I recently evaluated a woman who came to the office seeking breast augmentation because she was unhappy with her lack of breast fullness and projection. She had moderate drooping of her breasts, so what she really needed was an augmentation and a lift. I discussed this with her in detail. After several days, she contacted me again after she had spent some time looking at pictures online of patients who had undergone breast augmentation with a lift. She expressed concerns about having scars on her breasts, and was worried about the post-operative position and symmetry of the nipple-areolar complex. Her primary questions were, “Do I really need a lift?” and “Is there any type of implant that I could receive that would eliminate the need for a breast lift?”

Breast augmentation is performed only to increase the volume and fullness of a breast. Breast lift can be performed to reshape the breast, to tighten the skin envelope, to reposition (elevate) the breast tissue, to reposition (elevate) the nipple-areolar complex, and to re-shape or re-size the nipple-areolar complex. The picture above shows examples of women that require breast lifts along with their breast augmentation.

Many women understandably want to avoid the scars resulting from a breast lift. But it is important to understand that there is no type or style of breast implant that will lift a droopy breast or nipple-areolar complex up to an attractive youthful position and shape.

Each surgeon may approach breast ptosis in a slightly different manner. And after evaluating many patients over the years I have observed that there are times when some surgeons choose to avoid performing a breast lift as well. In my opinion, this decision is probably based on one or more of the following reasons. Recommending a lift requires placing scars on the anterior surface of the breast, and this may turn patients off. Breast augmentation procedures that are combined with a breast lift are technically difficult operations because they require planning for two operations (at the same time) that do completely opposite things to the breast; so the procedure is more complicated and revision rates can be higher than with augmentation surgery alone. Combined breast augmentation and lift procedures require additional operative time, so this also means additional expense. For the above reasons, surgeons and/or their patients may choose to avoid a combined breast augmentation and lift.

To avoid the need for a breast lift, when performing augmentation in a woman with deflated and drooping breasts, some surgeons may recommend placing the implant in a subglandular position and/or increasing implant size. Placing the implant directly behind the breast gland (above the muscle) allows the implant to more directly fill the skin envelope of the breast. In many situations this results in nothing more then an enlarged, and now heavier, breast that’s still droops. And this inevitably leads to skin stretching and thinning, additional drooping, possible rippling, and patient dissatisfaction. In addition, a subglandular position has a higher risk for capsular contracture.

If a surgeon chooses a subpectoral implant location, and wants to try to avoid the need for a breast lift, a more advanced dual-plane technique can sometimes be used to increase the interaction between the breast implant and the breast tissue. Since implants placed under the muscle do not act as directly with the overlying breast tissue, a dual-plane technique allows the implants more direct contact with the posterior surface of the breast tissue, and this helps to fill out the deflated skin envelope. This technique is really better for women who have only a small amount of drooping and do not need a full breast lift.

In women with ptosis, a breast implant can be placed to increase upper pole fullness and/or breast projection. But the implant itself does not lift the breast tissue or the nipple-areolar complex. So if a breast lift is avoided in a woman who really needs one, and only an augmentation is performed, the post-operative result may look even worse than the pre-operative appearance. The implant will give upper pole fullness and projection, but the breast tissue will fall and hang of the anterior surface of the implant. This result can have a very unnatural and unsatisfactory shape if the breast drooping is significant.

For women who have a small amount of breast drooping, and may be on the borderline for needing a breast lift, a staged procedure can be offered. The breast augmentation can be performed first. The implant can be allowed to settle, and then the result re-evaluated for the necessity of a breast lift. Persistent breast tissue hanging off the anterior surface the implant, and/or an inappropriately low nipple position are signs that the lift is necessary.

So for women that have moderate ptosis, although there are two options, there is really only one good option. Having a breast implant alone means that the woman will have to accept that her breast shape will be different, the nipple areola complex will not be properly positioned over the breast mound, and the breast will have an unnatural shape. Choosing to perform a breast lift and augmentation (augmentation mastopexy) at the same time will produce a nicely shaped breast with improved fullness and projection, and a correctly sized and placed nipple-areolar complex. There are no shortcuts to a good surgical result in this situation. The ultimate determination depends upon a thorough consultation and exam that evaluates goal size, implant style, tissue elasticity and redundancy, inframammary fold (IMF) position and symmetry, the relationship of the nipple to the IMF, the relationship of the breast tissue to the IMF, breast base width, a patient’s willingness to accept scarring, and a discussion of the anticipated outcome and the risks and benefits.