Breast Augmentation
Eleven Important Visual Lessons
“Perfection or change to a different breast is never an option. Improvement in the existing breast is the only realistic alternative. When looking at pictures, look for breasts that look like your breasts BEFORE surgery.”“Perfection or change to a different breast is never an option. Improvement in the existing breast is the only realistic alternative. When looking at pictures, look for breasts that look like your breasts BEFORE surgery”
Pictures best illustrate some of the most important principles in augmentation. Pictures can also be misleading and confusing. What you see depends on what you know. The more you know, the more thoroughly and systematically you can evaluate pictures. Many of the terms and concepts used in this chapter have been explained in earlier chapters, so this chapter will be most meaningful and useful if you have read the previous chapters.
These visual lessons in augmentation focus on important concepts that every augmentation patient should know.
Every woman’s augmentation result is determined by two factors:
1) What the woman WANTS, and
2) What the woman’s body (her tissues) will ALLOW HER TO HAVE (what the surgeon has to work with).
As you look at any pictures of augmentation results, remember:
This woman’s breasts are unique in shape and appearance, different from any other woman’s. this woman’s tissues are different from any other woman’s.
This woman’s wishes are different from any other woman’s.
It’s impossible to look at a catalog of breast pictures and pick out what you’d like to have, unless your breasts are exactly the same as the woman’s in the picture before surgery—and they are never the same! Remember, the three most critically important factors in determining optimal implant size can never be accurately assessed in any two-dimensional picture (without special equipment for scaling): 1) the base width of the breast, 2) the amount of stretch, and 3) the amount of existing breast tissue. It’s also impossible to know exactly what the woman in the picture requested. What she wanted might be very different from what you want. And, most importantly, the characteristics of her breast tissues are not exactly like yours.
We have chosen each set of images to make a point. Each breast is not the most beautiful breast or the most “perfect” breast. Any experienced surgeon can select a large number of “best” results, but if education is the goal, you need to see a full range of breast types, results, and common problems. As you study the lessons, focus on the message of each image. Don’t necessarily ask yourself whether you particularly like the breast. Remember, what you see in a before image is all the surgeon had to work with. Perfection or a change to a different breast is never an option. Improvement in the existing breast is the only realistic alternative.
Lesson 1:
Each woman’s breasts have unique tissue characteristics. The skin envelope and breast tissue are different in every woman. A surgeon can work only with what the patient brings (her unique tissue characteristics). Ideal choices are different for each woman, depending on her wishes and her tissues.
This important principle is illustrated by the following before-and-after case studies. Compare each case to the other cases. Focus on the substantial differences among patients’ tissues before augmentation and how those differences affected the results. Concentrate on the two major components of the breast: the skin envelope and the breast tissue (parenchyma) that fills the skin envelope. For each different combination of skin envelope and breast tissue, we will emphasize principles that affect the choices of implant and technique in each different type of breast.
Skin Envelope: Tight, Unstretched
Breast Tissue: Minimal
(Figure 16-1 A,B)
When the skin is tight and thin with minimal breast tissue to cover a breast implant, the most important considerations are these:
- Avoid an excessively large implant. The skin will stretch only a moderate amount without permanently damaging or thinning the skin. Choose an implant that will not cause excessive skin stretch.
- When tissues are thin and a patient can feel and see her ribs, she will also be able to feel the edges and possibly the shell of her implant regardless of the type of implant chosen.
- Positioning the upper portion of the implant partially under the pectoralis muscle (in a dual-plane or submuscular pocket location) reduces the risk of the upper edge of the implants being visible.
- Thin tissues will not support the weight of an excessively large implant as a patient ages. With an excessively large implant, the breast will sag more, the skin will become thinner, implant edges can become visible, visible rippling can occur, and shrinkage of existing breast tissue can occur from the weight of the implant pulling on the thin overlying tissues.
Skin Envelope: Stretched, Looser
Breast Tissue: Minimal
(Figure 16-2, A–C)
Breast enlargement with pregnancy usually stretches the skin, leaving the skin envelope looser. The breast tissue inside the envelope often shrinks following pregnancy. The result is less filler in a larger, looser skin envelope. The most important considerations with loose skin and minimal breast tissue are these:
- Adequately fill the loose envelope for the best result, but avoid overfilling. An excessively small implant will fill the lower breast, but leaves the upper breast empty (the rock-in-a-sock look). When the loose envelope skin is thin (note the patient’s visible ribs), the goal should be to provide just enough fill (implant size) to expand the envelope for a natural upper-breast profile. Any implant larger than that required for adequate fill will cause excessive stretching and further thinning of the envelope as this patient ages, and risks all of the same long-term problems described previously.
- A thin skin envelope with minimal breast tissue covering the implant almost guarantees that the patient may feel some portion of the implant, just as she could feel her ribs beneath the thin tissues.
- Notice the extremely thin skin in the cleavage area between the breasts. If the implants selected were wider than the existing breast tissue (Figure 16-2, C) in an attempt to narrow the gap between the breasts, the edge of the implant would be visible beneath the thin skin between the breasts. To avoid a visible implant edge between the breasts, an implant was selected that was slightly narrower than the patient’s breast tissue. The patient had to choose between a) narrowing the gap between the breasts more and risking a visible implant edge or b) accepting a slightly wider gap between the breasts and avoiding a visible implant edge. She chose option b.
Skin Envelope: Stretched, Looser
Breast Tissue: Moderate
(Figure 16-3 A,B)
- When more breast tissue is present in a stretched envelope, the breast tissue provides more cover for the implant, and the patient is less likely to feel portions of the implant.
- The combination of skin already stretched by pregnancy with adequate breast tissue to cover an implant is ideal for augmentation.
- The patient and surgeon can select from a wider range of implant sizes or widths without risking implant edge visibility when more breast tissue is present (a wider base width of the breast mound in front view).
Skin Envelope: Very Loose
Breast Tissue: Moderate
(Figure 16-4 A,B)
- The larger a breast, whether normally or during pregnancy or nursing, the more the skin envelope stretches. This patient’s stretched skin envelope could be the result of gravity pulling on a moderately large breast as she aged or could have resulted from breast enlargement during pregnancy or nursing. In either case, the appearance could be exactly the same.
- Although it’s important to adequately fill a stretched envelope for an optimal result, when we see sagging of the breast before surgery, the skin envelope tissues are sending a message. The skin envelope did not support the weight of the patient’s own tissue, or it wouldn’t have stretched and allowed the breast to sag!
- Although this stretched envelope could accommodate a very large implant and maintain a natural appearance, what will the excessively large implant cause when placed in an envelope that has already proved that it cannot support the weight of the patient’s own tissues? More sagging and more tissue thinning!
- The key to a good long-term result in this type of breast is to select an implant that will provide adaquate fill but avoid selecting the largest implant that the envelope could accommodate. The largest implant might look good, but only for a while. It would rapidly cause more stretch, more sagging with loss of fill in the upper breast, thinning of the skin envelope, increased risks of visible rippling in the upper breast, and increased risks of shrinkage of existing breast tissue. Excessive sagging could necessitate a breast-lift procedure (mastopexy) with additional trade-offs of more scars on the breast and possible increased loss of sensation. Making the right choices is important at the first operation.
Lesson 2
A woman’s breasts are never the same on both sides, and no two women have breasts that are exactly the same. No surgeon can make both breasts exactly the same; differences will always exist after surgery. Each type of breast presents unique problems, and every correction involves limitations and trade-offs.
In each of the following cases, we will point out the unique characteristics of the patient’s tissues, the different problems that each patient’s tissues present, and the corrections that were achieved by augmentation. In each case, we will also emphasize the limitations that each patient’s tissues imposed and the trade-offs that were present during the decision-making process.