Explore Plastic Surgery - Dr. Barry Eppley

Plastic surgery is one of the marvels of modern medicine, with a wide range of options for face and body improvements. And today’s media outlets make it easier than ever before to gather information on the latest plastic surgery procedures. But how does this information apply to you and your concerns?

Every person is unique and has his or her own desires. What procedure or combination of treatments is right for you? And what can you really expect? EXPLORE PLASTIC SURGERY with Dr. Barry Eppley, Indianapolis plastic surgeon, who can provide you with a wealth of practical and up-to-date insights into the world of plastic surgery through his regular blog posts. In his writings, Dr. Eppley covers diverse topics on facial and body contouring procedures. You will be sure to find useful information that will help broaden and enrich your plastic surgery education.

Background:  Breast augmentation remains one of the most commonly performed body contouring operations because it can successfully increase the size of a breast mound in a very short period of time. While the underlying implant makes the breast bigger, the final appearance of the breast is influenced by more than just the size and shape of the implant. The breast tissue that sits on top of the implant will effect the symmetry of the two mounds almost as much as the effect of the implant itself.

One of the key elements of the influence of one’s breast tissue on a breast augmentation result is the position of the nipple. While the nipple should be ideally positioned in the center of the breast mound, it often is not. The effects of pregnancy, weight loss and gravity frequently have the breast tissue sagging and the nipple low or even pointing downward over the lower breast fold. This poses problems for both the patient and the plastic surgeon alike. The hope of an uncomplicated  solution by the placement of an implant alone is not going to work.

Known as ptosis, breast sagging has the greatest influence on breast augmentation results. An implant placed behind a sagging breast will only end up pushing the drooping breast tissue and nipple lower and giving the impression that the breast implant was placed too high. In the presence of breast sagging, implants must be done with some form of a breast lift. While there are four basic types of breast lifts, once the nipple is below the lower breast crease vertically directed types of breast lifts must be done. This results in scars that extend beyond the nipple, something that patients had hoped to avoid. Often this need completely surprises a patient as they had thought that an implant alone would solve the sagging breast problem.

Case Study: This 40 year-old female from Indianapolis Indiana wanted to reshape her sagging breasts. After three children her breasts had not only lost their size but had sagged as well. The droop in her breasts was significant as the nipples were well below the lower breast crease and were essentially pointing towards the floor. She had a moderate amount of breast tissue but too much loose skin. She had hoped that implants alone would help lift up her breasts.

Under general anesthesia, vertical breast lifts were initially performed. Known as the ‘lollipop’ breast lift, it is so called because of the final scar appearance. With a circular scar around the areola that then extends downward, it creates a scar pattern that resembles the shape of the candy. While this is the final closure pattern and shape of the scar, the pattern of the initial breast lift is a vertical skin cutout. With the shifting of the underlying breast mound and attached nipple to the top of the vertical cutout, the skin closure then creates this lollipop scar pattern.

During the breast lift, round silicone implants of 300cc size were placed under the muscle. Dissection under the muscle and the making of a submuscular pocket was done through the lower end of the vertical skin cutout of the lift. Once the implants were in place, the breast mound was lift up on top of them and the skin closed.  

Vertical or lollipop breast lifts with implants can very effectively reshape and lift the sagging breast. It does so, however, at the price of a resultant vertical breast scar. This scar can remain red for many months and can take up to a year to achieve maximal scar maturation. Depending upon how this scars heals and how the breast mound settles on top of the implants (size vs skin tightening), secondary revision may be needed. It is important to wait at least six months after surgery before judging the final results, particularly how the vertical breast scars look.

Case Highlights:

1)      Candidates for breast augmentation often present with sagging or breast ptosis. Implants alone will not create a significant lifting.

2)      If the nipple is below the level of the lower breast crease/fold, a breast lift will be needed that creates scars that extend downward from the nipple into the fold.

3)      Concurrently performed lifts with breast implant placement is a challenging operation that not infrequently may require a revision to optimize shape and symmetry between the two breasts.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Lifting and reduction techniques are common methods of cosmetic breast reshaping. Whether it is to lift up a smaller sagging breast or to reduce a large and pendulous breast, pushing up breast tissue and encasing it in a smaller and tight skin envelope is the basic approach. It would seem logical that by so doing the upper pole of the breast would be made fuller. There is no doubt that this is initially true but what happens long term?

There have been numerous breast lifting and reduction techniques that claim improved and persistent long-term upper pole fullness. Some use sutures to sew breast tissue pillars up to the fascia while others move breast fat flaps upward to replicate the effect of an ‘implant’. While short-term pictures appear encouraging, there has been no objective measurements to assess the validity of these breast reshaping claims.

In the December 2011 issue of Plastic and Reconstructive Surgery, a well-crafted photometric study was reported on how well breast lifts and breast reductions work for creating upper pole fullness. The author looked at 82 international publications using a wide variety of breast reshaping techniques. Measurements were made on a variety of breast landmarks, including upper and lower pole fullness and projection. The study found that no method of lifting or reduction increased upper pole fullness significantly. In fact, nipple overelevation occurred in a significant number of studies (42%) undoubtably due to an initially full upper pole that went on to bottom out later. In over half of the studies, a tear drop nipple deformity was seen with a less than round areolar shape.

This study and other findings not mentioned here bring forth many breast reshaping misconceptions. The first as already mentioned is that no method of breast reshaping will enhance upper pole fullness long-term. Many patients think it will but it does not. This is why implants are often suggested as part of a breast lifting procedure to do exactly what it doesn’t…create long-term fullness in the upper pole. Secondly, breast lifts do not make a breast look bigger. Rather a breast lift or mastopexy is really a bit of a breast reduction as well. The breast may be uplifted but it will appear smaller. Again, another reason why an implant may be needed in a breast lift to overcome this ‘downsizing effect.’

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

When women are seen in consultation for breast augmentation, they are understandably enthusiastic about how the operation will change the appearance of their chest. Some will be surprised to learn, however, that they will need a breast lift with an implant to achieve the best result. Breast implants are perceived by some to have the ability to lift a sagging breast when, in some cases, they actually can create the need for it.

Conversely, a women may come in only requesting a lift for her breast sagging to discover that an implant will also be needed to get the best result. It is a misconception that a breast lift has the ability to make permanent upper pole fullness, one of the desired changes with a breast lift besides nipple repositioning.

This combination of a breast implant and a breast lift, technically called an augmentation mastopexy, can be a very challenging operation to do well. This is because both operations, albeit done together, are working against each other. The implant expands the breast mound while the lift raises and tightens the breast skin. Finding an acceptable balance between the two can be difficult and it does not help that there are two breasts side by side of which the expectations are near perfect symmetry. In the face of asymmetry which nearly every women with breast sagging has only adds to the complexity of the procedure.

For these reasons, I advise all women undergoing simultaneous breast implants and a lift that there is a high revision rate with this operation. It is not my goal to have to do a revision, nor is there any economic benefit for doing so, it is just a difficult operation There are many reasons that the need for a revision may be desired including implant asymmetry, differences in mound shape or residual looseness of breast tissue and skin over the implant (bottoming out of beast tissue over the lower pole of the implant), some wide or persistent redness of the lift scars, nipple-areolar asymmetry, and adjustment of implant size. Given that breast augmentation alone has a 20% to 30% revision rate in the first three years after placement (national statistics from the manufacturer) should indicate how the ante goes up when a lift is added to the breast reshaping procedure.

The number that I like to imprint on a woman’s mind during the consultation process is a 50% risk of the need for revision for a combination breast implant and lift procedure. For many patients given their breast issues, the risk may not be that high. And my own practice experience indicates that, on average, it is not that high. (probably closer to 33%) But when significant breast sagging exists, the risk of revision may well be 50% or higher. At the least, it is a number that captures the patient’s attention and makes it more than just an infrequent occurrence.

In breast augmentation lifting, there are numerous options based on how much sagging exists and what size of the breast a woman wants. It is a balance between how much breast scarring one can tolerate and how much upward movement of the nipple is acceptable in the face of the desired mound size. One other important consideration which exists in this combination breast operation is keeping the nipple alive. In either breast augmentation or breast lifting alone, this is virtually a non-issue. But when done together, maintaining a good blood supply to the nipple is , always a consideration. Too much skin tightening, too large of an implant, or too much breast tissue undermining can compromise the survival of the nipple. This is why in doing the procedure, if in doubt, I would rather ‘underlift’ the breast or place a smaller implant than risk having the nipple die. It is much easier to do a secondary breast reshaping/revision than it is to remake a nipple.

Without question, a simultaneous breast augmentation and breast lift combination is the most difficult body plastic surgery procedure to perform from an aesthetic perspective For this reason, some plastic surgeons prefer to separate the procedures into two stages in order to reduce the risks. This is a very acceptable approach although it does expose the patient to a 100% risk of a second surgery. (and maybe even a third) When done together, the risk of a second surgery (revision) is about half that of when it is staged.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background: Breast augmentation remains as one of the most popular body contouring procedures. In simplicity, breast augmentation works by using an implant to expand out the existing breast tissue. Therein lies how the final breast result will look…it will reflect nothing more than a ‘blown-up’ version of the existing breast mound in most cases.

Many women appear for breast augmentation that do not have ideal breast mounds. They have varying degrees of breast sagging and low nipple positions. This is particularly true in older women and those who have had multiple children. They often have the mistaken assumption that breast implants will correct the sagging breast problem. Nothing could be further from the truth. Such patients need to consider some form of a breast lift if they are to get the breast outcome that they desire.

Case Study: This 44 year-old female presented for breast enhancement, which was really revisional breast surgery. She previously had saline breast implants under the muscle by another surgeon. She was aware that her breasts were saggy but thought the placement of implants would provide a lift as well as give more volume. The potential need for a breast lift was never discussed before her original implant procedure.

At the least, her prior surgery proved that implants alone were inadequate for her breast sagging problem. For her revisional surgery, the need for a breast lift was discussed. Since her nipple needed to move at least 2 to 3 inches upward, she required a breast lift that would result in final scars around the nipples and down vertically into the lower breast creases.

During surgery, her saline breast implants were initially replaced with new ones that were larger. (250cc to 325ccs) Then a breast lift was performed to move the breast mound up on top of the implants with a vertical lift technique. The nipple was moved upward and the size of the areolas reduced as well.

Her postoperative recovery was quick and relatively painless. Most of the pain from breast implants comes with the muscle and pocket dissection. This was done with her original surgery. Implant replacement uses the established pocket which makes for no tissue dissection or pain. Breast lifts are not particularly painful since it is just skin and breast tissue manipulation.

At just one month after surgery, her breast size and shape is much improved. Her vertical breast lift scars will take time to mature, but they usually are much better looking than most patients expect. Breast lift patients must be willing to accept scars for a less saggy and better shaped breasts.

Case Highlights:

1) When considering breast augmentation, it is extremely important to consider the amount of breast skin and nipple position. Any sagging of the breasts will not be corrected by implants alone.

2) The decision for any type of a concomitant breast lift with an augmentation must carefully weigh the aesthetics of the scar trade-off for improved breast shape.

3) Vertically oriented breast lifts provide the greatest amount of sagging breast correction and nipple repositioning.

Dr. Barry Eppley

Indianapolis, Indiana

What are Arnica montana or bromelain and is it used in breast lifts?

These are common non-pharmaceutical supplements for healing that some plastic surgeons endorse and prescribe for surgery including breast lift surgery. Arnica is a well-known extract of the mountain lily flower that has been used for decades to prevent or clear bruising related to any form of trauma. Taken one week before and one week after surgery, it helps prevent some of the bruising that will occur as well as speeds its resolution after surgery. Arnica is most commonly used as an oral tablet but can also be applied directly to the bruised site as a topical ointment. Bromelain is an extract in oral or liquid form from the pineapple fruit that has anti-inflammatory properties. It is commonly used for sports injury, trauma and surgery to decrease swelling. Contrary to popular belief, eating pineapple will not increase your levels of bromelain as it exists mainly in the stem of the fruit.

Will I have stitches? Is there swelling and bruising?

All suturing done for breast lifts (like breast reductions) is internal and dissolveable. There are no external sutures that need to be removed. Ther6e is always some swelling and bruising after breast lift surgery. The bruising is usually located along the incision lines. The swelling involves the entire breast. Both will be completely gone by three weeks after surgery.

When will my stitches be removed after my breast lift procedure?

No sutures need to be removed. Only the outer surgical tapes will be peeled off during the first office visit.

Can I finance my breast lift?

Yes. Many cosmetic surgeries are financed and are done by a wide variety of outside companies. Plastic surgeons do not finance surgery themselves and merely provide a referral to outside companies that do. All of these financing companies take applications online and their decision process is very quick. Like financing a car, they offer a menu of terms from length of the loan and interest rates.

What will happen if I have another child or gain or lose weight?

Both of these events will cause changes in any breast result. The stretching of skin through weight gain or the loss of breast tissue (involution) from pregnancy or weight loss will not be beneficial for the improvements that were obtained from a breast lift. Increasing sagging of the breast will be the result. Whether it is minor or significant can not be determined beforehand.

Will I be able to breast feed after a mastopexy?

Yes. Breast lift or mastopexy surgery does not remove the nipple nor sever the breast ducts. Therefore the lactation capability of the nipple-areolar complex is unchanged.

Can a breast lift cause breast cancer?

No form of breast surgery, whether it be an augmentation, lift, reduction, or reconstructive procedure, causes breast cancer.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background: Breast augmentation is based on the principle of expanding one’s natural breast tissue by placing an implant behind it. Regardless of whether the implant is placed within the breast tissue above the muscle (subglandular) or beneath the muscle (submuscular), how it works is the same. As a result, how well most breast augmentations will look in the end has a lot to do with what the quality of the breast tissue was originally on top of it.

One of the most common complicating factors that affects many potential breast implant patients is breast ptosis. Known as sagging, and defined by where the nipple sits in reference to the lower breast fold, it creates concerns about how the breast augmentation should be performed and whether some form of a breast lift should be done at the same time.

On the long-term side of breast augmentation, the effects of aging, gravity and pregnancy can create ‘implant ptosis’. This is when the breast tissue has essentially slid off of the implant over time resulting in a nipple which is now on the ‘southside’ of the implant. This can occur when one has a fair amount of breast tissue to begin with and there was marginal or a grade 1 amount of ptosis initially present. A breast lift may have been initially avoided but eventually the tissues may stretch out, creating a need for such a procedure.

Case: This is a 60 year-old female who had saline breast implants placed over twenty years ago. She came in because she thought her implants were slowly deflating over time. In addition, she felt that her breasts had gotten more saggy over the years. On examination, it was not obvious that her breast implants were deflated. But her breasts did have significant ptosis. I suspected that she had breast implants that were initially placed too high or were done in the setting of some breast ptosis. With time, the breast tissue stretched out and sagged further off of the implants. With loss of upper breast fullness due to the sagging, it would be understandable to believe that the implants were ‘deflating’.

She subsequently underwent implant replacements with a change to silicone gel. The size of the implants was kept the same as her original volume. (and she did not have any deflation of her saline implants) A vertical breast lift was performed at the same time to get the nipples back up higher onto the implant and reshape the bottom pole of the breast. Unlike her first breast augmentation procedure, this second surgery decades later was virtually painless with very little recovery. (the hard work of making the implant pocket had already been done)

She had a rapid recovery and was very pleased with the change in the shape and appearance of her breasts. At three months, the lift scars were still maturing and are red. But the redness will fade over the course of the next six months.

Case Highlights:

1) After breast augmentation, ptosis of the breast can develop over time if the tissues become stretched and loose. This can potentially give the appearance of breast implant deflation or rupture.

2) Whether the original breast implant is replaced or not, a breast lift is needed to reposition the nipple and put the tissues back up on top of the implant.

3) Breast lifts done with the placement of a breast implant or done secondarily with implant exchange or replacement result in scars. Breast lifts are about accepting the trade-off of scars for improving the appearance of ptosis.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis Indiana

Background: Sagging of the breasts is a very common cosmetic problem that eventually affects most women. While time, gravity, and pregnancy accounts for much of the breast sagging that occurs, some women have it naturally even when they are young. Breast lifts, also known as a mastopexy, is a well-established plastic surgery operation used for a sagging and misshapen breast. While breast lifts can achieve an uplifted and reshaped breast mound with nipple elevation, it is fraught with some long-term recurrence of some sagging or bottoming out.  

When a breast lift is done, it is always ‘overcorrected’. This means that the upper pole of the breast is excessively full (stuffed up too high) and the bottom pole of the breast looks ‘cut off’. In essence, the breast can look like an inverted teardrop in cross-section. This is done this way knowing that the bottom pole or half of the breast will stretch out to some degree. This common phenomenon is built into the operation. While this helps prevent some of the bottoming out thata can be seen, it does not prevent it completely

For this reason, the laser bra lift was developed as another solution to recurrent breast sagging. The concept of this technique is based on the cause of recurrent sagging that occurs…the thin skin on the bottom half of the breast is what is holding the shape of the breast mound. It is not thick or stout enough to avoid being stretched out. It undergoes rebound relaxation because it is very thin.   

This is a classic case of breast sagging in a 42 year-old female There actually is a reasonable amount of breast tissue but there is too much skin so the breast sags. One of the most important steps in performing a breast lift (or reduction) is the preoperative markings. These lines and angles determine how much and how well the breast ends up being reshaped.

In surgery, the initial step is to make all the incisions based on the preoperative markings. The next step is what defines the laser bra lift. Rather then removing the skin that lies above the mound of breast skin that lies underneath and around the nipple down to the lower breast fold, it is largely preserved. Using a high-energy CO2 laser, the top layer of skin (epithelium) is removed through a resurfacing technique. Since the epithelium only makes up about 5% of the skin’s thickness, the rest of the skin (dermis) is left which is thick collagen like cowhide. The epithelium must be removed because it will make cysts and wound breakdown if any is left behind.

Leaving this dermis attached to the breast mound leaves an extra layer of support that ends up being closed over by the surrounding skin flaps in the breast reshaping. This effectively doubles the thickness of the skin on the lower pole of the breast for extra support. In short, this makes for an ‘internal bra’ by using your own natural tissue. Hence, the name laser (how it is done) bra (retained portion of the skin) lift.

After a laser bra lift, the postoperative management and what to expect is the same as a regular breast lift. Leaving an internal skin bra does not cause any extra pain or care. The breast incisions are taped and only internal dissolving sutures are used. In some cases, a drain may be left in place to be removed the following day. One goes home in just a surgical bra. Once can remove the bra and shower the next day.

The proven benefit of the laser bra lift is the better long-term maintenance of breast shape. Another benefit, in my Indianapolis plastic surgery experience, is that there are fewer separations at the junction of the vertical and horizontal incisions (inverted T) that are commonly seen about three weeks after surgery. While these separations do go on to heal on their own, they are certainly aggravating for patients.  

Case Highlights:

1)      Some recurrent sagging and bottoming out of the breast is a common cosmetic problems in many forms of breast lifting.

2)      Lack of adequate skin thickness and quality on the lower pole of the breast is the culprit for this problem. The laser bra lift leaves behind an internal bra of dermal skin that provides extra support and better long-term breast shape maintenance.

3)      The laser bra lift uses your own natural tissue and adds no extra surgical time or postoperative care.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

1.      What will a lift do for my sagging breasts?

Sagging of one’s breasts, known as ptosis, is a natural phenomenon that occurs from pregnancy, aging, and the weight of heavy breasts over time. It is the result of skin stretch and the weakening of the support ligaments between the skin and the chest wall, both of which causes the breast mound to fall over the fixed lower breast crease. Invariably, the nipple on the mound ends up pointing downward to some degree.

Breast ptosis has a formal classification system which is relevant because it impacts what type of breast lift is needed. The degree of ptosis is determined by where the nipple sits relative to the lower breast crease. Normal is above the breast crease, ptosis severity as graded I through IV is how far the nipple is below the crease.

A breast lift, also known as a mastopexy, comes in four fundamental types. Nipple (type I) and periareolar (type II) mastopexies keep the scars around the nipple but only produce a cm. or two of breast lifting. They work best when combined with an implant. Vertical (type III) and combined vertical and horizontal (type IV) mastopexies result in scars that leave the nipple and extend downward. They produce the greatest degree of breast lift and tightening and are aften done without an implant.

A breast lift has the potential to lift the nipple back up above the lower breast crease while improving breast shape. Matching the degree of ptosis with the type of breast lift is key to a successful result.

2.      What is the difference between a breast lift and a breast reduction?

From a skin and scar standpoint, a full (type IV) breast lift and reduction seems the same. The scars are identical, going around the nipple with a vertical extension down to the lower breast where it joins a horizontal scar. This breast scar pattern is known as the inverted T or anchor.

It is what is done, or not done, on the inside of the breast that is the difference. A breast lift removes no breast tissue, just lifts the nipple and tightens the skin around the breast mound. In contrast, a breast reduction not only does that but also reduces the size of the breast mound, making it smaller and weigh less. In short, a breast lift is not a breast reduction but a breast reduction always includes a breast lift.

3.      Can an implant be done at the same time as a breast lift?

Lifting a sagging breast alone is often not enough. Unless one has a significant amount of breast tissue, a breast lift will not make most breasts look bigger. In some cases, they will look smaller after being lifted. As a result, many breast lifts receive an implant at the same time.

This combination lift and implant breast reshaping is an artistically difficult operation to do. How much can you lift and tighten the skin vs the size of the implant makes for some key intraoperative judgments. And one must also be careful not to interrupt the blood supply to the nipple in performing each maneuver. As a result, the revision rate on this breast operation is not low and two stages are often needed to get the best result.

4.      Are the results from a breast lift permanent?

The initial results from most breast lifts must be overdone or overcorrected. The breast mound is lifted higher and fuller (on the upper part of the breast) to account for some settling which will invariably occur in the first month or two after surgery. Once the breast mound has settled ( 3 to 6 months), the result will be relatively

Stable.

There are many factors, however, that determine the long-term stability of a breast lift. Your age, will you get pregnant again, will you gain or less significant weight in the years ahead, and did you get an implant with your breast lift. The nipple position will stay the same but it is the shape of the breast mound and the tightness of the skin around it that can be affected by these other factors.

5.      What is a laser bra lift?

Some amount of recurrent sagging or bottoming out of a breast is well known to occur after breast lift and breast reduction surgery. The support of the lower portion of the breast only comes from the skin which is often thin and prone to stretch and relaxation

As part of a breast lift, the mound is tightened by the removal of skin and bringing the edges together. In trying to improve the postoperative problem of bottoming out, the laser bra lift uses the concept of skin preservation. Rather than cutting out and throwing away the excess skin, the laser removes the outer layer of skin (epithelium) that normally would have been thrown away and keeps the underlying collagen layer. (dermis)The reshaped breast skin is then closed over it during the lift. This preserved skin layer then acts like an ‘internal bra’, adding an extra layer of support to resist any sagging afterwards. The laser bra lift is simply a clever and effective use of your own tissue to improve a well known breast lift problem.

6.      What is the recovery after a breast lift?

Because breast lifts work only on skin and breast tissue, there actually is very little discomfort after surgery. Short of limited strenuous activity in the first two to three weeks, there are no other physical restrictions. One can return to work within days of the procedure.

When an implant is placed at the same time as a lift, there will be discomfort and recovery. Short of a lot of lifting, one can still return to work within seven to ten days after.

One also needs to factor in the ‘visual side’ of recovery, how long until the breast scars fade. This could take six months or longer until the breast scars have matured and reached their best appearance.

7.      Can a breast lift be redone later?

Because of the residual scars that are left from a breast lift, there is always the opportunity to use them to further lift and tighten a breast. If one undergoes pregnancy or weight loss, the breasts may need a secondary tuck-up or tightening.

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 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