Why Stage a Breast Lift and Augmentation? (Risk Explored)

Experiencing both sagging and volume loss (deflation) in the breasts after childbirth, breastfeeding, or significant weight loss is extremely common. The most effective way to solve both problems simultaneously is to combine a Breast Lift (Mastopexy) and Breast Augmentation (Implant) surgery. This combination surgery offers excellent results, giving the patient both lifted and full breasts under a single anesthesia. However, is every patient an ideal candidate for this combined procedure?

Are there situations where performing this procedure, also known as Augmentation-Mastopexy, at the same time is risky?

Yes, there are. In plastic surgery, patient safety always comes before aesthetic goals. In some cases, especially if the degree of breast sagging is very severe, performing both procedures at the same time can jeopardize the blood circulation to the most delicate part of the breast: the nipple-areola complex (NAC).

In this article, from the expert perspective of Plastic Surgeon Assoc. Prof. Dr. Yalçın Bayram, we will discuss in detail the situations in which breast lift and augmentation surgeries are not performed simultaneously, how this risk is identified in advance, what surgical path is followed in such cases, and the risk of nipple necrosis, one of the most feared complications of this surgery.

Why Are Breast Lift and Augmentation Surgeries Staged?

The main challenge in this combination surgery is that the surgeon is performing two different, and somewhat opposing, actions at the same time:

1. The Lift (Mastopexy): To move the nipple upwards and remove excess skin, the breast tissue must be "lifted." This action inherently compromises some of the blood vessel connections that feed the nipple.

2. The Augmentation: To place the implant, a "pocket" must be created under the breast tissue. This action also separates the breast tissue from the underlying chest wall, further stressing the blood supply.

In most patients, the nipple's blood supply is robust enough to handle both procedures at once. However, in some patients, applying these two surgical traumas simultaneously can lead to the nipple not receiving enough blood, resulting in tissue death (necrosis).

To avoid compromising patient safety, Assoc. Prof. Dr. Yalçın Bayram prefers not to perform this surgery in one go on patients where he anticipates the nipple blood supply to be critical.

The Risky Condition: Severe Breast Sagging (Ptosis)

So, which patients are in this risk group? We can say that the most important factor in determining this is the degree of breast sagging (ptosis).

Medically, the grades of sagging are determined by the position of the nipple relative to the inframammary fold (the crease under the breast):

• Mild Sagging (Grade 1): The nipple is at the level of the fold.

• Moderate Sagging (Grade 2): The nipple is below the fold, but still above the lowest contour of the breast.

• Severe Sagging (Grade 3): The nipple is far below the fold and is at the lowest point of the breast (points downward).

The highest-risk group for a combination surgery is generally patients with severe (Grade 3) ptosis. This is because, in this situation, the surgeon must move the nipple a significant distance upwards to its ideal position. Moving the nipple this far can cause the blood vessels feeding it to be stretched excessively or damaged. Adding an implant to this already risky procedure increases the pressure and tension on the tissue, seriously elevating the risk of necrosis.

Is It Possible to Detect This Risk Before the Augmentation-Mastopexy?

Yes, identifying this risk in advance is largely possible, and this is where the surgeon's experience comes into play. A surgeon carefully evaluates this risk during the detailed physical examination before the surgery:

1. Measuring the Degree of Sagging: The distance between the nipple's current position and its ideal new position is measured. These measurements must be evaluated along with other risk factors.

2. Previous Breast Surgeries: Prior surgeries on the breast negatively affect the tissue's blood supply and increase the risk.

3. Patient Habits: Smoking is the most significant risk factor, as it constricts blood vessels and severely impairs circulation. Performing a combination surgery on a patient who has severe sagging and is an active smoker is extremely risky.

4. Desired Implant Size: Requesting a very large breast implant can further increase the pressure and tension on the already stretched breast tissue, compromising blood circulation.

5. Comorbidities: Accompanying diseases such as diabetes and peripheral vascular diseases, which impair skin perfusion and delay wound healing, increase the risk.

If, as a result of the examination, the surgeon determines that these factors combine to create a high risk for the nipple's blood supply, they will not recommend performing the two surgeries at the same time.

What Surgical Path is Followed in High-Risk Cases? (Staged Planning)

Instead of taking risks with patient safety, the surgical plan is divided into two stages. This approach ensures that both operations are performed in the safest way possible, achieving the best aesthetic results.

Stage 1: Breast Lift Surgery (Mastopexy)

• In the first operation, only the Breast Lift procedure is performed.

• Excess skin is removed, the breast tissue is reshaped, and most importantly, the nipple is moved to its ideal position.

• Because no implant is placed, the tension on the tissue is kept to a minimum.

• A waiting period is observed for the nipple to fully adapt to its new location and for its blood supply to stabilize.

Stage 2: Breast Augmentation (Implant Placement)

• At least 3 to 6 months after the first operation, once the breast tissue is fully healed and the nipple's blood supply is secured, a second, simpler operation is planned.

• In this second session, the breast implant is placed under the muscle or in the appropriate plane, usually through the old lift scars (without creating new scars).

Although this staged approach prolongs the process compared to a single-session surgery, it reduces the complication risk to near zero and protects the patient's health.

What is Nipple Necrosis and How is it Treated?

Nipple Necrosis is one of the most serious, though rare, complications of breast lift surgeries. It means the death of the tissue in that area due to insufficient blood supply to the nipple-areola complex.

• Why Does it Happen? It generally occurs in patients with severe sagging, smokers, or those with circulatory disorders like diabetes, due to disruption of blood flow during surgery. Performing the two surgeries (lift and augmentation) at the same time is one of the factors that can increase this risk.

• What are the Symptoms? In the first few days after surgery, it manifests as a color change in the nipple—turning dark blue, purple, or black (different from normal bruising)—along with coldness and loss of sensation in the area.

• What Does It Mean? The breast loses its ability to breastfeed, and the unique sensation of the nipple is permanently lost.

• How is it Treated?

  1. Early Intervention: An experienced surgeon will notice this condition during early post-operative check-ups. Special dressings, medical treatments (medications, hyperbaric oxygen therapy) are started immediately to increase blood flow.

  2. Limited Necrosis (Superficial): If the necrosis is only superficial, this area will eventually form a scab, and new skin tissue will form underneath. Once healed, there may be some discoloration or slight tissue loss.

  3. Full-Thickness Necrosis (Deep): If the entire nipple or areola has lost viability, this dead tissue must be surgically removed (debridement).

  4. Reconstruction: Months after the wound has completely healed, a secondary repair operation (reconstruction) is required to recreate the lost nipple and areola. This procedure usually involves creating a new nipple from local skin flaps and using medical tattooing to recreate the areola's color.

In Summary; While combined Breast Lift and Augmentation surgeries are safe and effective for most patients, staging the two procedures is vital for those with severe sagging or high-risk factors (especially smoking). This decision must be made by an experienced plastic surgeon who analyzes your risks during an in-person examination. Patient safety is always the priority.