Choosing the right breast implant - 2010 edition

This is an update of a classic blog from 2008 - but the information I wrote then is still relevant to selecting the right breast implant size & shape, which is one of the most important factors in getting a nice result, and a happy patient!

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Breast augmentation is the most popular procedure in our practice (ed: still is now in 2010, too!)- we help several hundred women with this each year. In order to have a happy patient, one of the most important choices we make together is figuring out exactly the right size for the implant. The three of us - the patient, my nurse and I work together on this, until we've found "just the right one".

Many of my patients request something that looks "proportional" for their frame. Most of them want something in the mid-C to small-D cup size. Some want more, some want less. We try to give the patients "what they want", as much as possible.

In the old days, implants were chosen strictly by their volume - if you wanted to be 2 cup sizes bigger, you needed a 300-400 cc implant. Unfortunately, that calculation didn't take into account the patient's height, size of their ribcage, or other parameters that vary widely from one person to another. With this old fashioned method, some implants would be too wide - making the patient look heavy; some implants would be too narrow, leaving a big gap in the cleavage area. Not optimal.

I think the key factor is to get the implant width right. After all, most women who are signing up for breast surgery want a nice cleavage - and want to avoid a big gap in the center. Most augmentation patients also want to fill up the width of the breast nicely, but avoid looking excessively broad in the chest, with the implant being so wide that it ends up sticking way out the sides, under their armpits. Most patients want to stay "slim and trim" when it comes to the side of their ribcage.

While other doctors may have different opinions, here's a quick summary of what I do:

1) Start by measuring the width of each breast with a tape measure - going straight across from the inside of the breast (near the cleavage) to the outside of the breast. This will give you a number which varies from 11-12 cm in a petite patient, to 15-16 cm in someone with broad shoulders.

2) Next, measure the thickness of the patient's own tissue. This can be done by measuring the "pinch thickness" of the breast laterally. Subtract this number from the width number.

3) Now that we've determined the approximate "base width" - the footprint - of the implant, we can have the patient try on implants of this particular diameter in a sports bra and T-shirt, and see what she likes in the mirror. We know that these implants are going to be a nice proportional size for the patient's frame, which makes a good place to start our discussion. We make adjustments from there, depending on the patient's wishes...

Of course, the look of the implant in the sports bra isn't 100% identical to what we're going to see post-operatively, but it is a pretty good approximation of the size and weight, and it's probably more accurate than most computer imaging software is at the present time.

This try-on process takes a good bit of time with the patient, so that's the reason that many other surgeons don't do it - but it really makes a huge difference in the quality of the results and in overall patient satisfaction.

The "Mommy make-over"

Here at our Orlando plastic surgery practice, it's very common for me to see women in their 30's and 40's who would like to restore their body to the "way it used to be", back before pregnancy. Typically, the body parts most affected by the wear and tear of pregnancy are the tummy and breasts.

A tummy tuck and breast augmentation or breast lift can work wonders for these patients. We call this combination the "Mommy Makeover". Often, a proportionately-sized breast implant will restore the volume and fullness that was lost as a result of pregnancy. We might additionally suggest a breast lift, if the nipple position is low.

A tummy tuck can get rid of stretched out skin, and lower abdominal stretch marks - and can also repair separated abdominal muscles. If needed, we also do a little liposuction around the waist, which helps to give a youthful figure.

And we do our special belly button technique, that we've discussed in an earlier chapter of PSB, as part of our tummy tuck.

The Mommy Makeover can sometimes be done during one surgery, depending on the length of anesthesia needed. Other times it is best to divide the procedures up over more than one day. (It's really all about doing what is safest.)

The results have been very gratifying. When your patients say, "Doctor, I never looked this good, even before I was pregnant!" - you know you're really on to something.

Dr. Fiala now has an iPhone app

Yes, it's true - we're entering the age of the iPhone.

My friend, Dave Tessitore, has programmed an iPhone app for us, and it's now available through the Apple app store. Look for "Plastic Surgery with Dr. Fiala", or just click here (link). Currently, it's a free download. We're one of the first plastic surgery practices in the country with this new feature!

In addition to making it easy to make and keep track of your appointments with us, the app also helps you to remember any medications / supplements that you take, your physician contact list, allows direct email access to us, has links to our website and blog, and a number of other cool features.

An FAQ section will be added in an upcoming version. If people have suggestions for improving the app, let me know, and we'll see if we can add them in!

A Big "Thank you" to Dave Tess and Dashy Apps for their work on this project.

Breast implant exchange surgery

It's not uncommon for women who have already had a breast augmentation some years ago to come and consult with us about an implant exchange. Most commonly, this is for reasons of wanting a different size; most often a little bit larger, sometimes a little smaller. People do change their minds about the look they want, compared to their original implant choice, and we understand that.

In situations like these, where the breast is soft (doesn't have capsular contracture) and the pocket where the implant sits is in good shape, we can do what's termed a "simple" implant exchange surgery.

This involves helping the patient select the desired new size and shape, and going to surgery to replace the older implants. There's definitely a skill to selecting the new implant - and we've got a few little tricks for this!

With the resurgence in popularity of silicone gel implants, many women who first had breast implant surgery back in the "saline-only" era often consider switching to silicone gel implants. Here at our Orlando practice, four out of five patients who have experienced both types of breast implants tell me that they far prefer the gel implants. Gel implants also help to reduce wrinkle and ripple problems in the slender patient with saline implants. Using a different implant shape can also be a helpful suggestion. This keeps the implant width proportional to the patient's frame, but allows more (or less) fill up front, where most patients want it.

At surgery, we can typically use the same surgical incision - so there are no new scars. And if the old scar has widened out, we get a chance to revise it during surgery, and hopefully get a nicer looking scar.

Most women are pleasantly surprised: the recovery from a "simple" implant exchange is usually very easy, with little pain, bruising or swelling. Since the pocket for the implant is already present, and only few small adjustments need to be made to the tissue pocket, the recovery is much quicker.

More complex implant exchange surgeries involve the correction of tissue stretch or pocket expansion, or the correction of scar tissue / capsular contracture issues. As the name suggests, these surgeries are much more involved. But that's a topic for another day. Cheers!!

Shameless request for votes!

PSB- the Plastic Surgery Blog has been nominated as a top quality blog by the readers of the Orlando Sentinel. The Sentinel is running a contest, known as the "Orbbie awards", to determine the best blogs in town in various categories.

This blog is in the miscellaneous category, called "Out of this World".

If you like our blog, please take a minute to vote by clicking here. There is a maximum of one vote per category per day.

Thank you for your support!

Super Latisse & Botox combo deal

Hot off the press....

I just spoke with our Allergan reps: we will be one of the select few practices in Florida to offer this unbeatable combo bargain.

Buy Latisse (Allergan's eyelash growing treatment) for only $99 per box (regularly $120) and receive a rebate of $50 on a Botox treatment performed before the end of November, with the manufacturer's coupon. Call the office for details, at (407) 339-3222.

Fine print: Limit of 2 boxes of Latisse. While supplies last. Not combinable with other offers.

Choosing the right breast implant shape

Back in the dark ages, plastic surgeons recommended breast implants based only on their total volume.

Now, most modern surgeons realize that it is important to measure the patient's rib cage width, and match the width of the implant to the width of the patient, in order to obtain a result that looks attractive, proportional, and avoids an overly wide cleavage gap or excessive lateral (side) fullness.

In addition to picking the right size, there are several choices of implant shapes available. These are called "profiles" by the manufacturers. Choosing the right profile makes a major difference in the final appearance of the breast shape.

Many patients are unaware of these possible choices before their consultation with us, and have only thought about the number of cc's in the implant or the cup size they want. A useful question to consider is "How much fullness do you like in the upper part of the breast?" Someone who want a lot of fullness will pick a different implant than someone who just wants a little.

The most popular profile (implant shape) in our practice, whether it be silicone or saline filled, is a medium profile implant. About 70% of our patients choose this shape. It gives an attractive fullness in the upper part of the breast, but not "too much" for most people's taste. I call this the "Victoria's Secret catalogue model" look, and the proportions work well for most average frame patients.

The second most popular profile is the "high profile" implant. It gives more roundness and fullness in the upper part of the breast. For women that have a narrow ribcage and still want a generous implant volume, the high profile shape is worth considering. For women that want a larger, fuller implant without going to a wider implant, sometimes switching from a medium profile to a high profile implant is also a useful option. About 20%-25% of our patients choose this shape. But it's a "love-it-or-hate-it shape"; some women think it looks a little too overdone or obvious, especially in the larger sizes, while some women find it sexy and attractive. It's all personal taste.

The low profile implant is the third choice. It works for women that have a broad ribcage, but for whom the other profiles would give an implant volume that would be excessively big. It's a more conservative and "natural" look, and gives less projection or upper pole fullness compared to the other two profiles.

While some surgeons strongly recommend high profile implants for women considering a combination breast augmentation / breast lift surgery, I do not insist that women make that particular choice. It is true that a higher profile implant has a greater arc length over its highly curved surface, and so it fills up more loose skin compared to the lower profile implants. However, the patient may not want the size or shape that a properly selected high profile implant gives. I think its more important to the final result to pick the implant size and shape that the patient wants first, and then tailor the mastopexy around that as needed. In my opinion, this is much more likely to make the patient happy in the long run.

In our experience, there's no substitute for proper measuring, followed by trying on actual implant sizers in a sports bra and T-shirt. Once women see how it looks in the mirror, it's amazing how rapidly they are able to sort out the many different choices. Once they see the look they prefer, most women know it almost immediately! It's kind of like trying on shoes: you know if they fit or not.

Breast Augmentation & Surgical Drains

Recently, a patient asked me if I used surgical drains as part of my routine when performing breast augmentation surgery. It's a thoughtful question - as there are a few surgeons locally who do use drains during breast augmentation surgery, removing them at the first or second postoperative visit. Drains, by the way, are small diameter, soft plastic tubes, which are used to remove fluid from a surgical area. They commonly have a bulb-type collection reservoir at one end of the tubing, while the other end has a perforated segment placed beneath the skin, near the involved surgical area.

I don't think they are necessary for the routine, first-time breast augmentation patient. In my opinion, drains are uncomfortable, they leave a small additional scar at their exit site, slow down the speed of the patient's return to everyday activities, and complicate a straightforward post-operative recovery process. In general, I only use drains if their benefit outweighs their drawbacks.

Here's the science: In a recent review, published in Aesthetic Plastic Surgery, a retrospective study of over 3000 breast augmentation patients in the United Kingdom showed that the use of surgical drains actually increased the risk of postoperative infections fivefold! No benefits of drains were seen in this study.

I do use drains in breast cases where there is a significant chance of a postoperative seroma, such as following capsulectomies, some forms of complex revisional breast surgery, large volume breast reductions, and explantations.

Scars: Part one - Keloids and Hypertrophic scars

Many people have heard the word "keloid", and think it means "any bad looking scar". This is a common misconception. Scars fall into a couple of categories. Since different types of scars and scar problems are treated differently, it's important to diagnose the scar situation accurately.

A keloidal scar is a scar that continues to enlarge and spreads beyond the borders of the initial wound. They are more common in African-American patients as well as Hispanics, Philipinos and Orientals, but can occur in patients of any race. Keloids often recur after excision, and do not tend to improve with time on their own. They are common on the face, earlobes and the chest. They are more common in women than men.

A hypertrophic scar may be thick, raised or reddish in color - but the key diagnostic difference is that they do not spread beyond the boundaries of the original wound. Most of the "bad scars" that patients show me are in this category. Hypertrophic scars may partially regress over time, becoming more flat and pale. They usually show up during the first few months after a surgical incision. They occur in equal frequency in both men and women.

A third type of scar, called a "wide-spread scar", is also common. These are typically surgical incisions that remain flat, but widen out, like a stretch-mark. They do not have the ropey consistency of a hypertrophic scar. These scars have a normal amount of collagen in them (unlike keloids and hypertrophic scars). They typically have widened out from mechanical tension (pull) across the incision. These usually respond quite well to surgical re-excision.

Commonly used treatments for these abnormal scars can involve scar massage, pressure application, use of topical silicone sheeting or gel, use of steroid injections into the scar, in addition to various surgical excision methods. Since the recurrence rate with surgical excision alone in keloid scars is about 50%, surgical excision is usually combined with one or more of the other listed techniques.

We'll discuss more about surgical scar revision in future chapters of the blog.

"Sisters, not identical twins": breast asymmetry

As one of the busiest breast surgery practices in Central Florida, I see many patients who would like a breast augmentation performed. As part of our routine, we carefully examine the patient, and during our examination, it's very common to find several differences or asymmetries between the two sides.

Most patients have no idea about these minor asymmetries of the breast until we show them...and then they see them. The reason we do this, of course, is to explain that these asymmetries will still be there post-operatively after a standard breast augmentation operation, since they were present pre-operatively.

There are several interesting studies about pre-operative asymmetry in patients undergoing breast augmentation.

Rohrich, Hartley & Brown, in their 2003 review of 100 patients, published in Plastic and Reconstructive Surgery found:
- 88% of women had natural breast asymmetries when critically examined,
- 72% of these women had more than more asymmetric feature.

In other words, nearly nine out of ten women have some degree of breast asymmetry. We commonly say "Think of the two breasts as sisters, not identical twins!"

Common asymmetries in this study included:
- nipple / areola position differences in 53%
- breast volume differences in 44%
- infra-mammary fold position differences in 30%
- chest wall (bony) differences in 9%

Similar findings were seen in 2009 study by de Chardon and associates, who examined 200 breast augmentation patients. They found a higher incidence of chest wall asymmetries, at 17%, which was most commonly caused by scoliosis of the spine with secondary changes in the rib shape.

Perhaps the most interesting finding from this French study was, of the patients that complained about breast asymmetry after surgery, 83.3% (five out of six) of them had the same asymmetry pre-operatively.

This finding certainly indicates the need to explain to patients what is present prior to the implant surgery, and help the patients to understand which features can or can not be corrected by implants alone.

Cosmetic surgery and the competitive edge: looking good and the job market

Here's some interesting data from a press release from the American Society of Plastic Surgeons:

"Faced with news of difficult economic times, and a belief that hiring is based on looks, millions of American women are looking at cosmetic medical procedures to give them a competitive edge in the workplace. In a new telephone survey compiled by the American Society of Plastic Surgeons (ASPS) of 756 women between the ages of 18 and 64, many reveal cosmetic plastic surgery procedures now appear to be an important rung on the success ladder.

- 13 percent (more than 1 out of 10 of the 115-million working-age women) say they would consider having a cosmetic medical procedure specifically to make them more confident and more competitive in the job market.

- An astounding 3 percent (nearly 3.5-million working women) say they've already had a cosmetic procedure to increase their perceived value in the workplace.

- 73 percent (almost three out of four or, 84-million working women) believe, particularly in these challenging economic times, appearance and youthful looks play a part in getting hired, getting a promotion, or getting new clients.

- 80 percent (four out of five or 92-million working women) think having cosmetic medical procedures can boost a person's confidence."


Actually, this trend is not really that new. Men have been coming to me for years, getting their upper eyelids fixed, so they don't look like the "sleepy, old-guy-past-his-prime". Executives often have specifically told me that they want to look more like their youthful and energetic business competition, and want to have surgery to give the appearance of still being in their prime, rather than being perceived as being "tired" or "over-the-hill".

Investing in yourself is always a wise investment!

Problems with laser-liposuction: who's the Smart one now?

Over the last few months, I have seen an alarming increase in the number of patients that come in for a second opinion about poorly-performed liposuction (done elsewhere, I might add.) All of these casse have been performed with new high-tech liposuction machines, either laser-assisted (like the SmartLipo) or ultrasonic (like the VASER).

I've seen major skin laxity, uneven liposuction, and obvious over-resection of fat leaving major divots and dents. Many of these problems are very difficult to fix, even with fat grafting techniques.

Here's a few observations:

1. All of these cases were performed by physicians and surgeons operating way outside of their specialty. They were not done by plastic surgeons or dermatologists, who are trained during residency in this technique.

2. In the majority of these patients, physical examination of the patient revealed crummy skin tone and poorly elasticized skin. In other words, since this skin won't contract like we want it to after liposuction, it's completely predictable that the post-op results will be poor, with floppy, deflated areas, and a worsened appearance. A surgeon with any significant training or experience in liposuction would have recognized this - and would have avoided performing liposuction in these patients. It's the wrong tool for the job!

3. All of these patients were preoperatively told by their physicians, "This new wonder lipo machine will tighten your skin".

4. All of these patients now say, "Skin tightening clearly did not happen...now I look worse."

5. None of these patients have an easy fix for their issues. All will require complex and expensive revisional surgery.

Lessons:

A fancy hammer does not a good carpenter make. Any doctor can buy (or rent) a fancy lipo machine.

There is, as yet, no reliable scientific evidence that laser-assisted liposuction:
a) tightens the skin, or
b) works better than standard liposuction.
Any claims to the contrary are "spin" or marketing hype; consider the source and what they're selling.

That being said, the problems seen here were not caused by the type of liposuction machine - but by the doofus using it! While the concept of liposuction is easy, getting excellent results with liposuction takes significant skill.

Please be careful about whom you choose to perform your liposuction. Even if it's performed in an office setting, with local anesthesia, liposuction surgery is still SURGERY. Training, experience and credentials matter.

A Hero Passes

Last week, we lost a very special person here in the Orlando area, when Mark L. Parker passed away.

As a rookie Correctional Officer full of promise at age 19, Mark was seriously wounded in the line of duty, at a shootout at the Orlando courthouse some 25 years ago. Two other officers were killed. The gunfight left him a quadraplegic...and Mark spent the rest of his life in a wheelchair.

Now for most of us, this injury would be as mentally and emotionally devastating as it is physically devastating. Most of us would never really smile again, being endlessly angry at the world for the terribly unfair thing that had happened.

But not Mark. Mark's true greatness was in his positive, "can-do" attitude. I don't think I ever saw him "down" or feeling sorry for himself.

Not only did he continue to lead an active life - enjoying Sci-Fi conventions, NASCAR races, rock music, Civil War history and computer games, he volunteered at the local school, sharing his life experience and his time with the youngsters. Always positive and genuine, always upbeat and smiling, Mark made a habit of looking forward, not backward.

I got to know Mark and his family when I helped Mark with some reconstructive surgeries a few years ago for the inevitable pressure sores that occur from time to time, despite all the fantastic care that Mark received 24/7. While the surgery itself is completed in a few hours, the recovery and rehabilitation from these procedures takes weeks - so Mark and I had plenty of time to visit each day and get to know each other. I chuckle when I remember Mark saying, "Doc, let's get this thing (his wound) healed up - I gotta be ready to go watch the Daytona 500!" And sure enough, we got it done.

There are some people you meet in life that make a lasting impression - people you never forget. That's true for us surgeons, too - we have a few very special patients that stand out in our memories. Mark was definitely one of those people. The capacity crowd at his memorial service in Winter Garden last week shows that many, many other people shared my high opinion of Mark, too.

Godspeed, Mark Parker. I'm proud that you considered me your friend.

Special offers on injectables

Good news for those patients who are fans of Juvederm, Restylane, Evolence and Botox: the manufacturers seem to be trying to out-do each other with special offers, rebates and coupons. That means savings for you.

Here's some of the current special offers:

Botox cosmetic
- Schedule your initial botox treatment before February 28, 2009 and receive a $50 rebate coupon from Allergan. Make your follow-up treatment between May 1 and July 1, 2009 and receive a second $50 rebate.


Juvederm Ultra and Juvederm Ultra Plus injectable gel
- Schedule your Juvederm treatment before February 28, 2009, and receive a $100 rebate coupon from Allergan with your second syringe of Juvederm.


Evolence collagen dermal filler
- Schedule your Evolence treatment before December 31, 2009 and receive a $50 rebate coupon for each syringe used, up to $150.


Restylane and Perlane injectable gel
- Schedule your Restylane or Perlane treatments before February 28, 2009, and get the "buy-one, get the second half-off" special.

It seems like the time to get those wrinkles treated, doesn't it!

Latisse: Now available

Latisse, the eyelash enhancing formula made by Allergan, has recently received its FDA approval and is now available. We discussed this breakthrough product in one of my earlier blog chapters - I expect it to be very popular.

We'll be carrying it at our office - and let me tell you, the ladies on my staff are very excited to try it! I'm interested to see how it compares to earlier non-pharmaceutical strength formulations, like "MD Lash".

More details as they become available...

Trends in Breast Augmentation in Orlando

With a practice that is about 50% breast surgery, we are well-versed on the current trends in breast augmentation. Here are some of the patterns that we've noted.

1. Return of silicone gel: Three years ago, 90% of the implants we used were saline-filled. With the FDA re-approval of silicone gel breast implants, we've been offering our patients a choice of saline or silicone gel. Now, easily 75% of the implants that the patients want are silicone gel ones, due to their "more natural" feel and their lower rate of post-operative rippling in slender patients. The remaining 25% of our patients select saline implants due to their adjustability, their lower cost, or their desire to avoid anxieties about silicone gel altogether.

2. Credit crunch: Prior to September 2008, many younger patients were using third party financing to pay for their surgery. With the meltdown in the credit markets, these loans are more difficult to get, especially for people with marginal credit. Some are taking advantage of our cash-only discounts, but many are holding off on surgery for the moment.

3. Lack of interest in the "gummy bear" implants: Despite the buzz in the American plastic surgery societies about the impending FDA approval of form-stable silicone gel implants (commonly known as "gummy bears" due to their thick gel formulation) patients seem unimpressed. Once I describe the significantly bigger surgical incision required for their placement, patients seem to rule out that choice, despite their potential advantages. Our patients also don't seem to care for the tear-drop shape, either - the majority of our patients specifically ask for some fullness in the upper portion of the breast. This reflects the American sensibility for breast shape, which interestingly, is different than what is popular in Europe or South America. (More on than later!!)

Hello, Evolence!

Here's a new twist on an "old friend" - collagen is back, in a new & improved way. Known as Evolence - and don't ask me how they come up with these names - it's an FDA-approved filler with a good track record for wrinkle correction after being on the market several years in Europe. It's now available in the USA.

Compared to the old collagen products (Zyderm & Zyplast), Evolence offers several advantages:

1) no need for a skin test prior to treatment to check for sensitivities or allergies, which happened in about 1% of people with the old product;

2) much longer-lasting correction. European studies show a duration of about 12 months; and

3) minimal bruising from the injection.

Overall, it looks promising, and we're now going to offer it in my practice, adding another option to the many other FDA-approved fillers we have.

What will be really interesting is a head-to-head comparison study comparing Evolence to some of the better hyaluronic gel fillers. This study is underway. "Which filler will reign supreme?"...we'll have to wait and see!