• Question: Will High Profile Breast Implants Give Me Natural Looking Breasts?

I am 5’4″ 125lbs, 31″ ribcage, 34C (wanting at least a DD) and my breast measures 13cm wide. I told my PS I wanted large, very nice looking (not high and ball-looking) breasts. He told me he will use a smooth, round, high profile, 500cc silicone implant and it will look “very nice” with a “nice downward slope”. Everywhere on the internet says that high profiles don’t give a really nice natural look, and that moderate profiles do. Will high profile breast implants give me large, full, and natural-looking breasts with nice cleavage?

• Answer: Although I use Moderate+ or Moderate profile prosthesis in the vast majority of cases, given your base width dimension of 13.0cm and your wanting a 500cc implant, a high profile implant would be appropriate.

In answer to your question, it is not so much the size of the prosthesis that results in a ‘natural’ or ‘unnatural’ look but rather the surgical technique used in relationship to the pre-operative breast appearance. If, on examination, your nipple to inframammary fold distance is 5.0cm – 6.0cm (meaning that the fold does not need to be lowered excessively), then a high profile implant can be placed nicely, so that you would get adequate inferior/lower pole projection without having an overly round upper pole (which is what creates the ball-looking, ‘unnatural’ look you don’t like). That said, there are many women who like the look of round, projecting breasts with upper pole fullness (high cleavage) – neither is right or wrong (assuming it’s my job to get as close.

Breast implant profiles: high vs moderate plus vs low

Before diving into a few specific recommendations given the measurements you provided, here are my general thoughts on each of the 3 Mentor breast implant profile types:

• High Profile Breast Implants or “HP” implants have the narrowest base width but the most outward projection (think thin & tall), creating a very full, round and youthful look. When used appropriately (re: in cases where the width of the breast, amount of breast tissue, nipple position, amount of skin, elasticity of the skin will benefit from HP’s shape and fill), high profile implants can achieve a very pleasing final result.
• Moderate Profile Breast Implants are comparable to a softly domed circular pillow (though much smaller of course). The width of the chest covered is moderate-to-wide and outward projection is perky yet still very natural, especially in comparison to the original “Low Profile” models which are quite a bit flatter. Compared to “High Profile” implants, Moderates will typically create a more natural looking upper breast appearance (by providing a flatter & more gradual downward slope). **That said, Mods do not fit well within patients with average-to-narrow base widths who want a lot of volume (e.g. 400cc and higher).
• Moderate Plus (or “Mod+”) Profile Breast Implants are a relatively newer model. Their shape is, as the name implies, in-between the Moderate and High Profile implants. Their shape, which basically splits the difference between the base width and projection of High & Moderate profiles, works best in the vast majority of augmentation cases I perform, making Mod+ the most popular profile choice of my patients.

When considering HP implants, many women believe that they will give them more fullness high on the chest (the “upper pole”) and that a low profile implant will shape the middle & lower parts of the breast. And yet, the opposite is true. Because a high profile implant pushes out from the chest wall more than any other profile, the implant will push out the central and lower parts of the breast the most. Thus, high profile implants create a pointy, much more rounded breast. Conversely, lower/moderate profile breast implants push the areolas out from the chest wall the least, which creates a softer, flatter, more ‘natural looking’ breast.

The other important technical consideration when using a larger high-profile prosthesis is ensuring adequate release of the inferior (re: lower) origin of the Pectoralis muscle. Doing so allows the chest to expand adequately and helps to avoid/minimize a constricted, overly tight appearance – which will cause the prosthesis to sit too high and you’ll get the exact opposite effect of what you would like to achieve.

Mentor Silicone Breast Implant Profiles - Low, Moderate, Moderate Plus & High

And while I now almost universally use moderate or moderate plus prostheses (~13% and ~80% respectively), given your base width dimension of 13.0cm and your wanting 500cc of added volume, high profile implants (which I use ~7% of the time) would be appropriate. If correctly performed, you should be able to achieve your desired result.

An example of 350cc high profile saline breast implants (filled to 390cc) in a 5'0", 108lbs patient. Before & after photos taken from the front demonstrate a substantial amount upper pole fullness.

Same patient - before & after high profile breast implant photos taken from the oblique angle do a great a substantial amount upper pole fullness.

In the example case above, 350cc in either a moderate or moderate plus profile would have caused issues given the space constraints of the patient’s petite 5ft frame. In cases similar to this, selecting the right implant size and profile allowed me to fashion an almost imperceptible inframammary incision and optimally positioned breast pocket.

• Question: Undecided, Lift or Implants. Surgery in 3 Weeks, Opinions Please

Hello. I have my breast surgery scheduled in June, however, am still undecided which route I should take. Would 500cc saline implants be sufficent to give me some volume, or will I end up with large, saggy breasts? If I decided to go just for a lift, my boobs will be tiny and scared. Hence, I’d rather go for implants even if I will have to get a lift 10 years down the road.I don’t want both surgeries, so it will be either tiny or big. What to do? I’m 40, 1 child. Thank you.

- via RealSelf.com

With deflated breasts, a lift + implant is needed for best result

• Answer: For the best result possible, a vertical breast lift + submuscular, moderately sized implant is needed

In response to your question and based on your photos, this is not really a one or the other type of situation. You really need to have both a lift and an augmentation. If you do them separately you will probably not be satisfied with the eventual outcome. You have significant loss of volume, and if you were to only proceed with skin tightening all that would be accomplished is a higher position of the nipple areola complex. There would be no superior fill and an even smaller appearing breast mound.

The best indication for a vertical mastopexy alone is when the breast is of adequate volume particularly in the superior pole but there is also inferior fullness and droop. This is not present in your case. When you remove the excess skin the breast will appear even smaller, and you are not overly large to begin with. If you go with augmentation alone, as you noted, you will just be larger and droopy which would not be aesthetically pleasing.

Also in your case palpation of the prosthesis would be increased since a significant portion of the prosthesis would need to be placed in a subglandular position. Also a 500cc prosthesis is much too large in your situation. You would be much better off having a submuscular augmentation with a reasonably sized prosthesis to give you the superior fill you need, and a vertical mastopexy to reposition the nipple areola complex and take the lower portion of your breast off of your chest wall. Hope that helps and good luck with the surgery.

**Update: I thought it would be helpful to add a link to a patient who presented with deflated breasts similar to your own. As you can see from her before & after breast augmentation + lift photos, combining the two procedures yields a beautiful end result.

• Question: Am I Being Realistic with the Breast Augmentation Results I Want?

My plastic surgeon wants me to bring in pictures of what I want so he can be sure that he understands what results I’m wanting. We’ve discussed this at my consultation; however I did not bring any pictures with me. My surgery is on the 5/26/2011. At my pre-op visit we will go into the specifics of the results I’m looking for. The first two pictures are of my before pictures and the third is what I want. The measurement from my collar bone to my nipple is 21 cm on both breasts. Am I being realistic? Thank you!

Photos of a patient's breasts before surgery alongside a photo of what the patient would like her breasts to look like after breast augmentation

• Answer: For a similar result to the breast augmentation look you want, a lift is needed

I agree with my colleagues that it is difficult to compare apples to oranges since every breast has its own unique characteristics, but since the photo you chose as an example of your ideal postoperative outcome is mine, I will give you my thoughts on the situation. (n.b. here’s a link to the breast augmentation case you cited as an ideal result).

In your case you have what is called glandular ptosis; where the inferior pole sits below the nipple areola complex and there is loss of superior fill. It also results in an increased distance from the base of the nipple areola complex to the inframammary fold and this situation is difficult to address solely with an augmentation. The woman that you utilized for your desired postoperative result had loss of volume from child bearing, but not significant glandular ptosis. That made her an ideal candidate for an augmentation alone. If you wish to achieve a nice round appearance with a tight inferior pole, then you’ll need to have a vertical breast mastopexy with augmentation. This approach allows your surgeon to create a nice round breast mound with the prosthesis and through the vertical limb excise a portion of the ptotic breast tissue. The trade off will be a vertical scar, but I think that you will get a much better result than just doing a straight periareolar breast lift. A periareolar breast mastopexy (aka Benelli breast lift) would not elevate the ptotic inferior breast tissue appreciably in my opinion.

For a closer approximation to your situation, please see the before and after photos of this recent vertical breast lift with submuscular augmentation case I performed that I believe does a good job matching up with both the before and after breast photos you shared. I hope this helps and good luck.

I’ve always enjoyed playing class professor for an hour or 2 during open-house style info-sessions/discussions that explore the ins and outs of a specific cosmetic procedure, new/innovative surgery technique or medical product. The diverse interests of a small (or smallish) group has a tendency to generate lively discussion on a wide range of topics due to all of the different questions which get asked. And with the almost overabundance of procedure options and cosmetic solutions available today, I think it’s more important than ever to help people interested in cosmetic surgery be as informed about their choices and options as possible.

It’s been several months since our last info session, but now that our new office is running like a well oiled machine, I think that if the demand is there, we could certainly make these open houses a more regular occurrence. In the meantime, our game plan is to put on another get-together in May. The topic will could be quite a bit different than the presentation embedded below. On the other hand, there are few questions more essential than the exploration of traits that distinguish good from great plastic surgeons so perhaps I’ll continue along with this topic.

The slideshow above does not include several sets of before & after photos from recent cases (which we discussed in greater detail during the presentation). For those interested in downloading (or sharing with a friend via email) just the first half of the deck without the before and after photos, click here.

Innovation Life-Cycle. A cartoon by Tom Fishburne

Since Dr. Illouz and Dr. Fournier first brought liposuction to the United States in 1982 – when I was beginning my residency in plastic surgery – there have been only two truly game-changing developments in how board certified surgeons approach/perform liposuction:

1. Tumescent Liposuction – First introduced in 1985, the tumescent technique involves injecting a special ‘tumescent’ solution directly into the subcutaneous fatty layer (which builds up between the skin and muscle layers) that not only makes the entire treatment zone numb, but also acts to constrict surrounding blood vessels so that very little blood loss and trauma to the surrounding tissue, vessels and nerves occurs during the procedure. In surgery, less trauma means less post-operative swelling. Less post-op swelling means less post-op discomfort and a quicker recovery. In most of my liposuction cases, patients are back on their feet the very next day and pain free soon-there-after. The use of local anesthesia in combination with very light general (re: light complete sedation) not only provides a very comfortable experience for my patients but also enables me to be fairly aggressive and precise while addressing multiple locations which contain large amounts of fatty tissue.
2. Power-Assisted liposuction (PAL) – Approved for general use by the FDA in 1998, power-assisted liposuction differs from un-powered suction-assisted liposuction (SAL) through the use of a special canula that vibrates rapidly (like an electronic tooth brush) while being moved through the fatty tissue by the surgeon. Without power, pushing and pulling the canula in the standard forwards and backwards motion through the fatty tissue requires quite a bit more effort and force. With power, the canula becomes like a hot knife through butter as it gently breaks up the fat before suctioning it out. The benefits to the PAL approach have been well documented and include less time under anesthesia, less bruising and swelling, a faster recovery and most importantly, smoother, more precise results.

All other ‘advancements’ in liposuction, SmartLipo™ included, have had, at best, an incremental effect on the quality and consistency of result and at worst, done more harm than good (especially when used outside of their very-specific use-cases). As with most new products, after the initial hype and marketing settles down, the indications for use diminish. When laser liposuction (Coollipo™, Smartlipo™, Slimlipo™) first came on the scene, it was touted as a stand alone procedure. But after it became clear that the initial results were less than ideal, traditional liposuction got added to the procedure in order to achieve satisfactory results. Perhaps, in very limited use-cases (e.g. under the chin) there can be some added skin tightening, but as I have seen over the years, if properly performed on a properly chosen patient, there’s really no better option than power assisted tumescent liposuction.

Ultimately however, it remains the skill and talent of the sculptor rather than the make or model of their chisel that determines whether or not one ends up with a superlatively sculpted thigh, hip, neck, buttocks, arm, or abdomen. When I first began performing liposuctions some 28 years ago (during my 8 years of formal residency/training) a professor told me that nothing can substitute the skill and technique of a master plastic surgeon who has, through years of training and experience, refined his technique to the point where such procedures becomes less about suctioning and more about sculpting. I remember thinking that this was easy enough for him to say given that he had already attained master-level status. But when I reached equivalent status, it became clear that he was right. For a young, wet behind the ears surgeon, so much of one’s success depends upon how much pure natural talent, spacial intelligence and aesthetic ‘taste’ one has. Over time however, most first-rate plastic surgeons become much more intuitive and feel-driven in their approach to procedures like liposuction. And while the difference in CCs of fatty tissue suctioned out may not be much, the smoothness of shape and consistency of silhouette between the treatment area and surrounding tissue is more often than not, dramatic.

Related articles

• Experts warn about ‘awake’ plastic surgery (msnbc.msn.com) – a worthwhile read for anyone considering liposuction from anyone other than a board certified plastic surgeon.

I recently started answering questions on the plastic surgery Q&A website RealSelf.com – it’s a neat, quickly growing service that has the potential to be truly great (they just need to improve a few key features which I plan to write about in a later blog post). That said, from reading and answering the many questions that come into my email inbox each day I think what stands out most is the frequent lack of clear and completely open communication between patients and their doctors (exemplified most often in questions by patients who have recently completed their surgery).

It is of critical importance that post-op, patients feel 100% comfortable asking their surgeon if x, y or z “looks ok”, “is a normal part of the healing process”, etc. etc. What’s more, many other people do not appear to have a clear understanding of what to expect going into their procedure, what the results will/should look like, and what the post operative healing period entails. This causes them to become worried and concerned and seek advice and reassurance in the form of answers from other plastic surgeons who make use of this excellent web site. This isn’t to say that the members of realself.com shouldn’t be asking such questions. On the contrary, they should be asking every question they have and more! I just hope that they are sharing these questions with their own surgeons as well, since they should have a much more intimate understanding of the questioner’s body and/or condition. If they aren’t, then I can’t help but wonder why? Given the quality of questions asked on realself, I get the feeling that there are doctors who aren’t making clear to their patients that when it comes to cosmetic surgery, there are few if any questions not worth asking.

Confused? I sure am - not good!

Through the course of pre-op evaluation, consultation, and preparation, questions should be answered to their fullest and the patient should know precisely what to expect in the early post operative period as well as going forward. Also it is important to realistically portray what can and cannot be done with the procedure, through the use of multiple photos so that unrealistic expectations are not created. This is the way I have always handled my patients. It is most important for them to feel that they are a unique case and they have your undivided attention and concern and most importantly, that they can ask me anything with total confidence that they will receive a complete and honest answer in return. It is our practices belief that no question is without merit and if you have the slightest concern, both pre- or post- operatively, we will see you as soon as is possible. I always carry my cell phone and patients are surprised that they can reach me at any time. Many of us no longer make house calls, but at the very least we can be easily accessible to our patients, particularly when an elective procedure is involved. The practice of medicine should be personal, not assembly line in nature, but todays economic demands make the assembly line approach more the norm than it should be. Everyone of us in the practice takes pride in the opposite approach of personal care. Not exactly Marcus Welby, M.D. but as close as one can get in this day and age.

So unlike the warden in Cool Hand Luke,  we make sure that clear communication is a top priority at every step of our patient’s journeys… because uncertainty and/or confusion should never ever be a part of the cosmetic surgery experience.

Debbie, who has years of experience handling front desk operations and staff, now greets everyone who enters the office as a long time acquaintance while handling call scheduling, visits and consults with ease and the utmost grace. She is the Offensive Coordinator.

Gloria my personal assistant over the last 12 years makes it possible for me to practice knowing that everything is covered. She remains unfazed and up-beat and I have never seen her off her game. If I had a dollar for every time a patient remarked how wonderful Gloria was in handling all their issues, I probably would not be doing this blog! She is our Peyton Manning without the audibles.

Through the recommendation of one of my physician friends our new nurse Brianne has been an excellent addition. Although she has no previous plastic surgery experience, her enthusiasm, intelligence, willingness to work hard and attention to detail has allowed her to absorb the play book without too many rookie mistakes. She is our first round draft pick, and it appears that our scouting reports were accurate.

Of course, what would a team be without a beautiful new stadium to play and practice in every day? Thankfully, that end has been taken care of brilliantly by Amy DeLuca, our very talented interior designer. The colors, lights and fabrics of our office are really quite special and combine to create an experience unlike any other cosmetic practice I have ever visited.

So what are we playing for every day? I believe the force driving our team forward is a deeply held commitment to a common held goal – which is providing the best care and service possible to each and every patient we serve. Our Lombardi Trophy is knowing that every patient we care for leaves the office feeling that their every concern and need has or will be met in a gracious, warm and personal fashion without even so much as a hint of the assembly line approach so prevalent in medicine today.

A new season has only just begun. But already, I sense our goal is to become a dynasty.