A woman in her late 20’s who had been thinking about breast augmentation since she was 18. She feels that she is tall at 5’8” and 147 lbs. and has full hips and wanted to have fuller breasts that were more proportional to her frame, but still natural in appearance. She is a 34 B cup bra before surgery and a full C after. She is shown before and again, 8 weeks after bilateral partial subpectoral breast augmentation with the placement of Sientra, 5 th generation silicone cohesive gel round smooth high profile implants placed in a partial subpectoral position through an inframammary incision. Her Inframammary fold was reinforced at the time of surgery by anchoring it to the rib periosteum with long lasting absorbable sutures.
Discussion: After careful sizing and measurements in the office she has a base width of 12.2cm on her left and 12.4cm on her right. Her nipple to Inframammary fold distance on stretch (to simulation the weight of the implant) is 8 cm on her right and 8.5 cm on her left. She liked a volume of 385 cc in her Bra. The Sientra 385 HSC implant has a base width of 12.3 cm and a projection of 4.9 cm. So the base width is just under the diameter on her left and just over on her right. In my experience it is possible to go just slightly wider than the base of the breast as shown here without giving an overly round “implant” look. The ideal IMF-Nipple distance for a 12 cm base implant is typically suggested as 8 cm so the base width of the implant is perhaps 2 mm wider than ideal given this distance on her right. To decrease the risk of the fold “’giving way” and “bottoming out” it was reinforced at the time of surgery.
At 8 weeks she already has a natural appearance which should appear even more natural over the next few months as the breasts gently stretch to accommodate the new implants. In the side views we will notice that early on she has mild fullness of the right breast upper pole which is expected now that we know the IMF to fold distance on stretch before surgery of 8 cm, and no upper pole fullness on the left which had the IMF to fold distance on stretch of 8.5 cm.
A mother of 4 in her early 50’s who is bothered by a deflated appearance of her breasts after pregnancy. She is 5’ ½” and 112 lbs and is shown before and again, 6 weeks after subglandular placement of Sientra Opus smooth round high profile 280 cc cohesive silicone gel implants placed through an inframammary incision.
Discussion: She has early breast ptosis but because of her petite size the implants were enough to fill up the breasts and correct the drooping appearance. She is on the borderline of requiring a breast lift and the implants were placed in a subglandular space so that they will drop with the breasts and avoid a “waterfall” appearance that would be likely to happen in her case with a subpectoral placement which would have the breasts “falling off” of the breast implant. 6 weeks is still early and we can expect the breasts to drop and settle more over the next few months.
A woman in her early 30’s who is petite at 5’5 and 112 lbs. She has a very narrow breast width at 10.6 cm and a nipple to inframammary fold distance on stretch of 7.2 cm. She wanted to be fuller but still natural in appearance. She also has a mild pectus excavatum (depression of the chest bone) and an accessory nipple on her right. She is shown before and again, just 6 weeks after bilateral partial subpectoral placement of smooth round high profile Sientra Opus implant through inframammary incisions. The base width of this implant is 10.5 cm. A slightly larger implant was tried at the time of surgery and appeared unnatural. The breasts will typically continue to settle and appear even more natural over the next 3-4 months.
A mother of 2 in her mid 30’s who is bothered by a deflated appearance of her breasts after pregnancy. She described herself as a 34 A cup and wanted to be a B or C cup if possible, but still natural in appearance. She is 5’ 3 ½ inches in height and 119 lbs. She is shown before and again, 6 weeks after bilateral partial subpectoral placement of 270 cc Ideal Structured Saline implant filled to 270 cc and placed through an inframammary incision.
Discussion: She liked the idea of not having to worry about a silent rupture and chose the ideal structured saline implants. Her chest diameter at the IM fold is 29 inches which would place her in a 32 inch bra. (3 inches is added to this distance to get the bra band size). Her nipple to inframammary fold distance on stretch is 7.2 cm on her right and 8 cm on her lift. Her breast diameter is 11.3 cm. The dimensions of the Ideal 270-305 implant at 270 is 10.7 cm with a projection of 4.3 cm. Because the implant is shaped to fit on a curved surface such as the chest wall I would typically add 3 mm to the width to be equivalent with a “standard” implant. So 11 cm base equivalent is smaller than her existing base width so her breast does not have an overly round “implant” look and the nipple to fold distance of 11.2 accommodates an implant base of 11-11.1 without giving too much superior pole convexity or unnatural fullness of the upper breast. Tattoos have been blurred for her privacy.
A mother of 2 in her early 40’s who is bothered by a deflated appearance of her breasts after pregnancy. She described herself as a 34 A cup before surgery and wished to be a full B-C cup but still natural in appearance. She has breast ptosis, with her nipples being lower than her breast fold. She is shown before and again, 18 months after an augmentation mastopexy. She had Mentor high profile 325 cc silicone gel micro-textured implants placed in a dual plane position through an inframammary incision and combined with a periareolar round block mastopexy using a Gortex suture to prevent spreading of the areola.
Discussion: when the breasts are “loose” after pregnancy, a smooth implant is more likely to shift to the side. Although aggressive textures such as the Allergan texture have a higher association with Breast Implant associated anaplastic large cell lymphoma (BIA-ALCL) it is much less common in the less aggressively textured implants such as the Mentor and Sientra devices, and many surgeons feel that texture still has a place in decreasing the risk of implant shifting in carefully selected cases such as this. At 18 months, her implants have remained soft and stable and have not shifted laterally or inferiorly. She has maintained volume in her upper breasts.
A woman in her early 20’s who described herself as a 34 A cup and wanted to be a full C but still natural in appearance. She is 5’4” and 135 lbs. She is shown before and again, 5 months after bilateral partial subpectoral placement of 325 cc Sientra smooth round 5th generation cohesive silicone gel implants with a moderate plus profile, placed through an inframammary incision. I have recommended that she remove and not replace her nipple piercings to decrease her risk of capsular contracture. Nipple ducts have bacteria, and a piercing in this area may allow bacteria to enter the bloodstream and travel to the implant. I also recommend against oral or vaginal piercings after surgery for the same reason.
Update: Our patient is now seen 6 months after surgery. The breasts have settled and appear even more natural in appearance.
A mother of one in her early 30’s who is bothered by a deflated appearance of her breasts after breast feeding. She describes herself as a 36 B but wanted to be a full C. She is 5’4” and 158 lbs and is shown before and again, 4 ½ months after bilateral subglandular breast augmentation with Ideal Structured Saline implants filled to 410 cc.
Discussion: She has pseudoptosis with her nipples being located just at to above her breast fold. Caliper pinch of her breasts shows a thickness of 4.5 cm. A subglandular placement was chosen because she has enough breast tissue thickness to hide the implant and a subpectoral placement puts her more at risk for a “waterfall effect” with her somewhat loose breast falling off of the breast mound. With a subglandular placement, the implant drops with the breast, avoiding the potential for a waterfall effect. She has the Ideal 370-410 cc implant. The empty implant volume is 56 cc and the inner lumen is filled to 214 cc. The outer lumen is filled to 145 cc to give a total implant volume of 410 cc. This higher fill volume is similar in profile to a high profile silicone implant and gives a little more fill to the upper breast. She is pleased with the soft feel of the Ideal Implants which are nearly as soft to the touch as silicone implants. She is also happy to not have to worry about silent rupture.
An Asian woman in her early 20’s who wished to have fuller breasts. She described herself as a 32-34 A cup and wanted to be a C cup is possible but still natural in appearance.
She is shown before and again, 6 weeks after breast augmentation with 5 th generation smooth round cohesive silicone gel implants placed below the pectoralis muscle through an infra mammary ( at the breast fold) incision. Implants used were Sientra Opus 255 ml moderate profile cohesive silicone gel implants. She is petite at 5’3” and 116 lbs. This was the largest implant that would fit the dimensions of her breast and still maintain a natural appearance, without an overly round “implant” look. Her inframammary fold was reinforced at the time of her surgery by anchoring it to the rib periosteum with long lasting but dissolving sutures to prevent “bottoming out” and dropping of the breast fold.
Update: Our patient is now shown 7 months after surgery. Her breasts have settled and appear even more natural in appearance.
A woman in her early 20’s who described herself as a 34 A cup and wanted to be a full C cup if possible but still natural in appearance. She is 5’4” and 135 lbs. and is shown before and again, 6 weeks after bilateral partial subpectoral breast augmentation with the Sientra Opus 5 th generation cohesive gel round smooth moderate plus 325 cc implant placed through an inframammary incision (at the breast fold).
Discussion: Her breast width is 12.5 cm and the fold to nipple distance is just 5.5 cm but increases to 8 cm on manual stretch. The Sientra 325 moderate plus implant is 11.8 cm at the base. This fits within her measured base width so the breasts will not look overly round after augmentation. The nipple to fold distance on stretch of 8 cm would theoretically allow an implant base of up to 12 cm without being overly full on top. She is still at some risk of “bottoming out” if the inframammary fold ligament were to detach from the extra pressure of the implant so I reinforced the fold at the time of surgery with slowly dissolving but strong anchoring sutures. This allows us to use the largest possible implant that will fit her measurements without appearing unnatural. On close observation you may notice nipple piercings before surgery. I ask patients to remove these at the time of surgery and never replace them because I think it can increase the risk of capsular contracture. The nipple ducts, like the mouth and vagina have bacteria and a piercing in these areas may allow bacteria to enter the blood stream, travel to the implant and lead to bacterial contamination of the implant with biofilm and a subsequent capsular contracture. Piercings in other areas without bacteria such as the umbilicus, do not seem to have the same issue.
A mother of 1 in her early 30’s who is bothered by a deflated appearance of her breasts after pregnancy and breast feeding. She describes herself as a 36 B and would like to be a full C. She is 5’4” and 158 lbs and is shown before and again, 6 weeks after bilateral subglandular placement of Ideal Structured Saline implants 370 filled to “100%” fill of 410 cc.
Discussion: Our patient wanted a natural but fuller appearance and wanted to restore some volume to her upper breasts. Her breast width is 13.97 on her right and 14.3 on her her left. Her nipple to breast fold distance on stretch is 9 cm. The diameter of the Ideal Implant she selected and filled to 410 is 11.7 I usually add 3 mm to the base width of the Ideal because is it designed to sit on a curved surface. So 12 cm is less than her breast width, so it will not “look like an implant”. Her nipple to breast fold on stretch is 9cm. Any more and she may be a candidate for a lift. If her implants were placed below the muscle the implant would move separately from the breast and the breast which is slightly lax would have a tendency to drop off of the implant- this is sometimes called the “waterfall effect”. In a case like hers where the breast is lax, a subglandular placement allows the implant to move with the breast and settle with the breast, giving a more natural look. The tradeoff for a subglandular placement is a slightly higher risk of capsular contracture.
The 370 implant has an empty implant volume of 56 cc. The inner lumen is always filled to 214 cc. The outer lumen is filled to 145 cc, giving her a total implant volume of 410 cc. This gives a higher profile, which helps to add some volume back to her deflated upper breast.
Update: Our patient is now seen nearly 1 year after surgery. Her breasts have settled and appear even more natural in appearance. She remains thrilled with the improvement in shape and size.