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Remodeling the aging breast

Paris — Breast augmentation has become a commonly practiced procedure, with several techniques available to the plastic surgeon.

When choosing a specific breast augmentation procedure for each patient, the plastic surgeon must take numerous crucial factors into consideration to obtain optimal cosmetic results. The challenge is to achieve symmetry, natural shape and, most of all, small scars, as well as long-lasting results.

French plastic surgeons Jean Marie Faivre, M.D., and Ziad Elias Feghali, M.D., of the Andre Gregoire Intercommunal Hospital Center in Montreuil, France, discussed their extensive experience in breast augmentation and spoke of the newest techniques at the disposal of cosmetic surgeons at the 2006 Anti-Aging Medicine World Congress, here.

"We have seen that there is a significant increase in the demand for breast augmentation in patients with hypotrophic breasts associated with varying degrees of ptosis," Dr. Feghali says. "As there are no clear indications for the procedures used in mastopexy with augmentation in the textbooks, we, as plastic surgeons, are challenged to devise and create novel operative techniques, keeping the symmetry and the natural breast shape in mind, as well as minimizing scar tissue."

Techniques

The techniques that the surgeons usually use when performing a mastopexy with a breast implant are periareolar scar, vertical scar and inverted T scar techniques. The patients who will qualify for one of these techniques are those who have undergone significant weight loss, post-pregnancy patients and especially elderly patients. In the clinical pre-op examination, the surgeon must critically assess three crucial factors, namely the degree of ptosis, the condition of the skin and the dimensions of the base of the breast.

Assessing the breast

When assessing the degree of ptosis, the surgeons measure the distance from the sternal notch to the nipple and, very importantly, the position of the nipple in relation to the inframammary fold.

According to Dr. Feghali, the second measurement is preferred because this measurement is less dependent on the height of the patient, and ultimately crucial for the final optimal cosmetic outcome. When examining the skin condition, the degree of skin aging (e.g., elasticity, retraction) and striae must be assessed, as well as any possible previous scar tissue.

When assessing the base of the breast, the surgeons judge the distance to be considered in proportion with the width of the chest. Here, it is important to evaluate this distance for the volume of the breast implant to be used. Dr. Faivre says that measuring the base of the breast can give the surgeon an idea of the excess of skin in the lower quadrants of the breast. He adds that the bigger this distance is, the larger the amount of skin in the lower quadrant, and so the bigger the implant.

"If the position of the nipple in relation to the inframammary fold is less than 2 cm below the inframammary fold, we prefer to perform a periareolar mastopexy with breast implant," Dr. Feghali says. "If it is between 2 and 5 cm below the inframammary fold, we either perform a vertical mastopexy with breast implant or an inverted T mastopexy with breast implant, depending on the skin condition. If it is more than 5 cm below the inframammary fold, we usually opt for the inverted T mastopexy with breast implant technique."

The mammary implant is in subglandular position and is a "high profile" implant.

The surgeons claim that the breast implant will cause a projection from the chest wall, which gives an illusion of a breast lift, and that the higher the breast implant is, the greater the illusionary effect will be. They admit, though, that this effect will be short-lived if the implant is not associated with a mastopexy procedure. The illusionary effect of the breast implant is directly proportional to the volume of implant employed.

According to Dr. Faivre, a 200 cc implant will give no illusion of breast elevation. A 200 cc to 300 cc implant will effect 1 cm to 2 cm lift (depending on the degree of skin retraction), and an implant of 300 cc or more will effect a 2 cm elevation, or more, depending on the implant size. This is why the position of the nipple in relation to the inframammary fold measurements can be stretched if the volume of the implant is greater, especially if this distance is between 2 cm and 5 cm.


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