A woman in her early 20’s who is a 38 DD cup and is bothered by back pain, shoulder pain, difficulty exercising even with 2 bras on, as well as problems with her posture when she is trying to sit up straight at her desk. She is 5’5” and 148 lbs and is shown before an again, 3 ½ months after a bilateral breast reduction with the removal of more than 500 gms of tissue from each breast. It is still early after her surgery as scars will typically get redder and thicker for the first 6 weeks and then will soften and improve over the next 2 years. She is thrilled with her new shape and size, and using topical silicone as recommended to help with the scarring. Her back and shoulder pain has resolved.
A woman in her 70’s who described herself as a 32 DD who is bothered by shoulder and neck pain from the weight of her breasts, as well as by the drooping appearance. She is shown before and again, 4 ½ months after an inferior pedicle short T scar reduction mastopexy with internal plication sutures. Scars will typically continue to fade and improve over the first two years or longer. She is already thrilled with her new shape and size ( small C cup) and her symptoms have resolved.
A mother of 4 in her later 40’s who wears a 32 G cup bra and has trouble with her posture, grooving and irritation of her shoulders from her bra straps, back pain and neck pain as well as difficulty exercising and a rash under her breasts in the warmer months. She is shown before and again, just 2 ½ months after bilateral short T scar breast reduction with more tissue being removed from her left than her right breast to balance the difference in size.
Although scars will typically improve over the next 2 years she is already settling well with the topical silicone and is thrilled that her pain is gone. The short T scar approach utilizes an inverted T scar but gathers the skin at the inner and outer aspect to that it does not show along the sides of the breasts with revealing clothing styles.
A mother in her later 50’s who was treated for bilateral ruptured silicone breast implants and bilateral nipple hypertrophy. She had had breast augmentation in the late 80’s by a plastic surgeon who had since retired. Her breasts had been hard since her surgery. She was also bothered by “long nipples” that were overly prominent in clothing and for which she would wear silicone nipple shields to hide them. The nipples were also very sensitive in the shower and in her clo6hing. I recommended an MRI to assess her implants which had been in place for 23 years, and it showed that bilateral subglandular silicones implants with intracapsular ruptured. Her original operative report was obtained and showed that she had 175 cc silicone gel implants. She wished to be a little fuller but still wanted a very natural look. She is petite at 5’2” and 115 lbs and is active at the gym, so did not want to appear unnatural in workout gear.
Sizing was performed in the office and she elected for a very modest increase in size to 250 cc moderate plus smooth round implants. Although there are benefits of placing the implant below the muscle, she did not want to worry about an animation deformity and elected to keep her implants in the subglandular space. She and family members have a history of easy bleeding and bruising and although a hematology workup was non-specific, I recommended against textured implants in her case which, although they may decrease the risk of capsular contracture in a subglandular position can have a potential problem with late bleeding and hematoma which I felt she was at more of a risk for.
She is shown before and again, 3 years after bilateral removal of her ruptured implants and creation of a new pocket below her breast capsule but above the muscle. A “top hat flap” nipple reduction was performed at the same time to reduce the projection and diameter or her nipples. She remains quite pleased with her new size. Her breasts have remained soft. And she no longer has nipple irritation in clothing or the shower, and no longer is embarrassed by excessive nipple projection.
A mother of one in her later 20’s who is bothered by inverted (retracted) nipples. Her right side was moderate and her left side severe according to the classification of Han and Hong. According to Han and Hong, mild or grade I retraction is where the nipple can be pulled out easily and maintains its projection without traction. Moderate or grade II is when the nipple can also be pulled out manually, although not as easily as with grade I and has difficulty maintaining its position with a tendency to retract. Severe inversion, or grade III the nipple is difficult to pull out manually. Nipple retraction is caused by short and retracted milk ducts. To correct this, these ducts are divided under local anesthesia with a special blade through a micro incision and held out to length temporarily with a traction suture while healing is taking place.
She had initial correction with the micro-incision technique under local anesthesia in the office. Although it is rare, she did not achieve satisfactory correction with the first procedure and continued to have some retraction. We returned when she was available for surgery 10 months later and she had a second micro-incision technique on each side. She is shown now at 6 weeks after this second procedure, and has maintained a normal nipple projection. She is happy to “feel normal” again and “confident” about the appearance of her breasts after correcton.
A woman in her early 50’w with a 3 week history of a spontaneous deflation of her left breast implant. He had saline implants originally 22 year before and had a deflation 17 ½ years ago. She was pleased with her size although she had some rippling of the implants which are sub-glandular. Her initial implants had been placed through an axillary incision. Her replacement had been performed through an inframammary incision. She had her implant cards and operative report and was noted to have Siltex (micro-textured) mentor saline implants 325-375 filled to 375cc. She has had a remarkably stable result over the intervening years and after discussions the decision was made to replace her implants with the same implant style and shape and size, through her inframammary incision and keep them in the same sub-glandular ( above the muscle) plane. The capsule of tissue that forms around the implant does shrink and contract after the implant has deflated and a temporary breast sizer was used at the time of surgery to check the space and perform a precise capsulotomy ( release of the contracted capsule) to accommodate the new implant. She is shown before and again, 2 ½ months after replacement. All implants will fail eventually. The advantage of a saline implant is that this rupture is not “silent”- it is easy to detect on exam. A silicone gel implant will require an MRI or an ultrasound to check its integrity. A good rule of thumb is that about 8% of all implants whether silicone gel, saline, or even the highly cohesive “gummy bear” have leaked by 10 years. We do not yet have a number for the Ideal Structured saline implant but so far at 7 years it has an even lower failure rate compared to the numbers of other breast implants at 7 years
A man in his early 20’s who has bilateral gynecomastia which started at the age of 16. He is right handed and muscular, with his right pectoralis muscle being larger and more prominent than his left. Arms up view demonstrates the prominent breast.
He was able to be treated with Power assisted liposuction using the S.A.F.E. technique ( Suction Aspiration Fat Equalization) with the removal of 550 of fat from each side of his chest. There was no palpable breast tissue present after the liposuction was completed so an excision of breast tissue through a peri-areolar incision was not needed. It is difficult to tell before surgery whether or not an excision of breast tissue will be needed so we typically plan for this and make the final decision in the operating room after the liposuction is complete. Liposuction will not remove breast tissue, so this is the advantage of being in the operating room rather than under local anesthesia in an office setting.
He is shown before and again, nearly 5 months after surgery. His pectoralis muscles are now able to be seen under the skin and he no longer has a feminine appearing chest. The S.A.F.E. technique uses a liposuction cannula with fins to mechanically break up the fat. This is used before suction is applied. Then the liposuction is performed with a traditional cannula. The fat cells are looser and easier to remove more precisely but any remaining fat is still viable. After liposuction is completed, then the fat is “equalized” again with the finned cannula to break up the remaining fat and move it around, giving a smoother final layer.
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.