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Breast augmentation is a very popular operation in aesthetic surgery, in spite of the ban on silicone gel implants by the FDA; in the USA, the number of patients looking for larger breasts has increased in last decade [1, 3]. The ultimate objective in this procedure is to obtain an aesthetic result and fulfill patients’ desires [8]. The ideal breast shape and volume vary considerably in different countries and are influenced by culture and fashion, an important factor being the surgeon’s criteria. It is my strong belief that we, as plastic surgeons, should follow universal patterns of beauty. A beautiful breast must look natural and in proportion with the rest of the body; unfortunately a number of patients have erroneous ideas about this and are sometimes fixed with the impression that the bigger the breasts the more attractive they are. Hammond [6, 10] and others agree with the opinion that larger implants will give more complications and less natural results especially in thin patients; therefore, it is very important that the surgeon orients the patient before the procedure.

Background In our experience, most women seeking correction of the “small” ptotic breast have a history of previous pregnancies and breastfeeding. Objective We propose a classification of postpartum ptosis into 4 groups and describe the appropriate surgical treatment for each category of ptosis. Methods We defined categories of ptosis on the basis of the remnant mammary gland, skin condition, position of the nipple-areolar complex (NAC), and distance from the NAC to the inframammary fold (IMF). Patients in group 1 (n = 15), with the NAC in good position, were treated with the use of simple subglandular augmentation mammaplasty. Patients in group 2 (n = 8), with grade I ptosis in which the nipple required elevation of no more than 3 cm and the distance from the inferior border of the areola to the IMF was less than 4 cm, were treated with the use of crescent-moon mastopexy. Patients in group 3 (n = 20), who demonstrated a higher degree of skin flaccidity and grade I or II ptosis and in whom the distance from the NAC inferior border to the IMF was between 4 and 6 cm, were treated with the use of circumareolar mastopexy. Patients in group 4 (n = 24), with moderate to severe skin flaccidity and ptosis in whom the distance from the NAC to the IMF was more than 4 cm, were treated with the use of modified vertical mastopexy. Results Eight-five percent of patients were satisfied with their results. Unfavorable results were related to dissatisfaction with breast shape and postoperative scarring; such results occurred most often in group 4 patients. Complications were within reasonable limits, including 2 cases of hematoma and 3 cases of decreased NAC sensibility in group 3 patients and minor dehiscence in 3 patients in group 4. Conclusions Careful patient evaluation and choice of technique, as determined by the classification proposed in this paper, enabled us to achieve high rates of patient satisfaction with low rates of complications and revision.