Donovan Rosas, MD

A traditional abdominoplasty scar will run from hip to hip and involve a scar around the belly button. A short scar abdominoplasty or "mini" will involve a lower scar burden but is reserved for a particular group of patients: -Minimal skin laxity -Skin laxity limited to the area below the belly button -No muscle laxity While this is an option, most patients will not be great candidates for one or more reasons. Based on your photos, you skin excess extends above the belly button which would make you a better candidate for traditional abdominoplasty. As always, discuss your concerns with a board certified plastic surgeon (ABPS).

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. With regards to your specific question, it is crucial to remember that these procedures are mutually exclusive and do different things. A lift will not restore volume and an augmentation will not lift. Based on your photos, you appear to be a reasonable candidate for augmentation (however, an exam is needed to be certain). Nipple position appears to be preserved making a full circumvertical/lollipop lift unnecessary. A donut lift is an option for very mild sagging. 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.

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. With regards to your specific question, given your measurements, your implant choices sound large. None of the available sizing options are 100% accurate. But they are useful tools. Volume is not necessarily different post op but shape and projection will change (leading to the tendency to go bigger). As always, discuss your concerns with a board certified plastic surgeon (ABPS).

There are numerous practitioners of plastic surgery. However, only a select few are board certified by the American Board of Plastic Surgery (the only board recognized by the American Board of Medical Specialties). Board certification ensures completion of a rigorous training program of at least 6 years (with at least 3 years of dedicated plastic surgery training. Board certified surgeons have also completed written and oral examinations to determine competency and participate in a continuing medical education programs as a prerequisite of maintaining certification. Ultimately, certification ensures a measure of certainty when comparing surgeons. You can be assured that your board certified plastic surgeon has seen and treated it all before and is uniquely qualified to manage you pre-operatively, intra-operatively, and most importantly post-operatively. It is difficult to know the qualifications of a "cosmetic surgeon" as there is no board recognized by the board of medical specialties for this particular "specialty."

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. 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. Based on your photos, you are a reasonable candidate for dual plane augmentation. It is difficult to assess the need for a lift without an exam. You appear to be a borderline candidate. It is possible to stage the 2 procedures. 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.