Consistent outcomes begin with implant selection and systematic surgic

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The first step in any surgical procedure is patient education, which ensures the patient assumes responsibility for decisions.
Highly cohesive, form-stable implants are the ideal choice for a patient with constricted lower poles because they have the ability to maximize lower pole expansion as well as impart shape to the breasts.

Dr. Adams

The constricted lower pole breast is one of the more difficult problems that plastic surgeons may encounter when performing breast augmentation. As in all augmentation cases, a quantifiable approach to implant selection based on dimensional and tissue analysis, together with a standardized and systematic dissection sequence, are the cornerstones of my technique.

The first step in any surgical procedure is patient education, which is essential not only for informed consent but also for managing expectations, defining the "decision tree" for the patient and ensuring that the patient assumes responsibility for decisions. The importance of communication between the patient and surgeon cannot be overstated, especially when the patient presents with challenging anatomic features that can be significantly improved but cannot be made "perfect."

PRE-OPERATIVE MEASUREMENTS AND TISSUE ASSESSMENT A quantifiable approach to implant selection requires careful pre-operative measurements using what are called the "High 5" principles. I start with the most important, the base width of the breast, which is measured from the parasternal border to a point just medial to the lateral breast. This measurement represents the transverse width of the surgical pocket and, generally, indicates the width of implant I'll be using.

Next, I assess the envelope by the skin stretch measurement (a tight envelope being predictable in a constricted lower pole breast), and I estimate the relative amount of parenchymal fill. The nipple-to-inframammary fold distance is then measured; it is important to do this on maximal stretch.

Figure 1: Patient with lower pole constriction shown before and 6 months after one-stage breast augmentation using highly cohesive form-stable implants (Allergan Style 410, 245g), as demonstrated in the live-surgery CME series "Excellence in Cosmetic Surgery 2." (Photo credit: William P. Adams, Jr., M.D.)

Finally, I feel the mobility and elasticity of tissue at the inframammary fold. While I frequently am able to handle the more moderate case as a one-stage procedure, I have found that patients with more severe deformity, including severe nipple herniation and extremely tight fixed tissue along the inframammary fold, often need to be treated in two stages: first placing an expander to allow optimal expansion of the lower pole, and later inserting a permanent implant and addressing the areolas. In the surgical demonstration "Augmentation of the Constricted Lower Pole Breast," (The Johns Hopkins University/National Cosmetic Network CME series, "Excellence in Cosmetic Surgery 2"), my patient had relatively good mobility of the tissue at the inframammary fold, which allowed me to augment the breasts in one stage while achieving adequate lower pole expansion and a good overall result (Figure 1).

IMPLANT CHOICE Highly cohesive, form-stable implants are the ideal choice for a patient with constricted lower poles because they have the ability to maximize lower pole expansion as well as impart shape to the breasts. There is a 12-year international experience with these implants, and they have been studied in the U.S. under FDA-approved PMA clinical trials for six years. The data show that form-stable implants have a lower capsular contracture rate and lower rupture rate than other implants. Perhaps from the patient's standpoint, the most psychologically beneficial aspect is that, because of its semi-solid consistency, the gel will not migrate even if the shell were to rupture.

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Consistent outcomes begin with implant selection and systematic surgical sequencing

Article-Consistent outcomes begin with implant selection and systematic surgical sequencing

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