Front And Centre.

In this article, we round up some of Asia’s most famed plastic surgeons as they explain breast augmentations’ many forms, their ideal candidates, and how surgeries are performed. Later, our experts dive into mastopexy’s fundamentals, disclosing the differences between augmentations and lifts, while explaining its limitations and how procedures are executed.

Dr Marco Faria Correa - May 22, 12:04 PM

Breast augmentation is the planet’s most popular cosmetic surgery. It ranked number one on the American Society of Plastic Surgeons’ 2017 annual plastic surgery procedural statistics list. Colloquially known as ‘boob jobs’ or ‘breast augs, ‘surgeries often involve breast implants or fat grafting to elevate cup sizes. Augmentation mammoplasties can also be applied to volume restoration after significant weight loss and pregnancy, for improved fullness, contours and shape. Although ‘boob jobs’ have the ability of enhancing volume and projection, they cannot correct or lift severely drooping breasts. In order to elevate floppy, empty chests with downward-facing nipples, mastopexies or breast lifts are preferred. A surgery which can be done alone or in conjunction with augmentations, breast lifts aim to tighten redundant skin, shift mammary tissues, and reposition nipples, ensuring lifted, perky and more youthful breasts.
Breast augmentation is the planet’s most popular cosmetic surgery. It ranked number one on the American Society of Plastic Surgeons’ 2017 annual plastic surgery procedural statistics list
In this article, we round up some of Asia’s most famed plastic surgeons as they explain breast augmentations’ many forms, their ideal candidates, and how surgeries are performed. Later, our experts dive into mastopexy’s fundamentals, disclosing the differences between augmentations and lifts, while explaining its limitations and how procedures are executed.
Singaporean Plastic & Reconstructive Surgeon, Dr. Marco Faria Correa
Breast augmentations
Consultant Plastic and Reconstructive Surgeon, Dr. Lee Kim Siea, says the word ‘augmentation’ means ‘to enhance’. When the word ‘augmentation’ is used in breast augmentations, the procedure is classified as volume enhancement. Since both fat transfers and implants increase mammary sizes, both can be categorised as breast augmentations or augmentation mammoplasties. 
Choosing the right technique
In Dr. Lee’s practice choosing either fat grafting or implants or combination (hybrid) method boils down to patients’ needs. If individuals desire significant enhancements in cup sizes, then adipose tissue (fat) grafts are out of the question. Conversely, should patients prefer natural enhancements of only a cup-and-a-half size larger or better filling of hollow bras, then fat transfers are one’s best bet. “Selecting between options are accordant to unique needs. If you want major increases in size, volume and projection, there’s no point considering fat grafts lest you option implants or hybrid techniques which combine implants and adipose tissue grafts,” Dr. Lee advises. 
The motive behind hybrid techniques is because grafts allow small volume increments which permit smaller implants. If patients select large implants alone, there are higher chances for complications, including tissue compression and atrophy, Dr. Lee asserts. Furthermore, larger implants look and feel more artificial as well. 
Augmentation Limitations
Singaporean Plastic and Reconstructive Surgeon, Dr. Marco Faria Correa, reveals that fat transfers are one of his practice’s most requested procedures. Reasons for the popularity of grafting include its natural-looking outcomes. Also, because tissues are autologously extracted, this means patients aren’t exposed to foreign body risks and implant-based complications like scarring, capsular contracture, implant hardening etc. Besides, because of fat grafting’s permanent nature, patients needn’t undergo tedious implant replacements every eight to ten years. Finally, if implant sizes are inappropriately paired with ill-fitting body types, palpable rippling is apparent, increasing the risk of visible folds and implant edges. 
Despite being an excellent technique, fat grafting has its own challenges. Beyond small calcification and oil cyst risks due to big bolus injections, adipose tissue transfer’s most significant drawback is poor uptake. In Dr. Marco’s practice, he never injects more than 200cc of fat per breast. It’s also important to note that 50 percent of the transferred tissues are naturally absorbed. “Because of this natural resorption, patients will require at least two repeated procedures for increases of one cup size,” Dr. Marco says. He adds, “Like Dr. Lee has rightly explained, should patients desire significant enlargements then implants are the better option.” Although implants may not feel as naturally soft as fat transfers, they do offer better shape and projection. Fat grafting on the other hand, best serves individuals who’ve lost volume in the upper pole. Nonetheless, fat grafting patients can enjoy improved shape and contour through amalgamation implants and fat grafting solutions. These hybrid techniques – as specified by Dr. Marco – can either be performed in single sittings or separately (implants first, fat transfer later). In instances where patients prefer fat transfers alone, tissue resorption can be thwarted via repeat procedures or utilisations of BRAVA devices which expand tissues for optimal fat survival and acceptance. 
Implant types
All implants are available in two formats: round or anatomical (tear drop), Dr. Lee says. Turkish Consultant Plastic and Reconstructive Surgeon, Dr. Bulent Cihantimur reveals, “Implants are made of two materials – silicone gel or saline. Silicone implants are the most favoured because they’re lighter, while offering a more natural look and feel.” Implant surfaces however, are divided into smooth or textured. “In general, round implants are either smooth or textured. All anatomical implants are textured,” Dr. Lee states. 
How implants are inserted
There are three widely-used insertion methods – periareolar, infra-mammary fold (IMF) and axillary. All three pose its own pros and cons. In general, choosing between approaches is accordant to individual needs, concerns and surgeon recommendation.  Here’s our experts’ two cents on the matter. 
Dr. Lee: To me, the axillary approach affects in the most visible scar in our population, as marks are especially visible along the armpit. If periareolar methods are applied, scars are discernible when bras are removed. In my opinion, IMF scars are the least visible because marks are hidden under breasts when standing, it is however more visible when lying down. While individuals have options, I normally encourage patients to option the IMF approach as it employs the easiest insertion method notwithstanding indiscernible scars, fewer complications and less pain. 
Dr. Marco: I practice all three methods. Choices between approaches depend on patients’ needs and concerns. In my opinion, periareolar techniques provide the best cosmetic outcomes as scars are well hidden. Nonetheless, it’s not applicable to breastfeeding mums. Plus, slight nipple sensation loss is a possible risk. While periareolar approaches offer the best cosmesis, they’re not so great function-wise. The armpit technique is also a good solution to those desiring good cosmesis. Scars not only fade beautifully but also won’t affect in keloids. Contrarily, axillary methods remain the most complicated and hence, expensive, as scopes are necessary during implant insertion. The IMF technique – according to literature – is the most medically popular because cuts aren’t contaminated by armpit or nipple bacteria. Likewise, surgeries are faster and easier to perform with fewer complications. Nevertheless, IMF approaches do affect in obvious scars. Although this may not apply to patients who enjoy good healing or whose breasts fall beautifully, marks are discernible among skinny individuals. This is because IMFs tend to change positions following implant insertions. And, the more patients undergo follow-up surgeries, the more IMF scars will move, making it the most noticeable scar of the three approaches.
Breast augmentation with implants (Pictures courtesy of Dr. Bulent Cihantimur)
Where implants are inserted
Implants can either be placed under muscles or skin. Although there is no ‘best method’ to implant placement, both Dr. Bulent and Dr. Lee prefer locations beneath muscles to reduce device visibility and palpability, allowing natural outcomes with limited implant rotation risks. In Dr. Marco’s hands, anatomical implants are preferably placed under skin for optimal cosmesis. Still, each implant type, placement and surgical approach poses unique advantages and disadvantages. That is precisely why consultations are important in determining needs, prospective outcomes and concerns.  
Cihantimur’s Breast Beautification Techniques 
There have been many augmentative trends and modifications in surgical methods over the years. In Dr. Bulent’s opinion, trends are leaning towards more natural outcomes sans scars, with comfortable healing periods. Breast beautification is a unique solution invented by Dr. Bulent. It aims to beautify, reform and refresh the chest and breasts. By applying Dr. Bulent’s Spider Web and Cihantimur Fat Transfer Techniques, ageing signs which are the result of structural changes are reversed to not only increase mammary proportions by up to two sizes, but address floppiness too. 
Breast augmentation with fat transfer (Pictures courtesy of Dr. Bulent Cihantimur)
The Cihantimur Fat Transfer and Spider Web Techniques
When Dr. Bulent examines the breast’s anatomy, he observes and applies the structures of the spider web. There are no muscle tissues in this anatomical region, only supporting tissues which provide the breasts’ size and shape. Over time, this structure – like the spider web – tends to lose tautness and tension, becoming loose and saggy. Dr. Bulent adds extra strength to these anatomical structures via the Spider Web Technique which helps lift and shape breasts. In instances where individuals desire increased volumes, Dr. Bulent may combine Spider Web Techniques with Cihantimur Fat Transfer solutions which employ stem cell-enriched fat grafts autologously extracted from the patient’s own body via non-scarring micro openings.
Dr. Bulent's Spider Web Technique (Pictures courtesy of Dr. Bulent Cihantimur)
How fat transfers are conducted
Fat transfers are a pretty straight forward procedure, combining both liposculpturing and fat injection. Following donor site location – tummy, thighs, flanks or any area of concern – fats are carefully harvested. Tissues are then centrifuged to remove oil and water, leaving behind pure fat. Although tissues are now transfer-ready, Dr. Bulent and Dr. Lee advocate cell-enriched fat treatments where a portion of extracted fats are used for stem cell extraction. Once stem cells are isolated, they will be mixed with the remaining pure fat, birthing stem-cell enriched fat grafts. Dr. Lee says, “Although fat-derived stem cells aren’t necessary, they do improve uptake levels by exponentially improving tissue survival rates. Despite an advocated solution, it is elective and therefore, increases overall costs and surgical time,” Dr. Lee informs.

Augmentation surgery results
Patients should wait at least six months before final results can be seen, says Dr. Lee and Dr. Marco. Apart from swelling and bruising which take time to resolve, implant positions will similarly change with weight and gravity. 
In Dr. Bulent’s practice, recovery periods are easily accepted because precise surgical methods and personalised care are the cornerstone of his Breast Beautification techniques. Downtime will, of course, conform to applied pathways and individual pain tolerance. In general, because fat transfer solutions don’t require sutures or incisions, patients are either admitted for one night or discharged within the day. Individuals should also experience minimal downtime and expect to be back to work after a few days. 
Breast lifts
As stated by Dr. Bulent, breast lifts or mastopexies are procedures which address saggy or droopy breasts through existing tissue repositioning. While it’s the recommended approach for sagging or laxed skin correction, lifts don’t increase volumes and sizes. Ideal candidates, according to Dr. Lee, are those with moderately sized breasts whose nipples have drooped below the IMF. In order to fashion the best cosmetic results, surgeries may involve combination lifts and augmentations for firmer, perkier outcomes. Procedural amalgamations depend on severity, says Dr. Marco. If patients have small breasts which are slightly saggy, then good results can be had with high-projection implants. When breasts are well-sized but shapeless, then mastopexies alone may reshape, lift and tighten the skin. Dr. Marco explains, “Good mastopexy results are dependent on desired sizes and how much volume is present. These factors will dictate whether surgeons remove and lift skin, remove skin and insert implants or insert implants alone.”
Breast lifts or mastopexies are procedures which address saggy or droopy breasts through existing tissue repositioning. While it’s the recommended approach for sagging or laxed skin correction, lifts don’t increase volumes and sizes (Pictures courtesy of Dr. Bulent Cihantimur)
How mastopexies are performed
Like mammary augmentations, there are three widely-used mastopexy methods – periareolar, lollipop (vertical) and anchor (Inverted-T). All three approaches have their own advantages and disadvantages. Choices between the three are accordant to individual needs and current breast conditions. 
Dr. Bulent: The advocated surgical pathways are contingent to patients’ body proportions, how much correction is needed, and expected goals. Although methods can only be established through consultations, crescent breast lifts are usually suggested to patients with minimal sagging. This method offers the best scar as surgical marks are nicely hidden within naturally dark areolar pigments. If individuals sport mild sagging, periareolar incisions may be advised. If patients have moderate laxity, surgeons could advocate the vertical breast lift. In the event of severe drooping, inverted-Ts are best, as they allow dramatic breast content augmentations and skin tightening. 
Dr. Lee: For mild ptosis, surgeons may lift breasts through periareolar methods. To do this, doctors will make asymmetrical cuts around the nipple areolar complex to stitch and shift the nipple up. Despite a good option which also reduces areolar sizes, periareolar pathways are only able to reposition nipples by three to four centimetres. When patients seek more elevated breasts, individuals may be advocated full mastopexies which leave behind more scars. These scars can either look like lollipops (around the areolar and down to the IMF) or anchors (around the areolar, down and along the IMF fold). In my practice, I routinely perform periareolar cuts in conjunction with implants because Asians aren’t commonly heavy-breasted. 
Dr. Marco: Although peri-areolar cuts deliver optimal cosmesis, it offers the least adjustments of only a few centimetres around the periareolar complex. For better elevation, less redundant skin and improved envelopes, periareolar cuts including vertical incisions are necessary. When the skin is laxed in addition with heavy breasts, then lollipop cuts plus horizontal incisions are called for. At the end of the day, though vertical and Inverted-T incisions result in the worst scars, they’re the best approaches when tackling moderate to severe sagging and laxity. In my practice, most breast lifting procedures engage anchor techniques. Simply because there’s no point in creating scars if patients sport minimal redundancies. Once there’s moderate to significant drooping and sagginess, patients might as well opt for Inverted-T methods for ideal skin removal and the best tissue repositioning. Although the lollipop approach is available, it’s a harder technique as vertical scars can turn horrible, travelling beyond the IMF and down the chest. 
Lifts and Implants
Mastopexies are combined with implants because patients crave fuller, perkier, shapelier breasts with higher positions. Although lifts have propensities of relocating nipples and somewhat rearranging breast content, deflation – the result of drooping and laxity – is still present. Patients may similarly complain of hollowness along the mid-chest and sternum. These problems can only be addressed through implants or fat transfers. If surgeons only repositioned nipples without adding volume, expectations could fall through.
 
Did you know?
There have been reports of a breast-implant-associated cancer called Anaplastic Large Cell Lymphoma (ALCL). This non-Hodgkin’s lymphoma (cancer of the immune system) has been found in scar tissue and fluid near implants, which can spread throughout the body. Although uncommon – and not deadly – ALCL has been noted and linked with highly-textured implants. There are two types of textured implants in the market – textured and micro textured. These ridges atop devices have one role – to ensure minimal movement under tissues. In Dr. Lee’s practice, he errs on the side of caution by only advocating micro-textured implants to circumvent cancer exposure. Unfortunately, highly textured implants are still available due to their rare and non-deadly nature. If you want to avoid any possible dangers, speak to your doctor about implant options and their associated risks. 

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