BREAST ENLARGEMENT

Breast Augmentation: seeking natural-appearing results

Having practiced plastic surgery in the 'breast augmentation capital of the world' (Los Angeles), I have developed some fairly strong opinions about this operation. In thinking about breast augmentation surgery, I believe that the most important question for a prospective patient to ask themselves is this: Am I seeking a natural-appearing result? When the goal of this operation is a natural breast enhancement, the results can be absolutely beautiful.

However, if the goal is to create a breast profile which is out of proportion to a woman's body, the results (by definition) never appear natural, and these patients not infrequently end up having a series of operations to address problems with their abnormal appearance. For that reason, I encourage women who are investigating breast augmentation to consider an implant size that will help them 'fill out clothes better' and improve the overall proportions of their body, not one that makes them look like "the gal with the boob job".

Quite a number of my breast augmentation patients are moms. After one or more pregnancies, most women experience a loss of breast volume combined with some 'stretching out' of the breast skin. In many of these patients, an implant of moderate size will restore a very pleasing breast contour. These patients are NOT looking to raise eyebrows at work or around the neighborhood - they just want to throw their padded bras away, and to feel better about their appearance in private.

When there is laxity of the breast skin that makes the breasts appear somewhat droopy, the addition of an implant of moderate size can 'fill up' the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or 'mastopexy'). This is often a situation that exists after pregnancy and lactation, but I also see quite a number of patients with significant breast skin laxity who have never been pregnant. In patients with more advanced drooping of the breasts, particularly when the nipples are pointing downwards instead of slightly upwards, a mastopexy (breast lift) needs to be combined with the augmentation surgery to tighten the skin envelope of the breasts, in order to produce a result that is truly youthful and aesthetically ideal. This procedure is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming. It is discussed in greater detail as the next topic under the heading 'Body Contouring Surgery'.


Attention to detail

While the issue of 'over' or 'under' the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall. In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.

In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear 'bottomed out', with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast - another situation with a distinctly unnatural appearance.

The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Excessive lateral dissection of the implant pockets will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal 'side by side' appearance. As it is lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an 'hourglass figure', careful attention must be paid to ensure that lateral breast projection is not inadequate.

Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient that is 5'3" will be inadequate for a large-framed patient that is 5'10". Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.


Choosing the implant size

In consultations I listen carefully to each patient to ensure that I clearly understand their goals for breast augmentation surgery. Based on that discussion, and on the physical examination, I go into surgery knowing what the ideal volume should be within two or three implant sizes. However, the patient and I do not decide on one particular size prior to surgery. There is absolutely no way, in my opinion, to know exactly what size implant is the ideal size for a particular patient in advance of creating the implant pockets in the operating room. For that reason I keep a wide range of implant sizes on hand in the surgery center.

If natural is the goal, then the way to get the size right is to 'try out' different implant volumes in the operating room. Once the implant pockets have been created, I place a 'sizer' in one implant pocket and have the upper half of the O.R. table raised so that the patient is in an upright 'sitting' position (chest fully upright). The sizer is then inflated gradually to the point that the breasts appear full, but not unnaturally so. In this manner the exact volume that produces a full but natural breast profile is determined.

For any patient there is obviously a range of implant volumes that would be considered natural. While one patient may seek an augmentation that is 'the small side of natural', another may be interested in something that is more on 'the large side of natural'. By using implant sizers to determine exactly what breast profile a given implant volume produces in the O.R., I am able to provide patients with the closest possible approximation of their preoperative goals.


Incisions and implant position relative to the pectoralis major

Breast implants can be placed through different incisions and in different positions relative to the pectoralis major muscle. No two patients are alike, so it is important to individualize the surgical plan for each patient's own needs. The most commonly used incisions are peri-areolar (from about the 4 to 8 o'clock position along the areolar border), infra-mammary (in the fold below the breast) and axillary (underarm area).

An advantage of the peri-areolar incision is that the color difference between areolar skin and the adjacent breast skin conceals the resulting scar very nicely. In many patients the scar is almost undetectable after only a few weeks. The infra-mammary scar works very nicely for patients who do not have a marked color difference between areolar skin and breast skin, and who have adequate fullness in the lower pole of the breasts. As full breasts conceal the infra-mammary fold very well, the scar is never visible when standing or sitting upright. The axillary or underarm area incision is primarily used for sub-pectoral ('under the muscle') implant placement, particularly in patients with small areolae (where the peri-areolar incision is not ideal) and smaller breasts (where the inframammary fold is not concealed).

The decision to place breast implants 'on top of' or 'under' the muscle is individualized to the specific needs of each patient. I think that the term "under the muscle" is a bit misleading for the following reason: when implants are placed below the pectoralis major muscle only about half of the implant surface is actually beneath the muscle - the medial/upper half - while the lateral/inferior half is immediately below the breast. Sub-pectoral placement is advantageous in patients who are slender and very small-breasted preoperatively, as the pectoralis muscle helps to conceal the implant in the most important place aesthetically: the cleavage area. In other patients, sub-muscular placement affords no significant advantage, and sub-mammary (on top of the pectoralis major muscle) placement is preferable.

Again, the decisions regarding the surgical incision and the placement of implants relative to the pectoralis major muscle are completely individualized, as no single approach is the best approach for every patient. The decisions are based upon physical examination at the time of the physician consultation, and on discussion with each patient of the 'pros and cons' of each alternative.


Saline or Silicone Gel?

Since 1992 there has been an FDA moratorium on the use of silicone gel implants for primary aesthetic breast augmentation. While there is no unequivocal, scientific evidence that silicone gel implants produce the systemic illnesses that have been the subject of a great deal of litigation, the moratorium remains in place. Patients undergoing breast reconstruction (after mastectomy, following injury or for congenital problems) may receive silicone gel implants, and silicone gel implants are currently available for aesthetic breast augmentation in a few practices as part of scientific studies.

Does any of this affect my practice? Not in the least, and here's why: saline implants of a moderate (and in my opinion, appropriate) volume look and feel natural. The implant sizes I most commonly use blend in nicely with existing breast tissue, and patient satisfaction is high. In the ten years I have been using saline implants I have yet to have a patient with saline breast implants return to say "I'm not happy with these…take them out and put silicone gel implants in their place."