Dr. Feldman's Answer:
Do I need a breast lift (mastopexy) or not?
This is probably the most common question asked by my cosmetic breast patients with any droopiness or ptosis of their breasts. There is no absolute or correct answer. It depends on your (the patient's) expectations and desires. Just remember the implant needs to be centered directly behind the nipple, so wherever your breasts/nipple sit currently this is approximately where you can expect the implant to be positioned/settle. Breast implants alone simply add volume to your breasts. They do not lift or shape your breasts. If you are happy with the look of your breasts and just want them to be a bit fuller then a breast augmentation alone may work.
In my practice, my patient's generally expect superior pole fullness/cleavage and a youthful, perky breast appearance without wearing a push-up bra so I tend to offer more lifts. Most of these patients are initially hesitant about the scarring, when in fact they should be more concerned about breast shape, contour and nipple position. I educated them that scars mature and fade over 6-12 months, when breast shape, contour and nipple position generally don't improve and, may in fact, worsen over time.
In my experience you could certainly have an augmentation alone and end up with a "natural" or "matronly" result. You may be perfectly happy and satisfied with your result. However, many of my patients who chose this route then will come back with a horizontal tan line across their chests (above the top of their implants) from a sundress or tube top, asking why when they wear a sundress or top without a bra, their breasts sit low, or do not have superior fullness. I re-explain that the implant must be centered behind their nipple and that generating this superior fullness would require a larger implant combined with a lift. Some elect to have the lift, and others chose to push their breasts up in a bra to generate superior fullness and cleavage.
Finally, attempting to avoid a lift by using an extremely large, high or extra high profile implant is a nothing more than a short term Band-Aid, and does not address the root cause/problem (i.e. stretched/lax and excess skin/tissue). This does nothing but postpones the lift for a short period of time and will only lead to further tissue stretch and thinning requiring an even larger lift to fix. Ultimately, this approach generates a much more complex (and expensive) surgical problem just months to a few short years down the road, so I never encourage patients to go with this approach.
Some of you may then ask why some surgeons you've seen offer this approach to droopy breasts, typically without discussing the other abovementioned options and each options pros and cons. The truth is that it's far easier and quicker for a surgeon to place a large implant without regard for the durability, or lack thereof, than perform a more technically challenging, and longer, lift procedure.