11 VISUAL LESSONS
Chapter 16 - Breast Augmentation: 11 Important Visual Lessons
In Chapter 16, we illustrate 11 very important visual lessons with actual case results. You'll get a totally new perspective on many critical concepts from these visual lessons!
Excerpts from Chapter 16
Pictures best illustrate some of the most important principles in augmentation. Pictures can also be misleading and confusing. What you see depends on what you know. The more you know, the more thoroughly and systematically you can evaluate pictures. Many of the terms and concepts used in this chapter have been explained in earlier chapters, so this chapter will be most meaningful and useful if you have read the previous chapters.
These visual lessons in augmentation focus on important concepts that every augmentation patient should know.
Every woman's augmentation result is determined by two factors:1) What the woman WANTS, and
2) What the woman's body (her TISSUES) will ALLOW HER TO HAVE (what the surgeon has to work with).
As you look at any pictures of augmentation results, remember:
This woman's breasts are unique in shape and appearance, different from any other woman.
This woman's tissues are different from any other woman.
This woman's wishes are different from any other woman.
It's impossible to look at a catalog of breast pictures, and pick out
what you'd like to have, unless your breasts are exactly the same as the
woman's in the picture before surgery. It's also impossible to know
exactly what the woman in the picture requested. What she wanted might be
very different from what you want. And, most importantly, the characteristics
of her breast tissues are not exactly like yours.
We have chosen each set of images to make a point. Each breast is not the most beautiful breast or the most "perfect" breast. Any experienced surgeon can select a large number of "best" results, but if education is the goal, you need to see a full range of breast types, results, and common problems. As you study the lessons, focus on the message of each image. Don't necessarily ask yourself whether you particularly like the breast. Remember, what you see in a "before" image is all the surgeon had to work with. Perfection or a change to a different breast is never an option. Improvement in the existing breast is the only realistic alternative.
Lesson 1:
Each woman's breasts have unique tissue characteristics. The skin envelope and breast tissue are different in every woman. A surgeon can only work with what the patient brings (her unique tissue characteristics). Ideal choices are different for each woman, depending on her wishes and her tissues.
Case examples from Chapter 16 illustrate how different tissue types can
affect the potential result from an augmentation.
Skin envelope: Tight, unstretched
Breast tissue: Minimal
Skin envelope: Stretched, looser
Breast tissue: Minimal
Skin envelope: Stretched, looser
Breast tissue: Moderate
Skin envelope: Very loose
Breast tissue: Moderate
How will the results differ in women with these different
breast types?
See for yourself in Chapter 16!
Lesson 2:
A woman's breasts are never the same on both sides and no two women
have breasts that are exactly the same. No surgeon can make both breasts
exactly the same; differences will always exist after surgery. Each type
of breast presents unique problems, and every correction involves limitations
and tradeoffs.
These different patients prior to augmentation emphasize the extreme variations in breast characteristics from one woman to another (Figure 16-5, A-L). To further appreciate the differences, pick one characteristic at a time from the following list, then scan across the top and bottom rows, comparing that one specific characteristic from patient to patient.
Breast size
Breast shape
Nipple location on one side compared to the other (one higher or lower)
Nipple tilt (pointing up or down)
Nipple orientation (pointing inward or outward)
Breast size variation from side to side in each patient in front view
Width of the breast in front view
Gap between the breasts in front view
Sag of the breast in side view
Upper breast fullness in side view
All breasts look different after augmentation because all breasts
look different before augmentation. A surgeon can only improve
what the patient brings. A surgeon cannot exchange a patient's tissues for
a different set of tissues. In the before-and-after illustrations that
follow, notice that each result is only an improvement over what the patient
has before surgery. The appearance of the breast before surgery is a major
factor affecting the appearance of the result. Breast augmentation surgery
offers improvement, not perfection.
Visual examples from Chapter 16 show you how different tissue types and different sets of problems differ from patient to patient. More importantly, the examples show you what it's possible to correct, and what sometimes can't be corrected.
Tissues: No pregnancies, skin envelope not stretched, minimal breast tissue, thin tissues.
Problems: Breasts too small for torso, left smaller than right, left higher than right, left nipple higher than right, wide gap between the breasts, inadequate upper fullness.
Corrections, limitations, tradeoffs: Size and proportion improved, left nipple higher than right (patient declined lifting the right nipple to avoid more scars and possible loss of sensation), gap between breasts narrowed some. Patient elected to accept a slightly wider gap following surgery rather than risk a visible implant edge in the cleavage area if we had selected a wider implant to further narrow the gap.
Tissues: Two pregnancies, skin envelope moderately stretched, moderate breast tissue, tissues thin (note visible ribs beneath breasts).
Problems: Loss of upper fullness, loss of forward projection, excessively wide gap between the breasts or not enough cleavage,
Corrections, limitations, tradeoffs: Improved upper fullness, cleavage, and projection. Better overall proportion with torso by widening breasts at the sides. In front view, widening the breasts at the sides improves the balance of breast width with hip width and makes the waist appear smaller.
Tissues: Two pregnancies, stretched envelope, minimal breast tissue
Problems: Very narrow breasts in front view with wide gap between breasts, thin skin in gap between breasts, thin skin envelope with ribs visible, breasts too triangular or "pointy" rather than round in front view, no upper breast fullness.
Corrections, limitations, tradeoffs: Overall improved appearance, with a rounder, fuller appearance. Gap between breasts narrowed some, but limited because of thin skin between breasts and risk of visible implant edge if wider implant were used to narrow the gap more. Dramatic improvement in upper fullness and overall breast shape while preserving a natural breast appearance after augmentation.
Tissues: Two pregnancies, but minimal stretch of the skin envelope, moderate amount of breast tissue, envelope already relatively full (note upper breast is relatively full in side view before surgery).
Problems: Patient desires more cleavage, larger, fuller breasts to improve balance with hips and torso, overall figure balance.
Corrections, limitations, tradeoffs: Dramatic improvement in cleavage was possible because the gap between the breasts was narrower prior to surgery, the breast tissue was wider (to cover the edges of the implant), and the patient's skin was thicker in the gap between the breasts. All of these factors reduce the risk of seeing an implant edge between the breasts, and allowed use of a wider implant to maximally improve the cleavage. Overall breast fullness improved, overall balance with figure improved.
Tissues: No pregnancies, skin envelope not stretched by pregnancy, but stretched by gravity pulling downward on breasts over time. Moderate amount of breast tissue, located primarily in the lower portion of the skin envelope. Breast shape determined by developmental factors during puberty and by gravity over time.
Problems: Extreme down-pointing breasts, nipple-areola located low on breast mound and down-pointing, sagging appearance, inadequate fullness upper breast, inadequate cleavage or fullness in the middle area of each breast. Nipples located toward the outside of each breast mound rather than more centrally.
Corrections, limitations, tradeoffs: Patient declined nipple repositioning due to tradeoffs of scar around nipple-areola and possible sensory loss. Overall appearance improved, but with limitations. Nipples lifted, but still somewhat down-pointing. Nipples still located toward the outside of each breast mound. Upper fullness improved, overall breast shape improved, cleavage improved. Narrowing of the gap between the breasts limited due to risk of visible implant edge under the thin skin between the breasts if a wider implant were placed.
Tissues: Envelope thin, not stretched, virtually no breast tissue present.
Problems: Very little skin to work with, very difficult to achieve a normal appearing breast without the implant being obvious, lack of fullness in all areas of the breast, figure imbalance breasts with torso and hips, lack of cleavage with wide gap between the breasts.
Corrections, limitations, tradeoffs: Improved overall breast shape and fullness, natural appearing breast, implant not obvious, improved cleavage and narrowing of gap between breasts but limited due to thin skin between breasts and risk of implant edge visibility.
Lesson 3:
What is enough, and what is too much?
A critical lesson that many patients, unfortunately, learn about after it's too late!
Lesson 4:
You won't look like your friend
Let's assume that two friends (we'll call them Sharon and Janet, but the names are fictitious) decide to have breast augmentation. Sharon has her augmentation first.
Janet sees Sharon's result, and says, "I want my result to look just like Sharon's." When we examined Janet, we found that her breasts were very different than Sharon's. Can we produce the same breast that we produced for Sharon? Of course not, because the breasts were so different before augmentation. Janet's result is shown in Figure 16-14, C-D.
Note the differences Sharon and Janet before surgery:
Sharon |
Janet |
| Wide breast in front view | Narrow breast in front view |
| Narrow gap between breasts | Wide gap between breasts |
| More breast tissue in skin envelope | Less breast tissue in skin envelope |
| Thicker skin envelope | Thin skin envelope |
| Skin envelope not very stretched | Skin envelope very stretched |
A surgeon cannot change the differences in these two patients' tissues before surgery. Different tissues before surgery guarantee that their breasts will be different after surgery.
Lesson 5:
A certain size implant does not produce a certain size breast.
We go back to sharon and Janet again in this lesson to prove to you that a certain size implant does NOT produce a certain size breast! You'll need to see for yourself!
Lesson 6:
Cleavage-what makes it and how much can I get?
In this lesson, we show you what actually creates cleavage, and factors that may limit how much cleavage you can get without incurring problems and tradeoffs that you are probably not aware of!
Lesson 7:
A certain incision location or pocket location (beneath breast or beneath muscle) does not produce a specific appearance in the result.
If you looked through our extensive before-and-after pictures in our office, you absolutely cannot tell by looking at a picture whether an implant is placed above muscle (behind breast tissue only) or beneath the pectoralis muscle. An experienced augmentation surgeon can produce almost exactly the same result above or below muscle, provided the surgeon has adequate experience with both locations.
This lesson gives you visual proof that you usually can't tell from a picture whether the implant is above or below muscle.
Lesson 8:
Nipples point where they point. Surgically repositioning nipples involves substantial tradeoffs.
Can we change the position of nipples or the direction they point? If so, when is it reasonable to do so? These examples help you understand the tradeoffs.
Lesson 9:
A round implant can produce a breast that looks good but may have a folded implant shell that can fail earlier. An anatomic shaped implant can be filled adequately to protect the shell and still achieve a natural appearing upper breast.
If your breast looks good, would you care if your implant might rupture sooner? How could this happen with a round implant? This lesson shows you.
Lesson 10:
The prices you can pay for selecting an excessively large implant
The skin envelope of the breast stretches to accommodate the enlargement of the breast during pregnancy and nursing, but this enlargement is a natural, physiologic process that occurs over several months and is usually limited to a moderate amount of enlargement. Breast augmentation enlarges the breast very rapidly, and the amount of enlargement depends on the patient's wishes and her tissues.
When a woman selects excessively large implants, she may enjoy the result for a while, but she is choosing long-term risks that she may not like. The skin envelope of the breast does not improve as a woman ages. Visualize your grandmother's breasts. Skin usually gets thinner and stretches as gravity pulls on the breast over time, with or without an implant. The larger the implant, the heavier the implant, the more stretch and thinning of tissues occurs, and the more rapidly it occurs. Excessively large implants can cause any or all of the following problems:
Excessive skin stretching
Sagging of the breast
Loss of upper breast fullness as the lower breast stretches
Thinning of the skin envelope
Shrinkage of the patient's own breast tissue from pressure by the implant
Visible implant edges
Visible rippling caused by the heavy implant pulling downward on the skin envelope (Figure 16-24)
Distortion of breast shape.
What implant size is safe and what is excessive?
Chapter 16 has the answers.
Lesson 11:
What is capsular contracture?
When a medical device is placed in the body, the body forms a tissue lining around the device. This lining, called a capsule, forms around every breast implant in every patient. In most patients, the lining surrounds the implant, but does not cause any problem. In a small percentage of patients, the capsule contracts or tightens excessively, squeezing on the implant, making the implant feel too hard, and often pushing the implant out of position and distorting breast shape.
What does capsular contracture look like?
How is it corrected, and what is the appearance after correction?
It's all in Lesson 11.
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