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



                    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



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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)


     LINK to the second page of Cleavage Determinants


Related  Breast Augmentation Links:   To Other photo Illustrated Procedures:

Important  Information  About  Implant  Breast  Enlargement

Trans-Axillary Breast Augmentation
Trans-Axillary Breast Incisions Scars
Breast Augmentation Shape Evolution
Breast Augmentation Shape Determination
Cleavage Determinants
Post-Op Implant Massage Technique
Implants Over versus Under the Muscle
Special Considerations in Augmentation
Breast Surgery in African American Women
Breast Augmentation FAQs
Breast Augmentation with Mastopexy or Breast Lift
Revision Surgery for Augmentation Problems
Important Information about Silicone Breast Implant Use
Nipple Reduction/Shaping
Mastopexy or Breast Lift

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Thomas M. DeWire, Sr., MD, FACS
Advanced Art of Cosmetic Surgery
3974 Springfield Road
Glen Allen, VA 23060
Richmond, Virginia, USA
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ęCopyright 1997-2013  Advanced Art of Cosmetic Surgery:  Thomas M. DeWire, Sr, MD, FACS   Revised:   September 09, 2014 06:03 PM