Throughout my years as an aesthetic plastic surgeon in Baton Rouge, I've counseled thousands of women with regard to breast rejuvenation surgery. By this, I'm referring to those patients who consulted me, after either nursing their children, going through weight gain and loss, or simply experiencing the effects of "time and gravity," and watching their breast position descend steadily downward. Some may still have ample breast size, but most lack desirable size, as well. These women become self-conscious about their breast appearance, which now differs dramatically from what it may have been years earlier and also differs substantially from what they notice in other (usually younger) women. When I meet with these patients during their initial consultation, they often hope to hear that their breast "look" can be easily restored with a "simple" breast augmentation, but they quickly learn that, at the very least, a breast lift (mastopexy) will be required. I plan to go through the frequently asked questions (FAQ's) that tend to arise with these patients, just as I did elsewhere relating to the topic of breast augmentation. I hope this discussion will help women to clarify the reasons why a breast lift is required and what they should expect from this procedure. I will also divide these FAQ's into categories, the way I have done with other topics.
There's frequently confusion among patients who desire breast rejuvenation, but are uncertain whether or not a breast lift would be required. If you decide to come to me for help in deciding what would be the best way for you to achieve your desired result, I will examine you, discuss your wishes and consider the following points:
- When a breast lift really isn't necessary—If you are a patient who, after passage of time, has noticed her breasts becoming smaller and "empty" in appearance, but the position of your nipples has stayed about the same, then it's likely a breast lift is not necessary and simple implant placement would provide your best result.
-
Unwillingness to accept breast lift scars—There are many patients who come to see me thinking rejuvenation of their breasts can be done with implants alone, but because of the extent to which their breasts have already dropped, they must be informed of the need for a lift. Some of these patients are unprepared for that information and can't bring themselves to accept the idea of acquiring the additional scars that must go along with a breast lift. For such patients, it may be better to avoid any breast surgery until they come to a realization that the "look" of their breasts, even with the scars of a lift, would be much better than the appearance of their breasts without the lift. Only then are they ready to accept the compromise of "pretty breasts with scars" as being a more acceptable alternative than "sagged breasts without scars."
-
The ideal breast lift patient—Some women are happy with their breast size and unconcerned about the possibility of breast lift scars. All they want is "perkier" appearing breasts. If their breast examination shows their breast position to have dropped below an acceptable level (breast ptosis), then these are indeed the best candidates for a breast lift. This is the exact set of conditions for which the mastopexy was originally designed.
-
More than just the breast lift—There are those patients who know they need a breast lift, but who also want their breast size changed. If they would like to have larger breasts after surgery, they require a breast lift with implant placement (augmentation mastopexy). If they want smaller but "lifted" breasts, they should have a breast lift with a simultaneous small reduction in breast volume (mastopexy with minor reduction). If they want their "large" breasts both lifted and made much smaller, they shouldn't have a mastopexy for cosmetic reasons. A medically recommended "breast reduction" for health and comfort reasons, is the procedure they require.
Though you may find these points to be helpful in determining your possible need for a mastopexy, you probably would be well advised to make an appointment for evaluation by a plastic surgeon, who is the true expert to confirm or dispute your suspicions.
If all I want is the breast "look" I had in the past, why must I now consider a breast lift (mastopexy)?
We must start to answer this question by agreeing that the ideal "look" of a youthful breast (with good shape, appropriate size and location of the areola, as well as smooth, unblemished, elastic skin) cannot really be created through cosmetic breast surgery. If a patient's breasts have "dropped" over time, it's a known fact that relaxed and stretched breast skin was necessary to allow the breast to shift in that downward direction. This "dropped" condition, known as "ptosis," which produces noticeable breast sagging, is one of the things that makes breasts appear less youthful and which can only be improved with a breast lift. If there has only been a small amount of breast sag, and the patient's breast skin has fairly good elasticity (provided she is also agreeable to an increase in breast size) there may be the choice of just placing implants to "tighten" the breast and improve its position. Very often, however, the breasts have dropped beyond the level for which implants alone will produce an attractive "look" (and breast position), and the only solution then is to add a breast lift to the surgery plan. Always, the judgment regarding "just using implants" is in the hands of your plastic surgeon who, because of training and experience, can do the necessary evaluation and determine the best procedure for the improvement you desire.
Are all the scars that I see on the Internet when I view "lifted breasts" really necessary?
A breast lift works to raise the breast by tightening the skin of the breast, and at the same time it moves and changes the size and position of the areola. There are a few different surgical methods by which this can be done, but all such operations require scars longer and often wider than the "simple small scars" used for breast augmentation. Without the scars, it would not be possible to tighten the skin of the breast and cause the desired lift. The number and size of the scars is actually related to the extent the breast must be lifted. Hence, a small degree of lift may be associated with a smaller scar than when a large amount of lift is needed. This is another piece of information to be learned in consultation with your plastic surgeon after your breast appearance has been carefully assessed.
How is a breast lift performed?
It's often hard for patients to understand how a breast lift (mastopexy) can actually lift the breasts to a better position and shape. It's also difficult for the plastic surgeon to explain this process to prospective patients. Fortunately, our "American Society of Plastic Surgeons" (ASPS) has made available a very helpful animated video that shows and explains each of the available breast lift techniques. Hopefully, you're able to access that video. There's an additional ASPS web page that provides an online version of the same mastopexy information packet that is frequently distributed to patients by individual plastic surgeons. Spending some time at each of those sites should help you answer your question about how a breast lift is performed.
What are the various types of breast lift?
The four types of breast lifts are listed and well described in the animated video on the website of our "American Society of Plastic Surgeons" (ASPS), which I previously recommended viewing. I would like to add my comments concerning each of the types, based upon my many years of experience using each.
Crescent Technique
This operation is a very minor upward adjustment of areola position caused when a crescent of breast skin is removed from the area adjoining the upper half of the perimeter of the areola (left side of figure). When this is then sutured, the upper areolar margin is pulled further upward, leaving a scar along the upper half of the margin of the areola (right side of figure). I don't really consider this to be a breast lift but merely an upward shift of the areolar position. I only find this procedure to be useful for making a minor adjustment when one areola is slightly higher than the other.
Doughnut (Circumferential) Technique
The doughnut mastopexy (also known as the Benelli or doughnut mastopexy) received enthusiasm when it was first introduced, because it was felt to be a way to tighten loose breast skin by removing a doughnut shaped strip of skin from the area of breast adjacent to the "new" areolar margin (left side of figure). When this doughnut area was then sutured, the skin was tightened and only a single circular scar at the margin of the areola resulted (right side of figure). Unfortunately, very few patients with this procedure have an excellent result. Problems include wide scars at the areolar margin, wrinkled breast skin at the areolar margin, stretched out areolae (often to different diameters right and left) and an increasing amount of flattening of the breast as the amount of loose skin to be removed increases. In my opinion, this operation is suitable only for the occasional patient who needs a small amount of lift, is willing to accept the above mentioned risks and cannot convince herself that opting for a vertical scar technique would be a better compromise.
T-Incision (Anchor Scar) Technique
This is the "full" mastopexy technique, which removes a "keyhole" pattern of loose skin and is always associated with the familiar "anchor" scar. It offers the plastic surgeon the ability to remove excess breast skin in three dimensions and therefore produce the most "shapely" lift regardless of the amount of breast sag. I find this to be the operation most suitable for the largest number of patients. If the maximum benefit from a lift, with regard to improved position as well as improved shape is the goal, this is the most reliable technique to give that result.
Vertical Incision (Lollipop) Technique
This technique, also referred to as the lollipop or Benelli-Lollipop method, is the procedure I prefer to use when a patient has minimal sag, such that skin tightening along the breast crease is not necessary. It is then possible to lift the breast, leaving only a simple scar shaped like a "lollipop” rather than the full "anchor". Using this technique lessens the likelihood of the problems with the doughnut method of its bad scars and breast flattening.
How long does a breast lift take?
The length of time it takes me to perform a breast lift is about one and a half hours. From the time a patient must arrive at the accredited outpatient surgery facility, until she is ready to be discharged home, is about four hours. The last hour of that time is spent in recovery under the care of experienced nurses.
What kind of anesthesia is required for a breast lift?
I perform breast lifts under either IV sedation (twilight sleep) or general anesthesia (fully asleep). For a full lift with the "anchor" incision, I usually prefer a general anesthetic.
How much pain is involved with a breast lift?
All surgery is associated with some pain. For a breast lift without implants, the pain is relatively mild. If implants are used, there is greater pain, but it is still quite controllable and easily tolerated by almost all patients.
Must I have someone with me on the day of my breast lift?
Because of the drugs necessary for your anesthesia and relaxation, a responsible person is required to bring you to the surgery center and take you home after surgery. You must also have a responsible person with you through the first post-operative night and until the next morning.
After surgery, are there stitches that must later be removed?
All sutures I use for a breast lift are self-dissolving. There is no need for removal of stitches.
How long before I can return to work (school)?
I normally tell patients to plan to miss at least five days of work or school. Better, yet, if they can afford to miss more, I advise seven days.
Will I be able to nurse children following a breast lift?
During breast lift surgery, breast tissue is not normally removed, and the surgery avoids interfering with the natural communications (ducts) between the patient's milk glands and her nipples. Consequently, there's no reason for a breast lift to interfere with your future ability to nurse children.
Do I stand a chance of losing feeling in my nipples after breast lift?
If a breast lift is performed without also placing implants, nipple feeling should not be permanently lost. If, however, implants are placed at the same time, the risk of losing nipple sensitivity rises to the same chance as with breast augmentation.
What are the risks associated with breast lift?
As with all surgical procedures, breast lift surgery (mastopexy) has the usual surgical risks of anesthesia difficulties, post-operative bleeding, post-operative infection and, because skin and breast tissues are shifted around to create the "lift," there's an additional risk that disturbed blood flow could result in the failure of some of the skin edges or the nipple and areola to survive and heal properly after surgery. All of these risks are increased in patients who smoke, and avoiding all Nicotine for at least two weeks before and after surgery is strongly recommended. If implants are also used with the breast lift, the normal risks associated with breast augmentation also apply. Fortunately, when this operation is performed on healthy patients by a properly trained surgeon and his staff, these complications are infrequent.
Will I require additional breast lifts in the future?
No one can predict the length of time a patient will remain satisfied with her breast appearance after a breast lift. For certain, the breast appearance will gradually change with passage of time as it always does. Without experiencing future pregnancies or extreme fluctuations in body weight some of the benefits of a breast lift can last a lifetime. If, because of diminishing skin resilience and elasticity, the breasts do begin to drop again and the patient becomes (once again) disconcerted about her breast appearance, additional rejuvenation surgery often requires less than a full redo of the original mastopexy. Much depends upon a patient's own view of her breast appearance as to whether she would find future need to repeat a breast lift.
How long, after a breast lift, before the swelling disappears and my breasts look natural?
After a mastopexy there is some swelling, to be sure, that goes away for the most part in three to six weeks, but it isn't totally gone until six to twelve months after surgery. There is also, at first, a somewhat abnormal shape to the breasts, caused by the way the newly tightened skin lifts the breasts, and this requires about six weeks or more before the skin relaxes and the breasts "settle in." So I usually tell patients they will have to wait a couple of months before their breasts look completely normal, except for the presence of new scars. For those scars to lose their pink color and "blend in," six to twelve months are usually required.
What are the normal follow-up visits after breast lift surgery?
If everything seems to be going well for the patient (we depend on phone contact), she is given an appointment for her first return examination in about one week. At that time, she is examined, reassured about any concerns, and instructed about the things she should (and shouldn't) start doing at home. The next visit is in two to three months to confirm the breasts appearance when the skin has relaxed and the breasts have had a chance to "settle in." A final visit takes place six to twelve months later, when the scars have had an opportunity to blend in.
How long is it after breast lift before I can get a tan on my breasts?
There is some concern about excessive sun exposure and, also, tanning bed usage possibly causing scars to turn a darker brown color during the first six months of healing (when the scars are still pink). So, tanning the breasts, during the first six months may risk that type of scar discoloration, unless the scars themselves are protected with a good quality waterproof sunscreen (e.g. Murad Waterproof Sunblock SPF 30). Since breast lift scars are "hidden" around the areola and on the under surface of the breast, the "normally exposed to view" upper areas of the breasts can be tanned without similar concerns.
Can breast lift be combined with other types of surgery?
Breast lifts can and frequently are combined with other types of surgery. Occasionally, they are performed in the hospital along with procedures by other specialists (e.g. gynecologists performing hysterectomies). More often, breast lifts are combined with other forms of cosmetic surgery, like abdominoplasty, liposuction, facial procedures, thigh lifts, labiaplasties, etc. This is usually at a cost savings over having the cosmetic procedures performed separately.
Why, after having my breast lift, do I still not have the "full" breasts I wanted?
Frequently, after the initial swelling and skin tightness of a breast lift has disappeared, women begin to notice a "flattening" occurring over the upper portion of their breasts that makes them unhappy. That isn't the way they imagined their breasts would appear after a "lift," and they request an explanation. This is probably the greatest source of disappointment for many women who have undergone this procedure, and it's usually due to unrealistic expectations about what this operation is really capable of achieving.
Describing a breast lift on its simplest terms, I would say it's a procedure to lift the "contents" of the breast to a higher position, to raise and decrease the size of its overly large areola and to bring some of the breast's volume that has spread toward the side of the chest into better alignment within the breast and more centered on the nipple. The design of the operation is remarkable in that those things can all be accomplished with just the removal of a pre-selected area of skin, making modest adjustments to the breast tissue and then suturing it all back together.
The limit to how much a breast lift can "reshape" the sagging breast is very much determined by the quantity and quality of the breast tissue (breast "contents") that the operation must lift. This breast tissue quality varies from one patient to the next, from being very rich in "glandular" content (which is moderately firm and already has a nice rounded shape) to being almost totally "fatty" content (which is soft and shapeless and sinks downward within the breast, not providing upper breast fullness). Because of this variation in the quantity and quality of breast tissue, there's likewise a variation in the results when one patient after breast lift is compared to the next. Unfortunately, all cannot have the same result with respect to breast shape. Adding an implant at the same time as the lift may help this somewhat, but with the presence of little natural "glandular" tissue, even that breast may soon settle and fail to maintain the "perky and full look" a patient desires.
Why do I now have this "infection" with drainage under my breast?
During the process of surgically lifting a breast (depending on the type of breast lift required) it's often necessary to suture "skin corner" areas together after the skin has been shifted and is now being tightened. Depending on the patient's blood flow to those corner areas (frequently not so good in those who are smokers), there may not be enough blood available to keep the areas completely alive. In these patients, the skin corner area turns dark and eventually opens up (usually within the first two to three weeks), creating a space that's moist and produces drainage. This really isn't an "infection," as patients are prone to think. It is a problem that eventually repairs itself if it's kept clean and given sufficient time. It may cause the final scar in that area to be somewhat thicker than normal but, even then, rarely requires scar revision surgery. I'm very willing to see my patients more frequently during this troubling time until things are on a course to good healing.
Why does one of my areolae differ in size from the other after my breast lift?
The surgical planning for a breast lift (mastopexy) includes preoperative skin marking with the patient sitting up and using templates and measuring instruments to achieve the best possible symmetry between the right and left breast. Even when the two breasts are noticeably different before surgery (as they almost always are) I try to produce good symmetry with this procedure. Unfortunately, the two breasts really are two "different" breasts, and they go through somewhat different influences during the healing process. As a consequence, the skin of one lifted breast may relax and stretch in different ways than the skin of the opposite breast. No breasts end up exactly equal. If the skin behavior after surgery of one breast allows for a widening of the areola, but the same doesn't happen with the opposite breast, there will be, in the end, differences between the two areolae. Try as I may to create breast and areola symmetry with this procedure, there are no guarantees as to how the healing process will cooperate with my intentions. The best I can do, after the fact, is to help my patient decide whether further surgery should be considered in an attempt to improve areolar symmetry.
Why are my scars becoming thicker and more tender?
Scar thickening can happen after any deep skin injury or any surgical incision. With breast lift, the surgical incisions are sometimes long and have a greater chance of thickening. Whether or not scar thickening occurs is frequently related to the type of skin and is an inherited characteristic. We know that genetically darker skin (e.g. African-American, Asian or Mediterranean) is more likely to form thick scars than very light skin (e.g. Scandinavian), but there are very frequent exceptions to this general rule. The best a surgeon can do is to handle the skin properly during surgery and use quality suture material with meticulous suturing technique. Even doing that, many scars thicken and some eventually require scar revision. Occasional improvement is achieved with Cortisone injections, but because of possible risks this is a decision that must be made by your surgeon.
What is this firm lump I can now feel under the skin of my breast?
Many patients, during their first year after breast lift (mastopexy), notice bumps or lumps under the skin that they can feel. Naturally this raises concern, but they can almost always be easily explained and likely are nothing serious to worry about. Some of the possible causes include suture knots under the skin that have not yet dissolved away, areas of deep surgical scar that have yet to soften, or a condition called "fat necrosis," which is the hardening of a section of breast fat that has been deprived of some of its normal blood flow. None of these items require treatment, but consultation with the surgeon is advisable so he (or she) can make a determination regarding diagnostic testing.
Why are my breasts dropping again after having my breast lift?
Life goes on, as does the aging process. Once a breast lift has been performed, the breasts have been lifted, as we know, by tightening the breast skin. But skin is living tissue, with the ability to be stretched once again. Aside from future pregnancy or extreme weight gain or loss, the main thing trying to once again stretch the breast skin is the weight of the breasts, themselves, under the influence of gravity. The more "elastic" the patient's breast skin, the less likely it will stretch and let the breasts drop. With some women, the breasts drop more quickly, but in all women, gravity seems to "win out" in the end.
What are these dark areas within my areola?
One of the most dreaded complications of a breast lift (and also for a breast reduction) is the situation in which, because of insufficient blood flow, the nipple and areola fail to survive after the surgery. With this (extremely rare) complication, black discoloration occurs in the dead tissues of the nipple and areola, and surgery is often required to rebuild those tissues. More often, when blood flow to the nipple and areola becomes deficient, there is a failure to survive of only portions of the areola. It is then that the patient wonders about the black areas that occur within the areola. These areas may take weeks to fully heal, but the areolae have good healing capability, and it's unusual for additional surgery to be required. The likelihood of this problem is greatest for breasts of patients who smoke, breasts that require an extreme lift, those that undergo simultaneous placement of large implants, or those revision procedures in which the breasts have undergone a previous breast lift or other breast operation.
