Breast Augmentation with Lift

Dr. Carli is one of less than 3% of surgeons that provide the breast lift procedure without the lollipop or vertical incision to minimal your scarran result. For additional information please click on the minimal scar breast lift banner.

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:

If minimal, usually the augmentation itself will correct the sagging without a lift, placing the implant under the muscle.
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.
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. The 2 layer 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. Besides, it minimizes the tissue damage and the complications. Furthermore, at the time of the second stage, adjustments can be performed 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 aTift. 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. 2 months later the second stage is performed.

The scar tissue has formed around the implant. We are ready for a stable, 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 was 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. It leaves 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. The breast 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 of this technique was the need to make 2 pockets sub-glandular and sub-muscular with more dissection. The second was the time it takes for the breast shape to look normal, usually 2 to 3 months. These 2 drawbacks slowly led me to devise 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:

Most of the reshaping of the breast is achieved intraoperatively, without waiting over two to three months for remodeling.
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.