To answer your questions...

Cosmetic breast questions, vol I


Question #1:

>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 or at the very least with a newer generation silicone implant that may have a lower leak rate.

(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 #2:

>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 catalogues 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 2-4 weeks or so.
Thanks for your question,
John Di Saia, M.D.

Question #3:

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?. Thank you.

An Answer:

Dear Miss,
The subject of breast augmentation and cancer has been a subject of debate for years. There is a ton of conflicting literature. 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 argued:
(1) Patients may be the best at screening themselves...many 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 cancers early is good screening, so you really need to examine your breasts regularly. You should do this with or without breast implants.
(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 1:8.
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 #4:

>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 augmentation, 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 abdominoplasty 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. 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 multiple procedures on different patients. Multiple procedures on the same patient get a discounted rate relative to doing them separately however. 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 #5:

>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.
>Thank you for your time.
>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 (sic) do. Thank you again.

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.

The FDA has solved this problem in a way as currently (unless you are in an investigational group) saline implants are still the most widely available for augmentation. Silicone gel implants were once again approved by the FDA last year, but the consent process and continued studies show that the FDA knows they pose more of a risk�at least in my opinion.

With regards to a good surgeon in your area, I gave up trying to develop a referral section online here. A few general points of information on the page Cosmetic Surgeon vs Plastic Surgeon might also be helpful in your search.

Costs are highly variable (assuming augmentation alone will be all that is needed) in the range of $4000-9000 (this is a "guess-timate"). Incidentally scientific studies of the sort involved take on the order of ten years or more to yield conclusions.
Thanks for the question,
John Di Saia, M.D.

Question #6:
(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)! This is a trap as the surgeon will put exactly what you say in the implant. It is very difficult to predict the ultimate size of a woman's breasts after augmentation. 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 immediately 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 truthful (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 cup bras 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 # 7

>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.

Question #8:

>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 #9:

>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 likely 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 #10:

(Editor's Note: This one came in four parts)
1. Can you explain the differences, advantages and disadvantages 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 pretty 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 mismatch...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. I have had some patients coming back after years and I appreciate that. It is nice to see how things held up�no pun intended. The saline implants have improved in the last ten years. In the eighties, 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.

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.