Breast Augmentation

I specialize in doing tasteful and classic breast augmentations. My style is conservative; I don’t use overly projecting implants that look huge or “stuck on”.
My clientele prefers a natural yet beautiful appearance; enhancement rather than distortion is my preferred outcome.

Many women are self conscious about their disproportionately small breasts. Some have always been that way—genetics and a thin stature generally cannot be changed without some surgical help. Many acquire smaller and droopier breasts after breast feeding their children. Restoration of a fuller and perkier look is frequently the goal of women who have lost breast volume following weight loss as well. To view all of my before and after photos, click here to visit my gallery.

breast-aug This woman breast fed three children. She stated she was always small, but after breast feeding, everything “dried up” and her chest “caved in”. She wanted to look like a girl again, and especially wanted to fill out the periareolar spots that were indented.

breast-aug2 Her result at six week following subpectoral augmentation shows good correction of both volume loss and her areolar indentation.

There are many different ways to perform breast augmentation. Implants can be put in through a variety of incision locations.

breast-design

  • The most common incision location is inframammary, as this is the least visible long term and allows for implant removal and replacement at a later date.
  • While the periareolar incision used to be quite popular, new data shows up to a 33% incidence of long term numbness in the area. There is a slightly increased risk of infection as breast ducts containing bacteria are encountered using this approach.
  • Transaxillary incisions have lost popularity as there is a high incidence of late implant malposition. This incision is used with saline implant augmentation.
  • The periumbilical approach can only be used with saline implants. While the lack of a scar in the breast region sounds good, a significant scar at the belly button—more frequently exposed than the breast—can cause a permanent deformity.

Implants can be put in the subglandular position-just under the breast tissue—or in the subpectoral position.

submammaryor

Submammaryor subglandular placement

subpectoral

Subpectoral implant placement

With submammary implant placement, the implant is located under the breast tissue, with the pectoral muscle left undisturbed. When this approach is used, the top of the implant is more likely to be seen as a definite line or bulge. With time, the implant is likely to “ball up” and eventually may bottom out, leaving the top of the breast hollow. Capsular contracture, rippling, and implant migration are more common with this approach.

Subpectoral placement in a “dual plane”—top of the implant under the pectoral muscle, the lower outer aspect under the glandular tissue—has been the international standard for many years now. This location has been shown to reduce the risk of capsular contracture, to provide more soft tissue coverage so that implants last longer, and to provide a more natural upper pole appearance without a “hump”. A very important factor in my choice of using this approach is mammogram quality. When taking a mammogram, if the mammographer excludes the implant placed subpectorally the entirety of the breast can be imaged.
With subglandular placement, much of the breast tissue is not able to be imaged.

saline

Saline or gel? Many people still view saline as “safer” than gel implants, despite FDA approval of several brands of gel implants for use in breast augmentation.
The lifetime of a saline implant is generally quite a bit shorter than a cohesive gel implant’s. Most saline implants last about ten years; the new “gummy bear” type implants last 20-25 years, barring trauma. The gel implant on the left has less rippling than the saline on the right.

saline2

When viewed from the side, you can see that the saline implants tend to “bottom out”, with the volume gravitating downwards. This tendency leaves the upper pole hollow. Gel implants tend to retain more volume in the upper pole. They tend to migrate down and out into the armpit less than saline implants. Saline implants tend to deflate suddenly, causing an urgent need for repair. Cohesive gel implants do not suddenly lose volume. A significant injury would be needed to cause the gel to leak out of the shell. Because they last longer, hold a better shape, and need less replacement, I tend to use cohesive gel implants for most of my patients.

Textured gel breast implant, below

textured-gel

Smooth gel breast implant

smooth-gel

Textured or smooth implants? Textured implants were popular for a while as they were supposed to reduce the incidence of capsular contracture. However, my experience has been that contracture is actually more common with these implants. They feel a bit more firm than smooth implants, and don’t tend to shift naturally like smooth gel implants do. They are good for patients with recurrent migration. Otherwise, most of my patients prefer the smooth cohesive gel implants for a top long term result.


Question: “I went to another doctor who only uses high profile implants. Why won’t you put in implants with a high profile?”

Answer: See the patient below. She went to a doctor who “only” uses high profile implants. Her outcome was not satisfactory. Because the high profile implants have a very narrow base and a lot of projection, using them is like stuffing a grapefruit into a breast. The shape is all wrong. There is an upper hump and no lower pole fullness. The look is very unnatural.


hump-breast

Patient (not my surgery) with a high profile implant

My “rules” of breast augmentation:

    • The ideal proportion of a breast is 40% of the volume above the nipple; 60% below the nipple
    • The nipples should point forward, not up nor down.
    • There should be a pretty round curve of the lower breast with a well-defined inframammary crease.
    • The upper pole of the breast should be full, without a defined ridge or “hump”.
    • The entire breast should be filled out without a flat spot on top nor a big gap between the breasts.
    • The décolleté should have a gentle swell, not a flat spot, then a bump.
    • The key to a good outcome is using the broadest implant that fits each individual’s frame. I use smooth round moderate implants for most of my patients. As you can see, this does not result in a flat silhouette. The higher profile implants tend to have a base that is too narrow to give the desired contour.
    • Never go too large. Big implants make people look fat, matronly, or trashy. I recommend thinking about this as a lifetime choice; classy and tasteful will last much longer than a dramatic overstatement!

breast-befor-after img-shadow

This patient’s before (left) and after results (right) show all of my criteria for a good breast augmentation outcome, numbers 1 through 8.

There are risks with any surgery, such as bleeding, infection, contracture, migration, or implant failure with age or trauma. While complications are rare, the best outcome occurs when we take a “team” approach. I can do the surgery, but the postoperative care and activity restriction can only be done by the person who has had the surgery. Minimizing activity following surgery in order to allow time for healing to optimize is very important. Each patient must tune in and follow the guidelines in order to protect her investment.