What is a Breast Lift and Who Needs One? (Ep 17)

Dr. Hall: Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I’m your host, Dr. Jason Hall.

Dr. Hall: Breast lift surgery is something that I do a lot of. A lot of my patients are women that are in the ages where they’re done having kids, and the question comes up a lot: “Do I need a lift? Do I not need a lift? And is an implant going to do the job by itself?” Because what most women are afraid of with a breast lift are the scars.

And we’ll talk about the scars here in just a second, but I really want to kind of talk about what a breast lift is, who needs it, who doesn’t need it, and the ins and outs of the surgery itself. When women are done having kids and are looking to rejuvenate their breasts, one of the questions that is gnawing in the back of everybody’s mind before coming to see a plastic surgeon is, “Am I going to need a lift or not?” And unless you are genetically blessed, chances are if you’ve had children and you’ve breastfed, that you’ll probably need some form of breast lift in addition to an augmentation, if you’re looking to increase size, volume, and fullness that may or may not have been present before having kids.

So, the question is, “Who needs a breast lift?” There are really two groups of women that need a breast lift as part of their surgery. One is women whose breasts have become ptotic, which is kind of a fancy word for saying saggy. And then the other group—and these are the women who tend to get surprised during their consultation—is women who don’t necessarily have breast ptosis or droopiness, but their skin and breast tissue have relaxed because of the hormone changes that occurred during pregnancy and the skin damage and breast tissue damage that happens as a result of the expanding and contracting of the breast tissue. Over time, that skin becomes loose and kind of floppy, even if it’s not directly sagging.

In those cases, the lift part of the operation is really more to tighten skin around our implant or to tighten the skin around our fat grafting and prevent future drooping that will happen over time. So, the quick rule of thumb is that if you stand undressed in front of a mirror, take a pencil and put a pencil in your breast crease, if you can keep a pencil supported between your chest. That probably means you’ll need a breast lift when we start talking about breast rejuvenation. The big thing about breast lift, whether it is a lift by itself or a lift and implants, that is not often discussed is that breast lifting is really an operation that is about tissue quality: skin quality, and breast tissue quality. It’s often thought that droopiness or sagginess is really the main component of breast lift surgery; that’s really the symptom of the underlying problem, which is one of tissue quality.

What happens is that because of the hormonal changes that occur during pregnancy, the ligaments, the suspension of the breast itself—most people don’t even know your breast has ligaments in it that support the breast tissue that kind of anchor your breast tissue to your chest wall—and the underlying muscles, those get stretched out over time. And when those gets stretched out, that’s what contributes to the breast dropping over time. The other thing that happens is that dense breast tissue over time, especially with pregnancy, tends to change and atrophy, or soften and sort of shrivel up for lack of a better term. And so, the breast loses support both from the ligaments and from the breast tissue.

Thirdly is that the skin actually can get damaged. If you see stretch marks, those are indications that the elastic properties of the skin have been damaged and they can’t support the breast anymore. And so, when we talk about doing breast lift surgery, it really is an operation that is taking breast tissue skin and ligament tissue that has quit doing its job and then asking it to do its job again. And so, we really need to make sure that we have realistic expectations in mind and that we’re not trying to ask that skin breast tissue and support tissue to do more than it really can. And the point that I’m really trying to make is that sagging of the breasts, even after a breast lift, with or without an implant, is still going to happen. There’s nothing that we’re going to do that’s going to prevent recurrent sagginess.

What we want to try and do is do everything we can to help slow that process down and help to prevent that. How we do our surgery is one way to do that, how you take care of the results of your surgery is another way that we can help to slow that aging process down. The fact that the breast tissue has kind of given up, for lack of a better term, is also why just using an implant to fill out the skin that is empty or sagging doesn’t work. Because if you look at women who have had breast augmentations—and Instagram before and after pictures on any plastic surgeon's website is full of them—most of those patients are very young patients who haven’t had kids, their breast tissue, their skin is still very tight and elastic. And what’s happening is we’re putting an implant in and the breast tissue and skin are fighting back. They’re squeezing down around that implant. And that interplay between the implant and the skin and breast tissue is really what is responsible for a lot of the look that accompanies a breast augmentation.

That look can be very difficult to get if our breast tissue is not really elastic anymore because then we’re relying on your surgeon—me, in my patients’ cases—trying to tighten that skin and breast tissue down around an implant, and that skin doesn’t want to stay tight; it wants to loosen. And in the case of lift with implants, we’re really having to walk a very fine balance between not tight enough and too tight. Too tight causes complications. Not tight enough causes early recurrence. So, there’s a very sort of narrow line that we have to try and walk. And that is why during your consultation, it’s important that we walk through those things so that we all understand where we are.

Now, goals of breast lift surgery. One is we want to reposition your breast back up on your chest where it belongs. The second goal is we want to reposition the nipple-areolar complex—so your nipple and areola—back on the center part of your breast. So, we want to get the breast in the chest, we want to get the nipple back on the breast. And then the third thing which kind of accompanies those two is we want to reshape your breast.

And in a lot of cases of postpartum women, women who have had kids and are finished having kids, a lot of what we refer to as involutional changes or loss of volume happens in the upper part of the breast. And that’s where we want to try and bring volume back when we reshape the breast. For some women, we can actually use your own tissue and augment the upper part of your breast with your own breast tissue. For other women, you simply don’t have enough tissue there to be able to fill out the upper pole of the breast and so we have to start looking at other alternatives: things like implants, things like autologous fat grafting where we do liposuction, and then transfer fat up to the upper part of your breast.

The next part of breast lift surgery that needs to be discussed is the question—for most women in my practice—we end up discussing combining volume augmentation, typically in the form of a breast implant, and a breast lift at the same time because most women want that volume restored, they want a more youthful appearance, they don’t want the ski slope appearance that can accompany some breast lifts, where you just don’t have a lot of volume in the upper pole anymore. And when we talk about a lift with implants, it’s important that we do that operation as safely as possible. Ten years ago, a lift and implants was, I don’t want to say frowned upon, but was much less common than it is today because as a group, we’ve learned how to do that procedure more safely. 10, 15 years ago, a lift and implants had a very high complication rate and most surgeons just did not want to do those two because they did not want their patients to have a high risk of having complications from an elective surgery. We still don’t want that, but because our understanding of this operation and the yin and the yang of these opposing forces, we know how to do that operation now much more reliably and much more safely.

With a lift and implants, it’s important that we choose an implant size that is going to get you the volume that you want, but then at the same time is not going to put too much strain on your tissues such that we can’t get the kind of lift that we want, we can’t get the nipple repositioned because we’ve put so much volume in your breast, that we can’t make those movements, and that we don’t put so much pressure on things once—as we’re trying to close incisions—that we either have vascular problems, either the skin or the nipple itself doesn’t get enough blood and ends up dying, which is a complete disaster because it means that we have to take your implants out and start all over. That is fortunately a very rare complication, but does happen. Or the other possibility is that we don’t tighten enough and then we’re talking about a breast that is too saggy too early and we need to do it is sort of a little tuck-up or a little secondary lift to help tighten things up. When I’m talking to my patients about this specific procedure—a lift with implants—there are really two ways that we can go, a lot of women will bring in pictures of a look that they’re going for, which I encourage because it helps further our conversation and make sure that our goals are the same, but a lot of times the pictures that people bring in are pictures of 20-year-old women with a breast implant by itself. And these women have never had kids and so we’re kind of trying to compare apples to oranges.

It’s still a good idea because we get to talk about breast aesthetics and what is attractive to you and what is possible. A lot of times where the discussion ends up going is that there’s some compromise that we make. We can’t get quite as much fullness and roundness or shape in the upper pole as we necessarily want because we won’t be able to get the lift that we need, or we’ll put too much pressure on the skin and risk complications. So, we either downsize our implant a little bit, or we end up talking about staging the procedure which we mentioned earlier. A lift that is a little too low is much easier to correct than a lift that’s too high, or dead nipples or open incisions or things like that.

If we’re going to have a mistake, if we’re going to have a problem, we want it to be a problem that’s easy to fix. In that case, the trade-off is either stage of the procedure, which really gives you a hundred percent chance of having two operations within the first year of our consultation, or we do our best to get the look that we want understanding that we may have to return to the operating room to tighten up that lift. And typically women who choose to have a single operation, somewhere between 10 and 20, 25% of them may need a second operation in the first year. So, your choice is a hundred percent chance of a secondary operation in a year, or 10 to 25% chance of a second operation within a year if your tissue relaxes too much. And so, in my practice, most women will choose a single operation because it is unusual to have to go back and do a second surgery. Most women get a great result, very happy and we don’t end up needing to do that.

A question that often comes up during a consultation for breast lift with implants is what size implants that we’re going to end up using. And I would refer you back to the podcast episode and videos we did that discuss how breast implants are sized, how we pick the appropriate size. It’s a combination of what you’re looking for in terms of cosmetic result, and then your chest measurements, your breast tissue, and what we call kind of a body planning to choose an appropriate size implant. Then it’s a matter of seeing what that implant actually looks like in the operating room. We have things called sizers, which are kind of like testers that we use in surgery and I’m able to really finely tune what that implant size is going to be in surgery.

It’s pretty good, after a number of years, over 12 years of doing this, of getting really close with our body planning in the operating room, but sometimes we do have to change, especially in women who have some chest wall asymmetries, if you’ve had previous implants, those types of cases, it’s good to have lots of sizes around so we can be very fluid in our implant choice and choose the one that works the best for you. Lastly, one of the big questions that comes up during a breast lift or lift and implant consultation is what type of incisions are going to be used. And there are three types of incisions that are used for breast lift surgery, and they build on top of each other. So, we have kind of the small, medium, and large incisions based on how much lift is necessary, and these incisions kind of add to each other. So, with the small one, you get that one for pretty much every breast lift, the medium one adds another incision, and if we move up to the large incision, it’s a combination of small and medium, plus a third incision.

What we would call the small one is a doughnut or periareolar mastopexy. And this is an incision that is around the areola. It takes, in cases of women who have very dilated areola after having children, or who were just born with large areola, we make the areola smaller, we make them more symmetric, and we’re able to do the surgery through those incisions. So, in a lot of cases, that’s the only incision that you have. Now, that is really for women who need very little lift of their areola, and little to no repositioning of the breast tissue. This is commonly used in conjunction with an implant.

The medium incision is kind of referred to as the lollipop incision. So, it takes that doughnut that periareolar mastopexy incision, and then adds a vertical component to it. So, running from—in various lengths—from the bottom of the areola down to the breast crease itself. And this allows me to tighten the breast tissue, create a nice shape to that breast, whether or not an implant is being used. And some surgeons will use that donut—that vertical mastopexy for pretty much every mastopexy no matter how much lift is needed.

I don’t do this primarily because in order to do that, you have to allow that scar to go down past the breast crease on to the abdomen and then count on that kind of working its way out over time. And what I found in my practice is that most of my patients don’t want the uncertainty of a scar that you know we think is going to ride up on the bottom part of their breast as things settle out and heal over the course of the first few months. And especially when an inframammary or breast crease incision is hidden in the crease and heals very well.

That kind of brings me to the third or the large mastopexy incision, which is kind of the standard anchor or teddy bear pattern incisions where we add a breast crease incision to that lollipop incision. And that breast crease incision is varying lengths. We try and keep it as short as we can, but has to be long enough to allow for reshaping of the breast and for removal of any excess skin and breast tissue in the lower part of the breast that can’t be repositioned. This inframammary scar is well-hidden, is in the breast crease, so even in underwear or swimsuits, you can’t see that scar if it’s done well. And in the event that it heals and is a little thick, it is something that can be either lasered or we treat those with steroids and get them to flatten out and go away, or at least be much less noticeable.

The periareolar mastopexy and vertical incisions tend to heal very nicely. Breast lift surgery is done as an outpatient. So, you come into the surgery center here, we do your surgery, you go home the same day. It’s unusual for me to use drains for breast list surgery. And similar to breast augmentation, the recovery is really limited to lifting and bouncing movements for the first six weeks after surgery. I like to let your breasts settle.

Most of my patients opt for a lift with implants, and so we treat that very similar in terms of recovery to a breast augmentation. We want an implant capsule to form around that implant to keep it where it’s supposed to be and really let your breast heal before we start doing too much activity.

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Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.