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Home   »   Article  »   Sheibani Cosmetic Breast Surgery Algorithm By: Shane Sheibani, MD, FAACS, MBA

Sheibani Cosmetic Breast Surgery Algorithm

By: Shane Sheibani, MD, FAACS, MBA

After performing thousands of breast cosmetic surgeries as well and many thousands of other types of surgeries in the last decade, I have been able to develop an algorithm that I use in order to help patients achieve the natural cosmetic surgical results they desire most while minimizing the healing time and surgical scars on the patients' breasts. I am constantly looking to improve this algorithm and any feedback or suggestions from the colleagues are most welcomed.

To get the maximum use of this algorithm; we need to keep a few very obvious but crucial points in mind:

Point 1:
After years of experience as a surgeon, I have been humbled realizing that the best surgeons in the world along with their patients as a team only contribute to fifty percent of the outcome of any surgical procedure. The other fifty percent of the outcome is dependant on variables that neither the surgeon nor the patient can control such as the patients' nature, genetics, healing capacity, the degree of immune reaction and scarring capacity of the body among many others.

Point 2:
We must keep in mind that a surgeon has to always be aware of the fact that other external variables such as family members, significant others and friends, culture, fads, marketing, advertising, entertainment and media; fashion designers and the style of clothing in fashion and regional preferences play major roles in our patient's preferences at various times. What they prefer at a certain time may not necessarily be the same as what they may want once some of the external variables have had time to influence the initial decisions of these patients. So too we must remember that every cut heals with a scar and although we may be able to improve them, at this time we can not completely erase scars once they are formed. It is always safest to do less cutting; more conservative surgery, less invasive procedures and respect the concept that we can always do more surgery later, and less is more in cosmetic surgery.

Point 3:
Cosmetic Breast Surgeries are some of the most common procedures performed in cosmetic surgery today. They are some of the most popular and most in demand procedures and really one of the safest cosmetic procedures that can be performed on an outpatient basis. While performing breast cosmetic surgery is a relatively simple and easy endeavor, the outcome of the procedure can be life changing and immensely positive if it achieves the outcome that the patient is looking to have. To achieve that end; a surgeon must clearly identify the patient's needs and desires while considering the options that are available to the patient according to her body morphology; life style; genetic limitations and social factors. Often; due to individual variables specific to the patient, the patient's desires and needs are not easily achievable. It is extremely important and crucial to plan the surgery with direct involvement and full knowledge of the patient in order to be able to successfully manage the patient's expectations of the surgery. An important credo to remember is to "under-promise and over deliver"; that is, promise much less than you know you can deliver as a cosmetic surgeon.

After years of experience performing thousands of cosmetic breast surgeries; I have come to formulate an algorithm that I am constantly looking to improve. This algorithm is intended to help the cosmetic surgeon and the patient to cooperatively decide which options fit that specific patients' needs best.

Sheibani Cosmetic Breast Surgery Algorithm :

Cosmetic Breast Surgeries involve breast augmentations with or without breast lifts (mastopexies) as well as breast reductions. Breast augmentation can generally be performed in two different ways, either by transferring fat from certain parts of the body to the breast area or by placement of implants. The Sheibani Algorithm at this time focuses on breast augmentation with implants with or without mastopexies. I am still working on expanding this algorithm in order to help it become more inclusive of breast reductions and fat transfer.

At this time, for the most part, breast augmentation is performed using an implant. While consulting with a patient; we must make several distinctions :

1) Implants: silicone vs. Saline, and Textured vs. Smooth implants; high profile vs. medium profile
2) Approaches: transareolar vs. transaxillary vs. transumbilical vs. Inframammary approaches
3) Pocket placement: under the muscle; over the muscle; under the fascia, bi-plane
4) Mastopexies: none; crescent, Circum-Areoolar/Benelli; Vertical/Key Hole technique; Vice Pattern/Anchor Lift.
5) Considering Fat transfer

The following algorithm helps us decide which patient would benefit most from fat transfer vs. implants; if we decide on implants for augmentation; which implant; which approach; with or without a mastopexy and then if the patient wishes to have a mastopexy; which type of mastopexy would best fit the patient's needs..

For Clinical decision making purposes, let's divide breasts into five Types :

Type 1: Breasts that are natural, youthful; non-ptotic, firm with sufficient breast parenchyma thickness (approximately 2 inches of thickness on pinch test). The amount of parenchyma and its consistency is important for the coverage of the implant rippling. Type one breast is for the most part the typical nulliparous breast of average patient.

Type 2: Breasts that have lost a small amount of skin elasticity with glandular pseudo ptosis and nipple/areola complex above the infra-mammary folds (no nipple areola ptosis)

Type 3: Type 2 Breasts with grade 1 ptosis

Type 4: Type 2 Breasts with grade 2 ptosis

Type 5: Type 2 Breasts with grade 3 ptosis

There are currently two types of implants available for implantation in the United States. Breast implants are either silicone or saline and either smooth or textured; high, low or medium profile.

The treatment options for Type 1 breasts is quite diverse; almost any type of breast augmentation approach including transareolar, transaxillary, transumbilical or inframammary approach; they can have any implant type; silicone or saline; they can have their implants placed over or under the breasts and they need no lift. The decision can be easily made according to the patient's preference for the placement of incisional scar. I have used all the different approaches for the placement of my implants (peri-areolar, transumbilical; transaxillary; sub-mammary) and I believe that the periareolar approach overall gives the surgeon the best visual and tactile control over the pocket and the chest wall anatomy while allowing him to create extremely naturally attractive results with minimally conspicuous scars. From the patient's point of view, the peri-areolar scar is the most versatile scar to have; since it is easily covered with clothing; usually is minimally visible after the healing process is completed; can be improved with non-invasive dermatologic procedures and can be used later for breast biopsies and breast lifts if necessary.

Patients with Type 2 breasts generally by definition have their breast gland dropping under the inframammary fold, and once the implant is placed under the muscle; if not immediately, with time the breast tissue will continue to descend downwards and eventually it will end below the location of the breast implants under the muscle and hence this breast gland position results in a higher risk of suffering from double bubble deformity. To prevent the double bubble deformity a surgeon can approach these patients with caution and consider to avoid the double bubble deformity in several different ways. If the patients have sufficient breast parenchyma to successfully camouflage the breast implant ripples, and they are willing to consider placement over the muscle; and they are willing to accept a natural breast contour, these patients can have their implants over the muscle and preferably have silicone implants used to minimize the appearance of ripples with natural minimally rippled appearance with soft contour. However; if the patient prefers an a sub-pectoral placement; then, one must either consider a mastopexy. If mastopexy scars are unacceptable to the patient depending on the grade of breast parenchyma ptosis below the inframammary fold one can either lower the inframammary fold or perform a bi-plane breast augmentation by transecting the inferior border of the Pectoralis muscle from the insertion into the skin slightly above the inframammary fold.

Type 3 same as Type 2 in addition to a crescent lift.

Type 4 same management strategy as Type 2 with a lollipop lift or a vertical lift.

Type 5 same as 2 plus an anchor lift (Vise pattern lift).

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