Breast lift with implants: Better to do in one stage or two?

Very often, patients requesting a breast lift benefit from having an implant placed at the same time, but plastic surgeons disagree on whether this is safe to do in one operation or whether it should be staged in two sessions. I prefer to do the operation in one stage in most cases, but it is important to understand why it is not always done this way.

A breast lift (mastopexy) is typically done when the breasts sag or deflate following pregnancy and breastfeeding, weight loss, or menopause. The skin and the supportive ligaments in the breast weaken and stretch, the nipple drops lower, and the breast loses projection and fullness even if it doesn’t get smaller. Mastopexies are very effective at raising the level of the nipple and reshaping the breast, but not as effective at restoring fullness in the upper breast. Adding a breast implant can restore that fullness and add volume and projection. Combining these two procedures in one operation is called augmentation mastopexy.

Plastic surgeons who prefer to perform augmentation mastopexy in 2 stages point out that after a mastopexy, there are changes in the breast over a few months as swelling goes down and the tissues settle into position. They note that the lift can be done with minimal tension on the skin, possibly leading to better scars, as opposed to doing implants where the skin has to be re-draped over the additional volume of an implant. Skin and breast tissue that is already thin may not support the implant under these conditions, possibly leading to uneven settling of the implants and widening of the scars. Larger implants compound the problem, so even if one stage is planned it may be limited to a smaller than desired implant. Waiting a few months before placing the implants might lead to more predictable outcomes. For these reasons, one stage augmentation mastopexy has a high rate of revision surgery, around 16% in one large study.

On the other hand, surgeons like me who prefer one stage augmentation mastopexy point out that staging in two sessions is equivalent to a 100% revision rate since everyone automatically gets two operations. Each surgery requires downtime for recovery, and the overall expense is higher because there are two anesthetics required and two trips to the operating room. Another benefit is that often adding an implant changes the type of lift required, by “filling up” a loose skin envelope so less skin has to be removed. This potentially means less scarring, for example doing a Benelli lift instead of a lollipop pattern.

I recently reviewed my own experience with augmentation mastopexy, and found a 15% revision rate with augmentation mastopexy. Importantly, most of the revisions could be done under local anesthesia with minimal recovery time. So for the vast majority of patients, a one-stage plan is appropriate and sometimes gives a better result, and even when revision is required it is less of an ordeal than two major operations.