What's the deal with women and breast implants? I was at the Arnold Classic last weekend, and I saw a lot of very un-natural looking breasts-too big, too close, too far apart. What's up with that?
While I would like to say that we, as plastic surgeons, get it right every time, that's just not the case. Sometimes what you see is the function of poor planning or poor surgical technique, and sometimes what you see is the result of a patient pushing her surgeon beyond what might be ideal for her body. The result in such cases can be peculiar or even downright disfiguring; and often, fixing the problem is 
much more difficult than you might think. I'll focus on a few examples of things that I saw last weekend as I wandered the Arnold Expo.
First off, we've all seen the woman whose breasts are just too big for her body. Now, guys, I know that you think that's not possible, but really, as bodybuilders, we should be the most cognizant of the aesthetic ideals for the human form. Regrettably, many women find themselves in the same vicious cycle as men; thinking that bigger is always better and you can never be big enough. Alas, I have had a few patients in whom I've done an initial breast augmentation with a great-and proportionate-result, only to have the patient come back a few years letter and insist on going not just bigger, but to a size that is really out of proportion for her body. I emphasize to them the stress they're placing on the skin envelope, which in many cases is quite thin as a result of weight training and dieting, along with the stretching of the skin over an overly sized implant, and I will also caution them with regard to other musculo-skeletal problems that might arise related to their oversized breasts, including back and neck problems. Usually, I am able to keep them to something reasonable, but not always. I suppose I could refuse to perform the procedure, but it's difficult to turn your back on a patient with whom there is an established a relationship over the years, so I focus on performing the best possible procedure for them and avoiding problems.
Some of the other things you've mentioned, relating to the position of the implants, can result from pre-existing anatomic issues or from technical issues at the time of surgery. Specifically, sometimes it looks like the implants are too far apart. This sometimes occurs in women with a broad chest who opt for a small implant, or if, for example, a high profile implant is used inappropriately. The implants are positioned centrally under the nipple, so that if a woman's nipples are located laterally, the implants may appear to be further apart. If one was to position the implants closer, ignoring the relationship to the nipple, the breasts would end up looking like the comedian Marty Feldman, who could make his eyes look out to the sides. Not attractive, to say the least.
Implants come in a variety of profiles: low, moderate, moderate plus, and high profile. As you move toward a higher profile, the implant has a narrower base and provides more projection. The implants with a narrower base are great for petite women, and for women who want a larger implant without increasing the base diameter, thereby avoiding excessive projection into the armpit or a "uni-boob"-technically referred to as "synmastia." This latter problem can be disastrous, and it can be very difficult to fix. What happens in that case is that the pocket into which the implant is placed is over-dissected toward the middle of the chest, and the two implants nearly touch with just a small amount of tissue in between them. Fixing it can require removal of the implant for a period of time to allow for the pockets to scar down, following which new implants need to be placed, basically starting all over again. Obviously, this can get costly.
Finally, I noticed a few women who had very obvious implants, even though they weren't necessarily big. This is usually the case with implants that are placed over the muscle. Many plastic surgeons prefer this approach, particularly in bodybuilding women, since they are concerned that the implant may change position over time if it's under a large and active pectoralis muscle. With the increased availability of silicone gel implants again, many surgeons will be more comfortable placing the implants over the muscle again, since the gel implants have fewer problems with visible rippling that has been a major issue with saline-filled implants. Unfortunately, in bodybuilding women, with thin skin and decreased breast tissue, their implants can look like they were just stuck on their chest with a thin layer of plastic wrap over the top to hold them in place, especially in women in contest condition, and for this reason, I prefer to place the implants under the muscle to provide a more natural appearance.
Next year, I may have to keep my camera handy so that I can include a few photos!
Dr. Rick Silverman is a Boston-based plastic surgeon, whose practice is rooted in bodybuilding. One of his first patients in 1992 was a bodybuilder with gynecomastia, and his involvement with these patients eventually led him to the competitive stage, where he competed from 1996 to 2005, achieving professional status in the WNBF and competing in the masters level in the NPC. His practice focuses on providing optimal care for gynecomastia, breast enhancement, liposuction and other body contouring procedures, with a minimal interruption in your work-out regimen. He can answer your questions about bodybuilding and plastic surgery in the forum at http://forums.rxmuscle.com/showthread.php?t=34335
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