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Archive for the ‘breast implants’ Category

Case Study – Donut Breast Lift with Implants

Sunday, September 17th, 2017

 

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

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

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

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

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

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

Highlights:

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Wide Sternal Gap in Breast Augmentation

Sunday, September 3rd, 2017

 

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

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

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

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

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

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

Highlights:

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Lifting Effect of Breast Implants

Wednesday, August 9th, 2017

 

Background: Many women who present for breast augmentation have varying degrees of breast ptosis or sagging. Some have the belief that a breast implant has the capability to lift the sagging breast and avoid the need for some type of breast lift. Unfortunately this is almost never the case much to the chagrin of the patient.

Burt there are cases where with right size off breast implant and with a breast sag that is not too severe that a breast augmentation procedure by itself can lift up a sagging breast. The key is the type of breast sag. As breast ptosis is defined as the position of the nipple relative to the breast (inframmammary) fold, a breast sag where the nipple is just at the level of the fold is a preoperative sign that an implant alone will suffice.

Case Study: This 38 year-old female presented for breast augmentation. She had small breasts but had lost most of her breast volume after having children.

Under general anesthesia, an inframammary incisional approach was used to place 400cc high profile silicone breast implants in a dual plane position. As judged by her after surgery side view picture comparisons of her elevated nipple position caused by the breast mound enlargement.

Nipple positions at or above the level of the inframmary fold will be elevated from the placement of breast implants. This will occur even when the implant is placed in the submuscular position. The size of the breast implant also plays a role with ‘larger’ implants being more effective than smaller ones. To some degree there is the effect of the ratio of implant to natural breast mound tissue. The greater this ratio the more effective the lift will be.

In some cases when the implant to natural mound tissue is more even, the initially uplifted breast tissue can ‘fall off’ of the implant over time. This is because the weight of the breast tissue is not well supported by the implant size. This is not the case int this example but can be in more marginal patients who are better off having a lift with the implant placement.

Highlights:

  1. Breast implants do not have a great ability to lift up a sagging breast.
  2. A good size implant in the properly selected patient can have some breast lifting effect.
  3. Over time the augmented ‘breast lifted’ patient may have some glandular tissue slide off the implant due to gravity and tissue stretch.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Vertical Breast Lifts with Implants

Monday, July 31st, 2017

 

Background: The sagging of the female breast is a common sequelae to age, pregnancies and weight loss. The shape of a woman’s breast is rarely a static structure over their lifetime being subject to a variety of forces that work to make the breast mound lose its shape. Stretching of the mound skin and loss of breast volume are the anatomic reasons for ‘the breasts heading south’.

Correction of breast sagging, therefore, necessitates addressing the loose skin and lack of adequate volume. Various types of breast lifts combined with a large range of breast implant sizes creates options for rejuvenating the sagging breast mound.

The use of a combination breast lift and implant placement is a common breast reshaping procedure. But mixing the type of breast lift and the size of implant defies an exact scientific method to do so and not every women can get any breast implant size with their lift that they desire.

Case Study: This 34 year-old female had developed significant sagging and loss of breast volume after four pregnancies. She needed as much of a breast lift as she did that of more breast volume.

Under general anesthesia, she underwent a combined vertical breast lift with the placement of 400cc silicone breast implants. Her results shows that the size of the breast lift chosen can dictate how much of a breast lift result can be obtained.

In the combined breast lift and implant surgery, also known as an implant mastopexy, the effects of the two procedures often are at a conflict. Since a breast lift achieves its effect to some degree by skin removal and tightening and an implant exerts its effect by skin expansion, it is easy to see how combining these procedures often creates the need for compromise. For more of an uplifted and perky breast, a smaller implant must often be chosen. For larger implant volumes the amount of lifting effect will often not be as great.

Highlights:
1) Breasts lifts are often done at the same time as the placement of breast implants in certain amounts of breast sagging.
2) Large amounts of breast sagging or the desire for large breast implants may necessitate a staged approach to lifting and implant placement.
3) The use of breast implants in the sagging breasts may often be to just maintain upper pole fullness.

Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Breast Augmentation with Nipple Lift for Asymmetry Correction

Friday, June 23rd, 2017

 

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

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

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

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

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

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

Highlights:

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Round Breast Augmentation Result

Sunday, June 4th, 2017

 

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

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

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

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

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

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

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

Highlights:

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Implant Replacements with Vertical Lifts

Sunday, May 21st, 2017

 

Background: Breast augmentation patients present with a variety of breast shapes that may necessitate additional procedures other than just the placement of an implant.Such is the case with sagging of the breasts. While many patients think that an implant will lift a sagging breast, this is not so. While it is true that nipple positions can be elevated by breast implants, that only occurs when the nipple is at or above the inframammary fold. (no breast sagging)

Women that have had breast implants for a long time often present for implant exchange/replacement. This is due to a variety of reasons such as implant failure and the desire for larger or smaller implants sizes. It is common that at the time for new breast implants the breasts have changed from the first time the implants were put in. Due to weight gain/loss, pregnancies and gravity, breast tissue that was once on top of the implant has now slide off of it. This creates a unique form of breast sagging known as implant sagging.

Thus breast implant replacements may necessitate the need for a concurrent breast lift procedure. Whether the implants size is the same, bigger or smaller a breast lift is needed to get the breast mound and nipple back up over the implants.

Case Study: This 47 year-old female had saline implants placed 14 years previously. (400cc size) While her breast implants remained intact, she was not happy with the appearance of her breasts. Her breasts had become saggy as the mound tissue had fallen off of them. She also wanted larger breast implants.

Under general anesthesia she had vertical breast lifts performed as well as replacement of her implants. Her saline implants were replaced with 550cc moderate plus profile silicone implants.

Depending upon how much breast tissue one has at the time of the original breast implant placements will determine to a large degree how the breasts will ‘age’. The more breast tissue one has initially the more likely subsequent tissue sagging will occur. Implant replacments years later may then require a simultaneous lift.

Highlights:

  1. The combination lift and implant operation is a challenging breast reshaping procedure that its associated with a high risk of revision.
  2. There is a delicate balance between the size of the breast implant desired and the amount of lifting needed.
  1. Many breast implants over time will have the natural breast tissue slide off of the implant creating the secondary need for a lift at the time of their implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

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


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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