Explore Plastic Surgery - Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

Background: Breast augmentation works because it is a synthetic implant that makes the breasts bigger. While it is true that the role of the plastic surgeon is critical to get good implant placement in the proper position and as symmetrically as possible, but in the end the implant itself plays a major role in the final breast appearance. To a large degree, and often not appreciated by patients, is that implants merely magnify what the breasts initially looked like.

Stretch marks are usually the result of rapid stretching of the skin. They occur because the underside of the skin, known as the dermis, can not take the pressure from the rapid stretching and it tears. Stretch marks are, therefore, a form of scarring in the skin. But because they are located on the underside of the skin, they are generally resistant to improvement by any form of known treatment. While initially appearing as red or purple, they often fade in color to white.

When stretch marks occur on the breasts, usually from pregnancy, they occur in a radiating pattern from the areolas. This is reflective of the circular expansion of the breast mound against the natural lines of skin tension (Langer’s lines) of the breast skin. How fast the breast mound expands and the natural thickness of the skin will determine whether and how severe stretch marks may develop.

Because pregnancy causes some degree of loss of breast tissue, many women after they are finished having children desire breast augmentation. Pregnancies have left them with smaller deflated breast mounds that often have stretch marks as well. A very relevant question from them is what will happen to their stretch marks after getting breast implants. Will the stretch marks look worse?

Case Study: This 23 year-old female from Columbus Indiana wanted breast implants to improve the size and shape of her breasts. She had been through two pregnancies in the past four years and had lost most of her natural breast tissue. She also had very severe stretch marks that radiated widely out from her nipple-areolar complexes, were wide and many in number and were white in color. While she wanted larger breasts regardless of how the stretch marks would appear afterward, her question about what would happen to them after surgery was common.

Under general anesthesia, she had saline breast implants placed through a transaxillary approach. She was very small in size (5’ 1”, 102 lbs) and the implants were inflated to 375cc which stayed within the dimensions of her natural breast base diameter. During surgery it could be seen that her breast stretch marks did get wider from the expansion of the implants but they did not look worse in appearance.

When seen at one month after surgery, her breast implants were symmetrically placed and of acceptable size to her. Her stretch marks were still very apparent and actually a bit more red than before surgery. When comparing before and after photos, it could be stated her breast augmentation neither improved or made worse her pre-existing stretch marks.

This breast augmentation case shows a woman with very significant stretch marks on her breasts. Few women will present with a more severe case of breast stretch marks. While breast augmentation did not improve their appearance, nor would it be expected to, the procedure did not make them look worse. For some women whose breast stretch marks are relatively new (in the past few years) the rapid expansion of the breast skin from implants may make them initially more red. But this red color will fade as the breast skin relaxes after surgery. So while augmentation does make the stretch marks somewhat bigger, it does not necessarily make them look worse in the long run.

Case Highlights:

1) Stretch marks from pregnancy are common findings on many women considering breast augmentation. There is usually the concern that their appearance may be worse after surgery.

2) The expansion of the breast skin from implants does widen stretch marks but does not usually make them look worse in appearance.

3) Some stretch marks may initially get more red right after breast augmentation but this fades with time and skin relaxation.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Breast augmentation is one of the most dramatic of all the body contouring operations. In just an hour in most cases, the breast mound is enlarged and the entire shape of the chest wall changed through the insertion of a synthetic implant. While the operation is short and the change is immediate, the actual recovery from breast augmentation is much longer. The feel and shape of the breasts will go through a series of classic phases of recovery of which most patients are unaware or do not expect fully.

For whatever reason, many breast augmentation patients seem to expect that the final shape and look of the breasts are achieved in days to just weeks. Many of the questions in the first month after surgery are very typical and range from concerns about size, shape, feel and symmetry between the two breasts. While a breast implant causes an immediate size increase, it does so without the skin yet being adapted to the pressure of this volume increase. When this is combined with the swelling and bruising that occurs from the trauma of surgery, there is a predictable series of phases that one can expect in their breast augmentation recovery.

The first phase of breast augmentation recovery (week 1) is associated with the immediate stretch of the breast skin and the trauma of surgery. This is seen in the swelling and extreme tightness of the breast which does not peak for up to 48 hours after surgery. The swelling of the breasts for some women will make them feel like they are going to pop. This swelling is seen by how shiny the skin becomes. Even though the same procedure was done to both breasts, they never swell exactly the same and one may note some asymmetry of the two mounds. Bruising may occur but it usually isn’t seen for days and will often appear not on the breasts but on the sides of the rib cage to the sides or below the breasts. The breasts will appear very round and often will look too high with a lot of upper pole fullness. They will feel anything but natural and will be as hard as a rock. Some women may feel some fluid moving around (residual irrigation fluid from surgery) or even hear the breast implant make noises (squeak) as it slides over the ribs underneath.

The second phase of breast augmentation recovery is from the first to the third week after surgery. The very visible swelling of the breasts begins to subside and whatever bruising occurred is completely absorbed. The breasts do not feel quite as tight and they may not look as high. They will not feel quite as stiff although they are still not soft and natural feeling. There will be persistent numbness on the lower pole breast skin and the nipples may still feel hypersensitive with shooting sensations or easy irritability. They will likely be some persistent asymmetry of the breasts and this should not be a concern at this point.

The third phase of breast augmentation recovery is from three to six weeks after surgery. At this point all the significant swelling of the breasts is gone and they are beginning to feel more natural and soft. The once high position and fullness of the breasts has usually subsided. They will move freely and no longer feel stiff. Nipple sensation is usually back to normal. The skin on the bottom half of the breasts will still feel numb however. At six weeks after surgery, it is reasonable to assess breast size, implant position and symmetry. The skin has nearly fully adjusted (stretched and relxed) to size and weight of the implants.

The fourth and final phase of breast augmentation recovery is from six weeks to three months after surgery. It is during this time that all of the residual effects of the change are realized. The breasts are soft and fully relaxed, nipple sensation is normal and most of the numbness of the skin has resolved. This is the time to become critical about the final results of the surgery in terms of implant size and asymmetry.

These four phases of breast augmentation recovery show that the time to be concerned about how the results look is not until three months after surgery. Patients will have many understandable concerns along the way but most of these will be self-resolving with time and tissue adaptation.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The goal of breast augmentation surgery is to achieve both a bigger size and a better shape of the breasts. Understandably, women spend a great deal of time before surgery pondering what they want their after surgery breasts to look like. Using pictures of breasts, with or without implants, is a common method of communicating to their plastic surgeon what their breast goals are. While most women will show generic pictures from plastic surgery or breast implant manufacturer’s websites, some women will show specific clothed celebrity breasts and cleavage images.

In a recent published survey from the International Society of Aesthetic Plastic Surgery, which celebrity breasts were most commonly identified by patients was reported. According to the results, many women wanted breasts like those of Pamela Anderson. Other desired breasts included Gisele Bundchen, Britney Spears and Xuxa. Conversely, celebrities with the least desired breasts were ironically Pamela Anderson and Dolly Parton and Victoria Beckham. The survey results also indicated that many women have unrealistic expectations regarding their results after breast augmentation.

While surveys like this are entertaining, they are not particularly useful in terms of providing any practical guidance about how to achieve satisfied breast augmentation results. Using celebrity and magazine pictures of breast shapes and sizes is not realistic for the vast majority of patients. Such pictures are often a warning sign that the patient has a disconnect between what their breasts can ultimately look like and what they want them to look like. Breast size and shape is much like art, the opinion about them and their appeal is a reflection of a person’s interpretation and tastes. What one patient may love, the next patient may find horrific. Such is why Pamela Anderson makes the top of the list for both desired and most undesired breasts.

While celebrity pictures are not useful in breast implant consultations and I don’t like to see them, I do find the use of some pictures very helpful. While no patient can truly look like another, pictures of postoperative breast implant results help convey an impression about the ‘look’ that one is after. Going to websites like Love Your Look, where thousands of before and after surgery pictures are posted, can help one select an approximate size of the final breast that they want.

It is not important to find someone on breast implant websites that has one’s similar height and weight or even a comparative before surgery breast size and shape. What counts is what their impression is of how the augmented breast looks on the chest wall, particularly in terms of size. It is about understanding the image of what they want their breasts to ultimately look like. This may seem similar to comparing it to celebrity breasts but it is not. Like all celebrity pictures, they are taken to show their best angles in glamorous settings and a full view of their breasts is not shown.. Celebrity comparisons also imply other potential desired characteristics which raises the level of patient’s expectations. Random breast images of ordinary people do not carry with them such enhanced characteristics. This makes one focus on actual and realistic breast augmentation results.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

One of the most important considerations, if not the main one, that most women ponder when undergoing breast augmentation is what size they want to be. How big of an implant should one get? Much thought goes into the size of the breast implant from both the patient and the plastic surgeon. There is no exact science in making an implant size choice and this is reflected in the many methods that are used to help this decision process.

Considering a woman’s breast base diameter measurement compared to that of an implant’s is the simplest and most measureable method that we have. While this will ensure that a breast implant will never be too large (exceed the natural breast base width), there are other breast tissue considerations that this measurement does not take into account. How much natural breast tissue one has and the amount of breast skin and its elasticity will also play an important role in the outcome of the breast augmentation result.

Plastic surgeons think about quantifiable elements of breast augmentation such as implant volume and base diameters and projections. Women think mainly in about cup size, which while being a measure of breast volume, is hard to accurately define. In the end, however, there is only one issue that matters…how does the breast look.

In that context, I find it helpful in my Indianapolis breast augmentation patients to have them tell me what ‘look’ they want. Not cup size but an overall final breast look that they are after. This does somewhat relate to the nebulous concept of cup size but women can think better if it somehow relates to what they are familiar with. I ask patients to review these descriptions and select the one that best describes what breast augmentation look they want.

A ‘small’ breast augmentation is when only the lower pole of the breast becomes fuller. There is little to no change in the upper pole of the breast. The upper pole only becomes a little fuller when there is little to no breast tissue prior to surgery. If one has some pre-existing breast tissue, which exists only in the lower pole, the breast becomes modestly bigger but its shape does not change. Many women would call this type of breast augmentation result a full ‘B’ cup.

A ‘medium’ breast augmentation is when some change in the upper pole of the breast occurs as well as the lower pole. But the upper pole fullness is not significant enough that it looks round or unnatural. It does not appear that one has breast implants. There is a change in the size of the breast and some alteration of its overall shape, but the breast does not look round or surgically altered. Women will often call this a small to medium ‘C’ cup.

A ‘large’ breast augmentation is when there is a very noticeable change in the entire breast mound. The upper pole is just about as full as the lower pole and the breast acquires more of a round shape. The inner pole near the sternum and the outer pole toward the armpit will now have greater roundness as well. It will be more obvious that one has breast implants but the breast implant does not exceed one’s natural breast base diameter. This is often called a full ‘C’ cup or a small ‘D’ cup.

An ‘extra large’ breast augmentation result is when the entire breast mound in all poles becomes expanded. The breast will look very large and round and assume a more spherical shape. The implant will have exceeded the base diameter of the breast and it will be very obvious that one has had a breast augmentation. This would be referred to as a full or double ‘D’ Cup result.

While no method of breast implant size selection is perfect, knowing what final breast look a woman wants is very helpful. There is always a range of implant sizes that can achieve these type of breast augmentation outcomes.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

While breast augmentation is largely about altering the size and shape of the breasts, there are other aspects of the procedure that are of interest. While women want many certain aspects of their breasts to change after surgery, feeling and function of the nipple-areolar complex is not one of them. While some women don’t have significant nipple feeling and are not concerned if it is lost, many women do and it is an important concern.

There is always some temporary loss of feeling of the skin after breast augmentation, largely restricted to the lower pole or the area between the nipple and the inframammary fold. This reflects the skin area of the breast that has been undermined the most so it is no surprise that it will be immediately numb. This usually completely resolves with time over two to three mnths after surgery. Nipple sensation and erection changes can also occur and can either be that of numbness to hypersensitivity. Similarly this usually revolves itself also but the risk of permanent loss of nipple feeling can occur.

It has long been conjured that the approach or incision used to place the breast implant influenced the potential for permanent loss of nipple sensation. Of the four incision options for breast augmentation, (nipple, fold, armpit and belly button), it is assumed that the nipple incision has increased risk of permanent nipple changes. While this seems intuitive, previous studies have shown conflicting results on this issue.

In the October 2011 issue of Plastic and Reconstructive Surgery, a study is reported that looks at the sensation of the nipple-areolar complex after breast augmentation. This was a retrospective study conducted over six years on 1,222 primary breast augmentation patients. Any other type of breast procedure, such as a lift, done with the augmentation excluded a patient from the study. They found that the only factor associated with changes in nipple-areolar sensation at six months after surgery was the type of skin incision used. The periareolar incision was associated with a three-fold increase in persistent nipple numbness and pain over an inframammary fold incision.

It is presumed that the periareolar incision in breast augmentation increases the risk of diminished nipple sensation by cutting the nerves that supply it. Stretching the nipple and the surrounding tissues in putting in the implant, particularly the larger silicone implant, is also not helpful. Nerve regeneration or recovery may also be limited by the scar tissue that forms under the nipple from the path of dissection downward.

While the risk is reasonably low, around 6% in this study, loss of some or all of nipple sensation is a potential issue that every breast augmentation patient should be aware. Since this risk is higher with a periareolar incision, I avoid its use completely. Now that prefilled silicone implants are used more commonly than saline in breast augmentation, it is harder to insert them through a small nipple that many small-breasted women have anyway.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background: Breast augmentation continues to be a very popular body contouring procedure for women. Whether it is to improve a natural underdevelopment or the effects of pregnancy and gravity, increasing volume is one of the key components of breast enhancement. The majority of breast implants are placed in women under the age of 45, particularly in the age range of 21 to 35. Because of this understandably age-skewed patient population and the amount of press and publicity that younger women get for undergoing the procedure, many older women wonder if they too can have the procedure.

I have had many older women (age 50 or older) in my Indianapolis plastic surgery practice ask if it is ‘safe’ for them to have breast augmentation. This concern about safety in ‘older’ patients relates to what the recovery would be like and are implants more prone to cause breast problems in older tissues.

Recovery after breast augmentation, due to the most common positioning of the implant under the pectoralis muscle, relates to a muscle injury recovery. While an older patient may take a little longer to recover from a pulled muscle than a younger one, that difference is relatively small. (if it exists at all) I have not noted that older breast augmentation patients report a more difficult or protracted recovery process nor are their complaints about immediate postsurgical pain any more significant.

Because breast cancer occurs more commonly in middle-aged and older women than younger ones, it is a legitimate question to ask if implants interfere with its diagnosis. There is no question that there is mild interference with radiologic imaging of the breast from implants, but this is overcome by taking additional mammographic views. When it comes to MRI detection, there is no imaging difficulty.

The one issue that older women pose that many younger women do not is breast sagging or ptosis. The incidence of the need for breast lifts with implant placement is much higher in the older patient as the effects of gravity and aging have taken a greater toll.

Case Study: This 56 year-old female wanted to improve the shape of her sagging breasts. She had had four children and her breasts had lost both volume and sagged. She was currently a small C cup and wanted to at least be a D cup. She choose saline implants because they could be placed in a ‘scarless’ method (no incision on the breast) and their lower cost.

Under general anesthesia, saline implants were placed through a transaxillary (armpit) incision in a submuscular position. The implants were 500cc in volume and were filled to 550ccs on each side. (Mentor, moderate plus profile) Her armpit incisions were closed with small dissolveable sutures. She went home as an outpatient and was placed on arm stretching exercises that began that very night after surgery.

Her recovery was quite rapid and within ten days left for a beach vacation. She had a much improved looking result with good fill of her breast skin and some degree of a lifting effect as seen in her side view. Her breasts were rejuvenated with a much better look in clothes with the resultant upper pole breast fullness caused by the implants.

It usually takes about three to four weeks after surgery until breast implants settle into their final position. This is particularly true in using the transaxillary approach as the release of the lower breast tissues is done more effectively by an open inframammary crease approach.

Case Highlights:

1) Breast augmentation is just as safe and effective in older women as it is in younger women.

2) In the aging breast, the higher incidence of breast sagging may require the consideration of some form of a breast lift or the acceptance of less than ideal breast shape and nipple position.

3) Recovery after breast augmentation in older women is no more severe or prolonged than that of younger patients.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background: The immediate and long-term success of breast augmentation is totally dependent on the use of an implant. Most of the risks of this surgery are implant-related, with infection being the most significant in the short-term and implant rupture in the long-term issue. While both can happen despite the best surgical efforts, the technique of handling the implant during surgery can influence the likelihood of their occurrence.

The traditional insertion of a silicone gel breast implant depends on substantial manual manipulation. The implant is removed from its sterile packaging, often soaking in an antibiotic solution first, and then placed into the breast. Inserting an implant into a breast pocket requires that it pass through an incision. In every primary breast augmentation, the length of the incision is almost always less than the diameter of the implant. Fortunately, silicone gel implants are very malleable and able to be deformed and distorted to fit through a hole that is smaller than it is.

Depending upon the size of the incision and the breast implant, this passage into the patient may go easily or with a lot of difficulty. Easily is defined by having minimal distortion of the implant as it passes into the patient. Difficulty is defined by the implant being severely distorted as it is pushed and poked through a disproportionately small incision. While there is no documented evidence that these insertion maneuvers influence the long-term risk of shell rupture, it would seem logical that it does.

Case Study: This 21 year-old female had long desired breast enhancement since she had been a small B cup since her mid-teen years. As she was about to start her first job after college graduation, she rewarded herself with a long desired breast implant procedure. She desired to be a full C cup.

Under general anesthesia, her breast pockets were developed in the submuscular place through an inframammary or lower breast crease incision. The length of the incision was 3.5 cms. The size of the breast pocket was developed with sizers. The implant packages were opened and an antibiotic solution poured over the implants and into the half-shell plastic container. Then using a Funnel device, it was opened and an antibiotic solution poured into the funnel to wet its inner lining.

The breast implants were then dumped into the Funnel without touching them. The back end of the Funnel device was wrapped around the implant pushing it towards the smaller opening.

The smaller Funnel opening was inserted through the incision and into the breast pocket. Squeezing of the back end of the Funnel propelled the breast implant through the smaller end into the breast pocket. The incision was then closed.

The Funnel device allows a breast implant to be inserted in the most sterile fashion from the package to the patient. No human hands ever touch the implant. This would help reduce the risk of infection. But the best feature of the Funnel is that it allows smaller incisions to be used without severe distortion forces placed on the implant’s outer shell. While the implant still does have to be distorted to pass through a narrow opening, the Funnel device allows those forces to be more evenly distributed across the shell of the implant. This would seem to lessen the risk of weakening through point areas of fatigue and subsequent early implant rupture.

Case Highlights:

1) Breast augmentation using the Funnel device offers a ‘no-touch’ technique for implant insertion.

2) The benefits of a ‘no-touch’ breast augmentation technique is a potentially lower risk of infection and less handling of the implant.

3) The Funnel breast augmentation technique exposes the implant to less shearing and distortion forces which likely increases the longevity of the implant before it eventually ruptures.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Breast augmentation is a popular body contouring procedure, not only because it is successful, but also due to its instantaneous result. Unlike many types of plastic surgery where the final result takes time to see, the enlargement of the breast by an implant is immediately apparent. While temporary swelling and some bruising accompany this change, the immediacy of the size change has all patients doing close scrutiny and checking their investment.

While breast size changes dramatically at the time of surgery, it takes much longer until the breasts really feel like natural breasts. Understanding the evolution of breast augmentation recovery will reduce one’s anxiety and allow time to pass before judging the final result.

While the instantaneous size change makes for a more satisfying breast size, it does so at the expense of the elastic properties of the skin. The implant makes for stretched skin that is very tight. When combined with swelling that takes up to two days after surgery to peak, the breast will become more than just firm, they can become as hard as a rock. Some women’s breasts get harder right after surgery than others based on how firm or loose their breast tissue and skin was prior to surgery.

This breast firmness will subside as the swelling goes away and the skin’s elastic fibers relax and adjust to the new volume. It is a process that will actually take months, gradually getting better each week. That is why if you look at many early breast augmentation results that are often posted online or on various websites, the breasts look too round and even high. Just because they look this way early does not mean they will look like that six months later. The skin has yet to relax and the breast mound settle. The true feel and look of the breast can not be judged for at least three months after surgery.

Many women are concerned that as the swelling goes down so will their breast size. Largely this is not true. As the swelling subsides over a few weeks, the breast changes little in size but because less tight. Any perception of size change over time is the result of the implant settling down and not having such a high or proud position.

Regardless of the incision location used for breast implants, the skin of the breasts will develop some numbness. I am not talking here about the nipple but the skin. This numbness is primarily located over the bottom or lower pole of the breast. While some of this numbness does go away, not all women will develop completely normal feeling in this area. Fortunately the skin of the breast does not have great two-point discrimination so this is never a long-term problem, just a temporary nuisance.

While the size of the breast after augmentation occurs quickly, the feel of the breast takes much longer to develop a natural softness and normal mobility on the chest wall.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Breast augmentation achieves it success because it uses an implanted device to do so. Similar to orthopedic joint replacements or cataract eye surgery, the implant is the key part of the operation. The surgeon may get a lot of the credit for the initial results of implant procedures but, in the end, the long-term success of the operation will depend on the longevity of the implant. What is unique about breast augmentation, contrary to many implant operations, is that they are largely placed in young patients who have long remaining lifetimes.

One of the very common misconceptions about breast augmentation, and is often not thought of before the surgery, is that the implant will not last forever. Many patients assume that a breast implant will last forever. Breast implants are man-made devices which means, by definition, that they will not last forever. They will come a time, which can not be accurately predicted, when the implant will fail and need to be replaced.

Implant failure is when the bag or shell that contains saline or silicone develops a hole or tear, allowing what is inside to leak out. With saline implants, this will be relatively immediate and the implant will go flat. In silicone implants, the breast doesn’t lose volume because the synthetic gel material can not be absorbed. But silicone implant ruptures may cause discomfort or some hardening of the breast as the body reacts to the material.

This is highlighted by a recent report from the FDA that states ‘women who get silicone breast implants are likely to need additional surgery within 10 years to address complications such as rupturing of the device’. “The key point is that breast implants are not lifetime devices,” said Jeff Shuren, director of the FDA’s Center for Devices and Radiological Health. “The longer you have the implant, the more likely you are to have complications.” “Most women reported high levels of satisfaction with their body image and the shape, feel and size of their implants,” the FDA report further added.

This FDA report is not revolutionary or offers new information in regards to breast implants. It is what most plastic surgeons probably preach or highlight to every breast augmentation consult. I make it a point when talking to potential breast enlargement patients that this will not be their last breast surgery. Depending upon their age when they are implanted, even in the best scenario, that they will be having at least one and maybe two more breast implant surgeries in their lifetime. This is the reality of a fluid-filled medical implant. While many patients seem to be surprised by that insight, it has never seemed to deter a single patient from going forward with the breast implant surgery.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis Indiana

When women are seen in consultation for breast augmentation, they are understandably enthusiastic about how the operation will change the appearance of their chest. Some will be surprised to learn, however, that they will need a breast lift with an implant to achieve the best result. Breast implants are perceived by some to have the ability to lift a sagging breast when, in some cases, they actually can create the need for it.

Conversely, a women may come in only requesting a lift for her breast sagging to discover that an implant will also be needed to get the best result. It is a misconception that a breast lift has the ability to make permanent upper pole fullness, one of the desired changes with a breast lift besides nipple repositioning.

This combination of a breast implant and a breast lift, technically called an augmentation mastopexy, can be a very challenging operation to do well. This is because both operations, albeit done together, are working against each other. The implant expands the breast mound while the lift raises and tightens the breast skin. Finding an acceptable balance between the two can be difficult and it does not help that there are two breasts side by side of which the expectations are near perfect symmetry. In the face of asymmetry which nearly every women with breast sagging has only adds to the complexity of the procedure.

For these reasons, I advise all women undergoing simultaneous breast implants and a lift that there is a high revision rate with this operation. It is not my goal to have to do a revision, nor is there any economic benefit for doing so, it is just a difficult operation There are many reasons that the need for a revision may be desired including implant asymmetry, differences in mound shape or residual looseness of breast tissue and skin over the implant (bottoming out of beast tissue over the lower pole of the implant), some wide or persistent redness of the lift scars, nipple-areolar asymmetry, and adjustment of implant size. Given that breast augmentation alone has a 20% to 30% revision rate in the first three years after placement (national statistics from the manufacturer) should indicate how the ante goes up when a lift is added to the breast reshaping procedure.

The number that I like to imprint on a woman’s mind during the consultation process is a 50% risk of the need for revision for a combination breast implant and lift procedure. For many patients given their breast issues, the risk may not be that high. And my own practice experience indicates that, on average, it is not that high. (probably closer to 33%) But when significant breast sagging exists, the risk of revision may well be 50% or higher. At the least, it is a number that captures the patient’s attention and makes it more than just an infrequent occurrence.

In breast augmentation lifting, there are numerous options based on how much sagging exists and what size of the breast a woman wants. It is a balance between how much breast scarring one can tolerate and how much upward movement of the nipple is acceptable in the face of the desired mound size. One other important consideration which exists in this combination breast operation is keeping the nipple alive. In either breast augmentation or breast lifting alone, this is virtually a non-issue. But when done together, maintaining a good blood supply to the nipple is , always a consideration. Too much skin tightening, too large of an implant, or too much breast tissue undermining can compromise the survival of the nipple. This is why in doing the procedure, if in doubt, I would rather ‘underlift’ the breast or place a smaller implant than risk having the nipple die. It is much easier to do a secondary breast reshaping/revision than it is to remake a nipple.

Without question, a simultaneous breast augmentation and breast lift combination is the most difficult body plastic surgery procedure to perform from an aesthetic perspective For this reason, some plastic surgeons prefer to separate the procedures into two stages in order to reduce the risks. This is a very acceptable approach although it does expose the patient to a 100% risk of a second surgery. (and maybe even a third) When done together, the risk of a second surgery (revision) is about half that of when it is staged.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana