Breast augmentation for plus size women. Could they achieve good results from this surgery?
It is important to note that no body contouring surgery is ideal for significantly overweight or obese patients who are susceptible to poor healing. Also, there is no point of improving one’s figure with the help of any surgical enhancement if the underlying problem is one’s inability to maintain a healthy weight.
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Breast augmentation or any body contouring surgery entails getting closer to one’s weight goal through healthy and sustainable means, i.e., regular exercise and proper diet.
Meanwhile, diet fads, pills, and “extreme” weight loss programs must be avoided for at least 2-3 months because these may cause [temporary] malnutrition and poor healing after surgery.
While there is no weight limit on breast augmentation patients, the vast majority of surgeons will not operate on obese women because of the increased risk of poor healing, infection, and anesthesia-related complications.
Another issue is the implant size. To compensate for the large abdominal and chest girth, overweight patients will need implants that are significantly larger than what most women would use.
As of this writing, the biggest implants are about 800 cubic centimeters, which are too large for women of average build but not enough for significantly overweight individuals, particularly if they want a huge cup size increase.
The first step to achieve good results from breast augmentation is to reach one’s ideal weight through a sustainable, healthy lifestyle that must always include proper diet and regular exercise. While shedding the extra pounds could lead to drooping appearance and skin laxity, at least there is an option to reshape the breast before an implant is positioned.
Breast lift is occasionally performed prior to breast augmentation for plus size women, particularly if there is a drooping appearance or the nipple-areolar complex has sagged at the level or beyond the inframammary fold. It is important to note that using implants without properly addressing pre-existing tissue laxity can lead to larger, droopier breasts.
Aside from body frame (in terms of height and weight), the ideal implant size is also determined by age, lifestyle, chest/breast anatomy and dimension—and the most important of all—cosmetic goals. For this reason, an honest discussion between the surgeons and their patients is of paramount importance to achieve high satisfaction.
The breast augmentation navel procedure refers to the incision technique in which the belly button is used as the point of entry of implants. This method has become possible thanks to recent advancements in endoscope, which is an articulating tiny fiber optic camera attached to a monitor.
Some doctors have criticized that using the navel as the incision site during breast augmentation surgery can increase the risk of asymmetry and less than optimal results. While this is a reasonable concern, a 2007 study has suggested that the rate of complications was almost similar to other incision methods, namely, breast crease, peri-areolar (within the areola’s border), and trans-axillary (through the armpit).
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It is important to note that the study included patients of board-certified plastic surgeons who were specifically trained to perform breast augmentation navel procedure, or medically referred as trans-umbilical breast augmentation or TUBA.
It cannot be dismissed that TUBA requires a steep learning curve, thus formal training from an advanced fellowship program is of great importance.
Due to the distance between the point of entry and the breast pocket, surgeons with limited experience or lack of formal training in TUBA may find it hard to position the implants in a highly symmetric fashion. For this reason, novice doctors generally choose the inframammary fold technique, or “through the breast crease,” because it is the most straightforward approach, thus it is currently the gold standard method used in Los Angeles plastic surgery.
During TUBA, the surgeon creates a tunnel through the abdominal fatty tissue where he can push the “empty” saline implants towards the breast pocket. For a small number of patients, a permanent V-shaped track along the upper abdomen may occur.
Another caveat with the use of navel incision site is that saline implants are the only option because they can be positioned in the breast pocket while empty before inflating them with saline or sterile solution of saltwater. Silicone implants, meanwhile, are not used.
Silicone implants are always prefilled by their manufacturers. Surveys have suggested that they provide more natural results and “feel” than saline implants because their filler material—a highly cohesive silicone gel—behaves just like the breast tissue.
Patients with “limiting factors” such as pre-existing breast asymmetry, sagging appearance, and limited soft tissue coverage are not ideal for breast augmentation via navel incision.
For women with the aforementioned anatomies, they will always require direct incisions (inframammary fold or peri-areolar technique) in the breast. Oftentimes, the resulting scars are small and imperceptible because they are hidden within the natural skin folds or around the areola’s perimeter.
Breast lift and shape: These are the two main concerns of women with breast ptosis or sagging who want to undergo plastic surgery to correct the condition, according to Upland Plastic Surgery Institute.
First and foremost, the postop shape is primarily determined by the incision pattern and the patient’s underlying anatomies. The goal is to create a soft rounded lower pole, a nipple area positioned a few inches above the submammary fold, and possibly a “curved” upper cleavage, as opposed to a flat sloping upper breast.
Patients who need the most amount of lift and/or adjunct breast reduction will need the standard technique to achieve the most ideal postop shape. However, the patient must accept the appearance of an inverted T scar resulting from “donut” incisions around the areola’s border, within the submammary fold, and vertically in the lower pole.
Standard breast lift technique.
While the modified forms of breast lift result in shorter or fewer scars, due to the natural diffusion of loose skin they could lead to less than optimal shape especially in patients with large, droopy breasts.
But for the right patients, the vertical lift technique—which eliminates the horizontal scar within the submammary fold—can provide a good shape. The consensus is that it is suitable for women who only need their areola complex raised about 3 inches or less.
For the right patients, the vertical lift can provide a nice perky shape that has a “soft” rounded bottom or “moundish” look, as opposed to a boxy appearance.
“Boxier” breasts may occur after an over-aggressive surgical maneuver, which left the skin overly tight. However, some doctors have also noticed that this appearance also affects a good number of “heavier” patients with a lot of fatty tissue lateral to their breast.
Contrary to popular belief, breast lift is not just a skin operation. To hold the planned shape, the vast majority of doctors use internal sutures that reshape and support the tissue.
To further achieve a more natural shape, the stretched, large areola must be reduced as well. This adjunct procedure is particularly important if the patient will receive breast reduction at the same time.
Despite best efforts, any form of breast lift will have no or very little effect on the upper breast pole. For this reason, it is sometimes combined with round breast implants, which in essence are shaped like a flattened sphere, although once placed vertically in their pockets their contour will resemble a teardrop due to the effects of gravity.
Regardless of the surgical maneuvers used, a skilled surgeon will make every effort to create a breast mound that has upper and lower pole ratio of 45:55.
Breast augmentation results should appear natural in terms of shape and size (relative to the patient’s body frame), thus it is of paramount importance to take into account the underlying anatomies.
The general rule of thumb is to use breast implants whose size/volume, profile or forward projection, and width will reflect the chest/breast measurement and the soft tissue coverage.
To further achieve natural-looking breast augmentation results, any pre-existing asymmetry must be identified prior to surgery, as suggested by experts at the reputable California Surgical Institute.
While all patients have some form of asymmetry, in most cases it is barely noticeable or at least can be easily ignored. However, women with visible lopsidedness will need additional procedures to achieve the best possible result from breast augmentation via implants.
If there is a visible difference in breast size, it is possible to use implants of different volume to achieve a more balanced look. However, asymmetry is often associated with disparity in shape, projection, and nipple position as well, further complicating the surgery.
If one breast sags more than the other, breast lift may be necessary to create a more balanced result. In this adjunct procedure, the skin is tightened, the deeper tissue is reshaped with internal sutures, and the nipple-areolar complex is repositioned higher.
Aside from breast size and shape disparity, Snoopy deformity must be also addressed to achieve natural-looking results from breast augmentation. Women with this condition have their nipple area and the tissue around it looking herniated and “puffy,” so the silhouette of the breasts resembles the famous cartoon character.
In patients whose Snoopy breast deformity is severe, a modified form of breast lift with implants is needed to create a more natural appearance. But in mild cases, implants are usually enough to deliver a good amount of improvement.
Over the Muscle Implant Placement Vs. Dual Plane Technique
Some doctors suggest that using dual plane technique—in which the upper half of implants is positioned behind the chest muscle, while their lower half is only covered by a strong tissue called fascia—is ideal for women with Snoopy deformity.
Meanwhile, patients with Snoopy breast deformity and ptotic (sagging) breasts may want to avoid the subglandular technique in which the implants lie above the chest muscle, with only the breast tissue covering and supporting them.
Occasionally, reducing the size of an overlarge areola—or the pigmented part of skin—is needed to achieve a more balanced and youthful result from breast implant surgery. However, this is only attempted when the patient specifically asks for the procedure.
Breast augmentation cost greatly varies from patient to patient, although using silicone implants instead of saline implants can make the surgery about $1,000 more expensive. The use of Exparel injection, pain pumps, and other supplemental devices that give patients a comfortable recovery can also add up to the price.
According to some Upland plastic surgery experts, as of this writing the average cost of breast augmentation is $6,500. However, some patients may expect to pay as high as $14,000 especially if they are having adjunct procedures (such as breast lift) and/or their surgeons cater to high-profile individuals.
Meanwhile, more than 70 percent of breast augmentation patients today are choosing silicone implants due to their more natural results and feel. But due to their higher manufacturing cost, they are more expensive than the saline implant, which are only inflated with a sterile salt and water.
Aside from the higher cost of silicone implants, they also entail MRI scan at least every two years to detect asymptomatic or “silent” leak. Most patients can expect to pay anywhere $1,000-$2,000, which most insurance issuers will not cover unless the patients have had their implants after a cancer surgery followed by breast reconstruction.
A regular MRI scan is not prerequisite for saline implants because in the event of leak the problem is immediately visible, with the affected breast appearing smaller than the other one.
Despite the lower cost of saline implants, their price should not influence the patient’s decision, especially if the goal is to achieve optimal results. It is important to note that women with little soft tissue to begin with are poor candidates for these implants because of the increased risk of palpability and rippling.
Aside from the upfront cost of surgery, patients who wish to augment their breasts with implants should expect revisions in the future. According to several studies, these medical devices can last an average of 10-15 years.
Most US breast implant manufacturers today offer 10-year or even lifetime product warranties. Nevertheless, the patient should still pay for other things such as anesthesiologist and surgeon’s fee, operating/recovery room fee, follow-up office visits, and postop supplies (dressings, painkillers, garments, etc.).
A prudent patient should never shop for the lowest breast augmentation cost, which does not always equate to good value. In most cases, a price that is significantly lower than the average means some unacceptable compromises that increase the risk of infection and poor cosmetic results.
The goal of any prudent patient is to find a qualified plastic surgeon—i.e., board certified by the American Board of Plastic Surgery and other reputable affiliations—who performs breast augmentation on a regular basis.