Breast Augmentation & Mastopexy (breast lift) and the role of tissue stretch ... Continued
In reality, as of this writing, almost all of my patients whom I have taken this approach did not require a lift after all. I'll explain this shortly. When planning this type of surgery, the surgeon has to make a thorough assessment of the breast including measurements of the breast width, tissue thickness at various points on the breast, and the forward stretch of the breast as well as the distance from the nipple to the lower crease. The quality of the tissue must be assessed: is it firm or soft, is the skin elasticity good or has it been damaged, is the skin envelope tight, normal or lax? All these factors go into the equation in planning the operation. There simply is no good substitute for intelligent planning and lots of experience.
I want to digress for a moment and talk about lower pole tissue stretch. This is an example of something that the surgeon cannot control. Normally, the lower breast tissue is supposed to stretch an appropriate amount to accommodate the implant. When there is excessive lower pole stretch, the lower portion of the breast overstretches causing the implant to sink down into the pocket. When this happens, there is inadequate fill in the upper breast and the nipple may tilt upward look too high as the breast “bottoms out” with most of the breast volume now in the lower breast. This phenomenon is more commonly seen in younger women who have tighter breasts, typically those individuals who never bore children. I cannot eliminate the risk of excessive tissue stretch, but I can minimize it by not placing an excessively large implant into the breast. Now, take the case of a naturally stretched out breast that clearly needs a lift. The tissue is severely compromised from the very start, usually by previous pregnancy and lactation. Even without an implant, the tissue is sagging. The reason I am discussing this issue is to demonstrate that when one performs a breast augmentation, or any cosmetic surgical procedure for that matter, the more variables that enter into the picture that you cannot control, the less you can control the final result. That is why I am hesitant to combine two operations that have contouring effects on the exact same area, such as a breast augmentation and a breast lift. This is not to say that I will not perform this combination of procedures (breast augmentation and breast lift), rather, I will do so but only after I have discussed this information with the patient and have offered her the opportunity to have the surgery performed in two stages so that she is empowered with the knowledge to make the choice that best fits her needs. This is why the dual plane approach is so powerful. With the dual plane approach, as originally described in 2001 by John Tebbetts, MD, I can now achieve a wonderful breast augmentation result in a breast with sagging without needing to perform a breast lift in the majority of the cases that I see!
As a plastic surgeon, it is paramount that I understand as well as explain to my patients factors we can control as well as those that we cannot control. When planning any cosmetic surgical operation, the more variables under our control the better, the more variables not under our control, the less chance we have to control the result of the surgery. When performing a breast augmentation, I have control over the volume and shape of the implant, where I place it (above the muscle or below the muscle - I prefer the latter), the location of the incision and the size of the pocket or space where the implant is placed within the breast. That's about it. Now let's look at what I cannot control. I cannot control how much the breast will stretch to accommodate the implant, whether or not the lower half of the breast (from the nipple to the crease) will over-stretch, and how far forward and upward the nipple will move as the implant volume redistributes to the lower breast, pushing the nipple forward and often upward until the implant reaches its final position. As the implant "settles" there will be loss of fullness at the top of the breast, which is desirable as initially after surgery there is excessive upper breast (upper pole) fullness. The implant is not actually moving downward, but rather the volume is redistributing with more volume moving to the lower breast and less at the upper breast due to gradual stretching of the lower breast tissues, creating a larger space in the lower portion of the breast for the implant to fill. When planning a breast augmentation, I have a fair idea what will happen with these variables I cannot control based upon my experience, but sometimes the final result is different than I predicted. This is because neither the patient nor the surgeon can alter the biology and healing processes on the patient’s tissues. Fortunately, the difference between what I am planning and obtaining is usually not significant and further surgery is rarely indicated. How is this significant? At the time of this writing (September, 2011) in my practice, the re-operation rate at three years for silicone breast augmentations is less than 2% whereas the same figures in the FDA silicone gel implant premarket approval studies are approximately 20% and higher.