Graduating From a Donut to Full Lift- Which Pedicle Technique (Wise Pattern) To Avoid Nipple Necrosis?

I am looking to obtain a full lift & downsize to smaller implants. To be clear, I do not smoke and attempt to avoid all secondhand smoke to the best of my abilities. However, I have read that nipple necrosis can still occur, especially when graduating to a more aggressive reduction/lift w/ augmentation. Given my previous donut lift history, which pedicle technique (inferior, central, superior,etc.) would afford me the least chance of blood supply problems and necrosis?

Doctor Answers 11

Mastopexy and associated skin designs.

There is a significant difference between techniques used for breast lifts and techniques used for reductions. A brief review of the two procedures may help you to understand blood supply to the nipple.

In breast reductions, both skin and breast tissue are removed. You can combine any skin excision pattern (Wise, vertical, apron) with any underlying breast pedicle (inferior, medial, superior, etc.) The pedicle is essentially the breast tissue that is left behind to keep blood supply to the nipple.  

In a lift, the breast tissue is not removed, but rather it is reoriented - only skin is removed to tighten and shape the breast. When performing a large lift with extreme relocation of the nipple, a pedicle may make it easier to reposition the nipple. These types of lifts typically require a Wise pattern or anchor scar to remove enough skin to tighten the breast envelope. For smaller lifts, periareolar (Donut, Benelli, etc.) mastopexies don't really use a "pedicle" but rather free the skin from the underlying breast to close it down around the nipple, elevating and repositioning the nipple in the process.

The concern for nipple necrosis is higher whenever an augmentation is performed at the same time as the lift. Internal pressure on the blood supply to the nipple combined with reducted blood supply from the skin excision can lead to problems with nipple vascularity. However, in patients who are downsizing their implants and having a revision lift at the same time, the risks is typically less than for an initial procedure. This is due to improved vascular supply resultant from the original operation (known in our field as a "delay" phenomenon). Hence, in your situation, reducing implant size with a previous donut mastopexy will likely require less nipple repositioning, more skin excision (thus a vertical or anchor scar), but unlikely to have an elevated risk of nipple necrosis.

Although a bit wordy, I hope this clarifies your understanding.

Boca Raton Plastic Surgeon
5.0 out of 5 stars 25 reviews

Secondary lift

These can be very challenging cases and many times what I do is dependent on the amount of breast tissue remaining and where I think the blood supply to the nipple is.If the tissues of the berast are thin many times I will do it in 2 stages the first being implant removal and then the lift.

Robert Brueck, MD
Fort Myers Plastic Surgeon
4.9 out of 5 stars 62 reviews

Nipple necrosis after redo breast lift

This is a tricky situation and you are wise to be concerned.  The best advice I can give you is to have your orginal surgeon evaluate you as he/she knows what your current situation is.  If you want to have a new surgeon take on your case, make sure you provide him/her with all your operative records so he/she will know what type of procedure was done, what plane the implants are in, what size the implants are etc.  Good luck.

Lisa Lynn Sowder, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 72 reviews

Safety and Happiness with Revision Breast Lift- Don't get the Cart before the Horse

Hi there-

The pedicle is probably not as important as other variables in terms of maximizing your safety and happiness...

  • If possible, get the report of your first surgery and bring with you to consultations
  • In terms of minimizing your risk of complications and maximizing your chance of happiness, the most important variable will not be the technique used, but WHO does it

Choose a surgeon with a great deal of experience and skill in breast surgery, and you should be safe and happy regardless of the details of the technique.

Armando Soto, MD, FACS
Orlando Plastic Surgeon
4.8 out of 5 stars 157 reviews

Secondary mastopexies after doughnut lifts

The risk of nipple areolar complex necrosis does increase with secondary mastopexies depending on how the first doughnut Mastopexy was performed. If the doughnut incision was full thighness into the subcutaneous tissue, then the blood supply would be coming from the breast tissue itself. Thus, I think an inferior or superior pedicle would allow for the nipple areolar complex to be maintained on a larger amount of breast tissue and hence a better blood supply. A medial or lateral pedicle approach often requires undermining the nipple areolar complexes which may compromise the blood supply. You should discuss this with your surgeon, especially the one that did the doughnut Mastopexy so you know exactly what was done the first time.

Todd C. Case, MD
Tucson Plastic Surgeon
4.9 out of 5 stars 55 reviews

Revision lift

There is always a slightly greater risk of nipple necrosis with revision procedures. It is always helpful to know the previous pedicle used to lower the risk of problems.  Usually a donut lift is just an areola lift and not divided from surrounding tissue or it may have been a vertical type pedicle.  Better to ask your surgeon.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 28 reviews

Having a previous lift has been shown not play a role in future pedicle choices.

Inferior pedicle has the poorest blood supply as the anatomical studies showed.  For that reason I rarely perform (if ever) inferior pedicle lifts.  Medial pedicle has the most robust blood supply.  But ultimately, the safest technique is the one your surgeon has most experience with. 


Additionally, these days a wise pattern is not required unless you have droopy breasts.  In my practice I perform wise pattern incisions only in massive weight loss patients who have dramatic volume loss and excessively droopy breasts.



Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 457 reviews

Full Breast Lift After "Donut" Lift

I rarely perform donut breast lifts due to the fact that they don't really provide much lift. Patients usually continue to sag and can end up with a distorted areola and a wide or irregular scar. I do however convert a lot of Benelli or donut mastopexies to full lifts with nice outcomes and grateful patients. I currently prefer the superior pedicle technique and have never experienced skin or nipple loss. I have even been successful after a previous inferior pedicle lift so your donut lift will pose no problem if performed correctly. In addition, during a superior pedicle lift, breast tissue can be removed from the lower portion of your breast, aiding in the reduction you are requesting and help prevent "bottoming out" in the future. Seek out a board certified plastic surgeon and you should end up with the breast shape and size that you wanted at the start.

Lawrence W. Shaw, MD
Arizona Plastic Surgeon
4.9 out of 5 stars 73 reviews

What Pedicle for a mastopexy

I have found that donut "lifts" seldom satisfy patients for long so your predicament is not unusual.  In your situation the first question I would ask is where was the approach made to create the pocket for your augmentations?  The incision for the donut was all the way around the areola, but chances are the the incision down through your breast was made through the lower half of that incision which would have compromised the inferior pedicle blood supply.  I have had the best results using a superior pedicle in these instances.  The blood supply is better and the pedicle shorter.  A small transverse incision can also be done to round the contour of the breast a bit more which make it look like you have had a Wise (inferior) pattern lift, but the scar along the fold is much shorter.  Good luck.

Lori H. Saltz, MD
San Diego Plastic Surgeon
4.3 out of 5 stars 28 reviews

Breast lift and nipple necrosis

You are doing your homework but have missed the most important thing here - whether the implant is above or below the muscle!  Above the muscle has deprived the breast of much of the blood flow that comes directly up into it from the muscle and risks nipple necrosis higher than below the muscle.  The key is to know this placement, tell the doctor and make sure they have great experience and have done this hundreds of times.

Richard P. Rand, MD, FACS
Seattle Plastic Surgeon
4.8 out of 5 stars 67 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.