Deep Plane Brow / Face Lifting

by Dr. Dennis Nigro MD, FACS, FICS

Breast surgery is a multifaceted multidisciplinary concern that requires an extensive amount of training and may be the most misunderstood discipline by prospective patients.

First, we will discuss the aesthetic considerations of a good breast result:

In my opinion, a good result should have both the patient and any observer not aware that any surgery has been done. The breasts' shape, position and size are complimentary to the patient's general body shape without being obtrusive.

I frequently tell the patient that it is my goal that no one can tell (from the gynecologist to the more casual observer) that there has been any breast surgery done. Obviously, when there is skin excised there are scars and this does not apply to close visual inspection, but the shape, size and position should be within those parameters, no matter if it is a breast cancer reconstruction or purely an aesthetic operation.

Also, I strongly feel that only Board Certified Plastic Surgeons should be doing any kind of breast surgery because their spectrum of training, their understanding of the issues at hand are far better developed and we are far better trained than a surgeon who has learned to put breast implants in someone and really does not understand anything other than pumping out a skin envelope with an implant.

Those types of surgeons, in my career, have characteristically demonstrated a very superficial understanding and their training and expertise is so limited that the patient is stuck with a limited set of answers for the problems they may present. It is a combination of good fortune for the patient and those to mesh. Too frequently, the less trained surgeon will try to wedge a patient into a technique that is not even close to being the right one for the patient's problems.

Breast Augmentation Breast augmentation refers to a way to place an implant into a patient to bring about the natural balance that has been lost or the patient never had. Most commonly, this is after weight loss, pregnancies, or lack of primary development. This constitutes the most majority of the patients that a busy breast surgeon sees in his practice.

Over the past 25 years, the female population has worked harder and harder to get fit. We see female patients having lower body mass indexes (BMI) and these lower amounts of fat affects their breast size. Consequently, bringing their breasts back into balance, after they have essentially dropped their body fat into the sub 20% range, often requires some form of augmentation. The basic genetics, in some of the patients, will also preclude breast development, which is proportionate.

My recommendations to the great majority, if not all of the patients, is to place an implant either saline or silicone, underneath the pectoral muscle with either release of the muscle or keeping the muscle intact, depending on the patient's clinical parameters. I have strongly been of the opinion that silicone implants are the implant of choice unless there is some reason for saline to be selected.

There are some age priorities associated at this time with the acquisition of silicone implants to deliver to patients under certain age criteria. These are imposed at the current time and are something we will have to deal with at least for the immediate future.

The critical concept in breast augmentation, as well as other breast surgeries, is that we start with the same basic anatomic parameters that we have in other areas of aesthetic surgery and, that is, the multiple layers, their presentation, and the need for individual correction of anything in those layers to bring about an acceptable result.

The breast and chest wall may have more variation in it, from one side to the other, than the face. It is my opinion that it does and over the years the recognition of these basic anatomic asymmetries have helped make decisions which have led to happy patients. Embarking on a plan, which misses this on the onset, no matter how well executed, will lead to an unsatisfactory result.

The skeletal chest wall and skeletal component of breast surgery is absolutely critical to the result and must be analyzed very carefully. Many patients have such significant variations from one side to the other and from the top to the bottom of their chests that the plan has to be altered from one side to the other or from top to the bottom. These items have to be carefully studied, planned out and, in my opinion, executed in a way in which the sequence of the procedure leads directly to a shorter surgical procedure and a more predictable result.

For example, one frequently missed item that a patient does not see prior to surgery is that of rotatory scoliosis. Specifically, the base diameter or platform where the implant or any reconstructive effort including breast cancer, breast reduction, breast lifting and especially implants sits is different from one side to the other. If a patient has rotatory scoliosis where they are rotated slightly to their left, their right chest wall diameter appears to be wider and their left chest wall base appears to be narrower and will indeed slope away from the front on observation. My usual approach is to approach the narrow side of what I call the smaller side first. In breast augmentation, this may mean the narrow base is the defining distance of what can be put in the patient so the implant lays flat and does not roll over on itself, thereby causing some buckling and changes, which could be problematic.

Placing implants in position, in our practice is done primarily through areolar incisions or transaxillary incisions and both saline and silicone implants can be placed this way.

The choice of incisions is also very important based upon a number of factors. Certain procedures cannot be done through a transaxillary procedure or cannot be done as well. Similarly, very small areolar complexes in the patient who has never had a pregnancy or had a baby may preclude the ability to put an implant in through a periareolar or transaxillary approach.

Sensation Concerns Competent surgeons know where the nerves of sensation lead to the areola and nipple complex and try to avoid disturbing these areas and are usually successful. There are two circumstances, which may obviate this - a patient who has some anatomic variant, about 1% or 2% of the population or a patient whose skin is so tight and basically has no breast tissue just the stretching of the area may cause some either hyper or hypo sensitivity. This has to be watched. Frequently this latter condition abates but it may have some sensory changes that persist for a number of months. This can be permanent but fortunately is rare.