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Tag Archive for 'breast enlargement'

Where to place the scar in breast augmentation?

Published
on August 1, 2009
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breast-augmentation

Patient question:

Hi Dr. Yates, You do great work. What incision you prefer and why? Do you think periareolar incision has a higher chance of loosing nipple sensitivity? I saw most of your example are crease incision. Please also advise the BA fee, saline & silicone. Thank you.

Dr. Yates Reply:

Personally, I think of the three major decisions: 1) type of implant, 2) size of implant, and 3) location of scar, that the scar location is by far the least important.  As I am sure you have read I do not prefer the armpit or belly button incisions for their lack of accuracy, leaving the periareolar and crease incisions.  I used to believe that the periareolar incision had the opportunity to hide better because of the anatomic boundary between nipple and skin that you could hide the scar.  I think the crease is even a better anatomic boundary.  However, If the crease incision starts at the crease it usually ends up a little above it on the breast which is not desired.   It does take some skill and experience to allow the final scar to END UP at the crease.

Yes there is a slightly higher risk of issues with nipple sensitivity and also breast feeding with the periareolar incision.

The cost of breast augmentation in my office is $4100 for saline and $5200 for silicone.   My fee has not changed substantially in 6 years and it will likely increase at the first of the year when I audit my fee schedules.

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New silicone breast implant size options now available

Published
on July 23, 2009
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The Mentor corporation has announced more options in their already excellent selection of memory gel silicone implants.

Silicone MemoryGel Breast Implants

Smooth round memory gel implants by Mentor are my current preferred choice for silicone implants.  I received a fax from the company yesterday that they have manufactured eight new size options.  Two of these are in high profile implants 475 cc and 750 cc.  Four of these are in a moderate plus profile 425 cc, 475 cc, 525 cc, 575 cc, 650 cc and 750 cc.

As opposed to saline implants, silicone implant come pre-filled.  Previously silicone implants came in 25 cc intervals starting at 100 cc to 450 cc in high profile and 400 cc in moderate plus profile.  Above that, the implants came in 50 cc intervals to 700 cc.  This meant that for patients choosing implants above 400 cc they would have to jump up considerably to the next size.  These new implants fill in some of the gaps giving patients and plastic surgeons more options.  Good job Mentor, but what took so long.

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Breast augmentation scars

Published
on June 15, 2009
. 2 Comments

Accuracy is the key

There is a lot of discussion at the time of breast augmentation consultation regarding the scar.  In my opinion “where is the best place to hide the scar?” is an important question but an even more important questions is “through which incision is breast augmentation most accurate?”

There are three main incisions for breast augmentation, around the nipple, under the breast crease and in the armpit.  There are two other uncommon incision choices, through the belly button (TUBA) and through an abdominoplasty incision.

Implant pockets must be symmetric

The most important variable that determines the outcome of breast augmentation is the quality of the implant pocket created.  For perfect results, these pockets have to be perfect.  Not just close.

Although no plastic surgeon (including myself I hate to admit) could ever expect to achieve a perfect result every time, the odds are much better through incisions close to the implant pockets.   Those being the crease incision beneath the breast and the incision around the nipple.  The other incisions are great in theory but just not as accurate.

Rather than assessing the pocket size, spacing and symmetry with the surgeons gloved fingertips simultaneously, the pockets are assessed individually with a long instrument.

Imagine the task of simply writing your name.  The armpit incision would be the equivalent of holding the end of a 3 foot long pen.  The belly button incision would be the equivalent of a 10 foot pen in the dark.

Breast incisions are more accurate

The scars around the nipple and under the fold heal very well and are generally not bothersome to patients.  For saline implants, they are about 1″ long, for silicone about 3″.  If they are well placed they hide very well.  I do not charge for scar revisions and can count the number of these scars I have had to revise on one hand!

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Breast implant sizing. How to get it right.

Published
on June 6, 2009
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breast-augmentation-23

Unhappiness with breast size is one of the most common reasons for revision surgery after breast augmentation.  There is a best breast implant size for each patient and there is an art to getting it right.

The breast implant should fit the body type.

  • Large implants on a short of stature patient just make them look heavy.  Conservative sizing is important.
  • Large implants on the very thin patients look “augmented”, top-heavy and generally overdone.
  • Large implants are best suited for medium to tall height patients who have wide hips and larger lower bodies.
  • Symmetry in nature is beautiful.  There was a recent study published in Plastic and Reconstructive Surgery that looked at body type.  Photos of the same woman were “morphed” at various heights and builds.  Patients with thin hips were found to be most beautiful with small to medium breasts and the opposite was true with fuller hips.  “The top should match the bottom”.

It can be very difficult for a patient to adequately communicate the final breast size that they are looking for, particularly when they often aren’t entirely sure themselves.  A few tools are available to help a patient feel comfortable with their decision

  • Review pictures, look for patients with your similar build and breast size.  Record the size of implants they got and start making notes.
  • There are commercial breast implant sizers available to wear in your bra.  You can wear them in different situations and with different clothing styles.  There are a few available, I have provided a link to one such sizer.  They cost about $60 and come with a bra and variety of sizers.
  • If you don’t want to pay for sizers, simply filling plastic baggies with rice or water will do.  Measure the amount that gives you the result you are looking for.  A little less convenient but a good option.
  • Make sure there are open lines of communication between you and your plastic surgeon.  Personally, I feel that natural looking augmented breasts are far superior to “done” or augmented looking breasts but that is only my opinion.  This is one place that I give a great deal of responsibility to the patient.  Of course, if they choose a size that I feel would be a problem we discuss the reasons for this.  Patients are generally good judges of what is best for them when armed with information.
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How to prevent complications in breast augmentation

Published
on June 5, 2009
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Breast augmentation is a fairly routine procedure in most plastic surgeons offices.  There are risks associated with every procedure.  There are a number of steps that can be taken with breast augmentation to help to minimize these risks.

1) Unhappiness with size.  This one is largely the responsibility of the patient.  Although your plastic surgeon can recommend a certain size based on his perception of your goals and your body frame, in reality your goals may change after surgery.  Many women have fears about going too large before the surgery and as a result are conservative with their choice.  After surgery many feel they should have gone larger.  My recommendation would be to go as large as you feel comfortable.

As an editorial side note, I actually believe that most augmented patients choose a size that is too big for their frame.  Symmetry in nature is beautiful.  The circumference of the breast matching that of the hips is what I would consider ideal for any patient (take a tape measure and try for yourself).

2) Deflation/ rupture.  Saline implants deflate if they fail whereas silicone implants rupture.  For saline implants this risk can be minimized by overfilling the implant.  The deflation rate has been found to be much less significant in fully filled or over filled implants.  Under-filling or filling to only the minimum fill volume can lead to a “fold flaw” similar to a crease on a newspaper where the implants simply wear out from the repeated folding.

3) Rippling.  Rippling is a visible or palpable irregularity of an implant through the breast or skin.  Silicone implants are less likely to ripple because they hold their own shape better.  Additionally, overfilling saline implants helps avoid rippling as well.  Thin patients with small breasts generally have a higher risk of rippling and in some cases are better candidates for silicone implants to help prevent this

4) Capsular contracture.  There are a number of factors that lead to hardening of the breast over time.  Silicone implants are more likely to have contracture.  Low grade infection, hematoma, and placement above the muscle are also risk factors.  I prefer to give patients antibiotics before and after breast augmentation and I place the implants in an antibiotic solution before augmentation to help minimize infection risks.

5) Implant displacement.  The key is proper pocket formation.  For this reason I do not prefer the “remote” incisions; armpit or particularly the belly button.  They are simply less accurate.  Success should be measured in terms of millimeters with this operation.  The patient has some responsibility in this one as well.  In the first few weeks after surgery, over doing it can cause implant displacement and limiting aggressive physical activities for 6 weeks is important.

6) Nipple numbness.  This is actually quite uncommon in my practice.  Avoiding cutting along the course of the nerves to the nipple is the key.  Occasionally there will be temporary numbness from stretch of the implant over particularly large implants.

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Breast Implant Warranty

Published
on May 26, 2009
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Breast implants are a significant investment and one that can last for a very long time, hopefully a lifetime.  Breast implants can fail for a number of reasons and many have to be replaced.  The manufacturers of breast implants have provided excellent “warranties” for their implants so that in the event a replacement is necessary because of failure of the implant due to rupture or deflation the patient is covered financially.  It is important that patients understand that there are other potential problems that may require implants to be replaced for which these warranties do not apply including; capsular contracture, infection, rippling or unhappiness with the size of the implants.    

The two major manufacturers of breast implants are Mentor and Inamed (Allergan).  Both have an excellent lifetime warranty of their implants that comes standard.  Patients are automatically enrolled for the standard warranty.  Both also provide an additional “extended warranty” for an additional fee.  Mentor has an excellent new promotional program for their MemoryGel™ implants

Allergan Medical

Allergan’s standard program is called ConfidencePlus™

  • Applies to all implants placed after April 1, 2002
  • Automatic enrollment free of charge
  • Lifetime product replacement
  • Saline and silicone implants covered
  • 10 years of financial assistance of up to $1,200 if replacement is necessary (for surgeon, anesthesia or facility fees)

Allergan’s extended program is called ConfidencePlus™ Platinum

  • $100 enrollment fee
  • Up to $2,400 financial assistance if replacement is necessary
  • Replacement of the other implant at the surgeons’ request

Mentor Corporation

Mentor’s standard program for saline implants is called the Mentor Advantage Limited Warranty 

  • Applies to all implants placed after May 1, 2005
  • Automatic enrollment free of charge
  • Lifetime product replacement
  • Replacement of the other side at the surgeons’ request
  • 10 years of financial assistance of up to $1,200 if replacement is necessary (for surgeon, anesthesia or facility fees)

Mentor’s extended warranty for saline implant is called the Mentor Enhanced Advantage Limited Warranty

  • $100 enrollment fee within 45 days of surgery
  • Up to $2,400 financial assistance if replacement is necessary

Mentor has a new program called the Mentor Premier Advantage Limited Warranty for MemoryGel™ silicone breast implants.

  • Limited time offer May 1, 2009 to December 31, 2009
  • Free of charge
  • Lifetime product replacement
  • Replacement of the other side at the surgeons’ request
  • 10 years of financial assistance of up to $3,500 if replacement is necessary (for surgeon, anesthesia or facility fees)

If you have breast implants that have ruptured or deflated, they may be covered by the manufacturer.  You may file a claim by contacting the product evaluation department to see if they are covered.  The number for Allergan Medical to submit a claim is 800-624-4261.  For Mentor the number is 866-250-5115.

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Breast enlargement creams, and pills – too good to be true!

Published
on April 4, 2009
. 4 Comments

Breast enlargement creams?, breast enlargement pills?, There are claims everywhere that you can increase you breast size one to three cup sizes without the costs and risks of surgery. Sounds too good to be true? Lets look deeper.

Breast enlargement cream and breast enlargement pill claims These creams and pills generally claim to work as phyto-estrogens. These are “naturally occurring” herbs and other chemicals that are involved with modulating a woman’s hormone levels. They claim to be safe, because the active ingredients are natural and although they cause a modification of the woman’s own hormones, there are no hormones in the product. Reviewing product ingredients, most of these contain one or a combination of saw palmetto, fennel seed, black cohosh, dong quai, Fenugeek, and L-Tyrosine. Some of the top selling brands including Perfect Woman, Breast Actives, Cleavage, and Embrace “work” in this manner. Another common breast enhancement cream, Benefil, claims breast enlargement from dilation of the blood vessels in the skin from caffeine. Also, they claim that their cream tightens collagen which improves breast tone and lifts saggy breasts. This does not work hormonally. I am actually sure that it doesn’t work at all, as this makes no medical sense.

Breast development physiology 101

Breast development is a complex process that is largely hormonally driven. The three main hormones involved are estrogen, progesterone, and prolactin to keep it simple. During puberty estrogen starts the process of breast development. After a woman begins to menstruate, progesterone comes into play and there is a delicate balance between estrogen and progesterone that triggers various points of the ovulatory cycle. During pregnancy the progesterone levels increase significantly and there is a second large peak in breast size. This is maintained during breast feeding by estrogen, progesterone, and prolactin, which is the breast milk producing hormone which stimulates the breast ducts and engorgement of breast feeding.

Safety and effectiveness of breast enhancing pills and creams.

It would make sense that if science could find a way to hormonally trick the breasts into thinking they are pregnant, going through puberty, or breast feeding that breast enlargement would occur. Yes this is possible. No this is not safe! There are many cancers including uterine cancer and breast cancer which estrogen exposure has been associated as a risk factor. Hormones are at a constant state of balance and equilibrium. Disrupting this balance could cause a cascade of problems that only time and further research will demonstrate.

So they may be dangerous, but do they work? First, none of these pills or creams are FDA approved. The FDA has stated that claims that these substances cause breast enlargement are misleading. They are sold as herbal supplements and as such are not subject to the rigorous safety and effectiveness standards of the FDA. As a plastic surgeon, I have yet to meet a patient who claims to have experienced any beneficial effect from these products. I see several women every day that are very concerned with the size of their breasts. It would make sense that if these products worked I would have heard at least one success story by now! The alternative is breast augmentation surgery which has a proven track record of safety and effectiveness for the last 40 years and it is only getting better.

Don’t waste your money. Don’t be an experiment. Don’t be a sucker. Breast enlargement creams and pills truly are too good to be true.

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Which are better, saline or silicone implants?

Published
on February 2, 2009
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It is interesting to me that there is often an almost religious or fanatical attachment for some patients to either saline implants or silicone implants. I frequently hear “I don’t want those silicone implants that caused all of those people to get sick”, or “I don’t want those fake looking saline implants”.
In November 2006 the FDA lifted its moratorium for the use of silicone gel implants in primary augmentations. The moratorium was the result of a number of women complaining of connective tissue disorders that were felt to be attributed to the implants. The implants were taken off the market while further scientific research on the implants was performed. It is unfortunate that those women had gotten ill but after further research it was determined that the implants were not the cause. In other words, these were illnesses that would have occurred with or without implants. With the release of silicone implants for primary augmentation, the patient again has the choice of saline or silicone implants. So which is better?
Both saline and silicone implants have an outer silastic shell. The silicone implants are filled with a cohesive silicone material and the saline implants are filled with sterile salt water. The newer generation of silicone implants is more cohesive than previous implants which may decrease the risks of gel “bleed” and capsular contracture.
The advantages of saline:
1) cost – about $1000 cheaper
2) adjustability – implants are filled to allow the surgeon a little more flexibility to “fit” an individual patient or to even up size asymmetries.
3) shorter scar – My incision is only 1″ long, the implant is filled after insertion.
4) Easier to diagnose a rupture or deflation – it simply goes away.
5) Lower incidence of capsular contracture.
Disadvantages of saline:
1) Less natural feel
2) Higher risk of rippling – this is visibility of the implant most commonly beneath areas of poor coverage over the implant.
Advantages of silicone:
1) Better feel
2) less rippling
Disadvantages of silicone:
1) cost
2) lack of adjustability
3) longer scar – usually at least 2″
4) difficulty in diagnosis of rupture – may require an MRI
5) higher risk of capsular contracture
Notice that I did not state that one looks any more or less natural than another. Aside from cases where rippling occurs with saline implants, I would submit that they look the same. In my opinion, silicone implants are ideal for the thin patient with little breast tissue coverage. With more coverage (larger breasts or more subcutaneous fat) the advantage of the feel of silicone is lost and saline implants are better for all of the reasons listed above.
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