A: The key to knowing whether a lift or the addition of volume can make the breast look better depends on the position of the nipples. If it sits above the lower breast fold, then volume is the answer. While I do not know exactly what your breasts look like, knowing that the distance from your nipples to the sternal notch is only 22 cms tells me that your nipples are definitely above the inframamammary folds. That is essentially a completely normal or ideal nipple position. (the normal range is 18 to 22 cms depending in the length of one’s torso)

Since more breast volume is the answer, the question of whether it can be done with an implant or fat injections becomes very relevant. The use of fat injections for augmentation of a variety of body areas has become very popular in plastic surgery recently. While it is widely accepted for volume augmentation of the face and buttocks, its use in the breast is currently controversial. This is because there already exists an augmentation method that works well and is very reliable, an implant. For overall breast augmentation, an implant works better, is a one-step procedure, and will cost less. If there is just one area of the breast that needs filled in, then fat injections becomes the preferred treatment.

Dr. Barry Eppley

Indianapolis, Indiana

A: When it comes to getting a natural breast augmentation result, it does not matter whether a saline or silicone implant is used. That has nothing to do with making a difference between looking augmented or not. Rather it is a function of implant size and implant location (above or below the muscle) as well as what your breast tissues look like now. As a general rule, it is almost always better  to go below the muscle so that there is a natural slope in the upper pole of the breast. If you keep the implant base width at the same size or less than that of your natural breast base width, you will almost always look fairly natural. The size of breast implants is directly related to their base diameter. The larger the base diameter, the larger the implant. A simple tape measurement of your breast base diameter would help considerably in making a good implant size selection for you. 

Dr. Barry Eppley

Indianapolis, Indiana

A: There are is no absolutely best position for breast implants in any particular patient. There are advantages and disadvantages to both approaches. The vast majority of patients today have implants placed beneath the muscle for better pocket stability, a more natural look (upper pole shape), better tissue coverage, a lower rate of rippling and less interference with mammograms. The one downside to under the muscle is that there will be animation deformities, meaning the implants will be pushed to the side unnaturally with pectoralis mucle contraction when the arms are extended.  The one benefit to an implant being above the muscle is when there is some breast tissue sagging, it can fill out the sagging tissues better. The other under the muscle benefit is for someone who was looking for less recovery time and pain and could not avoid adjusting their fitness regimen or someone who has to have the procedure done under local anesthesia for medical and fear of anesthesia reasons.

In the end, one has to weigh these advantages and disadvantages from the perspective of their own breast anatomy and shape. As a general rule, always remember that any implant in the body always does better in the long run (i.e., less complications) when placed under a thicker soft tissue cover particularly when under well-vascularized muscle.

Dr. Barry Eppley

Indianapolis, Indiana

A: It is impossible to say with an certainty that there is a relationship of the symptoms you are having and your breast implants. What we do know for sure is that breast implants do not release toxins, poisons, or any other harmful chemicals. While you have had a good breast screening work-up, mammograms and ultrasound are not 100% accurate when it comes to detecting an implant rupture. If anything, that is where my suspicion would lie as it relates to your left breast pain. If it persists or increases in severity, I would consider getting an MRI which is the most accurate test we have to detect breast implant rupture.

Dr. Barry Eppley

Indianapolis, Indiana

A: Breast lifts do an excellent job of lifting and tightening the shape of the breast mound. By keeping the same amount of breast tissue and lifting and tightening the ‘bag’ which contains them, this does create a less saggy and more round breast. This is particularly true in the bottom pole of the breast and less so in the upper pole of the breast. In the beginning right after breast lift surgery, the upper pole of the breast is quite round and full.  But as the tissues relax and settle, much of the upper pole fullness will be lost.  If one doesn’t ming some rebound flattening of the upper breast pole, then I think you would be fine with a breast lift alone. However, if your goal is to have a rounder and more full upper breast pole long-term, then a small implant will be needed to accomplish that breast shape goal.

Dr. Barry Eppley

Indianapolis, Indiana

The reality of breast implant surgery, however, is far from this image. There are certainly a minority of women who do want this look. But the  vast majority of women who choose to have breast implants are much more interested in finding the right size for their body and not to have overpowering breasts that become the focal point of their appearance.

Most breast augmentation patients are average women who simply want to look good in clothes and sport attire. I have seen many women who have told me that they are embarrassed to wear a bathing and won’t go to the pool or beach with their family. While breast underdevelopment is the most common motivation for getting implants, there are numerous other reasons. These include such breast conditions as postpregnancy sagging, asymmetrical breasts, body proportioning, breast asymmetry and reconstruction after mastectomies.

Pregnancy and nursing can have an adverse effect on a woman’s breast shape and size causing sagging and, almost always, a change in the amount of breast tissue. Many women are unaware that it is completely normal to lose breast tissue after pregnancy, a phenomenon known as involution. For some women who have had multiple pregnancies, they lose all of the breast tissue they originally had. When combined with stretched out skin, the change in a woman’s breasts can be deflating for their self-image as well. These are women who simply want to return to their pre-baby size and shape.

There are many women who have breast asymmetry where one breast is larger or different in shape than the other. In some cases the breast size difference can be as much as a cup size, sometimes even more. For women so afflicted, finding a bra to fit comfortably and properly is not as easy as going to Victoria Secret’s and pulling a good fit off the rack. Often they are forced to add padding to create a more even look in their clothing.

One of the most recognized and easily understandable reasons for implants is in breast reconstruction. The physical and emotional devastation of going through any form of a lumpectomy or mastectomy procedure can be softened knowing that an immediate or even a delayed reconstruction can be done. While numerous forms of breast reconstruction exist, including flaps that form the breast mound out of your tissues, implants remain the backbone of how most breasts are recreated.

Dr. Barry Eppley

Indianapolis, Indiana

One other trend in breast augmentation is a noticeable size difference. Many plastic surgeons have commented that women are asking for bigger breasts than they were a decade ago. Historically women would usually ask to go a cup size bigger. Today it is not uncommon for a women to want two or three cups bigger, particularly the younger they are. Women state they want to get a good value for their investment and they want to make a noticeable difference in their clothed appearance.

What accounts for these trends in breast augmentation? By far I would say that it is simply more accepted than ever before. As we enter the upcoming decade of 2010 to 2020, this is the beginning of the third generation of women who have had access to breast implants for cosmetic enlargement. It is a normal part of society now and younger women’s mothers and soon grandmothers will have had the procedure.

Breast augmentation has a track history of safety as well as effectiveness. Despite the hullaboo of what transpired in the early 1990s, the procedure has been proven to cause no medical problems or makes people systemically sick.. While it is far from a perfect procedure, because after all it is an implant in the body, its complications are local in nature and often aesthetic in significance.

The social trends of today play a major role in its popularity as well. Just go through the checkout counter at the local grocery store and the magazines are full of articles about celebrities who have had or are assumed to have had some form of plastic surgery. Many of these are women actors and performers who have enhanced their top half. The influence of these magazine, TV shows and now the internet have made it seem that having breast enhancement is now the new norm.

There are more choices in breast implants today than ever before. Since 2006, both saline and silicone implants are available in not only differing sizes but projection and styles as well. With the potential for gummy bear breast implants to be available perhaps later this year, increasing implant options appeal to an even broader spectrum of women. Just like the many aisles in a drugstore, multiple options for a single product line result in more sales.

The rise in breast augmentation is a result of greater societal acceptance, safety of the devices, influence of famous people, and a wide variety of implant options. I suspect the upcoming decade will see the number of implanted women continue to rise.

Dr. Barry Eppley

Indianapolis, Indiana

A: Fat injections for breast augmentation (FIBA) at this time is a procedure that is in a state of development. The reliability of the procedure and whom is the best candidate for it will take time to know better. The fairest statement one can make about the FIBA procedure is that the result can not guaranteed (breast volume and shape), can cost more than traditional breast implants, and may likely take two or three injection sessions spaced 3 to 6 months apart to get the desired result. Then there are the very real risks of fat necrosis and lumps throughout the breast.

To the best we know at this time, FIBA may be a reasonable alternative for a woman whose breast size goal is modest (B cup, maybe small C) and is willing to assume multiple procedures and the associated risks. This is not to mention that one must have enough fat to harvest on one’s body for transfer.

Compared to the success of traditional breast implants, FIBA is not for the vast majority of women considering breast enlargement today. It may be a different story (or not) five or ten years from now.

Dr. Barry Eppley

Indianapolis, Indiana

A: Whether breast augmentation with the medical history of lupus is a good idea would depend on what the extent and how symptomatic this autoimmune disease is in you. Do you have any known healing problems as a result of your lupus? Have you had surgery in the past and did you have any problems with healing or infections after surgery? Are you on any steroids or other immunosuppressive medications? What symptoms do you currently have from your lupus? What are your titer levels of ANA and other blood tests from your doctor?

 Ultimately, what your doctor or rheumatologist would say about your lupus condition would have a lot to say about the adviseability of breast augmentation for you. Despite the past allegations that silicone breast implants cause autoimmune disease from the 1990s, that has now long been disproven.

The issue is are you more prone to breast implant complications from your lupus? Infection risk in the short term and capsular contracture in the longer term are the issues. If you have skin problems, such as banding and contractures, than you would be likely to get problematic breast implant capsules. If not and your lupus is stable and relatively asymptomatic, then breast augmentation may be a satisfactory procedure for you.

Dr. Barry Eppley

Indianapolis Indiana

Recently, a flight attendant’s breast prosthesis (external) became an unfortunate source of controversy that  illustrates the  growing conflict between one’s privacy and that of air travel security. New TSA screening rules include the use of either full-body scanners or pat-downs for selected passengers, the inclusion criteria of which is not clear. Incredulously, the flight attendant was made to remove her implant as part of the screening process.. This event has understandably raised concerns amongst some plastic surgery patients about their right to having to reveal their most intimate of physical information.

If you are traveling and have any implants, breast or otherwise, do you have to tell screeners that you have implants? According to the TSA website, “It is recommended (but not required) that you advise the Security Officer that you have an implanted medical device, and where that implant is located. If you have an implanted medical device that you would like to remain private and confidential, ask the Security Officer to please be discreet when assisting you through the screening process.”

While having breast implants is a personal matter, stepping onto a public airline mandates that you may be asked to give up all your rights to privacy. This offends all of us but this issue has long had a legal precedent. A similar issue confronted us decades ago in the height of the first wave of terrorist activity in airlines…the introduction of the need to pass through a metal detector. Similar concerns were raised then and the highest court in the land ruled that making you do so was not unconstitutional.

The body scanner has the ability to not only see breast implants but many other types of implants as well. From facial implants, chemotherapy ports, shunts for water on the brain, any artificial orthopedic joint replacements and even testicular implants. No one knows the actual statistics but I would estimate that at least one out of every three people traveling have some indwelling implant. Pat downs, of course, can tell almost none of these internal issues but they are infinitely more offensive.

I am certain that the TSA doesn’t care if you have had breast augmentation. But you can argue that their concern about them has some validity. Intelligence reports have come forth that indicates that terrorists may be having women implanted with breast prostheses filled with explosive material. This would be all too easy to do and is a potential reality. It only requires a method of activation, an indwelling receiver to make it work. And this is exactly what a body scanner can hopefully pick up.

Dr. Barry Eppley

Indianapolis, Indiana

I am only 28 years old.  I want to feel young and beautiful again!  I know I deserve to and my husband deserves to have a wife who feels good about herself again.  My kids deserve a mother that feels comfortable enough to take them swimming. I would love to be able to eventually wear a bikini.

I know that some people may get depressed after they have surgery; whose to know how I will be after surgery.  Seeing that a lot of the causes of my depression are due to the way I feel about myself or view my body. I know surgery could not make my depression worse; if anything it will help improve the way I see myself and think about my body.  The only way surgery would worsen my depression is if I had surgery by a surgeon who did a lousy job.

I am not interested in looking fake.  I just want to look normal again. I would like to either be a full C or small D regarding my breast.

I suppose a ‘Mommy Makeover’ is what I am really looking for. What are your thoughts?

A: Of your situation and feelings, I understand completely and could not be more emphatic. Pregnancies can definitely take a toll on your body, and between the skin stretching and shrinking and the inevitable breast involution (loss of breast tissue), some women can not even recognize  the current skin and body that they now have.

As you have correctly pointed out, surgery is not a cure for depression. But at least it can improve one recognizeable and understandable cause of it…the way one looks. The body problems can definitely be improved and, hopefully with that, one’s self-image elevates. In my experience with women and these type of popular ‘Mommy Makeovers’, patient do report a dramatic improvement in their self-confidence and clothing options.

The classic ‘Mommy Makeover’ is some form of combined abdominal and breast rehaping plastic surgery procedures. This is usually a tummy tuck with or without liposuction and breast implants with or without a lift. In about a four hour surgery (or less), a dramatic body transformation can occur.

Dr. Barry Eppley

Indianapolis Indiana

A: The first thing to appreciate is that there are numerous type of breast implants from which to choose. They all will work and are FDA-approved with the exception of the gummy bear implant to which you refer. It has yet to be shown that there is one type of breast implant that is superior to any of the others. They all have some advantages and disadvantages and each woman has to weigh out those implant differences to determine what is the best breast implant for them. If there was one specific type of breast implant that was definitely superior that would be the only one that I would be using in my Indianapolis plastic surgery practice.

The gummy bear implant is a different type of silicone that is more firm than regular cohesive silicone gel. Hence the name gummy bear as it resembles this consistency. It is a textured anatomic implant that remains under clinical trials through the sponsoring company Allergan. It has not received FDA-approval as of yet. Because of its textured surface and its more form consistency, it must be placed through a larger lower breast fold incision than would be used for either saline or cohesive gel breast implants. Whether its added firmness is an advantage in cosmetic breast augmentation is a matter of debate. Its physical properties seem to offer advantages in breast reconstruction where the breast tissue may be thinner and more prone to contracture deformity. Gummy bear implants can and do ‘fracture’, requiring removal and replacement.

Dr. Barry Eppley

Indianapolis, Indiana

A: The appeal of using fat instead of a synthetic material certainly is of interest to some patients. If fat worked just as well as implants, and was no more costly to perform, then it truly would be a better option. However, as of today, fat remains a breast technique in evolution and development. The harvesting and injection of the fat are standard plastic surgery methods. However, fat after injection is not yet completely predictable and is prone to resorption, uneveness and lumps. It is also highly likely that multiple sessions of fat injections would be needed to get close to what most women would want. With multiple treatments, the cost would exceed what breast implant surgery would cost.

Scarring and lumps in the breast are also a concern for long-term breast cancer surveillance. It is not yet known if fat grafts into a non-reconstructed breast who has not had a mastectomy interferes with the detection of breast cancer.

Until the science of fat transplantation is better understood, fat injections into the breast should only be considered for those patients who are willing to accept the risks that come with being an early adopter of a surgical technique. For now, the use of a breast implant is more predictable and economical.

Dr. Barry Eppley

Indianapolis, Indiana

A: The anatomic determination of whether any breast needs lifting is based on where the nipple is sitting relative to where the lower breast crease or fold is. If the nipple is at or above the lower fold, one will not need a lift in combination with breast implants. If the nipple sits below the fold, whether it be a little or down so far the nipple points to the floor, then a combination implant and lift will be needed to get a well shaped breast that has the nipple centrally positioned on the mound and pointing forward.

When a women has had more than two pregnancies, it is almost a certainty that a breast lift will be needed. I do not recall ever seeing in my Indianapolis plastic surgery practice a patient with three or four pregnancies who has not needed one. When you combine the number of pregnancies with up and down body weight, there has undoubtably been a lot of stress and strain on the breast skin. This translates into breast skin that is loose, deflated and has a low nipple position. This will happen to most breasts whether one has breastfed or not.

A breast implant will add volume to the mound but will not significantly lift a downturned or low nipple position. That is exactly what a breast lift does…get the nipple back up to where it once was or close to it. 

Dr. Barry Eppley

Indianapolis, Indiana

A: The combination of a breast lift (skin reduction and tightening) with an implant is a very common procedure for the breast that is small in volume but has an excess amount of skin that sags over the lower breast crease. With the breast in this kind of shape, all three procedures are needed simultaneously to give a more pleasing and uplifted breast shape. This is the most difficult of all cosmetic breast procedures and is best thought of a breast reconstruction rather than a simple breast reshaping.

Unlike breast implants alone, this more extensive form of breast reshaping will result in scars on the breast. The scars will be similar to that of a breast reduction. Because of the difficulty of the procedure, secondary revisional surgery is not rare to get the best shape and symmetry between breasts that often start off not only badly shaped but different.

Dr. Barry Eppley

Indianapolis, Indiana