Cardi B got on X Spaces last week and said the thing half my revision patients say in the exam room. “I’m not gonna lie, I want to get my titties done already.” Then: “For some reason, I’m very scared of getting my boobs done. I don’t know why.” Eighteen years with the implants, four kids since. “I’ve had these titties for a really long time and they’re sagging really bad.” Billboard ran the whole thing.
I will not diagnose a woman from an audio clip. I do not have to. What she described is the breast revision consult I have more than any other.
Here is what happens, in my words from the exam room.
What Four Kids Do to an Implant
“It really depends on what happens during pregnancy. If there are big changes in weight, the breasts also get much larger and the skin and tissues get stretched.”
“Once pregnancy and breastfeeding are done, the breast shrinks back in size and the skin somewhat retracts, but not always to the same extent as pre-pregnancy. That is where bottoming out, ptosis or sagginess, and rippling can happen. Those are the reasons for a revision.”
The implant did not change. Everything over it did.
Why the Implants Look High and the Breast Looks Low
“The level of droopiness determines whether the patient will require a lift or not. If the nipple areola complex is below the inframammary fold, then a full lift, anchor type incision, will be necessary. If the nipple areola complex is at or slightly above the inframammary fold, I will often recommend a circumareolar lift or donut lift. The ideal sternal notch to nipple areola distance is anywhere from 19 to 22 centimeters. Any number greater than that should consider some type of lift. If the lift is not performed during the augmentation and there is considerable sagging, then the implants will appear to be higher up, even though they are in the right place, and the nipple areola and breast tissue will hang over it.”
That last sentence is the one to reread. The implant is where I put it. The breast slid off it. Patients call that sagging; I call it the lift that was skipped, or the lift that pregnancy wrote into the plan later.
The Rule I Use, Not the Feeling
| Nipple position | What it usually means |
|---|---|
| Above the fold, sternal notch to nipple 19 to 22 cm | Swap or reposition the implant, donut lift at most |
| At or slightly above the fold | Donut (circumareolar) lift |
| Below the fold, or the distance runs past 22 cm | Full lift, anchor pattern |
“So when a patient comes in for a lift, usually they do need a full breast lift, unless the nipple areolar complex is above the inframammary fold, in which case we can offer a circumareolar, or donut, lift. Once we’ve identified that a lift is necessary, we ask the patient whether they want to stay the same size or slightly smaller, or if they want to be larger. Of course, if they want to be larger, we will need an implant or a fat transfer to the breast.”
“I generally don’t recommend a lollipop type lift because it has a high incidence of bottoming out. Nevertheless, it is a good procedure on very select patients.”
The longer version is in what nobody tells you about a breast lift.
Why I Put a Bra on the Inside
“In a breast augmentation, the mesh helps support the weight of the implants and creates a tight capsule, to prevent lateral and inferior displacement.”
“In a breast lift and a breast reduction, it actually helps reshape the breast tissue and support it, just like a push-up bra, to gain more upper pole fullness and avoid bottoming out and lateral displacement.”
“The mesh supports the tissues for a period of up to two years. As it dissolves, it leaves behind collagen deposits, so the support remains there even well after the mesh has gone.”
And on the rippling that shows up after the kids, when the tissue over the implant has thinned:
“It is important to also realize that there are risks involved with not using a mesh. These risks include rippling, implant palpability, and implant displacement.”
“One of the ways to make this better is to put some fat here, to make it thicker so that there is more between the skin and the actual implant. I inject it under the skin so it pumps that layer up and it gets thicker.”
The rest of the rippling story is in breast implant rippling.
The Expectation I Set Every Time
“I think a lot of patients are afraid of this surgery because they feel like they’re going to need the full anchor type incision. By offering the circumareolar, or donut, lift for patients whose nipple and areola are above the inframammary fold, this can be a game changer. Also, expectations need to be handled. A lot of patients having a breast lift with implants are expecting a lot of upper fullness and a very high implant placement, which is just not possible at the same time as a breast lift. A breast lift will always give a perkier look, more upper fullness, and cleavage, but it’s going to have usually a natural slope on top.”
Why the Fear Is Usually Misplaced
Cardi B has had two operations on her buttocks to remove injected polymers and says the breasts are the one thing that scare her. I get it. The first operation is the one you remember. A revision after kids is not a bigger operation than the first one. It is a more precise one, because I already know what your tissue did under load.
“If a patient just wants to have a breast lift, then they have to understand that they may be the same size or slightly smaller, maybe half a cup size to a cup size, because we are removing that excess skin. The breast will be perkier, but it’ll also be tighter, and it may appear smaller. Regardless of the combination of procedures we perform, I do recommend using an internal bra with mesh support, with GalaFLEX or DuraSorb, to give us that support of the breast weight, so that we’re not just relying on skin, which has lost all its elastin and is not reliable long term.”
“Should I Wait Until I’m Done Having Kids?”
This is the question under Cardi B’s story.
“Patient who wants augmentation before she is done having kids: go ahead. There are still going to be changes in the breast with or without implants. Surgery may be necessary after pregnancy even without implants, for a more cosmetic and aesthetic look.”
Pregnancy changes every breast, augmented or not. Waiting buys you nothing but years without the result you wanted. For the first-timer who wants the light version, the numbers are in the breast lift beat the implant at ISAPS. The surgical version of this post, with the options side by side, is on agulloplasticsurgery.com; the consultation version is on the Southwest Plastic Surgery post.
Why Choose Dr. Agullo
Dr. Agullo is certified by the American Board of Plastic Surgery and the American Board of Surgery, completed his plastic surgery fellowship at the Mayo Clinic, and serves as Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. He has been a Castle Connolly Top Doctor for thirteen consecutive years, 2014 through 2026. Breast revision, including fold repair with internal mesh support, lift with implant exchange and fat grafting over thin tissue, is a core part of his practice in El Paso.
Ready to Talk?
If your implants changed after the kids, bring the old photos and come in. The exam takes ten minutes and the plan is usually simpler than you fear.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful
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