When it comes to anything and everything breast-aesthetics related, La Jolla, CA plastic surgeon Robert Singer, MD says his number-one piece of advice is that you do it for your own reasons and, coming in a close second: Be realistic about your expectations. “No matter what procedure you may choose to get, you should be medically fit, healthy, not pregnant, old enough that your breasts have fully developed, and not a smoker—as this will increase the risk of delayed healing. Plus, like with any aesthetic surgery, you need to be fully aware of benefits and risk.” Here, plastic surgeons break down the core range of options:
What it is: As the name suggests, this is the procedure that aims to increase breast size, which is typically done via implants, but can also be done with fat transfer (although Dr. Singer stresses most patients will get longer-standing results with implants and, realistically, you can only go up one cup size via fat injections).
Who’s a good candidate: “Breast implants are for the patient seeking to increase the size of her breasts for personal reasons, restoration of breast shape/volume following mastectomy, or breast asymmetry,” says Eugene, OR plastic surgeon Mark Jewell, MD.
Who’s not a good candidate: According to Dr. Jewell, anyone with thin tissue, a loose envelope (which may be better suited for a mastopexy, plus implants), a previous history of radiation therapy, a compromised immune system, presence of infection anywhere in the body, unrealistic expectations, medical conditions, bleeding disorders, or someone who is pregnant or nursing, is not someone he would recommend for a breast augmentation.
What else to know: Accurate management of size expectations is absolutely necessary, Dr. Jewell notes, adding that this also includes the importance of discussing with your surgeon implant location, based on your activity profile and amount of issue. Two falsehoods he clarifies: “Women with breast implants who plan pregnancies should be able to successfully breast feed their infants, according to published studies. Published outcome data also indicates that around 92-percent of patients who have breast augmentation are satisfied with their outcome at 10 years following surgery.” As with all the below surgeries, breast augmentation should also only be performed by an experienced, properly board-certified plastic surgeon in an accredited facility (office surgery unit, free-standing ambulatory surgery center) under intravenous sedation/local anesthesia or general anesthesia).
By the numbers: New York plastic surgeon Jeffrey S. Yager, MD shares that he finds the most anxiety-provoking part for the patient is deciding which sized implant to go with—and he relies on a very visual method to alleviate concerns. “I’ve found that the most accurate method is to show photos of my patients after surgery, and to ask if they appear to be the right size, too big or too small. If I ask what cup size they want, you need to understand that all bras are different, and more than 85 percent of women wear the wrong bra size.”
Inside tip: In general, Pasadena, CA plastic surgeon Lily Lee, MD stresses, the best breast plastic surgery candidates are people who are stable in weight and not going through major life changes (pregnancy, breastfeeding or menopause). “The best candidate for augmentation is a client who is young enough that pregnancy and breastfeeding have not caused ptosis (necessitating a lift), and yet she is mature enough to understand that this is a permanent change to her body. Often times if the client is very immature and has not completely thought through the process, it can lead to regret—which nobody wants.” Dr. Singer adds that trying on sizers of different sizes and shapes is critical for better communication concerning outcomes.
What it is: With time and aging, things change, and Dr. Singer says a revision breast surgery doesn’t necessarily mean you had bad results that need to be fixed, as many assume. “Even if you had good results with a first breast surgery, you lose volume with normal aging over time, or you may simply want a change.” Likewise, Dr. Lee says revisions can happen years—even decades later—as the body changes. “It is important to remember that our bodies are dynamic, while an implant is not.”
Who’s a good candidate: There are millions of women with aging breast implants who find benefit with breast implants, Dr. Jewell says. “Some may require ‘maintenance’ surgery to maintain their outcomes, while other women may require revision surgery to correct capsular contracture or implant malposition. In some cases, it may be possible to change the location of the implants to in front of the muscle or change the position to behind the muscle. Small size increase/decrease is possible. Sometimes, a mastopexy (breast lift) is needed to correct loose skin. Some women with textured-surface implants, who otherwise have no issues with their implants, elect to change to a smooth round implant. Revision surgery is required if there is a broken or deflated implant. Depending on the timing of the reoperation from the original surgery, patients may be able to make a warranty claim.”
Who’s not a good candidate: Dr. Jewell warns that individuals who have extremely large implants cannot easily go much smaller, even with surgery (unless they also have a lifting procedure).
What else to know: Like with augmentation, implant revision should be performed by an experienced plastic surgeon in an accredited facility (including an office surgery unit, free standing ambulatory surgery center) under intravenous sedation/local anesthesia or general anesthesia). “Depending on the extent of planned revision surgery, general anesthesia may be the best choice,” Dr. Jewell explains.
What it is: This one typically comes down to pain and discomfort, according to Dr. Singer, who also points to having strained posture, limited range of motion or a difficult time finding clothing that fits as main factors that propel a patient to consider the surgery, which is also referred to as reduction mammaplasty. “This is one of the most rewarding surgeries I do,” Dr. Yager says. “To make a patient not only look great, but to alleviate years of back and neck pain, is a wonderful feeling for us both.”
Who’s a good candidate: “Individuals who have disproportionately large breast often have back, neck, and shoulder discomfort,” Dr. Jewell says. “Others have rashes on the undersurface of the breasts.” And, as Dr. Lee reiterates, many breast reductions are performed, not just for improved appearance of the breast, but primarily due to medical necessity. “Women have such large breasts that their back constantly hurts or they have serious issues with rash in between and under their breasts.”
Who’s not a good candidate: “Individuals who are obese may not achieve a good aesthetic outcome. Individuals planning future pregnancies who want to breast feed may want to delay a breast reduction until they have completed their family,” Dr. Jewell says.
What else to know: Dr. Jewell calls this surgery a “very satisfying operation” that can help reduce musculoskeletal pain and rashes caused by excessively large breasts. “Depending on the technique used for the reduction mammaplasty, nipple sensation can be preserved.” In addition, medical insurance may cover the cost.
What it is: Breasts can sag for a lot of reasons, including genetics, age, weight gain and loss and pregnancy. “A breast lift is really the only way to reposition and reshape the breasts,” explains Dr. Singer. “There are no non-surgical procedures than have been verified to lift the breasts.”
Who’s a good candidate: According to Dr. Jewell, women who have looseness in their breast where the nipple/areola is below the level of their breast fold may want to consider a breast lift, which is also typically part of a Mommy Makeover. “Depending on the amount of looseness and amount of native breast tissue, a breast lift without implant may be sufficient. If there is the need for both tightening of the breast tissues and volume increase, a breast implant is required. While these procedures are often performed at the same time, some women with extremely loose breast tissues may require a breast lift first to reshape the breast for a later augmentation in the future.”
Who’s not a good candidate: It’s important to know the breast lift (mastopexy) has visible scars. “There are a variety of techniques for breast lift, from a minimally-effective doughnut mastopexy, to an ice cream cone-shaped technique (circumvertical mastopexy), to the anchor-shaped Wise pattern mastopexy,” Dr. Jewell says.
What else to know: According to the American Society of Plastic Surgeons (ASPS), breast lift surgery has an overall patient satisfaction rate of 96 percent, while 93 percent of women said that their confidence was improved following breast lift surgery.
Implant + Breast Lift
What it is: According to Nashville plastic surgeon Daniel Hatef, MD, “Augmentation mastopexy is the ideal way to obtain a beautifully shaped breast in a patient who has loss of elasticity of their breast tissue from breastfeeding, pregnancy, age, or a combination of the above. The other patient who needs this surgery is the patient with a tuberous breast, but be sure that you see a board-certified plastic surgeon who has a large aesthetic breast practice; many patients I see that are unhappy went to a ‘cosmetic surgeon’ who didn’t recognize that the patient had tuberous breasts.”
Who’s a good candidate: Like with the “lift” patient, Dr. Lee notes this surgery is best for someone whose skin envelope has stretched such that there is ptosis, but unlike the lift only patient, this person either has lost or has never had the breast volume that they desire. “Typically, a mastopexy alone will not provide enough volume for long lasting upper pole fullness and adequate cleavage,” adds Dr. Hatef. “The addition of fat grafting and/or breast implants is often necessary to obtain the desired goal.”
Who’s not a good candidate: As Dr. Hatef stresses, “In the hands of a well-trained, board-certified plastic surgeon who helps you choose appropriately sized implants, the mastopexy scars will turn out to be very minimal. It is not uncommon for a patient to come for a breast augmentation consult, but they need augmentation along with a mastopexy. Whether it is because of age, breastfeeding, or tuberous breasts, I will recommend a mastopexy along with implants. These patients sometimes recoil at the thought of the scars associated with a mastopexy, and request that we stick to implants only. In these cases, we will use larger implants to fill out the envelope, and avoid doing a mastopexy. In my experience, I have never seen a truly great result doing this, except in the patient who has a mild tuberous breast deformity, in which we score the tuberous band and place a large implant. I strongly recommend these patients all consider augmentation mastopexy, and do not fear the resulting scar.”
What else to know: This is one procedure that isn’t always so simple. In his 24 years of solo private practice, Dr. Yager estimates he has done well over 5,000 breast procedure. “This certainly teaches you a lot about getting great results, but you don’t get the chance to do 5,000 surgeries if your results aren’t great.” His most important piece of advice: “Select a properly board-certified plastic surgeon, make sure they do the procedure often and ask to see at least three of their before-and-afters of similar cases to yours to make sure you like the results.”
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