Question #1:
>Dear Dr:
>
>BACKGROUND
>My wife has undergone bilateral breast augmentation twice during 1997.
The first time (1/96) she told the doctor (certified) she wanted to go
from a 34A to 34C (she was asked to bring in a "target-size" bra which
she did). Based on her size (34-25-33, 105lbs, 5'4"), he recommended using
a Mentor H/S saline filled implant size 300CC (+ 25cc overfill) to be inserted
axillary and under the pectoral muscle. After the swelling and bruising
went away, she was dissatisfied with the results. Apparently she felt the
final size, while larger than she currently had, was still to small giving
the procedure and the expense. She went back to her doctor and explained
her dismay and he agreed to perform the operation (at no additional cost)
again. This time my wife brought in pictures of what she wanted (Jenny
McCarthy, Demi Moore, and Pamela Anderson) the surgeon suggested a size
of 525cc (+25 overfill) and my wife said "If I have to do this again I
want to go a little more to be sure." The doctor (who by the way is a world
renowned pediatric reconstructive plastic surgeon) agreed and they settled
on a 575cc implant (+25 overfill) or 600cc's in total; the operation took
place on 9/97.
>
>THE QUESTION
>
>While the procedure turned out fine and she actually went to a 34D
size, there is a small notch on the right side of her right breast (near
the armpit). Her doctor said it is due to him not dissecting enough of
the pectoral muscle (i.e. making a large enough pocket) while at first
it seemed perceptible, over time (i suppose due to gravity) it has abated.
there still remains a very very slight "notch" on that side. Is this O.K.
from a safety standpoint ? will this cause the implant to fail over time
? Also, a very small "ball" about the size of a head of a pin has formed
on her right breast, it fells like a fleshy piece, like when someone gets
there ears pierced and lets the hole close up there's a small ball-like
structure in the lobe that can be manipulated slightly. Is this O.K. ???
Is it normal to feel "ripples" from the saline implant through the skin
(mostly on the bottom of the breast ??
An Answer:
I am not a fan of the trans-axillary approach to breast augmntation. The operation has occasional complications even when performed with better exposure (peri-areolar or infra-mammary approaches). The "notch" you describe is probably not of functional significance. Things do change over time however as the implants settle. Regarding the "ball" you mention, it seems to be consistent with a suture granuloma from the way you describe it. On occasion, the sutures we use (even those that are supposed to dissolve) can incite a small local reaction in the tissue that surrounds them. This is not a danger, but can cause the area to be palpable from the skin surface. As long as this area has been seen by a surgeon, I would not become overly concerned about it.
On ripples, they are frequent with saline implants as the viscosity
of water is much less than that of silicone. Remember that the implants
are only partially covered by muscle. The pectoral muscles cover it mostly
towards the cleavage and upper- mid breast. The sides (toward the armpit)
and undersurface therefore may show these ripples if the ratio of the size
of the breast prior to surgery and the implant size is too small. Obviously,
if the breast tissue is very small relative to a large implant, the implant
tends to be more visible.
Thanks for the question,
John Di Saia, M.D.
Question #2: >hello and thanks for all the information! I was wondering if you know anything about women who have breast implants who scuba dive. I heard a story about a woman who went diving and her implants ruptured due to the pressure, and she died. Is this just a myth?
An Answer:
I have not heard that story. It seems true that breast implants would
be at increased risk to rupture at depth, but rupture does not result in
death. I know of no cases of this happening.
Thanks for the Question,
John Di Saia ,M.D.
Question #3: >I'm 35 and have had 3 children. I have always had large breasts and while I'm not really interested in reduction or augmentation, I would like to know more about what can be done to reduce sagging and increase firmness. I recently lost a considerable amount of weight through increased exercise. The exercise did seem to help a little with the sagging, but the firmness problem is worse than ever. Would implants be a possible solution to increase firmness ? I'm currently a 38DD so naturally, I don't really want to increase my breast size dramatically. But I don't really want a decrease either. Any thoughts on what type of procedure I should look into?
An Answer:
The procedure to "lift" the breasts is called mastopexy. It does not
really increase firmness though. It is not necessary to reduce the breasts
in size at the same time. Sometimes a small implant is used to increase
projection.
Thanks for the Question,
John Di Saia, M.D.
Question #4:
>I received augmentation approximately three months ago. A 350 cc smooth
implant was placed under the muscle using the armpit approach. When the
ace bandages were first removed two days later. the results were not ideal.
The implants were placed very high. My surgeon told me to keep them in
a downward position with the ace wrap for another week and to move the
implants around. I moved them around but they were not always soft-at times
they would be hard and other times soft. The positioning was not only high
but uneven as one breast is about 1/2" higher and looks flatter. At first
I wondered if the implants were the same size. they never really bounced
when I walked. Now the implants are still firm-one round, the other higher
and flatter. Although at times they are soft, especially when I wear a
sports bra that keeps them in a more downward position When I remove the
sports bra, however, they resume their higher position and become very
firm. They are also soft when I lean forward and upon awakening in the
am. My plastic surgeon says I have formed capsular contracture and has
scheduled a bilateral capsulotomy with an underneath the breast incision
approx. 2 to 2 1/2" to remove the implants whole, loosen the capsule, and
to bring them downward. Could the pockets be made deeper while leaving
the implants in place by using the breast fold approach with a smaller
incision? Do the scars tend to fade and stay in the fold of the breast?
I don't know whether my capsules are making the breast firm or are the
pockets are just too small.
An Answer:
The fact that you have (as it appears) severe capsular contracture does make a capsulotomy a good option. This may improve your situation somewhat although the recurrence rate can be as high as 50%. The "armpit" (Axillary) approach to breast augmentation has some disadvantages. Less control of the result is certainly one of them. It is common to have the implants "ride high" and the acewrap that your surgeon is having you use is one way to improve the result. It has not been shown that the axillary approach makes capsular contracture any more likely though.
With regards to your mention of asymmetry between the breasts, this is a judgement call. Spending a fair amount of time before the operation examining the breast helps most women realize that all breasts are asymmetrical to an extent. The degree of difference is that which determines a "natural-appearing" versus "un-natural-appearing" result. With an axillary approach, the element of control is less and significant asymmetry may be more likely. This is a matter of opinion however.
The performance of a capsulotomy does require a different incision,
most commonly the infra-mammary incision that your surgeon mentioned to
you. Doing the procedure through another incision is more difficult and
would not be as complete. Considering the amount of work in a capsulotomy,
the incision size you cite is not long at all.
Thanks for the Question,
John Di Saia, M.D.
Question #5:
>Dear Doctor: I am a happily married 32 year old mother of two, ages 7 & 3, and have decided to have breast augmentation. Surgery is in April. After reading ALL of your questions and answers, I did not find anyone with my concerns.....1. What to tell my 7 year old daughter who is sure to notice. I really don't want to lie to her, but I just can't come up with what I'll say to her. 2. My 3 year old still requires alot of picking up (lifting up) I will have full time help with me for 5 to 7 days, but how long before I should try to pick him up or carry him (32 pounds) and what will happen if I HAVE to lift him? 3. Now for my MAJOR concern, GUILT. I am having feelings of guilt regarding choosing to do something to myself that could possibly harm me physically, therefore putting a strain or hardship on my family. I have always been self conscious of my chest size and I feel augmentation will really make me feel better about myself. Any comments you have on my concerns will be greatly appreiciated.
An Answer:
I cover this briefly in the section on the web page "Is this Really
For Me?" I feel getting into it more deeply over the internet would be
unethical. I usually discourage patients with major misgivings (like your
self) from having surgery until they have dealt more adequately with these
very personal issues. Even the best surgical result may not please a person
who really had not decided to accept a procedure before actually having
it.
Thanks for the Question,
John Di Saia, M.D.
Question #6:
>Dear Dr. Di Saia,
>I have considered breast augmentation for years, and more seriously
>since a friend recently had surgery that I am interested in. Her story
is >very different from any I have ever heard. She has contour/tear drop
shaped >implants that have been placed under the muscle via the arm pit
which still >have tubes connected to the implants. A layer of skin has
grown over these >tubes since surgery but is easily accessible via the
arm pit with an >incision. (If you look under her arm, you can see an "O",
circular shape.) > Her doctor has left these tubes for the prupose of her
breast size >satisfaction. If she should want to increase of decrease her
size after >surgery it would only require a simple office visit. This is
absolutely the >perfect answer to breast size complaints ! The problem
however; is the >doctor is located on the East coast and I live on the
West. > >My questions are as follows: > > *Could you recommend a doctor
in the San Francisco area that performs >the same procedure? > *Could you
advise if this is a conventional method to date? I have >spoken to many
doctors offices in search of this method and have been >unsuccessful in
locating a doctor who performs this method let alone uses >contour/tear
drop shape implants. Most I have spoken to use round implants. > I would
prefer tear drop shape for a more natural look.
An Answer:
I can't say that these new "anatomically shaped implants" are the preferred implant of most surgeons. To be honest, they are relatively new. Whether they indeed ultimately result in a more natural breast shape is unknown at present.
Regarding variable fill implants however, I have not been impressed. The current saline implant has several disadvantages one of which is its tendency to wrinkle at the surface. This can sometimes be seen through the skin. The only manner in which this can be minimized is overfilling the implant slightly. This is safe and is condoned by the implant companies. To allow for a variable fill is to "under-fill" the implant.
Another point is that the implant is ultimately surrounded by
an envelope of the patient's tissue which will eventually limit the further
expansion of the implant. Over-expansion of an implant once the capsule
is fully developed may be painful and certainly would not look very natural.
It is also theoretically possible via the procedures used to change the
implants fill volume that the implant could become infected. I would seriously
consider whether you really want to entertain these risks in order to have
this implant.
Thanks For The Question,
John Di Saia, M.D.
Question #7:
>Dear Dr. Di Saia:
>I would really appreciate it if you would answer my two questions.
I have had two children and have stretch marks on my abdomen and breasts.
Is it possible for a plastic surgeon to remove stretch marks on the breasts
when doing breast enlargement surgery? Also, the stretch marks on my abdomen
go to slightly above my belly button. Would abdominoplasty completely remove
these? Thanks very much for the info. You seem like an incredibly intelligent
and compassionate surgeon.
An Answer:
Thanks for the kind words, but I'm afraid that I don't have the greatest news for you. Breast augmentation will not remove stretch marks from your breasts. If you needed a breast lift (mastopexy), then some may be removed at the cost of more incisions which leads to more scarring. For those with a good deal of droop (ptosis), the scars are in exchange for the droop.
Regarding the abdminoplasty, patients can have a good deal of
their stretch mark-laden skin removed, but don't count on it all going
away.
Thanks For The Question,
John Di Saia, M.D.
Question #8:
>I had breast augmentation two days ago and have a couple of questions:
>
>1. Today my breasts have felt "fuller" and tighter; is this normal?
>
>2. I have bruising with only one breast. Does this suggest internal
bleeding or is it normal?
>
>3. My breasts feel warm, not really too hot. Is this normal?
>
>4. I am reluctant to sleep in any position but elevated on my back
because of the implants. Will this feeling subside?
An Answer:
It is normal to feel fuller and/or tighter as your body adjusts
to the new volume (the implant) under your breast and skin. One breast
can bruise more than the other. Similarly, one can feel more sore or more
numb. These things should subside with time. If you form a "bump" on one
however that seems to be enlarging, call your doctor to inquire. The warmth
you describe is also common, probably being related to the body having
an initial reaction to the implant. As long as it is not deeply red (mild
redness is normal), I wouldn't be overly concerned. This is where judgement
comes into play, which is why most surgeons will want to see you shortly
after the procedure (a few days) to check your status. Sleeping on your
back for a few weeks may be uncomfortable (to those who may like to sleep
on their bellies), but is defintely better for the wounds.
Thanks For The Question,
John Di Saia, M.D
Question #9:
>I WOULD LIKE TO KNOW WHAT THE DANGERS OR RISKS OF LEAVING IMPLANTS ALONE IF THE BILUMEN TYPE, WHERE THERE IS A SILICON IMPLANT SAC SURROUNDED BY A SALINE SAC, THE SALINE SAC HAS COLLAPSED BECAUSE OF HAVING A CLOSED CAPSULOTOMY. THERE IS SLIGHT SAG AROUND THE IMPLANT WHERE THE SAC HAS COLLAPSED. THIS WAS FOUND ON MAMMOGRAPHY FILMS.
An Answer:
This is difficult to ascertain. If the breasts are not firm, you might opt to just observe them. You could also opt to remove them to replace them with saline implants. You should see a qualified surgeon in your area for futher guidance.
Thanks for the Question,
John Di Saia, M.D.
Question #10:
>Dr,
>I am very active in softball, horseback riding and other sports. Will
having >breast augmentation require me to limit my participation in these
sports or >will my participation in these sports increase the chance of
rupture ?
An Answer:
I would say that theoretically the answer to your question is "yes." The problem is that I cannot say this with certainty as studies have not borne out this conclusion. A rough estimate for rupture incidence is 5% over 15 years.
On the other hand, would I say that you should limit your activity because
of the operation? For a while post-operatively, you should take it easy.
After that, most patients go back to their normal routine.
Thanks for the Question,
John Di Saia, M.D.
