A mother of 3 who is bothered by a delated appearance of her breasts after breast feeding. She was a D cup when breast feeding. She feels that her breasts are “flat” and not as full as before children. She wants to have a natural appearance after surgery. She is 5’ and 130 lbs and is shown before and again, 6 weeks after bilateral subglandular placement of 375 cc smooth round moderate profile saline implants through an inframammary incision.
Discussion: Her case is more complicated because she has early drooping of the breast with her nipples being located at to just below her breast fold. If the implant is placed below the muscle, the breast may fall off of the mound ( a “waterfall” effect) and look like a rock in a sock.) A breast lift could be performed but would add a visible scar around the areola. She has elected for a subglandular placement. With the implants above the muscle, the implants will drop with the breast and avoid the potential waterfall effect. This is one benefit of the subglandular approach. She is willing to accept the tradeoffs of a potentially higher rate of capsular contracture and the possibility of more visible ripples with time- her tissues are thick enough with a caliper test of 3.5 cm that this may not be a problem in her case.
She has also elected to have saline implants. Although they have a higher chance of having ripples it is easier to tell if they have leaked down the road without an ultrasound or an MRI.
A mother of 3 in her mid 30’s who is bothered by a deflated appearance of her breasts. Her nipples are each located 1 cm below her breast fold, which is the definition of ptosis or drooping of the breasts. When the nipple is below the breast fold it is generally best to add a mastopexy (breast lift). She is shown before and again, 11 months after augmentatioin mastopexy. 350 cc High profile round textured implants were placed in a “dual plane” location. An inverted T mastopexy was performed.
Explanation of choices made: I prefer round implants for breast augmentation-a recent study showed that trained plastic surgeons cannot tell the difference in photographs between properly sized round and shaped implants. And shaped implants can flip or turn. So round is our choice. When breasts are “loose” there is a tendency for the implants to drop more or slide to the side (lateral shift) with time. Texture may help to stabilize the result. So Texture was chosen. There can be problems with late seroma formation and pseudocapsule formation with more aggressive textures, so I prefer the less aggressive textures for my breast augmentation patients. It is important to “fill “ the breast but not overly stretch the breast. In a tight breast I prefer a moderate profile implant, but breasts that are looser after children (or weight loss) may need more volume to fill the upper breast. So a high profile implant was chosen here.
Implants can go above or below the muscle- below the muscle has the benefits of less capsular contracture, easier to do a mammogram, the breasts “age” better. But in a loose breast the breast can drop off the mound (“waterfall effect” and look unnatural. Implants can go above the muscle, so that they will drop with the breast. But they tend to stretch the breast more, make it more difficult to do a mammogram, have a higher risk of capsular contracture and less “padding” over the cleavage portion of the implant. A dual plane allows the edge of the pectoralis muscle to come up, so that the implant sits below the muscle in the upper breast , and sits below the breast in the lower breast- so that was chosen here.
Mastopexy skin patterns achieve different results. Because the nipple to breast fold distance on stretch was 10 cm in her case, a vertical mastopexy would not work as well and a horizontal component of skin is excised at the breast fold to shorten the distance- this gives an inverted T scar, sometimes called a “WISE” pattern after a physician who described it. Scars will typically continue to fade for another year, but she is already thrilled with her result.
A mother of 2 in her mid 50’s who describes herself as a 34 A cup but does not fill her bra. She feels that her breasts are too small for her body and does not feel feminine. She is a runner and is thin at 5’8” and 117 lb. She would like to regain some fullness in her upper breast but still look natural. An infra mammary incision was used. Texture was chosen to decrease the risk of lateral shifting of the implants with time, but we chose the Mentor texture which is the least aggressive of the three companies and may therefore have a lower risk of pseudo-capsule formation and late seroma.
Our patient is now shown 8 months after surgery. The texture has helped to stabilize the implants and prevent shifting of the implants to the side. This is demonstrated by viewing the implants with the patient in a supine position. Texture can be a benefit to decrease excessive shifting of the implants in patients who may be more at risk because of decreased elasticity that can come with age, pregnancies or weight loss.
A woman in her late 30’s who is 5’ 2” and 115 lbs and describes herself as a 34 A- AA cup and would like to be fuller, but still natural in appearance. She is shown before and 2 ½ years after bilateral partial subpectoral (below the muscle) breast augmentation with 325 cc smooth round moderate profile plus silicone gel implants placed through an infra mammary (at the breast fold) incision.
A 49 year-old mother of 1 who was up to 100 lbs heavier with her pregnancy. She is currently 5’2 and 122 lbs and is bothered by a deflated appearance of her breasts which she describes as a 34 padded A cup. She is shown before and 5 months after bilateral breast augmentation with 300 cc high profile textured silicone gel implants placed in a partial subpectoral position through and infra-mammary incision. She liked the 300 and the 325 cc implants when sizing in the office but still wished to have a natural appearance. The 325 cc implant was judged to be too large to appear natural at the time of surgery. She is thrilled with her result.
Texture was selected to decrease the risk of lateral shift of the implants with time. The mentor texture has the advantage of having the same “coefficient of friction” (a measure of the “grip” ) as the most aggressively textured “salt loss method” textures but with a potentially lower risk of late seroma formation.
Our patient had an abdominoplasty at the same time.
An athletic woman in her later 20’s who wanted a modest increase in size but did not want overly full breasts that might make her feel too heavy. She is 5’5” and 165 lbs and selected a 305 cc Sientra textured round moderate profile cohesive gel implant. At 10 ½ months after surgery her breasts have ‘softened” in appearance and look absolutely natural.
A mother of one in her late 30’s who has lost 90 lbs- her breasts have deflated and she “feels like a boy”. She wanted a fuller but still natural appearance, and wished to maintain some fullness in her upper breast. A highly cohesive round, textured silicone gel implant was placed through an infra-mammary incision in a dual plane position below the muscle. She is having great fun picking out new bathing suits and is thrilled with her result. The highly cohesive and textured implants take a little longer to “settle” but may maintain more fullness in the upper breast.
A mother of 2 in her late 50’s who wants to be fuller but still natural in appearance. She describes herself as a 34 A cup. She is 5’ and 114 lbs and is shown before and again, 4 ½ months after bilateral partial subpectoral (below the muscle) placement of 250 cc round smooth moderate profile plus silicone gel implants.
She is thrilled with her fuller but still natural appearance