To answer your questions...

Reader's questions addressed, vol VI


Question #1:

>My question relates to the round vs tear drop shaped implants. I have talked to a few doctors and they have given me different opinions. I am a small framed person and do not want large implants. I am an "A" and would like to be a "B". One doctor commented that he was concerned that shifting of a tear drop shape implant could result in an unsatifactory breast shape, whereas, a round implant would hold it's shape better.
>Thanks for your answer.

An Answer:

It's fairly controversial the effect of using an "anatomic-shaped" implant. Initially , it seems to make sense that they should make a difference until you realize that the current implant is basically a glorified "water balloon." The silicone elastomer shell really gives little structural support to the thing. The shape is more a function of the volume of water and the tethering effect of the overlying skin and soft tissues.

I do not routinely use these "anatomic" implants for simple augmentation as I always place the implants sub-muscular. If I was to place the implants sub-glandular, perhaps an anatomic implant might make more of a difference.
Thanks for the question,
John Di Saia, M.D.

Question #2:

>I am considering undergoing a second operation (after 2 years) to change my saline breast implants which are presently 240cc and 280cc for 700cc and 740cc.
>I was originally an "34A", I am a small"34C" presently and would like to be a "34DD". I am 5'-7" and 120 lbs. I would like to know what the (added) risks are regarding:
>- scarring (capsular contraction), some occured on my right breast;
>- ulcers due to weight of implant; any other.
>Is there a maximum size of implant I should not exceed?
>Thank you for your very informative site!

An Answer:

How did you decide upon the size of the implants? I always caution patients when they do this. There is really no rule that states that a certain volume of saline will produce a certain breast cup size. Regarding size, certainly a larger implant will have more risk of a less than natural appearing result.

I believe that patients come to operation for either a "natural" result or a "super-natural" result. The former patient is seeking balance and the latter imbalance. This is not a judgemental statement. I want to give patients what they want.

With this being said, larger implants do have more associated problems. Certainly, scarring and contracture are going to be potentially more pronounced as less tissue is placed under greater force by the pressure of the underlying implant. "Wrinkling" will also be more visible for the same reason.

Regarding recurrent contracture, even for a simple re-do (without placing a very large implant), the recurrence rates for contracture (once already present) are roughly 50%. You will almost certainly have some contracture...exactly how much is uncertain. I have not seen ulcers underneath breasts with implants.
Thanks for the question,
John Di Saia, M.D.

A Reply:

>Thank you so much for your answer. To answer your question on how I decided the size, I used large balloons (30") filled with a stuff called "Gak" which a semi liquid weird slime that kids play with (available in toy stores). The empty baloons are flat and round and about 6" in diameter. It allowed me to define the amount in cc a wish to add. Works great!
>This being said, I have two more questions (if you have time of course...).
>I have met with 2 surgeons. The one who did the first surgery and another one.
>Originally, the operation was done through the armpits. Now, one surgeon tells me that he can go through there again and use the same pocket albeit enlarged. The other says that he must go under the breasts, remove the scar tissues if any and then create new pockets. I obviously prefer the first option but I'm puzzled by those two very different opinions. Could you advise me on this?
>Thank you again for your time.

An Answer (Part 2):

You have developed an interesting method of size determination. Just as you have found your preferred manner of resolving your problem, different surgeons will present you theirs. If you ask five plastic surgeons for an opinion on an issue, you will likely get at least three opinions. Different surgeons will approach different problems in different ways.
Thanks for the Question(s),
John Di Saia, M.D.

Question #3:

>Thanks for making this home page available. I'm 28 and about 6 weeks ago, I came down with chicken pox. Thankfully I had no complications and heading everyone's warning, I DIDN'T scratch or pick at the scabs. However, now I'm left with dozens of purple spots resembling something like the scar left after a burn...smooth and a bit shiny and very unsightly! Are these permanent scars? If so, is there a procedure you know of to remove them?
>Thanks and looking forward to your answer.

An Answer:

Wounds of any type are destined to form scars. The question is not whether or not scars will form, but how conspicious they will be. At present, there is no way to prevent scar formation. It is also quite a matter of opinion as to how to minimize the formation of unacceptable scarring.

Keeping the areas out of the sun is helpful to prevent increased discoloration in the scars. Gentle massage of the affected areas after scabs resolve may be helpful. There are a number of moisturizing creams on the market which may be helpful. Over all keep the wounds clean.

Scar remodeling occurs over months to years. I would follow you re-examining the areas over the interval. Some of the resultant scars may become objectionable enough to warrant excision at a later date, but most do not. The role of the laser in the treatment of scars is currently under investigation. They may be of some use in the future.
Thanks for the question,
John Di Saia, M.D.

Question #4:

>My wife and I are looking into the possibility of breast augmentation and frankly I am quite uncomfortable with the idea due to the negative information surrounding the issue. However, sometime around 1987 there was an article in "Muscle and Fitness" magazine by a doctor in California discussing the idea of using tissue removed by liposuction and adding it to the breast. It sounds strange but interesting. I was wondering if you had heard of such a procedure?

An Answer:

Liposuction can remove a substantial quantity of fatty material...fatty material without a blood supply. This fat has been used to "fill out" small contour irregularities (such as those under sunken scars) with a variable effect. The fat seems to be digested even in restricted uses like these. Only ten to twenty five percent remains after six weeks. I am unaware of any reputable surgeon using this fat for breast augmentation where the requirement is for much more volume. The fat in this instance would almost certainly be absorbed (at best). It could also liquify leading to scarring. I am told that years ago, this type of procedure was attempted with poor results. Beware those suggesting this procedure. Are the physicians here Board Eligible or Board Certified Plastic Surgeons (by the American Society Of Plastic And Reconstructive Surgeons- ASPRS)?
Thanks for the Question,
John Di Saia, M.D.

Question #5:

>What is your opinion of following septoplasty/uvulectomy procedures with abdominoplasty? In a woman who is in good health, participates in aerobic exercise 4 hours weekly, who is moderately active, 38 years old, with an "apple shaped" body (as does the majority of her family, ie: sister, mother, maternal aunts, maternal grandmother, maternal great-grandmother) reduce her risks of heart disease by resculpting her torso shape? Once the abdominoplasty is performed, and the patient is healed, when working out regularly (after released by physician) will the fat in other areas come off easier since the majority of the fat which was in the abdomen was removed?
>Thank you for your time and consideration.

An Answer:

The first question is impossible to answer as there are several important factors:
(1) The health of the individual patient as determined from history, physcial exam and lab tests (as needed).
(2) The length of time needed for the specific procedures for a particular surgeon. How long is your surgeon intending upon keeping you "under?" Are you to have a general anesthetic?

As for your second question, there is some evidence that a patients lipid profile improves following liposuction. The inference is that since the result leads to an increase in HDL (the "good" cholesterol) that cardiovascular risk may decrease significantly. The study was published in Aesthetic Plastic Surgery in 1995 by Dr Samdal. The question as to what degree this logic follows in abdominoplasty is open.

On the third point, I would not infer anything as to the fate of remaining fat following liposuction or abdominoplasty. The patients do note a change in the way they gain or lose weight in that suctioned areas tend not to gain fat following the procedure (scarring). The ability to lose weight or gain weight overall is probably not changed.
Thanks for your question,
John Di Saia, M.D.

Question #6:

>I have heard that there is a procedure that allows one to have fat removed from one area (thighs, buttocks) and placed in the breasts. How does this work? Is it long-lasting? I am relatively thin, with an extra few inches on the above mentioned areas and would prefer to use something my body created to increase my bust size as opposed to implants.

>Is this a costly venture? Is there a minimum amount of fat required to even bother? Thank you for helping out! Thanks for a very informative and helpful page!

An Answer:

I don't know of any reputable plastic surgeon performing this surgery. What we know of the fate of autologous fat (removed from and transplanted back to the same person) indicates that only about 10% of this fat (at best) survives. The risks include infection and scarring. Furthermore, the fat in the process of scarring can calcify making future mammographic interpretation tricky. Breast cancer is too common to allow this to occur. You should be very wary about having this procedure performed on yourself.
Thanks for the question,
John Di Saia, M.D.

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Question #7:

>My boy friend and I have an odd question... what does the new breast feel like? Can money be spent with you to view augmented breasts and possibly feel them ? We mean this stricktly in a professional way, not perverted.

An Answer:

I don't think that would be possible. Although your intentions may be entirely honorable, this may (quite understandably) raise questions. It's a shame as the question is a good one. The way an implanted breast ultimately "feels" is a function of a number of things:

(1) The amount of breast tissue present before the operation. More breast tissue here leads to a more natural feeling breast.

(2) The relative size of the implant. A large implant:breast size ratio leads to a less natural feeling result.

(3) The nature of the capsule that the patient forms in response to the implant. This is the real "kicker" as it is for the most part an unknown quantity. Breast massage may have an effect here, but for reasons mostly unknown some women (less than 2%) will form an objectionable capsule about the implant. All women form some sort of capsule as teh body seeks to "wall off" the implant (a "foreign" body).
Thanks for the question,
John Di Saia, M.D.

Question #8:

>my wife is considering breast augmentation surgery, however, we were wondering what options were available besides silicone.
>thanks for any help

An Answer:

The current implant available for breast augmentation is a saline-filled implant. All of these have a shell composed of a hard silicone elastomer (polymer). This shell has not been associated with the ill effects of the gel silicone. The silicone gel upon further study (as an aside) also does not appear to be statistically associated with rheumatolgic diseases as previously thought. The silicone gel did however cause some problems with inflamation in some patients in whom the implants leaked.

The newer implants that are under investigation all have similar shells of hard silicone. It is the filler material that is under study. At present the only FDA-approved implant for breast augmentation is the saline-filled model.
Thanks for the question,
John Di Saia, M.D.

Question #9:

>Dear Dr. John Di Saia
>My wife and I have several questions regarding breast augmentation.

>First of all, we are no strangers to breast augmentation. My wife has been augmented on three separate occasions. We have tremendously researched this subject in interviews with her surgeons or prospective surgeons, in literature, and on the net.

>Before I continue, let me give you a physical profile on my wife. She is 5'4" tall and medium boned. Her shoulders are somewhat wide and her torso tapers in a V-shape to her waist. She's currently average weight, about 134 lbs. Her original breasts were extremely high and firm and tubular shaped. At that time their volume was approximately 150-175 cc. She wore a 36A bra. The areolae measured approximately 45 mm.

>She received her first augmentation in November 1986 with 200 cc silicon tear drop shaped implants. She went from a 36A cup to a 36B cup. Her newly augmented breasts had a natural shape and it was difficult to tell she had implants. Unfortunately we were not happy with the size in relation to her frame and one of the breasts encapsulated and we decided to have the implants removed in February 1989. The areolae did enlarge to approximately 57 mm.

>She received her second augmentation in August 1989 with 240 cc silicon round shaped implants. She went from a 36A to a fuller 36B. The results once again looked relatively natural and there was no encapsulation. However, we still weren't satisfied with the size and silicon was receiving a alot of bad press. in addition, she became pregnant and the breasts ended up having a pseudoptosis shape and the areolae stretched to nearly 80 mm. The end result was implant removal in December 1991.

>She received her third and most recent augmentation in December 1995 with 500 cc saline round shaped implants. Prior to this she had a second pregnancy and hadn't completely lost the weight. Her breasts became more ptotic and the areolae stayed at 80 mm. Her surgeon recommended a donut mastopexy to reduce the areolae size and correct the pseudoptosis. She opted to skip this procedure. Her post augmentated breasts were extremely tubular and the areolae measured 80 mm. She went from a 36B cup to a 36DD.

>It was also obvious where the implants ended and her natural breasts began. In all cases the implants were put in using an inframammary incision and placement between the breast tissue and the chest muscle. In this last case, the upper part of the implant is partially covered by muscle. Firmness wasn't too bad due to the additional weight.

>Over the next few months she lost all the weight to her present 134 lbs. In June she underwent a donut mastopexy and had the areolae reduced to approximately 40-45 mm. This reduced breast projection and also effectively reduced her nipple size. The weight loss reduced her cup size from a 36DD to a 36D to a 34DD to its present 34D. It appears that her remaining natural breast tissue is approximately 100-125 cc.

>There is a marked indentation where the implants end and her natural breasts begin. The breasts are extremely firm when she is upright and more so when she is on her back. She experiences some discomfort when laying on her stomach and the tightness on her back is distracting. Her present size puts her in proportion with her hip size. She is not top heavy and her breasts do not overpower her frame.

>We are unhappy with the present results and would greatly appreciate any input you can provide concerning the following issues. We understand that you only have the information that we have provided in this email and no photographs etc. We are simply trying to gather additional input from an informed source to make an educated decision on any future surgeries.

>1. Would a similar sized (500 cc) anatomically shaped (tear drop) implant improve her breast contour and reduce the indentations on the underside of her breasts? It's our understanding that these implants give more natural contours and feel better. We believe that these implants allow for more projection and possess a smaller diameter base.
>2. If question 1 is true, would it be unrealistic for her to move up to 650-700 cc saline anatomically shaped implants? She would like go from her present 34D cup to a very full 34DD cup with an overall slight to moderately top heavy appearance. Nothing in the range of the large breasted exotic dancers.
>3. Given her discomfort, have we exceeded what's realistic for her body or is this more a biproduct of the type of implants used and their placement?
>4. What's the average band and cup size of your pre augmentated and post augmented patients?
>5. We've also considered getting them completely removed, again. We anticipate that her natural breasts might be somewhat ptosis and hollow in appearance. Is this assumption correct? She is 32 years old.
>6. We've also considered the anatomical implants in a 250-275 cc range. We anticipate a full 34B in this scenario. We feel this might be the best compromise between small natual breasts and large implanted breasts with regard to a naturally appearing shape and size. It may also offer a compromise between softer natural breasts and firm or extremely firm implanted breasts. Our only concern is she's been this size before and we were unhappy. What are your thoughts? HELP!

An Answer:

You put forth a good set of questions which of course are difficult to answer without seeing your wife. Nevertheless I will answer with general statements.

In general I am surprised that her implants are subglandular. In most cases, I have placed implants in the submuscular position.

On your first question, don't expect an anatomic saline implant to solve your shape concerns. The silicone shell is soft and these (like any implant) tend to conform to the shape of the pocket in which they are placed. This pocket in your wife's case is for the most part defined by her previous operations. Some work to change it can be attempted.

On enlarging the implants, this can be performed, but the un-natural edge contour that you describe may be come more noticeable.

The fact that she has discomfort may be a function of her multiple procedures (scarring) and/or the large size of her implants coupled with a subglandular position (little padding).

Average sizes for patients in my experience have been starting with an A cup and produceing a large C to a small D. Averages don't really mean that much although it is said that an increase of 2 sizes (from the original) is associated with better patient satisfaction.

On getting them removed entirely, this is a personal choice. The resultant appearance will be unattractive as she has a fairly large implant. She has ptosis now which will increase following simple removal.

If she is replaced with a smaller implant, she will more likely than not require a mastopexy of some sort. Donut style mastopexy is only good for a small difference. She will probably (unfortunately) need one involving more incisions (traditional).

I would consider placing an intermediate sized implant in a submuscular position to provide the padding I had mentioned. This assumes however that her muscle is still intact (pressure effects from the implants certainly have decreased it's bulk). Placement of an implant of this size may place her in the position to have another donut mastopexy with an adequate outcome. Reduction is size without a mastopexy can potentially lead to more ptosis. She will also need her capsules addressed via capsulotomy or capsulectomy.

As you have seen, multiple procedures can be a nuissance. Scarring increases with each procedure and may make more likely a poor outcome (severe contracture).
Thanks for your question,
John Di Saia, M.D.

Question #10:

>I am a 31 year old female. My upper lip is very thin as opposed to my lower lip that looks very full. I have been thinking about upper lip augmentation for a long time. I don't quite know the procedures and the risks. I have been told about fat transfer and gortex. Could you please let me know of a good procedure for this and the risks involved.

>I also would like to do liposuction on my mid section. I know two surgeons who perform it. One is not a plastic surgeon, but only does liposuction 2 a day 6 days a week, the other surgion is a plasticsurgeon but he only has 3 years of experience, and does not seem to have much of experience in liposuction ( No before after pictures either).

>I don't quite know how to choose between the two, I have called the county and there have been no complaints (on either of) the surgeons.

An Answer:

Lip augmentation obviously involves the placement of something into your lip to make it larger (relative to the lower lip). As you have mentioned a few possibilities are your own fat and artificial substances (such as gortex). Other possibilities include the use of a strip of muscle from the side of the head, a piece of skin (first stripped of it's epidermis) or collagen injection.

Each option (as you'd suspect) has its own risks and advantages. The collagen injection is easy (can be done in the office examination room) but alas it is not permanent. These injections are digested by the body over six to eight weeks. Fat injection is similarly short-lived and involves more surgery. Muscle and skin placement can dissolve to an extent but generally some remains. Each of these involves an operation in an operating room. Gortex is permanent, but more dangerous. If it becomes infected or is actually extruded ("spit" out from the skin) it can be cosmetically devastating and difficult to repair.

On the liposuction, you should read my section "Cosmetic Surgeon vs Plastic Surgeon." Going to someone who is not a plastic surgeon may not be wise. Many other specialists are doing the procedure as it is lucrative. Few people outside the plastic surgery field have actually been trained to do it. Listen carefully to the way each of these doctors present themselves and get your questions answered before you have the procedure.

Incidentally, seeing as this involves your abdomen, has either of these surgeons suggested abdominoplasty? It may be appropriate if your abdominal wall seems lax (such as following pregnancy). A plastic surgeon can do this as well if liposuction alone failed to correct the problem. Another specialist can only address this by liposuction (which may not be adequate alone depending upon your build).
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       John Di Saia, M.D.