Breast Lift: Introduction
Thanks for coming to see me today to learn more about a breast lift. This is also called a “mastopexy” and that’s the doctor term for a breast lift. It’s actually one of my most favorite procedures. And the reason is, is because there’s only really two procedures that I can think of in plastic surgery that give us such immediate feedback with such an easy recovery. A breast lift and the ear reshaping, or otoplasty. Both of those procedures give us an … immediate feedback where the … first time you look in the mirror it’s like … wow, what a change? And typically, with … very little bruising and … a very easy recovery. In fact, a breast lift is a little harder on me … but easier on you from a recovery standpoint … than a breast implant. It may take me a little longer, but it’s such an easy recovery in most cases.
And we’ll talk a little bit more about that. So first I’d like to kind of help you understand what it is that a breast lift is and then what it does. The basic concept is to take the breast which has settled some over time, typically with pregnancy or weight loss, or just with time that gravity has taken a toll on the breast. And so, the breast tissue has begun to settle some. And when that happens, we often tend to lose some volume in the breast. And so, the whole breast is drooping or hanging. And the doctor term for that is “ptosis,” and I’ll talk a little more about the ptosis soon. The idea with the breast lift is to … reshape and reposition the breast higher on the chest wall … to put it back to where it used to be … and to lift the nipple up … (and reduce the areola).
In the areola (or the colored area around the nipple), we want to make that smaller as well, because I think that’s a more youthful appearance. And so what we want to do is create a perky, pretty breast, positioned higher on the chest wall, with a smaller areola, and a more shapely breast, and minimize the differences between the breasts … and also close it all up so that we can create the prettiest scars. And there’s a lot of attention that we place upon trying to get the most fine-line scars possible. And the reason for this is with a breast lift, we’re essentially … trading a shape … for a scar. So, we want to have the best scar possible for you.
Best Candidates & Timing
So, who are the best candidates for a breast lift? A patient who’s healthy, who’s a non-smoker, who has a stable weight. Now, smoking any form of nicotine can squeeze the blood vessels and compromise the blood supply and lead to unsatisfactory results. So, it’s very important to stop smoking before surgery, ideally one month before and absolutely two months after surgery. Stable weight … it’s important to not have a significant weight fluctuation before or after surgery, because some of the breast tissue is actually fat. And if you were to lose a significant amount of weight, that may have an impact upon the volume of breast tissue that you have. Now, breastfeeding, we like to … wait about six months after you finish breastfeeding … to let the body naturally involute the breast (or shrink the breast) to see where we’re starting from before we proceed with the breast lift.
Ptosis & Procedure
Now, I’d like to talk to you a little bit more about the breast lift procedure. And I’d like to start by clarifying a couple of misconceptions about a breast lift. Patients will often share with me their concerns about losing the sensation, or having the nipple cut off, or having bad scars. And with the breast lift, the nipple does not get cut off. The nipple stays in place. We just remove the tissue around it and then lift it and reposition it. I actually think that you have a lot … less risk of numbness with a breast lift … than you do with a breast implant … because an implant stretches the tissue, thereby stretching the nerves. And sometimes that may lead to some numbness. So, what I have discovered, it’s very uncommon for a patient to have numbness after a breast lift. Certainly, it’s possible, but that’s not to be expected. And it’s quite unusual.
The second concern relates to the scars and patients are often very concerned about the scarring. And as I mentioned, you essentially … trade a shape … for a scar. And I believe that if you take the time and are willing to pay attention to the details … and perform precision surgery and … do layered closure of the incisions, and then focus on the quality of the scar … after surgery … not only during surgery … that we can create some very fine-line scars in most cases. And I’d like to share with you a number of those examples.
But first I’d like to talk to you a little bit about the drooping and the different types of breast lifts. As we talk about drooping, the doctor term for drooping is “ptosis.” And I want to show you a few diagrams to help you understand that when we talk about drooping, we’re talking about … the position of the nipple … as it relates to the inframammary fold, which is the fold below the breast. So, we have Grade 1,2,and 3 ptosis. So, if this is the chest wall, and this is the breast … a young patient, the nipple is above the fold (no ptosis). As time goes on, the breast will often do more like this, where the nipple tends to get perhaps a little bit lower with time.
And if this is the fold here, Grade 1 ptosis would be the nipple here. Grade 3 ptosis would be the nipple at the very bottom and Grade 2 would be in between. So sometimes after pregnancy and significant weight loss, we’ve lost that upper fullness and a lot of the breast tends to be hanging down lower. And if the fold is here and the nipple is down in this area, then obviously this is the concern and we want to take and lift the nipple back up higher on the chest wall. So, if I can perhaps help you understand … ideally the nipple areola complex would be above the fold. This would be what we call the “inframammary fold” and this is what we call the “nipple areola complex,” which is the nipple combined with the areola area.
So, ptosis refers to, how does the nipple relate to this fold? In this case, there’s no drooping, there’s no ptosis (Grade 0). If the nipple were down here, then that would be Grade 1. In other words, here’s the fold and the nipple would be along this line (inframammary fold). As the breast begins to droop more, the areola is often larger and it then begins to run under that fold. And that would be a Grade 2. And then finally Grade 3 might be something thing like this, where the nipple is at the very bottom of the breast and pointing towards the floor. So hopefully that’s a helpful understanding of what the concept is with a breast lift, where we want to correct the drooping, lift the nipple areola complex back on the chest wall, and get it above the inframammary fold.
Implant vs Lift
Now, I’d like to touch base a little bit on the concept of, how much drooping there is … what is the best type of lift to perform? And some patients share with me a concern regarding possibly an implant. And after I can take a look and see what your tissues would tell me, that’ll give me an idea of how much breast volume you have, what degree of ptosis that you have, and then what would be the best procedure. Whether that’s more of the vertical lift or perhaps more likely the Wise pattern, traditional breast lift procedure. Some patients have an idea that what they want is a perky, pretty breast and other patients said, well, I want perky, pretty, but I also want to go larger. And so, my question first of all is which is more important? Is it more important … to be perky and pretty, or is it more important … to be bigger?
And if we talk about … an implant and a lift at the same time, they’re actually somewhat … opposite procedures and … they tend to conflict with each other. So, the preferred method is … if there’s a fair amount of drooping is to … first do the lift, allow everything to heal, to have fine line scars. And then if we’d like, come back and … put an implant in later. The way that I do a breast lift is basically to take the breast apart … to turn your tissues into its “own implant” … to lift it up, reshape, and reposition the breast and … do a breast lift in a way that I think … looks a lot like a breast implant. And quite often, patients are very happy with that. And even though they may have thought that perhaps they wanted a breast implant before surgery, they find that they’re so pleased with their results after surgery, that they’ve determined they really don’t need a breast implant later.
On the other hand, some patients would … like to go a little bigger and the preferred approach is to lift it up, tighten the tissues, get the best scars, and then perhaps go back and … put an implant in a later date. If … both procedures are done at the same time … they tend to conflict with each other. A lift will take something that gravity has worked on … and has settled down. You want to lift it up, tighten the skin. And if you want to have the prettiest scars, you want to have the least tension on the scars. An implant, on the other hand. will … add a weight to the breast, and that will … tend to stretch the skin. So, they do tend to conflict with each other. And the one thing that you don’t want (or two things that you don’t want) is either … an implant here with your breast falling off the implant … or “a rock and a sock,” which would be an implant down low.
So, there are … times where an implant alone may work. And sometimes if there’s not a lot of breast tissue, not a lot of drooping, then perhaps a somewhat larger implant will fill that tissue and bring it up. And the patient may be very pleased with that. So, it really depends on what they say in Texas, which is, “You got to dance with the one that ‘brung’ you …not the one that brought you.” In other words … your body will determine … what is really going to be the best option for you. And it’s my obligation to look at your tissues and to tell you what I think will give you the best result, because … it’s never a good idea to do the wrong operation. What we want to do is figure out where you want to go, and what’s the very best way to get there. And so we’ll talk a little bit more about that after we’ve had the opportunity to take a look and see what your body will tell us.
Types of Breast Lifts
Now, I’d like to talk about the three basic types of breast lifts. The first one is called a Benelli named after an Italian doctor. It’s also called a Donut. The second one is a Lejour named after Madeline Lejour in Belgium, and that’s the vertical lift. And the third one is the classic Wise pattern. And that’s the one that is the traditional lift. And that’s the one that goes not only vertical, but also underneath. And that’s the most common lift. Now, I want to go over each of those with you. I’d like to talk about the first type of breast lift called the Benelli lift (this is also called the Donut lift). Now, in a patient with some degree of drooping, say the areola is enlarged and we’d like to make it smaller and lift it up. The Benelli lift or the Donut lift gets its name because what happens is, if this is the areola out here (the colored area) it’s been stretched out with, often with pregnancy or weight loss, or the increased size of the breast.
And so the idea is to make it look more youthful, to bring the areola in and make it somewhat smaller. So a Donut lift will take and cut out the skin in between. So it takes the outer skin and pulls it into the smaller skin, and then puts a purse-string suture all the way around that. And that’s where it gets the name of a Donut lift or a Bonelli lift. The problem is, because of the tension, if you take the tension from out here, bring this skin into here, bring this skin into here, and pull it together to put a purse-string suture, that sutures around here have a lot of tension on them. And that often tends to widen the scar. Then what happens is, it tends to stretch out the areola as it heals.
And it often ends up being very flat across the top of the breast. Doesn’t lift very much … and the scar can be quite thick and often irregular. And that’s why the … Benelli lift is not a very popular procedure because it usually doesn’t work well. And we can show you some examples of that. The next type of lift that I’d like to show you is the Lejour lift. And the Lejour lift is the vertical lift. And the vertical lift is most helpful in a patient who perhaps has, say a very large areola and not a lot of lifting. Like let’s say, we’re going to take the areola, make it smaller. We want to move the nipple say here.
And in this case, a Lejour is designed like this to remove this skin excess here, move the nipple up here and bring the skin together. And what often happens is it provides some push this way. It tightens the skin this way, brings the nipple up some, and at the end, the scar goes around and down. And then frequently we need to remove a little excess skin down here so it goes up underneath. So that’s called the vertical lift or the Lejour. And that works … if we’re not lifting the skin up very much … or if the areola tends to be quite large and we want to get out as much of the skin around there as possible. Sometimes that’s done in some cases with a breast implant because there’s not as much skin that gets removed. So that’s the Lejour.
Now the downside to the Lejour is it … doesn’t push up as much as far as repositioning the nipple areola complex. Now the most common breast lift would be the Wise pattern. And the Wise pattern is named after Dr. Wise. And if we want to lift the nipple from here to here, make the areola smaller, we use a little “cookie cutter” that we put over that, and we’re going to move the nipple all the way up there. And the way that we remove the skin excess is a keyhole type pattern.
In which case the surface skin is removed. Through here, this skin is lifted, this skin is lifted. And the way that I do it, I take this tissue, take the surface skin off and essentially turn it into your own “implant” and push this up and then bring the skin over the top. And that’s what enables me to create a breast lift that actually ends up looking very much like a breast implant. Now, often we take out just the surface of the skin. The goal is … to lift the breast not so much to make it smaller … but we very often need to remove a little of the excess tissue on the side … so it doesn’t bulge over here. And I can show you some pictures to help you better understand that. Now with the Wise pattern, the scar goes here, here, and then it tends to run up underneath the fold. And there’s a lot of discussion as far as, what about the scar in the breast lift? Because the goal is to trade a scar to get a better shape and a perkier breast.
I prefer a somewhat smaller areola, well, I’ll show you in the pictures, rather than the larger one. There’s two different standard types of cookie cutters. There’s the 38 millimeter and the 42 millimeter that are the standards, that are most commonly used. And what we do is, it’s truly like a sterile cookie cutter with a hole in the center. We center that over the nipple, and that enables us to make a perfect circle. I think the … smaller one looks a little bit more youthful. I think the … larger one tends to look more matronly. And the goal is a perkier, prettier breast. But the scar goes around the areola, goes down the center and then up underneath. And with the Wise pattern, by coming to the sides, it really allows me to push up on the breast and really tighten that skin envelope.
Now, when we first see, we can see the scars, but the breast will often settle rather quickly. And the fold up underneath tends to be not so noticeable and often not noticeable. The one around the areola tends to fade with the color change from the areola, the pink to the normal skin. And it’s the vertical scar, that’s the one that tends to be most visible. Although if it’s done well, it typically heals very, very nicely. And that’s why I put so much energy into minimizing the scars and providing the layered closure and multiple layers, and all the energy and attention that we place towards minimizing the scars after surgery.
Poor Results – What to Avoid
As we’ve discussed, the Donut lift or Bonelli lift often … doesn’t work out as it’s designed. If we take the large areola and make it smaller, what frequently happens is we … get very little lifting. And when you do that purse-string suture, where you take the big skin, bring it down to the small and then put a purse-string suture around it, the … tension on the scar often tends to pull on the areola … and stretch it back out. And very often … the areola is then mis-shaped and … the scar is often sometimes thicker. Now, frequently, some surgeons will do this. And at the same time, they’ll add an implant with the idea that they’re going to provide some lift and make it somewhat bigger. Well, unfortunately this rarely works as designed. And I think the best example for that would be Tara Reid. And as we all may recall in 2004, her dress fell off, the top of her dress fell down while she was on the red carpet in New York.
And these are a few photos from awfulplasticsurgery.com, where they showed the paparazzi taking pictures of her breasts. And what they showed was that she had what they described as really bad plastic surgery. And they said she had a really bad boob job and she must have had a really bad plastic surgeon. In essence, what she had was a Donut lift with an implant. And my contention is she may or may not have had a bad plastic surgeon, but what she had was a bad procedure, because this is what would be expected. This is called a “Franken-Nipple,” is what they called it … stretched and badly sewn. And they show how it’s very irregular and how the scar is so thick. And to me, it’s very obvious that that’s the procedure that was done because nothing else causes that type of problem.
So again, the Donut lift where you take the skin, the big skin, and sew it down to the small, and then add an implant behind it, that stretches it out. And as I mentioned, it frequently doesn’t work as well as it’s designed, often leading to a very irregular areola with an irregular scar around it. This is another example, next of a patient who came to see me about re-doing her breasts. And she’d had a number of procedures of her breast, but as you can see a very irregular nipple-areola with a rather unsightly scar around the areola, where she had the implant and lift combo. Again, this … seldom works well, not because of the skill of the surgeon per se … but because of the conflicting nature of the two procedures. Now, here is another example of a patient who talked to me about re-doing her surgery.
Now, please note, these are not patients that I have done their breast surgery. These are patients who came to me after they’ve had surgery elsewhere and asked how they might be improved upon. And in her particular case, she had the implant-lift combo with the Benelli lift or the Donut lift. And as you can see, it really didn’t provide very much in the way of lift, and with the implants, the areola has now been stretched back out and she has mis-shaped, and I think quite large areola. In fact, this areola is 70 millimeters (7 centimeters) in diameter and this one is 60 millimeters (6 centimeters) in diameter. Compared to when we do a breast lift, the cookie cutter that we use is a 38 millimeter diameter typically, or up to 42, but this is about two to three centimeters larger in diameter.
And I think that you would understand her concerns in that she didn’t get much of a lift and she has rather large areola. And in her case, the scars around the areola have actually healed very well. So … had she had the lift only (without the implant) … she would’ve had perkier breasts with a smaller areola, with only a fine line scar here that I think would’ve created a much more aesthetically pleasing result. So, I think sometimes it’s helpful to gain an understanding of what we’re really talking about when we discuss the implant and lift combination at the same time.
Now, that I have helped you hopefully better understand where the incisions are placed and how the tissues are moved around with the diagrams that I drew. I’d like to direct your attention to the brochure by the American Society of Plastic Surgeons. And let’s look at the diagrams that they have shown us. And I think in the first one, you’ll notice that the patient does indeed have some ptosis, in this case Grade 2 ptosis, because the nipple is below the fold, but not pointing to the floor. As we look at the next diagram, you’ll see the dotted area that shows you the incision. The green area shows you the area of the surface of the skin that’s removed. And the blue arrow shows you how the nipple is being lifted up. And again … the nipple is not taken off … it’s left in place, but the surface skin is removed and then that’s lifted up.
The next picture shows you with the blue arrows, how the skin comes together in order to reshape the breast. And then finally, the last picture shows you the incisions that go around the areola, straight down, and then up under the fold.
Procedure in Action
Now, let’s talk about how the breast lift operation is done. First of all, the morning of surgery, I’ll have you sitting up and I’ll do some extensive marking. The drawings that I’ve shown for you, I want to draw the right markings for you on your breast. And it’s been said that “you want to measure twice and cut once.” In this case, you’ll see, it’ll take me a while, but I’m very precise in the markings and how we go about doing that. And I’ll show you how the breast tissue gets moved around and where the nipple gets moved up to.
And I think it’s very helpful for your husband or your caregiver to be there so that they too can understand what it is that we’re doing. And then go back to the operating room. After we put you to sleep, the first thing we do is we sit you up in the bed so that we can kind of take a look and see to make sure everything is even, because during the procedure, I will sit you up and lay you down, sit you up and lay you down. The arms are out on the arm board so that they stay in place. And that helps me see in real time exactly what it is that we’re doing.
So, in a breast lift, it’s similar to a breast reduction, both of which involve lifting the breast. A lift is going to take that which is droopy, lift it up, and tighten it, make the areola smaller, and lift the nipple up. The difference between the two is a breast reduction is designed to not only lift the breast, but also make it smaller. So, most patients, one breast is a little different than the other. In a breast lift, we’ll start with whichever breast is smaller, we’ll lift that up first, and optimize the size and shape. And then on the other side, we will lift it up and then make it a little smaller in order to match this breast.
On a reduction it’s the opposite. We start with the biggest breast, make it as small as it will go and still create a pretty breast with a nice blood supply to the nipple, and then take the smaller breast and get it to match. In both cases, what I like to do is I start with one breast. I reshape it and then bring all the skin together. And then I go to the other side and do the same thing. And then once I’ve done one breast, I reshape it, sit you up and compare, and optimize the size and shape. And then I do the other and optimize the size and shape of that one. And then I want to compare between the two. And I’m a bit of a perfectionist, so the “tweaking” is what takes me a bit of time, but it’s really worth the effort. That’s where you want to spend the additional time.
I mean, if you don’t care whether the breasts are the same size, same shape, whether the sensation is there, whether the scars heal well, whether the blood supply is good. If none of that matters … you can be done in a hurry.
But if any of that matters … it’s going to take a while. And that’s where … precision surgery comes in. It’s much better, as my mother said, “If you’re going to do it … do it right … or don’t do it at all.” I don’t promise perfection … but I won’t quit until it’s as good as your body allows me to get you.
And what I’d like to do is, I’ll show you some intraoperative photos that I think will really help you understand this. In fact, one day as I was doing the breast lift, as I finished one side, I’d sit you up. And then what we’ll do is we’ll staple the skin (just temporary) … and at the end we take out the staples, but it allows me to “tweak” during the surgery. So, I have the markings on both breasts. I do one breast, I sit you up, and I optimize it, and staple it. And then next, I go to do the other one. And I thought, “I should take a picture of this” … because there’s no better way to understand what a breast lift really is. Because right there … when “one is up and in” …and the other “one is down and out” … that’s a breast lift. I mean, I can show you before and after photos all day, but it doesn’t quite ring true as well as seeing the actual picture during surgery. So now I’d like to share with you a couple of those examples to help you really better understand the breast lift procedure.
Intra Operative Photos
I’d like to share with you some of the intraoperative breast lift photos. Now, these photos are not meant to scare you, but rather to help you really understand what a breast lift is. And it occurred to me one day, again, I start with a smaller breast, lift it up, and then bring the skin together, and then do the same on the other side. But … when I lift up one and … compare it with the “one up and in” and perky … and the other “one down and out” and droopy … it occurred to me, I should take a picture of this. There’s no better way to describe what a breast lift is than to see it in real time. I can show you the before and after picture all day long. And you say, “Yeah, I see it.” But when you see … the same patient with “one up” …and “one down,” you really gain an appreciation for … the power of the breast lift.
And this is why it’s one of my all-time favorite procedures. So, I want to share with you some of these photos. This is a young lady who came to me initially for a mommy makeover. And she wanted to do the breast enhancement, the tummy tuck, as well as the lipo. She wanted “tummy & above” and “tummy & below.” And we started with the “tummy & below.” We did a tummy tuck and the lipo of the thighs. And now she wanted to come back and do the breast lift. So, as you can see, the left breast is a little smaller than the right one. The inframammary fold is here. So, she has Grade 2 ptosis. The areola are enlarged. And so what we do, these are the Wise pattern markings, and I’ve marked the midline in the sternum, as well as the midline of the body.
This is the midline of each breast, or also called the “midline breast meridian.” And this is where I’ve marked the nipple to be. And the markings with a Wise pattern kind of keyhole type markings will show around the areola so that we can remove this excess pink skin. We put a “cookie cutter” over the nipple to make a smaller areola, remove the surface skin within the area, within the keyhole pattern, lift up the skin flap on the inside, on the outside, take this lower part of the breast and turn it into her own breast “implant, essentially”. So, we lift this up, lift this up, turn this into her own breast “implant” (with her own tissues), and then bring the skin over the top. And the first thing I’ll do is I’ll start with the smaller one. I’ll lift it up, optimize the shape of that breast, and then I’ll staple it together, and then I’ll do the other breast.
And then I’ll staple that one together. And the reason I use the staples is just temporary, but it allows me to be able to “tweak” the breast. Because I’m a perfectionist. Now, I don’t promise perfection … but I won’t quit … until it’s as good as your body … allows me to get it. So, the whole goal is to match the breast as close as possible. And as I said, if it doesn’t matter whether the breasts are the same size or same shape, or if the scars are fine-line, or whether the scars heal well, or the blood supply is good, or the nerve sensation is good. If none of that matters … you can do it in a hurry. I prefer to take my time to do whatever I can to optimize your results, because that’s why we’re there. So these are the markings.
The next picture will show you, and again, I will … operate while you’re lying flat and … then sit you up to compare. Because … what you see when the patient lays flat is … not the same as what you see when they sit up. So, this is her sitting up while she’s asleep, and this is showing both sides stapled in place. Now, at this point, once I’ve optimized the size and shape, and got them to match, and lifted them up, and made them perky, then I’ll take the staples out, and then sew it up, in multiple layers. And at this point it usually … takes me several hours … just to close everything up in order … to minimize the skin tension in order … to get the best possible scars.
Now, the next patient, I think really helps to understand the power of a breast lift. I think you can see in her right breast, the areola is enlarged. Her fold is here. We mark the nipple at the fold, but when we’re finished with the procedure, the nipple actually is designed to come even higher than that. So, as you can see on her right breast, the areola is enlarged. She has Grade 2 ptosis. Here’s the Wise pattern markings with the keyhole. And this one has been lifted first and stapled together. And you can see the one on her left is “up and perky’ and the one on the right is “down and out.” This is a little closer view of the same patient. And I think you can see the power of the breast lift and what a significant change it can be, and what a much prettier shape of the breast after the breast lift.
Now, the next patient is 65 years old. She initially came to me for a facelift. So, we did her facelift and she was very happy with that. And then she said, she’d like to do a breast enhancement. And we discussed either an implant or a lift. Now, in her particular case, she has very little breast volume and not much drooping. And she could benefit from an implant alone if that’s what she was wanting. She was 65. She didn’t want bigger breasts. She just wanted to be more perky. So, I did a breast lift procedure. So even in a breast that’s not too big, that’s not drooping very much. I think you can see the power of a breast lift and what a significant change we are able to create with the Wise pattern lift. Again, the same patient. And in this photo, it’s a little closer up, but you can see that we mark the nipple here and it actually ends up being even higher once I bring all the tissues together.
The staples are temporary. We do the smaller one, lift it, make it perky, and then do the larger one and get it to match. And then “tweak” them to get them to match as close as possible, and then take out the staples, and sew it up in layers in order to get the best possible scar for her.
Now, the next patient, I think you can easily see why she was such a great candidate for a breast lift. This is a nurse who’s had five children and the areola are very large. She does not have a lot of breast volume, but she has a lot of really loose tissue that is really hanging down quite low. So here I’ve marked the midline. This is where I marked the nipple in the center of the keyhole. And I’ve made some adjustments to my scars or to my incisions, or my markings preoperatively to allow me to remove even more excess skin.
The nipple is not removed. I put the cookie cutter directly over this to make a smaller areola, remove this surface skin, lift the skin flaps up, create a space here, reshape the breast, lift it up, and actually snug the breast to the chest wall, and then reshape. And I think you can see what a dramatic change that is. Now, this is while she’s in a sitting position. If we look at her while she’s lying, I think you can truly see the power of a breast lift. And very often when I do this, it does take me a while and the nurses will sometimes take a break. And one of them will come in and say, “Dr. White, wow, she looks great. What size implants did you use?” And I said, “Well, I did a lift.” And they said, “Well, I know, but which implant did you use?” And I said, “Well, I didn’t.” And they said, “Well, I mean, it looks like an implant.” And I said, “Well, ha, ha. That’s the whole point … do a lift in a way that … looks like an implant.” And I think you can see what a really pretty shape we’re able to achieve. Now, in her case, you can see the nipple is almost off her chest here, and now it runs down the center of her chest. So, I’ve repositioned this and I want to reshape and create the prettiest breast mound for her body. Now, in some cases, we will take out a little tissue on the side so that we don’t have a bulge over on the side, but I think you can appreciate what a difference that makes for her.
The next patient, I think really demonstrates a breast lift procedure very well. As we can see in her intraoperative photo, the one on her left, you can see that if this is the fold, the nipple is marked at the fold. So the nipple is below the fold, but not pointing to the floor. So she’s Grade 2 ptosis. The areola is enlarged. So here we are with the Wise pattern markings. Before on the left, and after she’s been lifted up and everything has been stapled and placed on the right. Now, you can see it folds a little bit, but that’s because she’s sitting up. When she stands up, that tends to go away. The next picture is a little different view. And I think you can see, even though the nipple is marked here, it actually ends up being even higher, typically at the top of the keyhole marking. So that’s, instead of “down and out,” it’s now “up and in.” The view from below helps you to see how the breast is essentially falling off the chest. The nipple is actually beyond the side of her chest wall.
And now it’s been repositioned here in the center. And again, the goal is to reshape her breast and to create the prettiest breast mound for her. Now, finally, this is the one picture that I think really clarifies a breast lift most of all. If we look at the picture on the left, the areola is not removed (the areola or the areola) whichever term you prefer, I place a cookie cutter around this and leave the skin around the areola but make it smaller. These are my markings here. This skin, we just take the surface skin off in the area within the keyhole markings.
This skin where the skin is lifted up on the inside, and on the outside, and I create a space up underneath here, much like an implant. For an implant, I create … a space under the muscle … for the implant. In this case, I create … a space under the breast … (on top of the muscle), take the surface layer of the skin off here, much like a skinned- knee, and then take her breast and essentially turn it into its own “implant.” Push it up into the chest, and bring the skin over the top, and then tighten that, and reshape that, to get the prettiest breasts for her.
And if we look at her right breast now, we’ll see for the very same patient … this is before … and this is after. And if we look at the upper portion of her breast, I think you can see how that looks very much like a breast implant. And I have now made the space up above, repositioned this tissue up, and then brought the skin over the top, and then stapled it. After this one is done, I then do the next one. And then afterwards, I “tweak’ them to get them to match as close as possible. And at that point, I take out the staples, and then close everything in multiple layers … in order to get the best possible scar. But I thought this one picture really helped clarify my method of doing a breast lift. And I think it is really worth the added time and extra effort to get this type of result.
PreOp & PostOp
Now, let’s talk about the pre and postoperative care for a breast lift or mastopexy. Preoperatively, we typically get a mammogram in advance. Be sure and get that well in advance. Just in case, if there’s any question, they may want to bring you back in for a sonogram or get an extra study. And depending upon what the result is, on occasion, we may have you see the breast surgeon so they can kind of ‘bless the breasts” to say everything is okay for us to proceed.
The pre-op visit, we usually see about three weeks in advance or several weeks in advance. And at that time there’s a lot of information. We have you watch a video, which is all about surgery in general, or pre-operative video. At that time that we sit down and we go through a bunch of information, we give you an informational booklet that talks all about the procedure. We go through the consent forms. We take a lot of pictures, answer any questions. And so there’s a lot of information to be gained.
Avoid aspirin or Motrin are things that cause bleeding for about two weeks before and two weeks after. And make sure that those who smoke stop all nicotine in advance and absolutely all nicotine products for two months after surgery. Because again, nicotine can squeeze the blood vessels and that can lead to issues with healing.
Now on the day of surgery, it’s a good idea to have your caregiver, your husband, boyfriend, whoever it may be, to be there with you, because that’s when we’re going to take the time to do the extensive preoperative markings that I had talked to you about. And I think it’s helpful for them to be able to see that. And then after that tell them to go to work. Don’t take off that day. I don’t need them that day, but we’ll just call them whenever we get through.
So the day of surgery, after we’re finished, sometimes patients will choose to go home. Sometimes they’ll spend the night, but as I said, it’s one of my favorite procedures because it tends to be such an easy recovery. We will often use a small drain that may stay in for about a week or so. Sometimes we don’t need one. Sometimes we do. It just kind of depends upon your tissues.
But this is one of the easiest recoveries. Typically, we have very little … often no bruising whatsoever. The steri-strips are on for about three weeks, and then we use the silicone sheeting, and then after that, the liquid silicone gel. You’re in the postoperative bra early. And then as time goes on, we’ll reconfigure the bras and put you in the super spiffy support bra.
Now, the healing following a breast lift or a breast reduction involves lifting the breast, tightening the skin, and essentially fighting gravity in order to maintain the results. And so now I’d like to show you the diagram that helps you understand how I like to minimize the potential for recurrent drooping of the breast or ‘bottoming out,” or “squaring” out of the breast … and how we’re able to use the shapers to provide an upward push in the inside of the breast to maintain that pretty shape. I think it’s very important to understand what we did. We were … fighting gravity in order … to reposition the breast to a higher perkier level … on the chest. And so after surgery, the vertical line here, and what we want to do is maintain a very pretty contour here. Now … if we don’t wear a bra after surgery … and we let gravity take its toll, then what may happen is that … the breasts will tend to go … to the side at night and … down during the day.
So if we can … keep them up during the day … with a nice snug bra … and in at night … we can maintain our cleavage. And so I think that’s … very important to wear a bra in order … to prevent them from settling … over time. Now, what may happen if we’re not cognizant of it and trying to prevent it is that as the breast begins to settle a little bit, there’s something called “bottoming out” or “squaring off” of the breast. And if you’re not working against gravity, the breast may settle a little bit and you can lose some of this pretty curvature, and it can kind of “square out” a bit. And that’s obviously frustrating because we … had a pretty result and … then we lost it over time. So, the goal then is let’s maintain that result and let’s maintain that pretty shape and contour.
And what I have discovered that works very well is from a postoperative standpoint, is let’s put additional attention to the inside in here and in here by putting a “push up” in this area. And what we do is we wear a little “shaper” right over this area, and that puts a little general “push up” so that if it does settle a little, it tends to settle over on the sides and it maintains this pretty shape. So this is an example of the silicone shaper that can be helpful during the postoperative period to provide pressure in the inner part of the breast underneath to push up in that area, to make it less likely for it to settle over time. Regarding the long term results, patients will sometimes ask, well, how long does a breast lift last? And the answer is, well, it’s just like a facelift.
I mean … it lasts forever … but time marches on. The difference is, in a facelift, you really can’t wear support to maintain the results, whereas in a breast lift, you can. And so …the secret to really maintaining the result over time … to get the best result is … to wear a properly supportive bra in order to be able to … support the breast during the day … whenever you’re upright and prevent them from settling down … and also at night … to provide the support on the sides, to make them less likely to settle off to the side. And I think this is a very good idea … for any woman with really … any amount of breast tissue. I discovered a number of years ago, the power of maintaining the supportive bra.
I had a patient, her name was Loopy. She was 69 years old and she came to me for a tummy tuck. And she said, “I’d like to do a tummy tuck.” And I said, “Well, that’s great.” And she said, “No, no. I mean, I’m healthy.” And I said, “Okay.” She said, “My brother, he’s a doctor. He said it’s okay.” And I said, “Well, I understand.” And I said, “But why do you want to do a tummy now … because you’re 69?” She said, “Well, I’ve had five kids.” And I said, “Okay, but why now?” She said, “Well, it’s been bothering me all these years.” And so she said, “Please, can I do this?” And I said, “Well, okay, we can.”
She did absolutely beautifully. In fact, after she left the hospital … she only took one pain pill for the arthritis in her arm. But what I learned most from Loopy was when we were taking her preoperative pictures. I noticed that even though she’d had five children, she breastfed all five children.
At 69 years old she had two of the prettiest breasts that I’d ever seen. And I had to ask her, I said, “Loopy, how can your breasts look that good?” And she said, “Aha. My grandmother told me … always wear a supportive bra.” She said, “Because you’re fighting gravity. You got to … keep them up. You got to … keep them in.” And I thought, “You know what, Loopy’s grandma was absolutely right.” And it really does help over the long term to wear a supportive bra … either after implants … after breast lift … after reduction … or patients who’ve never had any surgery … if they have a fair amount of volume and weight to the breast. That’s an important thing to keep in mind in order to get the best result, long term, following your breast lift operation.
Next, I want to talk about the scars for breast lift or breast reduction. Essentially the incisions are the same and the scars have the same considerations. And I pay a great deal of attention towards getting the best possible scars. Because what we’re doing is we’re essentially … trading a shape for a scar. If this is the incision, and we’re going to close that incision, we could do it one layer, two layers, three layers or more. But if this is a single layer closure, the tension, when it comes together, as you bring it together, that’s where the tension is, is right there at the suture line. And … if there’s not much support … it’s going to tend “to give” or widen … and the scars tend to widen. So very commonly, you’ll see some, if you go out on the internet, you may see some really unsightly scars and very often on a breast lift that you see … the pictures from the side. And that’s … because the surgeon doesn’t really want to show you the frontal views … because the scars can be objectionable.
I want to show you the scars, because I think if you really put a lot of attention into it, you can get typically very nice fine-line scars. So again, if this is the incision, I prefer to use multiple layers of closure, two or three layers in order to minimize this tension. So that as it’s healing, we have additional support. And these sutures all dissolve over time, but they last at least six weeks because that’s when the scar strength is there. And the final scar strength is only 80% as strong as it was before it was injured. So, in order to get the best scars, again, we want to use precision surgery, maximize the blood supply, minimize tension, multiple layered closure. And then after surgery, once we put everything together, what we want to do is put pressure on the scar to keep it from widening.
And in that setting, we use steri-strips typically over the incision, and that … puts pressure to keep it from getting raised … and takes the tension off … to keep it from widening. Now, the steri-strips will usually stay on for a period of several weeks. After that, I like to use this silicone sheeting, which tends to work very well. It puts pressure on the scar and again, takes the tension off to keep it from widening. This is important during the first six weeks during the healing process, the early healing process, where the scar is getting to its full strength. When it’s fully healed at six weeks, it’s only 80% as strong as it was before it was injured. And that’s the science of any wound healing. At that point, it shouldn’t widen further.
So, once we’ve protected it for the first six weeks, the next thing we’d like to do is then penetrate down into the tissues. And that’s where the silicone scar gel can be very helpful, because the scar gel, if we rub it in, it will penetrate down into the tissues and work from the inside. And that has been shown to decrease redness and darkness up to 70%. The scars tend to fade over a period of several years. The lighter the complexion, the lighter the skin, often tends to be somewhat more red. And I think those are the patients who may sometimes benefit the most from the scar gel. Although I think it’s beneficial for all patients and I highly encourage you to use it.
This is the fun part. I’d like to share with you now some of the before and after photos. And I think you’ll gain an appreciation for the power of the breast lift and why it’s one of my favorite procedures. The first patient is 30 years old. And I think you can appreciate from the before photo in the frontal view, the inframammary fold, the nipple is below the fold. The areola is enlarged. She has Grade 2 ptosis. And after surgery, the nipples are at the same level, the areola are made smaller. And I think it’s a very pretty shape to the breasts with an almost imperceptible scar around the areola, down the midline, and then under the fold. If we look at the oblique view, if we can see, this is where the fold is … and the entire breast is now above the fold. And I think that creates a very pretty shape, from the side where the breast is drooping, and the nipple is pointing downwards … versus after surgery.
I think that looks quite a bit like a breast lift. And if we look at a closeup, I think you can gain an appreciation for the fact that if you take the time to be very careful in doing a precise operation and very careful in closing the incisions to get the best scars that we can often achieve very nice fine-line scars over time.
The next patient is 31 years old, has two children, and she has a fair amount of breast tissue. And as you can see, below the fold, she has Grade 2 ptosis with an enlarged areola, and she wanted to have more perky, pretty breasts. And so after the breast lift, I think this is a great example of the power of the breast lift procedure, the way that I do it. To reshape the tissue, she has a greater volume so that I’m able to create more fullness and give the appearance of a breast implant.
Now, this is just a breast lift and not an implant, but I think you can see the nipples are at the same level. She has a fine-line scar around the areola. The vertical midline scar is almost imperceptible. And the incision underneath, that scar tends to fade very nicely and the breast will settle a little bit so that that’s hidden up under the fold. In the oblique view, I think you can appreciate her inframammary fold and almost her entire breast is below the fold. The power of the breast lift procedure is to be able to reposition her breast higher on her chest wall, and then reshape the breast. The nipple is now well above the fold. There’s nothing hanging down below, and again, a very fine-line scar around the areola that tends to fade with the color change of the areola. The vertical scar is almost imperceptible.
It’s now two years after her surgery at the time the photos were taken. And from the side view, you can see the degree of drooping versus the degree of improvement afterwards. Now, there is a little settling of the breast over time. The way that … I do the operation now … is even better than this … in that I now take the breast (as the last part of the procedure before I close the incision) and … I actually support it and secure it to the chest wall to give additional support and make it less likely for it to settle over time. And I think it’s been a really nice addition to the breast lift procedure in order to get an even better result with time.
The next patient, I think is another excellent example of my approach to a breast lift. Whereby I take the breast tissue, the patient’s own tissue, and essentially turn it into a breast “implant.”
Patients are always concerned about the scars and sometimes what we discover is the darker skin types are perhaps more likely to scar. And that’s why I like to show close ups of the scars to help patients really understand what the difference truly is. This is a young lady who is approximately 35 years of age, and she’d had twins and had a lot of involution of her breast. She has a considerable amount of breast tissue. If we look at her fold, she has a lot of breast tissue, which is all below the fold. And if we look at her before … to her after, you can see how the areola are much smaller, the nipples are at the same level. And I think she has a very pretty shape to the breasts. You can see the fold here where essentially the entire breast is down below the fold … and the after where the breast has been lifted up.
And then again, from the side view, you can see how much drooping she really has … versus after surgery. I think that looks a lot like a breast implant and it’s actually all her own tissues. And you can see the scar around the areola has faded very nice with the color change, the vertical scar you can barely make out. And the scar underneath tends to fade nicely up under the fold.
This patient is 46 years old and in her case, she’s a great example of a breast lift whereby the patient wants a lift, but actually needs a little bit of a reduction. In other words, by the time I lift her breasts up, the breasts are so full that they would be bulging too much around the perimeter. So, she goes from the preoperative photo on the frontal view where you can see there’s a large amount of breast tissue well below the fold, essentially the entire breast is down below the fold with Grade 2 ptosis.
And in the frontal view, I think you can see what a much prettier shape she has, how much the nipples have been lifted, the areola have been made smaller. And I think that’s a very pretty shape. Again, taking her tissue, taking it apart, lifting up the flaps, reshaping her breast, placing it higher on the chest wall, securing it to the chest wall, and then reshaping the skin over the top in order to achieve a significant lift of the breast. And what I think are rather fine-line scars around the areola, down the vertical fold which is barely perceptible, and the one underneath tends to fade quite nicely.
This patient is a 37 year old patient who came to see me from Shanghai and she wanted the mommy makeover. And in her case, we did the breast lift as well as the tummy tuck. She’d had twins. And after the twins, noted that she had a significant drooping of the breasts, whereby essentially her entire breasts are now below the fold. And I think that’s best seen in both frontal as well as the oblique view. The areola are enlarged and the nipples are at the lower part of the breast. So she wanted to have a breast enhancement with the breast lift procedure.
In the frontal view, I think you can see a significant lift of the nipple and the nipple-areola complex, where the nipples are at the same level. She has much smaller areola and I think much more youthful and perky breasts. And again, as an Asian skin type, one might expect that with a little darker skin, perhaps she might have worse scarring, but I think she’s healed very nicely. The scar around the areola tends to fade very well.
The one along the fold, it is visible, but I think that is healed very nicely. And the one under the fold, again, tends to fade very nicely and the breast settles a bit such that that tends to be covered. So I think that’s a rather significant change where the nipple was pointing on the lower part of the breast before surgery and then after surgery, I think this is a very nice change. Now, should she desire larger breasts at a later date, now that the breasts have been lifted up, they have been reshaped, and the size has been evened, I think that if she wanted to go larger, then at that point she could have an implant placed at a later date. She however was very happy to be perky again and had no interest in an actual breast implant.
This is a 51 year old patient who was concerned regarding the drooping of the breast, as well as the fullness in the tummy and came to see me for the mommy makeover with the “tummy & above,” with the breast lift as well as the tummy tuck. And if we look at the breasts, in the frontal view, we note where the inframammary fold is, and she has a considerable amount of drooping with Grade 2 ptosis. The areola are really near the bottom of the breast, and here we are before … and then after.
And I think you can see that’s a rather significant lifting of the breast and shortening the distance from the clavicles (or the collarbone) to the bottom of the breast. By lifting the breast up, placing them higher on the chest wall, and then reshaping them, taking her tissue, making a pocket for it, and essentially turning it into its own implant, I think that creates a very pretty, very natural look that looks quite a bit like a true breast implant, although it’s only her own tissues. So, you can see where the nipples are at the same level. I think that’s a very pretty shape.
Now, in her case, she’s a redhead. She has a lot of freckles, a very light complexion. And so the redness is a bit more visible. However, that continues to fade over time. This was an operation I did a number of years ago before I’d used the silicone gel. And at this point I would encourage a patient such as this to use the gel because it decreases that redness by about 70% over time. If we look at the oblique view, I think you can see how much drooping the patient had. Before surgery, the fold is at this level, almost the entire breast is below the fold … and then after surgery where the breast is much higher on the chest wall. And as we look at the side view, the nipple is almost pointing downward versus the side view after surgery, again, a very pretty reshaped breast.
I’d like to share with you some close-up pictures to show her scars. And if we look carefully, we can see the scar around the areola has faded very well. The vertical scar has also healed very well with a very fine tinge to it. And the scar underneath has also healed very, very well. So again, I believe it’s worth taking the extra time in order to do the layered closure, to do precision surgery in order to maximize the blood supply to the skin, to get better healing, and better scars.
This is a 41 year old patient who came to see me for the mommy makeover and she’s had two children. And first she wanted to do the “tummy & below,” the tummy and lipo of the thighs. And then later the breast enhancement with the breast lift procedure. In her case, she has only a limited amount of breast tissue. The nipple-areolar complex is somewhat enlarged and is at the lower part of the breast.
And she could go either way … either with a larger implant to fill the skin soft tissue envelope … or with the breast lift. She was not interested in an implant and she didn’t want to make the breast any larger. She just wanted to make them more perky. And I think you will see that with the vertical Lejour lift in this particular case, I was able to get quite a bit of fullness in the breast by reshaping the breast and lifting the nipples at a higher level. The scar again, I think has faded very nicely around the areola, down the vertical line, and just a little bit underneath. And you can see from the lateral view what a nice difference I was able to achieve.
This is a 56 year old patient who has lost a considerable amount of weight with massive weight loss. She initially came to see me for the mommy makeover with a “tummy & above,” and she wanted a tummy tuck as well as the breast lift procedure. And in her case, I felt that it was best to do this in two steps. She felt as though the tummy was her priority. So we started with her tummy tuck, and now she has decided she wants to proceed with a breast lift.
And I think you can see in her case, if we look at the frontal view, the fold, the inframammary fold, is at the top of the breast, and the entire breast is down below her chest wall, hanging down over the top of her abdomen. This is Grade 3 ptosis where the nipples are pointing downwards. And from the before … to the after, I think you’ll see that this is a great example of my approach to breast lift, where I take the breasts apart, make the areola smaller, make a pocket up underneath the skin on either side, take the surface of the skin off of the breast, reposition the tissue higher on the chest wall, and then reshape the tissue over the top.
And I think that her … after picture looks very much like a breast implant. The nipples are at the same level, the areola are much smaller, and I think it’s a very pretty shape. But if we look at the oblique view, the inframammary fold lies here and we can see the entire breast is now up on the chest wall. And in the lateral view, where the nipple is at the very bottom of the breast pointing to the floor … after surgery it’s positioned where it should be … well above the inframammary fold. And she has healed very nicely. The scar around the areola is hard to perceive. Then we have the vertical scar, and the one that lies underneath. And I think she’s had a very nice result as a 56 year old patient after substantial weight loss.
This is a 37 year old patient who’s had two children and came to see me for the mommy makeover. And in her case, she wanted the ‘tummy & above,” the tummy tuck, as well as the breast enhancement with the breast lift operation. If we look at her before picture, we’ll notice a considerable difference between the breasts where the left breast is larger and lower compared to the right. And if we look at her after photo, I think you can see the benefit of my approach to the breast lift, whereby I elevate the skin, create a space or a pocket, reshape the breast, lift it higher, turn her breast into its own “implant,” and then reshape the breast in order to create a very pretty shape to the breast, which does look, I think somewhat like a breast implant.
And notice the difference between the nipple position in the preoperative photo … versus after surgery, how the nipples are at the same level … the breasts are the same size. I think that the areola are much smaller. The scar around the areola has faded very well. There’s a very fine line for the vertical scar. And then the scar underneath is almost imperceptible. What is also interesting about this patient is if you’ll notice on her preoperative photo on the left breast, she has this beauty mark right near the midline. If we look at the same patient in her after photo, you can see that the nipple, the top of the nipple, is now at the same level as that beauty mark. And that gives you an idea of how much that nipple was elevated on that side.
And if you look at the before again, she had a considerable amount of asymmetry between the breasts where the left one was much larger than the right one. And after surgery, the breast lift not only allows us to create a more perky, pretty breast, but also to minimize the asymmetry, and to match the breasts as close as possible. And I think this was a very nice change for her. And if we look at the after photos in the oblique view, we can see that the breast is largely below the inframammary fold … versus after surgery the inframammary fold lies here and the majority of the breast is now above the fold. So I think she was able to achieve a very perky look following the breast lift procedure.
Thank you again for taking the time to watch this video. I know that I’ve given you a lot of information, but I think it’s very important for you to fully understand the procedure. I look forward to visiting with you to answer any questions that you may have, and also gain a better understanding of what it is that you hope to achieve. Thank you again very much.
Key Points – Elegant Precision™ Breast Lift
Key Points – Elegant Precision™ Breast Lift
Key Points – Elegant Precision™ Breast Lift
Key Points – Elegant Precision™ Breast Lift
Key Points – Elegant Precision™ Breast Lift