“Everything I do is about responding to the body as it changes over time, and to each patient’s changing needs,” observes plastic surgeon Dr. Cindy Wu, who specializes in breast and body surgery with Cynthia Gregg Face & Body Specialists in Cary. “Because, just as our bodies change as we grow and age, so does our relationship with our bodies change.”

Breast surgery in particular illustrates the kinds of changes—physical and psychological—that occur at different stages in a woman’s life. “For a young woman with small breasts,” notes Dr. Wu, “implants may serve to create a more balanced body. Years later, as her body ages and her life evolves, the implants may no longer suit her physiology or lifestyle. She may have had children that are now grown; her body has changed and so has she. And she will want her breasts adjusted to fit her.

“Although there are similar reasons women choose to alter their breasts,” says Dr. Wu, “the truth is that each patient has a different life story, a unique physiology. Surgery of this kind is incredibly personal, affecting how we feel internally and how we present ourselves to the world. And those things change over time; just as our bodies change over time.”

Health&Healing: How do breasts change as women age?

DR. WU: In two important ways. As breasts age, the elasticity of the skin and the connective ligaments in the breast declines. As with any other skin on the body, collagen degrades over time. In the breast, that results in sagging of the nipple position because the skin supporting the nipple is not as taut. The loss of elasticity will also cause the skin at the bottom of the breast to sag, creating skin-on-skin contact between the breast and upper abdomen, which can be quite uncomfortable.

The other major change in breasts as they age is a loss of volume in the upper part of the breast—especially in women who have breastfed or who have lost weight. That loss of volume is a major reason that women seek plastic surgery, and we can offer different options for restoring volume.

H&H: What are the options for breast augmentation?

DR. WU: One is, of course, implants which have historically been the primary choice. Now, however, we can also restore volume with fat grafting, which is an ideal choice for women who want a smaller increase in volume and a softer, more natural look. Again, where a woman is in her life, and how her body has changed over time will influence the choices made.

A patient who is a candidate for just an implant—without a breast lift—is generally younger, with no sagging of the nipple or breast tissue. However, a different option would work better for someone who maybe has a little bit of extra skin, maybe she’s had children, maybe she’s breastfed, or perhaps she’s had a cycle of significant weight gain and loss. Whatever the reason, if  skin elasticity has decreased, the woman is more likely to be a candidate for a breast lift—either just a breast lift or breast lift with implants.

The difference between the two is that if you have enough of your own breast volume and you want to keep that same volume, then we would just be looking at doing a breast lift for you. If you’re someone who wants to be bigger in breast volume and also has sagging, then we would do an implant with a lift.

Fat grafting is an alternative to implants for adding or restoring breast volume. And I am seeing more and more women request this option because of its benefits. They like that it’s their own tissue, and has a softer, natural look, and that the infection risk is lower. The fact that you get improvement in two areas of the body is another plus, since the fat is collected from liposuction of the abdomen, the flanks, or inner thighs.

There are downsides. Fat grafting requires more than one surgery and more time, because not 100 percent of the fat will survive when transferred the first time. So, we wait a minimum of three months before the second procedure to allow the swelling to go down and the fat to take up a new blood supply.

The patient’s goals are also a factor. With fat grafting, you can expect to have improvement in the shape of the upper part of your breast. However, it won’t produce more than half a cup size increase. So, if you’re looking for an increase of one to two cup sizes, I’ll recommend an implant instead.

H&H: Implants also presumably change over time. How long do they last and how might they change?

DR. WU: Breast implants come in two materials: either saline or silicone. In terms of longevity, they’re about the same—they’re not made to be lifetime devices—meaning that, at some point in your life you may want to switch them out for another pair.

Today’s implants are designed to last more than a decade, and, in many cases, breast implants can remain in good shape for 20 years or more.  Every patient is different, of course, and although the risk of rupture is low, it increases by about one percent each year. So, the older your implants are, the greater your risk of rupture or other complications.

Currently, what we’re recommending is that at around 10 or 12 years—possibly 15—women should have a discussion with a plastic surgeon about electively replacing their implants. And we recommend doing it before there’s a rupture or a capsular contracture, or before there is sagging. If done before there’s a problem, it’s a routine type of procedure. However, if there’s a rupture or capsular contracture, that surgery becomes a little bit more complex.

And, even if there are no problems, many women choose to remove rather than replace their implants.

H&H: Why might a woman want to remove her implants?

DR. WU: This relates to the fact that women’s bodies and lives change over time. Some women are in a very different stage of life than when they got their implants. They’re older and their kids are gone. The implants served their purpose when they were young. But now they’re older and more fit; maybe they’ve lost weight or have a different breast aesthetic. Or maybe they have health problems that they attribute to their implants. Whatever the reason, they’re feeling what I call “implant fatigue.”

They want to have their implants out—but removal typically involves a new breast to match where they are in their lives. We might, for example, do a lift at the same time. We might replace the volume with some fat transfer. And there are some who simply want the implants removed. So there are options. My job is to restore their breasts to a more natural aesthetic, one that’s aligned with their current, active lifestyle. And it’s important to remember that, for many women, a 20-year-old implant simply doesn’t fit her body. When you’re 30, you’re probably lighter than when you’re 50; people tend to gain weight over time, including growth in breast tissue. Weight gain, pregnancy, menopause—all those things can also increase your breast volume. It’s not the implant that’s getting larger, it’s the breast tissue around the implant that’s getting larger. As a result, a 50-year-old woman will find that her breasts are larger than she had intended them to be when she got implants at age 30. So, she will want them out because they’re too large.