Breast Q&A: To Breast Lift or Not to Breast Lift, With or Without Implants?

Perhaps the two most frequently asked questions I receive from women interested in breast enhancement surgery are:

  1. “Do I need a breast lift with or without implants?”
  2. “Can I get an ideal result with just breast implants?”

As with most operations, it’s always best to get things right the first time around. And when it comes to breasts, getting it right doesn’t typically mean looking great for only a few short years before the effects of gravity and time undue all the good work that was done.

So when I advise my mastopexy (breast lift) patients on what their options are for achieving the best and most youthful looking breast possible, I always make sure that they have a crystal clear understanding of what their surgery options are and how each option will look and feel over time (re: 1 year, 5 years, 10 years etc.) rather than just what they can expect to look like during the immediate post-operative period.

9 times out of 10, the best path forward is clear and the patient is in full agreement that the procedure’s pros outweigh any cons that may inherently be involved (e.g. a slightly longer incision in return for a stronger, more longer lasting lift).

Of course, not every breast fits perfectly into one of the the breast types described below, but most do, so hopefully readers will find the following example photos and procedure recommendations helpful and/or informative , especially if they are considering their options for a breast lift with or without implants/augmentation.
 

How To Determine Your “Breast Type”

Plainly put, breast type is based on a.) the position of the nipple in relation to the breast crease and b.) which direction the nipple is pointing (down, slightly down, straight ahead, slightly up, etc.)

When determining the type of breast a patient has and how best to correct it, there are 3 important features that need to be measured/considered during the examination:

breast droop test

  • Front-view nipple position test – First, the surgeon must correctly classify the position of the nipple areola in relation to the rest of the breast. In an implant-only breast, it should be easy to see the lower pole of the breast (re: the underbelly of the breast beneath the areola) when viewed straight on.
  • Side-view breast droop test – Second, from the side, the nipple areola should sit higher than the sweep of the breast. If that is not the case, then the patient has what is called ptosis, or a drooping of the breast tissue.
  • Pencil-under-breast fold test – An age old test that helps assess breast ptosis. A pencil is placed below the breast and depending on where the breast falls in relation to the pencil, stages of breast ptosis can be determined.

There are, of course, a few caveats to the above. first, an inability to see the lower pole of the breast is sometimes related to a short distance from the base of the nipple areola to the inframammary crease and b.) glandular tissue of the breast has dropped inferiorly along with the nipple areola and is sitting lower down on the chest wall.

After over 1,750 breast operations, and thousands of breast consultations, I’ve found that the vast majority of breast lift and augmentation patients fit into the following 6 “breast types”.
 

Breast Types That *Do Not* Require a Breast Lift
(with or without implants):
 

Type 1 – Nipple is in proper position,
but breast is deflated and/or without volume

implants-alone

If on examination the patient has a properly positioned nipple areola but has lost breast volume superiorly, then a straightforward submuscular augmentation is the appropriate treatment. New mothers who have recently finished breast-feeding make up the majority of these types of cases. The final result can often mirror what the breasts looked like during labor or just before, which is what many patients desire.

As you can see in the example below, while pregnancy has deflated the breast, it hasn’t caused the nipple to droop, so implants alone were enough to create the desired, ideal look.

If your breasts look like this, no mastopexy is needed! A standard breast augmentation (using an inframammary or periareolar incision) should more than suffice.
 

Type 2 – Nipple is slightly lower than inframammary fold,
but significant sagging (2+ inches) *is not* present

significant-sag

Sometimes, when the nipple areola sits slightly lower than the ideal position but does not yet demonstrate significant droop, then a dual plane augmentation in which the lower portion of the breast prostheses sits in a subglandular plane is usually the best approach.

The difference between a dual plan and submuscular augmentation is that in a dual plane, only the upper two thirds of the prostheses sit beneath the muscle. This allows for a slight superior rotation and elevation of the nipple areola. In my patients, dual plane augmentations have held up very well over time and generated enough upward rotation to create an attractive, mastopexy-free result.
 

Breast Types That *Do* Require a Breast Lift
(with or without implant):

These types possess more droop, deflation and/or lax skin tissue. Surgery plan may vary depending on the experience and training of the plastic surgeons you speak with. For example, surgeons with extensive experience using the periareolar approach can often use it in situations where another surgeon would simply go with what they know best… the vertical ‘lollipop’ approach.

Vertical “Lollipop” Approach:
lolipop-beforelolipop-approach
Periareolar Approach:
periareolar-approachafter-circle

Type 3 – Nipple is below inframammary fold
and 1st or 2nd degree ptosis (2+ inches) *is* present

When the nipple areola has descended further down on the chest and the degree of ptosis is between first and second degree. In those cases, straight augmentation whether submuscular or dual-plane is not appropriate. The patient will need a breast lift with implants for long lasting results. Historically, many plastic surgeons have utilized a subglandular augmentation as their treatment of choice, to avoid any lift-style scars on the breasts. They also utilized excessively large prostheses to fill the stretched skin envelope.

What makes this approach controversial is that in the short term (re: less than 5 years), many of these cases will appear OK esthetically. However, sooner rather than later, the breasts will eventually begin to take on the “two melons hanging low on the chest” look, which will require another surgery to correct. This effect becomes even more apparent when saline implants are utilized.

I have found in these borderline cases that a submuscular or dual-plane placement of the implant with a periareolar “Benelli” mastopexy is an excellent compromise. Although you cannot elevate the nipple areola to a great degree, usually 2.0cm – 3.0cm maximum, it does bring it into a position where the inferior skin envelope can be seen from the front.

When properly performed, a Benelli lift with submuscular or dual-plane implant will not flattened the areola, nor spread or stretch it out.

When incorrectly executed, it often will – so this is definitely an option you want to make sure your surgeon is in 100% agreement with.

If I show patients photos of people who have come to me with implants (often above the muscle) placed by other doctors who needed a lift but decided not to get one and ask if they would be happy with that look in a few short years, they have never, in all my years of practice, said they would like that look.
 

Type 4 – Nipple is low or below inframammary fold
and distance between the areola & crease is short

short-crease

When the nipple areola is in that lower position, but the distance between the areola and the inframammary fold is short – which is sometimes the case in tubular or tuberous breasts – then 1.) lowering of the crease and releasing the inferior breast tissue through a periareolar incision; 2.) placing the implant in a dual plane position and 3.) performing a periareolar mastopexy typically yields an excellent aesthetic results.
 

Type 5 – Nipple is below inframammary fold
and grade 2 or grade 3 ptosis is present

vertical-downsides

When the glandular tissue is sitting well below the equator of the breast, and sits on the chest wall, the patient should pass what we call the “positive pencil test” (re: you can put a pencil beneath the breast and it would sit securely in position). In these types of cases, without any tightening of the inferior pole, bottoming out of the breast would recur, or persist if conservative augmentation was performed. A breast lift and augmentation is recommended for patients presented with this breast type.

In those cases, I recommend a vertical or “lollipop” mastopexy where the prostheses can be placed in the full submuscular position, the nipple areola elevated more aggressively to a higher position and the excess/ptotic inferior pole breast tissue excised. That truly places the breast mound higher on the chest in a more youthful and natural position. It also holds up very well over an extended period of time.

The downsides to a vertical lift are: a.) the vertical scar can sometimes indent (though this can be corrected secondarily) and b.) there is a limit to the amount of skin that can be excised. can easily be corrected after the initial recovery period.

I recently saw a former patient who had this situation and underwent a vertical mastopexy and augmentation and in a subsequent five years had had a child and breast-fed. Her breasts still sit high on the chest without any signs of ptosis “droop” and the scars have faded dramatically. That would not have been the case with a lesser procedure.
 

Type 6 – Nipple is below inframammary fold,
and breasts are very or completely deflated
and there is excessive loose skin (due to major weight loss)

In the cases of massive weight loss, when there has been a dramatic loss in breast volume and there is a marked redundancy of skin, then I generally utilize an inverted T approach. This allows for adequate resection of the skin after placing the prosthesis again in the muscular plane. This approach likewise will withstand the test of time but fortunately it comprises less than 10% of the breast lifts I perform.

*     *     *

In closing, there is (rightly) no one-size-fits-all approach to breasts that will benefit from an augmentation and lift. The main responsibility plastic surgeons have in most every breast lift case is to provide a long-term solution rather than a short-term band aid (that often leaves the breasts looking worse after a few short years).

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