Large breast reduction surgery, which entails removing at least 1 pound (or 454 gram) of tissue, typically involves patients whose disproportionately huge breasts are causing physical problems such as poor posture, chronic back and neck pain, rounded shoulders, and migraine headaches.
In extreme cases, some patients even experience shortness of breath and numbness in their fingers, a symptom stemming from the excessive weight pulling on the nerves around their shoulder and collarbone.
Recently, leading Los Angeles plastic surgeon Dr. Tarick Smiley performed a surgery involving drastic “downsizing” to eliminate physical discomfort experienced by a patient.
The said patient requested for a smaller breast size not just for physical relief but also for improved body proportions. (She has a medium frame body.)
During surgery, which was recently posted on Dr. Smiley’s Snapchat, he created an anchor shaped incision—i.e., the incision went around the areola, down the midline, and across the base of the breast.
The resulting scar around the areola’s border and the one across the base of the breast will be inconspicuous due to their strategic placement. Even the vertical scar, despite its more visible position, is expected to fade into the background within 6-18 months.
One of the most notable benefits of anchor breast reduction technique is the pleasing contour because it allows surgeons to remove excess tissue, fat, and skin quite uniformly. Modified incision patterns, meanwhile, tend to provide less natural shape (i.e., boxy) particularly when the incision across the base of the breast is eliminated.
After reducing the breast size, Dr. Smiley incorporated some breast lift techniques to create a more pleasing contour and to provide additional fullness to the upper cleavage. After all, these two surgeries share the same incision pattern.
Breast lift in general involves suturing the tissue and transposing some of the lower breast pole tissue to the upper cleavage to create a more youthful result.
To further ensure cosmetically pleasing results, Dr. Smiley raised the drooping nipple about 8 cm. The goal was to create at least a 3 cm distance between the areolar complex and the breast crease. In addition, its size was reduced to complement the smaller breast size.
Achieving a pleasing breast shape after breast reduction surgery is possible with deep tissue work and the creation of “appropriate” cup size, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
In the past, breast reduction surgeries were primarily concerned with the removal of excess tissue and redraping the skin over the smaller breast. However, the approach has a fundamental weakness: The skin stretches over time and so the initial perkiness is lost invariably.
To prevent breast sag, or at least prolong the perky appearance of the breast, Dr. Smiley says he performs deep tissue work alongside his breast reduction surgery.
His deep tissue work is the same with the breast lift technique in which internal sutures and breast tissue “elevation” are used to create a pleasing shape—i.e., some fullness in the upper breast pole.
With the suturing techniques, the breast shape is not dependent on the overlying skin, which is known for its inherent weakness, but rather on the deeper structures. This approach promotes longer lasting perkiness and more favorable scarring and healing since the skin receives no or very little tension.
When there is little tension on the skin, the scar tends to fade and heal much better, says Dr. Smiley.
“Sufficient reduction” is another critical element to promote a pleasing breast shape that can last for many years. It should be noted that one of the most common causes for “bottomed-out” breasts after surgery is that they are not made small enough.
Patients with overlarge breasts who want a conservative size reduction should realize that they remain susceptible to bottoming out or sagging due to the excessive weight that is causing the skin below the nipple area to stretch out.
It should be noted that the surgery does not change the quality of skin, although making the breast smaller and lighter can diminish the effects of gravity.
The breasts appear perky in the first few weeks postop until they gradually settle (i.e., lose some of the fullness in the upper breast pole) within 6-12 months.
Some patients require areola reduction and breast augmentation to achieve the most aesthetically pleasing results possible. It should be noted that large areolas make the breasts appear matronly even though these are not droopy.
Leading Orange County plastic surgeon Dr. Tarick Smiley has recently demonstrated on Snapchat the areola reduction and breast augmentation surgery performed in a patient who had “double bubble deformity” in which her breast tissue looked like it was hanging from the implant.
The patient requires areola reduction as part of her reconstructive-revision breast surgery.
To correct the double bubble deformity and allowed the new implants to settle into their most natural position, Dr. Smiley also performed a simultaneous breast lift.
The patient’s breast lift involved donut-shaped incisions to reduce the size of her areola. Supplementary incisions from the bottom of the areola and the inframammary fold that were extended across the base of the breast were also used to improve the overall shape and projection of the “breast mound.”
Dr. Smiley reduced the size of the areola by creating a circular incision around the desired diameter, which is about 38-42 mm, and another one at the dark-light skin junction. This donut-shaped incision pattern allowed him to shave off the skin (epidermis) in between, a technique medically referred to as de-epithelization.
Dr. Smiley said all efforts are made to reduce tension during the closure of areolar incisions to prevent healing problems and re-expansion or “spreading” of the areola, which may happen over time. Hence, he used several deep rows of sutures in which the tissue, not the skin, would receive most of the “tautness.”
Reducing tension on the skin would also allow the scar to fade nicely into the background, said the celebrity plastic surgeon.
Because the circumference of the outer incision was larger than the inner incision, the skin of the areola’s margin was “gathered” during the closure. This resulted in the pleated appearance of the new areola’s border, although within a few months this will flatten out.
To further achieve a nice breast shape and size, Dr. Smiley created “more distance” between the areola and the inframammary fold. In most cases, the ideal areola position is about 3 cm above the breast crease, he explained.
Over the past several years, plastic surgeons have been using a biological mesh that serves as an internal bra to hold the breast shape and maintain its “perky” appearance long term. However, some experts say that due to its flat or two-dimensional shape, its contouring effects on a curved surface such as the breast could be limited.
To rectify the inherent problem of flat-surfaced biological mesh, one company has released a three-dimensional scaffold called GalaShape. Unlike its earlier design, this new breast lift technique has a curved surface with a rim that closely resembles a bra cup, which can be easily wrapped around the breast and fixed to the tissue.
Photo Credit: galateasurgical.com
According to the company website, GalaShape is a biological mesh made of poly-4-hydroxybutyrate that triggers minimal inflammatory response. Thus, once positioned beneath the breast it triggers the body to create more collagen or scar tissue, which will hold the new contour of the breast.
It takes between 12-18 months before the biological mesh is completely absorbed by the body, leaving just the internal scar tissue to support the perky appearance of the breast long term.
The use of biological mesh, or any type of scaffolding or internal bra, is sometimes referred to as scarless breast lift technique because it only entails one incision that fades into the background—i.e., precisely at the border of the areola.
Despite the invisible scar, leading Los Angeles plastic surgeon Dr. Tarick Smiley says that scarless breast lift only works in patients with mild to moderate sag, which means that the areolar complex has not drooped way below the breast fold.
Should the areolar complex sag below the breast crease, Dr. Smiley says the traditional breast lift remains the best approach. This involves incisions around the areola, which then go down the midline and across the base of the breast, resulting in an inverted-T scar.
The traditional breast lift relies on soft tissue rearrangement to improve breast projection and shape. When done properly, most surgeons would agree that the use of additional materials like biological mesh is unnecessary.
When patients ask about the long term effects of breast lift, oftentimes they refer to the longevity of the shape. While many surgeons would say that it would probably last between 10-15 years, the truth is there is no definite answer due to the large number of variables.
The quality of skin, weight, sun exposure, diet, exercise, pregnancy, use of bra, and smoking and other lifestyle factors will have an influence on how long the breast contour and “perkiness” would hold. And while no surgery can stop aging, patients who have had breast lift in general will experience progressive sag that is significantly slower than someone who did not get the procedure done.
While aging and pregnancy contribute to breast ptosis (sag), leading Beverly Hills plastic surgeon Dr. Tarick Smiley says lifestyle factors also play a critical role in its appearance.
Dr. Smiley says that controlling lifestyle factors that have a detrimental effect on skin elasticity remains important after surgery.
Cigarette smoking reduces dermal collagen and skin tone, leading to breast ptosis. One previous study involving pairs of twins has clearly established its deleterious effects on skin elasticity.
Large weight fluctuations lead to breast volume deflation or involution, which can accelerate breast sag. Hence, the ideal candidate for any body contouring surgery should be committed to a healthy lifestyle, which they can adhere to long term. Diet pills and diet fads, meanwhile, are nothing but a palliative or temporary solution.
- Exercise and healthy diet
Combined with superb diet, exercise is the key to healthy weight and ultimately perkier and more youthful breasts. Of course, this only applies to women who make sure that they always wear a good fitting supportive bra.
Aside from smoking, UV rays also destroy the dermal collagen that gives the skin its youthful tone and elasticity. A good rule of thumb is to minimize sun exposure and use sunscreen regularly.
Breast augmentation and lift accomplishes two important things in one surgery: Increase the “cup size” and correct the sagging appearance. But sometimes, they are done separately to minimize risk of complications, which can be an issue if the patient wants bigger implants.
Breast augmentation, which is accomplished with the use of saline- or silicone-filled implants, increases the volume, while breast lift tightens the skin and deeper tissue. While combining these two procedures is known to enhance the overall contour, it is important to note that they have conflicting effects—tighten and expand the skin simultaneously.
The first step to achieve high satisfaction rate is to identify the ideal candidates for the combo procedure, and whether the surgeries can be performed simultaneously or in stages, says leading Inland Empire plastic surgery expert Dr. Tarick Smiley.
The placement of the nipple is one of the key elements that determines if a concomitant breast lift is warranted. One established aesthetic guideline suggests that the ideal distance between the nipple and the sternal notch (dip between the collarbone and neck) is 17-21 cm. Of course, women with longer torso and larger breasts can have a “larger gap” without their breasts looking saggy.
Furthermore, the nipple area should lie a few centimeters above the submammary fold, but then again the exact distance will depend on the breast size. Nonetheless, one study has suggested that the nipple position should “support” the 45:55 breast volume “distribution” ratio, which leads to the teardrop shape.
If there is too much distance between the sternal notch and the nipple, or the nipple falls at the same level as the submammary fold or beyond, a simultaneous breast lift is warranted lest an implant-alone approach can exacerbate the sagging appearance.
The standard or anchor breast lift suits women whose “breast bottom” has sagged more than 6 cm below the submammary fold. This entails a donut-shaped incision around the areola’s border, a vertical one between the nipple area and the crease, and another one that goes across the base of the breasts.
Meanwhile, patients whose nipple area remains above the submammary fold but can still benefit from a conservative elevation of their areolar complex will only need a donut-shaped incision technique.
After elevating the breast tissue and repositioning the nipple higher, implants are then propelled into their pocket, which should lie centrally behind the nipple area. The use of overlarge implants (or more than 600 cc) is generally discouraged unless breast augmentation is performed at a later date, ideally 3-4 months after breast lift.
If overlarge implants are simultaneously used during breast lift, they tend to ride higher on the chest wall leading to unnatural fullness in the upper pole/cleavage. In addition, they increase the risk of poor wound healing and less than optimal results.