Aesth Plast Surg (2013) 37:922–930
DOI 10.1007/s00266-013-0197-y
ORIGINAL ARTICLE
Stiffness, Compliance, Resilience, and Creep Deformation:
Understanding Implant-Soft Tissue Dynamics in the Augmented
Breast: Fundamentals Based on Materials Science
Manuel R. Vegas • Jose L. Martin del Yerro
Received: 28 January 2013 / Accepted: 11 July 2013 / Published online: 14 August 2013
Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013
Abstract
Background Postoperative tissue stretch deformities are
among the possible complications in breast augmentation.
These deformities are responsible for many potential risks
such as bottoming-out deformity, breakdown of the infra-
mammary fold, permanent tissue atrophy, sensory loss, and
breast distortion (visible implant edges and traction rip-
pling), among others. Although the elastic properties of the
breast are a major concern for plastic surgeons, concepts
such as stiffness, compliance, elasticity, and resilience have
not been sufficiently defined or explored in the plastic
surgery literature.
Methods Similar to any other material, living tissues are
subject to the fundamentals of the mechanics of materials.
Based on their experience with more than 5,000 breast
augmentations, the authors explored the basic fundamen-
tals of the mechanics of materials in search of a rational
explanation for long-term results in breast augmentation
and augmentation-mastopexy.
Results A basic law of the mechanics of materials
determines that when a material (e.g., breast) is loaded with
a force (e.g., implant), it produces a stress that causes the
material to deform (e.g., breast augmentation), and this
behavior might be graphed in a theoretical material’s
stress–stress curve. This deformation will increase with
time although the load (implant) remains constant, a con-
cept termed ‘‘creep deformation.’’ Because the breast, like
all human tissues, is a viscoelastic material, the application
of concepts such as elastic and plastic deformation,
M. R. Vegas (&)
J. L. Martin del Yerro
Plastic, Reconstructive and Aesthetic Surgery Service, Hospital
Quirón, C/Diego Velazquez 2, 28223 Madrid, Spain
e-mail: jmrv2020@yahoo.com
123
BREAST
stiffness, compliance, resilience, and creep deformation
can and should be applied to breast augmentation surgery.
Conclusions The authors have found that the principles of
the mechanics of materials can provide plastic surgeons
with some clues for a predictable, long-lasting good result
in breast augmentation and augmentation-mastopexy.
Future studies are needed to develop these concepts and
evaluate how they might individually determine the mid-
and long-term outcomes of augmented breasts.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Bottoming-out deformity
Breast
augmentation
Compliance
Creep deformation

Resilience
Tissue dynamics
Introduction
The breast is a composite of mechanically different mate-
rials and tissue types (glandular, fibrous, and adipose), and
they all, due to the viscoelasticity of human tissues, obtain
their elasticity from elastic fibers and their structural sup-
port from collagen fibers (mostly type 1) [3]. Understand-
ing and consciously addressing breast tissue dynamics is
crucial for a long-lasting, rewarding breast augmentation.
Short- and long-term tissue stretch deformities are
among the possible complications in breast augmentation.
These deformities are responsible for many potential risks
such as bottoming-out deformity, breakdown of the infra-
mammary fold, permanent tissue atrophy, sensory loss, and
breast distortion (visible implant edges and traction
Aesth Plast Surg (2013) 37:922–930
rippling) [5]. In fact, a survey performed among aesthetic
plastic surgeons [6] found that skin elasticity ranked first
among the vital preoperative considerations in breast
augmentation.
To a large extent, the relationship between breast tissues
and the mammary implant is a reciprocal stress and strain.
Therefore, a mechanical understanding of the factors
affecting breast deformation and shape (e.g., the properties
of skin and breast tissue) may affect both reconstructive
and aesthetic procedures [4]. However, many of the factors
affecting the results of the final implant shape are not well
understood by the plastic surgery community nor by breast
implant manufacturers. These factors include how the
implant distributes its volume in the tissues, how the
implant and breast tissue change over time, and the effect
that the shape of the implant (round vs anatomic) has on the
final breast shape. Independent dynamics for the chest and
the implant as well as forces created by the persistent
contact between the surrounding tissues and the implant
create a strongly coupled system whose simulation can
easily become largely unstable with time [1].
Materials and Methods
Because the augmented breast is stressed by the implant,
the authors, with 20 years of experience and performance
of more than 5,000 breast implant procedures, explored the
fundamentals of materials science to widen our knowledge
of the breast tissue–implant relationship and dynamics.
Results
Mechanics of Materials: Background Concepts
and Definitions
Instant Deformation (Stress–Strain Curve)
A basic principle in materials science determines that
materials undergo immediate deformation (strain) when
loaded with a force (stress) [13]. This behavior is described
by the material’s stress–strain curve, which shows many of
the material’s properties [15] (Table 1). Although the
stress–strain curve for each material is unique, the different
curves share some fundamental characteristics [12]
(Fig. 1).
Depending on the amount of stress, materials strain
differently. Below a certain load, the material deforms but
still keeps the faculty to regain its original shape and size at
removal of the stress (i.e., nonpermanent deformation).
This ability is termed ‘‘elasticity.’’
923
Beyond a certain amount of stress (termed ‘‘elastic
limit’’ or ‘‘yield point’’), the material loses the elastic
behavior and begins to deform permanently (i.e., perma-
nent deformation). This is termed ‘‘plastic behavior’’ or
‘‘plasticity.’’ Beyond the plastic region, the material finally
enters the necking stage. At the necking stage, the mate-
rial’s cross-section starts to stretch significantly and finally
to fail (fracture or rupture) [15, 21, 32].
In the elastic deformation region, the ratio between
stress and strain (termed ‘‘Young’s modulus of elasticity,’’
‘‘elastic modulus,’’ or ‘‘modulus of elasticity’’) is the
mathematical description of the stiffness of a material (i.e.,
its resistance to being deformed when a force is applied to
it). The stiffness (rigidity) of an object indicates its resis-
tance to deformation in response to the application of a
force, the property of being inflexible and hard to distort.
A stiff material has a strong supporting structure and
does not deform much when a stress is applied. The stiff-
ness of a material is represented by the ratio between stress
and strain (Young’s modulus of elasticity, elastic modulus,
or modulus of elasticity). Stiff materials, by definition,
have a high modulus of elasticity (i.e., considerable stress
is needed for a minor deformation).
Compliance (flexibility) is the inverse of stiffness and
represents the tolerance of a material to undergoing
deformation, the property of being flexible and easy to
distort. Compliant (flexible) materials, by definition, have a
low elastic modulus, and only minor stress is required for a
considerable strain. Highly compliant materials are easily
stretched or distended.
In materials science, resilience is the ability of a mate-
rial to absorb energy under elastic deformation and to
recover this energy at removal of load. It indicates the
competence of a certain material to hold a certain stress
without permanent deformation.
In the stress–strain curve, the area under the material’s
elastic region indicates that material’s resilience. By defi-
nition, resilience is directly proportional to stiffness
(Fig. 2) (i.e., high stiffness implies high resilience, and low
stiffness implies low resilience).
In psychology, the term ‘‘resilience’’ has been assigned
to the individual’s faculty to cope with stress and adversity.
In vascular dynamics, healthy arteries are said to be resil-
ient because when stretched, they keep their shape and
elongate, and when released, they snap back. As applied to
breast augmentation, resilience represents the ‘‘ability of
the breast to hold the implant without further long-term
distortion (i.e., further stretch).’’
Overall, it is accepted that a high resilience determines a
low creep deformation (see later). Instead of the charac-
teristic linear (Hookean) curve of many materials (e.g.,),
due to their viscoelastic properties, biologic soft tissue
materials (including tendon, ligament, dermis, and blood
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Table 1 Mechanics of materials: background concepts and definitions

Stress Force per unit area
Strain Change in length per unit length
Young’s modulus Constant of proportionality between stress and strain. Units are the same as for stress (i.e., force per unit area), and the
most commonly used are pounds/in2 (psi), Pa (pascal), kilopascal (kPa), and megapascal (MPa)
Elasticity Property of a material to regain its original dimensions (size and shape) at the removal of load or force (e.g., steel is more
elastic than rubber)
Plasticity Property of a material to deform permanently when subjected to external load beyond the elastic limit
Yield point (elastic Stress at which a material begins to deform permanently (i.e., plastically). Before the yield point, the material will
limit) deform elastically (nonpermanently) and then return to its original shape when the applied stress is removed. Once the
yield point is passed, some fraction of the deformation will be permanent and nonreversible (plastic, permanent
deformation).
Ultimate strength Maximum stress that a material can withstand while being stretched or pulled before necking, the stage during which the
specimen’s cross-section starts to stretch significantly and finally to fail (fracture)
Stiffness (rigidity) Resistance to undergoing (elastic) deformation in response to the application of a force, the property of being inflexible
and hard to distort. A stiff material has a strong supporting structure and does not deform much when a stress is
applied. The stiffness of a material is represented by the ratio between stress and strain (called ‘‘Young’s modulus of
elasticity,’’ ‘‘elastic modulus,’’ or ‘‘modulus of elasticity’’). Stiff materials, by definition, have a high modulus of
elasticity (i.e., a considerable stress is need for a minor deformation)
Compliance Reciprocal of stiffness, representing the tolerance of a material to undergo elastic deformation, the property of being
(flexibility) flexible and easy to distort. Compliant (flexible) materials, by definition, have a low elastic modulus, and only minor
stress is required for a considerable strain. Highly compliant materials are easily stretched or distended
Resilience Ability of a material to absorb energy under elastic deformation and to recover this energy at removal of load. Resilience
is indicated by the area under the stress–strain curve till the point of elastic limit
Creep Deformation of a material due to the constant load for a long period. It is the time and temperature dependent property of
materials

vessels) exhibit a nonlinear J-shaped curve (Fig. 3). Due to
the uncrimping of collagen fibers and elasticity of elastin,
the initial portion of a biologic sample stress–strain curve
has a high-deformation/low-force characteristic known as
the toe region. In this region, characterized by a high
compliance, the material stretches without much force.
As strains are increased, the toe region is followed by a
fairly linear (elastic) region, the slope of which represents
the elastic modulus of the biologic material and,
consequently, its stiffness. In this region, the material
becomes stiffer and more difficult to extend. For example,
if you pinch your earlobe and try to pull it downward, you
will see that initially, it is quite easily stretched but that
with larger extensions, it becomes more difficult to
extend. After the linear elastic region, with large strains,
the stress–strain curve can end abruptly or curve down-
ward as a result of irreversible fiber failure or fracture [2,
4, 12, 31].

Fig. 2 Stiff materials have a high elastic modulus (slope) and, by

Fig. 1 Typical stress–strain curve of a ductile material (e.g., many definition, a high resilience. In contrast, compliant materials have a
metals) with the various stages of deformation low elastic modulus and, by definition, a low resilience

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Aesth Plast Surg (2013) 37:922–930 925

Fig. 3 J-shaped curve of biologic materials. It is generally accepted

that during the initial region (toe region), the collagen fibers align Fig. 4 The continuous, time-dependent strain under a constant load is
themselves parallel to the maximum stretch direction whereas the termed ‘‘creep,’’ which is a major characteristic of the mechanical
elastin, proteoglycan matrix, or both provide resistance to deforma- behavior of human tissues
tion. Once the collagen fibers are sufficiently aligned, further
extension of the skin requires extension of the collagen fibers,
causing a significant increase in skin stiffness (elastic region)

Creep Deformation (Stress–Time Curve)

Essentially, if a weight is suspended from a material, it

elongates instantaneously. This is an elastic response,
represented by the material’s stress–strain curve. Thereaf-
ter, the material continues to elongate for a considerable
time although the load is constant. This continuous, time-
dependent strain under a constant load is called creep,
which is one major characteristic of the mechanical
behavior of human tissues and very much related to their
viscoelasticity [9, 17].
Creep deformation does not occur suddenly at the
application of stress. Instead, strain accumulates as a result
of long-term stress. It occurs as a result of long-term Fig. 5 Similar to any other material, when a breast is loaded with an
exposure to high levels of stress that are below the yield implant, it undergoes deformation
strength of the material (Fig. 4). Creep deformation lays
the foundation for tissue expansion and mechanical closure deformation will not remain constant over time because the
devices, among others. Creep failure underlies stretch augmented breast (and the implant) will undergo a variable
marks in pregnancy and breakdown of the surgical wound amount of creep deformation.
in undue tissue expansion. The creep deformation of the augmented breast is
dependent on three factors: (1) the constant implant size/
Mechanics of Materials as Applied to Implant-Breast weight (amount of load), (2) the through-life changing
Tissue Dynamics supporting structure of the breast (stiffness/resilience), and
(3) time.
When a breast (material) is loaded with an implant (stress),
it undergoes instant deformation (i.e. augmented breast) The Implant
(Fig. 5). Conversely, the stretched breast exerts a load on
the implant. Both behaviors are subject to the fundamentals Due to gravitational forces, dynamic daily activities, and
of materials science and might be represented by a theo- location of breast implants behind the breast, the implants
retical stress–strain curve [25] that has not yet been exert a constant stress over the lower pole of the breast.
determined in the current literature. Moreover, this This stress is directly proportional to the implant size and

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projection (amount of load). As a consequence, with time,
the augmented breasts, especially with big/high-projecting
implants, may show some or all of the characteristics of
low-grade chronic tissue expansion/creep deformation
including parenchymal atrophy, tissue thinning, and lower
pole stretch [7, 8, 14]. These undesired effects might be
even more evident in relation to the natural through-life
causes of breast support loss (e.g., gravity, breast feeding,
weight variations).
The Supporting Tissues of the Breast
Encased by the inframammary and the less defined lateral
breast folds [1, 5, 10, 20, 22–24], all the breast tissues play
a role, although it is accepted that the skin and the fascial
system of the breast (superficial/deep fascial layers and
Cooper’s suspensory ligaments) are the most important
suppliers of breast support [3, 16, 18, 19, 23, 24, 26]
(Fig. 6). Specifically, Gefen and Dilmoney [11] indicated
that the most highly loaded soft tissue structure in the
breast, either during static body postures or during dynamic
activities, is Cooper’s suspensory ligament system, which
in fact is the component with the highest elastic modulus
(stiffness) of the breast [11] (Table 2).
Findings have demonstrated that fascial thickness is
greater in the lower and lateral aspects of the breast [27],
which might be a natural response to counteract the grav-
itational forces during the supine and upright positions.
Although with substantial variations among women, breast
support changes in relation to age, breast size, weight, body
Fig. 6 Fascial supporting system of the breast. Cooper’s suspensory
ligaments of the breast (blue arrow) are the stiffest structures of the
superficial fascial system. The dermis is attached to the superficial
fascia via superficial retinacula cutis fibers (red arrow)
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Aesth Plast Surg (2013) 37:922–930
Table 2 Mechanical properties of the tissue components of the breast
(as reported by Gefen and Dilmoney [11])
Tissue type Elastic modulus (kPa)
Ribs 2,000,000–14,000,000
Pectoralis major and minor muscles 0.75–30
Pectoralis fascia 100–2,000
Suspensory ligaments of Cooper 80,000–400,000
Glandular tissue 7.5–66
Adipose tissue 0.5–25
Skin 200–3,000
kPa kilopascal
mass index, and glandular activities [11, 23]. As a result,
the stiffness of the breast is not constant but changes
(usually decreasing) throughout life.
Breast Augmentation Technique
Different surgical maneuvers and options are available in
breast augmentation surgery, and they surely have an
influence on breast support and tissue dynamics. These
options include pre- versus retropectoral implant position,
dual-plane technique, fascial/breast scoring, and transec-
tion of the inframammary fold, among others. As a con-
sequence, although difficult to evaluate independently, they
unquestionably play a role in how the augmented breast
will behave with time, especially in the low-resilient/low-
stiffness breast.
Discussion
The interaction between the breast tissues and implant
forces over time, combined with the inflexible aging
changes of the breast tissues, determines the long-term
stability of the augmented breast. Handel [14] showed that
the long-term presence of implants great in size or pro-
jection causes changes in breast anatomy and physiology,
including parenchymal atrophy and tissue thinning. Tebb-
etts and Teitelbaum [30] warned against using high and
extra-high projecting implants to avoid mastopexy in
patients with glandular ptosis due to the high risk of mid-
and long-term sequelae. These authors developed the
TEPID [28, 29] system because they found that implant-
soft tissue dynamics affect the short- and long-term results
of augmentation in both primary and reoperation cases.
Two concepts should be considered whenever a breast is
augmented with an implant: compliance/stiffness and
resilience/creep. These two concepts are intimately related
to the quality of the breast support (Figs. 7, 8).
Aesth Plast Surg (2013) 37:922–930 927

Fig. 7 (1) With poor tissue

support, low-stiffness/high-
compliance/low-resilience
breasts are at risk for intense
creep deformation when loaded
with large or high-projecting
implants. (2) With excellent
tissue support, high-stiffness/
low-compliance/high-resilience
breasts are very likely to
maintain the postoperative
result in the long term

Low-Compliance, High-Stiffness/High-Resilience In such cases, a ‘‘tight’’ breast augmentation will remain

Breast
The tight nulliparous envelope, some types of lower pole
constrictions, and tubular/tuberous breasts might fall in this
category. With excellent tissue support, this type of breast
is not easily stretched to the point of accepting a large/
high-projecting implant and, for the same reason, will not
easily soften with time after the augmentation.
tight for a long time because of its low compliance and
high resilience. For the same reason, except for the possi-
bility of natural breast changes, a stable long-term result is
very predictable in these cases because postoperative long-
term creep deformation will be low.
High-Compliance, Low-Stiffness/Low-Resilience
Breasts

The revisional surgery, the empty hypoplastic breast after

Fig. 8 For a given patient, different implant volumes (load) deter-
mine different types of creep deformation and, consequently, a stable
or an unstable long-term result
pregnancy/nursing, and most of the augmentation-masto-
pexy procedures might fall in this category. With poor
tissue support, this type of breast accepts large/high-pro-
jecting implants, but because of its low resilience, it might
easily undergo a substantial amount of creep deformation
with time.
In such cases, preservation of the supporting structures
of the breast is crucial as is the selection of a moderate-
sized/projected implant if a stable long-term result is
desired (Fig. 8). In the high-compliance/low-resilience
breast, filling a large pocket with a big implant can be
disastrous months or years after the surgery because of an
unavoidable creep deformation.
The bottoming-out deformity is a complication of breast
surgery involving inferior displacement of the breast gland
(with or without implants), hyperexpansion of the breast’s

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Fig. 9 Creep bottoming of the augmented breast. Left no bottoming.
Center bottoming with preservation of the submammary fold
(hyperexpansion of the lower breast pole, downward displacement
of the implant, moderate upward tilt of the nipple–areola complex,
concave upper pole). Right extreme bottoming deformity with failure
of the inframammary fold
lower pole, and a consequent upward tilt of the nipple–
areola complex. It may or may not be associated with a
lower displacement of the inframammary fold.
In primary breast augmentation, two causes can
underlie the deformity: a poor surgical technique
(excessive undermining of the lower breast pole with
Fig. 10 Bottoming deformity
Fig. 11 Moderate inferolateral
tissue stretch corresponding to
moderate creep deformation
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Aesth Plast Surg (2013) 37:922–930
aggressive disruption/lowering of the inframammary
fold) and long-term imbalanced implant-breast tissue
dynamics (creep bottoming). With excessive load relative
to the support capacity, the high-compliance, low-resil-
ience augmented breast, because of the time-dependent
creep deformation, will stretch and cause hyperexpansion
and remarkable tissue atrophy of the lower pole. As a
consequence, the nipples show upward tilt, and the
implant bottoms out.
In patients with naturally compliant or surgically
weakened folds, there can be a breakdown of the inferior or
lateral breast folds, which may cause the implant literally
to slip off the breast (Figs. 9, 10, 11, 12).
Evaluating the compliance, stiffness, and resilience of a
specific breast in terms of preoperative evaluation of breast
augmentation probably is not possible at the moment.
However, these concepts should be understood and con-
sidered by plastic surgeons to improve the long-term
results in breast augmentation. Although difficult to eval-
uate independently, some surgical maneuvers (e.g., dual-
plane, pre- vs retropectoral, fascia/breast scoring proce-
dures) might have an impact on breast tissue dynamics that
merits further research.
Aesth Plast Surg (2013) 37:922–930
Fig. 12 Because of substantial differences in breast support, breast
asymmetries are clear examples of different tissue dynamics. The
stiffness, compliance, and resilience of both breasts will be very
different
This report describes basic raw concepts of the
mechanics of materials that undoubtedly are relevant in the
mid- and long-term evolution of the augmented breast.
Future research should be undertaken, probably more by
materials engineers than by surgeons, to expand this area
and guide surgeons and implant manufacturers to provide
our patients with safer and longer-lasting good results from
implant-based breast augmentations.
Disclosure Dr. Manuel R. Vegas declares that he has no conflicts of
interest to disclose. Dr. Martin del Yerro is a consultant to Mentor
Corporation (Santa Barbara, Calif.) but has not received stipends or
any other form of payment for conducting or publicizing the research
described in the article. He has no commercial associations that might
create a conflict of interest with regard to the information presented in
the article. He has no patent licensing arrangements, stock ownership,
or other equity interests in companies that manufacture products
mentioned in the article.
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