“Her breast is like a bird,
delicate, slightly convex; slightly convex and
delicate like the breast of a dark-feathered dove.”

——————

James Joyce,
Portrait of the artist in his youth

Table of Contents:

  1. Sagging and retracted nipples
  2. Uneven breasts, or asymmetry
  3. Macromastia and Gigantomastia, when the breasts are too large
  4. Drooping breasts
  5. Breasts after pregnancy
  6. Breasts that are too small, or micromastia
  7. Overgrowth of the nipples
  8. Ruptured or deformed breast implants

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 6-12 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. Then the patients are encoouraged to wear a preciselly fitted wired-bra for even up to 12 months. In the case of implant based surgeries, a so called „Stuttgarter’s Belt” must be worn for at least 2-8 weeks. Regardless of what kind of breast surgery is being performed, it may take up to 7-12 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)

Mastopexy-augmentation

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, heals slowly but usually in the end completely inconspicuously. 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 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 augmentation using ultra-light implants

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 followed by wired-bra and 2 weeks of the Stuttgarter’s belt. Then you can enjoy your new reshaped beautiful youthful breasts.

Ruptured or deformed breast 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 (link to „breast implant replacement”) or removing the implants and conducting mastopexy (link do „Breast lifting, 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 (link) or to model the breasts with fat tissue (link). 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 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. 

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.