Cleavage Determinants after Breast Augmentation: Advanced Art of Cosmetic Surgery

Advanced Art of Cosmetic Surgery Thomas M. DeWire, Sr., MD, FACS Specializing in Cosmetic Plastic Surgery Richmond, Virginia, USA


	Breast Surgery
	*Cleavage Determinants in Breast Augmentation*

Cleavage Determination in Breast Augmentation:
	Cleavage depth and width attainable after implant breast augmentation is not equal for every patient, and is greatly dependent on many factors, most of which are predictable before breast augmentation is performed. These factors are greatly dependent on existing chestwall shape and breastbone prominence, as well as the amount of overall body fat, and the extent of native fatty tissues that overlie the sternum, and soften the contour transition from sternum onto the breasts. Other key factors are the actual starting separation of the breasts, and the position of the nipples, as well as the orientation of the breasts, regarding their degree of divergence from a line drawn straight forward from the breast bone. These anatomical factors vary widely from patient to patient. Several examples are noted below. Be sure to view both pages, as the volume of data is too large to present on a single page.

Ideal Cleavage Starting point: Normothoracic Chestwall and Adequate soft tissues:

A 33 year old woman with a relatively flat chest wall with forward direction of nipples and neutral position of breastbone relative to the slope of the chestwall. A chestwall with this shape is Normothoracic . The augmentation was done via a trans-axillary approach.			Pre and Post-op photos of this patient in supine position shows gentle round slope of the chestwall from sternum and ample soft tissue at the transition from the breasts to the breastbone, creating the potential for deep cleavage.
			Red lines mark the shape of the chestwall relative to the sternum, and the blue lines note direction of the nipples from the plane of the chest pre- and post- augmentation
Like a house built on level
Age: 38 Ht: 4'11" Wt: 108 lbs. Approach: Trans-axillary Implants: Mentor Saline Type: Smooth Round Submuscular Volume: 325cc bilateral Size: 34D			An excellent starting shape and adequate soft tissue transition from the breasts to the breastbone makes an ideal candidate to achieve excellent cleavage
			Side views show projection of breast relative to position of the breastbone (red) and the lateral extent of the breast (dots) . Note in side view that more of the breast will project forward of the breastbone relative to the patient shown below. Even without a bra, this allows for ample cleavage.

Prominent Breastbone with Sloping Chestwall and Divergent Breasts ("Pigeon" breast or Pectus Carinatum):

A 33 year old woman with significant sternal prominence and marked divergence of the breasts is seen before and after breast augmentation by trans-axillary approach. This is a moderate expression of pectus carinatum or "pigeon- breast".			Pre- and post-op photos show the impact of the prominent sternum and steep outward slope of the chestwall on the achievable cleavage. Frontal views are shown below for comparison. The result is pleasing, but depth of the cleavage is limited by the chest shape configuration.
			Red lines mark the position of the breastbone and the ribs in this patient with a prominent sternum and steeply sloped chestwall with asymmetry. Note in the post-op photo the more forward directed nipples which have been rotated inward by the implants.
Like a house built on an outward slope
Age: 33 Ht: 5'6" Wt: 120 lbs. Approach: Trans-axillary Implants: Mentor Saline Type: Smooth Round Submuscular Volume: 425cc bilateral Size: 36C			A prominent breastbone is responsible for some loss of potential cleavage, since the depth of the cleavage is limited by forward sternal position, and divergence of the breasts to the sides. Modest cleavage is still obtained, but will be greatly enhanced by a proper bra.
			Side views show projection of breast relative to the position of the breastbone and the lateral extent of the breast. Note in side view that less of the breast will project forward of the breastbone relative to the patient shown above. This reduces the amount of cleavage projection. A bra will help by directing the breasts closer and forward.

Depressed Breastbone configuration, or Pectus Excavatum:

A 40 year old with borderline ptosis, pectus excavatum, and scoliosis with marked chestwall and breast asymmetry is shown before and after augmentation via a crease approach. Apex breast lift to correct the asymmetry was declined.			Supine photos before and after surgery are shown, revealing the very deeply depressed breastbone that is seen with marked cases of pectus excavatum.
			Red lines mark the chest contour and very deeply depressed sternum in this patient. The nipples point straight forward both before and after the augmentation. A yellow ellipse marks the depth of the sternal position
Like a house built on an inward slope
			Frontal views show deep cleavage achieved with pectus excavatum, despite the abnormal shape of the chestwall, and thin tissues. Post-op asymmetry reflects the significant asymmetry seen pre-op. An apex lift would have corrected the nipple position, but was declined by this patient.
Age: 40 Ht: 5'7" Wt: 120 lbs. Approach: Crease Implants: Mentor Saline Type: Smooth Round Submuscular Volume: 325cc bilateral Size: 36C			Oblique views show the position and depth of the breastbone, with nipples almost pointing inward after the augmentation. That is due to the inwardly sloped chestwall as it approaches the very deeply recessed sternum.
			Side views show projection of breast relative to position of the breastbone (red) and the lateral extent of the breast (black dots)