Breast Lift Without Augmentation & With Augmentation

Breast Lift Without Augmentation

Many women decide to have breast surgery because they want to achieve a more aesthetically pleasing appearance. Yet, when scars remain noticeable after surgery, it is usually difficult to feel completely satisfied with the end results.

Age, pregnancies, lactation, and hormonal factors cause the breast tissue to become fatty, i.e., brittle or friable, and to loose volume while the skin looses its elasticity. The consequence is stretching and sagging of the breast, which can be corrected by a breast lift.

This article is written for my patients to clarify concepts about the breast lift. First, the patient is examined. Then, the indications and the surgery are described.

Two questions women ask, are about scars and size.

The first and foremost question pertains to the scars. The breast lift covers about 100 years of surgical evolution. In 1919, Girard, a French Surgeon, published the first technique. Multiple techniques have been devised since then. Today, scars remain the patients' major concern. A review of techniques will be covered. Breast lift combined with breast augmentation is treated separately in another article.

The second most common question pertains to the size. "Will the lift make my breasts smaller?" The answer is no. The lift is not a reduction. By definition, the lift repositions and reshapes. Thus, the breasts will go back where they should be and regain a nicer shape. The lifted breast is no longer hanging down, and gives the impression of being larger.

Consultation For Examination & Decisions

Breast Lift Consultation:

At the time of the consultation, first I ask the patient if she wants larger breasts, higher breasts, or both. We then discuss the degree of ptosis and the type of skin and breast tissue. For instance, stretch marks may indicate that the skin and breast tissue are stretchable. The size and the position of the nipple and areola is measured, along with body height, weight, and type of ribcage. These are all factors that will determine the type of surgery.

Once the evaluation is completed, the Surgeon and the patient discuss the best procedure needed to reach the patient's goal:

  1. If she wants larger only, a breast augmentation may be sufficient to correct minor ptosis. (Contact the office or log on to my website for my Breast Augmentation book).
  2. If the patient wants larger and higher, then an augmentation and a lift may be required. (Contact the office or log on to my web site for my article).
  3. If the patient wants higher only, she needs a lift only. Two situations then arise:
    1. The breast is heavy, or very heavy (larger than a "D" cup). A lift would probably not hold the weight of the tissue. Stretching and sagging would recur not long after surgery. In that case, a breast reduction is better indicated. It will reduce and lift the breasts durably at the same time.
    2. The breast is not too heavy (no larger than a "D" cup). The lift alone is done for a good, long term result. In this case, several techniques can be offered and the patient decides which surgery she would prefer.

Surgery Review

A review of techniques is presented in three parts:

  1. The Skin Techniques
  2. The Glandular Techniques
  3. Benelli Breakthrough

The Skin Techniques

Removing the excess of skin to reposition and reshape the gland is the oldest technique and can still be used. This technique follows three patterns:

A: The anchor pattern, the most commonly used in the United States, is reliable and not that difficult technically. The major drawback is the extensive scar.

B: The lollipop pattern, rather recent in the United States, has the advantage to leave less of a scar than the anchor pattern. The technique was created in the late 1960's by Claude Lassus (Nice, France).

C: In 1984, Louis Benelli, (Paris, France) designed the doughnut pattern, leaving the scar only around the areola. This last technique is more difficult, but it eliminates large scars on the breast. Not published in English at the time.

All of these techniques involving the skin can only obtain a good lift on breasts that are small with good skin. However, these two conditions are lacking in most saggy breasts, which have poor breast tissue and skin. Stretching and sagging will usually recur.

The limitations of the skin lift led to another type of lift, the glandular lift.

This breast lift is based no longer based on the skin, but on the gland.

The Glandular Techniques

Glandular techniques allow a good durable lift in all kinds of saggy breasts because the breast tissue is tailored and reattached to the chest wall. We do not just rely on the skin anymore. Everything is done on the gland, while the skin covers the gland without supporting it.

Thereby, the result is much more durable and predictable. Some sagging may recur with time if the quality of the breast tissue is poor. However, this is usually much less than with the skin technique. That new concept started with Claude Lassus' lollipop pattern, using part of the gland to secure the whole breast on the chest wall.

In 1990, Serge Krupp, (Switzerland), devised another technique that was more versatile.

These authors were not published in English until 1994 when Madeleine Lejour, (Brussels, Belgium), published a book and video tapes that popularized these procedures in the U.S.

In 1990, Benelli published his round block technique (Doughnut pattern) in English with 2 glandular techniques. Please see below.

In 1991, Sampaido Goes (Brazil), innovated an internal brassiere. Through a doughnut pattern, he does a complete undermining of the skin and then places a nylon mesh around the breast. The mesh is in turn secured to the chest wall. His results are excellent, but it is a very extensive surgery, and the risk of infection with the mesh is the major objection. For this reason, it has not gained popularity in the U.S., nor in Europe.

In 1998, Benelli published his second article in English.

In 2001, Ruth Graf, (Brazil), found another good technique, which is quite reliable, but implies a lollipop pattern versus a doughnut pattern. Some U.S. surgeons use it.

Benelli Breakthrough

In 1984, Benelli made a major contribution. He eliminated the anchor and lollipop scar patterns used for breast lift and breast reduction. At first he developed a new skin procedure, he called the "round block", that he followed with two glandular techniques that were quite innovative. His technique leaves a scar around the areola only, we coined the "doughnut" pattern. Benelli was invited for a presentation in the U.S., (Beverly Hills, Century Plaza Hotel), in 1987. His technique did not gain popularity in the U.S. due to its difficulty. Several U.S. surgical authorities tried, without being convinced. In 1989, he was re-invited this time for a surgical workshop in San Diego. We could see him perform. After his demonstration, U.S. surgeons remained reluctant and didn't have the "stomach" to try it. Impressed but apprehensive, I felt more exposure was necessary before "going for it". Therefore, in February of 1991, I went to Paris to watch him. He kindly offered me the opportunity to assist him in surgery. I became convinced. The learning curve is not short, but within the reach of any qualified Plastic Surgeon.

Today, Benelli remains the master of the technique. You can log on his web site. He also performs breast reductions thru the doughnut pattern. Though well respected in the U.S., still less than 5% of U.S. surgeons use his technique. They are more comfortable with the anchor and lollipop patterns. In 1998, he republished his technique in English with a few changes, making the technique easier to learn. In Europe and South America, the "Benelli" has become the gold standard. I perform it in all cases of breast lift, except when the breast has lost too much tissue. In this case, I have devised another technique described in my article, "Breast Augmentation with Lift".

All of these glandular lifts give good durable results. They are far superior to the skin lifts. The following is the first article published in 1990 by Benelli in English.

The Benelli Periareolar Mammoplasty:

  • The Round Block Technique ("Doughnut Pattern")
  • The technique is illustrated below by figures 1 thru 6.
  • The suture is circumferentially positioned (blocked) to achieve the desired areolar diameter, usually about 4 to 5 cm.
  • A drain is then placed. In order to avoid a protrusion of the areola due to the inframammary pressure, two crossed sutures are placed - one in the horizontal diameter of the areola and the other in the vertical diameter. These points of the braided nylon 2-0 are threaded onto a straight needle and crossed under the nipple in the center of the areola. These stitches are simply put into place and should not be tied tightly. A tuberous appearance of the areola is prevented by these sutures (Fig. 5).
  • The dressing is held in place by a supportive brassiere. It is important to wear the brassiere for 2 months day and night.
  • The Benelli Periareolar Mammoplasty:
  • The Round Block Technique

Principle:

The aim of this operation is to obtain a pleasing breast shape with the areola in its proper locations and, above all, free from any tension that would cause postoperative enlargement of the incision. The round block technique produces a very solid, circular dermis-to-dermis scar around the areola, fixed by a nonresorbable suture. This suture, which encircles the areola and fixes definitively its diameter, should preferably be of woven nylon fiber to allow the "anchoring" at the breast of the periareolar scar block. The remodeling of the breast curve is completed by a crisscrossed periosteal mastopexy. This mastopexy is used to increase the breast projection, to refine the lower quadrants, and to add to the upper quadrants. The glandular unions and anchoring should be performed with a nonresorbable suture of monofilament nylon 2-0. The round block technique has its keystone, the supra dermal and subdermal periareolar blocked suture, which is nonresorbable and fixed. It ensures the permanence of the result.

Technique:


FIGURE 1
Outline of the measurements for elevating the nipple-areola complex to point A is shown. The base of the new areola is point B. The amount of de-epithelialization (points C-D) for removal of the excess skin is estimated, S, submammary fold. (From Benelli, L: A new periareolar mammaplasty: Round block technique. Aesthetic Plast. Surg. 14:93, 1990).


FIGURE 2
Subcutaneous dissection of the inferior and medial areas of the mammary gland is carried out but is not extended inferior to the submammary fold. (From Benelli, L: A new periareolar mammaplasty: Round block technique. Aesthetic Plast. Surg. 14:93, 1990).


FIGURE 3
After dissection of two glandular flaps, the external flap is crossed under the internal flap and anchored to the presternal periosteum. The internal flap is crossed over the external flap and anchored to the costal periosteum.


FIGURE 4
A. The position of the periareolar nonabsorbable suture is shown alternating in the supra dermal and subdermal levels along the de-epithelialized margin. The skin is evenly distributed along this suture. (From Benelli, L: A new periareolar mammaplasty: Round block technique. Aesthetic Plast. Surg. 14:93, 1990). B. Cutaneous suture by continuous horizontal mattress suture with Vicryl 4-0.


FIGURE 5
Vertical and transversal U sutures, which protect against postoperative protrusion of the areola.


FIGURE 6
Round block cerclage stitch of 2/0 Mersilene made with a long straight needle passed in a purse-string method. This stitch is passed in a regular plane in the deep dermis 5 mm beyond the edge of des epidermization. This round block cerclage facilitates good control of the areola and scar and can be used in many aesthetic tumoral and reconstructive periareolar operations.

Summary:

The patients are very pleased. Good, stable, and durable augmentations lifts are achieved. The two stages eliminate stretching and thinning encountered with the one-stage technique. As for the scar, the "nipple incision" only, or at most the doughnut pattern, eliminate the conventional long scar patterns.

In 1976, I started performing breast lifts. For almost 25 years, I have seen scars and results that would not please me. My frustration led me to these techniques that give me consistently good results, with practically no scar.

Breast Augmentation With Breast Lift

The lift combined with breast augmentation

Age, pregnancies, lactation, hormonal factors, size, weight loss as in gastric bypass, large subglandular breast augmentation, and a loss of breast tissue volume are the usual problems that will lead to breast ptosis.

The problem may not be just cosmetic, but functional as well. To correct the sagging of the breasts, many women do tighten up the bra straps, which sometimes causes pain in the neck and shoulders. Intertrigo, though quite rare, is also possible.

In Europe, Breast Augmentation is not popular. More reduction and lifts are done than breast augmentations. If an augmentation is done it is generally with small implants. For that reason, surgeons are rarely asked to combine a lift and augmentation. When they are, the implants they use are too small to have any significant adverse effects on the breast lift.

The situation is quite different in the United States. Rarely does a woman want just a lift; They almost always want an augmentation as well, in order to regain the size they were before pregnancies or just because they desire larger breasts. In the U.S., women want implants rather large. The techniques currently used to achieve lift and augmentation depend on the degree of breast sagging and the degree of enlargement desired by the patient.

The degree of sagging:

  1. If minimal, usually the augmentation itself will correct the sagging without a lift, placing the implant under the muscle.
  2. In some rare cases significant sagging occurs with a dense breast tissue covered by good skin. In this situation, an implant large enough can correct the sagging without a lift, if the implant is placed under the gland. The disadvantage, of course is that the implant is not under the muscle. In these rare cases where the tissue is very good and the implant not large, a sub-glandular approach is acceptable.
  3. In most cases, the sagging is pronounced and women request rather large implants. A lift is required to obtain a good result. The enlargement of the breast is done under the muscle for a good stable, durable augmentation, whereas the breast gland itself is moved up and secured to the muscle at the right level. In other words, the sub-muscular implant works as a scaffold upon which the breast gland is lifted.

Several techniques have been devised to combine augmentation and lift. Practically all of these techniques place the implants under the muscle for the reason explained above. They differ in the work done on the gland to move it up and reattach it higher on the chest wall where it used to be. They also differ in the type of skin pattern using an anchor, lollipop or doughnut pattern. A lot of combinations are possible between muscle, gland and skin but the basic principles are the same as well as the problems.

The One Stage Approach

This approach is a source of problems. I believe the most common problem encountered in a lift/augmentation done in one stage is due to the effect of the implant on the tissue. Indeed, the muscle is dissected, so is the gland as well as the skin. Once all of these tissues have been cut on, an implant is then added for the augmentation or vice versa. A good result can be and is achieved in most cases.

However, in cases where the muscle is thin, the breast tissue more fatty than glandular, that is to say more friable and is covered by a skin already thin and stretched, the implant had some adverse effect on these 3 tissues. They will further stretch, thin-up and deform by the sheer pressure of the implant.

A good result can be expected only when the tissues are very good. We rarely can know that pre-operatively for sure. We never can predict how the tissues will tolerate and support the implant. This is the real problem.

I routinely used the doughnut pattern since 1991 till a few years ago. In case the tissue would stretch in the lower pole of the breast, I would convert it into a lollipop pattern to reinforce the padding and the support.

Between the conversion from doughnut and lollipop pattern as well as secondary reduction of the diameter of the areola or scar revision, the rate of touch-up or secondary procedure was beyond 30% in the one stage augmentation/lift. Hence, actually one-third of the patients ended up having some sort of second stage. Besides, the incidence of complications with one stage was significant. This is due to a basic surgical principal: The more the dissection at a time, the more the complications.

That's why the 2 stage approach is far more reliable and became the standard nationwide at the 2001 ASAPS Meeting in New Orleans.

The Two Stage Approach

I started realizing this concept in 1990. This was the year of the "silicone crisis". The silicone gel implants were replaced by saline implants. It took a few years for the plastic surgeons to agree that the saline implants had to go under the muscle and not under the gland as we used to do with silicone implants in most cases. The saline implant is more traumatic to the tissues than the silicone gel, and in order to get a better support and coverage of the saline implant, placing it under the muscle became a must. To me, I didn't have to change my approach since I was already going under the muscle routinely since 1980 with silicone implants.

I saw patients done elsewhere, coming to me with saline implants placed under the gland. They had developed rippling or thin spots with some degree of sagging. The standard to remedy the problem is to replace the implant from under the gland to under the muscle. I was familiar with the technique since I've been using it in case of capsule formation for implants under the gland since the late 1970's. In addition, in cases of sagging I started reattaching the gland higher on the muscle, i.e. doing a breast lift.

After doing a good number of these conversions from under the gland to under the muscle, with lift of the gland, I noticed:

  • It usually completely corrected the rippling.
  • The need for a larger implant (usually between 10% to 30% larger) is needed to get a good fit. This larger implant is placed between the existing thinned up sub-glandular pocket and the newly created sub-muscular pocket.
  • * And at the same time a dramatic improvement of the sagging. Indeed, the saline implant with time had not only thinned up the gland causing the rippling but also stretched it causing the sagging. The reattachment of the gland higher on the muscle was rather easy and achieved a good durable lift.

After doing enough of these cases, I understood. The implants placed under the gland induces the formation of a plaque of scar tissue on the inner aspect of the breast gland and on the top of the muscle, that is to say all around the sub-glandular pocket. After replacing the implant under the muscle, the implant can no longer damage the tissue that is protected by 2 plaques of scar tissue. These 2 layers of that scar tissue on top of the muscle and on the inner surface of the gland constitute a strong protective shell for the implant. In turn, when the breast tissue is attached higher on the chest wall, i.e. on the muscle, in order to lift the breast, the stitches are between these 2 plaques of scar tissue, breast and muscle. This attachment is solid since we are not stitching muscle to friable breast tissue to scar tissue that contains collagen.

This mechanism understood, I then thought of reproducing the same condition for patients requesting augmentation and lift. The only problem was 2 stages. Women were reluctant to the idea of 2 stages. I had to explain the advantage of the 2 stages. There is a much higher chance of good results and less scar while minimizing tissue damage and complications. Furthermore, at the time of the second stage, adjustments can be made to improve the shape, size, level and symmetry between the two breasts.

Also, a certain number of women are happy after the breast augmentation and feel they don't need or want a lift. With the one stage approach, the lift would have been done needlessly. Thus, I recommend to have a breast augmentation first and decide about a lift after. A lift can always be done later if they are not sure.

The first stage consists of placing the implants under the gland. Two months later the second stage is performed.

Now the scar tissue has formed around the implant and we are ready for a stable and more predictable breast lift. With this technique, there is no need to use a doughnut pattern as I had learned form Benelli. The doughnut pattern is a major breakthrough over the anchor and lollipop pattern, but is still leaves a scar all around the areola. Due to the pressure of the implant, the scar and the diameter of the areola can widen, leaving a conspicuous scar and/or an enlarged areola.

A "nipple" incision is sufficient to reposition the implant from sub-glandular to sub-muscular and lift the breast on the muscle. Using a supra-areolar vs. infra-areolar incision facilitates the procedure and allows a good lift of the breast and position of the nipple/areola.

While the breast is lifted at the right level, it is secured to the muscle, achieving a strong and stable lift, since it is stitching scar tissue to scar tissue.

The first problem with this technique, was the need to make two pockets; subglandular and submuscular, with more dissection. The second problem was the time necessary for the shape of the breast to remodel, at least two to three months. I now rarely use it, and these two drawbacks led me to a better alternative.

The Alternative

I first used a Benelli's procedure like a lift without breast augmentation as you can read in my article, "Breast Lift Without Augmentation". I quickly noticed in most cases, the breast tissue was not sufficient in volume and/or quality for a Benelli technique, so I developed another second stage approach.

The first stage augmentation is submuscular versus subglandular (Figure 1).

The submuscular implant is like a scaffold to prepare for the second stage. A minimum of eight weeks later, when a layer of scar tissue has formed around the implant as shown in Figure 2, the scaffold is now stable. The Stage 2 breast lift can now be done. A small wedge excision shortens the upper pole (Figure 3a). The breast tissue is separated off the muscle attachments of the lower pole of the breast (Figure 3b). It allows an upward rotation of the sagging lower pole of the breast. Stitches secure that rotation of the lower pole of the breast high on the muscle of the upper pole (Figure 3c). Then the breast tissue of the two poles is re-approximated (Figure 3d). The combination of shortening the upper pole, and rotation of the lower pole, achieves the breast lift. The rotation of the lower pole can be reinforced by "U" stitches in the infra areolar breast tissue, which are anchored to the breast tissue of the upper pole 4-5 cm above the areola.

In cases where the lower pole needs shortening versus the upper pole, the wedge excision is performed in the infra areolar area. If in doubt about which pole to shorten, upper or lower, the direction of the nipple is a reliable guide. When the nipple points down, the most common case, the upper pole of the breast needs to be shorter.

The nipple pointing up, (called pseudo ptosis of the breast), usually requires shortening of the lower pole. Examining the patient in the upright and supine position helps determine the direction of the nipple and the length of the lower and upper poles of the breast. It is most important to recognize which pole has to be shortened, to obtain a good shape of the breast and position of the nipple. Doing a supra areolar wedge excision with the nipple pointing up, would result in the nipple being too high and the upper pole too short. Vice versa, an infra areolar wedge excision with the nipple pointing down, would worsen the deformity and pull the nipple too low.

BREAST AUGMENTATION WITH BREAST LIFT - ILLUSTRATIONS


Fig X.
Before any surgery. Prior to First Stage Augmentation.


Fig 1.
First stage submuscular breast augmentation usually done thru an armpit approach to minimize trauma and scar tissue. The implant will work as the 'scaffold' for Stage 2.


Fig 2.
Maturing of submuscular pocket for at least 2 months during which a thin layer of scar tissue has formed around the implant. The 'scaffold' is stable.


Fig 3a.
1. In most cases an upper skin and breast tissue crescent is removed off the supra-areolar (upper areolar) area.
2. In rare cases, when more breast tissue or skin needs to be lifted, a lower crescent is removed off the infra-areolar (lower areolar area).


Fig 3b.
Breast tissue is separated off the muscle attachments in the lower pole of the breast.
Note: The cutting and raising of these tissues is being performed below the surface of the areola and nipple in order to avoid an additional scar to the lower part of the areola.


Fig 3c.
Breast tissue of the lower pole once freed from the muscle, is lifted and secured high on the muscle of the upper pole, accomplishing the breast lift.


Fig 3d.
Edges of breast tissue of upper and lower poles are now "kissing" after the lift of the lower pole of the breast on the muscle of the upper pole.


Fig 3e.
Breast tissue and skin are closed and the scar lies over the upper half of the areola only, in most cases. In some rare cases, if more work needs to be done to improve the contour of the lower pole, the scar would be around the areola.

This technique offers two advantages over the first one:

  1. Most of the reshaping of the breast is achieved intraoperatively, without waiting over two to three months for remodeling.
  2. Only a submuscular pocket is used, without a subglandular pocket, minimizing the dissection and the risk of complications.

As in the first procedure described, an augmentation lift is achieved with practically no scar. It is versatile, with very few complications. I use it routinely.

Summary:

The patients are very pleased. Good, stable, and durable augmentation/lifts are achieved. The two stages eliminate stretching and thinning encountered with the one-stage technique. As for the scar, it is limited to the "nipple incision" (Figure 3e), or at most the doughnut pattern, which eliminates the conventional long scar patterns.

In 1976, I started performing the breast augmentation and lift. For almost 25 years, I have seen scars and results that would not please me. My frustration led me to these techniques that give me consistently good results, with practically no scar.

Dr. Carli, a leading plastic surgeon in the greater Los Angeles area, would be happy to help you achieve your aesthetic goals! Feel free to call us at (951) 688-8660 with any questions or concerns that you may have regarding Dr. Carli, the Magnolia Surgery Center, or cosmetic surgery. We also offer the option of filling out our online contact form. We look forward to speaking with you!