DD - sagging and back pain - Considering a reduction, lift or augmentation. What should I do? (Photo)

Question

Im a 32 year old 5‘9 138 lb female that has always naturally had DDs. Over time, they have started to sag more and they give me such back pain. It constantly bothers me always having to wear a push up bra and readjusting them. But I also am torn from doing a reduction and lift since I dont want a scar or for them to be disfigured from doing a reduction. Thus, i am leaning towards an augmentation. I am questioning if it will leave me with more back pain and if with an augmentation if they will sag over time and id need to wear a bra either way. Is it possible to do a reduction with a smaller implant and a lift? or will it leave them disfigured? Above all, i want them to be visually appealing the most.

Finny George, MD · Answer

Hi, thank you for sharing your question. If the breasts are heavy, you may benefit from a reduction. A lift will be done as part of the procedure. An implant will add to the weight of the breasts and should only be considered if you’re worried you won’t have enough projection or volume after the lift or reduction procedure.

Pey-Yi Kevin Lin, MD · Answer

You will likely have to consider a breast lift with an implant to lift your nipple areolar complex into a more natural higher position and reshape the breast . An implant will help provide you with a rounder shape and more cleavage. 
You may also consider a breast lift by itself, which would help you achieve a natural look, but would not have the augmented cleavage appearance. 
If the weight of your breast bothers you, then you may want to mention this to your surgeon. You may consider a small breast reduction with an implant. Although this sounds counter-intuitive, to do a breast reduction for a patient and at the same time, place an implant to enlarge the breast; I am finding myself doing such a procedure more often with patients. These patients often have large hanging breast who want to be slightly smaller or the same size, but with an augmented breast appearance.

Daniel Barrett, MD · Answer

Dear Powerful833274,

my preferred lift is a lollipop lift when a periareolar won't do (ie greater than 2cm lift required). The lollipop technique was created by a Canadian plastic surgeon named Elizabeth Hall-Findley and treats the breast as a three dimensional structure instead of two dimensions (anchor - lift). Most importantly it does not require the horizontal component scars that the anchor-lift requires and breasts appear much more natural, lifted, and less boxy. Lastly, the lift lasts longer because the lollipop doesn't rely on the skin to hold the breast up, its actually breast tissue thats being brought together to support the breast and hence improves longevity.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Ira H. Rex III, MD · Answer

Choosing the best surgery for you depends on your expectations.  A breast lift would reposition your nipples to a much more youthful site and you would have a better opportunity to not need a bra.  Many woman in this situation would also had a small breast implant to give them a more round, aesthetically pleasing breast.  Some women do not want too much volume and a common combination of surgeries is a small reduction, lift, and implant altogether.  A consultation with a plastic surgeon would certainly be useful to explore all these options.

Arthur Dean Jabs, MD, PhD, FACS · Answer

You seem to be at cross purposes. Let's look at options to fix your issues.

Your breast shape is determined by the content (fat and breast tissue) and the skin brassiere.
Your photo shows nipples that are below the inframammary crease, L lower than R, and a flat upper pole.

You need to remove some skin and reposition the nipples to the level of the inframammary crease. You will not go down in appreciable volume doing this but you will not get back lost volume in the upper poll completely. To do that you need an implant.

In summary, you need a lift with or without implants. I often advise my patients to do the lift first without increasing volume to see if they are happy. Since you have back pain concerns already I would not advocate an implant. Proper measurements would be very helpful.

Best of Luck

Dr. Jabs

Donovan Rosas, MD · Answer

Candidates for breast reduction will typically have documented evidence of neck/back and shoulder pain as well as rashes and bra strap grooving attributable to the increased breast weight. They will often demonstrate that these symptoms have been resistant to more conservative measures like therapy, weight loss and pharmacologic intervention. This is needed for insurance coverage.

In addition to establishing a case for medical necessity, there are also requirements for resection weight (when covered by insurance). This may be a standard "500 gm per side" stipulation or a more variable standard based upon body surface area/Schnur scale.

Insurance coverage is contingent on the meeting the requirements (which will vary) for establishing a case for medical necessity.

Based on your narrative and photos, you are likely a better candidate for an augmentation, mastopexy. However, the decision is entirely based on goals. If you are seeking relief for the weight then reduction is preferred. Reduction will lift the breast as a side effect as well as deliver relief from the weight. It will not fill the upper pole. An augmentation is necessary in conjunction to achieve fullness. Yet the addition of weight may seem counterintuitive if you are seeking weight relief. Thus it is ultimately a question of priorities.

As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Donovan Rosas MD

Board Certified by the American Board of Plastic Surgery

Member: American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons

RealSelf Verified Member

RealSelf Top 100

Emre Guvercin, MD, FEBOPRAS · Answer

Hi there &mdash; what you’re describing is very common in women who naturally have DD-sized breasts. With time, the weight of the breast causes sagging and often significant neck and back pain.
If you like your current breast size, an augmentation will not help &mdash; implants only add weight and can actually worsen back pain and sagging. In your case, a Push-Up Lift (a modern internal-lift technique) can elevate the breast, restore upper-pole fullness using your own tissue, and reduce symptoms without making you larger.
If you feel your breasts are too heavy, then a Push-Up Lift with a conservative reduction is the best option. This removes just enough tissue to ease back pain while reshaping the breast into a rounder, perkier form.
None of these options “disfigure” the breast &mdash; modern techniques create very natural, visually appealing results. And yes, both lift-alone or lift-plus-reduction options typically reduce back and neck pain significantly.
Overall:✔ Like your size → Push-Up Lift only✔ Too heavy → Push-Up Lift + small reduction✔ Implants → Not helpful for support or pain
Hope this clarifies the best path for your goals.

Harry T. Haramis, MD, FACS · Answer

Sagging is best treated with a lift/ slight reduction. Trade off, unfortunately, is T scars.

Small implants can be added for more upper fullness.

Breast augmentation alone without a lift will means them sagging over the implants.

An exam and consultation with a plastic surgeon is recommended to discuss your options and expectations.

Ted Eisenberg, DO, FACOS, FAACS · Answer

An augmentation only makes them bigger.  If your back pain is really associated with your breast the augment might make the pain worse?! A reduction is similar scarring to a lift and makes the breast smaller. A lift and augment can be done together. Again the lift will cause scaring and the augment may or may not increase the pain. You have to decide if the appearance is worth the risk. Either way I recommend an in person consultation with a plastic surgeon to discuss your goals and be measured. After I measure and discuss goals with my patients, we then look at pictures of women (my patients) with similar measurements with different size and style breast implants, if interested. They also get to see what they would look like when the breasts have fully dropped and fluffed and in clothes. You get to see actual results and the surgeon's experience and not a virtual idea of what can be achieved. Women tell me that this process is very helpful in determining what size and style breast implant is right for them. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Tyler Frew, MD · Answer

Hi there,
I would not recommend an implant alone at this time. It will stretch your breast out even more and end up looking lower and wider than you want. Unfortunately you are going to have to put scars on your breast for best results. 
If you want to look natural and are ok with being smaller, do a lift with mesh support. 
If you want to be about the same size or slightly larger do a lift, small implant, and mesh support 
The scars on the breast usually heal very well
All the best

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