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.
A man with recurrent gynecomastia. He first presented at age 38 when he was 5’7 1/4 and 169 lbs. and had gynecomastia treatment by myself with external ultrasound assisted, power assisted liposuction combined with the direct excision of breast tissue through a periareolar (around the lower areola) incision with the specimen of breast tissue weighing 63 gms on the left and 70 gms on the right. He did well after surgery, with a good result at 5 months.
He returned to see me two years later.
He continued to smoke Marijuana (which can lead to gynecomastia) and also gained 15 lbs. and developed recurrence of gynecomastia, with new development of some firm breast tissue in the lateral lower breasts. This was a little surprising and not common in my experience, especially with direct excision of the breast tissue under the areola at the initial surgery. We returned to the operating room and performed liposuction again, along with the direct excision of 49 gms of breast tissue from the right and 40 gms of breast tissue from the left. The new breast tissue was located more laterally and inferiorly in the breast this time.
He again did well. He is seen again, 5 years after this second procedure. He reports having one treatment of cool sculpting to his upper chest for a little more refinement. He has lost one pound since his second surgery, but has been spending more time at the gym. His case illustrates a few points. Recurrence of gynecomastia is uncommon, but can happen, and may be impacted by gaining weight and significant marijuana usage. I have other patients who have continued to use marijuana without recurrence of their gynecomastia, so a recurrence like this has been uncommon in my experience. Weight gain after surgery can certainly contribute as well.
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.
A woman in her early 50’s who describes herself as a 38DDD cup and has had problems with back pain, grooving and irritation of her shoulders, a rash under the breasts in the warmer months, postural difficulties and problems with exercising due to the size of her breasts. She is over her ideal body weight at 5’ tall and 193 lbs but has had difficulty loosing weight. She is shone before and again, just 4 ½ months after a bilateral short T scar inferior pedicle breast reduction with the removal of more than 600 gms from her right breast and more than 500 gms from her left breast to bring her down to a full C cup. Her symptoms have resolved and she is thrilled with her new shape and size. Scars will typically continue to fade and improve over the next 2 years.
A man in his mid 30’s who has had gynecomastia since middle school. He describes developing breasts at 11-212. He was smoking marijuana at that time, and continues to smoke marijuana on a regular basis. Marijuana use has been associated with gynecomastia development in some studies.
He is bothered by the appearance of his chest with his shirt off and also in fitted shirts. He has worn compression garments to hide the appearance of his chest.
He is shown before and again, just 6 weeks after bilateral gynecomastia treatment with A modified S.A.F.E. technique combined with a direct excision of breast tissue through an incision around the areola. External ultrasound is used to soften the fat before the finned cannula is used to mechanically disrupt the fat. Then liposuction is performed through an incision behind the pectoralis muscle and beneath the areolar. Remaining breast tissue is excised through the periareolar incision and then the fatty layer is mechanically smoothed with the finned cannula.
Scars are at their thickest and reddest at 6 weeks and will now begin to fade and improve over the next 1-2 years. He is already thrilled with his improvement and is looking forward to going the beach this summer and wearing fitted shirts.
A mother of 2 in her early 30’s who was a 34 DD cup before surgery and had problems with her posture due to the weight of her breasts. She was having increasing problems standing up straight, as well as back pain, shoulder pain, a rash under her breasts in the summer months, and grooving and irritation of her shoulders from her bra straps. She is shown before and again, 7 months after breast reduction with the removal of more than 400 gms of tissue from each breast, bringing her down to a 34 C cup. Scars will typically continue to fade and improve over the next 18 months. She is already thrilled with her new shape and size, and her symptoms have all resolved.
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 man in his early 30’s with gynecomastia. He first noted breast development at the age of 15-16. This bothers him with his shirt off and in fitted shirts. He wears additional shirts to camouflage the appearance of his chest. He does not have a history of marijuana or anabolic steroid usage. He has had endocrinology screening which is normal.
He is shown before and again, just 6 weeks after a modified S.A.F.E. technique using power assisted liposuction and external ultrasound assist, combined with a direct excision of breast tissue through an incision around his areola. The S.A.F.E. technique (Suction Aspiration Fat Equalization) uses a cannula with fins to mechanically loosen up the fat followed by power assisted liposuction to remove fat and then the finned cannula again to smooth or “Equalize” the remaining fat. In my hands this allows the most aggressive removal of fat with less chance of dimples and irregularities. I modify this technique by starting with external ultrasound to soften the fat. After the liposuction is performed I check the chest and if there is a distinct mass of breast tissue (as in his case) I excise this through an incision around the lower aspect of the areola. A gynecomastia vest is worn continuously for 6 weeks along with micro-pore tape. We have just removed his tape in the office. Although scars are typically the reddest and thickest at 6 weeks, he already has an excellent contour. He is thrilled to have a normal appearance of his chest again.
A 71 yo woman who describes herself as a 32 DD cup. She did not like the drooping of her breasts, and also felt that they were out of proportion to her frame and embarrassing in some clothing. She had shoulder and neck pain. She has had problems since she first developed breasts but has finally decided to do something about it. She is shown before and again, 7 months after bilateral breast reduction with an inferior pedicle/ short T scar technique. She is 5’2’ and 120 lbs and had just over 300 gms of breast tissue removed from each side to reduce her to a C cup.
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.