Alexander Slocum, MD, PhD, FACS

Before discussing a procedure we should really focus first your anatomy, and then consider your goals. In short, no your breast is not "saggy", it just looks that way because of the position of the fold.

You have breast asymmetry, which is normal. The "sagging" breast appears to have an elevated inframammary fold (IMF). The two photos you posted are mirror images, so I cannot tell if it is the left or the right breast. In my practice I check for this by asking patients to raise their arms straight up above their head, which lifts the breasts and helps to visualize the position of the fold (IMF). My guess is that the breast with the larger NAC (the "saggy" breast as you call it) has the elevated IMF, so the shape of the breast is overall different and would be unlikely to be corrected with a mastopexy only as it doesn't change the position of the fold. Also, the level of your nipples is not that far off.

I would also want to measure the distance from the nipple to the IMF and assess the compliance of the skin and breast tissue (how much this distance increases under gentle tension). More compliant tissue means that If your goal is improved breast symmetry only, then a small periareolar lift (what you refer to as a "donut", most likely) should suffice. Remember, though, it won't change the position of the fold so your "saggy" breast will still appear to be "saggy".

If you were also considering increasing the size (with an implant), then I would recommend you consider bilateral breast augmentation with adjustment of the fold on the "saggy" side, as well as a peri-areolar mastopexy to correct the assymetrical size of the nipples and also ensure they end up even. I would reposition the fold through a peri-areolar incision and reinforce this with permanent sutures.

Remember, it is totally normal to have asymmetrical breasts, and you should consider a consultation with a board certified plastic surgeon to discuss your anatomy and your goals (sometimes finding photos from other plastic surgeons websites is very helpful!). Try to avoid going into the consult with a procedure already in mind, and good luck!

Harvesting a rib cartilage graft is not always necessary, and it is not without significant risk (pneumothorax, or dropped lung). Your surgeon is absolutely correct that in some patients with a history of previous nasal surgery where the septum (our favorite graft donor site) was involved, a different donor site is needed and Rib cartilage is a very nice option.

It does not have to be YOUR rib cartilage (which is an autograft) however, and I sometimes will use cadaver cartilage in revision rhinoplasty patients who don't want me to use their own rib cartilage. Cadaver cartilage (called an allograft) is a safe alternative (there are still risks) that does not require you to have a second surgery site, and at the end of the day your body will end up incorporating it almost as if it is your own. There are a few suppliers of this type of material, however it is not cheap and can be around $1000 or more per piece. It also requires planning because the graft is usually delivered with dry ice and must be used within a few days, unless your surgeon has access to an OR with a super-cold freezer where they can store it until your procedure.

Best of Luck!

Dr. Slocum
Portsmouth, NH

In short, most likely no, not by itself. There are a lot of options for improving the areas around the eyes, and your surgeon needs to be thinking about how each part of your anatomy (hairline, forehead, brow [shape and position], eyelids, cheeks, and temporal region) can be involved in a plan to properly address your concerns.

Based on this limited photo, the "furrows" (they are often called "11s") could be treated with botox or a corrugator resection. You also have some temporal hollowing, and I would encourage you to consider fat grafting in addition to any blepharoplasty and/or browlift procedure. Fat grafting is simple in principle, and more of an art than a science when it comes to achieving excellent results. It is performed using small amounts of fat removed from your tummy (or another area) using a syringe, and it can be combined with other procedures to augment their effects. Because the fat that "takes" is essentially permanent, for patients who are unsure I sometimes perform trial injections using an HA filler (hyaluronic acid, such as Juvederm) which can be dissolved if they do not like the result.

You should see a Board-Certified Surgeon (trained in Plastic Surgery OR Facial Plastics) and ask to see photos of previous patients, as not everyone is OK with being on a website or social media. Best of luck!

- Dr. Slocum (Portsmouth, NH)