Are you a candidate for a breast reduction and will insurance cover this? June 24, 2011
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Reduction mammaplasty, the medical term for a breast reduction, is one of the most common plastic surgery procedures. In my experience, it also has one of the highest rates of patient satisfaction of any procedure in the specialty. I think this is for two reasons: women with very large breasts are usually pretty miserable and appreciate the relief obtained and results are, aesthetically, usually pretty nice.
There is no “cookbook” formula for who is a candidate. If you have large, full breasts and are having symptoms from these, then you are probably a candidate. Cup size is not always helpful. While most women with problems with have bra cup size in the D and larger range, I have seen women with significant problems who wore a C cup.
I take a very comprehensive history when evaluating patients for breast reduction surgery. In addition to their cup size I want to know about any aches and pains in the back, neck, and shoulders. Problems with rashes under and between the breasts are common with large breasts. Some women complain of a “pulling” sensation on their chest and discomfort with laying down, as the large breasts spill to the sides. Numbness and tingling down the arms, into the hands and fingers, can be caused by large breasts. A physical examination, of course, will confirm that the breasts are large. I take detailed measurements and always document the size of the breasts with photographs. Very helpful is the presence of grooves in the shoulders where the bra straps dig in. This is an objective, tell tale sign of a problem.
Once I determine that a patient is a candidate for surgery, the next step is to obtain approval for the surgery from their insurance company. This can be interesting. Insurance companies are all over the place with their policies regarding this surgery. Some policies do not cover this surgery at all. Those that do often put all sorts of pre-conditions on their coverage, some of which make no sense at all. The most common requirement is that a minimum weight of breast tissue must be removed for the surgery to be covered. This amount may be so great as to be absurd. There is no accepted standard for how much a breast needs to be reduced for this to be therapeutic. Some policies require ridiculous things like some form of documentation that you have tried different bras (what woman hasn’t?) without really explaining how this is to be done, have had a trial of physical therapy (no evidence that this is the least bit effective in the long term), and have tried a course of pain medications (why should a woman be made to take pain medications for the rest of her life when an operation is nearly 100% effective in curing the problem!?).
After the consultation, I will contact your insurance company, provide them with your clinical information and a photograph of your breasts (required by all insurers before they will consider coverage), and wait to see how they respond. If the response is favorable, all that needs to be done is schedule a date. If coverage is denied, I will follow the necessary steps to appeal this, as far as I can. Sometimes, I can get an initial denial reversed.
If, after all is said and done, we cannot get you covered, or if you simply have no medical insurance, I can offer this procedure in our own, private ambulatory surgery center housed in our office. We can do these very safely and comfortably and our total fee for the entire surgery is very reasonable. Our patient coordinator will be happy to give you a quote for this surgery.
There are many misconceptions about breast reduction. Even many primary care physicians are misinformed about the surgery. Some men, including doctors and non-doctors, do not understand how uncomfortable large breasts can be and discourage women from seeking this surgery. Breast reduction surgery is quite safe with few complications and only very rare serious ones. Postoperative discomfort is very modest and most patients are surprised at how little pain there is. It is nearly 100% effective in relieving the symptoms of large breasts. Of all the operations I perform as a plastic surgeon, breast reduction has the closest to a perfect track record of satisfied patients.
After surgery, the breast will have scars on them and, as with all scars, the quality of these cannot be guaranteed. They are usually pretty good and more than justified by the results. The breasts may loose some sensitivity- larger breasts are more likely to do this. Conversely, very large breasts usually have less sensitivity to begin with. Various techniques exist to reduce large breasts. Some use limited incisions to minimize scars but these may also compromise getting the best shape and aesthetic result. A breast reduction will simultaneously lift a saggy breast, producing a more youthful, perky look. Breast feeding after a reduction can be problematic. Much depends on the technique used and preoperative size of the breasts. I have had some patients who successfully breast fed after surgery but I tell all patients to expect not to be able to do this. Breast reduction does not impair the ability to obtain a good mammogram. Some studies suggest that reducing a large breast may somewhat reduce the risk of breast cancer later but this has not been judged to be enough of a factor to warrant it being used as a justification for the surgery.
You will need to anticipate about 2 weeks to recover from surgery but can probably resume routine, day-to-day activities sooner than that. Vigorous physical activity, such as sports, going to the gym, etc. can be resumed in 4 weeks. I follow patients for a full 6 months after surgery to be sure that everything goes as it should and the outcome is a good one.
For women with large breasts, who are having problems with them, breast reduction is a very successful procedure with a few complications. It produces the double benefit of relieving symptoms and making the breasts more “perky” and attractive; truly a “win-win” situation!
Dr. Millard June 24, 2011
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He was one of the two most influential men in my life; my father is the other. He was also one of the most influential men you never heard of. He passed away on Father’s Day. In a professional career spanning over 50 years, plastic surgeon D. Ralph Millard, Jr., MD, wrote or co-wrote 9 books, published 149 papers in peer-reviewed medical journals, and wrote 53 chapters in medical textbooks. He developed the operation used throughout the world today for the repair of cleft lips. He personally repaired thousands of cleft lips and palates.
A supremely innovative surgeon with a lifelong thirst for perfection of his craft, he also developed numerous procedures and surgical instruments. He was an acknowledged master of one of the most difficult procedures in the specialty- total nasal reconstruction and his results sometimes looked better than the patient’s original nose.
As impressive as these accomplishments were, perhaps his greatest professional legacy were the hundreds of residents and fellows that he trained in the science and art of plastic surgery over 28 years as head of the division of plastic surgery at the University of Miami/Jackson Memorial Hosptial. His list of students reads like a Who’s who of plastic surgery. Some have returned to their home countries to use what they learned to serve patients and, in turn, pass on this legacy to their own residents. In the U.S. many of Dr. Millard’s protégés have become heads of training programs and trained several generations of plastic surgeons. Anyone who has ever required the services of a plastic and reconstructive surgeon has benefited in some way from the influence of Dr. Millard.
In 2000 Dr. Millard was named one of the top 10 plastic surgeons of the millennium by the American Society of Plastic Surgeons and some would argue that he was at the top of that list. His influence is felt to this day.
One of his unique and lasting contributions, not only to plastic surgeons but to readers in any walk of life was the publication in 1987 of his landmark book, Principlization of Plastic Surgery. Nominated for a Pulitzer Prize, it was unlike any other medical textbook. Written in a narrative style and copiously illustrated, it had something for everyone from the most accomplished surgeon to the interested non-medical readers. The book innumerated 33 principles of plastic surgery which could be equally applied to life as to the specialty. By emphasizing principles, which do not change, over procedures which become obsolete as the next best thing comes along, he insured that his book would be as relevant decades later as the day it was published.
An imposing figure even in his 80’s, Dr. Millard had a steely gaze that could cause great discomfiture in any of his residents or patients who did not meet his lofty expectations for them. He demanded the absolute best of himself and those who trained under him. Stories about him are legion among those who knew. There was the applicant for a position in his program who arrived in the operating room only to be greeted by “the Chief” and instructed to go to the white board in the corner of the room and draw a horse!
Dr. Millard was one of those rare surgeons whose waiting list of patients extended not weeks, or months, but years. He eschewed celebrities and felt more at ease with a young couple bringing him their child with a cleft and praying for a miracle. With Dr. Millard, they often got it. His passing closes a glorious chapter in the history of plastic surgery in the U.S. and abroad.
Dr. Millard was my professor and mentor for 2 years. I have been grateful ever since.
What style breast implant should I choose June 8, 2011
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What implant style should I choose?
It seems most patients coming into for a consultation for breast augmentation these days are doing a lot of research online before seeing a plastic surgeon. Among the various decisions that have to be made about implants is what style of implant to choose. Choices in both saline and gel implants include round/smooth, round/textured, tear drop/smooth, and tear drop/textured. Round implants are broken down even further into moderate, moderate “plus”, and high profile implants. How is a person to choose among these?
Let me explain texturing first. A ‘textured’ implant has a surface that looks and feels rough or fuzzy. This surface texturing is intended to encourage the attachment of the tissues around the implant to the surface of the implant. Think of a Velcro-like adherence. The idea behind this is that the surface texturing and tissue adherence will reduce the likelihood that the pocket around the implant might contract, squeezing the implant and making the breast feel hard and/or distorting the shape. This condition is called capsular contracture and is one of the main reasons some women get a less than perfect result. There are several issues with textured implants.
One is that they are stiffer than non-textured implants and thus have a significantly higher failure rate over time. Another issue is that the texturing simply doesn’t do what it is intended in many cases (I would say in most cases, in my experience). I rarely remove textured implants where I see significant tissue adherence to the surface of the implant. Textured implants are much more prone to having collections of serum, called seromas, form around them so that in most cases, the use of a drain in each breast is advisable. Drains are, quite frankly, a nuisance for patients, and a potential source of introducing infection into the implant pocket, a disastrous occurrence. When tissue adherence does occur, combined with the added stiffness of the implant, visible and palpable rippling of the implants is more common.
Smooth implants do not have the above issues.
As to tear drop, also called “anatomically shaped” implants versus round implants it would seem that the former would work better. After all, a natural breast is not really round but has a natural tear drop shape, right? True, but it is an interesting fact that when women with round implants have x-rays taken of their breasts while sitting up, the round implants settle into a tear drop shape due to gravity. When they lay down, the implants change to a rounded shape, allowing the breasts to settle more naturally. Because tear drop shaped implants have this shape built into them, they maintain the same shape regardless of position so this natural change does not occur. In addition, they are prone to spinning, flipping, etc. and this can make the breast assume unusual contours. The only way to avoid this is to secure the implant in the pocket in some way, such as by using surface texturing but then, you have the issues with texturing that I mentioned above.
It is for these reasons that when plastic surgeons are polled as to their preference in implant style, nearly 85% primarily choose round/smooth implants. They have a lower failure rate, produce great results in most patients, can move around in the pocket without altering breast shape, and just happen to be less expensive than the textured and tear drop shaped implants, as well. I call this a win, win, win, and win situation!
As to moderate, moderate plus, and high profile implants, the choice of these relate in large part to the width of the chest and the patients stated goals. Do they want large implants but have a fairly narrow chest? Then high profile implants might work best. Are they an average size, with fairly typical moderately small breasts, and a little loose skin? A moderate plus profile implant will work well. Much of this is very subjective and determined by the patient’s stated goals, the situation they present with, and the surgeon’s aesthetic sense. There are no formulas or computer programs that can precisely predict the best implant size and style for each patient with reliability and consistency. That is part of the “art” of breast augmentation.
R. Bosshardt, MD, FACS
8 June 2011
A great commentary on liposuction April 10, 2011
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I am not above posting the comments of other plastic surgeons if I feel that they have something to say, and are saying it well. This post by Dr. Paul Howard, in Birmingham, Alabama, on liposuction is excellent, and very well written. I agree with everything in it. Dr. Howard is a board certified plastic surgeon and also an alumnus of the training program that I graduated from, in Miami, Florida, under Dr. D. Ralph Millard, Jr. Maybe great minds DO think alike! Just kidding…but, seriously, the post is well worth reading for anyone contemplating liposuction these days. It is so hard to separate the hype from the reality. Check it out: http://liposuctionbirminghamal.com/
Breast Implants and Cancer risk March 13, 2011
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When the movie “Jaws 2″ came out, the tagline was “just when you thought it was safe to go back in the water….. After the breast implant scare that surfaced in 1990 with the “expose” by Connie Chung, it was over 10 years before enough data was gathered around the world to confirm, to a medical certainty, that breasts implants did not make women ill, and did not put them at risk for breast, or any other cancer. Women returned to plastic surgeons offices in droves to have the implants put in that they had desired, but postponed, during media hysteria. Unfortunately, in a distressing nod to Jaws 2, it can be said: “just when you thought it was safe to get back into the plastic surgeon’s office….. Now, there is new data suggesting a possible association between implants and a very rare cancer.
Medical certaintly is not the same as 100% sure. For one thing, it is not possible to prove a negative. No one can prove now and forever that breast implants do not cause cancer because there is always the hypothetical possibility that some woman, some where, under just the right set of circumstances, may experience just that. All it takes is one case to blow medical certainty out of the water.
Medical knowledge is not static. It is constantly changing as new information is discovered. Doctors can only practice according to what knowledge is available at the time. Until recently, there has been no connection observed between women having breast implants and increased risk of any cancer.
Recently, reports have begun to surface of a few women with implants developing a very rare form of cancer, anaplastic large cell lymphoma (ALCL). This is a cancer of the lymphatic system. In the United States, ALCL occurs in 1 out of 500,000 women. ALCL arising in the breast is much rarer still, with an incidence of 3 out of 100 million women.
Between January 1997 and May 2010 a total of 34 unique cases of ALCL arising in the breasts of women with implants has been reported to the Food and Drug Administration. Two thirds received implants for reconstruction following breast cancer treatment. Most of the others were for cosmetic breast augmentation with a few not specified. More than half of the implants were silicone gel filled versus saline. In only four cases was the implant type, smooth surface versus textured surface, noted and in those all were textured implants (This does not seem terribly surprising given that textured implants, which have a “fuzzy” surface, are more prone to seromas than the smooth style. It remains to be seen if this connection is borne out with more investigation).
Nearly all the women with ALCL had their implants for 8 years or more. Most cases were diagnosed when the women underwent revision surgery for persistent fluid (seroma) around the implants and/or for hardening of the breasts. In all cases the cancer was confined to the space between the implant the capsule of scar surrounding it.
Because of past concerns regarding implants and their potential to cause illnesses or cancer, which led to a moratorium on silicone gel implants for cosmetic use for nearly 15 years, the FDA is moving very quickly on this. The FDA and the American Society of Plastic Surgeons have collaborated to establish a registry of patients with ALCL and breast implants and are asking that new cases be reported immediately. Because of the rare nature of ALCL, especially in breast patients, it may be as long as ten years, possibly more, before there are enough numbers of women to be able to draw conclusions.
In the FDA white paper published in January 2011 (http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239996.htm ) three key findings were noted. There may be an association between breast implants and ALCL. At this time it is not known what type of implant may be associated with a higher or lower risk of ALCL. The connection to textured implants is tenuous at best. The true cause of ALCL in women with breast implants is not known.
What are women with implants to do now? Because of the small numbers and the inability to make statistically valid conclusions, the FDA does not recommend that women with breast implants have these removed if they are not having any problems. At this time, the FDA does not feel that this issue is sufficient to warrant any change in the safety status of breast implants. As new information becomes available, this will be made public. One of the lessons learned with the implant controversy of the 1990’s- 2000’s was the importance of transparency in averting uninformed speculation and misinformation in the media.
Women who have noted hardening of their implants after years of being soft or who note swelling or fluid around their implants should have these checked. Routine breast surveillance for cancer is as important for women with implants as for those without them. It is important not to lose sight of the fact that women have a lifetime risk of breast cancer of between in 1 in 9 and 1 in 11, with or without implants, compared to the tiny risk of ALCL.
Finding a bra after your breast augmentation October 7, 2010
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Many patients ask me about bras after they have had breast augmentation surgery. As I tell every patient w
ho comes in seeking this enhancement, breast augmentation is an inherently unnatural thing to do. Breast implants, while good, are not perfect in duplicating what is naturally missing so the final result will rarely look and/or feel 100% “natural”, although very nice none-the-less. One aspect of this “unnaturalness” (is that a word?) will be how the augmented breasts fit into a bra. Fitting for bras normally can be a challenge. Trust me on this: there is no standard out there for cup size. If you buy the same cup size from ten different manufacturers, they will all fit you differently. I do not use bra cup size as a measure of breast size because there is so much variation. There are numerous formulas for fitting bras and they may give very different results. Victoria’s secret, for example, will size most women a full cup size large than anyone else. I think they feel this makes their customers feel better. When performing breast augmentation I try to use an implant size that will achieve a result that will satisfy my understanding of the patient’s desires, make them look as natural as possible, produce a visible increase in fullness, and, hopefully, avoid unnecessary problems for them, now and in the future. Women often don’t realize that the result will be with them for years, or even the rest of their lives, and I try to look down the road. But, I am getting off track. Back to bras……..
My advice regarding post operative bras is to wear comfortable sports bras, without underwires or thick seams, for the first month or so after surgery. The breasts may be sensitive and the implants will not have fully settled, so fitted bras will probably not fit well, underwires may be uncomfortable, and sizing may be inaccurate. Once the implants have settled and the breasts assumed their final shape, that is the right time to get fitted. The bottom line is that the best bra for you is the one that fits you well and gives good support. This may require a little trial and error. Most large department stores and lingerie stores have people trained to fit customers for bras. Admittedly, some women just happen to have that combination of chest circumference and breast shape/size that makes them very difficult to fit after breast implant surgery. There is one brand, Le Mystere (www.lemystere.com), that makes bras specifically for women with implants. The are a bit wider along the curve of the underwire and have some other modifications to better fit these individuals. They are available in many department stores, such as Macy’s and Neiman Marcus. They are not cheap at $76 each but if they are your best fit, they are worth it.
Sports bras are great but some don’t give enough support for women with larger breasts. One of my patients is a runner. A week after her augmentation, she ran 20 miles in a long distance relay! I don’t recommend this, but she was committed and did not have any problems. She searched extensively and came up with two sports bras that she felt were excellent. One is the Enell sports bra (www.enell.com) and the other is the “Tata Tamer” (no, I am not making this up) (www.lululemon.com). She states that both were extremely comfortable and gave “the girls” great support when she ran.
Many of my patients express a desire for superior fullness from their implant surgery. This is very difficult to produce on purpose and, usually, when there is superior fullness due to the implant, it does not look natural and can look a little strange. The best way to get that fullness is with a good “push-up” bra. The same thing applies to cleavage. Most small breasted women do not have much cleavage. I can try to enhance this by bringing the implant pockets closer together but I have to do this very carefully. Too close and I risk disrupting the skin attachment to the breast bone. This can produce what some call “bread loafing” and others call a “uni-breast”, where the implants are too close together and, again, look strange. This is VERY difficult to correct. Cleavage after breast augmentation has done what it can, is best produced with a good bra to push the breasts together.
I do recommend that my patients limit how much they go braless. The only support your breasts have is the skin and some fine ligaments that connect the skin to the muscle. The ligaments are called Coopers ligaments (in medical school, we called them “Coopers Droopers” because they stretch out with age and allow the breasts to sag). You will sag more over time if you go braless a lot. A comfortable, well fitted bra is your best defense against sagging.
If you discover any great bras out there please let me know so I can pass this on to patients.
What can you tell me about the Lifestyle Lift? Do you do these? January 16, 2010
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It seems the Lifestyle Lift has become very popular and we get a lot of questions about this procedure. I can’t tell you much about this procedure specifically. The reason is that this is a proprietary surgical procedure. This means that the doctor who developed it, David Kent, D. O., an otolaryngologist, has registered the Lifestyle Lift as a trademark and the only way a physician can learn details about it is to pay him for the privilege. It costs several thousand dollars to take his course and learn how to perform the Lifestyle Lift. However, as a plastic surgeon with 21 years of experience I can tell you some things based on having seen patients who have had this procedure done. As a plastic surgeon, I perform facelifts frequently. I am familiar with the different types of facelifts and variations of this procedure, I know the anatomy well, and the changes that occur with aging which a facelift is intended to correct. I also know the limitations of the procedure.
The Lifestyle Lift is a variation on a mini-facelift. Mini facelifts differ from full facelifts in that there is much less cutting and releasing of the skin from the underlying muscles. Less skin is removed. The surgery takes less time, carries fewer risks, and recovery is quicker. All good, right? The problem is that the results are less too. The surgeon who trained me, Dr. D. Ralph Millard, Jr., who performed many thousands of facelifts in his 40+ year career said it best: “Mini procedures give mini results”. I think this is as true today as when I trained over 20 years ago.
The Lifestyle Lift brochures and web site are very impressive and show results that border on the unbelievable. It has been my experience that when something sounds too good to be true, it usually is. Looking at the Lifestyle Lift a little more closely there are some things that just don’t sound right. On the one hand, the procedure promises incredible results with an hour of surgery. This is pushing things even for a mini-facelift. The brochures and web site, however, also state that many of the patients underwent an additonal “neck firming” procedure. What was that? The brochures and ads don’t say. I can tell you from some former Lifestyle Lift patients that their surgery took a lot longer than an hour and more than a week to recover from. None of the results that I have seen have been remotely as impressive as what I see on the brochures and several patients were very unhappy with their experience as the doctor did not spend much time with or explain the procedure well, and they did not get the results promised.
I seriously question the accuracy of the claims and results boasted by the Lifestyle Lift. I just know too much about facial surgery to believe that they can deliver these results as promised. One telling incident occurred in New York State where the Lifestyle Lift company was fined $300,000 for false and misleading use of the internet. It seems that employees of the Lifestyle Lift were passing themselves off as satisfied patients on the internet in order to lure prospective patients. New York Attorney General Andrew Cuomo called the company’s attempts to lure patients “devious, manipulative, and illegal”. If you know how infrequently false advertising charges are pursued, it gives you an idea how egregious this action of the Lifestyle Lift company was. The situation is ironic when you read the Lifestyle Lift Code of Internet Conduct and Assurance on their website.
The Lifestyle Lift boasts that all of its surgeons are “board certified”. That may well be true, but board certified in what? Any physician with an MD or a DO degree can lay claim to the title of facial plastic surgeon or plastic surgeon if they wish. When surgery is done in an office setting, as the Lifestyle Lift is, there is no law that prohibits any physician, even non-surgeons from performing surgery in their own facility.
We have seen many procedures come and go over the years and are always cautious about new procedures that promise amazing results with minimal effort. Remember the non-surgical facelift using barbed threads, the Feather Lift? Where is that today? Gone, because not only did it not work. There were too many patients with complications and visible bands under their skin from the threads. We predicted this at the beginning and refused to jump on that bandwagon. Remember laser facelifts and eye lifts? Also ineffective and abandoned after an initial flurry of interest.
There are other proprietary mini-facelifts out there. One that comes to mind is the Quick Lift. The advertising for this one is very similar to the Lifestyle Lift. There are probably some other procedures out there now whose names I don’t know. If you want to look into something like this for yourself, go ahead, but go in with your eyes wide open and ask a lot of questions. By all means get a second opinion from a board certified plastic surgeon who is not affiliated with the Lifestyle Lift. Beware of grandiose claims of incredible results with minimal surgery.
Two very important things to consider in approaching any cosmetic surgery. One is to be sure that the facility where your surgery will be done is accredited by an organization approved to certify ambulatory surgery facilities. These include the American Association for the Accreditation of Ambulatory Surgery Facilities (AAASF), Accreditation Association for Ambulatory Health Care (AAAHC), and the Joint Commission. Beware of bogus certifications. The second thing is to ask if your surgeon has privileges to perform the same procedures in a hospital that he or she performs in their office. Hospitals take great care to ensure that their doctors are properly trained and certified to be doing the operations they perform. Doctors are free to do pretty much whatever they wish in their office.
Plastic Surgery in Adolescents September 3, 2009
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(This appeared as one my columns in the Orlando Sentinel in January 2001)
Q: A recent article in the paper was about a 15 year old girl who was seeking breast enlargement surgery with her mother’s blessing. There seemed to be a lot of concern about this, presumably because of her young age. Is there a minimum age for plastic surgery?
A: The answer to this question depends on whether you are speaking of cosmetic or reconstructive surgery and must take into consideration both physiologic and psychological concerns. Reconstructive surgery is done routinely on children and even infants. Timing in such cases, however, is crucial. An excellent example is the repair of cleft palate. In this deformity, the two halves of the roof of the mouth fail to fuse leaving a gap which typically affects the muscles of the soft palate. Because there is no separation between the mouth and nose, food and liquid can go up into the nose when the infant eats. In addition to this, speech cannot develop normally since an intact palate is essential for normal speech.
Repair of the cleft palate is a significant surgical procedure which cannot be done until the baby has reached a sufficient weight to withstand the surgery and , equally important, the anesthesia. If repair is done too soon it can affect the growth of the upper jaw. If done too late, after speech has begun to develop, then the results of the repair will not be as good. Most cleft palate surgery is done around 18 months of age for these reasons.
Otoplasty, or correction of prominent ears presents a different problem. Prominent ears do not cause any difficulties with hearing. The concern here is more of a psychological and/or social one. Children are not overly concerned with their appearance until around 5 or 6 years of age. This coincides with the time kids start kindergarten and become more socialized. Around this time clothing and appearance become more an issue. This is when teasing usually begins in earnest and, unfortunately, children with prominent ears often bear the brunt of teasing from their peers. Corrective surgery is fairly simple but can stunt growth of the ear. Full growth of the ear is not achieved until adolescence but the ears reach about 80% or so of their adult size by the age of 6 or 7. In this case, to prevent unnecessary emotional distress, we fix the prominent ears at this time since any affect on future growth will be minor.
Unlike reconstructive surgery, cosmetic plastic surgery is done to try to improve the appearance of an otherwise normal structure. Medical necessity and functional problems do not apply. By definition, cosmetic surgery involves a change in appearance, sometimes a fairly dramatic change, and therefore the body image of the patient must always be taken into consideration. The adolescent, i.e. the teenage years, are a time of tremendous changes in appearance and establishment of a healthy body image is one of the desired results of this period of passage into adulthood. That this is a difficult transition is clearly evident from the prevalence of eating disorders among teenage girls.
A lack of sufficient conclusive studies on the effect of cosmetic plastic surgery performed on teenagers has made it impossible to establish any consistent guidelines regarding how to approach this issue. It would , however, seem obvious that such surgery should be approached with great caution. Age alone, should not be the only consideration and emotional maturity and basic physiological facts should be taken into account.
In the case of breast augmentation, breast development varies greatly among women, both in age of onset and in ultimate size of the breasts. In my opinion, a 15 year old girl with small but otherwise normal breasts is young to be considering breast augmentation. Significant breast development may occur in the years that follow. I would hesitate to recommend this procedure for women under 18 years of age. By then, breast size should be fairly stable.
The situation is different if one breast is normal and the other is visibly smaller, a cup size or more. This situation does not correct itself spontaneously and can be emotionally very distressing. Augmentation of the underdeveloped breast, sometimes with an adjustable implant to allow for future growth, can provide great psychological relief.
How can I tell if I need a breast lift or implants? June 16, 2009
Posted by bosshardt in Breast surgery.20 comments
Breast lifts and breast implant surgery are totally different procedures that do very different things. They can complement each other in that some patients need both but how does one know which is best for her? Ptosis, the medical term for sagging, is defined by the position of the nipple relative to the crease under the breast. You can do a very simple test to see if you have this. You may have heard of the “pencil test” for breast sagging. Lift up on your breast with one hand, place the pencil horizontally under the breast, right in the natural crease, and then let the breast go. Release the pencil and if it falls, there is no ptosis. If the breast holds the pencil in place, then there is some element of ptosis. If the pencil is held, note the position of the nipple. If the nipple is above the level of the pencil, then you have a “deflated” breast, called pseudoptosis. This is common in women who have breast fed and lost volume in their breasts. If the nipple is at the same level as the pencil, you have grade I ptosis. If the nipple is below the pencil, you have grade II, and if the nipple is the lowest point on the breast (sometimes referred to as a “National Geographic” breast, for all the photos in that magazine of women in primitive cultures whose breasts point to the ground!), you have grade III. Breasts with pseudoptosis and grade I ptosis usually do not need a breast lift and will do well with just adding more volume, i.e. a breast augmentation with implants.
Women with grade II and III need a breast lift, called a mastopexy. Putting implants alone in such breasts usually produces a less than aesthetic result because now you will have a big, droopy breast. Some women can accept this to avoid the scars and expense of a lift, but it is not ideal. A mastopexy is a terrific procedure which will produce a “perky”, non-saggy breast. The down side of this is that it is a fairly extensive procedure, takes longer to perform than a breast augmentation), and leaves additional scars. At a minimum, there will be a scar along the margin of the areola. Additional possible incisions may leave a vertical scar from the areola to the crease under the breast and a scar along the crease itself. In most cases, the aesthetic improvement is worth the scars. The lifted breast will be more compact, because skin is removed, and therefore you may not fill out your bra as well as before and you might even go down a cup size.
Breasts that just need volume do beautifully with implants. See my earlier blog which is an online breast consultation to read details of this surgery. Sometimes, patients need both procedures because of sagging AND loss of volume, the double whammy. In those cases, I recommend doing the lift first followed by the augmentation 3 or more months later. I feel it is easier and safer to do the lift first. Some patients may find that after the lift, they are content and do not go on with the implant surgery. I usually try to dissuade patients from doing lifts and implant surgery simultaneously. These two operation work directly counter to each other. The lift is tightening the breast and making it more compact; the augmentation is trying to expand the breast out and make it bigger. Each operation raises the risks of complications from the other. Inevitably, some compromise will be required. Either the lift and/or the augmentation may have to be underdone to avoid the potential for postoperative complications. The cost savings and savings in time for recovery for doing multiple procedures is, in my view, more than offset by the added risks and compromise of doing the two together.
The patients in whom I am more comfortable combining these procedures are those who need just a little lift and /or a small implant. That is why the consultation is so important, to understand your desires and to see what your breasts will need to have done to accomplish your goals. Expectations are very important and it is equally important to remember that this is real surgery.
I do nearly all breast lifts in our office under general anesthesia. A full, extensive lift will take about 4 hours to complete because of the cutting, shaping, and suturing involved. All sutures the type that dissolve. Scars are usually quite faint and fine. We now have a very nice laser that we can use on problem scars. Though uncommon, they are annoying to patients.
Risks and complications of breast lifts include all those seen in most surgery: infection, bleeding, poor scars, healing issues, unintended injury, anesthesia related problems, and even life threatening problems (although the latter is exceedingly rare). Specific complications include: skin slough leading to bad scars, unsatisfatory size and/or shape of the breasts, loss of feeling in the nipple/areola area, and asymmetry.
An on-line consultation for breast augmentation December 17, 2008
Posted by bosshardt in Breast surgery.3 comments
(Revised 24 June 2011) This is a summary of my standard discussion with patients desiring breast augmentation. It cannot replace a personal, face to face discussion of this important surgery but may answer some questions in advance of an office visit with me. Please understand that this reflects my personal preferences and opinions. Other surgeons may differ in their approach and their are many minor variations in how surgeons do things to get the best results for their patients. All plastic surgeons want good results and happy patients and we do what works for us. This is what works for me.
The only way to add meaningful volume or fullness to your breasts is to use breast implants. You cannot do exercises, take pills, use creams, or use “vacuum pumps” to accomplish this goal.
Together with your consultation with me, the information contained herein will make you more knowledgeable about breast augmentation than 99% of women.
The decision to have a breast augmentation is a major one with life-long consequences. Please be sure you understand this operation well and have all of your questions answered before proceeding. Once surgery is done, it can never be totally undone.
Our facility
Breast augmentation is an outpatient procedure. I do these in our own ambulatory surgery center (ASC). My partner and I built our office to house a state-licensed surgery center, one of the few in a private office in the state. The operating room is on par with those of hospitals and is subject to the same inspections and credentialing. Our ASC has all the necessary staffing, equipment, and resources to handle emergencies to perform surgery with the safety our patients deserve. I recommend doing the surgery here because we can better preserve confidentiality, our staff are very familiar with the surgery since we do so many, and the facility costs are significantly lower than at other ASC’s or hospital operating rooms. I have full staff privileges at Florida Hospital Waterman and Leesburg Regional Medical Center, and courtesy privileges at South Lake Hospital in Clermont, FL. Because this is a state licensed ambulatory facility, patients cannot be kept overnight. Since we moved to our present office in 1996, none of my patients have ever been unable to go straight home after their surgery.
Anesthesia
I perform breast augmentation under general anesthesia. Another option is using local anesthesia with heavy sedation but I do not recommend this. Many patients require so much sedation that they are essentially undergoing general anesthesia without the safeguards. Patients under sedation often feel pain and squirm while undergoing surgery, making the procedure more difficulty to perform. Even though most do not remember this, it still makes surgery more difficult for the surgeon. Many practices only offer this type of anesthesia because they are not accredited to do general anesthesia. We do not have this limitation. In 24 years of practice, I have never had a single patient experience any complication from anesthesia during, or after, a breast augmentation.
Incisions
Several incisions are used for breast augmentation. They are along the edge of the areola (the colored skin around the nipple), in the crease under the breast, the axilla (armpit), and the umbilicus (belly button). The last one is known as the TUBA (Trans-Umbilical Breast Augmentation). It somewhat controversial and not widely done. I feel is somewhat of a “gimmick” used to market a practice. Only a tiny fraction of augmentations are done this way. I don’t feel that this approach has any significant advantages over others and choose not to offer it at this time. The axillary incision, while popular 20+ years ago, has fallen out of favor. Even the surgeon who popularized it no longer uses it. It is awkward and not widely used. Of the first two, I prefer the incision in the crease under the breast. In this approach, no breast tissue has to be cut, unlike with the areolar incision. In patients who make perfect scars, there really is no difference between the two. If the scar is less than perfect, it is less conspicuous underneath the breast. I use a 2.3 cm (less than 1 inch) incision, the smallest possible, to insert a deflated, rolled saline implant. I have never had to revise anyone’s scars from this incision. Gel implants require a larger incision because they are put in already filled, usually around 3-4 cm.
Implant position
Once an incision is made, I have to create space for the implant. This space is called a pocket and can be placed in one of two locations, relative to your pectoralis muscle, a large, flat triangular muscle which sits under the breasts. When I examine you, I have you contract this muscle to assess it’s size, position, and degree of development. Most breast augmentations are done with the implant placed under the muscle. An advantage of this position is that there is more tissue on top of the implant, making it less prone to be seen or felt through the skin. Under-the-muscle implants are less likely to experience tightening of the scar tissue that naturally forms around the implant. This is called capsular contracture and will be explained below. Under-the-muscle position makes it a little easier to obtain acceptable mammograms later. For some patients, such as those with very developed muscles or some breast sagging, above-the-muscle placement may be advantageous. The pectoralis muscle must be partially released from it’s attachments to the ribs in under-the-muscle placement. This should result in no appreciable loss of upper body strength or arm motion. Implants under the muscle will move, and the breast shape will change when the muscle is contracted. This may be minimally to very noticeable. It does not cause any problem beyond this and only rarely justifies attempts at correction. Most breast implants done in the U.S. today are done under the muscle.
The Implants
On November 17, 2006, the FDA lifted the moratorium on the use of silicone gel implants for breast augmentation. This means that women now have the choice of silicone or saline implants for their surgery. I still feel that for the vast majority of women, saline implants (filled with sterile, salt water) provide a result that is on par with silicone gel implants and will continue to recommend them to my patients as my preference. They are excellent implants and provide wonderful results for most patients. One advantage to saline is that if these implants ever rupture or leak, the saline is harmlessly absorbed by your tissues and eliminated. Replacing a leaking implant is quite simple and easy to do. Some women, especially those with unusually thin skin and minimal breast tissue, may benefit from the gel implants because these are less prone to show visible rippling. This can be important because the implants may be more visible under thin tissue. The new gel implants have a more viscous gel that will not run, so leaks should not be as messy as in the past. One of the potential problems with gel implants is difficulty detecting leaks and it is recommended that women get an MRI (magnetic resonance imaging scan) 3 years after implantation and every 2 years after that to check for leaks. One problem with this is that MRI’s are expensive ($800-900) and insurance will not cover this examination for the purpose of diagnosing a leak in a cosmetic implant. I do not feel that it is realistic to expect a breast implant to be in your body for decades without a significant chance of a leak at some time in the distant future.
Saline implants come in several styles. There are round/smooth, round/textured, anatomical/smooth, and anatomical/textured. Textured implants have a higher leakage rate and are more prone to show visible rippling through the skin than smooth implants. Anatomical implants may move around inside the pocket. They can rotate, spin, flip, etc. and this can affect the contour of the breasts. Anatomical and textured implants can be useful in some patients but nearly 85% of breast augmentations in the U.S. are done using round smooth implants because these produce the best results in most patients. For most of my patients, I recommend round, smooth implants.
The most important decision to be made which will determine your results, and satisfaction, is the size of implant chosen for you. There is no formula, computer program, or method outside of surgery which can precisely determine the best implant for you. Putting implants in your bra will not tell you what these will do inside your breasts. I believe that intra-operative sizing is the best way to decide the ideal implant size for you. I encourage you to tell me what your goals are. Unless, you wish otherwise, I try to produce a result that will look natural, look well proportioned to your body, have normal sensitivity, and feel as normal as possible. Sizing is done by putting a sizer into each breast and inflating these until the desired result is seen. I have sized nearly every patient I have done over 24 years and less than 1% have not been satisfied with the size chosen. When patients have chosen their own implants, they have almost invariably been disappointed. If you are unhappy with your implant size, I will recommend that you live with them for one year. Some patients simply take longer to adjust to their new appearance. If, at the end of that time, you still wish for a bigger, or smaller, implant, I will offer to exchange your implants for new ones for the cost of the implants plus a fee to cover out-of-pocket expenses. This offer is good for one year from the date of your surgery.
Bra cup size
Please understand that there is no established standard for what is an A, B, C, or D cup bra. No two manufacturers make bras using the same criteria for cup size. The style of bra, type of material, shape, and each patient’s own preferences determine what cup size she wears. This is why using cup size to describe breasts is very imprecise and I have not found it very useful. While I will do my best to get you the cup size you wish, my primary goal is not a specific cup but, rather, a happy patient. If you are happy with your results, then cup size is irrelevant. If you desire something more conservative, or “showy”, please let me know. As long as it is not medically inappropriate, or dangerous, I will do my utmost to help you achieve your goals.
Recovery and convalescence from surgery
Some postoperative discomfort is to be expected from all surgery and breast augmentation is no exception. You will receive medications for pain and this will usually keep you fairly comfortable. Most patients are off of the prescription pain medications within a few days. A few may need a refill. You should remain sedentary and quiet for the first 5-6 days. After I see you for your first postoperative visit, if you are doing well, I will no longer restrict your activities. This means that you can resume doing whatever you can do comfortably. Just use common sense and don’t overdo things like exercise, etc. for a week or two. You should be back up to 100% within 4 weeks. The total recuperation period is between 3 and 6 months and I always follow patients for at least 6 months before discharging them, to be sure everything has turned out well.
Photographs
Photographs will be taken of your breasts before surgery and at your final visit. This is to help plan your surgery and assess the final results. They do not show your face and are not shown to anyone without your express, written permission. You are welcome to have copies of your before and after pictures if you wish. You may be asked for your permission to use your photographs in our practice and this would be greatly appreciated but you should feel no obligation to allow their use if this makes you uncomfortable.
Breast augmentation; the Upside
Among operations in general, and cosmetic surgery in particular, breast augmentation has one of the highest satisfaction rates. In studies of patients who have had breast implants for over ten years, the satisfaction level is consistently greater than 90%. It is very uncommon for patients to be less than satisfied with the results of their surgery. Even those patients who have complications, or less than perfect results, tend to prefer their breasts with implants over how they were before surgery. My goal is that six months after your surgery, you will regard this as one of the best decisions you have made and be able to say that you would do it over again if given this opportunity.
Breast augmentation; the Downside or Risks/complications/limitations-
Breast augmentation, like all surgical procedures carries risks, and complications can occur. Every effort is made to prevent complications but no operation, and no surgeon, is perfect. Every procedure has limitations in what it can accomplish. Below is a listing of the more common risks and limitations.
Capsular contracture- All breasts will form a layer of scar tissue around the implant. This scar is called a capsule. If the capsule shrinks (contracts), and/or thickens, it can begin to squeeze the implant and this can make the breast feel hard. Severe contracture can distort the breast shape or even be painful. No one knows exactly why a few patients do this. Contracture to some degree occurs in between 3 and 5 % of patients and it is not possible to predict who these will be. If a contracture occurs severe enough to produce an unacceptable outcome, correction will require revision surgery. There will be an additional cost for this, beyond that for the augmentation, which will cover only the expenses of surgery. As with changing implant size, I do not profit from this. You may be asked to follow a program after your surgery to prevent contractures. This may include taking vitamin E orally, massaging your breasts, and wearing a compression bra or strap. Not all surgeons do all these things. It is very important to follow my instructions carefully, but even diligent adherence to this program does not guarantee that a contracture will not occur. If you experience capsular contracture, undergo a revision attempt, and the contracture re-occurs, I will not do another revision, since I feel the chance of success at that point is very low. If the result is not acceptable, I will offer to remove your implants at no additional cost to you.
Capsule stretching- Less common than contracture, in some patients, the implant pocket may gradually stretch. This can result in too much visible movement of the implants. When you lay down, the implants may shift too far to the side. When you sit up, the implant may sit too low on the chest, making the nipple look too high on the breast. This problem is difficult to correct and requires surgery to tighten the implant pocket with stitches. There will be a fee for this type of corrective surgery, including a surgeon’s fee as this correction is difficult. Successful correction of this condition cannot be guaranteed.
Leakage- Saline implants have a risk of leaking of between 5 and 9% in the first 10 years. After that, the failure rate increases by 1% per year. Your implants carry a lifetime replacement warranty. If they leak or fail for any reason, you will be given new implants by the manufacturer. For the first 10 years after surgery, the manufacturer will pay the costs of replacing the implant, up to $1200 (or $2400 with the enhanced warranty, which you can obtain for an additional $125- you will receive information about this option after your surgery). Leakage is harmless, as noted above. Some leaks occur overnight. Others may take weeks to become obvious. All leaks eventually become obvious. The presence of capsular contracture increases the risk of implant failure. Gel implants have a leak rate of between 0.5-2.7% over 3-4 years.
Visible rippling and wrinkling- Implants cannot perfectly mimic the breast tissue that you do not have naturally. Saline implants, as they settle, can produce visible and/or palpable ripples and winkles in the skin of the breasts. This is more likely the larger the implant is relative to the natural breast. Contracture of the pocket makes implant failure more likely. You must understand that breast augmentation is an unnatural process that tries to produce a natural result. A few patients may get that perfect result which looks and feels entirely natural. Most patients get a very nice result, but one that is not 100% perfect. Rippling and wrinkling only rarely cause dissatisfaction with the procedure.
Abnormal movement of the implants- because implants are not the same as your natural breast tissue, the way they move in your breasts will not exactly mimic breast tissue. You may see the implants shift as you change position. This is more likely in patients with very thin breast tissue and skin. If your implants are under the muscle, when you forcefully contract the muscle, the inner, lower area of the breasts will probably flatten and the implant will visibly move. This is only rarely objectionable.
Loss of nipple/areola sensitivity- 90% of women will not lose any of the natural sensitivity of the breast, especially the nipple/areola area. Most patients will have some numbness in the breast skin, most often in the lower half of the breast. This usually resolves in a couple of months. Hypersensitivity of the nipples can occur and this usually resolves more rapidly. In a few patients, loss of some degree of normal sensitivity may be permanent, and in a rare patient, the breasts may be quite numb. So far, no patient has ever returned dissatisfied with the surgery because of loss of feeling. Removing the implants is not expected to reverse loss of sensitivity.
Calcifications in the breast tissue- over years, calcium deposits may form in the tissue around your implants and this can appear on a mammogram. The calcium deposits are harmless but can make interpretation of mammograms difficult. Rarely, clarifying the nature of a calcium deposit may require a biopsy of the breast. Any surgery on your breasts carries the risk of harming the implants in some way.
Cancer and other illnesses- At this time, it is almost universally accepted that women with breast implants do not have an increased chance of developing breast cancer. Numerous studies over the past 20 years, of tens of thousands of women, have failed to demonstrate any link between breast implant surgery and increased risk of developing any disease, whether autoimmune or not. While this is not a guarantee that this cannot happen in some exceptionally rare circumstance, it should reassure patients that the chances are extremely remote. **Recently, the FDA has begun a registry to look at a possible connection between breast implants and an extremely rare form of lymphoma of the breast. To date, some 35 or so women with implants have developed this lymphoma. The numbers are too small to draw any conclusions. Most case seem to involve implants placed for reconstruction, implants older than 8 years, and textured implants. It may be 10 years or more before we will know if there is any connection here. The FDA has not felt this problem justifies any change in the status of breast implants as a medical device.
Interfering with mammograms- implants do block x-rays and produce a shadow on mammograms. To get around this, mammogram techniques are modified for women with implants. An Eklund, or displacement, technique is used to push the implants out of the way, and additional views are taken. Most, but not all, of the breast tissue can be seen. It is theoretically possible that a small lump might be missed, and if this lump were cancerous, this could result in a delay in diagnosis and treatment. Studies have compared breast cancer patients who had breast implant surgery with those who never had implants. No statistical difference has been found in the results of the cancer treatment between the two groups. Capsular contracture, by making the breasts difficult or impossible to compress can compromise mammography. Breasts that stay soft can be examined by mammography more effectively. This is why I feel compliance with the program of breast massage, taking vitamin E, and using a compression garment to help keep your breasts soft is so important.
Complications common to all surgery- Breast augmentation also has many complications in common with other surgeries. These include, but are not limited to, such things as infection, bleeding, poor quality scars, delayed healing, injury to structures in or around the area of surgery, complications related to anesthesia, and complications which can be serious, or even life threatening, such as blood clots in the legs or lungs, heart attack, stroke, and pneumonia. The likelihood of any of these happening to you is less than 1%. There are many more potential complications of surgery, enough to fill a book, but these are exceedingly rare and will probably not be seen in a surgeon’s career.
Summary of complications-While complications from breast augmentation are rare, they can and do occur. The only way to completely eliminate the potential for complications is to avoid surgery.
Future surgery
It is highly likely that at some time in the future you will need, or simply desire, another operation on your breasts as a result of implant surgery. The most likely would be to replace a leaking implant but you may also elect to remove them at some time, exchange them ( for something larger, smaller, or, perhaps, a newer, better implant than is available today), correct a late occurring contracture (this is rare but can happen), perform a breast lift for sagging, or some other procedure. Because breast augmentation is a cosmetic procedure, any surgery related to this will probably be regarded as cosmetic by most insurance companies and, therefore, not covered by insurance.
What will your breasts look like years from now?
Many things will affect your appearance over the years. Pregnancy (if applicable), weight loss or gain, health issues, habits (exercise, sleep, diet, smoking, drinking, etc.) the manner in which you age, and your genetic makeup, to name a few. It is therefore impossible to predict how your breasts will look. After implant surgery, your breasts will be heavier and gravity will affect them more. I recommend that you not go braless routinely. Beyond your skin and some fine ligaments, both of which will stretch with time, a bra is the only support your breasts have.
Smoking and breast augmentation
Besides being one of the worst things for your health, smoking can have very significant adverse effects on the results of breast augmentation. Patients exposed to cigarette smoke during the critical period before and after surgery are much more prone to developing capsular contracture, which I discussed above. This holds for those who smoke themselves, and those who inhale much second hand smoke. I have all patients sign a disclaimer that states they will be responsible for any ill effects of smoking. If contracture occurs in a smoker, I do charge a surgeon’s fee to perform corrective surgery in addition to the expenses of the surgery. Smoking should be stopped for 6 weeks before surgery and abstained from for a full 3 months afterwards.
Guarantees
When I perform breast implant surgery, I can only guarantee one thing; that when I do the surgery, I will bring to bear all of my skill and experience on that day to provide you with the best result that I can. There are innumerable variables that can affect the outcome of any operation. Many of these are out of my control, and yours. You must understand, and accept, this small degree of uncertainty if you wish to undergo a breast augmentation. If you decide to move forward with the surgery, it is my hope that six months later, you will be glad that you had the surgery, and would do it all over again if given the chance. I will do my utmost to achieve that goal.
