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.
A 39 year old woman who described herself as a 34B but wished to be a full C to D but still relatively natural in appearance. She was concerned about capsular contracture because of a friend who has breast augmentation elsewhere and wished to do everything to avoid this. She wanted to have some superior pole fullness as long as it would look relatively natural. After discussing the different implant choices she elected for an Ideal Structured Saline implant because she did not want to have to worry about a silent rupture. She is 5’5” and 137 lbs and elected for a 455 cc implant placed through an inframammary fold incision and below the pectoralis muscle.
She is shown before and again, 10 months after her surgery.
Details: We used the 405 cc Ideal Structured saline implant with the empty implant volume of 60 c. The inner lumen was filled to 235 cc and the outer lumen was filled to the maximum recommended volume of 160 cc to give a total volume of 455cc. ( “100% fill “) Because of the relatively large size of the implant that she selected, I reinforced her inframammary folds by anchoring her inframammary fold ligament to the rib periosteum at the time of surgery with a strong dissolvable suture to decrease the risk of “bottoming out”. This can be an issue with a larger implant when additional force is placed on the fold, causing it to “give way” and allow the implant to drop excessively. She is thrilled with her very full but still natural appearance, and her inframammary folds have been stable.
A more than 17 year follow-up on a woman who is now in her 40’s but had a breast augmentation with us at the age of 24 with saline implants. She had per-areolar incisions with partial sub-pectoral placement of 300-325 filled to 305 on her left and 325 on her right. She continues to do well and just stopped in for an implant check in our office. Her case illustrates 3 important concepts of breast augmentation.
First, pick the right size but don’t use an overly large implant. She is 5’2” and 117 lbs and has not had issues with too much stretching of her tissues because we did use too large of an implant for her tissues. 17 years later she still looks good.
Second: Don’t keep the nipple piercing in after surgery ( or a tongue or vaginal piercing) because they may increase the risk of capsular contracture by allowing bacteria that lives in the nipple ducts/ mouth or vagina to get into the blood stream and travel to the implant, leading to biofilm and a capsular contracture. Her breasts remain soft after 17 years.
Third: One huge benefit of saline implants is not having to worry about a silent rupture- the implant will go flat when it eventually leaks. So it is nice to be able to tell her that her implants are fine without getting an MRI or an ultrasound as would be need at this point to check on the integrity of a silicone gel implant.