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How can I tell if I need a breast lift or implants? June 16, 2009

Posted by bosshardt in Breast surgery.

Breast lifts and breast implant surgery are totally different procedures that do very different things. They can complement each other in that some patients need both but how does one know which is best for her? Ptosis, the medical term for sagging, is defined by the position of the nipple relative to the crease under the breast. You can do a very simple test to see if you have this. You may have heard of the “pencil test” for breast sagging. Lift up on your breast with one hand, place the pencil horizontally under the breast, right in the natural crease, and then let the breast go. Release the pencil and if it falls, there is no ptosis. If the breast holds the pencil in place, then there is some element of ptosis. If the pencil is held, note the position of the nipple. If the nipple is above the level of the pencil, then you have a “deflated” breast, called pseudoptosis. This is common in women who have breast fed and lost volume in their breasts. If the nipple is at the same level as the pencil, you have grade I ptosis. If the nipple is below the pencil, you have grade II, and if the nipple is the lowest point on the breast (sometimes referred to as a “National Geographic” breast, for all the photos in that magazine of women in primitive cultures whose breasts point to the ground!), you have grade III. Breasts with pseudoptosis and grade I ptosis usually do not need a breast lift and will do well with just adding more volume, i.e. a breast augmentation with implants.

Women with grade II and III need a breast lift, called a mastopexy. Putting implants alone in such breasts usually produces a less than aesthetic result because now you will have a big, droopy breast. Some women can accept this to avoid the scars and expense of a lift, but it is not ideal. A mastopexy is a terrific procedure which will produce a “perky”, non-saggy breast. The down side of this is that it is a fairly extensive procedure, takes longer to perform than a breast augmentation), and leaves additional scars. At a minimum, there will be a scar along the margin of the areola. Additional possible incisions may leave a vertical scar from the areola to the crease under the breast and a scar along the crease itself. In most cases, the aesthetic improvement is worth the scars. The lifted breast will be more compact, because skin is removed, and therefore you may not fill out your bra as well as before and you might even go down a cup size.

Breasts that just need volume do beautifully with implants. See my earlier blog which is an online breast consultation to read details of this surgery. Sometimes, patients need both procedures because of sagging AND loss of volume, the double whammy. In those cases, I recommend doing the lift first followed by the augmentation 3 or more months later. I feel it is easier and safer to do the lift first. Some patients may find that after the lift, they are content and do not go on with the implant surgery. I usually try to dissuade patients from doing lifts and implant surgery simultaneously.  These two operation work directly counter to each other. The lift is tightening the breast and making it more compact; the augmentation is trying to expand the breast out and make it bigger. Each operation raises the risks of complications from the other. Inevitably, some compromise will be required. Either the lift and/or the augmentation may have to be underdone to avoid the potential for postoperative complications. The cost savings and savings in time for recovery for doing multiple procedures is, in my view, more than offset by the added risks and compromise of doing the two together.

The patients in whom I am more comfortable combining these procedures are those who need just a little lift and /or a small implant.  That is why the consultation is so important, to understand your desires and to see what your breasts will need to have done to accomplish your goals. Expectations are very important and it is equally important to remember that this is real surgery.

I do nearly all breast lifts in our office under general anesthesia. A full, extensive lift will take about 4 hours to complete because of the cutting, shaping, and suturing involved. All sutures the type that dissolve. Scars are usually quite faint and fine. We now have a very nice laser that we can use on problem scars. Though uncommon, they are annoying to patients.

Risks and complications of breast lifts include all those seen in most surgery: infection, bleeding, poor scars, healing issues, unintended injury, anesthesia related problems, and even life threatening problems (although the latter is exceedingly rare). Specific complications include: skin slough leading to bad scars, unsatisfatory size and/or shape of the breasts, loss of feeling in the nipple/areola area, and asymmetry.



1. Lisa - July 5, 2010

I know I don’t need implants my breasts are DD’s. But 35 years of carrying them around has made them sag. I think a breast lift is called for.

2. How do I know if I need a lift? - Breast Augmentation, Breast Implants, and Plastic Surgeons Forums - July 7, 2010

[…] about this, I have a 'deflated breast' on my left breast (pseudoptosis) which I found from here: https://bosshardt.wordpress.com/2009/…t-or-implants/ I've also measured my sternal notch to nipple & its 17cm which I thought mean't I didn't need […]

3. Ellen McAdams - August 24, 2010

i guess if you notice that your breast is too small, you better do the breast augmentation.

4. Breast Augmentation Kentucky, Breast Surgery Louisville - September 23, 2010


if you only have to read one post then see this post on Breast Surgery report…

5. Santa Dusik - September 23, 2010

I know this is a little something most have heard but did anyone see about the new show bridalplasty I think everyone is getting down on this subject and really should take some soul searching into what the show is about, that people want to change their lives and just want to be accepted.

6. mom - September 29, 2011

primitive cultures?

wow. hey by the way, if you havent heard, if you have grade 2 or 3 you NEED a breast lift, none of our grandmothers possibly got through life without having surgery for something that naturally happens to the breasts and isn’t life threatening.

bosshardt - October 4, 2011

Whoa! Sorry if my post made it sound as though I think every women with sagging breasts NEEDS a lift! Far from it. What I was trying to say is that if there is grade 2 or 3 sagging and a women is looking for breast enhancement, a breast augmentation with implants probably won’t be her best option. The question in my blog presupposes that a woman has come in for breast enhancement and wants to know her options. Sagging needs a lift to properly correct. For the record, although it may sound counter productive for a plastic surgeon to say this, my philosophy as regards all cosmetic surgery is this: If you can make peace with the aging process and accept the changes in your body that come with age, and accept your natural appearance as it is without “enhancement”, I think you are better off. If you cannot come to grips with these, that is why I am here. No one NEEDS cosmetic surgery. They desire it for specific reasons, some good, some not so good. It is my job to advise patients of their options and, most important, inform them fully of the pros and cons of having, and not having, surgery. Anything less, is doing patients a disservice.
Thanks for calling me on that. I like to be very clear with my blog and I can see how what I said might be misconstrued.

7. felisha - November 18, 2011

alot.of people on here keep sayin that they are wanting breast lifts because of age or breastfeeding but I’m only.18 and I think that I want to get a breast lift. is that normal.

bosshardt - November 18, 2011

Hi Felisha,
As to whether your desire is “normal” or not, the best answer is: it depends. If you do not need a lift and yet want one, that might suggest that you have a problem with your self image. If you do need a lift, then desiring one would be considered quite normal. Lifts fix one thing only- loose, sagging breasts. They raise the nipple position on the breast and/or tighten the skin of the breast around the available breast tissue. A lift is the only thing that will do this. It will not make you more full or larger. On the contrary, your breasts will probably be more compact after a lift. The trade-off for getting more youthful, “perky” breasts is that they will have scars on them and the quality of these scars cannot be guaranteed for anyone. As a result, the breasts after a lift will always show visible marks that they have had surgery. Lifts are much more surgery than a simple breast augmentation with implants. The best way to determine if you are a candidate for a lift or not is to seek a consultation with a plastic surgeon.
I hope this information helps.
R. Bosshardt, MD, FACS

michelle - January 25, 2012

Can I send u a pic to see if I need a lift? My bf says no but I know I do….I get depressed about it

bosshardt - January 26, 2012

Hi Michelle,
Yes, you can email a photo or photos to rtbosshardt@aol.com. While photographs are useful, they cannot substitute for a face to face visit because only then can I really assess all aspects of your breasts: skin elasticity, firmness of the breast tissue, etc. Photographs are 2-dimensional and this limits the evaluation somewhat. I can give you at least an opinion at to whether you might need a lift or not. Some patients who they are sagging truly are not. They have just experienced loss of fullness for any number of reasons, e.g. weight loss, child birth, etc. If the sagging is minimal to moderate, implants alone may correct or disguise this and avoid the need for a lift, at least for a few years. I will be happy to give you an opinion.
R. Bosshardt, MD, FACS

8. get bigger boobs - November 30, 2011

I will right away take hold of your rss as I can not in finding your e-mail subscription link or newsletter service. Do you’ve any? Kindly allow me recognise in order that I may subscribe. Thanks.

bosshardt - January 26, 2012

Not quite sure I understand what you are asking. I don’t have a “newsletter service” or e-mail subscription link that I am aware of. You can certainly sign on to follow my blog if you wish. By the way, I checked out the web site getbiggerboobs.net. This is totally bogus. You are throwing your money away if you purchase any pill, cream, “system”, etc. which promises to increase your bust size. None of these work, period. The only way to enlarge breasts at this time is through implant surgery.
R. Bosshardt, MD, FACS

9. MO - December 13, 2011

primitive culture remark – not cool. perhaps the “primitive culture” is the one altering their looks!

10. plastic surgery forum - December 21, 2011

Hi there, just become alert to your blog via Google, and found that it’s truly informative. I’m gonna watch out for brussels. I’ll be grateful in the event you continue this in future. Many other people can be benefited from your writing. Cheers!

11. michelle - January 26, 2012

Thank you so much I will be sending them soon….embarassed 😦 and kind of scared to hear something I don’t want to hear but that’s ok…


bosshardt - January 26, 2012

Nothing to be embarrassed about. The desire to look your best is perfectly natural and understandable. Trust me, I have seen breasts that look much worse than yours possibly could.

michelle - January 26, 2012

What’s the opinion…..ready to hear it

12. michelle - January 26, 2012

ramonmichelle@yahoo.com I prefer…for opinion

bosshardt - January 26, 2012

Michelle, I sent you a reply by email. I think you would do well to consider waiting a few more years before trying to surgically enhance your breasts. I think they are too nice as they are to risk this. My opinion, for what it is worth.

13. Lift or Implants - February 27, 2012

Im a 38D and very happy with my breast size but they do sagg and my aeriola is rather large now after 4 children. I would like to lift them but I will loose some cleavage and go down a bra size. So Im assuming that I can add some CC’s to bring the size back to where they are now. I just cant determine whether I need a mini or a maxi lift, and should I get the implant. Any good plastic surgeons in Atlanta, GA I would like to here from you. I would like to get this done within the next few weeks.

bosshardt - February 27, 2012

I would suggest either Dr. T. Roderick Hester or Dr. Mark Codner. Both are affiliated with Emory University and have excellent reputations. When discussing lifts one of the major differences between “mini” and “maxi” lifts is the extent of the incisions and resulting scars. Beware of techniques that promise to limit scars to just around the areola. If too much lifting is attempted with them, you may be left with permanent puckers around the areolae and a less than desirable shape to the breasts. Better to have a few additional scars with a nice shape to the breasts and no puckering. While you may, indeed, lose some fullness with a lift, if you are a true D cup size, you will probably still have pretty full breasts after a lift and, hopefully, will not need implants too. I generally recommend against putting implants in at the same time as a lift is done as these two operations work against each other and may compromise the final result. Better to do the lift, wait 3 months or more, and then proceed with the implant surgery if you still wish this. Many patients are very pleased with the results of a lift alone. All breast lift techniques can reduce the size of a large areola.

14. S - March 12, 2012

Hi Bosshardt,
I have just sent you this email – hope you got it, i will paste it here too.

Hi there, ?bosshardt?

I was just reading a post to you on a web, I am in England. Nice to speak to you – HOPE YOU DONT MIND!!

I am going to have breast augmentation soon. I am a black woman. I have saggy breasts, did the pencil test = grade 111 😦 . However I do not want that horrible vertical scar that the uplift leaves – i also have large areolas. Im sooo worried about scarring.

The thing is, ive breast fed 3children and my nipples now point down.they are like empty sacks. Ive lost 5stones via gastric bypass :-). However, you can see just the 1/2 moon (top half) of my areolas at front view – and nipples, but i dont think that looks so bad. With a push up bra, my contour is good – even sexy?? as im just 5ft 1 1/2ins tall and now weigh 9st2. I look good in my clothes but am lacking fullness – naked in my breasts. Im going to have a TT as well.

The thing is – ive never seen anyone who has had JUST implants with a saggy breast – does this look terrible?? is there absolutely NO uplift without the ‘uplift procedure and scarring’?? will I look silly?. I thought if i had a bigger implant like 500cc it would fill out my empty sack? as i sed, i used to be a D cup before the kids and weight loss.

Im frightened that if i go for the initial consultation, that i will be ‘talked into’ an uplift and therfore a permanent scar – that i will later regret! I know the surgeon is very very professional – but im still worried. I guess Im worried that im not sure what implant into a saggy breast would look like. Do you know where I could look at this type of breast? Ive shown pictures of myself to the surgeon and he thinks he could do wonders with an uplift and implants with me, but also says if im happy to have implants without the uplift then he will do what i desire – if im happy with a long/saggy breasts?…. this sounds awful. Would it BE that bad?? would there be absolutely NO slight uplift at all then?
I’d be grateful of a reply from you, as you seem very knowledgable

Kindest regards


bosshardt - March 12, 2012

Dear S,
Thank you for your inquiry. It is difficult to answer your question specifically for you without knowing more. I can give some general guidelines that I tell my patients about breast lifts versus implants. If the breast show a grade 2 amount of sagging (the nipple is below the level of the crease under the breast) then a lift should at least be considered. There are degrees of grade 2 and those at the more sagging end will generally not look good with implants alone. Implants do not life breast, at all. If the breast shows minimal sagging (grade 1 or very minimal grade 2) an implant may, by adding volume, disguise the sagging a bit. The problem is that is often takes a relatively large implant to fill out such a sagging breast and that can present problems of its own. I have found that once patients get past the issue of scars, they are often extremely happy with the perky new look of their lifted breasts. Many don’t move forward with implants because they are satisfied with their lifted breasts. It is important to have a thorough discussion with your surgeon, look at photos of patients who have had lifts, and make your decision after time to reflect on everything. If both a lift and implants are going to be likely, I very rarely feel comfortable doing both simultaneously. These are two very different operations work counter to each other (the lift tightens up the breast while implants try to stretch the breast out) and therefore both procedures have to be compromised. The risks of doing simultaneous lifts and implants is much greater than either of them alone. Don’t hesitate to get more than one opinion from reputable surgeons who do a lot of cosmetic breast surgery. I wish you success. Let me know how it goes.
R. Bosshardt, MD, FACS

15. lisa - May 22, 2012

hi,ive just been reading all the info on here-im 38&just recentley have noticed my breasts appear deflated&would love to do something about it,ive had 3 children&just recently started to excercise alot ie running&pole excercise thinking it would improve the pertness in my breasts,sadly no-ive lost weight-weigh 8stone 6& my breasts seem to have deflated more!!! ive done the pencil test&both breasts hold the pencil although not majorly-if i moved slightly pencil would drop.when i stand still though the pencil is almost level with my nipple maybe slightly below,i measure at a 32 dd but the top half of my breasts are very flat but i dont have excessive amount ov skin-ie i cant pinch the skin&pull loads up if you know what i mean? so does that mean i would be better opting for implants or a breast uplift? also if implants would be suitable do you think id have to have them behind the muscle or on top? im not too keen on the idea of an uplift as im not keen on the idea of scarring-ive also measured the distance between my collar bone to the nipple&its nearly 22cms but the nipples arnt pointing down at all,any advice would be greatly appreciated,many thanks.lisa x

bosshardt - May 22, 2012

Lisa, Thanks for sending your questions. I am going to be brief as right now things are very busy and I just don’t have the time I would like to give you a lot of particulars. You sound like one of those patients who are on the fence with regards to whether you would do better with a breast lift with or without implants, or with implants alone. A lift will tighten up your breasts and make them more perky but also make them a little more compact, i.e. you may not fill a bra as well. A lift will also be more expensive and leave more scars. In the right situation, lifts are great and nothing can replace them. Implants do one thing: add volume. If the breast is just a little droopy, the added volume may disguise the sagging for a while. If there is significant sagging and you don’t want to have a lift, you can do implants alone and accept that you will have larger, but still saggy, breasts. In this case, you would probably have to go with implants above the muscle. Most surgeons, including me, prefer to put implants under the muscle for a variety of good reasons but in droopy breasts, without a lift, this is just not going to look good. You can do lifts and implants together and this saves time, money, and recovery but is much more complicated than either alone and the risks of complications are greater. As you can see, your situation is not a simple one. You need to have a thorough discussion with a plastic surgeon with whom you are comfortable, listen to his/her recommendations, then make your decision. Realize that there is no perfect surgery that can give you what nature didn’t. It is not natural to operate on breasts and lift them and/or put implants in them so to expect totally natural results is just not realistic. Beware of anyone who promises results that sound too good to be true. They usually are. Good plastic surgeons try to present a balance view of surgery, including the downside.
I don’t know if this helps or not. If you have further questions, please feel free to write back.

16. Elisha - May 29, 2012

I just came from plastic surgeons office I’m a 34b now nursed 2 children. I was a little dissapointed when I was told I needed a lift. I went in thinking I can do with a augmentation. I am supper concerned w future ability to nurse. Im single now but don’t want to cancel that I might meet someone & we may want a child together. I thought cutting into aerola would hurt future chance of nursing. Plus I have a lot of sensation now & don’t want to lose that. Worried I want larger breast but unsure if I really need lift since I’m small busted but do have sagging. Torn.

bosshardt - June 7, 2012

Without knowing what your breasts look like, I have to go with the recommendation of your plastic surgeon. If you let them know your concerns, they can do your surgery in ways that will most likely preserve your ability to breast feed later. In my experience, very few patients lose feeling in their nipples after a lift alone. If you are small enough, and not sagging too badly, an augmentation alone may serve you very nicely. It is hard to advise without knowing what you look like. I hope this helps.
Thanks for taking the time to write.
R. Bosshardt, MD, FACS

17. Ashley - April 13, 2013

I have breast fed both of my sons, altogether it’s about 3 years. This has left my breast the smallest they have ever been, smaller than a B. I am wanting implants but have been advised I need a lift. I’d like to take them rather large, DD? If I opt to not get the lift but just the large implant, will it make them full and natural looking? I’d like to see the implants first then if I am unhappy, go back for the lift at a later time. I also have a little loose skin around my belly button and the old belly button piercing isnt flattering, are there any smaller less extensive procesures that could fix this, instead of a tummy tuck? What is your recommendation?

bosshardt - April 13, 2013

Hi Ashley, It is always a little iffy trying to answer questions like yours without more information. I can give you some general information that may be helpful. Going from an A/small B to a DD is a substantial increase that will take large implants. I find that many women that come in seeking very large implants really have no idea what they are asking for. First, breast implant surgery is an inherently unnatural thing to do to breasts. To do this and expect totally natural results is simply not realistic. While the breasts may look and feel pretty nice, they will usually not feel or look 100% natural. There are physical features of your chest that will, or should, limit the size implants you get. To try to exceed your natural chest dimensions with too large an implant is setting yourself up for some real problems later; problems that may never be totally correctable. Large implants are not the answer when a patient needs a lift. The answer is to do the lift! When women try to correct sagging by using very large implants to fill the breasts out, what they often end up with are very large breasts that are still droopy. Better to do the lift and then add implants later, than vice versa. It is both harder and riskier to do lifts in women who have implants. Doing lifts and implants simultaneously is something I tend to discourage except in certain specific cases because the two operations run counter to each other and both have to be compromised.
As to the abdomen, I am afraid that for loose skin, the only solution that works reliably and looks good is to do a tummy tuck. Many women that have had children will have loose skin in the abdomen, often with stretch marks, and the only thing to do is operate to remove the extra skin, i.e. a tummy tuck. Liposuction will not do this, not even the newer laser assisted liposuction that seems to be getting so popular. We offer this but find that the amount of skin tightening that the laser will accomplish is very modest and the quality of the results is unpredictable, unlike a tummy tuck, where the outcome is very predictable, and which will produce the tightest, flattest abdomen possible. You may not need a full tummy tuck. Some women can get by with a limited or even “mini” procedure to tighten up the loose skin. The clean up the belly button, you will to cut into that area and tighten the skin around the belly button. Again, without seeing you, it is hard to be more specific.
I hope this helps. Thanks for writing.
R. Bosshardt, MD, FACS

18. Leeann Savage - August 17, 2014

Hi, I had 240 cc saline implants when I was 21 yrs old in England, behind the muscle, one ruptured and had replaced 2 yrs later with 250 cc hydrogel implants. I only recently asked for my medical records from the surgeries and now realise I had tubular breasts to begin with, which I was unaware of before. I was size A and went to a large c, small D. I was happy with size, but I am 5ft 8 and 121 lbs ,and felt I could have gone a bit larger. I have had two kids and breast fed for short time. It is now 16 yrs from my last implants and they have deflated, my left breast is an A and my right a small B. I measured and am 20 cm on left nipple and almost 21 on the right nipple, I did the pencil test and there is no hold at all on the left and on the right the pencil holds. I have seen two surgeons the first said I needed a lift and gave me no idea of what size of silcone implant to choose. The second surgeon was more professional, he said I did not require a lift and asked me to think about if I wanted to proceed with surgery and if I did to return to him to decide on the size of implants, he also said I may be better with teardrop rather than round but would decide while preforming the surgery and would place the implants behind the muscle. I would like to know what your opinion is on what sizes and shape would be normal for someone in my situation ? I will not be having anymore children, as I have had surgery for health reasons, I am also now a diabetic type 1 the last 5 yrs . I would appreciate any advice you could give me. Regards Leeann.

bosshardt - August 18, 2014

Hi Leeann, Thank you for your inquiry. As you can imagine, a lot changes in 16 years. It would be impossible, and improper, for me to advise you specifically without having seen you or, at the least, some photographs. That said, I can make some general comments regarding your situation. I am not really sure what you mean when you say your implants have “deflated”. I not familiar with “hydrogel” implants; there is no implant with a comparable name here in the U.S. Silicone gel implants do not deflate. They rupture and leak, but the silicone stays put inside the pocket around the implant and the volume of the breast does not change. Saline implants will deflate if they leak and the breast will lose all the volume from the implant. leaking gel implants should always be removed. Deflated saline can be left in place but removal is so easy that there is little reason to do this. There are many details missing from your note so much would depend on your particular circumstances. I am not a big fan of shaped or tear drop implants for a number of reasons. These are usually not as good in situations like yours, where there is already an established implant pocket. Sizing is something I usually do in the operating room since I rarely feel comfortable committing to an implant size pre-operatively. Make sure you and your surgeon are on the same page when it comes to what size you are looking for. It does not sound like you need a lift and I would recommend avoiding a lift until it becomes unavoidable. All lifts leave extensive, visible scars on the breasts and they will never look as natural. If your implants are now above the muscle, putting them behind the muscle may be a good idea but is much harder to do now then it is when the implants are first inserted. Advantages are that the muscle coverage better hides the implants from view in the upper half of the chest, the implants tend to stay softer, and the breasts are more easily examined with mammograms. Disadvantages are that the surgery is more extensive and difficult to do and there may be very visible distortion of the breasts when you contract your muscles.
I hope this helps. Sincerely, R. Bosshardt

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