Breast Surgery FAQ

This is more common than people think. Almost no one is perfectly symmetric. These surgeries are more challenging than the routine breast augmentation. I get lots of referrals form other surgeons to tackle these cases. There is not one remedy. I have used expandable implants, staged procedures, and dissimilar operations on each breast at one operation. For instance, the small side may get an expandable saline implant where we can adjust or overstretch the small side. The larger side may need to be lifted or made smaller. I will discuss each of the different breast lifts in another section. Most of these patients are ecstatic having suffered with a difficult problem that’s hard to hide even with fillers for the bra.

This is a common question we are often asked. Basically an implant can fill the space of a droopy breast only so much. If a larger implant is necessary to lift the breast it may do so for only a short time. A breast that has already demonstrated that it does not stay up after a breast augmentation like weight gain or pregnancy, probably will sag again when a large weight is placed upon it. A reduction of the amount of skin, sometimes with a small implant can both increase the size and return the breast to a more perky position on the chest wall. If the patient desires a smaller size, the lift can be done with a small reduction to unweight the breast allowing it to stay up longer.

There are basically four different breast lifts that can be done. They extend from the shortest scar to the longest based on how much skin has to be removed, how high the nipple areola has to be raised and how stretchy the skin is.

The smallest lift I do is called the crescent lift. It produces a small scar around the top one third of the margin of the upper areola. Only very small lifts of less than 3/4 of an inch are amendable to this surgery without elongating the vertical height of the areola.

If more than this amount of lift is needed sometimes we will do what we call a purse string mastopexy. Here, the scar extends all the way around the areola. It’s done be making essentially two circles. The outside larger one is purse stringed down to the smaller one. Because it can flatten the breast shape and does not do a good job of lifting the bottom of the breast, we use it for small lifts or for misshapen breasts that are pointy in a side view.

For the vast majority of patients, to achieve a pretty shape and deliver a result that is long lasting, a vertical lift will be necessary. In this procedure, the extra skin is removed in two directions. Some around the areola and some in a vertical direction. Patients are often fearful of the scars from breast lifts. I find they are discussed much more before the lift than after. They are not all perfect but we will do all that we can to improve their appearance. We have every laser that has ever been used to improve the look of scars. After some time, all scars seem to fade.

Revisional breast surgery is a big part of my breast surgery practice. During the time from 1992 until November of 2006, silicone gel implants could only be used by most plastic surgeons for breast reconstruction or breast lifts.

I was fortunate to be chosen by both the Allergan and Silimed corporations to be an investigator for the FDA trials for the newest types of silicone breast implants. I saw patients from all over the US for problems from prior surgeries. I have developed my own techniques to remedy some of these problems form prior surgeries.

The common secondary concerns are misplaced implants too low, too high, too far apart and sometimes too close together. For the misplaced implant, I have instituted the use of part of the scar tissue around the implant as a shelf, holder or buffer to better hold the position of the implant correctly. I have also been using a mesh made from suture material if added strength is needed. Most surgeons still try to place multiple stitches to reef up the scar tissue. In my experience, this does not hold up long and the patient shortly thereafter seeks out another opinion.

For severe scars around old silicone gel implants that may have leaked, I have developed my own approach. Here I will use the tumescent canula that we use to place the fluid before liposuction to pressure separate the scar from the normal breast tissue. I have found this method to be most satisfying for my patients and me as it allows for less bruising and pain than the older methods.

This is a tough question that has no right answer. I have found that most patients at one week out think they are too big. Somewhere between six weeks and one year they seem to be satisfied. After that some will say, “I could have gone bigger.” You can’t win. Yes you can go bigger later but the same scenario will likely occur as the breast gland and skin stretch to accommodate the new larger size. The size you end up is what you start with plus the implant. They do not come in sizes that are named after letters. (B, C, D). We as plastic surgeons deal with cubic centimeters. Thirty cc’s is one ounce. It usually takes about 350 cc’s to go up one cup size. The number attached to the bra size will not change, as this is a measurement of the bony circumference around the chest wall.

My nurses spend a good deal of time in sizing the implant and use various factors. The most important is the width of the chest wall that the implant is going to fill. The diameter of the implant should be at or just larger than the innate breast width. Otherwise, it will either stick out the side and touch the arm, be too close in the middle or worse sag below the natural crease creating an unnatural look where the nipple is pointing upward. I don’t believe in sizers in the operating room. This makes no sense to me. I know, based on these above constraints, the range of sizes that will work.

We then let the patient “try on the implant” by placing the sizers on top of her breast and using a stretchy bra to approximate what that size will look like. This is not as accurate as seeing the effects of the implant when placed either under the muscle of under the lining of the pectoralis muscle. Vectra 3D imaging has replaced the “trying on of the implant” in our office. We have been pleasantly surprised how accurate this 3D image an be.I have found that women who have always been small have a poor understanding of what the letters of the bra correspond to the look on her body. With the right size and an understanding of the limits of that size as communicated by me at the consult, the vast majority of my patients are happy.

This is the hardest part of the process and the most important. Find a few to see. Ask around from friends, relatives, nurses and doctors whom they recommend. Lots of women today use the Internet. Understand that many of the websites with official sounding names are merely paid advertisements for surgeons. It does not mean they are better than others, they have simply chosen to present themselves as an option for a fee to the site. Sometimes the busiest surgeon in town may not be listed.

Don’t pick your surgeon based on price. The lower fee may be of necessity to be able to attract a patient base. When you go see these doctors, see how you feel. Is the office well run, organized, staffed adequately? Is your time respected? If you pay for a consult, you should be seen in a timely fashion. When consults are free, no worth is attributed to them. You get what you pay for. I see all my consults myself. I believe I am the best person in the office with the best knowledge base to come up with a plan for each patient.

Also, do you like the surgeon and the staff? Are you comfortable with them? Sometimes you will hear conflicting opinions from each surgeon. Nobody is right or wrong. That is the art of plastic surgery. If you have questions after seeing someone after me, call us, email us or come back to get things straight. By all means go to a Board Certified Plastic Surgeon. There is another location on this site with details about that.

As everything I do is totally elective, safety is of the utmost importance and I take it seriously. For the most part, healthy patients having sensible amounts of plastic surgery can be safely operated on in an outpatient setting either in one’s office or in a certified ambulatory surgery center. By sensible I mean amount of time a few hours or less. Some procedures I believe will have better outcomes when an overnight facility is utilized. Sometimes, monitoring of vital signs, delivery of narcotics, watching fluid levels will best be done by a qualified nurse in an approved overnight center.

Safety is more important than how pretty the room is. I like to know in an emergency that there are lots of people of various talents to attend to the immediate needs of my patients. Fortunately this is rare. I do the vast majority of my cases that require anesthesia at the Jewish Outpatient Facility right across the street from my office. For procedures requiring only a local anesthetic, my office procedure room is used.

Board Certification I believe is imperative to test and demonstrate a level of expertise, knowledge and safety necessary to achieve optimum results in any specialty. The words Board Certified have been used sometimes to mislead the potential patient. There is a governing body called the American Board of Medical Specialties (ABMS). This Board oversees the training and certification requirements of all of the specialties in Medicine. These are the common specialties that we all know such as: OB/Gyn, Pediatrics, Allergy and Immunology, General Surgery and Plastic Surgery.

Unfortunately, there are also many self proclaimed Boards that sound very impressive as well. They may lack the residency or written and oral board tests required of the real Board recipients. The doctors with these Boards will often include the words Board Certified in their advertisements to sound equivalent to the standard bearers of the real American Board of Plastic Surgery.

I believe there is no short cut to the training necessary to become a consummate aesthetic plastic surgeon. That is why we have residencies: where graduated levels of experience are acquired under the watchful eye of an experienced plastic surgeon.

So don’t be fooled.

Ask the potential surgeons, which Board are they certified by. Any doctor can call himself or herself whatever they want. If you only practice in your own facility, there is no governing body overseeing that the prerequisite training and test completion have been achieved. Hospitals and certified ambulatory surgery centers however check credentials, residency training and board certifications. I could call my self a Neurosurgeon tomorrow. I could say I am board certified (I in plastic and general surgery). When I went to apply for privileges at the local hospital of my choice, I would be turned down because I have no formal training in neurosurgery. If I could only do brain surgery in my office it would be OK.

Both saline and silicone gel implants have the same outer shell which is made of a silicone elastomer (rubber). The saline is filled with salt water and the gel with a cohesive gelatinous silicone jelly. Saline implants can be adjusted in size in the operating room or post operatively with an implanted valve under the skin. The feel, if filled properly, is that of water in a baggie. If they are grossly overfilled, they feel somewhat firm and unnatural. They often wrinkle in women with thin overlying tissues, as the water will seek a gravity layering in different positions. They do cost less and the incision to place them can be smaller as they can be filled inside the pocket made to hold them.

Silicone gel implants on the other hand feel more natural, wrinkle less, and are not changeable in size once they are in. Also, because they are pre-filled with gel, they may require a larger incision to be able to place them in the pocket behind the breast. Silicone breast implants today cost more than saline implants. The gel implants will always fill the upper part of the breast better than the same size saline implant as they don’t collapse when placed in their vertical position as a saline implant would. Both saline and gel implants come in smooth and textured surfaces. The textured surface was useful in the older style of gel implants to help reduce the scar tissue that forms around an implant and could make it feel hard. It is unclear if it is beneficial in that same way with these newer low bleed, cohesive gel implants where the gel is thicker and does not readily leech through the shell.

Both implants come in different heights relative to their base widths. There are essentially three shapes: flatter (moderate profile), medium height (moderated profile plus) and high profile. Each has its uses and will be discussed with each patient at consultation. There are also shaped implants.

Inamed, now Allergan, has the Style 410 form stable gel implant. This implant is shaped like a breast with a tapered top. Three different variables, height, width and well as projection can be chosen for an implant. Dr. Salzman was one of the original 55 plastic surgeons chosen by Allergan to do the pilot approval study for the FDA. We now have 410 patients that are 6 years after surgery. This implant, although popular in Europe, is not yet available for free and unrestricted use by plastic surgeons in the US. This is the “gummy bear” implant as its consistency is that of the candy gummy bear. The gel, even in the absence of the shell, will retain its shape. We had great success with this implant and patiently await its FDA approval.

Silimed is another brand of implants not presently sold in the US. Their pilot study also began 5 years ago. Dr. Salzman was one the original 15 US surgeons selected by Silimed to examine these gel implants for the FDA trials. We have one of the largest experiences with these implants of any surgeon in the US. Silicone gel implants have only been available for free and unrestricted use by all plastic surgeons since November of 2006. Our experience with these implants is some 6 years longer.