Dr. Giese: In this oblique view, it appears that the patient has a double-bubble deformity. In addition, her breast mound and the implant appear unequal; her left breast seems higher on the chest wall than the right.

To avoid the occurrence of a double bubble, I would not have chosen to obliterate the natural inframammary fold, if possible. The natural inframammary fold acts as a very strong sling to keep the implants properly positioned on the chest wall. Here, the implant has fallen beyond the natural portion of her breast and into the surgically created inframammary fold pocket. This patient needed an augmentation mastopexy. I like the periareolar approach and the subpectoral position with a round, smooth saline implant, but, again, I would have tried to avoid lowering or changing her natural inframammary folds. Maybe that would have meant using a smaller implant. I do not know what necessitated lowering the folds.

Dr. Colen: Dr. Hammond, what would your initial approach to this patient have been?

Dr. Hammond: If I felt that she needed a mastopexy, I would have performed a periareolar mastopexy without hesitation. When I am already in the periareolar incision, I use that to gain access to the breast; it is a very nice approach to the lower breast apron. The inframammary-fold incision sometimes masks the location of that fold when the implant is inserted. But from above, through the periareolar incision, you can really see that lower apron quite nicely.

Lowering a fold is a maneuver that should be approached with tremendous care and performed only when absolutely indicated. You can see where the original fold was, and the distance from that point up to the areola and the nipple is certainly adequate to accommodate an augmentation of this size. If the folds are inadvertently lowered, of course, this can result in a double-bubble situation. I would perform a capsular manipulation along that fold, incising along the capsule and using the capsule as an apron to hike the fold up superiorly to restore the breast to its original fold location. Revising the fold would reposition the implant in the breast and improve the double-bubble deformity. I agree with Dr. Giese that the left nipple still looks low. She may need a revision of the periareolar lift to raise the nipple.

Dr. Colen: Dr. Graf, how would you correct this problem if the patient was unhappy with this double bubble and wanted her contour restored?

Dr. Graf: If the implant was vertically positioned and problem-free, I would keep it intact. There is excess skin in the inframammary region that can be diminished or eliminated with the vertical technique, in which skin is moved inferiorly. This technique would enable me to correct the asymmetry of the nipple-areolar complex, elevating the left side.

Dr. Colen: Are you saying that a vertical incision would improve her lower breast contour?

Dr. Graf: Yes. Through the vertical incision, I can perform an internal fixation of the previous inframammary fold, correcting the double-bubble deformity.

Dr. Colen: Dr. Hammond, do you think a vertical incision would be helpful?

Dr. Hammond: I do not think that the vertical approach would be the best approach. It is basically a horizontal problem; adding another vector would not help the double-bubble phenomenon.

I believe that Dr. Graf was actually referring to the ptosis of the nipple and the areola. Adding a vertical component can help tremendously in shaping the breast and providing a more cone-shaped appearance. But a vertical incision is not going to help that double-bubble deformity along the inframammary folds.

Dr. Colen: When you look at her tan line, it appears that the top of her nipple is quite close to the top of her tan line. Would you be concerned about raising her nipple? How would you perform the periareolar mastopexy?

Dr. Hammond: It looks as if the left side is slightly lower than the right, so I might perform a unilateral mastopexy. The right side actually looks okay, except for the double-bubble deformity. If I were to use a periareolar approach, I would stabilize the opening through which the mastopexy is performed and then allow the areola to sit in that opening without tension. I would cut the areola at a diameter of 50 to 52 mm — greater than what I ultimately will need. The outer incision is performed superiorly, as far as necessary, to achieve the desired lift. I use a Gore-Tex suture (WL Gore & Associates, Elkton, MD); it is permanent, strong, very slippery, and slides easily through the dermal cuff around that areolar opening. You can control that opening, millimeter by millimeter, as you cinch the knot down. I actually cinch it down to an opening that is less than 52 mm to about 44 mm. With the patient upright, I can convert that opening into a perfect circle by deepithelializing a small additional bit of skin if needed. Then the nipple and areola can be raised and will fit into that opening without tension. That has been a very effective way to create a natural-looking nipple and areola that does not appear plastered against the apex of the breast.

Dr. Colen: Dr. Giese, do you think anatomically-shaped implants would benefit this patient?

Dr. Giese: No. She has adequate breast tissue, and a round implant placed in the subpectoral position produces essentially the same aesthetic result as an anatomically shaped implant. Another reason not to choose an anatomically shaped implant is the possibility that the implant will turn and create additional deformity; it would just add an additional variable without providing a clear benefit.

Dr. Colen: Dr. Graf, if this patient wanted silicone-gel implants instead of saline, would there be specific considerations in choosing the size or the shape of the silicone implant to replace a saline implant?

Dr. Graf: Silicone gel is often preferred in Brazil because these implants are felt to produce a better breast shape. But in this patient, the size and shape of the saline implants look good. I would not change the implant shape to an anatomic one, because it could worsen the inferior pole fullness that we are trying to correct with the vertical scar.