A tight cleavage is almost always a request from my patients here in Toronto. Unfortunately, when doing a breast augmentation, be it subglandular, subfascial or submuscular, there is a midline zone, over the chest bone (sternum) where we, plastic surgeons, must keep intact and refrain from detaching from the chest bone, the reason being the avoidance of a post-op complication called SYMMASTIA (literally “one breast”). Think of symmastia as a “unibrow” of the breasts where the skin in the midline lifts up, either immediately after surgery or more commonly in the few months post-surgery with the use of the patient’s upper extremities and return to sports. It is therefore very important to avoid the excessive use of the pectoral muscles post breast augmentation, as their contractions tend to push the implants towards the middle and slowly lifts the central skin. For the same reasons, I ask my patients to avoid push-up bras initially post-surgery. The use of very large implants is also discouraged for the same reasons.
Symmastia is correctable but it is a more complex procedure that necessitates a return to surgery (and the associated costs) with a reopening of both pockets and the use of permanent sutures to close the inner pockets on each site.
So how do I provide a patient with beautiful augmented breasts with fuller upper poles and inner breasts for a tight cleavage without symmastia? With fat grafting. We call this CBA: composite breast augmentation.
Prior to going to surgery, I mark on my patient an area of about 2,5cm centered on the midline where the skin will not be detached. This maneuver has allowed my patients (females and transgender females) to enjoy beautiful augmented breasts without symmastia. I also mark the donor sites where fat will be harvested, from areas of excessive fat deposits such as abdomen, flanks, bra rolls, outer thighs, inner knees, etc. Fat is cleansed and decanted, to which I add the patient’s own PRP (platelet-rich plasma), and then infiltrated gently and in multiple layers, in the inner parts of the breasts to augment the area where the implants end, centrally but also in the upper poles as my patients always enjoy a fuller upper pole. I always use a “test implant” first to determine where the fat is needed as to not risk any contamination or injury to the real implants. I then draw the areas to be lipo-filled (fat grafted), the deep subglandular plane (blue) and the more superficial subcutaneous plane (yellow). All healthy cells, including the stem cells, are transferred. As mentioned, I also take the opportunity to inject in the upper pole of each breasts as the upper poles never get as full as most patients would like with implants, even when using round implants; gravity always leads to fuller lower poles.
CBA (composite breast augmentation) also allows me to recommend a slightly smaller implant to my patients which is beneficial long term (less stress on the skin envelop and subsequent sogginess aka ptosis). Issues in breast augmentation long-term is pre-surgical thin overlying tissues and then thinning of the soft tissues over time. The ratio “pre-existing pre-surgical soft tissues” over “size of implant” is an important one and the higher the ratio is, the better it is for patients. So adding to the soft tissue with fat transfer and reducing the implant size will favour more successful breast augmentations over time. And patients can benefit from a small liposuction at the same time.
Then my patients can enjoy a tight cleavage and a fuller rounder upper pole without the risk of symmastia.
Dr Marc DuPéré, aesthetic plastic surgeon