Do You Really Want an Augmentation?

Rian A. Maercks, MD
Article by
Miami Plastic Surgeon

With the relatively recent boom in frequency and acceptability of plastic surgery patients and doctors of all kinds seem very eager to augment something whether it be lips, breast, cheeks, buttocks or pretty much anything you can think of. This over-exuberance toward making things bigger has created many plastic surgery nightmares that attract a lot of public attention and give the field a bad name.

Breast augmentation is among the most popular cosmetic procedures performed, but is it really bigger that is better?It has become very acceptable to have breasts that appear plainly fake and unnatural because of their commonplace appearance in the media and general public.

Patient satisfaction is even high when breasts are very separated, very high with poor nipple position and have a clearly visible implant edge as long as they are indeed bigger.

I have quite a different philosophy in my practice.

I believe in creating and restoring beauty through focusing on a naturally beautiful human form. A natural breast has a gentle slope to the superior pole and not a ’shelf-like’ appearance. A natural breast is not a circle with a form independent from the pectoral fold (the fold of muscle coming down from the armpit).  It is rather a gentle beautiful slope that starts at some visually unidentifiable point just below the armpit. It transitions outward from the pectoral fold creating a smooth curved profile distinct from the chest wall and slopes around an inferior fold to a point where it seamlessly disappears 1-2 centimeters from midline. This description does not match the image conjured in the public eye by the word ‘augmentation.’

More frequently than not, a patient’s concern is breast form and not breast size. A breast augmentation can be used to address all of these issues, but to achieve beautiful breast form, the dimensions and qualities of the implant as well as the technique used must be carefully considered. A breast implant that does not match a patient’s ideal ‘breast footprint’ as defined by the individual chest wall will never look natural while a perfectly selected and executed augmentation can offer a form that does not at all resemble an ‘augmentation,’ but a beautiful natural breast.

Similar issues relate to procedures for facial rejuvenation.

Off the shelf filling agents have become more and more popular over the years and have been adopted by practitioners with the spectrum of professional background and training. It has been customary at many doctors’ practices as well as medspas to ‘plump up’ the face in order to treat wrinkles, a sort of shotgun face augmentation. While it is true that adding volume to the face reduces or obliterates wrinkles, it is also true that wrinkles themselves are rather trivial aesthetic problems. To understand this, one must also understand a bit about human perception and neurology. Working together your eyes and brain make an aesthetic judgment in about 300 milliseconds. That’s faster than you can think! The way this happens is that your eyes scan key reflex points taking in light, shadow, space and negative space. Wrinkles simply do not go into the equation, they are afterthoughts once the aesthetic judgment is already made. What does this mean? Yes, there are some wrinkles that can be completely addressed with fillers as a secondary benefit to restoring beautiful facial form, but there are many types of skin problems, wrinkles, and unpleasant contours that should not be addressed by adding volume!

One of the many reasons there are so many strange appearing people walking around is that the majority of practitioners that inject these substances have no knowledge or training regarding the facial structure below the skin. For this reason, these well intending practitioners are usually not even cognizant of what their manipulations are doing to the aesthetic impression of the face, and are simply concerned with creating wrinkle free, smooth skin. Sadly, these patients are much better off with wrinkly loose skin than a strange ballooned out and nonhuman appearance.

There are many ways to deal with wrinkles, but primarily any aesthetic intervention should communicate beauty to the unconscious working of the human mind, a much more powerful impression. It is also difficult for practitioners that are not well versed in human facial soft tissue, ocular and skeletal anatomy to perform exactly the correct procedure. For example, mid-facial augmentation needs to be high, necessitating an intimate knowledge of the anatomy of the eyelid/cheek junction, the complex anatomy of the eyelid and orbit. This explains why unnatural appearing ‘low’ cheek augmentations are so prevalent—practitioners are trying to avoid this complex anatomy.

Now consider the lip. Lip augmentation is ever present and incredibly unnatural in the media. It has become acceptable to simply create a swollen appearing ‘cigar’ that obliterates natural labial anatomy. The structures that create a beautiful lip include skin, fat, mucosa, and a complex interdigitating circular arrangement of muscle fibers with very specific zones of adhesion to the overlying skin and ligamentous connections between the skin and deeper structures. Using this knowledge and extensive experience in performing cleft lip repair as well as post-traumatic and post-neoplastic deformities, it is possible to perform what I call ‘anatomic lip sculpting.’ Sure, the lips are generally made larger, but with a very specific goal of lip balance and total facial harmony. Using this technique as can be seen in the non-surgical, Juvederm, fat grafting and lip augmentation photo galleries, a more beautiful, young appearing lip is created that not only blends with the face but actually brings out more beauty of the face by restoring balanced harmony.

The same concepts apply to gluteal augmentation and virtually all other cosmetic interventions. So ask yourself, do you really just want an augmentation? Or do you want an aesthetic improvement to your face, breast or body that can only be guided by a practitioner with an aesthetic eye, diverse experience and exposure to all nonsurgical and surgical options and a focus on you as an individual patient? Remember the dangers of having only a hammer in your hand, as the world starts looking like it is filled with nothing but nails!