Breast Implants

A well-augmented breast has a natural fullness, with gentle sloping off the chest wall. There should be natural cleavage without webbing between the breasts and only a certain amount of perkiness.

There are three main telltale signs of unnatural-looking breast augmentation:

1. Breast implant margin: This should be soft and imperceptible, as obvious implant edge visibility, especially in the midline, will resemble the Tori Spelling or Posh Spice look.
2. Breast implant size: An implant that is too large for a small frame is usually an obvious give away that a patient has had a breast augmentation. The best example of this is Pamela Anderson-style breasts. Women wanting to go from an A cup to a full D cup need to understand the limitations of Breast skin.
3. Perkiness: An augmented breast that is too perky will tend to look fake, as a small amount of droop is natural. When a patient lies on her back, the breast implants should roll to the side like natural breast tissue and not sit up like rigid peaks.

There are three main Breast "looks" that patients strive for:

1. Natural Look: In-proportion
2. Natural Look: Out of proportion
3. Augmented Look

Please refer to my extensive Photo Gallery to get a guide to what type of Augmentation you are after.

Dr Tavakoli has come up with the 6 following broad categories of patients seeking Breast Enhancement in Australia. Most patients should fall into one of the categories:

Enhancement

1. Tight Skin, Poor Shape & Small Breasts

2. Good Skin, Good Shape & Small Breasts

3. Good Skin, Good Shape & Moderate Breasts

Restorative

4. Tight Skin and Tuberous shaped (Grades 1-4)

5. Poor Skin, Good Shape (Weight Loss &/or Post-Pregnancy)

6. Poor Skin, Poor Shape (Weight Loss &/or Post-Pregnancy)

There are six main clinical parameters for breast implants on initial consultation:

1. Patient's body build and height
2. Patient's own breast size, shape and symmetry
3. Nipple position in relation to the breast mound
4. The quality of breast skin (thickness & stretch marks)
5. Chest wall shape and dimension (Hollowed vs Pigeon Chest walls)
6. Patient's desire for new cup size: Under-proportion, In-proportion or Over-proportion augmentation

After establishing the crucial parameters in the clinical examination, the process of tailor-making the 'correct' breast augmentation begins.

I specialise in Minimal Incision Technique & Minimal Pocket  Bleeding producing Rapid Recovery after Breast Augmentation.

There are three choices about where to make the skin incisions for breast enlargement. They can be in the breast fold (inframammary), around the nipple (periareolar) or underneath the armpit (transaxillary). These incisions can all produce scarring ranging from excellent to poor. Although patients may voice some initial concerns about the location of their scars, they are ultimately far more concerned with the final shape and size of their breasts. In fact the rate of scar revision for unsatisfactory scarring in Breast Augmentation is less than 0.05%.

Generally, a great majority of patients in my practice opt for the inframammary incision (breast fold). I also find this incision has the least amount of interference with breastfeeding and nipple sensation and it generally heals very well.

I find the periareolar incision particularly useful in some Asian and African patients with higher risk of keloid scarring but the nipple-areola must be at least 4.0 cm in diameter. Furthermore, the periareolar incision also allows one to perform the full Benelli breast lift or nipple lift where this may be indicated in mildly droopy breasts.

Transaxillary (armpit) incision carries high risk of cleavage problems (too much gap) and is reserved for a few select patients with small chest wall. The transumbilical (belly button) incision popularised by the Fox reality show Dr 90210, is ONLY reserved for the use of saline implants. As I am not a huge fan of saline implants due to extremely high risk of problematic "rippling" I do not personally favour the  "belly button" incision.

Please note that my Clinic has the latest World Laser technology FRAXEL. The fractionated laser works amazingly well in most scars to eliminate the redness and improve texture of scars in cosmetic surgery patients with poor healing. To read more about this technology refer to my LUXE Medispa website.

The choice of breast implant varies from round to teardrop (anatomical) shapes. Both the round  and teardrop breast implants come in both low and high-profile varieties. The shape variation is in the width and projection of the breast implant for any given size.

In the Round range there are 5 profiles or projections:

1. Low Profile
2. Medium or Moderate Profile
3. High Profile
4. Extra High Profile
5. Ultra High Profile

In the Anatomical range there are 3 main bases and also 5 Profiles (projections) like above:

1. Short Oval Base
2. Long Oval Base
3. Round Base

The spectrum of breast implants available to the surgeon can therefore provide much greater versatility in achieving a more natural look. The majority (60%) of patients in my practice elect to have round shaped implants and 40% Anatomical/Tear drop shaped.

Since I prefer placing the implant in a submuscular pocket in most patients, implant edge visibility in the upper pole of the breast can be avoided even in the round implants.

The round implant tends to be ideal for those patients with well-shaped natural breasts who desire a straightforward enlargement.

Use of the teardrop (anatomical) shape depends on the patient's desire, as well as her breast shape. In general, there are two groups of women who benefit from teardrop-shaped breast implants. It can be the ideal choice for women who have mild droopy and/or tuberous breasts. Mild elevation of the nipple in relation to the breast mound can be achieved without the need for extra scars on the actual breast (unlike breast lift scars). In these cases, the implants may be inserted in a subglandular or subfascial pocket (under the breast tissue) or Dual Plane Submuscular Pocket.

In moderate to severe cases of droopiness, breast lift must be performed at the same time as breast augmentation in order to restore aesthetic shape.

Secondly, some patients specifically want less fullness in the upper quadrant. Teardrop breast implants certainly offer less fullness in these particular situations. It should be noted however, that this request tends to be very personal, as most women are seeking breast augmentations in order to obtain upper pole fullness. It should also be noted that teardrop or anatomical implants do have a tendency, estimated at about 2-5 percent, to rotate. Unfortunately, this problem can only be corrected by secondary surgery. The rate of tear drop implant rotation in women who continue to use the chest muscles in their exercise routine is much higher. Round implants do not cause "rotation" issue.

Please also note that Polyurethane coated tear drop  (anatomical) implants have a much lower rate of rotation of around 0.5 percent.

Breast implant size is one of the most important decisions in a breast augmentation procedure. Because of this, a good surgeon will take several approaches to help the patient make the best decision based on their anatomy, personal preferences and the appearance they wish to achieve. In general, attractive breast augmentation should be in proportion or slightly out of proportion to the woman's overall body shape.

In a recent survey, over 80 percent of patients undergoing breast augmentation stated an average to full C-cup was their desired postoperative goal. D-cup was the second most popular request. Small C-cup is the third commonest followed by full-D and Double D cups.

Final breast implant size is a complex function of the elasticity of a patient's skin envelope, chest wall diameter and implant dimensions but most importantly preexisting breast volume.

For this consideration, I always begin by showing the patient numerous photos of actual patients who have had breast augmentation. By finding someone who has a similar preoperative appearance and evaluating their results with the size of implant they chose, the patient can get an idea of her own final result and increase or decrease the implant size according to her wishes.

I will also measure the patient's breast and chest shape, paying particular attention to the base and projection of the breasts. This gives me an idea of what size breast implant will help achieve the patient's desired size postoperatively.

As breast implant size increases, so does the diameter of the breast implant. In most cases, there is a breast implant that will be an ideal match for the diameter of the patient's natural breast, and I find this is a good starting point for discussion.

Choosing a breast implant smaller than the patient's natural breast shape will not provide the proper cleavage and shape following the procedure. Similarly, choosing a breast implant too large for the patient's natural chest shape is more likely to give an unnatural appearance. It is noteworthy that very large implants can create more issues and future complications such as stretch marks, implant migration and symmastia.

Unfortunately, breast implants do not come in cup sizes. Rather, they are categorized by the volume of gel that they are designed to hold. There are several reasons for this. First, the final cup size will be partially determined by the preoperative breast size, and every patient is different in this regard. Second, a C-cup from one bra manufacturer is not necessarily the same as a C-cup from another manufacturer.

Although every woman is built differently and bras are not manufactured to a set standard, it can be expected that a B-cup implant size is approximately 250g (cc) and a C-cup is 330cc in a woman of average height and average build. That number will be higher if the woman is tall or has broad shoulders. Similarly, if the patient is shorter than average or has a narrower chest, that number can be expected to be slightly lower. Although a desire for a certain cup size is helpful in guiding the patient in the selection of the proper breast implants, I find it is more helpful to focus on the desired shape and appearance that patient wishes to achieve.

The next consideration is where to place the breast implant - on top of or behind the muscle. In general, I prefer to place breast implants behind the muscle so that they are partially covered. I find the pectoralis muscle allows a smooth takeoff from the chest wall. If put directly on top of the muscle, the breasts can look like rounded balls on the chest which is a definite giveaway. It is also my opinion that placing the implant under the muscle will, in the long run, have an impact on breast droopiness. Also for older women that need breast screening, it seems that behind the muscle placement is superior from a mammogram and ultrasound imaging point of view. A further advantage of the submuscular pocket is a lower rate of capsular contracture.

It is not all perfect with the submuscular placement of implants. The negatives of the submuscular pocket is that it may create "winking" on animation or flexing of the pectoralis muscle. Implant migration and displacement is also more likely in this pocket.

In women with mild droopy (ptotic) breasts, I use the dual-pocket technique of dissecting both on top of and underneath the pectoral muscle, but inserting the breast implant behind the muscle. This new technique popularized by Texan Plastic Surgeon Dr John Tebbett is proving very successful with most types of breast augmentation that I see in my practice.

In rare cases of moderate droopy breasts where the patient does not wish to undergo a breast lift procedure for fear of scaring, I will consider placement of the implant on top of the muscle. This pocket is referred to in the plastic surgery literature as ‘subglandular” or “subfascial”. Generally speaking, it is a relatively painless pocket with excellent short term benefits but in my opinion far less long-term advantages compared to the “submuscular” or “subpectoral” pocket placement.

This issue of different coatings is controversial. Implant surfaces can be generally Smooth, Textured or Polyurethane. The reason for the differing implant surfaces is one day there can be the "perfect" implant with a low capsular contracture rate and yet feels very soft and natural. No matter what the coating on the outside of the implants is, the inside material of all the implants are still silicone gel or Saline (salt water). The research in implant technology is ongoing and new advances are continuously emerging.

Smooth implants generally gives a softer feel in many cases, particularly in thinner patients, but the downside is that the patient needs to massage the implants for at least 6 months to help prevent capsular hardening.  The rate of hardening with smooth implants is 10-15%. Please note that implant migration is also higher with smooth implants.
Polyurethane coated implants from the manufacturer Silimed (Brazilian made Furry) or Polytech (German made Microthane) are proving to be very effective in treatment of capsular contracture. Currently I prefer to use these implants in some selected primary cases and all revisional cases of capsular contracture. Please note that the Polyurethane coated Implant also have silicone gel in the centre of the implant and has been TGA product approved for only 2 years here in Australia. Please note that Polyurethane implants are not risk free and feel much firmer than both smooth and textured implants although they do soften up after 9-12 months. It is certainly correct that in the anatomical range Polyurethane implants have an almost zero rotation rate.

Generally speaking, textured or rough surface implants are said to reduce the rate of capsular hardening or contracture and have a lower rate of pocket migration, but they are also known to create more wrinkling or rippling issues later on in particular if patients lose a lot of weight. This wrinkling is normally felt in the lower edge of the breast where the implant is closest to the skin surface. My recommendation based on 3000 Implant cases is to use textured implants in most patients and specially for extremely fit athletic girls who may shift the implant pocket due to overexertion.  They are very safe and have been around for 30 years and represent in my opinion the lowest re-operation rate. Textured implants also have a much lower rate of capsular contracture than smooth implants. Going forward polyurethane coated implants are a viable alternative to textured implants but the plastic surgery fraternity needs more time in order to fully study and understand them. Just remember that heavy marketing push and chit chat on the blogosphere can not replace good old experience and clinical trials.

I do not believe any credible plastic or cosmetic surgeon can use just one type of implant material. An experienced Implant surgeon will not only use all different types of implants depending on the patient requirements but also do not commit to one implant manufacturer. Remember that as a general rule surgeons that use one implant type have a financial association with that breast implant company and not your best interest in mind.

I almost always use the cohesive silicone-gel and rarely the saline-filled breast implants. The new generation silicone-gel breast implant is very safe and generally feels and looks more like a natural breast.

Most breast augmentation operations in Australia are performed with silicone-gel breast implants (98%). In December 2006, the United States Food and Drug Administration approved the use of gel implants in the US market. The decision was based on a great amount of scientific research into the safety of silicone-gel implants. As a result the use of gel implants worldwide is 90%.

The gel usually comes in low and high cohesiveness (soft touch or firm touch), and you should ask your plastic surgeon for different samples at the time of the consultation so that you can make the most informed choice possible. Generally speaking the firmer gel implants are “form responsive” like the gel found in the tear-drop implants. The round implants can be soft (80% fill) or firm (100% fill) depending on the manufacturer.

Saline implants were popular in 1990s as they were made from salt water they promised to revolutionize breast implant surgery. However because of the fact that they felt very unnatural to touch, rippled heavily as water has different density to breast tissue and they almost all ruptured needing replacement at the 7 year mark the Saline implants are no longer used except by few older surgeons.

Dr Tavakoli has developed a large practice specialising in Correction of Tuberous breasts deformity.

The Tuberous (snoopy or cone-shaped or constricted base) breast deformity is a rare entity affecting young women bilaterally or unilaterally. There is mild, moderate and severe grades of this condition. Women have usually inherited this condition and when severe they cause significant psychological issues.

The Tuberous deformity is characterised by a constricting ring of tissue at the base of the breast, which leads to deficient horizontal and vertical development of the breast with or without herniation of the breast tissue toward the nipple-areola complex and areola enlargement. Tuberous breasts are invariably asymmetrical in size in 90% of cases.

Interestingly enough pregnancy and rapid weight loss can convert a Mildly tuberous breasts to Severely tuberous.

As you can imagine surgical correction is quite complex. The treatment in simple terms include:

1. Mild forms: Augmentation with Anatomical implants only
2. Moderate & Severe forms: 3 procedures need to take place. Breast reduction and flap procedure to get an even breast thickness in ALL quadrants, Periareolar Breast Lift & Augmentation with anatomical implants. In some cases Fat Grafting may be needed at 6-12 months post-operatively to complete the transformation.

Medicare item numbers exist for this condition making correction of tuberous breast a reconstructive/corrective operation. Please click here read the following CASE STUDY on this condition.

Click here to view Dr Tavakoli's extensive Tuberous Correction Breast Gallery

The Von Heimburg classification describes 4 grades:

• Grade I: hypoplasia lower medial quadrant,
• Grade 2: hypoplasia of both lower quadrants with adequate areolar skin,
• Grade 3: hypoplasia both lower quadrants with limited areolar skin,
• Grade 4: hypoplasia of all quadrants.

This is a very common problem (up to 80% of ALL women) as women seldom have identical breasts. Breast Asymmetry can be corrected in many ways. Implants can be used as well as Breast Lift procedures.

Dr Tavakoli uses different size implant for each breasts in 25% of all his cases. Generally speaking Dr Tavakoli only corrects asymmetry of more than 1/4 cup size. Very slight breast asymmetry are recorded but best left untreated.

NB. Dr Tavakoli will advise if you need any extra procedures and explain the exact reason at the time of your initial consultation. The extra cost will also be discussed well in advance. Please note that only a properly specialised plastic surgeon can carry out these extra procedures combined with breast augmentation.

Correction of significant Breast Asymmetry

Correction of significant Breast Asymmetry

Correction of significant Breast Asymmetry

Correction of Extreme Asymmetry

Correction of Extreme Asymmetry

Correction of Pectus Excavatum

Although mild cases of rib abnormalities are common in up to 25 % of my patients undergoing Breast Augmentation, more severe cases need special attention.

Pectus Excavatum is an abnormal development of the rib cage where the breastbone (sternum) caves in, resulting in a sunken chest wall deformity. Sometimes referred to as "funnel chest," pectus excavatum is a deformity present at birth (congenital) that can be mild, moderate or severe.

There are many radical operative ways of treating this condition involving complicated and dangerous Cardiothoracic Surgery to remodel the bone but I prefer to use breast implants in female patients to camouflage this condition as shown in this case study in a 27 year old girl with severe pectus excavatum further complicated by breast ptosis (droopiness) after massive weight loss.

There are essentially 4 methods  of breast lifting that I perform at the time of implant augmentation:

1. Implant Augmentation for Slight droopyness
2. Benelli (around areolar only) or Mini-breast lift for Mild Droopyness (ptosis) for very deflated breasts. Always with an implant
3. Le Jour (lolly pop scar) or Major- breast lift for Moderate Droopyness (ptosis). Can be performed with or without implant
4. Inverted T or Anchor Scar or Mega-breast lift for Severe Droopyness (ptosis)

Success of Breast lift is 50% in diagnosis and correct planning and only 50% in surgical technique.

For more information on "Combined breast lift (Mastopexy) - augmentation" please click here to refer Dr Tavakoli's article on this topic.

To view the related before and after galleries:

• Le Jour (vertical "lollypop" scar) Mastopexy or Breast Lift with Implant
• Le Jour (vertical "lollypop" scar) Mastopexy or Breast Lift without Implant
• Benelli (Around Nipple scar) Mastopexy or Breast Lift with Implant

Nipple or Crescentric Lift

In minor cases where nipple is pointing downwards but the breast is not droopy, this simple procedure can enhance the final breast shape. This is a simple nipple alignment procedure usually performed on one nipple to bring it in symmetry with the opposite nipple areolar.

The scar is only located at the top of the nipple-areolar and heals very well. Nipple sensation is usually preserved with this procedure.

Long "floppy" nipple condition usually occurs as a result of prolonged breast feeding. More commonly is seen in Asian patients. If not corrected the nipples can be quite obvious after breast augmentation as nipples can be seen protruding in tight T-shirts etc... Dr Tavakoli prefers to perform this operation on women who have finished with breast feeding duties.

Click here to view the Nipple Conditions Gallery

Bilateral Implant Exchange for severe Capsular contracture and mastopexy (breast lift)

Capsulectomy or Excision of capsule for hardness

It is not fully understood the reason for this occurrence of this condition. Capsular hardening or contracture is more common in certain ethnic groups such as Asians and Africans. It can however affect any racial group. The hardening is caused by excessive scar tissue forming around the implants. It can occur as early as 6 weeks after surgery and as late as 10 years. The best way of preventing this is to massage the augmented breasts in the postoperative period so the capsule forms softly around the implant. The breast hardening process or capsular contracture can have both cosmetic and pain implications.

Capsulectomy operation removes the hard capsule and the new implants are inserted in a fresh pocket preferably behind the pectoralis muscle. In these situations the use of Polyurethane coated implants are recommended.

There are many reasons why one would opt for change of implant pocket.

A. Rippling and Implant Edge Visibility are hard to get rid of. One sure way is for the patient to be a small amount of weight around her breasts. Exchange of implant to smooth high filled implant &/or going behind the muscle also can be very helpful manoeuvres.

B. Placing the implant behind the pectoralis muscle can create an issue namely "winking". In most patients this is not a major issue but in some women with strong muscles, flexing the pecs can create a pull effect that may look undesirable. I normally recommend no surgery for this condition, but some may want to opt to have the implant placed in front of the muscle.

Change of Implant Pocket

Implant Pocket Re-adjustment or Capsulorrhaphy

Implant Pocket Re-adjustment or Capsulorrhaphy

48 yo female with change of pocket to submuscular, and capsulectomy. Old implants 12 years old. Selection of much better implant dimensions.

Implant Malposition & Displacement: Migration can occur from time to time usually in patients that exercise excessively. If the condition doesn't respond to taping then a formal pocket re-adjustment or new pocket formation needs to take place.

Excessive Cleavage Gap

Between breasts creating eg "Tori Spelling" & "Posh Spice" boobs. This condition usually arises from poor choice of implant and inadequate submuscular dissection.

By further dissection and appropriate use of a broader based implant this condition can be improved. Please note that some women are prone to having this issue as a result of the poor curvature of their chest wall.

This condition is described where there is no cleavage or very tight cleavage. Patients can be born with this condition or acquire it after Breast Augmentation.

If apparent immediately after breast augmentation it occurs as a result of overdissection centrally and/or use of very large based implant so that the implants are left too close in the middle. It can also develop months later but overzealous use of "push-up" bras creating thinning of tissue centrally. Eitherway the condition of Symmastia is very distressing to patients.

Surgical treatment is possible but needs complex re-adjustment of the pockets using permanent suture technique and smaller size implants with narrower base.

In Mild cases a Thong Bra (www.thongbra.com) maybe all that is needed and avoiding push up bras.

In Moderate cases if the implants are submuscular the choices are either to suture down the tissues centrally with permanent sutures and dissect the pocket laterally so the implants have room to shift outwards. If the implants are subglandular the implants need to be placed in a new submuscular pocket.

In Severe cases the implants have to be removed for 6-12 months and replaced after pocket healing has taken place.

Post operatively ALL patients need to wear a Special Bra for 3 months with no activity.

Correction of Congenital Symmastia

Correction of Congenital Symmastia

Correction of Symmastia using suture technique

Correction of Acquired Symmastia

For poor scarring such as Hypertrophic scar or Keloid. Prior to scar revision I recommend the FRAXEL laser technology to improve the quality of the scar. Failing the latter then formal surgery on the scar by re-cutting and suturing will certainly improve the scar.

For size issues (usually for bigger size) or content (usually Saline To Gel)

This is a condition where the implant and the native breast are in completely different anatomical levels. Routine subpectoral mammary augmentation in women with a small breast lower pole deficiency often results in poor late results with the appearance of a double-bubble deformity. The surgical correction is complex and requires the need for a series of a. excision of breast tissue, b. pocket adjustment or capsulorrhaphy and c. exchange of implants or any combination of the above.

Correction of "Double-Bubble" syndrome

Correction of "Double-Bubble" syndrome

Thailand Breast Augmentation creating a severe case of Double- Bubble and now corrected by Dr Tavakoli

Correction of "Double-Bubble" syndrome by Dr Tavakoli

Reconstruction after Removal Of Infected Implant

Implant infection is extremely rare but as this overseas breast job demonstrates they can occur.

Reconstruction was successfully performed in this case demonstrated by Dr Tavakoli.

Breast Implant Bottoming Out

This condition is a form of Implant migration. Although can be seen with all types of augmentation it is more common with smooth implant.

The treatment is very complicated and involves pocket repair/exchange.

Although ruptured breast implants are usually rare, the topic has received an enormous amount of press in 2012 as as result of the faulty French manufacturer PIP. Dr Tavakoli has NEVER used these implants but in the photo attached has removed a PIP implant late in 2011 from a patient visiting from London. As you can appreciate the implant is completely disintegrated highlighting the extremely poor manufacturing standards of PIP implants.

Ruptured Implant

Breast Correction After Implant Rupture and Capsulization