**1. Rationale**

 The ability to correct both breast ptosis and deflation is a critical component in any successful cosmetic breast practice. In most offices, the percentage of patients desiring correction of both the aforementioned deformities is significant if not a majority. Multiple factors lead to both ptosis and deflation, including pregnancy and lactation, weight loss and congenital abnormalities, any of which can ultimately result in descent of the nipple-areola complex (NAC) below the inframammary crease. This is usually accompanied by some degree of reduction in breast volume, leading to the desire for "larger and perkier" breasts which is a common request from the affected patient population. The required manipulation of these multiple components, the breast skin envelope, glandular area and position, NAC position and size, inframammary fold position and chest wall anatomy is what makes this procedure technically and strategically challenging. However, mastery of this combination procedure will yield far more dramatic and esthetic results then either augmentation or mastopexy alone [1, 2]. The remainder of this chapter will be focused on helping the reader better understand both the obvious and subtle factors in performing this procedure in a reliable and predictable fashion with minimization of risks and complications. Simultaneous breast lift and augmentation carries a high litigation rate because the complication and revision rates are much higher than the majority of cosmetic surgeries. Trying to simultaneously adjust two breasts for a new submuscular implant pocket, new NAC position, new parenchyma arrangement, new infra-mammary fold (IMF) position, great symmetry, perfect amount of skin and fat removal, with great scars all while maintaining vascularity is

#### **Figure 1.**

*Simultaneous breast lift and augmentation is extremely gratifying when it works well but carries a high litigation rate because it is a very challenging procedure and risk are relatively high for complication. Removing and tightening skin at the same time one increases volume of the breast with an implant by its nature risk nipple-areola complex (NAC) necrosis.* 

no small task. But, by improving so many issues of the ptotic breast, potential positive changes and patient's happiness can be wonderful and rewarding (**Figure 1**).
