Do 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

Women who have minimal 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 twenty 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 (20's and 30's) will generally opt for a breast augmentation, and older women (40's and older) more readily accept a breast lift. However, I certainly have operated on plenty of women in their thirties 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 fiftysomethings. 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 lift/augmentation is the right combined operation. 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.

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 doing an augmentation 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, there is no substitute for a breast lift.

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 lift is minimal. Usually, the nipple level stays about the same after an augmentation alone.

The Benefits of a Breast Lift

Reduction of areolar size is seen 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 horizontal scar 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 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.

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 women with less than 300 grams of tissue removed also report significantly less symptoms of neck, shoulder, and back pain after surgery.

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. The shape remains "bottomed-out." It is better to remove extra breast tissue from the lower pole, where it is not needed, and add to the upper pole, where it is welcome.

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'd 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. Breast tissue is simply too malleable.

Sometimes women say, "I'm satisfied with my size, I just want a lift." They 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 the upper poles. That is why implants are recommended, even if they are small ones. It is much more common for me to perform augmentation/mastopexies than mastopexies alone.

Pregnancy

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.

Breast-feeding

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.

Combined Procedures

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. Women may also desire fuller breasts. They have lost firmness and find the upper portions of their breasts 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; it is simply held in a tighter envelope. Patients wonder if 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 none if an inverted-T approach is used. 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).

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 forties and fifties, 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 for me 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 is over (to avoid restretching the tissues later), so it often works out that the timing is right for both at the same time. 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. This avoids a second operation.

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.