Breast Augmentation:
I like to use several methods to determine size, shape and projection of the implants. First and foremost is your communication to me at our consult. I couple that with photos that you have selected or bring to help communicate your desired outcome. I will also take measurements to determine what size would fit your torso and chest wall. Lastly, and very importantly I will try sizers out in the operating room to determine the final size, shape and projection of the implant. I do this with you sitting up, while asleep to give us the most accurate determination.
So, you can see it is a multifactorial assessment to arrive at the best size for you.
Another issue is saline versus silicone. Saline is wonderful because our bodies are largely composed of saline and when saline implants fail or leak (all implants do at some point) it tells you that they have leaked by getting smaller. That’s terrible when you are on a cruise, but at least you know and can correct the problem. Another positive about saline implants is they seem to have less capsular contracture or tightening than their silicone competitors. The problem with saline implants is the rippling! Women hate that and choose silicone for that reason. So, you must go with what is most important to you and with what you feel best about.
Silicone implants are wonderful because they don’t ripple as much as saline. They have a more natural feel. This is the most popular choice right now for women. The problem with silicone is that we cannot tell when they have ruptured or failed, hence the term “silent rupture” unless we order an MRI study which is very expensive and a nuisance. The FDA suggests getting MRI’s after the third year and every other year thereafter. Rarely is this done. Very, very few women do this.
Choose a surgeon with experience, skill and judgement, who is willing to listen and communicate with you and help you determine what is best. There are so many factors that go into making a wise decision, it is best to select a surgeon you can trust and partner with to help you choose the very best and unique option for yourself.
Fantastic results of course! When we carefully assess and set expectations accordingly, you can and will have a great outcome.
Initially, you will be swollen from surgery and the implants can “ride” a little high at first, but usually settles down after six weeks.
Your pain won’t be horrible either, because we will place a long acting anesthetic in the pocket to help. After a day or so we will place you on ibuprofen and that works amazingly well for pain control.
Yes! We want to have your breast size at normal for you so we can size you appropriately at surgery. A good suggestion and guide is to wait 3-6 months after breast feeding.
Breast Lift:
Breast lift or mastopexy is very different from simple augmentation. Augmentation does not really lift the breast. That is a bit of a myth. Sure, the breast skin will be tighter with augmentation, but that can relax over a very short time. In fact, when an augmentation is done to lift the breast, you can usually count on a less that desirable outcome. It can lead to a very disappointed patient.
There are a host of factors that go into a decision to lift a breast and even more factors that go into deciding whether to lift and augment at the same time. Stretch marks or striae, postpartum involution and decrease in breast size, and where the nipple resides in relation to the breast are just a few. Most women understand the word “sagging” as it relates to their breasts and when I hear that in a consult before examining the patient, I can usually predict the patient will need a lift.
If a patient’s breast can hold a pencil in the inframammary fold that is another simple do at home test that can predict the need for a lift.
Usually this is a very simple and easy decision, but occasionally there are borderline cases, and this again requires a consultation and discussion about expectations and outcomes so the appropriate decision can be made.
There are three basic types of breast lifts, the circumareolar (around the nipple areola), the lollipop or circumvertical, and lastly the anchor or (wise pattern) type. We can help you decide what is best for you.
It is very important to decide whether an implant should be used with a lift.
A small or even a large implant will give “upper pole” fullness that is almost impossible to get any other way. Many women crave that upper pole fullness they used to have while breast feeding or before children. This is why we often combine augmentation with a lift to achieve that look. Again, it is so important to team up with an experienced surgeon who can guide you in these decisions.
There is always risk associated with everything we do like driving our car or taking a walk. Thankfully, risks associated with elective cosmetic surgery are usually very low. Common to any surgery are risks such as infection, and bleeding and need for further surgery. Unique to breast lift surgery are risks such as loss of nipple sensation, or poor scarring, or risks associated with breast implants such as capsular contracture, or implant failure.
If a patient is healthy, not obese, does not smoke and is active. The risks are usually very low for elective cosmetic surgery and breast lifts specifically. Don’t be afraid to bring this topic up with your surgeon. Ask if the surgeon has had any such complications. The answer will be telling. All surgeons have complications, the key is how those are recognized and managed. Again, choose wisely a surgeon with a proven track record, and experience doing breast lifts or whatever and then have a frank discussion of any of your concerns.
Breast lift surgery results are long lasting and durable and fortunately don’t require too many repeat surgeries. Augmentation with a breast lift is a challenging procedure but can be incredibly gratifying and long lasting.
Adjusting surgery to fit the patient makes for much more durable and lasting results. Considering height, weight, BMI, breast size, skin elasticity, activity levels and setting reasonable expectations make for the most long-lasting results.
A breast lift alone is very well tolerated and usually without much post-operative pain. Breast lift with augmentation is obviously more surgery and because the breast implant stretches the pectoralis muscle it is more painful –very similar to breast discomfort with breast milk coming in.
Recovery is closely monitored. Patients can shower the next day. They can drive when off pain medication. They can go out to eat, or shop or watch a movie. However, in the first two weeks, care is taken to avoid heavy lifting (over ten lbs.), straining, and exercising. The exercise-of- choice is walking. After 4-6 weeks full and unlimited activity is permitted.
Your breasts will initially be swollen and high, but this will resolve in the first 2-6 weeks post op. Surgical changes along suture lines will smooth over 3 months and the incision lines will lighten and become less conspicuous over time. It is well to remember that scars take 8-12 months to fully mature. Therefore, I insist that my patients wear a bra and tape the incisions at least for 6 weeks.
Tummy Tuck Or Abdominoplasty:
Tummy tucks are great procedures for the right candidates! Usually, but not always tummy tucks are for patients who have lost significant weight and the skin is loose and “floppy”. Tummy tucks are for patients who have skin laxity for whatever reason such as weight loss, pregnancy and resulting stretch marks, or for those patients where the abdominal (rectus abdominus) muscles have spread apart. This can be defeating for a patient who works hard to control weight and exercise only to find a bulging abdomen in the midline.
It is generally suggested that this procedure be done after a woman completed child bearing. There are exceptions of course, and massive weight loss and other considerations are explored at the consult.
There are many different types of tummy tucks including a circumferential or extended type. Standard tummy tucks are most common but are being replaced by a newer and improved technique popularized by Brazilian surgeon Osvaldo Saldanha. This is a combined liposuction and tummy tuck procedure that is truly remarkable. Other kinds are mini and skin- only tummy tucks and a technique called an umbilical float or belly button floating technique for more minor type skin issues.
Tummy tucks have become much more refined and the introduction of “Exparel” and progressive tension sutures along with lipoabdominoplasty have made for incredible advances is this very popular and sought-after procedure.
All of these should match the concern of the patients and be guided by an experienced and skillful surgeon familiar with these techniques.
Safety is always paramount, and patients who are overweight increase the risk of surgery. Smokers, obese patients and those who are prone for blood clotting must be carefully screened and counseled before surgery.
Tummy tucks or abdominoplasties are very much like going through a C-section. Many women can relate to that. It takes about six weeks to get back to a routine exercise regimen and one must be careful particularly in the first two weeks to be careful with activity levels to avoid postoperative bleeding.
One remarkable medical breakthrough has been the introduction of Exparel, a long acting type of “Novocain” that can decrease pain significantly by providing anesthetic relief for approximately 3 days. We have been using this for several years now and it has been a game-changer for tummy tucks. Patients can move more freely and tolerate the muscle repair much more easily, almost that we must remind patients to curb their activity levels early on.
Most patients can shower the next day. Patients are encouraged to walk about the house initially and then increase that activity. Patients can drive once off pain meds and ibuprofen is introduced early on to get patients off the narcotics which cause constipation and feelings of nausea.
Liposuction:
There are several different techniques, cannulas and devices that can be used for liposuction. Some systems vibrate, others use water, still others use heat and of course many patients have heard of CoolSculpting which uses freezing to remove unwanted fat. The wonderful truth about liposuction is that you can “spot reduce” an area of fatty deposition. You can sculpt and contour which is almost impossible with exercise, diet or medications. To be able to “spot reduce” an area of unwanted fat is the incredible benefit of liposuction. The key consideration is the overlying skin and its elasticity. This is critical and makes for a wonderful result as compared to a mediocre or disappointing result.
Liposuction is performed by first marking and identifying the area of concern. Then after adequate anesthesia, either local or general, the fat is removed via a cannula (tube) with suction. Myriad techniques abound, but I prefer using a technique labeled SAFE by a plastic surgeon in Louisiana. This means initial fat Separation and Fat Equalization. This particular technique uses a vibrating system to separate and then smooth the area after suctioning the fat away. The results are usually excellent and depend heavily on patient selection and site location.
The key principle again is assessing the overlying skin and determining if the skin can tighten after removal of fat. Much like the skin tightens after pregnancy.
The ideal candidate is a patient with a localized area of fat, and who has excellent skin elasticity. It is not a weight loss procedure. It is a sculpting procedure and can provide dramatic and long-lasting results.
A wide array of areas is commonly treated including the neck, bra roll and upper back, the lower back or flanks, abdomen, inner and outer thighs, knees and ankles. Each area has unique considerations and require different approaches and technique.
Liposuction is often used in conjunction with other procedures such as face lifts, tummy tucks and fat grafting procedures. The newer infiltration techniques coupled with power assisted liposuction and special cannula configurations make liposuction very popular.
Botox
The main concern with Botox is if it somehow finds its way into the wrong anatomical area which can then paralyze the wrong muscle, leaving the patient with an unusual facial animation. Fortunately, this is short-lived and temporary but still a risk—although it be very rare.
Other risks are outlined in most literature and consent forms. There is always a risk of a small bruise at the site of injection. This probably is the most common risk.
Another concern is over- treatment of the forehead muscles, which can smooth forehead wrinkles, but drop the brows. This can be annoying and again, temporary.
Botox continues to find more and more uses not just in plastic surgery, but other medical disciplines as well. Migraines are commonly treated now with Botox.
Most common areas to be treated are the corrugators or the wrinkles between the eyebrows, the wrinkles just lateral to the eye commonly called crow’s feet. Other areas are the forehead to smooth the wrinkles there along with the DAO (depressor angularis orris) which can help with the corners of the mouth, the chin, and the neck or platysmal bands so common in very thin patients.
Generally, three months. After injection it may take 24-72 hours for the onset of effect and then excellent persistence for 3 months. There are a very few patients which can develop antibodies to the Botox and the effect is lessened or requires higher dosage. Dysport another form of “botox” can be used as well.
Male Breast Reduction
When a young man or even a middle -aged gentleman is fearful or embarrassed to remove his shirt at the pool or the beach because of enlarged breasts (gynecomastia) then there is good reason to consider male breast reduction surgery. It is one of the most gratifying procedures both for the surgeon and patient.
I recall a fourteen-year-old who came to visit me an almost refused to take his shirt off. He was so embarrassed. After his surgery it was life-changing for him. He would look me in the eye, easily remove his shirt and had a great burden lifted from his life.
Patients who are in good health, don’t smoke, and are motivated make the best candidates. Skin quality and size of the breasts are important factors. Some patients with very large and pendulous breasts will need more aggressive surgical maneuvers to achieve the desired result.
Sometimes different drugs and marijuana can cause the male breast to enlarge and become feminine (gynecomastia). A careful history to rule this out is important. Another contribution may be increased weight which can cause the breast to appear larger.
Usually a combined approach is wise, using liposuction and actual surgical removal of hard to suction breast tissue. The incision is usually made at the areola junction and is inconspicuous. Occasionally we can simply suction the breast and get a very nice result and conversely a very small subareolar gynecomastia can simply be removed surgically without any suction.
