A breast lift without implants works well in patients who are satisfied with their breast size but not satisfied with sagging and excessive overhang of their breasts and a low nipple position. A breast lift will reshape the breast, raising the nipple to a better position and reducing the overhang of the breast. The breast will not be smaller than it was before, just higher. There will be better fullness of the breast behind the nipple as the tissue is pushed upward and held in a tighter “skin envelope”. However, there is no way of reliably creating more fullness in the upper pole of the breast without using an implant. And since the scars of a breast lift are in the lower breast and hidden beneath a bathing suit, a lift will not tighten the loose skin of the upper breast; only restoring volume with an implant will fill out a truly deflated breast.
Many patients who want to increase their breast size and fullness with implants want to avoid the additional scars of a breast lift. However, if the breast is too low and too overhanging past the crease under the breast, this skin and tissue will not be properly filled out by the implant and may have the appearance of “hanging off” the implant. This is also called a “double bubble” or “Snoopy” breast. This is because the bottom of the implant pocket is at this inframammary crease. If the breast hangs too low past this point, the implant will have little effect on filling it out. And if the nipple is low, it may become even more down pointing as it is too far below the midpoint or “equator” of the implant.
In summary, breasts implants do not lift breasts, they fill them out where they are. And if the breast hangs too low, they won’t even do that very well.
When the cosmetic surgeon examines you, measurements are made to assess where the nipple lies in relation to the fold under the breast, and how much breast overhang if any there is past this fold.
There are some patients whose breasts are “borderline” in terms of whether a breast lift is needed. The nipple may be somewhat lower than ideal, and there may be more breast overhang than ideal but not too excessive. In many cases a “dual plane” technique may be used in order to obtain a good result without the additional scars of a lift. This involves placing the implant under the muscle, as is usually done for better implant camouflage and a lower risk of capsular contracture, but releasing the attachment of the muscle to the overlying breast tissue a little to encourage the implant to “fill out” the loose tissue at the bottom of the breast. If this is successful, the nipple may look a little higher (even though it is not) as the bottom of the breast is filled by the implant. In this way, some of these borderline patients may avoid a breast lift. But if they want a higher breast or higher nipples, they will need a lift.
The breast lift with the least scarring is the periareolar or Benelli breast lift, which has a scar just around the areola and no vertical scar. In this lift a larger circle is drawn out from the areola, the top of this outer circle placed where the areola will be raised, and an inner circle is drawn within the areola (designed to reduce the size of a stretched-out areola). The skin between is removed, a purse-string suture is placed at the outer circle and cinched down around the inner, smaller circle, thus tightening the skin, reducing the areola size, and raising the nipple position.
Although most patients who need a lift want to avoid the vertical scar, there are serious limitations to this periareolar lift. If anything more than a very mild lift is required, the cinching down of this larger circle creates a gathering, puckered effect that leads to unsatisfactory scarring. Also, this tightening can lead to flattening of the breast shape that even an implant will not help counteract. (This lift is usually not attempted in patients without an implant, as the flattening effect and very minor lifting effect is not enough to obtain a good result.) Also, there is less control over the final size and shape of the areola, since late stretching of the areola can occur even with a permanent purse-string suture.
The vertical breast lift adds a vertical scar to this periareolar lift. This vertical scar has a very strong and effective shaping effect on the breast. A periareolar purse-string suture is still used, but closing the vertical incision reduces the size of the large outer circle and reduces the gathering effect. There is a difference of opinion among surgeons as to how effective this type of lift is at reducing significant breast overhang.
The anchor breast lift consists of a scar around the areola and a vertical scar, and adds a scar under the breast that allows very effective lifting and reduction of breast overhang. Moreover, the skin removal that raises the nipple to a better position and reduces the areola size does not require the dependence on a purse-string gathering suture; instead, skin is trimmed in a keyhole pattern than closes around the newly reduced areola with an exact fit. Thus the control over areolar size and shape is the most reliable, and the periareolar scar is of the best quality. Many surgeons believe this is the most effective breast lift with the best scar quality.
This is a controversial topic. Some surgeons never perform these at the same surgery, while others always do. Essentially, these two procedures can “work against” each other: breast augmentation expands the breast while a breast lift tightens the breast. You might think that you could place an implant and just “tailor” and trim the skin around it. Unfortunately, a certain amount of skin removal is required in order to lift the nipple to the correct position, close the defect where the nipple and areola used to be (and large areolas make this even tighter!), and adequately reduce the overhang of the breast. The tightness of this skin removal can restrict the size of an implant that can be safely placed, and this can be smaller than the patient desired. With too tight a closure, incisions can come apart, skin can lose its blood supply and die, healing can be prolonged, and the scars that result can be very wide and unsightly.
Another issue is the blood supply to the nipple. Dissecting a pocket for an implant can reduce the blood supply to the nipple, as can the dissection required to move the nipple higher as part of a breast lift. When performed separately, it would be extremely rare to have any blood supply issues; when performed together, this could tip the balance and loss or necrosis of the nipple and areola has been known to occur, especially with larger implants, tighter closures, and in patients with thinner tissues.
In general, patient who require minor lifts and have thicker tissues can often have both procedures performed at the same time, while patients with thinner tissues who need more major lifts may be safer having the lift performed first and the implant placed later. This staged approach takes a loose, overhanging breast that is not a good candidate for an implant, and reshapes the breast so that, once healed, it becomes a good candidate for breast augmentation.
No one wants extra scars that are not necessary, but many breast augmentation patients try to avoid a breast lift at all cost even when it is needed. This sets them up for a poor result and more surgical procedures in the future. Some surgeons will place too-large implants above the muscle in an attempt to fill out the loose skin and avoid the breast lift that the patient needs but does not want. Ultimately this may lead to even more tissue stretching and breast sagging, and require more complex surgeries to fix the problem. It is better to have a well-shaped breast with scars that generally fade nicely over time than an implanted breast with an unsatisfactory shape and contour.