Scientific Forum

A Classification and Algorithm for

Treatment of Breast Ptosis
Laurence Kirwan, MD

Background: The Regnault classification of breast ptosis is insufficient for determining

surgical strategies for different stages of ptosis.
Objective: A new clinical classification of breast ptosis is proposed that allows greater
precision in the development of an appropriate surgical plan.
Methods: Breast ptosis is classified in 1-cm stages, beginning with stage A at 2 cm above
the inframammary crease and continuing through stage E at 2 cm below the inframam-
mary crease, with any level of ptosis beyond stage E defined as stage F. Increments of 1
cm were chosen because each level predicts a different amount of skin excision necessary
to elevate the nipple-areolar complex to an ideal aesthetic level. An algorithm is provid-
ed for defining options for surgical management of the ptotic breast with and without
augmentation and for the previously augmented breast.
Results: Seventy-three cases of breast ptosis were treated with augmentation mammaplas- Dr. Kirwan is in private practice in
Norwalk, CT, and London,
ty, simultaneous areolar mastopexy breast augmentation, Wise mastopexy breast aug-
England.
mentation, and other procedures following the proposed classification system and
Material included in this article
treatment algorithm. has been previously presented as
Conclusions: The new system for staging of breast ptosis is simple and easy to remember and an Instructional Course at the
67th, 68th, 69th, and 70th
can assist in the planning and evaluation of surgery. (Aesthetic Surg J 2002;22:355-363.) Annual Scientific Meetings of the
American Society of Plastic

F
rom ancient times to the present day, the aesthetic female breast has been por- Surgeons, 1998 to 2001; The
trayed in art and photography as an organ symmetrical with the hips and sup- Aesthetic Meeting 2001 and
2002 of The American Society for
ported by its own internal structure. Artistic representations of the ptotic breast in Aesthetic Plastic Surgery; and
which the breast has lost volume and is supported by the chest wall are synonymous was published in the Proceedings
of the Annual Breast Surgery and
with aging, infirmity, and loss of attractiveness. Body Contouring Symposium,
cosponsored by The American
Society for Aesthetic Plastic
In the primary or nonaugmented breast, the ideal aesthetic nipple lies 7 cm above the Surgery and the Plastic Surgery
inframammary crease (IMC), or at least 5 cm above the IMC if the nipple/IMC dis- Educational Foundation, August
2001, Santa Fe, NM.
tance is short. A distance less than 5 cm above the IMC combined with a loss of the
obtuse angle between the breast and the abdomen denotes some degree of ptosis. Since Accepted for publication March
22, 2002.
1998, I have recommended that the ideal nipple/IMC distance in the augmented breast
Reprint requests: Laurence
be 7 to 9 cm. Progressive descent of the breast results in the gland resting on the
Kirwan, MD, 605 West Avenue,
abdominal wall. The pencil test can be used to demonstrate ptosis. A positive test Norwalk, CT, 06850.
occurs when a pencil positioned at the IMC crease, with the patient in the standing Copyright © 2002 by The American
position, is held in place by the weight of the breast resting on the lower rib cage. Society for Aesthetic Plastic
Surgery, Inc.

In this article, the Regnault classification of ptosis is reviewed. A new system of staging 1090-820X/2002/$35.00 + 0

of breast ptosis is described, and the stages defined in this system are linked to an algo- 70/1/126746

rithm for surgical treatment. doi:10.1067/maj.2002.126746

AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 2002 355

 Scientific Forum

Figure 1. Classification of ptosis.

The Regnault Classification

The classification is based on 4 assumptions:
In the Regnault classification,1 the “pseudoptosis” desig- 1. The normal nipple position in the nonaugmented
nates a breast configuration in which the gland is inferior breast is 5 to 7 cm above the IMC.
to the IMC and the nipple is above it. Grade I ptosis is 2. A nipple less than 2 cm above the IMC denotes some
diagnosed when the nipple is at or up to 1 cm below the degree of ptosis when the angle between the breast
crease. Grade II ptosis describes the nipple at a level 1 to and abdominal wall is less than 90 degrees.
3 cm below the crease. Grade III ptosis describes a nipple 3. The term “pseudoptosis” is irrelevant from the view-
more than 3 cm below the crease or at the inferior pole point of planning surgical treatment.
of the breast. 4. The concept of an inferior pole NAC is not necessari-
ly an end point of ptosis.
The inferior pole nipple-areolar complex (NAC) (grade III)
is designated as an end point of ptosis, although the same The new classification begins with stage A (nipple 2 cm
anatomic configuration may occur in a tubular breast above the IMC). This is the level at which a breast aug-
deformity with a high inframammary fold and lower pole mentation may fail to give an adequate correction of a
parenchymal hypotrophy, as described by Brink.2 ptotic deformity. Above this level, the breast can be aug-
mented without an additional mastopexy and with an
The Regnault system is based on 4 assumptions: optimal aesthetic result. Similarly, stage F (nipple greater
1. “True” ptosis occurs when the nipple drops to the than 2 cm below the IMC) is beyond the therapeutic lim-
level of the IMC its of a periareolar mastopexy combined with an augmen-
2. The term “pseudoptosis” applies to a ptotic breast tation. These parameters are intended as guidelines only
when the nipple is above the IMC. and are not dogmatic.
3. An inferior pole NAC requires a special designation.
4. An inferior pole NAC represents an end point of ptosis. Stages B to E are set at 1-cm increments because each
level defines a different amount of skin excision necessary
The Author’s Classification
to elevate the NAC to an aesthetic level, based on its ini-
The author has proposed a new system of staging for tial and final relationship to the IMC. To evaluate the
ptosis of the primary or nonaugmented breast.3-6 In this nipple level, a 12-inch ruler with a centimeter scale is
system, 6 stages of breast ptosis covering a 5-cm distance placed at the IMC. The IMC level is marked at the mid-
are defined (Figure 1). They are named alphabetically to line with the ruler held in a horizontal position. With the
avoid confusion with the Regnault system. Stages A to E same ruler, the nipple level is also marked at the midline.
progress in 1-cm increments as follows: The difference in centimeters is measured.
• Stage A: nipple position 2 cm above the IMC
• Stage B: nipple position 1 cm above the IMC The ptotic augmented, or secondary, breast is classified
• Stage C: nipple position even with IMC into 2 stages, depending on how much nipple elevation is
• Stage D: nipple position 1 cm below the IMC required.7-9 In the secondary (previously augmented)
• Stage E: nipple position 2 cm below the IMC. breast, the nipple should be at or above the center of a cir-
In patients with either stage A or B ptosis, a positive pencil cle delineated by the implant and the overlying breast.
test advances the staging of ptosis by one stage. This is defined as a positive target sign. The nipple is situ-

356 Aesthetic Surgery Journal ~ July/August 2002 Volume 22, Number 4

 Scientific Forum

Management of Breast Ptosis

Staging

Stage A: Nipple position 2 cm above IMC

Stage B: Nipple position 1 cm above IMC
Stage C: Nipple position even with IMC
Stage D: Nipple position 1 cm below IMC
Stage E: Nipple position 2 cm below IMC
Stage F: Nipple position > 2 cm below IMC

Treatment

Without With Previously Augmented Breast

Augmentation Augmentation

Stage A: AM/AMIM Stage A: BA/SAMBA*

Stage B: AM/AMIM Stage B: BA/SAMBA*
Stage C: WAM Stage C: SAMBA Stage 1 Stage 2
Stage D: WAM Stage D: SAMBA (periareolar skin (periareolar skin
excision < 8-cm diameter) excision > 8-cm diameter)
Stage E: WAM Stage E: SAMBA/WAMBA
Stage F: WAM/WM Stage F: WAMBA/WMBA AM with an implant WAMBA/WAM

Figure 2. Algorithm for management of breast ptosis. AM, areolar mastopexy; BA, breast augmentation; IM, internal mastopexy; IMC, inframam-
mary crease; SAMBA, simultaneous (peri)areolar mastopexy and breast augmentation; WAM, Wise pattern areolar mastopexy; WAMBA, Wise
pattern mastopexy combined with an areolar mastopexy and breast augmentation with a short horizontal scar; WMBA, Wise pattern mastopexy
and breast augmentation.

ated in the center of the circle, or “target,” outlined by the incorporating a vertical scar can be performed, often com-
implant and overlying breast. Stage 1 is defined by a nip- bined with an areolar mastopexy to limit the length of any
ple that is 0 to 4 cm below the midpoint; stage 2 is defined horizontal scar. This is described as a Wise pattern areolar
by a nipple that is more than 4 cm below the midpoint. mastopexy (WAM). The third option is a standard Wise
pattern mastopexy (WM), usually combined with a superi-
An Algorithm for Surgical Treatment of Ptosis or pedicle and inferior wedge excision. The correct proce-
dure may be determined during operation. The treatment
I have previously presented the “SAMBA” technique10 options for each stage are as follow:
and an algorithm for augmentation of the ptotic breast • Stage A: AM/AMIM
(Figure 2).3-7 • Stage B: AM/AMIM
• Stage C: WAM
Treatment of primary breast ptosis • Stage D: WAM
without augmentation • Stage E: WAM
• Stage F: WAM/WM
There are 3 options for management of the ptotic breast
Treatment of primary breast ptosis
when electing not to perform an augmentation. An areolar
with an implant
mastopexy (AM) can be performed, either alone or com-
bined with an internal mastopexy (AMIM). A mastopexy The options for treatment of breast ptosis with an implant

A Classification and Algorithm for Treatment AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 2002 357
of Breast Ptosis
 Scientific Forum

A B

C D
Figure 3. A, C, Preoperative views of a 32-year-old woman with stage E ptosis. B, D, Postoperative views 1 year after Wise pattern areolar mastopexy
(combined areolar mastopexy and vertical mastopexy with a short horizontal scar).

A B

C D

E F

Figure 4. A, C, Preoperative views of a 31-year-old patient with stage A ptosis. B, D, Postoperative views 9 months after SAMBA with 550-cc gel-
filled round smooth implants. E, F, Close-up views of scar.

358 Aesthetic Surgery Journal ~ July/August 2002 Volume 22, Number 4

 Scientific Forum

A B C

D E F
Figure 5. A, D, Preoperative views of a 42-year-old woman with stage B ptosis. B, E, Postoperative views 16 months after SAMBA with 360-cc gel-
filled round textured implants. C, F, Postoperative views 6 years after SAMBA.

Treatment of the secondary (previously

are breast augmentation alone (BA), Simultaneous augmented) ptotic breast
(peri)areolar mastopexy and breast augmentation,
(SAMBA), Wise pattern mastopexy combined with an As mentioned previously, the augmented ptotic breast is
areolar mastopexy, and breast augmentation with a classified in 2 stages, depending on the amount of nipple
short horizontal scar (WAMBA), or a standard Wise elevation required. Stage 1 ptosis requires a periareolar
pattern mastopexy and breast augmentation (WMBA). skin excision of less than 8 cm diameter. The minimum
The treatment options for each stage are as follows: treatment is AM.
• Stage A: BA/SAMBA
• Stage B: BA/SAMBA Treatment of stage 2 ptosis requires a periareolar skin
• Stage C: SAMBA excision of more than 8-cm diameter. The recommended
• Stage D: SAMBA treatment is either a standard Wise pattern or modified
• Stage E: SAMBA/WAMBA Wise pattern mastopexy combined with an areolar
• Stage F: WAMBA/WMBA mastopexy and short horizontal scar (WAMBA). If the
implant is removed at either stage the maximum treat-
In this algorithm, either breast augmentation alone or ment is usually a WAM.
breast augmentation mastopexy may be appropriate for
correction of stage A or B ptosis. SAMBA is generally Results
appropriate when the nipple is 0 to 2 cm below the IMC
and may also be appropriate when the nipple is 0 to 2 A total of 73 breast ptosis cases were treated from June
cm above the IMC. Areolar mastopexy is contraindicat- 1998 through May 2001 (Table). Among the 54 patients
ed for stage F ptosis with an implant. Areolar mastopexy in this series who were treated with an augmentation
may succeed with a breast augmentation but is usually mastopexy, 30 patients had a primary SAMBA procedure,
compromised, leading to a less-than-ideal aesthetic 9 had SAMBA, 5 patients with implants in situ had a com-
result. A mastopexy alone would result in a vertical scar. bined capsulectomy, mastopexy, and breast augmentation,

A Classification and Algorithm for Treatment AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 2002 359
of Breast Ptosis
 Scientific Forum

A B

C D

Figure 6. A, C, Preoperative views of a 36-year-old patient with stage C ptosis. B, D, Postoperative view 1 year after SAMBA with 360-cc gel-filled
round textured implants.

A B

C D

Figure 7. A, C, Preoperative views of a 36-year-old patient with stage C ptosis of the left breast and stage D ptosis of the right breast. B, D, Postoperative
views 6 months after SAMBA with 360-cc saline–filled round textured implants.

360 Aesthetic Surgery Journal ~ July/August 2002 Volume 22, Number 4

 Scientific Forum

A B

C D

Figure 8. A, C, Preoperative views of a 49-year-old patient with stage C ptosis of the right breast and stage E ptosis of the left breast. B, D, Postoperative
views 18 months after SAMBA with 300-cc saline solution–filled round smooth implants. E, Left periareolar scar revision 3 months after SAMBA.

and 10 patients had a WMBA. An additional 19 patients Table. Breast ptosis procedures performed
were treated with a mastopexy alone. During the same
time period, 83 breast augmentations were performed Procedure No. of cases
without mastopexy. In all cases, the author’s classification Augmentation mastopexy 54
of breast ptosis and treatment algorithm was applied. Primary SAMBA 30
Representative cases are illustrated (Figures 3 to 10). Secondary SAMBA 9
Augmentation mastopexy + capsulectomy 10
Discussion (implants in situ)
WMBA 5
Mastopexy only 19
A new system of staging of breast ptosis is described that
is simple and assists in planning and evaluation of surgery
in a reproducible fashion. The advantage of this classifica-
tion is that it indicates appropriate surgical strategies for

A Classification and Algorithm for Treatment AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 2002 361
of Breast Ptosis
 Scientific Forum

A B

C D
Figure 9. A, C, Preoperative views of a 29-year-old patient with stage 2 ptosis after prior augmentation. B, D, Postoperative views 11 months after
WAMBA with 340-cc gel-filled round smooth implants.

A B

C D

E F

Figure 10. A, C, E, Preoperative views of a 41-year-old patient with stage F ptosis. B, D, F, Postoperative views after WAMBA with 300-cc gel-filled
round smooth implants.

362 Aesthetic Surgery Journal ~ July/August 2002 Volume 22, Number 4

 Scientific Forum

each specific stage of breast ptosis described. By contrast, therapy. It is simple to remember and a useful tool for
the Regnault classification system is less useful for deter- evaluating and measuring results. ■
mining a surgical strategy. Regnault grade II includes
degrees of breast ptosis consistent with treatment by use References
of a SAMBA procedure, as well as vertical scar mastopexy 1. Regnault, P. Breast ptosis: definition and treatment. Clin Plast Surg
techniques. Grade III is no different, in terms of surgical 1976;3:193-203.
treatment, from an end-point grade II. 2. Brink RR. Management of true ptosis of the breast. Plast Reconstr
Surg 1993;91:657-662.

The proposed classification system makes no attempt to 3. Kirwan L. Instructional course. 67th Annual Scientific Meeting of the
American Society of Plastic Surgeons, Boston, MA, October 1998.
isolate a breast shape on the basis of a definition of
4. Kirwan L. Instructional course. 68th Annual Scientific Meeting of the
pseudoptosis or an inferior pole NAC, because these des- American Society of Plastic Surgeons, New Orleans, LA, October 1999.
ignations are irrelevant to the decision-making process 5. Kirwan L. Instructional course. 69th Annual Scientific Meeting of the
and add another unnecessary layer of complexity and American Society of Plastic Surgeons, Los Angeles, CA, October 2000.
confusion to the clinical conundrum. 6. Kirwan L. Instructional course. 70th Annual Scientific Meeting of the
American Society of Plastic Surgeons, Orlando, FL, November 5, 2001.

The high inframammary fold and lower pole parenchy- 7. Kirwan L. Instructional course. Aesthetic Meeting, 2000 of the American
Society For Aesthetic Plastic Surgery, New York, NY, May 2001.
mal hypotrophy is relevant in the management of the
8. Kirwan L. Algorithm for augmentation of the ptotic breast.
ptotic breast but is not isolated from the general staging
Proceedings of the Annual Breast Surgery and Body Contouring
of ptosis. It is a marker of a tight IMC that may fail to Symposium, Santa Fe, NM, August 23, 2001.
release with insertion of an implant, even with parenchy- 9. Kirwan L. Wise-pattern areolar mastopexy breast augmentation—the
mal release as described.2 SAMBA procedure. Surgical strategies for the ptotic breast.
Proceedings of the Annual Breast Surgery and Body Contouring
Symposium, Santa Fe, NM, August 24, 2001.
Conclusion
10. Kirwan L. Augmentation of the ptotic breast: simultaneous periareolar
mastopexy/breast augmentation. Aesthetic Surg J 1999;19:34-39.
A new clinical classification of ptosis for primary and aug-
mented breasts is presented that is a predictor of surgical

A Classification and Algorithm for Treatment AESTHETIC SURGERY JOURNAL ~ JULY/AUGUST 2002 363
of Breast Ptosis