Background: A woman’s breast is not a stable structure over her lifetime. It is exposed to many changes from its initial development throughout puberty to an older woman. Undoubtably the greatest changer of breast shape is pregnancy, causing gradual expansion and then a relatively rapid deflation. With this overall yoyo of breast shape comes loss of breast tissue and stretching of the skin as a consequence. When the process is repeated more than once, the loss of breast shape and position on the chest wall is inevitable.
Sagging of the breast (ptosis) and loss of volume (involution) has many women seeking breast reshaping plastic surgery. For some women, the simple placement of an implant not only restores volume but provides just enough of a lift that this is the only corrective procedure they need. This can be foretold before surgery by the location of the nipple. If it is above the lower breast fold, then no concomitant lifting procedure will be needed. These are the fortunate of breast reshaping patients.
When the nipple is at or below the lower breast fold, an implant alone is not going to be enough to restore an aesthetically pleasing position of the nipple on the breast mound. Implants simply do not create any substantial breast lifting effect, no matter what apatient hopes or has read. When this degree of breast ptosis exists, the need for a lift with an implant can not be avoided. While some patients do not desire a lift, they may elect to have an implant placed first to prove whether a lift is really ultimately needed. I am not opposed to this approach as long as patients do not confuse hope for oversight on my part afterwards.
Breast lifts come in a variety of types, differentiated only by the amount of scar they create and how much breast mound lifting is achieved and the nipple position is moved upward. To no surprise, there is a fairly direct correlation between the amount of scarring and the amount of overall breast lifting. The more scar that is created on the bottom of the breast below the nipple, the more lifting that is achieved.
Case Study: This 25 year-old Hispanic female wanted to improve her breast shape and size after having two children. She had lost much of her breast volume and developed a Grade III ptosis in both breasts. (nipple at or just below the lower breast fold) In discussing a combination implant and lifting procedure, the concerns about scarring were stressed. This is of particular relevance in patients with increasing skin pigmentation. As skin pigment increases, the more the scar may be noticeable or develop some hyperpigmentation after surgery.
Under general anesthesia, she had 500cc saline implants placed in a partial submuscular dual plane position. She also had a full vertical breast lift with resulting vertical scars down to the fold and some horizontal extension of the scars along the fold as well.
Her postoperative course was typical in that the implants initially were high early after surgery. But with the resolution of the swelling and some skin relaxation, the implants settled into the desired position. This settling resulted in some loss of upper pole fullness which she had really liked in the early period after surgery. While she has not complaind about the scars, I do not personally like them even though I would consider them typical for her skin pigmentation.
Now that it is one year after surgery, she is going to have a revision. She is debating whether to just add more volume to her existing implants or place new larger implants to get back some more upper pole fullness. This is a financial decision. At the same time I will revise her vertical breast scars as I think they can turn out better. (more narrow)
Case Highlights:
· Reshaping of the deflated and sagging breast requires a combination of implant volume addition and nipple lifting and skin tightening manuevers.
· Scars are an inevitable consequence of the breast lift part of the procedure and must be considered an aesthetic trade-off of thecombination breast reshaping procedure.
· Breast reshaping through a combination lift and implant placement is one of the hardest body contouring procedures to perform and the need for revision for optimal results is common.
Dr. Barry Eppley
Indianapolis, Indiana