Dear Dr. Neavin, I have been to a few plastic surgeons now to go over my options for breast augmentation. One wanted to use shaped implants (I think they’re called tear-drop or anatomical online), one said he wanted to put the implants over the muscle, one said he wanted to go under the muscle, one said I needed a lift, and the others said I didn’t. How can there be so much variation in plan and technique over something as simple as a breast augmentation?!
Hi, Debbie. That’s a good question. It’s not unusual to get different opinions from different plastic surgeons when it comes to procedures, even something as simple (as you described it) as a breast augmentation.
Every year there are a dozen or so regional or national plastic surgery meetings where plastic surgeons from all over come to share their ideas in the form of lecture to others in the field. A main reason these meetings exist is because plastic surgery is as much of an art as it is science. We often agree to disagree on many aspects of the discipline. And by doing so, we can all learn from each other and improve upon safety and efficacy with the field.
Even Leonardo Da Vinci and Michelangelo disagreed on aspects of art in the 16th century. Michelangelo often criticized Da Vinci’s sculptures and Da Vinci took aim at delivering is less favorable opinion about Michelangelo’s painting style. And these are not just masters disagreeing, they are true geniuses and pioneers that etched a deep place in history.
When it comes to anatomy, there are certain ideals that exist – in part to Leonardo da Vinci’s Vitruvian man and his subsequent studies on human proportions. Naturally, his ideals have evolved over time. And in 1955 a plastic surgeon by the name of Jack Penn, who also happened to be a sculptor, studied the aesthetic ideals of the female breast and came to several conclusions about shape and proportion to very specific measurement points of the nipple, the sterna notch, and the breast fold. Suffice it to say, the results are beyond the scope of this answer, but the point is that the human form exists in incredible variety. And as such, the ideals still remain somewhat subjective in nature.
How does this relate to your consults? Well, shaped implants offer advantages such as a more accurate slope of the breast than their round cousins – particularly in women with virtually no breasts at all. But most plastic surgeons do not feel this slight advantage in a very small population warrants their use. Shaped implants are much more expensive to purchase (which translates into increased costs for the patient), and they can rotate after implantation creating deformities that would require additional surgery to correct. (Note that a rotated round implant does not change shape).
Similarly, when it comes to lifting a breast, in many cases the decision is easy. If the nipple position is well below the fold and pointing down, then only a lift will restore its perkiness. But when the nipple sits at the level of the fold or just a hair below it, often an implant alone will due the trick. But some plastic surgeons appreciate more predictability, and offer a lift at the same time of an augmentation. Without seeing your breasts, this may be the case for you.
Under the muscle and over the muscle augmentations are less frequent among plastic surgeons. There exists few good reasons to place implants below the muscle knowing that under the muscle provides a clear reduction in capsular contracture (hardening of the breast tissue around the implant). One is if a woman competes in body building competitions. Implants under the muscle in women with very large pectorals muscles may generate animation deformities when flexing. This is rare, but certainly possible. In these individuals, it may warrant the placement of implants under the muscle. Two is a pseudoptosis, which describes a breast shape where the nipple sits above the fold but there is slight sagging of the breasts. Sometimes, an implant placed over the muscle can improve the breast she better than under the muscle. However, with dual-plane approaches where both an over the muscle and under the muscle dissection is created and the implant is placed under the muscle, pseudootosis can often be corrected just the same.
In summary, one must remember that your body functions as a science but is visible as an art. A canvas of beauty to improve upon its beauty. No two artists may agree on every aspect of what defines true beauty, nor does every plastic surgeon agree on what approach one must take to achieve a desired aesthetic outcome. If Michelangelo and de Vinci couldn’t see eye to eye on art, it’s unlikely that every plastic surgeon will agree on their decisions to create art.