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Patient Details
This is a 34 year old who is 5’1″ and 155 pounds who came to my office with a history of a previous mastopexy / augmentation performed elsewhere in 1997. A mastopexy / augmentation refers to a procedure that lifts the breasts and uses a breast implant as well. She said that she had two children afterwards and this resulted in significant changes in her breasts. She says they are too large now and the shape isn’t right. You can see in her preoperative photos that she has large, pendulous breasts with very wide areola and scarring that isn’t optimal. The shape is poor overall with lots of lateral breast fullness.
This is a complicated case from several different angles for sure. If I focus only on the breast alone this is challenging enough, but the other concern is that she is overweight and she struggles with her weight. This has a huge impact on the success or failure of my surgery and this must be taken into consideration so I can pass judgment about the appropriateness of the surgery. I must look at the patient as a whole and not just the breasts.
The fact is that I spent a lot of time in “counseling” with this patient. I felt that she was motivated to success and she was certainly very realistic. I performed a first stage large volume liposuction and abdominoplasty. She did very well with these procedures. She came back for her second stage breast revision. The goal was to make her breast higher and tighter and perkier—not a simple request considering the size of her breasts and the poor quality of her skin and tissue.
She is seen in the second set of photographs after a BRA procedure (Breast Reduction with Augmentation). I removed 230cc saline implants that she had under the muscle and replaced them with 350cc silicone implants in the same pocket after I adjusted the pockets on both sides. I reduced 360g of tissue on the right and 538 g of tissue on the left (the left breast was larger).
Why did I use a larger implant when we wanted to make her higher, tighter and perkier? I did this because the basis of my procedure is to REDUCE the breast tissue and add volume and shape with the implant superiorly (where most women prefer it most). The implant gives the breast the shape. The tissue reduction is performed because this tissue hangs and is of poor quality – it’s not something I want to build the new breast from. Think of this analogy: if your home was hit with a tornado (pregnancy!) and it was torn to shreds and you had the option of using the scattered pieces versus using new wood or steel in the construction (breast implant), I’d bet that you would prefer the better building material.
There was a big improvement after this procedure. You can say it is night and day. Her breasts are better shaped, smaller, higher and tighter for sure and more symmetrical. One caveat to this revision is that it is complex, complicated and risky in the best of hands. The risks include big time issues like loss of the nipple areola complex, implant extrusion and exposure, as well as big time wound healing problems and asymmetry. This is not something you would want to experience to say the least. I offered this as an option to her only because I have a lot of experience with this procedure, she was well versed on the risks and accepted them, and we had discussed alternatives that we would take depending on the circumstances of her surgery. She had a small wound problem that healed quite well with local care.
Low and behold, she returned about two years after this procedure and wanted her breasts even perkier. She didn’t like the fullness she had on the sides of her breasts. She said that her breasts looked old and saggy! I agreed to modify the results again (breast revision) with the goal of removing some lateral breast fullness with liposuction and tissue removal as well as excising excess skin near the lateral part of her breasts and under her armpit area. She is seen in the third set of photos after the removal of 500cc of fat by liposuction and the reduction of about 50 grams of tissue from each breast as well as adjusting the implant pocket so her implants stationed themselves more centrally on her chest (moved them towards the middle). There is clearly an improvement from the second set of photos, especially along the lateral aspects of her breasts.
A long case indeed that illustrates several points: First, pregnancy, age, hormones and not wearing good support after surgery can detrimentally affect your results. Second, sometimes to get the outcome that you desire, additional procedures may need to be performed. It may also be necessary to stage procedures for safety and to achieve the best outcome. Third, breast revision surgery is complex and complicated and associated with significant risks and revisional surgery and anyone who gives consent for these procedures must understand what they are getting themselves into. It’s never a big deal if it all goes well. It becomes a very big deal if the problem patient is YOU. This is why I am very selective on which patient I will offer my services to because they have to accept this as reality and work with me if things don’t work out exactly as we would prefer (which, thankfully, is very uncommon).
