Breast Sculpting – why it works

Early in his career, Dr. Cruise utilized the same traditional breast lift that almost all plastic surgeons currently perform. His results were similar to what is still commonly seen today. Results that showed improvement but did not achieve the sexy, youthful, perky look that is common in young women who had straight forward breast augmentations. Most breasts appeared still somewhat saggy with a matronly emptiness of the upper breast. In short, they still had a maternal look instead of a youthful look. This observation became much more dramatic with larger breasted women. This is why you rarely see large breasted women in Before and After breast lift galleries. It became apparent that traditional breast lifting only worked well on small breasted women. Even then, there were issues that were unacceptably common.

These issues included poor scarring, implants bottoming out or sliding toward the arm pit, rippling, significant asymmetry, persistent sagging, enlarged areolas, and wide cleavage. To be fair, breast lift with implants is often considered one of the most complicated cosmetic procedure in plastic surgery. This is why plastic surgeons would rather treat breast sag with implants alone even though it may not achieve the best results. Still, there had to be a better way; one that would provide consistently good results with excellent incisions. More importantly, one that would allow the surgeon and patient to have more control over the results. This began Dr. Cruise’s evolution of Breast Sculpting, a common sense technique that, in his hands, achieves exactly these objectives.

Summary by Dr. Cruise

Who is the best candidate for a breast lift?

With traditional breast lifts, the best results are with small breasted women. This is why good examples of Before and After photos on the internet are rarely of large breasted women. This is particularly unfortunate considering that larger breasted women have a much greater need for breast lifting. Traditional breast lift techniques are very limited in getting similar youthful, perky results in moderate to larger breasted women as it does in those with small breasts. This is why it is routine to see breast lift results with persistent sag, low hanging breasts, and empty upper breasts; the very reasons women seek out breast rejuvenation in the first place.

1 Change image AFTER Front images of a large breasted woman who had a breast lift/aug but still has some sag, implants are low hanging, and there is significant emptiness of the upper chest. These results should not be bad results just low hanging.

2 Change image AFTER Lateral images of a large breasted woman who had a breast lift/aug but still has some sag, implants are low hanging, and there is significant emptiness of the upper chest. These results should not be bad results just low hanging.

[1,2) Show good Front and Lateral AFTER images of a larger breasted woman who had a breast lift/aug but still has some sag, implants are low hanging, and there is significant emptiness of the upper chest. These results should not be bad results just low hanging.

Breast lifting in smaller breasted woman will achieve a more youthful look because their breast tissue is the right thickness to allow itself to wrap around the implant and create the desired youthful, natural lower breast rounding. Thicker breast tissue will not allow this. Recognizing this, Dr. Cruise realized the only way to achieve perky, youthful results was to reduce and sculpt thick breast tissue down to that of a small breasted woman. This is the foundation of breast sculpting. Breast sculpting allows patients to have greater control over their breast shape regardless of breast size.

[3,4) Show B/A Front images of a small breasted woman with good results. Results are very natural with minimal upper breast definition. I.E slopy upper breasts. Demonstrates how small breasts often get good results even with traditional technique. Ideally, their would be a hint of bottoming out to demonstrate lowering of the fold.

3 Change image. Show Before Front images of a small breasted woman with good results. Results are very natural with minimal upper breast definition. I.E slopy upper breasts. Demonstrates how small breasts often get good results even with traditional technique. Ideally, their would be a hint of bottoming out to demonstrate lowering of the fold.

4 Show After Front images of a small breasted woman with good results. Results are very natural with minimal upper breast definition. I.E slopy upper breasts. Demonstrates how small breasts often get good results even with traditional technique. Ideally, their would be a hint of bottoming out to demonstrate lowering of the fold.

5 Put the image with caption “Large breasted before – Front with Breast Sculpting” here. Discuss how implant size is whatever patient wants. Can be smaller. Key is to sculpt tissue down.

6 – Large breasted after – Front with Breast Sculpting

7 – Large Breasted Before – Lateral with Breast Sculpting.

8 – Large Breasted After – Lateral with Breast Sculpting. Notice no breast sag even in this previously large breast. Large breast now shaping like small breast.

[5/6) Show B/A Front images of a large breasted woman who had Breast Sculpting breast lift. Take image from the image with the caption “Large breasted Before – Front with Breast Sculpting” and “Large breasted after – Front with Breast Sculpting.”

7/8 Show B/A Lateral images of same large breasted woman who had Breast Sculpting breast lift.7 -Take image from the image with the caption “Large Breasted Before – Lateral with Breast Sculpting.” and 8 from “Large Breasted After – Lateral with Breast Sculpting.”

5,6,7,8 show how Breast Sculpting can reduce large breasts down to get small breast results in higher position.

9 – Example of how a small breast can become whatever you want based on experienced implant selection and secure implant positioning. With new shaped implants the options range from very little upper breast fullness to extremely defined.

9,10, and 11. Bill Mings lateral views show how a small breast with sag can easily be lifted and augmented to either a moderate breast (10) or a large breast (11)

With breast sculpting, the shape of the the breasts is completely up to the patient. Very natural looks are achieved by smaller, lower profile implants. Whereas, moderate and more dramatic looks are achieved by larger, higher profile implants. With traditional techniques, the shape of the breast is less controllable as it depends heavily on how much breast tissue there is and where it is located. “Expand this to show patients ability to determine most aspects of breast shape”

Large breasted female

After Breast Lift wit no implants

After breast lift reduction and augmentation

12,9 Bill Mings lateral view of 12 on the left – Large breast with sag and 9 – small breast with sag on the right. This demonstrates what Breast Sculpting does. It first reduces a large breast to a small breast.

Image 10 Image 9

As straight forward as it seems, there were a few hurdles to cross to allow breast sculpting to occur; otherwise, traditional techniques would be doing it as well. The most significant hurdle seemed insurmountable. It involves implant support. Traditional techniques have no muscle coverage over the outer or lower part of the implant. Removing breast tissue over these areas would seriously compromise implant stability. Until this problem was solved, breast sculpting would have wait.

First, lets look at the significant differences between the two techniques. 2) How standard breast lift techniques treats excess breast tissue Standard breast lift with implant techiques require that the majority of breast tissue must remain attached to the breast wall. This significantly limits the ability to sculpt the breast tissue as only a limited amount of breast tissue can be removed. Mommy Beautiful techniques make it possible to reduce and sculpt the breast tissue to achieve ideal tissue thickness and shape.

12 – 12,13 and 14 – Show lateral of thick, large breast with nipple at IMF facing 8 degrees downward, 4 cm of breast descent, and breast thickness 7 cm at level of IMF but only 1 cm of breast tissue 5 cm above IMF. Highlight breast tissue at IMF and below in light red. This represents tissue that can be removed with standard breast lift techniques.

13 – Breast tissue removed with traditional breast lift. Notice how the breast tissue directly over the breast fold is not removed. It needs to stay in place to help support the implant.

14 – Tissue in purple represents the additional amount of breast tissue that is removed with Breast Sculpting. This tissue is not necessary for support as the complete muscle coverage provides tremendous support.

12,13 and 14 – Show lateral of thick, large breast with nipple at IMF facing 8 degrees downward, 4 cm of breast descent, and breast thickness 7 cm at level of IMF but only 1 cm of breast tissue 5 cm above IMF. Highlight breast tissue at IMF and below in light red. This represents tissue that can be removed with standard breast lift techniques.

Elaborate on how traditional breast lifts require the breast tissue above the breast fold to remain intact. Otherwise, there would be no intact support holding the implant from bottoming out or sliding into the arm pit.

This ideal thickness allows the breast tissue to smoothly wrap around the implant (or central breast tissue if no implant is used) to create a youthful perky lower breast. While breast sculpting is preferable with all breast sizes, its advantages become more evident with larger breasts.When not removed, excess breast tissue will look bulky and often have persisant sag. Traditional techniques that do not sculpt and reduce this tissue leave plastic surgeons with two options; neither is ideal. Since traditional breast lift techniques do not have the same ability to reduce and sculpt excess breast tissue, plastic surgeons have to decide what is the best way to handle this excess tissue. One way is to accept the thicker tissue and allow for some sag to persist. The problem with this is that the implant will sit higher on the chest and the breast tissue lower. This creates an elongated, maternal breast look.

Effects of traditional technique’s limited ability to sculpt tissue

This inability to create a smooth, thin breast tissue envelop can often create a host of significant problem unless you are small breasted. The ability of Breast Sculpting to reduce all aspects of the breasts to the optimal thickness means that all breasts, not just the naturally small breasts, can enjoy the benefits of the optimal breast envelop.
1) Persistant sag – not reducing adequate breast tissue means that there will likely be breast sag AFTER the procedure. The sag is significantly reduced but there is a tremendous aesthetic and psychological advantage of “failing the pencil test.”
2) Flat, boxy appearance of the lower breast – Not being able to remove optimal breast tissue where necessary means the surgeon needs to remove as much lower breast tissue as possible to limit the residual sag as much as possible. This disproportionate removal of the bottom breast tissue increases lower breast tension and more importantly the tension across the incision. This tightness results in an unappealing flat, boxy, “chopped out” lower breast appearance.

3) Widen scars – Perhaps the most undesirable result of not reducing the breast is the impact the excess breast volume has on the incisions. As already mentioned, the most common cause of widen and unsightly incisions is tension across the incision. Thinning the breast tissue reduces volume evenly, thus, reducing tension. Less tension means less scarring.
4) Less control over breast shape – Retaining dense breast tissue interrupts the youthful, rounded breast contours of the breast that make a breast beautiful. This is particularly true near the arm pit where reduction is critical. However, with the traditional technique lateral breast tissue is particularly important because this is where there is no muscle coverage at all. With breast sculpting breast shape is chosen by you during your consult and displayed on 3D imaging.

5) Increased emptiness of the upper breast/unattractive shortening of the abdomen – Out of necessity, retaining excess breast tissue means that the breast implant needs to be placed lower because the overall center of breast gravity is lower. The implants needs to be lowered so that the bottom aspect is on the upper abdomen (lowering of the breast fold). This makes the abdomen look shorter and stockier. In addition, implant lowering means there is less implant volume where it is really needed – the upper chest. This can be improved with significant bra support but most women go through the procedure to reduce their dependence on bra support.

6) Matronly, elongated appearance of the breast – by placing an implant in its proper breast position it is not uncommon with the traditional technique for excess breast tissue to accumulate low and create a “water fall” type appearance. This “water fall” look means that the implant is higher on the chest and the breast tissue is hanging below. This creates a maternal, elongated look. Clearly, it is ideal for the breast tissue and the implant to align to achieve the desired youthful, sexy look.
7) Increased likelihood of breast sag in the future – it stands to reason that more breast tissue means more sag as breast tissue support diminishes with time, weight fluctuation, and pregnancy. Removing the excess breast tissue means there is less breast tissue to sag.

8) Breast cancer risk reduction – Breast reduction has been shown to decrease the risk for breast cancer. Breast sculpting is a form of breast reduction and enjoys the same risk reduction. In fact, patients without any signs of breast cancer but who have a increased family or genetic risk for developing it are sculpted more aggressively to further decrease the risk. We are undergoing studies to access to who and to what degree this is effective.

Of note, for patients interested in future breast feeding, breast sculpting can still be performed but not to the same extent. In addition, breast tissue removal is more strategic in order to decrease the risk of preventing functional lactation.

15) Front view – Show elongated, bottomed out look and breast tissue still sagging onto abdomen.

Classic example of moderate to large breasted woman who underwent traditional lift

16-Large Breast high risk breast cancer patient. Frontview of above patient. Significant breast volume and sag. Loss of structural breast support in the future would have all but assured significant breast sag which often acts as a hanging weight on the shoulders not to mention on physical activity and on the psyche. Before the surgery her sag would worsen each day. Post surgery her incisions improve every day. Her she is less than 6 months out. In time these incision will be unnoticeable. Yet, sag will not even but in her consciousness. Her breasts will stay in alignment with the way she acts and feels.

17-Removal of greater than 85% of her breast tissue. Excellent areola reduction and scars that will continue to fade with time. While her likelihood of sagging again is virtually eliminated.

18-Lateral view of above patient. Significant breast volume and sag. Loss of structural breast support in the future would have all but assured significant breast sag which often acts as a hanging weight on the shoulders not to mention on physical activity and on the psyche. Before the surgery her sag would worsen each day. Post surgery her incisions improve every day. Her she is less than 6 months out. In time these incision will be unnoticeable. Yet, sag will not even but in her consciousness. Her breasts will stay in alignment with the way she acts and feels.

Breast sculpting as a means to decrease the risk of breast cancer Breast reduction has been shown to decrease the risk of breast cancer by up to 80%. The beauty of breast sculpting as performed by Dr. Cruise is that it can be adjusted to leave as much or as little breast tissue as desired. Dr. Cruise developed this originally to allow the patient to have excellent control of her breast shape. However, removing almost all the breast tissue while still leaving the nipple as a means of decreasing the risk of breast cancer is an exciting extension of where breast sculpting is going. It is rare that an advancement of a procedure from a cosmetic standpoint can have benefits far more consequential. Note: Breast Sculpting is not meant to treat breast cancer. Women at high risk and very high risk need to see a breast cancer specialist who will determine your best plan of action. However, as you can see, breast sculpting can be adjusted to remove up to 90% of breast tissue. In the case of performing a free nipple graft over 95% of breast tissue can be removed yet still providing amazing looking breasts. In the typical non-high risk patient, slightly more breast tissue is left behind to achieve the absolute best results possible.

16,17,18,19 are unchanged. Make it look better.

Complete Muscle Coverage – The back bone of Breast Sculpting

The most important reason Breast Sculpting is possible is the complete muscle coverage of the implant. Covering the implant entirely with muscle provides a soft tissue coverage that softens the appearance of the breast, provides amazing, lifelong support, decreases the risk of implant infection, and likely decreases capsular contracture. This soft tissue coverage prevents the “over defined/bolt on” appearance that implants placed over the muscle can have. More importantly, complete muscle coverage provides the implant with significantly more support. This importance of the integration of breast sculpting with complete muscle support can not be over stated. In our hands, it offers functional and cosmetic benefits not possible with traditional breast lifts. It complexity discourages others from utilizing it but like anything else worth achieving, once you master it, it opens up doors we never thought possible. In fact, it is the reason we have dedicated our careers to breast lifting.

Traditional breast lift techniques do not utilize full muscle coverage or breast sculpting as a means of significant breast tissue reduction. “You don’t need a lift. We can get away with doing just an augmentation” This is the most common solution to sagging breasts in existence today! Many of the breast lifts that we see at Mommy Beautiful are actually are revisions. Revisions from breast augmentations that were supposed to take care of the sag. The reason is simple. Woman do not want the scars from a lift and surgeons do not spend the 4-5 hours it takes for them to perform a lift. They would much rather perform a straight forward breast augmentation which is often done in 1 hour. The problem with this logic is that this does not correct the sag. Once breast tissue falls more than 1.5 – 2 cm below the breast fold, the best solution is a lift. However, given the choice between breast sag and the scarring from standard breast lifts, many patients felt the lift was simply not worth it. It was this connundrum that led Dr. Cruise and Mommy Beautiful to develop and advance the breast sculpting technique with complete muscle coverage. A technique that creates the desired youthful breast appearance yet signficantly decreases the wide scarring and problems seen with traditional lifts.

20 – When is a breast lift necessary? While the answer certainly depends on several important variables, it is clear that once your breast tissue falls more than 1.5 – 2 cm below your breast fold, a breast lift must be considered.

21 – Real world examples of what the decision making process is regarding when a breast lift is necessary.

20) No Change.

Show lateral of moderate sized breast, no implant, breast sag 2-3 cm below IMF, nipple at IMF, and about 3-5 cm of breast tissue thickness at IMF. Show dotted line at the level 2 cm below IMF demonstrating the breast tissue is below 2 cm.

21) No Change

Show real image to match Bill Mings 10) above. Show lateral of moderate sized breast, no implant, breast sag 2-3 cm below IMF, nipple at IMF, and about 3-5 cm of breast tissue thickness at IMF. Show dotted line at the level 2 cm below IMF demonstrating the breast tissue is below 2 cm.

What does it mean to treat breast sag with an implant?

Breast augmentation alone will lift the breast somewhat. The amount of lift depends on how much breast sag there is, the position of the nipple, the size of the implant, and the placement of the implant. This is discussed in greater detail in the section “Do I need a breast lift.” When looking at the above variables, you will notice that if the surgeon is not doing a lift, the only two things he can change to achieve a lift is 1) to significantly increase the size of the implant and 2) to lower the position of the implant.

Unfortunately, lowering the implant means that part of it is located on the abdomen. Putting implants low often requires large implants to fill up the addition real estate. A serious long term and not uncommonly short term complication of this treatment is the effects of the implant weight on the remaining support structures of the breast and abdomen. Over time this already pendulous, hanging breast will continue to descend.

What the patient really wants is a youthful, perky breast that will hold up over time. A look that is elegant and proportional; not inappropriately large or heavy looking. The breast implant should be in the breast area. I know this sounds obvious but traditional breast augmentation techniques often lower the breast implant so that part of it is located on the upper abdomen. This lower placement creates more lift. The lower implant makes the nipple and breast tissue seem higher. In fact, lowering the implant raises the breast tissue and often gives better proportion to the breast. Traditional breast augmentation techniques all but require releasing many of the breast support sturcture and lowering the breast fold in order to achieve proper breast proportion. This goes for all breast augmentations not just those with a lift.

23 – Front view with 3 cm breast sag

22 lateral view with 3 cm breast sag

23,22 become side by side. Front and Later

24-29 No Changes except UI

24) Lat view –Implant at 6th rib – Show 11) with implant in ideal position with complete muscle coverage (bottom of implant at bottom of 6th rib). Show nipple slightly higher but facing more downward i.e 15 degrees, 2.5 cm of breast sag but it hangs like a waterfall. The implant is clearly higher and separated from breast tissue below. Does not look good. Upper breast is slightly convex.

24 – Lat view Implant 1 cm below 6th rib -Show 11) with implant 1 cm below bottom of 6th rib. Muscle gap uncovers 3 cm of implant. Nipple is 1 cm higher that 12) and is facing almost straight i.e 4 degrees downward, 1.5 cm of breast tissue sag which hangs a little but not too bad. The overall image shows a slight separation of implant and breast tissue but not bad. However, the upper breast area is more empty with 1 cm longer distance from clavicle to top of breast tissue-slight concavity and abdomen 1 cm shorter.

25)Lat view Implant 1 cm below 6th rib -Show 11) with implant 1 cm below bottom of 6th rib. Muscle gap uncovers 3 cm of implant. Nipple is 1 cm higher that 12) and is facing almost straight i.e 4 degrees downward, 1.5 cm of breast tissue sag which hangs a little but not too bad. The overall image shows a slight separation of implant and breast tissue but not bad. However, the upper breast area is more empty with 1 cm longer distance from clavicle to top of breast tissue-slight concavity and abdomen 1 cm shorter.

26 – Lat view Implant 2 cm below 6th rib – Show 11) with implant 2 cm below bottom of 6th rib. Muscle gap uncovers implant to top of implant. Nipple is 2 cm higher than 12) and is facing straight (looks good), 0.5 cm of breast tissue sag which appears loose but does not hang. There is no separation of implant/breast tissue. The upper breast emptiness is more dramatic which is accentuated by the upper breast concavity. The abdomen length to BB is noticeably shorter.

27 – Slight sag but reasonable. Significant loss of abdomen.

28 – Implant signficantly lowered. Good relation with breast tissue and nipple but no upper breast fullness, loss of abdomen, risk of further migration

29 – Almost no muscle coverage. Implant has migrated into arm pit especially when laying on her back.

26) Lat view Implant 2 cm below 6th rib – Show 11) with implant 2 cm below bottom of 6th rib. Muscle gap uncovers implant to top of implant. Nipple is 2 cm higher than 12) and is facing straight (looks good), 0.5 cm of breast tissue sag which appears loose but does not hang. There is no separation of implant/breast tissue. The upper breast emptiness is more dramatic which is accentuated by the upper breast concavity. The abdomen length to BB is noticeably shorter. These images show that lowering the implant can correct breast sag; but this lowering comes at a cost. The breasts are not really lifted so that maternal, hanging feeling you have with breast sag actually is accentuated because now there is more volume in it. This is called a “rock in a sock” effect. In addition, lowering the implant requires releasing the supporting structures of the breast which can cause the implant to bottom out or slide into the arm pit. Clearly, placing the implant in its correct position and securing it so that it does not migrate over time is important. This leads us to the second fundamental technique of a Mommy Beautiful breast lift: Complete muscle coverage of the implant.

Complete Muscle Coverage – Why would you cover only part of the implant?

Early in the history of breast augmentation, implants were placed above the muscle. To plastic surgeons this location made sense. Natural breast tissue is located on top of the muscle so it stands to reason that this is also where the implant should go. However, it soon became apparant that above muscle placement commonly created thick scar tissue over the implants that made them severely distort and become painful. This is called capsular contracture and it was extremely common during this early period.

30) No Change

Show an old time picture of capsular contracture – Picture should look old to represent the 1970’s

30 – Example of capsular contracture in above muscle implant, circa 1970.

31) No Change

Lat view of Ideal placement of implant above muscle. Implant on top of pec major – bottom of implant at bottom of 6th rib. Breast/Implant relationship is ideal. Breast looks good. Capsule is thin over implant.

31 – Above muscle placement. Good position. Little soft tissue coverage allows for margins of the implant to be seen and often felt; especially laterally

32 – Capsule thickness surrounding implant has gone from approximately 2 sheets of paper to 15 sheets. Implants has risen, has more defined margins, is harder, and may be painful.

32) No Change

Lat view of Capsular contracture above muscle. with very thick capsule over implant. Implant has been pushed up so that Bottom of implant is at bottom of 5th rib. Upper breast is very round. Nipple facing downward about 30 degrees.

What does “Below Muscle” mean?

Technical advancement discovered that covering the implant with muscle significantly reduced the risk of developing capsular contracture. This was a major break-through. Instead of putting the implant above the pectoralis major muscle, plastic surgeons began putting it underneath. For reasons we still do not fully understand, placing the implant under muscle decreases capsular contracture. Below muscle coverage has become the standard technique utilized by the vast majority of plastic surgeons today.

33- Put image 34 here- Image just to the right

34 – Comment on how implant is able to drop into correct position. This is called “Dual Plane”.

33) Put image 34 here

34) Put Image 11B – Please flip image so that 33 and 34 are oriented the same.

with implant under pec major. Pec major is completely attached to entire 6th rib (from bottom to top of 6th rib). This causes the implant to be positioned too high with the nipple on the lower part of the breast mound and facing 8 degrees downward. Does not look right To allow proper positioning, it is necessary to cut through the muscle and other breast support structures to allow the bottom part of the implant to drop into position. This is known as “dual plane” implant placement. Dual plane is the most common implant placement currently used

Below muscle, however, does not mean that the entire implant is below muscle. It only means that the implant is under the pec major muscle. Notice that the entire outer part of the implant remains uncovered. However, the problem with below muscle implant position is that the muscle attachment to the 6th rib acted like a barrier – preventing the implant from dropping into proper position.

Dual Plane

35) No Change

with the pec major

35 – The lower part of the pec major has been released from the 6th rib allowing it to drop below the 6th rib. This fills out the lower pole of the breast and properly positions the implant under the breast tissue.

36 – Front view of partial muscle coverage with pec major but with its attachments released from the 6th rib allowing the implant to drop into better alignment with the breast and nipple. Notice how only 50% of the implant is covered leaving the entire lower and outer parts of the implant supported only by dermal attachments and breast tissue attachments.

cut and the bottom of the implant at the bottom of the sixth rib. The muscle retracts up exposing 1/4 of the implant. (We will call this “ideal below muscle position”). Nipple now faces forward in good position. Breast looks good.

36) Show front version of 21) “ideal below muscle position”. Showing only about 40-50% of the implant covered. Put simply, dual plane means that the implant has two different types of coverage. The upper part of the implant is covered by both muscle and soft tissue (breast tissue and skin). The lower part of the implant, however, does not have muscle coverage; only breast tissue and skin are covering it. When the muscle is released it retracts upward. Notice how only about half of the implant is covered by muscle. The entire lower part and outer part of the implant only has skin or breast tissue to hold the implant in place. Ironically, these are the two areas that need the most implant support. Implant malposition is very common. This is particularly true in breast lift patients who, by definition, have breast tissue with weakened support. This lack of lateral support often causes the implant to migrate laterally particularly over time.

36) Show GIF of pec major flexing, causing the implant to push laterally. This causes a distinct gapping of the cleavage. In addition, the implants may migrate into the arm pit region which is uncomfortable when standing and quite upsetting when laying on the back.

5 bounces

The purpose of the muscle release, aka dual plane, is to allow the implant to drop into proper position. It has the additional advantage of correcting small amounts of breast sag. The problem, however, is that the support structures of the breast are connected to this lower part of the pectoralis major muscle. Thus, the release of the muscle will often weaken these support structures as well. This not uncommonly causes the implant to drop or slide into the arm pit area more then desired over time or sometimes even right away. This excessive dropping is referred to as “bottoming out.”

37/38 – Show front and lateral of bottomed out implant at 7th rib. Nipple is facing up, emptiness of upper chest. The muscle retracts up exposing 2/3 of the implant. The bottom of the implant is only covered by skin.

Bottoming out

Breast implants that have bottomed out appear differently depending on the appearance of breast tissue and the degree of bottoming out. In general, bottoming out is never desirable as it means the implants are hanging low on the abdomen and sliding into the arm pit area; especially when laying on your back. Bottomed out implants are only covered by skin which often can be felt and may cause rippling that can be visible. Over time, this skin only support will likely further give way causing more bottoming out or thinning of the skin.

39 – Example of bottoming out causing “double bubble” which is when the implant slides below the breast tissue resulting in a very defined crease. The implant in this position is only covered by skin.

40 Profile view showing how the low position of the implant creates a “double bubble”.

39,40 – No Changes

41. Bottomed out implants to make an illusion that breasts are lifted. Result: heavy breasts crowding the abdomen.

42. Bottomed out lateral. Shows emptiness of the upper chest

41, 42 – Front and lateral of bottomed out implants. The image we have is good but please come up with another. One where the abdomen is really shortened and the upper chest is empty. Also for both this one and the new one I need both the front and lateral. The lateral to show the emptiness of the upper chest area.

42a,42b – Front and lateral of Before images of bottomed out woman at bottom of the page
42c, 42d- Front and lateral of After images of same woman

42a. Correction of bottoming out

42b. Smaller implants, longer abdomen.

42e, 42f – Front and lateral of Before images of the other bottomed out woman at the bottom of the page
42g, 42h – Front and lateral of After images of same woman.

42g. Bottoming out

42f. Bottoming out

42g. Bottoming out

42h. Corrected

These are GREAT images! Better than 41, and 42 but please display all as they all have a story to describe.

As outlined above, both patients and surgeons would much rather treat breast sag with an implant alone. For patients, this means less incisions. For surgeons, it means a much easier, and quicker procedure. This is why placing large implants low on the chest is a common treatment for breast sag. However, patients do not realize that when the implant is placed low on the chest this will cause a loss of upper breast fullness. Upper breast fullness is often a primary reason why breast lift patients have the procedure in the first place. Dr. Cruise noticed many of the negative side effects of “lowering the fold” and partial muscle coverage even in his own patients. Worst of all, correcting these problems is very difficult and unpredictable.

This lack of predictability was frustrating; especially as Dr. Cruise was trying to figure out a way to sculpt breast tissue to allow patients to choose their breast shape. Precise breast sculpting is pointless if the unlying implant is out of place. There had to be a way to more secure way of positioning the implant. One that would not allow the implant to move with normal aging or pregnancy. The traditional “below muscle” coverage is really not accurate when in reality only about half of the implant is covered by muscle. More importantly, the part that is not covered, the lower and outer part, is the part that needs it the most!

As is always the case, using the patients own tissue is best. With this in mind, Dr. Cruise began putting the implant under the pectoralis minor. Immediately, he noticed the enormous stability this muscle provided. So much so, it dramatically improved cleavage because of how well it held the implant toward the sternum. From there, he used the other adjacent muscles (serratus anterior, external oblique, and the upper part of rectus abdominis) that ultimately provided complete muscle coverage. Most importantly, it provided inferior and lateral support which is exactly what was necessary to prevent bottoming out and/or sliding of the implant laterally.

43 – We are waiting for this image from Bill. It is a modified version of 27 with the muscles labeled.

Modified 27-Pec minor, Serratus Ant., Ext Oblique, Rect. Abd.

The additional support from these four muscles which are located exactly where they need to be has shown to be more effective than expected. The stability provided by complete muscle coverage is what makes Breast Sculpting possible without the concern of implant movement. As many have said, if partial muscle is good wouldn’t complete muscle coverage be better?

44, 45 – Dual plane on left, CMC or right (Bill is modifying this currently so 45 will have to wait).

Dual Plane

Complete muscle coverage. Muscle thinned out for visual effect.

Dual Plane CMC – Modified 28

It certainly looks like complete muscle coverage is far and away the better choice. Why wouldn’t everyone use it?

The problem with complete muscle coverage is that it has a very steep learning curve. It requires that the surgeon has a precise knowledge of the muscle anatomy and can determine it using only his fingers as a guide. It requires elevating the lower 2/3 of the pec. minor, the serratus anterior from the 5th and 6th rib, the 6th rib component of the external oblique, and the upper muscle fibers of the rectus abdominis.

This elevation has to be precise, otherwise, the implant would be significantly out of position. Furthermore, the additional coverage means that the implants will take longer to drop. These additional muscles need to stretch. For this reason, complete muscle coverage takes a little longer for the implant to drop into correct position. You would expect this because muscle and fascia takes longer to stretch than breast tissue alone.

An unintended benefit of elevating all the muscles together as unit is that they actually are connected. They cover the implant as one continuous sheet which, in itself, has several important benefits. Not least of which is infection prevention and cancer screening. This integration of breast sculpting with complete muscle support is constantly evolving to apply it to more and more aspects of breast lifting and breast augmentation. Its value is undeniable. We feel it will be particularly useful for breast cancer risk reduction. Regardless, in our hands it is a dramatic improvement over the current methods and has allowed us the ability to achieve results that were not previously possible.

Video of benefits of woman who had partial muscle Coverage and was converted to CMC

Above muscle

34 – Comment on how implant is able to drop into correct position. This is called “Dual Plane”.

Complete muscle coverage. Muscle thinned out for visual effect.