To answer your questions...

Reader's questions addressed, vol I


Question #1:

>I have a friend who I'm concerned about. After having 10 children, her stomach muscles are very stretched out, and together with being overweight, she appears as if she will give birth within a week. She is talking of doing liposuction as well as tightening of the stomach muscles. (She has tried many diets but has always regained the weight.) I am very concerned and think she should research more before she decides on this operation.
>Could you help me give her some basic information by answering the following questions:
>1. Will the fat removed by liposuction return if she eats normally (which happens after dieting)?
>2. Is this major surgery? What are the risks of complications, immediate and many years later?
>3. How long is the hospitalization, and how soon do most people return to normal functioning?
>4. How many years has this operation been done and have many people had it?

>I guess what I'd really like is a detailed brochure that discusses this procedure and answers these questions. I've also heard of a tummy tuck and wonder if this would be better for her. However, I don't know enough details. Would you have an official brochure that discusses these procedures, and could you send it to me? I would be most grateful.

An Answer:

Miss _______,
This is a multi-faceted question. I will answer several aspects in the liposuction/abdominoplasty sections of my WWW site when they are done. But in short.....

It sounds like your friend probably would require abdominoplasty ( a "Tummy Tuck"). When there is muscular laxity in addition to fat, liposuction alone will probably not result in a marked difference in her appearance. As far as the safety of the operation, it has been performed for over fifty years. Complications are not terribly common but include blood clots in the legs (Deep Venous Thrombosis), infection, and scarring. If properly selected patients seem satisfied with the results. Fat can return as can abdominal laxity, but this is variable in patient with stable weight. The procedure does not specifically prevent the re-accumulation of weight and is not a "weight-loss" operation specifically. Most patients are done as "outpatients" for cost concerns, but we routinely recommend specialized "aftercare" facilities. Patients spend between one and three nights in such a facility. The degree of disability again is variable (pain tolerance is highly variable) with most people getting up and around well by two to three days post-operatively. Brochures are available at the offices of many Plastic Surgeons, but there is (to my knowledge) no one standard brochure that all surgeons provide.

John Di Saia, M.D.

Question #2:

>Have you any information on silicone leakage into the body ? Factual Of course!!!

An Answer:

Dear Miss _______,
The answer to certain aspects of your question is debatable at present. The silicone implant controversy has lead (is leading?) to a large settlement re: collagen vascular diseases (rheumatoid diseases). The first prospective randomized studies are coming to completion and are showing no difference in the incidence of these diseases in people with and without silicone breast implants. The local reactions in tissue when silicone from such implants leaks however I have seen personally. These vary depending upon whether the inflammatory process is isolated by the body or not. Firm nodules can form some of which are painful and make surveillance for breast cancer difficult. My recommendations for patients with silicone breast implants remains the same:

(1) If the implant is leaking, have it removed/replaced with a saline implant.

(2) If the implant is not leaking/problematic, it may be watched for changes. The statistics of leakage are commonly cited as 5% per 15 years although it may be more or less.

I hope this helps,
John Di Saia, M.D.

Question #3:

>Is it possible to have my breasts augmented so that I become a couple of inches bigger too. I understand the logic in going from say a B cup size to a D cup size. But what about going from say a 34 to a 36 as well.
>And how long (and how painful) is the rehabilitation process.
>Thank you.

An Answer:

It is difficult thing to exactly predict post-operative size as different people seem to form different degrees of contracture around the implant. In general the implant causes increase (as you mentioned) in cup size as opposed to chest size, but both will change. The best thing (I've found) is to have patients provide "targeting pictures" (usually obtained from anything from Victoria Secret catalogs to Playboy) of the size/shape they'd like to have. Rehabilitation is a highly variable issue. Some patients are back to light work in less than a week. "Working out" and athletic activity is usually restricted for 2 weeks or so.
Thanks for your question,
John Di Saia, M.D.

Question #4:

>Dr. Di Saia,
>(Is this how you prefer to be addressed? E-mail is usually so informal) Anyway, on a rather slow day at work, I came across your plastic surgery home page. The actual thought of having liposuction/sculpture? has intriqued me for quite sometime as I have 5 nagging lbs on my abdomen that refuse to go away through the traditional methods.
> I have numerous questions about the procedure, far too many to address here, so I'm limiting my questions to two: 1) What are the long term reprecutions of fat removal on an otherwise thin/petite person? Will I need that extra fat somewhere down the line (e.g. child birth/wilderness survival etc. ) or will I be doing myself a favor by getting rid of it now (I'm 29)? I'm 5'3'', petite, exercise frequently and all my unsightly weight is pretty much centralized on my stomach.
>Any info you have would be great. Thanks.

>P.S. Incidentally, I was your 801st web-site visitor.

An Answer:

Dear Miss ______,
It is funny that you should worry how to address me. When I am answering questions regarding medical subjects, I feel it appropriate to label my name with the title. It underscores that I do know what I'm talking about. I don't mean to be pretentious.

When dealing with younger people, I usually mention that the changes of liposuction are (as you'd mentioned) "sculpting." A definite post-operative picture cannot be drawn for you. It is more appropriate to talk about relative change. A good aspect to your age is that your skin has more of a tendency to contract following suction thereby leaving you less likely to form a "skin fold" over the area of suction.

With regards to "need" for fat....liposuction does not prevent you from forming fat. It seems to change your tendency to gain weight in particular places (those suctioned) because of scarring. So, it changes your fat distribution. You may gain weight in new and interesting places (if you gain weight post-operatively).

Thanks for your input,
John Di Saia, M.D.

Question #5:

>I am interested in liposuction in the thigh area and the lower stomach area. I saw the Q&A section with an answer to the stomach area so my questions will be about the thigh. I would like to have the front and back done. Is this separate procedures? how long are the procedures for people looking to shed a few extra bags of weight and how long are hospital stays. Any information would be more than I have now. I live in Pacific Northwest.
>What is a good way of finding qualified doctors for this type of surgery.

An Answer:

Dear Miss ________,
This surgery is usually done as an outpatient (you go home the same day). The procedures you mentioned could be performed at one sitting. Look for a Board Qualified/Board Certified surgeon (American Society Of Plastic And Reconstructive Surgeons). You want someone that successfully completed a proper training program in plastic surgery. Otherwise, you could be treated by anybody from a Dermatologist to a Gynecologist. There are no laws (of which I know) against anyone performing Cosmetic Surgery, as long as a facility grants privileges. There are a few agencies that aim to refer you to a surgeon, but I have yet to see one that isn't a paid service (by the surgeons). In this situation, I would be suspect. A referral from a friend is best, but demand information on the training of your surgeon. A qualified surgeon (as long as the question is phrased respectfully) will not object to this kind of questioning.
Thanks for your input,
John Di Saia, M.D.

Question #6:

I am contemplating getting the breast augmentation and went for a mammogram today. Are you concerned about the chances of developing breast cancer and if so, is it detectable? Are you finding women who have had breast augmentation are still happy with them or wish they never had the implants? What is your view on this. I appreciate anything you can contribute to this.

An Answer:

Dear Miss,
The subject of breast augmentation and cancer has been a subject of debate for years. There is a ton of literature on it. Some have said that the breast cancer that develops in a patient with implants may be further advanced (i.e. delayed detection). Others have said this claim is unjustified.
With regards to breast cancer, several things are known:
(1) Patients are the best at screening themselves...indeed most breast cancer patients come to their doctor feeling the "lump" On routine screening examinations, physicians find less than 20% of all breast cancers.
Why is this pertinent?
Do you examine your breasts? The key to finding breast cancer early is early detection. Some physicians still believe that this means patients examining their own breasts.
(2) Patients with a maternal family history (mother, mother's mother,...) of breast cancer are at a higher risk for ultimately developing cancer in their breasts.
(3) The overall risk of breast cancer in American women is approximately 1:9.
So should you be worried about breast implants per se?
They can contribute to more uncomfortable mammograms as many women with implants have stated. Squeezing an implant (not to mention your breast) between metal plates is not a pleasant experience.
With the newer saline implants, the silicone issue is non-existent (although silicone implants have never been statistically shown to increase the risk of breast cancer either). You will still need to closely watch yourself (as any American women should). Do saline breast implants cause cancer? There is no proven association at this juncture.
I hope this helps,
John Di Saia, M.D.

Question #7:

>I would like to know not only the cost involved for multiple procedures (abdominoplasty/breast augmentation), but also if both were done at the same time. How and where the procedures are done (office or hospital), how long of a stay, time off work to heal for each procedure, how much notice to schedule the procedure. I am in Michigan, so would I be able to fly out and have the consult the same day as the procedure to lower my time away from home. Also I have two other friends interested in breast augmentations, would we be able to get a group rate? Seriously! Well, I think I have grilled you with all my questions at this time, I would appreciate all the information you can give me.
>Thank you,

An Answer:

Dear Miss,
For both tummy tuck and breast augmentation, it is possible to do the surgery as an outpatient. Your surgeon should see you in consultation however at least several days before the procedure to answer questions and help you decide whether the procedure is right for you. If you require more than a simple breast augmentation (maybe a lift) or more than a simple tummy tuck, you might be best served by having the operations at different times. I can't think of many people who would feel right about doing an operation (cosmetic) on a patient the day he/she met that patient. In addition, operating room time is a limited commodity.
On group rates: People occasionally ask questions like these. I do not routinely give group rates as my overhead costs are not different for grouped procedures. I discuss rates with patients at the initial consultation where appropriate.
With all this being said, I would be more than happy to see you.
Thanks for the question,
John Di Saia, M.D.

Question #8:

>I found your web page informative. I have considered implants for several years, but only recently have saved the money to take a serious look at the possibility. My main question involves the implants themselves. Since I am interested in shape as well as size (if not more so), I'm not sure I would be happy with saline implants (I have heard that saline implants have a more natural bounce, but that they don't hold a 'half orange or melon' shape. (In addition, my mother had saline implant when she was young and one day she woke up flat in one breast).
>Last year, I heard about a new type of implant that they are testing (it's made out of a natural fat or something like it). From what little information was available, it seemed to be safer than saline (doesn't interfere with mammograms) and holds a 'shape' better than saline. Do you know anything about these new implants and whether they have been approved for use yet (they said they needed to be studied for a year before approval could be gained)?
>Of course, I'm also curious as to the approximate cost of breast augmentation surgery these days. I have some money saved, but it would be nice to know if it is enough.
>P.S. Can you also provide recommendations for cosmetic surgeons in the Sacramento area? One of my biggest concerns about this type of surgery is making sure the doctor is good at what they do.

An Answer:

Dear Miss,
With regards to saline implants:
If implants are placed under the pectoral muscles, they do not interfere with the interpretation of mammograms as much as when placed above the muscle (beneath the gland). Whether the alternative implant materials which are still investigatory (only used in studies currently) will prove to be more of less of a problem is currently open to debate. Any implant can leak, but a current estimate of deflation rates is again variable. A commonly cited figure is 5% over 15 years. It may be more common. With a saline leak (as you'd mentioned), the body simply absorbs the saline. This usually results in a little burning sensation and then a noticeable size change. With the alternative materials, the question of how the breast will react to such a leak (should it happen) is again open to question. Amongst the currently materials under investigation are: peanut oil, soybean oil, and olive oil. It is thought that thicker solutions will result in a better feel.

Silicone gel implants have once again been approved by the FDA for augmentation although some surgeons still believe they require additional surgery over the long term. The routine breast MRIs recommended in the consent paperwork are expensive and will likely not be obtained by the average patient. I would recommend that you stick with saline unless you have particular needs.

With regards to a good surgeon in your area, I can't recommend anyone in your area. A few general points of information on the page Cosmetic Surgeon vs Plastic Surgeon might be helpful in your search.

Costs are highly variable (assuming augmentation alone will be all that is needed) in the range of $7000-9000 (this is a "guess-timate"). Incidentally scientific studies of the sort involved take on the order of five years to yield conclusions. This figure may get yet longer with the breast implant controversy since the 1990 FDA action (removing silicone implants from the market).
Thanks for the question,
John Di Saia, M.D.

Question #9:
(Eds Note: This one came in two parts)

Please advise on suggested size of implants best to augment a size 34b to c or d - can you advise to my mail address on which is best:
My advice has been 300ml size implants but what effect would 400ml or more make ?
Your response appreciated !
--- I forgot !
I HAVE INVERTED NIPPLES. IF I HAVE AN AUGMENTATION AS HAS BEEN SUGGESTED 300ml or more will this affect my inverted nipples as I am not unhappy with them. Will they become normal and extended.

An Answer:

The question raises a few good points:

(1) Don't get caught up in the volume (in cc)! It is very difficult to predict the ultimate size of a woman's breasts after augmentation especially without a proper exam. There is swelling post-operatively which decreases over a few weeks. Then your body forms a capsule around the implants (as part of its reaction to this "foreign body"). This will cause further shrinking over the next few months.
Therefore I always tell patients that right post-operatively they will have larger breasts than they requested. Furthermore, in the pre-operative discussion I inform the patient that targeting a specific cup size may not always be accurate. Being between one size and another is probably more accurate (say between large "C" and small "D").
Perhaps the best way to gauge a woman's requested size is to bring a photograph (usually obtained from a lingerie catalog or Men's magazine). This target photograph shows not only a size, but a general shape that you desire. It leads a pre-operative discussion of goals nicely.

(2) Any surgeon that guarantee's a certain size must not take into account the great variability in bra manufacture. I've seen many B and C cups that fit a given patient perfectly.

(3) Inverted nipples are the result of an arrangement of ligaments in the nipple. They may or may not change during the procedure as dissection is in the vicinity of this tissue (if the peri-areolar approach is used). The augmentation procedure however does not specifically address the issue of the inverted nipple.
Thanks for the question,
John Di Saia, M.D.

Question # 10

>Thank you for your informative web pages. Could
>you tell me how the decision is made whether to put
>breast implants below or above the muscle? Thanks
>for any info you can provide.

An Answer:

Most plastic surgeons today prefer to place the breast implant beneath the Pectoralis major muscle. The reasons for this are:

(1) improved soft tissue coverage for the implant resulting in a more natural appearance
(2) potentially reduced scarring (long term)
(3) separates the breast tissue from the implant which may make mammography easier to perform/read post-operatively

An argument for a sub-glandular placement:
(1) Ease of operative dissection (faster, more straight-forward) - meaning many surgeons who weren't trained as Plastic surgeons can do this operation. The same surgeons may "shy away" from a submuscular operation.

Women with very little breast tissue are often better served with a sub-muscular placement.
Thanks for the question,
John Di Saia, M.D.

Please note that this information (as well as that on all my pages) is offered freely to individuals considering cosmetic surgery. No rights are granted and it is not to be reprinted or copied without the author's prior written consent. Beware that although efforts have been made to assure accuracy, many of the issues discussed here are a matter of professional opinion. Consultation with a qualified Plastic Surgeon should be obtained to answer more detailed and potentially personal questions.




© John Di Saia, MD... an Orange County California Plastic Surgeon       John Di Saia, M.D.