Phẫu Thuật Thẩm Mỹ Vòng 1: Các Khái Niệm Và Kỹ Thuật (Aesthetic Breast Surgery)

I began practice in 1983. At that time my ocus was on general reconstructive
surgery, and my patient consultations were conducted individually. Over time,
the ocus o my practice has shi ted to aesthetic surgery, and more recently to
aesthetic breast surgery, breast reduction, and abdominoplasty. My approach
to patient consultation and education has also evolved. I now provide patients
with a number o educational tools and conduct group seminars as well as in-
dividual one-on-one consultations. The process has become more ref ned, e -
f cient, and help ul to my patients. It consists o the ollowing components:
• Preconsultation assessment
• Patient education DVDs and handouts
• Group seminars
• Nurse assessment
• Patient photographs
• Individual consultation
• Patient coordinator meeting
• In ormational binder
• Preoperative preparation
• Preoperative phone call rom the nursing sta
TH E CONSU LTATION
Preconsultation Assessments
I use preconsultation assessments and group seminars be ore seeing patients in-
dividually. The patient is required to send in registration and medical history
orms. I practice in a town o 8000 people, which is a 11⁄2-hour drive rom the
nearest city, Calgary, with 1 million residents. Because I operate at both the
small hospital in my town and at my own surgical acility, I need to make certain
that my patients are all good candidates or what is essentially a primary care–
level acility, but ully accredited.
The nurses in my o f ce review all the medical history orms and prescreen pa-
tients or any signif cant medical conditions that might make them better can-
didates or a tertiary care acility. Some o these charts are reviewed by one o
the anesthesiologists be ore the patient comes in or a consultation so that a more
appropriate re erral can be made as necessary. Patients who are obese or who
have a potential or signif cant complications, such as massive weight loss, are
not considered good candidates. Smokers are not accepted or consultation, ex-
cept when the individual wants a breast augmentation alone without a mastopexy.
Young patients are accepted or breast reduction or asymmetry correction and,
i they want to proceed, a f nal decision will be made, depending on whether
the patient (and usually the mother) comprehends what is involved. Patients
or breast augmentation are seen in consultation at any age, because some o
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Part I • Concepts and Principles

them are in fact tuberous breast or asymmetry cases. It is unusual for me to per-
form a simple breast augmentation on a patient who is still a teenager. I often try
to discourage patients in their early twenties who are seeking augmentation un-
less I am convinced of their level of maturity.
Older patients are accepted for consultation if they are in good health. One of
my oldest breast reduction patients was in her eighties, and one of my oldest
breast augmentation patients was in her seventies. Both patients were extremely
pleased with their decision to have surgery.
Patients are charged for cosmetic surgery consultations, but we do not charge
young patients for consultation on breast asymmetry problems. Patients with
medical symptoms indicating the need for a breast reduction are also not charged
for consultation, but I have been shifting my focus to a purely aesthetic practice,
where the breast reductions performed are considered cosmetic rather than re-
constructive procedures. I have learned over the years that individuals who in-
sist that their surgery be covered for medical reasons are often the ones who
complain the most about their cosmetic result. We no longer apply the consul-
tation fee to the procedure fee if the patient chooses to proceed with surgery.
Patient Information DVDs and H andouts
After we receive and review the registration and medical history forms, patients
are sent a DVD on which I explain what is involved in each procedure. I ini-
tially taped a group seminar for breast reduction and found it so useful that
I made DVDs of all the procedures I perform. Over the years I have found that
these DVDs are among the most effective patient education tools I provide.
Before I limited my practice to the breast and abdomen, I had DVDs for all
cosmetic procedures; these were particularly useful for explaining the differ-
ences among various facial procedures, such as blepharoplasty and brow lifts.
In each DVD I discuss who would be a good candidate; what is involved in the
surgery, preparation, and recovery; and the limitations and potential complica-
tions associated with the procedure. After the DVD is sent, a staff member calls
to see whether the candidate has watched it before the consultation is scheduled.
Initially it was not easy to create the videos for these DVDs, but they certainly
have paid off in time saved. They allow me to focus on each patient’s individual
issues rather than engage in time-consuming repetition of basic information.
DVDs can be very effective patient education tools. Though they
may be time-consuming to create, they can save the surgeon valu-
able time preoperatively by presenting basic information.
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Chapter 4 • Patient Selection, Education, and Surgical Decision Making

Group Seminars
I have patients attend a group seminar at which they view a PowerPoint pre-
sentation that lasts about 1 hour. Although they have seen the DVDs, I f nd
that patients appreciate the rein orcement o the in ormation provided in the
group seminar. These seminars are attended by about eight patients, and they are
held in my o f ce reception area. I have three presentations: breast reduction,
breast augmentation and mastopexy, and abdominoplasty. Mastopexy patients
are usually brought in separately or are included in the augmentation seminar.
I tried having the nurses present the in ormation, but ound that I can estab-
lish a better relationship with the patient i I conduct the presentation mysel .
The patients appreciate it when I present the PowerPoint talk mysel , and they
can get a better idea o how I run my practice. They also eel that I have spent
more time with them than just a 10- or 15-minute individual appointment.
I doubt that many surgeons entering practice could start out giving group sem-
inars unless they are in a purely reconstructive practice. The group seminar idea
would work well or breast cancer patients, or example, where much o the
same in ormation needs to be repeated.
Some patients do not like the idea o a group seminar, and others want to talk
about multiple procedures. These individuals are accommodated with individ-
ual appointments.
Immediately be ore the group session, we provide patients with an in orma-
tional booklet that covers the same issues included in the PowerPoint presen-
tation that is shown during the group session. These booklets contain preop-
erative and postoperative photos, with appropriate interpretations, as well as
examples o di erent breast shapes, sizes, and scars and such complications as
nipple necrosis. Because these booklets can also be downloaded rom the web-
site, many patients now arrive in the o f ce already airly well in ormed.
We limit the group seminar to women so they are not intimidated and eel more
com ortable asking questions. Men (partners or relatives) are encouraged to
watch the DVD and read the booklet; they are then allowed to participate in the
individual consultations, which are held immediately a ter the group seminars.
Because my patients travel a distance to see me—sometimes 1 to 3 hours—they
are advised be ore the consultation/ group appointment that the whole process
will be time intensive and that they should be prepared to spend at least hal a
day in my o f ce.
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Part I • Concepts and Principles

Group Seminars Versus Individual Consultations
I initially introduced group seminars or breast reduction patients with some
trepidation. I was worried that my patients would not like this approach, and
o ten they expressed concern be ore they arrived. Once the seminar was over,
I gave all participants a questionnaire about the process to f ll out be ore they
le t, a ter seeing the patient coordinator. The response was almost universally
positive, with patients saying that they elt these seminars were use ul. The re-
sponses to these questionnaires also convinced me to exclude men rom atten-
dance at the seminar.
Because o these initial experiences with breast reduction patients, I expanded
the group seminar process to include breast augmentation and abdominoplasty
patients. I still see the asymmetry and gynecomastia patients on an individual
basis. Anyone who objects to the group seminar process can be seen individu-
ally, but it might take longer to be scheduled or an appointment. I stopped
per orming acial cosmetic surgery in 2007, but those patients went through
the same process with the prescreening and a DVD. It certainly made it much
easier to explain brow li ts versus blepharoplasties versus neck li ts versus ace
li ts i they had seen the DVD f rst. I could spend my time concentrating on the
patient’s particular problem rather than repeating the same in ormation over
and over.
Nurse Assessments
Following the group seminar, some patients are sent out or co ee while others
remain in the o f ce. The nurse then weighs each patient and reviews her his-
tory. While patients are waiting, they are given a orm to f ll out that inquires
about their goals, concerns, and problems. Breast reduction patients complete
a symptom questionnaire and a separate orm that asks what is more important
to them—size or sagging. They are also asked to check o the breast shapes
they like best. This is most help ul or a patient who likes her current breast size
but is not sure about increasing upper pole ullness with an implant.
Photographs
Next, one o my sta members takes a series o rontal and lateral photographs.
Patients are told during the seminar that they will be photographed individu-
ally. I explain that these photographs make it easier to show the patient what
her issues are; I actually draw on these images to demonstrate what can and
cannot be accomplished surgically. I tried computer imaging in the past, but I
ound it to be too specif c, and patients concentrated on small details that were
essentially unpredictable rom a surgical standpoint.
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Chapter 4 • Patient Selection, Education, and Surgical Decision Making

Reviewing photographs is also better than having the patient look in the mir-
ror while I explain about her breast ootprint (high-breasted or low-breasted),
lack or presence o upper pole ullness, and other characteristics. These images
are very help ul in managing patient expectations. I make notes on the photo-
graph and keep a photocopy in the chart.
Individual Consultations
My consultation with each patient ordinarily takes approximately 10 to 15 min-
utes. I examine her breasts care ully and make note o the breast ootprint, breast
shape, and the patient’s desires. I point out her specif c physical landmarks to
be addressed, such as being low- or high-breasted, asymmetries, and upper pole
ullness. I o ten use the photos in the booklet to demonstrate how this patient’s
preoperative condition and potential postoperative results compare with those
o other patients.
I requently need to explain that I cannot always make their breasts as small as
they want with a breast reduction, and that I cannot increase their upper pole
ullness without using implants. I tell them that they will get more “perkiness”
or projection with a vertical reduction or mastopexy, but I cannot change the
position o the breast on the chest wall ( ootprint), and I cannot alter the up-
per slope o the breast. I a patient exhibits any ptosis and pre ers an augmen-
tation without a mastopexy, I am care ul to point out that her breasts will still
be ptotic a ter the procedure.
Breast reduction patients are told that the three main considerations are scars,
sensation, and breast- eeding. They are in ormed about the more common (but
usually minor) complications and the less common (but sometimes more seri-
ous) complications. Breast augmentation patients are told about the issues in-
volving the use o breast implants.
I usually see patients in consultation only once be ore the surgery, but I do
spend time with them immediately be ore the procedure to review the issues,
take photographs, and per orm the markings.
Patient Coordinator and Informational Binders
A ter my consultation, the patient sees the patient coordinator, who reviews ees,
policies, and potential surgery dates. She is given a binder to hold all the in or-
mation sheets and booklets. The binder contains the ollowing in ormation:
• Financial policies
• Quotation or the costs associated with surgery
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Part I • Concepts and Principles

• List o medications to avoid 2 weeks be ore surgery
• In ormed consent document based on ASPS guidelines
• Review o preoperative preparation and what to expect be ore, during,
and a ter the surgery
The binder is use ul, because patients are less likely to lose it than i all the doc-
uments were placed in a older or manila envelope.
PREOPERATIVE PREPARATION
All patient charts are reviewed by one o the anesthesiologists. Recommenda-
tions or any consultations or preoperative testing are made. One sta member
is responsible or making certain that all these tests are arranged and that the
results are received be ore the scheduled surgery.
All breast patients are asked to have a mammogram i they are over 40 years old
or i they are between 30 and 40 and have a signif cant amily history o breast
cancer. A mammogram per ormed in the last year or so is acceptable. One sta
member is responsible or ensuring that all these tests have been per ormed and
that I have seen the results and completed a dictation.
Every time a sta member has a telephone or email contact with the patient, a
note is made in her electronic chart. I f nd this very help ul not only or my own
in ormation, but also so that we can provide patients with consistent in orma-
tion and instructions. These notes are also use ul i a sta member raises a red
ag about a patient. We then review the issue as a group and determine the best
option. I have never regretted cancelling surgery, but I have def nitely regret-
ted not cancelling surgery. I am ortunate in that most o my surgery is not only
elective but also cosmetic, and I am ree to deny any procedure.
When I see a patient immediately be ore surgery, I review all the sta notes and
results, and I can see what instructions and in ormation she has been given.
I can also review any notes on issues that may need to be resolved just be ore
surgery.
All communications should be recorded in each patient’s electronic
chart so that it is accessible to all staff. This information may be
helpful for determining whether or not a patient is a good candi-
date for the procedure.
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Chapter 4 • Patient Selection, Education, and Surgical Decision Making

Presurgical Phone Call
Patients are called 2 weeks be ore their surgery to make certain that they have
settled their f nal bill and to give them all their preoperative in ormation. They
are told to review the medications-to-avoid list and are given their arrival times,
NPO instructions, and other specif c in ormation. There is a place in the binder
to enter that in ormation. Patients are told to bring their binders with them
and to have their caregiver read it be ore arrival.
Ongoing Management and Follow-up
We take photographs at each patient ollow-up visit, and patients are given
copies o their photographs to take home. This allows them to see how their
breast shape is resolving. I have not ound that these photographs are ever used
negatively by patients. They have, in act, saved me numerous explanations, and
patients can easily see their results in relation to their preoperative asymmetries
or other problems. The photographs are better than any notes that I make, and
they allow me to keep the notes to a minimum.
PATIENT EDU CATION
Patient education is an essential part o the preoperative process. Candidates
or breast surgery need to understand the limitations o the planned procedure:
• Patients cannot expect their breasts to move up on the chest wall. Some
patients have low breasts with low breast ootprints. Patients must be in-
ormed that the distance between the clavicle and the upper breast bor-
der will not change. I tell them that the level or position o the bra band
or underwire will not change (although sometimes I can purposely raise
it 1 to 3 cm in a reduction), and the upper breast border will not change
(although it can be raised slightly with an implant).
• Although patients rarely lose sensation completely, they need to know
about this possibility. Breast skin, especially in eriorly, can also lose sen-
sation, and its recovery is unpredictable. Loss o sensation is less likely with
a breast augmentation than with a reduction, mastopexy, or mastopexy-
augmentation.
• Patients cannot expect more upper pole ullness than what they had pre-
operatively. It is my experience that i we push tissue into the upper pole,
even sutured to the chest wall, it will drop down and cause bottoming
out. The only way to improve upper pole ullness is with an implant, or
possibly with at injections.
• Patients may not be able to breast- eed a ter surgery. Breast augmenta-
tion patients are likely to be able to breast- eed, but reduction patients
are told that the likelihood is about 50/ 50.
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Part I • Concepts and Principles

• Breast reduction patients need to be in ormed that their resulting breast
size may be larger than they desire, because there are limits to how much
breast tissue can be resected while still maintaining an acceptable shape.
In some mastopexy and mastopexy-augmentation patients, some in erior
breast tissue will need to be removed. All breast implants cause some pto-
sis, and excessively large implants will succumb more quickly to the e -
ects o gravity.
• Patients need to know that liposuction used or peripheral contouring
has limits, and that excess skin cannot be removed with liposuction.
• Breast augmentation patients need to know the limitations and potential
problems o breast implants. They are given detailed in ormation on the
issue o disease and cancer risk, but most important is a discussion o po-
tential mechanical problems.
• In overweight patients, the resulting shape will not be as aesthetically
pleasing as in a patient o normal weight.
• Overweight patients have a higher rate o complications.
• Necrosis o the nipple and areola is a possibility in breast reduction, mas-
topexy, and mastopexy-augmentation.
• Breast shape can change with time, weight changes, and pregnancy.
• Patients undergoing surgery or breast asymmetry or congenital de or-
mity usually require more than one procedure.
• Patients must understand that revisions are part o plastic surgery and that
I will per orm corrections i we both agree that there is an indication.
I usually do not charge or corrections unless the second procedure is or
issues such as size change.
Surgical Decision Making
BREAST REDU CTION
My pre erred method or breast reduction is a medial pedicle vertical approach.
In patients with a signif cant amount o excess skin (especially i the skin is o
poor quality), I still use a medial or superomedial pedicle, but I excise the ex-
cess skin with a lateral curve (J or L) or an inverted-T pattern. My practice does
not include many overly large breast reductions, but I do not hesitate to use
ree nipple gra ts i I am worried about either the blood supply or an overly
large pedicle. Be ore deciding on a method or breast reduction, the surgeon
must be able to visualize the f nal result and determine how much o the breast
needs to be coned, how much should be excised to achieve the patient’s de-
sires, and how much tissue should be removed to prevent descent with recur-
rent glandular ptosis.
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Chapter 4 • Patient Selection, Education, and Surgical Decision Making

The best candidates for medial pedicle vertical breast reductions are those who
require small to medium-sized breast reductions (100 to 800 g); however, the
principles apply equally to women undergoing larger breast reductions and to
massive-weight-loss patients. If we look at the pedicle, parenchyma, and skin
separately, we can still follow the principles that allow the remaining breast tis-
sue to maintain its shape.
There are a few patients who are candidates for liposuction-only breast reduc-
tion. These are patients (usually older) whose breasts are mainly fatty and who
have high nipples. Such patients are informed about liposuction being an al-
ternative choice, but they need to know that they will lose projection, even
though some slight elevation of the breasts and the nipples may be achieved.
Pedicle
One would think that a long pedicle should have a good blood supply; as the
breast grows, so should the blood vessels. But that assumption may not be ac-
curate. If I am concerned, I tell the patient that I will try a medially based pedi-
cle, but she must be prepared for the eventuality that I may need to use free
nipple grafts. I am often pleasantly surprised by the quality of the circulation,
and the need for conversion to free nipple grafts is rare. An overly large pedi-
cle will limit the ability to resect enough breast tissue and may make some bot-
toming out inevitable, so the decision may not always be completely based on
blood supply.
Parenchymal Resection
The problem with really large breasts (over 1000 g) is more about the extra
skin and pedicle size. A combination of direct resection and liposuction can still
produce a nicely shaped breast. When more tissue needs to be removed, it is
best to create the lateral pillar and then bevel out the resection laterally and take
more tissue parallel to the chest wall. Tissue should only be removed from the
upper pole of the breast when there is excess in that area. The tissue left behind
should resemble the Wise pattern brassiere design.
Skin Resection
Whether to remove excess skin horizontally cannot be decided based on exact
numbers; it will depend on the desired size of the breast, the vertical length of
the incision, and the quality of the remaining skin. A vertical length (distance
from the lower border of the areola to the inframammary fold) of 7 cm looks
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Part I • Concepts and Principles

good with a B cup, 9 cm looks good with a C cup, and 11 or 12 cm looks ne
with a D cup. The “5 cm rule” is used (and is necessary) when per orming an
inverted-T resection, which relies on the skin or shaping and holding the breast
shape. Un ortunately, the inverted-T skin resection pattern results in some at-
tening or decreased breast projection, because the vertical skin stretches with
time and the short distance is necessary to try to prevent bottoming out.
BREAST AU GMENTATION
During the consultation, I show patients photographs o themselves to demon-
strate how the breast ootprint can and cannot be altered. I draw on the pho-
tographs to show them that the breast shape they have initially will determine
the f nal shape (see Chapter 5).
We advise patients to per orm a “rice test” at home. They are given an unpadded
cotton bra in their size with loose cups. They take it home and are instructed
to place between 1 and 2 kitchen cup uls o uncooked rice (250 to 500 cc) in a
so t plastic bag or an old nylon stocking. They should make certain that the rice
is airly loose so they can mold it around their existing breast. Di erent amounts
o rice can be worn, each or a ew hours, to see what size they pre er. Although
they can try sizers in the o f ce to determine their desired size, I don’t f nd these
nearly as use ul as either the rice test or a review o photographs.
Patients have reviewed photos at the consultation, and I review them again just
be ore surgery. I remind them that their desired size is only part o the equa-
tion. The breast and chest wall dimensions are important, and I tell them that
a size change will only rarely be considered, and not without extra ees. They
know that f nal size decisions depend on numerous actors that cannot be pre-
cisely determined preoperatively. I will correct any problems that both o us
agree can and should be corrected, and I will do this without charge. I will not,
however, necessarily agree to a size change. I I do agree, then it is not with-
out charge, and patients will be expected to pay hal o the original surgical ee
and ull anesthesia, acility, and implant ees.
Patients are in ormed that the breast position on the chest wall will not change
signif cantly, and they know that the in ramammary old (their underwire level)
will o ten drop to some degree, especially with larger implants. They also are
told that the upper breast border can only be elevated slightly with an implant.
The pros and cons o incision location and placing implants above or below the
muscle are reviewed at consultation and conf rmed preoperatively.
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Chapter 4 • Patient Selection, Education, and Surgical Decision Making

MASTOPEXY
Patients are asked i they like the size (not the shape) o their breasts in an un-
padded brassiere. With that established, it is easier to decide whether a patient
needs an implant. Next, we discuss upper pole ullness. It is important to un-
derstand whether the patient actually wants more upper pole ullness or whether
she will be satisf ed with better projection.
I a mastopexy alone will be acceptable, I usually use the central ap held up
under a pectoralis strip. This can give a slight increase in upper pole ullness, a
def nite increase in projection, and a long-lasting result, because it entails re-
arrangement o the breast tissue and coning by bringing the lateral and medial
pillars together. O ten a small amount (30 to 60 g) o tissue is removed in eri-
orly to tailor the in erior curve o the lower pole.
MASTOPEXY-AU GMENTATION
I the patient wants an increase in size or in upper pole ullness, an implant is
indicated. I believe it is important in a mastopexy to rearrange the breast tis-
sue that the surgeon would remove in a breast reduction. Pushing the breast tis-
sue up and trying to hold it there with skin and dermal aps has not worked in
my experience. Un ortunately, I have not f gured out a way to rearrange the
breast tissue and include an implant at the same time. It would not make sense
to create a central pedicle and then add an implant, because creating either a
subglandular or subpectoral pocket would damage the blood supply to the ap.
Because I cannot rearrange breast tissue, it is more important to remove any
excess lower pole breast tissue; otherwise, the breast will develop glandular pto-
sis, with breast tissue dropping o the implant. It can be di f cult to explain the
concept o a “reduction-augmentation” to a patient, but the breast tissue will
not stay up i pushed up and suspended with a skin brassiere. The breast tissue
and the implant act independently o each other, and the principle o rearranging
or removing the ptotic breast tissue is a key concept to understand or both the
surgeon and the patient.
The weight o the implant itsel can either lower the in ramammary old or con-
tribute to glandular ptosis, or both. Mastopexy-augmentation is a procedure
that has competing elements that o ten cannot be adequately addressed.
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Part I • Concepts and Principles

Some mastopexy-augmentation patients may have di f culty under-
standing why tissue is removed and not rearranged. Although this
can be a challenging concept to explain, it is an important one that
should be discussed with each patient.
BREAST ASYMMETRY AND CONGENITAL
DEFORMITIES
Patients undergoing surgery to correct breast asymmetry or a congenital de-
formity are warned that multiple operations may be necessary to achieve a fairly
good result. It is almost always easier to operate on both breasts than to try to
match one breast to the other. Patients need to understand that using an im-
plant on just one side will often give that side more upper pole fullness than can
be achieved normally. Patients often do not like the feel of different-sized im-
plants, and in older patients I try to remove parenchyma on the larger side so
that I can use similar-sized implants. In younger patients I try to retain as much
tissue as possible to preserve future breast-feeding potential, and I warn them
that further growth and pregnancy will result in more asymmetry.
Patients are instructed that the problem in asymmetry is not that the hormones
were different on one side of their body, but that the response of the breast tis-
sue was different. They need to be informed that the response of the breast tis-
sue and skin to surgery is also different, and somewhat unpredictable. As they
grow and develop further, there will be resulting asymmetries. As they mature
and go through pregnancies, the breasts will again respond differently to cir-
culating hormones, and further asymmetry will result.
Sometimes different-sized breast implants are indicated to manage the breast
footprint. It is important, especially in asymmetry cases, to match the base di-
ameter of the implant to the desired breast base diameter rather than match the
implant to the existing breast base diameter.
Patients with breast asymmetries should be in ormed that multiple
surgeries may be needed, because their breast tissue and skin will
continue to develop asymmetrically postoperatively, in response to
surgery and pregnancies.
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Chapter 4 • Patient Selection, Education, and Surgical Decision Making

REFLECTIONS
Every practice is di erent, and each surgeon needs to f nd a com ortable method
o patient communication that adapts well to the way his or her practice is man-
aged. I would not have been able to hold group seminars when I f rst entered
practice, but I can see them as having great potential or surgeons earlier in a
reconstructive setting—but perhaps later, once an aesthetic practice becomes
more established.
As my practice has matured, I have ound the group seminars to be very use-
ul, and patient acceptance is surprisingly rapid. These seminars save me a lot
o time so that I need not repeat things, and I f nd that I can spend my time
more e ectively with patients. There will always be some patients who are re-
luctant to participate in a group seminar, and these individuals are accommo-
dated separately.
Concepts to Recall
• Patient communication and education are essential or a success ul plastic
surgery practice.
• A well-in ormed patient is a surgeon’s best ally.
• DVDs prepared by the surgeon require time and e ort but are well worth
it to maintain a smooth-running practice.
• Group seminars are an e ective way o both providing in ormation and
establishing a rapport with patients. Initially, some patients may be resis-
tant but are typically appreciative a terward.
• H aving patients meet with multiple sta members is e ective or deter-
mining whether or not patients are good surgical candidates.
• Photographs taken at consultation and reviewed with the patients are an
excellent patient education and surgical evaluation tool.
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Part I • Concepts and Principles

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gery: a look back and a look ahead. Plast Reconstr Surg 101:1136-1142, 1998.
Sarwer DB, Wadden TA, Whitaker LA. An investigation o changes in body image ol-
lowing cosmetic surgery. Plast Reconstr Surg 109:363-369, 2002.
Turhan-H aktanir N, Gecici O, Emul H M, et al. Temperament and character traits o
women admitted or breast reduction and comparison o body perception. Aesthetic
Plast Surg 34:359-364, 2010.
Wells KE, Roberts C, Daniels SM, et al. Comparison o psychological symptoms o women
requesting removal o breast implants with those o breast cancer patients and healthy
controls. Plast Reconstr Surg 99:680-685, 1997.
143
Chapter 4 • Patient Selection, Education, and Surgical Decision Making

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Part II
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Breast
Augmentation
Chapter5
147
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148
Part II • Technique
T
here is perhaps no better place to discuss the roles o art and science than in
breast augmentation surgery. Not only do we need to appreciate the various
concepts o beauty, but we need to understand what we are seeing. We need
to “see” what we are “looking at.” The best way to do this is to record measure-
ments and analyze the results. With that understanding we can then make artis-
tic decisions. When a surgeon understands the ollowing principles and how
they a ect clinical outcomes, it is easier to educate and in orm the patient so
that she will better appreciate and accept the f nal result.
SU RGICAL PRINCIPLES AND CLINICAL OU TCOMES
With a breast reduction, mastopexy, or mastopexy-augmentation, we can move
the nipple. There ore we need to understand what to do with the mound to
determine the new location or the nipple. Conversely, in breast augmentation
patients we need to adapt the mound to the existing nipple position.
Breast augmentation patients must understand that we cannot move
the nipple and have only a minor amount of control over the bor-
ders of the breast footprint.
H igh-Breasted Versus Low-Breasted
Breast augmentation results will be very di erent in these two patients. The pa-
tient on the le t has a very high breast base (or ootprint) on the chest wall, with
the upper breast border only 14 cm rom the clavicle. The patient on the right
has a breast base (or ootprint) that is quite low on the chest wall, with the up-
per breast border 19 cm rom the clavicle. Neither patient has any breast pto-
sis, but the patient on the le t is high breasted and the patient on the right is
low breasted.

149
Chapter 5 • Breast Augmentation
Impact o Implant on Breast Footprint
Upper Breast Border
With breast augmentation the implant must be adapted to create a mound be-
hind the existing nipple position. We can elevate the upper breast border only
a couple of centimeters, and almost always lower the lower breast border.
We need to use the implant base diameter (in all directions) to shape
the mound to the desired base dimensions and to f t the mound ap-
propriately behind the existing nipple position.
These photos show that the upper breast border can be raised with a breast im-
plant. Although this patient’s nipple does not appear to have been lowered, her
suprasternal notch-to-nipple distance has increased from 22.5 cm on both sides
to 24.5 cm. Her nipple-to-inframammary fold distance has increased from 9 cm
to 14 cm on the right, and from 11 cm to 14 cm on the left. H er suprasternal
notch-to-inframammary fold distance has lengthened from 19.5 cm to 23.5 cm.
Subglandular, inframammary fold,
moderate-pro le, smooth-walled, cohesive I silicone gel implants, 350 cc/325 cc,
4-month follow-up

150
Part II • Technique
The stretching o the lower pole length is not a static e ect. In some patients,
breast implants will drop with time, with loss o upper pole ullness and lower-
ing o the upper breast border.
The implant in this patient has dropped so that the mound is no longer cen-
tralized behind the nipple. The white arrow indicates her upper breast border,
and the black arrow shows where the upper breast border should be. The nip-
ple should not be centered over the mound, but centralized about one third to
one hal the distance up the mound. The upper breast border has been lowered
unintentionally. There is now more volume in the lower pole, which has un-
balanced the breast mound-to-nipple relationship. She had 250 cc saline im-
plants placed elsewhere, but this type o result is, un ortunately, common in all
practices and di f cult to prevent in patients with poor skin quality.
This patient has subpectoral breast implants that are too high. The implants
should be centralized behind the nipple; the result is unbalanced. Patients o -
ten wish that the implant will f ll the upper pole and extend into the at area o
the chest wall; however, in this patient, that e ect is odd and unsightly. The
upper breast border should not be above the preaxillary ullness.

Lower Breast Border (Inframammary Fold)
151
Chapter 5 • Breast Augmentation
The location o the mole on this patient’s breast indicates that the in ramam-
mary old has been lowered and the upper breast border elevated. The in ra-
mammary old was lowered inadvertently; however, this patient is high breasted
and can tolerate some lowering. H er suprasternal notch-to-nipple distance in-
creased rom 22 cm to 24 cm on the right and rom 21 cm to 23.5 cm on the
le t. H er nipple-to-in ramammary old distance increased rom 6 cm to 10 cm
on both sides. H er suprasternal notch-to-in ramammary old distance length-
ened rom 21 cm to 23.5 cm.
In some patients, the inframammary fold needs to be intentionally
lowered. It is easier to achieve acceptable results with lowering the
fold in high-breasted patients.
Subglandular, inframammary fold,
moderate-pro le, round, smooth-walled, cohesive I silicone gel implants, 300 cc/300 cc,
19-month follow-up
Lowering the old is essential or a good result in this patient. The implant is used
to expand the breast to centralize the nipple (one third to one hal the distance up
the breast mound). It is important to reconstitute the ascial f bers that create the
in ramammary old to prevent bottoming out. The breast is not attached to the
chest wall; it is held in place by the in ramammary old skin– ascial connections.

This woman had small implants with a base diameter that was too small or her
ootprint. Capsular contracture has made it worse. She originally had a sub-
glandular 175 cc saline implant on the right breast and a 200 cc implant on the
le t side. She is shown 8 years a ter the original surgery. The capsules were re-
moved, and the implants replaced with 354 cc silicone gel textured implants in
the subpectoral location. She needed implants with a wider base diameter to f ll
out both the medial and lateral breast borders.
152
Subpectoral, inframammary fold,
textured-surface, highly cohesive low-pro le implants CML, 295 g/295 g,
15-month follow-up
An implant with a larger base diameter than the existing breast
horizontal width will move the lateral breast border laterally.
Breasts look best when the lateral border is at or just slightly past the lateral
chest wall. I a patient wants a larger implant, a higher-projecting implant may
provide more exibility in size choices, obviating the need or a large implant
that extends too ar past the anterior axillary line. The position o the mole on
the midline o this patient’s chest wall indicates that the in ramammary old has
been unintentionally lowered.
Lateral Breast Border
Part II • Technique

153
Medial Breast Border
The medial breast border is less easily modif ed. The ollowing two patients
show that a normal medial breast border remains relatively unchanged
with breast implants. It is important to warn patients that the width o
their cleavage will remain basically the same as it was preoperatively.
Chapter 5 • Breast Augmentation
Subglandular, inframammary fold,
smooth-walled saline implants, 225 cc/225 cc,
4-month follow-up
Subglandular, inframammary fold,
smooth-walled saline implants, 325 cc (275 cc 50 cc)/300 cc (275 cc 25 cc),
4-year follow-up
This patient had relatively narrow cleavage that is maintained postoperatively.
The implant was placed in a subglandular position.
Conversely, this patient had relatively wide cleavage that remains unchanged
a ter surgery.

This bodybuilder had relatively wide cleavage, which was made wider by plac-
ing the implant in a subpectoral position. Patients need to understand that the
implant will be lateral to the muscle origins on the sternum.
An abnormally placed medial breast border can be changed to some degree with
an implant (and with at injections).
154
Part II • Technique
Subpectoral, inframammary fold,
smooth-walled saline implants, 270 cc (240 cc 30 cc)/270 cc (240 cc 30 cc),
1-month follow-up
Subglandular, inframammary fold,
smooth-walled, cohesive I silicone gel moderate plus pro le implants, 200 cc/200 cc,
7-month follow-up
In this patient the implant has been used to f ll the medial breast border and to
lower the medial in ramammary old level. This is an important consideration
in some patients and an essential element in treating a patient with a tuberous
breast de ormity (see Chapter 12). She later developed bilateral capsular con-
tracture (Baker III).

Impact of Implant on Breast Shape
155
Chapter 5 • Breast Augmentation
Subglandular, inframammary fold,
smooth-walled, responsive silicone gel, high-pro le (Style 20) implants, 325 cc/325 cc,
6-month follow-up
In this woman, the upper breast border has been elevated and the inframam-
mary fold lowered. The nipple remains centralized on the breast mound.
Normal
breast shape
Normal
breast shape
Nipple ptosis
without
glandular ptosis
Glandular ptosis
without
nipple ptosis
Nipple and
glandular ptosis
Pseudoptosis
Good breast shapes can have some ptosis. Nipple and glandular ptosis need to
be evaluated separately. Pseudoptosis occurs when the inframammary fold drops
out. If the nipple is higher than the inframammary fold, the postoperative shape
will remain similar to the preoperative shape. Over time the shape can drop to
some degree.
Lateral View of Shape
Patients need to understand that the shape that they have before surgery de-
termines the shape that will result after breast augmentation.

156
Part II • Technique
Although it may appear at times that the nipple position is elevated, this is an
illusion (a good one). The actual measurement from the suprasternal notch to
the nipple lengthens an average of 2 cm. The nipple appears to be higher, be-
cause the increased projection afforded by the implant allows the nipple to move
upward, much as a pendulum or a child on a swing. If the inframammary fold is
lowered, the nipple may also seem higher in relation to the new fold level. The
lower pole of the breast stretches even more than the upper pole, with mea-
surements routinely increasing by several centimeters. It is impossible to use ex-
act formulas based on measurements of the lower pole of the implant, because
the skin envelope is dynamic. It is important for the surgeon to understand
these changes to better use the implant to create the desired mound.
Subglandular, inframammary fold,
smooth-walled saline implant, 360 cc (330 cc 30 cc)/360 cc (330 cc 30 cc),
4-year follow-up
Subpectoral, inframammary fold,
smooth-walled, responsive silicone gel, moderate-pro le (Style 15) implants, 371 cc/339 cc,
6-month follow-up
Although the shape of this patient’s breast remains similar to the preoperative
shape with some glandular ptosis, the weight of the implant has dropped the
breast mound. The position of the mole on the arm relative to the breast shows

157
how much the breast has dropped even though the implant was placed in a sub-
pectoral position. I do not believe that the muscle holds the implant up except
when it heals in an abnormally high position. Sometimes contraction of the pec-
toralis muscle actually pushes the implant down. Although the nipple position
is still centralized on the breast mound, the nipple itself is lower and the dis-
tance from the nipple to the inframammary fold is much longer than it was be-
fore surgery. Complicated calculations using the curve of the lower pole of the
implant are less important than analyzing and measuring patient results over
time.
Frontal View of Shape
Many patients would like to have the shape shown below, but, just as the pre-
operative lateral view determines the postoperative lateral appearance, the same
applies to the frontal view.
Subglandular, inframammary fold,
smooth-walled, moderate plus pro le cohesive I silicone gel implants, 225 cc/225 cc,
12-month follow-up
It is important or surgeons to explain that we are restricted by the
preoperative anatomic shape and cannot change the existing shape to
any signif cant degree when per orming only a breast augmentation.
Chapter 5 • Breast Augmentation

158
Part II • Technique
Subglandular, inframammary fold,
smooth-walled, moderate-pro le, responsive silicone gel implants (Style 15) 371 cc/371 cc,
10-month follow-up
Subfascial, inframammary fold,
smooth-walled, cohesive I silicone gel moderate plus pro le implants, 275 cc/275 cc,
3-month follow-up
This patient does not have ptosis, but, on the rontal view, her breasts tend to
angle outward. This shape will be maintained postoperatively.
This patient would only have been able to alter her preexisting shape i she had
undergone a mastopexy at the same time. The implant can be used to shape the
ootprint somewhat, but it cannot reshape the mound to any signif cant degree.
Because she is low breasted, a mastopexy would alter the shape but would not
raise the breast itsel on the chest wall.

Correction of Breast Asymmetry
When the ootprint is asymmetrical, the implant can be used to adjust the
mound to reshape its borders to some degree. In most o these cases,
changing the medial and lateral breast borders by choosing a larger im-
plant base diameter and creating a pocket to f t can be very e ective.
159
Chapter 5 • Breast Augmentation
Right: Subglandular, inframammary fold,
smooth-walled saline implant, 350 cc.
Left: Superior pedicle vertical mastopexy with
subglandular smooth-walled saline implant, 180 cc.
1-month follow-up
This young woman needed an implant on the right side to f ll out both the lat-
eral and medial borders to match her breast borders a ter a mastopexy on her
le t breast. She had smooth-walled subglandular saline implants: 350 cc on the
right and 180 cc on the le t. She also had a superior pedicle vertical mastopexy
on the le t. The implant on the le t side had to match the increased upper pole
ullness rom the right augmentation.
Altering the inframammary fold can lead to complications of bot-
toming out. The surgeon can help prevent bottoming out after dis-
secting below the existing inframammary fold by carefully closing
the fascial and skin attachments. Unfortunately, this three-layer clo-
sure does not always prevent bottoming out of the fold.

This patient’s breast asymmetry was corrected by lowering the left inframammary
fold. Both folds also needed to be lowered laterally. Although the nipple could
not be moved, the mound behind the nipple could be shaped by analyzing the
borders of the footprint and altering them as needed. Note the position of the
mole below the left inframammary fold to see how much it has been lowered.
160
Part II • Technique
Biocell textured silicone gel implants (Style 115), 272 cc each,
placed through an inframammary incision into a subfascial location

161
Chapter 5 • Breast Augmentation
Laterally Sloping Chest Wall
The chest wall is rarely f at—it usually slopes outward much as a roo
slopes outward rom the center (the sternum). Just as the chest wall can
have an abnormal inward slope, it can also have an abnormal outward
slope. A slight outward slope is normal.
When the chest wall slopes outward, the nipples tend to appear out-
wardly displaced. I the surgeon does not use an implant with a
large enough base diameter or i the surgeon tries to narrow the
cleavage at the expense o f lling out the lateral quadrant o the
breast, the result may be unacceptable.
Subglandular, inframammary fold,
Biocell textured, responsive silicone gel high-pro le implants (Style 120) 300 cc/ 300 cc,
21⁄ 2-year follow-up

162
Part II • Technique
Subfascial, inframammary fold,
moderate plus pro le cohesive I smooth-walled silicone gel implants, 325 cc/325 cc,
6-month follow-up
It is important in patients who have very laterally placed nipples to
use the implant to f ll the lateral quadrant as much as possible.
Normally sloped chest
with implants
Narrowly sloped chest
with implants
Narrowly sloped chest
with wider implants
The slope o the chest wall is important to consider when choosing an implant
base diameter. With a signif cantly sloping chest wall, a larger base diameter
needs to be chosen to f ll the lateral aspect o the breast so that the nipples do
not appear to be too laterally placed.

163
Chapter 5 • Breast Augmentation
Prominent Sternum
This woman required a large enough implant to camou age her prominent up-
per sternum. She was relatively high breasted with minimal tissue in the lower
pole; there ore some lowering o the in ramammary old was indicated. Note
the mole (arrow) on the patient’s arm in relation to the in ramammary old be-
ore and a ter surgery.
Subpectoral, inframammary fold,
Microcell textured surface, low-pro leCML highly cohesive silicone gel implants, 335 g/335 g,
6 month follow-up
PATIENT EVALUATION
Patient evaluation and education can be di f cult or augmentation patients be-
cause o the varying opinions expressed by riends, other plastic surgeons, and
the Internet. Patients need to be in ormed that they may receive many con-
icting recommendations, because we do not know the right answer to many
questions about breast augmentation. The best breast augmentation is o ten
the breast augmentation that a particular surgeon does the best.
It helps to take photographs o the patient at the time o consultation to show
her the issues specif c to her case. Patients see more (and understand more)
when they view photographs o themselves rather than look in the mirror. It
can be help ul to point out whether they are high breasted or low breasted. Pa-
tients are o ten unaware o preexisting asymmetries be ore looking at the pho-

tographs. They rarely look at their breasts rom the side; there ore the lateral
view can be used to discuss ptosis and whether a mastopexy is indicated. I show
them photographs o patients with breast augmentation alone, mastopexy alone,
and mastopexy-augmentation. I can get a good idea o what approach to rec-
ommend by judging their reaction to various results.
I draw on the patient’s photographs to provide a general idea o the results rom
each procedure. I f nd these ill-def ned drawings better than computer imag-
ing, because we are not actually able to predict the results with the precision
achieved with computer imaging. I will o er patients a range o implant sizes
and explain that I will f rst assess the desired (not the existing) base diameter,
and then vary the prof le to achieve some exibility in size choices. Patients
o ten bring in photographs rom magazines that are not reasonable or their
breasts and breast ootprint; I make sure that they understand some o the
limitations.
PLANNING
Choice of Implant
My implant choices are limited because o Canadian ederal regulations. Our
choices are somewhat di erent rom those in the United States. Similar to the
United States, Canada also had a moratorium on silicone gel implants—in our
case, rom 1992 to 2002. From 2002 until 2006 we had to apply or permis-
sion to use silicone implants or each patient under the special access provisions
at H ealth Canada. A ter 2006 we were allowed to use only certain Mentor
(Santa Barbara, CA) and Allergan (Irvine, CA) implants. The approved implants
have been either smooth or textured round implants but only with a relatively
low cohesiveness. We are, however, also approved to use the higher-cohesive
Style 410 implants.
My experience rom 1983 to 1992 was mainly with Dow Corning silicone gel
implants and some polyurethane implants. I did not like saline implants because
o their watery nature, along with the increased problems with palpability and
visibility o ripples and olds. I also ound that the capsular contracture rate
(Baker II-IV) was airly high, whether or not the implant was placed under the
muscle (see the table on the opposite page).
My best results were with the higher cohesive CML and CMH implants made
by CUI (Carpinteria, CA). These were the implants that I used during the spe-
cial access restrictions rom 2002 to 2006. In primary breast augmentations,
I used subglandular, sub ascial, and subpectoral placement. My capsular con-
tracture rate was low in all three locations—lower than with the previous saline
implants and the subsequent gel implants.
164
Part II • Technique

The newer gel implants per orm ar better than the gel implants o the 1980s,
although not as well as some o the CML and CMH implants used in patients
in my practice. I decided to compare my own results with the di erent devices
to get a better idea about per ormance di erences. Although I used di erent
devices, I did not alter my surgical techniques. For the patients shown in the
ollowing table, I used a povidone-iodine (Betadine) prep, perioperative an-
tibiotics, and a povidone-iodine/ bupivacaine rinse. I did not change gloves and
did not use drains.
My study extended rom 2006 to 2009. I did not include patients with less
than a ull year ollow-up. I used one third smooth Allergan (Style 15 and 20),
one third Biocell textured Allergan (Style 115 and 120), and one third smooth
Mentor (cohesive I) implants. I did not use the textured Mentor (Siltex) im-
plant, because it did not adhere and patients sometimes had a small seroma at re-
165
Chapter 5 • Breast Augmentation
Capsular Contracture Prof le Primary Breast Augmentation
No. of

Capsule

Capsule

Total Capsular
Implant

Pocket

Patients
Baker II (%)

Baker III (%)

Contracture (%)
Saline*
Subglandular

152

12 (8%)

26 (17%)

38 (25%)
Sub ascial

—

—

—

—
Subpectoral

39

6 (15%)

3 (8%)

9 (23%)
TOTAL

191

18 (9%)

29 (15%)

47 (25%)
CML/ CMH †
Subglandular

53

1 (2%)

0 (0%)

1 (2%)
Sub ascial

53

1 (2%)

0 (0%)

1 (2%)
Subpectoral

22

0 (0%)

1 (5%)

1 (5%)
TOTAL

128

2 (2%)

1 (1%)

1 (2%)
115/ 120‡
Subglandular

27

1 (4%)

0 (0%)

1 (4%)
Sub ascial

5

1 (20%)

0 (0%)

1 (20%)
Subpectoral

13

0 (0%)

3 (23%)

3 (23%)
TOTAL

45

2 (4%)

3 (7%)

5 (11%)
15/ 20§
Subglandular

30

2 (7%)

2 (7%)

4 (13%)
Sub ascial

5

0 (0%)

0 (0%)

0 (0%)
Subpectoral

13

0 (0%)

0 (0%)

0 (0%)
TOTAL

48

2 (4%)

2 (4%)

4 (8%)
MPP ¶
Subglandular

30

1 (3%)

4 (13%)

5 (17%)
Sub ascial

6

0 (0%)

0 (0%)

0 (0%)
Subpectoral

14

1 (7%)

1 (7%)

2 (14%)
TOTAL

50

2 (4%)

5 (10%)

7 (14%)
*Saline (1992-2004): smooth-walled, both Allergan and Mentor saline implants.
†CML/ CMH (2002-2007): Microcell textured highly cohesive implants made by CUI (CML low prof le, CMH high prof le).
‡115/ 120 (2007-2009): Allergan Biocell textured responsive gel implants (115
moderate prof le, 120
high prof le).
§15/ 20 (2007-2009): Allergan smooth-walled responsive gel implants (15
moderate prof le, 20
high prof le).
¶MPP (2007-2009): Mentor smooth-walled cohesive I gel-f lled implants (moderate plus prof le).

vision. I also thought that they had more rippling. I used a ew shaped Biocell
textured Style 410 implants. The results showed a higher capsular contracture
rate in the textured implants because o late seromas and double capsules, re-
gardless o the plane (see the table on p. 165; pp. 200 through 204.) These
numbers are not high enough or proper statistical evaluation, but they have
the advantage o being a single-surgeon series with minimal variability in pro-
cedure or capsular contracture assessment.
I now use only smooth-walled silicone gel implants in either the subglandular or
the subpectoral plane. These newer silicone gel implants per orm ar better than
the ones I used in the 1980s. They also per orm ar better, in my experience,
than the saline implants. They eel more natural and have ewer capsular con-
tractures and ewer problems with rippling.
I no longer use the Biocell textured implants because o the incidence o late
seromas and double capsules. The tissue adherence with the Biocell implant is
not strong enough to resist shear orces and can separate, causing late seromas
and double capsules. I have documented 14 cases o double capsules and have
had to take back two patients on an emergency basis or expanding seromas.
The Siltex textured sur ace does not adhere, and I have not seen double cap-
sules with it.
I have only tried a ew shaped implants but did not particularly like the results,
because patients appeared to have an inordinate increase in lower pole volume,
with what I would describe as glandular ptosis. Many patients at consultation
already have most o their volume in the lower pole; they want an increase in
upper pole ullness, which is only provided by a round implant. The shaped im-
plant does not improve the upper pole enough, because most o its volume is
designed to be below the nipple.
I would like to be able to use the polyurethane-coated implants again, but they
are not available in Canada. The principle o tissue ingrowth o the capsule does
reorient the f bers perpendicular (rather than parallel) to the implant sur ace so
that the capsule is less likely to tighten around the implant. The polyurethane
implants truly had a “one-breast eel,” and my limited experience with them was
excellent. I realize, however, that there was a problem with breakdown o the
polyurethane. Solving this problem would make these implants very appealing.
166
Part II • Technique

Implant Size
The main ocus o most breast augmentation patients is breast size. When dis-
cussing size with patients, it is important or them to understand that the size
determination will always be an estimate and that I cannot guarantee a certain
brassiere size. (They seem surprised that a 36 C is the same cup size as a 34 D
and a 38 B.) So much depends on how a woman wears the brassiere and what
style she chooses. I like to initially ask about brassiere size but then explain that
we make a f nal decision based on the patient’s photographs and body propor-
tions. The initial size that patients request during the consultation o ten gets
much larger when we discuss it again during the immediate preoperative visit.
I try to encourage patients not to pay attention to implant size and brassiere
size when they bring in photographs rom the Internet. O ten they have looked
at so many pictures that they start to understand how con using it is. They know
that they cannot pick either a size or shape. The photographic review is only
used as a guideline or me to know what to aim or. They also understand that
I have other restrictions to deal with such as skin envelope elasticity, chest wall
and breast diameter, and the act that an overly large implant will succumb to
gravity at an early stage. They understand that I will not necessarily agree to a
size change in the uture.
I give the patient a so t cotton brassiere to take home a ter the initial consulta-
tion to try the rice test. I f nd this more use ul than either using implants or siz-
ers during the consultation. The implants do not mold around the breast prop-
erly, and the sizers tend to have most o their volume in the lower pole. Patients
are told to use di erent amounts o rice in a loosely f lled bag so that they can
mold it around their existing breast. Most women now wear a oam-type
brassiere, which is usually padded and not particularly good or testing. The
cotton brassiere can also mimic some o the sagging that will occur with larger
and larger implants, and it will discourage patients rom thinking that the breasts
will be elevated on the chest wall. The f nal decision is made just be ore sur-
gery. At that time I also f nd photographs o other patients quite use ul.
It can be rustrating, but I have learned not to try to persuade a patient to go
much smaller than what she requests. I may not like the result o an overly large
implant, but dealing postoperatively with patient dissatis action is stress ul. When
I f rst see patients in consultation, i they want larger than what I consider to
be normal (outside my bell curve as a surgeon) then I re use to accept them as
patients. I have also learned to always err on the side o a result that is slightly
larger than what the patients show me in photographs (especially i they are
167
Chapter 5 • Breast Augmentation

168
Part II • Technique
Transaxillary
Inframammary
Infraareolar
worried about what others will notice), because most patients will wish that
they had gone a bit larger. Rarely do they say that their breasts are too large.
Many o them do understand, however, that larger implants have more prob-
lems with gravity and ptosis, and they accept the compromise.
Dealing with the long-term consequences o excessively large implants is equally
stress ul. I am pleased that most o my patients want to be more proportional
in size. My average breast implant size is about 300 to 350 cc. This is o ten
somewhat larger than what I think is ideal, but at least it f ts within what I con-
sider to be acceptable. I will not accept a patient who tells me that she has a
right to demand that I place overly large implants because she is the patient and
she has the right to decide what she wants. I in orm her that I have an equal
right to re use to per orm the surgery.
Incisions
Most o my patients have an in ramammary incision. This was especially neces-
sary or the more cohesive implants, which usually require a 5 cm incision or
an average 300 cc implant to avoid racturing the internal gel. A somewhat
smaller incision can be used or the currently available responsive silicone gel
implants, because they are so ter and the gel is less likely to rupture.

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Chapter 5 • Breast Augmentation
Subpectoral, inframammary fold,
Microcell textured surface, highly cohesive low-pro le CML implants, 295 g/ 295 g,
15-month follow-up
These scars are slightly higher than desired but well camou aged when the pa-
tient stands.
In the past, I occasionally used an axillary incision, with implants either above
or below the muscle. This worked well, but I did not like the lack o control when
creating the dissection pocket and my inability to adjust and then secure the in-
ramammary old. I rarely used the endoscope and decided instead to place most
o my implants through an in ramammary incision. The in ramammary old in-
cision allows a care ul three-layer closure when the in ramammary old is low-
ered. The cohesive gel implants that I am using now are so ter. I can sometimes
use a slightly shorter incision but never as small as the 2 to 3 cm incisions that
I used with saline-f lled implants. Patients are told that the incision will be at
least 2 inches long.
Inframammary Incision
The in ramammary incision is ideally placed in the new in ramammary old, but
the new level is not always obvious. Sometimes the in ramammary old will el-
evate with capsular contracture.
It is better or the in ramammary incision to remain slightly above
the old. This placement gives some f exibility or patients when
they are wearing bathing suits and raise their arms, potentially ex-
posing the scar.

170
Part II • Technique
These inframammary scars are shown 1 year after surgery. They can be thicker
than the periareolar scars, but they are less visible when the patient is standing.
Periareolar Incision
Occasionally I use infraareolar scars—usually only on patient request. I believe
periareolar scars interfere with nipple sensation more than the other scars (un-
proven). I do not like to dissect through breast tissue. In addition, these peri-
areolar scars can sometimes become thick and therefore more visible. Some scar
retraction can develop.
This patient had saline implants placed through an infraareolar incision into the
subglandular position. A 330 cc implant was placed in the right breast, and a
305 cc implant was placed in the left breast. She is shown 5 months postoper-
atively. The scars are still slightly red.

This augmentation mammaplasty patient came to see me to inquire whether I
could correct her scars. I explained that it was unlikely that a revision would re-
sult in improvement. I also explained that, i I had per ormed her original sur-
gery, the same type o scarring would likely have resulted. (The asymmetry did
not bother her.) This result is a good example o how odd the di erent nipple
locations look despite similarity o the breast mounds.
Transaxillary Incision
I used the transaxillary incision occasionally or saline implants, because the in-
cisions could be small and the implants f lled in situ. Because a larger tunnel is
required or pref lled implants, there is a higher risk o the implants sliding up to-
ward the axilla (see p. 228). I would have used both the subglandular and sub-
pectoral position or the implants, but I did not have as much control over
pocket shaping as I desired. I could not control the level or reconstruction o
the in ramammary old as I wished. I tried the endoscope, but I did not f nd it
worth the increased di f culty associated with the use o the equipment. The
scars could be good, but they could tear anteriorly when a silicone gel implant
was orced through a small incision. Actual implant gel racture is more likely
when orcing a highly cohesive implant through a small incision. Axillary scars
are actually more visible than in ramammary incisions in some situations, such
as when a woman is wearing a bathing suit or a sleeveless dress. I have also ound
revisions di f cult to per orm through a previous axillary incision.
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Chapter 5 • Breast Augmentation

172
Part II • Technique
This patient demonstrates an early transaxillary scar on her right side and an im-
proved scar on her left axilla several months later.
Crescent Incision
It is sometimes tempting to try to insert an implant through a supraareolar in-
cision while excising a crescent of skin and/ or areola in an attempt to elevate
the areola to achieve a lift or improved symmetry. I do not believe this strategy
works for either. The skin inevitably stretches over time, and any short-term
correction is lost. Perhaps removing both skin and parenchyma could achieve
some elevation.
Subfascial, right inframammary fold,
left crescent, smooth-walled, responsive silicone gel high-pro le implants,
Style 20 400 cc/400 cc,
13-month follow-up
A crescent skin excision was performed on the left breast of this patient. She is
shown 13 months postoperatively with recurrence of the asymmetry.

This woman had a crescent excision of skin to elevate her left areola for better
symmetry. The preoperative markings were drawn to accommodate some ex-
pected stretching, but the areola dropped to a lower position than it was pre-
operatively.
In my experience, the only way to achieve lasting results with areolar elevation
is to use a permanent Gore-Tex–type suture or (a better choice) to add a ver-
tical skin component to match the areolar and skin circumferences. (See p. 229
for a discussion of problems with Gore-Tex sutures.)
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Chapter 5 • Breast Augmentation
Subglandular,
smooth-walled saline implants, 300 cc (270 cc
30 cc) each,
15-month follow-up
This patient achieved good symmetry of her nipple position, but only because
tension was removed by adding a vertical incision (arrow) that allowed the are-
olar skin opening to match the areolar circumference. She had smooth-walled
silicone gel cohesive I implants placed in the subglandular location, with 325 cc
on the right breast and 300 cc on the left breast. She is shown 15 months post-
operatively.

174
Part II • Technique
Implant Placement
I choose subglandular placement or many o my patients and subpectoral place-
ment or women who need extra padding. I no longer use sub ascial placement.
The subglandular position gives the most natural result overall.
H owever, in a thin patient, the subpectoral location may produce
a more natural result.
I believe that the only reason to place an implant in the subpectoral plane is or
padding. The downside is muscle movement (the so-called dancing breast syn-
drome) and a wider cleavage. I do not believe that the subpectoral pocket is
better or preventing capsular contracture (see the table on p. 165) or or hold-
ing up the implant.
I did try to use sub ascial placement in a series o patients. The ascia is not use ul
or padding; however, it may help blunt the upper edge o the implant, because
it pulls up on the muscle itsel , with tension on the capsule. I was trying to see
i I could prevent the lateral slide that occurs with saline implants when a pa-
tient lies down. Sub ascial placement may work to mitigate lateral slide, but the
dissection is tedious and bloody. It is also my impression that the silicone gel
implants (smooth or textured) do not slide laterally as much as saline implants.
I used the sub ascial pocket or many o my highly cohesive silicone gel im-
plants, with excellent results. Initially I wondered whether it was the sub ascial
location that was giving me such good results both cosmetically and in capsular
contracture rates (see the table on p. 165). With a review o my results, how-
ever, it has become clear that the pocket location did not seem to be the de-
termining actor.
I the upper pole pinch is less than 3 cm and the medial pole pinch is less than
2 cm, then I will recommend subpectoral placement. I explain that the two
main reasons or subpectoral placement are padding and mammograms; mam-
mograms are more di f cult to per orm in patients with implants in place and
Subglandular
Subpectoral
Subfascial

may require extra views with more radiation. H owever, sometimes sub-
pectoral placement makes mammographic visualization somewhat easier.
With improved techniques and the addition o ultrasound, I think that
the pocket location is less important today.
Both patients and plastic surgeons seem to believe that placing implants in a
subpectoral position tends to hold the implant up and prevent ptosis. I do not
believe this is true. Implants can sometimes heal in too high a position, but, i
they heal in the desired pocket location, I do not believe the muscle supports
them. Sometimes the muscle actually pushes them downward.
175
This patient had implants that were too high initially. She is shown 1 month,
5 months, and 14 months postoperatively. It is presumed that initial spasm o
the lower aspect o the pectoralis muscle caused the implants to be high dur-
ing the f rst ew weeks a ter surgery. It is important not to dissect too ar supe-
riorly when per orming subpectoral placement.
Preoperative

1 month postoperatively
5 months postoperatively

14 months postoperatively
Subpectoral, inframammary fold,
smooth-walled, responsive silicone gel implants, Style 15 339 cc/339 cc
Chapter 5 • Breast Augmentation

Sometimes patients insist on ollowing their “street advice,” and, i it does not
really con ict with mine, then I ollow their request. It can be di f cult to undo
some o the misin ormation that they have read on the Internet or have been
told by others.
OPERATIVE APPROACH
Markings and Design
There are multiple options or access. I pre er the in ramammary incision or
the more cohesive gel implants, because a 5 cm incision length is needed or an
average 300 cc implant. I can adjust the breast ootprint borders more easily
through the in ramammary incision; I can also control reconstitution o the in-
ramammary old f bers when needed.
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Part II • Technique
I make the ollowing measurements and markings or breast augmentation;
however, many o these are only or study purposes with the patient standing.
I begin by measuring the breast base diameter (12 cm and 11 cm in the patient
shown above), suprasternal notch-to-nipple distance (21 cm and 22 cm),
nipple-to-in ramammary old distance with the skin stretched (7.5 cm), and
suprasternal notch-to-in ramammary old distance (21 cm on the le t and
22 cm on the right). I measure the chest wall circum erence both above and
below the breasts to help my sta choose a postoperative brassiere size.
I do not think that we need measurements to make good choices in
any one particular breast augmentation patient. But we do need
measurements to know, in general, how to predict what will hap-
pen postoperatively. To use an implant for adapting the breast
mound to the existing nipple location, the surgeon needs to stand
back and assess both the breast footprint and shape.
1
5A-1 Preoperative
markings for
subglandular breast
augmentation
5B-1 Preoperative
markings for
subpectoralbreast
augmentation

I note the nipple position and how it relates to the existing and desired breast
borders. I then determine i any o the borders need to be altered by adjusting
the implant base (either vertically or horizontally) to get a good mound f t be-
hind the existing nipple position. Asymmetries are noted, and a decision is made
about using di erent implant sizes or base diameters to try to correct one asym-
metry without exaggerating another.
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Chapter 5 • Breast Augmentation
The intraoperative markings are shown. The incision is marked in this patient
at her in ramammary old. The medial aspect o the incision is on a line dropped
rom the medial border o the areola (dotted line). The plan or this patient was
to use a 400 cc implant; there ore a 5 cm incision length was marked. Because
her breast was a bit ptotic and she already had a 7 cm distance between the
lower border o her areola and her in ramammary old, the decision was made
to place the incision directly in the old.
Initially the incision is marked at the level o the in ramammary old. When the
old is intentionally lowered, the incision is lowered as well. I try to make sure
that the incision is slightly above where I expect the old to settle. I would rather
have the scar slightly above the old than below it. Alternatively, when the old
needs to be signif cantly lowered, the incision line should be appropriately
dropped. For an average 300 cc implant, the incision is usually placed about
6 cm below the lower border o the areola.

178
Part II • Technique
The base diameter o a 300 cc moderate prof le implant is 12 cm. I one is mea-
suring the base diameter without taking into account projection, it would ini-
tially be assumed that 6 cm rom the lower border o the areola to the incision
would be too long. But the base diameter exists only in two dimensions. The
skin curves over the sur ace o the implant. This 6 cm distance will usually stretch
at least 2 cm. The in ramammary old itsel may also drop. H owever, when the
third dimension is taken into account, 6 cm is appropriate, in most patients, to
accommodate an average 300 cc implant. This depends on how much volume
and ptosis the patient has preoperatively. The distance rom the nipple and are-
ola to the incision will be longer (6
x cm) than hal the base diameter o the
implant (6 cm).
A line is dropped rom the medial border o the areola to the in ramammary
old; this is determined to be the medial extent o the incision. For the average
300 cc implant, the incision must be about 5 cm long to allow ease o insertion
without gel racture.
It is better to place the incision too far laterally in the inframam-
mary fold than too far medially.
6
x cm
6 cm