Changes in breast shape and volume during pregnancy and after child birth often take the mother through a mammary roller coaster ride. This is because the breast changes associated with this process often go from one extreme to the other. During pregnancy, the expectant mother is often pleasantly surprised with the more robust and perky breasts she develops. Usually, she is very happy with this natural breast augmentation.

Unfortunately, the newfound breast enhancement does not last. After child birth the engorged breasts lose their volume. Not uncommonly, the breasts become even smaller than they were before pregnancy. In addition, the expanded skin has lost its ability to tighten back leaving the breasts sagging. In addition to the sagginess, one breast is often lower or smaller than the other leaving the breasts not only saggy but quite asymmetric. To compensate for these changes, the new mother often will wear push up bras to recreate the cleavage and the upper breast fullness that she has lost. Actually, the bra does a reasonably good job because the sagging breast tissue is easily lifted. The problem comes, however, when the bra is removed. This can be quite disturbing. The droopy breasts make the woman look much older than she feels and certainly less sexy.

The reason why I have gone over the above scenario is because we hear it very commonly from our mommy make-over patients. They know that they have been blessed by their children but they are saddened by the toll it has taken on their breasts. This purpose of the mommy make-over section is to let you know that many other mothers are feeling the same way; even if they are not saying it.

I have provided a very detailed section in Breast Enlargement and Breast Lift outlining all the various technical considerations regarding these procedures. Both sections outline my thought process during patient evaluation. I encourage you to review these sections to see what procedure is best for you.

Outlined below is the technical answer to the question I most frequently get from my mommy makeover patients, "Do I need a breast lift?" and if so, "what will my scars look like?" I will go over how this decision is made. As always, other plastic surgeons may do things slightly different but the thought process remains the same.

It is extremely important to find out exactly what the patient wants to obtain as far as breast lifting goes. Some women are only concerned with correcting the sagginess while others are also concerned with cleavage and fullness in the upper breast. It is important to be able to predict both breast size and shape after the breast lift. Some women want a fuller look, therefore, are best served by adding an implant in addition to the breast lift. This is all personal preference, but it is important to understand the desire of each patient so that the procedure can be tailored to her particular needs.

1. Incisions

Incisions are perhaps the biggest concern that my patients have. They have seen or heard of horror stories of breast lifting gone wrong leaving the patient with significant scarring. It is important to understand that plastic surgeons do not control how an individual patient scars. Some patients scar worse than others. Plastic surgeons can, however, control the placement and precision of the scar. This is part of the artistry of plastic surgery.

I understand your concern about putting scars on your breast. I take this into consideration before I operate on any patient. The truth is, if you have significant sag, a proper breast lift with augmentation is far superior to an augmentation alone. In fact, an augmentation alone may give you a very elongated, older appearing breast. This has been given the nickname "rock in a sock" look. What we are looking for is a lifted, round appearance seen in a youthful breast.

It is important to find a plastic surgeon with considerable experience with this procedure. Breast lifting with augmentation is very challenging as there are many variables going on all at once.

When evaluating sag, the entire breast along with the patients wishes need to be taken into consideration. To make things as simple as possible, I will discuss the two most important considerations. They are not absolute measurements. These are the

• relationship of the nipple to the Infra-mammary Fold (IMF)
• the relationship of the bottom of the breast to the IMF. Other factors, of course, will need to be discussed at the time of consultation.

Before we get started, it is important to point out that breasts with more natural breast tissue are more likely to need a lift. This is because the bottom of the breast will continue to fall. To remedy this, removing this breast tissue with a lift will correct the sag and actually decrease the chance of sag in the future.

Another consideration is the size of the implant. A bigger implant will provided more lift. This makes sense as more volume will fill the excess skin envelop more adequately. Of course, you should not go with a larger implant for this reason as the amount of lift that an implant can provide is limited.

Doing a breast lift alone rarely produces a great result as usually there is very little breast tissue in the upper chest. This can only be adequately treated by augmentation. Even patients with significant breast tissue usually benefit from the upper breast fullness created by an implant. In these cases, I usually will remove all the undesirable sagging breast tissue and put in a relatively small implant to create an attractive upper breast with cleavage.

There are four common breast lifts:

1. Augmentation Alone
2. Augmentation with Donut lift
3. Augmentation with Lollipop lift
4. Augmentation Anchor lift

Common Breast Augmentation Incisions

Peri-areolar Incision
(Donut Lift).

• Augmentation Alone

Once again, this will depend on the size of the implant. Usually, augmentation is all that is necessary when the nipple is above the level of the IMF and the bottom of the breast is no greater than 1 cm below the IMF. This is especially true when there is not much breast tissue. Heavier breasts require more to lift them.

37 year old female with minimal breast sag corrected by breast implant alone.

• Donut Lift

The Donut lift is also known as the peri-areolar lift. It involves removing skin in the shape of a circle around the areola and placing a suture within this circle. This circular suture acts as a purse string to tighten this bigger circle into a smaller circle. This elevates the nipple into a higher position and tightens the skin envelope. The down-side of the Donut lift is that the purse string effect of the suture can flatten the breast. This is why an implant is highly recommended to combat this flattening.

One misnomer is that the Donut lift is more of a nipple lift than a breast lift. This is because it does not really lift sagging breast tissue that has dropped more than 2 cm below the IMF. It does however, elevate the nipple. It is ideal for the breast that has minimal sag and not much tissue.

• Lollipop Breast Lift

This type of breast lift involves an incision around the areola and straight down the bottom of the breast. Patients often do not want this lift because they do not want the vertical incision. This incision, if properly placed, is quite acceptable. The reality is, if it is necessary, it is a far better procedure than the donut lift as it actually removes the hanging breast tissue. Further sag in the future is dramatically reduced or prevented.

• Anchor Lift

The Anchor lift is quite similar to the Lollipop lift except that it has an additional incision that falls within the IMF. This extra incision is necessary to remove excess skin from breast sag. The horizontal incision within the IMF is actually not visible in a standing position and is quite hard to see.

Candidates for the Anchor lift are women whose breast tissue falls significantly below the IMF. Whether or not this horizontal skin removal is necessary depends on many things. If the bottom of your breast is greater than 5 cm below the IMF a horizontal incision will usually be necessary.

The length of the horizontal incision depends on how far the bottom of the breast falls. For example, a breast 8 cm below the IMF will need a longer horizontal incision than one with 6 cm below the IMF.

2. Implant or No Implant

Breast Lifting does a wonderful job of lifting breast tissue that has fallen below the level of the IMF. It does not, however, do a good job of creating upper breast fullness and cleavage. This is why I strongly recommend using an implant to accomplish what the lift alone cannot. While I still do breast lifts alone, the result is compromised. Fortunately, most women in Southern California are willing to accept an implant in return for an improved result.

If you are considering a lift without an implant you can always add the implant later. Some surgeons actually prefer this way as it does make the procedure easier. I will recommend a two stage approach if the nipples have fallen greater than 10 cm below the IMF. This is because when the nipple is elevated greater than 10 cm there is a risk of loss of blood supply to the nipple.

Once the decision is made to add an implant the next choice is to decide on which implant is best. Those of you who have survived reading this far, I give you credit. This additional information is provided in the Breast Enlargement section. I encourage you to go there as it is really good information.