The incision that I have preferred for virtually all of the primary breast augmentations that I have performed on my patients over the years has been the inframammary one. There have been several reasons for this including the relatively inconspicuous location and scar healing, a lower risk of the development of capsular contracture (firm scar around the implant making the breast feel hard), better surgical exposure that also allows for greater control and precision for the dissection and what intuitively seemed to me to be an approach with a lower risk of affecting the nipple-areola complex sensation. There was no large study performed that evaluated the possible effect of the incision location on nipple-areola complex (NAC) sensation … until now.

Finally, we seem to have a more definitive answer to this issue.

A large retrospective (evaluating patients who already had surgery) study was performed in Italy that evaluated the possible effect of incision location for breast augmentation on the subsequent sensation of the nipple-areola complex. This involved over 1200 women who had the surgery performed by a single surgeon over a more than 6 year period of time using either an inframammary or a periareolar incision. Variables evaluated included patient age, breast implant size, and implant pocket location (in front of or behind the muscle).

What were the findings?

Implant size had no significant impact on the sensitivity of the nipple-areola complex postoperatively. Neither did the age of the patient nor whether the implant was placed in a submuscular pocket (behind the muscle) or submammary pocket (in front of the muscle). The only factor that had a statistically significant effect on the sensation and discomfort of the NAC was the incision location. The periareolar approach resulted in either a decreased or total loss of sensation in 9.5% of patients versus 3.5% with the inframammary one. This translates into a 2.7 times greater risk for sensory loss with the periareolar incision as compared to the inframammary one. The analysis also revealed that the periareolar incision led to a 3.5 times greater likelihood of experiencing areolar pain.

This study provides even more scientific proof of the superiority of the inframammary incision for breast augmentation surgery.

For more information on breast augmentation surgery or on any other plastic surgery procedure that I perform, or to schedule a consultation with me, you can call my office at 480-451-3000.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

Breast augmentation is the number one cosmetic surgical procedure that women undergo. It is also among the top two in overall satisfaction with 94% stating that if they had to do it all over again they would still make the same decision. That is an amazingly high number particularly in light of all the risks and complications that plastic surgeons must discuss with their patients prior to this breast enlargement surgery.

One of these risks in breast augmentation and one which I review in detail with my patients is the occurrence of numbness of the nipples and the breast skin in general. How common is numbness of the nipples? Is it temporary or permanent?

As with many surgical procedures where incisions are made and the skin elevated (lifted), there will be some postoperative numbness, albeit usually transient, and such is the case with breast enlargement surgery. Right after surgery, the skin of both breasts can/will be somewhat numb which is also compounded by the initial swelling. Over a period of a few weeks, most if not all of this will resolve in a majority of women; others can take several months. There is a very small percentage of women who may take a year or more for their sensation to return.

The incidence of permanent loss of sensation of the nipples as identified by several studies is around the 3 – 5% range though in my practice, it is extremely rare. This risk is influenced by many factors including surgical technique, skill of the surgeon, incision location and breast implant size. Incisions placed around the areola have a substantially greater risk of resulting in temporary and permanent numbness than those placed through one situated either in the lower breast crease (inframammary fold) or the armpit (axillary approach). Breast implants that are disproportionately large in relation to the chest wall and starting breast size also elevate the risk.

For more information on breast augmentation surgery in Scottsdale or on any other plastic surgery procedure that I perform or to schedule a free consultation with me, please call my office at 480-451-3000.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

Patients who have undergone breast reduction surgery have the highest rate of satisfaction of all major plastic surgery procedures. This even includes breast augmentations where 94% of women would make the same decision again. Furthermore, they are so happy and appreciative of the improvement or resolution of their symptoms that they frequently accept aesthetic results that women undergoing other procedures might take more note of.

The following patient of mine illustrates the dramatic improvements that can be obtained through pursuing a reduction mammoplasty. This 29 year old female was experiencing debilitating neck back and shoulder pains secondary to the massive size of her breasts for which she wore a 36G bra (photos A, C and E). Her activities including sports and working out were severely limited due to the pain and discomfort that she would experience as a consequence of her massively enlarged breasts. She already had deep grooves present in her shoulders from the weight of her breasts causing the bra straps to dig into the skin.

A.) frontal view - preoperatively

B.) after breast reduction surgery

C.) side view - preoperatively

D.) after breast reduction surgery

E.) oblique view - preoperatively

F.) after breast reduction surgery

This patient underwent an inferior pedicle technique for the breast reduction which involved anchor shaped incision. The nipple-areola complex was reduced in size and elevated to a proper position while still maintaining its blood supply. A total of 5 pounds of breast tissue was removed (photos B, D, and F).

As a result of the breast reduction, she has had complete alleviation of her neck, back and shoulder pains and is engaging in far more vigorous activities than she had for many years. To her delight, she now wears a “C” or “D” bra as opposed to the gargantuan “G” size which she wore prior to surgery, feels far more attractive and is no longer self conscious about her breasts. Another pleasant surprise is that the sensation of her nipples has been preserved.

If you would like more information on breast reduction surgery or any other plastic surgery procedure that I perform or to schedule a consultation with me, please call my office at 480-451-3000.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

Among the many ideal goals in breast reduction surgery is to preserve the general appearance of the nipple and at least some sensation. These can be achieved much of the time with procedures that maintain the attachment of the nipple to the underlying tissues including ducts, nerves and blood vessels. However, for those women with exceptionally massive breasts, a procedure called a free nipple graft breast reduction may offer them the best opportunity to obtain more ideal results.

This technique facilitates the removal of an appropriate volume of breast tissue and with greater finesse while allowing for more ideal breast contouring with greater predictability of results, shape and durability. The scar pattern is the same as that of most other techniques. However, the biggest drawback to this approach is that the nipple-areola complexes are removed as “skin grafts” to be placed back on the breasts later in surgery at an ideal position. Their blood supply and nerve fibers are necessarily disrupted and their survival will depend on re-growth of the circulation. Because of this, most nipple-areola complexes will display some degradation of their normal anatomy.

What are some of these visual changes? Commonly, there is loss of some or all of the nipple projection and what may remain is a semblance of a nipple. The areola may also be thinner and not as domal shaped. Darker complected individuals also have a substantial risk of depigmentation of the areolas, either temporary or permanent. As with any skin grafting procedure, there is a risk for partial or total failure of the nipple-areola complex to heal and survive. This risk is higher particularly in smokers, diabetics and those with autoimmune disease.

The photo below demonstrates the appearance of a nipple-areola complex in one of my patients who underwent this free nipple graft breast reduction. She has maintained some nipple projection and has not lost pigmentation.

Breast reduction with free nipple graft

If you would like more information on a reduction mammoplasty or any other plastic surgery procedure that I perform or to schedule a free cosmetic consultation with me, please call my office at 480-451-3000.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

A patient recently sought my expertise regarding the poor results that she obtained from a mastopexy with implants that was performed elsewhere (by a surgeon who was not board certified). She was very unhappy with the outcome for many reasons but the abnormal shape including the flatness and lack of appropriate projection and the low position of her breast on the chest were the most important issues. To her, the breasts looked bizarre making her feel very self-conscious and frustrated.

She originally presented to the surgeon with drooping (ptosis) and wanting to be larger. The physician recommended a lollipop mastopexy to her without enumerating its pros and cons and did not discuss the much more commonly used inverted-T incision. (A lollipop mastopexy is a breast lift that involves an incision around the nipple-areola complex that then extends down to the breast fold but does not extend along this fold which is employed in the inverted-T technique.)

Her photos can be seen below on the left:

The patient's "lollipop" mastopexy performed by another surgeon. Note the flatness of the breast and droopy appearance with it hanging down well below the breast crease.

This is a mastopexy using a T-shaped (anchor) incision. Note the more pleasing and natural conical shape with greater projection and fullness.

Ignoring factors specifically related to the surgeon, her results also reflect the inherent deficiencies with a lollipop mastopexy. As I noted elsewhere (Periareolar Mastopexy: Sacrificing Shape for Less Incisions), the goal of a breast lift is to recreate a more conically shaped breast with the nipple-areola positioned at the most projecting part. The “standard” inverted-T or anchor shaped approach allows for the precise recontouring of the skin envelope in addition to the underlying breast tissue by utilizing a three dimensional approach. This also facilitates greater accuracy in the placement and size of the nipple-areola so as to create a well shaped aesthetically pleasing breast.

Though the lollipop mastopexy can provide a better shape than what can be obtained with the even more restrictive periareolar mastopexy, its shortcomings are obvious as you can see in these photos. Without being able to adequately remove most of the vertical skin excess that occurs with droopy breasts, the breast remains droopy and abnormally flat including at the nipple-areola complex. Volume that could be used to increase forward projection and yield a more conical shape is instead hanging down, well below the breast crease that is should remain largely above.

Similar to my sentiments regarding a periareolar mastopexy, it is my opinion that a lollipop mastopexy is rarely indicated except for limited situations involving very minor drooping. The tradeoffs in shape and position are too high a price to pay for most women versus the vastly superior results that can be obtained with an additional incision along the breast crease.

If you would like additional information on breast lifts, breast augmentation or any other cosmetic surgery procedure that I perform or you would like to schedule a complimentary consultation, you can contact my office at 480-451-3000.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

There are many advantages of placing breast implants behind the pectoralis major muscle for a breast augmentation, breast lift (mastopexy) and in breast reconstruction. The most significant of these include:

1. Better ability to detect abnormalities on mammograms versus in front of the muscle (submammary)
2. Lower risk for capsular contracture (hardness of the breast caused by the formation of scar tissue around the implants)
3. More soft tissue coverage overlying the implant resulting in a lower risk and extent of visible rippling
4. Provides a better and more natural interface of the implant with the chest wall
5. Serves to provide better support of the implant long term as compared to above the muscle where the weight of the implant will cause greater stretching and thinning out of the skin over time as well as its descent on the chest wall

Implants above the muscle. Note the rippling, harsher contours, stretched areolas and unnaturalness of the result. (not my patient)

Implants behind the muscle. Note the more natural shape and smoother curves. This approach is recommended for most of my patients.

Except for some rare exceptions, most women are best served with the submuscular placement of their implants. As a result, this is my recommendation for virtually all of my patients.

If you would like additional information on a breast augmentation, breast lift, breast reconstruction or any cosmetic surgery procedure or to schedule a consultation, you can call my office at 480-451-3000.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

A periareolar mastopexy, also known as a purse string, doughnut or circumareolar mastopexy, is a breast lift that accomplishes the result with just one incision: around the areola. Many women find the idea attractive because of the idea that there may be fewer scars on the breast. Unfortunately, unless there is minimal drooping to begin with, the trade-off is a poorly shaped flattened breast.

The goal of a breast lift or mastopexy is to recreate a more somewhat conical shaped breast with the nipple-areola situated at the summit of the most projecting part. A “standard” inverted-T or anchor shaped incision allows for precise reshaping of the skin envelope in addition to the underlying breast tissue by utilizing a three dimensional approach. The nipple-areola complex can then be more accurately placed and sized so as to result in an aesthetically pleasing contoured breast.

Inverted "T" Shaped Incision

The periareolar mastopexy approach eliminates the vertical scar as well as the horizontal scar in the fold at the bottom of the breast. Through a two dimensional approach involving just the incision around the areola, it has to both lift and reshape the breast. It accomplishes both by removing excess skin asymmetrically around the areola, taking a larger circle and purse stringing it to make a smaller circle, thereby tightening the skin.

With this approach, the area of maximum tension is centered around the areola. Some of the untoward consequences of this can include but are not limited to:

1.)    a flattening of the breast shape creating more of a pancake configuration than a cone
2.)    stretching and flattening of the areola causing distortions and irregularities of shape
3.)    unsightly pleating of bunched up skin around the areola resulting from the purse string closure
4.)    widened and thickened scars around the areola
5.)    limitations in the precise positioning of the areola on the breast
6.)    difficulty in obtaining closer symmetry is breasts that are significantly different prior to surgery

Periareolar Mastopexy (A). Though mild in this case, flatness and some pleating of the skin of the left breast can be seen centered at the areola (not my patient)

Periareolar mastopexy (B). Greater flattening can be seen including at the lower part of the breast

I strongly feel that a periareolar mastopexy is very rarely indicated except for certain limited situations involving very minor drooping. The trade-offs as noted above are too high a price to pay for most women versus the far superior results that can be obtained with a few more incisions.

If you would like additional information on breast lifts, breast augmentation or any other cosmetic surgery procedure that I perform, you can contact my office at 480-451-3000.

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

Many of my breast reduction consultations ask me the following question before I even discuss the procedure: “Dr. Turkeltaub, will my breasts also be lifted when I have a breast reduction?”  After making what I think is a humorous comment about that it would depend on their insurance plan, I let them know that this is an intrinsic part of the procedure.

A breast reduction, also called a reduction mammoplasty, involves a significant reduction in the size of the breast, lifting the tissue up to a more appropriate level, making the breast less wide, reducing the diameter of the nipple-areola complex and elevating it to an ideal vertical height. Most of the time this is accomplished through an anchor shaped/ inverted “T” shaped incision. The result is a smaller, lighter, higher, perkier and more rejuvenated appearance.

Just what the Doctor ordered and what my patients want!

Before Breast Reduction

After Breast Reduction

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona

Asymmetry of the breasts is present in the majority of women. Some might have been aware of the differences whereas some never even noticed the difference until it was pointed out much to their surprise during their consultation. Differences can involve breast shape, size, positioning on the chest wall, drooping, chest wall variations and nipple-areola asymmetries such as size, shape, positioning, contour and projection. Of course, whether or not there is a difference or if it ever was recognized previously, many expect perfect symmetry following surgery.

Breast augmentation surgery will not correct asymmetries. Some differences may be diminished whereas others will persist or may even be accentuated.

A frequent question regards differences in the vertical heights of the areolas and whether they will be situated at the same level following surgery. The answer to this is that they will remain dissimilar most of the time so that one will continue to be higher than the other (see photos). Furthermore, because the breast implants are placed so as to be at the same vertical height on the chest, aesthetically, one nipple-areola complex will always seem to not be in the ideal position. In situations where the areolas are located more to the side of the breast than centrally preoperatively, this malposition may be magnified postoperatively.

Despite these relatively minor issues, a breast augmentation still provides women what they desire from this procedure – fullness, projection, cleavage and a more attractive and alluring appearance.

Different nipple-areola heights preoperatively (frontal view)

Nipple-areola heights following breast augmentation (frontal)

Different nipple-areola heights preoperatively (oblique view)

Nipple-areola heights following breast augmentation (oblique)

Steven H. Turkeltaub, M.D. P.C.
Scottsdale and Phoenix, Arizona