A mother of 2 in her late 40’s who is bothered by a deflated appearance of her breasts after pregnancy. She describes herself as a 34 B cup and would like to be a C to CC cup. She is 5’2” and 132 lbs and is shown before and again 2 ½ years after bilateral partial sub-pectoral placement of 350 cc smooth round moderate profile plus cohesive silicone gel implant, placed in a dual plane position through an inframammary incision.
Discussion. She has a drooping appearance of the breasts but her nipple is still located above the breast fold. When part of the breast falls below the fold in this way it is called “pseudo-ptosis”. Pseudo means “false” and ptosis is a word for drooping so “false drooping” because the breasts look droopy but the nipple is still located above the breast fold. A dual plane approach releases the lower edge of the pectoralis muscle to allow it to ride up, so that the implant sits under the breast in the lower breast but under the muscle in the upper breast. This gives some of the benefits of being below the muscle (easier to do a mammogram, less capsular contracture, more padding over the implant) but also allows the implant to settle more with the breast which is an advantage of the sub-glandular approach (above the muscle). There is then less of a “waterfall” effect with the breast dropping off of the implant.
Breast Augmentation Revision/Ideal Implants – Patient 291
Breast Augmentation Revision/Ideal Implants – Patient 291
A mother of 3 in her early 30’s who had subglandular breast augmentation with saline implants 9 years before through a trans-axillary incision. She has had her 3 children since that time and would like her breasts to be fuller and more like they were before children. She is also bothered by visible and palpable wrinkles, especially in the cleavage area and upper breast when she leans forward. She is 5’5 and 127 lbs and wears a 32 cup bra.
She is shown before and again, 6 weeks after replacement of her saline implants with Ideal Structured Saline implants 370-415 filled to 415 cc total volume and placed in the original sub-glandular position though an inframammary incision.
Discussion: She already has some stretching of the lower part of her breast which is at 9.5 cm from the infra-mammary fold to the nipple. Her breast tissues are relatively thin with a caliper pinch of 2 cm. She had her implant card which showed Mentor moderate profile 275-300 cc implants filled to 300 cc. The base of this implant is 11.7 cm and it projects 4.3 cm She was sized in the office by adding Mentor sizing shells to her existing volume and she liked the addition of 125 cc but 150 cc started to look too full for her petite frame. In addition, the larger the implant, the more weight related stretching of the breast tissues so we elected for the 415 cc size Ideal structured saline implant, which is similar to a high profile silicone implant. In the case, the empty implant volume is 56 cc and the inner/back lumen is filled to 214 cc and the front/outer lumen is filled to 145 cc to give the total volume of 415 cc. This Ideal implant has a base of 11.7 when filled to 415 and has a projection of 5.3 cm. So is fits the space of her old implant but does not require any modification of the lower breast implant capsule- we can preserve the capsule to help support the new implant and help to protect her tissues from more stretching. She could have changed to a silicone gel implant to have less ripples and wrinkles but did not like the idea of a possible silent rupture- she liked being able to detect a leak with the saline implants on exam. She was changed to the Ideal structured saline implant and loves the new feel. She says that the wrinkles and ripples are nearly gone and do not feel like “a baggy filled with water” like her old implants. The higher profile gives a little more fullness in the upper breast.
A woman in her mid 60’s who is bothered by drooping and fullness of her breasts. She was a B cup when younger but now describes herself as a D-DD cup. She is over her ideal body weight with a weight of 184 lbs at 5’1” giving her a BMI of 34.8. She is shown before and again, nearly 9 months after a bilateral breast reduction mastopexy using a central/inferior pedicle . She is pleased with her new shape and size. Scars can be expected to continue to fade and improve over the first two years or more.
A woman in her early 50’s who has been troubled with macromastia for many years and describes herself as a 38G cup. She has had problems with back pain, shoulder pain, irritation and grooving of the shoulders, and a rash under the breasts in the warmer months. She is 5’2” and 190 lbs and is shown before and again, 4 months after a breast reduction using an inferior pedicle and an inverted T scar, with the removal of more than 2 lbs of tissue from each breast to reduce her to a full C cup. Scars will typically continue to fade and improve over the first 2 years after surgery. Her symptoms have resolved and she is thrilled with the new size and shape.
A nurse in her early 50’s who describes herself as a 38 HH cup and has had problems with back pain, shoulder pain, grooving and irritation of the shoulders, a rash under the breast in the warmer months and difficulty exercising due to the size of her breasts. She did not want to be too small after surgery. She is shown before and again, 1 year after a breast reduction extended to contour the lateral thorax, with the removal of more than 1100 gms of tissue from each breast. She is happy to be proportional now with a full C cup, and her symptoms have all resolved. Scars will typically continue to fade and improve for the first two years.
A mother of 3 in her early 50’s who described herself as a 38 D cup bra and has had problems with upper back pain, shoulder grooving and irritation, shoulder pain, neck pain, a rash under the breast in the warmer months and difficulty exercising. She is 5’7” and 194 lbs. She felt that because of the size of her breast and symptoms she was feeling increasingly fatigued at the end of the day and had difficulty exercising.
She is shown before and again, 7 months after bilateral breast reduction with the removal of more than 750 gms of tissue from each breast. She is thrilled with her new shape and size. She is also thrilled to no longer have the symptoms and pain from the weight and size of her breasts. Her energy level is back to normal and her symptoms have all resolved.
A woman in her later 30’s who wishes to have fuller breasts. She has not had children or significant weight loss but does work out 2 hours a day at the gym and finds that her breasts have deflated in appearance. She is 5’6” and 133 lbs and describes herself as a 34 A to small B cup. Based on her tissue dimensions she was sized in the office and felt that a 400 cc implant was too large but liked the 350-375 cc size in clothing, using the Mentor sizing system.
After discussions she elected for a Mentor 375 cc high profile micro-textured implant placed through an inframammary incision in a partial sub-pectoral position. She is shown before and again, 5 months after surgery. She is thrilled with the fuller but still natural appearance of her breasts after surgery.
Discussion: A high profile was chosen to try and add some fullness to the deflated upper breast. Breast implants tend to shift to the side and to drop with time. This is more of a problem in “looser” breasts after weight loss or pregnancy. Texture can decrease the risk of this shifting. But texture can also increase the risk of Breast-implant associated ALCL, a kind of lymphoma that can start in a late fluid collection (seroma) around an implant and is felt to be related to Biofilm around an implant. Although rare, it has only been reported after the use of textured implants. It is more common in aggressively textured implants. When we chose to use texture I prefer the micro-textured implants such as the Mentor, which gives us the benefits without as many risks. In our patient’s case, after discussing the tradeoffs, she felt that the greater stability of the implant was worth the small increased risk of BIA-ALCL that is seen with texture.
Update: Our patient is now seen close to 2 years after breast augmentation. The micro-textured implants have remained stable and have not shifted as we might expect to have seen with smooth implants.
A woman in her mid 40’s who has lost 70 lb with diet and exercise and would like her breast to be fuller. She described herself as a 34B cup and wanted to be a C to full C cup. She was fearful of silicone and silent rupture and wanted saline implants. She is 5’6” and 134 lbs. Sizing was performed in the office based on her tissue dimensions and using the Mentor sizing shell system. She liked an implant size around 400 in clothing and felt that 450 was too big.
She is shown before and again, 9 months after bilateral partial subpectoral (below the muscle) placement of Ideal Structured Saline 370-415 cc implant filled to 415 ( the equivalent of a high profile implant) placed through an inframammary incision ( at the breast fold). She is thrilled by the fuller but still natural appearance of her breasts.
Tattoos have been blurred for her privacy. The photos are otherwise untouched.
A woman in her late 60’s who describes herself as a 42DD- DDD cup and is bothered by the size of her breasts. She is 4’10” and 150 lbs. She is also bothered by the severe drooping of her breasts. They feel “heavy” to her and cause back pain. She is shown before and again, 1 year after bilateral reduction mastopexy with the removal of more than 3 lbs of breast tissue. The techniques that we use with patients who have severe drooping of the breasts after weight loss were used with internal suturing and shaping of the remaining breast tissue to give a better breast shape and decrease drooping after surgery. She is thrilled to be a C cup now and has maintained an excellent breast shape despite the decreased elasticity of her skin.
A mother of 3 in her early 40’s who had a right breast saline implant deflation. She had had breast augmentation 10 years earlier in another state and noticed that her right breast deflated shortly after a recent mammogram. They were subpectoral and placed originally through an inframammary incision ( at the breast fold). She obtained her old records and had Mentor 300-325 cc implants filled to 325cc. She liked the fact that she could tell when the implant failed without an MRI, but was bothered by the ripples and “baggy filled with water” sensation when she touched her saline implants. She elected to have both implants replaced with the 335 cc Ideal Structured Saline implant. The posterior chamber was filled to 188cc, the anterior chamber to 95 cc and with the empty implant volume of 52 cc this gives her a total volume of 335 cc. They were replaced through the original inframammary incision. She is shown just before and again, 6 weeks after surgery. She likes the feel of the Ideal implants much better, which do not feel “like a baggy filled with water” and do not have the ripples on the sides.
Discussion: The Ideal structured saline implants are not the exact size of the mentor implants. The 300 cc mentor implant filled to 325 cc is 12.1 cm wide at the base and projects 4.3 cm. The Ideal Structured saline implant is 335-375 and filled to 335 has a base of 11.4 cm and a projection of 4.5 cm. The base measurements are not identical because the Ideal implant is curved at the base to sit on the curved chest wall and not flat on the base like the Mentor implant. This seemed to the the closest match in dimensions. She did not want to be significantly larger.
Her right nipple is lower than the left. It is not enough of a difference though to justify the scar of a mastopexy (breast lift) around the nipple. I typically wait until there is a least a 2.5 cm difference before a mastopexy is recommended. We tell women that breast are “sisters and not twins” and typically are not identical in appearance. No implants last forever and the typical statistics suggest that 8% of all breast implants have leaked by 10 years. This is true for the cohesive silicone implants, “gummy bear” implants and saline implants. The Ideal implants do not have 10 year numbers yet. But their 7 year numbers are actually better than the other implants at 7 years so we will have to wait and see if this holds true at 10 years as well.