2301 Plastic Surgery

If breast augmentation is being performed for reconstructive reasons (such as significant breast asymmetry), it can be performed under 18 with parental consent. If augmentation is desired for strictly cosmetic enhancement of the breasts, the FDA has approved saline implants for women 18 and older, and silicone for age 22 and up.

Patients who are either considering breast enhancement or currently have implants should be aware of “BII” and BIA-ALCL, both of which are receiving media attention. Knowledge of the current scientific understanding of implants and associated risks should help alleviate some stress that can be generated by social media and news coverage.

Capsular contracture is the name given to hardening of the breasts caused by aggressive shrinking of the scar capsule around the breast implant. Any time an implant is placed in the body, it will be incased in a layer of scar. For most types of implants (such as chin implants lying on the jaw bone or titanium plates used to repair finger fractures), it does not matter if the scar capsule shrinks tightly, as the implants are firm and cannot be deformed by the relatively weak force of the scar. Breast implants are a different matter. The goal of breast augmentation is to enhance breast volume and for the breasts to feel natural and soft–ideally, you should not be able to feel the implant. In this setting we are asking the scar around the implant to do something different than is desired everywhere else in the body: we do not want it to shrink. (You would love it if the skin incision used to place the implant shrinks down to a tiny line!) If the scar capsule around the implant is soft and wider than the implant, it won’t be noticed at all and the only thing you might feel is the wall of the implant. If the scar is thick, aggressive and shrinks tightly around the implant, then it will feel like a rock in the breast and we call it capsular contracture. There are several theories why a patient might form this type of aggressive scar, the two most relevant being a genetic predisposition to aggressive scars or an irritant theory (your body might find something irritating about the implant, such as a low-grade infection hiding on the implant wall, or silicone leak such as that which occurred with old-generation implants). There is no way to test to see if you have a genetic pre-disposition to forming aggressive scars–and luckily this does not happen often. There are steps that can be taken to reduce the other possible causes of capsular contracture, including using current generation implants and antibiotic use during the surgical procedure. With smooth implants, I recommend performing displacement exercises to decrease the chance of capsular contracture.

Everyone knows smoking is bad for your health and increases the risks of getting cancer. From the standpoint of a plastic surgeon practicing cosmetic surgery, smoking increases both short-term and long-term risks. Smoking (or even just nicotine use) has a vasoconstrictive effect, and thus slows blood flow. Peripheral tissues (like the skin) really see this effect. Chronic smoking accelerates skin aging by reducing the ability of skin to heal from the constant damaging forces we see during normal life (such as sun exposure.) This means that smoker’s skin will wrinkle faster than non-smokers, and will also stretch out faster as the youthful elastic properties of skin are lost. For implants, this means “perky” breasts will drop faster, and the chance of implants “bottoming out” is higher. In the short term, smoking around the time of the operation increases all surgical risk due to the reduction of blood flow and the delay in healing. Scars will tend to be wider and more visible, and infection rates are higher. For breast augmentation, I recommend stopping both smoking and nicotine products for 3 weeks before and after surgery.

The recommended age to start screening mammograms varies in the literature, and depends on the family history of the patient. For women who have no family history of breast cancer, screening mammograms start at age 40 (ACR / SBI guidelines) or 50 (USPSTF guideline). For women with a strong family history of breast cancer, it is recommended to start screening at age 30. Breast enhancement surgery significantly changes the breast in a number of ways: a breast augmentation elevates the breast tissue off of the chest, and the implant reduces the amount of breast tissue that can be seen in mammograms. Breast lift or breast reduction operations require re-arrangement of the breast tissue itself, and could potentially spread a cancer if it was crossed during the operation. For these reasons, I recommend a screening mammogram within the last year for all women over 40 (30 if there is a strong family history).

The answer really depends on when you stop breast feeding. You breasts will be enlarged with milk, and it will take some time after stopping breastfeeding for your breasts to finish involuting (shrinking). You want to be sure that your breast has stopped shrinking before considering augmentation, otherwise your breasts will not be as full as desired after surgery. It is reasonable to consider augmentation somewhere between 3 to 6 months after finishing breastfeeding.

It is very normal to have altered nipple sensation for a period of time after breast augmentation. Think about it – the implant is adding volume to the breast and stretches the skin. Nerves that run through the skin are stretched, and stretched nerves are not “happy”. They tend to fire-off more easily or sometimes don’t transmit signals very well. For these reasons, the nipple may become hyper-sensitive or less sensitive for a period of time (typically 1 or 2 months) after surgery. During this time, slight contact on the nipple (clothing brushing lightly across the nipple) may make it feel like it is on fire. To make this more tolerable, silicone nipple shields can be very helpful. Aside from the nerves being stretched, there is a possibility that the nerves important for nipple sensation may pass right through were the implant needs to be. If this is the case, nipple sensation may be permanently lost (but this does not happen often).

Yes. Anywhere you place an incision, there will be a permanent scar. No one can guarantee that you will have a perfect scar, but there are things you can do to achieve the best scar possible. (Please visit my Scar Care page for more info.)

All implants (both saline and silicone) have the risk of being “seen” through the skin — either in the form of ripples on the implant surface or seeing the edge of the implant. The chance of this happening is related to how much coverage you have over the implant. Women who are very thin and athletic are more at risk for visible ripples than women who are more fully proportioned. The more “padding” you have in-front of the implant, the less likely you will notice any ripples. This was more of an issue during the 14 year period when we were forced to use saline implants for all women seeking cosmetic augmentation, as saline implants are more prone to rippling. For these reasons, most surgeons started favoring sub-pectoral placement of the implants. Other benefits of sub-muscular placement include a more natural appearance in both the short and long term and improved breast cancer surveillance with mammograms (compared to above the muscle placement). Additional data suggests implants placed below the muscle may have lower capsular contracture rates.

With sub-pectoral placement of the implants, the muscles can affect implant position. The implants are partially covered by the muscle, so muscle action will attempt to “squeeze” the implant out from underneath, which translates to the implant moving down and to the side. Smooth implants are mobile, and potentially could “drift” this direction due to muscle action. To prevent this from happening, I recommend that my patients perform upward breast implant displacement exercises to counteract this muscle action.

For the first 2 weeks after surgery, I recommend avoiding all exercise to reduce the chance of post-operative bleeding. (You can walk as far as you like, but at a “sight-seeing” pace rather than an aerobic pace.) After 2 weeks, you can start lower body exercise, and resume upper body exercise at 3 weeks. Regular athletic women will feel back to normal about 6 to 8 weeks after surgery. Extreme athletes who demand more from their pectoral muscles will take longer to recover to normal (3 to 6 months).

This really depends on how quickly you stop taking prescription pain medications. You should use the medications while you need them, and once you are off the medications for 24 hours, you should be OK to drive. While you are taking pain medications, you are impaired and should not be driving. For most patients, this is 3 to 7 days after surgery.

80% of patients should be able to return to “desk work” 2 days after surgery. Recovery after breast augmentation surgery depends a lot on how much you expect from your body. The amount of discomfort that an individual patient experiences depends on a number of factors, including overall “pain-tolerance”, the size of implant chosen (larger implants create more stretch and thus hurt more), and how easily the breast accepts the implant. (A woman seeking augmentation to change from an A cup to the C cup volume that she had while breast feeding will experience much less discomfort compared to a woman who has never had children who has the same A to C goals.) In general, most women feel noticeable discomfort requiring medications for the first two days after surgery, and then will have tolerable discomfort during the daytime, reserving pain medications for nighttime use to help with sleep. As with any surgery, there is always a risk of bleeding after the operation, so I recommend that you abstain from any activity that would raise your blood pressure or heart rate for 2 weeks after surgery. (This includes working out, strenuous activities, or lifting more than 15 lbs.)

I recommend the use of general anesthesia (GA) when performing breast augmentation surgery. While it is true that you can perform breast augmentation without GA, it is also true that you can perform a life-saving leg amputation on a battlefield without GA. However, neither case is ideal. (Just because you can do something doesn’t make it a good idea!) GA allows the surgeon to perform more extensive and intricate dissection than is possible with sedation surgery and it is safer for the patient. You may find some physicians who suggest that GA is dangerous and that sedation is safer – I suggest you review their credentials. Often these are not real plastic surgeons, but rather they are physicians certified by some other medical board and are not privileged to perform breast augmentation surgery in a hospital operating room. Because of this, they are forced to do the surgery in their office and many anesthesiologist will not work with them in this setting. To put a marketing spin on this negative fact, they instead say GA is dangerous, and suggest that it is safer to use sedation. This simply does not make sense: In the sedation case, one physician is juggling several tasks, including keeping you comfortable, monitoring your breathing, and performing surgery trying to achieve the desired result. With GA, you have an anesthesiologist fully concentrating only on your comfort and vital functions, while the surgeon is free to fully concentrate on obtaining the desired surgical result. It is true that GA is more expensive than sedation (you have to pay for the anesthesiologist), but as the saying goes: “You get what you pay for.”

Yes. It is actually fairly common to combine a tummy tuck with some sort of breast enhancement operation, to the point where this operation is termed a “mommy makeover“. Having children predictably affects both the breasts and abdomen, so it makes sense that women who consider breast enhancement after childbearing might also want to improve their abdomen. Typical surgical times for a tummy tuck plus breast augmentation range from 3 to 5 hours.

With the infra-mammary fold approach, breast augmentation surgery takes between 30 to 60 minutes to complete. The time variations arise due to differences in anatomy as well as the number of implant / volume combinations that I need to try to find the best “fit” for patients with asymmetries. The trans-axillary approach is technically more demanding, so it takes up to 30 minutes longer.

Assuming that you want to achieve a natural look after breast augmentation, choosing the right size implant is related more to your breast dimensions and skin elasticity rather than cup size. There is no science behind cup size – the companies that make bras are not uniform in their sizing issues, and therefore shopping for bras is not straightforward. For example, if you find a bra that fits perfectly in one brand, you cannot just use the same number/letter combination to buy a bra from a different company. You will need to try on their bras until you find one which fits well, and it will likely have a slightly different size. The best way to predict if you will achieve results you would be happy with is to look at the results achieved by other women with a particular surgeon by reviewing their before-and-after gallery. See if you like the results as a whole. If you think the average result looks good, then you have the same ideals of beauty as the surgeon, and you are a good match. If you think the results are generally not to your liking (too small, too big, too round, not round enough, etc.), then you should keep searching.

Dr. Bogdan uses sophisticated 3D imaging to predict the surgical outcomes so that you can see how your body would look with different sized implants.

Both saline and silicone implants are approved for use for primary breast augmentation. As with any surgical operation, you must weigh the pros and cons of specific choices, and decide which option is best for you. Here are some points:

• Similarities
  • Both implants add volume to the breast
  • Both are available in a number of shapes, sizes, and textures
  • Both implants have a silicone elastomer shell. Since the shell is flexible, it has the possibility of developing fatigue cracks and leaking during the life of the implant
  • Surgical risks (such as bleeding, infection, scar, deflation, capsular contracture, etc) are present with both implants
• Differences
  • Saline implants
    • Cost less
    • Tend to be easier to “feel” in thin patients
    • Visible rippling more likely than with silicone
    • Wall defects are easy to identify (saline is absorbed by the body and the breast deflates)
  • Silicone implants
    • Cost more
    • Are thought to feel more like breast tissue
    • Have less rippling issues
    • FDA restricts the use of silicone implants for women age 22 and older
    • FDA recommends surveillance MRIs to check for wall ruptures starting 5 to 6 years after surgery