The goals of breast lift with or without breast augmentation are to restore shape, volume, and nipple-areola position. However, simultaneous breast lift and augmentation present multiple problems, speciﬁcally because it becomes harder to control all of the variables aﬀecting the outcome when combining the two procedures. No single method is best to treat all types of sagging (ptosis), and maintaining a good blood supply to the nipple-areola complex is of paramount importance, so a staged procedure may be necessary at times.
Why is combining a breast lift and breast augmentation the most diﬃcult of all cosmetic breast surgery procedures? The surgery involves manoeuvres that can be counterproductive to each other since the skin is being removed and when closed back up again, pushes the breast in and upwards, whilst an implant stretches the skin in an out and in a downwards direction. These conﬂicting tensions can adversely aﬀect the blood supply to the breast and skin which may aﬀect wound healing, scar quality etc. Positioning of both the nipple and breast fold also becomes more challenging during simultaneous lift and augmentation. Secondly, no two breasts are the same, and each patient is seeking a diﬀerent endpoint, sometimes with unrealistic expectations.
The ﬁrst thing that I do when evaluating a patient for a breast lift is to ask them if they are happy with their present breast volume. You can simply do this by pinching the skin below the breast and pushing it up where it belongs. Most women are amazed at how little of breast volume they actually have. If that is the case, then volume enhancement, usually with an implant, is necessary along with a lift. If the volume is satisfactory, then a breast lift will suffice.
The second thing to do is grade the amount of breast sagging. This is done by using Regnault’s classiﬁcation which looks at the position of the nipple as follows:
1) Grade 1 (minor): nipple at breast fold
2) Grade 2 (moderate): nipple is below the fold but above the lower breast contour
3) Grade 3 (major): nipple is below the fold and below breast contour
4) Pseudoptosis (“false sagging”): nipple lies above the fold, there is little breast volume, some of which lies below the fold
Other characteristics that one looks out for are:
1) Skin: elasticity and excess;
2) Breast tissue: ﬁrm and ﬁbrous or soft and fatty; and
3) Skin-breast tissue relationship: ﬁrm and adherent or loosely adherent and is the breast full or empty. Skin quality and the skin-breast tissue relationship are the key factors in determining the breast lift procedure and the quality and longevity of the ﬁnal result.
As a general rule, if the skin elasticity is normal, the breast envelope is full, and the skin is adherent to the underlying breast tissue, then the scars would be limited, and vice versa. In other words, one progresses from limited scars such as periareolar scars (scars around the nipple-areola complex) to periareolar-vertical scars (scars that run down the front of the breast below the nipple-areola complex) to more extensive, full-length inverted-T or anchor scars.
For the patient with “pseudoptosis,” inserting a breast implant alone, usually tear-dropped shaped, is typically all that is needed. For Grade I sagging, an implant alone or a lift plus an implant may be required.
Depending on a number of factors, the lift may be performed via a crescent, periareolar, or vertical approach. A vertical approach is preferred if there is signiﬁcant looseness below the nipple. However, the periareolar incision is generally used in just a few speciﬁc situations. Since this skin-only incision is unable to lift much weight, it is an option in women with small breasts who need only a small amount of nipple repositioning, usually < 2 cm.
In addition, it is considered advantageous in women with pointed, conical or tubular breasts, because it causes areolar ﬂattening and eliminates the tubular nature. The main issue I have with performing a periareolar breast lift is its tendency to cause areolar ﬂattening and leave the areola more prone to stretching.
In Grade 2 sagging, especially where the breasts are large and heavy, a vertical breast lift is often required because it will eﬀectively lift the breast tissue to achieve increased projection. However, a periareolar incision may still be considered for women with light breasts. When performing a vertical breast lift, the procedure may be converted into a short inverted-T lift if a difficulty is encountered controlling the nipple-to-breast fold distance.
With Grade 3 sagging, the lift technique depends on the nipple-to-breast fold distance. If it is > 10 cm, most surgeons perform an inverted-T breast lift. Otherwise, vertical breast lift remains an option that will enable control of the nipple-to-breast fold distance, as the vertical scar tends to shorten in the post-operative period with scar contraction.
Thanks for reading!
Dr. Tim – Sydney Cosmetic Plastic Surgeon