BEFORE AND AFTER PHOTOS
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How Do I know If I Need a Breast Lift?
Women’s breasts sag as they get older due to gravity, pregnancies, hormonal changes after menopause, or after substantial weight loss (over 50 pounds). Heredity is also a factor. Women are often aware of other female family members who are similarly affected.
Sagging never gets better with age, and does not respond at all to exercise, wearing a bra all the time, or any lotions that are applied to the skin.
Women with troublesome sagging who wish to correct it may benefit from a breast lift (“mastopexy”), which may often be conveniently performed at the same time as an augmentation.
When is sagging troublesome? Here are some clues:
Breast Implants to Restore Fullness—Still the Gold Standard
Women who have borderline breast sagging may be best treated with implants alone, which improve fullness. Breast implants reliably increase breast projection and upper pole fullness. The nipple is not changed in relation to the surrounding skin, but the increased volume of the breast causes the nipple to project farther. A breast augmentation may be the right choice for the younger patient who can accept a mild, natural degree of sagging if this means she can avoid the extra scarring that comes with a breast lift. Of course, she can always wait and have a breast lift in the future. It is also the right operation for an older woman (over 40) who wants to look good in her bra but is not too concerned if the nipple position is still low. She’ll tell me, “I’m not trying to be 20 again.”
Most patients, however, do want to correct the sagging and do not wish to have their nipples riding low on their breasts.
I find that younger women (20s and 30s) will generally opt for a breast augmentation, and older women (40s and older) more readily accept a breast lift. However, I certainly have operated on plenty of women in their 30s who have elected to have a lift with their augmentation, particularly if their nipples are already starting to point down. They recognize that the problem is not going to improve and they are going to have a lift at some point anyway, so why not do it now? It is also true that younger women will generally prefer larger breasts than forty and fifty-somethings. Of course, larger breasts can give the illusion of being heavier, and older women prefer the svelte look, undoubtedly because it is harder to achieve as we age. They do not wish to appear matronly.
Breast Augmentation vs. Breast Lift
For women whose primary concern is breast sagging, or downward drift of the nipples, a breast augmentation and lift (augmentation/mastopexy) is the right combination. These women are basically fed up with their breast sagging. They tell me that they don’t feel comfortable in bathing suits or dresses or that they feel sloppy and this makes them self-conscious. It affects their self-esteem. These women are often less concerned by scarring if this procedure can give them the lift they want.
If a woman lifts her breasts up in the cups of her hands and says “This is what I want,” the operation of choice is breast lift and implants (“augmentation/mastopexy”).
The downside of a breast lift is more scarring and this must be weighed against the improvement in shape. For patients who simply wish to fill out their bra, or if they do not wish to have the breast lift scars, I recommend implants alone. The patient may always return at a later date for a breast lift.
If correction of sagging is a priority, then a breast lift is recommended. Breast augmentation alone will not suffice. For women who wish to wear clothing that does not rely on a bra, such as bikinis, halter tops, or dresses with spaghetti straps, a breast lift is recommended.
If a patient reacts negatively to the scars on viewing before and after photographs I show her in my office, a breast lift is obviously not for her. If there is any hesitation about the scars I tell women to wait. There will be a time later on when they will look at the scars, look at the shape, and say: “When can we do it?” With this approach, my breast lift patients are among my happiest. Patients would not trade their scars for sagging breasts, even if their scars are not ideal. They find their scars are hidden in most bathing suits and evening gowns.
Breast augmentation alone provides minimal improvement in sagging. One would think that a breast implant would take up the slack in the breast and provide the desired elevation, but the amount of breast lift is minimal (0.6 cm), compared with 5 cm for a breast lift and 4 cm for the combined implant/lift. Usually, the nipple level stays about the same after an augmentation alone. The crease under the breast (“inframammary fold”) actually lowers after implants (Swanson E. Photometric evaluation of inframammary crease level after cosmetic breast surgery. Aesthetic Surg J. 2010;30:832–837.). Many women, and even plastic surgeons, believe that the nipple will ride up once implants are inserted, but measurements show this is not the case. If low-set nipples are a concern, there is no substitute for a breast lift, which is very effective at elevating the nipples. The average lift in nipple position after a breast lift is almost 6 cm (4.5 cm for the combined procedure), compared with only 0.3 cm after implants alone. (Swanson E. Prospective photographic measurement study of 196 cases of breast augmentation, mastopexy, augmentation/mastopexy, and breast reduction. Plast Reconstr Surg. 2013;131:802e–819e.).
The Benefits of a Breast Lift
Many women regard the reduction of areolar size as an acceptable trade-off for a scar that goes around the areola. There is a scar around the areola and a vertical scar, which form the “lollipop” scar. By avoiding the long horizontal “anchor” scar (a shorter scar may still be used in the inframammary crease to avoid a scar continuing on to the abdomen) used in the past, the trade-off (improved shape vs. scars) is much more favorable today for women having a breast lift. The decision to have a breast lift is an important one. But there are enough clues that it is unusual for the patient and I not to come to a consensus after talking about these issues and looking at photographs. Women often wonder what their husbands or boyfriends will think of the scars. The easiest way to handle this is for the significant other to be there at the time of consultation and also review photos showing the scars. In my experience, feedback from male partners has been very positive. But, the bar I set is high. In the patients I treat, the trade-off has to be strongly in favor of the lift. Women with mild sagging are probably best to accept the sagging rather than commit to the scarring that comes with a lift.
In severe cases of sagging, the nipples may be located at the lowest part of the breast, pointing down. Women with downward pointing nipples find their breasts unattractive and understandably wish to have their nipple lifted up where they are supposed to be. Women may find that they have a positive “pencil test”—they can hold a pencil under their breasts without using their hands. In this case, “positive” is not good. One patient of mine joked that she could pass a “bar of soap” test too!
Does Wearing a Bra Prevent Sagging?
Women sometimes ask me if wearing bras helps prevent sagging. To my knowledge, there has never been a study done to assess this, but certainly wearing bras does not prevent it—American women by and large wear bras and still develop sagging.
Degrees of Sagging
Traditionally, when plastic surgeons have discussed breast sagging, they have referred to the position of the nipple in relation to the crease under the breast (inframammary crease or inframammary fold), the Regnault classification. In youthful, attractive breasts, the nipple sits at about the same level or above this crease. With progressive breast sagging, the nipple typically drops below the level of this crease as it descends with the breast.
A New Breast Measurement System
A limitation of the Regnault classification is that it relates the nipple position to the level of the inframammary crease—which can change after surgery—rather than to the breast. This system is one-dimensional, and cannot describe breast shape. Three-dimensional methods have been used, but are complicated. Until recently, breast projection and upper pole fullness had not been precisely defined. To remedy this deficiency in our measurement capabilities, I developed a new breast measuring system (Swanson E. A measurement system for evaluation of shape changes and proportions after cosmetic breast surgery. Plast Reconstr Surg. 2012;129:982–992; discussion 993) based on a reference plane—the plane of maximum postoperative breast projection (MPost). This system provides a means to measure breast projection and upper pole projection, two desirable characteristics. This reference plane is also used to determine the “breast parenchymal ratio”—the ratio of breast area above and below this plane. The preferred ratio is about 1.5:1. Women with sagging breasts often have a ratio of 0.8. Women prefer more fullness of the upper breast than the lower breast, which is not surprising in view of the purpose of bras.
Another measurement, the “lower pole ratio,” assesses the tightness of the lower pole. A semicircle has a ratio of 1.73. Lower pole ratios over 2.0 start to appear boxy. The inverted-T techniques were prone to creating boxy breasts because of the geometry of the procedure, which trades breast projection for width, the reverse of what is needed (Swanson E. Comparison of vertical and inverted-T mammaplasties using photographic measurements. Plast Reconstr Surg Glob Open 2013;1:e89). The vertical breast lift procedure does just the opposite, trading breast width for projection. The geometric effect is favorable—more projection and a tighter, more conical, lower pole.
Swanson Breast Measurement System (2012)
Saggy and Too Large
Mae West was not talking about breasts when she said, “Too much of a good thing is wonderful.” Over-endowed women have just as much trouble as under-endowed women, or more, because there may be physical problems in addition to the psychological ones. There is an operation for every degree of breast sagging and size. It is possible to reduce the breast size slightly by taking out a small amount of breast tissue with the skin, or dramatically reduce breast size (at which point it is called a breast reduction), by removing skin and a lot of breast tissue. Insurance companies often use 500 grams as their benchmark for deciding when a breast lift amounts to a breast reduction. They don’t want to pay for breast lifts, which they consider cosmetic.
Interestingly, our study found that not only breast reduction patients, but also women with less than 300 grams of tissue removed per breast (normally considered “breast lift” patients) report significantly reduced symptoms of neck, shoulder, and back pain after surgery. The finding that women who had smaller resection weights also had relief of symptoms shows that the distinction between a breast lift, typically considered a cosmetic procedure, and a breast reduction, traditionally done for symptomatic relief, is artificial. A breast lift can be considered a small reduction and these patients can feel better in addition to looking better. (Swanson E. Prospective outcome study of 106 cases of vertical mastopexy, augmentation/mastopexy, and breast reduction. J Plast Reconstr Aesthet Surg. 2013;66:937–94).
Both procedures—breast lift and reduction—have functional and aesthetic benefits. The incisions for a breast lift and reduction are the same if the preferred vertical method is used. The only difference is the weight of breast tissue removed, and whatever weight standard is used to separate the two is arbitrary (I use 300 grams).
Saggy and Too Small
Many women have breasts that have gotten saggy and lost volume too. This typically happens after pregnancy. For these women, the sagging may be treated with a lift, and the breasts are simultaneously enlarged with implants: a breast lift and augmentation. Plastic surgeons call this operation “augmentation/mastopexy.”
Women need to know that a breast lift alone will not give them more fullness in the upper poles. You might think that the plastic surgeon could simply push the existing breast tissue up, filling out the upper poles, but, in reality, this does not work, despite the efforts of many plastic surgeons over the years to achieve it (Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301.). Breast tissue is simply too malleable. The failed notion of using breast tissue as a surrogate for a breast implant is called “autoaugmentation.” (Swanson E. Breast autoaugmentation: An enduring myth. Plast Reconstr Surg. 2015;135:779e–781e.) The good news is that implants perform very well in maintaining shape. The implant and the capsule that forms around it provide the firmness and durability that are needed to fill out the upper poles. In this situation, these “unnatural” qualities of the implant and capsule are working to our advantage. Indeed, it may be said (and I often do) that the bad thing about implants is that they are not just like breast tissue and the good thing about implants is they are not just like breast tissue.
The “Minus-Plus” Concept
Measurements show that mastopexies (the medical term for breast lifts) that just remove skin and do not remove breast tissue from the lower pole, the so-called “skin-only breast lifts,” are ineffective (Swanson E. A retrospective photometric study of 82 published reports of mastopexy and breast reduction. Plast Reconstr Surg. 2011;128:1282–1301). Skin is simply too elastic to hold shape and the breasts typically remain “bottomed-out.” A better strategy is to remove extra breast tissue from the lower pole, where it is not needed, and add to the upper pole, where it is welcome. The only way to reliably increase upper pole fullness is by using implants. This is the “minus plus” concept originally described by Regnault and Daniel.
“I Like My Size and I Just Want a Lift”
Sometimes women say, “I’m satisfied with my size, I just want a lift.” Intuitively, one might think that these patients would be best served with a breast lift alone and no implants. But measurements show this is not the case (measurements again win out over intuition). These women need to know that if a breast lift is done properly, and extra breast tissue is removed from the lower pole along with skin, their breast size will actually decrease, and there will be no net gain in upper pole fullness. For this reason, I recommend implants for women who just want to maintain their size, usually of a modest volume. This is one reason it is much more common for me to perform augmentation/mastopexies than mastopexies alone. But there are other reasons too, and these are discussed later.
These illustrations, drawn to scale, depict the mean breast measurements before (left), after a breast lift alone (middle), and after a breast lift with implants (right). A breast lift alone corrects the sagging of the lower pole, but slightly reduces the breast size and does not fill out the upper pole. The breast does not appear to rise relative to the chest wall. An implant improves upper pole projection. The combination of an implant and a breast lift provides the appearance of a lifted breast.
In fact, mastopexies without implants are indicated only for women who want to correct sagging, and do not mind if their breasts are reduced a little in size, and accept wearing a bra to produce upper pole fullness. Or in women who simply don’t want implants.
So what if just skin is removed from the lower pole, preserving breast volume (a skin-only mastopexy)? The answer is not surprising. The patient may have the same breast size she had before, but it will still be saggy, so she is no better off. This fact explains the high rate of patient dissatisfaction after traditional breast lifts. It has nothing to do with unrealistic expectations, as is sometimes suggested. Flowers called this problem “the mastopexy-wrecking bulge,” referring to uncorrected lower pole excess in these patients. Experienced surgeons learn to remove not just skin, but breast tissue from the lower pole to avoid this problem.
Indeed, only an augmentation/mastopexy can provide the illusion of a breast lift. A mastopexy alone only tightens the lower pole and corrects the lower pole excess. For some women, this is enough. A mastopexy does not give the illusion of a breast that has been lifted up relative to the chest wall (see Illustration). Any woman who grabs her breasts from below and lifts up, saying “this is what I want,” should consider an augmentation/mastopexy.
Patients may have concerns about implants, which they may not have considered in the first place, but after being informed that they cannot expect to have unaided (no bra) youthful upper pole convexity without implants, and after looking at photographs of other women treated with and without implants, they often elect to have implants. In doing so, they are making an informed decision. Saline implants are often used. There are no safety issues related to saline as an implant filler, and there is enough existing breast tissue so that any feel advantage of silicone gel implants is marginal at best.
For those women who are planning to have more children, it is usually best to postpone a breast lift. The breasts will go through more stretching with another pregnancy and will lose tone. Although a breast lift may be retightened at a later date with no additional scars (the original vertical scar is removed along with extra skin), it is usually advisable to wait and have just one operation. However, this does not mean that a woman who is not sure if she will have another child in the future should put off this helpful procedure indefinitely, especially one that can make such a difference in self-esteem. Recommendations are individualized and, often in plastic surgery, there are exceptions to the rule.
A breast lift is unlikely to affect breast feeding capability. The ducts going from the breast tissue to their openings in the nipple are preserved. Only the extra skin is removed, and a small amount of breast tissue at the lower pole, so that breast function is usually maintained.
BREAST LIFT AND IMPLANTS (AUGMENTATION/MASTOPEXY)
Breast Lift and Augmentation
The consistency of breast tissue changes with age—it loses its firmness. Women would like to restore the firm consistency they had as a teenager. Their breasts have lost firmness and the upper poles have flattened. Ideally, they would like to have a pleasing fullness of the upper part of the breasts, which they may have enjoyed when they were younger and before they had children. Of course, the consistency of the breast tissue is not changed by the lift. Patients wonder whether the lift itself can push their breast tissue up to round out the upper parts of their breasts. Unfortunately, a vertical breast lift alone provides minimal increase in upper pole fullness and an inverted-T approach (a method I used in the past but now consider obsolete) provides none. No matter how much the plastic surgeon pushes up on the tissues, the reality is that a breast lift alone does not fill out the upper part of the breasts.
If a patient desires greater firmness, or fullness in the upper poles and a fuller cleavage, implants are recommended. Most of my patients having a breast lift decide to have implants simultaneously. Implants may be inserted using the same incision used for the breast lift. Of course, this combined procedure introduces the possible complications of breast implants along with the benefits. The concept is “minus-plus,” more fullness where you need it (the upper poles) and less where you don’t (the lower poles).
Before, 1 month, 3 months, 6 months, 13 months, 20 months
Longitudinal study of frontal orientation-matched views of a 39-year-old patient before and after a vertical augmentation/mastopexy (right 110 grams, left 148 grams) using a medial pedicle and submuscular Mentor Moderate-Plus profile saline-filled implants inflated to 275 cc. Three months after surgery, the exaggerated fullness of the upper pole has settled and the nipple is correctly positioned at the level of maximum breast projection. The lower pole has a desirable semicircular profile, and the upper pole has a pleasing convexity. This patient had a simultaneous abdominoplasty and liposuction (a mommy makeover).
Breast Lift and Removal of Implants
Patients who have had breast implants in the past may wish to have them removed and have a lift done at the same time to tighten the breasts, which have been stretched by the presence of the implants. Without a lift, the breasts will look deflated after removal of the implants. A lift alone may be sufficient in women who had at least a moderate amount of breast tissue at the time of their breast augmentation, at least a B-cup size.
In patients who started with small breasts, it is best to replace the implants at the same time as the breast lift. Otherwise, the breasts will still look unfilled, even with a lift, and these women have gotten used to having something there to fill their bra. In this situation, which is more common one, the breast implants will be replaced. The size of the new implants may be the same size, smaller, or larger than the original implants, depending on the patient’s wishes.
For women in their 40s and 50s, a large breast size may not be as desirable as it was when they were younger, particularly if the large breast size makes them look matronly. Their breast implants may be removed, replaced with smaller saline implants, and the breasts tightened as necessary with a breast lift. This gives the desired lean, but feminine, contour.
Breast Lift and Abdominoplasty
It is not unusual to combine a breast lift with other procedures, such as liposuction of the lower body or an abdominoplasty. Typically, women who have breast lifts have had children and their tummy has been stretched out along with their breasts. They may wish to have the tummy tightened at the same time their breast lift is performed. Both of these procedures are best performed after child-bearing to avoid restretching the tissues, so it often works out that the timing is right for both at the same time, a combination labeled a “mommy makeover.” The breast lift procedure is the less painful procedure. Women who have both procedures simultaneously are aware of their abdominal tightness and discomfort after the abdominoplasty, but barely notice any breast discomfort. Because the breast lift does not add much to the postoperative discomfort, and adds nothing to the recovery time, it makes sense to do it at the same time, avoiding a second operation.
Is Combining Surgery Unsafe?
Some plastic surgeons believe that combining procedures is unsafe. However, this view is not well demonstrated in the literature. Of course two procedures will have more complications than one, but the risk does not appear to be super-additive. It is important that any plastic surgeon doing combined surgery be proficient in the procedures done individually so that the surgery is not overly long and blood loss is not excessive.
Safe anesthesia is a crucial element of elective plastic surgery. Plastic surgery is done under various forms of anesthesia. I prefer total intravenous anesthesia and use it for all of my procedures, even abdominoplasties and lower body lifts. The patient is asleep, but breathing spontaneously (not relying on a breathing machine), is not paralyzed, is not intubated (a tube is not inserted down between the vocal cords), and is not positioned prone (face down) during surgery. I call this “SAFE” anesthesia (Spontaneous breathing, Avoid gas, Face up, and Extremities mobile) (Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2:e160.) This type of anesthesia is also less likely to cause blood clots in the deep veins of the thighs. Patients tend to wake up quickly, are seldom nauseous, and are usually ready to go home 60–90 minutes after surgery. Sometimes patients worry that they might wake up during surgery. They can be reassured that, with this type of anesthesia, awakening during surgery is not going to happen, because the anesthetist would detect movement (the patient is never paralyzed) long before waking up. The patient wakes up in the recovery room, only minutes after surgery.
Breast Lift and Liposuction
For years, liposuction has been the most popular cosmetic surgical procedure now performed in the U.S., although breast augmentation may be even more popular today. Not surprisingly, many women combine breast surgery with liposuction of other parts of their bodies, usually the lower body, to balance their proportions. Liposuction helps with the transformation from a pear shape to an hourglass figure.