Jeremy Powers, MD

Thank you for your question. It is smart of you to consider whether or not you may need a lift at the time of breast augmentation as there is a dynamic interplay between the skin envelope and the underlying breast implant, that can be unappreciated at times. It appears from your photos that you don’t have significant breast ptosis and you may get by without having a lift. However the final determination would of course be with your plastic surgeon, based on your goal, your pre-op physical exam, and possibly the intra-operative findings with the breast implant or sizer in place. Sometimes a periareolar mastopexy, while not moving the nipple a significant amount, helps to improve the skin envelope to breast implant relationship and can really enhance the results. It is really important to have these discussions with a board certified plastic surgeon prior to surgery so that your expectations best match the surgical plan and outcomes.

I think your goals are very reasonable and you would get a great result. It is often patients who want a dramatic/disproportional change who are disappointed. Discuss with your surgeon your specific goals and draw attention to the sloping chest and desire for cleavage and he/she will discuss the maneuvers that we use to make sure those areas are addressed. Best of luck!

Thank you for your question. Based on your photo and description, I think your surgeon is concerned about capsular contracture. Montelukast is anti-inflammatory and may help soften the capsule. If this is not effective, further surgery may be necessary to release or remove the tight capsule, with exchange of the implant. If this becomes necessary, most implant companies have warranties for their implants that cover capsular contracture and should help cover the costs of the replacement implant and surgery. Best of luck with your continued recovery.

This is a great question and the answer depends on a number of factors.

Implant based reconstruction can either be tissue expander at the time of mastectomy followed by implant placement at a second operation, or “direct-to-implant” placement at the time of mastectomy. While direct-to-implant is convenient, generally implant sizes are smaller than what could be achieved the tissue expanders although this depends on your preoperative breast measurements.

With regards to surgical swelling, most of it will be gone by 6 weeks but the last 5-10% will hang around for another 6 weeks. That’s why most surgeons will say to wait at least 3 months for what should be closer to your final result in terms of overall shape. For reconstruction, the needs of the cancer treatment dictate the type of mastectomy, lymph node excision, and radiation, all of which have an impact on the reconstruction. I advise patients to give it at least 3 months to heal, and to expect to have some contour irregularities and scar revisions that may need to be addressed at a secondary revision operation with fat grafting, etc. Finally, nipple/areola reconstruction can be performed as the final phase of reconstruction at least 6 months after the last operation.

Of course, the results will continue to change slowly over time (years), as the forces of gravity continue to act on all parts of your body, including the reconstructed breasts. The larger the breast implants, the more force on the tissues and the more rapid the rate of descent/change. In practicality, this may mean you notice that the implants have dropped to a less desirable position at 5-10 years instead of lasting 10-15 years in a good position. For patients frustrated with or having issues with breast implants, revision of implants or replacement with your own tissue both may be options.

Breast reconstruction is an art and a science and requires a skilled plastic surgeon experienced in breast reconstruction. It is important to seek out a board certified plastic surgeon to meet with prior to your reconstruction procedure. It is also too important to note that there are implant-based and your-own-tissue-based options for breast reconstruction. You may also want to make sure that your plastic surgeon is skilled in all methods of breast reconstruction, both implants and tissue, so that you have all options available to you and you can select what you think is best for you and your unique situation.

The appearance of breasts after mastectomy and reconstruction will depend on several things including the type of mastectomy performed, whether or not lymph nodes were taken, whether or not radiation was performed, whether or not there were complications after any procedures, and of course, what reconstructive technique was employed.

Nipple sparing mastectomy has the best aesthetic results, however, not every patient is a candidate for nipple sparing. Whether or not you are a candidate will depend on your breast cancer type, location in relation to the nipple/areola, the size of your breast, the degree of breast ptosis, and several other factors. This is an important conversation to have with your general/breast surgeon, as well as your plastic surgeon.

If you are not a candidate for nipple sparing due to having large/ptotic breasts, then a wise pattern/skin reducing mastectomy can be a great option to improve the aesthetics/shape of the breast following reconstruction. A standard skin sparing mastectomy, which is sometimes the best option given the circumstances, will result in a transverse scar across the front of the breast. There is flattening of the anterior breast post reconstruction due to the horizontal pattern of skin removal, and sometimes dog ears on either side of the closure that need to be removed.

If lymph nodes are taken, then this often leaves a divot below the armpit area that can be noticeable. This is not often correctable at the initial stages of reconstruction. However, this is an area that can benefit from fat grafting in order to add volume to the area where tissue was previously removed. If radiation was performed to the axilla after lymph node removal though, it can be very difficult to correct the resulting contour irregularity and sometimes flaps may need to be employed if it becomes a major issue.

If radiation is required after breast reconstruction it will change the position and shape of the reconstructed breast. Radiation will cause the skin and tissues to contract, shrinking the overall breast envelope/shape. The position of the breast will typically move superiorly on the chest wall, especially in comparison to the non-radiated side. This may result in the need to perform procedures to correct asymmetries after radiation.

Certainly while the task of breast reconstruction is to recreate the form, shape and appearance of a breast after a mastectomy, the ultimate goal is to reconstruct breasts that will appear normal in clothes. It is definitely possible to achieve outstanding aesthetic results that make it seem as if one never went through mastectomy even when unclothed. When this is not possible, which is most of the time, it usually has to do with many of the factors listed above which are necessary to treat the breast cancer. As plastic surgeons caring for the whole patient, we must prioritize the cancer treatment first and optimize the aesthetics of the reconstruction wherever we are able within that process. The importance of a multi-disciplinary team in which the oncologic breast surgeon and reconstructive plastic surgeon work closely together, cannot be overstated.