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Michael Law MD Aesthetic Plastic Surgery

Attention to detail in breast augmentation

For the experienced and meticulous surgeon who is dedicated to creating natural-appearing breast augmentation results, every breast augmentation patient (and therefore every breast augmentation surgery) is different. There are subtleties of implant selection, pocket dissection, pectoralis major release and modification, breast shaped modification and soft tissue envelope management that all may significantly impact the ultimate outcome of surgery. Careful attention to each of these important details can be the difference between an aesthetically ideal result vs. an average result vs. a disappointing result, one which may require secondary surgery.

Managing the inframammary fold

In many breast augmentation patients, the inframammary fold (IMF) 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. Ideally the implant should be centered directly behind the nipple-areola complex (NAC). Lowering the IMF requires careful planning, as one wants the scar that results from the breast augmentation procedure to reside within the new IMF, and not above it on the lower pole of the breast or below it on the chest wall.

A potential downside of lowering the inframammary fold is that doing so creates some risk of the original, preop IMF being visible along the lower pole of the breast. This can in some cases be severe enough to create one version of the ‘double bubble’ deformity, where there is a visible demarcation between where natural breast tissue ends (at the original IMF) and where the implant contour begins. Techniques to avoid a ‘double bubble’ appearance include internal, radial scoring of breast tissue at the level of the inframammary fold which allows the IMF crease to expand, and fat grafting of the subcutaneous tissue at the original IMF and immediately above and below it, so that the transition between natural breast and implant contour in the lower pole is no longer visible.

When lowering the IMF, care must be taken to ensure that the new IMF is well-defined and not subject to change over time. Through an IMF incision sutures can be placed that anchor the connective tissue layer of the skin to the chest wall, helping to define and maintain the position of the IMF over time. One must be careful to avoid postop failure of the new IMF and descent of the implant below the IMF, which requires surgical correction if it occurs.

Likewise, if the inframammary fold is lowered too far, the augmented breast will appear ‘bottomed out’, with an excessively full lower pole, an under-filled upper pole, and a nipple/areola complex that appears to sit too high on the breast. This is another problem that creates a distinctly unnatural appearance, and one that requires surgical correction: repair of the inframammary folds by means of inferior capsulorrhaphy (closing down the inferior capsule with sutures), superior capsulotomy (expanding the implant pocket superiorly), and potentially placing a material that will help support the weight of the implant in the lower pole (GalaFORM, Strattice, etc).

Upper pole profile
In profile (side view), the natural-appearing breast is not convex in the upper pole, so an excessively convex and overly full upper pole is a dead giveaway that a woman has breast implants. In addition, inadequate release of the inferior origin of the pectoralis major will allow the muscle to hold the implant in too high a position, and may even cause the implant to displace upwards (as high as the collar bone in some patients) when the muscle contracts. Patients with this problem require reoperation to release the inferior origin of the pec major and/or the inframammary fold, and potentially replacement of the implants with a profile that appears more natural in the upper pole.

It is critical to select an implant profile that creates a natural slope in the upper pole of the breast. For this reason, patients with significant natural breast projection and upper pole fullness preoperatively generally require a low, low-plus or at most a moderate profile implant; while those with little projection and minimal upper pole fullness often require a moderate plus or even a high profile implant to achieve the most aesthetically favorable outcome. While high-profile implants can produce a natural breast profile in some patients, one must be very selective about the use of these implants.

Horizontal implant position and medial / lateral implant projection
The horizontal position of breast implants also requires a great deal of attention, both during the pre-operative planning phase and when the implant pocket is created 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. The result may (or may not) be tolerable in the upright standing or sitting position, but when the patient lays down in supine position (on their back) the implants may fall far to the side and produce little to no anterior breast projection in this position.

Patients with this problem almost always want it corrected, and the treatment once again is surgical: a lateral repair of the implant space (lateral capsulorrhaphy), to restrain the implants from falling off to the side. The natural slope of the chest wall, which varies greatly from patient to patient, plays an important role in lateral implant displacement. When the chest wall slopes steeply to the side, breast implants will always have a tendency to displace laterally.

Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal ‘side by side’ appearance. It is lateral projection of the breasts beyond the lateral border of the chest wall (in frontal view) which, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an ‘hourglass figure’. While one does not want to over-dissect the lateral extent of an implant pocket, careful attention must also be paid to ensure that lateral breast projection is not inadequate.

Implant base diameter
Breast implant base diameter is also of crucial importance. The base diameter (the side-to-side dimension of the implant) must be ideal for the preoperative horizontal dimension of the breasts, as well as the breadth of the anterior chest in general. It is obvious that a given implant volume and base diameter that works well for a small-framed patient who is 5’2″ will be completely inadequate for a broad-chested patient who is 5’10”.

One wants to increase cleavage area fullness and lateral breast projection in most cases, and an implant of inadequate base diameter may accomplish only one of those goals, while too wide an implant will be overprojecting in both directions and tends to make a patient appear ‘stocky’ or heavier than they actually are. Careful evaluation of all of these breast and implant dimension issues is necessary if the ultimate goal of the surgery is a natural-appearing breast augmentation.

Altering preoperative breast shape
A number of modifications to breast shape are possible during breast augmentation surgery, beyond the mere expansion of breast volume by means of implant placement. Constricted / tight lower poles can be expanded. Tubular breasts can be released and reshaped. Conical areolas can be modified so that they are less projecting. Inadequate cleavage area breast fullness, widely separated breasts and bony-appearing sternums can be improved by means of structural fat grafting of any area where greater natural soft tissue fullness is desirable.

Make sure that the surgeon you select can discuss all possible measures that are available to create the most aesthetically ideal breast augmentation result possible. Attention to these details can be the difference between a breast enhancement that is both stunning and very natural-appearing versus one that is bigger but not necessarily a lot better.

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