Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘breast augmentation’

The Ideal Implant for Breast Augmentation

Friday, May 6th, 2016


Historically the choice for women considering breast augmentation were either saline or silicone devices. These very contrasting breast implants choices have very well known advantages and disadvantages. Saline breast implants offer the most economical approach to the procedure with aesthetic device issues such as rippling, an unnatural feel in some patients and the risk of an eventual dramatic and inconvenient failure event. Silicone breast implants offer an improved and more natural feel and no risk of a dramatic deflation event albeit at a higher surgical cost.

Ideal Implant Dr Barry Eppley IndianapolisAlong has come the Ideal implant which marries characteristics of both saline and silicone breast implants. The advantages of the Ideal breast implant over either traditional saline or silicone implants are numerous. They offer the benefits of both types of implants without any of their downsides. The Ideal implant has an external feel that is similar to that of silicone implants (no rippling) but without the use of any silicone filler material. For those women that may harbor some persistent concerns about silicone gel, this provides peace of mind. It will also not suffer a complete implant deflation which lets the patient know their implant has a problem (partial deflation) but yet will not go completely flat.

Ideal Implant structure Dr Barry Eppley IndianapolisIdeal Implant internal structure Dr Barry Eppley IndianapolisHow does the Ideal implant achieve these improved physical characteristics over the traditional saline breast implant? It is in its proprietary and clever internal design. The implants has an internal structure which has an inner shell around the inner chamber which contains the inner saline filler and an outer shell around an outer chamber which holds the outer saline filler. Between these two shells are several baffle shells. This specialized type of inner structure controls the movement of saline inside the implant.

Bernoulli's PrincipleEven in a saline breast implant which has been filled to the point of stretching out the silicone containment bag (shell) and appears full, fluid does move around in waves inside it. But why does a traditional saline implant have ripples and feel so soft and extremely pliable? Using  the well known Bernoulli’s Principle, the pressure in a moving fluid decreases as its speed increases, and increases as speed decreases. Thus the saline in a traditional implant moves very rapidly and therefore exerts a low pressure on the outer shell. The innovation of the Ideal breast implant is that its internal structure chambers and baffles slow the movement of the saline down and, as a result, increases the pressure on the outer shell which dramatically reduces wrinkling and makes it feel more firm. (like a silicone breast implant)

Ideal Implant shape Dr Barry Eppley IndianapolisSuch fluid dynamics also affect the shape of the implant. The Ideal implant maintains a higher profile with lower edges and better upper pole fullness than that of a silicone implant. It does not develop the so called ‘ash tray’ effect that almost all silicone implants do that occurs when the implant is laying on a flat surface.

Dr. Barry Eppley

Indianapolis, Indiana

Large Breast Implants

Tuesday, April 26th, 2016


While there many important issues to consider in breast augmentation, the size of the implant is one that women spent the greatest amount of time pondering before surgery. There are a variety of implant sizing methods and they all have their merits, but the reality is that breast implant sizing is not an exact science. No patient can really know for sure how they like the implant size selection until they swelling goes down and they have ‘worn’ it for awhile.

Women for breast augmentation usually want an implant size that looks natural, fits their body frame and does not stand out as their most notable feature. What that implant size may be is open to interpretation and highly subjective. But there are women who do want to have large breast implants and their goal clearly is not to be subtle in the result and a natural look is not their goal.

Breast implants come in a wide range of sizes from 150cc to 800cc. Because silicone implants are prefilled, their maximize size is 800cc volume. Saline implants, however, are alway overfilled and their volume can well exceed 1000ccs if desired. Considering these options in breast implant sizes, a large breast augmentation is going to be in the range of 600cc to 800ccs. For some women the volume may be much more.

For a variety of reasons, many plastic surgeons are opposed to larger breast implants. Such opposition is based on two basic and understandable reasons. Large breast implants are associated with a higher rate of complications such as loss of tissue support (bottoming out), implant asymmetries and deflations. (saline implants) The fundamental teaching in plastic surgery is to not place implants that exceed the ability of the tissues to support them long-term. The second reason for objection is the long-term consequences of the stretched out breast tissue. Large implants do deform the breast tissue irreversibly and their removal or reduction in size in the future will necessitate major breast lift surgery and its associated scars.

But breast implant size is a very personal decision and as long as the patient has been educated as to its potential consequences, large breast implants are a patient’s choice. The most common women who seeks large breast implants in my experience is the one who already has breast implants. They may have had them for years and now desire a much larger size. They may have had children or lost weight and their overall breast size has gotten smaller and a lot more volume is needed to fill out the loose skin. In these cases it can take a lot of implant volume to adequately expand the stretched out breast skin. In many ways these women are much more ‘qualified’ for large breast implants because they have a better frame of reference.

Some first time breast augmentation patients do seek large breast implants but they are far less common. Big for them might be up to 500ccs or so in small frames and 600cc to 700ccs in larger framed women. This is big for them given where they started but are not that big compared to women who are changing their existing breast implants.

The concept of large breast implants is open to interpretation but would be anatomically one where the implant width exceeds that of the the natural breast base width. While this may contribute to better cleavage it equally means that the side of the implant will protrude out beyond that of the chest wall.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Nipple Lifts with Breast Implants

Tuesday, February 9th, 2016


Background: Sagging or ptosis of the breasts is seen in s wide variety of forms, all of which can influence breast augnentation results. Severe or Grade III and IV breast ptosis is an easy breast lift decision to make as there is no other choice. Grade I breast ptosis is also an easy decision as breast implants alone will have a lifting effect on its own.

The intemediate or Grade II breast ptosis is challenging decision. A breast lift will provide the needed upward change of nipple position but will create undesired scars in so doing. Implants will avoid visible breast scars but may make the appearance of the breast worse with a lot of upper pole fullness but a nipple-areolar complex that is oriented more to the lower pole of the breast.

Case Study: This 34 year-old female presented for breast implants. She knew she had a bit of breast sagging but did not want any scars that went beyond the margin of the areolas

Breast Implants with Nipple Lift results front view Dr Barry Eppley IndianapolisUnder general anesthesia she had 400cc smooth silicone breast implants placed through small inframammary incisions using a funnel technique. At the same time nipple lifts were performed by removing a superior crescent skin at the superior aspect of the areolas of 1 cm in height at the central aspect.

Breast Implants with Nipple Lift results oblique view Dr Barry Eppley IndianapolisSmall to moderate degrees of sagging pose issues for optimal breast augmentation results. Many patients understandably think that implants will have a breast lifting effect which is only true if the nipples are right at or above the inframammary fold level. Often in more minor amounts of sagging the patient may not even recognize that they are ‘droopy’ since they may have been that way for a long time.

Breast Implants with Nipple Lift result side view Dr Barry Eppley IndianapolisThe nipple lift, formally called a superior crescent mastopexy, is not a true breast lift. It is really a nipple edge relocation procedure. While it may not centralize the nipple during the placement of breast implants, it can prevent it from having a worse and lower mound position after its enlargement.


1) Ptosis or sagging of the breasts is not usually fixed by breast implants alone.

2) Borderline breast lift patients can be treated by a superior crescent mastpexy (nipple lift) with their breast augmentation.

3) Nipple lifts offer an alternative option to the scars of a more formal breast lift albeit with a much less lifting effect.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Implant Settling

Thursday, January 21st, 2016


Breast implants create their effect by causing an instantaneous expansion of the overlying breast mound. This relatively simple and obvious concept causes a variety of postoperative effects on the shape of the breast that are often incompletely understood by patients…although understandably so.

Breast Asymmetry Breast AugmentationSome of their well known effects is that implants just make the breasts that a woman has already bigger. Therefore any pre-existing breast asymmetry, no matter how slight, will become magnified when the breast mounds become bigger. This has lead to the well worn phrase used by plastic surgeons of…‘breasts are sisters and not twins’…in preoperative expectation of what some women will see afterwards.

One of the most known after surgery effects of breast augmentation surgery is that the ‘implants will settle’. This indicates that the implant may initially look high. (too much upper pole fullness and/or an inframammary crease that is also too high) But with time and healing the implant will drop or settle into a more natural or desired position.

There is little question that the breast implant settling phenomenon is real and will affect all breast augmentation patients. But why this occurs may not be exactly clear. A not infrequent question, and an understandable one, is why the surgeon does not just put the implants in the desired position so they do not have to settle. In reality, the surgeon does place the implants where he/she wants them and on the operative table they do and are properly positioned.

But it is important to remember the tissue recoil effect. When breast implants are placed they create an immediate and dramatic stretch on the overlying skin and their elastic fibers. Like a rubber band that gets stretched out its natural elasticity will ‘fight back’. When you add in the immediate postoperative swelling that occurs, this combination will drive the implant upward where there is more tissue space. This is why early after surgery breasts look too round, too high and the skin even looks shiny.

Breast Implant Settling front view Dr Barry Eppley IndianapolisBreast Implant Settling oblique view Dr Barry Eppley IndianapolisIt is much easier for a breast implant to move upward after surgery where there is much more skin that is not as stretched. The bottom pole of the breast is where the skin and underlying tissues are stretched the most and they are often naturally vertically short. (this is why the inframammary incision is almost always placed lower than the native inframammary fold) Thus it takes time for the bottom half of the breast tissues and skin to relax and allow the implant to come back down.

Breast Implant Settling side view Dr Barry Eppley IndianapolisThe breast implant settling process is one of months duration. Looking at a breast augmentation result can show some significant changes between the first month after surgery and six months later.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know – Mondor’s Cord

Sunday, January 3rd, 2016


A Mondor’s cord is a painful and hardened ridge which  may appear weeks after breast augmentation surgery emanating downward from the lower breast crease. (if an inframammary incision was used) It may also develop in the upper arm if a transaxillary breast augmentation technique was used. This is not a complication of breast augmentation surgery but an infrequent temporary annoyance that occurs in some women.

Mondor's Cord after Breast Augmentation Dr Barry Eppley IndianapolisMondor’s cord is is caused by an inflammation of the draining veins from around the incision, more commonly known as superficial thrombophlebitis. Trauma to the veins from the procedure is the cause very much like the same condition that can develop in the hands and forearm after having an IV inserted. It usually does not develop for several weeks after surgery and becomes most apparent when one is stretching or reaching with their arms which makes the restriction of the cord most apparent. In some cases more than one vein may be involved giving rise to more than one cord.

Because it is a hard cord it can cause some discomfort. It is a self-resolving condition but can be treated by anti-inflammatory medications and warm compresses. It will take several weeks to go away. One is not a risk for any blood clots or the throwing an emboli.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Augmentation in Small Saggy Breasts

Friday, January 1st, 2016


Background: Breasts that are either deflated or have developed sagging are prime reasons to pursue breast augmentation surgery. Pregnancy and weight loss are the most common culprits for causing this type of breast shape change. Breast augmentation surgery is the solution to these breast shape concerns.

With loss of the supporting breast volume combined with stretched out skin, the breasts not only get smaller but that likely will develop some sagging as well. While breast sagging occurs in a variety of degrees of magnitude, these degrees of sagging are definjed by where the nipple sits relative to the inframammary fold. The relevance of this to the breast augmentation patient is whether their breast sagging will require some type of lift with their implant placement or not.

The most difficult breast sagging patient is the one whose nipples are right at the level of the inframammary fold. This makes them marginal for whether they can just have breast implants alone. Will the implant volume create enough of breast mound and nipple elevation to avoid the need for a breast lift? Two factors play into whether this is possible, the implant volume’s and the potential for lowering the existing inframammary folds.

Case Study: This 24 year-old female wanted breast implants. She was very small framed and thin and had two pregnancies. As a result, she had lost all of her breast tissue and the stretched out skin had a little sag.

KA Breast Augmentation results front viewKA Breast Augmentation results oblique viewUnder general anesthesia, she has smooth round high profile silicone breast implants of 400cc size placed. Through an incision placed lower than her existing inframammary folds, a dual plane partial submuscular position was made which also lowered the fold levels as well.

KA Breast augmentation results side viewWomen who are marginal candidates for needing a breast lift can avoid this undesired possibility by a combination of an adequately sized implant and dropping down the level of the lower breast folds. There is also some risk of developing bottoming out of the breasts but this must be balanced with how much one wants to avoid the scars from a breast lift procedutre.


  1. Breast implants can adequately ‘reinflate’ breasts as long as they do not have appreciable breast sagging.
  2. In many mild cases of breast sagging, the inframammary folds must be lowered to get the implants adequately centered behind the nipples.
  3. The size of the breast implant chosen will determine how well any breast sagging and excess breast skin is filled out.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Implants and Tattoos

Sunday, December 13th, 2015


Background: Placing implants to increase breast size is the most common surgical method of breast enhancement. The most common non-surgical method of breast enhancement are tattoos. When it comes to breast tattoos, there is an endless variety of patterns, sizes and colors. From words to images to some incredible artistic patterns, breast tattoos are as individual as the patient themselves. While most breast tattoos are fairly small, some of very large and can even cover the entire breast mound.

As breast implants enlarge the breast mound some enlargement of the existing tattoos is likely to occur. The closer it is to the center of the breast mound the more the tattoo will increase in size. But rarely does it ever distort the tattoo that it is not longer appealing.

Case Study: This 35 year female came in for breast augmentation. Across her sternum on the lower half was large inverted moth tattoo. The lower body of the moth;’s wings were on the inner lower portion of the small breast mound.

Moth Breast Augmentation results front viewMoth Breast Augmentation result oblique viewUnder general anesthesia 450cc high profile smooth round silicone gel breast implants were placed through inframammary incisions. The implants enlarged the breast mounds to the desired size and gave the back wings of the moth tattoo a ‘lift’ as well,

There are no contraindications to getting breast implants with any form of a tattoo on the breast mounds. The tattoo may change slightly with a modest increase in its size as would be expected.


  1. Some women that present for breast augmentation have a multitude of tattoo sizes and patterns in their breast mounds.
  2. The incisions to insert breast implants rarely disturb breast mound tattoos.

3) Some tattoos may increase in size some what as the breast mounds get larger due to the placement of breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Nipple Lift with Breast Augmentation

Tuesday, December 1st, 2015


Background: Many women who are to undergo breast augmentation surgery have asymmetric breasts. These asymmetries may be in breast mound size, breast mound shape, amounts of sagging and the nipple position. Preoperative education about how breast implants will impact these asymmetries is of critical importance as breast implants alone will not correct many breast asymmetries. In some cases they make even make them worse. This has led to the well worn phrase in breast augmentation surgery of…’they are sisters, not twins’.

Almost all differences between two breasts, however, are reflected in some degree with the position and shape of the nipple. Nipple size differences can exist but the most important and visually distracting nipple issue is that of a horizontal discrepancy. When one nipple sits lower than the other nipple based on a horizontal line drawn between the two, this is a critical preoperative diagnosis to make. It usually is the result of one breast having a little more sag than the other one and women often state this was the primary suckling breast. This diagnosis is important as the placing of breast implants will always increase any horizontal nipple discrepancy.

Managing a horizontal nipple asymmetry is almost always done through a nipple lift, also called a superior areolar mastopexy. In reality it is just a lift of the superior margin of the areola and has no breast lifting capabioity as suggested by the mastopexy name. This is a simple procedure of skin removal and areolar margin adjustment that has no detrimental effect on nipple sensation or prolongs the recovery from breast augmentation surgery.

Case Study: This 46 year-old Asian female presented for breast augmentation surgery. She has lifelong small breasts of B cup size and wanted to be a fuller C cup. On examination her right breast had more sag and an appreciable lower upper margin of the areola with a 12mms discrepancy.

Nipple Lift BAM results front viewDuring her breast augmentation surgery, 300cc high profile round smooth silicone gel breast implants were placed through inframammary incisions. At the same time a superior crescent of skin was removed above the right areolar to better match the horizontal levels of the nipples.

Nipple Lift BAM results oblique viewRight Nipple Lift Scar Dr Barry Eppley IndianapolisHer postoperative results show larger breasts that appear more symmetric in both size and nipple position. Even though she was of Asian origin, her areolar scar shows on signs of hypertrophy or hyper pigmentation afterwards.

A superior nipple lift is a simple and effective method for improving breast asymmetry in some women undergoing breast augmentation surgery. The preoperative diagnosis of horizontal nipple asymmetry is critical and one that even some women are not aware that they have. Some women may defer to wait after surgery to see whether they want to do it or not. And that is easily done under local anesthesia in the office should they so decide. But bringing it to their attention before surgery and offering the nipple lift option, either during their breast augmentation surgery or after in the office, is sound pre surgical education.


1) Many women have varying degrees of breast asymmetry of which one feature is that of a horizontal nipple asymmetry.
2) A simple nipple lift can be an effective solution to a horizontal nipple asymmetry which will become magnified with the placing of breast implants.

3) A nipple lift is not a breast lift and only changes the upper location of the areolar margin.

Dr. Barry Eppley

Indianapolis, Indiana

Aesthetic Insights – Wide Spacing of Breast Implants

Sunday, November 29th, 2015


For women undergoing breast augmentation surgery, the location as well as the size of the breast implants is of critical importance. While women can participate in the selection of the size of their breast implants, they have little say in where they are positioned on the chest wall. Ideally the plastic surgeon centers the implant with the nipple-areolar complex  positioned over or close to the center of the newly projected breast mound.

But many women’s native breast mounds are not usually symmetric and the position of the nipple-areolar complexes may be positioned fairly far to the side. Such widely spaced breasts mound and lateralized nipples pose an aesthetic compromise that is important to diagnose and discuss before surgery.

Wide Spaced Breast Augmentation result front view Dr Barry Eppley IndianapolisWhile many women want to have their breast implants create cleavage, or be as medialized as much as possible, the limits as to what can be achieved is their natural breast mound location. Widely spaced breasts simply pose limits as to how close breast implants can be placed to the sternum. A good rule of thumb is that no more than two-thirds of the implant’s base width can be placed medial to the areolar edge. By making this measurement it can be seen before surgery how close the breast implants can be placed to the sternum. (or how much of a sternal gap will persist afterwards)

It is often said that breast implants don’t make cleavage…that is what bras do. While there are certainly examples of where breast implants can be placed very close up to the sternum, this is primarily a function of the woman’s natural breast mound position as well as the size of the breast implants used. For many women undergoing breast augmentation, their desired close spacing of the breast implants is often not a reality.

Dr. Barry Eppley

Indianapolis, Indiana

The Effects of Breast Implants on Native Breast Tissue

Saturday, November 28th, 2015


Breast Augmentation in Asians Dr Barry Eppley IndianapolisBreast augmentation using breast implants is the tried and proven method to increase breast size. It does so by an outward displacement of the overlying breast tissue (parenchyma) and skin due to the push of the implant. Plastic surgeons have recognized for years that the push/pressure of the implant causes a reduction or loss in the amount of breast tissue that existed before surgery. This is easily observed in any breast implant replacement surgery where the removal of the old implant shows a near concave appearance of the breast in many women as the patient is in the horizontal position on the operating room table. While a well recognized phenomenon, such breast implant effects have not been quantitatively evaluated.

In the November/December 2015 issue of the Aesthetic Surgery Journal, an article appeared entitled ‘Evaluation of the Effects of Silicone Implants on the Breast Parenchyma’. In this clinical study the authors used volumetric magnetic resonance imaging at six and twelve months after the subglandular placement of silicone braesy implants. A total of thirty-four (34) women were studied with twenty-four (24) of them receiving the breast implants compared to a control of ten women. They found that at one year after surgery there was a 22% reduction in the amount of natural breast tissue that was initially present.

This is one of the few studies that provides quantitative evidence of the loss of breast tissue with implant placement. The parenchymal atrophy is a direct effect of mechanical compression. One theory is that such compression impinges on the tissue’s blood supply but it is equally likely that it is a direct effect on the cells themselves with pressure-induced apoptosis of the fat cells. But regardless of the mechanism the effect is real and is of considerable consequence when a patient considers implant removal (one does not return to their preoperative breast size and shape) or implant exchange. (this is why more implant volume may be needed later just to maintain the same breast size)

Large Breast Augmentation result oblique view Dr Barry Eppley IndianapolisThere are lots of problems with this clinical study including the location of the implant in the subglandular position and the use of textured polyurethane implants…two breast augmentation variables that are not done in the U.S.. Whether smooth saline or silicone implants placed in the partial submuscular position would create an exactly similar effect can only be speculated. There is also the highly variable impact of the size or volume of breast implants on how much breast tissue one has go start with and the tightness of the overlying breast skin. Large volume breast implants placed in breast mounds with lower amounts of breast tissue would be expected to cause considerable breast parenchymal loss over many years of implantation.

The main pertinent point of such a study like this to women considering breast augmentation is that it should be considered an aesthetically irreversible procedure. While breast implants can always be easily removed, one’s breasts will never return to their original size and shape. Fortunately only a minority of women ever progress to the point in their lifetime that they want their breast implants removed.

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.

Read More

Free Plastic Surgery Consultation

*required fields

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits