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Breast Augmentation Raleigh

Breast Augmentation in Athletic Patients

I think the two most important considerations are implant selection and implant placement. My approach is almost always the placement of a shaped form stable device in a subpectoral position through an inframammary fold incision. Most very athletic patients have a very slender frame, a fairly thin layer of subcutaneous fat and a small starting breast volume, perhaps, an A cup or a small B. With not a lot of tissue to conceal the implant, the shape of the implant is going to determine the shape of the augmented breast. A shaped form stable device has the natural shape of a breast. It’s a bit taller than it is wide. I think that’s the most appropriate selection for these patients. The point of maximal projection is low on the implant compared to a round device. If you place a round implant into a patient with not a lot of soft tissue coverage, you get a round-looking breast that’s not always that natural appearing. With a shaped device, I think you get a much more natural appearing result. Regarding placement of the implant, I strongly prefer subpectoral placement. A big concern about subpectoral placement that you’ll find online is breast animation, which means that, when the muscle contracts the implant can jump around and the muscle contraction can also change the shape or appearance of the breast. This is completely avoidable if the pectoralis major muscle is released across the entire length of the inframammary fold. The advantage of subpectoral placement is that you get coverage of the upper pole of the implant by the pectoralis major muscle creating a very smooth, natural slope to the upper pole of the implant. If an implant is placed in a submammary position, on top of the pectoralis major muscle, you tend to get a rounded contour in the upper pole that creates a very obvious augmented appearance. If you’re an athletic patient seeking breast augmentation, find a surgeon who is comfortable with the placement of shaped form stable device in a subpectoral position. Ideally, this is someone who can show you a lot of before and after photos of those kinds of patients and who has athletic patients who are breast augmentation patients in that practice who can speak to you about their experience.

Can Patients With Tubular Breasts Get a Great Result From Breast Augmentation Surgery?

Well, yes. Absolutely. Tubular breast augmentation patients are some of the happiest breast augmentation patients in my practice. They go from feeling extremely self-conscious about their breast appearance preoperatively, to feeling absolutely great about their breast appearance post-operatively. Now to get a full, beautiful, natural looking result in a patient who is starting with tubular breasts, it really requires thoughtful pre-operative assessment and planning, careful implant selection, and the utmost attention to detail in the operating room. There are a number of important things that need to be accomplished when transforming a tubular breast into an aesthetically beautiful breast. Number one, all of these patients require lowering of the inframammary folds. In concert with inframammary fold lowering is expansion of the lower pole so that the skin envelope will accommodate the volume of the breast implant in the lower pole. Implant selection is important, and so is radial scoring of the under surface of the breast so that natural breast tissue will expand over the breast implant in a natural way. Lastly, structural fat grafting really helps to provide missing contour in the lower pole, and helps to blend the transition from natural breast tissue to implant contour. A new implant that is available, is the shaped-form stable breast implant, just FDA approved in the last one to two years. These implants have a point of maximal projection that’s lower than a round implant. These will provide a beautiful really natural appearing lower pole in patients who are starting with a tubular breast.

How Do You Know If You Need a Breast Lift or Just Breast Augmentation?

This is a really common question, especially moms who have experienced changes in their breasts with a series of pregnancies. Now the answer may be fairly obvious to you if your breasts are still really perky or if your breasts are very droopy. But if you’re patient that is somewhat in the middle, and you are not sure, then you absolutely need the assistance of an experienced board-certified plastic surgeon to make the decision. Now the decision in part rests on what kind of outcome is acceptable to you. If you have some droopiness, but not enough to really require a lift, then the result you get with an augmentation alone will be a breast that’s fuller and beautiful, but has a relatively low nipple-areolar complex position, and is still somewhat pendulous appearing. If that is acceptable to you, it’s a fine choice. But, if your hope for the outcome of the surgery is to have really youthful, perky breasts, that allow you to go without a bra in a sundress, then you probably want to have a mastopexy procedure, or breast lift, performed at the same time as your breast augmentation surgery. The thing that you really want to avoid at all costs is this: the appearance of a breast drooping off of an implant. That’s an extremely unnatural appearance. It looks like something went wrong, and in reality, something did go wrong. A surgeon has not done a lift when one was absolutely required.

How Should You Choose Your Implant Size?

Well, ideally the implant size selection is a decision you are guided through by your plastic surgeon. Ideally, your plastic surgeon is using Biodimensional planning principles to determine the ideal implant for you. The reality of breast augmentation is this: Based on what you are starting with, your breast base diameter, the stretchiness of the skin of the lower pole, the amount of breast tissue that you have to conceal the implant, there truly is a limited range of implant volumes that will work well for you, and will produce an aesthetically desirable full but natural appearing result. The problem with using implants that are too small is you end up with breasts that look somewhat lonely and separate, and the problem with going too big is that you end up with a high risk of the problems that lead to reoperation for breast augmentation: visible folds and ripples, skin stretch deformity, and position problems like “bottoming out”. In my practice, I see in general two groups of patients. One group of patient’s is looking for that perfectly natural implant that is right in the middle of the range that is recommended by Biodimensionalplanning principles. I see a second group of patient’s that are looking for the fullest implant volume that their body’s natural tissues can reasonably conceal. Both are fine choices, and I am happy to do both for each group of patient’s as long as we are staying within the limits, within the constraints, of Biodimensional planning principles.

Should Breast Implants Be Placed In Only a Subpectoral Position?

In my opinion, absolutely yes, and there are two compelling reasons behind my opinion. First, radiologists have let us know that they can best image breast tissue mammographically when an implant is in a subpectoral compared to a submammary position. For that reason alone, I think subpectoral position should be the only choice. Another compelling reason is aesthetic. The pectoralis major muscle serves as an additional layer of soft tissue coverage for the upper pole of the implant, and it tends to flatten the upper pole of the implant somewhat creating a very smooth and natural appearing contour to the upper pole.

What Are Shaped Form-Stable Breast Implants?

Shaped-form stable breasts implants are implants that are designed with a lower point of maximal projection, and they are designed with what is considered an anatomic shape. In some patients they provide a more natural appearing breast augmentation result. This is a shaped form-stable implant. They come in a wide variety of sizes and shapes. This one is a little bit taller than it is wide. It has a fairly low point of maximal projection, and it’s an intermediate projection implant. Are shaped form-stable implants the best device for every patient? Well, no. If you have a breast that’s already full in the lower pole and somewhat elongated, you will get a perfectly good result with a round implant in most cases. However, if you have a very small starting breast volume (A or small B), and especially if you need to have the inframammary fold lowered to achieve an ideal implant position on the chest wall then shaped form-stable implants provide a lot of advantages.

Which Breast Implant Is The Best Implant?

Well the reality is that there is no single breast implant that’s the ideal implant for every patient. The exciting thing about breast augmentation surgery currently is the fact that there are three implant companies that have FDA approval to market and sell their implants in the United States. This provides a wide variety of implant selections. There are smooth and textured implants, round and shaped implants, and an almost endless variety of base diameter, projection, and volume. For any given patients starting point, it’s possible to fine tune an implant selection that is almost a perfect fit. Competition in the marketplace is good for any marketplace, and it has been especially good for the breast augmentation consumer. I strongly recommend that you seek a surgeon that has a relationship with more than just one implant company. You will have more choices when your implant is selected.

What Does It Mean When Breast Implants Bottom Out?

We use the term bottoming out to describe the situation where breast implants descend on the chest wall to a point that is lower than what is aesthetically ideal. This creates fullness in the lower pole, hollowness in the upper pole, and the nipple-areolar complex appears to rotate upward on the breast mound. It is an aesthetically unfavorable appearance to be avoided at all costs. One reason bottoming out can occur is the setting where overly large implants are placed that over time stretch out the skin and soft tissue of the lower pole, creating more space inferiorly leading to the bottomed out appearance.

What Can Be Done to Prevent Bottoming Out of Breast Implants?

Well, first and foremost, the surgeon should use breast implants that are of an appropriate size and shape for a patients starting point. Overly large implants frequently over time will stretch out the skin and the soft tissue of the lower pole allowing the implant to descend and create that bottomed out appearance. Some patients need to have their inframammary fold lowered in order to achieve an aesthetically ideal implant position, and that is another setting that creates some risk of, over time, a bottomed out appearance. There are things that can be done, however, in the setting of intentional lowering of the inframammary fold to prevent that outcome. One important thing to do is to use an inframammary fold incision, and at the end of the procedure, after the implants are placed an anchoring suture can be placed to secure the deep connective tissue of the skin to the connective tissue of the chest wall. This creates at least temporary barrier as the implant is healing reducing the likelihood of the implant settling over time. Another important thing to consider is implant selection when you are lowering the inframammary fold. Currently implants are available with a high degree of capsular adherence to the implant surface. If the capsule that your body forms around the implant becomes adherent to the implant surface, then this will help it to remain positionally stable over time.

What is a Dual Plane Breast Augmentation?

Well, we use the term dual plane to refer to a subpectoral breast augmentation. In essence, all subpectoral breast augmentations are dual plane, in that the implant sits both behind the pectoralis major muscle in the upper inner part of the breast, and behind the breast itself in the lower outer part of the breast. There is no pectoralis major muscle coverage in the lower outer part of the breast so all subpectoral augmentations are in essence dual plane. We use the terms dual plane one, two, and three to refer to the level at which the muscle is separated from the breast. All subpectoral augmentations are at least a dual plane one, meaning that the pectoralis major muscle has been released across the entire length of the inframammary fold. We use dual plane two to refer to a situation where the muscle is released up to about the lower border of the areola. Dual plane three is a release to just above the top of the areola. Which level of release you choose depends on: 1) what the patient is starting with, 2) the implant you are using, and 3) the outcome you are trying to achieve.

What Should You Look For When Reviewing Breast Augmentation Before and After Photographs?

Well first of all, you need to see photographs of patients shot from multiple perspectives. For each outcome, you want to see a frontal view, and oblique view, and a full lateral view to have some idea what the true outcome of surgery is. Also, when you are looking at photographs, don’t just try to find the after photos that appeal to you. Look for the before images that you think are similar to your starting point. What you’re starting with has a huge on the kind of result you get, so that’s going to tell you a lot about the kind of outcome you might expect. Lastly, you want to see lots and lots of photographs. You really need to feel convicted that your surgeon’s aesthetic sensibility is the same as your aesthetic sensibility.

Why Is It That Even Small Breast Implants Can Produce an Unnatural Appearing Result?

Well the issue boils down once again to Biodimensional planning. If measurements are carefully taken during patient consultation, one can determine an ideal base diameter given a patients starting breast shape and starting chest wall width. If the base diameter is inadequate, then implants appear too far apart on the breasts, sort of lonely and separate, and it is truly an underwhelming and aesthetically unfavorable cosmetic surgery result.

Why Is It That Two Patients With Very Similar Starting Points Receiving Identical Implants Can End Up With Completely Different Outcomes?

This really boils down to the conduct of surgery in the operating room. Attention to detail during implant pocket dissection is of utmost importance. If the inferior origin of the pectoralis major muscle is not completely released across the entire length of the inframammary fold, two problems occur. 1) The patient will end up with an animation deformity, meaning that when the pectoralis major muscle actively contracts the implant is squeezed upward, or outward, or both. 2) The other problem is that the pectoralis major muscle unreleased at its inferior origin will hold the implants too high producing a very full in the upper pole appearance, and a very inadequately augmented lower pole appearance. That is certainly one reason why patients end up with different outcomes from what would seem to be identical surgeries.

What is a Keller Funnel?

The Keller Funnel is a clear plastic disposable sleeve that’s designed to facilitate the atraumatic insertion of breast implants through relatively small insertions. The funnel is used by dropping the implant from the sterile packing after irrigating it with antibiotic solution into the funnel. The antibiotic solution provides some lubrication so that the implant easily glides through the Keller Funnel and into the pocket. So, with general pressure at the top of the funnel and with the end of the funnel inserted into the incision the implant can be gently propelled into the implant pocket. The implant is never in contact with the surgeon’s gloved hands or the assistant’s gloved hands. The implant is dropped directly from the sterile packaging after irrigating it with antibiotic solution into the funnel and then propelled into the implant pocket. What are the advantages of using a Keller Funnel? Well, for one: you are minimally deforming the implant surface and reducing the likelihood of implant fracture and implant shell rupture during insertion. Without a funnel one has to take the implant and place it up to the incision site and then use index fingers to deform the implant and to try to shove it and force it into the implant pocket. This is often a bit of a struggle and creates some risk of internal gel fracture and possible damage to the shell of the implant as well. The other very important reason to use a Keller Funnel is that it’s another thing that a surgeon can try to do to reduce the rate of capsular contracture. We think that most cases of capsular contracture are related to contamination of the implant surface the day that it is placed in surgery. The skin can be prepped with anapestic solution but skin cannot be technically sterilized. There are hair follicles, sweat glands, sebaceous glands, all sorts of structures just below the skin’s surface that can harbor bacteria and pressure the skin’s surface during surgery and may force some of the bacteria out of these glands onto the skin’s surface, where it can potentially contaminate the implant. If you introduce the implant with a Keller Funnel, you are bypassing contact with the patient’s skin and thereby potentially reducing the rate of capsular contracture long-term. Make sure that the surgeon that you see for breast augmentation is using the Keller Funnel. It provides significant advantages that may reduce your rate of contracture and implant failure over time.

What are Gummy Bear Implants?

When people talk about gummy bear implants, what they’re talking about are highly cohesive, form stable silicone gel breast implants – the latest generation of breast implant technology. I think the term ‘gummy bear’ is rather unfortunate because it gives you the idea that the implants are very firm, or even hard. When in reality, they are quite soft and supple. This is an example of a round, textured, non-form stable breast implant. This is an older generation of breast implant technology and when you attempt to stand it on end the implant basically collapses on itself. They’re not form stable, so they don’t hold their shape. This is an example of a shaped, highly cohesive, form stable breast implant. And when you place it in your palm it stands upright and essentially holds its shape. I think that these implants have many advantages. They tend to provide a better breast shape overall. They have a much lower rate of visible folds or ripples and there is some evidence that they may have a lower rate of failure over time. It’s important to know that the three implant companies that are FDA-approved all have various features in their product lines. So, the shaped form stable breast implants that are available vary somewhat in performance and characteristics from company to company. You’ll be best served by seeing a surgeon that has a relationship with all three implant companies. The surgeon will, therefore, be able to make a selection that is custom tailored to your individual needs.

Is implant rotation a problem with the new generation of shaped or teardrop breast implants?

The answer is absolutely and unequivocally, no. Rotation was a problem with the older generation of shaped implants, available about 20 years ago. There were other problems, as well, which led to those implants being taken off the market. Rotation is not a problem with the new generation of shaped breast implants. In reality, the new shaped form stable, highly cohesive breast implants are actually a completely different medical device than those that were available many years ago. For a shaped implant to look natural it has to maintain a vertical orientation. If the implant rotates to either side it looks unnatural. A patient with that problem requires a revisional surgery. The older generation of shaped implants came in both saline and silicone gel versions. The saline implants had a high rotation rate and also had a fairly high failure rate. The implants also felt firm and unnatural and fell out of favor pretty rapidly. The silicone gel devices that were briefly available also had a high failure rate. The shell of the implant was fairly thin and the gel could actually bleed through the surface of the implant without the implant failing. Those implants quickly went of the market as well. The new generation of shaped form stable, highly cohesive implants has a number of advantages over the ones that have been previously available. These implants are not only shaped, but they’re form stable and highly cohesive. So, if you cut one of these implants in half, you’re holding two halves of a solid device. The implants are available in a wide variety of shapes and sizes and a custom fit, therefore, can be found for just about any patient. The implants have a much lower failure rate than was seen historically and they also have a lower capsular contracture rate – and of course that varies by implant manufacturer. Don’t let concerns about rotation that was the experience with the older generation of breast implants steer you away from the new generation of shaped implants which does not have that problem. Actually, one of the shaped implants’ manufacturers has reported a series of almost 1,800 patients in which the rotation rate was zero. These are great devices, they’re not the perfect implant for everyone, but if you would benefit from a shaped device, don’t worry about rotation. If the implant is placed by a skilled, experienced, board-certified plastic surgeon the rotation rate should be close to zero.

Why Do Some Breast Implants Look Too High on the Chest?

Why is it that two patients with very similar starting points, receiving the same pair of breast implants get a completely different results? This usually boils down to what happens in the operating room. Pocket extension is extremely critical. One reason that patients sometimes end up with breast implants that appear too high one the chest wall is that the inferior origin of the pectoralis major muscle is not completely released. This leads to an unnatural appearance and is also unfortunately will lead to breast implant animation when the pectoralis major muscle contracts the implant appears to shift upwards or laterally or both.

Why Can Small Breast Implants Look Unnatural?

“Dr. Law, why do breast implants look so different? My sister and I both had implants, the same size, the same shape, the same manufacture, in the same placement. Mine are very natural, hers are small but they look like oranges stuck on her chest, how can that be?” The same pair of breast implants with patients with similar starting points can produce widely varying results depending on the technique the surgeon uses. In subsubpectoral breast augmentation it is critically important to release the inferior origin of the pectoralis major muscle. If this is not done, two problems are created. 1) The implant will be deformed by muscle contraction, we call this breast implant animation. 2) The implant will not settle to a low enough position on the chest wall to look natural. Quite often when breast implants appear high on the chest wall it’s because the inferior origin of the pectoralis major muscle has not been completely released. Other difference between breast implant results and similar patients with same pair of implants can be the result of different approach to pocket dissection.

What is the Difference between Subfascial and Subpectoral Breast Implants?

What is a dual playing breast augmentation? We use the tern dual playing to refer to the fact that with subpectoral breast augmentation the implant always rest behind the pectoralis major muscle and behind the breast itself. In essence all subpectoral breast augmentations are dual playing, because the pectoralis major muscle only covers the upper inner aspect of the breast implant. The lower outer half of the breast implant is submammary or right behind the breast, there’s no muscle coverage in that area. We often refer to dual playing 1, 2, and 3 approaches to breast augmentation. Dual playing one refers to limited release to pectoralis major muscle across the entire length of the inframammary fold. With the dual playing 2 approach you are releasing the pectoralis major muscle from the under surface of the breast up to about the level of the nipple. With dual playing 3 you release it to a level that’s above the upper edge of the nipple areola complex. What dual playing you choose depends on what outcome you’re looking for and what breast you’re starting with.

What is a Sientra Shaped Breast Implant?

What are shaped formed, stable breast implants? Shaped formed, stable implants are designed to have a lower point maximal projection, ideally better simulating a natural breast appearance. This is a shaped formed stable implant, that instead of being round is a little bit taller than it is wide, and has a pointed maximal projection that is relatively low on the breast implant. Are these the best implant for every patient? Well that really depends on what you’re starting with. If you have a breast that is already fairly full on the lower pole, you most likely will get a great result from a round implant. However, if you’re starting off with a very small breast volume, especially if you have a situation where the inframammary fold needs to be lowered to achieve a natural appearing implant result.

I Want Natural Looking Breast Implants – How Do I Get Them?

Can breast implants really look natural? The answer is of course yes, but it depends on the approach your surgeon takes to breast augmentation surgery. To get natural appearing results it’s important to use bio dimensional planning principles. Bio dimensional planning refers to a set of measurements that is taken at the time of patient examination, to help determine the ideal base dimeter, the ideal projection, and the ideal overall size and shape of the breast implant for each individual patient. If the surgeon you’re using uses bio dimensional planning principles it will be evident on their website when you review their before and after photographs. You’ll see based diameters that match a patient’s body and you’ll see a projection that looks natural in a natural slope to the upper pole. Look at lots, and lots of photographs.

Why Is It That Small Implants Can Produce an Unnatural Looking Result?

Well the issue once again boils down to once again bio dimensional planning. If measurements are properly taken during patient consultation, once can determine an ideal based diameter given a patients starting breast shape and starting chest wall width. If the based diameter is inadequate the implants appear to far apart on the breast sort of lonely and separate, and it is truly an underwhelming and esthetically unfavorable cosmetic surgery results.

What Are Shaped Form Stable Implants?

Shaped formed stable breast implants, are implants that are designed with a lower point of maximal projection and they are designed with what is considered an anatomic shape. In some patients they provide a more natural appearing breast augmentation result. This is a shaped form stable implant, they come in a wide variety of sizes and shapes. This one is a little taller than it is wide, it has a fairly low point of maximal projection and it’s an intermediate projection implant. Are shaped form stable implants the best devise for every patient? Well, no. If you have a breast that’s already full in the lower pole, and somewhat elongated you will get a perfectly good result with a round Implant in most cases. However, if you have a very small starting breast volume, A or small B especially if you need to have the inframammary fold lowered to achieve an ideal implant position on the chest wall then shaped form stable implants provide a lot of advantages.