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Archive for the ‘breast implants’ Category

Case Study – Transaxillary Saline Breast Augmentation

Sunday, December 3rd, 2017

 

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

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

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

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

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

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

Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Mentor Xtra Breast Implants

Sunday, November 5th, 2017

 

Silicone breast implants have been back in clinical use for the past decade. While there are various features of these implants, such as the gel composition and the characteristics of the enveloping shell, that get a lot of attention one overlooked feature is that of implant fill. This refers to how much the enveloping shell is filled which impacts the implant’s shape.

Historically silicone breast implants have been not fully filled. This creates the well known ‘ashtray’ effect where a crater or concavity exists on the top of the implant when it is laying on a flat surface. (or when the patient is in the horizontal supine position) It was never clear to me why the implants were never fully filled but my assumption is that a lower fill made them more deformable (to fit through a smaller incision) and made them feel softer. But by so doing more folds occur in the implant shell in the vertical sitting or standing position and less fullness is retained in the upper half of the implant.

Breast implant manufacturers have begun introducing more fully filled silicone breast implants that go by different names. This is illustrated in the new Mentor Xtra silicone breast implants which received FDA approval in April 2017 and have now become available for clinical use. They are available in a wide range of sizes and with different projections as well.

When laid side by side to ‘normal fill’ implants, the Mentor Xtra implant shows how the implant’s projection and shape is better maintained. (no ashtray effect) There is also less shell wrinkles when the implant is positioned on its side, which is how it would be in a patient when they are standing or sitting. Less wrinkling or implant folds also decreases the risk of developing fold flaws (tears in the implant shell), also known as implant ruptures.

It is finally time that more fully filled silicone breast implants became available. This has been a ‘flaw’ in breast implant designs/offering for a long time. The merits of having underfilled implants that have an ashtray effect has always been unclear to me.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation in Widely Spaced Breasts

Sunday, October 22nd, 2017

 

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

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

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

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

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

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

Highlights:

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Donut Breast Lift with Implants

Sunday, September 17th, 2017

 

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

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

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

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

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

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

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


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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