Recurrent ptosis refers to the condition in which the breasts sag again after cosmetic breast surgery. The primary cause of recurrent ptosis is an inaccurate initial surgical indication and plan.
As a consequence, many cases of recurrent breast ptosis are left without healthy skin, present with fibrotic and hardened tissue, significant loss of glandular volume, and imbalance in the nipple-areola complex - in terms of position, size, and proportions - along with poorly placed scars from the previous procedure. These factors pose major challenges for future reconstructive surgery.
Below is the insight from Dr. Ho Cao Vu, MSc, on the challenges of treating recurrent breast ptosis:
– Tissue and skin deficiency for implant-based reconstruction:
Ptotic breasts typically involve excess skin and, in some cases, excess glandular tissue. As a result, correction procedures often include excision of redundant skin and breast tissue, with or without implant placement depending on the surgeon’s recommendation and the patient’s aesthetic goals. However, when too much tissue and skin are removed during the initial surgery, and the patient later experiences dissatisfaction with the outcome or recurrent ptosis, subsequent reconstructive procedures become extremely challenging. In severe cases, the patient may no longer be a candidate for implant placement at all.
– Scarring:
Poor scarring outcomes such as hypertrophic scars, contractures, overly wide scars extending across the breast mound, or scars extending beyond the inframammary fold are common in mastopexy procedures. These can result from various factors, including poor vascular supply, hematoma, excessive fluid accumulation in closed spaces, infection, improper implant selection, inadequate or overly tight compression garments creating excessive tension on the incision, or the use of electrocautery causing widespread thermal injury to the tissue — all of which negatively affect the healing process.
Depending on the degree, location, extent of stretching, scar age (mature vs. immature), pigmentation, and scar characteristics, a thorough examination is required for the surgeon to develop a treatment plan for recurrent ptosis that ensures both safety and aesthetic outcomes.
In cases where the scar has spread extensively, and the fibrotic tissue is firm and inelastic, it becomes significantly more challenging for the surgeon to excise and reconstruct a well-shaped, aesthetically pleasing scar.
Scar fibrosis can reduce skin elasticity and disrupt the uniform stretching of the skin and subcutaneous tissues. This makes it more difficult to reshape the breast and increases the risk of compromised vascular supply, which may lead to fibrosis and tissue necrosis during surgery.
– Difficulty in redistributing glandular breast tissue:
Glandular breast tissue varies in both volume and position across the breast area, depending on factors such as age and childbirth history. This tissue contributes not only to the aesthetic contour of the breast but also to its functional and symbolic significance in womanhood.
However, when the glandular tissue is excised unevenly, excessively, or repositioned asymmetrically during the initial procedure, redistributing it in a secondary correction becomes highly challenging. The intricate vascular network within the glandular tissue plays a critical role in supplying blood, oxygen, and nutrients to the breast — and significantly impacts the outcome of secondary aesthetic breast surgeries.
Therefore, in surgery for treating recurrent breast ptosis, the surgeon must proceed with great care when repositioning the glandular tissue and the nipple–areola complex to a higher position. It is crucial to preserve key blood vessels to avoid complications related to compromised vascular supply — especially in cases with fibrotic scar tissue. Abundant glandular tissue or the presence of scarring increases surgical complexity and requires advanced vascular pedicle preservation techniques to ensure the viability of the nipple–areola complex.
Before undergoing mastopexy, patients should self-assess their breast condition, clearly define their aesthetic goals, and choose the most appropriate technique to avoid recurrence and the need for second or even third revision surgeries, which can affect both health and cost.
– Grade 1–2 breast ptosis:
For patients with grade 1 or 2 breast ptosis, it is recommended to stand in front of a mirror, arms relaxed at the sides, without wearing a bra. If the nipple lies at or 1–2 cm below the inframammary fold, this indicates grade 1–2 ptosis.
For cases of grade 1–2 ptosis, Dr. Ho Cao Vu recommends implant-based augmentation without additional surgical intervention. With modern techniques, surgeons can create a dual-plane pocket using the Dual Plane II technique, which is ideal for patients who wish to enhance both the shape and size of the breasts while addressing mild to moderate ptosis.
– Grade 3–4 breast ptosis: Patients with grade 3 or 4 ptosis can self-assess their current glandular volume, skin elasticity, and the appearance of stretch marks.
In cases where there is either excessive or insufficient glandular tissue, loose skin, and prominent stretch marks on the breasts after childbirth (caused by overstretched skin leading to rupture of collagen and elastin fibers), and the patient is predisposed to sagging with poor skin elasticity, if the goal is thorough correction of ptosis, Dr. Ho Cao Vu recommends mastopexy with preservation of the breast glandular tissue without implant placement. This approach offers definitive correction of ptosis while minimizing the risk of recurrent sagging.
In cases with limited glandular tissue, good residual skin elasticity, and vertically oriented grade 3 ptosis, Dr. Ho Cao Vu advises patients to undergo breast augmentation combined with areola reduction. However, he recommends performing these procedures in two separate stages to avoid excessive tension on the incision, which increases the risk of poor scarring.
Patients may choose to undergo implant placement first to assess the degree of improvement, followed by areola reduction or proceed in the reverse order.
