Breast augmentation and cleavage enhancement. Can these two cosmetic goals be achieved, or should the patient accept some compromises and limitations?
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted photos on Snapchat demonstrating a patient with bony indentations and wider gap between her small breasts.
With the use of a slightly wider breast implant, Dr. Smiley is able to hide the bony indentations along the patient’s sternum.
To “hide the bony indentations and create a “very soft and natural cleavage,” Dr. Smiley said he used a slightly wider breast implant to “fill in the gap and visible dents.” Nonetheless, he made sure that the horizontal measurement of the implant would still “reflect” the patient’s pre-existing soft tissue coverage to prevent rippling and increased palpability.
“A lot of followers asked if I used fat grafting or injecting to hide the bony indentations. I did not. The right implant design is enough to deliver good results for this patient,” he said.
The patient shown in the picture also received a conservatively sized implant, 400 cc, further reducing the risk of rippling, scalloping, and palpability, problems that plagued overlarge breast implants.
The implants were propelled into their pocket through a peri-areolar incision, meaning a small U-shaped scar was positioned at the lower border of the areola. At three months, it is almost undetectable thanks to meticulous wound closure technique in which no tension was put on the skin.
“That’s why you should always respect the skin. The scar is just three months old and is already unnoticeable. It will continue improving up to 18 months,” Dr. Smiley said.
The patient has been deemed a good candidate for the said incision technique because of the stark color contrast between her areola and the surrounding “normal” skin, making it easier to hide the scar.
Dr. Smiley said he follows a “nine point system of breast perfection” to achieve natural and proportionate-looking breasts.
“The nipple should be right in the middle of the breast, at the most projected part, and should lie at least 2 cm above the inframammary crease. Most of the volume should go to the bottom or lower breast pole, while the upper pole should receive a moderate degree of fullness. The lateral bulge, meanwhile, should not account for more than 10 percent of the total volume,” he explained.
The inframammary fold breast augmentation technique places an incision within the “new” breast crease so the scar blends well into the background. About 50 percent of the breast implant surgeries is performed through this method due to its “simplicity” and direct access to soft tissue layers of the chest.
Hence, the risk of asymmetry is perceived to be lower when the inframammary fold breast augmentation is used compared with other techniques.
In spite of the many advantages of this technique it has one major caveat: the visibility of scar.
The use of Keller Funnel allows Dr. Smiley to shorten the incision, leading to more hidden scar within the breast crease.
Nonetheless, leading Beverly Hills plastic surgeon Dr. Tarick Smiley says certain steps can prevent or at least minimize risk of visible scar, with patient selection being the most important variable.
In Dr. Smiley’s recent videos on Snapchat, he demonstrated a patient he deemed to be a suitable candidate for the incision technique: She had mildly droopy breasts, which resulted in deep folds that could make it easier to hide the scar compared to someone without a prominent crease.
Dr. Smiley says breast implants can give the patient “more symmetry and fullness,” particularly when the implants would “reflect” her anatomy and cosmetic goals.
The patient received silicone breast implants known to provide softer results and more natural contour than saline implants.
Silicone implants are filled with silicone gel, while saline implants contain salt water solution and thus they have a strong predisposition to appear globular and firm once inside their pocket. This is particularly true for patients who are thin or small breasted, meaning they have little soft tissue coverage.
Proper marking prior to the placement of incision and pocket creation is the first step to ensure a well-hidden scar. Dr. Smiley marked the pre-existing inframammary fold and placed a short incision (not longer than 3 cm) slightly above the line.
The incision and its resulting scar are expected to remain on the underside bulge of the breast. (Note: In the first two months of recovery, the implants typically ride higher leading to excessive upper pole fullness; however, this rather unnatural appearance almost always corrects itself as the prostheses settle to their more natural location.)
Aside from proper patient selection, the risk of visible scar was further reduced with the use of Keller Funnel, a device that resembles an icing bag that propels the implant into its pocket with just a few successive squeezes. Not only it reduces the scar length, the amount of trauma around the wound edges is minimized as well, further promoting the best scar possible.
Because the patient’s pre-existing right breast was smaller than the other side, Dr. Smiley used a slightly bigger implant size to improve their symmetry.
And lastly, he closed the incisions in several rows, ensuring that the deeper layers received most of the tension while the skin was spared from “excessive pull,” thus further promoting the most hidden scar.
Upper pole fullness after breast augmentation can be achieved with precise physical examination of the breasts. The idea is to identify the “challenges” and anatomical variables that must be overcome to achieve the best shape and projection possible.
Of course, the patient must be able to describe in details her cosmetic goals and expectations. Hence, patient-doctor communication plays a crucial role in the satisfaction rate, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
Dr. Smiley has recently posted a series of Snapchat videos showing one patient whose primary goal was to achieve increased upper pole fullness after breast augmentation.
While the patient’s pre-operative breasts had adequate soft tissue, they were remarkably pendulous that her areola sagged a few centimeters from its breast fold (or submammary crease). Further aggravating the sagging appearance was the deflated or “empty” upper breast pole.
Due to the extent of her breast sag, Dr. Smiley performed the standard breast lift technique in which an incision goes around the areola’s perimeter, down the midline, and then across the breast fold. The resulting scar from this method resembles an anchor, and so it is also aptly named as anchor lift.
before and after photos
Despite the growing popularity of modified breast lift techniques, the patient remained suited for the standard incision pattern because her areola required more than 5 cm of elevation, something that cannot be achieved with shorter incisions.
The anchor lift has allowed Dr. Smiley to remove some tissue and skin at the bottom of the breasts before lifting and reshaping the remaining tissue with the use of internal sutures. But as a stand-alone procedure, breast lift cannot give ample fullness on the upper poles of the breast—this is where implants become helpful.
Because the patient was more concerned about the final breast shape and fullness of the upper pole, a smaller or conservative-sized implant would suit her.
While showing the patient’s before and after photos, Dr. Smiley said “there is no significant change in her breast volume even with the use of implants, although the upper pole has received significant improvement in terms of looking full and youthful.”
Breast lift with augmentation scars will depend on the extent of ptosis (sagging appearance). Nonetheless, a good plastic surgeon will make every effort to place the incisions in the most inconspicuous areas such as the areola’s border and within the breast crease/submammary fold.
The standard or full breast lift requires a scar around the areola and from the nipple area down to the breast crease; another incision is created parallel to the submammary fold. Simply put, the scar pattern resembles an inverted T.
However, incorporating breast implants could mean additional internal lifting effect and so the patient may avoid the submammary fold incision, which is quite prone to small wound separations. This breast lift technique is referred to as lollipop lift due to the final shape of the scars.
The lollipop lift is also called vertical lift because only the vertical scar is visible from the anterior view. Over time, it is expected to fade into color that resembles the patient’s skin.
It is important to note that every time the skin is cut or injured, scar will inevitably form and so it is critical to place it in the most concealed areas. Furthermore, the quality of wound closure can have a large effect on the final results.
While breast lift with augmentation scars generally fade significantly over time, no surgeon can 100 percent guarantee favorable scarring since one’s predisposition to aggressive scars is largely determined by genetics. Studies have suggested that ethnic patients (dark skin) are more susceptible to keloids compared to Caucasians.
Despite the genetic factors, leading Beverly Hills plastic surgeon Dr. Tarick Smiley suggests that wound closure will still play a critical role in the final scar appearance. In his recent educational video posted on his Snapchat account, he is seen closing the incisions in which there was no tension on the skin surface.
“We just suture the dermis beneath the skin, while the actual skin edges are just allowed to kiss each other. This ensures favorable scarring,” says Dr. Smiley.
To further minimize superficial tension, the celebrity plastic surgeon places tapes or steri-strips to hold the skin edges together, and requires a proactive scar treatment approach once the wound is clinically healed—i.e., the scabs have fallen off by themselves.
Dr. Tarick Smiley often instructs his patients to use silicone sheets for several weeks postop to reduce the risk of aggressive scarring (keloids and hypertrophic scars).
Out of town breast augmentation requires advance planning to avoid complications and to achieve optimal results from the surgery. In general, patients are required to stay within the vicinity 3-4 days postop for follow-up visits to ensure that they are healing nicely.
Patient safety always starts with pre-op testing to rule out medical conditions or any other factors that can lead to increased risk of complications. For out of town patients, their local primary care doctor may order lab work whose results are faxed to the plastic surgeon who will conduct the surgery. With this “arrangement,” they can arrive as early as 2-3 days prior to the operation for an in-person consultation.
Photo Credit: nitinut at FreeDigitalPhotos.net
Ideally, the lab tests are performed not later than 10 days before surgery.
Aside from lab tests, out of town patients might also be required to fax results from breast MRI and possibly mammogram as well.
Even before the actual meet-up, there should be good rapport between the patient and the surgeon performing the out of town breast augmentation. Skype or video online chat is particularly helpful to allow both parties understand each other’s goal.
Meanwhile, it is important to avoid tobacco products, aspirin, ibuprofen, and medications and supplements known to increase bleeding for at least three weeks. The goal is to achieve one’s optimal health and thus minimize risk of healing problems and other complications.
Complete smoking cessation is particularly critical because it is closely tied to increased risk of capsular contracture in which the normally thin scar capsule around an implant inadvertently thickens, leading to painful, deformed breasts that require a revision surgery.
Factors linked to increased bleeding and hematoma (i.e., clotted blood beneath the skin or within the implant pocket) such as use of aspirin and aspirin-like products and hypertension must also be avoided and “controlled” well in advance of the surgery to reduce the capsular contracture rate.
After surgery, most patients are instructed to stay within the vicinity for at least three days (or sometimes even longer) for follow-up visits. After this period, most can travel by plane or car provided that a friend or family member will accompany them.
During the initial healing stage, patients should avoid heavy lifting (that’s why someone else should carry their luggage) and rigorous activities to prevent healing problems. Furthermore, they should never drive themselves when taking narcotic painkillers because these can cause poor coordination and lethargy.
In Beverly Hills plastic surgery, many doctors continue to monitor their patients up to one year, with some even permitting online video chat should their patients find it inconvenient to travel long distances just for a follow-up visit (provided there is no major concern).