“Her bosom was as a bird’s, soft and slight,
slight and soft as the breast of some dark
-plumaged dove.”

James Joyce,
A Portrait of the Artist as a Young Man


Your breasts

Breasts after pregnancy

So you’ve decided to embark upon the most unique challenge of your life, you’ve decided to become a mother. Your body lets you know that you have given birth to your baby and your identity has changed forever. You notice, after your pregnancy that your breasts have also changed. Have your breasts lost their previous vitality? Has your chest become heavy and saggy, making you feel self-conscious or unattractive? Are you experiencing neck and back pain or finding it difficult to find clothes that fit well? Are you having trouble with hygiene and posture because of the size of your breasts? If the answer to any of these questions is yes, then choosing to have a breast reduction is the right decision for you. A breast reduction is always accompanied by a mastopexy, so your breasts will be lifted, firm and full after the procedure. Together we’ll help you regain self-confidence by bringing back that youthful look that you desire. In most cases we will only work with the patient’s own tissue which produces a natural appearance.

Not all women experience breast enlargement as a result of pregnancy. Instead, some loose elasticity of their breasts or breasts begin to sag. Is this true for you? If your breasts are the desired size for you but have lost their vitality, a mastopexy is the solution for you. A Mastopexy, which is another word for breast lifting, can be performed in many different ways. You can find out more details about it here: mastopexy.

Often breastfeeding can cause an asymmetry of the breasts. This is especially common when predominantly using one breast over the other when nursing. A „mastopexy” also resolves this issue.

If your breasts grew larger during pregnancy and nursing, you might dislike the fact that your breasts shrunk after you stopped feeding. Oftentimes women report missing having the firm, full breasts that accompanied breastfeeding. In that case you can have your breasts augmented. Different methods of breast augmentation exist e.g. transaxillary, periareolar, with ultralight implants or using polyurethane implants. All the methods will be discussed in the mentioned chapters. Minor breast volume changes can be addressed using transfer of your own fat tissue.

Macromastia and gigantomastia, when your breasts are too large

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Sagging breasts

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Micromastia, when your breast are too small

Have you always dreamed of having beautiful, perky breasts? Do you desire that sensual cleavage that you’ve observed in other women? Maybe your breasts have lost their fullness after pregnancies and breastfeeding and you long to restore them to their original shape and firmness? Or maybe you just want to have bigger breasts?
You can make your dreams come true. Now you can choose from a variety of implants and ancillary procedures available on the market. Procedures such as concomitant breast lift or lipofilling allow for various makeovers ranging from obtaining a natural, firm shape as well as a more pronounced one.
There are various methods for breast enhancement; They differ in the access through which the device will be placed, the type of implant pocket and of course there is a variety of breast implants available on the market. Every method has its pros and cons, but above all, the method must be fitted precisely to each person. In a separate section below, I discuss the most commonly performed approaches; Transaxillary breast augmentation, Breast Augmentation using polyurethane coated implants, Breast augmentation using ultra-light implants, trans areolar breast augmentation, Breast Lipofilling and their variations.

Unequal Breasts, the asymmetry

Breast asymmetry concerns most women and small differences in volume and positioning are a completely natural matter. We are never 100% symmetrical, so differences in the build of the two sides of the rib cage result in the breasts being positioned in varying manners on each side. With the occurrence of congenital muscle defects such as Poland Syndrome or the connective tissue supporting the glands, as in the case of tuberous breasts, the asymmetry is compounded. Additionally, differences in breast volume develop after pregnancy and as a result of breastfeeding. Obviously, any procedures done on the breasts, such as removing benign and malignant tumours, cause differences in their size. Apart from aesthetics, significant asymmetry leads to uneven weight distribution affecting the spine and leading to its degeneration and curvature.

If you are suffering due to an asymmetrical bosom, your posture is compromised, you experience back pain, it’s hard for you to find undergarments, plastic surgery can offer you permanent solutions to having even and beautiful breasts.

Tubular breasts

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Intraflected Nipples

So you are suffering from nipple inversion. Are you afraid you will never be able to breastfeed? Maybe you are yet to experience the pleasure of nipple stimulation and you want to discover this? Maybe it’s just something that causes you discomfort ? The nipple inversion is mostly congenital and it is not rare, since the prevalence lays between 1,8 to 3,3%. There are certainly different grades of nipple inversion, ranging from protractible – through manual manoeuvres with uncompromised milk ducts to severely permanent, retracted with constricted milk ducts. The milder grades can potentially be corrected by wearing a retractor – day and night, for at least 6 months. However, a simpler, stabler solution is a surgery that can be performed on an out-patient basis and under local anaesthesia. Alternatively, for direct nipple inversion repair, an indirect correction can be obtained by means of inserting highly-projected breast implants, that would push the breast tissue forward, extraflecting the nipple. In most cases breastfeeding ability will be preserved. The most severe grades of nipple inversions require direct surgical correction.

Nipple hypertrophy

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Areolar hypertrophy

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Ruptured or distorted breasts implants

Have your breast implants which used to make your bosom beautiful, firm and lifted changed shape as the years have passed? There could be many reasons for this, with the most common cause being the so-called contracture of the connective tissue capsule, produced by our body to isolate the foriegn body – in this case the implant. If the capsule contracts a lot or grows, it can cause deformation of the breast and at times, even pain. In rare cases, the shell of the implant can rupture, leaking its contents into the pocket. An extremely rare problem which could cause misshapen implants, is a BIA-ALCL, in other words, lymphoma.

In the case of any implant deformation, it is imperative to see one’s surgeon or simply to consult a plastic surgeon, for diagnosis and treatment.
In most cases I am able to determine the cause based on a clinical examination and recommend a course of corrective treatment, such as: implant replacement or removing the implants and conducting mastopexy.

It is important to note, that not all deformations are the fault of the implants. After many years, our tissue is subject to the natural process of ageing and can droop below the implant, we call this a „Waterfall Deformity”. It is not always necessary to remove the implants, sometimes it is enough to do a mastopexia or to model the breasts with fat tissue. Conversely, implants can ‘slip down’ or the glands may increase in size due to hormonal changes, resulting in a deformity called a „double bubble deformity” or „bottoming out”. In both cases, replacing the implants would be indicated for aesthetic purposes.

Breast Augmentation:

Transaxillary breast augmentation

There are various methods of breast enhancement. Transaxilliary augmentation is an excellent method for primary augmentation and is my preferred technique. It does not leave a visible scar as the only short cut is placed and hidden behind the axillary fold. It is a perfect, quick procedure – especially if the skin is very thin or the breasts are underdeveloped with an absent inframammary fold. This technique constitutes over 90% of the primary breast augmentations that I perform. It is also perfect for individuals undergoing gender reassignment due to its regard for anatomy. Most of my patients love the natural shape, relatively low levels of pain and completely inconspicuous scaring. Since anatomy is mostly respected with a transaxillary approach, even temporary loss of sensitivity in the nipples is much rarer than after other methods.

Your choice of implant is crucial for the optimum effect and I guide you with my expertise, ensuring that you choose the implant most suitable device for you.

Every implant has three dimensions: width, height, and projection and it is necessary to precisely match these dimensions to your body phenotype. Therefore, it is a mistake to solely think about volume here, as all three of the dimensions as well as the type of the implant and its fill are what create volume. A good support of undamaged tissues in the transaxillary breast augmentations allows for using almost every type of surface of the breast implants, including smooth ones.
Implant positioning is significant. Subglandular positioning is possible, but rarely applied through the axilla. The subfascial position is limited to smaller implants, however, it provides good support. The submuscular position is the most common for transaxillary access. In the latter method the implant is anatomically more cohesive by being secured behind the muscle and is less palpable.

As the patient’s health is of utmost importance, an immediate post op is crucial after breast augmentation. After the surgery an 8-week period of compression with a sport’s bra and a Stuttgarter’s belt is required. It may take up to 7-8 months for breasts to heal and obtain their final shape and position.
I am looking forward to seeing you in my office to answer your questions and provide even more details about the procedure. With precise measurements and productive collaboration we will choose the right implant for you.

Breast Augmentation using poliurethane coated implant

The most common method of breast augmentation, around the world, consists of inserting the implants through the inframammary fold incision. There is a lot of data on this procedure. It only leaves a 3-6 cm, a slight lateral scar in the IMF which can sometimes be relocated up to a centimetre upwards, causing no problems whatsoever. This type of breast augmentation allows for the placement of any type of device including highly cohesive, anatomically shaped implants. It is also the first choice for revision surgeries or secondary augmentations. I use this method, in more challenging breast augmentations; If you have a very wide chest or you are very tall and thin, we may obtain better results with anatomical implants, as they can be tall, short, wide or narrow. The key is the appropriate choice of base for you – wide and short or, narrow and tall. The variety of shapes will provide us with good tools to obtain natural results and breasts that match your phenotype. A highly textured or polyurethane coated surface ensures that the anatomical device won’t dislocate or rotate once in the pocket. The polyurethane coated implant also has the best grip – making it almost immobile; in simple words it gets glued in with your tissues and therefore does not drop. This feature is desirable while using an inframammary approach, because the tissues in the lower pole of the breasts get weakened by this incision. Using these devices we virtually eliminate the risk of wound dehiscence and implant exposure. Furthermore, polyurethane implants can also be safely fitted under the gland, if indicated.
It requires 6 weeks of compression and 2 weeks of the belt. Then you can enjoy your new reshaped beautiful youthful breasts.

Breast augmentation using ultra-light implants (b-lite)

A choice of the right breast implant fill is one of the crucial factors in obtaining a good result. Saline solution is rarely recommended, whereas, a variety of silicone gels, ranging from soft to firm, highly cohesive gels, or double gel are utilized. The B-Lite gel with compressed air bubbles is 25% -30% lighter than standard implants. It is a technology developed by the Israeli Defence Forces and used successfully in space missions by NASA. The implants are excellent for very thin patients and subcutaneous placements, but are slightly harder than regular devices. Lighter implant means less load to your tissues in the lower breast pole, therefore the implant has virtually no tendency to drop. Nowadays, the standard for breast augmentation is the dual plane position. Muscle fibers are dissected in the lower part without causing any discomfort or problems. The implant is covered by the muscle in its upper and central part and then the gland, only by skin, in the lower region. Lighter implant means less load to your tissues in the lower breast pole, therefore the implant has virtually no tendency to drop there. This produces a very natural look. If your breasts are already slightly dropping maybe a „multi-plane breast augmentation” is a good choice for you and the advantages of the light weighted implant will be emphasized. Less weight means also less load to your spine, therefore you can choose even a larger implant without compromising your back. The right postoperative follow up requires 6 weeks of compression and 2 weeks of the Stuttgarter’s belt. Then you can enjoy your new reshaped beautiful youthful breasts.

Removing breast implants while maintaining a beautiful shape

An indication to remove implants does not mean that your breasts will be sagging and shapeless. Plastic surgery will return your breasts to their beautiful shape or even improve upon it. When implants are removed, the stretched skin requires cutting and the nipple with the gland has to be lifted, in other words, a mastopexia. If you’d simultaneously like to keep the larger size of your breasts, it’ll be necessary to fill the space left empty by the implant with a fat transplant.

Transareolar or periareolar breast augmentation

In the peri/trans areolar access breast procedure the scar can be completely unnoticeable, since it is placed exactly on the border between the skin and areolar tissue. The scarring depends on a patients’ intrinsic healing capacities and the skin colour. It is very successful with women who have a large areola while in some cases it can leave a slightly visible scar. Furthermore, this method gives even access to all the parts of the breasts. It allows the creation of the so-called „triple plane”, which is a great approach for moderate breast augmentations, especially with smooth implants.
After the procedure, usually 6 weeks of compression and 2 weeks of belt wearing are required.

Breast implant replacement

Despite commonly held beliefs, breast implants do not have to be replaced. Only (link to „ruptured or distorted breast implants”) in the case of deformations which were previously discussed there can be indications to replace the implants.

However, if you’d like to radically change the shape or size of your breasts, replacing the implants or modelling with the help of fat tissue will be the right path for you. The technology used in producing implants is constantly undergoing a dynamic evolution. The contents, shell and weight are changing. Many of the issues that used to be associated with implants are a thing of the past with use of the newest models. All serious producers give a life-long warranty on the shells rupturing and many years of warranty on implant deformities related to growth of the connective tissue.

Breasts reduction:

Inverted nipple correction

So you have decided for an intraflected nipple repair. Good, because after the healing is over, new nipple sensation and an improved shape will add a lot to your quality of life quality. There are few different techniques of repairing a nipple intraflection, but be careful, because some of them consist of dissecting the ducts, so you will never be able to breastfeed. I never use these methods, since I always want to preserve the possibility for a woman to breastfeed. It doesn’t always mean it will be possible, because there are many other factors that play a role in the correct functionality of mammary glands; for example if the ducts have become atrophic, then unfortunately no surgery will permit you to have that functionality. Fortunately, in most cases, you will be able to breastfeed after surgery. The procedure is routinely performed under local anesthesia. The nipple is manually reverted and under the nipple a small tunnel is created. Two small flaps are inserted into this tunnel and sutured on the opposite site, so they become a good scaffold that reinforces the new nipple’s position. After the surgery you will have to wear an external device till stable healing is achieved. It usually takes three weeks and within this time you will have to keep this device clean. It is small, so it won’t disrupt you in your day to day activities. Thereafter we wish you well on a new chapter in your life.

Hypertrophic nipple correction

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Areolar reduction

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Breast Reduction

There are many methods of breast reduction. The differences are based on the skin resection pattern (circular, vertical, horizontal, circumvertical, introverted T) as well as on the type of pedicle on which the nipple-areola-complex is moved upwards. The skin resection pattern depends on the type of skin and the amount that needs to be resected or redraped. The scars that are the longest remain after the inverted T resection. However, the horizontal scar is well hidden in the IMF and this pattern gives the most reliable breast reshaping. The gland with the NAC are moved to a new position on different pedicles depending on the extent of the sagging and the sensitivity of the breasts to hormonal stimulation as, for example, duration menstruation. An areola reduction is routinely performed. A free nipple transfer is very rarely performed due to the fact that it completely eliminated feeling in the nipple and also because a well created pedicle can move your nipple even over 20 cm upwards!

An interesting but limited reduction method is a breast liposuction. This method might be indicated in a double stage breast reduction, but only in predominantly, fatty breasts.

To me, your health comes first. Therefore, if there is any suspicious lesion found in breast ultrasound, MRI or Mammography, it will be excised and histopathologically examined during surgery. Cystic breast changes should be examined before through a fine needle biopsy by your senologist.

The amount of time dedicated to a breast reduction is substantial can vary. It can take from 1.5 hours to 5 hours for gigantomastia. The greater the resection, the more sophisticated the reconstruction of the internal “scaffold” of the breast to give it a good shape and prevent it from further sagging. Usually, you will have to stay overnight in the clinic. My favourite method of breast reduction, based on postero-inferior pedicle, takes maybe more time than others, but at the same time is absolutely most universal and provides most stable results. The most professional postoperative care is crucial after the breast reduction. This includes wearing a compressive bra during the day and at night for 6 weeks after the surgery. In most cases the breasts are positioned very high during surgery so that they can drop naturally and take on a beautiful, natural shape in the first 6-72 weeks after the operation. Postoperative pain is well controlled with prescription-free painkillers like paracetamol, ibuprofen, metamizole, and others, for the first 10 days after surgery. You can return to normal activities after 2-3 weeks.

Breast Lifting:

Breast Lifting, Mastopexy

Breast lifting is one of the most sought-after plastic surgery procedures. This term encloses a wide variety of different plastic surgery procedures, that have one goal, to beautifully reshape your breasts. The beautiful and youthful shape is achieved by elevating the nipple-areola complex (NAC) upwards, approx. 17 – 21 cm from your sternal notch and shaping the breast gland into an attractive form and elevating it higher up on the chest. Since some skin will be resected, at first you might get the sense that visually your newly reshaped sexy breasts have gotten smaller after the procedure. However, once you put on your old bra, you’ll notice the volume is the same, but you do not need a push-up anymore.
Due to the gland and NAC lifting maneuvers a classic mastopexy is very similar to a breast reduction, with the difference that in the mastopexy only the skin is being excised, whereas in breast reductions we remove a large amount of gland tissue as well. In selected cases shorter and less invasive procedures are possible.

Nonetheless, a vertical scar running from Areola to the inframammary fold is unavoidable. Do not get scared though, because the scars will be less noticeable with time, until they disappear almost completely in some women.
A mastopexy can be combined with Lipofilling or with breast Augmentation, then it is called a mastopexy-augmentation.
Whichever you choose, soon you will enjoy your fresh uplifted breasts.

Breast Reconstruction

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A mastopexy-augmentation is a procedure that gives you youthful, beautifully shaped breasts, whilst making them larger. This procedure gives you a good and stable upper-hemisphere fullness with a pushup shape! Since the skin envelope gets refilled by the implant, the skin reduction does not have to be as aggressive as with mastopexy without the implant. For this reason, it is possible, in many cases, to obtain excellent results without a vertical scar; You will only have the scar around the areola which, in most cases, heals completely inconspicuously, and possibly another scar in the inframammary fold, if we choose to insert the implant that way. In order to obtain a good solid base on which we will reshape your breasts, a stable breast implant is needed. For this reason I tend to use the polyurethane-coated, ultralight, or highly textured implants, which will not drop with time.
After a healing period, comparable to a breast implant surgery, you will quickly get used to and enjoy your new large and firm breasts.

Breast Lipofilling

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Breast Symmetrization

If you’d like for your breasts to be symmetrical and beautiful, the key aspect is to determine your expectations and to evaluate the starting point together. Please answer for yourself if, in addition to symmetrizing your breasts, you’d like to enlarge them, lift them or make them smaller. There is a whole assortment of techniques available to us: mastopexia, reduction, enlargement.

We can combine these methods at will and for instance enlarge one breast and lift the other or the reverse – in order for your bosom to be shapely and symmetrical after the procedure. We will discuss the details of this complex issue during a consultation and I know we will find the perfect solution.


Safety and understanding breast surgeries

Like all surgical procedures, breast operations have their tradeoffs and possible complications. You will have to get prepared for the procedure.
First of all, a breast ultrasound is necessary before any breast procedure. In case of any suspicious lesions a fine-needle biopsy, MRI or mammography should be undertaken. Alternatively, I can remove the solid lesions during surgery and have them examined histopathologically.

When preparing for the breast surgery you must ask yourself which tradeoffs you are willing to accept?

For instance, the breast reduction will always leave an inverted-T-shaped scar and that is unavoidable. However, please notice that a horizontal component is well hidden in the inframammary fold, so it is not noticeable at all. The vertical component (the scar running from the areola to the IMF) will bleach with time, so it will not bother you much. If you have a rare tendency to keloid wound healing, please inform me about it during consultation.

As the wounds can be long, a wound dehiscence can occur that requires 2-3 weeks of medication and sometimes scar revision. Small haematoma and swelling may also occur. There are also very rare complications which may arise. These may include temporary or permanent loss of sensitivity in the nipple as well as complete necrosis of it. In the latter case a NAC reconstruction can be undertaken but the loss of sensitivity will remain. Long term complications can be recidival breast sagging as well as asymmetry.

However, this is very individual matter and depends on the patient’s own tissue and the postoperative care such as nutrition, weight imbalances …etc. It is of course possible to have a revision surgery in any case. These revisions are almost always minor surgeries and can be performed under local anaesthesia, but cannot take place any sooner than 6 months after the primary surgery.
The follow up is crucial after breast surgeries. A well fitted sports or a compression bra is necessary for at least the first 6 weeks after every breast surgery. In the case of implant based surgeries, a so called „Stuttgarter’s Belt” must be worn for 2-8 weeks. Regardless of what kind of breast surgery is being performed, it may take up to 7-8 months for breasts to heal and obtain their final shape and position. Therefore in most of my breast surgeries I tend to exaggerate initially – lifting the breasts very high, so they may appear „plastic-fantastic” at the beginning. After some time the breasts will drop obtaining a beautiful sexy natural shape. Since we are not sculpting stone but rather in your living body, your body can react unexpectedly to the surgical procedure, especially since we are dealing with the organ that is so sensitive and subjected to hormonal influences. Each of your breasts may heal differently and due to this, some asymmetries may develop during the healing process. Rest assured permanent asymmetries occur very rarely and can be easily corrected by lipofilling or changing the position of nipple-areola-complex.

In breast augmentation extremely rare complications are implant infections, which at worst, may require implant removal. Another, rare complication, but a serious one, especially in smokers and patients with thin tissues is implant exposure through the wound in the inframammary fold. This is caused by an excessive weight, pressing on a fresh wound. The same mechanism of the implant load on the tissues may participate in developing a so-called „bottoming out” or „double bubble deformity”. While using the inframammary approach, I tend to prevent all these complications by using ultralight devices that produce less load on the lower breast pole or polyurethane implants that „stick” to the chest wall. All these problems usually do not occur at all in my favourite transaxillary access technique, since the wound is above the implant and the lower breast pole integrity is undamaged.

Implant dislocation is another possible complication. It usually occurs due to a so-called „muscle animation”. Many techniques were developed to deal with this problem.The most popular is the so-called „dual plane technique”. In this method the pectoralis major muscle fibers are dissected in the lower part without causing any discomfort or problems. As a result the implant is covered by the muscle in its upper and central part, whereas the lower pole of the implant remains covered only by the gland and the skin, so no animation upwards would occur.

As the implant is a foreign body, the immune system interacts with it. Since the implant cannot be expelled outside the body, the immune system creates a capsule so that the implant stays isolated. This capsule may contract with time, especially if there is even the slightest bacterial contamination. The progressing capsular contracture might deform the implant, break it or even cause persistent pain. In such cases the implant must be replaced with another implant or removed and exchanged for a fat graft. If strict hygiene and proper implant choice are followed the potential for complications is minimized. Nonetheless, there is a risk that if all precautions are not taken and infection sets in, the implant may activate an immune response. In such a case it can potentially lead to Breast implant associated anaplastic large cell lymphoma. This is an extremely rare illness which was only recently identified. It is easy to diagnose with a very good prognosis, but nevertheless, the patient must undergo an implant removal and oncological therapy. In order to reduce the risk of all these problems the manufacturers have developed alternative surfaces.

Despite some of these possible complications, it must be said that I use devices only from the best manufacturers to counteract these problems. These devices provide life-long warranties for surface continuity breakdown and 10-year-guarantees for excessive capsular contractures (grade 3 or 4 on the Baker scale).