Q & A with Board Certified Plastic Surgeon Dr. Tim Sayed
A common question posed by plastic surgery patients is if they need a breast lift and/or fat grafting with their explant surgery. Here, Board-Certified Plastic Surgeon Dr. Tim Sayed, a renowned expert in cosmetic breast surgery, answers this and other questions in detail to help you better understand your breast explant options and which surgical strategies may work best for you.
Q: How Do We Decide if a Breast Lift is Beneficial with Explant Surgery?
A: The amount of skin removal advised depends on 3 basic factors:
- How big is your natural breast (knowing what cup size you were before implants is helpful, and it is also affected by whether you have had pregnancies or breastfed after implants)
- How big are the implants? Larger implants “smush” the natural breast tissue more and stretch the skin envelope more, so when you remove larger implants, there is more redundant skin to remove. Think about someone losing massive weight: the clothes they wear when heavier have more cloth than the clothes they wear when they lose the weight. The skin of the breast will have too much area for the size of the breast volume if some skin removal is not done, and this is especially true the larger the implants.
- Where do the nipples and natural breast tissue sit? If they are sitting at or below the peak of the fold under the breast (inframammary fold), then it is likely that with deflation of the breast from removing the implant, the breast will look saggier with folds of extra skin and a lower nipple position. This often gives the appearance of a “rock in a sock” or “Christmas stocking” shape. A lift will help correct the imbalance of skin redundancy and sagginess but comes at the tradeoff of having more incisions and a slightly longer recovery.
Q: What is the Typical Scar Pattern with an Explant Breast Lift?
A: In most cases, we end up recommending the full Wise-pattern “anchor” incision because it allows us to remove extra skin in both north-south (top-bottom) and east-west (side-side) directions on the breast. In some cases, a lift can be done with just a circle around the nipple and an incision in the fold (which we call the “no vertical-scar lift”), but not all patients are candidates for that. To be a candidate, it helps to have relatively small implants, a B or larger natural breast, and very little overhand of the natural breast over the fold.
Q: What Option Exists for Skin Removal without Cutting Around the Nipple/Areola?
A: Patients who do not want the lift incisions may be candidates for explant/capsulectomy just through the incision in the breast fold, followed by a “tuck” at the bottom of the breast. In this procedure, the extra skin between where the fold is WITH THE IMPLANT IN and the fold position AFTER THE IMPLANT COMES OUT is removed, but the soft tissue of the breast beneath that skin is preserved and tucked under to give a little boost of projection to the lower pole of the breast. In this technique, the tissue is not moved into a rounder upper pole, and the nipple position is not moved at all. This results in a much flatter upper breast and teardrop shape but is a compromise solution for some patients who don’t want the lift scars. Some patients elect this procedure and are happy with the outcome, and others may come back later for breast lifting and/or fat grafting depending on how the fold settles, how much flattening there is of the breast, and whether there are indentations or concavity of the breast shape.
Q: Who are the Best Candidates for Fat Grafting?
A: Fat grafting (or “fat transfer,” same thing) is a procedure where fat is taken from other parts of the body through liposuction and injected into the breast tissue to add volume and help with shaping. If you are considering liposuction of other body areas or a tummy tuck at the time of your explant, it may make sense to “recycle” the fat that would otherwise be thrown away and inject it into the breast to help with volume and shape. Some patients have so little breast tissue that they are likely to have concave, indented breasts after explant surgery (especially if the implants are very large). These patients may benefit from some fat transfer to add shape to the breast, although they are likely to only have a small amount of fat to obtain from donor sites, since most very thin patients also have fairly small breasts, and vice versa. However, the effect of a little boost and changing the breast from concave (indented) to slightly convex (small teardrop) may make a big psychological difference for a lot of these smaller-breasted patients. Larger-breasted patients and those who would be wanting a tummy tuck or lipo anyway are good candidates to add a little boost with fat grafting, even though they likely would be happy with their natural breasts after explant. Sometimes a patient has adequate fat elsewhere and is concerned that after explant, the tummy will look too large compared to their smaller breast. These are good candidates to consider lipo and/or tummy tuck at the time of the explant, along with fat grafting. In this way, the abdomen can be made to look smaller and leaner, and the breast will have more projection than it would naturally, so together, this creates the visual effect of rebalancing the breast and tummy and avoiding the patient feeling like her stomach is now too large.
Q: What are Some of the Risks of Fat Grafting?
A: The main risk is that not all of the fat “takes” or survives the grafting process long-term. A ballpark is about 60% of the fat injected will live permanently. What happens to the fat that does not survive? Mostly it just dissolves, and the breast loses some of the volume enhancement, but whatever does survive behaves as living tissue in the breast thereafter. Occasionally, however, lumpiness may occur and, in some cases, it can be tender or uncomfortable. There may be options to remove lumpy fat (fat necrosis or “oil cysts”) if they occur. Liposuction itself has some risks, and it is essential to take note of the skin quality of the donor site to see that we take fat from areas where the skin re-draping can be predictably good. This is often from the love handles (flanks) and lower back, and sometimes from the mid and lower abdomen, bra rolls, upper arms, and thighs. With the aid of the Renuvion device, we can get better skin tightening in patients with somewhat loose skin in combination with liposuction at the time of fat transfer.
Interested in Learning More?
If you would like more information about breast lift and fat grafting with explant surgery, your next step is to schedule a consultation with Dr. Sayed. In this consultation, he will evaluate you, listen to your goals and reasons for considering the procedure, and ultimately create the surgical plan to achieve your desired results.