Breasts after major weight loss: mastopexy, reduction and scars

How to assess it in the mirror

I teach this to all my patients. Standing in front of the mirror, draw a horizontal line between the shoulder and the elbow, at the point where the upper two thirds of the arm meet the lower third. That's where the nipple-areola complex should sit. In consultation we go further: the nipple may be in place while the volume isn't. If the glandular tissue has dropped below the breast fold, we talk about ptosis, which can be skin, glandular or mixed. The technique depends on that.

Men too

It isn't only a women's issue. Men who had gynaecomastia when young and later gained and lost weight can be left with a sagging chest. And it often bothers them more, for a simple reason: men take their shirt off in social situations; women have a bra. If you're a man with this question, ask.

What a mastopexy is

Mastopexy means lifting: repositioning the breast tissue on the chest. Depending on the degree of ptosis and the distance from the sternal notch to the nipple, I choose the technique. It can be with implants, without implants or with an auto-augmentation, which uses part of the breast tissue itself to provide volume and position it higher, working the gland on one side and the skin on the other.

I want to be clear: I'm not against implants; I use them a lot. But there is a growing number of patients who don't want anything non-biological in their body, and for them there are alternatives.

The scars

There are three basic patterns: around the areola (periareolar), with a vertical extension down to the fold, and the one that continues along the breast fold (T or L). Today the techniques I use most are short-scar, L-shaped ones that don't reach the bra line and can be hidden, with or without implants.

A shorter scar doesn't automatically mean a better operation. Each surgeon proposes what they master best, and that deserves respect. What matters is balancing surgical possibilities, anatomy and what you're looking for.

Breast reduction

When the breast is very large and very droopy, we combine volume reduction and repositioning, and in that case implants are set aside: we use the patient's own tissue. Height also counts: in taller patients we reposition one way; in shorter patients with very large breasts, the reduction tends to be more decisive to achieve the proportion they want.

Deciding together, and what happens over time

I propose a balance between what your body tells us, what I think and what is aesthetically appropriate. In post-bariatric patients, tissue stability and shape influence which technique and implant they may or may not need.

Will the breast stay forever where we left it? The answer is called life: motherhood, weight changes, gravity and time. Some techniques are more stable than others, but surgery at 20 or at 40 may need a revision decades later, and that depends a lot on each patient's satisfaction in the mirror.

Post-bariatric and aesthetic surgery

I rely on international safety standards. There is no contraindication that says a post-bariatric patient cannot combine, for instance, liposculpture with an abdominoplasty. The key is selection: haemoglobin, haematocrit and protein at adequate levels, and a completed process. With that, we can do the same as with any other patient, with the usual complication rate described in the literature.

An implant isn't always needed. It can't always be avoided either. The goal isn't volume: it's proportion.