-499 cc (n=82)	500-599 cc (n=52)	600-775 cc (n=18)
Ptosis improvement with implant alone	33% (1)	46% (16)	54% (44)	52% (27)	67% (12)
No improvement with implant alone	67% (2)	54% (19)	46% (38)	48% (25)	33% (6)
Improved after mastopexy revision			2	2

Conclusion:   Primary subpectoral breast augmentation alone can correct Grades 2 and 3 ptosis in approximately 50% of patients. Unfortunately, there are no objective criteria to identify the individuals who cannot be satisfactorily corrected with implants alone. Patients with Grade 2 or 3 ptosis prior to primary augmentation must be informed of the potential need for a mastopexy either at the time of augmentation or as a later revision. Our preferred approach is to insert the implant first, evaluate the degree of ptosis correction, and then proceed with short-scar vertical mastopexy whenever the residual ptosis appears problematic. This results in high patient satisfaction, superior results with little scarring, and fewer secondary procedures. It also ensures that smaller implants can be used in patients who are averse to very large breasts.