WHAT THE SURGERY WILL DO
breast implants will make small breasts larger. To help our patient understand
what this will do for her, the breasts are visually examined. At this time, with
the patient partially disrobed, the patient may be asked what it is she would
like to accomplish, and it is wise to listen carefully and make a note of what
is said; the responses differ. Also the patient can be shown with a red felt tip
pen where the incisions can be placed and which site in the doctor's opinion
might be best for her (the incision that would provide the best result and leave
the least noticeable scar).
patient is told that we have a lot more information for them about the
operation, and a booklet is given to them. We then offer to show the patient and
whoever is accompanying them many before and after photographs.
site information is provided at www.ascbs.us
to help determine what patients would gain in appearance from the operation, and
a videotape can be shown which explains many pros and cons of the operation,
such as the common complications of the procedure and how to manage them.
23 May, 2002
seven choices we give our patients are:
Size of implant
Site of incision
Type of implant
Hospital or Office
General or Local Anesthesia
Subpectoral or Subglandular
the patient these choices allows them to have more control. A patient who is
fully informed and makes a reasonable choice is less likely to be unhappy than a
person who has no opportunity to choose.
of these choices may be explained to the patient, though the choice is generally
in agreement with what the doctor recommends. The size of implant and site of
incision are easy to explain and understand.
the type of implant, of anesthesia, and whether to place the implant above or
below the muscle, most will follow the surgeonís advice. The patient has very
little to rely on except the information they are given.
the patient to choose or to participate fully in the choices is recommended for
a more pleased and happy patient. It
is advantageous if someone such as a friend or relative can also participate and
offer the patient advice and support in discussion of the options and pros and
cons. It can be very helpful both
to the patient and the surgeon. Listening
very carefully to the patient's remarks and expressed desires, writing them down
as she speaks, and going over them again for a full understanding is a good
technique. These notes can then be
reviewed again with the patient the morning of surgery.
better informed patient is less afraid, feels more in control of her destiny,
knows what to expect, and is easier to manage.
frequently, a few months after surgery the patient wishes the implants were
larger, and yet before surgery the same patient was afraid they would be too
big. The same patient may wish they were smaller for some occasions, such as
jogging and participating in athletics, and would like them larger at other
times, such as for evening wear or to fill out a bathing suit. Let us recognize
that cosmetic patients are the type of persons who are displeased with their
appearance, and though the surgery may improve the appearance, it does not alter
the personality type. They still wish to be better, which is a healthy,
wholesome attitude so long as they are not inclined to take excessive risks to
achieve tiny, unnoticeable, vague, and ill-defined gains.
most common question regarding size patients ask is "What size would I need
to be to fill a C or D cup bra?" Or
the patient may simply say, "Make me just large enough to fill a C cup with
a little fullness." This
request sounds simple and direct enough, but not only will it require a
different size implant for each person, but may require a different size for
each breast on the same patient.
answer to the question of how many ccís (cubic centimeters) of implant size
are required depends upon how much breast tissue the patient already has. This
may be different for each breast, and the two breasts may already be unequal in
size, shape, and position of areola and inframammary folds.
The patient also may genuinely and truly be unaware of the differences in
the breast until they are pointed out to her, even though she may realize one is
a little smaller than the other. Also, the different bras and manufacturers have
different dimensions for a C or D cup.
best answer to size is the sandwich baggy technique.
the patient will go and purchase an inexpensive bra with the cup size she
desires to fill, then she can easily determine how much additional volume will
be needed to fill the cup of the bra in cc's with a sandwich baggy filled with
the patient takes some socks in her handbag to the store with her, she can fill
the bra with the socks while trying it on to see that it is the one she wants to
make her look good.
when she gets home with the bra she has selected, she fills a sandwich baggy
with water until she has the size that produces the most desirable appearance.
She does this simply by placing the filled sandwich baggy in the bra.
she has determined what sandwich baggy volume makes her look the best, all she
needs to do is measure the water in the sandwich baggies by pouring it in a
kitchen graduate marked in cc's or milliliters. We demonstrate this and show the
patient how to do this on her first visit to the office. We have her place
sandwich baggies filled with 250 to 350 cc's of water in her bra in the privacy
of an exam room with an assistant to help her. She can do this in front of a
large mirror, so that she may understand the idea and see how she will look with
her top on and off using different volumes of water.
this SANDWICH BAGGY TECHNIQUE, the patient can determine as exactly as anyone
what size will be best for her. It should be pointed out to the patient that
there is almost no detectable difference in 10% more or less, and we ask our
patients to grant us a variation of at least that amount, depending on what
looks best at the time of surgery.
water-filled sandwich bag sits out in the bra and does not fill all the areas
that need to be filled to provide the forward bra cup filling projection and
shape. In other words, the sandwich
baggy technique usually underestimates the volume required to produce the
expected result, and this is especially true if the implants are placed in the
submuscular position. As a general rule for the above muscle position, we
recommend adding 10% to the estimated volume, and for below the muscle, 20%.
there be problems with the implants in the future - capsules, sagging,
stretching of the breast skin due to pregnancy, breast cancer, etc. - one may
find that the problems with the implants are less severe if the implants are
smaller. Larger implants may cause
some pressure atrophy and thinning of muscle, subcutaneous fat, and breast
tissue, or possibly even affect the ribs if placed in the submuscular position.
the patient will choose implants that are too large, and have to be told that if
an attempt were made to over stretch the skin, stretch marks could develop.
Also, the smaller the implant, the chance of capsule contraction occurring will
be smaller. This is because relatively more breast tissue will be covering the
small implant, and therefore there will be less of a noticeable feeling of
firmness, as well as less possibility of distortion with the same amount of
capsule formation if the implants are small.
patient who appears to be choosing too small a size should be informed of the
nicer appearance larger breasts may have, and the before and after pictures are
helpful in explaining this. As soon as you have done 10 cases you will have a
nice collection of before and after photos to show patients.
most common error in all of the choices made by patients is having chosen too
small in choosing the size of the implant. Allowing the patient to have as much
choice and play as much of a role in choosing every part of the operation leads
to greater patient satisfaction and decreases the possibility of regret or
remorse from not having the most desirable result.
the patient a book of before and after photographs allows the doctor or his
assistant to ask which ones the patient would like most for herself. It also
helps the patient understand what she will obtain from the procedure if she sees
someone who looks like she did before surgery, then to see what the patient
looks like after.
this point it wise to explain to the patient that while there are some choices
the patient may have, the exact shape of the breasts, the areola and the nipples
cannot be chosen with any certainty with surgery limited to placement of breast
implants. Implants control the size or volume of the breasts but not
the shape (except to a limited degree), and they do not mitigate the sagging,
drooping, size or shape of the areolae or nipples, or the symmetry in position
in volume can be adequately corrected, and occasionally this, combined with a
change in the position of the inframammary fold on the smaller side, can do a
lot to make the breasts look more alike. Other asymmetries, such as an inverted
nipple on one side, a large areola on one side, a unilateral ptosis, etc., can
be corrected by various techniques, but not by breast implants alone.
the patient to bring in pictures from Playboy or other topless photos can be
helpful on a preoperative visit. This can allow the surgeon and his staff to see
if the patient's expectations are realistic.
very clearly worded disclaimer (such as the one our surgery consent provides) is
needed, which states that the patient will not look exactly like any certain
photographs, drawings, or other persons.
it is not a good idea to see the patient's desires in photos she has chosen on
the morning of surgery for the first time. They may be a long way from what can
2. Site of incision
the patient to choose the site of the incision may sound like an unsettling idea
to some surgeons, but more than 98% of the patients will accept the doctor's
recommendation anyway, so why not allow the patient to have as much say in the
matter as possible?
the patient whose breasts droop enough that the skin of the breast is touching
the skin of the chest wall when the patient is standing erect, the inframammary
incision placed slightly up on the breast just 1/2 to 1 cm above the new
inframammary fold should be almost completely hidden, and may be the preferable
and most recommended site.
the patient with very small areolae, the areola incision may be nearly
impossible. It is preferable to have this incision at least 2 cm long, and if it
is to be less than1.5 cm, and the patient really insists on not having it under
the arm, we may insist on permission to extend it laterally as much as 1/2 to 1
cm in each direction because it may not be possible to get an implant of over
200 cc volume through it.
we tell our patients the following: 1.) The areola incision made in the wrinkles
of the brown skin of the areola heals with the least scar, 2.) The inframammary
incision is most visible, except in pendulous breasts, and 3.) The axillary
incision is the least visible of all, unless the patient is a ballet dancer or
for some other reason has her arms in the air with the axillae exposed very
techniques of the different approaches and associated problems will be discussed
in detail in further chapters, but the patient may wish to know that the areola
approach is the only one of the three that invades the breast tissue. Yet, in
performing this incision technique in hundreds of women (and knowing others who
have also done hundreds of women with this approach), I have yet to see or hear
of breast nodules or cysts developing in the lower portion of the breast because
of this approach. Many patients I have done with this approach have subsequently
become pregnant and were able to breast-feed.
with the areolar approach, there has been no greater incidence of hypaesthesia
of the nipple or lower breast skin than with the other incisions in my
experience with more than 500 surgeries using this approach.
is an article in the literature that states that patients who have the areolar
approach have more difficulty breast-feeding than those with the axillary or
inframammary incision. This is a retrospective study and is unreliable, but
still the suggestion may be correct.
3. Type of implant
always the patient will accept the doctor's recommendation for the type of
implant. There were seven implant manufacturers before 1992 and the FDA. Now
there are only three - McGhan, Mentor and PIP. Their names, addresses and phone
numbers are listed together on a separate page in your workbook. The choice of
implants for the surgeon is discussed in chapter twelve.
times these companies will have videotapes on how to do the surgery. Wells
Johnson supplies endoscopic equipment for the umbilical approach and has
videotapes of that approach.
the patient wants is the best possible result, with no future problems. Many of
the reasons for choosing a saline over a gel, or a combination, or the Meme is
because of the rationale each one has for reducing the chance of or preventing
the capsule contracture problem. The Meme was the best. But since it was covered
with polyurethane foam, it was removed from the market and will probably never
return. It was this interface of texturing that led to the textured silicone
the beginning, after it was discovered that silicone injections could lead to
unacceptable complications and silicone was first placed in a silicone bag, the
first implants in the early 1960s were silicone gel and they were firm and
teardrop shaped. The capsule contracture rate was greater than 90%, with most
being as hard as your elbow, except for whatever breast tissue was overlying
them. So, softer implants were developed in the late 1960s.
softer implants would assume a teardrop shape in the upright position, and so
the teardrop shape was no longer necessary. Dacron patches then were popular to
hold the implants up, and while they do this to a certain extent, the capsule
contracture rate again approached 100% due to reaction to the Dacron. Also, the
breast tissue continued to sag over the implants even when the implants stayed
firmly fixed to the chest wall, resulting in distortion.
Dacron patches are very rarely used now.
the early 1970s saline filled implants were introduced and were softer than the
gel implant in the same patient when one side to the other was compared by
independent observers. The problem with the saline implants is the leakage and
deflation rate (which seems to be about 50% over a period of 10 years in my
experience with about 100 pure saline and around 500 combination gel and saline
patients). Yet many of the pure saline and many of the combination
saline/silicone gel implants that I used 15 to 20 years ago are still intact.
deflation often necessitates an additional operation, and since there is no
doubt that some capsule contraction occurs with saline implants, why should a
woman have to suffer an additional problem of deflation? For example I took out
some saline implants that had been put in elsewhere, and had already required
one revision because of deflation, and one side was completely collapsed and the
other had a capsule. The implants were small, and the patient could have
tolerated the firm side but was chagrined to have the asymmetry of a complete
collapse of the other, so we replaced them both with gels. So gels had more and
harder capsules, but were more popular than saline because of the deflation
problem. Not because the result was more natural or softer. The saline, in fact,
considering gel bleed as a cause of capsule contraction, please note that many
patients have a capsule develop only on one side, and usually the capsule
firmness and thickness is unequal on the two sides. Not only are a few capsules
unilateral, but most patients have unequal firmness, and often it is markedly
unequal with a soft breast on one side and spherical contracture and deformity
on the other. These well known findings must be considered for any theory of
capsule contracture. Gel bleed would occur almost equally and could not cause
such asymmetry in capsule formation.
choices in 1997 were all saline - textured or smooth and to be filled with a
valve or pre-filled.
shells have thicker walls and ripple more. The McGhan textured is deeper and the
implant will not move or flow in the pocket. This appears less natural. But this
deeply textured implant is less likely to have distortion and capsule
contracture. It ripples more and feels firmer, and is more palpable below the
nipple where the tissues are thinner. The 468 implant is a shaped, overfilled,
fairly firm implant, but it does not allow much of a stuck on appearance.
Because it is overfilled and less mobile, it does not seem as natural as the
softer, slick salines.
smooth implants have less rippling, are less palpable and are less firm than the
McGhan 468. But they are subject to more capsule contracture.
noted by the FDA, August 1991 BG pp2, "Since the saline filled implants do
not have the silicone gel, they are probably even less likely to increase the
risk of autoimmune diseases or cancer. But
since both types of implants have the silicone rubber envelope, such effects
cannot be totally ruled out, even for the saline filled implants."
the FDA presumption is that the silicone gel is more likely to cause autoimmune
disease or cancer than solid silicone. Yet these reactions on the immune level
are microscopic and the difference in the gel and the solid silicone chemically
on the level of the molecular structure is analogous to the difference in ice
and water. And if the chemistry is the same, the molecular reaction should be
approximately the same.
Other factors for the choice of implants will be discussed further in chapter 12. Even if gel were to return, many probably would continue to use saline because of possibly decreased liability, being accustomed to them, reduced incidence of capsule contracture, smaller incisions being required, and an overall reputation of greater safety from all the unproven but suspicious problems associated with gel.
This is page #2.
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