A mother of 3 in her mid 40’s who is bothered by the deflated look of her breasts after pregnancy and breast feeding. She would like to be fuller but still natural in appearance.
She is shown before and again, 6 weeks after augmentation/mastopexy. She is 5’3” and 111 lb and had 325 cc high profile cohesive silicone gel microtextured implants placed in a dual plane position through an inframammary incision (at the breast fold) combined with a periareolar mastopexy using a round-block Goretex suture.
Discussion: Her breasts are very atrophic (thinned) after her pregnancies and breast feeding. Her nipples prior to surgery are below the breast fold and so a mastopexy (lift) is needed. The distance from the bottom of her areola to the fold is not significantly increased however, it is 9 cm on stretch. So she is a candidate for a Vertical lift ( “lollipop scar”) which was our original plan. At the time of surgery, after placing her implants, I felt that we could accomplish her goals with a peri areolar Mastopexy (“circle lift” ). The peri areolar mastopexy is only possible in very few cases, because it does not give much of a lift and it flattens the breast. But in a case where the breasts are narrow / “pointy” as we have here, it improves the shape of the breast. In a breast that is already wider at the base it would tend to make the breast “boxy”. But in her case it was just right. This is also called a “concentric circle” mastopexy because a larger circle that reaches to the top of where we want the areola to go is drawn around a second circle that defines the new areola. A goretex suture that is permanent is used to prevent the areola from stretching out to the size of the larger circle. It “blocks” the areola from stretching out.
Although we could have placed her implants through the peri areolar incision and avoided the inframammary incision, her tissues are very thin, and I felt that is was safer to keep the space where her implant was placed separated from the incision around her nipple. This decreases the risk of the implant becoming exposed if the incision were to separate after surgery. It also avoids having to split the breast tissue which has breast ducts and bacteria, giving a higher risk of capsular contracture when the implant is placed through the peri areolar incision.
A high profile implant was used. In a tight breast it might appear overly “bulgy” on top, known as “superior pole convexity”. But in a loose breast that is deflated as we have here it is usually good to try and replace some of the lost volume with a higher profile implant. We are trying to “fill” the breast without overly stretching it.
A micro-textured implant was used. Smooth Implants tend to drop and fall off to the side with time, especially in a loose, stretchy breast. Texture may help to prevent this shifting of the implant. Texture can be controversial however because it could increase the risk of BIA-ALCL, which has only been reported in textured implants. It is felt to be an interaction of Biofilm when bacteria gets on the implant, with the texture. The risk of BIA-ALCL is very low however, is very treatable when recognized, and is more common in the aggressively textured implants. It is less common in the micro-textured implants, that have a less aggressive texture. So if we are going to use texture, I feel that the micro-texture is my choice, and of course we use our “14 steps” to avoid bacterial contamination of the implant.
The dimensions of the implant were carefully selected based on her tissue dimensions and confirmed by her in a bra with the Mentor sizing system in the office.
So, a lot of thought and planning to size the implant properly, pick the implant profile and texture and plan the surgical approach. There is no right or wrong way to do this surgery. But these are the tradeoffs that the patient and I together decided were best in her particular case.
This is an early result, and we can expect the breasts to settle and the scars to fade over the following months. But her case illustrates some of the tradeoffs that go into planning a mastopexy augmentation
A 3 year followup on a mother of 2 in her late 30’s. She wanted to be able to fill her swimsuit and bra without padding, but wanted to look natural. She also wanted to avoid an overly full “matronly” look. She is 5’5” and 144 lbs and has a 325 cc smooth round cohesive gel moderate profile plus implant placed through an inframammary incision below the pectoral muscle.
Discussion: She has had a nice result after surgery. I always tell my patients that the breasts are “sisters and not twins” . Her right breast is fuller and the nipple is lower, both before and after her surgery. In the photo she is seen to have a nipple piercing. She also had a tongue piercing prior to surgery. Both of these can increase the risk of capsular contracture if they are replaced after surgery. There is bacteria in the mouth and in the nipple area that can get into the blood stream with minor trauma and travel to the implant. It can attach to the implant (“biofilm”) and lead to a capsular contracture as the body tries to “fight” the bacteria. So I have recommended that she never put these piercings back. Her breasts have stayed soft. I also recommend that my breast implant patients take a single dose of antibiotics one hour before dental procedures, including a cleaning, for the same reason. Vaginal piercings can cause the same issue. This does not seem to be a problem with other piercings such as umbilicus (belly button) or the ear.
A mother of 2 in her early 40’s who is bothered by a deflated look of her breasts after pregnancy. She is 5’4” and 124 lbs and liked a 400 and a 375 cc implant in the office but wanted to look natural. At the time of surgery the 400 was tried and was simply too large for her frame so a 375 cc implant was chosen. She is shown before and again, 6 years after bilateral partial subpectoral placement of smooth, round, cohesive, high profile silicone gel implants placed through an inframammary incision.
A mother of 2 in her early 40’s who describes herself as a 34-36 A-B cup and would like to be a full b but still natural in appearance. Sh is 5’4: and 117 lbs. She was sized in the office using her tissue dimensions and liked a 275 cc implant. She is shown before and again, 2 years after bilateral subpectoral placement of a smooth, round 275 cc cohesive gel moderate profile plus implant placed through an inframammary incision.
A mother of 2 in her early 50’s who is bothered by a deflated appearance of her breasts after pregnancy, and is also bothered by inverted nipples. She wanted a full but still natural look and selected a 375 cc size. She is shown before and again, 6 weeks after bilateral partial sub-pectoral breast augmentation with a dual plane placement of 375 cc high profile textured silicone gel implants placed through an inframammary incision. High profile was chosen to restore some of her lost upper breast fullness. The pros and cons of texture were discussed and a textured implant with the least aggressive texture was chosen to decrease the potential lateral shifting of the implants with time. A Keller funnel was used to place her implants along with antibiotic irrigation and nipple shields to decrease her risk of biofilm contamination, subsequent capsular contracture and possible BIA-ALCL A micro-incision release of the inverted nipples was performed at the time of her breast augmentation. It has been just 6 weeks since her surgery and we can expect the breasts to “settle” and appear even more natural over the next 4-5 months.
An medical professional and mother of 1 who describes herself a s a 32 A cub. She was a C cup with her pregnancy and wanted to be a C cup again if possible. She did mind a slight implant look if needed to achieve her goals as long as she did not look overly unnatural. She has a mild pectus excavatum ( a depression of the sternum) She is shown before and again, 6 weeks after bilateral partial subpectoral breast augmentation with the placement of 350 cc high profile textured silicone gel implants using the milder texture.
Surgical planning: The width of her breast were 12.1cm on the right and 12.6 cm on her left. The nipple to inframammary fold distance on stretch is 8cm on her right and 7cm on her left. There is a mild laxity of her tissues from her previous pregnancy. The 350 cc high profile implant has a base width of 11.7 cm and this was the largest implant that would “fit” without requiring us to lower her inframammary fold and risk a double bubble or collapse of the fold and bottoming out. Texture was chosen to prevent medial migration of her implants over time into her pectus excavatum. Texture can be controversial because of it’s association with the rare condition of BIA-ALCL but seems to be less of a problem with the milder textures. It also is felt to be related to biofilm formation and we used the typical measures during surgery to avoid this: nipple shields/insertion sleeves ( “Keller funnel” ) as well as antibiotic irrigation. I also recommend that my breast implant patients take oral antibiotics just before dental cleaning or procedures to decrease the risk of bacteria from the mouth going through the blood stream and settling on the implant after surgery. In her case, after discussion she felt that the possible tradeoffs of texture were worth the benefits of better stability of the implants over time.
A woman in her early 30’s who wished to have fuller breasts. She described herself as wearing a padded B cup bra and wished to be a C cup without the padding. She had initially seen us two years previously and was not comfortable with the implant choices available at the time. She chose the Ideal breast implant once it was available, because it has a more natural feel than the traditional saline implant but without the risk of a “silent” rupture. It appealed to her to be able to follow her implants after surgery by simple observation rather than with ultrasound or MRI which is needed to detect the failure of a silicone gel implant.
She is 5’5” and 131 lbs and selected a 270 cc implant in the office. She is shown before and again, 6 weeks after partial subpectoral placement of 270 cc Ideal structured saline implants through an inframammary ( at the breast fold) incision. She is thrilled with her fuller but still natural appearance. The Ideal implants have two lumens and can be filled to give either a moderate or a full profile look. In this case the 270 is similar to a moderate profile standard saline implant in projection. It could also be filled to 305cc to give the equivalent of a high profile.
A woman in her mid 40’s who has lost 80 lbs and is bothered by a deflated appearance of her breasts. She has always wanted breast implants but was concerned about the possibility of a silent rupture with a silicone implant, but did not like the potential problems with rippling and wrinkling that can be seen with traditional saline implants. She wanted to be fuller but still natural in appearance, and wanted some volume back in the upper portion of her breasts. She was excited that the Ideal structured saline implants are now available and after careful sizing in the office based on her nipple to fold distance on stretch and the base width of her breasts we selected a 415 cc total volume Ideal breast implant. When it is filled to the full capacity it has the profile of a “high profile” silicone implant which is good for restoring some fullness to the upper breast. She is 5’5” and 134 lbs and is shown before and again, 6 weeks after bilateral “dual plane” placement of the Ideal breast implants through an inframammary incision
A mother of 3 who is bothered by a deflated appearance of her breasts and would like to have fuller breasts. She is 5’ 5” and 128 lbs. She is shown before and again, nearly 4 years after bilateral partial sub-pectoral placement of smooth round 350 cc moderate profile plus silicone gel implants through an infra mammary incision.
A mother of 3 who is now in early 50’s. She was bothered by a deflated look of her breasts after pregnancy and wished to be fuller but still natural in appearance. She is 5’6” and 167 lbs and is now 11 years after bilateral partial sub-pectoral breast augmentation with smooth round moderate profile 375 cc saline implants, She stopped by the office for a quick check and to see if she needed to “do anything” now that her implants are 11 years old. This is a question that comes up frequently. Breast implants in general have about an 8 % rupture rate in 10 years- that means that in 10 years, 8 patients out of 100 will have developed a leak. If she had silicone gel implants it would be reasonable to send her for an ultrasound or an MRI to see if the implants are intact- a “silent” rupture can occur with silicone implants and it may not be possible to tell if the implant is intact without one of these tests. With saline implants its much easier. If the implants are still there when you look in the mirror, then they are intact! So this is the big advantage of saline implants. If the implant leaks, the saline gets absorbed by the body and the implant shell goes flat. The breast “deflates” and it’s obvious. Not a panic situation but time to consider a replacement. But she is doing great, her breasts remain soft, and she can wait until she has a deflation. This could be 20 or more years. I have personally seen patients who are 30 years out from saline implants (before I started my practice) who still have intact implants. I generally recommend that my patients with Silicone gel implants get an ultrasound at 9 years after their surgery-a silent rupture doesn’t cause any immediate problems- there may be some slow thickening of the capsule of scar tissue around the implant over the years, but if it is failed it is better to know before the warranty has expired at 10 years.
This case also illustrates the importance of choosing the proper sized implant. An overly large implant is heavier and may cause more stretching of the tissues with time.