Are all breast lift (mastopexy) techniques equal?

Find out the preferences of three top plastic surgeons

Many women who are explanting also elect to undergo a second or third aesthetic procedure to reshape, volumize, and tighten sagging breasts. According to the American Society of Plastic Surgery, a total of 87,051 breast lift (mastopexy) surgeries were performed in 2020. Google Trends is a tool that measures what the world is looking for. Breast Lift searches are on the rise, with approximately 2,000% more queries in 2021 compared with the previous year.

Since this procedure has a variety of techniques and outcomes, here, we explore the differences and similarities of the below five techniques. Three top plastic surgeons share their experiences and preferred approaches to breast lift and fat transfer procedures. Dr. Randall Feingold from Great Neck, New York, Dr. David Rankin from Jupiter, Florida, and Dr. Kevin Brenner from Beverly Hills, California, have been gaining broader exposure by leveraging their expertise and credibility in the breast implant illness communities.

Each of these highly trained and qualified plastic surgeons has their procedural preference, yet they share one thing in common—they truly care about women’s wellness, aesthetics, and holistic health.

What is a breast lift procedure?

A breast lift procedure’s goal is to reshape and reposition breasts that have sagged and dropped due to changes, including pregnancy, weight loss, breastfeeding, age, and breast implant removal surgery. During the procedure, the nipple and areola (the pigmented circle around the nipple) are moved to a higher position on the breast mound, the breast mound is moved to a higher position on the chest wall, and excess skin is removed, reshaping the breast. A variety of incisions are used depending on the selected technique. In most cases, breast and nipple sensation can be preserved, but this is not guaranteed, and it varies from woman to woman.

The five common breast lift techniques

Since each technique has its distinct characteristics and advantages, it’s important to be familiar with the options before deciding. Below are the five common breast lift techniques, although your plastic surgeon may use a combination of more than one for better results.

1. Donut lift For women with moderate to mild breast sagging. It is also often used to reduce the size of the areola. The technique involves making a circular incision around the areola. This technique repositions the areola and nipple higher on the breast while simultaneously tightening the breast skin.
2. Periareolar mastopexy A breast lift is performed with an incision that goes around the areola. The incision is located just below the lower half of the areola.
3. Crescent lift Less invasive than the donut lift, this technique involves only a semi-circular incision along the top half of the areola. It is commonly used for the mildest cases of sagging and is perfect for minor adjustments to the nipple and areola.
4. Lollipop breast lift The oldest of the breast lift options is ideal for correcting a moderate amount of sagging. Here, a circular incision is made around the areola along with a vertical incision from the bottom of the areola to the breast crease. Unlike the anchor lift, the incision does not extend along the crease.
5. Anchor breast lift An anchor mastopexy involves three incisions: one around the areola, one vertical incision extending from the bottom of the areola to the crease, and one in the infra-mammary fold. The anchor lift is the incision for women with severe sagging.

What do the doctors prefer?

I asked Dr. Feingold, Dr. Brenner, and Dr. Rankin to discuss their preferred approach to breast lifting and in what instances it is advised not to perform a breast lift.

Fat grafting or fat transfer has become more popular, so let’s hear what the doctors have to say about performing fat grafting together with breast lift and explant surgery.

Dr. Randall Feingold’s preferred approach to breast lift

“My preferred approach is to provide an effective elevation of the nipple and tightening of the lower breast with the least amount of scarring. This may be accomplished by as little as a circle around the areola or a “lollipop” vertical incision, but even if a full anchor pattern is needed, the goal is to reduce the chance of needing to come back for another procedure.

There could be more risk in performing mastopexy if the implant was placed behind the breast gland through an incision at the border of the areola. In some of these cases, I have seen the capsule stuck to the back surface of the nipple-areola, and while removing the capsule should be safe, adding another incision around the areola at the same time would risk damaging the blood supply to the nipple.”

Dr. David Rankin’s preferred approach to breast lift

“There are many ways to approach a breast lift, and the chosen technique depends on the patient’s unique anatomy and surgical history. I typically rely on a superior pedicle approach when appropriate but will change to an inferior pedicle or dual pedicle when I need to. This refers to the direction of the blood supply to the nipple/areola.

Patients who have undergone radiation in the past, have had serious problems with wound healing, for example, necrosis or nipple loss with a previous lift, or have unrealistic expectations of the possible outcomes are not great candidates for a breast lift. Otherwise, with careful history taking and surgical technique, most patients are candidates for a breast lift.”

Dr. Kevin Brenner’s preferred approach to breast lift

“In my practice, a full or anchor-pattern mastopexy utilizing a superior or superomedial based pedicle is the workhorse for breast rejuvenation. Although other types of lifts may sometimes work, I have found that a full breast lift is the most powerful and effective for reducing excess breast skin. Further, using a superior technique for the pedicle (where the blood flows to and from the nipple-areola complex) helps to maintain fullness in the upper breast pole. It also allows much more precise and aggressive contouring of the lower breast pole with sutures, and in cases where breast tissue needs to be reduced, it allows removal of the heavier, more sagging portions of tissue. Ultimately, a full breast lift results in a better and longer-term breast aesthetic.

“In most cases, mastopexy can be performed in the same setting as explant and capsulectomy. However, there is a small subset of women who have such scant, thin, and/or atrophic breast skin and tissue that I do not feel that a breast lift can be performed safely. For these patients, I will hold off on performing a breast lift. After they have healed completely, I will then reassess their candidacy.”

Would you combine a breast lift with fat transfer in the same surgery?

This is where the three plastic surgeons differ significantly in their approaches.

Dr. Feingold says, “I prefer fat grafting at the time of capsulectomy/explant/mastopexy whenever possible. Even small volumes of fat can minimize depressions, hollows, or shadows following explant, and sometimes a moderate volume of fat transfer can be accomplished to restore a half-cup or full cup of lost volume. While larger volumes of fat grafting can be performed several months later, my strategy is to minimize the number of operations, expense, and downtime by beginning the volume restoration process on the day of explant.”

Dr. Rankin says, “I usually allow the breasts to heal from the lift before doing fat grafting. I feel there is a more robust blood supply after a minimum of six months to allow the new fat to ‘take’ or gain a blood supply. If only a small amount of fat grafting is necessary, I may choose to do this at the same time as the lift.”

Dr. Brenner is not a fan of performing a breast lift and fat grafting in the same procedure. “Although I will routinely perform explant with capsulectomies concurrently with breast lifting, I feel strongly that adding fat grafting at the same time is too risky. Not only will the addition of liposuction and fat grafting increase the overall surgical time beyond what is safe, but the action of grafting fat in and around the blood vessels remaining following a lift can harm the arterial blood flow to or, more commonly, the venous blood flow from the tissues. Although a surgeon may ‘get away with’ doing all three procedures concurrently on some patients, I personally do not want to run the risk of having an irreversible vascular injury. Staging the fat grafting later is not only safer overall, but in my hands, I get a much higher percentage of fat graft when the two procedures are separated.”

Attitude towards patient education

Dr. Randall Feingold – “We usually stand in front of a mirror and evaluate where the nipple position is relative to the equator of the breast. If the nipple is in the ‘southern hemisphere,’ then a lift of some type, depending on how loose the skin is, will be helpful. If the nipple is at the ‘South Pole,’ then a full anchor pattern will be needed. I also evaluate the amount of remaining breast tissue and try to project what the breast size will be without the implant. That is where fat grafting can make a difference for women who are particularly concerned about downsizing after explant. We look at potential fat donor sites, for example, abdomen or thighs, to see where we can ‘rob from the rich to give to the poor.’”

Dr. David Rankin – “We discuss which procedure/s are possible and the expectations of each method. We then decide, together, the patient’s goals and choose the proper technique to try to achieve those goals. Each patient has unique expectations and anatomy, and an honest conversation is necessary to determine if their goal is realistic. Of course, we discuss the risks, benefits, alternatives, and possible complications as well, using story taking and surgical technique.”

Dr. Kevin Brenner – “In my office, patient education begins at the initial consultation. Following a thorough history and physical exam, complete with a discussion of each patient’s goals and desires, I start to create a surgical plan that is tailored to each case. This includes a discussion of the risks, benefits, advantages, and disadvantages of each surgical option. Then, I will commonly draw the surgical markings on the patient so she may see what incisions she will have, how the breast lift will have an impact on the overall breast shape, and where the resulting scars will be located.”

Final note

Women who had implants in the past for aesthetic reasons are now faced with the difficult emotional choice of removing what used to be perceived as perfect breasts in exchange for their health and wellness. However, fear of the unknown is often debilitating and may stop women from proceeding with the surgery,

Knowing these doctors are providing a safe yet aesthetically appealing alternative makes it less painful to go ahead with explanting. While each of these excellent plastic surgeons has their surgical preferences, they all agree that information and open communication with their patients is an essential part of the process.

Dr. Feingold reminds patients that “feeling comfortable with yourself was behind the decision to place the implants in the first place, and even if implants need to be removed for health reasons, we can still strive to optimize breast aesthetics at the time of the capsulectomy.”