In short
- 🔑 There are three different pictures, and they are not corrected the same way: true recurrence of ptosis, lower pole descent and waterfall deformity over an implant.
- Recurrence is the most frequent medium-term complication after a lift with implants: 5.2% in the meta-analysis with most cases (95% CI 3.1-7.8).
- In true recurrence the nipple has dropped again. In lower pole descent the nipple is still up and what has filled out is the part underneath.
- And how far the lower pole descends has been measured: the nipple-to-fold distance, shortened by 63% in theatre, went back to 88% of its original measurement over a follow-up of more than two years.
- Waterfall deformity is the gland slipping in front of and below an implant that has stayed high. In primary augmentations it appeared in 7% of cases, and previous ptosis was a risk factor (15%).
- ⚠️ A second lift is not repeating the first. The literature describes combining an implant with skin reduction as surgery of opposing forces.
- 🔴 And there is a condition before any decision: waiting. Nothing is reconsidered in the heat of the moment.
It is one of the most frustrating consultations there is, and it usually arrives with the same sentence: “I had surgery years ago and it is back to how it started”.
It is almost never true that it is back to how it started, and that difference matters: under “they have dropped again” hide three different pictures, with different causes and different solutions. This page separates them.
⚠️ This page is about what happens to a breast over time, not about what anyone did wrong. Recurrence of ptosis appears among the described complications of the procedure: it is a known possibility, not necessarily a mistake.
The three pictures
Before talking about operating you have to know what has happened, because the three things look alike in the mirror and are not the same.
1. True recurrence of ptosis
The nipple-areola complex has descended again below the inframammary fold. It is ptosis exactly as defined, all over again.
It is the most frequent late complication: in the meta-analysis of 23 studies and 4,856 cases of single-stage lift with augmentation, recurrence of ptosis was the most common complication, at 5.2% (95% CI 3.1-7.8), ahead of poor healing (3.7%) and capsular contracture (3.0%).
Why it happens: because surgery repositions but it does not stop the ageing of the skin, gravity, weight changes or later pregnancies.
2. Lower pole descent
The nipple is still where it was put, but the lower part of the breast has gradually filled out and dropped below it. In surgery it is called bottoming out, and it is what technically corresponds to pseudoptosis: the nipple above or level with the fold, with the breast dropping below it and a nipple-to-fold distance often greater than 6 centimetres.
And it has been quantified. In a follow-up of 40 women over a mean of 110 weeks — a little over two years — after a short-scar lift:
| Measurement | What happened |
|---|---|
| Sternal notch-to-nipple distance | Fell by 22% with surgery and remained stable |
| Nipple-to-inframammary fold distance | Shortened by 63% in theatre, went back to 88% of its original measurement |
🔑 Read it slowly, because it demolishes “everything has dropped again”: the nipple stayed where it was put. What gave way was the lower pole. They are different problems and the second is corrected in a different way.
In another series of 70 patients with a mean follow-up of 23 months, this descent was recorded in 12.8% of breasts.
3. Waterfall deformity (over an implant)
It only happens if you have an implant. The gland slips forwards and downwards over the implant, which stays in place or even high. The result is two contours: the implant above and the breast below, like a waterfall.
In a series of 200 primary augmentations with silicone implants and a minimum follow-up of 12 months, double breast contour appeared in 7% of cases — all of this type — with 6.5% minor forms and 0.5% major forms. The risk factors identified were previous breast ptosis, submuscular placement and high malposition of the implant: with previous ptosis the rate rose to 15%.
⚠️ And one figure to gauge how much it really bothers people: satisfaction in the group with double contour was 85.7%, against 91.9% overall. It fell, but it did not collapse.
Why an implant makes it less stable
If your lift included an implant, there is a structural reason behind what has happened, and it is well described in the literature.
A review of secondary augmentation-mastopexy puts it like this: increasing the volume of the breast while simultaneously reducing its skin envelope amounts to surgery of opposing forces.
Translated: the implant pushes outwards and, over time, downwards. The skin, which has been reduced and tightened to hold it, has to take more weight with less surface. It is an intrinsically less stable combination than a lift without added volume.
And the figures bear it out: in the meta-analysis of lift with augmentation, overall reoperation was 10.7% (95% CI 6.7-15.4), and total complications 13.1%.
⚠️ This does not mean that a lift with implants is a bad operation. It means its durability is not the same and that it is worth knowing beforehand, not after. The decision whether or not to add volume is on the guide to breast lift without implants.
Can it be done again?
Yes, and it is not rare. But it is worth saying precisely how it differs from the first.
What changes in a second operation:
- The tissue is not virgin. There is internal scarring, the blood supply has changed and the nipple’s pedicle may be compromised by the previous surgery. That shapes the technique and sometimes limits it.
- You need to know what was done the first time. The previous operation note is not a formality: it is the information that determines what can safely be done now. If you do not have it, ask the clinic where you had surgery.
- The cause governs the technique. Correcting a true recurrence, a dropped lower pole or a waterfall over an implant are three different operations.
- If there is an implant, it enters the equation. Exchanging it, changing its plane or removing it may be part of the solution or the whole of it.
What does NOT change: the general risks are still those of a mastopexy, and they are in breast lift risks.
🚨 And the condition beforehand: waiting. Nothing is reconsidered on a recently operated breast. The tissue has to mature and so does the scar, and that means months. A rushed revision operates on a result that was still changing.
How long to wait, specifically: a year since the previous surgery. Before that the tissue and the scar are still changing, and you would be operating on a result that is not yet the definitive one.
And if what has happened is lower pole descent — the breast has “spilled” underneath while the nipple is still in place — the manoeuvre that corrects it is a shortening of the lower pole: the distance between the nipple and the fold, which is what has lengthened, is taken in.
🔑 If you had surgery at another clinic, there are two things worth taking to the consultation:
- the reports from your surgery — which technique was used, which pedicle, what was resected;
- and above all, if you had implants, the implant card. Without it there is no knowing what model, what volume or what surface is inside, and that shapes the entire plan. If you have lost it, the clinic where you had surgery should keep it in your notes, and the manufacturer can identify the model from the batch number.
Before assuming another operation is needed
Three checks that sometimes change the conversation:
Has your weight changed? Breast volume follows body weight fairly predictably. A significant gain or loss since surgery explains much of the change. It is in empty, dropped breasts after weight loss.
Has there been a pregnancy or breastfeeding? They enlarge the breast again and afterwards it involutes once more. It is in breast surgery after pregnancy and breastfeeding.
How much time has passed? A result changing at ten years is not the same as at ten months, either clinically or in terms of what can be expected from a revision.
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Frequently asked questions
I had surgery years ago and my breasts have dropped again, can it be done again?
Yes, and it is not uncommon. The first thing is to determine which of the three pictures you have — true recurrence, lower pole descent or waterfall deformity — because each is corrected differently.
What is pseudoptosis or a breast dropping over the implant?
They are two different things. In pseudoptosis the nipple is still level with the fold or above it and what has dropped is the tissue below. Waterfall deformity only happens with an implant: the gland slips in front of and below an implant that has stayed high.
Is it common for them to drop again?
Recurrence of ptosis is the most frequent late complication after a lift with augmentation: 5.2% in the meta-analysis of 23 studies and 4,856 cases. Lower pole descent was recorded in 12.8% of breasts in another series.
Has everything dropped again?
Probably not. In a follow-up of more than two years, nipple height remained stable after falling 22% with surgery; what gave way was the lower pole, which went back to 88% of its original measurement. They are different things.
Is a second lift more complicated than the first?
It is different. The tissue has internal scarring, the blood supply has changed and the nipple’s pedicle may be affected by the previous surgery. That is why the previous operation note is a key piece.
Did it happen because I had implants?
The implant does not cause it, but it does make it more likely: the literature describes combining an implant with reduction of the skin envelope as surgery of opposing forces. And in primary augmentations, previous ptosis raised the double contour rate from 7% to 15%.
How long do I have to wait before considering a revision?
Nothing is reconsidered on a recently operated breast: the tissue and the scar have to mature, and that means months. The specific interval is set by your surgeon.
Sources
- Khavanin N, Jordan SW, Rambachan A, Kim JYS. A systematic review of single-stage augmentation-mastopexy. Plast Reconstr Surg. 2014;134:922-931. Systematic review of 23 studies and 4,856 cases of single-stage augmentation with mastopexy; the pooled total complication rate was 13.1% and the reoperation rate 10.7% (95% CI 6.7-15.4); the most frequent complication was recurrence of ptosis (5.2%; 95% CI 3.1-7.8), followed by poor healing (3.7%) and capsular contracture (3.0%). https://pubmed.ncbi.nlm.nih.gov/25347628/
- Hilewitz D, et al. Long-term Breast Shape Analysis After Short-scar Reduction Mammaplasty: A Critical View. Plast Reconstr Surg Glob Open. 2025. Forty women with a mean follow-up of 110.1 ± 65.58 weeks were measured before surgery, during it and at least a year afterwards; sternal notch-to-nipple and upper pole-to-nipple distances fell by 22% and 43% and remained stable; the nipple-to-inframammary fold distance, shortened intraoperatively by a mean of 63%, lengthened again to 88% of its preoperative measurements; no correlation was found between the long-term changes and reported satisfaction. https://pubmed.ncbi.nlm.nih.gov/39810903/
- Gümüş N. Outcomes and Complications of Mobile Inferior Pedicle Breast Reduction as a Modification of Inferior Pedicle. Aesthetic Plast Surg. 2026;50:3166-3175. Retrospective study of 70 patients with a mean follow-up of 23.37 months; the nipple sat at the breast apex in 87% of cases, the overall complication rate was 22.8% and lower pole descent was recorded in 12.8% of the breasts assessed. https://pubmed.ncbi.nlm.nih.gov/41495550/
- Médard de Chardon V, et al. Double breast contour in primary aesthetic breast augmentation: incidence, prevention and treatment. Ann Plast Surg. 2010;64:390-396. Analysis of 200 primary aesthetic breast augmentation patients with silicone gel implants and a minimum follow-up of 12 months, assessed with standardised photography and the Massiha classification; the incidence of double breast contour was 7%, all type I (waterfall deformity), with 6.5% minor forms and 0.5% major forms; the risk factors were preoperative breast ptosis, submuscular placement and high malposition of the implant, with a rate of 10.5% in submuscular augmentations and 15% in the presence of preoperative ptosis; satisfaction was 85.7% in the group with double contour against 91.9% overall. https://pubmed.ncbi.nlm.nih.gov/20224340/
- Spring MA, et al. Secondary augmentation-mastopexy: indications, preferred practices, and the treatment of complications. Aesthet Surg J. 2014;34:1018-1040. Review of the indications for secondary augmentation-mastopexy, the techniques for performing it safely, complementary procedures and the treatment of complications; the authors note that increasing the volume of the breast while simultaneously reducing its skin envelope amounts to surgery of opposing forces, and that growing demand has increased the popularity of these combined procedures and of their secondary or revision surgery. https://pubmed.ncbi.nlm.nih.gov/25168806/
- Martinez AA, Chung S. Breast Ptosis. StatPearls, NCBI Bookshelf, updated November 2023. Regnault classification according to the position of the nipple relative to the inframammary fold; it defines pseudoptosis as the configuration in which the nipple sits above or level with the fold, most of the breast lies clearly below it and the nipple-to-fold distance is often greater than 6 cm. https://www.ncbi.nlm.nih.gov/books/NBK567792/
- Toomey AE, Cape JD. Mastopexy (Breast Lift). StatPearls, NCBI Bookshelf, updated December 2024. Mastopexy repositions the nipple-areola complex while preserving breast volume; recurrence of ptosis features among the described complications of the procedure. https://www.ncbi.nlm.nih.gov/books/NBK610682/
Book your consultation
If you had surgery years ago and notice that your breasts have dropped again, the first thing is not to look for a surgeon: it is to understand which of the three pictures you have, because the solution is not the same. And there is one concrete thing you can prepare that is worth more than any amount of searching: getting hold of the operation note from your previous surgery.
With that note and an examination, the conversation stops being about what happened and becomes about what can be done.
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