Donovan Rosas, MD

Choosing an implant size/style is an important decision which is best made in concert with your surgeon. Ultimately, options are based on a number of factors including: -Chest dimensions: This point is crucial as the width of your breasts defines the available "real estate" on which the foundation of your augmentation is built. This "foot print" is the absolute limit with which you are dealing. Too "large" is not so much the risk as too "wide." You cannot build a 3 acre mansion on a half acre plot. An implant which is too wide (exceeding the available space on your chest) will generally over hang laterally making it more noticeable and occasionally contributing to discomfort and nerve symptoms (numbness or tingling). This will also contribute to a more unnatural look. -Tissue quality: This relates to size in the sense that the implant will be suspended by your tissue. Too large an implant may place took large a stress on these suspending tissues leading to healing problems in the short term and bottoming out in the long term. -Patient desire (what is the look you are hoping to achieve?) My role as a surgeon is to manage expectations and guide you towards a prudent choice which can satisfy these reasonable goals. Often times, a surgeon can guide a patient toward a size/cc range and patients will make determinations on implant style/profile. Patient seeking more or less projection, or seeking a more pronounced or subtle upper pole volume increase can be guided toward an implant which will help them best achieve their goals. Additionally, technique variations (sub muscular vs. sub glandular) can also aid in obtaining the look you desire. There are a number of tools available to help guide patient/surgeon decision making including sizers, 3D imaging and goal photos. Each modality can help better communicate your goals to your surgeon and vice versa. Ultimately, it is important to not marry oneself to a particular "cc" as oppose to a particular "look." Communication is key as you and your surgeon create your custom surgical plan. Based upon your photos, your implant choice seems reasonable. Cup size prediction is by no means an exact science. However, I would revisit your options with your surgeon and perhaps establish a range of sizes which would be acceptable which will allow for some flexibility intra-operatively. As always, discuss your concerns with a board certified plastic surgeon.

Skin necrosis can occur after abdominoplasty if the blood supply to the skin flap is compromised. This can occur with over-dissection or aggressive upper abdominal liposuction. Evidence of necrosis will become apparent in the early post operative period. Discoloration is an early sign which can eventually progress to tissue loss. Outside of the first few weeks, new onset skin necrosis is unlikely without outside insult (i.e. compression). As always, discuss your concerns with a board certified plastic surgeon (ABPS).

Weight loss can alter the appearance of the breast unpredictable ways. The loss of volume will affect shape and can ultimately distort the appearance of the NAC. While restoration of volume can sometimes correct the changes associated with weight loss, however, there are no guarantees. Ultimately you do have options including revision mastopexy with the aim of addressing the areolar changes. As always, discuss your concerns with a board certified plastic surgeon (ABPS).

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach. Subglandular Augmentation (“overs”): • Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster when compared to subpectoral augmentation. • Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection). • Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space. • Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling. Subpectoral Augmentation (“unders”): • Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients. • Subpectoral implants have a lower rate of capsular contracture. • Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion. • The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle. Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other. With regards to your specific question, division of the muscle will cause a slight decrease in upper body strength. However, for most the difference is negligible. You should be able to perform the same activities as prior. It is a compromise not in ability but rather intensity. As always, your board certified plastic surgeon can help guide you in your decision making process.

Patient concerns regarding the appearance of their breasts can typically be divided in two pools: volume, ptosis (droop). The procedures to address these issues are as different as the issues themselves. However, these concerns are not mutually exclusive. Many patients, whether they are aware or not, will benefit from both. There are two factors which can help to answer the question of which surgery will deliver the most satisfying result: mastopexy, augmentation or both. Patients must first consider the position of the NAC (nipple areolar complex i.e. the pigmented portion of the breast) as it relates to the inframammary crease. If the nipples are at or below the level of the crease the patient may benefit from a lift or mastopexy. The breast lift is designed to elevate sagging breasts to a more youthful position. It also helps to reshape and tighten the skin of the breasts. This is typically accomplished via a periareolar (around the nipple) incision with or without a vertical incision. Mastopexy is an effective way to address sagging breast, however, the changes which accompany weight loss or pregnancy can also decrease volume of the breasts. When a woman wants the volume restored, or increased, a breast augmentation will also be needed in conjunction with mastopexy. Augmentation can help restore the volume loss which is well known to women following children. There are a number of options available to women considering augmentation ranging from size and implant type to access incision. A breast augmentation alone may also be appropriate if ptosis is mild. If the patient is comfortable with the natural appearance of the breasts but desires them to be larger, a breast augmentation alone is the right procedure. Augmenting significantly ptotic or sagging breasts tends to magnify the problem. In these cases, a mastopexy performed in conjunction with an augmentation is preferred. Based upon your photos, you demonstrate moderate ptosis (NAC appears to be slightly lower than your fold) with associated glandular ptosis/pseudoptosis. A lift would be beneficial. If you are hesitant, you could stage your procedures (beginning with an augmentation and following with a lift should you choose to). There is a procedure for every problem. To determine which technique is right for you, consult with a board certified plastic surgeon Patient should discuss their concerns with their physicians in order to make an educated decision.