With athletic women, there are a number of changes that occur to the female breast and chest wall, but four major changes affect how we approach breast augmentation in these athletes. These concepts are used in every primary (first augmentation) that we undertake in athletes, but they are critically important in women athletes undergoing breast augmentation revision.
1) The Breast Gland itself is smaller and has less height than what is seen on examination.
As women (or men for that matter) effectively cut weight, subcutaneous fat is lost from areas that you want to lose it from (abdomen, neck, thighs, etc.), but it is also lost from areas you don’t want to lose it from (breast, face, buttocks). When the breast “shrinks” secondary to weight cutting, the first area that loses volume is the upper central pole of the breast, followed by the upper pole of the breast. This results in not only a loss of upper pole volume but also effectively shrinks the vertical length of the breast, especially if weight loss is combined with muscle gains. In essence, women lose the upper pole projection of their breast, and it appears that they have a shorter vertical height to their breast. However, the appearance seen here is deceiving, and commonly, athletic women are given lower height implants as they are classified as having a deficient breast height. This is a common mistake that we see in revision cases.
Solution: Most women are looking to enhance cleavage and upper pole fullness with breast augmentation, without the proverbial “bolt-on” unnatural appearance, and athletes are certainly no exception. In fact, due to the false reduction in vertical height, we have found that athletes are better acclimated for high profile and ultra-high/extra-full profile implants. They tend to integrate naturally and beautifully in this remarkable group of women.
2) The presence of hypertrophic pectoralis major muscle indicates a robust subpectoral fascial plane.
When it comes to augmentation in athletes, support is critical. Women athletes are going to put more pressure on their implants than non-athletes. Luckily, we have developed a fascia sparing technique for women receiving augmentation that allows Dr. Durkin to support and cover your implant in the lower pole, as the muscle covers the upper pole. This fascial plane is not as critical in non-athletes, but in those women who undertake load-bearing exercise, this specific plane is absolutely critical to appropriate implant placement, and maintenance of implant position. The subpectoral fascia, especially in breast implant revisions, must be identified and utilized to cover and support the breast implant. Failure to do so can result in “bottoming out”, and implant malposition.
Solution: In women who have adequate fascia left after their initial augmentation, this can be used as a support buttress to hold the implant in an appropriate position. However, if the fascia is unable to support the implant, we commonly utilize biologic meshes (Belladerm®-LINK) to create and fashion an “internal bra”, which can offer indefinite support for the implant position and its fullness.
3) Reduction in body fat in athletes tends to leave the implant with thin coverage, causing rippling along the edges of the implant.
This is a big issue with women athletes. To minimize the appearance of rippling, we always utilize “gummy bear” silicone gel implants, and we are particularly fond of the 97% ultra-cohesive implant by Allergan. The ultra-cohesive implant offers greater longevity, improved firmness and projection, and tends to ripple less than its counterparts. Also, contrary to general beliefs, strong muscle does not cause implant failures.
Solution: In women who have low body fat, and less than average volume breast tissue, the implant should be placed below the pectoralis major muscle plane(LINK) for insulation and coverage of the breast prosthesis. Even with these steps, small degrees of rippling can occur along the lateral aspect of the implant (along the armpit side). Lastly, for women who absolutely want to avoid rippling, placement of a Belladerm® mesh along the lateral chest wall will formally cover the implant, which absolutely minimizes the chances of the implant rippling onto the skin.
4) My implant lives in my armpit.
This is our most common complaint in female athletes. While strong tensile strength will not rupture or damage the implant, it will commonly displace the implant laterally towards the armpit, especially if the subpectoral fascia is incised rather than elevated as a flap. The implant will traditionally follow the proverbial “pathway of least resistance”, which is laterally towards the axilla (aka armpit).
Solution: The solution for this is SUPPORT, SUPPORT, SUPPORT. We have to add support to the implant laterally, allowing the implant to sit more medially (towards the center cleavage line). Our personal choice for this is Belladerm®(LINK). Dr. Durkin and his team have extensive experience with this biomaterial, especially in athletes. This biologic mesh is sewn into the lateral chest wall, the inferior border of the pectoralis muscle, and medially along the pectoralis major muscle insertion. This creates coverage for the lower and lateral poles of the implant, minimizing rippling, and maximizing medial placement of the implant.
Belladerm® acts as an extension of the pectoralis major muscle in these cases and provides a support scaffold similar to an external bra. The mesh itself is based on human epidermal tissue, and integrates into the breast capsule, providing superior support and longevity to the result of your breast augmentation. While traditionally used in revisional surgery, many women also opt to have it placed during their initial augmentation to prevent lateral displacement of their implants.
Breast Augmentation Revision – Preop
View of patient preoperatively. Note that there is poor overall upper pole fullness, and that the implants are laterally placed in the armpit area.
Breast Augmentation Revision – One Month Postop
One Month following Bilateral Capsulectomy, Ocean Drive Internal Bra Procedure® with Belladerm, exchange of implant for Extra Full Ultra Cohesive Silicone Gel implant.
Breast Augmentation Revision – One Year Postop
One year following revisional breast surgery. Note how the implant has maintained shape, size, projection, and position.