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Background: One of the most vexing problems in breast augmentation for the plastic surgeon is the women with breasts that has some sagging. No woman electively wants the scars from a breast lift unless their breasts have severe sagging and even they know it is an unavoidable issue. It is the women that wants only breast implants and feels (justifiably or not) that augmentation alone will lift up the amount of sagging that they have.

In these more mild cases of breast ptosis (Grade I or even II), there are two treatment options. Breast implants can be placed alone and the patient can gamble that a lifting effect will occur. A formal breast lift can always be done secondarily if the breasts still have some sag off the front of the implants. The patient can just concede that a breast lift is needed and then choose between a type of breast lift where the scars stay restricted to the areolar-skin junction.

Breast lifts where the skin that is removed around the areola probably should not be called true breast lifts. They really change the nipple position slightly upward but have no true breast mound lifting effect. Only skin that is removed from the breast mound and leaves skin scars can truly reshape and lift the breast. Of the two areolar lifts, they include the superior crescent and the periareolar excisions/lifts. The nipple lift will move the nipple upward for about 10 to 15mms but may elongate the nipple as well. Its scar is restricted to the upper half of the areola. The periareolar may lift the areolar up slightly more also has some skin tightening around it s well. It does do at the expense of an incision entirely around the areola and the subsequent risk of scar widening, particularly when done with implant mound enlargement.

Case Study: This 45 year-old female wanted to enlarge her breasts and suspected that a breast lift may be involved in doing so. She was adamently opposed to any breast lift that created visible skin scars. She wanted the least scarring as possible and was willing to accept that a skin scar breast lift may be needed later.

Under general anesthesia in the prone position, 550cc high profile silicone gel breast implants were placed in the submuscular dual plane position through inframammary incisions. To help move the nipple slightly higher on the breast mound, a superior crescent nipple lift was performed with the new implants in place with a 15mm curved skin excision.

Her results show that even with implant enlargement and an upward nipple adjustment  that ideal nipple position on the breast mound is not achieved. But for those women willing to make that trade-off without excessive breast sagging, the adjunctive use of a superior nipple lift can be helpful. Whether that may be enough to eventually avoid a breast lift can not always be accurately predicted. The scars from an upper nipple lift does not fade considerably but remain evident in the first few months after surgery.

Case Highlights:

1) The saggy breast (ptosis) poses a challenge that breast implants alone often can not completely overcome.

2) Many women need a breast lift with their implant augmentation but do not want the resultant scars.

3) A nipple lift (superior crescent lift) can provide the illusion of some lifting by nipple adjustment that may be enough in cases of mild sagging to avoid further scars around the areola and down vertically on the lower pole of the breasts.

Dr. Barry Eppley

Indianapolis, Indiana

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