Breast lift and augmentation in 2 stages or one procedure? (photo)

A lift with an implant is controversial for two reasons.  First, when you perform a lift you are making everything tight and closing the wounds under tension.  It you add the expansive forces of the implant at the same time, you are fighting against yourself.  There are forces on the wound which try to make them separate, which results in wider, thicker, more irregular scars.  In the worst case, the wounds will open.  So compromises are usually made in the operating room by the surgeon because they cannot close the lift wounds over the appropriate sized implant.  Either less of a lift is performed so that the skin is not as tight and therefore there is less tension on the closure.  Or a smaller implant than would be appropriate is used so as to decrease the expansive forces.  Either way, you are compromising the aesthetic outcome.  Often the outcome is so compromised that a second revision surgery is required.  If however, you plan to have the lift first and then the augmentation after everything has healed, then you have two operation that are planned, both with much lower risk than the combined mastopexy/augmenation.  The outcomes of the two meticulously planned operations are much better and a more aesthetically pleasing, and a safer outcome is achieved.

The second reason the combination of mastopexy and augmentation is controversial is because of the risk of nipple necrosis (death of the nipple).  By making the skin tight for the lift, you are putting external pressure on the veins that supply the nipple.  By putting an expansive force on the undersurface of the breast with an implant, you are putting pressure on the thin walled veins that supply the nipple.  If the pressure by squeezing the veins between the implant and the skin is greater than the venous pressure in the veins, the flow will stop.  If the venous outflow stops, the arterial inflow is stopped.  If the arterial inflow is stopped, there is no oxygen for the healing wounds and the tissue dies.

Placing the implant on top of the muscle in combination with a lift puts the blood supply to the nipple at a much higher risk because in addition to the issue of pressure on the veins, you have to divide the blood vessels that are traveling from the pectoralis muscle directly into the breast (and to the nipple) in order to place the implant between the breast tissue and the muscle. This adds a third element of risk to an already risky operation.  Mastopexy/augmenation with sub glandular implant placement is by far the riskiest way to address your anatomic question.

Both are reasonable options, although with your very loose tissue, I would side with the surgeon who recommends 2 stages. I would lift and reshape the breast removing some tissue. Your breasts will be smaller but in better position and with a better shape. Often patients find they are happy with just the lift and can avoid having implants with the potential issues of having the weight of the implant in a breast with poor quality tissues with the possibility of stretch with time. 

Thank you for your question.  Looking at your pictures I would recommend doing your breast lift first and then your implant at a later date.  Reason being is you are significantly droopy and if you place the implant first you may not get as good of a lift as if you waited to place the implant.  Each surgeon would have their own recommendation on how to move forward on a case like this.  I would suggest going with the surgeon you feel most comfortable with.  Best of luck to you. 

Your breasts are too low on the chest wall and pointing downward.  I never recommend the anchor lift because of the ugly vertical scars, loss of nipple sensation and the inability to breast feed.  600 cc implants weigh over 1 lb each and will make your situation worse.  The technique I recommend is The Bellesoma Method.  This will reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage.  Vertical scars are avoided, nipple sensation and the ability to breast feed are maintained.  At the same time or later, fat transfers can be performed if additional volume is desired.  Implants are not lifetime devices.  Fat transfers are permanent and incorporated into the body.  Best Wishes,Gary Horndeski, M.D.

Based upon your photos I believe that either a one or two stage approach is acceptable.  Doing lifting and augmentation at the same time is one of the more complex  breast surgeries that we perform as plastic surgeons.  It sounds like you are doing your research.  I would recommend you choose the surgeon that you are most comfortable with.  Best of luck to you!

Thanks for your inquiry and pictures,  if you were my patient I would recommend a staged procedure to get the best result.  I believe your mound and nipple areolar complex need to be re-centered on the chest prior to augmentation. A three month delay for the augmentation makes sense, good luck. 

An excellent question and thank you for sharing your photos. Also congrats on your weight loss, a wonderful achievement! I would recommend a two stage plan. First performing a breast lift to not only lift the nipple but the entire breast support structure. 3-6 months later I'd perform the augmentation. 
There are several advantages to this approach and one negative. The negative is that it takes two operations. The advantages including, better preservation of nipple sensation, less risk of implant related complications, much more accurate selection in choosing the exact implant youd like because your breasts will be in the optimal position when you look at sizing.
Id recommend this two stage approach in you specifically because of the length of the breasts and nipple position. Otherwise its very appropriate and reasonable to do a lift and augmentation at the same time. 
Best wishes,
Dr. Jan

Based on your photos, the fact that you have heavy breasts and history of weight loss, you may expect, regardless of one or two stage procedure, to have breast tissue ptosis starting several months after breast lift with or without implants. Gravity works against patients with large breasts and although they show significant improvement several months after surgery, this result changes due to descend of breast tissue and stretching of skin. Implants stay in the same position but breast tissue slides down. We found that reducing volume and amount of breast tissue (doing reduction instead of lift) gives better long term result in patients like you. In other words, breast reduction (most of that is done with liposuction to diminish blood loss and preserve circulation and nerve supply) should be the first step and breast augmentation with larger implant (to compensate for volume loss after reduction) is to follow. Liposuction to shape lateral breast tail and chest wall should be performed as a part of breast reduction surgery. This can be done in a single surgery by an experienced surgeon or in two stages having reduction as a first stage. Good luck.

I agree with Dr Rand.  You are in danger of high complication rate with a one stage procedure and most experienced surgeons will tell you this.  Sometimes it doesn't make a difference which is done first and the surgeon can give you their reasons.  Great question!!

I recommend one procedure. The implant selection should be based on a combination of your desired size, soft tissue dynamics, breast base diameter and skin elasticity. I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable with. Finally, make sure your surgeon is a Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery (ABPS).
Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach TrainedDouble Board-Certified, Double Fellowship-Trained Beverly Hills Plastic Surgeon