BREAST LIFTS Part 3 – Combined Breast Lift-Augmentation Surgery

Blog |  Dr Eddy Dona

Wed 5th Feb 2020

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This is part three of my series of breast lift surgery videos where I’m going to discuss breast lift/augmentation surgery.

A combined breast lift/augmentation surgery (which means performing a breast lift and inserting implants during the same operation) is far more complex than either one of the procedures done separately. It is the most difficult of all cosmetic breast surgery procedures performed and because of this many plastic surgeons choose not to do them.

And whilst some are much easier than others, in general they are extremely challenging.

So prior to undergoing surgery patients need to be made aware of the complexity of this combination procedure, have realistic expectations, and understand that additional surgery (along with the additional recovery time, time off work, stress, expenses etc) may be necessary in the short or long-term.

So why is it so complex?

There are numerous things that a surgeon must (or at least should) assess and consider before contemplating and planning a surgical breast lift (with or without an augmentation).

They include:

  • Skin quality
  • Degree of sag
  • The nipple direction
  • The skin distance from the nipple to the lower breast fold
  • Nipple areolar size
  • Breast tissue quality
  • Breast tissue volume
  • How “detached” the breast tissue is from the chest wall muscles
  • The patients’ desired look
  • And finally, Time, and how that will impact on the results.

A concept that one needs to understand is that a breast lift/augmentation surgery requires the surgeon to increase the breast size with breast implants, whilst at the same time reducing the breast envelope (that is, removing skin and breast tissue in order to achieve the breast lift). These two potentially counterproductive actions must be balanced as perfectly as possible in order to achieve the desired results.

Ultimately, the surgeon needs to lift the nipple and breast tissue to ensure a uniform and “tight” distribution of the natural breast tissue over the chosen implant to create a uniform appearing and feeling breast mound.

During breast lift procedures the nipples remain attached to their blood and nerve supply while they are repositioned. Some of the technical difficulties and limitations of a breast lift surgery is related to ensuring that you surgically don’t completely cut off all the blood supply to the nipple, which would basically mean the nipple would literally die and fall off!

Performing a breast lift without an implant allows the surgeon to apply more surgical “manoeuvres” designed to lift up the breast tissue to maximise the chance of the breast tissue remaining high. Every surgical step involved in a breast lift does to some degree cut off part of the blood supply to the nipple. When an implant is added to the equation, many of the steps involved in creating a pocket for the implant, and the pressure effect from the implant, further compromises the blood supply to the nipple. Therefore, the surgeon often needs to limit the “manoeuvres” required to maximally lift the breast tissue. They also need to reduce the “maximal size” of the implant that could otherwise be used for a simple breast augmentation. These limitations can add to the potential issue of the breast tissue re-sagging early after surgery.

The potential for “re-sagging” is even greater with breast tissue problems such as:

– large volumes

– breast tissue that is very soft and lost its elasticity

– breast tissue that is “detached” from the underlying muscle and slides around

– skin that is thin and has lost its elasticity

Given that women wanting a breast lift typically have one or more of these problems, then you can appreciate that one of the main issues with a breast lift/augmentations is that the breast tissue doesn’t stay where we want it to stay.

Essentially the patient is needing a breast lift because they have weak and soft breast tissue quality which has sagged – yet that same breast tissue and skin still exists after surgery, and it’s therefore still wanting to sag. No surgery and no surgeon can change the quality or consistency of the breast tissue and skin. All the surgeon can do is try to reposition and sculpt the breast tissue.

In addition to breast tissue that doesn’t necessarily stay where it’s meant too, breast implants don’t necessarily stay where we wish they would. Therefore, breast implant related problems such as positioning (too low, lateral slide etc.) can occur and may be a reason for returning to the operating room for further surgery. This is especially the case in those women needing a breast lift because there breast tissue envelope is typically soft without any structural support so it easily stretches again resulting in a very mobile implant.

In the end, often the “full perky” look that many women want is simply not achievable due to the persons chest wall shape, breast footprint, and nature of the persons natural breast tissue.

If you need a breast lift and also want implants, then the surgical options I’ll recommend will depend on the state of your pre-existing breasts and the look you’re after. The two possible options include: the single combined lift/augmentation operation, or two separate operations.

The single operation approach basically means having a combined breast lift and augmentation. Many variables are considered before I decide who is suitable for this, and it is decided on a case by case basis. As a very general guide the ideal candidate for this is someone who has minimal breast tissue, mild to moderate sag and still has relativity firm tissue and elasticity. However, even in the ideal candidate, I would quote about a 20% chance of the patient requiring further surgery to “fine tune” the results.

The Two Staged (or two operations) Approach means performing a breast lift first, and an augmentation as the second operation at a later date. This is the option taken for those when I believe it is too risky to attempt a combined lift augmentation. Who that may be is decided on a case by case basis, but generally speaking the typical patient who is offered this option has significant sagging and/or has a large volume of soft breast tissue. Trying to do a lift and augment in one operation for this group of patients would be risky and has a high chance of significant complications and a much greater chance (more than 50%) of requiring further surgery. That is, whilst you could offer a single combined lift augmentation operation to this group of women, more often than not a second unplanned surgery is required to fix problems.

The rationale for a two staged approach in such women is simple:

  • The breast lift alone is designed to create an improved breast shape with the nipples sitting at the correct level. Then approximately 6 months later a well planned breast augmentation is performed as it is easy to make what is now a good breast shape into a bigger good breast shape. However, many patients don’t proceed with this augmentation as they are just happy to have a good breast shape!

An important aspect of the breast lift alone is that such patients will most likely not achieve a long-lasting upper pole fullness as the breast tissue will settle into a lower position. Hence most of these women do want augments to address this problem. 

I will briefly mention here that upper pole fullness can also be achieved to a lesser degree with fat transfers but that’s a separate topic that I’ll cover another day.

So basically you opt to do two well scheduled and well planned operations – a lift first then an augmentation later – to have the best chance of achieving a great long term result. This is far better than doing one planned operation, a combined lift augmentation, where we have a high chance of needing further unplanned surgery to try fix problems, patients not happy, surgeons not happy and we are less likely to get the best long term outcome.

Basically, we want to choose the best pathway, safest pathway, least potential problems pathway to achieve the best long term results, and if that means two planned operations, then that’s how it needs to be.

And finally, with a planned two stage approach, the surgeon could potentially, and safely, use a larger implant than would otherwise be possible with a combined lift augmentation.

Anyway, I hope you’ve enjoyed my 3 part breast lift series  (see part 1 and part 2), and that it’s shed some light on the complexity of breast lift surgery.

In the end, do your homework, always consider second opinions, and if you want my opinion, give my office a call to schedule a one on one consultation with myself.