Breast Lift / Mastopexy Information Resource for Southern California, including Orange County, Los Angeles, Newport Beach, San Diego, and Beverly Hills.
Breast Lift
Dr. Cruise's philosophy regarding breast lift
Breast lifting, with or without augmentation, has become very popular across the United States and especially here in Orange County. This is because many women are no longer willing to accept sagging, deflated breasts as a necessary consequence of aging and/or childbirth.
A good part of my practice is devoted to understanding the physical and emotional issues that women have concerning their breasts. Typically, they are healthy and well adjusted women. Their self-esteem, however, has been deflated because their once youthful, perky breasts are now hanging at a level that makes them feel older than they really are. These women want to feel attractive again. They want to be able to wear stylish, sexy clothes. Finally, they are tired of wearing special bras that do not create the look they are hoping to achieve.
A fact well recognized within the world of plastic surgery is that breast lifting with augmentation is a particularly complicated procedure. This is because there are many variables involved, many of which have conflicting effects on the results. On one hand, the lift component reduces the breast and removes sagging volume. On the other hand, the breast implant component augments the breasts and adds lifting volume. For this reason, with breast lifting it is particularly important for you to find a plastic surgeon who has considerable experience with the procedure along with the desire to find out exactly what you want to achieve by surgery.
In my practice, I have gone through an evolution of technique. I was never happy with the common techniques of performing breast lifts that attempt to lift breast tissue back into its previous position. I spent the early part of my career doing it this way, but was often disappointed as the natural breast tissue would succumb to gravity and sag again. In addition, I was troubled that the shape of the lower part of the breast was never round like that of the youthful breast. Instead, it had a flat, rectangular, and hanging appearance that left an overall aged and deflated look.
After analyzing these breasts, I decided that the breast tissue that hangs below the breast will never be attractive and will always return to its sagging position. Therefore, my current technique is to remove the tissue that sags below the level of the breast fold, then gather in the breast tissue from the sides. This eliminates the hanging, rectangular breast appearance and creates a full, round appearance like that of the youthful breast. Finally, when all the breast tissue is in the correct position and the round shape has been created, I will often add an implant to restore upper breast fullness and cleavage.
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| Breast Lift Anchor with augmentation - Silicone Breast Implant 350cc Moderate Plus Profile - Mentor. Three months post-op. 35-year-old patient. | |
A byproduct of this technique is that I am able to substantially reduce the length of the incision. In fact, my incisions never travel anywhere near the midline or the outside part of the breast. The horizontal incision remains hidden below the breast. This allows my patients to wear bikinis or any low-cut dress they chose without any concern of the scar being visible. Some even elect not to wear a bra at all, something that was not even remotely a consideration prior to the breast lift. Although this is possible, it is recommended that you wear support most of the time. .
It is extremely important to find out exactly what the patient wants to obtain as far as breast lifting goes. Some women are only concerned with correcting the sagginess while others are more concerned with cleavage and fullness in the upper breast. Some women want a fuller look and are best served by placing an implant in addition to the breast lift. This is all personal preference, but it is important to understand the desire of each patient so that the procedure can be tailored to her particular needs. It is also important to be able to predict both breast size and shape after the breast lift.
During your plastic surgery consultation, it is very important that you and I both understand exactly what you want to accomplish. Different surgeons, of course, will have different methods, but I will walk you through the thought process that I go through during every one of my consultations. At the end of your consultation, you must feel that your plastic surgeon clearly understands the look you are after. Forgive me if the following information is somewhat involved, but I feel strongly that it is important for you to have it.
1. Incisions
Incisions are perhaps the biggest concern that my patients have. They have seen or heard of horror stories of breast lifting gone wrong, leaving the patient with significant scarring. It is important to understand that some patients scar worse than others and that plastic surgeons do not control how an individual patient scars. Plastic surgeons can, however, control the placement and precision of the scar. This is part of the artistry of plastic surgery. You must keep in mind that incisions are necessary and that scars will never go away completely
I understand your concern about putting scars on your breast. I take this into consideration as we decide together what is best for you. The truth is, if you have significant sag, a proper breast lift with augmentation is far superior to an augmentation alone. In fact, an augmentation alone may give you a very elongated, older appearing breast. This has been given the nickname "rock in a sock" look. What we are looking for is a lifted, round appearance as seen in a youthful breast.
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Patient treated with breast augmentation alone who really needed breast augmentation in conjunction with breast lift. The surgeon placed the implants very low to avoid a breast lift. This created a very elongated, aged appearance of the breast and a significantly shorter abdomen. |
Breast lifting with augmentation is very challenging, as there are many variables to consider all at the same time. The most important thing is to find a plastic surgeon with considerable experience with this procedure. I cannot stress this enough.
When evaluating sag, both the entire breast and the patient's wishes need to be taken into consideration. To make things as simple as possible, I will discuss the two most important considerations. They are not absolute measurements. These are:
- the relationship of the nipple to the inframammary fold (IMF).
- the relationship of the bottom of the breast to the IMF. Other factors, of course, will need to be discussed at the time of consultation.
It is important to point out that breasts with more natural breast tissue are more likely to need a lift. This is because the bottom of the breast will continue to fall. Removing excess breast tissue with a lift will correct the sag and actually decrease the chance of sag in the future.
Another consideration is the size of the implant. A larger implant will provide more lift. This makes sense: more volume fills the excess skin envelope more adequately. Of course, you should not choose a larger implant for this reason alone, as the amount of lift that an implant can provide is limited.
A breast lift alone rarely produces a great result as there is usually very little breast tissue in the upper chest. This can only be adequately treated by augmentation. Even patients with significant breast tissue benefit from the upper breast fullness created by an implant. In these cases, I usually will remove all the undesirable sagging breast tissue and put in a relatively small implant to create an attractive upper breast with cleavage.
There are four common breast lifts:
- Augmentation alone.
- Augmentation with Donut Lift.
- Augmentation with Lollipop Lift.
- Augmentation with Anchor Lift.
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Augmentation Alone
Once again, this will depend on the size of the implant. Usually, augmentation is all that is necessary when the nipple is above the level of the IMF and the bottom of the breast is no greater than 1 cm below the IMF. This is especially true when there is not much breast tissue. Heavier breasts require more to lift them.
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Donut Lift
The Donut Lift is also known as the Peri-areolar lift. It involves removing skin in the shape of a circle around the areola and placing a suture within this circle. This circular suture acts as a purse string to tighten this larger circle into a smaller circle. This elevates the nipple into a higher position and tightens the skin envelope. The downside of the Donut Lift is that the purse string effect of the suture can flatten the breast. This is why an implant is highly recommended to combat this flattening.
Because the Donut Lift does not lift sagging breast tissue that has dropped more than 2 cm below the IMF, it can be considered more a nipple lift than a breast lift. It does elevate the nipple and is ideal for the breast that has minimal sag and not much tissue.
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Lollipop Breast Lift
This type of breast lift involves an incision around the areola and straight down the bottom of the breast. Patients often do not want this lift because they do not want the vertical incision. This incision, if properly placed, is quite acceptable. If it is necessary, it is a far better procedure than the Donut Lift, as it actually removes the hanging breast tissue. Further sag in the future is dramatically reduced or prevented.
This woman has nipple descent 4 cm below the IMF and breast descent 5 cm below the IMF. She will most likely need a breast augmentation with a Lollipop Breast Lift.
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Anchor Lift
The Anchor lift is quite similar to the Lollipop Lift except that it has an additional incision that falls within the IMF. This extra incision is necessary to remove excess skin from breast sag. The horizontal incision within the IMF is actually not visible when you are in a standing position and is quite hard to see otherwise.
Candidates for the Anchor Lift are women whose breast tissue falls significantly below the IMF. Whether this horizontal skin removal is necessary depends on many things. If the bottom of your breast is greater than 5 cm below the IMF, a horizontal incision will usually be necessary. The length of the horizontal incision depends on how far the bottom of the breast falls. For example, a breast 8 cm below the IMF will need a longer horizontal incision than one with 6 cm below the IMF.
This woman has nipple descent greater than 4 cm below the IMF and breast descent greater than 5 cm below the IMF. She, most likely, will need an Anchor lift.
2. Implant or No Implant
Breast lifting is highly effective in lifting breast tissue that has fallen below the level of the IMF. It is not, however, effectively create upper breast fullness and cleavage. This is why I strongly recommend using an implant to accomplish what the lift alone cannot. While I still do breast lifts alone, the result is compromised. Fortunately, most women in Southern California are willing to accept an implant in return for an improved result.
If you are considering a lift without an implant you can always add the implant later. Some surgeons actually prefer this as it makes the procedure easier. I will recommend a two-stage approach if the nipples have fallen greater than 10 cm below the IMF. This is because when the nipple is elevated greater than 10 cm there is a risk of loss of blood supply to the nipple.
Once the decision is made to add an implant, the next choice is to decide on which implant is best. There are several characteristics to breast implants that need to be considered: size, shape, and saline versus silicone. Let's go over each individually.
3. Implant Size
Deciding on an implant size for a breast lift is somewhat different than that for a straightforward breast augmentation. It requires a bit more three-dimensional thinking as you have to consider the breast tissue already present. Taking it one step further, you have to consider how the breast size and shape changes as the sagging breast tissue is elevated into position.
With breast augmentation, we utilize bra sizing to determine implant size. With breast lifting, this cannot be done so easily. This is because the elevation of breast tissue changes the breast size and shape. When only a Donut Lift is necessary, we still perform bra sizing as it is still quite accurate. With both the Lollipop Lift and the Anchor Lift, there is too much change in breast tissue to allow bra sizing to be accurate.
While the entire scope of this topic cannot be covered here, one thing to consider is that the breast skin has already shown that it has a tendency to sag. Therefore, it is wise not to go too large as it will stretch the skin further.
On the other hand, the implant should be large enough to give fullness to the upper pole of the breast and to create cleavage. Given the many variables to factor in, exact sizing can only be done during consultation.
4. Shape of Implant
To me, shape is the most overlooked part of breast enlargement. This is especially surprising considering how important it is. During my consultation, I ask all my patients to consider what shape is desired in the upper part of the breast. I divide it into three options: Natural, "California" Natural, and Dramatic.
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Natural
Natural means a straight or even a slightly concave upper part of the breast. This is what you would find in a youthful, non-augmented breast. It is full, but does not look like it has been augmented. It is ideal for someone who does not want anyone to know she has been augmented but still wants to have a sexy, more proportionate shape to her breasts.
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| The patient, 5'10", 150 lbs., went from 36B to 36C/D. Saline Implant 440-460cc Low Profile filled to 460cc. Implants were placed under the muscle. Notice the gentle slope of the upper breast despite using a large implant. | |
5. Implant Profile
I purposely placed "profile" directly under "shape" because profile has a significant effect on shape. There are three different types of profiles: low, moderate, and high.
For the most part, I utilize moderate profile as I feel it does the best job of obtaining the right size and shape. Low profile is ideal for patients who want a smaller implant (i.e., below 350cc) and want to be as natural as possible. In fact, I do not even call it "low" profile as I prefer the name "natural" profile.
I use high profile implants on patients who want to go quite large (i.e., above 600cc). In these women, moderate profile implants would be too wide to fit on their chest without spilling over into the arm region.
There is a difference in shape between saline and silicone. For a given volume, silicone will have a more natural shape in the upper breast. For this reason, saline implants tend to look larger even though the volume is the same. This can be minimized by not filling the saline implants to the top of their fill volume. This gives a more natural appearance. Under filling too much, however, increases the risk of rippling.
With silicone implants, I am more likely to choose high profile implants if the women wants the "California Natural" or more dramatic look. You should always remember that more projection means less width and less width may mean a bigger gap in the midline. Conversely, the low or "natural" profile saline implants create an almost silicone type appearance. This is ideal for the woman who wants a natural look but does not want silicone implants.
6. Silicone Implants Vs. Saline Implants
This is usually a decision I leave up to the patient. I merely provide the facts. The facts are that both implants can provide a great result. Many plastic surgeons strongly recommend silicone because it has a lower rate of rippling. Rippling is not very common in my patients, and I believe this is because I place the implant under both the serratus anterior and pectoralis muscle.
Silicone implant versus saline implant simply put: silicone implants have a more natural feel. So I tell my patients, "If a natural feel is very important to you, go with the silicone." Another advantage of silicone is that it produces a more natural appearance to the upper part of the breast. Some people want this natural look others want a more full look, i.e., "California Natural."
Still, it possible to create a "California Natural" look with silicone by using a high profile implant. A high profile silicone implant creates a shape similar to a moderate profile saline. A moderate profile silicone implant creates a upper breast shape similar to a low or "natural" profile saline implant.
The major advantage of saline is that if it ever ruptures the saline simply gets flushed out of the body. Silicone, on the other hand, will stay in place. Sometimes, it is hard to tell if a silicone implant has ruptured as it maintains it shape relatively well.
In summary, choose silicone implants if you want the most natural feel and the most natural shape. Choose saline implants if you are concerned about the effects of silicone gel.
I should point out that women who already have a fair amount of breast tissue do not necessarily need silicone implants since they already have enough tissue to obtain a natural feel even with saline implants. On the other hand, women with almost no breast tissue should seriously consider silicone implants as they do not have much coverage. Saline implants in these women would look much less natural than silicone.
7. Implant Placement (Above or Below the Muscle)
Let's first define what we mean by above or below the muscle. The muscle we are talking about is the pectoralis major muscle. It runs along a diagonal from the chest to the shoulder.
Pectoralis Major Muscle runs across the chest diagonally to the shoulder.
Breast Implant Above the Pectoralis Major Muscle
Breast Implant Under Pectoralis Major Muscle
Good results can be obtained by placing implants either above or below the pectoralis major muscle. I strongly believe, however, that under the muscle placement provides the best results for several reasons. The most important reason is that it lowers the chance of capsular contracture or "hardening of the implant." Also, the muscle acts as a constant massager of the implant and helps to keep it soft. From an aesthetic standpoint, it has several advantages. It acts as a buffer giving an added layer of implant coverage. This is especially helpful in the upper part of the breast. The muscle diffuses the implant over a greater area preventing a "shelfy" and overly round appearance. In addition, placing the implant under the muscle significantly decreases the chance of rippling except along the lateral part of the breast where the pectoralis major muscle does not exist.
Implant Under Pectoralis Major Muscle. Notice how the lower lateral portion of the implant is not covered by muscle.
As you can see, the entire lateral part of the implant is uncovered even when the implant is placed under the muscle. To provide better coverage, I have developed a unique way of putting the implant under another muscle along the lateral chest wall to almost completely cover the entire implant. This muscle is called the serratus anterior. I believe this is why my saline implants rarely having rippling.
Implant Covered by Both Pectoralis Major and Serratus Muscles
In addition to providing valuable coverage, the Serratus Anterior also prevents the implant from migrating into the armpit. Furthermore, this muscle pushes the implant toward the midline giving enhanced cleavage. Think of it as a bookshelf that prevents the implants from sliding outward.
8. Asymmetry
Asymmetry is important to point out, as virtually every woman has some degree of it. The key is to determine what is causing the asymmetry and correct it as much as possible. Complete correction of asymmetry is not possible. The three most common asymmetries involve nipple height, inframammary fold level, and breast volume.
- Nipple Asymmetry. Typically, I do not treat a discrepancy in nipple position unless there is a greater than 1.5cm difference between the two breasts. When the difference is 1.5cm or greater, this difference will become apparent when a tight shirt is worn and the nipple location is clearly visible. In this case, I recommend a Donut Breast Lift to even out the nipples. See the section on Breast Lift.
- Inframammary Fold Asymmetry. The inframammary fold is the crease at the bottom of the breast. When there is a difference of IMF height, it can make the breast look asymmetric. This often can be easily corrected by lowering the higher of the two IMFs during the breast augmentation procedure.
- Breast Volume Asymmetry. Most differences in breast volume will not be noticeable after augmentation even if the same implants are used on both sides. In fact, I try not to use different sized implants as this can actually create asymmetry, especially within the upper breast. The reason for this is that putting a bigger implant in the smaller breast may improve the volume asymmetry but will create breasts with two different shapes. When the volume difference is great, than two different sizes are necessary. In this case, I usually recommend silicone so that the difference in shape of the upper breast is minimal.
9. Excess Fat near Armpits or Lateral Breast Roll
At the consultation, it is important to discuss fat deposits around the breast as it has a big impact of the overall look. The two most common areas that are a problem are the axilla and the lateral breast roll. Liposuction of these two areas can easily be done at the time of breast implantation. I must warn you that concomitant liposuction will make the breasts bruise and swell more than breast augmentation alone. Since most women who have these two fat deposits have grown to really despise them, they find the tradeoff acceptable.
The two most common fatty deposits that often need to be addressed with breast augmentation are the axillary fat and the lateral breast roll fat.
Examining these areas shows that the plastic surgeon is looking at the entire breast area and not just the breast itself. If these areas bother you, be sure to point them out to your plastic surgeon if he does not do so himself.
10. Tuberous Breasts
Tuberous breasts are breasts that have not fully developed, especially along the lower part. This causes the bottom of the breast to look tight and constricted instead of a full and round. Tuberous breasts often have a very short distance from the bottom of the areola to the inframammary fold. This distance should be at least 5 cm.
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| Example of tuberous breasts. Notice underdevelopment of lower part of the breast and its correction with breast implantation. | |
Often, women with tuberous breasts do not realize that this is abnormal. They may feel ashamed of their breasts which may prevent them from seeking help. Fortunately, breast augmentation can significantly help this condition. This is especially satisfying to me as the results can be dramatic.
I know this is a tremendous amount of important information but, believe it or not, I have condensed it the best I could. It always surprises and pleases me how much my patients understand when the information is presented to them in an easy to understand and sensible fashion.
It is your job to understand the material the best you can. It is my job to understand the fine nuances that go far beyond the scope of this presentation. This is where the art and science of plastic surgery come together and make it all worthwhile.
Breast Lift / Mastopexy Information Resource for Orange County, Newport Beach, Los Angeles, San Diego, Beverly Hills, and Southern California