Good Question. For some women their breasts have so much sagging that if a surgeon tries to correct the problem with only an implant, it will not look good. The breast tissue and extra skin will be left hanging off the bottom of the implant, not a pretty result. So in a situation of a significantly saggy breast, a surgeon will often also recommend a lift and an implant.................................So why do the results sometimes still look saggy or droopy?...............Because the combination of a lift plus an implant is very complex operation, and the two procedures tend to work against each other, which is why surgeons often recommend that they be done in two stages. Patients, understandably, don't want to have two operations to achieve a nice looking breast (two operations, two recoveries, time between lift and augment, extra cost, etc), but depending on the degree of sagging, skin excess, nipple position, it is simply not possible to achieve consistently good results in a single operation in some patients. But too often surgeons will try to satisfy the patients desire to have it all done in one operation and save time and money, and the result, predictably, still looks saggy.
So if we see a patient that has a significant amount of sagging, we will recommend a lift and an implant, and recommend that they be done in 2 stages. The lift is done first which involves elevating the skin, moving the breast tissue and nipple back up the chest wall, then trimming off the excess skin and closing it all up. A lot is going on in this operation, and trying to put an implant in at the same time can compromise the surgeons ability to do a really good lift, and the result can then look sagging. If the lift is done well initially, then the surgeon can come back in a few months after healing and he/she will have much more flexibility in picking an implant to get the long term look that the patient really wants.
So, should all lifts plus implants be done in two stages? Not necessarily. Patients can have different degrees and types of sagging, so some patients can have it all done in one stage, and get a nice result. The skill and experience of the surgeon can play a big role in determining when to do it in one or two stages, and being able to get a good result in one stage if that seems reasonable.
It is much easier to obtain a great result with just an implant for someone who has a smallish well shaped breast with minimal sagging and good skin quality. But once a patient has developed a significant sagging, then the skill and experience required for achieving good consistent results are much greater. If your surgeon recommends that you need a lift and implant, make sure that you have a thorough discussion about whether it will require one or two stages to achieve the best results.
Breast implants alone do not actually lift the breast and correct the droop. They merely simulate a lift by filling out the lower pole (below the nipple-areola) and filling in the upper pole. Most so-called lifts, particularly those done with implants at the same time, are not true breast lifts and usually aren't needed so the effect is mostly the simulated lift of the implant. If you truly need a lift then the best approach in most cases is to do a true mastopexy first and then later see if more volume from an implant is desirable.
There general rule of thumb is that if the nipples sit below the
inframammary fold (the crease under the breast), then a lift is recommended.
However, there are several other anatomic factors of the breast as well
as the patient's desires and expectations that further determine whether a lift
is performed or not with or without an implant. If you really do need a lift based on your breast anatomy, but you just get implants you will end up with a snoopy dog deformity whereby the sagging breast tissue kind of hangs off the bottom of where the breast implant sits (up higher) - not an attractive look at all.
traditional lift technique only reshapes the breast and does not elevate the
breast mound higher on the chest wall.
This results in the sagging drooping appearance that you have
observed. For this reason, I recommend a
new technique called Breast Augmentation with Mini Ultimate Breast LiftTM. Using only a circumareola incision it is
possible to reshape your breast tissue creating upper pole fullness, elevate
them higher on the chest wall and more medial to increase your cleavage. Through the same incision, implants can be
placed. Aligning the areola, breast
tissue and implant over the bony prominence of the chest wall maximizes
anterior projection with a minimal size implant. Small round textured silicone gel implants
placed retro-pectoral look and feel more natural, are more stable, less likely
to ripple or have complications needing revision. Implant profile is irrelevant in the
retro-pectoral position since the muscle compresses it.
Gary Horndeski, M.D.
A lift can certainly dramatically improve the look of the breast. However, a breast lift can never return the skin to its original state.
Kenneth Hughes, MD
Los Angeles, CA
Thank you for your question. It is a very intelligent question and shows that you're quite observant.
When you see photographs of patients who have breast lift and augment and looks saggy afterwards a usually means that the combination breast lift and augment was attempted in one procedure. It is very difficult to estimate the effect of the breast lift and whether or not the breast will sag after the lift.
I would suggest that you have your breast lift first, wait 6 months before your breast augmentation. At 6 months the success of your breast lift can be evaluated and the breast implants placed more appropriately. In addition if the breasts have sagged again, the breast lift can be revised at the time of your breast augmentation.
The effects of gravity and aging continue, like death and taxes. Unfortunately, the reason that some women have saggy breasts (ptosis) is that they have thin skin and tissues that do not hold up well to the effects of gravity. We place implants into the breasts to help with the lack of volume up at that top of the breast because of the tissues inability to stay high on the chest. Therefore, the breast will then hang off of the implant a bit and give you a more natural look than a patient that had no breast tissue. You can simply look at the outline of the breast implant in many patients who didn't have much breast tissue and will have a difficult time looking natural. With time, it is likely that the breast will continue to drift south and you could want another lift. We can't stop the aging process or gravity, but we can keep resetting it. If you need a lift, a breast augmentation alone is not the answer. A lift and an implant will give you the best results. If you are unsure if you need a lift, seek a second opinion from another plastic surgeon. Hope this helps, and best wishes.
Thank you for the question. Without photos, this cannot be answered for your particular case. In general, the breast on the chest wall has a "foot print". Some women are high breasted and others are low breasted. This is determined by your anatomy. Another variable is that women with very large breasts or with poor skin elasticity will have saggy breasts. An augmentation combined with a breast lift is a challenging operation. The augmentation enlarges the breast in all dimensions and a lift tightens the skin envelope and raises the breast. These are very tricky operations at times it is best to do them separately. Do the lift first, and then the augmentation. If one combines them, the re-operation rate is about 28%. Sometimes, the mistake some surgeons make, is that they do not remove the saggy breast tissue below the implant in the lower breast. If this tissue is pushed up, repositioned or even sutured to a higher place on the chest wall, within a short time it will be saggy again. This ptotic, or sagging tissue must be removed to have a nice result. Your surgeon might be right in noting that you need a lift as well (no photos). If you are still unsure, seek another opinion from a board certified plastic surgeon. Good luck.
I would say one word - Elasticity. If a patient has lost all the elasticity in her skin, it doesn't matter if she gets a lift, we can't give her better skin, so some of the sag comes back no matter how tight we made her. If you have nice thick skin, you will do much better. But patients who have had children and had the skin stretched out need to be very realistic in what they expect. We can definitely make them better but we cannot give back the prepregnancy skin quality.
One word--gravity. If you notice, most women with smaller breasts tend not to be as ptotic or saggy. They have less weight to the breast therefore less of a chance to sag. Women with larger breasts have more weight pulling on a thin skin envelope and with gravity in effect this will pull the breasts down. Adding in implant into the mix only weighs the breasts down further. Even with a lift, the breasts will continue to be affected by gravity and age (with age the skin thins and is less supportive of a heavier breast). Many women feel that they do not need to wear a supportive bra after a breast surgery (augmentation and/or lift) because the breasts are perky again, however, with a larger breast the skin needs help to support the weight and a good supportive bra is key to delaying the inevitable recurrent droop of the breasts. I think it is important to counsel patients that they need to consider this in choosing an appropriate implant size, in being compliant with wearing a supportive bra after surgery, and in having realistic expectations that in say 5 or 10 years (give or take, of course) you may need another lift.