Does current breast size make a difference in how big an implant will look? Also, how much tissue is removed during lift?

Question

Hi doctors, I hope all is well. I know I should ask my PS about this, but it’s the weekend so I can’t and my surgery is in 8 days. I’m getting an anchor lift with Mentor HP Xtra implants in 535cc (12.7 cm diameter). I’m 28, 5’5, 132 lbs with 32DD saggy/deflated boobs thanks to nursing 2 kids. My BWD is 14 cm. Will the 535ccs be too narrow? The nurse said they won’t since I have 1-2 cm of my own breast tissue to add but this confuses me because some breast tissue will be removed during my lift..

Christopher V. Pelletiere, MD · Answer

Certainly, if you use the same size implant on two patients, the more breast tissue you have of your own the bigger the breast will look compared to someone who has very little of their own breast tissue.  As far as how much tissue comes out, that is completely variable. Sometimes none at all.  Other times a fair amount.  It is all about tailoring the breast around the implant itself.  That is something you would need to address with your board certified plastic surgeon (not the nurses), along with the implant width.  I hope this helps.

Richard H. Tholen, MD, FACS · Answer

Of course, your present size, MINUS the skin and tissue removed to perform the lift, PLUS the implant size, will EQUAL your final size. With 32DD deflated breasts, you have a petite chest circumference, lots of loose skin, and (an unknown amount of) your own breast tissue. Let's say you have B cup volume in DD skin--so estimate 400g of your own tissue. 
NO MORE than 30-45g of skin need be removed for any breast undergoing lift plus enlargement, and to this you want to add 535cc (or 590cc from another of your questions), so you could potentially end up with around 900cc breasts trying to be contained in a reduced skin brassiere. This may not work. Surgeon's solution (doesn't want to junk to too-large implants--that costs $1700 or half, if only one implant is placed before s/he finds out the skin is too tight and won't close): just remove some tissue and now it will fit.
And tell the patient that this provides "more upper pole fullness," or makes "your lift last longer!"
I call BS on that!
Why would you remove REAL breast tissue and replace it with implants, even if they are designed to resemble and "feel" really close to breast tissue, when you already have real tissue and wish for more volume? Leave what you have, remove the least amount of skin necessary (trust me, even with huge deflated breasts, it's NO MORE than 1-2 ounces of skin, and I proven that for over 30 years) to do the lift, and add implants to the desired size, or if that is larger than the skin capacity will safely accept, use the largest safe implants that "fit."
Most, if not all, plastic surgeons are trained (if this surgery--lift plus implants--is being done as a single-stage operation) to do the skin removal first, create the implant pockets, place the desired or chosen implants, and THEN (try to) close the incisions. And if it doesn't "fit," what then??!! You must either try to "HONK it shut" after more dissection (bad if skin dies), use smaller implants (costs more, plus bad to have to explain that to a patient, especially if she remains too small), or remove tissue (but we now have "excuses, er, advantages" to removing tissue and adding large(r) implants.) 
And we now have professors actually training tissue removal (more than just the 1-2 ounces of skin to tighten the skin brassiere) and use of (larger) implants, justifying this with the reasons noted above.
How about actually removing the ounce of skin to do the lift, actually CLOSING the lift incisions (leave 4cm open in the crease incision to later add the implant) FIRST, and now you have lifted, perky, still too-small breasts that you can now add implants to, through the incision still left open (same operation, just different order of steps)! This allows proper implant choice and prevents the too-large implant being "forced" into too-tight closures that fall apart or have inadequate skin circulation so the skin dies. You have probably seen plenty of those photos here on RealSelf! Closing the lift incisions, and THEN picking implants that fit, I would humbly submit, is a BETTER WAY (safer, more exact) to perform a single-stage lift plus implants! I can't be the only PS who has figured this out.
Sorry, but 400g of tissue MINUS 250g of tissue PLUS 535g (cc) of implant weighs the EXACT same as 400g MINUS 30g (skin for lift) PLUS 315cc implants (685g per side). And this weight exerts the same amount of gravitational stretch on your new skin brassiere. So lifts "lasting longer" with larger implants after more tissue removal is not true! 
If the lifted skin allows bigger implants and you want an even larger look, then great, go for it! Why some surgeons' answers to your similar question have expressed a thinly-veiled skepticism at 535cc or even 590cc implants has nothing to do with width, but volume. Width (profile) is easy--once your surgeon decides what implants you want (and that fit), then choose a width (profile) in the desired size that is 1cm narrower than the actual in-surgery pocket diameter. (BWD is measured so differently by different surgeons it is not applicable, except by that specific surgeon-measurer. I may measure differently, but in the same manner for each of my own patients, so my numbers and choices work, for me).
I know, choosing implants in the operating room can't be done if your surgeon has to order a few sets of implants for your surgery, so a decision HAS to be made pre-op. I prefer using ACTUAL measurements from the operating room, with the patient's sizing goals, and goal photographs of the desired result, and THEN decide what implants to use after the lift has already been (nearly completely) closed. (Our surgical facility stocks all sizes and profiles for two cohesivities of silicone implants, and saline implants, so we have the ability to choose final implant size in the OR.) If the result is not big enough, "forcing" too-large implants into not-enough (after tightening) skin is a recipe for disaster. Or you have to remove more tissue. You can always heal, soften, stretch, and settle for 6-12 months, and then come back for larger implants, if that is your goal.
I hope this answers your question, and perhaps the other as well. For more information (more about augmentation than lifting), you may be interested in my Comprehensive Guide to Breast Augmentation found by clicking on the web reference button below. Best wishes! Dr. Tholen

Milind K. Ambe, MD · Answer

If you are doing just a breast lift with implants and not a reduction there should be little to no breast tissue removed (only excess skin).  I would recommend you communicate your concerns to your plastic surgeon so you feel more at ease.  Best of luck to you.

Connie Hiers, MD, FACS · Answer

With a lift, skin is mainly removed and not breast tissue. Your initial size does make a difference as to your final size. Your surgeon who has measured you will be the best one to determine what size implants will be best for the size you have selected.

Tom J. Pousti, MD · Answer

Thank you for the good question. No two patients are identical. In other words, every patient differs when it comes to where she starts anatomically and what she wishes to accomplish. Therefore, every patient will likely have a different amount of tissue removed during breast lifting surgery; this may range from skin only (no tissue removed) to a very significant breast reduction.Some general thoughts regarding this combination procedure may be helpful to you:
 Generally speaking, patients undergoing the breast augmentation/lifting combination operation should understand that it is significantly more complex than breast augmentation surgery only and that it is associated with a significantly higher risk of complications and need for additional surgery. 
Also, patients undergoing the combination breast augmentation/lifting surgery should understand that there are limits as to how large of an outcome can be achieved, given that breast lifting surgery does involve breast skin removal. On the other hand, breast augmentation surgery is expanding the breast skin “envelope” while breast lifting is (by definition) tightening up the breast skin envelope. These 2 forces are counteracting each other. 
Therefore, it becomes important to remove the appropriate amount of breast skin and to use the appropriate size/profile of breast implants to balance these 2 forces appropriately and to allow for achievement of the patient's goals while minimizing risks of complications. 
In my practice, "tailor tacking" is an important part of the mastopexy and mastopexy/augmentation procedure. It involves TEMPORARY  closure of the skin (for example with temporary skin staples)  to double check the amount of skin that is to be excised during the procedure. This maneuver is done to ensure that enough skin, but not too much, is removed. On the one hand, it is important that enough skin be removed to achieve the aesthetic breast lifting results the patient is looking for; on the other hand, is important not to move too much skin creating tension upon closure and potential wide scars.
 
Also, generally speaking, the best online advice I can give to ladies who are considering breast augmentation/lifting surgery (regarding breast implant size/profile selection) is:
1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. Ask to see lots of examples of his/her work. 
2. Again, have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining which operation and/or breast implant size/type/profile will most likely help achieve your goals.
In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural breasts” or "C or D cup" etc means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup size may also be inaccurate. The use of computer imaging may be very helpful during this communication phase.
3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery. The use of temporary intraoperative sizers with the patient in the upright position makes selection of the best breast implant size/profile relatively easy.
Best wishes.

Jon Ver Halen, MD, FACS (license suspended) · Answer

Hello and thank you for your excellent question. Based on your description, I think that the implants you have chosen will very likely fit your frame perfectly. In general, I try to pick an implant that is 1-2 cm narrower than a patient's breast width, depending on how much breast tissue you have. To answer your second question, if you are having a lift, most lifts remove about 150cc of breast tissue. It sounds as though your evaluation is spot on. Good luck!

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