Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘breast augmentation’ Category

Case Study – Breast Augmentation and Cleavage

Wednesday, September 28th, 2016


Background: One of the well known mottos amongst plastic surgeons regarding breast augmentation is that implants merely take what you have and make it bigger. While simplistic, this statement is largely true. Other than mound enlargement and the potential creation of enhanced cleavage from that effect, many of the other breast features remain the same albeit larger.

There is a difference between younger vs. older breast augmentation patients. Younger women who have not had children have breast mounds that are well shaped with good overlying breast tissue. Older women, or younger women that have had children, often have breast mounds that are not well shaped and have stretched out overlying soft tissues. That difference alone can make a big difference in the aesthetic outcome of breast augmentation surgery.

Case Study: This 3o year-old female presented for breast implants. She had small but wide breast bases with well centered nipples on the mound and well defined inframammary creases at the bottom of the mound. In addition she had breast mound swhere the nipples where pointed directly forward and the breasts were almost too close together. (compared to many other women)

breast-augmentation-with-cleavage-results-front-view-dr-barry-eppley-indianapolisUnder general anesthesia and through 3.5 cm inframammary skin incisions, 450cc round high profile silicone gel breast implants were placed in the partial submuscular position.breast-augmentation-and-cleavage-results-side-view-dr-barry-eppley-indianapolis

breast-augmentation-and-cleavage-results-oblique-view-dr-barry-eppley-indianapolisHer breast augmentation results clearly show how the implants made all features of her natural breasts simply bigger. There was no reason to lower her natural inframammary folds which is actually very uncommon in my experience. She already had a good distance between her nipples and inframammary folds despite her small natural breast volume. The naturally close position of her breasts allowed for actual cleavage to be achieved even without a bra.


1) Breast implants take the breast mounds a patient has and merely makes them bigger.

2) Breast implants make cleavage if the breasts are spaced close together naturally.

3) The east-west nipple position after breast augmentation remains exactly the same as it was before surgery.

Dr. Barry Eppley

Case Study – The Perfect Breast Augmentation

Tuesday, August 30th, 2016


Background: With almost a million breast implants placed per year in the U.S. for aesthetic breast augmentation, the results achieved are highly variable even though the implants have the same basic shape. This is due a basic breast augmentation concept….all breast implants do is take what you have and make it look bigger.

Breast implants do not have the capability to fix natural breast asymmetries, sagging breasts, where the breast mound sits on the chest wall or change the position/shape of the nipple-areolar complex. Implants are simple mound enlargers that have no other magical properties to do more. For this reason it is critical that the patient be aware of what breast implants will or will not do before surgery so their postoperative expectations are realistic.

While most women will achieve satisfying results from their breast implant surgery, few women ever achieve a perfect result by either patient or surgeon assessment. This is for the simple reason that few breasts are ever perfect initially and that the placement of paired synthetic implants into the body can create different responses in healing.

Case Study: This 20 year-old female presented for breast augmentation desiring a full round breast look result. She opted for high profile silicone implants.

Perfect Breast Augmentation results front view Dr Barry Eppley IndianapolisUnder general anesthesia she had 350cc high profile silicone implants placed trough 3.5 cm long inframammary incisions in the partial submuscular dual plane position. (it required her nipple piercings to be removed right before surgery)

Perfect Breast Augmentation results oblique view Dr Barry Eppley IndianapolisPerfect Breast Augmentation result side view Dr Barry Eppley IndianapolisHer breast augmentation result is as good one as one can get. This is judged by the symmetry of the breasts and their rounded shape which she desired. While good placement and surgical technique was needed, it was aided by the good symmetric shape of her breasts before surgery.


1) The best breast augmentation results occur in those women who have the best breast tissue/shape before surgery.

2) A high profile silicone breast implant produces a fuller looking breast mound with good upper pole fullness.

3) Symmetry is an important element of a good breast augmentation result.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Implants and Cleavage

Wednesday, July 6th, 2016


cleavageBackground:  Cleavage is defined as the area between the breasts. It usually confers that the inner or medial part of the breast mound encroaches upon the flat sternum which lies between the breasts. While the term defines a certain breast appearance it usually refers to a look that is seen in clothing such as a low cut shirt or blouse, lingerie or swimwear. For Western cultures cleavage is usually viewed as an important element of femininity and sexual attractiveness.

Patients have many expectations from breast augmentation surgery and having cleavage afterwards is often one of them. Having much fuller inner breast mounds that are more prominent and rounder with the breasts fully exposed is often their goal. This is somewhat ironic in that how cleavage is usually perceived is in clothes with a low neckline. Thus surgically enhancing a fully exposed breast that has a cleavage appearance  is a bit unnatural and is asking the breast implant to do what clothing usually creates. This is particularly true in today’s modern positioning of the implant in the submuscular location.

But what defines whether cleavage is the result of placing breast implants or not is the patient’s chest anatomy and the size and positioning of the implant. Breast mound and nipple spacing between both sides is a major factor. Many women simply have very widely spaced breasts and no matter what size breast implant is placed, augmented inner breast fullness is not going to occur.

Case Study: This 42 year-old female presented for breast augmentation. She had small breast with good skin. Her nipples were located on the breast mound at the mid-clavicular level.

Breast Implants and Cleavage result front view Dr Barry Eppley IndianapolisBreast Implants and Cleavage results oblique view Dr Barry Eppley IndianapolisUnder general anesthesia she had smooth round silicone breast implants placed of 375cc through inframammary incisions. Her results show the creation of unsupported fullness in the inner poles of her breasts.

Whether cleavage will result from breast augmentation depends on the spacing of the breast mound and nipples, the location of implant placement (subfascial vs submuscular), the size and projection of the breast implant and the amount of tissue quality that makes up the breast mounds. For most women undergoing breast enhancement prominent cleavage will not be the result. But when several of the natural breast characteristics are just right, some women will indeed develop an inner breast appearance that can appear without clothes to what it may be in clothes.


1) Breast implants rarely create cleavage for most breast augmentation patients.

2) The spacing of the breasts and the width of the sternal gap are the main natural limitations to breast augmentation cleavage.

3) When the distance from the sternum to the nipples is 12 cms or less, and the breast implants are of adequate size, postoperative cleavage can occur.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Teardrop Breast Implants

Wednesday, July 6th, 2016


Background: Breast implants have obvious effects on increasing the size of the breasts. While volume of the breast obtained per implant size will vary amongst patients, it is obvious that the larger the implant is the larger the breast becomes.

But when it comes to breast implant shape, the effect on the outer breast is not so straightforward or always completely predictable. In round implants they come in different projections (e.g., medium, medium plus and  high) which makes alterations in the height vs width measurements within the same implant volume. Such changes in implant dimensions, however, are not as significant as that between implant shell shapes.

Teardrop Breast Implants Dr Barry Eppley Indianapolis copySilicone implant shells come in two shapes, round and anatomic. (aka tear drop) The anatomic implant. also called the shaped breast implant, has a defined difference in its upper and lower pole configuration. By making the bottom part of the implant fuller (2/3s of the implant’s volume) it will have the same shape regardless of whether the patient is standing or laying down. Because of having this shape, it is important that the implant does not move around or rotate after surgery. Thus the implant shell has a textured layering on its outer aspect making it thicker than a smooth silicone implant. This means the implant will feel more firm and will not move regardless of the patient’s position.

Case Study: This 35 year-old female wanted a breast augmentation result that was very natural looking. Her definition of that breast look was that it was not too round on the top part of the breast.

Teardrop Breast Implants result results oblique view Dr Barry Eppley IndianapolisUnder general anesthesia she had shaped breast implants placed of 350cc silicone through inframamammary incisions.

Tear drop Breast Implants result side view Dr Barry Eppley IndianapolisHer six week after surgery results show a very natural looking result of modest size with good implant symmetry. This satisfactorily achieved her breast enhancement goals.

Shaped or teardrop breast implants have a role to play in breast augmentation surgery. They give women an option that has a more powerful effect on the final breast result that does implant projection.


1) The design of a breast implant shell has both an initial and long-term impact on the external shape of the breast.

2) Anatomic breast implants allow for less initial upper pole fullness and a quicker attainment of a natural breast shape.

3) Anatomic breast implants are best inserted through an inframammary approach to ensure optimal implant orientation which is critical in these type of breast devices.

Dr. Barry Eppley

Indianapolis, Indiana

The Role of the Nipple Lift in Breast Augmentation

Monday, July 4th, 2016


Some women that undergo breast augmentation surgery have various breast asymmetries. These could be differences in the mound size, level of the inframammary fold and the size and shape of the nipple-areolar complex. Because it is the most visible part of the female breast, the size and location of the nipple on the breast mound often plays a major role in how a breast augmentation result is perceived from a symmetry standpoint.

Differences in the horizontal position of the nipple need to be recognized before surgery. As implant enlargement will almost always make a horizontal nipple asymmetry worse. If not recognized before surgery patients may perceive that it was the fault of the surgeon or the implant surgery in general. When pointed out before surgery this gives the surgeon and the patient the opportunity to review management options.

Breast Augmentation with right nipple lift results oblique view Dr Barry Eppley IndianapolisBreast augmentation with right nipple liftresults front view Dr Barry Eppley IndianapolisThe only surgical management option is a superior crescent mastopexy (SCM) or, more accurately, termed a superior nipple lift. (SNL) Not a true breast lift, it is where the superior border of the areola is moved upward through a skin excision shaped like a crescent. The areolar margin can be moved upward from 10 to 12mms in most cases. This is usually enough to either make the upper margins of the areolas even or at least much closer.

It is important to realize that a nipple and a breast mound that is significantly lower than the other side may require a different management strategy. When the horizontal nipple distance is greater than 15mm,  a vertical breast lift would be more effective.

A superior nipple lift does so at the expense of small line scar at the areolar-skin margin. This scar will be red for a few months but usually fades to be inconspicous with more healing time.

Dr. Barry Eppley

Indianapolis, Indiana

Natural Breast Augmentation

Friday, June 17th, 2016


One basic preoperative concept of breast augmentation has taken on a contemporary approach of tissue-based planning. Such an approach strives to achieve a ‘natural breast augmentation’ result by not overwhelming the breast tissues with implants that are more than the tissue can accommodate. By having good tissue support for the implant there is a  lower risk of bottoming out, implant malpositions and reoperation rates. To some degree this fundamentally means that smaller breast implant sizes are used.

Based on a study of natural breast beauty the ICE principle has been described. This is an acronym that stands for Implant dimensions, Capacity of the breast and Excess tissue required. This is a simplified approach for calculating the inframammary fold incision placement and to create a 45:55 ratio between the upper and lower poles of the breast. The key element in this approach is the location of the new inframammary fold.

In the June 2016 issue of the journal Plastic and Reconstructive Surgery, a paper was published entitled ‘Design for Natural Breast Augmentation: The ICE Principle’. The paper described a study of 50 women who had primary breast augmentation using the ICE principle. The study looked at both round and anatomical silicone breast implants using the implant meridian relative to the nipple-areolar complex. For an anatomic implant it is 50:50 compared to a round implant of 45:55. The mean upper pole:lower pole ratio changed form 52:48 before surgery to 45:55 after surgery. Mean nipple angulation improved from 11 degrees to 19 degrees upward. The accuracy of the inframammary incision location was 99%.

Asian Female Breast Augmentation result oblique view Dr Barry Eppley IndianapolisThe ICE principle takes into account that in the vast majority of breast augmentations the inframammary fold must be lowered. Much of the work of a breast implant occurs in the lower pole of the breast which must be expanded. If not the upper pole will develop excessive fullness and the position of the implant will cause the breasts to look too high and unnatural. Expansion of the lower breast pole requires extra skin which comes from the abdomen. Knowing where to place the incision in the new inframammary fold location is key. This is not only to avoid a visible incision below the new fold but also to allow a greater amount of the implant to sit below horizontal level of the nipple-areolar complex. Knowing the diameter of the implant allows these measurements to determine the location of the new inframammary fold.

Natural Breast Augmentation Indianapolis Dr Barry EppleyA natural breast augmentation for most women means a breast that has an upper pole that is less full than the lower. Achieving this look does not always require a smaller breast implant to achieve it. The amount of available breast tissue, the natural width of the breast and the elasticity of the tissues may mean a larger breast implant by volume can still allow for a bigger breast augmentation result to still look natural.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Hispanic Breast Augmentation

Wednesday, June 8th, 2016


Background: Breast augmentation is a common body contouring procedure. Of the many pictures of breast augmentation results on the internet, the vast majority are of Caucasian type. The main difference with Hispanic or Latin women is their increased propensity to develop dark pigmentation at incision/scar sites. While they almost never develop hypertrophic or keloid scars, the color of the scar may still make it noticeable.

Case Study: This 21 year-old hispanic female never had any breast tissue develop. Her chest was completely flat with a small diameter areola.

Hispanic Breast Augmentation results front view Dr Barry Eppley IndianapolisUnder general anesthesia she underwent the placement of 300cc smooth high profile silicone breast implants through a high axillary incision. (3 cms length) Her implants were placed using a funnel insertion technique.

Hispanic Breast Augmentation results obique view Dr Barry Epley IndianapolisHispanic Breast Augmentation result side view Dr Barry Eppley IndianapolisHer result at six weeks after surgery showed a scarless breast augmentation with tight skin over the implants. With six to none months more time her very round breast augmentation result will soften and they will become more natural and softer.

Young Hispanic breast augmentation patients may want to avoid even the smallest scar at the inframammary fold area. The transaxillary incision offers a scarless approach that is appealing to women of increased pigments. Being placed in the hair bearing skin of the axilla, it heals very well and rarely develops any significant hyperpigmentation.


1) Breast augmentation can make a dramatic change in one’s self image for young women who have no breast tissue. (flat chest)

2) The young juvenile appearing female chest with tight skin will create more of a rounder appearing breast implant result.

3) Hispanic breast augmentation women may prefer a ‘scarless’ method using high axillary skin incisions.

Dr. Barry Eppley

Indianapolis, Indiana

The Ideal Implant for Breast Augmentation

Friday, May 6th, 2016


Historically the choice for women considering breast augmentation were either saline or silicone devices. These very contrasting breast implants choices have very well known advantages and disadvantages. Saline breast implants offer the most economical approach to the procedure with aesthetic device issues such as rippling, an unnatural feel in some patients and the risk of an eventual dramatic and inconvenient failure event. Silicone breast implants offer an improved and more natural feel and no risk of a dramatic deflation event albeit at a higher surgical cost.

Ideal Implant Dr Barry Eppley IndianapolisAlong has come the Ideal implant which marries characteristics of both saline and silicone breast implants. The advantages of the Ideal breast implant over either traditional saline or silicone implants are numerous. They offer the benefits of both types of implants without any of their downsides. The Ideal implant has an external feel that is similar to that of silicone implants (no rippling) but without the use of any silicone filler material. For those women that may harbor some persistent concerns about silicone gel, this provides peace of mind. It will also not suffer a complete implant deflation which lets the patient know their implant has a problem (partial deflation) but yet will not go completely flat.

Ideal Implant structure Dr Barry Eppley IndianapolisIdeal Implant internal structure Dr Barry Eppley IndianapolisHow does the Ideal implant achieve these improved physical characteristics over the traditional saline breast implant? It is in its proprietary and clever internal design. The implants has an internal structure which has an inner shell around the inner chamber which contains the inner saline filler and an outer shell around an outer chamber which holds the outer saline filler. Between these two shells are several baffle shells. This specialized type of inner structure controls the movement of saline inside the implant.

Bernoulli's PrincipleEven in a saline breast implant which has been filled to the point of stretching out the silicone containment bag (shell) and appears full, fluid does move around in waves inside it. But why does a traditional saline implant have ripples and feel so soft and extremely pliable? Using  the well known Bernoulli’s Principle, the pressure in a moving fluid decreases as its speed increases, and increases as speed decreases. Thus the saline in a traditional implant moves very rapidly and therefore exerts a low pressure on the outer shell. The innovation of the Ideal breast implant is that its internal structure chambers and baffles slow the movement of the saline down and, as a result, increases the pressure on the outer shell which dramatically reduces wrinkling and makes it feel more firm. (like a silicone breast implant)

Ideal Implant shape Dr Barry Eppley IndianapolisSuch fluid dynamics also affect the shape of the implant. The Ideal implant maintains a higher profile with lower edges and better upper pole fullness than that of a silicone implant. It does not develop the so called ‘ash tray’ effect that almost all silicone implants do that occurs when the implant is laying on a flat surface.

Dr. Barry Eppley

Indianapolis, Indiana

Transgender Breast Augmentation

Wednesday, May 4th, 2016


As transgender plastic surgery becomes more prevalent, the number of patients seeking such face and body transformations are steadily increasing in number. In the male to female transgender patient, facial feminization surgeries and body enhancements of the breasts and buttocks are the mainstays of the physical metamorphosis.

In considering breast augmentation, there are initial obvious differences in the shape of the female vs. male chest. The absence of the development of a natural breast mound, the thickness of the pectoralis muscle and location/adherence of the inframammary fold are all considerations in how the phenotypic male chest will respond to the stretch of a breast implant.

Transgender Bresat Augmentation intraop result 2 Dr Barry Eppley IndianapolisThe ability of the overlying skin to stretch is essentially the same between male and females. Male chest skin and underlying soft tissues is going to be tighter due to the absence of an overlying breast mound. This makes many transgender breast augmentation results look very round and have a lot of upper pole fullness. This may not relax as much over time and, if this breast mound shape is bothersome, one needs to consider an anatomic (tear drop) implant shape initially.

The pectoralis muscle is thicker in males and will thin to some degree with hormone therapies. The greater muscle thickness will contribute to increased upper pole fullness when the implant is placed in a partial submuscular or dual plane position and may be an accompanying reason with tighter skin that a rounder breast implant look often occurs. This can become even more evident or magnified when high profile saline implants are used.

Transgender Breast Augmentation intraop result Dr Barry Eppley IndianapolisThe inframammary fold poses an interesting issue as all transgender breast augmentations require its release and lowering. This runs the traditional risk of a persistent horizontal crease across the lower pole of the new breast and the creastion of a double bubble problem. But my experience has been that this is less likely to occur in transgender breast augmentations than in traditional female breasts. This may be because the male inframammary fold is actually less adherent and defined as that of the female one which was developed to hold up the position of the lower breast mound.

Transgender breast augmentation is a very successful procedure that creates a satisfactory breast mound despite some anatomic differences in the shape of genetically formed male chest.

Dr. Barry Eppley

Indianapolis, Indiana

Large Breast Implants

Tuesday, April 26th, 2016


While there many important issues to consider in breast augmentation, the size of the implant is one that women spent the greatest amount of time pondering before surgery. There are a variety of implant sizing methods and they all have their merits, but the reality is that breast implant sizing is not an exact science. No patient can really know for sure how they like the implant size selection until they swelling goes down and they have ‘worn’ it for awhile.

Women for breast augmentation usually want an implant size that looks natural, fits their body frame and does not stand out as their most notable feature. What that implant size may be is open to interpretation and highly subjective. But there are women who do want to have large breast implants and their goal clearly is not to be subtle in the result and a natural look is not their goal.

Breast implants come in a wide range of sizes from 150cc to 800cc. Because silicone implants are prefilled, their maximize size is 800cc volume. Saline implants, however, are alway overfilled and their volume can well exceed 1000ccs if desired. Considering these options in breast implant sizes, a large breast augmentation is going to be in the range of 600cc to 800ccs. For some women the volume may be much more.

For a variety of reasons, many plastic surgeons are opposed to larger breast implants. Such opposition is based on two basic and understandable reasons. Large breast implants are associated with a higher rate of complications such as loss of tissue support (bottoming out), implant asymmetries and deflations. (saline implants) The fundamental teaching in plastic surgery is to not place implants that exceed the ability of the tissues to support them long-term. The second reason for objection is the long-term consequences of the stretched out breast tissue. Large implants do deform the breast tissue irreversibly and their removal or reduction in size in the future will necessitate major breast lift surgery and its associated scars.

But breast implant size is a very personal decision and as long as the patient has been educated as to its potential consequences, large breast implants are a patient’s choice. The most common women who seeks large breast implants in my experience is the one who already has breast implants. They may have had them for years and now desire a much larger size. They may have had children or lost weight and their overall breast size has gotten smaller and a lot more volume is needed to fill out the loose skin. In these cases it can take a lot of implant volume to adequately expand the stretched out breast skin. In many ways these women are much more ‘qualified’ for large breast implants because they have a better frame of reference.

Some first time breast augmentation patients do seek large breast implants but they are far less common. Big for them might be up to 500ccs or so in small frames and 600cc to 700ccs in larger framed women. This is big for them given where they started but are not that big compared to women who are changing their existing breast implants.

The concept of large breast implants is open to interpretation but would be anatomically one where the implant width exceeds that of the the natural breast base width. While this may contribute to better cleavage it equally means that the side of the implant will protrude out beyond that of the chest wall.

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.

Read More

Free Plastic Surgery Consultation

*required fields

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits