The art of Mastopexy: Nipple Placement

Human Proportion and Plastic Surgery: Nipple Location

When it comes to re-shaping the breast, i.e. through breast lift (Mastopexy), breast reduction (reduction mammoplasty), or breast reconstruction, the surgeon needs to have an artistic eye for human proportion in order to maintain the truest human form as the process and skill of the surgeon is comparable to that of a sculptor. This is especially important when it comes to post-surgery nipple placement. The female breast should be viewed as the combination of a dome and a cone, with the nipple being at the apex. Although there is no perfect position to assign to every breast and nipple due to the variety in shape and size, adhering to the principles of human proportion will ensure that the surgeon can locate the appropriate nipple position. It is essential to get the placement correct during the first procedure because failure to do so will give an abnormal or even deformed appearance to the breast. If the nipple is place in an incorrect position, it can be difficult, if not impossible, to correct.

The first step in perfecting the placement of the nipple is recognizing that the breasts do not normally point straight forward. They diverge from the midline plane of the body (see image), so that when one breast is seen in outline or silhouette, the other breast is seen in the full round. The second step is making sure that the nipple is located in the mid-axial plane of the breast, balancing between the center (medial) and the side plane (lateral).  Once the central line is drawn, a line from the naval to the acromion (outer high-point of shoulder) will pass through the projected placement of the nipple. If a measurement is made between the suprasternal notch (at the base of the neck) to the tip of the xiphoid bone (end of the sternum) and this distance is moved down to the umbilicus (naval). While the patient is standing, the upper measurement will be at the horizontal level at the preferred nipple location. This, in combination with the other measurements, will provide the ideal nipple placement. To confirm the location, the distance from the supra sternal notch to the nipple papilla (equal on both sides) should equal the inter-nipple papilla distance, making an equilateral triangle.

The human body and its proportions are well known to an artist who draws, paints, or sculpts the human figure. The surgeons at Fairbanks Plastic Surgery are also artists in the same capacity and it is evident through their work and experience. Proper nipple positioning in plastic surgery operations regarding the breast is not a complex subject; however, it does require that the surgeon have extensive knowledge of human body proportions and that they are able to apply that knowledge to their practice and ultimately, to the benefit of their patients.

At a major national meeting, a surgeon was presenting his self-proclaimed successful breast operation cases, completely disregarding the obviously misplaced nipples.  Dr. Fairbanks rose to address the issue by drawing attention to the nipple displacement and asked if it was a drawback of the particular procedure that the surgeon was promoting. The speaker, after a significant amount of time talking around the question at hand, declared it to be a non-issue. After the meeting, a female journalist from London approached Dr. Fairbanks and said, “Thank you for making the point you did. We women don’t think it’s a “non-issue!”

Cheek Implants and Chin Implants

 Fairbanks Plastic Surgery: The Professional Artist of Plastic Surgery



FACIAL IMPLANTS: Cheek implants and chin implants provide your surgeon the ability to create subtle changes in facial contour to enhance a given patient's appearence. Facial implants can be biologic, such as tissue taken from the patient themselves (cartilage or bone), or implants can be produced commercially. For the cheeks and chin, solid silicone works well and have a long success record. When it comes to implants in the nose, however, living biologic material is preferable. Custom implants created for traumatic loss of a portion of the skull (cranioplasty) can be made from a variety of materials.

FACIAL BEAUTY: The main points of beauty of the face are the nose, the cheeks, and the chin. It is the relationship between these prominences which historically has defined facial beauty. This must be balanced with soft tissue structures such as the forehead, the lips, the eyes and the neck. It is this balance in contour that artists and sculptors have been aware of for centuries. Ideal facial proportions were worked out in classical Greek times. Famous Greek sculptors such as Phidias, Praxitiles, Myron, Polycliltis, and others followed rules of anatomic design in order to create their sculptured masterpieces in marble, which are timeless, and continue to be admired today. It is important that Plastic Surgeons have the same artistic skills when it comes to sculpturing the human face.

Before                                                                                After

THE OPERATIONS: Changing the shape of any part of the face requires knowledge of the anatomy and being able to apply that knoqwledge to obtain the best result possible for the patient. For example, cheek implants are generally placed through an incision in the hollow area behind the upper lip where the lip meets the upper jaw. This is called the upper lip sulcus. Once an incision is made, the surgeon must create a pocket by dissecting directly on bone, so as to keep all the soft tissue over the implant. Using special soft tissue elevators, the dissection is angled toward the cheek bone prominence. Once the highest point is reached, an elevator with greater curvature is introduced to extend the dissection aroung the cheek bone (Zygoma). This must be a meticulous and exacting dissection. The nerve of sensation to the upper lip is close by, and this must be protected. A non-reactive implant of silicone which has been chosen by your surgeon for size, is next carefully inserted. The implant has a concave back, so it can conform to the cheek bone. Exltra care must be taken to assure equal placement of the right and left sides. Once properly placed, the wounds are closed, and the patient will be on antibiotics for a number of days to prevent an infection.

Placement of a chin implant is a more simple operation. It can be performed either through the mouth (lower lip sulcus) or through the skin immediately below the chin through a scar that no one sees. If performed through the oral route, there may be temporary muscle weakness to the lower lip. Again, care must be taken to avoid nerve damage, this time to the sensory nerve of the lower lip. In both cases accurate placement of the implant is essential, and the surgeon's artistic judgement must be relied on for size determination. Prevention of infection is paramount; if an inferction were to occur, the implant must be removed in order to resolve it. Displacement of the implant can best be prevented by avoiding trauma or pressure on the area of operation. For example sleeping on the side of one's face after surgery can displace a cheek implant. Once three weeks has gone by the implant will be fixed in position by scar tissue. Knowing the potential risks is important in order to prevent them.

RESULTS: Cheek implants and chin implants are an effective resource to Plastic Surgeons who seek to help patients concerned about contour improvments to their face. The results can be enormously satisfying to the patient accentuating their existing beauty in a subtle but powerful way. For the patient who is considering changing their facial contour for the enhancement of appearence, consultation with a board certified Plastic Surgery specialist is essential. During your consultation, you will become knowledgable about the procedure best suited for you, the alternatives, and the pros and cons of each. For additional information, and to view examples, go to our web page, (http://www.fairbanksplasticsurgery.com/saltlakecity/utah/procedure/facial-implant-surgery/) or call the office at (801) 268-8838 for a consultation. Your surgeons at Fairbanks Plastic Surgery have extensive experience in the area of facial implant surgery.

EAR RECONSTRUCTION FOR MICROTIA

Fairbanks Plastic Surgery: The Professional Artist of Plastic Surgery


Microtia is a condition characterized by an undeveloped external ear in a newborn child. It occurs as the result of a growth interruption during the embryonic stages of development. It is a manifestation of what in broader terms is called the first and second branchial arch syndrome. It is from these embryonic structures that the recognizable human ear forms. This is a much rarer congenital deformity than cleft lip or cleft palate. What results is a small nubbin of tissue on the side of the head with a variable amount of tiny twisted cartilage, attached to a high riding earlobe. The external ear canal is usually absent.

Fortunately plastic surgery techniques have been developed by which an ear can be reconstructed using living cartilage. If the surgeon has expert sculptural ability, the patient's own cartilage, taken from a portion of the rib cage , can be carved into a framework which closely matches an original ear cartilaginous framework. The pioneer surgeon of this technique was Dr. Radford Tanzer. Although refinements to Dr. Tanzer's technique have been added, the concepts which he proposed have stood the test of time, and provide the best reconstructed ears possible today by modern plastic surgery techniques. Your sculptor/ surgeon may even make castings of the opposite ear and model a plan for the new ear in preparation for the surgery.

If you have a child who has microtia, there are certain facts you need to consider before choosing a course of treatment for reconstruction. First and foremost, you must avoid ANY reconstruction in which the surgeon recommends using a synthetic material (plastic, silicone, polyethylene, etc.). Although the initial result may be pleasing to the eye, the material will eventually extrude through the thin skin layer and an infection will ensue. The synthetic framework will have to be removed in order to clear the infection. 

You may ask how then could a surgeon recommend using such a device. The answers are simple. The devices are marketed, and the surgeon lacks the sculptural ability to carve a cartilage framwork at the operation table. The carving process is tedious and exacting, and --face it-- few surgeons have the ability to do it. The synthetic route is quick and easy, but it eventually leads to an infection when it extrudes. This generally slams the door shut on doing a living reconstruction. Think about it; afer removal of the synthetic feamework and curing the infection, what are you left with? You guessed it ; a dense mass of unworkable scar tissue.

What are your options after a failed ear reconstruction? The patient must either live without an external ear or get an an external "stick-on" prosthesis, or fake ear. You must consider the fact that you have ONE chance to get a good result, and that is the first time. Revisionary procedures are fraught with problems which --except for rare exceptions-- cannot be overcome. This is not an operation to be performed by by the untrained, the inexperienced, or the less than skillful surgeon. It is important that you as parents of a child born with microtia do your homework carefully before choosing a program, because it is your decision which will affect your child's ultimate result.

Fortunately you have time to do your research. The sequence of operations for microtia do not begin before the child is six or seven years of age. It is at this age when the specific area of rib cartilage has grown large enough to create an ear framework. Fortunately there is an area in the rib cage where two rib cartilages fuse. This is called a synchondrosis; it is this specific area which can provide the necesary width to create a living ear. The reconstructive process requires three or four stages depending upon how complete and detailed you as a parent want the reconstruction to be. If your child has an inner ear capable of receiving sound waves, and transmitting them, surgery for making an external ear canal, and any middle ear surgery should be delayed until after the external reconstruction is complete. 

Remember to do your homework and choose your surgeon wisely. You may need to travel out of state to do this. Decline the services of any surgeon who recommends the use of synthetic materials. Do not allow someone to casually amputate your child's microtic ear, and tell you to get a prosthesis. A prosthetic ear is the Last resort, not the first. There will be financial considerations, but you have time to save for your child so that he or she can lead a normal life.

For more information, please visit us athttp://www.fairbanksplasticsurgery.com/saltlakecity/utah/procedure/microtia-ear-reconstruction-and-cosmetic-ear-surgery/.