Different surgeons have different approaches, as your story illustrates. This may be confusing at times, but can also be helpful in that it will make you think more critically about your goals and what you want to achieve. Ultimately, you should be better informed and able to make the decision that best fits your needs. Different recommendations are related to varying experience and preferences among physicians. With respect to breast lift, I believe there are a number of surgeons who try to avoid doing a lift in combination with an augmentation for two reasons -- because they think the woman won’t accept additional scarring, or because it’s a more technically difficult operation and therefore requires more time / effort and expense.
The major focus of a breast lift is to raise the nipple-areolar complex (NAC) and centralize it over the breast mound, reduce the size of the areola if necessary, and shape the breast by reducing / tightening the breast skin envelope. A breast lift may be performed in conjunction with breast augmentation if the breasts are small or have lost volume and the NAC will be positioned too low following augmentation alone.
"Ptosis" defines the amount of sagging a breast demonstrates, and it is usually graded based upon the position of the nipple in relation to the inframammary fold (IMF). As ptosis develops, the nipple moves inferiorly and the breast tissue overhangs the inframammary fold. The amount of ptosis will determine if a woman should consider a breast lift and this will directly affect the type of lift performed. To get a better idea of the position of the IMF, and whether any ptosis is present, tuck a pencil horizontally under the fold of each breast. A horizontal line through each pencil marks the position of each IMF; it is not uncommon for there to be some small discrepancies in position when comparing the right and left sides. If one or both nipples sag below the line of the inframammary fold you are a candidate for a breast lift.
For patients with only a small amount of volume loss and droop, augmentation alone may be sufficient for increasing breast size and re-establishing a more centralized NAC position. In a mildly deflated breast, the breast implant increases breast volume, and by doing so, raises the relative position of the NAC with respect to the inframammary fold (IMF).
There are some patients who may be considered "borderline” for a breast lift. To avoid the extra scarring associated with the lift, the surgeon can use a larger implant placed in a lower subpectoral or subglandular position; in essence, the implant is allowed to fall down into the breast. The result provides appropriate NAC positioning, but at the cost of a lower hanging breast mound with a moderate amount of the breast (and implant) hanging below the level of the IMF. Over time, many of these women often experience additional skin stretching and thinning, and become unhappy with their result. They ultimately require a breast lift and perhaps a site change to a subpectoral position. The alternative is to perform an augmentation with a lift, positioning the implant above the inframammary fold.
During your consultation it is important to discuss your goals and expectations of breast enhancement. The size and shape of your breasts, the quality of your skin, the amount of breast tissue present, the location of your breast tissue in relation to the IMF, the location of your NAC in relation to the IMF, and the implant volume chosen are all important in determining whether a breast lift is necessary and what type of breast lift technique will be used.
Breast lift techniques are numerous but change and progress as the amount of ptosis increases. Minimal lifting techniques may involve a partial or full circumareolar scar. If additional shaping and transverse tightening of the breast is required a vertical scar is added from the inferior border of the NAC down to the IMF. And, if vertical breast laxity still remains then a transverse scar placed in the IMF is added to finalize the lift.
My goal is to produce the best breast shape possible, and so I don’t hesitate to recommend a lift if I feel it is necessary. It is then up to the patient to decide if she wants to accept my recommendation. A thoughtful and caring surgeon should be able to help you understand the differences in breast shape and NAC position with or without a breast lift, and should be able to guide you during your decision making.
I hope this is helpful. Best wishes. Ken Dembny