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Dr. Barry Eppley

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Archive for the ‘breast augmentation’ Category

Case Study – Breast Augmentation in Pseudoptosis

Sunday, February 4th, 2018


Background: Since breast augmentation is about increasing breast size it is no surprise that so much thought goes into choosing implant size before surgery. This is the one single issue that patients focus on and are often indecisive about before the surgery. No patient wants to be too big or too small knowing that in the vast selection of breast implant sizes there is the right one for them.

Numerous methods of breast implant sizing have been used and each has their own merits. The one I prefer is the volumetric method using different overlay sizers so the patient can see how different implant volumes affect their breast size. While not a perfect method it has worked as wells anything I have ever used and I have yet to have a patient sho felt their implants were too big with this sizing method.

Between breast base diameter and volumetric sizers, these parameters will work well for most patients. The other breast variable that must be considered is the overlying skin envelope. The volumetric sizers assume the breast skin is tight but when it is loose or has a deflated appearance it is going to take more implant volume to achieve what the volumetric sizers show.

Case Study: This 30 year-old female presented for breast augmentation surgery having lost much of her breast volume from having children. Her nipples were above the inframammary fold but there was some loose skin hanging over it. (pseudoptosis) Volumetric sizers showed she like 350cc implant size.

Under general anesthesia and through inframammary incisions, 425cc moderate plus profile silicone breast implants were placed in a dual plane location.

It is important to remember that the amount of loose skin on the breast will take more volume to expand outward than one may think and should be considered in the implant size selection process. The loose skin has lost elasticity and often has stretch marks. It will take more implant volume to fill it than if the overlying skin were tighter and there was less of it.


1) The amount of loose breast skin does influence how much implant volume is needed to fill it.

2) While there is no exact formula to calculate how much extra implant volume is needed to fill the ‘extra space’, it is best to add 50 to75cc onto the original breast implant sizing estimate.

3) It is best to overfill and not underfill the breast with loose skin when it comes to implant size.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Effects of Breast Implants on Stretch Marks

Monday, January 15th, 2018


Background: Many women that undergo breast augmentation surgery have had children. As a result of pregnancy and breast engorgement, stretch marks commonly develop. They occur in a radiating fashion from the nipple in a perpendicular orientation to the relaxed skin tension lines of the breast,

Since so many women have breast stretch marks, it is a common question as to how they will appear after the breast is markedly increased in size. There has never been a definitive study of this question although plastic surgeons have an inordinate amount of anecdotal experience with this observation.

Since stretch marks represent incomplete tears of the underlying dermis, it would be reasonable to expect them to get wider as the breast mound inflates with an implant. This is much like the areola as its diameter increases as a result of breast augmentation surgery. But does this stretch mark widening persist and does it look worse on a long-term basis?

Case Study: This young female had two children previously. As a result she lost much of her breast volume and acquired a large number of stretch marks. With a loose and deflated breast mound the stretch marks were not that noticeable.

Under general anesthesia saline breast implants were placed through a transaxillary incisional approach. The implant size was 300cc inflated to 350ccs. Her 6 weeks after surgery rests show that her stretch marks has relax to the point that they looked no worse than before surgery.

Most of the time stretch marks after breast augmentation return to their presurgical appearance. With rare exception stretch marks can appear worse if their color turns red. This is somewhat dependent on implant size and how much stretch is placed on the breast mound.


1)  Many women that undergo breast augmentation surgery have stretch marks.

2)  Like the entire breast mound, stretch marks get bigger with with the push of underlying implants.

3) But with skin relaxation after surgery stretch marks return to their preoperative state.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transaxillary Saline Breast Augmentation

Saturday, December 30th, 2017


Background: One of the considerations in breast augmentation surgery is the choice of the incision. While it is important to remember that the incision is just a method of access to the making of the desired breast pocket, and what is done on the inside remains the same regardless of the incision used, it is big preoperative focus for many patients. That choice can also affect certain other aspects of the breast implant operation.

One incisional option is that of placing it in the armpit, known as the trasnaxillary breast augmentation approach. On the surface it offers the obvious advantage of being ‘scarless’ at least from a breast standpoint. It is also a scar location that heals exceptionally well as it is placed in the moist and thinner hair bearing skin of the axilla.

But it has advantages as well. It offers the most direct approach to getting into the submuscular plane for making the implant pocket. The axillary incision is directly right under the thickest part of the pectorals major muscle being just a few centimeters away. Once into the pocket the entire submuscular pocket can be easily elevated to all corners of the breast to make a good implant pocket. The only disruption of really firm tissue attachments that are needed is laterally beyond the edge of the muscle. This is the reason bruising often occurs in this chest wall area after surgery.

Case Study: This young female wanted to improve her breast size by a modest amount. She was a small B and wanted to be either a full B cup or a small C cup.

Under general anesthesia a transaxillary approach was used to place 225cc saline implants that were filled to 275ccs on each side. Even at just one month after surgery her axillary incisions were healing well and will fade to near obscurity in the next few months.

Because of the small size of transaxillary incisions (usually around 3 cms) this approach was originally used for saline implants. Because saline implants are placed deflated and in a rolled configuration,  they can be inserted through such small incisions without any difficulty regardless of the implant’s size. They are then inflated through a connecting tube once in place to the desired volume. But because of the use of funnel insertion devices today, silicone implants can also be inserted through such incisions. Such axillary incision may be a little bigger (3.5 to 4 cos) but silicone implants up to 550ccs can be placed through them.


1) The use of saline breast implants is the origin of the transaxillary breast augmentation incisional approach.

2) It is a blunt submuscular dissection approach that offers the shortest operative time .

3) While it causes the most swelling immediately after surgery, it also offers the quickest recovery time.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study -Breast Implants for Improved Mound Shape and Asymmetry Correction

Monday, December 25th, 2017


Background: The primary goal of breast implants for every patient is an increase in breast size. Such an effect is always achieved as one would expect from placing a permanent implant into the breast mound. But some women also desire that they have a breast lifting effect which is not nearly as predictable or should even be expected in most patients.

It is commonly stated that all breast implants do is take the existing shape of the breast and make it bigger. And this is certainly true when it comes to the shape of the breast. If one has a good mound with tight skin and a centered nipple then a very pleasing shape will occur afterwards. If one has a saggy breast with a low nipple position, breast implants will usually not create an improved shape and may well make the undesired shape more so albeit wth a bigger breast mound.

Case Study: This young female wanted a modest increase in her breast size. She wanted  a full B or small C cup size. She has tight breast skin with a short nipple to inframammary fold distance. This made her nipples point slightly downward. In addition she had asymmetry with the left breast mound being slightly smaller and with a lower nipple position.

Under general anesthesia she had high profile round smooth 300cc silicone breast implants placed in a dual plane position through small 3.5cm inframammary incisions. The implants were inserted using a funnel device.

Despite her small and tight breast mounds with asymmetry, her after surgery results showed improved symmetry and better shaped breast mounds. This effect is caused primarily by the influence of the increase in the fullness of the lower breast pole which is where two-thirds of the influence of the implants occur. If the skin is tight enough and the nipple position is still above the fold, no matter how slight, the effect of the implants will create a minor breast lifting effect.


1) Breast implants create a volumizing effect which may have a lifting effect.

2) The lifting effect of implants come from filling out the lower pole of the breast which drives the nipple forward and up.

3) The tightness of the breast skin and the size of the implant will determine whether a breast lifting effect is achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Transaxillary Saline Breast Augmentation

Sunday, December 3rd, 2017


Background: Breast augmentation can be done using two different types of implants, saline and silicone.  (technically three if you include the saline-filled Ideal implant) Both type of breast implant has their own unique advantage sand disadvantages Silicone offers the most natural feel and an implant that will probably last longer as it can not undergo a spontaneous deflation. But these benefits come at a higher cost of the implant.

Saline breast implants have as their main advantage that they are the most economical of all breast implants. They also can be inserted with the smallest incision as they are deflated and rolled to pass through the skin entrance site and then are subsequently inflated to the desired volume size. Such characteristics make them appealing to many younger women who may be more financially challenged and are often the most concerned about incisional scars.

Case Study: This 19 year-old female wanted saline breast augmentation. Her mother and her two sisters had prior breast augmentation over ten years ago with saline implants and have never had a problem yet.

Under general anesthesia through a 2.5 cm transaxillary incision, 200cc saline implants with 11.5 cm base diameter were placed in the submuscular position and inflated to 250ccs. This was done in a non-endoscopic fashion.

Her early two week result showed good symmetric implant placement and incisions that already looked good as this early point. In a few months these scars will fade and will probably be very hard to find.

While breast implants and the surgical technique to place them continue to evolve, the ‘old’ transaxillary saline breast augmentation technique continues to produce successful results for the patient who is willing to accept a saline-filled implant.


1) Saline breast implants remain popular particularly amongst young women.

2) The deflated and rolled insertion method for saline implants allows them to be placed through the smallest possible incision.

3) The transxillary incision for saline implants still remains a preferred method for their placement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation in Widely Spaced Breasts

Sunday, October 22nd, 2017


Background: The outcome of breast augmentation is affected by many variables that go far beyond the implant itself. The shape and position of the breast mound and its nipples profoundly impact how they will look when the implants are placed behind them. Too often patients believe that the enlarging their breasts will correct many of their undesired flaws.

One undesired feature of some breast augmentation patients is the wide spacing between the breast mounds. This wide sternal gap can be caused by a horizontally wide bony sternum, breast mounds that are positioned very lateral on the chest wall or a combination of both. The position of the nipples is the giveaway as to why the breasts are wide. If the nipple is at ir more lateral than a vertical line drawn down from the mid-clavicular point, then it is the laterally positioned breast mounds that are at fault.

Getting the breast mounds closer with implants can provide improvement. This is better achieved with implants in the subglandular position as the medializing effects of submuscular implants is limited by the position of the origin of the pectorals major muscles at the edge of the sternum.

Case Study: This 25 year-old female presented for breast augmentation surgery. Her biggest concern was that she did not like the wide spacing between her breast mounds.

Under general anesthesia she had smooth silicone breast implants placed through inframammary incisions. The implants were of 325cc size. Her after surgery results show less width between the breast mounds and a filled in effect of the medial poles of the breasts. But the nipples still look very lateral on the breast mounds.

It is important in preoperative counseling of the breast augmentation patient that wide spacing between the breasts will not be completely eliminated. Equally relevantly the nipples of the augmented breast mound will remain at the lateral edge of the breast mound and their position will remain unchanged regardless of implant size.


1) Widely spaced breasts poses aesthetic challenges in breast augmentation.

2) While the inner breast mounds can be enlarged and create decreased mound spacing, the position of the nipples will not change.

3) The fundamental concept in breast augmentation is that implants merely take what the natural anatomy is and make it bigger…but it is not a total reshaping of the breast.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Donut Breast Lift with Implants

Sunday, September 17th, 2017


Background: Many breast augmentation patients present with some degree of breast ptosis. When combined with the number of women that are of the belief that an implant can lift up their sagging breasts, it can be a surprise when the concept of a breast lift is discussed as needed with their implants..

While the need for a breast lift is often obvious in some breast augmentation patients (nipple below the inframammary fold), smaller amounts of ptosis present less obvious needs. When the nipple is at the same horizontal level as the fold (grade 1 ptosis), this raises concern as to what may happen to it when a breast implant is placed behind it?

The key to this question lies in the quality of the breast skin and mound tissue. If the skin is tight and the breast mound small, an implant alone will create all the lift that is needed. But if the overlying breast tissues are lax from aging and breast involution, some form of a lift will likely be needed.

Case Study: This 45 year-old female presented for breast implants. But she had first degree ptosis and loose breast skin from age and pregnancies. She did not want vertical breast lift scars.

Under general anesthesia she has saline breast implants placed with a periareiolar or don’t lift performed. Her postoperative result showed enlarged breast, no exaggeration of her preoperative breast ptosis and good areolar scars.

Of the four types of breast lifts, the donut technique is the second on the progression of increasing scar burdens to perform them. By removing an eccentric ring of skin around the areola some skin tightening and a minor amount of mound lifting can be achieved. But because of its limited lifting effect it almost always need to be done in conjunction with implant placement to have the best effect. It is still a ‘minor’ breast lift and should be only used in  cases of first degree ptosis. Prevention of periareolar scar widening is a function of the size of the breast augmentation and the amount of periareolar skin removed.


  1. Breast augmentation in the presence of small amounts of ptosis may benefit from some form of a breast lift.
  2. The periareolar or donut lift is a type 2 breast lift.
  3. The width of the scars from a periareolar lift depends on the size of the size of the breast implants and the amount of skin removed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Wide Sternal Gap in Breast Augmentation

Sunday, September 3rd, 2017


Background: Breast implants are capable of making dramatic changes to a women’s breasts. Increases in size with a much fuller shape are typical and expected. Implants achieve these effects by altering the soft tissue through their ability to be stretched and expanded.

But there are certain fixed features of a woman’s chest that may not change with breast implants. One of these features is skeletally-based and is the sternum. The bony separation of a women’s breasts create the natural spacing between them. Implants may expand the soft tissues next to them but they can not make the sternal distance smaller in most cases.

Sternal spacing is one differentiator between breast implants that are placed above or below the muscle. A submuscular implant is blocked by the muscle from encroaching onto the sternum. Conversely implants placed in the subglandular location (above the muscle) can stretch the soft tissues to hang over onto the sternal bone, thus reducing the sternal spacing between the breast mounds.

Case Study: This 28 year-plod female wanted breast implants. She has always had small breasts  and was very thin. She has lost what little breast tissue she had after having children. She had a very skeletonized chest with a wide sternum between her small breast mounds.

Under general anesthesia, she has saline breast implants placed through transaxillary incisions. The implants had a base size of 300cc and were inflated to 375ccs. Her wide sternal spacing remained although the enlarged breast mound made it appear somewhat smaller.

It is good preoperative counseling to advise women undergoing breast augmentation that the natural sternal spacing will determine how close their breast mounds will be. This its not under direct surgical control unless one wants to have their implants in the subglandular location.


  1. Implants change numerous aspects of the breasts but can not do much with wide sternal breast base spacing.
  2. Submuscular implants are blocked from narrowing a sternal muscle by the medial edge of the pectorals muscle.
  3. Only subglandular breast implants can narrow the distance between the two edges of the implants in a wide sternum.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation with Nipple Lift for Asymmetry Correction

Friday, June 23rd, 2017


Background: Many women that present for breast augmentation surgery do not have perfectly symmetric breasts. Women that have never had breast implant surgery rarely have symmetric breasts either. Yet, understandably, the woman who undergoes elective aesthetic breast surgery seeks the most symmetric result possible.

Of all the aesthetic breast deformities that exist, asymmetry is the most common and comes in many forms. The breast mound may be smaller on one side, there may be more sagging on one breast versus the other and/or the nipple may be lower. Since every women has some degree of asymmetry it behooves the surgeon and the patient to take careful note of it before surgery when a plan for intraoperative management can be done.

Differences in the horizontal level of the nipple is a very important asymmetry to note before surgery as breast augmentation will almost always make it worse. It is also often correctable by an adjustment done directly on the nipple. Known as a superior crescent mastopexy (SCM), ity is better referred to as a superior nipple lift. The superior half of the lower nipple can be lifted upward by about a centimeter or so through a crescent-shaped skin excision pattern.

Case Study: This 36 year-old female wanted a better breast shape. She was aware of her breast asymmetry with the right breast being bigger with greater skin sag and a resultant lower nipple position.

Under general anesthesia and through inframammary incisions, 400cc high profile breast implants were placed in a dual plane position. A right nipple lift was then performed through a half-moon shaped skin excision that was 1 cm at its central area.

Horizontal nipple asymmetry can and should be corrected at the time of breast augmentation with a nipple lift on the lower breast mound. Good implant sizing can overcome breast mound differences but will not on its own correct nipple level differences and may even make them worse. The superior areolar scar can heal quite well in most cases and does not create an aesthetic distraction.


  1. Breast asymmetry is the most common ‘deformity’ in prospective breast augmentation patients.
  2. Implants alone can not be counted on for correcting breast size or shape issues.
  3. A superior nipple lift on the more ‘saggy’ breast side during breast augmentation can help correct asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Round Breast Augmentation Result

Sunday, June 4th, 2017


Background: The size of the implant chosen is the single most important decision from a patient’s perspective. More time is spent on this aspect of the surgery than other factors such as implant type, pocket location, implant profile or even the surgeon performing the procedure.

How to match implant size to the patient’s goals, however, is not an exact science. The single best method in my experience is the use of volumetric sizers which can be tried on the patient’s breast before surgery. This certainly creates  a close approximation and almost never risks choosing an implant that ends up being perceived as too small.

One of the major goals for some women is to ensure that their chosen breast implant creates a sustained full upper pole. The desire is to have a rounder looking breast augmentation whose volumes appear equal in both the upper and lower poles. While it is commonly perceived that a high profile will ensure that occurs, and it definitely helps, but the volume of the implant ultimately makes the greatest contribution for this look.

Case Study: This 44 year-old female wanted breast implants and desired a full round look that also created cleavage. She had smaller B cup breasts with firmer skin  and just a touch of mild sagging. (non-centric nipples) Her preoperative sizing showed a 600cc plus implant size selection.

Under general anesthesia and through an inframammary incisional approach, a partial submuscular pocket was created and sizers inserted. That were inflated up to 650cc at which point the pocket was very tight. The sizers were removed and replaced with high profile 650cc silicone implants inserted with a no-touch funnel technique.

Her six week after surgery result showed a round breast augmentation result with equal distribution of volume both above and below the nipple.

While the projection or profile of a breast implant has value it remains secondary to implant volume. Filling the created implant pocket fully is the most assured way to have a rounder breast augmentation result.


  1. The selection of breast implant size is based own numerous factors but the most important one is what the patient’s goals are.
  2. Creating persistent upper pole fullness is related to both implants size and implant position.
  3. Filling up the implant pocket fully will create a rounder and higher breast look.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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