Question #1:
>Dear John,
>Hello! I know that you must be very busy; however, if you could find
the time to answer a few questions, I would be very grateful. I am a parachuting
instructor and jumpmaster. Last summer, my best friend made 3 student freefall
jumps, and for personal/family reasons, she had to quit jumping. Then,
in the fall, she had breast augmentation surgery (saline). She has now
decided to resume jumping and was told by her surgeon that it was safe,
i.e., no appreciable risk of rupturing them....
>Although I am a nurse, I have no knowledge of plastic surgery...still, I think that he might have given her this advice with ulterior motives. I have had many uncomfortably hard openings (of my parachute); complete with bruising and abrasions, and it seems to me that a sudden compression/jerk could rupture implants.
> She wrote to the United States Parachute Association, asking them for advice, but they told her that they had no information on the subject. Surely there must be women with implants skydiving? I guess they wouldn't exactly advertise themselves, though. In any case, I ran into her surgeon a couple of times when I worked nights at the civilian hospital in Abilene (where she is stationed now, and where I was stationed prior to this assignment), and he did not impress me with his sense of ethics; in fact, he gave me the creeps. So, anyway; it's just a feeling, but I wonder if his advice was somehow linked to the fact that, if they did rupture, he's stand to gain a lot of money by re-operating on her? If there are any studies you can reference, or if you have any information on this, it would be very helpful.
>Thank you for your time and help!
>
>Andrea (Andy)
An Answer:
On skydiving....I think your information is probably right. There is
no data of which I am aware. On the other hand, should the young lady change
her lifestyle entirely because of her implants? There could be an increased
risk of rupture. Seeing as good studies of any sort on breast implant patients
are hard to come by however, I don't foresee a major newsflash on the topic
appearing anytime in the nearby future.
Thanks for the Question,
John Di Saia, M.D.
Question #2:
>I need to know if you think it is safe to have breast augmentation
done in-office with mild i.v. sedative and what is the usual recovery time
after the procedure is done? If I have to reach in my job(dentist) would
I be uncomfortable for longer than 1 to 2 weeks? I would appreciate your
input. Thanks. Also, if you know of any great docs in the Denver area I
would appreciate your referral.
>--
An Answer:
Is it safe (IV sedative)......I guess.
Ask about the cost difference to have a general anesthetic. You'll probably
be more comfortable. The operation (depending on how equal in size your
breasts are) is usually quite straight-forward. Recovery time unfortunately
is quite variable, but light activity is frequently possible after 2-3
days.
Thanks for the question,
John Di Saia, M.D.
Question #3:
(Editor's Note: This one came in four parts)
1. Can you explain the differences, advantages and disadvanteges of
having the implants put in by the arm pit or under the breast...which do
you prefer.
2. I have had 6 children which has not only left me flat, but lop-sided
(sic) as well. How do you determine size, and guarantee equality
on each side?
3. I have been told that due to gravity and settling into the
body, the implants should be just a little bit bigger and higher at first.
Is this correct?
4. How many years on an average do the implants last barring accident
or impact of some kind?
An Answer:
With regards to the operative approach, there are three "main" approaches: via the arm pit (Axillary), the underside of the breast (Infra-mammary), and the areola (Peri-areolar). Each of these has advantages and disadvantages. The Peri-Areolar is currently the most popular as it allows fair exposure to allow the surgeon control of the result. It also leaves a fairly forgiving scar. The Axillary leaves no scar on the breast but is more difficult, takes longer and gives less control to the surgeon. Maintaining the implant in a low natural position is difficult with this technique. The Infra-mammary approach probably gives the best exposure and control, but has a tendency toward a larger more conspicuous scar.
On your second question, any surgeon who guarantees symmetry in the result in breast augmentation in my opinion is suspect. Breasts (as well as every other paired body part) are asymmetrical (i.e. there is always some degree of difference between them). A surgeon no matter how hard he/she tries will not be able to make an exact match. I always tell patient that there are maneuvers to correct marked differences (i.e. for droop...mastopexy, for size mis-match...different implant sizes/fill volumes). Nevertheless, there will be a difference between the breast post-operatively. The key is to make this difference seem the most natural.
Your third point is a good one: post-augmentation breasts do undergo some shrinkage and settling. The total reduction in volume is probably on the order of ten to twenty percent. The implants will come to reside in a lower position ultimately (gravity strikes again). In most cases, this is good as they become more "natural appearing."
Your last question is difficult to answer as breast implant patients
do not regularly provide their surgeons with long term follow-up. Some
will come back with problems, but the rest generally do not. The saline
implants have improved in the last ten years. Originally, they had a problem
with leakage at the inlet valve. This has been improved. The actual rate
of leakage is hard to pinpoint (for the same reason). A commonly cited
figure is 5% over 15 years. The question of contracture (firmness) leading
to re-operation is also questionable. A recent review by a single surgeon
describing his personal experience indicated that as little as 2% of patients
may have significant contracture. It is probably a greater proportion than
this.
Thanks for the question,
John Di Saia, M.D.
Question #4:
>Dear Dr. >In reviewing your chosen photographs showing women you believe
to have had reasonably good implant jobs, I wanted to scream!! The reason
so many women look like they have cantaloupes stuck on their breast wall
is because the surgeon is not concerned with aesthetics. I am attaching
a photo showing a properly augmented woman. Notice the implants do not
look unnatural; they have the right amount of cleavage and appear
to be correctly proportioned.
>
>Now, my question: how do I make sure to find someone who really cares
about the aesthetics and isn't just interested in performing as many surgeries
per day as he/she can? What are the guarantees that you won't end up looking
like your section one models (Pamela Sue comes to mind, so does every woman
in any x-rated video I've ever seen)?
>
>Thanks for your willingness to be candid!
An Answer:
The only point of your diatribe here is that beauty is in the eye of
the beholder. The sample picture that you'd sent shows only one thing:
your impression of a "properly augmented woman." The problem (in all seriousness)
is that the ultimate goals are a matter of opinion. The picture you'd sent
shows a small augmentation result. We do not know how far out from the
surgery she is. We do have the luxury of a pre-operative photo. We do not
know how her result will fare with time. How will she look in ten years?
The bottom line is that each surgeon/patient has his/her own idea of
a good result. Honestly, patients that are displeased with surgical results
overwhelmingly complain that their breasts are too small. I've only seen
one patient who complained that her surgeon had made her too large. Patients
should consider this fact. Also, pictures that patients provide as goals
help resolve the "target" size and shape issues. A last point: there are
no guarantees in plastic surgery. Anyone providing you one is suspect.
Be certain your conversation with your surgeon covers points you consider
important.
Thanks for your question,
John Di Saia, M.D.
Question #5:
>Hello:
>Actually I have two questions. My knowledge of breast augmentation
is very limited. I understand that mammography is still effective--especially
when the implant is placed under the pectoral muscle. However, I was wondering
if there is any impact on one's ability to breast feed?
>
>My second question has to do with some additional studies. Have there
been any attitudinal assessments of husbands and boyfriends of women who
have had the procedure. I really want the procedure for myself, but I don't
want to risk "turning off" my husband with these changes.
>
>Thanks much.
An Answer:
You present a fair set of questions. Unfortunately, they do not have simple (or definitive) answers. Nevertheless...
On the subject of mammography and breast cancer, saline implants are less obstructive to visualization than were silicone implants. Also, as you indicated, placement of the implant behind the Pectoralis muscle hinders mammographic examination less. There are still some investigators that claim that implants may reduce the effectiveness of mammography. This is a far less universally held opinion now however.
On breast-feeding, implants themselves do not directly affect the process of milk production. The surgery however involves a limited dissection of the breast. Scarring can potentially block some ducts leading to a reduction in the quantity of milk produced. Some ducts may not be able to empty well. There could be breast swelling or discomfort. These are problems reported in the journals with an uncommon frequency to which a number could not easily be placed. I have never seen a patient with the problem.
With regards to a person's reaction to the implants, this is a personal
question. I would be foolhardy if I were to suggest that all men (or women
for that matter) feel breast implants are attractive. On resolving this
issue, you are better off discussing it with the people concerned.
Thanks for your Questions,
John Di Saia, M.D.
Question #6:
(Editor's Note: This question I borrowed from a chat room. It is a little
modified and abbreviated.)
I have been contemplating the option of getting a breast reduction.
What are the pros and cons of doing this kind of procedure? Is it safe,
any precautions and tips if I do decided to go through with it? Will I
regret it?
An Answer:
With regards to breast reduction, patient satisfaction tends to relate
to the age of the patient and the actual reason (cosmetic versus symptoms)
that patients seek surgery. Younger patients with less symptomatology (like
back pain and deep bra furrows) seeking reduction for cosmetic reasons
tend to be less satisfied as the procedure leaves scars (which are of course
variable). Older patients tend to have more symptoms and/or are better
equiped to handle the scarring (probably both).
John Di Saia, M.D.
Question #7:
In regards to breast augmentation surgery, is there any body of information
that tracks loss or gain of sensitivity, especially in the nipple area
after breast augmentation surgery?
Are nipples affected in any way as to size, shape, response to stimulation,
blood flow (engorgement) or other factors that affect arousal and sensation?
An Answer:
With regards to the loss of sensation at the nipple/areola, all patients acutely note a change in their sensation post-operatively. Fortunately, only about 15% note a permanent change as sensation is regained. This change and subsequent return are similar regardless of the surgical approach used. Nerves maintaining nipple/areolar sensation mostly come from the side and less so from the mid-chest.
On the subject of engorgement or size/shape, there is no data to suggest
that these items change appreciably following simple augmentation surgery.
Thanks for the question,
John Di Saia, M.D.
Question #8:
Dear Dr. J., I found your letter quite interesting as I am scheduled for liposuction on my thighs on June11. I am really wrestling with this decision as I am happily married, athletic, and am considered thin at size 6. However, I've always hated my legs which relatively " thick". I was wondering if "lipo" is ever done on calves? What are the results? Does increase the chance of complications? Is it done very often? My husband is a physician also and won't even discuss this with me...He went ballistic when I mentioned adding the calves. (He suggested I have my head examined) What do you think?? Thanks for your input/opinion.
An Answer:
Liposuction works by removing (parts) of the fatty deposits in the area
of interest. Calves are not routinely done as they are more often composed
of muscle as opposed to fat. There is a layer of fat, but not the usual
deep layer that is especially amenable to liposuction. I would suspect
that liposuction on the calves may have a high incidence of causing "streaks"
or surface irregularities as a function of the anatomy of the fat present
there. I have not seen liposuction done in this location before.
Thanks for the question,
John Di Saia, M.D.
Question #9:
>I have two questions and I would greatly appreciate your response. Does a plastic surgeon require specialized training in order to perform the endoscopic transaxillary breast augmentation? As this is a relatively new procedure, and many surgeons still rely on the old traditional methods, how does one know for certain that a particular surgeon is skilled in performing the endoscopic transaxillary breast augmentation? My second question is whether the transaxillary breast augmentation is always under the muscle? I would prefer to have this method. Thank you in advance for your time.
An Answer:
This is not really all that new a procedure. Since endoscopic equipment has become available some surgeons have been trying to use it in breast augmentation surgery. This technique is really a modification of the more standard trans-axillary procedure.
With this being said I am not really a fan of the procedure although I took a course in endoscopic surgery following training that included this procedure. There are several reasons:
(1) This approach requires specialized equipment that would further increase my overhead.
(2) If I were to need to adjust the result for any reason, I would need to make another incision on the breast. This technique as I had mentioned is based upon the trans-axillary, a technique that next to the trans-umbilical (through the belly button) has the highest rate of revisional surgery.
(3) I am not in general happy with the shape of the breast that the trans-axillary apporach provides.
(4) I am very happy (as are my patients) with the shape and reliability of my current technique.
Thanks for the question,
John Di Saia, M.D.
Question #10:
>A friend of mine had silicon implants 5 years ago. Her doctor instructed
her to take antibiotics every time she went to the dentist; even for such
simple procedures as cleanings. Her understanding for the antibiotics is
that it prevents infection from settling around the implants. I have never
heard of this before. Is the taking of antibiotics for this reason a common
practice?
>Thanks for the informative web page!
An Answer:
This is unusual. I know of no other plastic surgeons that advise prophylaxis
for patients just for their breast implants. There is no data of which
I am aware indicating this is effective. Are you sure this individual does
not have perhaps a heart defect or some other reason to be on antibiotics
prior to procedures (dental cleaning, etc)? Has she had implant infections
before that may make her surgeon overly cautious?
Thanks for the question,
John Di Saia, M.D.
