DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

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Why might I need a breast lift?

The Problem: Breast Drooping

True Ptosis versus False Ptosis (Pseudoptosis)

In my breast augmentation practice, a large portion of my patients are mothers who wish to restore lost volume to their breasts, or attain a volume that they wished they had previously. Many of these women have ptosis, or drooping, of their breasts. There are two types of ptosis: true ptosis and false ptosis, also known as pseudoptosis. True ptosis relates to the position of the nipple with respect to the lower breast crease, also known as the inframammary fold. False ptosis describes the position of the glandular tissue with respect to the inframammary fold. The degree of ptosis and pseudoptosis can vary independently with respect to one another as they are two separate entities. Unfortunately, they happen to have similar names which causes the confusion. Except for those women with very little breast tissue to start with, most all of these women have a combination of both types of ptosis.

In my practice, the Dual Plane submuscular augmentation has clearly reduced the number of breast lifts I would have otherwise have done with my augmentations. Similarly, it has, in my opinion, eliminated the need for placing implants above the muscle (subglandular).

So with these things said, when do I do a lift?

I frequently see women who have been told by other plastic surgeons that they require a lift in addition to the breast augmentation surgery. Many of these women DO NOT require a breast lift. Using some of the latest advances and refinements in breast pocket dissection, coupled with proper implant size and shape selection, the implant can be fitted into the breast pocket so as to restore lost fill volume to the breast, thus advancing the nipple forward and rotating it upward. In these cases a lift is not necessary.

This cannot be achieved in every case, however, after a thorough analysis of the breast and careful measurements, the need for a mastopexy (breast lift) usually can be determined during the initial consultation. In other cases, such as when the nipples are at the lowest point on the breast when standing or if the nipples point straight downward, a lift is often unavoidable. In borderline cases, I have found it very helpful to perform the augmentation first, and allow the implants to settle into place. Six months later, if a lift is required, this can be performed. In my experience with these types of cases, a breast lift is almost never required or desired by the patient six months later.

Watch the video below for some insights on this topic:

I think everyone would agree that a small, tight, perky breast with the nipple positioned centrally on the breast, well above the lower breast crease will not need a lift when an augmentation is performed. On the other hand, in a case where the breasts have very saggy skin with poor elasticity, breast tissue that is not firm but in excess and the nipples point straight downwards, everyone will easily agree that a lift is definitely indicated in this case. The issue remains, what to do for everyone in the middle? This becomes a judgment call, based upon experience. That experience comes from performing thousands of surgeries, and seeing what works and what does not work.

Five factors that determine the need for a lift at the time of augmentation

  • The amount of excess breast skin – the more excess skin, the greater the likelihood to need a lift
  • The elasticity of the breast skin – the poorer the elasticity, the greater the likelihood to need a lift
  • The amount of the breast tissue – the more breast tissue, the greater the likelihood to need a lift
  • The firmness of the breast tissue – the softer the breast tissue, the greater the likelihood to need a lift
  • The position of the nipple relative to the lower breast crease – the lower the nipple, the greater the likelihood to need a lift

If you envision a breast with an implant behind it, the breast tissue is pushed forward of that implant. Gravity is going to act on that breast tissue. The more factors that are unfavorable, the more the breast will sag and will thus need a lift to restore proper aesthetics to that breast.

With regard to the skin envelope, think of it as a ziploc bag. If the bag has a capacity for a gallon, but you fill it with only one quart of water, all the water will fall to the bottom of the bag, leaving the majority of it unfilled and sagging. Same thing with a breast. If the skin brassiere (the skin envelope) has a DD-cup capacity because that is the size you were while breast feeding, but now you only have a B-cup of breast tissue to fill it, the breast will appear empty and sagging. It is a common misconception to think that adding an implant to make up the difference will remedy the matter. Furthermore, an implant DOES NOT lift the breast. The problem is that the skin is overstretched and has poor elasticity. If you add a very large implant to fill out the breast, the nipple will appear too low, and the weight of this very large implant will now cause additional thinning out of the skin and stretching, and in a few months the breasts will look even worse! The answer here is to remove some of the breast skin (as is done with a breast lift) and make the skin envelope smaller with the nipple now in the proper position, use a smaller implant and get a much longer lasting result, maybe a C or D-cup with the breast properly filled out and the nipple positioned properly.

With regard to the breast tissue itself, the more breast tissue there is to start, the more it will be pushed forward of the implant. Gravity will act on this tissue, causing it to sag. The firmer the tissue, the more it will resist deformation of shape under the influence of gravity. The more tissue to start with, the firmer it must be to stay upwards.

The nipple position is also a very important factor. Ptosis, or drooping, is always assessed by looking at the nipple position in relation to the lower breast crease, also known as the inframammary fold. I do not care what the measurement is from the collar bone or the upper breast bone at the base of the neck to the nipple when assessing ptosis. Only the crease. Of course, I record these measurements, but more for symmetry purposes than any other reason. Very simply stated, the breast is like a hemisphere, and we want the nipple to be placed on the part of the breast that projects forward the most. This should be approximately the center of the breast. You cannot reference what the center is unless you can also see what the bottom of the breast is (where the lower breast crease is).

Below are several different cases illustrating different variations of anatomy, skin and breast tissue quality, and nipple position. As you view the cases, there is a worsening in the progression of breast ptosis (sagging). In the first three cases, there is mild glandular ptosis (drooping) but the nipple is still in an adequate position. When only the breast glandular tissue is sagging and the nipple is still in the correct position, we call this type of ptosis “pseudoptosis.” I was able to correct the mild glandular ptosis using only a Dual Plane technique. This is achieved through the standard breast crease incision used to place the implant. No additional incisions are required. It involved repositioning the pectoralis major muscle. There is no need to reposition the nipple.

Then there is more severe ptosis of the breast gland in addition to ptosis of the nipple (nipple is too low), then a breast lift is required in addition to the augmentation. Click on the word “case” in each example to see an entire set of photos from all views for that patient with a description of that case.

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In the above case, the breast is small, tight, young, no history of pregnancy. There is minimal breast tissue, no excess of skin, breast tissue and skin of excellent quality, nipple in perfect position above the crease on the most projecting forward portion of the breast. No breast tissue lies below the lower breast crease (red line). Dual Plane I pocket for the implant. No lift is needed.

dpii

In the above case, the breast is a little larger, slightly lax, young, no history of pregnancy. There is a moderate amount of breast tissue, no excess of skin, breast tissue and skin of very good quality, nipple in perfect position above the crease on the most projecting forward portion of the breast. A small amount of breast tissue is lying below the lower breast crease, but the nipple is still well above it. Dual Plane II pocket for the implant. No lift is needed.

dpiii

In the above case, the breast is still of small size, there is no excess of breast skin. The skin has less elasticity, and the breast tissue has poorer quality than the above examples. More of the breast is now lying below the lower breast crease. Dual Plane III pocket for the implant. Still, no lift is needed.

dpi circumvert pexy

In the above case, the nipple itself is still slightly above the crease, but there is slightly more breast tissue and excess skin than the previous case studies, and the tissue quality of each is more compromised. More tissue lies below the crease, and the nipple lies very close to the crease, even though still on the most projecting portion of the breast. In this case, a lift was essential. I created a Dual Plane I pocket for the breast augmentation and a circumvertical (“lollipop”) mastopexy (breast lift) where the scar is around the nipple and also from the lower portion of the nipple to the lower breast crease.

dpi circumvert pexy 2

In the above case, the situation is similar to the case above, except that there is more excess skin with less elasticity, most of the breast is breast is now below the lower breast crease, the nipple is also below the crease, the breast tissue is more compromised than any of the above cases. A Dual Plane I pocket was created for the augmentation, along with a circumvertical (“lollipop”) mastopexy (breast lift).

dpi circumvert pexy 3

This case represents an even more exaggerated sagging of the breasts with all of the breast tissue lying below the breast crease, breast tissue is of very poor quality, nipple is well below the crease and now pointing downward. There is marked excess breast skin with extremely poor elasticity. In this case, I created a Dual Plane I  pocket for the breast augmentation along with a circumvertical (“lollipop”) mastopexy (breast lift).

Two Cases Where I Did Not Perform a Breast Lift at the Time of Augmentation

Below are two case studies of women who desired breast augmentation but did not want a breast lift. Both women had substantial deflation of their breasts following lactation with Grade II ptosis – their nipples were approximately at the level of the lower breast crease (the second case is a little more severe than the first case). In both cases, I did not perform a breast lift. What I did do to address the glandular ptosis (pseudoptosis) was to perform a Dual Plane III pocket dissection, repositioning the lower portion of the pectoralis muscle a little higher over the implant. The implant is still under the muscle on its upper portion, but the lower portion does not have as much muscle coverage. The upper muscle coverage preserves the natural transition from upper chest wall to the breast on the upper breast, but allows the implant to better take up the slack of the excess skin envelope on the lower breast.

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Patient Information: 32 year old female show pre-operatively, 2 days after submuscular placement of 339 cc round silicone gel filled implants placed via a Dual Plane III technique, and 5 months later. Note how the volume of the implant redistributes with time to the lower portion of the breast, rotating the nipple upward. Also, the excessive upper breast fullness corrects as well. Without a dual plane approach, this degree of correction with time could not be achieved. NO LIFT WAS REQUIRED!

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Patient Information: 40 year old female show pre-operatively, 2 days after submuscular placement of 400 cc round silicone gel filled implants placed via a Dual Plane III technique, and 4 months later. Preoperatively, these breasts are severely “deflated”, or demonstrate marked volume loss with relative skin excess. After surgery, note how the volume of the implant redistributes with time to the lower portion and especially the anterior portion of the breast, moving the nipple forward and rotating it upward. Note how the excessive upper breast fullness resolves. Without a dual plane approach, there would be a severe “Snoopy dog” deformity of the breasts, where the breast tissue would hang off the front of the implant. Again, NO LIFT WAS REQUIRED!

SECTIONS – Breast Lift/Mastopexy with Implants

Chapters – Breast Augmentation Guide

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