The decision to downsize breast implants, replacing existing implants with smaller ones, often raises the question of whether a breast lift (mastopexy) will be necessary. While the exchange procedure is generally straightforward, the impact of volume reduction on surrounding tissue is highly individual. Determining if a lift can be avoided depends entirely on the interplay between the new implant size, the amount of skin stretched by the previous implant, and the patient’s capacity for skin contraction. This assessment requires a professional evaluation to align the desired smaller size with a pleasing aesthetic outcome.
Assessing If a Lift Is Necessary
A surgeon’s primary assessment focuses on the degree of pre-existing breast sagging, known as ptosis, and the volume difference between the implants. Ptosis is typically measured by the position of the nipple relative to the fold beneath the breast and the lower curve of the breast mound. If the existing large implant has significantly stretched the skin envelope, removing it and placing a smaller one will immediately reveal the excess skin.
The critical factor is the amount of volume reduction planned. A small reduction, generally 100 to 150 cubic centimeters (cc), is more likely to be accomplished without a lift. A larger reduction, especially when moving from a very high-volume implant, almost always results in a skin envelope that is too loose for the new, smaller implant. The assessment determines if the skin will naturally “redrape” or if it requires surgical tailoring to match the reduced volume.
Patient Anatomy and Elasticity
The patient’s inherent makeup plays a substantial role in the success of downsizing without a lift. Skin elasticity, the ability of the skin to contract and tighten, is the most influential factor. Younger skin with robust collagen and elastin fibers has a greater capacity to shrink back to a tighter contour after the larger volume is removed.
Factors such as age, genetics, sun exposure, and smoking history can degrade skin quality and reduce elasticity. Pregnancy and breastfeeding also contribute to skin laxity, making the natural redraping process less effective. The thickness of the patient’s natural breast tissue helps to fill the space and support the new implant, camouflaging minor skin looseness. When skin quality is poor, the likelihood of avoiding a lift decreases significantly.
Surgical Techniques During Downsizing
When a lift is not performed, the surgeon employs specific internal techniques to manage stretched tissue. The pocket that housed the previous, larger implant needs to be resized to prevent the new, smaller implant from shifting or migrating. This is often accomplished through a procedure called capsulorrhaphy.
Capsulorrhaphy involves placing internal sutures into the scar tissue capsule surrounding the implant to tighten and reduce the pocket size. This process ensures the smaller implant is held securely in the correct position and prevents it from moving too far downward or laterally. The surgeon may also use these internal sutures to raise the position of the inframammary fold, the crease beneath the breast, to provide better support and projection. These internal maneuvers are compensatory measures designed to achieve the best possible shape without external skin excision and resulting scars.
What Happens to the Breast Shape
Choosing to downsize without a lift carries the risk of a compromised aesthetic result, which is the trade-off for avoiding lift scars. The most common outcome when a lift was indicated but not performed is residual skin laxity. This manifests as a deflated appearance, especially in the upper portion of the breast where the previous implant provided fullness.
The skin envelope, stretched by the larger implant, may hang loosely around the new, smaller implant. This can lead to increased ptosis, or sagging, where the nipple-areola complex sits lower on the breast mound than desired. While the overall breast volume is reduced, the shape lacks the firm, youthful contour that a mastopexy provides by excising excess skin. Managing patient expectations is necessary, as the goal of size reduction is achieved, but ideal projection and shape may be sacrificed.