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 50’s who is bothered by drooping and the size of her breasts. She described herself as a 34 DD-G cup before surgery and had probems with grooving and irritation of the shoulders, back pain, a rash under the breasts in the warmer months, and difficulty exercising due to the size of her breasts. She is a runner and wished to be closer to a middle C cup. She also felt that her breasts were out of proportion to her frame and was a size 6 in pants and a size 10-14 in tops She is shown before and again, 7 ½ months after bilateral breast reduction including liposuction of mild lipodystrophy in her anterior axilla that would show in an off the shoulder dress. She is 5’ 7 ½ “ and 157 lbs and had a superior pedicle/ Short T scar techinique with the removal of 421 gms of tissue from her left breast and 381 gms of tissue from her right breast, along with Power assisted liposuction of the anterior axilla using the S. A.F.E. technique. Her symptoms have resolved and she is thrilled to be able to run without her breasts getting in the way. Scars will typically continue to fade and improve for 2 years or more after surgery.
A mother of 3 in her mid 40’s who is bothered by the deflated look of her breasts after pregnancy and breast feeding. She would like to be fuller but still natural in appearance.
She is shown before and again, 6 weeks after augmentation/mastopexy. She is 5’3” and 111 lb and had 325 cc high profile cohesive silicone gel microtextured implants placed in a dual plane position through an inframammary incision (at the breast fold) combined with a periareolar mastopexy using a round-block Goretex suture.
Discussion: Her breasts are very atrophic (thinned) after her pregnancies and breast feeding. Her nipples prior to surgery are below the breast fold and so a mastopexy (lift) is needed. The distance from the bottom of her areola to the fold is not significantly increased however, it is 9 cm on stretch. So she is a candidate for a Vertical lift ( “lollipop scar”) which was our original plan. At the time of surgery, after placing her implants, I felt that we could accomplish her goals with a peri areolar Mastopexy (“circle lift” ). The peri areolar mastopexy is only possible in very few cases, because it does not give much of a lift and it flattens the breast. But in a case where the breasts are narrow / “pointy” as we have here, it improves the shape of the breast. In a breast that is already wider at the base it would tend to make the breast “boxy”. But in her case it was just right. This is also called a “concentric circle” mastopexy because a larger circle that reaches to the top of where we want the areola to go is drawn around a second circle that defines the new areola. A goretex suture that is permanent is used to prevent the areola from stretching out to the size of the larger circle. It “blocks” the areola from stretching out.
Although we could have placed her implants through the peri areolar incision and avoided the inframammary incision, her tissues are very thin, and I felt that is was safer to keep the space where her implant was placed separated from the incision around her nipple. This decreases the risk of the implant becoming exposed if the incision were to separate after surgery. It also avoids having to split the breast tissue which has breast ducts and bacteria, giving a higher risk of capsular contracture when the implant is placed through the peri areolar incision.
A high profile implant was used. In a tight breast it might appear overly “bulgy” on top, known as “superior pole convexity”. But in a loose breast that is deflated as we have here it is usually good to try and replace some of the lost volume with a higher profile implant. We are trying to “fill” the breast without overly stretching it.
A micro-textured implant was used. Smooth Implants tend to drop and fall off to the side with time, especially in a loose, stretchy breast. Texture may help to prevent this shifting of the implant. Texture can be controversial however because it could increase the risk of BIA-ALCL, which has only been reported in textured implants. It is felt to be an interaction of Biofilm when bacteria gets on the implant, with the texture. The risk of BIA-ALCL is very low however, is very treatable when recognized, and is more common in the aggressively textured implants. It is less common in the micro-textured implants, that have a less aggressive texture. So if we are going to use texture, I feel that the micro-texture is my choice, and of course we use our “14 steps” to avoid bacterial contamination of the implant.
The dimensions of the implant were carefully selected based on her tissue dimensions and confirmed by her in a bra with the Mentor sizing system in the office.
So, a lot of thought and planning to size the implant properly, pick the implant profile and texture and plan the surgical approach. There is no right or wrong way to do this surgery. But these are the tradeoffs that the patient and I together decided were best in her particular case.
This is an early result, and we can expect the breasts to settle and the scars to fade over the following months. But her case illustrates some of the tradeoffs that go into planning a mastopexy augmentation
A mother of one in her late 40’s who is bothered by a drooping appearance of her breasts as well as the size. She describes herself as a D cup and wished to be a C. She is shown before and again, 14 months after a mastopexy with the removal of around 200 gms of tissue from each breast to bring her down to a C cup, using a superior/medial pedicle and an short T scar technique.
A mother of 4 in her late 50’s who wears a 36D bra and is bothered by back and shoulder pain as well as feeling that her breasts are two big for her frame. She also has some fat deposition in her anterior axillary area. She is shown before and again, 4 ½ months after a superior medial pedicle breast reduction along with S.A.F.E. ( Suction Aspiration and fat equalization) liposuction of the axillary fat deposits (“axillary lipodystrophy”). We can expect her scars to continue to fade and improve for the next 20 months, but she is already thrilled with her new shape and size.
A mother of 3 in her early 40’s who has breast fed all 3 children and wants her breast to be fuller and less droopy- She still wishes to have a natural appearance and wants to look like her padded c cup bra that she wears now but without the padding. She is shown before and again, 7 months after a vertical mastopexy (“lollipop scar breast lift” ) and 350 cc round, textured, high profile silicone gel implants placed in a dual plane position. Texture was chosen to decrease shifting and dropping of the implants with time, but the implant company with the least aggressive texture (Mentor) was used to decrease the risk of possible problems seen with the more aggressive textures. “Dual plane” means that the implant is under the muscle above but just below the breast down below. This gives the benefits of a subglandular approach with the tendency of the implant to settle more with the breast but still giving the benefits of a subpectoral approach with better coverage of the implant above, lower risk of capsular contracture, easier to perform a mammogram, and better “aging” of the breasts. Her scars will typically continue to fade and improve for 2 years after surgery.
A 19 yo student who is shown before and again 18 months after a breast reduction using the short periareolar inferior pedicle reduction (SPAIR) technique. Her case is challenging because her areola is large and the typical “Wise” or anchor pattern would not allow us to get around the outside of her areolar without removing too much skin. The SPAIR technique I a perfect choice for her case, with the benefit of a shorter scar as well. This technique works best for smaller reductions in patients with excellent skin elasticity, because there is some “gathering” of the skin that has too be able to have enough elasticity to smooth out with time. She had 350 gm of tissue removed from her right and 200 from her left to correct her asymmetry.
A mother of 4 in her early 30’s who is bothered by a droopy and deflated appearance of her breasts after her pregnancies. She is a 36 B and was a DD when pregnant and liked the size. She would like to be lifted and fuller. Although she may have liked a DD size, eventually women will have problems with back pain and shoulder pain and she settled on a 36 full C to small D range. She is shown before and again, just 6 weeks after an inverted T mastopexy combined with a 450 cc round, textured, high profile, silicone gel implant. Texture was chosen to decrease the risk of shifting of her implants after surgery, especially given the decreased elasticity of her tissues after her pregnancies. She is now a 36 D and loves the size and shape. Scars are typically at their worst at 6 weeks and will continue to fade and improve over the next 2 years.
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 late 40’s. She is 5’3” and 152 lbs, having lost 20 lbs with diet and exercise. Her case is complicated by having a previous open gall bladder surgery. She also has an umbilical hernia.
She is thrilled with her early improvement, and is now able to feel comfortable in a 2 piece bathing suit for the first time in many years.