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Dr. Linder's Blog
Read more testimonials here
LIFTING THE BREAST WITHOUT USING IMPLANTS
In general, lifting the breasts without implants requires a form of a breast lift procedure. For patients who desire a lift, but do not want larger breasts, a breast lift procedure including a periareolar crescent lift or small lift, a vertical mastopexy for mild to moderate skin laxity or a formal mastopexy using the inferior pedicle Wise-pattern technique or anchor scar is useful for complete tightening of the breast pocket. Patients who present with significant amounts of breast tissue and grade 3 ptosis can have a nice breast lift without use of an implant. It should be noted, however, upper pole fullness without an implant is never the same as with an implant, even a small implant. As a result, patients often are not happy with breast lifts without a small implant because they do not achieve that same upper pole fullness as those women who have a prosthetic device placed in the superior, medial and central portions of the breast. To lift the breast without a prosthetic device obviously requires tightening of the breast with skin removal. Scarring is the most significant risk and this can include keloid hypertrophic scarring, widespread scarring, and hyperpigmentation.
We perform breast lifts in our Beverly Hills surgical practice every week. This is for both primary as well as the revision breast surgery in which patients present with double-bubble deformities, grade 3 ptosis or severe skin laxity.
DOUBLE BUBBLE BREAST DEFORMITY WITH
BREAST HYPERTROPHY AND UPPER POLE VISIBILITY
The patient below presents with disproportionately large breast implants that were placed for her body. The patient had a Benelli round block lift as well as large 500 moderate smooth silicone gel implants placed approximately 10 years ago. Unhappy with the appearance of the breasts with upper pole rippling, visibility as well as severe hanging and the lateral width is too wide, a better appearance for her body due to the narrowness of her hips, flanks and shoulder would be to use a more tapered implant such as the style 45, 460 cc Allergan gel implant, slightly downsizing in size or volume as well as recreating a complete formal mastopexy using the inferior pedicle Wise-pattern technique. The patient underwent complete removal and reimplantation with the 460 implants.
Note, her implant was actually ruptured on the right where the shell actually has ooze presenting out of it. After removing the implants and replacing them with the extra style 45, this greatly reduced visibility of the upper pole rippling.
The formal mastopexy was performed using the inferior pedicle Wise-pattern technique, removing a tremendous amount of skin which led to a greatly enhanced tightening of her breast as can be seen directly on the operating room table just prior to placing the patient’s dressings.
In order to correct severe double bubble deformities, the implants must be repositioned correctly, the skin envelope must be addressed where the nipple areolar complex must be superiorly raised and skin from along the inframammary fold and the vertical limb must be appropriately removed.
Below is a case example of a severe double-bubble breast deformity in which the patient presented status post augmentation mammoplasty procedure 26 years ago through a transaxillary approach which she thought were saline implants. Intraoperatively, the patient was found to have Becker double lumen silicone gel, internal lumen and saline external lumen implants. Note, on the photograph the outer layer of saline has actually ruptured and has leaked out through the shell; however, the silicone remains within the intra capsule. In any case, there is greater underfill of this implant which required reconstruction using style 45, 550 cc extra high profile Natrelle silicone gel implants, open capsulectomy and a secondary formal mastopexy. Her postoperative photos will be presented on a blog in approximately eight to 12 weeks.
Becker implants have been used for both cosmetic and reconstructive purposes in the past. I personally do not use these implants. We either use straight saline or silicone cohesive implants. The double lumen shall Beck implants have a relatively thin external shell and I have seen a significant number of ruptured Becker implants over the last 15 years. Patients often do not know what type of implant and what the viscosity of the implants are internally, silicone versus saline, and it is extraordinarily rare that they can remember having these double lumen Becker implants with saline exterior and silicone interior lumens.
Pseudoptosis refers to extra skin from the breast; however, the nipple areolar complex is located above the inframammary fold. There are four types of ptosis, Grade 1, 2, 3 and pseudoptosis. Pseudoptosis can easily be treated with a straight augmentation mammoplasty procedure, saline or silicone implants, without the need for a breast lift. The preop photo below shows significant amounts of involutional upper pole atrophy with skin ptosis. However, the nipple areolar complex is above the fold. As a result, placing the implant in the dual plane technique (two-thirds below the muscle, lateral third above) should easily fill out the tissue envelope, allowing for a beautiful fullness without the need for a breast lift. Postoperative photo shows 500 cc high profile saline implant placed under the muscle through a periareolar approach. She is now three months postop. Notice that the pseudoptosis has been completely taken care of the implant alone without the requirement of any formal breast lift whatsoever. Pseudoptosis once again is easily treatable by augmentation mammoplasty surgery without the need of a breast lift. Board Certified Plastic and Reconstructive Surgeons who specialize in breast augmentation and reconstruction should be able to identify pseudoptosis and correct this accordingly.
Breast augmentation costs will vary from region to region throughout the United States. In general; however, with the economy being in the state that it is, certainly augmentation mammoplasty, both with silicone as well as saline implants, has reduced significantly in the last 48 months. The straight breast enhancement surgery with saline implants is significant less than with silicone implants due to the reduced cost of saline implants themselves. Costs associated with breast enhancement surgery include the operating room fees, the anesthesiologist, the implant costs (saline versus silicone) and the surgeon’s fee. The implants fees in general are usually fixed and they vary according to the volume of implants that the specific plastic surgeon orders annually. Obviously, the more implants that are ordered, the reduced fee cost due to higher volume. Operating room costs can vary between $1000 and $1500 per hour, depending upon length in the operating room as well as anesthesia fees vary with the anesthesiologists throughout the United States. They can range between $500 and $1000 an hour with Board Certified Anesthesiologists. Saline implants in general can range between $250 to $800 per implant, depending upon Allergan and/or Mentor Corporation. Silicone implants usually are fixed between $750 per implant to $1250. The fees for straight saline augmentation without any form of lifting can range between $3500 and $6500. Silicone implant fees will range between $6500 and $10,000, depending upon different geographical areas throughout the United States. In Beverly Hills, due to the high cost of rent, labor and implants, fees are usually slightly higher than in other areas of the United States.
When considering breast augmentation, it is most important to see a specialist in breast augmentation, breast revision surgery, who is Board Certified with the American Board of Plastic Surgery. There are absolutely no substitutes whatsoever. The centers should be licensed and only Board Certified Anesthesiologists should be used. The only two FDA-approved implants are Mentor and Allergan Pharmaceuticals. We use currently Allergan Pharmaceutical implants, Natrelle implants which have a lifetime warranty on the implants, both saline and silicone. Remember, the final cost should not be the ultimate determinate of your surgery, but rather, to achieve the best surgical outcome with the most experienced qualified Board Certified Plastic Surgeon.
There is a fallacy in the community that silicone gel implants do not ripple. This is completely untrue. All implants, saline and silicone, can ripple. In fact, silicone textured implants can ripple more than smooth saline implants. Patients who have thin tissue, are ectomorphic, have minimal amounts of breast tissue and/or muscle, are at high risk of visibility and rippling. Rippling is increased with 1) placing implants above the muscle; 2) using textured implants; 3) having minimal amounts of tissue coverage; and 4) using under-filled silicone gel implants aka moderate profile versus extra high profile. In order to reduce visibility and rippling from silicone gel implants, a gel implant with more fill or more projection such as a style 45 or style 20, may greatly reduce visibility and rippling, especially along the medial breast area. Rippling is mostly notable along the lateral breast even when the dual plane technique or subpectoral augmentations are performed because there is no coverage of the outer 25% of the implant by muscle. The lateral border of the pectoralis major muscle is an oblique muscle, not vertical, and therefore the outer 25% to one-third of the implant will be covered only by glandular and/or breast tissue. Women often see visibility and rippling with silicone implants when bending over, with bikinis or dresses that would reveal the lateral outer aspect of the breast. The cure all for rippling includes 1) increasing tissue coverage by placing the implant in the submuscular dual plane technique rather than above the muscle (retromammary or subglandular); 2) using smooth gel implants instead of textured implants; and 3) using increased projection such as the style 45 silicone implant with increased fill and more projection.
Stuart. A. Linder, M.D., F.A.C.S. is a Beverly Hills plastic and reconstructive surgeon specializing in breast augmentation, liposuction, tummy tuck, and more.
Dr. Linder is certified by the American Society of Plastic and Reconstructive Surgeons and is a diplomate of the American Board of Plastic Surgery (ABPS).