To answer your questions...

Reader's questions addressed, vol XIII

Question #1:

I am posting on any boards I can locate about my plans to explant. I am having 24 year old silicone implants removed as soon as I can get it done. I ruptured one on Tuesday.

Please tell me what to expect post-op, if you will. I had them behind the muscle all those years ago and I am not replacing them with anything. I went from an A to a full B cup at age 24, in 1975. I am still thin and haven't gained much weight to offset the implant fullness post removal. What to expect?

duration (extent) of post-op pain, from your experience; have u explanted anyone? difficulty of ridding the ruptured area of the silicone (how is that done?) what is done with stretched out skin from 24 years of sporting an implant got any pics of this nature? Tell me anything you know, without reservation. Information is comforting power to me.

Oh, I have Thrombocytosis of 11 years standing etiology unknown. What part, if any, will this play in the (dangers?) surgery? I see my family doc tomorrow, and hope to get a PS consult ASAP.

An Answer:

If your implants were small as you describe you may be OK for just removal without a lift or replacement with another implant. This is something that would require an examination to determine however. You may notice a shallow depresion at the site of the implant on each side of the chest reflecting the change in your chest wall (ribs) from the implant's presence over the last twenty years however, assuming you don't opt for replacement or a lift.

If the silicone gel implant is ruptured, there will be a certain amount of gel that is free wihin the capsule that can be easily removed. There will however also be a quantity of the gel that has penetrated the breast tissue itself that cannot be removed without producing a deformity.

Pain is a personal issue and is hard to generalize. You should have quite a bit less pain than you had in the original surgery (as you described a submuscular placement). The "stretched out skin" would be treated by a lift if it was thought to be significant.

The issues relative to Thrombocytosis would be better described by a hematologist. Assuming you are on no medications that themselves impair healing , the effect may be mild.

Another issue: check your insurance company policy on this if you are going to try to get them to cover the surgery. They may cover only the removal on the implants and may make you do the surgery in a contracted facility that will likely have high cash rates. This latter part is important as you wil be expected to pay for all other fees for other procedures that are performed (lift, replacement).
Thanks for the Question,
John Di Saia, M.D.

Question #2:

>In a previous answer, regarding surgical procedure for inverted nipples, you suggested performing augmentation through a periareolar approach...what exactly is that approach?  How do you do it?

An Answer:

The incision is at the lower border of the areola. After the implant is placed, small ligaments within the nipple are severed in order to allow it to take a more raised position. It is usually effective.
Thanks for the Question,
John Di Saia, M.D.

Question #3: Answers Inline With This Multi-part Question

>Your site was exactly what I was hoping to find.  Thank you for sharing your information.  I am considering breast augmentation and have a few questions that I am concerned about.  I have read your entire Q&A section and every other page that you have presented.  Most of my questions have already been answered with the exception of the following:
>1.  I have read that one of the possible surgical risks involved is skin necrosis - skin tissue death resulting from insufficient blood flow to the skin, which could be a result, among others, from an implant too large for the available space.  Have you ever heard of this happening, how often does it occur, and how is it corrected?

I haven't seen a case. It would be complicated to repair.

>2.  I am 5'5", 130lbs, 34A, and am interested in being two sizes bigger.  I know that you recommend taking a picture to my consult, but would you consider a 34A (see attached photo) relatively small for an implant of around 325 to 375 cc's?

The image you sent was somewhat blurry. The implant you describe is not very large.

>3.  I read the Q&A about scuba diving and pressure.  One of my next adventures was to learn scuba diving.  Do I need to avoid deep water dives, because of the pressure?  Also, how about traveling in an airplane....does that put any pressure on the implants?

Unknown on these, but I don't recommend any change in lifestyle because of the implants.

>4.  I have several friends who have had implants, both submuscular (under muscle) and subglandular (over muscle).  Both post surgery procedures were entirely different.  Both doctors are "Chief of Plastic Surgery" at prominent hospitals.  One doctor, who prefers submuscular, simply places a three inch band around the chest after surgery and when that is removed, instructs that no bra is to be worn for six weeks, and exercises begin within two or three days after the surgery.  The other doctor, who prefers subglandular, places you in an upper body cast for a week and when that is removed, instructs you to wear a bra around the clock for a short period of time, and exercises begin after a couple of weeks.  How can the two procedures be so different?  Is it because of the placement of the implant?  I realize you prefer submuscular placement, so is your post surgery procedure the same as the one I mentioned above?

I don't have a special cast nor do I use a band...just a bra. My personal opinion on subglandular placement has been expounded upon ad nausum on this site.

>5.  I have heard both that an implant should and should not be filled to capacity.  Which is correct in your opinion?

It should be filled to capacity to avoid potential "fold-failure" and rupture. I don't know of anyone advising that the implants be underfilled.....careful with that surgeon.

>6.  Another possible implant risk is the implant shifting from it's original position, or pushing through a layer of skin.  How ofter does this occur?

Very rare. I saw one case of position change (fortunately) in another surgeon's patient following pregnancy. I have not seen a cosmetic implant pushing through the skin (fortunately).
Thanks for the Question(s),
John Di Saia, M.D.

Question #4: Again, Answers Inline With This Multi-part Question

>Dear Dr. Di Saia,
First of all I want to thank you for your website. I have found answers to many of my questions.  Thank You for keeping us well informed! My first question has to do with weight.  I heard once that a person should be at their ideal weight before proceeding with augmentation.  Is this true?

  I recommend that a woman be at a weight that she feels that she can maintain. Large gains or losses here following surgery can increase the patient's potential desire for more surgery later to adjust things.

>Secondly, my nipples are large or may appear large due to my small breast size. Can this be corrected during surgery?

Yes, this is not terribly difficult.

>Lastly, I was curious about financing the procedure.  There are companies that finance plastic surgery and refer you to their doctors.  Is this really safe?

  Well, many of them are and others aren't. It depends upon the criteria that the companies use in determining to whom to refer a patient. Many of these companies pay so poorly that "good" surgeons aren't willing to accept their rates, so they get "left-over" surgeons. You don't want a less than excellent surgeon operating on you. A more involved description of my stance on cosmetic surgery financing companies (and a solution to consider) can be found here.

>Also, where can I go to get information on my doctor?  How do I know who is safe and who is not?

  This is the hardest area for the potential patient. Only if a doctor has had written complaints will the state medical board know about it. You can contact them. The best referral source is from a patient who has had the procedure in which you are interested; even better is a good friend. Some unscrupulous doctors pay supposedly friendly referrers for the lead. I don't do this but many others do.
Thanks for the Question(s),
John Di Saia, M.D.

Question #5:

>Dear Dr. DiSaia,
>I have a problem.  My right breast is a 38D, while my left breast can
>hardly make a dent in the bra cup, (much much smaller).  When going
>through puberty, my left breast hardly grew, I think all the tissue went
>to the right side.  When I had a baby 5 yrs ago, I wore a 36C (for my
>right side), then shot up to a 38D  - my left breast grew just a
>little.  I am very self conscious of this situation, even when they are
>smooshed in a sports bra, I can still see the lopsidedness.  What kind
>of options do I have?  I would like my breasts to be as much the same
>size. Can I do that by removing a small amt of tissue from the rt, and
>inserting it in to the left?  Or is an insert my only option?  What
>about tissue expansion??  If you have any answers, please let me know.
>Until then, I will continue hiding under a padded bra!!!

An Answer:

This is not really all that uncommon. The options (dependent upon your examination) would include:

(1) If the smaller breast is really small or poorly formed: Two operations several months apart

The first would involve the placement of a tissue expander in the smaller breast. This would be progressively inflated over several weeks to months. The second would involve removal of this tissue expander and replacement with a permanent implant. The other breast could be reduced at this time if required.

(2) If the smaller breast is not all that small: One operation

The larger breast could be reduced and the smaller breast implanted.

From that which you describe the first option sounds more appropriate. An alternative to surgery would be the insert you mentioned.

Thanks for the Question,
John Di Saia, M.D.

 Question #6:
>I recently had breast augmentation (4 months ago). I was a 34B cup
>w/severe (I thought so) tsosis. My surgeon reccomended 375cc saline
>round implants, sub pectoraly. I took his advice. I have heard different
>opinions re; sub pectoral implants from "you can see permanent results
>after 3 months" to "it takes a full year to see results". The reason I
>am asking is that I do not have the desired tear drop effect. My
>implants are very full on top and because of the tsosis my breasts sag
>around the implant to some degree, making it rather obvious I have
>implants. I went from a 34B to a 34C w/ the 375 cc implants.
>My questions are:

>Do they have the potential to continue to drop to a more natural look over the next few months?

It depends upon the natural "tear drop" effect you look to achieve. I have found that individual women look to achieve quite different effects with their augmentation results. Some are possible and some are not depending upon the desired result and the patient's pre-operative state and the surgery performed.

>My right breast is also much firmer and aches at night if I lay on my back to long. I have been
>massaging every day. Is this a sign of capsular contracture?

It could be but at this early stage is much more likely your body trying to adjust to the implant (stretch and relaxation of the muscle and skin). More often than not, one side is more firm than the other which can alarm some women.

> I would also like to ask how difficult of a procedure is it to remove the implants and do a breast lift and would there be a lot of scarring involved?

This is possible but is more difficult than the first operation. It may also not give you the desired result. More often than not I have seen women who remove implants are later unhappy with their breast volume. Depending upon your breasts' appearance when the implants were removed, a modified or full breast lift may be required.

Thanks for the Question,
John Di Saia, M.D.

Question #7:

>I am a female university student. I am very self concious about my breasts, to be specific my nipples, one of my nipples >appears to be fine, the other however, is well the best way I can describe it it is inward. I realize that this sound trivial but I am >very self conscious about it and as a result avoid intimacy. Is there any sort of surgey that can help me.

An Answer:

Inverted nipples can be corrected via a fairly simple operation. It is usually effective and has very little downtime.

Thanks for the Question,
John Di Saia, M.D.

Question #8:

>After receiving laser treatment and/or dermabrasion, I understand that
>aquaphor is commonly used for treatment of the affected area.Healing
>time is a big concern of mine,is there a better product out there that
>will reduce the time it takes for the skin to return to its normal

An Answer:

I use aquaphor on my patients following laser re-surfacing. If I felt something was better I'd use it. In short, there is not a better product out there at present.

Thanks for the Question,
John Di Saia, M.D.

Question #9:

>I'm a 34 year old female, 5'5 tall. [4 months ago], I had an abdominoplasty and liposuction on
>abdomen and thighs. My concern is that, although the swelling has
>diminished, I gained 5-6K, which I cannot remove.
>Why [can't ] I lose weight? Because my body is still
>repairing the surgery or because of the anesthesia?
>If my recovery is slow (don't smoke, no diabetes, but
>low blood pressure and bad circulation), how many
>months do I will stay this overweight (6, 9
>months, a year)? I feel sad because my body was thinner
>before the operation.

An Answer:

Liposuction and abdominoplasty are not weight loss procedures. They do change contour, but patients need to understand that they do not guarantee that weight will be lost or will stay off. They are contour correction procedures. When used in people who watch their diet and exercise, situations like the one you describe are extremely rare, but they can happen. Surgery doesn't change a persons's metabolism, but rather rearranges a person's external appearance.

Thanks for the Question,
John Di Saia, M.D.

Question #10:

Thanks for having this site to ask questions!! My question my be different compared to others.I had a tummy tuck in May (two months ago) and I am not happy with the results.The doctor "cut me short" of what he had planned!! He had drawn and explained that my "pooch" would be gone but he did not cut where he had drawn (he left an incision line on my belly too where he cut the top layer)and he sewed up my bellybutton and made me a new one.He only cut out half of what he drew and he didn't tighten the abdominal muscles (said they were tight)---said that the cut was as tight as he could get it. Now I still have the pooch and not only is there an ugly crooked scar (I expect scars-I had a surgery scar there before) and the bellybutton he sewed shut along with the fat still there looks like a butt!!! If I could attach a picture (although it's dark), I would. My question is...have you ever had to do this? Have you had unhappy patients? He says that he may have to lipo the belly but why should he have to do that if he had done it right the first time. I am in tears every night,every time I look in the mirror and sit on the toilet and pinch the fat left there. I have not gained a pound since the surgery, have returned to work (am in construction, not a desk job) and I haven't lost anything either--still have that belly sticking out of my jeans. What would you say to this if I were your patient? I am crying everytime I talk to the doctor, he says I should be optimistic and I am also mad that it has cost me $8,000 total (losing work and all) and I see no difference except for the additional scars and the fat belly/butt look!! HELP--I would appreciate a quick answer. I am considering going to a big city surgeon for a second opinion too. Thanks again for listening and for your response.

An Answer:

Abdominoplasty is a big operation and at times there is the need to go back and adjust what was originally done (primarily due to the way the tissue heals).  I do not do these revisions free although I do discount them. Then again I talk with people before the operation to let them know that revisional surgery can at times be necessary. People often have the thought that you had: "He should have done it right the first time!" But you, your body and the way it heals also have something to do with the outcome. Patients very rarely consider this. Surgery is not like working on a car in that a car doesn't heal.

Although people don't really think about it, there is a high "cost of doing business" in plastic surgery. Either surgeons charge really high fees and do revisions free or charge a "market price" and charge for revisions. I don't know what your conversation with your surgeon was like prior to surgery, but it may have led you to believe that perfection was always realized. In reality, it is never realized. Some results are better than others but improvements can sometimes be made. This is not to say that patients should keep having surgery in hopes of realizing perfection. Perfection is that value to which we always aim. At times, we are close and at others we are farther off. Then again a "reasonable result" takes a reasonable person. Expectations have a great deal to do with what is considered acceptable.

I would wait a full year (following the surgery) and then look at where you are and consider a revision.

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.



©1996-2004 John Di Saia, MD... an Orange County California Plastic Surgeon       Dr John Di Saia, an orange county california plastic surgeon