Trends in breast augmentation are greatly influenced by media, social and cultural-based beauty standards, and prevalent lifestyle. Nonetheless, all efforts are made to create results that will satisfy the patients on a long-term basis.
While some trends in breast augmentation come and go, there remain some well-entrenched guidelines that aim to promote patient safety. For instance, board-certified plastic surgeons only use FDA-approved breast implants whose manufacturers are mandated to participate in longitudinal studies to further determine the safety and long-term effects of their medical products.
Liposuction collects fats from multiple donor sites. Then, these are purified and injected into the breasts to prevent implant wrinkling and palpability and other surgical stigmata.
Leading Los Angeles plastic surgeon Dr. Tarick Smiley says that a growing number of breast augmentation patients today are choosing a more conservative implant size, leading to a more natural proportion.
The conservative implant size range is also becoming popular as more women these days follow a healthy, active lifestyle. In the past, it was not uncommon for patients to ask for significant augmentation (i.e., bigger than D cup) even though the size would not match their physique.
Some patients are more concerned about the breast shape than the size, making them an ideal candidate for conservative-sized implants. A survey published in Evolution and Human Behaviour has suggested that while men’s preference in breast size greatly varies, almost everyone agrees that no matter what the size is, the aesthetically pleasing ones are always “perky.”
Hence, many breast augmentations today are performed concurrently with mastopexy (i.e., breast lift). The idea is to correct the droopy appearance and the insufficient “cup size” in one surgery.
And since there is a strong inclination to natural-looking results, many surgeons nowadays complement breast augmentation with fat grafting or injection. The idea is to create additional soft tissue padding to further conceal the implant edges, resulting in softer feel and more teardrop breast contour.
Nonetheless, fat grafting is rarely used as a primary method in breast augmentation, although many surgeons believe that it is a powerful supplemental tool in order to make the results more natural.
A simultaneous fat grafting is often warranted if the patients have very poor cleavage and little soft tissue coverage. Some women with pre-existing deformities (due to previous surgeries or congenital defects) can also benefit from this supplementary procedure.
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).