Breast Augmentation

Breast implant removal with smaller replacement can pose some challenges such as risk of sagging appearance and poor breast contour, although with close attention to details great results can be achieved.


Recently, leading Los Angeles plastic surgeon Dr. Tarick Smiley has performed a surgery on a woman with 500 cc silicone implants who wanted them replaced with 270 cc, which could slash her breast size by almost half.


breast implant removal with smaller replacement

The patient asked for breast implant removal immediately followed by replacement. But since the new implants were significantly smaller than the old ones, a simultaneous breast lift was performed to maintain natural breast contour.


Due to the significant downsize, she was deemed as a good candidate for a simultaneous breast lift. Without this procedure, her implants would settle too low, resulting in a drooping appearance and deflated-looking upper breast pole.


To remove the old implants along with their scar capsule, Dr. Smiley created a small incision within the breast crease (submammary fold), which would result in a well-concealed scar. He then replaced them with a new pair of smaller implants.


Next, he performed a standard breast lift in which the incision pattern ran around the areola, which was extended downward towards the crease and then across the base of the breast. This would result in an inverted T or anchor-shaped scar that is expected to blend into the background 1-2 years postop.


For long-lasting effects, breast lift should not just be about skin tightening and resection. After all, its elasticity makes it susceptible to the effects of gravity and aging. Hence, the celebrity plastic surgeon creates a more resilient support by remodeling the deeper tissue.


The use of “deep tissue work,” according to Dr. Smiley, also allows the surgeons to elevate some of the tissue of the lower breast pole, resulting in additional upper pole fullness. According to studies, the most preferred breast shape has a 45:55 upper to lower pole ratio (resembling a teardrop shape).


To further promote youthful and natural-looking results, the new position of the nipples should be horizontally and vertically aligned with each other.


Furthermore, tightening the deeper tissue allows the skin to receive no or very minimal tension, which is the key to good healing and “nice looking scars,” says Dr. Smiley.

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Breast augmentation transaxillary refers to the creation of a hidden incision at the deepest skin fold of the armpit, thus allowing the surgeons to propel implants into the breast pocket.


Celebrity Beverly Hills plastic surgeon Dr. Tarick Smiley says breast augmentation transaxillary is one of his favorite incision techniques, along with the peri-areolar method (or “through the nipple”), due to the well-concealed scar.


The breast augmentation transaxillary incision technique results in a well-hidden scar.

Aside from the well-concealed scars, Dr. Smiley says the incision technique offers other advantages such as perceived lower risk of infection, implant contamination, nipple numbness, and breastfeeding difficulty.


The benefits of this technique stem from the fact that the implants will not pass through the milk ducts, which are known to harbor staph bacteria.


But as with any breast augmentation technique, Dr. Smiley says the ideal candidate candidate should have aesthetic goals and breast anatomy that are in line with what the transaxillary incision can accomplish.


  • Women whose breasts are relatively symmetric and perky.


Since there is no direct incision on the breast, there is no way that the surgeon can elevate or transpose the sagging breast tissue. Hence, the technique is only reserved for women whose pre-existing bosom has a relatively good shape and projection.


Meanwhile, patients with sagging or pendulous breasts and those with deformity (e.g., tubular or torpedo breasts) are not good candidates for the “through the armpit” technique.


  • Patients who asking for moderate-sized silicone implants or saline implants of any size (provided they are within the breast/chest dimension).


It is important to note that silicone implants are always prefilled, while saline implants are propelled into the breast pocket empty (they are rolled up like a cigar) before they are inflated with sterile saltwater.


Hence, extra large silicone implants (or 600 cc and higher) require longer incision than that of saline implants, which of course makes it difficult or even impossible to hide the scar within the armpit.


Nonetheless, most patients today prefer silicone implants due to their softer, more natural results than saline implants. For this reason, Dr. Smiley typically uses Keller Funnel during surgery to ensure that the scar remains relatively short and well concealed within the armpit.


Keller Funnel is a disposable device that closely resembles a piping bag. This is used to propel the silicone implant into its pocket with one squeeze and so the implantation process is quicker and less traumatic to the tissue. Furthermore, doctors are able to use a shorter incision with this technique.


  • Patients with a strong history of keloids.


Several studies have suggested that darker skin is susceptible to keloids; hence, ethnic patients tend to choose breast augmentation transaxillary since the incision is placed in this hidden area, which is also known for being highly resistant to aggressive scarring.


Aside from ethnic patients, younger women (i.e., Millenials) often find it unacceptable to have scars on their breast and so they typically inquire about the possibility of placing the incisions within their armpit.

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Cohesive breast implants or silicone gel-filled implants are the popular choice among breast augmentation and reconstructive patients due to their natural results and feel, says leading Inland Empire plastic surgeon Dr. Tarick Smiley.


Saline implants, meanwhile, have no tinge of cohesiveness since they are only filled with saline—i.e., sterile saltwater.


cohesive breast implants


In a recent Snapchat video, Dr. Smiley has explained the three levels of cohesiveness of round silicone implants manufactured by Allergan, a US-based company known for its FDA-approved, high-quality products.


  • Least cohesive silicone implants (Natrelle INSPIRA Responsive)


According to company brochure, they result in 84 percent upper pole retention once placed inside the breast pocket. Despite being the least cohesive type in the line of silicone breast implants, they nonetheless provide more natural results than saline implants.


Regardless of the level of cohesiveness, it is important to choose implants that reflect the patient’s chest and breast dimension to achieve natural results and to avoid a wide range of surgical stigmata.


  • Moderately cohesive silicone implants (Natrelle INSPIRA SoftTouch)


While they provide 91 percent upper pole retention, they nonetheless remain soft to the touch thanks to their cohesive silicone gel filling. Of course, they are slightly firmer than Natrelle INSPIRA Responsive.


  • Most cohesive or “gummiest” version (Natrelle INSPIRA Cohesive)


They retain 97 percent of their upper pole, resulting in additional fullness in the upper cleavage; hence, they suit patients who want the “push-up bra effect.” Also, women with low body fat percentage or lack breast tissue, anatomy that predisposes them to higher risk of implant rippling, are good candidates for this gummiest version of silicone implants.


One caveat of this gummiest version is the firmer breast, although most patients who are at risk of implant rippling do find this tradeoff acceptable.


The most cohesive type also suits women seeking a revision breast augmentation to correct implant rippling, which commonly occurs around the upper breast pole where the tissue is the thinnest.

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In periareolar breast augmentation technique, doctors place a small incision right at the lower border of the areola, which is a ring of pigmented skin surrounding the nipple.


Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says he prefers the technique due to its well-hidden scar, thanks to the areola’s thin skin that makes it highly resistant to aggressive scarring (keloids). Moreover, placing the scar at the dark-light skin junction means it can blend easily into the background.


periareolar breast augmentation

This patient receives saline breast implant, which is propelled into the pocket empty. Once filled with saline, the tube, which has a self-sealing mechanism, is pulled out.

To further promote well-concealed scars, Dr. Smiley says it is important to close the wound with multiple rows of sutures without picking up the skin.


“The skin edges must be close enough that they are somewhat kissing. With no or very minimal tension, the skin can heal better as well as the ensuing scar,” says Dr. Smiley in a video he recently posted on Snapchat.


Dr. Smiley says he uses running stitch technique with the use of fine absorbable sutures (almost as thin as a human hair) that dissolve within 3-6 weeks.


One of the most common concerns of patients is the risk of reduced nerve sensation, which could also have an impact on their capacity to breastfeed in the future. However, Dr. Smiley says the risk is very small because the incision “goes down” and so the nerves and milk ducts are spared from significant injury.


“Because we’re not cutting above, which could injure more nerves around the nipple, the risk of reduced nipple sensation is very low, just less than 4 percent,” says Dr. Smiley.


Meanwhile, one major caveat of periareolar breast augmentation is that the incision is placed close to the nipple, which is believed to harbor staph bacteria that are linked to infection and capsular contracture.


To avoid complications, before implantation Dr. Smiley says he always irrigates the implants and breast pockets with strong antibiotic solutions, whereas other surgeons simply use Betadine in an attempt to sterilize the tissue and implants.


“Betadine is too caustic for the internal tissue and implants. At one point, the manufacturer even mentioned that their product should not be used in breast augmentation surgery,” Dr. Smiley says.


“Irrigating with antibiotics remains the best way to prevent or minimize risk of infection and capsular contracture, a complication in which the copious scar tissue forms around the implant, leading to unnatural breast contour and pain,” he adds.


To further minimize the risk of complications, Dr. Smiley uses the Keller Funnel technique in which a disposable cone-shaped device is used to propel the implant into the breast pocket with just one squeeze.

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High profile implants on small frame can provide natural results provided that their base diameter reflects the patient’s chest and breast measurement.


But before we delve into the exact effects of high profile implants, it is important to understand the impact of profile or forward projection on the surgery’s results.


high profile implants on small frame

Different breast implant profiles


Implant profile refers to how much it projects off the chest wall. Hence, low, moderate, and high profile implants of the same volume or size give different results.


In the past, moderate profile implants were the only option. Also referred to as classic or standard profile, they have a relatively wide base, while their forward projection is similar to the appearance of perky, un-operated breasts.


High profile implants, meanwhile, have high projection although they appear narrower on frontal view.


At the other end of the spectrum is the low profile implant, which has the least amount of projection but occupies more space at the chest.


Beverly Hills plastic surgeon Dr. Tarick Smiley says high profile implants on small frame generally provide more fullness in the upper breast pole, somewhat similar to the lifting effect of push-up bra.


The additional fullness does not appeal to every woman and so it is a sacrosanct rule to identify each patient’s cosmetic goals prior to surgery.


In general, high profile breast implants suit women with narrow frame whose cosmetic goals include more fullness in the upper breast pole and more noticeable breast projection on profile view.


Due to their additional forward projection, high profile implants also appear bigger than low and moderate profile implants of the same size.


Meanwhile, some patients deliberately avoid high profile implants due to the purported unnatural look (globular shape). But the truth is, this untoward “effect” is more commonly associated with saline implants, which are filled with sterile saltwater solution.


Whereas, high profile silicone implants generally provide a more natural result in terms of feel and shape thanks to their filler material, which is made of medical-grade silicone gel.


Also, silicone implants are less likely to ripple than saline implants. Shell rippling is closely tied to implant failure and so silicone implants are perceived to have a longer lifespan.

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Leading Los Angeles plastic surgeon Dr. Tarick Smiley has recently posted saline breast implants before and after photos on Snapchat to demonstrate their effects in terms of breast contour, perkiness, and symmetry.


Breast implants come into two types based on filler material: saline and silicone gel.



Most breast augmentations today are performed with silicone gel implants because of their more natural feel and contour compared with saline implants.


Saline implants, meanwhile, may cause feeling of firmness and/or rippling due to their filler material—i.e., saltwater solution. This is more pronounced when the patient lacks breast tissue or has low body fat percentage.


But since the patient shown in the photos has average-sized breasts, her saline implants are less likely to cause rippling and palpability.


To further minimize the aforementioned risks, Dr. Smiley created the implant pocket beneath the pec muscle, which provided additional soft tissue coverage. This implant placement has almost become the default mode when he uses saline implants; nonetheless, this remains beneficial even in patients having silicone implants.


In reality, the under-the-muscle implant placement, or submuscular technique, covers the upper half of the implant with muscle, while the bottom part is supported only by breast tissue and skin. This fosters a more teardrop breast contour due to the muscles pushing down the top of the implant.


Dr. Smiley says the upper pole fullness should have at least 30 percent of the breast volume; nonetheless, the exact volume distribution will depend on the patient’s specific goals. For instance, others may want the 45:55 ratio, which is believed to be the most natural or “classic” look.


During surgery, the patient’s saline implants were filled with 450 cc of sterile saltwater solution. These implants always come with a tube, which has a self-sealing mechanism when pulled out from the implant shell.


Since saline implants are rolled up like a cigar and propelled empty into the breast pocket they require a slightly shorter incision than silicone implants, which always come prefilled.   Nonetheless, this aspect should not be the main reason for choosing one over the other.


Dr. Smiley says silicone implants remain more popular than saline implants due to the former’s more natural look and feel thanks to their cohesive filler material, which is less likely to cause rippling. Implant ripples are believed to compromise the device’s long-term stability.

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