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Archive for the ‘breast augmentation’ Category

Preventing Infections in Breast Augmentation

Sunday, May 21st, 2017


Breast augmentation is one off the procedures in plastic surgery in which the use of an implant is mandatory and is inserted into patients in large numbers. While there are numerous complications that can develop from the procedure, the most dreaded one is infection. Such a complication risks everything with the likely outcome of the need to remove the implant.

The most common reason any implant infection occurs is bacterial contamination and inadvertent inoculation of the implant. While the implant may be sterile in the packaging there are numerous opportunities for it to become inoculated between the box and the implant pocket. While most plastic surgeons use numerous safeguards to prevent infection there are no standards of practice amongst all of them.

In the June 2017 issue of the Annals of Plastic Surgery, an article was published entitled ‘Antimicrobial Prophylaxis Practice Patterns in Breast Augmentation: A National Survey of Current Practice’. In this paper, a surgery was sent to members of the American Society of Plastic Surgeons to assess their practice patterns of preventing infections in breast augmentation surgery. Of all the members solicited just over 250 responses were obtained. The results of the surgery showed that Chlorhexidine was used for surgery site prep in just about 50% of the respondents and a triple antibiotic solution was used for both implants soak (40%) and pocket irrigation (almost 50%) before implant placement. Interestingly over 40% of the surgeons used a no-touch funnel for implant insertion. After surgery antibiotics included a first-generation cephalosporin (Keflex) in almost 80% of respondents and was used up to one week after surgery in about half of the reported surgeon’s practices.

While there was no accompanying reporting of the respondent’s rates of infections, it is clear that an aggressive approach to breast implant infection is generally used that presumably creates a low risk of postoperative infection. Preventing bacterial contamination is being done at multiple levels from surgical site preparation, pocket and implant decontamination to after surgery systemic antibiotic prophylaxis.

In my breast augmentation practice, thus multi-level approach is used to prevent postoperative implant infection. While every level of infection prevention is important, the funnel insertion technique in which the implant is not touched by human hands is an invaluable part of the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Bra and Breast Implant Cup Size Volumes

Friday, April 28th, 2017


In breast augmentation surgery women should choose implant size based on the way it makes the breast look. But the obvious question from prospective patients is what cup size will I be afterwards? Ot what implant volume is needed to give the cup size they want? Historically the common answer is that a cup size is about 100cc, more or less based on the size of the patient. The correlation between bra cup size and implant volumes has never been directly studied and compared.

In the May 2017 issue of the journal Plastic and Reconstructive Surgery a paper was published entitled ‘What Is the Standard Volume to Increase a Cup Size for Breast Augmentation Surgery? A Novel Three-Dimensional Computed Tomographic Approach’. The authors used five bra cup sizes from three different manufacturers to assess their volumes using linear measurements, water displacement and volume calculations from 3D CT reconstructions. In addition almost 80 breast augmentation patients were assessed comparing implant volume and patient questionnaires. Their reported results showed that amongst bra manufacturers an average volume of 135cc for each cup size increase was found. In patients the average volume increase per cup size was 138cc.

To no surprises the authors found that there was no standardization of cup sizes amongst the manufacturers studied. The authors conclude that a range of 130ccs to 150ccs is equivalent to a one cup size increase. Narrow bra widths need 130cc while larger bra widths need 150ccs.

While the size of the patient undergoing breast augmentation is well known to affect how the augmented breast will look, it is good to offer patients some general guidelines. Whether it is for a primary breast augmentation or for the patient changing implants for size reasons, the use of a 125cc to 150cc breast implant volume per cup size is vey helpful. For small women it is probably closer to 100cc while for larger women the use of 150ccs is more accurate.

Dr. Barry Eppley

Indianapolis, Indiana

Anatomic Breast Implants

Friday, March 24th, 2017


Anatomic Shaped Breast Implants Dr Barry Eppley IndianapolisBreast augmentation is primarily done using round smooth implants in the vast majority of cases in the U.S. Anatomic or shaped breast implants, while widely used elsewhere in the world, only became approved in the U.S.in 2012. The anatomic shaped implant have gained traction amongst some patients with the belief that they will look more natural. This seems perfectly logical when looking at the shape of the implant with less upper pole fullness to it. (a natural look being defined as less round looking)

But the use of anatomic breast implants is not without their own disadvantages. They cost more, can potentially rotate postoperatively and require some modification in the surgical technique to place them. They also have a textured coating on their outer shell (to prevent rotation) and can feel more stiff or firm than round smooth breast implants.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery an article was published entitled ‘Intraoperative Comparison of Anatomical vs Round Implants in Breast Augmentation: A Randomized Clinical Trial’. In this paper the authors looked at 75 primary breast augmentation patients with a round implant placed in one breast and an anatomical implant of similar dimensions and size placed in the other breast. After intraoperative pictures were taken the anatomical implant was replaced with a round one  before closure. The intraoperative appearance of the breasts was then assessed by blinded visual evaluations amongst plastic surgeons and lay reviewers.

The study results showed that no observable difference was observed between the two shapes of breast implants in 43% of the cases reviewed by plastic surgeons and 30% of the cases reviewed by lay reviewers. When a difference between the tow sides was observed plastic surgeons judged the anatomical side better in 51% of the cases. Lay reviewers judged the anatomical side better in 47% of the cases. Plastic surgeons identified the correct implant shape in only 25% of the cases. Based on these findings the authors conclude there is no aesthetic advantage provided by anatomic breast implants.

This study is very unique in that it tests how the two different implants look in the same patient. I initially thought the patient was going to be implanted and maintained with two different implants but ths study is understandably limited to intraoperative observations only. On the surface this study provides compelling evidence that anatomic implants do not offer a more natural result than that of round implants.

Anatomic Breast Implants results oblique view Dr Barry Eppley IndianapolisBut like all clinical studies, it has limitations that makes its conclusion not as compelling as it might otherwise seem. I find three specific issues that the study does not take into consideration which can affect the results. First, the final shape of any implant in the body requires tissue contraction around the implant. (not just swelling resolution) All implant pockets involve elevation of tissues from their natural position. How any implant looks with the tissues have yet to contract back down around the inserted implant can not be accurately predicted during surgery. Second, this study involves relatively small implants. (average size less than 300ccs) At this end of the implant size spectrum shape differences may not be as fully evident as in larger implant sizes. Lastly what the condition of the breast tissues are on top of the implant will affect on how it looks. Such a study variable can only be controlled by using prepregnancy breast tissues without ptosis that otherwise look fairly similar.

The most relevant conclusion from this study for me, and what I tell patients all the time, is that the use of anatomic breast implants should be done for compelling reasons. Such implants have some disadvantages that round implants don’t have. Thus their use should be for good reasons such as the patient’s desire to do everything they can to avoid a round breast augmentation result. This becomes particularly relevant as breast implant size becomes bigger.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: 18 Year Old Silicone Breast Augmentation

Friday, March 24th, 2017


Background: The use of silicone implants for breast augmentation has now been done since 2006 when this implant filler material was re-introduced as an implant option. One of the stated restrictions with their use was that patients had to be 22 years or older. This was a position imposed on the manufacturers as issued by the FDA. As a result this is on the package inserts as indications for clinical use.

This silicone breast implant guideline from the FDA causes considerable confusion. Many breast augmentation patients under 22 years old want silicone rather than saline implants but feel they can not have them. Plastic surgeons may also follow this guideline rigidly feeling that they don’t want to be violation with the FDA. They may also feel that implanting young patients with these devices may invalidate the manufacturer’s warranty.

There is some debate as to why the FDA imposed this clinical guideline. One belief is that there were no patients under 22 years old in the submitted clinical study used for FDA evaluation. This would seem to be the most logical explanation but apparently there some such patients in the study. It is more likely that there was simply not enough patients in this age group to draw the same conclusions as the older patients.

Case Study: This 18 year-old female wanted breast implants but preferred silicone over a saline implant fill. She developed little natural breast tissue and had small but visible breast mounds.

Young Breast Augmentation results front view Dr Barry Eppley IndianapolisUnder general anesthesia and through a transaxillary approach, 375cc high profile silicone implants were placed in a submuscular position. The implants were inserted using a funnel device to minimize any handling of the implants as well as to allow them to be placed in a ‘scarless’ fashion through a small hidden incision.

Young Breast Augmentation results oblique view Dr Barry Eppley IndianapolisYoung Breast Augmentation results side view Dr Barry Eppley IndianapolisHer after surgery results show excellent symmetry of the implants with an expected rounder shape to the enlarged breast mounds.  She had wide sternal spacing of the implants but this was to be expected based on her preoperative anatomy.

There is no clinical difference in the use of silicone breast implants whether one is older or younger than the age of 22 years old. Their use should be based on surgeon discretion and presurgical patient education.


  1. Per manufacturer guidelines, silicone breast augmentation is for patients 22 years and older.
  2. Silicone breast augmentation can be done on women as young as age 18.
  3. The tight skin of young patients will create more of a round breast look with implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Asymmetry Augmentation

Monday, March 6th, 2017


Background: While few women have symmetric breasts, it is not rare that many breast augmentation patients expect symmetric looking breasts after surgery. This common expectation has led to the plastic surgery phrase ‘breasts are sisters and not twins’, which is usually provided as part of the preoperative counseling.

While most breast asymmetries are caused by pregnancy and weight loss/gain and can be relatively minor, more significant breast asymmetries are congenital in origin. The breasts  simply developed differently. There will be differences in the size of the breast mounds and with that comes horizontal nipple-areolar and inframammay fold position differences.

In placing implants in more significant breast asymmetries, there is the obvious issue of implant size (in ccs) and whether two similar or different implant volumes should be used. But managing the nipple-areolar and breast fold differences is often of equal if not greater importance in some cases.

Case Study: This 21 year-old Indian female presented for breast implants. She had previously tried fat injections for breast size increase but the result was too modest. She now wanted implants to achieve a more profound breast size increase. The right breast mound was noticeably smaller with a lower nipple position and a higher inframammary fold level. Her right breast was really a variant of a constricted breast deformity.

Breast Asymmetry Augmentationresult front view Dr Barry Eppley IndianapolisUnder general  anesthesia and through a transaxillary incisional approach, 400cc high profile silicone breast implants were placed in a dual plane (partial submuscular) position. Her postoperative results at three months a much improved mound symmetry and level of the inframammary folds. Her nipple-areolar asymmetry remained unchanged, no better or worse.

Breast Asymetry Augmentation result oblique view Dr Barry Eppley IndianapolisBreast Asymmetry Augmentation result side view Dr Barry Eppley IndianapolisBreast asymmetries can be effectively improved by the placement of implants alone. If the preoperative differences in the breasts are not too great it is usually best to use identically sized implants.  Mound and breast fold differences can be improved but horizontal differences in the level of the nipples will not. This can be improved by either a simultaneous superior crescent nipple lift performed either at the breast implant surgery or deferred to later where it can be performed in the office under local anesthesia.


1) Breast asymmetry is a common preoperative finding in breast augmentation surgery.

2) Breast implants may improve or even make worse the appearance of breast asymmetry based on its anatomic basis.

3) Breast mound differences are usually improved by the placement of implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Implants and Stretch Marks

Sunday, February 12th, 2017


Background:  The finding of stretch marks on the breasts is common and reflects loss of skin elasticity from pregnancy and/or weight gain/loss. They always occur in a radiating pattern around the areola like rays of the sun. Careful inspection of the stretch marks will reveal that they are thinner than the surrounding skin and have less pigment. In many ways, they represent skin that has partially torn and is now a line of scar.

It is rare that breast implants ever cause stretch marks. It can happen, and it is an occurrence I have read about, but no a postperative breast augmentation finding that I have ever seen. Conversely, the other question is whether placing breast implants will make existing stretch marks look worse. Since so many women have them it is an understandable concern of will happen to them afterwards when the breasts become larger.

Case Study: This 32 year-old female came in for breast implants. She had lost most of her breast volume after multiple pregnancies. Despite the involution her nipples had good position above her inframammary folds. But she did have many wide and deep stretch marks radiating outward from her areola in a 360 degree pattern.

Breast Implants and Stretch Marks result front view Dr Barry Eppley IndianapolisUnder general anesthesia and through inframammary incisions , 325cc smooth round silicone breast implants were placed in a dual plane position. Her stretched out breast mound skin had no problem accommodating these modest size breast implants.

Breast Implants and Stretch marks result oblique view Dr Barry Eppley IndianapolisBreast Implants and Stretch Marks result side view Dr Barry Eppley IndianapolisHer breast appearance just a few weeks after surgery shows stretch marks that actually appear worse. Often times the immediate stretch of the tissues from the implants makes the scar hyperemic and the small capillaries in them dilate. This subsides over first couple months as the swelling goes down and the skin relaxes.


1) Having stretch marks on the breasts does not preclude one from having breast implants.

2) Breast augmentation surgery may temporarily make severe stretch marks look worse due to temporary redness.

3) Breast augmentation surgery, on average, does not appear to make stretch marks look better or worse in the long run.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Weight Loss Breast Augmentation

Saturday, February 11th, 2017


Background:  Significant weight loss, albeit through diet and exercise or bariatric surgery, will have a dramatic effect on all body areas. As the fat is burned off the support for the skin is lost. This causes an overall body sag that creates a well known collection of body changes that are most reflected centrally in the trunk.

For women one of the most affected areas is that of the breasts. The loss of breast volume allows the overlying skin to sag and the nipples to head south. What degree of breast sag that ensues depends on how large the breasts were initially and whether they had any significant sag before the weight loss. Smaller breasts develop less sag while larger breasts can have a dramatic sag with a large skin sleeve that ends up having them lay against the upper abdomen.

Breast implants are almost always needed for ‘reconstruction’ of the weight loss breast. Whether they can be effective by themselves without the need for a breast lift depends on how much skin sag exists.

Weight Loss Breast Augmentation Female before surgery Dr Barry Eppley IndianapolisCase Study: This 22 year-old female underwent a 60lb weight loss on her own without the need for bariatric surgery. The breasts must have been initially small ad the skin sag was slight and the nipples still remained fairly centralized on the reduced mound size.

Weight Loss Breast Augmentation result front view Dr Barry Eppley IndianapolisWeight Loss Breast Augmentation result right oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, a transaxillary approach was used to place 375cc saline breast implants that were filled bilaterally to 450ccs in the partial submuscular position. This filled out her breasts fully. Like many transaxillary breat augmentation approaches, the initial result will have slightly too much upper pole fullness which will settle over time.

Weight Loss Breast Augmentation result side view Dr Barry Eppley IndianapolisWith the nipples above the inframammary fold, breast implants is all that is needed in the large weight loss female. Unfortunately for many weight loss women the breast condition is not so favorable that implants alone will suffice.


1) Significant weight loss affects the breasts through loss of breast tissue and often creating a breast mound sag.

2) Breast implants can produce a dramatic change in breast size and shape in breasts that have lost a lot of volume. (weight loss breast augmentation)

3) Breast implants alone will work in the weight loss patient IF the position of the the nipple is at or just below the inframammary crease.

Dr. Barry Eppley

Indianapolis, Indiana

Anatomic vs Round Silicone Breast Implants

Sunday, January 22nd, 2017


Anatomic Breast Implants Dr Barry Eppley IndianapolisAnatomic or tear drop breast implants purportedly offer a more natural breast augmentation result. This seems to make complete sense when one looks at the shape of an anatomic implant where it has a teardrop shape that more closely mimics a natural breast than a round-shaped implant.

In the January 2016 issue of the journal Plastic and Reconstructive Surgery a paper on this topic was published entitled ‘Comparing Round and Anatomically Shaped Implants in Augmentation Mammoplasty: The Experts’ Ability to Differentiate the Type of Implant’. In this paper thirty (30) plastic surgeons and nurses looked at before and after pictures of thirty (30) submuscular silicone breast implants, either round or anatomic shaped) with an average volume of around 300cc (none greater than 340cc) within the first 3 months after surgery. Among the total of 1800 observations done, the observers could only accurately identify the correct implant style 50% of the time.

While previous studies looking at the same breast implant shape issue have shown similar inabilities to identify the type of implant shape used, this is the first one that has done so in a prospective analytical designed fashion. It is well known that the round or convex form of a breast implant will change into an anatomic shape in the standing position due to both the pressure of the overlying pectoral muscle and gravity. It only re-assumes a more rounded shape when laying down just like the implant looks when laying outside the patient on a table.

Anatomic Breast Implants results front view Dr Barry Eppley IndianapolisAnatomic Breast Implants results oblique view Dr Barry Eppley IndianapolisWhile these study results are both solid and I believe accurate, it is important to point out that its relevance is with smaller implant sizes and with them in the subpectoral pocket. Whether similar results would occur in larger breast implant sizes or in the subfascial position is open for debate. It has been my experience that in larger breast implants the effect of an anatomic breast implant is more relevant particularly in the short term. I would also have little doubt that a shaped implant would look more natural in the subfascial location.

When choosing an anatomic breast implant there should be compelling reasons to do so given their higher cost and risk of malrotation and breast shape deformation, a complication that does not exist with round implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Fat Injection Breast Augmentation Outcome

Monday, January 16th, 2017


Background:  Breast augmentation is the most common as well as recognized body contouring operation. Performed through the placement of an implant, its after surgery volume retention is assured. Its downside is that the use of a gel or saline-filled device makes it susceptible to numerous long-term implant related issues and further surgeries.

Fat injection breast augmentation (FIBA) is an appealing alternative to the use of implants in an elective aesthetic procedure. Since the breasts are composed of fibrofatty tissue, adding fat would be a natural and well accepted augmentation tissue. In addition, some patients do have excess fat they would like to get shed and putting in the breasts at the same time is more than a logical exchange.

But many younger women with small breasts have thin body frames. There can be a correlation between breast size and body habitus in some women. Even in women with some visible fat to harvest, it is important to remember the ‘halving principle’ in injectable fat grafting. This goes as follows…half of the harvested liposuction aspirate is removed by concentration, the concentrated fat is split or halved between the two breasts and half of the injected fat will be resorbed. (or 50% volume retention)

Understanding this principle helps patients to determine if fat injections are a good choice for their breast augmentation as well as to have realistic expectations about the volume increase outcome.

Case Study: This 20 year-old female wanted to have breast augmentation by fat injections. She did have some modest fat to harvest from her abdomen and flanks and was well informed that this approach to her breast augmentation would result in a very modest change at best.

Fat Injection Breast Augmentation Dr Barry Eppley IndianapolisUnder general anesthesia she had 845cc of liposuction aspirate harvested from her abdomen and flanks. The aspirate was concentrated down to 430cc of injectable material which was used to inject 215cc into each breast.

Fat Injection Breast Augmentation result front view Dr Barry Eppley IndianapolisFat Injection Breast Augmentation result obloque view Dr Barry Eppley IndianapolisHer one year after surgery results showed a visible augmentation benefit that was about a 1/2 cup size increase. She eventually decided to get breast implants for a much larger result.

Fat Injectionk Breast Augmentation result side view Dr Barry Eppley IndianapolisFat injection breast augmentation is a very appealing alternative to implants but patient selection is critical. Until the science of fat grafting is better understood and fat cell survival can be increased, its use in breast augmentation will remain limited to those patients seek very modest breast size increases.


1) The success of fat injection breast augmentation depends on how much fat one has to harvest and how much survives after being injected.

2) Enlarging the breasts by injectable fat grafting usually result in modest change in the range of a 1/2 cup bra size or so.

3) Potential patients need to consider the ‘halving principle’ when considering augmentation by injectable fat grafting.

Dr. Barry Eppley

Indianapolis, Indiana

Congenital Symmastia Correction

Friday, January 13th, 2017


One of the rare congenital breast conditions is symmastia. This condition is where the two breasts converge across the sternum eliminating the cleavage area and replacing it with the inner halfs of the breast mounds or a webbing. The name comes from Greek word derivation combining syn (together) and mastos. (breast)

While it is a well known complication from breast augmentation though disruption of the medial edges of the pectoralis muscle, as a congenital deformity it is very rare. Few cases have ever been reported and as a result no standard surgical treatment exists.

In the December 2016 issue of the journal Plastic and Reconstructive Global Open issue a paper was published entitled ‘Congenital Symmastia – A 3 Step Approach.’ In this described technique Liposuction was performed in the presternal area and the web between the breasts but was not extended beyond the lateral border of the sternum. An inframammary fold incision was made just 3 cm lateral to the midline of the sternum. Three quilting sutures were inserted in the intermammary area on each side of the midline between the dermis of the presternal skin and the periosteum at the lateral sternal border. After surgery a compression bolster was applied to the intermammary sulcus for several months on a continuous basis.

This approach to congenital symmastia correction includes three specific surgical manuevers. First excess subcutaneous tissue is removed between the two breasts which is most easily done with liposuction. Secondly the skin of the intermammary sulcus must be fixed down to the underlying periosteum by sutures either at the midline or at the lateral sternal border through the inframammary fold incision. It is almost always easier to place them at the lateral sternal border. The last step is postoperative compression for which there is no exact device/garment made for it. Various bolsters or bra modifications have to be devised.

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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