Adrian Richards: Hello, my name is
Adrian Richards. Welcome to the plastic surgery podcast, providing
information for patients from patients. I'm a consultant for
practicing cosmetic surgeons. During the podcasts, I'll be
talking to specialists in particular fields to get the latest
updates on treatments. During the second parts of these podcasts,
I'll be talking to patients who've undergone these treatments
to get their opinions and views on how the treatments work.
Today I'm going to be talking to Patrick Mallucci who's a very
well known plastic surgeon based in the London area. Patrick's
very well known for his breast surgery, but in particular,
for his innovative ideas on the idea of aesthetics of the breast.
Patrick will be discussing these in the first part of the podcast.
In the second part of the podcast, we're going to be listening
to an interview from Susan who's sent us a query asking how
you choose the ideal shape and size of the implant and also
whether it's ideally placed in front or behind of the muscle.
Patrick's kindly going to answer her queries at the end of
the podcast.
So, I'm here today with Patrick Mallucci who's the consultant
plastic surgeon, who I've known for quite a long time, 'cause
we're sort of contemporaries, aren't we, Pat? Can you just
tell me a little bit about your background, where you work,
and main interests?
Patrick Mallucci: Yeah, I'm a consultant plastic surgeon
at the Royal Free Hospital, and I have a private practice in town which goes
by the name of London Plastic Surgery Associates. My main interests are in
both reconstructive and aesthetic breast surgery, and probably of late, particularly
aesthetic breast surgery.
Adrian: OK. We've been talking today at a conference
in the Royal College of Surgeons to trainee breast surgeons, and I know you
were at Athens last week, weren't you, talking to international society of
plastic surgeons. And you've got some interesting ideas about breast aesthetics
and the ideal breast. So, I wonder if you could just tell me a little bit about
those, Pat?
Patrick: Yeah, I think with everything in plastic surgery,
it's important to understand what aesthetic ideals are. And we've seen this
in the face, we've seen it with proportions of the nose, and really, what I've
done is something similar with the breast. It's to analyze a breast, and ask
the question: What is it that makes a breast attractive? Are there some common
features which can be applied to all breasts that render them attractive. And
it turns out, actually, that there are. And what it centers around is really
the proportions of the breast above and below the nipple. Now, a while ago,
I did a study looking at models who'd been selected for topless modeling with
natural breasts, and I analyzed their breasts and looked at the proportions
to see if I could come up with a common thread. Now, it turns out that, pretty
consistently, what you find is that there is a division between the upper pole
and the lower pole of the breast, and this is the point at which the nipple
sits. It always sits slightly more towards the upper pole than it does the
lower pole. So, the lower pole is always slightly fuller, it has a nice pleasing
tension to it, and the upper pole needs to be flat, or even a little bit concave
with the nipple skyward pointing.
Now, if you manage to achieve that balance and those features,
you produce, essentially, an attractive breast. The more you
deviate from those proportions, the less attractive your breast.
Adrian: OK, can you just clarify that? By the upper
pole, you mean if I'm looking from the front, the amount of breast above the
nipple compared to the...
Patrick: Absolutely.
Adrian: So you've actually quantified it with numbers,
haven't you?
Patrick: Yeah, so the upper pole is exactly how you've
described it. It's that part of the breast above the nipple. So, what you want
to do when you're designing a breast enlargement, or if, for example, you're
revising previous work, is you want to try and get those proportions right.
In other words, you want a fuller lower, an emptier upper pole, and that nipple
sitting just above that horizon between the upper pole and the lower pole,
slightly skyward pointing.
Adrian: OK, and the numbers, I understand that you've
actually quantified it in 55% should be‑‑is that right?
Patrick: Well what I've done, I use the numbers 45/55,
essentially to simplify. And what 45/55 tells you is that it mustn't be 50/50,
because 50/50 is not quite the attractive norm that you're looking for. So,
the lower pole has to be more than 50% of the whole breast. And the upper pole
has to be less than 50%. Now, we're in the process at the moment of quantifying
that specifically, because while it's important that the upper pole is smaller
than the lower pole, equally, you can't overload the lower pole. So if, for
example, you had a proportion of 70% in the lower pole and 30% in the upper
pole, that's deviation from your norm in a different direction, but still gives
you an unattractive breast.
Adrian: Absolutely. We've talked a lot about sizes of
the implant, how you select an implant, can you talk me through how you analyze
a breast and work out roughly the size implant that will be ideal for an individual?
Patrick: Yeah, sure. Analysis of the breast really starts
off with talking to the patient and understanding what it is that the patient's
looking for. It's about trying to get a feel for what sort of size she's expecting,
what sort of look she hopes to get out of it. Perhaps, why she's doing it in
the first place. Those immediately will trigger clues as to what type of implant
you're going to be choosing in the back of your mind. Somebody who's really
saying to you, "Look, I want a really natural look, I don't want anybody
to notice, " immediately you'll be thinking anatomical implant, perhaps
lower profile round implant. Somebody on the other hand who wants to celebrate
that they've had a breast augmentation, is not bothered by people knowing about
it, and wants to look full, you're not going to be thinking anatomical, you're
going to be thinking fuller, high profile round implant.
Adrian: And there's basic measurements you take, aren't
there, of the breast. Just talk me through those, Pat.
Patrick: Absolutely. So, having established what you
think the patient wants, you then have to try and choose the implant that's
appropriate to that patient, a: to try and fulfill her desires, but b: it has
to be tailor made to that patient's size, chest wall, height, and of course,
breast dimensions themselves. So, the whole point of assessment is extremely
important. What do we look at when we look at the patient? We look at their
stature, we look at their chest wall, whether it's symmetrical, whether it's
asymmetrical, do they have one shoulder higher than the other, is there a natural
breast asymmetry, and what about the dimension of those breasts? Because, ideally,
you need an implant that fits that individual. And sometimes, patients will
need to be guided by the surgeon as to what is best for them, and what is likely
to give them the best results.
The patient may have, in her mind, an idea that she wants to
be of a particular size. It may turn out that that size is
simply not achievable on that frame and on that breast dimension,
and that's why it's so important to effectively tailor‑make
the implant for the patient.
Adrian: Yeah. So, I suppose what I'm hearing from you,
Pat, and what I would 100% agree with, is breast augmentation, to be done really
well, isn't the simple production line type procedure. How would you feel about
that?
Pat: I absolutely agree. I think people forget that
the breast is actually a very complex structure. It's a semi‑solid, semi‑liquid,
spherical, fluid object, which is actually very difficult to interpret. It
changes with movement, with posture, and all of these characteristics really
do, in many ways, complicate the issue. So, an awful lot of thought needs to
go into selection, measurement, analysis, in order to choose the most appropriate
implant for that individual.
Adrian: And also the long‑term outcome. The breast does
change with age, so any comment about that, Pat?
Patrick: Yeah, absolutely. I think all the more reason
to really guide people into being sensible about size change. People have to
realize‑‑a lot of young girls come in and they want to be very large, but they
have to realize the long‑term implications. Stretching the skin, the weight
of the implant, flattening of the actual breast tissue, and the likelihood
of more complicated procedures later on in life.
Adrian: Brilliant, Pat. Well, thanks very much for taking
the time to talk to me today, and hopefully we'll talk to you soon.
Patrick: Thank you very much. [music begins playing]
Susan: Hi, my name's Susan, I'm 36 years old, and I'm
the mother of two children. I've been trying to look around for information
on breast implants and I'm very confused about the language that's used on
the Internet that I've seen. I'm confused what "unders" are, what "overs" are,
whether you have the implants under the fold, through the nipple, through the
armpit. I've read the information on your Internet site, and I've listened
to other surgeons talking, and I'm wondering if you can tell me how I make
the choice, or how you would make the choice for me? And also, the shapes on
the market appear to be round shapes, which, obviously I don't want a full
looking breast, I want a very natural looking breast, and there's obviously
the ones that look like a teardrop, and, again, I'm not sure which would suit
me. Thank you.
Adrian: So, Patrick, I wonder if you'd be kind enough
to answer those questions from Susan about the shape of implants, best shape
of implants. How do you choose that? And also, the plane, the over or under
the muscles. Perhaps you could talk about the anatomical or round implants.
Patrick: Sure. It goes back to really what I was saying
about trying to choose the most appropriate implant for that particular patient.
I think the thing with round and anatomical implants, you'll find, is two things,
and I think, as a patient, this is important to remember when you go and see
people. There will be some surgeons who will have preference for one type over
the other. That doesn't necessarily mean that one is better than the other.
People are able to achieve very similar results with either. Some of it will
be down to surgeon preference. In my particular case, I will use an anatomical
or teardrop implant in somebody who really is after very natural, very subtle
results, and usually in somebody who's got very little breast tissue. In other
words, it really is the implant that's determining the shape of that breast.
Every so often, there will be somebody who has got virtually no breast tissue
in whom a teardrop, an anatomical implant will be the most appropriate implant.
That's not to say‑‑and this is very important‑‑that's not to
say that you can't get an actual result with a well selected
round implant, because I think you can, and I think most of
the implants I use are round. I think something else that,
perhaps, a lot of people don't realize is that there are many
types of round implants. A round implant is not a generic term
which describes all implants. We talk about lower profile,
much more subtle, round implants, and higher profile, much
more high‑impact round implants.
And, again, depending on the look, chest wall dimensions, you
can choose between the ranges of round implants in order to
best achieve the look you're after.
Adrian: And one of the advantages of round implants
is that with rotation‑‑do you see much rotation with anatomical implants?
Patrick: I mean, in truth, you don't see much rotation,
and rotation rates are probably at 4% or less in well‑dissected breast pockets.
But, of course, there is that possibility, particularly in active women, women
who enjoy sports, and that risk is potentially a little bit greater. So, you're
actually right, with a round implant, you eliminate that possibility.
Adrian: So, again, it's patient selection, talking to
the patient, but as a general rule, a very thin patient with very little breast
tissue, perhaps anatomical; someone with a slightly more padded bust, perhaps
a round might be the way to go.
Patrick: I think that's absolutely right. It's about
tailoring for that particular individual. People mustn't walk in thinking one
type is better than the other. It's about finding the right implant for the
right patient.
Adrian: I'll absolutely concur with that. Patrick, the
second question we've got, again, I'm asked this a lot, is over or under the
muscle. Now, I know you've got strong views about this, and perhaps you can
tell us how you select the ideal for an individual.
Patrick: Again, at the risk of sounding repetitive,
it is about tailoring to the individual. I think it's wrong to say that that
everybody needs their implants under the muscle or everybody needs them over
the muscle. And once again, I will say that I don't think one method is better
than the other. They're essentially fairly simple criteria which determine
which one you use in which situation.
Adrian: So tell me a little bit, why would you go under
the muscle?
Patrick: The main reason is because you want more cover.
So, in somebody who is very skinny and doesn't have much breast tissue, by
definition, they don't have much cover, so when you put an implant in, if you're
not going below the muscle, you do risk having that rather Victoria Beckham
look with a very see‑through globe type implant. That's a look that a lot of
women fear coming out with. So, in that sort of patient, then, every time that
implant needs to be place underneath the muscle. If, on the other hand, you've
already got a fair amount of breast tissue, you pass our "pinch test, " and
our pinch test basically is about determining the thickness of your breast
tissue, then there's no reason to go underneath the muscle.
Adrian: Can you just clarify how you do the pinch test,
Pat?
Patrick: Yeah, the pinch test is basically taking a
caliper which measures thickness, and the breast can be pinched typically above
the nipple, also at the sides, on the inner aspect, which ever works the best,
to determine the thickness of the breast tissue. In general, you need at least
two centimeters of breast tissue to be able to justify not going under the
muscle. If you're two centimeters or thinner, you probably ought to be going
underneath the muscle, because you're not going to have enough cover.
Adrian: And that two centimeters is actually two thicknesses
of breast tissue, isn't it?
Patrick: That's right, that's correct.
Adrian: So, because, in the pinch, you're picking up
two layers of skin, which gives you one centimeter of breast cover. So, what
are the problems you get if you place an implant in somebody under the [inaudible
16:12] in front of the muscle in someone with less than one centimeter of coverage?
Patrick: The main problems are with implant visibility,
palpability‑‑that means you can feel it‑‑and, I suppose the worst of all of
it is the rippling and the wrinkling that you can potentially end up with.
So, in that [inaudible 16:30], that's the whole point of going underneath the
muscle, is to provide that extra layer so that you get better disguise, more
tissue cover, you're not going to see or feel the rippling or the wrinkling
to the same extent, and generally, get a much more pleasing result.
Adrian: That's excellent, Pat. So, essentially, the
breast will look the same whether you go under or over the muscle, they'll
look the same‑‑can you just quickly, just before we finish, give me the pros
first of all of in front of the muscle?
Patrick: Where the pros of in front of the muscle are,
in terms of invasiveness to the patient, it's a bit less invasive, it's a bit
less painful, arguably recovery is a bit more rapid. There would be some argument
to say that it's the natural plane of the breast, and that you might get a
slightly more natural result‑‑I'm not terribly convinced of that, but it's
an argument that you can have. And I think particularly in the post‑pregnancy
mom, or somebody who's lost a bit of weight where there's a bit of empty skin,
I think this is a group in which the implant does very well in front of the
muscle, because you need that implant to inflate that breast as much as possible.
Adrian: OK, and the pros of behind the muscle?
Patrick: Pros of behind the muscle really are all about
producing very natural contour, avoiding the Victoria Beckham look, and really
providing padding on somebody who is thin, doesn't have much subcutaneous fat,
or very much breast tissue.
Adrian: And the cons, finally Pat, the cons of behind
the muscle?
Patrick: I think the cons of behind the muscle are‑‑I
think the mistakes arise when a: too much effort is put in to putting too much
of the implant behind the muscle. What happens in that situation is that the
implant has to be placed too high on the breast. I think the other problem
is, those who do go under the muscle, if they're not adequately releasing the
muscle, you can get some contraction of the pectoralis muscle across the implant,
which can be bothersome.
And I think, finally, in that group of patients that we were
talking about, the post pregnancy moms, potentially, if your
muscle is holding your implant down, it might not be expanding
that breast as much you want it to be.
Adrian: Well thanks very much, Pat. You know, it's very
useful to go through it. It's a complicated issue to get it absolutely right‑‑the
right implant, the right plane for an individual, so thanks for taking time
to talk to us today.
Patrick: A pleasure, Adrian. [music plays]
Adrian: That will do it for today. Thanks for listening
to the plastic surgery podcast, providing information for patients from patients.
For further information, or to leave feedback, please visit the Aurora website
at www.aurora‑clinics.co.uk. If you'd like to schedule an appointment with
one of our surgeons, please call 01844‑214‑362, or email us at info@aurora‑clinics.co.uk.
We're very keen to get a feedback, and if you are considering any of these
treatments and you'd 'like me to ask one of the resident experts about any
topic, please email us or send us an audio file, which we can play on the podcast.
I'm Adrian Richards, thank you for listening to the podcast, and thank you
to all of our guests.
|
