Breast implant sizers can help patients visualize the results of different implant volumes, which are measured in cubic centimeter (cc). But to further promote good patient-doctor communications, a prudent surgeon will offer other modalities that can help his “clients” make an informed decision.
During consultation, patients are often encouraged to try on different implant sizers that are worn in unpadded bras. Ideally, they should also bring along different types of outfits to make sure that their new size will complement their favorite wardrobe.
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Most Los Angeles plastic surgeons agree that sizers are particularly useful in the management of volume-related asymmetry, although they have limited use in lopsided appearance caused by shape disparity between the two breasts. However, the surgeon’s experience can compensate the limitations of this modality.
Aside from the implant volume, its placement (under vs. over the muscle technique) can also affect the postop size and overall appearance.
For instance, breast implants will look bigger and will stick out more if positioned over the muscle, as opposed to under-the-muscle placement.
As a result, a patient who is satisfied with a 350 cc sizer may actually need a 375-400 cc implant at the time of surgery if the device is positioned behind the muscle. It may be safe to surmise that about 10 percent of the volume is “lost” with this technique, as opposed to over-the-muscle placement.
While some doctors prefer breast implant sizers to help their patients decide on their new size, others favor the use of 3D imaging, which involves taking three-dimensional images of patients and then using software to alter the appearance based on different sizes and shapes of implants.
Proponents of 3D imaging technology suggest that the altered or “after” images are very close to the actual results of the surgery.
Meanwhile, proponents of low-tech modalities such as implant sizers and “rice test” suggest that they might be better than 3D imaging by allowing the patients to try on different sizes with their favorite clothing, as opposed to a “naked” diagram of their body.
Because each modality has its own benefits and limitations as well, some plastic surgeons offer more than one modality to help their patients preview or visualize the most likely results of their surgery.
Getting the desire postop size is of paramount importance because size dissatisfaction is one of the most common reasons for revision breast augmentation.
Breast implant incision under breast is the most commonly used entry point due to its benefits that generally outweigh possible downsides, as suggested by doctors at the reputable California Surgical Institute.
As long as the scar remains within the inframammary fold, or junction between the breast mound and the chest, there will be no visible “sign” of breast augmentation surgery.
(Photo credit: ASPS website)
However, a small scar that goes slightly above the inframammary fold but remains in the “underside bulge” of the lower breast pole is also ideal especially if the patients like to wear a skimpy bikini top, which may ride up every time they raise their arms.
Proponents of breast implant incision under breast also suggest that it causes fewer breastfeeding difficulties than the peri-areolar or “through the nipple” technique, making it ideal for women who are not yet done having children. Nevertheless, pregnancy will affect the surgery’s results to a certain degree, which sometimes entails the need for a revision surgery or breast lift.
Since the technique allows direct visibility when creating the implant pocket and positioning the device, it favors patients who want to minimize risk of visible asymmetry, or they need their inframammary fold to be slightly lowered for a more natural breast contour.
To create the ideal breast shape, which is believed to have a ratio of 45:55 with the nipple delineating the upper and lower poles of the breast, some women will need their inframammary fold to be lowered or readjusted.
Other possible benefits of the inframammary fold technique include reduced risk of infection, capsular contracture (i.e., scar capsule becoming thick and constricted), and loss of sensation.
Meanwhile, recent surveys have suggested that more than 70 percent of breast augmentation patients chose silicone implants, which require a slightly longer incision than saline implants (3-4.5 cm versus 4-6 cm).
Silicone implants are ideally introduced through the inframammary fold so the scars will remain hidden. While the armpit and the areola’s border can be used as well, it warrants the use of a longer incision, which may result in more visible scarring.
But one way to shorten the scar is to use Keller Funnel, which is a cone-shaped device that propels the implants toward their pockets without actually touching them.
Despite giving doctors more control during pocket dissection and implant positioning, the technique may not be ideal for patients whose breasts are notably small that no folds can be seen. Also, the scars might be visible when one is lying flat.
The patient’s underlying anatomy, i.e., amount of soft tissue coverage and breast shape, is one of the factors that will determine the ideal breast implant incision techniques, namely, inframammary fold, peri-areolar, trans-axillary or armpit, and TUBA or navel.
Almost all women have breast asymmetry due to projection or size disparity and nipple position, although it is often minimal that it can be ignored. But in extreme or noticeable cases of lopsidedness, breast implant surgery can help create a more balanced appearance.
Los Angeles plastic surgery expert Dr. Tarick Smaili says patients with visible breast asymmetry are generally suitable for inframammary fold or “through the breast fold” and peri-areolar or “through the nipple” techniques because they allow direct visibility that makes implant positioning and pocket creation easier compared with other entry points.
Using the armpit and navel as the entry point, meanwhile, makes it difficult to position the implants correctly. For this reason, the techniques are only suitable for patients whose breasts have a good amount of symmetry and have no skin and tissue laxity, Dr. Smaili adds.
Most breast augmentation surgeries today use the inframammary fold technique because the scars are perfectly hidden particularly in patients with deep folds, and it allows doctors a good amount of control.
Also, a good number of patients need their inframammary fold to be slightly readjusted so their implants will settle centrally behind the nipple-areolar complex, leading to a natural [teardrop] shape. Failure to alter the crease may sometimes result in high-riding implants or cantaloupe-looking upper breast poles.
The peri-areolar incision in which a scar is placed between the junction where the darker skin meets the lighter skin is also ideal for women with breast asymmetry, particularly sagging and tuberous deformity.
If loose tissue contributes to the asymmetric appearance, an incision around the areola’s border is almost always necessary to tighten the skin and its underlying structure, and to correct the downward pointing nipple area.
Patients with tuberous deformity in which the nipple looks herniated on top of the narrow base of the breast are also suitable for the inframammary fold and peri-areolar breast augmentation techniques.
But aside from breast implant incision, it is also crucial to use different sized implants if the asymmetry is caused by one breast being larger than the other. It is ideal to “treat” both breasts rather than only augment the smaller one so they will have the same feel and projection, and will “age” at the same rate.
Visible rippling is one of the most common concerns mentioned by patients of breast implants Beverly Hills surgeons. This problem is primarily caused by little soft tissue coverage, although this can be offset with the use of “correct” implant size, projection, and width.
The general rule of thumb, according to renowned plastic surgeon Dr. Tarick Smaili, is to use breast implants that are within the boundaries of anatomies—e.g., chest and breast measurement, amount of soft tissue coverage, and pre-existing breast shape and projection.
The lower and outer part of the breasts is believed to be the most susceptible to rippling and palpability, making it crucial to use implants whose width, projection, and vertical height match the underlying anatomy.
To further minimize the risk of rippling, Dr. Smaili says silicone implants are helpful because their cohesive filler material behaves and feels almost like the breast tissue. Saline implants, meanwhile, may result in rippling along the edges, especially in women with little soft tissue coverage.
Aside from choosing a conservative [silicone] implant size, he says it is equally crucial to select the right profile. It is important to note that too much “forward projection” can thin the skin and breast tissue, leading to increased risk of palpability and wrinkling.
Thin, athletic, and small-breasted women will also benefit from under-the-muscle implant placement to compensate for their lack of coverage. While the technique results in longer and more painful recovery, most patients feel that its long-term benefits far outweigh the temporary downsides, Dr. Smaili adds.
Despite the use of such precautions, some women remain susceptible to rippling unless their surgeons will add some thickness to their breast tissue; this is done with fat grafting or acellular dermal matrix.
Fat grafting involves collecting donor fats from one area of the body (example: abdomen and thigh) and then purifying them prior to re-injection. However, proper placement of grafts is crucial to promote high survival rate and good amount of coverage.
A technique called structural fat grafting is particularly ideal because the grafts are layered carefully between the skin and the implant, with small spaces between them to promote blood vessel ingrowth, hence allowing them to survive in their new location instead of simply being absorbed by the surrounding tissue.
ADM, meanwhile, is a soft tissue replacement commonly used in breast reconstruction and abdominal wall repair. This lab-made material is a skin in which all the cells are taken out, only leaving the collagen or “main structure.”
ADM allows the patient’s own cells to repopulate within its structure, making it ideal as a soft tissue replacement in breast augmentation and reconstruction.
Fat transfer is growing in popularity due to its many uses in Beverly Hills plastic surgery. It can rejuvenate the face and hands, increase the breast and buttock size, improve the results of breast reconstruction or implant surgery, and correct skin indentations such as those from acne scars.
The list below explains the most common uses of fat transfer and how the technique provides good outcomes for the right candidates—i.e., non-smokers, no healing and circulation problems, and have enough donor fats.
- Facial rejuvenation. Flat cheeks, hollowed temples, skeletonized eye socket, and thinning lips all contribute to the aged appearance. While dermal filler injection can be used, fat tends to provide more natural results and feel because they have the same cohesiveness as the surrounding tissue.
Fat transfer is often used to complement facelift surgery to achieve a more natural, three-dimensional rejuvenating effect.
- Hand rejuvenation. Having a youthful face and aging hand creates a dichotomy that might tell the “real” age of a person. For this reason, one study has suggested that about 5 percent of facelift patients also opt for this 15-20 minute procedure.
With fat grafting, the visible tendons and vessels are softened or concealed, while the skin suppleness is improved as well.
- Breast augmentation. As a stand-alone procedure, fat grafting can provide a modest increase, i.e., not more than a cup size. Aside from having realistic cosmetic goals, it is also important to have good skin quality and breast shape to achieve good results from this technique.
Meanwhile, one study has suggested that pre-expanding the breasts for a couple of weeks with the use of BRAVA, which is a bra-like device that releases negative pressure, could allow doctors to inject more fat grafts.
- Breast implants. Post-cancer patients who opt for breast reconstruction via implants face an increased risk of rippling and palpability; however, using fat transfer can help them avoid such “stigmata” by improving their soft tissue coverage.
But even in cosmetic breast implants, fat grafting remains a good complementary procedure for women who are innately prone to rippling—e.g., body builders and athletes with low body fat percentage, “older” women, and small-breasted patients.
- Brazilian butt lift. Instead of using buttock implants, a good alternative is to inject fat grafts to augment one’s “behind.” But just like in breast augmentation via fat transfer, the donor site largely determines the amount of “increase”.
Unlike implants which are positioned above the sitting area, Brazilian butt lift can reshape the entire butt cheeks, including the lateral area or hips.