The waterfall effect in breast augmentation

Abstract

The 'waterfall effect' is a descriptive term to indicate a sliding ptosis of parenchymal breast tissue over a fixed or encapsulated implant. It occurs more frequently than surgeons anticipate and especially over the longer term after augmentation. Certain breast implants are more prone to contribute to this problem as are implants placed in submuscular pockets that ride high, especially in women with anatomical musculoskeletal variance or asymmetry. This article describes the aetiology of sliding ptosis in more detail, the relevant anatomy and the surgical correction. Understanding the problem enables the surgeon to plan the appropriate procedure and obtain proper informed consent. It is possible that a two stage procedure is necessary should the upper pole of breast require a debulk, either early (3 to 12 months) or later as the breast may slide with ageing of the tissues. The waterfall effect of breast parenchyma over implants is only apparent when the upper torso of the woman is undressed and she is in an erect posture. A significant number of women are happy with this situation and therefore no further action is required. Those that want an improved appearance in these circumstances can try autologous fat transfer to rebulk the surrounding tissues but generally the most likely solution involves a mastopexy with or without implant exchange. The results are highly rewarding but the scars are the legacy. Mastopexy augmentation is a difficult procedure and should only be performed by experienced surgeons. Many surgeons prefer a two stage approach with either an implant based augmentation first to limit scars and see if the patient is happy with the outcome or a first stage mastopexy to decide whether implants or fat graft are actually required as a secondary procedure.

Keywords: Breast mastopexy; breast implants; breast parenchyma; breast ptosis; pectoralis major muscle; polyurethane breast implants; silicone.

Figure 1

Breast augmentation with round McGhan implants within submammary pockets showing sliding ptosis of breast parenchyma 10 years later. The breast volume filled a C cup bra pre-augmentation.

Figure 2

Subpectoral anatomical shaped McGhan implants have rotated and are now positioned too high on the chest wall causing a pseudoptosis effect of the overlying mobile breast tissue. The breast parenchyma is in fact in the correct position.

Figure 3

The longitudinal chest wall vectors, as originally drawn by Dr. Cara Connelly FRCS (Plast).

Figure 4

With good volume breast parenchyma there is always the possibility of a degree of sliding ptosis as the breast fat diminishes with pressure from the weight of implant. In this case the effect leaves a slightly fuller medial cleavage with mild waterfall of overlying parenchyma.

Figure 5

Superior pole mastopexy over adherent polyurethane implants. The upper pole waterfall effect is caused by adherence of breast tissue to the lower implant together with a reduced volume to the lower breast parenchyma after reduction.

Figure 6

Late rippling seen during a leaning forwards posture with mentor augmented breasts. The implants are in subfascial pockets and are mobile.

Figure 7

The levels of breast ptosis as defined by positioning of the nipple in relationship with the sub-mammary fold (SMF). The nipple areola complex (NAC) to SMF distance is crucial when deciding the need for mastopexy and indeed the projecting capability when using higher profile implants.

Figure 8

IC 360 camera imaging of a patient pre- and post-operatively after 3 months (8). Available online: http://www.asvide.com/articles/1479

Figure 9

A well-positioned small polyurethane implant in subfascial pocket that has contracted slightly and presents too high with a very mild waterfall effect of the overlying soft tissues. Simply increasing the volume of implant after inferior capsulectomy corrects this problem.

Figure 10

Removal of McGhan and overlying Baker four capsules. The capsule is only 2 mm thick.

Figure 11

A comparative waterfall effect of breast parenchyma in a breast augment patient part contributed by the short non-expanding NA to sub-mammary fold (SMF) distance.

Figure 12

Vertical scar right mastopexy over subfascial polyurethane breast implants. Forceps are distracting the breast parenchyma laterally and a horizontal blue line drawn on the parenchyma.

Figure 13

Same patient in a neutral position showing vertical displacement of the blue marker line, even in supine position.

Figure 14

Same patient showing the vertical blue-line glide of tissue over the breast implant capsule with gentle forceps traction.

Figure 15

Same patient showing fibrous breast tissue and anatomical glide occurring in the loose areolar tissue layer between the fibrous breast and the implant capsule.

Figure 16

Pre- and post-operative views after periareolar mastopexy and insertion of low projecting anatomical implants.

Figure 17

Vertical scar augmentation/mastopexy over conical polyurethane breast implants.

Figure 18

Same patient oblique view.

Figure 19

Pre-operative erect posture views showing sliding ptosis of conical breasts over polyurethane implants. On-table short horizontal scar mastopexy.

Figure 20

Showing pre-operative views and follow ups at 3 months and 3 years after mastopexy with conical breast implants. There is no evidence of sliding ptosis.