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Page 2 of 9 Kotti. Plast Aesthet Res 2018;5:16 I http://dx.doi.org/10.20517/2347-9264.2018.11

INTRODUCTION
The female breast is one of the rare anatomical organs that has no bony or cartilaginous supports. Suspended
to the trunk by its soft structures, the final shape is substantially influenced during growth by the bone,
cartilage and muscle elements that surround the breast’s bases. For an adult woman, the “perfect” match of
a glandular tissue, fat, skin and connective tissue that hold everything in place may theoretically give rise
to a “perfect breast”. The natural or pathologic excess of one of these anatomical tissues may lead to breast
sagging, or what we call breast ptosis.

Time and gravity also affect the breast and induce glandular and skin stretching, especially in the peri-
areolar area and in the lower pole where weight is maximal. In addition to the anatomical comprehension of
this auto-suspended organ, the aesthetic and social representation of the sexual organ defined over centuries,
including through artwork, provided guidelines for ideal measurements of the “perfect breast”, as well as
various classifications for ptotic breasts.

In this paper we will revisit the primary classifications we were taught during training, to ascertain their
inadequacies and to propose a new simple classification with a treatment algorithm that also takes the
patient’s wishes into account.

METHODS
We consider two important landmarks:

1. The sternal landmark is a single point on the sternum where the inframammary folds, or their extensions,
cross the midline. We call it the Breast Key point or “BK-Point” [Video 1].
2. The inter-nipple line or Breast Key line: “BK-line” is a virtual line joining the nipples for which we have
to restore the horizontality in case of an asymmetry, and make it cross the BK-point after treating the
ptosis [Video 2].

We examine the patient in a standing position hands down along the body in frontal, oblique and lateral
views and take photos for preoperative analysis and as a reference for the post-operative check.

We ask the patient to put her hands up and note the BK-line ascent and its eventual crossing of the BK-point.

Photos are also taken as a reference and are saved in the patient’s file.

The second examination was completed on the screen with an oblique view photo. We appreciated the angle
between the ipsilateral nipple to body rotation (right nipple to right oblique view and vice-versa), and the
BK-point and body meridian usually parallels the dorsal spine. We call this angle the Breast Key (BK) angle,
and we roughly appreciate its value compared to a right angle.

Our approach is simple:

With a patient’s hands down, there is no ptosis if the BK-line crosses the BK-point.

A “natural ptosis” exists when this match occurs after asking a patient to put her hands up. We call this
maneuver a “hands up test” positive.

A “confirmed ptosis” is defined when the BK-line remains under the BK-point with a hands-up maneuver.
We call this a negative “hands-up test” [Figure 1] [Videos 3 and 4].