Dr. Bosshardt’s Weblog

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.

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 my own ambulatory surgery center (ASC). This office houses 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. I have 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 privileges at Florida Hospital Waterman and Leesburg Regional Medical Center if you wish to go elsewhere for surgery. Because this is a state licensed ambulatory facility, patients cannot be kept overnight. In 17 years, 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 17 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 is very new, and somewhat controversial. 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 15-20 years ago, has fallen out of favor. 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 2.5 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 3 years after implantation and every 2 years after that to check for leaks. One problem with this is that MRI’s are expensive and it is unlikely that insurance will 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 17 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 expenses. This offer is good for one year from the date of your surgery. I do not profit from doing such revisions.

Bra cup size
Please understand that there is no established standard for what is an A, B, C, or D cup bra. The style of bra, type of material, manufacturer, and personal patient 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 secondary. 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 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 the calcium 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.

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.