Breast augmentation surgery is not all about placing an implant in each “pocket” to create a bigger bust size. Another equally important goal is to recreate the look of a youthful, “unoperated” breast through the use of highly individualized techniques that respect the patient’s underlying anatomy.
Augmenting the breasts without resolving an existing ptosis or saggy appearance more often than not leads to poor results. However, some patients with pseudo or slight ptosis in which the nipple-areola complex has not yet fallen below the inframammary fold (or breast crease) can do without breast lift as long as the right surgical techniques are used.
One common technique used by Los Angeles plastic surgeons for patients with slight ptosis is the subfascial implant placement in which the prosthesis is supported and covered by pectoral fascia, unhindered by the pectoralis major muscle.
Proponents suggest the technique has some lifting effect and at the same time allows the implants to drop in the most natural position because the pec muscle is out of the picture.
However, the subfascial technique is different from the subglandular or “over the muscle” implant placement, which is criticized for its high risk of rippling, palpability, and bottoming-out because only the breast tissue supports and carries the weight of implants.
The recently developed technique is also way different from the submuscular or “under the muscle” implant placement, which reduces palpability and implant rippling, but poses risk of breast animation especially in patients with a well-developed pec muscle (e.g., athletes and bodybuilders).
Proponents of subfascial believe that it eliminates the risk of breast animation linked to submuscular and at the same time provides a good amount of coverage and support unlike the subglandular technique. Despite being thin, the pectoralis fascia is a strong structure that can be separated from the thick pectoralis muscle.
They also suggest that the strong fascia, with the thick pec muscle out of the picture, allows the breast implants to “drop” in the most natural position, leading to a somewhat teardrop shape, which is an archetype of a youthful, “unoperated” breast.
But to prevent the slight ptosis from worsening, Los Angeles plastic surgeons always emphasize the importance of choosing a smaller or conservative-sized implant. The goal is to minimize skin thinning and “stress” on the breast tissue.
Another possible approach to correct minimal ptosis is to use a teardrop-shaped gummy bear [fifth generation silicone] breast implant that is said to slightly push the breast tissue up.
Since the introduction of Keller Funnel in 2009, the device has received nothing but praises from breast augmentation surgeons because it can significantly reduce the risk of breast implant contamination, which leads to other benefits.
The Keller Funnel resembles an icing bag whose internal surface has an oily coating that paves way for a quick and efficient implantation, explains one of the leading breast augmentation surgeons Dr. Tarick Smaili. Right after opening the silicone implant from its sterile package, it is poured inside the device which is then squeezed a couple of times to propel the implant into the pocket.
These are the top five reasons why Keller Funnel breast augmentation is good for you:
- It prevents the implants from touching the skin.
The cone-shaped device allows the transfer of breast implant into the pocket without allowing it to touch the skin around the incision site, which is known to harbor bacteria that could lead to shell contamination and infection.
The narrower end of the cone is positioned about 1 cm into the center of the breast pocket before it is squeezed several times to propel the implant into its proper place.
According to studies, compared to finger-push implantation the use of Keller Funnel can reduce the risk of bacterial contamination by up to 200 percent.
- The technique lowers the revision rate.
With no implant contamination or “deep” infection, the risk of capsular contracture or tissue hardening can be minimized as well. The theory is that a low-grade infection triggers the body to “over-react” and produce a copious amount of collagen around the implant, eventually leading to visible deformity and pain.
- Shorter incision is possible.
The main appeal of saline implants, which are filled with sterile salt water once inside the pocket, is the use of smaller incisions, about 1.4 inches or sometimes even shorter. Nevertheless, their results are not as natural as the silicone implants, which are always prefilled by their manufacturers.
With finger-push method silicone implants require an incision usually longer than 2 inches, but with Keller Funnel device they can be introduced into the pocket through the same opening as required by saline implants, leading to a shorter and less conspicuous scar.
- It can significantly reduce the amount of force.
Excessive force applied to any portion of the implant could affect its long-term stability (i.e., more prone to rupture), which is often unavoidable with the use of finger-push method.
But with Keller Funnel, the force is efficiently redistributed around the implant shell at the time of insertion. As a result, the stability of the prosthesis is relatively unaffected after surgery.
- This breast augmentation technique can reduce tissue trauma.
The insertion of silicone implant with Keller Funnel on average only takes 10 seconds, which reduces surgical trauma and at the same time shortens the surgery by 10 to 20 minutes, as suggested by several studies.
Since the early 80s, fat graft has been used to augment the “sunken” cheeks and other hollowed facial regions caused by aging or hereditary predisposition. However, the previous techniques only provided short-lived results because the body would eventually reabsorb the transferred fat.
It has only been recent when LA plastic surgeons have found ways to increase the survival rate of fat graft. First they use a gentle liposuction technique to harvest the excess fat usually from the tummy, and purify it by removing biomaterials such as blood. Meanwhile, the last but arguably the most crucial step involves the “micro-injection” of fat between tissues to make sure it can easily access the blood supply.
To date, a fat survival rate of more than 60-70 percent is deemed a success.
And with a higher survival rate, breast augmentation and butt enhancement through fat graft have become possible.
Nevertheless, breast augmentation via fat graft can only increase the size to about a cup in most patients because any attempt to inject more amounts of fat graft will not provide good results due to the limited space within the breast tissue.
Another concern with the injection of large volumes of fat graft is that the excessive pressure could lower its survival rate because of the impaired blood flow, which supplies nutrients and oxygen to the fat cells.
But a recent study published in the Plastic and Reconstructive Surgery medical journal, a team of plastic surgeons has claimed that “pre-expanding” the breasts could allow “mega-volume fat transfer.”
The study involved about 1,000 patients who had fat graft in an attempt to increase their breast size without the use of any synthetic breast implant. They were asked to wear Brava, a device that releases a negative pressure or vacuum effect to expand the breast and allow more amounts of fat graft to be injected.
But to achieve good results, the researchers are requiring women to wear Brava for at least three weeks prior to surgery. While the device does not cause pain, with its cumbersome design it might be difficult to hide under normal clothing.
With the use of Brava, the authors of the study believe that the volume of transferred fat could be increased by up to three times than the “conventional” technique.
Compared with breast implant surgery, augmentation via fat graft is considered as a less invasive procedure. However, not everyone is a good candidate for this technique particularly those who are naturally thin, i.e., patients who have insufficient amount of excess fat.
Breast implant bottoming out leads to a saggy appearance as the prosthesis settles too low, sometimes beyond the inframammary fold or “natural crease.” But with the right surgical maneuvers and “conservative” implant size, the problem can be avoided, if not significantly minimized.
Breast enhancement expert Dr. Tarick Smaili says that the first step to prevent bottoming out or any other type of implant displacement is to use the “right” implant size, profile, and measurement based on the underlying anatomy such as the amount of natural tissue and breast/chest width.
The general rule of thumb, he explains, is to use implants whose size and diameter is within the confines of the anatomy not just to prevent implant displacement but also to avoid a wide range of aesthetic problems such as rippling, palpability, and unnatural breast proportion.
The renowned plastic surgeon also highlights the importance of precise pocket dissection where the implants will be positioned.
Ideally, the pocket is positioned in the center of the breast mound, behind the nipple area. For this to be possible, some patients require their inframammary fold to be slightly lowered.
While lowering the inframammary fold is not uncommon in cosmetic breast augmentation, Dr. Smaili says that over-aggressive surgical maneuvers must be avoided so the inferior origin of the breast remains strong enough to support the implants.
Breast implant bottoming out is more of a concern of older women and massive weight loss patients who are more prone to tissue laxity than younger individuals who have managed to maintain a stable weight throughout their lives.
For patients with a significantly sagging breast, using implants alone without addressing the underlying problem could further lead to bottoming out in which the lower aspect appears excessively round in comparison to the flat or empty upper cleavage. As a result, it is not uncommon to perform augmentation surgery alongside breast lift to achieve the desired appearance.
Even when there is no significant drooping of the breast, but the surgeon thinks that his patient has tissue laxity, the use of acelluar dermal matrix (ADM) may be recommended. This biocompatible material is derived from cadaver or pig’s skin whose cells are completely removed, leaving behind the main framework so a person’s own tissue can grow around and inside it.
Because the patient’s own tissue and blood supply fuse with ADM, the biomaterial does not cause allergic reaction and is deemed ideal for cosmetic breast augmentation and breast reconstruction after mastectomy or cancer surgery.
Acellular dermal matrix or ADM, which is a biomaterial that comes in thin sheets, is gaining popularity in post-cancer breast reconstruction and cosmetic breast augmentation because it leads to a more natural appearance and “feel.”
In fact, a recent study published in the Plastic and Reconstructive Surgery journal has shown that post-breast cancer patients who had mastectomy followed by breast reconstruction reported high satisfaction in the cosmetic results of their surgery.
Nowadays, the most popular brands of ADM are Strattice and AlloDerm, which are products of LifeCell Corporation. Studies have suggested that they are both effective in reducing implant palpability, rippling, implant displacement (e.g., bottoming out or sagging), and unnatural breast shape by “thickening” the tissue and providing additional support.
Both products are notably safe because they virtually eliminate the risk of allergic reaction. Even Strattice, which is derived from pig’s skin, does not cause rejection because all its cells are removed, leaving only the main framework made of collagen that allows the patient’s own blood supply and tissue to grow around and inside the material.
The same is true of AlloDerm, which is derived from human/cadaver skin, which is also “highly processed” to remove all the cells.
While rejection is almost not a concern with any type of ADM because it always fuses with the natural tissue, it is important to note that seroma or fluid build up should be avoided because it could interfere with the graft’s adherence. Using compression garments and drains and avoiding rigorous activities for about a month can prevent this complication.
Studies have suggested that it generally takes two weeks for the patient’s own tissue to fuse with ADM.
Some plastic surgeons prefer to use AlloDerm because it has been around longer than Strattice and other types of ADM, which means that more studies can demonstrate its predictability and safety.
However, Strattice is stiffer than AlloDerm—which could also mean it provides a stronger support and more coverage—that it has become the preferred choice of some plastic surgeons who need to stabilize a large-volume breast implant.
If Strattice or AlloDerm is used to correct breast implant displacement or malposition (e.g., sagging, excessive lateral fullness, and uniboob), it is often used alongside internal suture techniques to further tighten the implant pocket and prevent “migration” in the future.