Many factors will affect the outcome of your surgery. The number one factor that determines your outcome is what your breast looks like before any surgery. Your new postoperative breast will be the sum of the size and shape of the implant plus the size and shape of your existing breast. Your breast may present a number of limiting factors that affect the results.
The chest wall is the foundation upon which the breast sits. The chest may be tall and narrow or short and wide. The circumference of the chest may be a barrel shape or wide and flat due to the way the ribs are curved. The breastbone may be flat, depressed, or protrude.
The quality of the skin over the breast may vary in appearance, pigmentation, and in how it heals. It may be thick or thin, and its elasticity will vary. It may have stretch marks. The layer of fat under the skin will vary in thickness from patient to patient and in different parts of the breast. It may vary from one side to the other. The amount and distribution of glandular tissue within the breast also varies. Pregnancy and breastfeeding will affect all of these elements.
The nipple areola complex varies greatly in its size, shape, color, and position on the breast. The nipple may project more, less, or be inverted. It may be of large or small diameter. The position of the nipple relative to the inframammary crease is one of the factors that determines a need for a lift. They may be farther apart or close together.
Achieving symmetry is one of the goals of surgery. However no one starts out perfectly symmetrical, so it is impossible to have a perfectly symmetrical result. Some types of symmetry can be corrected but other are exaggerated by breast implants. On examining a patient I look at the shoulders first. In most patients the right shoulder sits lower than the left, the right nipple and inframammary crease are usually lower as well. Usually the left breast is slightly larger than the right. Volume differences may be corrected by implants. Although if you fill two particular size implants to different volumes, the one with more fluid will be firmer. If you use different size implants, then the implant diameters will differ and therefore another asymmetry is introduced. An even more difficult problem is having one nipple higher than the other. Implants often exaggerate this asymmetry. Another fairly common symmetry issue is the levels of the inframammary crease. The creases are usually at different levels. The bottom of the implant sits at the crease level; therefore the upper edges of the implants may sit at different levels.
Also critical is the amount of soft tissue coverage over the implant. Soft tissue consists of skin, fat, breast, and muscle. The thickness of this tissue determines its strength and how well it will hold up the implant over time. It also determines whether there will be visible wrinkling and how easy it will be to feel the implant through the tissue. It also determines the final breast shape and how natural or unnatural it looks. One way to think of this is the ratio of breast tissue to implant. If the final result is 50% your tissue and 50% implant, it will look and feel very natural. If it is 90% implant and 10% your breast, then it will look and feel very unnatural. Some women prefer this unnatural, fake, or “Baywatch” look.
Another implant to tissue relationship is the distance between the breasts, or the cleavage. If that distance is narrow before surgery it tends to stay narrow after surgery. If it is wide before surgery, it will tend to stay wide. One must be careful using a wider implant to narrow the cleavage as the inner edge of the implant may be under some very thin soft tissue. This may create visible wrinkling even with an implant under the muscle. Another limitation in narrowing the cleavage occurs when the nipples lie far apart. The center of the implant needs to sit under the vertical line of the nipple. This determines where the inner edge of the implant is and therefore the distance between the breasts. Though this could be improved by using wider diameter implants, an unacceptably large size may be required to achieve the desired distance between the breasts.