VIP Room Breast Shape Talk


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VIP Room Breast Shape Talk

  1. 1. Understanding Breast Shape and How to Make Breasts Beautiful Joel A. Aronowitz, MD Chief, Division of Plastic Surgery Cedars Sinai Medical Center
  2. 2. Understanding Breast Shape <ul><li>What really determines breast shape? </li></ul><ul><li>How does breast shape change with age? </li></ul><ul><li>Why are some breasts pretty and others not? </li></ul><ul><li>Where are incisions best placed? </li></ul><ul><li>Why are two breasts so asymmetrical sometimes? </li></ul><ul><li>What can the patient and surgeon do about it? </li></ul>
  3. 3. The Tubular Breast Teaches Us About Breast Development <ul><li>Breast shape is the result of the breast bud responding to estrogen. It grows and stretches the skin envelope. (Above) </li></ul><ul><li>Under the skin a fibrous layer (mesenchyme) can this stretch and cause more growth toward an opening in the fibrous layer, the areola. </li></ul><ul><li>This results in a tubular shaped breast with a large areola. </li></ul>
  4. 4. The Cause of Tubular Shape <ul><li>If the fibrous layer over the breast bud is tight medially, toward the sternum, breast growth will be directed more toward areolar window and laterally. The breast skin will be tight on the inner quadrant </li></ul><ul><li>If the entire area is tight, the areola will be the only area able to expand as the breast grows resulting in a large areola and very tubular or “Snoopy Nose” shape. </li></ul>
  5. 5. Classifying the Tubular Breast <ul><li>Tubular breast shape depends on which area of the chest has the tightest fibrous layer. </li></ul><ul><li>Inner quadrant tightness causes a deficiency of skin toward the midline and sometimes a “Cross-eyed” look to the nipples. </li></ul><ul><li>A mild case may just show a pouty or “herniated” areola. </li></ul><ul><li>A very tight mesenchymal layer may inhibit breast growth so much that the size is affected. </li></ul>
  6. 6. Mild Tubular Breasts <ul><li>This 22 year old woman was treated with a surgical release of the fibrous tissue layer internally and 225 silicone gel implants placed over the muscle. The incision is around the areola. </li></ul>
  7. 7. Fibrous Tight Medially, Causing Tubular Breast Deformity <ul><li>Correction with Keyhole pattern tailoring of skin or mastopexy, and 225 cc silicone gel implant </li></ul>
  8. 8. Severe Tubular Deformity Note medial tightness, large areola typical of tubular breast. 17 yo treated with 500 cc silicone gel prosthesis and keyhole pattern mastopexy
  9. 9. Why Do Breasts Sag? A Disproportion Between Volume and Skin Envelope <ul><li>Breasts sag because there is too little breast tissue filling the skin envelope. </li></ul><ul><li>Stretching of the skin can occur with weight gain, pregnancy, or the effect of the breast weight w/ time. </li></ul><ul><li>Volume loss occurs with weight loss, age or after pregnancy and nursing. </li></ul>
  10. 10. The Breast Skin Stretches in a Predictable Pattern Over Time In the breast the largest diameter is in the lower pole therefore the skin below the nipple typically is under greater strain and stretches the most. The nipple decends with the breast.
  11. 11. Classifying Breast Ptosis (Sagging) <ul><li>Degree of Sag Based on Nipple to Inframammary Crease or Fold Relationship </li></ul><ul><li>No Ptosis; Nipple above the fold </li></ul><ul><li>Mild Ptosis; Nipple at Level of Crease </li></ul><ul><li>Moderate Ptosis;Nipple Below Crease </li></ul><ul><li>Severe Ptosis; Nipple and Areola Below Crease </li></ul><ul><li>Example of severe ptosis </li></ul>
  12. 12. Evaluation of Breast Droopiness <ul><li>1. Evaluate the chest wall for asymmetry, shape </li></ul><ul><li>2. Assess breast volume </li></ul><ul><ul><li>too small, correct volume, or excess volume </li></ul></ul><ul><li>3. Assess breast shape issues </li></ul><ul><ul><li>Tubular, asymmetry, xs areolar diameter, etc </li></ul></ul><ul><li>Volume adjusted by breast reduction or implant </li></ul><ul><li>Mild shape issues adjusted by internal correction, or minimal skin excision such as crescent lift </li></ul><ul><li>Major shape problems addressed by keyhole pattern lift </li></ul>Formulation of a Treatment Plan
  13. 13. A Disproportion Between Volume and Skin Envelope After 110 lb Weight Loss <ul><li>Mastopexy with keyhole pattern, Abdominal pannus resection, elevation of Mons </li></ul>
  14. 14. Patient 18 Augmentation with Mastopexy Nancy M., lift/aug
  15. 15. Patient 18
  16. 16. Patient 19 Mastopexy with replacement of implants Peggy lanier
  17. 17. Patient 19
  18. 18. Why the Larger Diameter Area of the Breast Stretches More
  19. 19. Bottoming Out; XS Nipple-IM Crease distance <ul><li>23 yo S/P 350 cc gel aug </li></ul><ul><li>Note amount breast below nipple preop </li></ul><ul><li>Postop; restoration of infra- mammary crease </li></ul><ul><li>Preop Postop </li></ul>
  20. 20. What is Bottoming Out? <ul><li>Bottoming out is drooping of the lower part of the breast without the nipple. </li></ul><ul><li>This leaves the nipple too high on the breast mound. </li></ul><ul><li>Eventually the nipple points up and the areola shows above the bra. </li></ul><ul><li>Bottoming out is caused by placement of an implant too low, i.e. below the crease or leaving the vertical limb too long in a mastopexy or breast reduction. </li></ul>
  21. 21. Correction of Post Augmentation Bottoming Out <ul><li>Preop </li></ul><ul><li>28 yo with 275 cc silicone implant placed too low, ie below the inframammary crease. </li></ul><ul><li>Postop </li></ul><ul><li>Restoration of infra-mammary crease </li></ul>
  22. 22. Pt 6; Bottoming Out; A Post Augmentation Deformity <ul><li>Restoration of normal inframammary crease, tailoring of skin envelope with Keyhole pattern, 700 cc silicone implants unchanged </li></ul>
  23. 23. Patient 6
  24. 24. Problems with Periareolar or Donut Lift Mastopexy Note large areola with wide scar and flattened shape
  25. 25. The Shape Problem with Periareolar Mastopexy; large areola and flat shape <ul><li>Correction with skin envelope tailoring via Keyhole pattern </li></ul>
  26. 26. Periareolar Mastopexy; shape distortion and wide scars <ul><li>Converted to Wise pattern breast lift </li></ul>
  27. 27. Improvement after Wise pattern Lift
  28. 28. LaPlace Explains Breast Shape <ul><li>1. The skin will stretch where it is pulled the most. </li></ul><ul><li>2. The Law of LaPlace states that pulling (skin tension) is greater where the diameter is larger. </li></ul><ul><li>3. In the balloon below the diameter is greater in the thick part, The diameter is greatest at the lower pole of the breast. </li></ul><ul><li>Therefore, the breast skin stretches relatively more in the lower pole resulting in the lovely shape of a woman’s breast,eventually and the droopiness we see with larger breasts and normal aging. </li></ul>
  29. 29. The WISE Pattern Allows freedom to tailor the breast skin envelope
  30. 30. Skin Envelope Tailoring… <ul><li>Breast reduction and mastopexy represent tailoring of skin envelope to improve shape </li></ul>
  31. 31. Wise Pattern Breast Reduction
  32. 32. Wise Pattern in Breast Reduction
  33. 33. Breast Reduction <ul><li>Breast volume reduction and skin envelope tailoring </li></ul>
  34. 34. Excessive Removal of Breast Tissue <ul><li>Breast augmentation, 225 silicone, </li></ul><ul><li>Repair of abdominal scar </li></ul>
  35. 35. Breast Implants <ul><li>Silicone gel now approved for augmentation, rapidly gaining in popularity </li></ul><ul><li>Smooth vs textured </li></ul><ul><li>Profile </li></ul><ul><li>Round vs Shaped </li></ul><ul><li>Becker expander withdrawn? </li></ul><ul><li>FDA rec F/U </li></ul>
  36. 36. Ptosis due to relative paucity of breast volume Volume restored with prosthesis, skin envelope unchanged Pt 3; Restoration of Skin:Volume Proportion with Prosthesis
  37. 37. Patient 3 Leah, Lift/Aug
  38. 38. Patient 3
  39. 39. Severe Breast Hypertrophy <ul><li>Breast Reduction of approx. 1,200 grams each </li></ul>
  40. 41. 79 year old woman with Severe Breast Hypertrophy
  41. 42. Wise Pattern Breast Reduction
  42. 43. Breast Reduction
  43. 44. Breast Augmentation <ul><li>27 year old with post partum breast atrophy, 400 cc saline prosthesis, over muscle, incision periareolar </li></ul>
  44. 45. Augmentation with 350 cc saline and Keyhole Mastopexy Post-partum breast atrophy, sagging due to lack of breast volume relative to skin envelope Rx; Reduction of skin envelope and addition of volume; ie, augmentation mastopexy
  45. 46. Patient 4: PB., Lift/Aug. Mastopexy before and after retropectoral augmentation with 400 cc saline
  46. 47. Patient 4
  47. 48. Patient 7: Ilene, Lift/Aug.
  48. 49. Patient 7
  49. 50. Patient 5: Dawn, Lift/Aug.
  50. 51. Patient 5
  51. 52. Patient 20: Grade IV capsular contracture, Rx; Mastopexy and Removal and Replacement of Implants
  52. 53. Patient 20
  53. 54. Retropectoral Breast Implants <ul><li>22 years s/p Retropectoral 250 cc silicone gel </li></ul><ul><li>Baker grade IV contracture </li></ul><ul><li>Typical distortion with pectoral contraction </li></ul>At rest flexing pectoral muscles
  54. 55. Breast Implant Removal <ul><li>Postop explantation, 250 cc silicone gel prostheses and removal of capsule </li></ul><ul><li>Baker Classification </li></ul><ul><ul><li>1: not palpable, not visible </li></ul></ul><ul><ul><li>2: palpable not visible </li></ul></ul><ul><ul><li>3: palpable, visible </li></ul></ul><ul><ul><li>4: palpable, visible and painful </li></ul></ul>
  55. 56. Capsular Contracture <ul><li>Baker 1 Baker 4 </li></ul><ul><li>The body forms a scar tissue capsule around the every implant, if the scar tissue tightens it becomes ball shaped and firm. This is a capsular contracture. </li></ul><ul><li>Baker Classification System </li></ul><ul><ul><li>1: not palpable, not visible </li></ul></ul><ul><ul><li>2: palpable not visible </li></ul></ul><ul><ul><li>3: palpable, visible </li></ul></ul><ul><ul><li>4: palpable, visible and painful </li></ul></ul>
  56. 57. Typical Sagging of Breast Over Implants Placed Under Muscle <ul><li>Patient underwent mastopexy and placement of 250 cc saline implant under the pectoral muscle. She complains of the double bubble shape and lack of medial fullness. </li></ul>
  57. 58. Breast Augmentation and Keyhole Mastopexy
  58. 59. Patient 8: Breast Aug and Keyhole Mastopexy Inez, Aug/lift
  59. 60. Patient 8
  60. 61. Patient 9: Marsha, lift
  61. 62. Patient 9
  62. 63. Patient 10: Cheryl lift/aug
  63. 64. Patient 10
  64. 65. Patient 11: Allison S. Lift
  65. 66. Patient 11
  66. 67. Some Final Observations <ul><li>Breast shape is understandable through a study of embryology and basic science. The correction and improvement of various simple and complex breast size and shape problems can be performed in a safe and predictable fashion. </li></ul>