Sometimes there is just too much droop (ptosis) or extra skin to get the best result from a simple augmentation. If your nipple is positioned at or below the level of the crease under your breast (inframammary fold), there may be a lift (mastopexy) in your future. A lift will provide a more youthful shape, and is great for also helping to correct asymmetric breasts and those with large or unattractive areolas. The lift may be as simple as a crescent scar that travels across the top of the areola (best for just asymmetric nipple height), a lollypop scar, or even an anchor type incision. For some patients it may be better to stage the procedures with the lift first, and then the augmentation once healed.
While many people would like to avoid the lift part (because of scars, complexity of the surgery, or cost), if it needs to be done, it needs to be done. Patients with ptosis or excess skin that require a lift but who choose to forego it will likely be disappointed in their results. Because of the complexity of the combined surgery it does have a higher rate of revision (up to 1/3 in published data). Again, if you need it and choose not to do it, you can pretty much guarantee you will want a revision.