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.
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.
Breast reduction with lift accomplishes two goals: shrink the breasts to make them more proportionate to the body, and improve their shape by elevating some of the tissue of the lower pole.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says breast reduction and breast lift have different goals, the former is often considered a medical necessity (to eliminate systemic discomfort that comes with overlarge, heavy breasts), while the other is viewed as a purely cosmetic procedure. Nonetheless, it always makes sense to combine them as they share the same incisions.
Dr. Smiley works on one breast first before operating on the other side. The goal is to create a nice template so both sides will have a good level of symmetry.
In a recent Snapchat video, Dr. Smiley says large, heavy breasts are almost always pendulous.
Dr. Smiley has recently performed breast reduction with lift on a patient. He also did a simultaneous areolar reduction to further ensure more proportionate and natural results.
Due to the significant breast ptosis (droop), Dr. Smiley elevated the nipple area by around 7 cm. The goal was to create a decent distance between the areola and the submammary fold; of course, the ideal distance primarily depends on the final breast size.
But before he was able to elevate the nipple, he removed the epidermis of the skin, a process called de-epithelialization. He was careful not to go deeper (ensuring that the dermis remained relatively intact) to minimize bleeding and to prevent inadvertent injury to the blood vessels.
By preserving most of the blood supply, Dr. Smiley says the risk of infection and healing problems is significantly reduced. Of course, lab screening prior to surgery is also critical to ensure that the patient is “healthy enough” to tolerate the operation and its ensuing recovery, he further explained.
Thereafter, he removed some breast tissue to reduce its size before elevating some of the lower pole tissue to give the patient more upper pole fullness and to correct the drooping appearance.
Instead of relying on skin tightening, Dr. Smiley says his breast reduction with lift depends more on internal lifting to ensure that the results can resist the effects of gravity and progressive aging.
After reshaping the internal structure of the breast, he closed the anchor-shaped incisions with multiple rows of sutures. The actual skin, meanwhile, was not included in the process and instead its wound edges were just allowed to “kiss” each other, similar to a jigsaw puzzle, to promote the best scar possible.
Reducing tension on the skin is the key to thin, faded scars, says Dr. Smiley.
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.