Cosmetic breast surgery that combines two or more procedures has become a common routine nowadays. In some situations, this is even a more preferable approach than having two separate surgeries in order to produce more natural results.
Today, the most common “combo” procedures are breast augmentation with lift, and breast reduction with lift, according to the California Surgical Institute website.
Breast augmentation with lift prevents a specific deformity called Snoopy due to its close resemblance to the profile of the classic cartoon dog.
When implants are used in sagging breasts without a simultaneous breast lift, their bottom edge might become visible beneath the lax skin, and thus there will be an appearance of two pairs of submammary fold.
But with a simultaneous breast lift, the implants will not “herniate” as the internal support and the actual breast tissues are reinforced with sutures. In addition, the south-pointing or low-lying nipple area is positioned higher to further achieve a proportionate result.
Breast lift is also commonly incorporated with breast reduction, a procedure that produces a smaller “cup size,” which in turn can provide instant relief from back pain, rounded shoulders, postural problems, and other ill effects of overlarge, heavy breasts.
Large breasts are susceptible to the effects of gravity (i.e., causing their skin to lose their elasticity), thus it always makes sense to incorporate some type of breast lift during the surgery.
Meanwhile, breast lift does not always entail a simultaneous breast reduction unless the patient specifically requests for a smaller cup size as well.
Cosmetic breast surgery involving combination procedures aim to produce a more natural-looking and youthful appearance—i.e., conical shaped, 45:55 breast ratio (i.e., most of the volume should be in the lower pole), proportionate nipple diameter relative to the breast size, and “ample” distance between the areola and the submammary fold.
A slight lateral bulge is also deemed ideal, although all efforts are made to prevent it from becoming excessive and thus giving an illusion that the breasts are too wide apart.
Also, it is ideal to produce a ski-slope appearance in the upper pole. In fact, one study has suggested that the ideal breast profile should have a 45:55 ratio, with the areolar complex serving as the delineating mark between the lower and upper breast poles.
Of course, good symmetry between the left and right breasts must be achieved during cosmetic breast surgery. For this reason, some patients may need different sized implants, or require more tissue removal or additional elevation on one side.
Mastopexy for tuberous breasts is designed to correct the herniated appearance of the nipple area. Oftentimes, it also incorporate the use of breast implants to further improve the overall projection and shape, as suggested by leading Los Angeles plastic surgeon Dr. Tarick Smiley.
Mastopexy, or breast lift in layman’s term, is typically performed to reshape the sagging breasts. However, women with tuberous breast deformity can also benefit from this procedure.
While the exact origin of tuberous breasts remains unclear, its physical manifestations have been widely studied: They are caused by constriction of the connective tissue around and behind the areola, and the weak and thin tissue support that leads to the puffiness and herniation of the nipple area.
Aside from areola puffiness, mastopexy for tuberous breasts also deals with asymmetry in variable degrees (i.e., some are very mild while others are highly obvious) due to differences in shape, nipple size, breast volume, and projection.
Other physical manifestations of tuberous breasts include little soft tissue, enlarged or wide areola complex, and drooping appearance.
Mastopexy for tuberous breasts not just corrects the drooping appearance. Oftentimes, the surgeon must also remove some tissue behind the areola complex to reduce its puffiness. This is achieved by creating incisions around the areola’s edges, which typically fade into imperceptible scars.
The round incisions along the areola’s edges can also allow the surgeon to reduce its size.
While the tuberous breasts could be improved with mastopexy alone (without breast implants), it is important to note that it has its own limits.
With a simultaneous breast implant surgery, the surgeon is able to reduce the wide spacing between the breasts and improve their overall shape and volume.
During mastopexy for tuberous breasts that includes implants, it becomes more important than ever to release the constricting bands of connective tissue. The goal is to allow the prosthetics to settle centrally behind the areola complex, leading to a natural-looking shape.
Mastopexy for tuberous breasts is technically more demanding than a breast lift involving an “average” patient (no significant deformity; only soft tissue laxity due to aging or pregnancy). For this reason, one should be extra strict when choosing a surgeon.
Aside from having appropriate board certifications, the “right” surgeon should also be performing mastopexy, breast augmentation, reduction, and reconstructive breast surgeries on a regular basis. Ideally, he must be able to present hundreds if not thousands of before-and-after photos of his actual patients, which can serve as a proof that he has extensive experience.
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.