To lift or not to lift?

For a range of areas of the body, as Plastic Surgeons, we often have to guide the patient to a modification or alternative to the procedure they initially thought they might need. A typical situation frequently occurs in breast enlargement surgery.

Typically a patient will come desiring a breast enhancement, but may not have noticed other key features of her breasts that will have a significant (negative) impact on the result of a breast augmentation alone. These might be a low nipple position, a droop to the breast, or differences (asymmetries) between her breasts. Importantly if there is a droop to the breast, it follows that the supportive tissues – from skin to internal breast ligaments – are not as strong as they once were (which is ultimately why the breasts have drooped).

The solution in this scenario is to combine a form of breast lift with a breast enlargement. However, this introduces factors that many patients had not considered. These include further scarring – more visible on the breast; potential alteration of nipple sensation and more complex and more expensive surgery with a longer downtime. These compromises are rarely welcomed of course, but after an open and frank conversation, possibly accompanied by demonstrating the issues (from a plastic surgery perspective) using clinical photographs, most patients understand the rationale for advising an alternative procedure.

However, if the prospect of further scarring on the breast to improve breast shape is vehemently opposed by the patient it leaves two alternatives. One is to have the operation without the breast lift and accept a suboptimal result. This may leave lax skin that feels dissociated from the implant underneath (the breast may feel like it “flops” off the implant); the nipple may lie too low and the implant may look too high on the breast. This is rarely satisfactory from either the surgeon or patient’s perspective. The second option is of course not to proceed with surgery at all – whilst this might not be welcomed, if the recommendations from the plastic surgeon are not accepted by the patient, the plastic surgeon may be wise not to proceed, as the outcome would otherwise likely be unhappy for both parties.

So what are the surgical options? The most common way of performing a breast lift at the same time as an enlargement (an augmentation mastopexy or mastopexy augmentation) results in a scar around the nipple, vertically down from the nipple to the breast crease and along the breast crease. The scar around the nipple is the consequent result of needing to lift the nipple higher, the vertical scar is from a combination of closing the path via which the lifted nipple travelled and also to help narrow the breast, and the transverse scar is to help tighten the residual breast skin around the implant.

Example of before and after a breast lift with implants as described in the text (augmentation-mastopexy)

Alternative approaches include a similar scar pattern to that described above, with a much smaller transverse scar – which might be appropriate if there is not too much skin excess present. Additionally, if the primary issue is a low nipple position without too much skin excess, then a scar confined to around the nipple-areola-complex might be possible. This final option is very popular as perceptually it addresses the nipple position with the minimum required scarring, so is often enquired about. However, whilst the vertical scar on the breast is the scar most women worry about, out of all the potential breast lift scars, it is the one that fades the most, and allows the most control over the breast shape. Therefore, most plastic surgeons would not recommend concerns about the vertical scar being used as a discriminator between these procedures…although it often is!

At the end of the day, it is all about compromise. To get from A to B certain compromises have to be made – you have to undergo surgery; surgery carries risk; there are always scars after surgery etc. The question is then what is the best compromise for an individual to get from A to B. In the case of augmentation mastopexy, it relates to the balance between enlarging the breast to the desired size whilst improving the shape and nipple position at the same time.

The fact that two opposing forces are being applied to the breast (enlarging it with the implant and tightening it with the breast lift) necessarily requires the most important compromise – between size and shape. The larger the implant used with an augmentation mastopexy, the more risky the breast lift becomes – risks to do with wound healing, infection and nipple death. From a plastic surgeon’s point of view, all augmentation mastopexies would be performed with a modest size implant, usually of moderate (as opposed to high) profile, to make the surgery as safe as possible, and the outcome as predictable as possible. Furthermore, as alluded to at the beginning of this blog, a breast with any degree of droop does not have good support, therefore a large implant is unwise as, despite the breast lift, it will still be the same skin and breast tissue supporting the weight of the implant (which can be heavy!). Again, this does not always suit some patient’s ideals, and an honest and open discussion between patient and surgeon is mandatory to minimise disappointment and dissatisfaction.

At the end of the day, augmentation mastopexy is an excellent operation and can transform the shape, nipple position and size of the breast. However, this all comes at the price of having to undergo the surgery (and accept surgical risks) and accepting the scars (that will fade with time). With realistic expectations, and a comprehensive understanding of why this procedure is being recommended over a breast augmentation alone, patients rate this operation highly (source – RealSelf worth it score – 96%).

If you would like any further information on breast surgery or to see one of our Consultant Plastic Surgeons, please contact us on 01892 536960 or email us at info@puritybridge.co.uk