If you’re anything like me then “small chested” is a compliment. I would say I’m a full A cup on a good day. And after baby B and 9 months of dedicated pumping and breastfeeding, my handful is now merely a shadow of its former self. While being engorged with milk was never comfortable, for the first time in my life I had cleavage!! And now that I know what I’m missing, I completely empathize with patients who come in with sad breast syndrome.
The most important information I need from you during our consultation is your goals. Wish pictures are the most helpful, if you do your homework and look for these before we meet, it is incredibly helpful! These photos give me an idea of the size you’d like to be and how much cleavage you desire. Remember, 70% of women wish they would have gone larger so if you are debating between sizes, I recommend you go up! Now, onto the doctor’s speech; when I look at breasts, I consider three things: 1) volume, 2) nipple position and 3) skin elasticity.
Most of us have asymmetric breasts. One is usually larger and/or droopier than the other. Many moms tell me they had one breast that was the milk producer. Even those who haven’t had children, one nipple may be lower than the other and the sizes may be different. You may have noticed that one bra cup fills in better than the other. The shape of your chest also plays a role in how your breasts appear. Some of us have ribs that stick out, some of us have pigeon chest (pectus carinatum) or a chest that caves in (pectus excavatum). If you look at yourself in photos, oftentimes one shoulder or one hip is higher than the other (scoliosis).
I then take measurements. This gives me an idea of whether you may need a lift versus an augmentation. Now, there are many tangents that we could spin off on such as patients with droopy breasts who don’t want breast lifts or breast lift patients who do not want implants. But for now, we’ll focus on the two most common breast surgeries: breast augmentation and breast lift with implants.
Breast augmentation is volumizing the breast pocket with an implant, either saline or silicone. The pocket that most of us plastic surgeons in America prefer is the subpectoral pocket which places the implant behind the pectoralis muscle. This has a lower rate of scar tissue formation around the implant (capsular contracture) and also with the muscle on top, the round implant gets a more natural, teardrop shape. The incision can be either around the nipple (periareolar), at the breast crease (inframammary) or in the armpit (transaxillary). There are pros and cons for each approach and I typically suggest one approach over the others depending on your anatomy and ethnicity. More than 90% of my patients choose the silicone gummy bear implants. They are the newest generation of silicone implants and have an improved gel that will not fracture or ooze if the implant shell breaks. They look and feel quite natural. Implants come in different profiles depending on your goals and your body measurements. During surgery, I use sizer implants which allow me to try on different sizes until I reach the size that most closely resembles the wish picture. Surgery is done under general anesthesia and takes about an hour. You go home the same day and are encouraged to use your arms and stretch your muscles because this will go a long way towards reducing your discomfort. Stitches are removed in about a week and you can return to full activity in about 4 weeks. I may show you how to massage your implants to help them settle into proper position. Most patients take between 1-3 months for the implants to fully drop into place. It takes about that much time for you to accept the implants as your own! They tend to feel alien in most people for several weeks to months!
Breast lift with implants is for those who have droopy or asymmetric breasts and who desire a fuller, perkier look. Cleavage is important to patients who need breast lifts. In order to get enough cleavage, an implant is usually necessary. The implant fills in the pocket and restores that upper pole fullness to give the breast the round look. The skin on breasts that need to be lifted is often skin that has stretch marks or is very thin. Nipples are often stretched out and low. Most people feel that they pour themselves into their bra cups and have gapping up top. During surgery, the implants are placed in a similar fashion to the breast augmentation procedure. Then, the nipple is re-sized and re-sited to a more aesthetically pleasing position and excess skin and breast tissue are removed to give the breast a rounder, perkier shape. The two most common breast lift techniques are the vertical mastopexy and the inverted-T mastopexy. The technique chosen depends on the amount of skin and breast tissue I am trying to remove that hangs below your breast crease. The resulting scar looks either like a lollipop or an anchor. The procedure takes about 2.5 hours under general anesthesia and you go home the same day. Unlike a breast augmentation, breast lift patients are instructed NOT to massage their implants as these tend to settle and drop naturally and I want them to stay as high as possible. Stitches are removed at 7-10 days.
For most patients, if you have surgery on Wednesday, you should be able to return to work the following Monday. Pain medication is provided but most people are off these after the first 2-3 days. The discomfort is mostly pressure from the muscle as it tries to accomodate a large implant.
Scars for both surgeries take up to a full year to completely mature. Silicone based scar gels can help to speed this process. I would wait until the 3 month mark to go shopping for new bras as the sizing may still change as the implants are settling. I encourage every breast patient to sleep on her back and to wear a supportive bra even at night to keep the implants in the proper position. Of course if you have a special occasion or THAT dress, I absolutely say enjoy and show off!
Complications with these procedures are fairly low. I always mention the risk of capsular contracture (scar formation and hardening around the implant) which can be 5-15% according to the implant manufacturers and increase with each revision surgery. Implant malposition is another that may require revision - this is when an implant stays too high even after aggressive massage or when an implant settles too low in the pocket. Typically these are minor and can be addressed in the office or under sedation.
All in all, breast augmentation and breast lift with implants are very satisfying procedures for patients. You do have to be a little patient as the implants settle but once that happens, you will thoroughly enjoy your bustier self!