INTRODUCTION

Breast augmentation is a cosmetic surgery procedure to increase breast size and enhance breast shape, typically through the placement of silicone or saline breast implants and more recently with fat transfer techniques. From a cosmetic surgeon’s perspective, the ultimate goal of breast augmentation is to enhance a patient’s natural proportions and create a more symmetrical, aesthetically pleasing breast profile. The exact procedure is tailored to meet a woman’s individual needs.

IDEAL CANDIDATE

If you are in good health, have a positive attitude and realistic expectations, you are most likely a good candidate for this procedure. The most common reasons to consider Breast Augmentation include:

• Very small breasts
• If you want to increase the size of your breast in order to be more proportioned with the rest of the body
• If your breasts have unusual shape (tubular breasts or Snoopy dog breasts)
• To correct asymmetry of the breasts (one breast is smaller than the other)
• Restoring breast fullness lost after pregnancy & breastfeeding
• Restoring breast fullness lost after massive weight loss
• Restoring breast shape and fullness when aging has affected the size and shape of your breasts
• Feeling more confident in a swimsuit
• Enhancing self-image

ADVANTAGES AND DISADVANATAGES OF BREAST AUGMENTATION

Advantages

1. Breast Augmentation is a procedure that results in long term correction of your breast shape and size
2. You will feel more feminine and you will have a more “womanly” figure.
3. You will feel better psychologically and you will have a higher level of confidence and self-esteem.
4. The procedure results in a more youthful look
5. The correction in size and shape after the surgery is obvious both with clothes or not and the fitting of clothes may improve and in turn, make you feel better wearing them.
6. Your breasts can have a more symmetrical appearance.
7. Changes that occurred following pregnancy, breast-feeding or weight loss can be corrected.

 

Disadvantages

1. Sometimes the breast implants have to be replaced
2. Sometimes (very rare) implants have to be removed
3. Even if it is a very common operation there are still common surgical risks
4. Breast implants sometimes produce an unnatural look

BREAST AUGMENTATION IS SAFE

• It is important for women with breast implants to keep in mind that while breast implants are intended to last your lifetime, replacement may become necessary. After breast implant surgery, you should have periodic examination by a board-certified plastic surgeon to monitor your implants.
• Silicone gel−filled breast implants have been under scrutiny for years, but after gathering detailed and meticulous research and data, the FDA has approved them for use in cosmetic breast enhancement surgery, finding no link between silicone gel breast implants and connective tissue disease, breast cancer or reproductive problems.

THE INITIAL CONSULTATION APPOINTMENT

During your initial consultation, you will have the opportunity to discuss your cosmetic goals. Your surgeon will evaluate you as a candidate for breast augmentation and clarify what a breast augmentation can do for you. Understanding your goals and medical condition, both alternative and additional treatments may be considered (see related procedures). You should come to the consultation prepared to discuss your complete medical history. This will include information about:

• Previous surgeries
• Past and present medical conditions
• Allergies and current medications
• Medical treatments you have received
• Medications you currently take
• Family history of breast cancer
• Current mammogram results

Your plastic surgeon will examine, measure and photograph your breasts for your medical record. Your surgeon will consider:

• The current size and shape of your breasts.
• The breast size and shape that you desire.
• The quality and quantity of your breast tissue.
• The quality of your skin.
• The placement of your nipples and areolas.

If your breasts are sagging, a breast lift may be recommended in conjunction with breast augmentation.

If you are planning to lose a significant amount of weight, be sure to tell your plastic surgeon. The surgeon may recommend that you stabilize your weight before undergoing surgery.

If you think that you may want to become pregnant in the future, discuss this with your surgeon. Pregnancy can alter breast size in an unpredictable way and could affect the long-term results of your breast augmentation. There is no evidence that breast implants will affect pregnancy or your ability to breast-feed, but if you have questions about these matters, you should ask the plastic surgeon.

Based on your goals, physical characteristics, and the surgeon’s training and experience, your surgeon will share recommendations and information with you, including:

• An approach to your surgery, including the type of procedure or combination of procedures.
• The outcomes that you can anticipate
• Associated risks and complications.
• Options for anesthesia and surgery location.
• What is needed to prepare for the surgery.
• What you can expect to experience after surgery.
• Show before-and-after photos of cases

PREPARATION FOR THE PROCEDURE

Your surgeon will provide thorough preoperative instructions, answer any questions you may have, take a detailed medical history and perform a physical exam to determine your fitness for surgery.

To help detect and track any changes in your breast tissue, your plastic surgeon may recommend:

• A baseline mammogram before surgery
• Another mammogram a few months after surgery

In advance of your procedure, your surgeon will ask you to:

• Stop or minimize smoking at least six weeks before undergoing surgery to better promote healing.
• Avoid taking aspirin and certain anti-inflammatory drugs that can increase bleeding.
• Regardless of the type of surgery to be performed, hydration is very important before and after surgery for safe recovery.

For breast augmentation using autologous fat transfer, you may be instructed to wear a special bra to expand the skin and tissue around the breasts to prepare them for fat injection.

Breast augmentation is usually performed on an outpatient basis. Be sure to arrange for someone to drive you home after surgery and to stay with you at least the first night following surgery.

OPTIONS FOR BREAST AUGMENTATION

The following options are available, depending on your medical history, body shape and aesthetic goals.

 

1. BREAST AUGMENTATION WITH IMPLANTS

 

Type of implants

 

1. Filling type: Saline, Silicone Gel, or Highly Cohesive Silicone “Gummy Bear” Implants. Neither is “best,” but there are some differences in cost, feel, and incision requirements that you need to consider. Your cosmetic surgeon will help you find the right implant type for you.

 

• Saline-filled breast implantsare filled with sterile salt water. They may be prefilled at a predetermined size or filled at the time of surgery to allow for minor modifications in implant size.

SALINE FILLED IMPLANT

• Silicone-filled breast implantsare filled with soft, elastic gel and are available in a variety of shapes. All silicone breast implants are pre-filled and may require a longer incision for implant placement.

 

SILICONE FILLED IMPLANT

• Cohesive gel silicone implants,also known as “gummy bear” or “form stable” implants, are filled with a cohesive gel, made of crosslinked molecules of silicone, which makes them a bit thicker and firmer than traditional silicone implants. This enables them to hold their shape better.

COHESIVE GEL FILLED IMPLANTS (LEFT) versus SIMPLE SILICONE FILLED IMPLANTS (RIGHT)

2. Shape: Saline & Silicone Gel implants are typically round, while gummy bear implants come in shaped and round Round implants will typically achieve a fuller upper pole (the top portion of your breast), while shaped or anatomic or tear-drop implants lend a gently sloping look to your breast profile. Both can look very natural with a skilled cosmetic surgeon’s help.

ANATOMIC OR TEAR-DROP IMPLANTS

ROUND SHAPE IMPLANTS

3. Profile: Your cosmetic surgeon will help you choose this based on your existing proportions and your goals. Generally, patients with a more petite frame will require a higher profile implant to achieve the desired size increase while ensuring the implants are not too wide at the base.

4. Size: Breast implants range in size from about 150cc to 800cc or larger. Many patients require a different sized breast implant for each breast; this helps to achieve the best possible symmetry. The size you choose depends on your existing breast size, your personal goals, and your cosmetic surgeon’s recommendations.
5. Surface of the implant: the surface of breast implants regardless if the filling is saline or silicone, can be either smooth or textured. Most of the newest generation implants are textured.

Where are the breast implants placed?

Multiple factors, including your anatomy and your surgeon’s recommendations, will determine how your breast implant is inserted and positioned. The implant is placed in a pocket either:

• Submuscular Technique – Underneath the pectoral muscle, which is located between the breast tissue and the chest wall.
• Subglandular Technique – Underneath the breast tissue and on top of the pectoral muscle (chest muscle).
• Subfascial Technique – Under the fascia of the pectoral muscle.
• Dual plane technique – Partially under the pectoral muscle and partially over the pectoral muscle.

Dual Plane Technique

Subglandular Technique

Schematic comparison between techniques

 

Comparison between Placement Techniques

Types of Incisions used

An incision can be made in one of four places:

1. Transaxillary: Near the axilla (armpit), where the arm meets the chest area
2. Periareolar: Around the lower edge of the areola, which is the dark area surrounding the nipple
3. Inframammary: Underneath the breast, just above the mammary crease

Breast implants are placed through three incisions. A. Axillary, or underarm, approach. B. Areolar approach. C. Inframammary, or breast fold, approach.

 

To help you with this process, we have created the following table with a number of important advantages and disadvantages of each breast augmentation approach for you to consider:

·         Transaxillary Incision  (Endoscopic)

Advantages

1. No scar on the breast
2. Scar often blends into skin crease well and is hard to detect
3. Usually least visible of augmentation scars
4. Endoscopic technique provides full visibility and precise surgical control of pocket creation, bleeding and implant placement

Disadvantages

1. A poor scar (which is not typical) may be visible in sleeveless tops
2. Limited in treatment of some cases of mildly sagging or tuberous breasts.
3. The longer (2-2.5 inches) scar needed for placement of silicone gel implants can be difficult to hide in small underarms.
4. Additional surgery, such as removal of scar tissue from around the implant (capsulectomy), may be difficult with this approach.
5. Very small risk of numbness of the skin around the underarm and upper arm.
6. Risk of scar tissue band formation under the axillary scar. But, if this occurs it usually resolves spontaneously over time.

·         Periareolar Incision

Advantages

1. Direct visibility of pocket creation and implant positioning.
2. Scar may be well hidden by areolar tissue.
3. Good approach for additional breast surgery.
4. Good approach for treatment of cases of mildly sagging or tuberous breast.

Disadvantages

1. Most women do not want this sensitive area operated on.
2. Scar is often visible and is at the focal point of the breast.
3. Exposes the implant to breast tissue and bacteria within the breast tissue.
4. Implant exposure to bacteria increases the risk of capsular contracture.
5. Some sensory nerves around the areola are cut. (However, increased risk of loss of nipple sensation with this approach has not been scientifically proven).
6. Greatest risk of problems with future breast feeding.

·         Inframammary – Breast Fold Incision

Advantages

1. Direct visibility of pocket creation and implant positioning.
2. In patients with deep folds, the scar is hidden by the breast.
3. Good approach for additional breast surgery.
4. Good approach for treatment of cases of mildly sagging or tuberous breasts.
5. Excellent access for placement of silicone gel implants.

Disadvantages

1. Scar on the breast.
2. Hard to hide scar on small, tight breasts, without deep folds.
3. Scar may be visible when you are lying flat.

 

1. BREAST AUGMENTATION WITH FAT TRANSFER

Introduction

Breast augmentation with fat transfer allows women to enhance breast size by using a completely natural alternative to breast implants—their own fat cells. This is also known as autologous fat graft breast enlargement. This is a unique procedure that can achieve mild to moderate increases in breast size by collecting fat from one part of the body and transferring it directly to the breast tissue, naturally increasing breast volume.

Ideal candidates

While breast augmentation with saline or silicone breast implants is a safe and effective means of breast enhancement, fat transfer breast augmentation is an excellent alternative to be considered for select individuals. For women who desire a small to moderate increase in breast size (1/2 to 1 cup size), who may also have areas of fat excess for which liposuction treatment is being considered, fat transfer breast augmentation may be ideal.  The best fat transfer breast augmentation candidates desire an increase their breast volume by one half a cup size, and no more than a full cup size. There must also be sufficient fat elsewhere from which to harvest the fat grafts for breast augmentation.

Advantages

• No breast incision – fat cells are “harvested” and then transferred to the breast through tiny needle sites
• No risks related to the use of breast implants – i.e. silicone leak, capsular contracture, infection.
• No need for possible implant exchange in the future.
• Liposuction of the areas where the “fat cells” are removed, such as the abdomen, the thighs, etc. These areas can be sculpted and contoured as part of the breast enlargement procedure.

The Brava® System

The best fat transfer results are achieved when the grafted fat cells are placed in close proximity with a rich blood supply within the tissues. To promote a well vascularized environment for the acceptance of fat grafts to the breast, the Brava system is used.

Worn on the breasts like a bra for a predetermined amount of time before surgery (ranging from days to weeks), the breasts are “expanded” in preparation for fat grafting. This process alone will temporarily engorge and enlarge the breasts, although without fat grafts the enlargement would not last. After appropriate engorgement and recruitment of blood supply with the Brava system, the results of fat transfer to the breasts may be more reliable and long lasting.

How Fat Transfer Breast Augmentation Works

Breast enlargement with fat transfer incorporates two procedures that are performed simultaneously—liposuction, which enables the harvest of fat cells, and the fat grafting procedure itself, wherein the harvested fat is carefully prepared and then transferred to the breasts.

During the initial consultation, the plastic surgeon will examine your body thoroughly and will discuss your desires in detail. Areas of excess fat that may include outer thighs, inner thighs, the abdomen (tummy), the lumbar region, and elsewhere will be evaluated, and the regions that will best contribute to fat transfer as well as improved body contour will be identified. The benefits of autologous fat grafting to the breast are therefore twofold, in that body contouring of the “donor site” is achieved.

Fat harvest is performed using liposuction techniques through tiny needle access sites. The fat required for fat transfer to the breasts is aspirated by hand, rather than with a suction aspirator, to gently remove the fat cells and to maximize fat graft “take”. The fat is prepared meticulously with the use of established protocols (centrifugion, washout) and is then transferred through small needle sites to the breast. The fat is transferred very gently into multiple planes of the breast to promote the best fat transfer breast augmentation results.

Risks

• Cysts
• Infection
• Microcalcification (which can be misinterpreted when checking your breast with a mammogram)
• Necrosis (death) of fat cells
• Possibility that some of the transferred fat cells will leave the breast area

 

THE DAY OF THE SURGERY

Your breast augmentation surgery should be performed in an accredited hospital. Most breast augmentation procedures take about one hour and a half at the most.

• Medications are administered for your comfort during the surgical procedure.
• General anesthesia is commonly used during your breast augmentation procedure, although local anesthesia or intravenous sedation may be desirable in some instances.
• For your safety during the surgery, various monitors will be used to check your heart, blood pressure, pulse and the amount of oxygen circulating in your blood.
• Your surgeon will follow the surgical plan discussed with you before surgery.
• After your procedure is completed, you will be taken into a recovery area, where you will continue to be closely monitored.

 

 

POSTOPERATIVE CARE AND RECOVERY

Immediately after breast augmentation surgery

After your breast augmentation procedure, you may be placed in a surgical dressing that can include a support bra or garment.

Breast augmentation surgery stretches the breast tissue and can be painful—especially when implants have been placed under the chest muscle. Typically, the most pain is experienced within the first 48 hours after breast augmentation surgery. Your level of pain will typically decrease each day and may be effectively treated with various pain medications.

Your breasts may feel tight and sensitive to the touch and your skin may feel warm or itchy. You may experience difficulty raising your arms.

Some discoloration and swelling will occur initially, but this will disappear quickly. Most residual swelling will resolve within a month.

When the anesthesia wears off, you may have some pain. If the pain is extreme or long-lasting, contact your physician. You will also have some redness and swelling after the surgery.

Recovery after breast augmentation

You should be able to walk without assistance immediately after breast augmentation surgery. It is very important that you walk a few minutes every few hours to reduce the risk of blood clot formation in your legs.

It is vitally important that you follow all patient care instructions provided by your surgeon. This will include information about wearing compression garments, taking an antibiotic if prescribed and the level and type of activity that is safe. Your surgeon will also provide detailed instructions about the normal symptoms you will experience and any potential signs of complications. It is important to realize that the amount of time it takes for recovery varies greatly among individuals.

The first week

• For two to five days, you may feel stiff and sore in your chest region.
• Any surgical dressings will be removed within several days. You may be instructed to wear a support bra.
• You will be permitted to shower between one and seven days after surgery.
• If you have external sutures, they will be removed in about a week. If your surgeon used tissue glue or tape, it will fall off on its own in a week or two.
• You may be able to return to work within a few days to a week, depending on the nature of your job.
• You should refrain from lifting, pulling or pushing anything that causes pain and limit strenuous activity or upper body twisting if this causes discomfort.

The first month

You should minimize excessive physical activity for at least the first couple of weeks after surgery. After that, take care to be extremely gentle with your breasts for at least the next month. Intimate contact will be guided by your comfort.

Long-term

Your surgeon will encourage you to schedule routine mammograms at the frequency recommended for your age group. Following breast augmentation, you should continue to perform breast self-examination.

Under normal circumstances, the results of your breast augmentation surgery will be long-lasting; however, it’s important to know that breast implants need to be replaced if they leak. Routine follow-up with your surgeon is important.

Fat transfer surgery has different expectations, including losing some volume over time.

Your breasts can change due to:

• Childbirth
• Aging
• Weight gain or loss
• Hormonal factors
• Gravity

After a number of years, if you become less satisfied with the appearance of your breasts, you may choose to undergo a breast revision to exchange your implants, or a breast lift to restore a more youthful shape and contour.

COMPLICATIONS AND RISKS

Fortunately, significant complications from breast augmentation are infrequent. Your specific risks for breast augmentation will be discussed during your consultation.

All surgical procedures have some degree of risk. Some of the potential complications of all surgeries are:

• Adverse reaction to anesthesia
• Hematoma or seroma (an accumulation of blood or fluid under the skin that may require removal)
• Infection and bleeding
• Changes in sensation
• Scarring
• Allergic reactions
• Damage to underlying structures
• Unsatisfactory results that may necessitate additional procedures

All surgical procedures have some degree of risk. With breast augmentation, minor complications occur occasionally, but do not affect the outcome. Major breast augmentation complications are very unusual.

Other risks specific to breast augmentation are outlined below:

• Infection
• Capsular contracture
• Implant rupture
• Mammography shadows affecting breast cancer detection.

BREAST CANCER DETECTION

If you are of an age in which you get regular mammographic examinations, it will be important for you to select a radiology technician who is experienced in taking x-rays of augmented breasts. Additional views of your breasts are often required.

Your aesthetic plastic surgeon, in some instances, may recommend other types of examinations, such as ultrasound or magnetic resonance imaging (MRI). It is possible that the presence of breast implants could delay or hinder the early detection of breast cancer.

You can help minimize certain risks by following the advice and instructions of your board-certified plastic surgeon, both before and after your breast augmentation surgery

CASE EXAMPLE

35 year-old woman with MICROMASTIA (small breasts) presented for breast augmentation. Top photos (a,b) before the surgery. Botom photos (c,d) six months after the surgery, with anatomical implants, dual-plane technique, submammary incision.

INTRODUCTION

Over time, the natural aging process can cause your breasts to sag and lose their shape. Pregnancy, weight loss and gravity can also have similar effects on your breast tissue. A breast lift, or mastopexy, is a surgical procedure performed to reshape and raise your breasts. By cutting excess skin and tightening supporting tissue, patients can achieve an uplifted, youthful breast contour.

INDICATIONS

• When the breast are sagging
• If the nipples are droopy
• If the breast are uneven
• If the breast are “empty”, especially the upper part
• If your surgeon thinks that breast implants alone are unlikely to achieve the contour you desire
• If the tissue surrounding the nipple or areola is stretched

ADVANTAGES

• You will have improved breast shape, projection, and symmetry
• Your breasts will have a more youthful appearance.
• You will look better in and out of clothes and feel more self-confident.

DISADVANTAGES

• The effects of a breast lift might slowly diminish over time because of gravity and aging.
• A breast lift leaves scars that will be hidden in a bra or swimsuit.
• Subsequent pregnancy may compromise your surgical results.

CANDIDATES FOR BREAST LIFT SURGERY

• Patients with breasts that are flat or elongated
• Patient with breasts that look “empty”.
• Patients with breasts that are not firm.
• Patients with nipples and areolas that point downward, especially below the breast fold.
• Patients with breasts that appear different from each other; one breast may appear firm and well positioned while the other does not.
• Patients with breasts that are uneven.
• Patients with breasts that are small.
• Patients who are finished with childbearing and breast-feeding.
• Patients who are in good general health
• Patients with positive attitudes and realistic expectations.

INITIAL CONSULTATION

During your initial consultation, you will have the opportunity to discuss what you want to achieve.You will be asked about:

• Previous surgeries in general and specifically about breast surgeries, including breast biopsies.
• Past personal medical history.
• Past family medical history in general.
• Allergies and current medications.
• Medical treatments you have received.
• Family history of breast cancer.
• Current and previous mammogram results.

The plastic surgeon will examine you, measure and photograph your breasts for your medical record. Your surgeon will consider:

• The current size and shape of your breasts.
• The breast size and shape that you desire.
• The quality and quantity of your breast tissue.
• The quality of your skin.
• The placement of your nipples and areolas.

If you feel your breasts are too large or too small, your plastic surgeon may recommend breast augmentation or breast reduction.

If you are planning to lose a significant amount of weight, be sure to tell your plastic surgeon. The surgeon may recommend that you may postpone the surgery until you reach the ideal weight.

Because pregnancy and breast feeding can alter breast size in an unpredictable way and could affect the outcome of the surgery, if you are planning to become pregnant, you may want to postpone the surgery. You should discuss that option with the Plastic Surgeon.

BREAST PTOSIS GRADES

• Grade I: Mild breast ptosis, which can be corrected withbreast implant augmentation, or with a periareolar skin resection (crescent lift), with or without breast augmentation.
• Grade II: Moderate ptosis, which can be corrected with a circumareolardonut mastopexy technique featuring Benelli cerclage suturing; and with circumvertical-incision (lollipop mastopexy) techniques
• Grade III: Severe ptosis, which usually can be corrected with the circumvertical and horizontal incisions of theAnchor mastopexy (inverted-T incision), regardless of the type of pedicle used (inferior or superior).
• Pseudoptosis: This is not a true breast ptosis. The nipple is at the right position (above the breast fold), but the bottom part of the breast is sagging

PREPARATION FOR THE SURGERY

• Stop smoking at least six weeks.
• Avoid taking aspirin, certain anti-inflammatory drugs and some herbal medications that are associated with bleeding.
• Reduce alcohol consumption
• Buy a sports bra or a bra without underwires, to fit the expected size.
• If you have children less than five years of age, you must have someone to take care of them for a week.
• Prepare not to lift heavy weights or drive for the first two weeks, so arrange for some help.
• Ha enough pillows to sleep with an incline for a few days.
• Avoid hot showers, hot tubs and saunas for two to three weeks.
• Decide what you will wear for the first few days; pick items that open in front.
• Be sure to arrange for someone to drive you home after surgery and to stay with you at least the first night following surgery.

SURGICAL PROCEDURE

A breast lift is performed under general anesthesia or intravenous sedation in an accredited hospital. Different techniques for removing breast skin and reshaping the breast determine the location of the incisions and resulting scars.

The plastic surgeon will propose a technique based on your breast size and shape, areola size and position, degree of breast sagging, skin quality and elasticity.

In general the Plastic Surgeon will remove excess breast skin and shift the nipple and areola to a higher position. If your areola has become stretched, it can now be reduced in size. The Plastic Surgeon will tighten the remaining skin, sewing the breast back together and placing sutures deep in the breast tissue to support the new breast position for a longer period of time. Scars are usually hidden under the breasts, although some light scarring may be seen on top of the breast. The nipples and areolas remain attached to underlying mounds of tissue, and this usually allows for the preservation of sensation and the ability to breast-feed. In some patients, it may be possible to avoid the horizontal incision beneath the breast as well as the vertical incision that runs from the bottom edge of the areola to the breast crease.

Surgical Techniques

• Crescent Lift: Minimal Scarring to Correct Minimal Sagging

The “Crescent” lift, which is less commonly used, is an incision that lies just along the upper half of the areola. Plastic surgeons may use the “crescent lift” technique for women who have a very small amount of sagging to correct or if nipple needs to be placed higher on the breast or in conjunction with breast augmentation. It cannot accomplish the same degree of lifting as the other incision techniques.

Crescent lift technique – red area is removed , nipple and breast are lifted, yellow is the final scar

 

• Peri-Areolar or “Donut” Lift: Corrects Mild Sagging with a Single Scar.

The “Donut” lift, or “Bennelli technique” also known as the “Periareolar incision,” uses an incision made around the perimeter of the areola only. It is suitable only for women with a mild-to-moderate degree of breast ptosis. This lift can also be effective in helping reduce areola size. The resulting scar traces the edge of the areola. When used in conjunction with the use of implants, it can produce a satisfactory result even for patients with more pronounced sagging. It has the least amount of scarring, but sometimes it is difficult to achieve good breast projection.

 

• Vertical or “Lollipop” Lift: Corrects Moderate Sagging & Provides More Extensive Reshaping

The “Verical mastopexy” or “Lollipop” lift, or “Keyhole” incision, made around the perimeter of the areola and vertically down from the areola to the breast fold, is ideal for women with a moderate degree of breast ptosis, who do not want breast implants. This is the most commonly used procedure. The main advantage is the reduced operating time, quick healing and less scaring that the first option.

“Lollipop” or “Vertical” breast lift – the skin over breast tissue in the middle of the breast under the areola is removed (the grey area) and the skin is tightened towards the midline, lifting up the breast like a sling

 

• Inverted T or “Anchor” Lift: Dramatic Reshaping to Correct Extensive Sagging

The “Anchor type” or “WISE pattern” incision, which is made around the perimeter of the areola, vertically down from the areola to the breast fold and horizontally along the breast fold, produces the most scarring. It is for women with a severe degree of sagging who will not be helped sufficiently by less invasive techniques. This incision, which is the oldest technique, is often used for a breast lift in conjunction with a breast reduction. It is a procedure with longer operating time, more scars but with very predictable results.

 

“WISE pattern” or “Anchor type” breast lift –  the skin over the breast tissue (yellow area) is removed and the skin left and right is tightened to the midline and the nipple lifted upwards (blue arrow)

Combining a Breast Lift with Augmentation

All these options can be combined with breast implants if needed to add volume. Then this procedure is called Augmentation – Mastopexy. In some cases, a breast lift alone may not achieve a patient’s desired results. If you feel your breasts look “empty” or have lost volume due to aging, weight loss, or pregnancy, your Plastic Surgeon can place breast implants during breast lift surgery to restore fullness and shape to the breast. If you have always wanted larger, lifted breasts, a breast augmentation with lift can help you achieve both with a single procedure and recovery. A breast lift with augmentation is a popular option to enhance the breasts.

Incisions

These vary according to the type of incision your aesthetic surgeon suggests for you. The most common method of lifting the breasts involves three types of incisions:

• Around the areolas – periareolar
• Extending downward from the areolas to the breast creases – vertical portion
• Horizontally along the breast fold – anchor type

Although incision lines are permanent, in most cases they will fade and significantly improve over time. Aesthetic plastic surgeons make every effort to place scars in hidden areas and minimize them with careful tissue handling and special suture techniques in order to minimize scars.

Summary of different types of breast lift incisions

THE DAY OF THE SURGERY

Your breast lift surgery will be performed in an accredited hospital. The Plastic Surgeon will give you an estimate of how long your surgery will last based on the details of your surgical plan.

• General anesthesia is commonly used during your breast lift procedure, although local anesthesia or intravenous sedation may be appropriate in selected case.
• Various monitors will be used to check your heart, blood pressure, pulse and the amount of oxygen circulating in your blood.
• Once the operation has begun, the surgeon will follow the original plan but he may decide to combine various techniques or change a technique to ensure the best result.
• Following the surgery steri-strips and a small gauze will cover the incisions.
• It is extremely rare to use drainage tubes. If they are needed they are removed the next day.
• You will be taken into a recovery area where you will continue to be closely monitored.
• Before leaving the hospital the plastic surgeon will examine you and will probably permit you to go home after a short observation period, if you are fully awake, able to go to the bathroom, walk, do not feel nausea and able to drink fluids.

RECOVERY

The Plastic surgeon and his team will discuss how long it will be before you can return to your normal level of activity and work. After surgery, you and your caregiver will receive detailed instructions about your postsurgical care, including information about:

• Drains, if they have been placed
• Normal symptoms you will experience
• Potential signs of complications

RESULTS

The results of a breast lift are visible immediately after surgery and will continue to improve as swelling subsides and scars fade. Most patients who maintain realistic expectations and thoroughly discussed their goals prior to surgery are satisfied with the look of their lifted breasts. While results are not permanent, If a breast lift is performed properly, your breasts should not return to their preoperative droop for many years, assuming you don’t have significant weight fluctuations or go through pregnancy. Some settling may occur, but the new nipple position should remain intact.

RISKS

Fortunately, significant complications from breast lift are rare. Bear in mind that all surgical procedures carry some degree of risk. Some of the potential complications of all surgeries are:

• Adverse reaction to anesthesia
• Hematoma or seroma (an accumulation of blood or fluid under the skin that may require removal)
• Infection and bleeding
• Changes in sensation (hypesesitive or hyposensitive nipples)
• Adverse Scarring – Hypertrophic scars or keloids
• Allergic reactions to medications or bandages
• Damage to underlying structures
• Revision surgeries
• Blood clots in the legs or lungs
• Infection of the implants if they are used
• Removal of implants if they are used

 

CASE EXAMPLE

Breast Lift (mastopexy) in a 45 year old lady, with the Vertical scar technique and without using implants. Left, before the surgery. Right, six months after the surgery

INTRODUCTION

Breast reconstruction is a surgical procedure commonly performed after a mastectomy to offer patients psychological and aesthetic benefits when recovering from breast cancer. The surgery rebuilds the breast so that it is about the same size and shape as it was before. The nipple and areola (the darker area around the nipple) can also be added.

Most women who have had a mastectomy can have reconstruction. Women who have had a lumpectomy may not need reconstruction. Breast reconstruction is done by a plastic surgeon. This procedure allows many women to fully return to the life they enjoyed before being diagnosed with breast cancer, with barely any signs of the disease remaining. Although the treatment of cancer is the main focus for both patient and doctor, restoring your appearance after breast cancer can often help ensure a complete recovery of body and mind.

BEAUTY FOR LIFE

Enhancing your appearance with breast reconstruction

Breast reconstruction is a physically and emotionally rewarding procedure for a woman who has lost a breast due to cancer or other condition.

The creation of a new breast can dramatically improve your self-image, self-confidence and quality of life. Although surgery can give you a relatively natural-looking breast, a reconstructed breast will never look or feel exactly the same as the breast that was removed.

NEW CHOICES IN BREAST CANCER SURGERY AND RECONSTRUCTION

Each year more than 250, 000 American women face the reality of either invasive or noninvasive breast cancer. Today, the emotional and physical results are very different from what they were in the past. Much more is now known about breast cancer and its treatment. New kinds of treatment, as well as improved reconstructive surgery mean that women who have breast cancer today have better choices.

Today, more women with breast cancer choose surgery that removes only part of the breast tissue. This is called breast conservation surgery (or lumpectomy or segmental mastectomy). But, some women have a mastectomy, which removes the entire breast. Many women who have a mastectomy choose reconstructive surgery to restore the breast’s appearance.

If you are thinking about having reconstructive surgery, it is a good idea to talk about it with your surgeon and a plastic surgeon experienced in breast reconstruction before your mastectomy. This lets the surgical teams plan the treatment that is best for you, even if you decide to wait and have reconstructive surgery later.

WHY ONE SHOULD HAVE BREAST RECONSTRUCTION

Women choose breast reconstruction for many reasons:

• to make their breasts look balanced when they are wearing a bra
• to permanently regain their breast contour
• to avoid using an external prosthesis (form that fits into the bra)

You will be able to see the difference between the reconstructed breast and the remaining breast when you are nude. But when the breasts are in a bra, they should be alike enough in size and shape that you will feel comfortable about how you look in most types of clothes.

Your body image and self-esteem may improve after your reconstruction surgery, but this is not always the case. Breast reconstruction does not fix things you were unhappy about before your surgery. Also, you may be disappointed with how your breast looks after surgery. You and those close to you must be realistic about what to expect from reconstruction.

There are often many options to think about as you and your doctors talk about what is best for you. The reconstruction process may require one or more operations. You should talk about the benefits and risks of reconstruction with your doctors before the surgery is planned. Give yourself plenty of time to make the best decision for you. You should decide to have breast reconstruction only after you are fully informed.

Breast reconstruction is a highly individualized procedure. You should do it for yourself, not to fulfill someone else’s desires or to try to fit any sort of ideal image.

Breast reconstruction is a good option for you if:

• You are able to cope well with your diagnosis and treatment
• You do not have additional medical conditions or other illnesses that may impair healing
• You have a positive outlook and realistic goals for restoring your breast and body image

It’s important that you feel ready for the emotional adjustment involved in breast reconstruction. It may take some time to accept the results of breast reconstruction.

PATIENT GOALS

Your Plastic Surgeon should discuss your breast reconstruction surgery goals with you realistically. Together you should decide which procedures will be performed in order to achieve your desired results. You will set a date for surgery and be given instructions about how to prepare. You will also schedule a pre-operative appointment to review your medical history, to take pre-operative photographs, and to be dimensionally fitted with tissue expanders.

BREAST RECONSTRUCTION CANDIDATES

Although breast reconstruction is a beneficial procedure for many women, it is not right for everybody. In order to undergo any kind of breast reconstruction surgery, women should be in good general health and able to handle the stress of a surgical procedure. Certain factors may increase your risk of complications with breast reconstruction surgery, and it may be best to postpone this elective procedure until risk factors are reduced.

Breast reconstruction is a highly individualized procedure. You should do it for yourself, not to fulfill someone else’s desires or to try to fit any sort of ideal image.

Breast reconstruction is a good option for you if:

• You are able to cope well with your diagnosis and treatment
• You do not have additional medical conditions or other illnesses that may impair healing
• You have a positive outlook and realistic goals for restoring your breast and body image Although breast reconstruction can rebuild your breast, the results are highly variable:
• A reconstructed breast will not have the same sensation or feel as the breast it replaces.
• Visible incision lines will always be present on the breast, whether from reconstruction or mastectomy.
• Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the back, abdomen or buttocks.

IMMEDIATE VERSUS DELAYED BREAST RECONSTRUCTION

In most cases, breast reconstruction can be performed at the same time as your mastectomy, and is referred to as “immediate reconstruction.” Reconstruction can also be performed weeks, months, or years later. This is known as “delayed reconstruction.”

The decision to have immediate versus delayed reconstruction is depends on many factors, including:

• Breast cancer stage
• Your medical condition
• Your preference and lifestyle
• Additional therapies (such as radiation) needed to treat the breast cancer

A. Immediate Reconstruction

Advantages

• Decreased risk of social or emotional difficulties
• The chest tissues are undamaged by radiation therapy or scarring.
• Better cosmetic results
• Possibly fewer surgeries and lower surgery cost
• No difference in rate of development of local cancer recurrence
• No difference in the ability to detect local cancer recurrence
• No significant delays in getting other cancer treatments

Disadvantages

• Harder to detect mastectomy skin problems
• Longer hospitalization and recovery times than if you had mastectomy alone
• More scarring than mastectomy alone

B. Delayed Reconstruction

Advantages

• Additional cancer therapy after mastectomy (such as radiation) does not cause problems at the reconstruction site
• Gives patients more time to consider breast reconstruction options

Disadvantages

• Mastectomy scar on chest wall
• Requires additional surgery and recovery time
• Sometimes difficult to reconstruct after scarring occurs
• Less optimal cosmetic results

DECISIONS ABOUT RECONSTRUCTION DEPENDS ON MANY FACTORS

There are a number of factors that should be taken into consideration when choosing which option is best:

• Your overall health
• The stage of your breast cancer
• Type of mastectomy
• Cancer treatments
• Patient’s body type
• The size of your natural breast
• The amount of tissue available (for example, very thin women may not have enough extra body tissue to make flap grafts)
• Whether you want reconstructive surgery on both breasts
• Your insurance coverage for the unaffected breast and related costs
• The type of procedure you are thinking about
• The size of implant or reconstructed breast
• Your desire to match the look of the other breast

INITIAL CONSULTATION

During your breast reconstruction consultation be prepared to discuss:

• Your surgical goals
• Medical conditions, drug allergies, and medical treatments
• Current medications, vitamins, herbal supplements, alcohol, tobacco, and drug use
• Previous surgeries

Your surgeon will also:

• Evaluate your general health status and any pre-existing health conditions or risk factors
• Examine your breasts and take measurements of their size and shape, skin quality, and placement of nipples and areolae
• Take photographs
• Discuss your options and recommend a course of treatment
• Discuss likely outcomes of breast reconstruction and any risks or potential complications

Be sure to ask your plastic surgeon questions. It’s very important to understand all aspects of your breast reconstruction. To help, we have prepared a checklist of questions to ask your breast reconstruction surgeon that you can take with you to your consultation.

It’s natural to feel some anxiety, whether it’s excitement for your anticipated new look or a bit of preoperative stress. Don’t be shy about discussing these feelings with your plastic surgeon.

QUESTIONS TO ASK

• When can I have reconstruction done?
• Can breast reconstruction be done in my case?
• What types of reconstruction are possible for me?
• What type of reconstruction do you think would be best for me? Why?
• How many of these procedures have you done?
• Will the reconstructed breast match my remaining breast and if not, what can be done?
• How will my reconstructed breast feel and will I have any sensation?
• What possible complications should I know about?
• How long will the surgery take and how long will I be in the hospital?
• Will I need blood transfusions? If so, can I donate my own blood?
• How long is the recovery time?
• How much help will I need at home to take care of my drain (tube that lets fluid out) and wound?
• When can I start my exercises and return to normal activity such as driving and working?
• Can I talk with other women who have had the same surgery?
• Will reconstruction interfere with chemotherapy or radiation therapy?
• How long will the implant last?
• What happens if I gain or lose weight?

BREAST RECONSTRUCTION AND CHEMOTHERAPY

Breast reconstruction should not delay chemotherapy treatments. Usually your medical oncologist will wait until you have healed from your mastectomy and reconstruction before starting chemotherapy. If you have complications such as wound healing problems or infection, chemotherapy may be delayed.

If you are undergoing tissue expansion at the time of chemotherapy, the surgeon may need to take blood. This is to make sure that your body can fight bacteria that may be introduced from your skin during the expansion process. Once chemotherapy is complete, your surgeon will usually wait at least a month before considering further reconstructive surgery.

BREAST RECONSTRUCTION AND RADIOTHERAPY

You may want to delay breast reconstruction until you are finished with radiation therapy. Radiation may damage your reconstruction and affect your final cosmetic result. If you require radiation, your surgeons may recommend that you use your own tissue for delayed reconstruction, either alone or with an implant. Implant-only reconstruction is not recommended, since radiation often results in implant complications, including:

• Infections
• Severe capsular contracture (scar tissue around the implant causes hardening of the breast)
• Fluid buildup
• Poor cosmetic result

If you may need radiation treatment, a tissue expander can be placed during the mastectomy to preserve the skin “pocket.” It provides a breast mound while you are waiting to hear if you need radiation.

If you do not need radiation, you and your surgeon can plan the final reconstruction. If you do need radiation, the tissue expander can be left in place. However, at MD Anderson, the tissue expander must be deflated while you are receiving radiation, which usually takes 6-8 weeks. The tissue expander is then re-inflated 2 weeks after radiation is complete. A delayed reconstruction is planned with your surgeon. Not all surgeons will recommend this option because there is an increased risk of complications by having a tissue expander in place during radiation treatment.

BREAST RECONSTRUCTION AND RISK OF CANCER RELAPSE

The risk of breast cancer recurrence depends on the stage of disease, biologic characteristics of the cancer and additional breast cancer treatments. Reconstructive surgery has not been shown to increase the risk of the cancer returning or make it harder to detect if cancer does return. The methods or tests used to screen for recurrence will be decided by your cancer care team.

WHERE IS THE SURGERY PERFORMED

Surgery for your breast reconstruction is most often performed in a hospital setting, possibly including a short hospital stay, and your doctor will likely use general anesthesia.

Some follow-up procedures may be performed on an outpatient basis, and local anesthesia with sedation may be used.

These decisions will be based on the requirements of your specific procedure and in consideration of your preferences and your doctor’s best judgment.

PREPARING FOR THE SURGERY

• Get lab testing or a medical evaluation
• Take certain medications or adjust your current medications
• Stop smoking
• Avoid taking aspirin, anti-inflammatory drugs, and herbal supplements as they can increase bleeding

Breast reconstruction surgery is typically performed in a hospital setting, may include a short hospital stay, and will likely use general anesthesia. Some follow-up procedures may be performed on an outpatient basis, and local anesthesia with sedation may be used.

These decisions will be based on the requirements of your specific procedure and in consideration of your preferences and your doctor’s best judgment.

Special instructions you receive will cover:

• What to do on the day of surgery
• The use of anesthesia during your breast reconstruction
• Post-operative care and follow-up
• Breast implant registry documents (when necessary)

Your plastic surgeon will also discuss where your procedure will be performed. Breast reconstruction surgery may be performed in an accredited office-based surgical center, outpatient/ambulatory surgical center, or a hospital.

 

RECONSTRUCTION WITH IMPLANTS

 

Implant-based reconstruction is a popular procedure that offers an acceptable cosmetic outcome without having to use tissue from another part of the body. There are two types of implants: saline-filled and silicone gel-filled. Both types of implants come in numerous shapes, sizes and profiles. Despite controversy over silicone implants in the 1990s, they have been ruled safe and effective by the Food and Drug Administration. Your surgeon will help determine which implant is best for your body shape.

Depending on their lifestyle and preference, patients may choose implants over tissue-based reconstruction.

The best candidates for implant reconstruction are women:

• with an adequate skin “pocket” to hold the implant (skin-sparing mastectomy)
• who don’t have adequate tissue of their own
• who have no available flap options
• who do not desire a flap operation
• who do not have compromised tissue at the mastectomy site
• who have no history of previous radiation to the breast or chest wall
• who are having prophylactic mastectomies
• who want bilateral reconstruction
• who are of a reasonable size and body weight
• who agree to have an operation on the opposite breast to help improve symmetry

You are not an ideal candidate for expander implant post mastectomy reconstruction if you have:

• compromised tissue at the mastectomy site (numerous surgeries or infection)
• been previously radiated (refer to effects of radiation)
• advanced disease
• autoimmune disease (may be a contraindication for gel-filled implants)
• a Body Mass Index greater than 30
• very large breasts

Advantages of Implant Reconstruction

• Decreased surgery and recovery time
• Fewer scars
• Satisfactory shape in clothing

Disadvantages of Implant Reconstruction

• Need frequent office visits for the tissue expansion process
• Two-stage procedure: tissue expander followed by exchange for permanent implant
• Hard to achieve nipple projection with nipple reconstruction, due to thinner skin
• Difficult to achieve symmetrical shape with the natural breast
• Need to replace implants periodically, meaning more surgery
• Breasts reconstructed with an implant alone will not create a natural droopy appearing breast and may appear fuller in the upper half compared with a natural breast.

Choosing Your Implant

Together with your surgeon, you will decide which implant best suits your individual needs. There are two general categories for implants:

• saline-filled
• the new generation of silicone cohesive gel-filled implants.

Saline implants have historically been more commonly used in breast reconstruction, and between 1992 and 2006 they were the only fully-approved devices in the United States. Silicone gel implants prior to 1992 were often well received by patients, but were sometimes associated with microscopic gel-bleed or leakage. This led to their removal from the marketplace in 1992. However, due to certain advantages over saline implants, product development continued worldwide. FDA studies in silicone safety led to FDA approval of the latest generation of silicone implants in 2006.

The advantages of gel implants are that they tend to be softer; with a feel that is more like natural breast tissue. Also, gel implants can have less rippling and visibility as compared to saline implants. Both types of implants come in numerous shapes, sizes, and profiles. There are smooth and textured designs (some surgeons use textured implants to reduce the risk of capsular contracture). Most importantly, the choice of implant style should be determined by the patient’s body shape.

Anatomic cohesive gel implant (tear drop implant)

SURGICAL PROCEDURE

A.Staged Surgical Procedure

1st stage

Following mastectomy, your reconstructive surgeon will insert a tissue expander (a silicone balloon filled with saline) in a pocket formed under the muscle and remaining skin on your chest wall. More saline solution is gradually added to the tissue expander during outpatient clinic visits, stretching the muscle and skin to the desired size. Often the skin is stretched slightly more than needed because it has a natural tendency to shrink when the tissue expander is removed.

Tissue expander placed under pectoralis major muscle and skin after mastectomy

 Skin expansion process

Expansion process performed in the office

 The amount of saline needed for each expansion may vary depending on the tightness of the skin. This process usually takes two to three months, but may take longer if you need other cancer treatments, such as chemotherapy.

2nd stage

Once the “pocket” has reached the desired size, the expander is left in place, stretching your skin for approximately one to two months more. Surgery is then scheduled to remove the tissue expander and replace it with a permanent implant, which is an outpatient surgical procedure. The permanent implant will either be filled with saline or silicone and will be much softer than the tissue expander. Your reconstructive surgeon can discuss the various types of available breast implants.

 

Final implant after tissue expander removed

Today, with the use of a dermal matrix the surgeon can usually place a higher volume of saline during the initial surgery. This may decrease the number of expansions needed later. The patient will be well on her way to having an immediate breast shape after the first operation.

Implant covered partially by ALLODERM (white patch)

 

B. Direct to Implant (“One-Stage”) Breast Reconstruction

Post Mastectomy Reconstruction

Post mastectomy reconstruction with a direct to implant, or “one-step” approach allows for a single-stage reconstruction of the breast mound in select patients. This approach is best suited for patients with good preservation of the breast skin after mastectomy. A permanent implant is inserted immediately following the mastectomy, forgoing the initial placement of a tissue expander and subsequent expansion process.

Placing the Implant

At the time of the initial post mastectomy reconstruction operation, the implant is positioned on the chest wall behind the pectoralis major muscle. Today, with the use of a dermal matrix, the surgeon can frequently use a permanent implant of the desired definitive volume during the initial surgery, provided the amount and quality of the breast skin remaining after mastectomy can accommodate the volume. The patient will have the definitive breast volume and approximate shape after the first operation.

Depending on the quality of the result after allowing the initial reconstruction to settle and heal for a few months, a second stage reconstruction creating a more refined breast shape may still be desirable. This is an outpatient procedure that involves minor refinements in contour and symmetry potentially without exchanging the implant. The initial implant placement, and possible second stage, each take about one hour in the operating room.

After implant reconstruction surgery

The Plastic Surgeon will give you specific instructions to follow for your recovery, including special exercises you should do to prevent stiffness and scar tissue build-up after immediate or delayed-immediate reconstruction, as well as how to care for the dressings, stitches, staples, and surgical drains.

It can take about 6 weeks to recover from implant surgery done at the same time as mastectomy. It’s important to take the time you need to heal. It’s also important to continue doing your arm exercises each day and follow any other routines your doctor or physical therapist prescribes for you.

When you have surgery to swap the tissue expander for a permanent implant (the second step of delayed-immediate or delayed reconstruction), it’s usually done as an outpatient procedure, which means you don’t stay overnight in the hospital. You’ll still be given general anesthesia, so you’ll need to have someone come with you to the hospital or clinic to drive you home. This surgery takes about an hour. Because this surgery is less involved than the mastectomy-tissue expander/implant surgery, recovery usually takes about 2 weeks.

Breast implants and risk of other illnesses

 In the past there has been concern that implants filled with silicone gel could cause connective tissue diseases or auto immune diseases. These are illnesses where something triggers the body’s immune system to attack its own tissues. They include conditions such as arthritis and skin conditions and may cause muscle and joint pains.

Some women who have had implants filled with silicone gel have developed these illnesses. Some of the women feel strongly that the gel inside their implants leaked out and caused their illnesses.

A great deal of research has been done to check for a link between silicone and these connective tissue diseases. All the studies have shown that there are no more cases of connective tissue disease in women who have had silicone gel breast implants than in the general population. There is no evidence that silicone causes these illnesses.

If you have had breast implants and are worried, you could talk to your surgeon about alternatives to implants filled with silicone. It may be possible for you to have an implant filled with salt water instead of silicone. These saline implants still have a silicone rubber envelope but silicone rubber has never been thought to be the cause of the connective tissue diseases. It is the silicone gel inside the implants that has been blamed as a possible cause of illness. This is something you need to discuss with your reconstruction surgeon. Many breast reconstruction surgeons think that saline implants are not as good as silicone for giving soft, natural results.

Possible complications with implant surgery

• Infection
• Accumulation of clear fluid causing a mass or lump (seroma) within the reconstructed breast
• Pooling of blood (hematoma) within the reconstructed breast
• Blood clots
• Extrusion of the implant (the implant breaks through the skin)
• Implant rupture (the implant breaks open andsaline or silicone leaks into the surrounding tissue)
• Formation of hardscar tissue around the implant (known as a contracture)
• Obesity,diabetes, and smoking may increase the rate of complications
• Possible increased risk of developing a very rare form of immune system cancer called anaplastic large cell lymphoma

 

Revisions in Implant Reconstruction

A common concern with implant reconstruction is thin skin that allows irregularities of the implant to show through. This can result in skin rippling, a problem, that is more likely with saline implants. In order to help correct skin rippling, a saline implant can be exchanged for silicone gel, or a higher volume device.

Capsular contracture complicating implant reconstruction may also require revisionary surgery. The capsule is the internal layer of scar that forms around an implant as a natural reaction to the presence of a foreign device. The capsule can contract (shrink), thereby causing a feeling of tightness. In the most severe cases, the tightness may be visible and associated with pain. Surgical treatment may require a capsulectomy to remove a portion, or all, of the capsule to soften the pocket. Capsular contracture is extremely common in patients who have had prior radiation.

Contour abnormalities following implant reconstruction can be treated with a number of approaches. If needed, the skin envelope around the implant can be reshaped. In areas with thin, soft tissue, contour may be improved with fat injections. In this procedure, fat is removed from other parts of the body with liposuction, and is then prepared for injection into the skin of the reconstructed breast. It is not always predictable as to how much fat will “take” or be accepted by the body. It is not unusual to need more than one procedure to get the desired final outcome. The fat that does survive should last forever.

Breast implant malposition and asymmetry, or a poorly defined inframammary fold, can frequently be corrected by placing stitches to alter the shape of the implant pocket. The inframammary fold position can be revised in this way, or by cutting the skin below the breast to help create a fold. Once the areas of revision have been addressed, and the breasts have completely healed, the nipple areola reconstruction can be done.

RECONSTRUCTION WITH YOUR OWN TISSUE – FLAPS

A. RECONSTRUCTION WITH LATISSIMUS DORSI FLAP (BACK FLAP)

 

The latissimus dorsi (LD) flap is a standard method for breast reconstruction that was first utilized in the 1970’s. The latissimus dorsi flap is most commonly combined with a tissue expander or implant, to give the surgeon additional options and more control over the aesthetic appearance of the reconstructed breast. This flap provides a source of soft tissue that can help create a more natural looking breast shape as compared to an implant alone. Occasionally, for a thin patient with a small breast volume, the latissimus dorsi flap can be used alone as the primary reconstruction without the need for an implant.

Many surgeons will resort to the use of an latissimus dorsi flap as a backup option if a patient has wound healing problems or soft tissue failure in the setting of an implant. The latissimus dorsi flap can also be used as a salvage procedure for patients who have had previous radiation, and are not candidates for other autogeneous procedures. A large open wound on the chest wall is also an indication for an LD flap in patients that need chest wall reconstruction alone, without creation of a breast shape.

The thoracodorsal artery is the primary source of blood supply to the latissimus dorsi flap. At the time of breast reconstruction, the muscle flap, with or without attached skin, is elevated off of the back and brought around to the front of the chest wall. The main vessels remain attached to the body to ensure proper blood supply to the flap. The LD flap provides soft tissue to allow complete coverage of an underlying implant.

The length of surgery for latissimus dorsi flap breast reconstruction is typically two to three hours, and requires one to three post-operative days in the hospital. The initial recovery time is two to three weeks. Depending on the patient, the scar from the LD flap donor site on the back can be placed diagonally or horizontally. A horizontal scar can usually be concealed under a bra strap. Patients generally have no major long-term physical limitations from taking the latissimus muscle. Activities of daily living and most exercise can be resumed without significant loss of proficiency.

Secondary procedures after an latissimus dorsi flap reconstruction can be done in about three months. These may include expander implant exchange, adjustment procedures to improve breast symmetry, and nipple areola reconstruction. As with any type of reconstruction, if chemotherapy is needed, any additional surgery must await completion of treatment. Such additional procedures are typically done as outpatient surgery with a rapid recovery.

You are an ideal candidate for latissimus dorsi flap reconstruction if you:

• are thin with a small breast volume
• have excess tissue laterally and upward across the midback
• have had previous radiation and are having an implant reconstruction
• are not a candidate for other autogeneous procedures
• are having a partial breast reconstruction in order to correct a lumpectomy defect
• have thin skin that requires extra coverage for an implant
• desire a more natural appearance than that of an implant alone
• are having immediate or delayed reconstruction

You are not an ideal candidate for LD flap reconstruction if you:

• do not wish to have additional scarring to a part of the body other than the breasts
• have had previous chest-wall surgery such as a thoracotomy
• participate in extreme competitive sports such as mountain climbing, skiing, and swimming

Advantages of LD flap reconstruction:

• Decreased surgery and recovery time
• Better coverage over the implant
• One-time surgery, if the implant placed immediately
• Good option for thin patients who have had radiation therapy

Disadvantages of LD flap reconstruction:

• A breast implant is usually required for the desired projection and size
• May have complications in the back where the tissue was taken from
• Muscle weakness in the back can affect rock climbers, swimmers and tennis players

Latissimus Dorsi muscle with skin paddle

Latissimus Dorsi muscle with implant underneath

 

1. RECONSTRUCTION WITH TRAM FLAP (ABDOMINAL FLAP)

The most common method of autogeneous tissue reconstruction is the pedicled transverse rectus abdominus myocutaneous (TRAM) flap. In this approach, the entire rectus abdominus muscle is used to carry the lower abdominal skin and fat up to the chest wall. A breast shape is then created using this tissue. In order to transfer the flap to the chest, the muscle is tunneled under the upper abdominal skin. Since the patient’s own body tissue is utilized, the result is a very natural breast reconstruction. Also, the patient will have the benefit of a flatter looking abdomen. The scar on the abdomen is low, and extends from hip to hip. The TRAM flap can be used for reconstructing one or both breasts. In a patient undergoing unilateral reconstruction, the TRAM flap can potentially offer better symmetry than using an implant.

Schematic drawing of right breast reconstruction with left TRAM flap

The TRAM flap is based on the superior epigastric vessels, which are considered to be the secondary blood supply to the lower abdominal wall skin. Some patients should not have this type of reconstruction because of limitations in the flap blood supply. For example, smoking, diabetes, and obesity are considered to be relative contraindications to having a pedicled TRAM flap breast reconstruction.

While the benefit of the TRAM flap is a natural looking and feeling breast, the primary disadvantages relate to the abdominal wall donor site. These include potential abdominal wall weakness, bulging, and hernia. To prevent hernia, most surgeons will use a synthetic mesh when closing the abdomen.

The TRAM flap operation is more involved than implant reconstruction. The length of surgery for a unilateral TRAM flap reconstruction is generally four to five hours. For bilateral reconstruction, it is approximately five to seven hours. The hospital stay is usually three to five days. The patient will have abdominal pain and tightness for several weeks, and it can often several months to return to a full range of activity.

Secondary procedures after a TRAM flap reconstruction can be done in about 3 months. However, if chemotherapy is needed, any additional surgery must await completion of treatment. At that point, the patient can have revisions to the breasts and abdomen, and the nipple areola can be created. Such additional procedures are typically done as outpatient surgery with a rapid recovery.

 You are an ideal candidate for TRAM flap reconstruction if you:

• desire autogeneous reconstruction
• do not want or are not a candidate for implant reconstruction
• have enough lower abdominal wall tissue to create one or both breasts
• have not had prior abdominal surgery
• previously had chest wall radiation
• have had failed implant reconstruction
• are having immediate reconstruction at the time of skin-sparing mastectomy
• are having delayed reconstruction following prior mastectomy

You are not an ideal candidate for TRAM flap reconstruction if you:

• do not have enough lower abdominal tissue to create the flaps
• have a large overhanging pannus of abdominal skin and fat
• have a BMI of 30 or above
• have diabetes
• are a smoker or quit smoking only recently
• have had previous abdominal surgeries such as abdominoplasty
• cannot tolerate anesthesia for long periods
• do not wish to have a lower abdominal scar

Advantages of reconstruction with TRAM abdominal flap:

• Natural breast shape, consistency and behavior
• Improved abdominal shape
• No breast implant required
• Adominoplasty (tummy tuck) at the same time

Disadvantages of reconstruction with abdominal flap:

• Longer surgery
• Requires a surgeon trained in microsurgery techniques
• Additional scarring on stomach
• Longer hospitalization and recovery
• Possibility of hernia

 

1. MICROSURGICAL RECONSTRUCTION WITH FREE TRAM FLAP (ABDOMINAL FLAP) / FREE DIEP FLAP (ABDOMINAL FLAP)

With advances in microsurgery over the last decade, there are several new procedures that are being widely sought after by women. While the pedicled TRAM flap is still the standard of care in the United States, some surgeons have expertise in advanced microsurgical techniques, which provide women with more elegant, optimal solutions when utilizing abdominal tissue. These options allow for achieving better aesthetic results with fewer donor site complications. Nevertheless, these are longer procedures with potential for other complications such as total flap loss. The success rate in transferring tissue in this manner is very high in the hands of surgeons who perform microsurgery regularly, in institutions with experience monitoring these flaps. However, if blood vessel thrombosis (clotting) occurs in the transplanted flap, urgent re-operation is required for flap salvage, or total flap loss will result. Before proceeding, the patient should ask the microsurgeon as to their volume of experience, and their overall rate of success.

DIEP Flap

The deep inferior epigastric perforator (DIEP) flap is based on the deep inferior epigastric vessels, an artery and vein at the bottom of the rectus abdominis muscle. These vessels provide the primary blood supply to the skin and fat of the lower abdomen. In the DIEP flap, the lower abdominal skin and fat is removed without having to harvest any of the rectus abdominis muscle. Instead, blood supply is provided through the perforator vessels that are teased out from the rectus muscle, using a muscle incision alone. The surgeon will apply judgment in the operating room to determine how many perforators are needed to provide sufficient blood supply for the DIEP flap to survive.

Once the DIEP flap is raised, a microscope is used to transplant the tissue to a recipient set of blood vessels on the chest wall. The tissue is used to create a breast shape without having to be tunneled under the skin (as in the pedicled TRAM flap).

In order to avoid using any muscle, it will take longer to harvest a DIEP flap than a TRAM flap. However, this results in the advantage of minimizing injury to the abdominal wall muscle, resulting in less pain, and a lower risk of hernia formation as compared with TRAM flaps.

 

Free TRAM Flap

The TRAM free flap is similar to the DIEP flap in that this type of flap is also based on the deep inferior epigastric vessels. In the TRAM free flap, the lower abdominal skin and fat is removed along with a small portion of the rectus muscle. The portion of muscle removed carries these blood vessels with the flap.

Using a microscope, the TRAM free flap can then be transplanted to a recipient set of blood vessels on the chest wall. As with the DIEP or SIEA flaps, the tissue is used to create a breast shape without having to be tunneled under the skin (as in the pedicled TRAM flap).

The advantages of this surgery as compared to a pedicled TRAM flap are two-fold. First, only a small amount of the rectus muscle is used, with less post-operative pain and less risk of abdominal bulge or hernia. Second, the blood flow to the skin and fat is much greater than that of the pedicled TRAM flap. This allows more abdominal tissue to be safely transferred, and patients who are not optimal candidates for the pedicled TRAM flap (diabetics, smokers) can usually be accommodated.

The disadvantage of the TRAM free flap is that the small amount of muscle used is still more than in the DIEP and SIEA flap approaches where no muscle is utilized. As such, compared to DIEP and SIEA flaps, the risk of abdominal wall weakness is slightly higher when the TRAM free flap is utilized.

Choosing the Abdominal Free Flap

In planning breast reconstruction with abdominal microvascular free flaps, the surgeon should explain the risks and limitations of these approaches. Ultimately, the final choice of free flap depends on the patient’s anatomy. In the course of surgery, the superficial vessels used for an SIEA flap are first encountered. If these vessels are adequate in size and could support the needed flap volume, an SIEA flap may be performed without incising or harvesting any muscle. Otherwise, the perforators from the deep system are exposed in order to elevate a DIEP flap. If these perforator vessels are sufficient, then the DIEP flap is completed. If the perforator vessels are found to be inadequate, the operation could then be converted to a free TRAM flap.

The length of surgery for abdominal microvascular free flaps can range from five to seven hours for one breast, and seven to twelve hours for both breasts. The hospital stay is typically three to five days, and the recovery can take several weeks before returning to a regular activity level. Secondary procedures after free flap breast reconstruction can be done after about three months; however, if chemotherapy is needed, any additional surgery must await completion of treatment. At that point, the patient can have revisions to the breasts and abdomen, and the nipple areola can be reconstructed. Such additional procedures are typically done as outpatient surgery with a rapid recovery.

You are an ideal candidate for abdominal microvascular free flap breast reconstruction if you:

• desire autogeneous reconstruction, and want to minimize muscle loss
• do not want or are not a candidate for implant reconstruction
• have enough lower abdominal wall tissue to create one or both breasts
• have compromised tissue at the mastectomy site
• have been previously radiated
• have had failed implant reconstruction
• are having immediate reconstruction at the time of skin-sparing mastectomy
• are having delayed reconstruction following prior mastectomy
• desire reconstruction to fix a lumpectomy or quadrantectomy defect

You are not an ideal candidate for abdominal microvascular free flap breast reconstruction if you:

• do not have enough lower abdominal tissue to create the flaps
• have had previous abdominal surgical procedures such as abdominoplasty (a C-section scar is usually okay)
• cannot tolerate anesthesia for long periods
• do not wish to have a lower abdominal scar

 

Advantages of reconstruction with free abdominal flap:

• Natural breast shape, consistency and behavior
• Improved abdominal shape
• No breast implant required
• Smaller chance of hernia compared to conventional TRAM flap

Disadvantages of reconstruction with free abdominal flap:

• Much longer surgery
• 5% possibility of flap necrosis (tissue dying)
• Possibility for reoperation during the first few days
• Requires a surgeon trained in microsurgery techniques
• Additional scarring on stomach
• Longer hospitalization and recovery

 

NIPPLE AREAOLAR RECONSTRUCTION

After you are happy with the shape and size of your reconstruction and time has passed for you to heal, you may consider having a nipple reconstructed. The nipple created by your surgeon will not be like your natural nipple. It will not react to temperature or touch by flattening and becoming larger, and will not have “feeling.” Depending on the type of breast reconstruction, reconstructed nipples may appear more or less “perky” than others. Because of this, many women are content to go without a nipple on their reconstructed breast.

If you choose to have nipple reconstruction, there are a variety of techniques. Most procedures involve using the skin of your breast reconstruction, such as the procedures shown below. Another option is to take a portion of natural nipple from your other breast (if it is large enough) and graft it to the reconstructed breast. These techniques often are done under local anesthesia or Intravenous Sedation and you can go home the same day

The areola (the colored portion around the nipple) is most often recreated with a tattoo. The illusion of a nipple can also be created by having a tattoo made with a central region that is darker than the rest. There are a variety of available flesh tone colors to create a natural-appearing areola. Areolar tattooing is usually painless and can be performed in an office setting. Most tattoos will fade as much as 40% over time and may need to be reapplied after a few years.

Another option is to use a graft of skin from another location of the body, usually your inner thigh or waist. Skin from these areas of the body has a natural tendency to heal darker when it is grafted. Areola grafts are performed in the operating room.

Summary of options

• Local skin flaps from the reconstructed breast
• Skin grafts from inner thigh or labia
• Nipple graft from other breast
• Tatoo

Example of Nipple Reconstruction with local flap (tissue from own breast): CV Flap

 

BALANCING PROCEDURES

Surgery on the Opposite Breast

It is important to consider the opposite breast when planning your reconstruction. While some women choose to leave the healthy breast untouched, many want to achieve symmetry with the newly reconstructed breast, with as little scaring as possible. Depending on the needs of the patient, symmetry may be achieved with a breast reduction, breast lift, or breast enlargement with an implant. The timing of these procedures will vary depending on what other treatments you may need.

Several months after you have healed from the mastectomy and reconstruction, you may have surgery on the opposite breast. If you need chemotherapy, surgery on the opposite breast can be done once your blood counts are normal. This usually takes about one month.

The approach to surgery on the opposite breast may vary depending on the type of reconstruction you have chosen. For patients with flap reconstruction, the opposite breast may be operated on during the second stage of surgery when the flap is revised and the nipple areola reconstructed. For patients with expander implant reconstruction, the opposite breast can be operated on when the expander is exchanged for the final implant, or it may require a separate third surgery. Because implants tend to be round in shape, having an implant placed into the opposite breast may offer better symmetry. The nipple areola will then be reconstructed at a later time, once the final implant and the opposite breast have settled and healed.

All of these are outpatient procedures, and generally do not require drains. The surgical time is relatively short, and although you will require several days to recover, you should be able to resume most normal activities within two weeks. It is important to discuss with your doctor what measures of follow-up care you will need. After altering the opposite breast, it is essential to continue screening for cancer.

 BREAST RECONSTRUCTION RESULTS

The final results of breast reconstruction following mastectomy can help lessen the physical and emotional impact of mastectomy.

Over time, some breast sensation may return, and scar lines will improve, although they’ll never disappear completely.

There are trade-offs, but most women feel these are small compared to the large improvement in their quality of life and the ability to look and feel whole.

Careful monitoring of breast health through self-exam, mammography and other diagnostic techniques is essential to your long-term health.

INTRODUCTION

Breast reduction, also known as reduction mammaplasty, is a cosmetic surgery procedure that reduces the size and weight of large, heavy breasts, helping to create a more aesthetically pleasing breast contour that is better proportioned to a patient’s body. Breast reduction surgery, is usually done to provide relief from these symptoms. By removing excess breast tissue, fat, and sagging, stretched skin, a plastic surgeon can not only make the breasts smaller, lighter, and firmer, but also improve breast symmetry and eliminate sagging.

ADVANTAGES OF BREAST REDUCTION

While many patients choose breast reduction to alleviate physical symptoms such as back, neck or shoulder pain, shoulder grooves, or discomfort while exercising, the cosmetic benefits of breast reduction should not be overlooked:

• Your breast will be lifted and firmer, helping you look more youthful
• Bras will fit more comfortably and attractively
• With better proportioned breasts, your overall silhouette will be more balanced and attractive
• Stretched areolas and/or large nipples can be reduced during the same procedure, helping you look better in and out of clothing
• Swimsuits, sports bras, and form-fitting clothes will look and feel better, helping boost your confidence during activity

FUNCTIONAL BENEFITS OF BREAST REDUCTION

• Women with large, heavy breasts may suffer physical pain from the weight of their breasts and may experience social discomfort due to unwanted attention to their breast size. Because of this, many women turn to breast reduction as a remedy.
• Large, heavy breasts can also cause strain on a woman’s body. The extra weight of heavy breasts can be harmful to posture and may lead to spinal problems. In addition to causing back, neck, and shoulder pain, excessively heavy breasts may also lead to breathing problems and other serious health issues. Breast reduction surgery can help a woman correct her posture and remove strain on the back, neck, and shoulders, reducing overall pain.
• In addition to seeking relief from the pain caused by heavy breasts, many women seek breast reduction surgery because they are uncomfortable with the unwanted attention that their breast size draws. This unwanted attention may cause a woman to become uncomfortable with her appearance. Breast reduction surgery can help a woman regain her self-confidence and positive self-image, as well as provide the motivation to participate in a wide range of physical and social activities.

BREAST REDUCTION CANDIDATES

Overly large breasts can cause health and emotional problems. In addition to self image issues, you may also experience physical pain and discomfort.

The weight of excess breast tissue can impair your ability to lead an active life. The emotional discomfort and self-consciousness often associated with having large pendulous breasts can be as important an issue as the physical discomfort and pain.

Breast reduction is a good option for you if you:

• Are physically healthy
• Have realistic expectations
• Don’t smoke
• Are bothered by feeling that your breasts are too large
• Have breasts that limit your physical activity
• Experience back, neck, and shoulder pain caused by the weight of your breasts
• Have shoulder indentations from bra straps
• Have skin irritation beneath the breast crease

INITIAL CONSULTATION

It is important to consider each aspect of the breast reduction procedure and your life after surgery before deciding upon the procedure. Prior to the procedure, we will meet with you to discuss your expectations from breast reduction surgery. At that time, they will inform you about the risks and possible complications of breast reduction surgery and the long-term effects of undergoing a breast reduction.

The success and safety of your breast reduction procedure highly depends on your complete candidness during your consultation. You’ll be asked a number of questions about your health, desires and lifestyle.

Be prepared to discuss:

• Why you want the surgery, your expectations and desired outcome
• Medical conditions, drug allergies and medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs
• Previous surgeries
• Family history of breast cancer and results of any mammograms or previous biopsies

Your surgeon may also:

• Evaluate your general health status and any pre-existing health conditions or risk factors
• Examine your breasts, and may take detailed measurements of their size and shape, skin quality, placement of your nipples and areolas
• Take photographs for your medical record
• Discuss your options and recommend a course of treatment
• Discuss likely outcomes of your breast reduction procedure and any risks or potential complications
• Discuss the use of anesthesia during your procedure for breast reduction

PREPARING FOR BREAST REDUCTION SURGERY

After researching the basics about breast reduction, many patients want to know what to expect before breast reduction surgery.

Prior to breast reduction surgery, you may be asked to:

• Get lab testing or a medical evaluation
• Take certain medications or adjust your current medications
• Get a baseline mammogram before surgery and another one after surgery to help detect any future changes in your breast tissue
• Stop smoking well in advance of breast reduction surgery
• Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding

Special instructions you receive will cover:

• What to do on the day of surgery
• Post-operative care and follow-up

Your plastic surgeon will also discuss where your procedure will be performed. Breast reduction surgery may be performed in an accredited office-based surgical center, outpatient/ambulatory surgical center, or a hospital.

LOCATION

Breast reduction procedures should be performed only in an  accredited ambulatory surgical facility or a hospital.

ANESTHESIA

Usually General Anesthesia is administrated

BREAST REDUCTION PROCEDURE

Plastic surgeons can use one of several different surgical techniques when performing breast reduction.  Which technique a surgeon will use for any given patient depends on the patient’s existing breast anatomy, the type and amount of tissue to be removed, and the patient’s desired outcome.

Breast reduction surgery generally takes a couple of hours, depending on the patient’s specific case, and is performed under general anesthesia most of the time.

Breast reduction surgery is usually performed through incisions on your breasts with surgical removal of the excess fat, glandular tissue and skin.

In some cases, excess fat may be removed through liposuction in conjunction with the excision techniques described below. If breast size is largely due to fatty tissue and excess skin is not a factor, liposuction alone may be used in the procedure for breast reduction.

The technique used to reduce the size of your breasts will be determined by your individual condition, breast composition, amount of reduction desired, your personal preferences and the surgeon’s advice.

Types of Incisions

Incision options include:

• A circular incision around the areola – donut technique or periareolar technique

• A keyhole or racquet-shaped pattern with an incision around the areola and vertically down to the breast crease (vertical technique

• An inverted T or anchor-shaped incision pattern – Wise pattern technique

Types (Techniques) of Reduction

A. Liposuction for Breast Reduction

In certain cases, breast reduction can be performed using liposuction alone. The advantages of liposuction for breast reduction are a shorter, less invasive procedure, virtually undetectable scars on the breast, and lasting results. However, this technique will only achieve optimal results in certain patients. The best candidates are those who need or desire a slight to moderate reduction in breast size, have good skin elasticity and little to no sagging to correct, and whose excess breast size is largely due to excess fatty tissue. If you have sagging, asymmetrical breasts, stretched skin, or a more significant amount of tissue to remove, one of the next breast reduction techniques will probably benefit you the most.

B. Short Scar Vertical Reduction or “Lollipop” Breast Reduction – SPAIR Technique

Patients who need a moderate reduction in breast size and have more noticeable sagging are often good candidates for a vertical breast reduction. This involves two incision sites: one is around the edge of the areola, and a second incision running vertically from the bottom of the areola to the inframammary fold, or the crease beneath the breast. After the breast tissue and skin is removed, we carefully sculpt the remaining breast tissue to make sure the shape of the breast is as ideal as possible. The nipple is moved up to the appropriate location as well. The short scar breast reduction is performed in most of our patients. The operation works especially well for younger patients. It is a much faster surgical technique, ideal not for gigantic breasts. The most important advantage is that there is now scar under the breast fold and the healing period is shorter. However, the breast shape initially may look “funny” compared to the classic Wise pattern or inferior pedicle technique. Over time one of the great advantages of the technique is that there is no “bottoming out” of the breast. While a vertical breast reduction leaves some scarring on the breast, it is limited to the area below the nipple and therefore can be easily hidden beneath a bra or bikini top.

Diagram of Vertical Reduction

C. Inverted-T or “Anchor” Breast Reduction – Wise pattern technique with inferior or superiomedial pedicle technique

The inverted-T breast reduction involves 3 incisions: one around the edge of the areola, one vertically from the areola to the breast crease, and one made along the crease underneath the breast. This technique allows for maximum amount of tissue removal and reshaping and most plastic surgeons typically use this technique for patients with very large ptotic breasts who need significant breast size reduction. The scars resulting from an inverted-T or anchor breast reduction are similar to those from a vertical reduction, with one additional, thin scar running along the crease beneath the breast. With proper care, scars typically fade considerably over the first year or so after surgery and are easily concealed by clothing, even a bikini top. This technique takes more time to perform than the vertical technique, described above. One of the advantages of is that the breast immediately after the surgery has a nice shape, however sometimes it takes more time to heal, especially where the incisions meet. Also the new breasts are more prone to “bottoming out” over time.  

Diagram of Wise Pattern Reduction

D. Free Nipple Grafting Technique

In most breast reduction techniques, skin, fat, and tissue from the breast area are removed to reduce the mass of the breast and the nipples are moved to a higher position on the breast, but remain attached to the nerves and blood vessels. For extremely large breasts, however, the nipples may need to be moved and grafted (like regular skin grafts) to a completely new location. In these situations, you will lose sensation in the nipple and areola. After the nipple is moved to its new position, the skin above the nipple is brought down and around the swell of the breast, and then stitched back to close the original incision.

Diagram of Free Nipple Graft Reduction

 RECOVERY

 After spending a brief time in supervised recovery, you will be able to go home that same day to continue your recovery. Your chest will be bandaged, and you will be sent home in a surgical or athletic bra, that you should wear for four weeks. We never send patients with drains at home. Initially after breast reduction surgery, your breasts will be sore, swollen, and bruised. The plastic surgeon will prescribe pain medications to help keep you comfortable during this initial period. Gently placing ice packs on top of the bandages can help alleviate discomfort and swelling as well.

The amount of time you need to recover from breast reduction will depend on your natural healing rate as well as the extent of surgery performed. You will be able to get up and you should walk around the same day of surgery, although you should have a trusted adult with you during the first 24 hours. You will be able to shower two days after surgery. You may need help getting dressed for a few days, as you will not have full range of motion in your chest and shoulders at first. You should be able to do all regular day to day activities within a week. You should also avoid heavy lifting and refrain from exercise and other strenuous activities for at least four weeks following the procedure.

Most patients feel ready to drive and return to a desk job within 1 week, after they are no longer taking prescription pain medication.  Most stitches are absorbable and the rest will be removed in two to three weeks after the breast reduction procedure. To ensure that the breasts are healing properly, breast reduction patients should attend follow-up appointments for several months after surgery.

RESULTS

The results of your breast reduction surgery can be immediately appreciated. With time the swelling will resolve and the incision lines will fade. Satisfaction with your new image should continue to grow as you recover.

LIFE AFTER BREAST REDUCTION

Breast reduction is one of the most rewarding plastic surgery procedures because it helps both to minimize the physical and emotional discomfort that large breasts create and at the same time it enhances the patient’s appearance. Patients usually experience an increase in self-confidence. At the same time they feel the freedom to wear the clothes they want to wear and engage in physical activities and exercises they had previously avoided.

While many patients experience an immediate relief from back and shoulder pain after breast reduction, it is important to understand that it will take some time for your final results to settle in. Swelling, soreness, and some time itching is typical after breast reduction. Sometimes the breast may have a “funny shape” for a few weeks before assuming the final shape you r surgeon and you would like. The new smaller breasts may appear a little larger than you had expected while initial swelling is present. Additionally, the breasts often heal at a different rate, so you may notice some asymmetry during the first few months of your recovery.

Your scars will be very noticeable for the first few months, often appearing red and lumpy. The scars will continue to fade into thin white lines over the next several months, but will never go away completely. Several treatment options are available to reduce the appearance of scars, including cortisone creams and silicone sheeting. Because of the benefits of breast reduction surgery, many women feel that scars are a fair trade-off. However, in some cases, abnormal scars can form, causing undesirable results.

After about 3 months, your final results will be more present, but you may notice subtle continuous changes for the first 6 to 12 months.

RISKS AND COMPLICATIONS

Part of the consultation with the plastic surgeon before the surgery is to  explain in detail the risks associated with surgery. You will be asked to sign consent forms to ensure that you fully understand the procedure you will undergo and any risks or potential complications.

• Hypertrophic or atrophic scars or keloids
• Infection
• Hypoesthesia (less feeling) or Hyperesthesia (more feeling)of nipple or breast sensation, which may be temporary or permanent
• Anesthesia risks
• Bleeding (hematoma)
• Blood clots
• Poor wound healing
• Breast contour and shape irregularities
• Breast asymmetry
• Fluid accumulation
• Excessive firmness of the breast
• Potential inability to breastfeed
• Potential loss of skin/tissue of breast where incisions meet each other
• Potential, partial or total loss of nipple and areola
• Deep vein thrombosis
• Pain, which may persist
• Allergies to tape, suture materials and glues, blood products, topical preparations or injectable agents
• Fatty tissue deep in the skin could die (fat necrosis)
• Possibility of revisional surgery

CASE EXAMPLE

42 year old female, after two children births, underwent a vertical type of breast reduction and lift, 350gms of breast tissue were removed from each breast. Left, before the surgery. Right, 6 months after the surgery

INTRODUCTION

Congenital abnormalities of the breast and chest wall are seen frequently in breast, pediatric and plastic surgery clinics. Management involves a multidisciplinary team approach. The treatment for many of these conditions includes surgical correction. If the child is still growing, treatment timing is crucial and many of the surgical corrective procedures require more than one operation over a number of years. These deformities have serious psychological consequences in adolescent patients. They can experience embarrassment, social isolation and complexities during sexual development, and this results in problems with relationships.

CONGENITAL ABNORMALITIES OF THE NIPPLE

 A. Accessory Nipples (Also Known as Polythelia).

Accessory nipples are seen in 1–5% of the general population and they develop along the milk line; more than 90% are seen in the inframammary region. These accessory nipples can be unilateral or bilateral and are quite well developed with surrounding areola. They are prone to the same diseases as normal nipples.

Accessory Nipple

There is some evidence that polythelia may be familial and related to urological abnormalities. Urological workup has been recommended to rule out associated abnormalities.

Most require no treatment unless the nipple causes irritation or is excised for cosmetic reasons. The excision is done under local anesthesia as an outpatient. There is minimal or no pain after the procedure and the patient usually returns the next day to his/hers normal activities.

B. Congenital Nipple Inversion.

It is seen in 2% of the general population, with a family history of such a condition in 50% of patients. The cause for this abnormality is thought to be tethering and shortening of breast ducts, and development of fibrous bands behind the nipples during the pregnancy.

It can cause mechanical problems with breast feeding; however, many can breast feed without any difficulty, probably because of changes that occur in the breast during pregnancy.

There are a variety of procedures described for the surgical correction (e.g., tightening of the areolar edge circumferentially and use of adjacent dermal flaps to augment nipple); however, loss of sensation and inability to breast feed are major concerns with surgical procedures.

Most of the procedures involve short circumareolar incision or an incision at the base of the nipple. The tight bands are stretched, but it is often required to divide the ducts. A stitch can be placed at the base of nipple when it is everted, but this is not recommended. Recovery is fast, pain is minimal but the nipples can be sensitive and the possibility for breast feeding can be altered. The procedure can be done with local anesthesia as an outpatient.

Congenital Inverted Nipples. (A & B) Pre- and (C & D) postoperative pictures.

C. Athetia

Complete absence of nipple and areola is termed as athelia. This condition can be familial and may be unilateral or bilateral, and is seen in association with amastia or rare syndromes such as scalp-ear-nipple or SEN syndrome (scalp nodules and ear malformation) and Poland’s syndrome.

A thorough investigation to rule out any other associated abnormalities is required. Nipple and areola reconstruction can be carried out using small tissue flaps along with tattooing of a new areola in the absence of any other deformity. Skin grafts could also be used to create areola.

The procedures are done with local anesthesia or intravenous sedation and do not requires hospital stay. The creation of new nipples is a relatively painless procedure.

CONGENITAL ABNORMALITIES OF THE BREAST

A. Accessory Breast Tissue or Supernumerary Breasts: Polymastia.

Accessory breast tissue or supernumerary breasts are seen in approximately 1–2% of the general population, but figures as high as 6% have been reported. There is a female preponderance with some reported as hereditary cases.

In approximately a third of patients, accessory breasts are found in more than one site; the most common site is the axilla. Axillary accessory breast tissue can have its own nipple–areola complex.

Bilateral Accessory Axillary Breasts.

Polymastia is usually diagnosed at puberty or during pregnancy when the accessory breast tissue develops along with the normal breasts. These are mostly asymptomatic, but can cause discomfort, and in some are seen as cosmetically unacceptable. Accessory breast tissue is susceptible to all the normal changes and disease spectrum seen in the normal breast. Breast cancer cases have been reported in accessory breast tissue.

Any surgery needs an experienced surgeon and careful preoperative marking. Scar placement for any surgery is vital; it should not extend beyond the edge of the chest muscles.

Liposuction is useful for the fatty element of accessory breasts, and in some cases it is the only treatment required. Liposuction is also valuable in helping to define the planes between accessory breast tissue and the underlying axilla.

A combination of surgery for the glandular element and liposuction of the fatty element has been described. Excess overlying skin should be excised in cases of large accessory breasts.

B. Asymmetry (Aplasia & Hypoplasia) of the Breast.

One breast can be hypoplastic or absent (aplasia) and this can occur in isolation or in association with a defect in (one or both) pectoral muscles.

Breast Hypoplasia. (A) Pre- and(B & C) postsurgery with (B)expansion followed by (C) implant insertion.

This ‘true asymmetry’ can be treated with various treatment options, including augmentation of the smaller breast with implant, reduction and breast lift (mastopexy) of the larger breast, or a combination of both these options. Where there is asymmetry in the skin, the use of expanders prior to permanent implant replacement can improve symmetry. To get true symmetry, there is usually a need to operate on both breasts. The best age to perform surgery is when the breasts have fully developed – usually approximately at age 17 or 18 years. More than one operation may be required.

C. Amastia

The total absence of breast tissue and nipple–areola complex is called amastia whereas absence of breast tissue only is called amastia.

Bilateral Absence of Breasts: Amastia

 

In amastia, the mammary ridge disappears completely or fails to develop. There is often evidence of associated defects such as cleft palate, isolated pectoral muscle and upper limb deformities, urological abnormalities, and even Poland’s syndrome. Familial cases have been reported. New breasts can be reconstructed using expanders and implants or using myocutaneous flaps such as the latissimus dorsi myocutaneous flap.

D. Tubular Breasts.

Tubular breasts are characterized by normal function/physiology of the breast tissue, but abnormal anatomical shape. It can be unilateral or bilateral, and the classical features include some or all of: lack of breast skin; breast hypoplasia and asymmetry; conical breasts; herniated nipple–areolar complex; large areola and a constricted breast base.

Tubular Breasts. (A & B) Pre- and(C & D) postsurgery.

Standard treatment includes placement of expanders through an inframammary fold incision following radial scoring and later replacement with implants. These procedures do not correct the ‘herniated nipple and areola complex’, and a second procedure is often required to correct this deformity, such as reducing the size by circular periareolar round block mastopexy (this could also be performed at the time of primary surgery in select cases).

The dual plane technique for tubular breast is now very popular. This technique differs from the subglandular position, in that the implant is placed in the subpectoral plane. The upper two thirds of the implant is covered by muscle and the lower third is covered by breast tissue. A short scar correction of the tuberous breast has also been described.^[11]

Lipofilling in the periphery of the breast (not recommended within the breast) helps to achieve a final better contour and adds volume along with the expander.

The long-term outcome from surgery is not always satisfactory with loss of sensation, scar issues and asymmetry being common complications.

 

E. Poland’s Syndrome.

Unilateral chest wall hypoplasia with ipsilateral upper limb deformity is called Poland’s syndrome. A patient with some of these features was first described by Alfred Poland from Guys Hospital London in 1841.

Poland’s Syndrome in a Man.

Poland’s syndrome in a Woman. Missing Left Pectoralis Major and Hypoplasia of the Breast. (A) Pre- and (B) postsurgery.

Poland’s syndrome consists of some or all of: absence or hypoplasia of the breast; absence of pectoralis major or minor; absence of nipple; absence of adjacent muscles and sometimes costal cartilage; rib abnormalities; and upper limb deformities (e.g., syndactyly, micromelia or brachydactyly). Familial cases have been reported.

Poland’s syndrome is three-times more common in males. Pectus excavatum and Poland’s syndrome, that include defects of the chest wall are the commonest forms of congenital chest wall defects. These defects can be corrected surgically.

Repair should be considered as a single-stage procedure in adults and two stages in children. Aplastic ribs can be reconstructed using bone grafts or prosthetic mesh. Muscle flaps and breast implants can be used to correct muscle and breast hypoplasia.

The aim of the treatment should be to achieve symmetry. Surgical procedures usually involve a combination of replaceable expanders (subsequently replaced by permanent implants), Becker expander/prostheses implants (shaped or round), placement of these devices in a dual plane (if the pectoral muscle is normal), and autologous muscle flaps such as latissimus dorsi flaps. The latissimus dorsi flap harvest can be performed endoscopically.

Another option is to use rectus abdominus transverse rectus abdominis myocutaneous flap (free or pedicled). A two-flap technique including free and pedicled transverse rectus abdominis myocutaneous flaps for chest and breast reconstruction has been described.

The best time for operation is in the late teens, but operations can be performed from 11–12 years onwards to help with self esteem and normal psychological, social and sexual growth.

The management of these patients requires a multidisciplinary team approach, including pediatrician, endocrinologist and plastic surgeon, to decide the optimum age for reconstruction. The future growth of the child should be considered in treatment planning.

INTRODUCTION

Gynecomastia literally means woman-like breasts. This condition affects 40% to 60% of men in one or both breasts. Although certain medications and medical conditions can contribute to the overdevelopment of the breast area in men, there is no official known cause. It can affect one or both breasts.

CAUSES OF GYNECOMASTIA

• Idiopathic (no particular cause)
• Marijuana use
• Alcoholism
• Obesity
• Steroids
• Certain kinds of medications (Zantac)
• Liver disease
• Testicular tumors
• Pituitary tumors (adenomas)

WHY SOMEBODY SHOULD GET TREATMENT

Men who have enlarged breasts are often self-conscious about their appearance and often struggle emotionally. Enlarged breasts in a male can produce a tremendous social stigma. Men with larger breasts may feel very self-conscious about their masculinity and become afraid to participate in sports or any outdoor activity that may require them to remove their shirt.

CANDIDSATES FOR TREATMENT

• Surgery to correct gynecomastia should performed on healthy, emotionally stable men of any age.
• The best candidates for surgery have firm, elastic skin that will reshape to the body’s new contours.
• Men with realistic expectations. Having realistic expectations about how your body will change and how those changes will affect your life is important. The surgery will by no means fix your life problems, save your marriage, personal relationships or cure depression.

CONTRAINDICATIONS TO SURGERY

Surgery may be discouraged or postponed:

• for obese men, or for overweight men who have not first attempted to correct the problem with exercise or weight loss
• for alcoholics
• for marijuana users, who do not stop using it
• for patients who use anabolic steroids
• for patients with testicular or pituitary tumors and other tumors producing steroids.
• For patients with unrealistic expectations

CONSULTATION

The initial consultation with your surgeon is very important. Your surgeon will need a complete medical history, so check your own records ahead of time and be ready to provide this information. During your initial consultation, you will have the opportunity to discuss what you want to achieve. It is important to be completely honest during the consultation. You will be asked about:

• Previous surgeries in general and specifically about breast surgeries, including breast biopsies.
• Past personal medical history.
• Past family medical history in general.
• Allergies and current medications.
• Medical treatments you have received.
• Family history of breast cancer.
• Current and previous mammogram results.

Your surgeon will examine your breasts and check for causes of the gynecomastia, such as impaired liver function, use of estrogen-containing medications, or anabolic steroids. If a medical problem is the suspected cause, you’ll be referred to an appropriate specialist.

The plastic surgeon will examine you, measure and photograph your breasts for your medical record. Your surgeon will consider:

• The current size and shape of your breasts.
• The quality and quantity of your breast tissue.
• The quality of your skin.
• The placement of your nipples and areolas.

QUESTIONS TO ASK

Don’t hesitate to ask your surgeon any questions you may have during the initial consultation

Male breast reduction surgery should be specifically tailored to your needs and desired goals. There are many different reduction techniques that offer certain benefits with varying types of scars.

You will be able to see the outcome of some of their surgeries by looking at before-and-after pictures. Have the surgeon explain the benefits of the procedure they recommend and why they feel this is the best option for you.

If general anesthesia will be used, make sure to speak to the anesthesiologist before you schedule a surgery, and inform them of any allergies or reactions you have to any medications. Make sure to tell both your surgeon and the anesthesiologist if you have any pre-existing medical conditions.

• Make sure you understand where the surgeon will make incisions and how the scars will look.
• Where will the surgery be performed ?
• Will your surgery consists of tissue removal only or will excess skin need to be removed as well?
• Will there be additional scarring ?
• Will tissue removal include surgical excision or liposuction ?
• Will the procedure be performed under general or local anesthesia?
• Is there a risk of significant blood loss?
• What is the risk of infection at the incision site?
• Is there any risk of losing sensation?
• If the amount of tissue removed is not sufficient, what are your options for a second procedure?

PREPARATION FOR THE SURGERY

Your surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating, drinking, and taking certain vitamins and medications.

The Plastic Surgeon may require for you to have an ultrasound of the breast to determine how much excess fat and glandular tissue is contained in the breast area and to rule out the small possibility of breast cancer.

Usually It is also required to be examined by an endocrinologist and do some basic hormonal blood tests to make sure that the gynecomastia is not the result of an imbalance and dysfunction of the endocrine system (for example pituitary adenoma).

SURGICAL PROCEDURES – OPTIONS

1. Liposuction

Today, cosmetic surgeons are able to treat a growing number of gynecomastia patients using liposuction. This is due in part to advances in liposuction technology, which have resulted in a wider selection of less invasive techniques.

Liposuction alone is usually the preferred method if the Gynecomastia is mild (Grade I), the breast tissue is soft and there is not much skin excess and if the patient does not want any scars at all. The patient however needs to understand that even if he chooses liposuction alone for the treatment, there may be a chance for a secondary procedure to remove excess skin in the future.

The procedure for treating gynecomastia with liposuction is typically performed using local anesthesia with sedation or general anesthesia, and involves a small incision on each side of the chest. Depending on your needs and the Plastic Surgeons’s preferred technique, incisions may be located along the edge of the areola or within the armpit or at the breast fold. Through these incisions, your Plastic Surgeon surgeon will initially inject a special fluid (Ringers lactated solution, lidocaine and epinephrine) called “Tumescent”, in order to minimize bleeding and to help remove easier with the liposuction machine the excess fat and/or glandular tissue, perfoming this way the sculpting of the chest. To facilitate the better suction of the breast tissue often Liposuction Devices that prepare the area with Ultrasound waves are used in order to achieve a better result.

Recovery from Liposuction

The recovery process following liposuction is typically quite tolerable. Patients are often given a compression garment to wear for the first few weeks after surgery; this helps to minimize swelling and offers support to the healing tissues. While vigorous exercise is typically off-limits for about 3 weeks, many men return to work or school within several days after their procedures. However, it is important to understand that everyone heals at a unique pace; your cosmetic surgeon will give you individualized instructions for recovery.

1. Male Breast Reduction with Tissue Excision – Subcutaneous Mastectomy

More severe cases of gynecomastia (with excess skin and breast tissue) may require surgical tissue excision to achieve optimal results. Additionally, patients who have stretched, sagging skin around the breasts will usually require this approach. Tissue excisions allows the Plastic Surgeon surgeon to remove a greater amount of glandular tissue and/or skin that cannot be successfully treated with liposuction alone.

The location and length of the incisions depends on the extent of surgery needed, but are typically located around the edge of the areola (peri-areolar incision) or within the natural creases of the chest. A trained, qualified cosmetic surgeon will take care to place incisions so that the resulting scars are as inconspicuous as possible.

Very often Liposuction is used in combination with Breast Tissue Excision In order to achieve better sculpting of the chest, especially at the edges of the breast.

Recovery from Breast Reduction with Tissue Excision – Subcutaneous Mastectomy

Male breast reduction with tissue excision is typically performed as an outpatient procedure using general anesthesia or local anesthesia with sedation. The recovery process is similar to that for liposuction; however, it is common for patients to experience soreness and some swelling. Typically, patients feel ready to return to work within 1 week of surgery, and a gradual return to exercise is usually permitted after the first couple of weeks.

RECOVERY

You may experience mild and moderate discomfort from the surgery which can be alleviated with medication. You will feel tired and sore for the first 48 to 72 hours. Any swelling or bruising will subside over the next few weeks. However, it may be three or four months before you see the full results of the procedure. You should avoid sun exposure to the treatment area for at least six months after the procedure as this can darken scars.

You will be given a compression garment that will help your chest to heal well. You may need to wear this for up to four weeks.

You will need to avoid reaching or lifting of any kind for at least 5 days. If you work and your job is not strenuous (no reaching or heavy lifting), you should be able to return to work after one week. If your job requires physical activity, you should wait two weeks before resuming a full work load.

Full physical recovery may take up to six weeks. Your scars may take up to seven months to completely heal; during this healing process you should avoid direct exposure to the sun as this may cause permanent irregular pigmentation of your scars.

RISKS

Any surgical procedure carries certain risks and the possibility of complications. Possible risks include:

1. Infection
2. Adverse reaction to the anesthesia.
3. Disappointing result because of over-correction.
4. Bleeding
5. Infection
6. Nerve damage
7. Poor scarring
8. Poor healing
9. Need for additional surgery
10. Changes in the nipple – numbness, loss of tissue or discoloration.

RESULTS

Male breast reduction surgery tends to be permanent; however, such factors as weight gain, alcohol consumption, drug and steroid use can contribute to the chest area regaining excess fat. Taking good care of yourself and staying healthy will help preserve your results.

INTRODUCTION

Tuberous breasts are a common developmental condition that has a widely variable impact on breast shape. With numerous labels including tuberous breast deformity, tubular breasts, constricted breasts, and herniated areolas, the physical manifestations of varying severity and asymmetry can have a profound effect on breast aesthetics, balance, and self-perception.

CAUSES

The tuberous breast deformity is a congenital breast anomaly that becomes manifest at the time of puberty and breast development. The exact etiology is unclear. It is theorized that the deformity has an embryologic origin, and while there may be a genetic predisposition, no clear link has been determined with tuberous breasts. Its physical manifestations are attributed to a combination of connective tissue ring-constriction around the areola, and thin or hypoplastic areolar fascial (connective tissue) support.

TYPES OF TUBEROUS BREAST DEFORMITY

• Type I Tuberous Breast Deformity – generally a milder form with lower-inner quadrant breast constriction and some breast droop
• Type II Tuberous Breast Deformity – varying presentation with more lower pole constriction, breast hypoplasia, and areolar herniation
• Type III Tuberous Breast Deformity – the most severe form

 

IS THE TREATMENT THE SAME AS IN A BREAST AUGMENTATION?

Tuberous breast deformity correction is a very specialized procedure that often incorporates breast augmentation when necessary, but requires a variety of various technical maneuvers to achieve the most consistent aesthetic outcomes. The most common problem is that tuberous breast deformity in its milder forms is commonly underdiagnosed. When unrecognized, treating the less obvious variants of the tuberous deformity with more common breast augmentation techniques will often fail to appropriately address the deficiencies and restrictions of the breast lower pole, and may worsen areolar herniation, resulting in a less pleasing breast shape. Moderate and severe forms of tuberous breast deformity require a delicate balance of breast reshaping, areolar balancing, and breast augmentation as indicated by the tubular breast deformity type and individual desires.

WHAT TO CONSIDER WHEN PLANNING THE SURGERY

1. Breast base constriction – mild, moderate or severe
2. Inframammary Fold Position – normal laterally, minor elevation medially, medial and lateral elevation, elevation of entire fold, or fold absence
3. Skin Envelope – sufficient, inferior insufficiency, or global insufficiency
4. Breast Volume – minimal deficiency (or hypertrophy), moderate deficiency, or severe deficiency
5. Ptosis – none, mild, moderate, or severe
6. Areolar herniation – areolar enlargement, herniation, or severe herniation
7. The incision location through which the shaping maneuvers are performed (and the breast implant is introduced)
8. The type of breast implant, silicone or saline
9. The incision type for correction and control of areolar herniation, asymmetry, deformity or ptosis (breast droop)
10. The pocket placement of the implant relative to the chest muscle
11. The number of stages required to achieve the best tuberous breast results

 

PREPARING FOR THE SURGERY

During the preoperative visit in the office approximately two weeks before tuberous breast surgery, prescriptions are given for medications to be taken before and after surgery are given, and the pre and postoperative instructions are reviewed. Sizing exercises are performed at this time. Anything that has a blood-thinning effect (aspirin, ibuprofen, etc.) is to be avoided for two weeks before surgery. Routine lab testing is ordered, and any breast imaging studies that are required (age and past medical history appropriate) are obtained.

THE SURGERY

The procedure is performed under general anesthesia in in an accredited hospital OR suite. The procedure duration is approximately 2 hours.

Common to most tuberous breast procedures is the release of lower pole breast constriction with a maneuver called “radial scoring”. This allows for the shaping of a more rounded lower pole of the breast from the inside.

The “pocket location” for the breast implants with tuberous breast correction can be below the muscle (submuscular augmentation), or above the muscle (subglandular augmentation). Because submuscular breast augmentation provides increased coverage of the implant, softens the upper pole of the breast, maintains long term stability of the pocket, decreases rates of capsular contracture, and lessens influence on mammography. A submuscular pocket plane is used exclusively for all tuberous breast corrections. In treating tuberous breasts, “dual-plane” augmentation is the type of submuscular augmentation that is most appropriate with the glandular shaping maneuvers used. This dual-plane approach promotes coverage of the upper pole of the implant by muscle, and direct expansion of the deficient lower breast gland.

One-stage tuberous breast correction with silicone breast implants can be selected in the majority of cases. In select cases of severe constriction and deficiency, a “two stage” approach may be required to adequately expand the skin and breast tissues. A tissue expander (which is a temporary adjustable saline implant) may be recommended at a first stage, which can be sequentially filled over the course of weeks or months following the initial surgery to achieve the best breast size, shape and proportion. It is then replaced with a permanent breast implant of desired size, texture and type.

Recovery

You will recover in a recovery room in the hospital and you will be discharged home with a friend or family member when you are fully awake and comfortable, generally 1–2 hours after the completion of surgery.

The Plastic Surgeon recommends returning to work or school after seven days, although with less physically demanding occupations, some may resume work as early as 4–5 days postop. During the first week you will wear a post-surgical bra provided by the office. Drain tubes are used which remain in place for approximately 4–5 days. Breasts may appear firm and swollen for approximately 10–14 days, with shape and size apparent around 12 weeks.

Exercise

Light exercise (cardio without impact) may be resumed at five to seven days, and more vigorous physical activity may commence three weeks after surgery. Strength training that excludes pectoralis muscle contraction (including lower body, core, and biceps/triceps toning with arms held below 45 degrees) may resume after seven days. Modified pectoralis exercises may be resumed at 4–6 weeks, and completely unrestricted training begins at 12 weeks.

Aftercare

Routine follow-up visits are at one week, six weeks, and 12 months. You will be provided with information regarding breast health, breast self-examination, exercises, and the timing for any breast imaging as required.