Breast augmentation involves two factors, one which is variable and another which is not. The insertion of a breast implant is a fixed factor. While the size of the implant may change, it will exert a push on the overlying tissues which is consistent. The spherical geometry of the implant puts an even force on the skin of the overlying breast. The overlying breast, however, is a variable factor having different amounts of skin, size and position of the nipples, and amount of natural breast tissue.
The variability of the patient’s natural breast tissue is the most significant factor in the outcome of a breast augmentation procedure. The amount of tight or loose breast skin and the associated position of the nipple on the breast mound are very important presurgical considerations. Known as ptosis, the amount of breast sagging determines whether an implant alone is sufficient to achieve the patient’s goal of an upright, nipple-centered, larger breast mound.
One of the common patient myths is that an implant can lift up a sagging breast. While an implant will expand and stretch out loose breast skin, it cannot really significantly lift the nipple position up higher on the breast mound. When the nipple sits at or below the lower breast crease (ptosis), an implant by expansion will not move the nipple up wards. The breast mound expands around it and it gets bigger, but the nipple does not change position.
While the treatment of ptosis in breast augmentation is usually best managed by some form of a breast lift, many patients are resistant to the scarring that results. This is not an issue in the most severe forms of breast ptosis (Grade III and IV) where the nipple literally points downward to the floor, smaller amounts of breast ptosis make however for a difficult aesthetic decision. The patient must then choose between an unscarred breast augmentation result that appears ‘top heavy’ (nipple positioned more on the bottom side of the breast) or a centered nipple with breast scars from a lift.
Each woman with ptosis that desires a breast augmentation must make that decision beforehand and it is important that one understand that a breast implant can only make a breast bigger. It simply takes the existing anatomy, regardless of where the nipple is, and makes everything larger. It can not lift and tighten breast skin and move the nipple upwards to a more central mound position. That, by definition, is what a breast lift does.
There is nothing aesthetically wrong with an implant alone in the face of some amount of breast ptosis. The patient just needs to understand that they will not end up with a perfect breast mound, well positioned on the chest wall, with a centrally located nipple. As patients look over many before and after photographs on various websites, they should look carefully at the shape of the breast tissue and nipple of these patients beforehand. Unless you look like them before surgery, you should not expect to have a similar breast augmentation result.
Dr. Barry Eppley
Indianapolis, Indiana