The female breast is the quintessential symbol of femininity and its aesthetic appearance has been an inspiration to artists for centuries. It has also been the source of much debate about ‘what looks the best’.
The ‘ideal breast’ should fulfil certain criteria:
It should be teardrop-shaped.
In profile, it should look ‘like a raindrop cut down the middle’.
All the volume should be above the inframammary fold (IMF), i.e. no ptosis or ‘droop’.
The volume should be distributed approximately one third in the upper half and two thirds in the lower.
The skin should be firm and elastic, with no folds, stretch marks or hollows.
The nipple-areolar-complex (NAC), should be 3-5cm, symmetrical and positioned on the most projecting part of the breast mound.
A breast should be assessed in a manner to achieve these ideals.
Considerations when planning the ‘Shape of a Breast’
• Patient Age: A rather obvious thought, but important to remember that ‘teenage breasts’ aren’t appropriate for women beyond a certain age. Breasts that are age-appropriate and suit the patient, are desirable.
• Overall health and fitness: Another obvious statement, but a patient must be able to undergo the surgery and convalescence involved.
• Previous Surgery: Previous surgery leaves scars and has great implications upon the skin envelope design, blood supply and sensation.
• Vascularity and sensation: Needs careful consideration in order to preserve skin and NAC viability and sensation during surgery.
Further assessment of the patient:
• Chest Wall: Of importance is the anatomy of the underlying chest wall, since it plays a great role in the ‘lie’ of the overlying breast.
• Breast Tissue: Consistency and health.
• Review of the landmarks: Position of the IMF, NAC and overall symmetry.
• Skin envelope: Nature thereof, elasticity and compliance.
What is done next?
Volume: This can be addressed in multiple ways and it can have a dramatic influence on the resulting shape of the breast.
The first option should be the patient’s breast tissue. If there is a sufficient amount thereof, it is often the best tissue for reshaping due to its natural consistency.
The next option is local or distant tissue in the form of ‘flaps’ of one or other form. Common examples are the lat-dorsi-musculocutaneous-flap and the transverse-rectus-abdominins-muscle-flap (there are many very elegant variations of this option).
The last option on the list is breast implants (a very versatile choice, with many possibilities). These can be anatomical or round by design, packaged in a variety of profiles (low, moderate, high, or extra high) and a multitude of sizes.
The final choice ought to match the needs of the patient and aspire to achieve the ‘ideal goals’ listed earlier.
How is the reshaping accomplished?
It can be done in a number of ways.It is important to remember blood supply at all times and the effects of tension upon it.
Natural breast tissue can be repositioned by realigning and shaping it with ‘parenchymal flaps’. These are designed on the blood supply, preserving the sensation to the overlying skin and placed to obtain volume where needed, for example the superior pole, as well as to achieve a natural shape. It’s difficult to describe in words how this is done, but a good analogy would be to imagine a paper plate with a segment cut out. The segment is kept attached centrally and positioned under the center of the plate (to ‘volumise’ it) and the two sides are brought together to create a conical shape. The use of an implant and the choice of one which confers a desired shape, is the simplest way of achieving a predetermined goal. This is done by accurately measuring the dimensions of the patient (breast bases and heights) and using tabled charts of implant shapes to choose a suitable implant.
How to handle the skin?
Elastic, pliable skin is very important in order to ‘wrap the breast’. It confers even more ‘shape’ to the breast if it is ‘snugly’ stretched over the underlying volume. An important lesson is to not rely upon the skin alone to confer shape, since this is an unreliable plan. A combination of chest wall position, volume, and skin envelope shaping is the best way to obtain an enduring result. A tight skin envelope alone is destined to stretch and lose its dimensions.
There are several possible skin envelope patterns:
Common ones include the ‘Wise-Inverted T’ (keyhole), the ‘Vertical mammlaplasty scar’ (lollipop) and the ‘Periareolar’ (doughnut).
What about the NAC?
This is the final but very important ‘icing on the cake’. The NAC should be planned to be the desired diameter and, utilising the skin envelope designs outlined earlier, can be carried with its blood supply and sensation into position.
It must be placed on the most projecting part of the breast mound, and once there, will bring the design together and bring harmony to the various components.
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