From your photos, you need a lift (with reduction on her larger, droopier side so that you will have improved symmetry of the shape and size of your breasts, allowing you to use same sized implants rather than different sized ones. If you really do not care about your nipples being more level, then you could just have an asymmetric augmentation as suggested by one of your consultants and then decide later if you really need that lift or not.
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.
Those all sound reasonable options, and if you go to five plastic surgeons, you will get six opinions. I think you maybe an excellent candidate for the Horndeski Method.
Given the wish pics you presented, I think that you cannot avoid having a lift. Seek a plastic surgeon that performs hundreds of these procedures, has great reviews and photos, and is an expert in this field.
Thank you for the question. Given your asymmetry, and the excess tissue on your right side, you would benefit from adding a lift to your augmentation.
Most obvious to me is the significant asymmetry in your breasts that placement of implants can hardly address. Right breast has significantly more skin as well as breast tissue volume than your left and without a full lift on that side the skin could not be made more symmetric. Not dealing with this at the initial surgery will simply in my opinion exaggerate the asymmetry leading to potential dissatisfaction.
Good luck and spend some time reviewing your options carefully before making a final decision.
Jon A Perlman M.D., FACS
Diplomate, American Board of Plastic Surgery
Member, American Society for Aesthetic Plastic Surgery (ASAPS)
ABC-TV Extreme Makeover Surgeon
Beverly Hills, California
Lifts can be done to different degrees. What I mean by that is a small lift will appear to only relocate the nipple, while a larger lift will reposition and reshape your breast. I do not think you will get to your desired appearance without a lift and I would suggest something more than just a nipple relocation
In general terms, a breast lift reshapes the breast, removes sagging and excess breast tissue and skin, and moves the nipple and areolar complex into an ideal position. Its possible and fairly common to combine breast lift surgery with a breast implant.
If both breasts look like your smaller one, then yes you could get your goal look without a lift. But, with the dramatic asymmetry your photos indicate, a lift is necessary.
do not adequately lift the breast when there is significant sagging, no matter
the size or type of implant, and will not produce a good cosmetic result in a
patient who also needs some variation of a lift.
Keep in mind that following the advice from a surgeon on this or any other
website who proposes to tell you exactly what to do without examining you,
physically feeling the tissue, assessing your desired outcome, taking a full
medical history, and discussing the pros and cons of each operative procedure
would not be in your best interest. I would suggest your plastic surgeon be
certified by the American Board of Plastic Surgery and ideally a member of the
American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are
comfortable with. You should discuss your concerns with that surgeon in person
and be very realistic about your potential cosmetic result.
Robert Singer, MD FACS
La Jolla, California