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Breast Augmentation Information Resource for Southern California including Orange County, Los Angeles, Newport Beach, San Diego, and Beverly Hills.

 

Breast Enlargement

 

 

Dr. Cruise's Philosophy Regarding Breast Enlargement

 

The beauty of breast augmentation is not only the dramatic results that it creates but also its predictability. Patient satisfaction when the surgery is in an experienced plastic surgeon's hands is very high. A woman's successful breast augmentation starts with finding a plastic surgeon who has experience and will take the time to find out exactly what look she is seeking. This is not as simple as it may seem. There are many variables that must be taken into consideration by you and your plastic surgeon. In this section I will go over my thought process so that it may guide you in achieving the look you want to obtain. I have broken the process into categories that I take into consideration during every breast augmentation consultation.

 

1. Size

One of the biggest reasons why breast augmentation patients have to be revised is because the wrong implant size was used. Therefore, it is critical to make sure that you know what you want and that this is conveyed to your plastic surgeon. You should leave your consultation feeling confident that your surgeon and patient coordinator have discussed thoroughly what size you want to be. This is more difficult than it may seem, as the same implant will have a completely different look on two different women. In addition, cup sizes are misleading as they vary significantly between different brands.

 

A key factor in determining proper implant size is that your plastic surgeon has an accurate process to do so. At Cruise Plastic Surgery, we have dramatically reduced the guesswork by devising a bra-sizing system. This system accurately demonstrates what the various size implants will look like on you while you look at yourself in a mirror. At your consultation, we will put the trial bra on you and let you stand in front of a mirror to see what your new breasts will look like. Ideally, you will bring along a significant other or close friend to help you make this decision. Our patient coordinators will help you with the process and give you their experienced opinion.

 

Often, the patient does not know what is best for her until she sees it on herself by this method of bra sizing. While other, methods may work as well, this one has really worked well for us. Once again, it is important that you feel your plastic surgeon truly understands what you are looking for when you leave your consultation.

 

2. Shape

To me, shape is the most overlooked part of breast enlargement. This is especially surprising considering how important it is. During my consultation, I talk about the shape the patient wants to achieve in the upper part of the breast. I divide it into three options: Natural, "California Natural," and Dramatic.

 

• Natural

Natural means a straight or even a slightly concave upper part of the breast. This is what you would find in a youthful, non-augmented breast. It is full, but does not look like it has been augmented. It is ideal for someone who does not want anyone to know she has been augmented but still wants to have a sexy, more proportionate shape to her breasts.

 

Natural Shape after Augmentation

Patient 5'10", 150 lbs - went from 36B to 36C/D. Saline Implant 440-460cc Low Profile filled to 460cc. Implants were placed under the muscle. Notice the gentle slope of the upper breast despite using a large implant.

 

 

• "California Natural"

I coined the term "California" Natural to describe women who want to have full upper breasts slightly rounder than natural but do not want the change to be too dramatic. Before I created this intermediary category, these woman would say they wanted to be "natural." Living in California, our perception of "natural" is slightly skewed to a fuller look than what natural really is. These women want a slightly rounded shape to the upper breast without a "shelfy" look. The "California Natural" breast has a slight convexity to it. It can look very natural in loose clothing but can look dramatic in a push up bra.

 

"California Natural"

Patient 5'4", 120 lbs. - went from 32A to 34C. Saline Implant 330-360 Moderate Profile was filled to 345cc, placed under the muscle. Notice the slightly rounded upper part of the breast.

 

• Dramatic

Dramatic speaks for itself. These woman want significant projection of the breast. This will create a dramatic look to the breasts even without a bra to push them up.

 

Dramatic Look

Patient 5'6", 140 lbs. went from 34B to 36DD. Saline Implants 510-540 Moderate Profile were filled to 550cc, placed under the muscle. Notice the rounded appearance of the upper part of the breast.

 

3. Profile

I purposely placed discussion of breast profile directly under breast shape because profile has a significant effect on shape. There are three different types of profiles: low, moderate, and high.

 

 

For the most part, I utilize a moderate profile as I feel it does the best job of obtaining the right size and shape. Low profile is ideal for patients who want a smaller implant (i.e., below 350cc) and want to be as natural as possible. In fact, I do not even call it "low" profile as I prefer the name "natural" profile.

 

I use high profile implants on patients who want to go quite large (i.e., above 600cc). In these women, moderate profile implants would be too wide to fit on their chest without spilling over into the arm region.

 

Their is a difference in shape between saline and silicone. For a given volume, silicone will have a more natural shape in the upper breast. For this reason, saline implants tend to look bigger even though the volume is the same. This can be minimized by not filling the saline implants to the top of their fill volume. This gives a more natural appearance. Underfilling too much, however, increases the risk of rippling.

 

With silicone implants, I am more likely to choose high profile implants if the women wants the "California Natural" or a more dramatic look. You should always remember that more projection means less width, and less width may mean a bigger gap in the midline. Conversely, the low or "natural" profile saline implants create an almost silicone type appearance. This is ideal for the woman who wants a natural look but does not want silicone implants.

 

4. Implant Placement (Above or Below the Muscle)

Let's first define what we mean by above or below the muscle. The muscle we are talking about is the Pectoralis Major muscle. It runs along a diagonal from the chest to the shoulder.

 

Pectoralis Major Muscle - runs across the chest diagonally to the shoulder.

 

Breast Implant Above the Pectoralis Major Muscle

 

 

Breast Implant Under Pectoralis Major Muscle

 

Good results can be obtained above or below the pectoralis major muscle. I strongly believe, however, that under the muscle provides the best results for several reasons. The most important reason is that it lowers the chance of capsular contracture or "hardening of the implant." The muscle acts as a constant massager of the implant helping to keep it soft. From an aesthetic standpoint, it has several advantages. It acts as a buffer giving an added layer of implant coverage. This is especially helpful in the upper part of the breast. The muscle diffuses the implant over a greater area preventing a "shelfy" and overly round appearance. In addition, placing the implant under the muscle significantly decreases the chance of rippling except along the lateral part of the breast where the pectoralis major muscle does not exist.

 

Implant Under Pectoralis Major Muscle. Notice how the lower lateral portion of the implant is not covered by muscle.

 

As you can see, the entire lateral part of the implant is uncovered even when the implant is placed under the muscle. To provide better coverage, I have developed a unique way of putting the implant under another muscle along the lateral chest wall to almost completely cover the entire implant. This muscle is called the serratus anterior. This is why, I believe, my saline implants rarely having rippling.

 

Implant Covered by Both Pectoralis Major and Serratus Muscles

 

In addition to providing valuable coverage, the Serratus Anterior also prevents the implant from migrating into the armpit. Furthermore, this muscle pushes the implant toward the midline giving enhanced cleavage. Think of it a a book shelf preventing the implants from sliding outward.

 

5. Location

Location is where the implant is placed on the breast. Most women, when given the choice, prefer the implant to be as close to the midline as possible. This provides better cleavage and prevents the implant from falling out laterally toward the armpit. To accomplish this I put the implant under the Serratus Anterior muscle. Plastic surgeons, however, must be careful not to place them too close to midline as this can cause symmastia and/or visible rippling.

 

Another aspect of location is how high to put the implant. A great example of this is women who have a small amount of sag. Here, it becomes useful to place the implant slightly lower so that it gives the breast the appearance of a breast lift. This is done by completely releasing the Pectoralis Major and Serratus Anterior muscle at its lowest point. This is called a "Dual Plane" implant placement. Dual plane means that the lowest part of the implant is actually not under muscle. Here, the fold below the breast is lowered slightly. Care must be taken to not lower it too much as this can create a "bottoming out" appearance.

 

Pectoralis Major Muscle covers half of the implant. It prevents the implant from descending.

 

Dual Plane - Notice how inferior part of muscle has been released allowing implant to go slightly lower.

 

 

6. Incision

The three most common locations for breast augmentation incisions are the axilla, the areola, and the inframammary fold.

All 3 incisions can provide excellent results. The incision along the margin of the areola allows for very accurate implant placement. The scar becomes almost imperceptible within 2 months in most women. The incision within the fold at the bottom of the breast can provide equally good results. It does not have the advantage of a darker color for the incision to hide within. Also this incisions tends to remain redder for a longer period of time than the peri-areolar incision. The axillary incision also can provide a great result but implant placement is more difficult because the implant is being placed from a remote location.

 

I utilize both the areola and the inframammary incision depending on the situation. I prefer the areola incision as the darker color of the areola hides the incision extremely well and is hard to see even in the early healing stages. I use the inframammary incision in woman who want silicone implants but have an areola smaller than 4 cm. Remember, silicone implants require a larger incision than saline implants. The inframammary incision is often the better choice in women who already have a moderate amount of breast tissue. In these women, the incision is well hidden by the breast tissue and it provides a more direct route for implant placement.

 

A fourth option for the incision is through the navel. Some plastic surgeons use this incision but the results when compared to the standard incisions are not as predictable. It is impossible to visualize the pocket where the implant will be placed. For this reason I, and most plastic surgeons, no longer perform breast augmentation via this approach. This is not to say that this incision cannot produce good results, it is just that the results are less predictable.

 

7. Silicone Implants Versus Saline Implants

I usually provide the facts and leave the decision up to the patient. The facts are both implants can provide a great result. Many plastic surgeons strongly recommend silicone because it has a lower rate of rippling. This is not so true in my practice as rippling is not very common. I believe this is because I put the implant under both the serratus anterior and pectoralis muscle.

 

Simply put, silicone implants have a more natural feel. So I tell my patients, "If a natural feel is very important to you, go with the silicone." Another advantage of silicone is that it produces a more natural appearance to the upper part of the breast. Some people want this natural look others want a more full look, i.e., "California Natural."

 

Still, it possible to create a "California Natural" look with silicone by using a high profile implant. A high profile silicone implant creates a shape similar to a moderate profile saline. A moderate profile silicone implant creates an upper breast shape similar to a low or "natural" profile saline implant.

The major advantage of saline is that if it ever ruptures the saline simply gets flushed out of the body. Silicone, on the other hand, will stay in place. Sometimes, it is hard to tell if a silicone implant has ruptured as it maintains it shape relatively well.

 

In summary, choose silicone implants if you want the most natural feel and the most natural shape. Choose saline implants if you are concerned about the effects of silicone gel.

 

I should point out that women who already have a fair amount of breast tissue do not necessarily need silicone implants. They already have enough tissue to obtain a natural feel even with saline implants. On the flip side, women with almost no breast tissue should seriously consider silicone as they do not have much coverage at all. Saline implants in these women would look much less natural than silicone.

 

8. Asymmetry

Asymmetry is important to point out as virtually every woman has some degree of it. The key is to determine what is causing the asymmetry and correct it as much as possible. Complete correction of asymmetry is not possible. The three most common asymmetries involve a) nipple height, b) inframammary fold level, and c) breast volume.

 

• Nipple Asymmetry. Typically, I do not treat discrepancy in nipple position unless there is a greater than 1.5cm difference between the two breasts. When the difference is 1.5cm or greater this difference will become apparent when a tight shirt is worn and the nipple location is clearly visible. In this case I recommend a donut breast lift to even the nipples out. See the section on Breast Lift.

 

• Inframammary Fold Asymmetry. The inframammary fold is the crease at the bottom of the breast. When there is a difference of IMF height it can make the breast look asymmetric. This often can be easily corrected by lowering the higher of the two IMFs during the breast augmentation procedure.

 

• Breast Volume Asymmetry. Most differences in breast volume will not be noticeable after augmentation even if the same implants are used on both sides. In fact, I try not to use different sized implants as this can actually create asymmetry especially within the upper breast. Putting a bigger implant in the smaller breast may improve the volume asymmetry but will create breasts with two different shapes. When the volume difference is great than two different sizes are necessary. In this case, I usually recommend silicone so that the difference in shape of the upper breast is minimal.

 

 

9. Excess Fat near Arm Pits or Lateral Breast Roll

Fat deposits around the breast are important to discuss during consultation as it has a big impact of the overall look. The two most common areas that are a problem are the axilla and the lateral breast roll. Liposuction of these two areas can easily be done at the same time of breast implantation. I must warn you that concomitant liposuction will make the breasts bruise and swell more than breast augmentation alone. It is certainly worth it for women who have these two fat deposits and have grown to despise them.

 

The two most common fatty deposits that often need to be addressed with breast augmentation are the axillary fat and the lateral breast roll fat.

 

Examining these areas shows that the plastic surgeon is looking at the entire breast area and not just the breast itself. If these areas bother you, be sure to point them out to your plastic surgeon if he does not do so himself.

 

10. Tuberous Breasts

Tuberous breasts are breasts that have not fully developed especially along the lower part. This causes the bottom of the breast to look tight and constricted instead of a full and round. Tuberous breasts often have a very short distance for the bottom of the areola to the inframammary fold. This distance should be at least 5 cm.

Tuberous Breasts

Example of tuberous breasts. Notice underdevelopment of lower part of the breast and its correction with breast implantation.

 

Often, women with tuberous breasts do not realize that this is abnormal. They may feel ashamed of their breasts which may prevent them from seeking help. Fortunately, breast augmentation can significantly help this condition. This is especially satisfying to me as the results can be dramatic.

 

11. Breast Sag

I saved this topic for last as it encompasses many things. It is explained in greater detail within the Breast Lift section. It is, however, important to talk about it so that you understand what is necessary to create the beautiful breasts that you are looking for. I understand your concern about putting scars on your breast. I take this into consideration as we decide together what is best for you. The truth is, if you have significant sag, a proper breast lift with augmentation is far superior to an augmentation alone. In fact, an augmentation alone may give you a very elongated, older appearing breast. This has been given the nickname "rock in a sock" look. What we are looking for is a lifted, round appearance seen in a youthful breast.

 

	Patient treated with breast augmentation alone who really needed breast augmentation in conjunction with breast lift. The surgeon placed the implants very low to avoid a breast lift. In reality this created a very elongated, older appearance of the breast and significantly shorter abdomen.

 

The most important thing is, and I cannot stress this enough, find a plastic surgeon with considerable experience with this procedure. Breast lifting with augmentation is very challenging as there are many co-existing variables.

 

"Rock in the sock" - correction

The same patient after anchor breast lift, elevation of inframammary fold and changing implant to a smaller size. Notice the upper fullness, improved cleavage and longer torso.

 

When evaluating sag, both the entire breast and the patient's wishes need to be taken into consideration. To make things as simple as possible, I will discuss the two most important considerations. They are not absolute measurements. These are the 1) relationship of the nipple to the Inframammary Fold (IMF) and 2) the relationship of the bottom of the breast to the IMF. Other factors, of course, will need to be discussed at the time of consultation.

 

Before we get started, it is important to point out that breasts with more natural tissue are more likely to need a lift. This is because the bottom of the breast will continue to fall. To remedy this, removing this breast tissue with a lift will correct the sag and actually lessen the chance of sag in the future.

 

Another consideration is the size of the implant. A bigger implant will provided more lift: this makes sense as more volume will fill the excess skin envelope more adequately. Of course, you should choose a larger implant for this reason alone, as the amount of lift that an implant can provide is limited.

 

A breast lift alone rarely produces a great result as usually there is very little breast tissue in the upper chest. This can only be adequately treated by augmentation. Even patients with significant breast tissue usually benefit from the upper breast fullness created by an implant. In these cases, I usually will remove all the undesirable sagging breast tissue and put in a relatively small implant to create an attractive upper breast with cleavage.

 

There are four common breast lifts with implants:

• Augmentation alone.
• Augmentation with Donut Lift.
• Augmentation with Lollipop Lift.
• Augmentation with Anchor Lift.

 

• Augmentation Alone

Once again, this will depend on the size of the implant. Usually, augmentation is all that is necessary when the nipple is above the level of the IMF and the bottom of the breast is no greater than 2 cm below the IMF. This is especially true when there is not much breast tissue. Heavier breasts require more to lift them.

 

Correction of Moderate Sag with Implants

37-year-old female with minimal breast sag corrected by breast implant alone.

• Donut Lift

The Donut lift is also known as the peri-areolar lift. It involves removing skin in the shape of a circle around the areola and placing a suture within this circle. This circular suture acts as a purse string to tighten this bigger circle into a smaller circle. This elevates the nipple into a higher position.

 

One might consider that the donut lift is more of a nipple lift than a breast lift. This is because it does not really lift sagging breast tissue that has dropped greater than 2 cm below the IMF. It does however, elevate the nipple. It is ideal for the breast that has minimal sag and not much tissue.

 

Good candidates for the Donut Lift have a nipple that is at or slightly below the IMF and the bottom of the breast no more than 2 to 3 cm below the IMF.

 

• Lollipop Breast Lift

This type of breast lift involves an incision around the areola and straight down the bottom of the breast. Patients often do not want this lift because they do not want the vertical incision. This incision, if properly placed by an experienced plastic surgeon, is quite acceptable. Truth is, if it is necessary it is a far better procedure than the Donut Lift as it actually removes the hanging breast tissue. Further sag in the future is dramatically reduced or prevented.

 

Candidates for the Lollipop Lift are women with nipples greater than 2 cm below the IMF and the bottom of the breast greater than 3 cm below the IMF.

 

Lollipop Breast Lift with Augmentation

51-year-old female with some breast sag corrected by Lollipop Lift with 430cc Implant.

 

 

• Anchor Lift

The Anchor Lift is quite similar to the Lollipop Lift except that it has an additional incision that falls within the IMF. This extra incision is necessary to remove excess skin from breast sag. The horizontal incision within the IMF is actually not visible when the patient is in a standing position and is quite hard to see otherwise.

 

Candidates for the Anchor Lift are women whose breast tissue falls significantly below the IMF. Whether this horizontal skin removal is necessary depends on many things. If the bottom of your breast is greater than 6 cm below the IMF, a horizontal incision will be necessary.

 

The length of the horizontal incision depends on how far the bottom of the breast falls. For example, a breast 10 cm below the IMF will need a longer horizontal incision than one 6 cm below the IMF.

 

Anchor Breast Lift with Augmentation

31-year-old female with some breast sag corrected by Anchor Breast Lift with 370 cc Low Profile Saline Implants.

 

 

I know this is a tremendous amount of information but, believe it or not, I condensed it down as best as I could. I know this information is important to you. It always surprises me how much my patients understand as long as the information is presented to them in an easy to understand, sensible fashion.

 

It is your job to understand the material as best as you can. It is my job to understand the fine nuances that go far beyond the scope of this presentation. This is where the art and science of plastic surgery come together and make it all worthwhile.

 

Breast Augmentation Information Resource for Orange County, Newport Beach, Los Angeles, San Diego, Beverly Hills, and  Southern California