Q.  When I was in my 20’s, I had a breast augmentation with large implants. After the surgery, I was a DD cup bra. Now 15 years and 2 children later, I am 20 pounds heavier than I was in my 20’s and my cup size is an E cup and I am huge. I know I can replace my implants for smaller ones, but I am so worried about what my breasts will look like if I go smaller. Is there any way that I can downsize without looking saggy?

A.  Without examining your breasts, it would be impossible to give you a totally accurate answer. Every breast is different in terms of quality of skin elasticity and how much natural breast tissue that is present. I can give you some general information about what you can expect. Since your implants have been in for 15 years and you have had 2 pregnancies, there is little doubt that you have experienced some stretching of the breast skin. Therefore, when the large implants are removed, you will most likely experience relaxation of your breasts and this may result in some sagginess. That being said, mild sagginess of a breast is not a bad thing and will not detract from the aesthetics of the breast. Remember you are not in your 20’s anymore and there are natural and expected changes that take place in the female breast with age. One thing in your favor is that you wrote that you have put on some weight since your original augmentation and this weight change has certainly added some natural fullness to your breasts. This additional fullness of the breasts may protect them from being too saggy after removing or downsizing your implants. If you are worried about sagginess, and you do not mind having implants, then downsizing the implants is a good choice. In order to see a significant reduction, you probably need to go down about 50% in implant size. If you are more interested in just getting rid of the implants, that is an option as well, but you should be prepared that the breasts may look saggy. In some cases, the resulting sagginess is not as bad as you might think and frequently patients are OK with the appearance. In other cases, patients will not be satisfied with the new look of the breasts without implants and will desire a breast lift to correct the sagginess. In my practice, I do not recommend doing the removal of the implants and breast lift at the same procedure. I recommend removing the implants and waiting at least 6 months for the breasts to recover, then reassess as to what the best plan of action is. In many cases (more than 75% of the time in my experience), the patient will decide that the amount of sagginess in not nearly as bad as she was worried about and therefore decides not to do any further surgery. If, however, you are not happy with the results, then a breast lift can be planned as a second surgery. In my opinion, doing the breast lift after the implants have been out for a while allows for a much more accurate planning and execution of the breast lift. Certainly, there are plastic surgeons who will perform the removal and lift at the same surgery; however, I feel that in my hands I can get a better result staging the procedure. I urge you to visit your surgeon who did the surgery and discuss your situation.