Shawn A. Birchenough, MD

Thanks for sharing your images and questions.  Tuberous breast augmentation can be a challenging surgery.  Also, there is no single solution for the different variants of these breast differences.  In general, I would typically approach the breast using a circumareolar incision (going around the areola) as the areolar commonly needs to be reduced in size due to the tuberous breast development differences.  Also, the implant can be placed above or below the muscle depending on the amount of breast tissue available using the pinch test.  Using a higher profile, firmer gummy bear gel can help round out the breast more.  A key maneuver is to radially release the bands from inside, underneath the breast tissue, to allow the breast to flatten out more over the implant. Some amount of areola mastopexy or breast lift is commonly needed. Any other differences in the height of the breast and the inframammary fold (the bottom of the breast where it connects to the chest wall) would need to be addressed surgically too.  It is important to discuss these and any other questions during your surgical consultation with a board-certified plastic surgeon. Best of luck!

Thanks for your questions and photos.  Weight loss discussions come up frequently with my patients - prior to any cosmetic procedure - facelift, breast surgery, abdominal surgery, liposuction etc.  I advise patients to get to a “maintainable” weight.  This is usually not their ideal or “perfect” body weight. We are all able to lose weight quickly with crash diets or over-exercising, but that weight rarely stays off when we return to our normal diet or exercise regiment.   Maintainable weight is the weight that patients can REASONABLY achieve with reasonable and permanent diet and exercise changes. This varies for every patient, and it won’t be listed in a table or book or online chart! In our practice, my wife (also an MD) has a wellness practice through which she can help and guide patients to their optimal weight and health prior to surgery with me.  Make reasonable and lasting changes in diet and exercise for your overall health and fitness, and you’ll likely feel better and be at the best weight for your surgery.  Discuss it at length with your board-certified surgeon. And best of luck!

Thanks for the questions.  It is important to note that doing back liposuction does require additional positioning.  This can be done prone, or face down, prior to doing the breast and abdomen surgeries, because we don’t want to put too much pressure on the breast right after surgery. (Just like I ask patients not to sleep on their stomachs after breast surgery!) Alternatively, surgery can be down with the patient in a lateral decubitus (lying on the side) position.  This side position can be used either before or after breast and abdomen procedures. Need for fat grafting in the breasts or buttocks can impact the positioning and sequence of surgeries.  Discuss it with your board-certified surgeon to see what considerations and concerns they have. And best of luck. 

Thanks for sharing your photos. And yes, I agree that it could be possible to do both breast augmentation and abdominoplasty together. And you appear to be an appropriate candidate for abdominoplasty, but a specific discussion and physical exam with your board-certified plastic surgeon should be done.  By doing the procedures together, patients can save on some costs, over doing the procedures separately.  There is time and cost associated with anesthesia and the OR at the beginning and end of every surgery, apart from the actual surgery time. You could save some of this cost in a combined situation. How much can be saved is specific to each situation.  Frequently, we provide 2 fee quotes to patients, one with combined surgery and one with 2 separate surgeries, so they can make that decision. The other primary consideration is the amount of functional and social downtime.  With separate surgeries, patients have to go through some downtime twice! Best of luck.

Patient safety is very important, especially during and after surgery.  While there is more risk with longer surgeries, anesthesia and surgical techniques are continually evolving to improve outcomes and safety.  I personally use a hospital-based operating room, with MD anesthesiology oversight of CRNAs. We offer overnight stays in the hospital for any patient who asks.  And for patients who have surgeries longer than 4 hours, I strongly recommend they stay overnight. All patients are seen either in the hospital or in my office the next day, regardless of their surgery day. I use blood thinners on patients at higher risks for DVTs (blood clots) especially if they are having abdominoplasty.  My personal limit is 5 hours of surgery for cosmetic patients, so if it would be longer, then a second surgery would be necessary.  It is important to discuss all of these issues with your surgeon prior to booking your procedure.  Good luck. 

Good question, and the photos show your concern. I agree that the implants are high on your chest wall, but more time is needed. There is no standard time for which to start using an augmentation band, but I usually will start within a 2 weeks of surgery if I think the implants are riding higher than I would like.  Give the implants at least 3-4 months to settle into the appropriate place, but continue to follow up with your plastic surgeon so they can monitor your progress.  Best of luck. Dr. Shawn. 

Good question.  While numbness of the breast and nipple areolar complex are known possible side effects of nearly every breast surgery, progressive numbness is less common.  The nerve injury is likely to be a stretch injury (and not necessarily being cut completely).  If larger implants, like yours, are used or the breast tissue is more elastic, then there can be stretching of the skin and breast tissue (and the nerves running within the tissue) over time.  Progressive numbness may result. Also, it can take 8-15 months for nerves to regenerate or heal after injury or after correcting the stretch injury. Sometimes the nerve function may never return normal.  Also, capsular contracture (hardening of the scar tissue around the implant) can progressively get worse and put traction on the nerves, resulting in progressive numbness. Make sure you get re-evaluated by your surgeon to see if something else is going on, and best of luck

Good question.  While numbness of the breast and nipple areolar complex are known possible side effects of nearly every breast surgery, progressive numbness is less common. You didn't mention what size implants were used or the technique used.  I wouldn't expect that textured implants would specifically be causing the numbness, as any implant or implant surgery can cause it. The nerve injury is likely to be a stretch injury (and not necessarily being cut completely).  If larger implants were used or the breast tissue is more elastic, then there can be stretching of the skin and breast tissue (and the nerves running within the tissue) over time.  Progressive numbness may result. Also, it can take 8-15 months for nerves to regenerate or heal after injury or after correcting the stretch injury. Sometimes the nerve function may never return normal.  Also, capsular contracture (hardening of the scar tissue around the implant) can progressively get worse and put traction on the nerves, resulting in progressive numbness.  Make sure you get re-evaluated by your surgeon to see if something else is going on, and best of luck. 

Good question.  Like many of these questions, it's difficult to tell without photos and an examination.  In general, your surgeon examining you is likely the best way to tell if there has been some displacement of the implant, swelling or bleeding.  Also, your surgeon would know what plane the implants were placed in and what type of supporting sutures were placed. Asymmetric swelling can cause them to look and feel different, even without any movement of the implants.  Swelling usually takes 6-12 weeks to nearly fully resolve.  Imaging (xray, mammogram, ultrasound) are not sensitive enough to differentiate small variations in the implant location, but ultrasound can show large amounts of fluid around the implant, if that is a true concern of your surgeon. Bleeding on the inside would likely show up as bruising at the skin level within a week. Talk it over with your surgeon, but usually you need to give it time to resolve or become more obvious. 

Every plastic surgeon has their preferences in a case similar to yours. Because I haven't examined you, I can't give a definitive answer, but in patients with similar breast shape and ptosis, I would prefer a mastopexy (breast lift) and submuscular implant placement (under the muscle).  By using an implant and placing it  under the muscle, I tend to have better results with getting the upper pole (top part of the breast) to fill in.  Typically this is the most deficient part of the breast after pregnancy, weight loss breast feeding, or agin. (it is also the hardest part to fill in! Also, I would tend to use highly cohesive silicone implants (gummy bear) implants in a patient with similar breasts to yours.  You do not necessarily need shaped (teardrop) implants, but I do like the silicone properties of the highly cohesive implants to help create an internal scaffolding to support the breast from the inside.  Best of luck!  And thanks for using board certified Plastic Surgeons.