Breast augmentation crease incision technique often results in a 1-4 cm scar concealed by the natural skin fold between the breast and the chest, although some doctors prefer that it lies slightly above the crease but still on the underside bulge of the lower pole for optimal scar concealment.
Despite the popularity of breast augmentation crease incision as it gives doctors the “best and most direct” view, celebrity Los Angeles plastic surgeon Dr. Tarick Smiley says he still personally prefers the peri-areolar or “through the nipple technique,” or the trans-axillary or “through the armpit method” should the patient has a small areolar complex.
In one of Dr. Smiley’s recent Snapchat videos, he says that the scar of breast augmentation crease incision has the tendency to thicken; this is particularly true for women with a strong history of keloid or hypertrophic scarring.
For most patients, the surgeon recommends placing a U-shaped incision precisely at the lower border of the areola so the scar lies within the light-dark skin junction thus it is very well concealed.
Should the patients have small areolas that could make the peri-areolar incision technique not ideal due to increased risk of visible scar, the surgeon says the trans-axillary or armpit site is often considered as a good alternative.
Despite some caveats that come with breast augmentation crease incision, Dr. Smiley says it also offers some advantages: It can be used again in the event of revision surgery; and the implant does not come into contact with breast ducts, which are believed to harbor bacteria.
However, the peri-areolar incision technique can be later used again in the event of revision surgery too; hence, this should not be the only reason to choose breast augmentation crease incision, he believes.
In terms of reducing the risk of implant infection of contamination at the time of surgery, a risk often mentioned when peri-areolar incision technique is utilized, Dr. Smiley says that this can be significantly reduced by irrigating the implant pocket with antibiotics.
The trend in breast augmentation surgery is leaning toward more conservative sizes, which are loosely defined as 400 cubic centimeter (cc) implant or smaller. The goal is to achieve natural results and eliminate the telltale signs of plastic surgery, such as rippling, palpability, and “rounded” look.
A 400 cc breast implant could deliver a 2 cup size increase for an “average” American woman. Nevertheless, the exact amount of augmentation depends on several variables such as body frame, chest and breast measurement, preoperative tissue, and other related anatomies of patients.
Most patients seeking a conservative breast implant size want to achieve just a certain amount of fullness that is within the range of what looks normal. They generally want natural-looking results and are averse to “too much” attention or appearance that “screams” plastic surgery.
Aside from personal preference, patients asking for a conservative breast augmentation result want to maintain their professional or corporate look. Women in the entertainment business, meanwhile, may request for more augmentation in an attempt to achieve a more “flamboyant” look that is often necessary to succeed in their industry.
While some surgeons attempt to describe conservative breast implant size as 400 cc or smaller, the most accurate definition is an implant volume that matches and respects the patient’s anatomy—not just the chest area but also the shoulder measurement, waistline, hips, height, and overall body frame.
The amount of augmentation, according to leading Beverly Hills plastic surgeon Dr. Tarick Smaili, should also match the amount of pre-existing soft tissue of the breast. The idea, he further explains, is to prevent skin thinning, visible scalloping or rippling of the implant underneath the skin, and implant displacement.
Dr. Smaili says conservative-sized implants also promote “graceful aging” of the breasts because of their minimal impact on skin and tissue elasticity.
In addition, conservative implant size is also popular among women with active lifestyle because it is less obtrusive and has no or minimal impact on their “center of gravity,” posture, and performance.
For many athletic women, another impetus for choosing smaller implants is the lower incidence of wrinkling and palpability, which they are at risk because they usually have low body fat percentage, explains the celebrity Beverly Hills plastic surgeon.
But Dr. Smaili says that choosing small breast implants may have one major drawback: they might not meet the postop size and overall look the patients want to achieve. For this reason, he highlights the importance of open, honest communication between a surgeon and his patient to make sure they are on the same page.
One survey has suggested that about 15 percent of breast augmentation patients were not happy with the postop size, with 13 percent of them saying their implants were too small for their liking, while the remaining thought they had gone too big relative to their body-frame.
Perhaps the best way to meet the desired breast implant result is use 3D computer imaging technology, which allows surgeons to show the surgery’s potential outcome and help them improve their communications with patients.
But aside from postop size, take note that dissatisfaction may stem from other factors such as breast shape, projection, nipple and scar position, cleavage appearance, and implant palpability.
If you’re not happy with the breast implant result, a good rule of thumb is to wait six months to a year. This might allow you to adjust to your new figure and be more “objective” when it comes to final appearance, as suggested by renowned Beverly Hills plastic surgeon Dr. Tarick Smaili.
The six-month guideline, Dr. Smaili adds, will also allow the residual swelling to subside and the implants to settle into their proper place, leading to a more natural breast contour and cleavage appearance.
In the first few months after breast augmentation surgery, Dr. Smaili says it is not uncommon to have high-riding implants that result in excessive cleavage and “fake” appearance, which for the vast majority of patients will resolve as the prostheses drop a bit, the muscle becomes more relaxed, and the skin redrapes to the new contour. This “process,” he explains, generally takes six months.
But if your skin has a good amount of elasticity and your original breast size is relatively small, the leading Beverly Hills plastic surgeon says it could take more than six months for the implants to drop into their final position.
In case that you remain dissatisfied with your breast implant result after a year or so, Dr. Smaili suggests that you talk to your plastic surgeon and try to be as clear as possible when describing your concerns, or you might seek a second opinion from another expert.
Dr. Smaili highlights the importance of your input and detailed discussion with your plastic surgeon to achieve the desired result and avoid the need for revision breast augmentation.
If a surgeon asks too little input from you, the renowned breast surgery expert says the right course of action is to find someone else who will demand your active participation.
Patients who are thin, athletic, and small-breasted are susceptible to breast implant rippling and palpability. To compensate for the lack of “coverage,” the prostheses are typically positioned underneath the thick pec muscle rather than above it, a technique called submuscular or unders.
But for these patients, muscle flex deformity is almost always expected and predictable, although once the chest muscle is relaxed the distortion immediately resolves on its own.
Also, the degree of deformity ranges from barely noticeable to easily seen, depending on a wide range of factors, as suggested by breast surgery Orange County expert Dr. Tarick Smaili.
One way to avoid muscle flex deformity is to position the implants above the pec muscle, a technique called subglandular or overs. However, this is not a viable solution for small-breasted and thin patients who are at significant risk to implant rippling and scalloping, which is deemed more problematic.
If the degree of muscle flex deformity is minimal and it does not bother the patient, a revision surgery is unwarranted. More often than not, this is the case for the vast majority of women who had breast augmentation, a procedure that resulted in up to 98 percent satisfaction rate according to a recent study.
But for women with an overdeveloped pec muscle—i.e., bodybuilders and professional athletes—the degree of muscle flex deformity tends to be problematic. Nevertheless, using the subglandular implant placement is not a good alternative because of the rippling and palpability issue.
If the muscle flex deformity is severe, there are two options to correct it without resorting to the subglandular implant placement. The first approach uses an acellular dermal matrix or ADM, which is a soft tissue replacement.
The idea behind the use of ADM is to “thicken” the tissue especially at the lower poles of the breasts where muscle flex deformity occurs. This treatment is also applicable to various reconstructive and cosmetic plastic surgeries, explains Dr. Smaili.
Another possible treatment for muscle flex deformity is the subfascial implant placement. Instead of using the entire muscle to cover the implant, the thin but strong fascia on top of the muscle is lifted and used to support the prosthesis, according to the leading breast surgery Orange County.
Advocates of this implant placement suggest that it combines the benefits of both the submuscular (good support to reduce palpability and rippling) and subglandular (without the breast animation).
Double bubble deformity after breast augmentation surgery occurs when there is a visible line or indention above the breast crease. Fortunately, in the hands of a good plastic surgeon who knows how to “respect” the anatomies, this complication rarely happens.
Dr. Tarick Smaili, one of the leading LA plastic surgeons, says that most cases of double bubble occurs when an inexperienced doctor uses breast implants that are too big for the body, specifically the original width of the breast.
If there is a short distance between the areola complex and natural breast crease (i.e., 2-3 cm), Dr. Smaili highlights the importance of using implants that are within the confines of the patient’s anatomy to avoid visible indentions and other cosmetic problems. Taking into account the limitations of the body, he further explains, is also a good way to achieve natural-looking results from any plastic surgery procedure.
Occasionally, breast augmentation patients are advised to choose an implant size smaller than intended to avoid double bubble deformity, breast implant displacement, rippling, and other types of cosmetic-related problems.
Aside from using the “appropriate” implant size based on the patient’s underlying anatomies, the risk of double bubble could also be reduced by lowering the inframammary fold or breast crease. This technique also allows the prosthesis to be centered on the breast mound, behind the areola complex.
And with the implants settling at the center of the breast mound, the result of surgery will look natural rather than “operated.”
But despite these guidelines, sometimes the old breast crease retains its “memory,” causing visible line across the lower aspect of the breast and below the new inframammary fold.
For women with saggy breasts, using implants could aggravate the drooping appearance and possibly result in double bubble deformity caused by the loose soft tissue looking “herniated” on top of the prostheses. To avoid these complications, breast lift as an ancillary procedure is almost a mandatory requirement.
In case the double bubble deformity occurs, most LA plastic surgeons recommend a revision surgery in which the inframammary fold is reattached to the chest. It may also involve replacing the implants with smaller ones or at least within the confines of the patient’s anatomy.