DC Breast 2025
Learn the Details About:
Breast Augmentation
Breast Reduction
Breast Lift
Note 06/24/25--- this site is still being updated please enjoy what's here and return soon.
What a difference a day can make
Introduction
This website has been up for about 10 years and is due for an update. So much has changed in the world of breast augmentation. There are more styles of implants than ever. Some styles have come and gone and some are out of favor. Some manufacturers have come and gone.
Lifts vs. reductions and the need for implants or not still continues to confuse patients.
This site is dedicated to answering the most common questions and concerns patients approach me with. I hope it is of value to you as well. Each topic, Augmentation, Lift, and Reduction has its own section. I have added an additional section about other procedures patients commonly combine with cosmetic breast surgery. All sections are personally written by me and I try to express how I approach my surgeries what I think works and what does not.
Additional surgeries are detailed in my main website www.ATCosmetics.com
I hope this website helps clarify and dispel the myths of the internet. It has been honed in from over 20 years of experience and common sense.
Augmentation FAQ:
How do you help your patients find the right implant?
Should it go above or below the muscle?
Who makes Implants in the USA?
What kinds of implants are there?
When do implants need to be changed out?
Can implants be combined with a lift?
When will I see my final results?
What is a capsular contracture?
Do I Need Implants?
Oddly enough this is one of the most common questions I am asked at an initial consultation and the most honest answer of course is “no one needs them.”
What I help my patients figure out is if it is their goals are reasonable, if they are healthy enough, and if they consider implants will it achieve their goals. Adding implants to a patient who is already a DD will only lead to issues later in life, adding implants to a small A cup patient will often make them feel more normal in their own skin… I shoot for normal.
How Do I Choose an Implant?
The best advice I can give my patients is don’t choose your implants based on photos on the web. In most instances you can’t tell how tall or broad the people in headless photos are. Two patients may look the same but have very different size implants to accomplish the same look.
In my offices we have actual implants to try on, on your own frame in front of a full length mirror. I think this is far more valuable and realistic than computer generated images.
Bring a shirt, bring a blouse, and/or bring a friend to your sizing session. Bring your wish pics, but don’t show them to me until after sizing. I don’t want to be biased until we find what we like. At that point the photos help me to see if we are on the right path to achieving your goals. Below is our implant sizing collection.
How Do You Help Your Patients Choose an Implant?
To me, augmentation is about the height, shoulders and hips of the patient. If an implant is too small and does not fill the width of the breast it will look like a torpedo. If an implant is too wide it will make a patient look heavy. In a sizing session I first start by changing the width of the sample implants. I like to see the diameter fill the width of the breast and have enough curve to balance with the shoulders and the curvature of the hip. A patient with slender hips might have a narrower implant, a patient with wider hips will balance better with a wider implant.
Once we like the width together, we can the change the size of the implant by going to a low, moderate, high, or even ultra high profile at that width.
Augmentation is not just about the breast it about the size of the individual patient.
Too big Too small Just right
Should implants go above or below the muscle?
Implants can be placed above the chest wall muscle, the “PEC” or pectoralis, or below.
I am a big fan of below the muscle. When implants are below this muscle they tend to look more natural, the risk if infection is lower, future mammograms are better and the risk of the implant becoming firm and tight known as “CC” or capsular contracture is lower. Under the muscle, you are essentially massaging the implants whenever you move your arms. This helps to keep them soft. There is also another reason to go under the muscle that is future thinking. Many patients will return years later needing a breast lift. Natural breast tissue, even with an implant underneath will relax and droop over time. Often childbearing weight gain and/or loss are a contributing factor. When a patient who has had an implant needs a lift, that lift is safer if the implant was placed under the muscle because the breast tissue is still attached to the muscle beneath it.
To me there is only one negative – when patients have implants below the muscle, if they vigorously flex their pecs, the pec will contract and pull on the implant leading to distortion. Medically this is called muscle flexion deformity. I really don’t think of it as a deformity, but more as a fact or consequence of submuscular placement. If the patient is a body builder it is certainly something to consider, but for the majority of my patients who don’t go around flexing, it is of little consequence.
Where is the Scar?
Breast implants can be inserted in a few different ways:
Infra Mammary: This means at the bottom of the breast or just above the fold. It is the most popular approach and offers good visualization.
Periareolar: This means a scar around the bottom of the areola where the pigmented areola and the less pigmented skin meet. While I still use this approach on occasion there has been recent evidence that capsular contracture (cc) rates may be higher. Transit through the areola involves cutting some of the breast milk ducts. The concern is that these ducts may carry bacteria leading to cc. For that reason I favor under the breast which usually will avoid the ducts.
Armpit: I have never favored this approach. I personally feel it is less predictable. I am aslo concerned about implant contamination from glands in the armpit.
Through the Belly Button: (“Trans Umbilical Breast Augmentation”) – This is a largely blind insertion of only saline implants. This one is not for me.
Through a Tummy Tuck: This is called “TABA” or “Trans Abdominoplasy Breast Augmentation” and, of course, you must be having a tummy tuck at the same time. This too I will use on occasion with saline implants, but it too is a partially blind dissection of the implant pocket so there can be a higher risk of bleeding or asymmetries.
What is the Recovery Like?
Breast augmentation is done under a light general anesthesia. I tell my patients that when they awake they may feel like a baby elephant is sitting on their chest. In surgery I inject local anesthesia into the muscles, the incision, and around the implant to make recovery easier. While each patient is different, most are off pain medication in about 48 hours. Most will take a week out of the office, but many will be able to work from home much sooner. I ask my patients to refrain from exercise for 21 days after surgery. We don’t want to elevate the blood pressure. Risk of bleeding diminishes by the end of the third week. Below is a laryngeal mask airway that is used to protect the airway during surgery. It is used for most breast augmentations and halps to minimze sore throat after surgery.
Who Makes Implants?
To produce and bring an implant to market is a huge undertaking. Manufacturers must go through a lengthy and expensive approval process. Many implants that are used around the world are currently not allowed in the U.S. I don’t know if that will change. We currently have five vendors:
Mentor — Mentor has been making implants for decades and has an excellent track record for customer satisfaction and reliability. I have used these implants since 1996. These implants have a very stretchy shell, which I believe translates into durability and longevity. Because of this they tend to be easier to insert with an implant funnel. They are now a subsidiary of Johnson and Johnson, who bought them out a number of years ago. Their implants are made in the USA which I like as well.
Allergan — Allergan purchased Inamed, formerly Mcghan, a long time implant maker, also currently producing in the US. They also make an excellent product. I find the shells somewhat thicker and for that reason, I tend to favor Mentor, but I have used both extensively.
Sientra — Sientra was an off shoot of Mentor, trying to bring more competition to the market. While currently made in the US, they initially had production problems at their Costa Rican plant and recently declared bankruptcy. While just recently purchased by another company, I don’t know what their future will be. I never used Sientra because they were silicone only. Many of my patients still request Saline.
Ideal/Serenity — The Ideal implant is gone. They went out of business in May of 2023. They produced a “Structured Saline” implant that was supposed to feel more like silicone with the advantage that leaks would be easy to detect. I used this implant a few times and found it cumbersome and prone to failures. The implant had some production issues and never gained popularity. The company shut down. It has now been repurchased and rebranded as the “Serenity” implant. I have yet to see it gain traction in the implant community.
Motiva — A silicone implant brand that has just recently been FDA approved in the United States. It has been used in Europe for about 10 years. They are marketing heavily here in the US. They boast a micro texture to the implant that has greater biocompatibility and claim a lower rate of capsular contracture. Time will tell.
What Kind of Implants Are There?
This is a big and often confusing question. I will do my best to clarify.
Silicone/Saline
The two main categories are Silicone or Saline. While they all have a similar outer shell silicone implants are filled with a silicone gel at the factory, saline implants are filled with salt water at the time of surgery. The volume of a saline implant can be adjusted. Currently the volume of a silicone gel implant can not. Silicone tends to be softer, mushier, and more natural looking and feeling. Silicone has less rippling around the edges that sometimes a slender patient may feel. Silicone implants can not have their size adjusted and there is recommend screening at intervals to make certain the implant is intact.
Smooth Surface or Textured
A Silicone or Saline implant can have a smooth surface or a rough, textured surface. There is some evidence that the rough surface may lead to a lower likelihood of the scar tissue contracting (capsular contracture or “CC”) around the implant. Contracted implants will feel firm and unnatural. I am not a fan of textured implants. They tend to stick to the tissues in the body and in my opinion, look less natural. I do not believe they make a big difference in contracture rates when implants are under the muscle. Lastly, They have been linked to an extraordinarily rare lymphoma known as Breast Implant Associated Anaplastic Large Cell Lymphoma. While extraordinarily rare and effectively treated I just don’t think the risk is worth it. I favor smooth implants.
Round or Shaped (Teardrop)?
Implants can be round or they can be shaped like a teardrop- meaning smaller at the top and larger at the bottom.
I have never like tear drops for three reasons.
1) These implants must be textured so they stay put, and as noted earlier, I find this stuck-on look less natural.
2) If the teardrop rotates, the breast may look odd. If a round implant rotates no one will ever know or care.
3) Silicone implants under the muscle will take on a teardrop shape. If these rotate no one will ever know.
Soft, Medium, or Firm?
Saline is always saline, and a firmer feeling implant, but gel implants can now be soft, medium or firm. All of today’s gel implants are “cohesive”, meaning that the gel sticks together if the implant shell ruptures, but some are more cohesive than others. The more cohesive, the more firm.
I favor the soft implants for two reasons:
1) I feel these look and feel more natural.
2) Soft implants can be placed through smaller incisions leaving smaller scars.
Low Profile, Moderate Profile, or High Profile?
All implants now have different projections, which means they can stick out from the chest to different degrees.
Allergan uses the lingo Low, Moderate and High – Mentor calls the same thing Moderate Classic, Moderate Plus, and High. Mentor even has an Ultra High.
In general, the most popular implant in my practice is the moderate plus. I call it the “did she or didn’t she” implant. I worry that the low profile may not do enough for all but the most petite of patients. I feel that the moderate plus can be shown off when wanted and hidden just as easily if desired. High profiles are pretty much the “hey look what I did” implant. You can’t hide ’em – The ultra high even moreso. From left to right below see how the projection of the implant increases.
Summary:
So, we have silicone or saline, smooth or textured, round or teardrop, and now low, moderate, and high profile. It can be daunting, and that is where I try to help my patients through the huge number of options.
Can Implants be Combined with Lifts?
Yes, implants can be combined with crescent lift, periareolar lifts (Benelli), lollipop lifts and full lifts. These are discussed in the FAQ on the breast lift page and in the next question.
Will I Have Cleavage?
This common question really depends upon your starting situation. When implants are placed under the muscle, they must stop where the pectoral muscle inserts into the sternum. Going beyond that can lead to “Synmastia” which basically means “one big breast.” I always go as close to the midline as the pec muscle will allow, but I can not change the sternal space. A patient with a narrow sternum will achieve more cleavage, a patient with a wide sternal space will have less. Regardless, cleavage still requires a bra. Implants are pushed outwards by muscular forces. When a patient lays down, the implants will move towards the arms, when they stand the implants will come back to the middle, just as a natural breast would do.
Above the muscle is not affected by the pec muscle insertion, but if they are too close, they have a higher risk of synmastia. As you know by now, I am a big fan of submuscular.
Do I Need a Lift with my Breast Implants?
This will be discussed more in the breast lift section, but to summarize here:
If you have just a little droop or no droop at all you will generally just need a routine augmentation.
If you have a lot of droop or sagging you will likely need a lift or the natural breast will hang below the implant.
Patients in the middle with a moderate degree of droop may or may not need a lift depending on the size and profile of the implant they have selected. Many of these patients will allow me to perform a lift if I feel they may need one once I have inserted the implant in the operating room.
Do Implants Require Maintenance?
Implants are a medical device and eventually they will fail. If you have ever destroyed a credit card by bending it back and forth until it cracks, you have created what is called a fold flaw. This is how the shell of a saline implant may give way over time. If you’ve ever heard the phrase “like dissolves like” in chemistry, this is how a silicone implant gives way. The molecules of silicone inside the implant slowly dissolve the shell over time.
If a saline implant leaks, you will generally know it quickly because you body will absorb the salt water and deflation is easily noticed. Silicone leaks are harder to detect because the silicone stays in the implant pocket an the patient may look perfectly normal. The FDA recommends an MRI 5 years after surgery and every two to three years thereafter to check for these leaks.
When Do Implants Need to be Changed Out?
We start to see a rise in the rate of saline leakage after about 10 years, but that does not mean the implant could not go longer. After 10 years, a patient could take a wait and see approach if they wish, or choose to go ahead and proactively exchange the implants. I prefer it if my patients see me at least once a year for evaluation. If I have seen that patient recently and I know there are no issues, then I am prepared for a routine exchange. If I have not seen the patient in years, I have no way of knowing if their status with the implant is deflated. This can affect how I plan the surgery.
We used to say that silicone implants should be electively changed at 10 years, and then we weren’t sure. All new implants on the market are more cohesive than their older versions so we expected them to last longer and behave better. Over the past few year I have begun to recommend 10 years once again (so has Allergan). I have had a number of patients who are well, look good, but unknowingly have ruptures discovered on their screening MRIs between 10 and 12 years. It is much easier to exchange a silicone implant before it leaks than after, so 10 years still makes sense to me. A ruptured implant can increase the risk of capsular contracture. Please don’t ignore routine folllow-up and screening with silicone.
When Will I See my Final Results?
When implants are placed under the muscle, the muscle initially pushes on the implant, pushing them upward. I call this “too big, too tight, too high, too swollen.”
Over the next 3-6 months, the muscle will relax and the fullness up top diminishes as the projection of the implant increases. Patients must be involved in this dropping process through massage and stretching exercises. If the implants do not drop evenly, that could mean a trip back to the operating room. Paradoxically, when the implant are at first too high, patients are concerned that they might have gone too big. When the implants drop to their final location, the same patient might feel too small. Bigger is not always better. As discussed above, I strive for a sense of balance.
Pre op Three weeks post Six weeks post
Can Implants Just Be Removed?
Implants do not have to be forever. Lives change, weight changes, age changes, and for some, there comes a time when they just don’t want to be bothered by future maintenance or exchanges. Saline implants can often be removed under local anesthesia. I prefer to remove silicone implants in the operating room in case they are leaking and a thorough cleaning of the pocket is needed.
With the volume of the implant removed, the breast will deflate, leading to laxity. By the time an implant is removed the skin has been stretched over it for many years and it will not go back to where it was. Many patients will choose to do a breast lift at the same time as implant removal.
Sometimes patients are unsure if they want a lift or even a lift with a smaller implant. For patients with saline implants we can deflate the implants without a surgery. The patient then has the opportunity learn once again the size of their natural breasts, decide if they want a lift, and even size for new implants. The old implant shells will eventually need to be removed.
Unfortunately, silicone implants can not be deflated in the office so a plan is made based on best judgement.
Whats a Capsular Contracture?
When implants are placed inside the body, as they drop and settle after surgery, the body makes a pocket of scar tissue around the implant. We call this the capsule and the implant will live inside the capsule. Massage and stretching are recommended so that the implants will drop to their desired location, but also so that there is extra room in the capsule so the implant can move around. Motion in the pocket lends itself to a more natural looking result.
In some cases, the scar tissue around the implant will tighten (Capsular Contracture) leading to a firm, immobile, and sometimes uncomfortable implant. Reported rates of capsular contracture vary widely. I believe it is far more common in breast reconstruction than in elective cosmetic breast augmentation.
There are many theories about the cause of capsular contracture, and every effort is made minimize the risk through meticulous technique and minimal touching of implants during insertion. I favor the use of an implant insertion funnel, which minimizes touching or contamination from the skin.
Whats a Capsulectomy?
If an implant becomes firm, scar tissue around the implant can be released (capsulotomy) or entirely removed (capsulectomy). Unfortunately, even with these measures in some patients, contracture can recur. Stratus is a material that can be laid inside the breast pocket after capsulectomy to diminish capsular contracture. There is evidence that capsular scar tissue does not grow into it. While it is approved for breast reconstruction by the FDA, use for cosmetic treatment, while not illegal, is considered an off label use of Strattice.
What is an Implant Funnel?
Implant funnels have been developed and marketed for use in silicone gel breast augmentation. Think of the implant funnel as a pastry funnel that shoots out implants as opposed to frosting. Implant funnels allow the already filled silicone gel implants to be easily inserted through smaller incisions. The funnel minimizes implant contact with both the surgeon and the skin to minimize the risk of infection and capsular contracture. I find them an essential tool in my practice. Because saline implants are inflated only after they are inserted, a funnel is not necessary.
What is BIA-ALCL?
This stands for Breast Implant Associated – Anaplastic Large Cell Lymphoma. It is a very rare tumor that can be found living around the capsule of the implant and most commonly presents as a swollen breast with fluid around the implant. It is almost exclusive to textured implants, which is why I have never favored textured implants. Regardless, any patient with sudden swelling needs to be evaluated and treated if necessary.
What is Breast Implant Illness?
Breast implant illness can be characterized by a variety of symptoms such as fatigue, muscle or joint pain, brain fog, hair loss, weight changes, or even weakness, anxiety, or depression. At this time, it is not an official medical diagnosis because it is difficult to link these symptoms directly to implants. Many other disorders can cause these symptoms as well. If patients have these concerns, their implants can be removed to at least take them out of the equation. While some will recommend complete capsulectomy, there currently is no medical evidence that it is necessary.
Summary TLDR:
Congratulations if you got this far. There is a lot of information above. As a general summary of my approach:
I enjoy sharing all the details with my patients. I hope you gleaned that here. For most patients I favor silicone over saline but continue to offer both. I favor under the muscle vs over. I almost exclusively use smooth implants, I have never cared for textured. I favor an incision under the fold of the breast. I enjoy helping patients to pick the right size that lends itself to balance and proportion. If you are interested in learning more, please reach out on my contact form. If you wish to learn about breast lift, lift with implants, or reduction please click these links or access the menu bar up top. More information is also available at my main website www.ATCosmetics.com
If there are further question you would like to see here please let me know.
Do I Need a Breast lift?
Will a Breast Lift Make Me Look Like I Have Breast Implants?
But I Just Want a Small Implant…
What Kinds of Breast Lifts Are There?
Do You Use an Internal Bra Mesh?
What is Recovery Like?
Will I Look Great From the Start?
Will the Scars be Visible?
TLDR Summary
Do I Need a Breast Lift?
This is probably one of the most common questions I encounter. Here is what I tell my patients:
“If you like the way you feel in your bra – you don’t want to be bigger and you don’t want to be smaller – but when that bra comes off, your breasts head south, then you may be a good candidate for a breast lift.”
“If you wish to be bigger in your bra, you might consider a lift with the addition of a breast implants.”
“If you wish to be smaller in your bra, you might consider a lift with breast reduction.”
The only time I will try to direct someone differently is if they are trying to have me lift very heavy breasts (and that is not uncommon!). Gravity always wins. Heavy breasts go south again more quickly than you might imagine. For the heavy-breasted patient I might recommend a lift with a reduction.
Will a Breast Lift Make Me Look Like I Have Breast Implants?
This is a common misconception. A lifted breast of any size will take on a teardrop shape, with most of the breast toward the bottom and likely some degree of droop. Ultimately, this is what natural breasts do and even a lifted breast is a natural breast. Implants provide increased volume, but mainly fullness at the top of the breast. I think in the media (perhaps because of people like me) we are more used to seeing implanted breasts than natural breasts. It is important that patients understand the difference, or they run the risk of disappointment with lift alone.
But I Just Want a Small Implant…
Again, I hear that a lot. Understanding that an implant enhances the top of the breast, many patients who like the size of their breast in their bra already will ask for just a small implant.
I wrote about finding the right width implant that fills the diameter of the breast in the breast augmentation section. This also determines the height of the implant. For most patients, if I pull out a small implant to add to their lift, it will have a small diameter. If I place that implant in surgery, it must sit at the fold of the breast and will not be tall enough to achieve upper pole fullness.
As I recommend the correct diameter, then the volume starts to go up in a patient that did not want to be larger.
What Kinds of Lifts Are There?
Crescent Lift: This is the smallest lift. It involves taking a pinch of skin from above each areola and pulling the nipple and areola upwards. It will make the areola slightly more oval in shape. I might turn to this lift if a patient has a small difference in their nipple position.
Periareolar Lift: Also called a Benelli lift or a purse string lift, this takes away a donut of skin around the areola. Patients must be warned, because there is a lot of puckered skin around the areola that takes a few months to flatten and relax. I use this lift sparingly because the tension in this lift can lead to areolar stretching or scar widening. This lift is sometimes used just to make the areola smaller. Even though we call it a lift, I think of it more as a moderate tightener.
Circumvertical Lift: Often called a lollipop lift. When this lift is closed, the scar looks like a lollipop going around the areola and then vertically down the front of the breast. I do not care for this lift. It tightens breast tissue from side to side, but most laxity is top to bottom, I just don’t feel that it does enough. Pulling out a diamond of skin from side to side elongates the height of the incision (think of closing a diamond into a straight line). The nipple has to be placed at the top of the scar and often when I see these posted, the nipples are just too high. To correct this, a wedge of skin is taken from underneath, which turns it into a full lift, which likely should have been done in the first place.
Window Shade Lift: (Name). Not really a mainstream lift. This pushes the breast upwards with vertical tightening only, like a window shade pulled down over your breast. Without a vertical frontal scar, there is no horizontal tightening. I find this leaves the breasts squarish looking. A full lift (see below) addresses this problem.
Full Lift: Also called an anchor or keyhole lift, but actually named after Dr.Wise in the 50’s (wise pattern lift). I call this the “big bad lift” because it leaves the most scars, with a scar around the areola, down the front of the breast and underneath the fold as well. However, because of those incisions, it allows us to remove the most skin and give the greatest tightening. It gives both a vertical and horizontal tightening of the breast. It is the mainstay of most breast lift (and reduction) surgery.
Scarless Breast Lift: Beware the internet…a few years ago people used this term to promote augmentation. Implants do fill loose skin, but that is not a true lift. Today I am seeing practices advertise radio frequency skin tightening with a probe that burns the tissue under the breast. No pre or post exams are shown, at least on that site. This one scares me so far.
Do You Use an Internal Bra?
An internal bra involves using an internal mesh (that will eventually dissolve) to add additional support to a lift. The idea is that an extra layer of scar tissue is left behind, lending further support to the breast. If a patient wants it I can certainly provide it, but to me, it is one more thing that could move or become infected. I believe the longevity of lifts are determined by the patients skin quality (some are more lax than others and will relax sooner) and the weight of the breast that is left behind. To reiterate, gravity wins and heavy breasts go south more quickly, mesh or not.
What is Recovery Like?
The most common complaint for a patient having a lift alone is a burning sensation of the incisions. It is a skin tightening operation, and skin tends to hurt less than operations I perform such as an augmentation or tummy tuck, where muscles are stretched or pulled. While performed under a general anesthesia, I leave local anesthesia in the tissues and the incisions at the end of surgery to decrease post operative pain. Most patients will take about a week off and, if allowed, can work from home. Once again, I advise no strenuous activity for 21 days.
Will I Look Great From the Start?
Short answer? No.
We as plastic surgeons make the breast slightly too tight because we know the breast skin will relax over the next three to six months. Initially, patients will look tight and flat on the bottom and somewhat bulgy on the sides. We call this “boxy.” Over those post operative months, the breast will round, settle, and take on its final shape. If we like the shape, we are done. If not. we talk about adjustments if necessary. While touch ups are rare, it is important to understand that what you see on day one is not what you will see six months later.
Will the Scars Be Visible?
All scars are visible, the only question is how much they will draw the eye. As a plastic surgeon, I am in the business of scars and I am always working to minimize their impact, but the patient’s genetics (Mom and Dad) may ultimately determine the degree of prominence and visibility. Lighter skinned patients tend to make thinner, less prominent scars than darker skinned patients genetically. I ask my patients “if you were to make a bad scar, would the surgery be worth it to you?” While most patients make good scars, this, in my mind, is the safest way to approach the surgery.
TLDR Summary
In this “blogsite” I don’t focus on every possible complication (which is done in the in-person consult), but mainly on the questions my patients come in asking. If you have read the above, we have discussed who needs a lift, the kinds of lifts, the expectations, and the post operative course. If you have a question you would like to see here please e-mail me. The next section “Breast Lift with Implants” combines the augmentation section and the lift section…… read on if you like.
So, I am not going to rehash the first two sections here, as the FAQ are very similar and the recovery is a blend of breast augmentation and breast lift recovery.
Breast augmentation with small lifts behaves mainly like an augmentation alone. Breast augmentation with a full breast lift (full mastopexy) is a very different animal, and worthy of discussion:
Follow me Here:
Breast implants under the muscle start out high, but as the muscles relax, they drop to their final resting position. Usually predictably.
The breast lift’s goal is to go from a low position and stay at a higher position. Again, usually predictably.
These two operations at the same time fight one another: We want the implants to drop evenly, while, at the same time, the lift is encouraging them to stay up. We want the lift to stay tight while, at the same time, the implants are trying to stretch it down.
This fighting can lead to either: implants dropping unevenly, or more laxity than desired as the skin relaxes.
Surgical Planning:
Because of this, the combination of implant and full lift at the same time has a higher touch up and adjustment rate in the United States than many other things we do.
Now, I am not trying to scare you off. This is one of the most popular surgeries that I perform, but I do try to guide my patients down the best path.
Patients with smaller or lighter sagging breasts tend to do better in the combo. There is less soft tissue swelling, leading to a less recurrent laxity effect on the implants.
Patients with large, dense, and heavy breasts tend to do worse. The post operative swelling in an already heavy breast want to bring it south. For that heavy breasted patient, I might recommend a lift alone or even a reduction (heavy breasts go south) first, and place the implants later once the lift has healed. Interestingly, I would say about 90% of these patients end up being happy with the lift or reduction alone.
Patients in the middle, not with light breasts, but not with overly heavy breasts are more challenging. They must be well informed about the combination and be willing to accept the variability. You can not do an aggressive reduction while doing an augmentation – it is too much stress on the blood supply to the tissues. Often I will perform some limited natural volume reduction. This effectively tips the moderately sized natural breast towards the smaller natural breast, at the same time removing some of the tissue that will want to go south over time.
This is complex, rarely discussed on other sites, but I hope it makes intellectual sense to you. as always please reach out with your questions and comments.
What is a Breast Reduction?
What Kind of Breast Reductions are There?
Will it Solve my Back Pain?
How do you Pick a Size?
Will I Look like I Got Implants?
Will my Insurance Cover This?
What is the Recovery Like?
It is paradoxical that in my practice, some of the happiest patients are those whose breasts I make bigger, but also those whose breasts I make smaller. Breast reduction can be life altering and I commonly hear “I wish I had done this years ago.” A lift is, by definition, part of breast reduction surgery, but as discussed in the lift section (LINK) lifted and reduced breasts behave and look like natural breasts.
What is a Breast Reduction?
Whether you realized it or not, we have mainly discussed breast reduction in the breast lift section. A breast reduction is basically a lift, but the remaining breast is made smaller before it is pushed upwards. While there can be different scar patterns, the most common is the still the “wise” pattern, also called the keyhole or anchor. Just like a full lift, this pattern offers both a vertical and a horizontal tightening of the skin. Recovery is very similar to a lift.
What Kinds of Breast Reduction are There?
A standard breast reduction attempts to preserve blood supply to the nipple and areolar area. For some, this will allow them to breastfeed and maintain nipple sensation, but it is not guaranteed.
A free nipple graft breast reduction is sometimes used for breasts that are so large or so droopy that blood supply to the nipple can not be maintained. In these patients, the nipple and areola are removed completely at the start of reduction, and then replaced at the end as skin grafts. These patients will lose sensation, and not be able to breastfeed. Often, some projection of the nipple is lost. Pigment can be lost as well, which would be more noticeable in a darker pigmented patient, but color can be restored later with tattooing.
Will it Solve My Back Pain?
There have been many studies that show breast reduction improves back, neck, and shoulder pain, and other symptoms of carrying excessively large breasts. While that has been my experience, I never promise resolution of the symptoms to my patients. While I strongly believe that decreasing the weight of a heavy breast is a step in the right direction, there can be other causes of these symptoms where reduction man not help.
How Do You Pick a Size?
This is perhaps the most difficult question. Breast reduction is both science and art. While I always want to accomplish my patient’s goals, there are limits to how much tissue can be removed while still keeping the nipple and areola alive. A cup ,B cup, C cup, D cup, and so on mean very different things to different people. Victoria’s Secret is notorious for telling clients that their cup size is much larger than it really is. I strive for a sense of proportion that is determined not only by the patient’s goals, but also their height, hips, and shoulders. This is very much like breast augmentation planning, but in reverse.
Because I Get a Lift With a Reduction, Will I Look Like I Got Implants?
Just like a lift alone, the reduced and lifted breast will take time to drop, settle, and declare its shape. When it does, it will take on a tear drop shape and some laxity like an un-operated breast. For patients wanting more fullness up top, an implant could be added after the reduction has healed, but rarely do patients do this.
Will my Insurance Cover This?
Sadly, in most cases, no. For many, it is excluded directly in their healthcare policy. Even if not, often patients have to jump through hoops to get it done. In some cases, insurance will not cover it unless a very large amount of tissue is removed, more than a patient might want. For appropriate candidates, we will try to help them navigate the insurance system but it is becoming more and more rare to see approvals. We offer a discounted elective cosmetic rate for elective breast reduction when insurance is not an option.
How Long is Recovery?
While each patient is different, the average patient will recuperate for a week to 10 days. Most are off pain medication in 48 hours. I ask my patients to avoid any activities for 21 days after surgery.
Fees
If you click on the link below it will take you to the fees section of my main website, www.ATcosmetics.com.
I hate to admit it but post-Covid pricing has increased dramatically. Many qualified personnel left healthcare, many left hospitals, some retired, and as a result, hospitals are paying more to get people back. If our practice were not competitive, we could not offer you the quality staff we have today. Inflation and high interest are also reflected in the drugs and equipment we must purchase and maintain. Personally, I think drug manufactures are gouging – many inexpensive drugs have become bizarrely expensive.
As always, I try to be candid and competitive in my pricing. Please know that our standard fees are inclusive of the anesthesia and facility. I don’t like surprises and I try not to give them to my patients. Pre-operative laboratory tests, clearances and post-operative medications are not included, but are covered within most patients health plans. If breast tissue is removed, by law it must be sent to a pathologist to make sure no breast cancers are found. While on some occasions the pathology fee may be covered by insurance, if it is not, you will receive a bill from the pathologist. It is the one fee I have no control over.
Some patients request Xparel. Xparel is a long acting local anesthetic that I mainly recommend for tummy tucks. Because it is under patent, hence, expensive, we offer it as an option for patients who want it. Xparel adds $500.
In certain special cases, I may have to alter pricing, but I always try to adhere to what is posted on the site. When patients are able to safely combine surgeries, savings on surgical fees can be offered.
LINK to ATCOSMETICS / FEES
Common surgeries perfomed with breast surgery
There is such a thing as “too much surgery in one day,” but with in the bounds of safety, it is common to add additional procedures. Breast surgeries, when combined with a tummy tuck, are often referred to as a mommy makeover. Below is a list of some of the commonly added procedures, and more can be found at my main site www.ATcosmetics.com
Other Combined Surgery Options:
Release of Inverted Nipple
Congenital inverted nipples are a common problem. They can easily be corrected under local anesthesia and can also be treated in time of breast surgery, reduction augmentation, and lift. In order to release the nipples, a small incision is made at the base of the nipple, and the breast ducts which tethered the inverted nipple are released. Because the release of the nipple involves the release of the underlying ducts, breastfeeding can be affected. If an inverted nipple is a new finding, it must be evaluated to make sure that there is no underlying breast cancer before surgery.
Nipple Reduction
For patients with overly prominent nipples, nipple reduction can be performed under local anesthesia or at the same time as other breast surgeries such as augmentation or lift. The prominent nipple is tucked back into the breast to give a smaller diameter and less projection. This is occasionally performed for male patients as well.
Areolar Diameter Reduction
Areolar reduction generally occurs as part of a full breast lift or breast reduction. In certain circumstances, patients can undergo areolar reduction under local anesthesia or as part of a breast augmentation and lift. This is called a purse string mastopexy, where the tissues are gathered around smaller areola, like tightening the string on a purse. Because this type of lift with areolar reduction can be more variable in the quality of the scar that it produces, I try to use it selectively.
Reducing the Puffy Areola
Some men and women have discrete fullness or puffiness of the areola. Under local anesthesia, tissue can be removed from under the entire areola to make it flatter. This procedure will generally result in some loss of sensation to the nipple and will certainly diminish the ability to breastfeed.
Scar Revision
Despite our best efforts, sometimes scars can be thick or widen over time. Regardless of race, color, or nationality, the techniques used for surgery always endeavor to make the finest scar possible. A genetic predisposition to thicker scars can sometimes be seen in patients, particularly those with darker skin pigmentation.
Even in this population scar revision will sometimes improve results because scar revision involves the removal of only a small amount of tissue. In breast lifts, reductions, and even sometimes augmentations, scars can widen because of tension on the skin. Scar revision is generally performed about one year after surgery when the tissues have relaxed and tension is minimal. In this situation, reapproximating the scar can sometimes give a better result. For small scars this can be done on local anesthesia.
Exchange of Saline Implant After Leakage or Rupture
For a healthy patient with a recently deflated saline implant, the implant can sometimes be exchanged or replaced under local anesthesia. This is evaluated on a case-by-case basis. For patients who have had a long-standing deflation, wish to change to a larger implant, or want a gel implant exchange, these procedures are generally performed under a light general anesthesia because in this situation, the implant pocket may need to the adjusted or enlarged.
Release of Capsular Contracture
Some patient’s breast implants, either silicone or saline, will become firm with excess scar tissue around the implant. This is known as capsular contracture. In some cases the scar tissue will be removed in its entirety, and in others, the scar tissue will simply be released. This procedure is generally performed under a general anesthesia.
Changing the Sub Glandular to Sub Muscular
I generally prefer breast implants underneath the chest wall muscle. They look more natural, mammography is better, infection rate appears to be lower, and capsular contracture rate appears to be lower. When the implant is under the muscle, there is a more gentle transition from the chest wall to the breast. When you see a sharp line of demarcation, e.g. like half a coconut stuck on the chest wall, it is usually a sub glandular breast augmentation. When patients elect to change the position of the implant from sub glandular to sub muscular, sometimes a larger implant or a breast lift may be required. This is evaluated on a case-by-case basis.
Correction of Asymmetry
There are many approaches that I use to correct breast asymmetry:
- Breast lift and or breast reduction alone, without implants
- Breast augmentation with different implants
- A combination of both of the above
The only thing I try to avoid is using just one implant for the purposes of symmetry. I find that augmenting just one breast never looks good. I would rather see two natural breasts with no implants, or two augmented breasts. Patients with just one breast implant to correct for volume always look asymmetric because the natural breast will always have more droop than breast with the implant. Each patient I evaluate for breast asymmetry is different. Utimately, when reasonable, I prefer to have similar breast implants and a similar amount of natural breast tissue.
Labioplasty
What is labioplasty and why talk about it on a breast surgery site?
Labioplasty is the trimming or removal of excess vaginal labial tissue (the vaginal lips). Some women with excess labial tissue experience difficulty or discomfort with sexual intercourse. Others simply wish to change the appearance of the external vaginal lips. Some women feel more comfortable in clothing or during exercise. The reason I include labioplasty in this site is that I have had a number of patients who did not know that a labioplasty was available to them. Had they known, they would have had the procedure performed while they were already asleep for breast enhancement. For the purposes of decorum, I have not included photos of this procedure there but I review examples are in consultation.
While I'm Asleep...
is a very popular phrase. Multiple procedures can be considered and are common as long as they can be done safely. Each patient’s plan is individualized. The most common “while you’re at it” combination is breast enhancement with liposuction of other areas or a tummy tuck. For a more complete listing of the other procedures I perform, please visit www.ATcosmetics.com
Some of the smaller more common requests while already asleep…
- Botox
- Facial Fillers
- Mole or Skin Tag Removal
- Tattoo Excision
- Earlobe Repair
- Lip Augmentation
- Labioplasty
- Carpal Runnel Release
About Dr. Adam Tattelbaum
The son of a jeweler and a clergyman, Dr. Adam Tattelbaum grew up in a household where artistry and enhancing the lives of others took equal place. “I always knew that I wanted an occupation where I could work with my hands but also make a positive difference in people’s lives. I can think of no field in medicine that is more creative, gratifying or exciting.”
Born in New York City, Dr. Tattelbaum has performed plastic surgery in the Metropolitan Washington D.C. area for almost 30 years. Trained at Columbia, Harvard, and Georgetown University, Dr. Tattelbaum is certified by both the American Board of Plastic Surgery and the American Board of Surgery. He is a member of the American Society of Plastic Surgeons as well as the American Society of Aesthetic Plastic Surgery which serves as a mark of distinction in cosmetic plastic surgery. He serves on the clinical faculty at Georgetown University, where he has taught. Listed on multiple occasions as one of Washingtonian’s Top Doctors and Bethesda Magazine. His greatest joy is the teaching and education of his patients. He offers a common sense approach to cosmetic surgery and offers the same advice to patients that he would offer to his family or friends
Husband and proud father of two, Dr. Tattelbaum and his wife live in Maryland.
