Many women clearly require breast implants along with their lift. There are two scenarios in which this is commonly seen. The first is the patient who desires breast augmentation and on examination is found to have sufficient ptosis to require a lift. The other is a patient who initially consults for a lift and desires upper pole fullness or a larger breast.
The decision must then be made whether to perform the augmentation and lift at the same or at separate operations. In situations where only minor lifting is required, I find it acceptable to perform the procedures at the same time. However, in patients with moderate to major ptosis of the breast, I strongly believe that it is better to perform the mastopexy first, and then perform a breast augmentation three or more months later.
There are also situations where it is not so clear-cut that both operations are needed. In the case of a woman who wants larger breasts and has only minor sagging, it is perfectly acceptable to put the implants in first and then see how everything looks before determining whether or not perform a mastopexy. Frequently in cases of severe ptosis, particularly when the patient wants the same size or smaller breast, a mastopexy will be performed at the initial stage. Many of these patients will elect to not even get implants so they do not have to deal with the potential complications and additional cost of those implants.
One of the more difficult situations that occurs is the case of a woman who has very large breasts, D or DD, who wants a lift but also wants to maintain or increase her size. This situation is even more difficult if she wants upper pole fullness. When the lift is initially performed the skin will be tight around the breast. However with the weight of the breast tissue the skin will stretch. As the skin stretches it becomes weaker. As the skin becomes thinner and weaker the breast will again sag. This will be compounded by the weight of an implant.
A breast augmentation performed alone has very few complications. A breast lift performed alone, has very few complications. However, when a breast lift and a breast augmentation are performed in a single operation, the incidence of complications seems to rise exponentially. There are several factors that contribute to this increased complication rate of the combined augmentation mastopexy. One is that women with mammary ptosis have weakened skin at the bottom of the breast. When an implant is added, the additional weight will further stretch and weaken the skin. If an incision is made at the bottom of the breast to perform a mastopexy then this further weakens the skin. The sutures may only strengthen it for a week or two until they began dissolving or cutting through the tissues much as a wire can cut through a slice of cheese. Also if the implants are placed under the muscle this will cause further downward pressure on the bottom of the breast where it can be least tolerated. Long-term this will often cause bottoming out of the breast.
The reasons for staging an augmentation and mastopexy are as follows:
- It reduces the variables of each operation so that it becomes more predictable.
- It decreases the complication rate.
- The complications that tend to occur in staged operations are usually less severe complications.
- The most severe complications are infection, capsular contracture, implant exposure.
- There is less risk of bottoming out of the implant.
- It allows for better muscle coverage at the second stage breast augmentation.
- It reduces the risk of unplanned secondary operations.
- It may prevent problems that are not correctable.
The unplanned secondary operation is one of the most distressing events in plastic surgery. It is distressing physically, emotionally, and financially.