Explore Plastic Surgery - Dr. Barry Eppley

Breast cancer continues to be a major health issue for women, averaging just under 200,000 new cases per year. It is the second leading cause of cancer-related deaths in women. From a plastic surgery standpoint, cosmetic breast surgery cases well exceed this number with over 500,000 procedures being performed per year. The crossing of these two breast treatments places plastic surgeons in a position to help improve breast cancer screening. Because all forms of cosmetic breast surgery produce irreversible changes to the breast parenchyma, the importance of presurgical screening is even more important.

In the November 2009 issue of Plastic and Reconstructive Surgery, Drs. Selber, Wu and colleagues looked at this very issue. Their study looked primarily at the behavior of plastic surgeons in knowledge and adherence to the American Cancer Society (ACS) Breast Cancer screening guidelines. The greatest relevance of their report, however, is to create awareness as to what preoperative breast screening should be done when cosmetic changes are anticipated to be done.

As a review of the ACS guidelines, women at average risk should begin self-breast examinations at least every 3 years for women in their 20s and 30s and yearly for woman over 40. Mammogram screening begins at age 40. This means that any woman undergoing cosmetic breast surgery under 40 should at least have a breast examination. Once over 40, all should have a mammogram as well.

These guidelines change for women at increased risk. A more aggressive screening program which may include MRIs should be done for women who are BRCA mutation carriers, a first degree relative of BRCA carrier and radiation exposure between the ages of 10 and 30 years of age. Women at increased breast cancer risk include two or more relatives with breast or ovarian cancer, breast cancer occurring before age 50 in an affected relative, one or more relatives with two cancers, male relatives with breast cancer, or a family history of breast or ovarian cancer with Ashkenazi Jewish heritage.

Because of the frequency in which cosmetic breast surgery (breast augmentation, breast lift, breast reduction) is done, plastic surgeons are in a unique position to screen women for breast cancer. Often, this would be the first and in some cases the only breast cancer screening that they may receive. Taking a family history, performing a breast examination, and referral for a preoperative mammogram if indicated are in the patient’s best interest. Women over age 40 should not undergo any form of cosmetic breast surgery unless they have been baseline screened regardless of their risk factor. Women under age 40 with moderate to high risk should have the same baseline breast information obtained prior to surgery.  

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The female breast is not a stable anatomic structure. Given the forces of gravity, aging, and pregnancies, breasts that become saggy aren’t a matter of if it will happen but when and how much for almost all women. If a woman has large natural breasts to start, sagginess or ptosis may occur sooner or to a greater degree than a smaller breast.

Whether it is a breast lift or reduction, these plastic surgery operations are designed to lift and tighten the saggy breast. While these procedures are very effective in the short-term, some relaxation or small amount of sagging will eventually return. The elevated nipple position does not drop, but the lower pole of the breast will bottom out to some degree. This is why these operations are ‘overcorrected’, the breast is made too high, to account for this inevitable postoperative change.

The main reason that some bottoming out of the breast occurs is that the support for the reshaped breast is that of skin only. This skin is usually very thin and is very prone to stretching out with immediate swelling from the surgery and the eventual weight of the breast tissue that it envelopes. Many efforts have been made as to how to improve internal breast support, from operative design alterations to synthetic mesh implants, but none has proved to be consistently successful or well accepted by most plastic surgeons.

A more recent innovation has been that of the Laser Bra Lift or the laser-assisted breast lift/reduction. The combination of laser surgery with standard breast lift/reduction procedures offers some real potential benefits. An integral part of every breast lift and/or reduction is what is known as de-epithelization of the pedicle’. This is traditionally done by hand with a scalpel. This operative step is supposed to remove the very top layer of the skin that overlies the underlying breast tissue and nipple which is being left behind. In a breast lift, this would be all of the underlying breast mound. In a breast reduction, this would be only that which lies right under and around the nipple.  In reality, this operative step leaves very little skin thickness behind and often none at all. As a result, there is essentially no support for the breast tissue other than the skin that is closed over top of it.

The laser is used to preserve the more of the skin’s thickness that overlies the pedicle of breast tissue that supports the nipple. Rather than discarding this valuable tissue, it is allowed to remain attached to the breast and can serve as an anchor point for suturing. This leaves an additional tissue layer (dermis of the skin) between the overlying skin closure and the breast mound, creating a ‘tissue bra’ for support. This is like placing a synthetic mesh for internal support except that it is your own tissue. The laser also helps reduce surgical time by up to 15 minutes per breast as well as lessens blood loss and postoperative bruising. This tissue layer feels completely natural with no hint of the presence of this additional tissue.

The laser bra lift can be used on any breast lift or breast reduction procedure. It places no greater risk to nipple sensation or survival than the traditional approach. While no definitive long-term comparative studies have been done between the laser bra lift and the standard approach in terms of support analysis, the concept is a sound one and is biologically appealing. Any tissue that is left behind that can add support to the lower breast pole is beneficial.  

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The breast that has a moderate to a significant amount of sag is commonly seen by plastic surgeons. Often such a patient is seen who is seeking breast augmentation. It is commonly perceived, although largely erroneous, that a breast implant will lift a sagging breast. Despite the wonders that an implant can do to reshape and rejuvenate a breast, it does not have the ability to move a nipple or the breast mound higher up on the chest wall.

Breast sagging, also known in plastic surgery terms as ptosis, is defined by where the nipple sits in relation to where the lower breast fold (inframammary crease) is. There is a ptosis classification system with four types which precisely defines the nipple-fold relationship. From a patient’s perspective however, what matters is…at what point will an implant alone not work well and I have to consider some form of a breast lift? The simplistic answer is when your nipple  is at or just  below the level of the fold. At this nipple position on the mound, a breast implant alone is not going to lift the breast. While it will make the breast much fuller and give the mound a nice shape, the nipple will still be located on the lower pole of the breast pointing downward.

Many wonder about the use of no implant and a breast lift alone in the sagging breast. While a lift will move the nipple up higher and provide breast reshaping, it will not in most cases make the breast look bigger. This is another erroneous perception. In fact, in some patients it may even make the breast look smaller due to less of a breast skin sleeve.

The consideration of the need for a breast lift with an implant is often a painful discovery when one is seeking breast augmentation. Scars on the breast create a new cosmetic  deformity that must be balanced against the sagging that it is replacing. For some, that trade-off is an easy one. For others, it is  a more difficult decision. Often times, a breast augmentation simply can not be satisfactorily done without a concomitant breast lift.

Combined breast augmentation and breast lifts can be done several ways. The degree of lift that can or should be done is controlled by the amount of scarring that a patient can tolerate. The scar burden must be balanced against how severe the sagging is. The use of a breast implant definitely helps a sagging breast and often may lessen the degree of breast lift that may be needed. Larger breast implants help fill out loose skin but will still not lift the nipple any appreciable amount. The stark reality about breast lifts is that the more scar that is created, the greater amount the nipple is lifted upwards,

With a breast augmentation some patients may find that some sagging is more acceptable than any type of breast scar. For others, the scars are more acceptable and the desire to improve the sagging supercedes any scar concerns. Looking at photographs of both fresh and mature breast lift scars can really help a patient better appreciate what degree of scarring that is involved. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

One of the most important features of a good-looking breast is the position of the nipple on the mound. Ideally placed at the central meridian of the breast, the nipple-areolar complex (hereafter referred to as the nipple) and its position imparts a significant impression about the youthful or aged appearance of the breast. As the nipple drops lower from age or pregnancies, the breast shape becomes defined by the degree of ptosis or sagging. The well-known classification of breast ptosis is based on the vertical relationship of the nipple to the inframammary fold.

Minimal sag or a Grade 1 ptosis (nipple is lower but is still above or just at the level of the lower breast fold) can be improved by repositioning the nipple upward. This is known as a nipple lift or a crescent mastopexy. In this procedure, a crescent shaped section of skin is removed above the areola. The nipple is then pulled upward to a new position and sutured into place. This allows the top of the nipple to be repositioned upward by about 2 to 3 cms. and will move the nipple up about 1 to 1.5 cms. This maneuver usually makes the nipple look slightly larger or elongated.

The crescent mastopexy is the minor form of a breast lift. Because its effect is limited to the nipple and does not change the shape of the breast mound, it is rarely if ever done alone. In my Indianapolis plastic surgery practice, I have observed that it simply doesn’t make enough of a difference to be a stand alone breast procedure. It is always performed in combination with a breast implant/augmentation. The implant causes an increased fullness in the breast mound and the crescent lift moves the nipple up slightly. Their combination is synergistic in making an overall better breast look.

As the nipple and breast sags further, more extensive breast lifts may be needed to achieve an ideal shape and nipple position. However, some women are understandably concerned about breast scars and may not be willing to accept an additional scar burden. In Grade II ptosis, a crescent lift with an implant may still be used as long as the patient is willing to accept less than an ideal result.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Breast reshaping in the extreme weight loss patient almost always require the combination of an extended breast lift and a breast implant. The loss of breast tissue from the weight loss and the now overstretched skin results in a deflated breast with a significant sag. The nipple lies below the lower breast crease and in many patients it points directly to the floor. Such a misshapen breast requires both volume (breast implant) and a radical skin reshaping. (lift)

While this combination breast reshaping procedure is commonly done, it is not easy to get a good symmetrical breast result. The need for secondary revisions with this approach is not rare. Revision rates may be as high as 25% to 35%. The reason this procedure is difficult from a cosmetic standpoint is that the breast lift and the implant work against each other in achieving their goals.  A breast lift is a skin reduction procedure that lifts and tightens, a breast implant is an expansion procedure that stretchs and lifts. There is no exact science that can tell a plastic surgeon exactly what size implant is needed for how much skin is removed in a lift. It is as much an art as anything else.

One valid approach is to do the breast lift first and defer the placement of the breast implant as a second stage months later. While this staged approach has its advocates, it condemns the patient to two operations 100% of the time. While the combination of a lift and implant may require a significant percent of patients to need two operations due to a revision, the majority of patients (> 50%) will be able to get a satisfactory result in one combined operation.

The primary objective of this form of breast reshaping is to get the nipple lifted and centered on the breast mound. This results in the classic anchor breast scars to achieve it and the blood supply to the nipple is always in jeopardy with the low but real risk of nipple loss. The implant is placed through the same approach as that of the breast lift.

The combination of breast scars, an uplifted nipple position, breast implants, and having two breasts makes achieving  perfect symmetry and shape between the two breasts a difficult proposition in the combined lift/augmentation procedure. Fortunately,  most extreme weight loss patients are quite satisfied with significant improvement in their breasts even when revisional procedures may be needed.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The severely sagging breast usually requires a combined breast lift with an implant, known as a mastopexy with augmentation in plastic surgery terms. This combined procedure lifts and repositions the nipple to a more central mound position, tightens and reshapes the breast mound into more of a conical form, and adds volume to create a fuller mound. In many ways, the different goals of this procedure work against each other….tightening the breast but making it bigger at the same time. This may seem like a trivial consideration, but it is these opposing forces which make a breast lift with an implant a difficult operation. It is difficult to do well and even more difficult to get both breasts as symmetrical  as possible.

An extended or full breast lift is needed in the extreme weight loss patient. A large amount of skin must be removed in a ‘keyhole’ or wedge-like pattern. While this skin excision is marked before surgery with a tape measure and the planned incisions made visually symmetric, few breasts are exactly the same to start with. This inherently makes even the most well marked and planned breast lift exposed to risks of asymmetry. In a breast lift, skin is removed but breast tissue (and the nipple) are not. The cutting and redraping of the breast skin provides a more uplifted and better shaped containment sac for the breast tissue. This results in a classic anchor or inverted-T scar pattern on the lower pole of the breast.

During the breast lift, there is ample opportunity and access to introduce and place a breast implant. Because of the blood supply that goes to the nipple through the breast tissue, it is prudent to place an implant under the pectoralis muscle rather than above it. Placing a breast implant above the muscle into the breast tissue may injure or disrupt the nipple’s blood supply, increasing the risk of losing the nipple after surgery due to necrosis. (turns black and dies) What size implant to use will vary greatly. You want to fill out the overlying breast tissue and make a nice round mound but you still want to be able to close the breast lift skin over it. Therein lies the  art and skill of the procedure. It is a delicate balance between choosing the right breast size (expansion) that still allows closing and tightening the breast skin (contraction)without too much tension. Too much tension of the breast lift skin closure will result in wide scars at the least and the possibility of suture line opening or breakdown after surgery.

Because of the complexities of making an improved breast shape through lifting and an implant, every patient undergoing this procedure should be aware of and accept that the need for revisional surgery is likely. Whether it be asymmetry of the nipples, positioning of the implants, and poor scarring from the lift, revisional surgery for this operation is not rare.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

One of the many unfortunate body changes that occurs after losing a lot of weight in women is a deflation of the breast. Rarely does any woman lose significant weight and not create a much greater sag of the breast. This breast sag is known in plastic surgery terms as ptosis. Occurring in varying degrees, severe breast ptosis results in the breast hanging completely below the lower breast crease with the nipple pointing toward the floor.

As a result, almost all extreme weight loss breast patients need some form of a breast lift. While some breast lifts may be accompanied with an implant for increased volume, an implant alone will not lift the breast or nipple. This is a common misconception of what a breast implant can do. It will merely make the breast look like a low hanging ‘udder’if a lift is not performed with it. 

Breast lifts common in a variety of forms based on the amount of movement that the nipple has to be raised.  If the nipple needs to be raised more than an inch or two, then a full or extended breast lift is needed. This is the case in almost all extreme weight loss or bariatric surgery patients. A full breast lift, from an incision and scar standpoint, is exactly like a breast reduction….with the exception that no breast tissue is removed. Only skin is removed which reshapes the whole breast. The skin is the sac or containment bag for the breast tissue. In a breast lift, the skin is radically removed and reshaped but the breast tissue and nipple is merely ‘re-wrapped’ so to speak. Because of the large wedge of skin that is removed, this results in the classic anchor or invert T scars. A scar runs around the new position of the nipple then down vertically to the lower breast crease which connects with a long horizontal scar in the lower breast crease. 

At no time is the nipple actually removed. It remains attached to the breast tissue and is moved up as the entire breast mound is lifted and reshaped from the skin portion of the operation. It is brought out through a new hole cut in the skin at a much elevated and more centrally located position on the newly shaped breast. That is why the nipple stays alive and in most patients will still have feeling after surgery. (although the risk of losing feeling is one of the surgical risks) 

A full breast lift is the foundation for reshaping the female breast after extreme weight loss. Because of the breast tissue loss, many such breast lifts require an implant for more volume also. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

For almost all extreme weight loss patients, reshaping the female breast requires a mastopexy or a breast lift. This procedure is mostly about reshaping the breast through removing excess skin, moving the nipple to a higher position, and reshaping the breast mound. The skin of the breast is much like a bra, providing support and form. When one looses a lot of weight, the skin stretches and the skin bra is no longer able to support the weight of the breast. This results in breast ptosis where the amount of loose skin exceeds the volume of breast tissue that it is supporting. As a result, the breast develops a lot of sagging.

By definition, drooping of the breast means that skin has to be removed to move the nipple to a higher position. The degree of breast ptosis or sag (the position of the nipple relative to the inframammary fold) determines how much skin must be removed as well as the location and length of the incisions (scars) that are needed to do it. One concept to grasp about breast lifting is that the uplifted breast will likely appear somewhat smaller (a ½ cup size) and will not maintain upper pole fullness over the long-term.

While there are different types of breast lifts, from small to major ones, most extreme weight loss patients require a full or extended breast lift. The full breast lift to which I refer is also known as the anchor technique. This breast lift method gets its name from the anchor-shaped scar that it leaves on the breast. This technique creates vertical and horizontal breast scars. ( an upside-down T) Think of this operation working like making a cone out of a piece of paper. Cutting out a wedge and bringing it together creates the breast cone. This is very much like the anchor breast lift technique. While this approach creates a lot of breast scar, half of the scar lies along the inframammary fold so it is hidden.
Such a full breast lift will not make the breast bigger but uplifted with a better shape. For this reason, many patients may want or require more breast volume to make the uplifted breast fuller as well. As a result, many breast lift patients require an implant to create more volume. The combination of these two procedures is called a mastopexy with implants or breast augmentation with a lift.

Lifting and implanting a saggy breast is frequently required after someone has lost a lot of weight. This is a tedious and very artistic procedure of which good symmetry between the two breasts is difficult to consistently achieve. For this reason, anyone considering this combination breast procedure must accept the risks of the potential need for revisional surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Of the many body deformities that result from excess skin after massive weight loss in the bariatric surgery patient, the most difficult in my experience is that of the breast. Loss of breast volume, a low nipple position, and sagging skin from a ‘deflated balloon’ creates a breast problem that offers a lot of challenges. Lifting and reshaping a bariatric breast is a four-dimensional problem consisting of tightening and lifting the skin sleeve, elevating the nipple into a more central position on the breast mound, adding loss breast volume, and trying to minimize the amount of scars necessary to do accomplish all these tasks.

 
The real challenge in making a better breast in the bariatric surgery patient is that lifting and reshaping the breast and adding volume through an implant (which is almost always necessary) makes it very difficult to predict an exact final result. Then when you factor in the important task of keeping the nipple alive through these manuevers (removing excess skin and putting in an implant can inadvertently knock off the blood supply to the nipple), raises the risk of further complications.

 
Based on these concerns, I advise patients that I will do my best to get a good result in one operation, but my experience has shown that it usually takes two separate procedures to get the best outcome. In other words, the revision rate in these types of breasts is quite high. Whether more skin needs to be tightened, the implants need to be repositioned or adjusted in volume, or the nipple needs to be lifted even higher, it is very difficult to get two, fairly symmetric breasts that match. Inevitably, some aspect of one breast or the other is ‘off”. Therefore, I advise my patients to think of their breast procedure as a two-staged operation with the hope that we do good enough that some patients will get by needing only one procedure. None of this has factored in the issue of scars and how they look which poses another risk. Fortunately, most breast scars turn out fairly well although it takes a considerable amount of time until they blend in well.

 
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Many women, usually after pregnancy, desire improvement from the resultant change that has occurred in their breasts. Usually the resultant breast involution (shrinking) that occurs after most pregnancies results in sagging or ptosis of the breast. the breasts may appear deflated but the problem is really one of too much skin now for the amount of breast tissue that remains. (yes, you will have less breast tissue after pregnancy)

While breast augmentation and breast reduction are highly successful procedures that achieve the goals of most patients and have acceptable tradeoffs for the benefits (augmentation = use of a synthetic implant, reduction = scars), the breast lift or mastopexy procedure is a different matter. Most mastopexies of significance result in breast scars but, unlike a breast reduction, the breast lift is a pure cosmetic procedure. Excessive scarring for the cosmetic patient may not be an acceptable tradeoff. Scars are very acceptable in breast reductions because the patient’s goal is primarily relief of back, shoulder, and neck pain. The dilemma in the potential mastopexy patient is a cosmetic one. Which is going to look better…..a saggy breast with no scars or an uplifted breast with scars. While it is true that some small mastopexies involve only a scar around the areola, breasts that require significant lifting involve vertical and vertical-horizontal scars.

Many mastopexy patients, and in about 80 - 90% of my mastopexy patients here in my practice in Indianapolis, are also candidates for an implant with their mastopexy procedure. A breast implant will provide volume and, most importantly, provide fullness in the upper pole of the breast. A breast lift alone will not in most patients result in restoration of fullness to the upper part of the breast. It may do so in the early postoperative period, but this fullness will be lost in the first few months. For this reason, a breast implant (even if small) can be very helpful. I have observed that one of the goals of most potential breast lift patients is a fuller breast as well. A breast lift tightens and lifts a breast but will not make a breast bigger or fuller.

If a patient elects to have a combined mastopexy-implant procedure, the next question is whether they should be done at the same time. I have always done these two procedures together but it can be a very difficult operation to get a symmetric and optimal result. The two procedures actually work against each other, tightening and lifting and increasing the size of the breast…..all at the same time. This can be artistically challenging. For this reason, I advise my patients that there is a very high revision rate with combined mastopexy-implant procedures. Whether it be to adjust the position of the implants, revise the scars, or do some fine-tuning of the breast shapes, the patient will frequently desire a revision. Conversely, however, staging the two procedures guarantees a 100% likelihood of two procedures.

The breast lift (mastopexy) procedure presents several challenging issues; Are breast scars worth the improvement in the breast shape? Do I need an implant with my breast lift? Can I live with the concept that a second surgery may be needed to get the best result?

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis