Systematic Review of Patient Satisfaction Following Mastopexy Surgery

Abstract

Background:

Mastopexy is a technique that repositions the nipple–areolar complex to a more aesthetically desirable position within the profile of the breast. The BREAST-Q is a vital tool that can be used to assess patient-reported outcome measures (PROMs). Given the known importance of PROM following mastopexy surgery, we aim to provide a systematic review of the literature to summarize the available information and provide direction for further optimization of patient care and research.

Methods:

A systematic review was performed using the Ovid (MEDLINE/PubMed) database in accordance with the preferred reporting items for systematic reviews and meta-analyses checklist. The inclusion criteria comprise studies in the English language from 1976 to 2024, female patients only, and studies reporting patient satisfaction following mastopexy or augmentation mastopexy. Case reports, studies without validated PROMs, animal studies, conference proceedings, and bariatric patients were excluded. Risk of bias was assessed using the Critical Appraisal Skills Programme checklist.

Results:

A total of 10 studies qualified for qualitative synthesis of data, and meta-analysis was performed where possible. A total of 510 patients underwent mastopexy procedures. The mean ages across studies ranged from 31 to 54 years. Mean body mass index values were reported in 6 studies, ranging from 20 to 27 kg/m². The mean follow-up duration varied from 6 to 38 months. Inconsistent data across all studies significantly limited the meta-analysis.

Conclusions:

Mastopexy procedure leads to higher rates of patient satisfaction and quality of life. This analysis has highlighted the need for more consistent PROM reporting in mastopexy surgery.

Takeaways

Question: How do different mastopexy techniques compare when assessed with patient-reported outcome measures?

Findings: Mastopexy surgery improves breast aesthetics and patient satisfaction, but outcome data are inconsistent.

Meaning: Standardized reporting and longer follow-ups are needed to optimize patient care.

INTRODUCTION

Mastopexy repositions the nipple–areolar complex to a more aesthetically desirable position on the breast.¹ Techniques include the vertical scar approach popularized by Lassus and Lejour, crescent mastopexy for mild ptosis,^2,3 donut mastopexy for small ptotic breasts or gynecomastia,⁴ the Y-scar technique for reduced scarring in mild ptosis,⁵ and the inverted-T approach for severe ptosis.¹

Although many studies compare mastopexy techniques, inconsistent and subjective outcome reporting hampers objective comparison. Additionally, most studies focus on surgical outcomes or complication rates rather than patient satisfaction.

Owing to limited systematic reviews assessing patient-reported outcome measures (PROMs), we aimed to synthesize existing literature on mastopexy and its impact on patient well-being. We hypothesized that outcomes would be heterogeneous across techniques, highlighting the need for standardized PROM reporting. The BREAST-Q, a validated PROM tool,⁶ exemplifies this shift toward patient-centered assessment.

METHODS

The study followed preferred reporting items for systematic reviews and meta-analyses guidelines and was registered on PROSPERO (CRD42024573420). A July 2024 PubMed/MEDLINE (Ovid) search used the terms “Mastopexy AND augmentation mastopexy OR augmentation-mastopexy AND outcomes AND patient AND reported OR PROMs.” Abstracts and titles were screened using Rayyan (Doha, Qatar). Cohen kappa was 0.40 for abstracts and 0.50 for full-text review, both indicating moderate agreement.

Inclusion Criteria

• English language only.

• Studies published between 1976 and 2024.

• Studies reporting patient satisfaction following mastopexy or mastopexy with breast augmentation.

• Female breasts only.

• All techniques of mastopexy included, with none omitted.

• No direct comparators were required in the identification of research studies. If comparators were present between different mastopexy techniques, then both techniques were included for analysis.

Exclusion Criteria

• Studies deemed by reviewers to have low validity.

• Studies without validated PROMs.

• Review articles/secondary sources of literature.

• Case reports.

• Conference proceedings/editorials.

• Animal studies.

• Studies with only an abstract available.

• Bariatric studies.

Two reviewers (R.W./D.S.) independently screened articles; disagreements were resolved by a third author (M.U.J.). Reviewers were blinded to each other’s decisions during full-text review.

Risk of Bias

The risk of bias in the included studies was assessed using the Critical Appraisal Skills Programme checklist. Two authors (R.W./D.S.) independently rated each study as low, high, or unclear risk; disputes were resolved by the senior author.

Data Extraction

Extracted data included demographics (age, follow-up, body mass index, sample size, and implant use) and outcomes from the BREAST-Q reduction/mastopexy module, the only validated PROM used across studies. This module is separated into 2 parts and consists of 88 questions in 2 areas: (1) patient satisfaction and (2) health-related quality of life (QoL). The satisfaction domain includes satisfaction with breasts, outcome, information, surgeon, medical team, and office team. The QoL domain includes psychosocial, sexual, and physical well-being.

The “‘satisfaction with breasts’” domain explores patient satisfaction with respect to breast size, shape, and symmetry, as well as appearance when clothed, unclothed, and in a bra. The “‘physical well-being’” domain addresses topics such as chronic pain and general discomfort. “Psychological well-being” addresses issues such as feelings of attractiveness, self-confidence, and self-worth. “Sexual well-being” addresses issues such as feelings of sexual attractiveness, sexual self-confidence, and comfort. The BREAST-Q scoring software was used to generate the Q-scores (scale ranging from 0 to 100, with higher values representing more favorable results).

Meta-analysis

The Review Questions

Does mastopexy increase PROM scores across each domain compared with scores before surgery? How do mastopexy techniques differ in their effect size? What are the factors that are associated with high and low satisfaction?

Data Collection

Data were manually extracted from the 10 included research articles and then entered into a spreadsheet. Any BREAST-Q scores were included, in addition to the SDs, means, sample size, and basic patient demographics. Results were categorized and tabulated by surgical technique to allow for ease of comparison.

Effect Size Calculation

Where both preoperative and postoperative scores were available, an effect size calculation was performed. This was done by assessing the standardized mean difference (Hedges d) when the SDs were available, or the raw mean difference when only raw means were available. For studies with multiple groups, the effect was combined by averaging the multiple group values. A positive effect size indicated an improvement in score, and a negative effect size indicated a decrease in the score. Explantation mastopexy cases were analyzed separately in instances of negative effect sizes to avoid skewing the combined scores, acknowledging the inherent differences in patient expectations and outcomes for explantation procedures.

The pooled SD was calculated as:

$${\displaystyle \begin{array}{l}{\displaystyle \mathrm{S}{\mathrm{D}}_{\mathrm{p}\mathrm{o}\mathrm{o}\mathrm{l}\mathrm{e}\mathrm{d}}=\surd ({\mathrm{S}\mathrm{D}}_{\mathrm{p}\mathrm{r}\mathrm{e}}^2+{\mathrm{S}\mathrm{D}}_{\mathrm{p}\mathrm{o}\mathrm{s}\mathrm{t}}^2)/2.}\end{array}}$$

Weight Determination

A weighted effect size for each PROM was calculated for individual studies using the formula for Hedges g. This adjusted for the contribution of each study according to its sample size to provide an unbiased comparison of effect sizes across studies.

Combining Effect Sizes

An overall weighted effect size was also calculated for each PROM. Studies with only postoperative or preoperative data were not used for effect size calculations. Only studies with pre- and postoperative data and SDs were included in each meta-analysis. For the physical well-being meta-analysis, where only 2 of these studies reported an SD, a decision was made to make an exception and include 2 studies without SDs, for which an estimate of SD had to be made. This was avoided for the subsequent PROM meta-analysis as it avoids assumptions and thus statistical inaccuracies. Explantation studies were excluded from the meta-analysis to avoid their negative skew on the combined effect calculation, with an isolated effect size provided instead.

The Overall Weighted Effect Size Value Explained

The overall effect size is displayed as a number (eg, 1.33 for physical well-being). This score is related to the SDs. It means that the average effect or difference between groups, when considering the quality and size of each study, is 1.33 times the SD of the data. This indicates a substantial effect, as it shows that the difference between groups is more than 1 SD, making it a significant and meaningful result. The stratification of effect sizes is explained by Cohen⁷ in his original textbook, whereby any score greater than 0.8 SDs between groups indicates a substantial improvement in test scores. A score of 0.5 indicates a medium effect, and 0.2 a small effect.

Visualization

For visualization of the meta-analysis results, tables are used to display the summary of effect sizes for each PROM assessed. A forest plot was then created using “R” to visualize the combined effect sizes.

RESULTS

Of 6377 articles identified, 6304 were excluded after title and abstract screening. A review of 73 full texts and their references yielded 22 abstracts—none of which met the inclusion criteria. Another 62 full texts were excluded for lacking validated PROM tools or for involving bariatric cohorts.⁸

Ten studies met the inclusion criteria and were analyzed qualitatively (Table 1). All used the BREAST-Q reduction/mastopexy module (Fig. 1).

Table 1.

Demographics of Included Studies

Source	Mean Age, y	Mean BMI, kg/m2	Mean Follow-up	No. Patients
Mastopexy with auto-augmentation
Zaussinger et al9	40	24.3	25	151 (102 respondents)
Megahed et al10	31	23.6	34.5	36
Augmentation mastopexy
Hubbard11	38	—	12.6	105 (36 respondents)
Hong et al12	34.9	—	38	53
Cogliandro et al13	54	27	9	55
Ma et al14	34	20	12	14
Explantation with mastopexy
Papadopoulos et al15	53.8	26.4	6	28
Mangialardi et al16	41.7	23.22	11.3	14
Gurunluoglu et al17	38–66 (no mean available)	—	13.5	20
Comparison of augmentation mastopexy with auto-augmentation mastopexy
Grünherz et al18	36	25	12	34

BMI, body mass index.

Fig. 1.

PRISMA flowchart of the review process. PRISMA, preferred reporting items for systematic reviews and meta-analyses.

Demographics and Patient Characteristics

Across 10 studies (510 patients; Table 1), the mean age ranged from 31 to 54 years, the mean body mass index was 20–27 kg/m², and follow-up ranged from 6 to 38 months.

Techniques

Four studies included augmentation mastopexy, 5 omitted implants, and 1 compared auto-augmentation with augmentation mastopexy (Table 2). Techniques included inferior dermoglandular and laterally based flaps, lipofilling, internal and crescent mastopexy, and refined periareolar approaches. Subanalyses by intervention type are detailed in Tables 3 and 4 and marked with asterisks.

Table 2.

Study Title, Mastopexy Technique Assessed, and Validated PROM Tool Used

Source	Article Title	Mastopexy Technique	PROM Tool
Mastopexy with auto-augmentation
Zaussinger et al9	Auto-augmentation mastopexy: inferiorly based parenchymal flap technique and evaluation of outcomes using BREAST-Q after 151 consecutive patients	Wise-pattern auto-augmentation using an inferiorly based parenchymal flap and a superior pedicle mastopexy	BREAST-Q
Megahed et al10	The versatility of the lateral-based mammary flap as an “auto-implant” for enhancing breast mound for patients undergoing primary mastopexy	Auto-augmentation using a laterally based mammary flap with a Wise-pattern incision	BREAST-Q
Augmentation mastopexy
Hubbard11	Vertical augmentation mastopexy with implant isolation and tension management	Vertical scar augmentation mastopexy and superomedial pedicle. Pectoralis split for implant placement to provide complete implant isolation from breast parenchyma	BREAST-Q and Spear survey
Hong et al12	Internal mastopexy: a novel method of filling the upper poles during dual-plane breast augmentation through periareolar incision	Dual-plane breast augmentation with internal suture mastopexy via an inferior areolar incision	BREAST-Q
Cogliandro et al13	Management of contralateral breast following mastectomy and breast reconstruction using a mirror adjustment with crescent mastopexy technique	Crescent mastopexy technique (n15) and implant in contralateral symmetrization for an immediate reconstruction. The crescent is compared with other augmentation mastopexy techniques (n40)	BREAST-Q
Ma et al14	Preoperative three-dimensional measurement based periareolar augmentation mastopexy: indication and breast crown approach	Periareolar augmentation mastopexy	BREAST-Q
Explantation with mastopexy
Papadopoulos et al15	Fat grafting and auto-augmentation mastopexy after breast implant removal: technique and evaluation of outcomes using BREAST-Q	Auto-augmentation using an inferior dermal or dermoglandular pedicle with or without lipofilling combined with superior or superomedial mastopexy	BREAST-Q
Mangialardi et al16	One-stage mastopexy-lipofilling after implant removal in cosmetic breast surgery	Combined superior pedicle-based mastopexy with a vertical (n5) and inverted-T (n9) approach combined with lipofilling after implant removal in a single stage	BREAST-Q
Gurunluoglu et al17	Outcomes analysis of patients undergoing autoaugmentation after breast implant removal	Auto-augmentation (inferior dermoglandular flap) after implant removal combined with a superior/superomedial pedicle mastopexy as a Wise or vertical pattern	BREAST-Q
Comparison of augmentation mastopexy with auto-augmentation mastopexy
Grünherz et al18	Long-term results measured by BREAST-Q reveal higher patient satisfaction after “autoimplant-mastopexy” than augmentation-mastopexy	Autoimplant with an inferiorly based dermoglandular flap with a Wise-pattern incision versus traditional implant-based augmentation mastopexy with a Wise-pattern incision. The inferiorly based dermoglandular flap is placed under the pectoralis muscle and fixed to the thoracic wall	BREAST-Q

Table 3.

QoL Domains: BREAST-Q PROM Outcomes for Each Study

Source	Physical Well-being (Preoperative)	Physical Well-being (Postoperative)	Psychosocial Well-being (Preoperative)	Psychosocial Well-being (Postoperative)	Sexual Well-being (Preoperative)	Sexual Well-being (Postoperative)
Mastopexy with auto-augmentation
Zaussinger et al9	—	—	43.5 (16.7)	80.3 (19.1)	48.2 (19.1)	83.9 (20.2)
Megahed et al10	—	—	—	—	—	—
Augmentation mastopexy
Hubbard11	—	—	—	—	—
Hong et al12	—	17.5 (3.8)	—	37.1 (5.8)	—	19.4 (2.9)
Cogliandro et al13*	—	73 versus 80	—	80 versus 82	—	53 versus 60
Ma et al14	90.6 (13.2)	96.5 (5.5)	38.6 (16.8)	63.8 (10.7)	28.7 (10.8)	48.9 (5.9)
Explantation with mastopexy
Papadopoulos et al15†	56/62/58	71.4/50.8/66.2	35/43/44	63.4/43.2/61.8	—	—
Mangialardi et al16	43.125	27.375	—	—	—	—
Gurunluoglu et al17	—	—	43 (17)	66.3 (10.2)	45.5 (16)	65.7 (16.3)
Comparison of augmentation mastopexy with auto-augmentation mastopexy
Grünherz et al18‡	—	81 (15) versus 90 (16)	—	55 (28) versus 64 [22)	—	56 (31) versus 58 (27)

^*This article had 2 groups. Data are presented as crescent mastopexy versus other mastopexy techniques.

^†This article had 3 groups. Data are presented as lipofilling combined with auto-augmentation, auto-augmentation with subsequent lipofilling, and auto-augmentation alone.

^‡This article had 2 groups. Data are presented as mastopexy with implant versus auto-augmentation mastopexy.

Table 4.

Satisfaction Domain: BREAST-Q PROM Outcomes for Each Article

Source	Satisfaction with Breasts (Preoperative)	Satisfaction with Breasts (Postoperative)	Outcome Satisfaction	Patient Satisfaction with Surgeon
Mastopexy with auto-augmentation
Zaussinger et al9	22.1 (16.3)	83.9 (15.5)	87.4 (20.1)	91.2 (22.2)
Megahed et al10	—	—	91.70	—
Augmentation mastopexy
Hubbard11		75.94 (16.52)	82.78 (19.29)
Hong et al12	—	58.9 (6.3)	21.2 (2.3)	—
Cogliandro et al13*	—	80 versus 77	—	—
Ma et al14	14.5 (12.5)	63.8 (9.5)	—	—
Explantation with mastopexy
Papadopoulos et al15†	38/42/38	65.5/41.8/57.4	—	—
Mangialardi et al16	39.857	61.267	72.357	—
Gurunluoglu et al17	50 (5.6)	75.2 (11.0)	—	—
Comparison of augmentation mastopexy with auto-augmentation mastopexy
Grünherz et al18‡	—	55 (16) versus 69 (18)	48 (26) versus 71 (18)	70 (18) versus 88 (18)

^*This article had 2 groups. Data are presented as crescent mastopexy versus other mastopexy techniques.

^†This article had 3 groups. Data are presented as lipofilling combined with auto-augmentation, auto-augmentation with subsequent lipofilling, and auto-augmentation alone.

^‡This article had 2 groups. Data are presented as mastopexy with implant versus auto-augmentation mastopexy.

Risk of Bias

The Critical Appraisal Skills Programme checklist indicated that most studies demonstrated clear research aims, used appropriate methodologies, and used robust recruitment strategies. All studies addressed the data collection requirements for their research issues and provided clear statements of findings. However, 1 area of potential concern is the consideration of the researcher–participant relationship, which was only explicitly addressed in 3 studies.

QoL Domains

The QoL domain includes physical, psychosocial, and sexual well-being and are displayed in Table 3. The pre- and postoperative reporting was variable, with a minority performing preoperative surveys.

Physical Well-being

The studies in Table 5 had recorded pre- and postoperative scores for physical well-being. There were 3 studies with both pre- and postoperative surveys for physical well-being, totaling 56 participants. Of these, 1 had SDs.¹⁴ Fat grafting and auto-augmentation mastopexy after breast implant removal was used by Papadopoulos et al¹⁵ in their patients (n = 28) and showed a mild improvement from preoperative (56/62/58) to postoperative scores (71.4/50.8/66.2) with a weighted effect size of 0.53. To control for the negative Hedges g of the study by Mangialardi et al,¹⁶ and to avoid combining an effect score of explantation mastopexy with augmentation mastopexy, both explantation mastopexy studies were combined to generate a combined effect score. The combined effect size of −0.54 (−0.86 to −0.22) demonstrates a decrease in physical well-being. Contrastingly, augmentation mastopexy had a positive effect size of 0.55, indicating an improvement, although this was not statistically significant as the confidence interval spanned 0 (−0.01 to 1.11). In another study, Mangialardi et al¹⁶ combined superior pedicle mastopexy with a vertical and inverted-T approach combined with lipofilling after implant removal and reported a drop in the physical well-being score (43.125 versus 27.375), and a drop in effect size of −2.68. A forest plot was not created for this PROM, as only 1 study had pre- and postoperative SDs.

Table 5.

The Effect Sizes and Subsequent Weighted Average Value of the Physical Well-being Scores

Source	Technique	Physical Well-being (Preoperative)	Physical Well-being (Postoperative)	Standardized Mean Difference (Hedges g)	No. Patients Who Responded to Survey
Explantation with mastopexy
Papadopoulos et al15	Auto-augmentation with inferior flap ± lipofilling after implant removal	56/62/58	71.4/50.8/66.2	0.53	28
Mangialardi et al16	Mastopexy lipofilling after implant removal	43.125	27.375	−2.68	14
Combined effect size: −0.54 (−0.86 to −0.22)
Augmentation mastopexy
Ma et al14	Periareolar mastopexy and implant	90.6 ± 13.2	96.5 ± 5.5	0.55	14
Effect size: 0.55 (−0.01 to 1.11)

Psychosocial Well-being

The combined weighted effect size is 1.98 (1.67–2.30). There were 2 studies that described pre- and postoperative scores with SDs and were included in the meta-analysis, totaling 116 participants (Table 6). The combined effect score of 1.98 indicates a significant improvement in psychosocial well-being. The forest plot is displayed in Figure 2.

Table 6.

The Effect Sizes and Subsequent Weighted Average Value of the Psychosocial Well-being Scores

Source	Technique	Psychosocial Well-being (Preoperative)	Psychosocial Well-being (Postoperative)	Standardized Mean Difference (Hedges g)	No. Patients Who Responded to Survey
Mastopexy with auto-augmentation
Zaussinger et al9	Auto-augmentation using inferior flap	43.5 ± 16.7	80.3 ± 19.1	2.04	102
Augmentation mastopexy
Ma et al14	Periareolar mastopexy and implant	38.6 ± 16.8	63.8 ± 10.7	1.68	14
Overall weighted average result: 1.98 (1.67–2.30)
Explantation with mastopexy*
Gurunluoglu et al17	Auto-augmentation with inferior flap after implant removal	43 ± 17	66.3 ± 10.2	1.59	20

^*Excluded from meta-analysis due to differing cohort (explantation), analyzed separately.

Fig. 2.

Forest plot of the meta-analysis for psychosocial well-being. CI, confidence interval; HK, Hoffman and Kringle; SE, standard error.

Auto-augmentation mastopexy using an inferiorly based parenchymal flap was performed by Zaussinger et al⁹ in 151 patients, of which 102 completed the survey. The psychosocial well-being score rose postoperatively from 43.5 to 80.3. This study had the greatest effect size of 2.04. A fair increase in scores was also reported by Ma et al¹⁴ (38.6 versus 63.8) with an effect size of 1.68.

Conversely, although separate from the meta-analysis, the poorest outcome in isolation was found by Hong et al¹² of 37.1 using their internal suture mastopexy combined with implant technique. This technique was for mild ptosis only, and the authors attributed this to poor tolerance of an infra-areolar scar in Asian women. A total of 3 studies had only postoperative scores (Table 3).

Sexual Well-being

The combined weighted effect size is 2.01 (1.53–2.49). The 2 studies that reported sexual well-being were included in the meta-analysis, totaling 136 participants (Table 7). The score of 2.01 indicates a significant improvement in sexual well-being. The forest plot is displayed in Figure 3. A big improvement was found in studies by Zaussinger et al⁹ with an effect size of 1.80, although the largest effect size was found by Ma et al¹⁴ with 2.17.

Table 7.

The Effect Sizes and Subsequent Weighted Average Value of the Sexual Well-being Scores

Source	Technique	Sexual Well-being (Preoperative)	Sexual Well-being (Postoperative)	Standardized Mean Difference (Hedges g)	No. Patients Who Responded to Survey
Mastopexy with auto-augmentation
Zaussinger et al9	Auto-augmentation using inferior flap	48.2 ± 19.1	83.9 ± 20.2	1.80	102
Augmentation mastopexy
Ma et al14	Periareolar mastopexy and implant	28.7 ± 10.8	48.9 ± 5.9	2.17	14
Overall weighted average result: 2.01 (1.53–2.49)
Explantation with mastopexy*
Gurunluoglu et al17	Auto-augmentation with inferior flap after implant removal	45.5 ± 16	65.7 ± 16.3	1.20	20

^*Excluded from meta-analysis due to differing cohort (explantation), analyzed separately.

Fig. 3.

Forest plot of the meta-analysis for sexual well-being. CI, confidence interval; HK, Hoffman and Kringle; SE, standard error

Patient Satisfaction Domain

The satisfaction domain results are displayed in Table 4. The parameters assessed here include satisfaction with the breast, outcome satisfaction, and patient satisfaction with the surgeon.

Breast Satisfaction

The combined weighted effect size is 3.89 (3.35–4.42). Of the 10 studies, 2 were included in the meta-analysis totaling 116 participants. A weighted effect size of 3.89 reflects the highest and most substantial improvement in satisfaction with breasts across the included PROMs (Table 8).

Table 8.

The Effect Sizes and Subsequent Weighted Average Value of the Breast Satisfaction Scores

Source	Technique	Breast Satisfaction (Preoperative)	Breast Satisfaction (Postoperative)	Standardized Mean Difference (Hedges g)	No. Patients Who Responded to Survey
Mastopexy with auto-augmentation
Zaussinger et al9	Auto-augmentation using inferior flap	22.1 ± 16.3	83.9 ± 15.5	3.85	102
Augmentation mastopexy
Ma et al14	Periareolar mastopexy and implant	14.5 ± 12.5	63.8 ± 9.5	4.18	14
Overall weighted average result: 3.89 (3.35–4.42)
Explantation with mastopexy*
Gurunluoglu et al17	Auto-augmentation with inferior flap after implant removal	50 ± 5.6	75.2 ± 11.0	2.77	20

^*Excluded from meta-analysis due to differing cohort (explantation), analyzed separately.

The biggest proportional improvement was found by Ma et al¹⁴ with their periareolar mastopexy planning (14.5–63.8) with an effect size of 4.18. Overall, both techniques demonstrated a positive effect size. Zaussinger et al⁹ used a Wise-pattern mastopexy using an inferiorly based parenchymal flap and a superior pedicle, achieving a strong effect size of 3.85. The forest plot is displayed in Figure 4.

Fig. 4.

Forest plot of the meta-analysis for breast satisfaction. CI, confidence interval; HK, Hoffman and Kringle; SE, standard error

Outcome Satisfaction

The study with the highest outcome satisfaction score (91.7) in isolation was Megahed et al,¹⁰ who used a laterally based auto-augmentation flap without an implant and a Wise-pattern incision (Table 4). The percentage scores ranged from 21.2 to 91.7.

Patient Satisfaction With Surgeon

Satisfaction with the surgeon was reported by 2 studies and was high for both Zaussinger et al,⁹ using their inferiorly based parenchymal flap (91.2) and Grünherz et al,¹⁸ using an inferiorly based dermoglandular flap and implant.

DISCUSSION

The number of patients seeking mastopexy has increased by 70% since 2000.¹⁹ As a complex procedure, mastopexy has evolved through multiple techniques addressing breast shape and volume, often combined with implant placement, auto-augmentation, or lipofilling. Technique selection depends on factors such as degree of ptosis, preexisting scars, asymmetry, skin and parenchymal quality, and the skin–parenchyma envelope mismatch.²⁰ Among studies in this review, data on preoperative breast characteristics were limited, and most procedures used parenchymal manipulation with varying pedicle designs and incisions (Table 2).

The development of BREAST-Q has provided a useful framework for assessing patient outcomes consistently and for developing an evidence-based approach to aesthetic surgery.⁶ The results in Table 8 highlight that the highest effect size in breast satisfaction is found with periareolar augmentation mastopexy.¹⁴ It is pertinent to note that although this study had a strong effect size in terms of its improvement, the postoperative score was by far not the highest. The technique of using breast tissue auto-augmentation with an inferiorly based parenchymal flap by Zaussinger et al⁹ scored more highly.

Across Tables 5–8, the lowest effect sizes were consistently found with implant removal procedures. It is pertinent to note that explantation studies were excluded from the meta-analysis in Tables 6–8, to avoid their negative effect on the weighted average. Instead, only a Hedges g score was calculated. The decision to exclude these patients from the main meta-analysis was made because they represent a very different subset of patients, with a significant loss in volume. The sudden decrease in breast volume and projection after explantation, and the inability of auto-augmentation techniques to compensate for this, means that their lower standalone effect scores are unsurprising. This clearly contrasts with the overall consistently strong effect sizes of augmentation mastopexy and mastopexy combined with auto-augmentation techniques without implants, including lipofilling²¹ and dermoglandular flaps.

The meta-analysis shown in Figures 2–4 evaluates effect sizes for auto-augmentation versus traditional augmentation mastopexy. Both approaches yield substantial improvements in PROMs, with neither technique demonstrating clear superiority. The studies where traditional implant augmentation was used are listed in Table 1 and include Hubbard,¹¹ Hong et al,¹² Cogliandro et al,¹³ and Ma et al.¹⁴ Unfortunately, only Ma et al¹⁴ included SDs and was included in the meta-analysis, so comparison with auto-augmentation mastopexy techniques was not comprehensive. The favorable PROMs of traditional augmentation compared with mastopexy or augmentation mastopexy are highlighted by Barone et al,²² Razdan et al²³ and Danilla et al.²⁴

The highest combined weighted effect size across all PROMs was for breast satisfaction. As per the ranking of effect sizes by Cohen,⁷ any score more than 1.20 is deemed a “very large” effect. The lowest effect size was 1.33. Thus, a general trend of a very large effect for improved patient satisfaction was observed across the studies for all PROMs.

An important and often overlooked consideration with mastopexy surgery is the need for standardization of the duration of follow-up when assessing outcomes. This is due to the well-known recurrence of ptosis that occurs after mastopexy surgery and the risk of implants bottoming out.¹ The patient-reported satisfaction, including physical and psychological well-being, has been reported to recover with time.²⁵ The mean duration of follow-up in months for the studies in this review ranged from 6 to 38 months. Without a consistent and lengthier follow-up comparison, the longevity of different techniques over time cannot be compared.

Mastopexy procedures can require revision surgery²⁶ and were reported in 3 studies only. Zaussinger et al⁹ performed 2 revisions in 151 cases. Indications for revision surgery were hypertrophic scarring and asymmetrical nipple position. Both were performed under local anesthesia. Hubbard¹¹ used vertical scar augmentation mastopexy with a muscle-splitting technique in 105 patients. In this study, 10% required a revisional periareolar lift, 9% required revisions for areolar shape, 3% required a scar revision of the vertical component, 3% required a revision for capsular contracture, 2% required a revision for implant displacement, and 1% required a revision for infection. No patients required revisions for pseudoptosis. Ma et al¹⁴ reported no revisions in their series of 14 patients. There was no comment specifically on the satisfaction rate despite the need for any revision surgery. There was no scoring after the need for revision surgery either. For dissatisfaction specifically, Hubbard¹¹ mentions a dissatisfaction with scars of 8.6%. No other article specifically comments on areas of patient dissatisfaction.

LIMITATIONS

Limitations of this review include a lack of any randomized controlled trials in the analyzed dataset. In addition, the studies included were retrospective in their methodology, and the data were heterogeneous due to a significant lack of preoperative scores and variable durations of follow-up. Some studies were also of a small sample size.

Despite these limitations, this review has provided a useful comparison of mastopexy techniques and a summary of the published PROM literature for mastopexy surgery during the past 5 decades. Furthermore, despite the variability in techniques and patient characteristics, PROMs offer an invaluable insight into the success and limitations of different techniques. Therefore, the data generated in this review can prove useful for surgeons to assess outcomes of different techniques. Prospective research would also require more robust study designs and consistent pre- and postoperative PROM reporting with a longer duration of follow-up.

CONCLUSIONS

Mastopexy patients demonstrate satisfaction with results and improved QoL. This analysis highlights the need for more consistent PROM reporting in mastopexy surgery. Unsurprisingly, due to sudden volume loss, explantation mastopexy shows less PROM improvement than traditional augmentation mastopexy and mastopexy procedures.^15–17 Ideally, future studies could maintain a prospective international database. PROMs should be recorded at consistent pre- and postoperative time points, with follow-up duration standardized. Techniques should also be clearly categorized for ease of comparison.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. The open access fee for this publication was funded by GC Aesthetics. GCA runs GCA Academy, a progressive learning forum for plastic surgeons (https://gcaacademy.com).