The Importance of Technical Expertise

Technical expertise and proper procedure selection are of critical importance for surgeons performing breast lifts and reductions. In a breast augmentation, the surgeon's skill largely comes to play in the proper dissection of the pocket for the breast implant. The incision is small and no alterations are being made to the nipple position. It is a procedure that many residents learn to perform competently during their training. It's "Breast Surgery 101"! Surgeons' websites often contain dozens of pictures of breast augmentation.

However, surgical expertise, results, and patient satisfaction are much more variable for breast lifts and reductions.

To be proficient at a breast lift/reduction, there is no substitute for experience and correct procedure selection. This operation should not be done by a surgeon with no specialized training in plastic surgery. While there are areas of overlap in surgical specialties, this is not one of those areas. This operation is strictly in the domain of the plastic surgeon, preferably a plastic surgeon who specializes in cosmetic surgery and who performs this procedure regularly.

Plastic surgeons often learn a particular style of doing a breast lift or reduction, become comfortable with it, and use it almost always on their patients in practice. In the right hands, this is an out-patient procedure. Experienced and skilled operators rarely find a need for a blood transfusion, inpatient stays in healthy patients, or surgical times exceeding three hours.

How much do you take out?

Patients often ask how I determine how much breast tissue to take out, or how much skin to remove. This is in the realm of the surgeon's judgment. They may be surprised to learn there are no mathematical formulae! The patient relies on the surgeon's judgment and experience.

Breast Lifts: Quality of Life and Aesthetics

Women with very large breasts are appreciative of the outcome even without an ideal result. This is because large breasts have a surprisingly negative impact on quality of life. These women are grateful to be relieved of the burden of weight on their chest.

Breast lift patients may be more discriminating. They are having the procedure purely to improve the appearance of their breasts and therefore are less accepting of a so-so result. Of course, breast reduction patients care about their appearance too and plastic surgeons should strive for improved aesthetics, not just relief of symptoms.

Some surgeons still use nipple grafts in some patients. This is an old technique that leaves the nipples completely numb and is unnecessary now that we have better options, particularly the vertical reduction with a medial pedicle ("pedicle" refers to the attachment of the nipple to surrounding tissue to maintain blood supply) which is safer than older techniques, like the inverted-T reduction, and less likely to jeopardize blood supply to the nipple.

The Incision

Because of its advantages in terms of less scarring, better shape, and shorter operating times, the vertical technique is preferred over the inverted-T technique, both for breast lifts and reductions. The vertical technique is also safe to perform with breast augmentation, which is a common and highly gratifying combination procedure. Both the old inverted-T "inferior pedicle" procedure and periareolar procedures have design flaws. The inverted-T technique is prone to bottoming-out and flatness of the upper poles. The periareolar technique tends to cause distortion and flattening of the areola without a tightening effect for the lower pole.

In order to avoid a persistent bulge of the lower pole of the breast, it is necessary to remove breast tissue and skin from the lower pole. If just skin is removed, the breast will remain bottomed-out. In fact, persistent sagging of the lower pole can sometimes occur even after a properly-performed vertical lift, and require a second operation to provide more tightening.

Pre-Operative Measurement and Marking

The surgeon first makes measurements on the patient's chest. It is important that the patient sit up squarely while the chest markings are made (not a good time for slouching), because the surgeon follows these lines closely at surgery. Except for the circular area around the nipple, all of the skin enclosed within these markings is removed. Patients are often surprised how much extra skin is present. The new nipple position will be located higher, at the level of maximum breast projection. This is determined in surgery. Markings help the surgeon create the tighter, more conical breast mound, and the nipple goes on top. This technique helps avoid locating the nipple too high on the breast, which is a common error and a difficult one to correct.

What happens to the nipple?

Patients often ask if the nipple is removed because pictures show an incision which goes circumferentially around the nipple, giving the illusion that it has been removed and then stuck back on at a higher position on the breast. In reality, it is the nipple that stays attached to the underlying breast tissue - the skin around it is removed. Patients with large areolae (the pigmented skin around the nipple) can have these reduced simultaneously. This is an extra benefit of the procedure and helps make the scar around the areola a more acceptable trade-off. The stitches dissolve on their own. There are no stitch marks or "railroad tracks", because the "subcuticular" suture weaves back and forth under the skin.

The Surgery

Patients sometimes wonder if there will be an incision above the nipple. When I see women in consultation in the office, they sometimes grab the skin around the collarbone and pull it up tight, thinking that a breast lift will be done in a similar fashion ("Why can't you just do this, doctor?"). In fact, this technique was tried in the early 20th century. But it is not used today, because the incision would be very conspicuous above the breast.

Why not stitch the breasts higher?

Patients sometimes wonder if stitches can be used on the inside to pull up the breast. This would be a nice way to accomplish the lift and avoid any scarring. Many surgeons have incorporated such sutures in their techniques. Unfortunately, these efforts have proved ineffective. Breast tissue is simply too malleable to be help up using deep stitches.

The Vertical Lift and Alternatives

To tighten the breast "envelope," the surgeon removes skin and excess breast tissue of the lower pole, and this produces the lift. But unlike a facelift, where the skin is pulled up with the underlying SMAS tissue, in a breast lift the extra tissue is removed from below, and the sides are brought together, pushing the breast up. The vertical scar is kept below the level of the nipple so it does not show, even with low-cut tops or bathing suits.

The incision usually includes a circular part running circumferentially around the nipple and areola. This incision is needed so that the nipple and areola may be moved out of the way temporarily to perform the breast lift and then repositioned atop the newly shaped breast cone. With the vertical technique, the breast is elevated and the nipple comes up with it, so that transposition is minimal. This is important because the more the nipple is transposed, the more it is at risk of losing blood supply, which could cause a disastrous loss of the nipple. Older techniques, such as the traditional inverted-T with an inferior pedicle, often involved long pedicles. The vertical technique with a medial pedicle allows much shorter transposition distances, with much greater safety for the nipple and areola. It also preserves superficial sensory branches to the nipple.

The nipple and areola are freed of the surrounding skin. In one operation, this is the only incision made. This is called the "donut mastopexy"- aptly named because a donut of skin is removed as a ring around the areola. Although this approach is appealing in its simplicity and avoidance of a scar below the nipple, it is limited in how much sagging it can correct. Most patients require tightening of the lower pole, so this incision is rarely used. My only indication is an occasional patient who wants her areolar size reduced but does not require a lift.

"Crescent mastopexies" tend to distort the areola without any tightening of the lower pole or improvement in breast shape. The extra skin is removed from around the areola, rather than from the lower pole, where reduction is needed to improve shape. Such "periareolar techniques," that avoid a vertical scar, are therefore of limited usefulness.

If a patient requires any degree of lift, and almost all do, then the vertical procedure (named after the scar it leaves) is the better choice.

The vertical technique makes use of a vertical extension from the areola to the crease under the breast ("inframammary crease"), allowing tightening from side-to-side. This leaves a scar around the areola, plus a vertical scar down to the crease. The inframammary crease is usually elevated.

This 34 year-old with 2 children wished to have her volume restored to a full C cup size and her breasts lifted.

Redo Breast Lift

Occasionally, a breast lift may be redone. This may be necessary because of gradual stretching of the breast skin over time, or if implants are removed in a woman who has had a previous breast lift. It may also be done when there is a persistent bulge of the lower pole. The original vertical scars are removed along with the extra skin. It may not be necessary to make another incision around the areola if the nipple is at the correct level. If the patient had a previous inverted-T lift or reduction, this horizontal scar may be reduced or sometimes even eliminated with the extra skin that is removed from the lower pole.