Breast Augmentation and Lift: One Stage or Two?

When can a Breast Lift and Augmentation Be Performed at the Same Time? When is Two Procedures Necessary?

There are surgeons who will only perform a breast augmentation and a breast lift at the same time, and there are some surgeons that will only perform the procedures separately. Why is this?

The reason is this: predictability and control of the final results. When performing these surgeries, there are several factors that both the surgeon and the patient cannot control:

-Tissue stretch: whether adding volume with an implant or removing skin and suturing the remaining skin together to elevate the breast, there will be stretching of the skin and breast tissue. The question is how much will the tissue stretch? Everyone is different. The surgeon cannot control the amount of tissue stretch but will try to get his/her best idea as to how much the tissue will stretch based upon past experience with other patients. This is why experience matters so much in this type of surgery.

-Breast thinning: the breast tissue will thin somewhat under the influence of breast implant underneath and the breast tissue redistributes its volume across the surface of the implant.

-Scarring: Wounds will heal with the lowest incidence of complications and best appearing scars when there is the least amount of tension. When performing a lift, there is a certain amount of tension along the incision when it heals. Now add additional tension caused by the pressure of an implant. Now, at least theoretically, there is additional tension on the healing wound.

In my experience, it is really the first factor, tissue stretch, that I am most concerned with. I have not really seen an appreciable difference in scar quality in my mastopexy (breast lift) patients with and without a simulataneous augmentation. The scar that I am most concerned with is the vertical scar on the lower breast and that is easily managed by off-loading the tension by the application of Brijjit clips which are adhesive-backed plastic clips I put on over the wound at the end of surgery to reduce tension. When the breasts are similar, breast tissue thinning is not a significant issue for concern.

So When Would I Perform a Breast Augmentation and Mastopexy (Breast Lift) in One Stage Versus Two Stages?

I prefer to perform the surgery in one stage in the vast majority of cases. The only situation where I find it adventageous to perform the surgery in two stages is when the breasts are of two different sizes and shapes, with one breast substantially more ptotic (drooping) than the other.

While as stated earlier, I cannot control tissue stretch. However, if the breasts are similar in shape and not too different in size, whatever tissue stretch does happen, should happen in a similar degree to both breasts. If the two breasts are fairly similar in shape, but perhaps one breast is a little larger than the other one, I can manage this with a breast lift using two different breast implant sizes. However, if the breasts are very different in shape AND size, then the mastopexy (breast lift) techniques may need to be different or quite possibly only one breast will require a breast lift. Now the degree of tissue stretching and breast thinning will be very different between the two breasts and this is extremely hard to predict.

How Do I Make the Results More Predictable?

The best way to handle the situation of very dissimilar breasts is rather than perform both breast augmentation and breast lift surgeries at the same time, I prefer to perform the lift first to make the breasts more similar prior to performing the augmentation with implants. By converting breasts with two very different skin envelopes, as well as amount and shape of breast parenchyma (glandular and fat tissue) into breasts now similar in this regard, I now improve the predictablilty for symmetry when implants are placed after the breasts heal from the first procedure. Is it possible to perform a breast augmentation and breast lift on very dissimilar breasts in one stage and get a good result? Absolutely, although I would attribute more of the result to luck than to skill because there are so many factors that cannot be controlled and I believe it impossible for a surgeon to reliably obtain the same results with a one stage procedure in these patients as can be obtained with a two stage procedure.

Below are two examples of such cases. In both cases, the right breast was far larger and more ptotic (drooping) than the smaller left breast. The surgical plan called for two stages:

Stage One: The right breast underwent a reduction. All reductions by definition consist of both a dimunition in breast volume AND a breast lift. By reducing the volume of the much larger right breast to that similar to the left breast, I will be able to use implants much closer in size than if I did not reduce the volume. The lift will change the skin envelope of the right breast to that similar to the left breast.
Stage Two: Breast augmentation. As the reduction from stage one will now allow me to use similar (but not necessarily identical) implant sizes, the proportions of implant and natural breast tissue to overall breast size will now be similar so that breasts will look more similar, feel more similar and age more similar.

You can view the entire set of before and after photos by clicking on the case number below each set of photos.