To achieve natural results in aesthetic breast augmentation, a thorough knowledge of the ideal female breast shape is important.

A morphometric analysis of the ideal breast shape of attractive females was performed by Mallucci and Branford by studying a series of 100 topless models with nonoperated breasts. They described 4 key recurring parameters in the studied breasts: an upper pole-to-lower pole ratio of 45:55% (ie, slightly fuller lower pole than upper pole), an upward pointing nipple (20-degree mean angle), a straight/mildly concave upper pole slope, and a smooth lower pole convexity ( Fig. 1 ).

( A ) Three-quarter view of a nonoperated attractive breast shape. Notice a fuller lower pole with respect to the upper pole, an upward pointing nipple and a straight/mildly concave upper pole slope with a smooth lower pole convexity. ( B ) Profile view of the same attractive natural breast showing a teardrop shape.

Once these ideals of shape aesthetics have been identified, perception studies evaluating the differences in shape preferences amongst plastic surgeons, patients undergoing the procedure and the general population stratified by age, sex, and ethnicity are necessary to assess variations in these aesthetic ideals amongst different groups and to verify a proposed aesthetic ideal as valid.

Studies analyzing the characteristics of the ideal breast have focused on its dimensions and shape regarding upper versus lower pole projection and the position and orientation of the areola, taking into account images in profile or oblique views. It must be acknowledged however that it is possible to differentiate between natural attractive breasts and operated nonattractive breasts ( Fig. 2 ) by observing images in the front-view and without the need to see the areola. The area between both breasts (ie, cleavage) is therefore a key area in determining both the attractiveness and natural appearance of the breast, independently of other considerations such as upper pole projection, breast shape, or the position of the areola.

( A ) Patient with previous subglandular breast augmentation showing a SB deformity. ( B ) Medial turnover capsular flap to provide volume at the cleavage. ( C ) Natural result after revision breast augmentation with a hybrid gliding breast augmentation combined with a capsular flap.

A careful analysis of the lights and shadows formed in the cleavage identifies 2 important parameters that are useful in defining breast aesthetics: the presternal light reflection (LR) and the vertical aesthetic lines (VALs) or shadow lines of the cleavage ( Fig. 3 ). The narrower the presternal LR and the closer together the VALs, the more attractive the breasts are, as previously validated through a cleavage attractiveness perception study.

( A ) Front view of the patient from Fig. 1 , showing a natural attractive cleavage. ( B ) Surface aesthetics of the attractive natural cleavage. Central gray square: presternal LR; white lines: VALs or cleavage shadow lines; yellow lines: blurred curved aesthetic line (B-CAL); magenta lines: sharp curved aesthetic line (S-CAL) or inframammary crease; crease-cleavage junction point or CAL midpoint at 45° from the nipple.

Further analysis of the surface aesthetics of the cleavage in attractive nonoperated breasts is valuable to understand the features needed to enhance this important region surgically.

The natural attractive cleavage is composed of VALs or shadow lines, which lie on the lateral border of the presternal light reflection and curved aesthetic lines. The curved aesthetic line or shadow line may be further subdivided into a blurred segment with a soft shadow and a sharp segment formed by a harsh shadow line, which constitutes the inframammary fold. The point where both curved aesthetic lines meet or crease-cleavage junction point coincides with the midpoint of the curved aesthetic line and should lie at approximately 45° to the nipple-areola complex (see Fig. 3 ).

An important characteristic of a natural and attractive breast is its softness in feel and a natural movement when displaced by touch and or by adopting different positions such when women lean backwards or forwards, lay on their back or raise their arms.

When studying the anatomy of the attractive natural breast with movement, the following observations can be made:

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  The breast is soft and pliable to touch and does not feel hard or rigid.

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  The breast glides on the chest wall when pushed upwards.

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  The breasts are displaced slightly laterally when the arms are raised, with minimal lateral displacement of the VALs.

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  The breasts are displaced slightly laterally, lose projection, and maintain a smooth slope toward the sternum when leaning backwards or laying supine.

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  The breasts are displaced slightly medially and increase projection when leaning forward ( Fig. 4 , [CR] ).

  

  ( A ) Natural nonoperated attractive breast in front view, notice surface aesthetics of the cleavage matching those presented in Fig. 3 B. ( B ) Gliding of the breast on the chest wall when pushed upwards. ( C ) Supine position. Notice the natural smooth slope of the medial breast with a loss of breast projection and a slight lateral shift of the breast.

In order to imitate the shape of a natural attractive breast, it is necessary to provide a teardrop ” morphology to the augmented breast. This implies achieving a straight upper pole slope and a slightly fuller lower pole than upper pole. It should be emphasized however that this is the goal to portray a natural (ie, nonoperated) attractive breast, and it should be understood that some patients might consider as attractive breast, more upper pole fullness with a convex upper pole slope. This overprojected upper pole fullness, is extremely rare to occur naturally without the aid of a push-up bra and usually denotes an operated look , which should be avoided when aiming for natural results.

The use of round smooth surface implants provides a significant advantage regarding natural movement and feel, especially when filled with softer cohesive gels. These implants acquire an anatomic or ergonomic shape when placed vertically, behaving differently than when placed horizontally flat. The softer gel migrates inferiorly when the implant is rotated vertically, shifting the point of maximum projection of the implant from the midpoint of the base of the implant when lying flat, to a lower position when tilted vertical, creating a teardrop shape. This was demonstrated with by Shah and Delaney through their in vivo evaluation of round breast implants in a stand-up MRI and is the normal behavior of all round breast implants when not overfilled with highly cohesive gels. To provide a more natural upper pole slope with round implants, these should preferably be of a moderate profile, as high-profile implants (ie, low base diameter with high projection) produce more upper pole convexity and fullness.

In order to further accentuate the teardrop shape of the augmented breast using round implants, a biplanar partial submuscular dissection is employed. The gland is completely dissected from the pectoralis major muscle in a subfascial plane and a second plane is dissected below the muscle, placing the implant in this latter pocket, ideally through an axillary approach. This provides 2 advantages: (1) it allows the muscle to shift upwards and compress the upper portion of the implant, effectively modifying the shape of the round implant into a more anatomic one, and (2) it allows the gland to shift downwards to increase the volume of the lower pole with respect to the upper one ( Fig. 5 , [CR] ). This biplanar approach varies with respect to the dual-plane technique described by Tebbetts, which in practice consists of a single plane of dissection. A suture is placed between the free edge of the pectoralis major muscle and the gland to avoid the implant from luxating and ending up over the muscle. A natural appearing shape to the breast may be achieved in this way, despite using round implants ( Figs. 6–8 ).

( A ) Diagram showing the profile view of a conventional submuscular pocket round implant breast augmentation. Notice upper pole convexity and unnatural projection. ( B ) Biplanar dissection cranially extended subpectoral pocket with a round implant. Notice the straight upper pole slope and teardrop shape achieved.

Three-quarter views of a natural appearing anatomic teardrop breast shape before ( A ) and 1 year after ( B ) hybrid gliding breast augmentation using smooth round implants on a partial submuscular biplanar pocket.

Three-quarter views of a natural appearing anatomic teardrop breast shape before ( A ) and 1 year after ( B ) hybrid gliding breast augmentation using smooth round implants on a partial submuscular biplanar pocket.

Three-quarter views of a natural appearing anatomic teardrop breast shape before ( A ) and 1 year after ( B ) hybrid gliding breast augmentation using smooth round implants on a partial submuscular biplanar pocket.

The subfascial plane is preferred not to add a layer to camouflage the implant edge (as this fascia is too thin to achieve this goal) but to obtain 2 benefits: (1) to contain the grafted fat, avoiding spill into the pocket and (2) to diminish contamination of the pocket with ducts from the breast parenchyma that contain germs and may increase the risk of bio-film formation and capsular contracture.