I see this situation ALL the time.  This may be:

1) Someone who comes in for an implant, but is droopy enough that I need to have a long talk about the possibility of a lift.  Or,

2) Someone who comes in for a lift, but may get the result they want via an implant without a lift.

There are two other possibilities as well:  absolutely needs a lift (with or without implant), and thinks they need a lift, but really just has a deflated upper pole, and who will do fine with an implant alone.

For example, the following lady has a concave upper pole, which is corrected after implants:

In this case, the upper pole (the portion of the breast above the nipple–if it were Earth, the Northern Hemisphere) is now fuller, and even convex.  This is to some degree modified by implant selection, which gets into personal preference.  And the nipple/areolas start a little bit in the lower pole of the breast, and so they end up in the lower pole of the breast.

 

Here is a similar case where the breast implant makes the upper pole relatively straight:

But I digress.  

The single biggest determinant of whether or not someone needs a lift is the position of the nipple relative to the inframammary fold.  (The fold, or the IMF, is the crease where the breast and the chest meet.)

So one thing you cannot always see on a picture is where the fold is!  So unless you examine the patient, it is somewhat hard to know what the situation was based on a picture.  Since the implant will sit at or above the fold, if the main portion of the breast tissue is below the fold, then an implant alone will not look right.

This lady has marked upper pole volume loss, and looks like she might need a lift, but she obviously did fine with “only” an implant.  While the breast are a little low on her frame, this is essentially where the breasts were just put, nd this is hard to modify.

On the other hand, this lady has enough tissue below the fold that we opted for a lift (also known as a mastopexy), in addition to an implant:

This results in a scar around the areola, down the front of the breast, and in the fold. 

So, for a final example, here is someone in whom I discussed the possibility of a lift, but who did fine without one.  You can see how the implant has filled out the lower pole–look at the near breast and the amount of skin you can see below the areola before and then after.

So I think we’ve covered a bit about the shape of the upper pole and the position of the nipple relative to the inframammary fold.  Other factors are volume of native breast tissue, skin quality, and implant volume.  And another idea you can get a flavor of from the above pictures (which is another topic!) is that the shape of the breasts before surgery influences the shape after surgery.

For more information on Breast Augmentation or Breast Lift, click on the links to my website.

And let me know if you have questions!