What is the best course of action for breast augmentation with a very short areola to inframammary crease distance? (photo)

I am 5'3'', 120 lbs with an A cup and have very tight areola to inframammary crease distance - around 2.5-3 cm. Two doctors have told if they put an implant in, my nipples would be pointed down. One recommended a Benelli to move the areolae up and to put in a small implant. Another said the Benelli procedure is actually just an areolae reduction and doesn't really move them up and can flatten the breast. Should I choose a small implant and go with a Benelli or can pocket creation solve my issue?

Doctor Answers 12

Augmentation with Short Areola to Inframammary Distance?

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Your situation can be challenging and potentially there are a couple of ways it can be addressed. The problem, as several surgeons you've seen have pointed out, is that with a short distance from the areola (and nipple) to the inframammary fold, if an implant is placed so that it settles out at the level of your natural fold, it will be too high and not centered behind your nipple. This will cause your nipple to be rotated downwards and your upper breast will be excessively full. This looks unnatural and most patients don't like the appearance. Therefore something must be done to lengthen the distance from your nipple to the fold.

One solution is to raise your nipple position so that distance is longer. This requires some version of a breast lift which means additional scars on your breast. Obviously patients would prefer to avoid additional scars, in particular the vertical scar that goes down the middle of the breast. This leads some surgeons to recommend a Benelli or donut type lift where the scar only goes around the areola. In most cases like this I would say that the Benelli lift is a bad choice. First, it is very limited in how much it can raise your nipple position. Second, it tends to flatten the breast which is the opposite of what is trying to be achieved. Third, in most cases such as this, the lower breast is tight or constricted. Adding in a Benelli lift only makes this tighter and when combined with an implant (further tightening), it will result in a flattened, widened areola and often a widened and irregular scar. If you have enough skin laxity that will allow for both a lift and an implant then the most effective and aesthetic lift would be a vertical or lollipop type lift.

Let's say you would prefer to avoid the scars of a lift or your tissues are too tight to allow for a lift plus implant. Then the other obvious solution to increasing the distance between your nipple and the fold is to lower your inframammary fold. Many surgeons are averse to doing this because of concerns of creating the dreaded "double bubble" deformity, and they will often suggest that getting a double bubble is an inevitable consequence of lowering the fold at the time of augmentation. This is simply not true. There are many times when lowering the fold is both cosmetically beneficial and sometimes necessary to achieve an aesthetic breast shape. The key is knowing how to manage the tissues of the lower pole and reposition them so that the implant ends up centered behind the nipple, and the tissues are made to redrape over the lower pole without creating a double bubble. The obvious benefit is that an aesthetic breast shape is achieved without having to introduce the additional scars of a breast lift. 

So as you can see, there are three potential solutions to your problem each of which has some drawbacks. In the first option there are no additional scars and no risk of DB but the breast shape is unnatural. In the second option there are additional scars, risks, and costs, In the third option there are some additional risks (for a DB) and possibly costs. Which would be best for you?..................To answer that would require an in person consultation, but here a couple of other things to consider. When one talks about the nipple (or areola) to inframammary fold distance, it should always be assumed that it is when the tissues are under stretch. As some surgeons have pointed out, an implant (particularly the new highly cohesive gel implants) will stretch the lower poles tissues over time resulting in a gradual natural lengthening of the nipple to fold distance. The problem is that this does not always reliably happen and it is an uncontrolled process. Sometimes it might be a matter of both lowering the fold a small amount (less risk of DB) and expecting some further stretch of the tissues of the lower pole under the pressure exerted by the implant. This is probably the approach that I would take in your situation. You would need to find a surgeon who is comfortable with and has a good deal of experience in managing the tissues of the lower pole in patients with a tight, underdeveloped, or constricted lower pole. 

Nipple to inframammary crease too small

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your nipple to imc distance on stretch determines your maximum ideal implant radius (1/2 the diameter) and ultimately your implant size. If you want a larger implant, you should consider a lift. By the way, the Beneli lift is the worst lift you can get; it is frought with poor areola scarring and suboptimal lift. You should really consider a vertical lift procedure. Please see examples below.

Best course of action.

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Thanks for your question. Without knowing your specifics and current breast dimensions it's difficult to answer this question. With that said,  I think you will look great with a moderate or high profile implant that has a small  diameter. Your breasts' base diameter looks to be only 10-11cm wide. Your surgeon may not need to even lower your breast crease at all with a smaller diameter implant. Good luck. 

You Can Go Either Way

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Looking at your photos, I see a left breast that would do fine with a straight breast augmentation. Lowering the IM fold a little may help, depending on the size of implant you want.

Your right breast is more ptotic and would benefit from a mastopexy as well as an implant. In my hands, my Tear Drop Augmentation Mastopexy is much better looking and durable than the conventional Benelli Mastopexy. 

To learn more, please read my book "Cosmetic Breast Surgery - A Complete Guide From A to Double D".

Breast augmentation for constricted breast patients

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An in-person examination is critical for evaluation, but my opinion based on your photo is that a standard dual-plane augmentation using a cohesive smooth round silicone implant via an infra-mammary incision would deliver a nice cosmetic result. No breast lift needed.

Breast Implant Sizing

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Thank you for providing a photo this time. Your N:IMF is definitely more than 3 cm, and you have breast ptosis too.  This is not the scenario that you described in your prior post. Regardless, it is still important to have the surgeon choose an implant based on your tissue dimensions. A Benelli lift would also improve areolar diameter and nipple position. Please visit a few ABPS certified/ASAPS member surgeons that specialize in breast surgery.

Best of luck!

What is the best course of action for breast augmentation with a very short areola to inframammary crease distance?

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I find the variety of answers that you received fascinating.  Obviously each doctor has different suggestions based on personal experience.  I would suggest that you should be conservative in your augmentation goals and I would recommend and at least discuss the option of a Benelli mastopexy to reduce the wider areola on the right side and slightly elevate your nipple position.  This can be done in a manner that does not decrease the areolae to inframammary crease distance in my opinion and if not done aggressively will not produce flattening of your breast.  Without a periareolar incision your areolae are likely to widen and be less aesthetic.  Again it is most important that you avoid too aggressive a volume expansion with too large an implant.  A partial subpectoral placement or dual plane placement will help to encourage the implant to settle.  I would also use a compressive bra after surgery

Good luck and best wishes.

Jon A Perlman M.D., FACS
Diplomate, American Board of Plastic Surgery
Member, American Society for Aesthetic Plastic Surgery (ASAPS)
ABC-TV Extreme Makeover Surgeon
Beverly Hills, California

Jon A. Perlman, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 31 reviews

Options for a short or constricted lower breast

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A beautiful breast includes optimizing the proportions of the breast features - shape, position on the breast on the chest wall, position of the nipple areolar complex on the breast mound and lastly the size of the breast. A smaller base dimension implant should produce a nice final shape without the need for an areolar reduction or elevation. Shaped and textured devices can achieve a more controlled stretch or expansion of breasts with tighter contours like yours. These devices have a variety of other trade-offs that need to be discussed during your consultation and may or may not be recommended. Hopefully your Plastic Surgeon will present a solution for you that is unique to your tissues. What is predictable is that too large of an implant will result in an unpredictable final breast shape with a high risk of lower pole problems such as bottoming out or double bubble. I would not recommend simultaneous areolar reduction or lifting. 

What is the best course of action for breast augmentation with a very short areola to inframammary crease distance?

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Good question. This is something we see almost on a monthly basis and is quite common. In cases like yours (every patient is different) no lift is necessary. A subpectoral implant of the proper size (you cannot use overly large implants) and a dual plane implant placement can be done. It then takes about 8-12 weeks for the tissues to adjust and you will have an attractive and natural look. Probably in the C cup or full C range. 

Short N-IMF

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Thank you for your question and photo.  From the photo it looks like your nipple to fold distance is short but not that bad. The important measurement is the distance from the NIPPLE to the fold, not the bottom edge of the areola to the fold. Don't go back to the surgeon who suggested a "Benelli" combined with implant. He doesn't have any idea what he's (or she's) talking about. Doing a "Benelli" lift will actually SHORTEN the distance from the nipple to the fold if it works like it is supposed to but is actually more likely to end up looking even worse than if you had just put in an implant with no lift.   I would also advise you against lowering your folds in order to increase the nipple to fold distance. That is a setup for getting a "Double bubble" deformity. If you were my patient,depending on your exam and actual measurements, these are the options that could be considered. 1. Do nothing and live with your breasts the way they are. 2. Use a high or ultra high profile implant in order to keep the diameter down and keep from creating too much upper pole volume. If this is done with a "dual plane" pocket, the nipple to fold distance will actually stretch over time and the breast will look better after a few months.  The downside is that the implants will shift off to the side when you lie down which may or may not be a problem depending on how much breast tissue you have. 3. Use a Sientra oval shaped implant of appropriate profile and volume to fit your breast.  4. Do a vertical scar breast lift as a first stage procedure in order to move the nipple up a bit and increase the N-IMF. I would not do this at the same time as the implant placement as the closure would be too tight if it could be closed at all and would at the very least result in a very wide vertical scar but, even worse, could compromise circulation to your nipples. This would allow me to use a wider implant matched to the width of your breast at the second stage without creating too much upper pole volume. Find a surgeon who has a lot of experience with this type of surgery and can show you pictures of patients with breasts like yours that he has done. Using a computer simulator like Axis Three or Vectra can be very helpful in showing you what you can look like with the different options. Choose a surgeon who is certified by the American Board of Plastic Surgery and preferably also a member of the American Society for Aesthetic Plastic Surgery and the California Society of Plastic Surgeons. And, again, DO NOT let anyone talk you into a "Benelli" procedure unless you want to end up on Botched. I hope this has been helpful to you.  

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.