In some cases, the breast implants move downward as the tissue that supports the device becomes weak and lax.  If this happens, the breast crease will settle lower on the chest, leading to a cosmetically displeasing result.

Fortunately, there are several ways to prevent this problem and one of the most effective is choosing the right implant size.  For instance, petite women who often have a limited breast tissue and skin are generally recommended to choose smaller sizes in order to prevent bottoming out; in this way, they can also avoid visible and palpable ripples in the shell.

It is important to remember that inordinately large implants can expose patients to a higher risk of bottoming out and premature breast ptosis (or sagging) because of the extra weight the tissue and skin has to carry.

Another way to avoid bottoming out is creating an implant “pocket” which should be in the right size, preventing gross movements of the device.  But in case that the room for implants has been over-dissected, the problem will usually occur just several weeks or months after a breast augmentation.

Meanwhile, the right placement of implant, particularly the complete submuscular technique, can also minimize the risk of bottoming out since the breast implants are supported by a thicker amount of tissue in the lower poles.  This is not the case in other implant placements in which the lower poles are only supported by the skin tissue.

Another advantage of complete submuscular or “unders” is it prevents visible and palpable rippling because the top two-thirds of the implants is covered by the pectoral muscle.

Some doctors also suggest that using a bra that provides a good support to the weight of the implants can prevent or at least minimize the risk of bottoming out and breast ptosis.

But in case the implants have bottomed out, the only way to treat this problem is through another surgery which often involves an incision made along the breast crease.  In this way, doctors can cut and roll up the tissue surrounding the device and then secure it with internal sutures.

Once the implant “pocket” has been corrected, the incision site is closed with tiny sutures.

For some patients, they may be asked to downsize their breast implants particularly if the main reason for bottoming out is the excess weight of the large implants.

But in case the non-surgical procedures did not solve the problem, plastic surgeons will most likely recommend gynecomastia surgery which involves incisions to remove the excess tissue and fats.  If needed, liposuction is also performed to further improve the breast’s contour by eliminating the extra fatty tissues.

But as an invasive procedure, male breast reduction surgery involves certain risks particularly for men who have health conditions that may predispose them to delayed healing, infection, bleeding, unnecessary scarring, and other complications.  For this reason, patients should meet these following requirements before they are considered as a good candidate for this surgery:

• They have realistic goals and expectations
• Well-rounded individuals
• Physically healthy with no serious illness
• Their breast development has stabilized
• They have passed their puberty stage (during this period, the hormonal imbalance may lead to overdeveloped breasts which will resolve on their own within several months)
• They are bothered by the appearance of their enlarged breasts

Because gynecomastia surgery often involves incisions, it is very important that the patients do not suffer from diabetes and other illnesses that inhibit the healing process and expose them to higher risk of infection and unnecessary scarring.

In most cases, the result of this cosmetic procedure can last a lifetime, although this may be affected or even completely reversed by a significant weight fluctuation.  With this consideration, plastic surgeons recommend their patients to maintain their normal weight through a healthy diet and regular exercise.

Also, doctors only perform this procedure on men who are within 25 to 30 percent of their recommended body weight.

Aside from being physically fit and having a normal body weight, it is also important that the patients are not smokers.  But in case that they are, they should quit the bad habit well in advance of the surgery and during their recovery to prevent the risk of skin necrosis (or death of skin tissue that may lead to unnecessary scarring).

According to a previous study, patients who are smoking are 1,500 times more likely to develop skin necrosis after a surgery compared to non-smokers because the nicotine affects the circulatory system and inhibits the oxygen from reaching the wound.

While this surgery can be performed at any age, most doctors recommend their patients to wait until they are at least 18 years old, a stage in which their breasts are fully developed.  Most experts also advise women to postpone breast reduction if they are considering having children in the future since their ability to breastfeed may be compromised.

Because breast reduction is relatively extensive, surgeons often perform this under general which can put a patient to sleep during the entire operation.  However, the surgery is typically conducted in an outpatient basis which means that a woman can return home on the same day of the procedure.

Nowadays, doctors use different incision patterns and techniques in order to achieve the most desired outcome.  But for women with excessively large breasts, the most ideal is the standard approach which involves an anchor-shaped incision—one around the perimeter of the areola, another cut that travels vertically from the nipple down to the breast crease, and a third one that horizontally covers the crease.

In some cases, the horizontal incision is removed particularly when only a small amount of tissue and skin is removed from the bust.

Once the incisions are made, the extra tissue, fats, and skin are excised in order to reduce the size of each breast.

In many cases, the nipple and areola remain to their original position.  However, doctors who are treating women with inordinately large, heavy breasts will have to remove and reattach this area to a higher position in order to achieve a more natural result.  And if needed, the sized of an enlarged areola is also reduced.

One major downside of detaching the areola and nipple from their original nerves and blood vessels may result to reduced or permanent loss of sensation.  In some cases, this procedure may also lead to a woman’s inability to breastfeed.

After a breast reduction surgery, the incisions are closed with tiny sutures and the chest is then covered with an elastic bandage or gauze dressing.

To treat this aesthetic problem, breast lift surgery is the most recommended solution as it provides a long-lasting result.  But still, it is important to note that the aging process may slightly affect the outcome of this procedure in the long run, although the breasts will not experience significant sagging.

Meanwhile, significant weight fluctuations and pregnancies may affect or even reverse the result of breast lift.  For this reason, most patients are advised to postpone this cosmetic procedure if they are 25 to 30 percent heavier than their ideal weight and if they are planning to have children in the future.

As with most cosmetic breast surgeries, this procedure involves the use of incisions which can lead to permanent scars.  But as much as possible, doctors will place the surgical lines in areas in which these will not be seen even if a patient will wear a low-cut top.

For women with large breasts and severe ptosis, the most recommended incision pattern is shaped like a nautical anchor: a horizontal cut across the breast crease, an excision around the perimeter of the areola, and a vertical incision starting from the areola to the breast crease.

However, there are cases in which the horizontal incision across the breast crease can be removed particularly if plastic surgeons only have to excise a small amount of skin and tissue.  With this minimally invasive technique, which is called lollipop lift, most patients can enjoy shorter recovery and one less scar.

Meanwhile, some women not just want to lift their sagging breasts but also desire to make their bust appear fuller.  For these patients, the most recommended approach is the donut lift (only the skin and tissue around the areola is excised) which is complemented with breast implants, preferably the silicone type in order to achieve a more natural result.

Because the weight of the implants may aggravate the ongoing breast ptosis, these devices are generally placed under the chest muscles so more amounts of skin and tissue can provide a better support.  On the other hand, placing the implants behind the tissue is not recommended since it can worsen the sagging in the long run.

When it comes to giving a natural appearance, most plastic surgeons believe that the silicone implant, which is filled with a cohesive gel material, provides a slightly better result compared to the saline version.  This is because it uses a filling noted for its ability to replicate the feel and natural movement of a breast tissue.

On the other hand, women with saline implants usually compare the feeling of having a water-balloon inside their breast.

Another advantage of the silicone implant is that patients can maintain their breast volume for many years unless if the shell breaks.  According to experts in plastic surgery, this may not be the case for women with saline implants which have a natural deflation rate of about 1 percent every year due to evaporation and other related factors.

Meanwhile, petite women or individuals with a limited amount of breast tissue and skin will most likely benefit from using silicone-filled implants which can lower the risk of rippling—a problem which may happen if the glandular tissue is not thick enough to cover the shell.

Many plastic surgeons also believe that patients who have had tumor removal will more likely benefit with silicone than the saline implants because they are usually left with a small amount of breast tissue.

Despite the notable advantages of silicone implant, plastic surgeons inform their patients that it has still some downsides.  For example, having this implant requires a periodic MRI screening—at least every two years—to identify any rupture in the shell which may go undetected for years if women will only rely on the “visible manifestations.”

On the other hand, this test is not a requirement for patients with saline implants because a rupture will immediately provide a manifestation in the form of breast deflation.  With this, they can easily seek a revision breast augmentation to correct such problem.

Since the saline implant is filled with a sterile saltwater, a rupture does not expose patients to serious health problems because the filling can be safely absorbed by the surrounding tissue.

Regardless of which type of breast implant is used, the primary purpose of this biocompatible, synthetic material is to increase the bust size, make the cleavage more prominent, and create a more womanly figure.

To correct the hanging, flat-looking breasts, mastopexy or breast lift surgery is the most recommended long-term solution.  In this procedure, surgeons create several incisions to remove the loose skin, tissues, and fats.

But since every patient has a varying degree of breast ptosis (sagging), there are different incision patterns and techniques used in this procedure.

• Anchor lift technique

This technique, which is recommended for women with large breasts with severe sagging, involves making an incision around the perimeter of the areola, or the pigmented part of the skin; another one that runs vertically from the nipple to the breast fold; and a third horizontal cut across the breast crease.

The anchor-shaped incision is the oldest breast lift technique and is often used in conjunction with breast reduction surgery.

• Lollipop incision

The incisions used in the anchor lift are also the same with this technique, minus the one that horizontally travels across the breast crease.  Consequently, patients can expect shorter recovery and one less scar.

This approach is suitable for patients with a moderate degree of breast ptosis.

• Donut lift

Also called as “Benelli” lift (named after the surgeon who pioneered its use), this technique only involves incisions made around the areola.  Meanwhile, this is usually ideal for women with minimal breast ptosis, although this can also be used for patients with a moderate sagging as long as it is performed in conjunction with a breast implant surgery.

• Crescent lift

This breast lift technique, which is not as commonly used as the three incision patterns stated above, involves making a surgical line just along the upper half of the areola.  After this, a crescent-shaped segment of skin is excised and the remaining part is tightened and reattached to the areola.

The crescent lift is suitable only for women with a very minimal degree of sagging and is usually complemented with breast implant surgery.

• Breast implant surgery as a standalone procedure

Breast implant surgery is sometimes used as a standalone procedure for creating volume and slightly lifting the breasts to a higher position.  But with the weight of the implants, most surgeons do not recommend this surgery for patients who have already developed noticeable sagging.

And since the implants can create more projection and volume, breast lift combined with these materials is also ideal for women who want to achieve a more noticeable cleavage.

To date, this approach is increasingly becoming popular among women who want to raise and increase the size of their sagging breasts.  But to fully enjoy the benefits of breast lift with implants, the bust size should not be too large and the ptosis should not be too severe.

Most cosmetic plastic surgeons perform this procedure through the use of an incision around the areola which is the pigmented part of the skin; in this way, they can excise the extra skin before they can insert the breast implants.  However, this excision technique may not be enough for women with a more pronounced ptosis which is why doctors may create a second incision that travels from the areola down to the breast crease.

After removing the excess skin around the incisions, doctors will then insert the breast implants.  Many of them will most likely recommend the silicone implant rather than the saline version to achieve a more natural outcome, something which is possible because it uses a cohesive gel filling designed to simulate the “feel” of a real tissue.

The average weight of implants is about 12oz or 350 which may aggravate the ongoing breast ptosis.  Fortunately, plastic surgeons can address this concern by simply placing the synthetic materials under the chest muscle instead above it so that a thicker amount of tissue and skin can support their weight.

Aside from providing a “bra-like” support, doctors in US plastic surgery also believe that the submuscular implant placement also prevents rippling which is a common concern of thin women with limited glandular skin and tissue, reduces the risk of capsular contracture, and creates a more natural result.

Meanwhile, some women are concerned that combining breast lift with implants may result to longer surgical period which means higher risk of complications and also prolonged downtime.  But according to plastic surgeons, the length of recovery and operation of this approach is almost the same with breast lift or breast augmentation when performed alone.

Contrary to popular belief, sagging breasts not just occur among large-busted, older women.  Some individuals with smaller breasts also have this aesthetic problem caused by major weight loss, several pregnancies, or just simply because of hereditary predisposition.

In US plastic surgery, most doctors prefer the anchor-shaped incision when dealing with large-busted women who have severe sagging.  As its name suggests, this technique involves a set of excisions that resembles a nautical anchor—one around the perimeter of the areola, another incision that starts from the areola to the breast crease, and one more that covers the entire breast fold.

Through the incisions, doctors can lift and reshape the underlying tissue in order to improve the breast contour and firmness, and then reposition the areola and nipple to a higher place without completely removing them from their original blood supply and nerve to preserve the sensation in the area.

If needed, cosmetic plastic surgeons will also reduce the size of an enlarged areola by excising the skin around its perimeter.

To compensate for the loss of elasticity, the excess breast skin is carefully removed and the sutures are layered deep within the tissue in order to support the newly shaped bust.  Once the necessary changes are completed, doctors will close the surgical wounds using skin adhesives, surgical tape, and/or sutures.

While the anchor-shaped incision provides a dramatic result, this approach is viewed as too extensive for small- to medium-busted women who have less sagging.  With this consideration, plastic surgery specialists will likely use a new breast lift techniques which involve fewer incisions which means faster recovery and shorter scars.

For medium-sized breasts with severe sagging and large bust with moderate drooping, most plastic surgeons recommend the lollipop lift which uses the same incision sites found in the anchor lift minus the one that covers the entire breast crease—the area which typically takes the longest time to heal; for this reason, patients can expect faster recovery.

Another minimally invasive technique designed for women with smaller breasts is the doughnut lift which only uses one incision around the areola.  And according to plastic surgeons, this approach is best complemented with implants to address a more pronounced sagging and to make the breasts appear fuller.

However, some doctors in cosmetic plastic surgery also use this procedure on men who have enlarged breasts due to the excess fats and tissue, a condition which is medically referred as gynecomastia.

Breast Reduction for Women

Nowadays, most doctors use the inverted T incision pattern in treating women with extremely large and heavy breasts.  With this approach, they place the excisions around the areola, horizontally across the breast crease, and vertically from the areola to the crease.

Through the excisions, doctors can reshape, reduce, and manipulate the breast tissue and then place the areola to a higher position without completely separating this from its blood and nerve supply.  But occasionally, employing the free nipple graft (completely removing it from its original site) is a better choice especially when treating inordinately large bust, although this approach has a higher risk of permanent numbness or reduced sensation in the areola.

Meanwhile, many cosmetic plastic surgeons do not recommend this procedure for women who are planning to get pregnant since it may affect their ability to breastfeed.

Breast Reduction for Men

Gynecomastia is a condition in which the male breasts become enlarged due to the excess tissue and fat.  To treat this aesthetic problem, many plastic surgeons prefer the use of excision technique which may be complemented with liposuction.

If gynecomastia surgery will include liposuction, most plastic surgeons perform this procedure first instead of the excision technique.  This is done by making several small incisions under the armpit or/and along the breast crease where they can insert a fat suctioning probe designed to destroy and dislodge the fatty tissues.

After removing the excess fats, the excision technique will follow. This is performed by creating an incision around the perimeter of the areola and another one that travels from the breast crease to the area above the nipple (using a diamond- or U-shaped incision pattern).  In this way, doctors can trim the excess skin and fats, manipulate the tissue, and reduce the size of an enlarge areola.

In general, plastic surgeons do not recommend surgery for pubescent boys with enlarged breasts since the condition may disappear on its own after their hormonal levels normalize.

For women who want to significantly increase their breast size, using saline or silicone implants is the most recommended technique in breast augmentation surgery.  But in this approach, they should remember that “bigger is not always the better” due to certain anatomical limitations.

For instance, petite women are usually discouraged to choose inordinately large implants because their limited tissue and skin may not be enough to support the weight of these synthetic implants and cover the shell, thus increasing the risk of breast ptosis (sagging) and visible wrinkling.

Using extremely large implants may also lead to more post-operative pain and discomfort, higher risk of developing back problems, and “heavy top look.” However, these potential complications may not be a concern for large-framed women who usually have more breast tissues and skin.

In the US, the saline- and silicone-filled implants are the only FDA-approved synthetic materials for breast augmentation surgery due to their high tissue compatibility rate and safety to a significant number of patients, although using these still involves risk of allergic reaction.  For this reason, plastic surgeons may recommend fat transfer as a substitute to the traditional technique.

In fat transfer, plastic surgeons collect fats to at least two sources such as the abdomen, thighs, upper arms, or any areas where fatty deposits are usually stored.  However, the safest amount which can be collected in a single treatment is not more than 200cc of fats, which is further reduced to 25 to 40cc after the purification method in which doctors separate and remove the blood, tissues, and other biomaterials.

Through a successful purification treatment, the collected fats will have a survivability rate between 65 to 85 percent which means that patients can expect a long-lasting result.   (See the picture below showing syringes with harvested fats.)

The primary advantage of fat transfer is that there is no risk of allergic reaction since no synthetic material is introduced in the body.

Despite the notable advantages of using a patient’s own fats, this technique is only ideal if the increase is not more than a “cup” size.  This means that women who want to significantly increase the size of their breasts may not achieve the result they are expecting.

Also, fat transfer is not ideal or even recommended for petite or thin patients because their fats are usually not enough to create a noticeable increase in their breast size.