S05E73 The Art and Science of Modern Breast Augmentation Explored

Discover the changing tides of breast augmentation as we sit down with plastic surgery experts Dr. Sam Jejurikar @samjejurikar from Dallas, Dr. Sam Rhee @bergencosmetic and guest host Dr. Lawrence Tong @yorkvilleplasticsurgery from Toronto, (subbing in place for Dr. Salvatore Pacella @sandiegoplasticsurgeon).

Our conversation goes to the results of a 15-year survey by the American Society of Plastic Surgeons, highlighting a decline in patient smoking habits, an uptick in sagging post-procedure, and a growing preference for certain surgical techniques. We dissect the impact of these trends on both the art of plastic surgery and the experiences of patients, from the decreased use of textured implants to the complex interplay of augmentation with mastopexy—ensuring you're equipped with the latest insights from the frontlines of cosmetic enhancement.

Navigating the considerations of breast lifts paired with implants, we discuss everything from patient suitability to the challenges faced during surgery. We share personal anecdotes from the operating room, debating the merits of various implant placements and techniques while emphasizing the crucial role of managing patient expectations. Our discussion stretches into the realm of the surgeon's responsibility in crafting results that not only meet but exceed patient desires—all without compromising safety or aesthetics. Join us for a look behind the surgical curtain, where informed decisions, experience, and innovation converge to sculpt the future of breast augmentation.

@3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic 3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

00:00:06 Trends in Breast Augmentation

00:12:57 Considerations for Breast Lift and Implants

00:21:45 Breast Augmentation and Mastopexy Techniques

TRANSCRIPT

S05E73 The Art and Science of Modern Breast Augmentation Explored

[00:00:00] Dr. Lawrence Tong: hi everyone, uh, this is Larry Tong and I am joined by Dr. Sam Rhee and Dr. Sam Jejurikar. Uh, we are at, at Yorkfield Plastic Surgery for Me. Sam Rhee is at Bergen Cosmetic and Dr. Jejurikar is at Sam Jejurikar. Uh, welcome gentlemen. Uh, today we have, um, a discussion about, uh, the current trends in breast augmentation.

This is a very common procedure, uh, that we all do. Um, but before we, uh, go on to that, uh, Sam is going to read our disclaimer.

[00:00:41] Dr. Sam Jejurikar: This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your qualified health provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in this show. Sam Rhee, you want to, uh, you want to lead this conversation about trends in breast augmentation? You were just telling us some interesting stuff you had found.

[00:01:11] Dr. Sam Rhee: Yeah. Um, so in 2022, A SPS, the American Success, uh. Society of Plastic Surgeons, uh, did a survey and they, um, analyzed, um, the trends over time in terms of breast augmentation. And a lot of plastic surgeons as part of the society logged their breast augmentation cases over basically 15 years from 2005 up until 2020.

And some of the interesting trends that they found with cosmetic breast augmentation included The following one was, I think, which is pretty obvious, patients are most less likely to smoke 12 percent versus 8%, which is staggering that 8 percent of patients are still smoking when having surgery. Um, they, uh, were more likely to have sagging 23 percent versus 20.

And we need to talk about this. Uh, I want to get to the sagging part of, uh, breast augmentation and dealing with that. Um, the use of inframammary incisions, which are the incisions under the breast fold, increased from 68% to 80%. The use of perrer incisions around the nipple decreased from 24% to 14%.

And then, um, the next to last statistic that I wanted to highlight was the Submuscular implant, or under the pectoralis major muscle that increased greatly from 22% to 56%. And I would really like to talk about. Implant placement above or below the muscle and and what you guys think and then the last one what

[00:02:45] Dr. Sam Jejurikar: just so I understand it, they're saying 15 years ago, only 22 percent of implants were put behind the muscle.

[00:02:50] Dr. Sam Rhee: that is correct

[00:02:52] Dr. Sam Jejurikar: Oh, wow. Okay.

[00:02:53] Dr. Sam Rhee: yeah, and and then the last one which I think is pretty obvious considering the ALCL and the issues with textured implants basically Textured implants have dropped to 0 percent at this point. They used to be, um, like 16 percent back in 2016. So, so there's basically no use of textured implants anywhere at this point.

So, um, what do you guys think of these initial, what's your initial take on these statistics and, and the changes over time with breast augmentation?

[00:03:25] Dr. Sam Jejurikar: Um, I'll go first. I mean, they all seem like they're science driven, which is good. Um, inframammary incision is more common because there's data that shows that capsular contracture, which is for the viewers, is hardness around the breasts, is less common through that axis, so I like that. Same with the trend towards subpectral, um, implant placement.

I mean, there's data that shows that. Subpectral has less capsular contracture than subglandular, which is behind the gland. So that sounds really good. I'm just, I guess the thing that got my attention was how little breast augmentation was actually done through a subpectral approach until recently, because we all trained at a place where subpectral was the, was the default.

And that has sort of been my default as well. You said that there was more sagging that doctors are seeing now than there was. Um, 15 years ago,

[00:04:17] Dr. Sam Rhee: Well, minor from 20 up to 23%.

[00:04:21] Dr. Sam Jejurikar: I guess that surprises me because at least the trend in my practice has been towards smaller implants and we use, um, we use, you know, scaffolding mesh a lot more to help try to prevent that complication. So that surprises me a little bit. What do you think about that, Larry?

[00:04:36] Dr. Lawrence Tong: I think that, um, sagging definitely occurs, um, post surgery. Uh, one interesting, uh, thing about it is that, um, if you, um, I think that if you put the implant under the muscle, that will diminish that because you're not having the weight of the implant just solely borne. On the skin, which happens when the implant is placed above the muscle.

Um, so, so I think, you know, with the use of mesh and using smaller implants, meaning more support and less heavy implants, uh, there's, you know, there's a trend to minimize that. Um, when, when Sam had just initially mentioned that statistic, I had initially thought that it was related to seeing patients with sagging.

Preoperatively, and I think that's actually an interesting topic, uh, to discuss as well. What do you do when you see a patient who has sagging, um, in general, we would have a discussion about, um, mastopexy or breast lift in association with, uh, breast augmentation. But, um, I find that once we get into that realm of discussion, um, there's a number of patients who are a little bit resistant, uh, with that.

Uh, because of a number of reasons and I'm just wondering, um, first of all, when you evaluate a patient and they have PSYCH and what are some of the things that you, uh, some of the criteria that you would, uh, use to evaluate as to whether or not they need a breast lift? 100

[00:06:15] Dr. Sam Rhee: I was gonna say this is probably the, there are several different, uh, I would say nexus or decision points that patients have to make when they're considering breast augmentation. And the first one is, should you even get breast augmentation with, with an implant? And that's something that we all, as plastic surgeons talk to patients and try to determine the reasons.

Behind, uh, why a patient would want it, would an implant help reach their goal in terms of aesthetics and what's going on with that. Understanding the risks and benefits, the benefits and risks with a, with an implant, which, um, which are very important, obviously, to, for patients to understand. And, and then there are a couple other decision points, size, um, you know, location.

And we just talked about like incision placement and implant placement. All of those things, uh, have to be discussed with the patient. Another big nexus point or decision point is Uh, as Larry just said, do you do with sagging? And, you know, some of it depends on the patient's goals. Uh, but the biggest one, I think, uh, that we're sort of headed toward to, uh, where we're headed when talking about, uh, aesthetic breasts is incisions and scarring and.

When you do a mastopexy or a, a regular type of breast lift, or, or most breast lifts, you're talking about significant number of incisions on the breast. Um, not only, you know, and we can talk about these and which ones do you guys prefer, but it's, it's a hard, it's a hard stop for a lot of patients to say, I'm gonna put a, an incision right in the middle of your breast, under your breast, around your breast.

Um, a lot of patients find that to be difficult, um, to accept for. Correcting saggy breasts. And, um, I think as plastic surgeons, that's one of the biggest things we have to work around when we're, when we're dealing with patients and their goals with their breasts. Uh, how do you guys deal with that when you first initially talk to patients?

[00:08:16] Dr. Sam Jejurikar: think, um, first of all, we even have to define what sagging means. Because, as weird as that sounds, I find that plastic surgeons and patients oftentimes define sagging differently. Um, plastic surgeons define sagging as generalized descent of the nipple and the areola on the breast mound and the nipple pointing downwards.

Patients, a lot of times, just mean that their breasts aren't sitting as high as they want. And so, um, you know, plastic surgeons, we're all sort of trained to I think that the breast should look a certain way, but sometimes patients aren't bothered by the same things that we are. And so I think it's important to talk to the patient and figure out, all right, what are your goals?

Many patients will tell us, look, I just want to have more volume and I want to wear a bra. That's going to allow me when I wear that bra to have more volume in the upper portion of my breast. And I'm willing to do that in that situation, even though a patient may meet the classical need for a breast lift.

Sometimes we'll, we'll compromise on that. We'll, we'll think about using an implant. If patients, though, tell me, look, I want to look as though I'm wearing, you know, I want my breasts to be standing up and I never want to have to wear a bra. I want my breasts to look like that. And they meet the definition of needing a breast lift.

There's no way to do that without the scars. And yeah, scars can be a hard sell for patients. But, nobody has ever come to my office, and I suspect it's the same with you guys as well, that said, hey Dr. Jejurikar, what I really, really want is all these scars on my breasts. I would really love an incision around the areola and a straight line coming down and maybe one across the bottom.

That's what I really want. Rather, the people that come in are just sort of reconciled that that's what they need in order to get the look that they want, and they know they're going to have to do some Pretty intense scar care for six months to a year to get the results that they want, and they're willing to do that.

So that, I don't know, I'm not sure I answered your question, but it kind of comes down to what patient goals are.

[00:10:15] Dr. Lawrence Tong: So, the way that I approach a patient is, um, Like you said, how we are generally trained, I tend to break up patients into three categories if they are coming in for breast augmentation. One category is that they clearly do not need a breast lift. That would be generally the younger patient who maybe hasn't had any kids or just generally has a youthful appearing breast.

That's the second category. Is the patients who definitely need or definitely would be recommended to have a breast lift. Those are the patients whose breasts are, you know, hanging down to their abdomen. Maybe they've had a lot of weight loss. Uh, maybe the elasticity, uh, of the skin is, is all gone because of various factors.

And those patients would generally not look, um, aesthetically normal if you just put an implant, um, in them because, um, for viewers. When we put an implant in, the implant is going to sit, sit eventually at where your breast fold is, and if the rest of your breast is hanging way below the breast fold, you're going to have volume up here where the implant is, and the rest of your breast, um, sitting low.

We call that, um, Snoopy breast, uh, deformity, and that generally doesn't look good. And then you have the sort of in between patients. Patients who you could Possibly recommend an implant with breast lift, or maybe just an implant on its own. And I think that's what Sam was alluding to. Sometimes you have to tailor the procedure to what the patient wants.

Because what I tell patients is,

[00:11:56] Dr. Sam Rhee: Um, Um, Um, Um, Um, Um,

[00:11:57] Dr. Lawrence Tong: if you just want to look good in a bra, then doing a lift won't really do much for you, because the bra is going to be doing the lift for you.

[00:12:05] Dr. Sam Rhee: Um, Um, Um, Um, Um, Um,

[00:12:06] Dr. Lawrence Tong: But if you want to look good in the nude, When you come out of the shower and you want to look in the mirror and have, you know, the breast, um, lifted and nice and high, then you have to consider, uh, getting a breast lift, um, with the, with the implant, um, and with that, there's going to be, you know, scars associated with it.

So, you know, even though you may think one procedure is better than the other, uh, oftentimes letting the patient guide you, uh, will, will be the right way, uh, to go. So I break it up into, you know, definitely does not need it. Lift, needs a lift, and sort of the in between patients. So the in between patients are ones who might have to spend a little bit more time on discussing the options.

As long as a patient knows what the, what the consequences or outcomes of any decision that they make, then I would be okay with that. So I,

[00:12:56] Dr. Sam Rhee: I

[00:12:57] Dr. Sam Jejurikar: Hey, can I, can I ask you?

[00:12:58] Dr. Lawrence Tong: So

[00:12:58] Dr. Sam Rhee: yeah, go

[00:12:59] Dr. Sam Jejurikar: Sorry, I was uh, I was gonna ask a question. So the question is, I know we started off talking about breast implants, but this is a really interesting thing kind of dovetailing on breast lifts. How many times do you guys find yourself talking to a patient that comes in Who wants a breast lift and wants an implant and you see a patient and you think, okay, I can do this, but I don't really even feel comfortable putting in an implant at the same time.

Do you ever encounter that? And who are the patients that you typically have a hard time putting an implant in at the same time you would do a breast lift?

[00:13:32] Dr. Sam Rhee: Um, go ahead Larry. No.

[00:13:39] Dr. Lawrence Tong: a patient, if they already have a fair amount of breast volume. Then, you have to ask why the patient wants a lift, meaning, um, you can sort of simulate what they would look like, um, when you're examining them, you know, you gather their skin and, and you show them, okay, if we just did a lift, this is what it would sort of look like.

Would you be happy with this sort of volume? And if they're okay with that, then I would say maybe you don't need a lift. Um, but patients who Um, we wouldn't put an implant in would be that type of patient or if a patient, um, is, you know, looking for something that's much larger than what can accommodate their, their skin.

Because when we put an implant in, uh, we're stretching the skin because we're putting more volume in. And then when we're doing the lift, we're removing skin as well. So you have this double whammy of, um, reducing the amount of skin. And if a patient wants an implant, that's. If it's too large to accommodate that, then, um, I wouldn't necessarily say they can't have an implant, but we have to talk about going to something smaller or, you know, having their expectations, um, changed.

[00:14:52] Dr. Sam Jejurikar: Does the degree of droopiness preoperatively have any impact for you at all?

[00:14:57] Dr. Lawrence Tong: Oh, yeah, so, so if patients clearly don't need a lift, then I would generally say, you know, it's not necessary because, you know, your nipple position looks good, you don't have Excess skin and, you know, oftentimes patients may be, uh, under the perception that they need a lift, but then when they come in to see us, and that's why, you know, we do the consultations.

We give them our advice. Oftentimes they'll

[00:15:24] Dr. Sam Jejurikar: guess what I was actually asking you is what if it's really, really, really droopy, like the nipples. pointing down to their feet and they're massive weight loss patients. Do you worry about, you know, doing a relatively large lift on someone and putting an implant at the same time? Do you have concerns about, about healing or blood supply or is that, is that not really a thing anymore?

[00:15:49] Dr. Sam Rhee: Uh, for me, um, I've gotten more aggressive as my experience has grown. So, as Larry said, an augmentation mastopexy is, and we were, we were taught this, one of the most challenging cases. They used to quote us that this was one of the most litigated cases ever, because what Larry said is you're stuffing Like a 10 pound sack of potatoes with 15 pounds and then tightening that sack at the same time.

So that, that is always, uh, been one of the challenges that traditionally we've learned about. Um, especially when you're doing all that tissue rearranging in a breast lift. And then you're squeezing the crap out of it by putting a tight, you know, making it tight by putting an implant underneath. Um, that was something that I've gotten more confident with over time.

I think knowing how tight to make it and how much you can get away with, depending on the degree of ptosis and how saggy it is, is something that All of us as surgeons have learned, I think, the more you do it. That being said, um, I have done it both ways where I've staged it, where I've done a lift and then I've done gone back and put an implant in.

I've also done a single stage with, uh, some pretty massive weight loss patients and been pretty aggressive with it. And I will say cosmetically it, I think the results at least for me tend to be better. Um, if I do the, the lift first and then I'll put an implant in, um, sometimes even with a little bit of a revision the second time around, but I've gotten some pretty decent to really good results doing it.

Um, and I've kind of pushed the boundary a little bit on that. And I think these massive weight loss patients also. are going to accept a little bit more sagging. Like, like you said, their concept of sagging and our concept of sagging is a little bit different. So, if I can get that implant in the right spot, if I can get the breast volume pretty good around that implant, Enough and avoid that Snoopy deformity or water to form a waterfall deformity that Larry's talked about, then I'm in a pretty good spot.

And I've, I've tried to do more and more of those. And I think, uh, you know, it's, it's a question of me sort of just. understanding what that relationship is between the two. How about you, Larry? Oh, Sam.

[00:18:19] Dr. Sam Jejurikar: Yeah, I, I, I don't, I was more picking your brain out of curiosity because there's not like a black and white answer to any of these things, you know, Larry was saying you don't want to pick an implant that's too big and I 100 percent agree with that, but then my concept of what that too big of an implant is or what the profile of that implant is changes over time and changes on what, what the patient is.

Um, yeah. I've, I've been putting it, you know, I've even had situations now where I put in some reasonably large implants, like in massive weight loss patients, you know, this is Texas after all, and, uh, everything is bigger in Texas and, um, but I'll use, I'll use mesh and I'll tell them, look, I feel pretty good that I can get.

I can get the, uh, the implant to stay in the right position, but your skin has a reasonably high probability of relaxing and getting this waterfall deformity afterwards. And we can, we'll have to do a revision in six months to a year on. And if that happens, but you know, it's at least during that first stage, you'll have the volume that you want and there's a chance that won't happen.

Um, and so I try to be upfront with people about the risks because. You know, you're putting this heavy weight in and you're, and you have minimal support. The reason we're there is because their support's not very good, but, but ultimately, yeah, I don't think there's any hard and fast rules to it. You just have to sort of weigh the pros and cons with each individual patient and see what they're comfortable with.

So

[00:19:42] Dr. Sam Rhee: I think Andy Trussler has always told us, I remember we did a, an episode with him and he talked about how, you know, these are sort of moving targets. Like you can do a mastopexy and it can look amazing. And then in 10 years, You know, gravity takes over. If you have a big implant and like you said, um, we try to mitigate that sometimes with more support, as you mentioned, but, um, none of these are forever procedures and I talk to patients about that, like, uh, especially if their life changes, they, they lose a lot of weight, they gain a lot of weight.

Like these are all. Sort of, um, things that can change, uh, even if on the table or the first year or two, like you said, they look awesome or they look great. Things, things change. And so what we're trying to do is figure out how to make these results as long lasting as possible, as stable as possible, uh, but also work within.

You know, a bunch of pretty complicated parameters sometimes when you're trying to figure out what, what's, uh, how to achieve a patient's goal.

[00:20:48] Dr. Lawrence Tong: I'm curious to hear, um, for both of you, um, when a, when a patient is sort of in that gray zone where they could get an implant, or sorry, could get a lift or not a lift. But they choose not to do a lift. Uh, are there other things, other procedures or other, um, ways that you would go about to try to achieve the best cosmetic result possible?

[00:21:14] Dr. Sam Jejurikar: you're talking about a patient who's got. Like,

[00:21:17] Dr. Lawrence Tong: Maybe a little bit of drooping. Yeah, maybe.

[00:21:21] Dr. Sam Jejurikar: Um, um, and so in those patients, we're already doing an augmentation on them. Sometimes, um, I will do a little bit of concomitant fat grafting in addition to an implant to add even more upper pole fullness than I might be able to get from the implant, knowing that the implant is going to be sitting a little bit on the lower side.

Um, but, um, I don't find mesh to be particularly useful in those situations because I'll find that if I use mesh in those situations, the implants, it's abnormally high, and they have even more of like a waterfall deformity or a snoopy deformity where the tissue is hanging off of it. Sometimes, if the patient, um, is amenable.

To it, we think about going slightly bigger with the implant to recruit more, uh, more soft tissue, but you know, that comes with risks that when you use a bigger implant, you create more, more force on the soft tissue and the laws of physics are merciless and never change. You know, Greater the mass of the implant, the more the force of gravity is working on it.

And the more long term sagging they may actually, you know, experience. Um, but sometimes we'll think about a bigger implant. Um, sometimes a bigger implant and mesh. There's not, there's not really like a set. It really again, comes down to what they're, what they're willing to tolerate in terms of implant size.

[00:22:39] Dr. Sam Rhee: Um, we talked about this just before we started the, uh, podcast. I don't do very many subglandulars if ever. Um, and I do know that there are some people out there that feel that subfascial can get you a, um, versus submuscular. Can get you a better look in, um, mild or moderate ptosis patients. Uh, do you guys do that?

[00:23:03] Dr. Lawrence Tong: I don't, I don't do that very often, but the theory behind it is that if you place the, uh, implant over the muscle, then you're sort of gonna fill out. Um, the skin envelope, um, a little bit better. And so you don't have as much apparent grouping, um, because the implant just sits slightly lower than what it would, where it would sit, uh, when it's under the muscle.

So I think that, uh, those, those options are definitely, um, on the table. Uh, there are, you know, pros and cons, uh, to that approach. Um, maybe a little bit more premature, uh, drooping as, uh, you guys have mentioned previously, but you know, I think subglandular or subfascial, the difference between that is when a subfascial you're going slightly, um, deeper or more, um, under a layer, uh, that's, um, that helps to give a better contour to the upper pole, uh, of the breast and maybe Uh, some improvement in reduction of sagging, but I, I think that's sort of certain at this point, uh, in the evolution of that procedure.

[00:24:19] Dr. Sam Jejurikar: I, I do do subfascial breast augmentations.

[00:24:22] Dr. Lawrence Tong: going to

[00:24:23] Dr. Sam Jejurikar: I wish I had mentioned that when Larry asked the question in the beginning, but I will use it for people that have that in that gray category. Um, you know, I, I guess the 1 thing where I feel a little differently than Larry is I don't really believe that going sub pectoral prevents um, Long term sagging any more than going subthascial.

Maybe it comes down to how much you release the lower portion of the muscle. You know, I think, um, I I'm fairly aggressive in that release. Um, but for that reason, I think to me, I don't think that the soft tissue, whether there's. know, that lower pole where there's not really even in a subpectral or a submuscular augmentation, there's not a lot of anything other than skin and breast tissue holding it.

I think that ultimately it comes down to implant size more than the plane of the plane of where you're putting the implant in terms of preventing the sagging. The theory behind subfascial sagging. is that this thin anatomic layer of the fascia of the pectoralis major muscle is enough to provide a barrier protection between the breast gland and the implant so that you have more protection against capsular contracture versus just going behind the gland itself.

And I say the theory because I don't know of any compelling long term data that actually shows that, and it's not the thickest layer in the world. So I do tell people, this is the theory. I can't tell you with certainty that it's as safe for preventing hardness of your implants than going behind the muscle.

But there's definitely patients that I will talk to about doing this and will do it for.

[00:25:58] Dr. Sam Rhee: You know, it's funny, I think this is one of the types of procedures where having a lot of experience does help. Like, I can't tell you exactly what degree of sagging objectively tell, prompt me to tell a patient, I don't think I can achieve the result you want without a lift, regardless of whether it's subfascial, subglandular, submuscular, but I do know it.

Like. I can see it, like, if I see it, I would be able to tell you, but I wouldn't be able to say, articulate it and write it down in some sort of analytic fashion about, um, this is, this measurement means this patient needs. Um, a lift, or this measurement definitely says this patient doesn't and can get away with a subfascial or whatever it is.

It's kind of weird to me. It's uh, it's just one of those things that I feel like, um, every, every surgeon is fairly individual with. I've seen a lot of different, um, sort of methods, thoughts, uh, analyses. And as long as I think experience counts, I think, uh, the more you do these, the more, you know, what you can achieve, the more you can try to understand the patient's goals.

Um, I mean, I really do understand most patients when they really don't want any scars on their breasts and I will do anything that I possibly can to avoid that. But there is a point where I see, um, someone's anatomy and I'm like, I'm sorry, you maybe go see someone else. Cause I personally will not be able to do that for you.

And. It's got, I've gotten to that point where I'm comfortable understanding which ones I can say that to, which ones I can, I can actually help them achieve their goals. It's, but, but it's taken me a while to get to that point.

[00:27:45] Dr. Sam Jejurikar: Yeah, for sure. Um, well, I'm sorry, Larry.

[00:27:52] Dr. Lawrence Tong: uh, when you guys do mastopexies, uh, breast lifts, uh, we had mentioned incisions. And so there are various forms of breast lift, and do you, do you guys, um, Use all the different forms or do you like to stick to your tried and true techniques when you do these surgeries?

[00:28:16] Dr. Sam Jejurikar: I think my general rule of thumb is, um, I shouldn't say rule of thumb. Sorry. My general rule is, um, is that, um, the milder the degree of droopiness, the fewer incisions that I want to use. Um, so, um. That being said, the traditional incision that is just around the areola, which is called a benelli for the listeners, isn't really great as a true breast lift.

I really use that just for patients who want their areolas made a little bit smaller. Um, I will sometimes do a lollipop lift for milder degrees, which is an incision around the areola and a vertical line extending downwards. But more often than not, I have to add a transverse component in the crease as well, just to Shape the breast the way that we want to.

[00:29:09] Dr. Sam Rhee: Yeah, I, I have gotten away from the Benelli, uh, which is just around the areola. Um, haven't done it in, in years and years. Uh, I will see if I can just do a lollipop, but most of the time I have to tee it off maybe about an inch or two on the bottom. Uh, it's really hard for me to get away from just even a little bit.

Um, and I always feel like if you're, if you've made that vertical incision, you've basically made the most visible, uh, scar. So to put a, on the breast fold an inch or two, just to tighten it up or, or, you know, sort of finish it, like to me is. Less of an issue than committing to that, that vertical incision, basically, but I will never, I don't know.

It's very rare that I would ever consider like Sam does. Like, I'll do it for a real reduction, but I will. I don't think I would ever offer a Benelli for, uh, for a real mastopexy.

[00:30:06] Dr. Lawrence Tong: Yeah, I, I would agree with everything both of you said, basically, you know, tailor your, your surgery to the anatomy. If you can get away with smaller procedures, smaller, um, smaller scars, then do that. Um, but as needed, you know, use the scars, use the incisions that you need to, um, get the best shape. Because I think in the end, uh, you know, the overall shape will really trump.

Uh, whatever scars patients had and I, I found that to be totally true. Patients generally, if they have a nice shape, they're going to be very happy and, and they're not as concerned, uh, with the resultant scars, because scars will fade, scars will heal. You can do things to improve them, um, as long as they know that, you know, they're never going to go away completely.

[00:30:49] Dr. Sam Rhee: I will say this. One thing I have learned is the key for me to getting a longer lasting repair is keeping that infra, uh, From the areolar down to the inframammary fold distance short. Like every time I've left that long or what I thought was okay, that always lengthens, uh, I think Trussler said it's like a tail on a lizard.

It just keeps growing. So if you can get that distance from the inframammary fold up to the areola, um, short, like. You'll, you know, meaning like I don't ever leave it more than maybe seven centimeters if possible. Um, even shorter to six if I can get away with it. Um, I generally feel like the long term result is going to be better for me.

[00:31:34] Dr. Lawrence Tong: Yeah. And implied with that, uh, for viewers is that, uh, in order to shorten that incision, you have to make that transverse incision.

[00:31:45] Dr. Sam Jejurikar: Yeah, I agree with that. Though there are certain implant selections where if you use a higher profile implant, sometimes you can recruit some of that skin. So that's true, but there's a few situations I find myself in where I can artificially reduce that length. But I'd say 90 percent of the time I make a transverse incision, so I'm not claiming that I don't.

I was just sticking to the spirit of the question. Why? Um, well, this has been very illuminating, gentlemen. I, uh As always, I've learned a lot from the two of you, and this is a trend that's continued over decades, so thank you for doing it again this morning. Do you guys have any closing thoughts before we wrap this up?

[00:32:28] Dr. Sam Rhee: Yeah, always, always a pleasure.

[00:32:31] Dr. Lawrence Tong: it's always a pleasure. We are recording this, um, on, in the morning of New, uh, sorry, Christmas Eve. So, um, by the time people will hear this, it'll be after the holidays. But I'll say to my buddies now, have a, you know, great holiday season. Spend some time with your family. And I look forward to seeing you guys again.

[00:32:52] Dr. Sam Jejurikar: Happy Holidays.

[00:32:54] Dr. Sam Rhee: well

[00:32:54] Dr. Lawrence Tong: Happy holidays. All right.