Posted on February 26, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
The trend of the week this week: questions to me, the plastic surgeon, about “how can I avoid you?” How can I do what I want without surgery?
I get it.
Surgery is a big deal. It is scars, and surgery with its risks, and recovery, and paying money. So I get it.
So. Back to the question: Can I do a breast reduction without surgery? Breast size is related to a bunch of things. And breast size and composition (breast tissue versus fat) changes over time. Two things come to mind which will reduce your breast size without surgery:
1. Lose weight. Particularly if you are overweight, losing weight will reduce the size of your breast.
2. Breast feeding. It doesnt’ happen for everyone. Some women stay the same size, and some swear they are larger afterwards, but the general trend I see is loss of volume after breast feeding, particularly the longer and more children you have.
But size isn’t everything with the breast.
When women come to me with large breasts they have two issues. 1. size (obvious) 2. droop. The skin is an important factor. One of the issues we have with liposuction of the breast is the younger large breasted women who have good skin tone (who’s skin will shrink if the breast is made smalller) tend to have dense breast tissue with little fat, which is not amenable to liposuction. The older women with the softer, buttery fat who would liposuction easily are droopy, so when you remove the volume, they just droop more.
So, as breasts get smaller, they flatten and droop. I fix this constantly in women in their 40s seeking a mommy makeover. If you want to go smaller AND reshape, lift, and firm up the tissue, you need a surgery. Welcome to my short scar vertical breast lift.
So it is just the size you don’t like? Or do you also not like the bungy jump when you take off your bra? If you want to lift and firm, you need surgery. Sorry.
Posted on February 22, 2010 in Breast, Post Pregnancy Breast, breast augmentation, breast implant, interesting & new
This is the age old question.
How can we make breasts larger without a foreign object? They have tried all sorts of things in the past. The issue with many of them is:
1. Screening of the breast for cancer
2. Injury or hormonal stimulation to the breast- could it cause cancer or make a cancer which is there grow faster?
There are medications which claim to make the breast larger. Be careful of anything hormonally based. Many “herbals” are basic forms of hormones and are as potent as the prescription strength hormones you get.
There is a machine BRAVA that applies suction, causing the tissue to swell and get new blood supply to make the breast larger. It does seem to work, but it requires 11 hours a day for a median period of 18.5 weeks to go up about 100cc. It has been around for over a decade and never got traction in the cosmetic market. Why? To quote a plastic surgical colleague of mine, “The patients hated it. It required a lot of nursing time and assist because it was difficult to use, and the results were not impressive.” But now, BRAVA, the “machine looking for an indication” may have found it. It may help fat survive when transferred to the breast to do breast augmentation using fat.
Fat injections may be a promise in the future. Really thin women don’t have enough fat to harvest, so for them, this will not be an option. For others, it may. I went to a recent meeting (Feb 2010) in Miami with surgeons who are innovative in the field. The main issue still remains, how do you get the fat to survive reliably? How can you make sure it is safe? How much does it impair the ability to screen for breast cancer?
I will continue to blog about fat grafting to the breast, or as some believe, “stem cell breast augmentation.” I am just not sure yet I am ready to do it. My base question always with patients is would I recommend it to a family member? And as of now, I wouldn’t feel comfortable telling them I know it is safe. But with more research, time, and hard scientific data, I believe it may be.
(NOTE: This is a hot topic. Beware of untrained doctors who call themselves “plastic surgeons” who are doing fat grafting to the breast. We do know fat grafting when done poorly has poor survival, causing oil cyts, hard nodules, and calcifications. You can also easily get into the wrong plane and cause a pneumothorax, or the possible risk of fat emboli. This is only a technique which should be done by experienced board certified plastic surgeons. We do breast surgery, from breast reconstruction to lifts/ reductions/ augmentations, and we trained as general surgeons (doing mastectomies, etc) prior to plastic surgery.)
Posted on February 11, 2010 in Breast, Post Pregnancy Breast, breast augmentation, breast implant
Now there is a title which gets your attention.
Nipples aren’t symmetric. Breasts aren’t symmetric. We always aim for them to be close, but as a colleague once said “breasts are sisters, not twins.”
I got an email from a breast augmentation patient saying her nipples are asymmetric. Most are a little. I looked at her preop photos and hers were always asymmetric. She was happy after her surgery at all of her visits, including a couple months out.
But she is sending me an email now, about 2 years after her surgery, saying they are asymmetric. What changed? Why is she now noticing there is a difference?
The most likely culprit for seeing a progressing nipple asymmetry when you have breast implants is a mild capsular contracture on one side (if it happened on both, your nipple position would likely be changing equally). If you notice one breast is softer than the other, you might be forming a mild contracture. When this happens, it often causes the affected breast to become a little rounder in shape, firmer, and it lifts the breast up a little. You may notice your nipple position changes or you look like you have more cleavage in the upper breast on one side than the other.
See your surgeon when you see this. Sometimes there are habits which may make one side age differently than the other. Do you sleep on your tummy? Only on one side? Do you wear good supportive bras? Did you have a child? Did you breastfeed evenly?
You can try nonsurgical ways to loosen it up. Massage, lying on a stack of books, vitamin E, singulair have all been described. I haven’t seen tremendous success with these, but it is worth a shot. We don’t do closed capsulotomies like they did in the old days (turns out you could rupture the implant when you were trying to break open the capsule). So it frequently ends up being a surgery. (ug.)
When to operate? Hmmm. Tough question. If it bothers you. If it is a grade III or IV capsule. If it is painful. If it is visible in clothing. The bad part is we still don’t really know what causes capsular contracture. Bleeding, fluid, infection, gel implants, in front of the muscle placement- all are associated. But then there is dumb (bad) luck. To fix it you can open up the capsule, cut out the capsule, or create a neopocket. The issue is there is no guarantee it won’t recur.
So. See your surgeon. And think- how much does it bother you? are you willing to do the time/expense/recovery of another surgery? how will you feel if it recurs? There is no rush. Remember your nipples were likely never exactly symmetric.
Breasts are like sisters, not twins. (But is nice if the sisters look like they are from the same family.)
Posted on February 4, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction, interesting & new
Ahhh. Marketing.
Do I sound like a broken record or what? I am just so dismayed by all of the hype and spin out there. It seems like everyone is trying to make a catchy new phrase for their surgery which will change the world, defy gravity, have no scars, and no downtime.
Bottom line still is when it sounds “too good to be true” it is.
I recently got an inquiry about the laser bra. Why don’t I do it, it only takes one hour to do, it keeps its lift better, etc etc. In general, good plastic surgery techniques get accepted by the general board certified plastic surgeon population over time. The hype and marketing things do not.
Lasers sound cool. They sound more modern, high tech, and less invasive. But there is a great deal of deception about lasers. When I was in residency and the CO2 laser came out, we all jumped on board. Now 15 years into plastic surgery, with a gazillion different lasers out there, I don’t use lasers at all. There are many types of lasers. Some address redness, some pigment, some promote collagen in the skin, some sandblast off the top layers. The one used in the laser bra is the CO2.
The CO2 laser does tighten the skin. I used to use it for resurfacing facial skin. I stopped using it due to issues with depigmentation, redness, and potential for scar. If you are using it on skin which subsequently is buried, those are not problems. The biggest thing with lasers is the amount of “tightening” is not much. Some people imagine lasers are like putting a wool sweater in the dryer. Oh. If that were only the case. We 40 somethings would jump in and laser every inch of us. But alas, lasers are more like an “iron”- they help remove fine light wrinkles only.
The laser bra involves lasering the top layer of skin, and then using that skin, tacked down to underlying tissue, as an internal “bra.” Sounds fantastic. Who wouldn’t want an internal bra to lift you?
But the laser bra will not “hold” the lift any better over time than traditional surgery. Traditional breast lifts already use the skin as an internal bra- we just deepithelialize it, not laser it. Regardless of what you do, skin stretches. Skin droops. This is deceptive marketing. I am saddened by the claims.
- “The Laser Bra surgeon can keep the breasts lifted in a natural, beautiful position.” Nothing can “keep” breasts lifted. They will droop again over time.
- The time claims of surgery are skewed. Normal breast reductions do NOT take 5 hours- in most hands it takes 2 1/2 to 3 hours.
- Finally, many of the photos involve augmentations. Implants will always help “lift” the breasts and give fullness in the cleavage area- and that has nothing to do with what reduction or lift technique you use.
I have done many different kinds of lifts over the years. The breast is made up of breast tissue and fat. In general
- the more breast tissue, less fat
- the smaller the breast
- the better you support the breast (ie good bras)
- the less you stress the breast (pregnancy, breastfeeding, jogging)
the better and longer your lift will last.
I find in my hands the best lift is the vertical lift. I do a lot of internal suturing. Why? It takes tension off the skin and shapes the breast better. Hmmm. Maybe I should make a catchy new term. “The hammock”? “The cone”? “The anti-gravity-little-scar-secret-special-exclusive-breast reduction-by-Dr. Greenberg” technique?
I think I will stick with being a good surgeon and leave marketing to others. There are many good breast surgeons to choose from. Meet a few. Look at photos. And beware of the gimmicks. When someone sounds like they are selling you a rainbow, they usually are.
Posted on January 8, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast augmentation, breast implant
Americans love to supersize. 
Big cars, Supersized fries, the super big gulp. But bigger is not better when it comes to breast implants.
I answered a question from a patient who had been an AA her whole life. She was teased and felt self conscious. So she decided to do breast augmentation. Her surgeon (not me, but easily could have been) told her he would not do a breast augmentation to make her a DD or larger. She was “shocked.” “Lots of women get breast implants WAY bigger than a DD, so why am I being told me request is unreasonable?”
Hmmm. I can understand her frustration. Implants cost the same, regardless of size…. If I get a 500cc implant instead of a 300cc one, I got 200 cc more for the same cost. Woo hoo, eh? This is my body, and if I want a DD, then I will get one! Hmmm. She can go to another surgeon. I’m sure she’ll find someone who will do it. But I think she is bothered by this because the surgeon she saw seems principled and experienced. She knows he is right.
Why would a doctor talk her out of a big size?
Many of us see our long term results years down the road. It does change the way we do things, and how we advise our patients
1. When you are thin, you have thin tissue cover over the breast implant. My skinny athletic Northern California women don’t have much padding. Whatever padding you start with gets thinner over time, as the weight and width of the breast implant thins it more. What does this mean in English? It means as your soft tissue padding thins, you will droop, potentially bottom out, and see wrinkling and other implant abnormalities.
2. If you go to a super large size, even if I put you in the narrowest implant, a high profile, it will be too wide for your chest. What does this mean? It means you will hit your breast when doing any movements along your side, like golf and tennis (what is the handicap for that?). It means your tissue on the side of your breast thins, and you will look round, shiny skinned, and again will see wrinkling.
3. The weight of the implant will cause you to droop. The implants come as cc measurements. The cc’s tells you the number of grams the implant weighs. Simple science: The heavier the implant, the more it weighs, the more you will droop with time. (Unless you live on the moon.)
4. The weight of the implant can cause back and neck pain, shoulder notching (where your bra straps go), and poor posture. See the issues large breasted women get, and why women who are a D, DD, on up come in droves to get lifts and reductions.
5. They will look bad. Unnatural. Round. Fake. Not pretty at all.
6. If you think you want it that large, wear it around for a while. This is more girlfriend’s advice, not a plastic surgeon’s, but do you want that kind of attention? Always? Try to jog. Try on shirts which button up. Try to have a conversation with eye contact.
I am not a Pam Anderson kind of doctor. My patients like people to look them in the face, and listen to what they say when they talk. (Oooh. Those ladies with thoughts and ideas…) I know. That was a horrible generalization. But I don’t see many women like this who want to be a DD or larger.
At least not at this point.
I do see many of these oversized implants down the road. Large, thin skinned, brassy, round. Droopy. Back pain. And NOW they want to downsize. This is now a much harder problem. Lifts are difficult when the tissue is too thin. Scars from a lift are much larger than a simple augmentation. And I can’t get the skin to “thicken” again.
So. Take a long term view. Bigger is not always better, particularly in my thin Bay Area patients. Go for a medium size. It’s bigger than what you’ve got. Go for natural, pretty. Go for breasts you can still jog with. And when you wish you were a little fuller on a Saturday night, wear a push up bra, and think how much better your breasts will look at age 60 than if you had blown them out at age 30.
Posted on December 28, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
Ah. The chicken and egg dilemma. 
Many women with large breasts are overweight.
Many overweight women have large breasts.
When you are overweight insurance will tell you your breasts are large because you are fat. Lose the weight and your breasts will get smaller. This is true. Especially as you age, breasts get fattier. Even women who when younger had “breasts which did not change with weight,” will see breast size change with weight change when they are older.
So. You are overweight and have large breasts. What to do?
Back to the chicken and egg dilemma…
If you are overweight you need to work out to lose weight. If you have large breasts, it is difficult to do the aforementioned exercise to lose weight because you can’t run, do aerobics, or do anything else which is bouncy. (Who can find a bra? Must you wear two bras?) Yes, yes. It is not impossible. You can work out with less bouncy things like swimming and biking. And yes, you can lose weight by watching what you eat. But it is more difficult.
Why try to lose weight before breast reduction?
The reasons are multiple:
1. Breasts are about proportion to your body. I don’t know what size to make you if I don’t know what size your body will be.
2. A breast reduction lifts the breast. If you lose weight after your reduction you will loosen up your lift. (This is not good. It will make you droop.)
3. If I make your breasts a perfect size and you lose weight, your breasts will get smaller. Again, it is all about proportion to your body.
4. If you are healthier, you will heal better and faster. There are higher surgical risk and complication rates when overweight, especially if your BMI puts you in the obese category.
So. Get working out. Double bra it and get moving. I love breast reductions and lifts. I think they can be life (and back pain) changing surgery.
Posted on October 2, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast augmentation, breast implant
Breast implants come in all shapes and sizes.
Basic differences in implants:
- volume
- shell: smooth or textured
- profile: low, medium, or high
- shape: round or anatomic / shaped
- fill: saline or gel
The gummy bear implant is the style 410 implant. It is essentially the fourth generation of gel implant. It is a shaped anatomic implant, firmer than current implants. Due to its shape, it has a textured surface so it will not move or rotate.
The gel implants we use now are cohesive gel implants. In English that means the implant fill is not a liquid, but thicker like jello. The reason to thicken the internal fill is to help prevent “gel bleed.” It is thought this microscopic leakage leads to capsular contracture, the hardening of the breast. The implants still feel soft. The gummy bear implant fill is thicker than current cohesive gel breast implants. It essentially is supercohesive, and the thought is it will have lower capsular contracture rates.
Great! I love the whole name gummy bear. This all sounds swell. Where can I get one?
Ah. Here’s the rub. The FDA approved cohesive gel implants in Nov 2006, but did not include the style 410. For some reason, they still have not been approved. Don’t be disheartened. Most women currently get round smooth gel implants. Why? They look natural and move like natural breasts. The most common type of implant most plastic surgeons use around the country is a smooth round implant. Why would we use round implants and not put in something supposedly shaped to look like a breast? Excellent question (I love my educated Bay Area crowd)! Textured shaped implants were the rage in the early 90s. They were supposed to look better, have lower capsular contracture rates, yadda yadda. But about 5-8 years out, we saw issues with them. They can rotate, have wrinkles which get stuck and are palpable, many have higher rippling rates, and many had higher leakage rates. A study came out which showed by MRI when behind the muscle the “shaped” implant gave no difference in shape than a “round” implant. In other words, when behind the muscle, they look the same. So the pendulum swung back to the round implant. (All of the implants you see on my website are smooth round implants.)
The style 410 may be an answer for some patients in the future. For patients with whisper thin skin, patients after mastectomy who have no natural tissue, or patients with recurrent capsular contractures no matter what they try, the gummy bear breast implant may be helpful. But it likely has many of the issues we have seen before in textured anatomic shaped implants. And due to its firmer fill, it can’t be compressed as much, so requires a larger incision. Most patients don’t want a larger scar.
So the gummy bear style 410 breast implant.
It will likely someday be another implant in our legion of implants we use. But currently there is no word on when they will be approved, and again, they aren’t for everyone.
Posted on in Breast, Post Pregnancy Breast, breast augmentation, breast implant
How do you pick a size? The most common thing I hear is “I want to look natural,” or “I want to look proportional.” Occasionally I meet someone who is set on a certain cup size. I must be a “full B,” “C”, “D.” So how does this work?
I consider my style of plastic surgery mentoring as a girlfriend’s guide to plastic surgery. I used to think male and female surgeons were the same. But over time, being female with all of the pregnancies and breastfeeding and bra shopping and jogging, I have come to the conclusion I look at breasts differently than my colleagues.
1. Don’t pick out a cup size. I can’t repeat enough there is no standard to bra sizing. What Victoria’s secret thinks is a 34C is not the same at Olga, Maidenform, Agent Provocateur (for you racy ladies), or La Perla (for you fancy ones). What you think is a 34C may not be what I think is one. The best way to pick a size is to try on sizing implants and look at yourself in a mirror in your normal clothes. I can’t believe here in Northern California, the Bay Area land of the educated female, I still hear of women who see a surgeon and the surgeon tells them, “I will choose it for you.” Egads! Given how frequently I find women decide on a size different from what they originally thought they wanted, I do not think having someone else pick it for you is a good idea.
2. Natural is not a size. Natural has to do with the shape of the breast, how it sits, how it moves. I can make a woman look natural and proportional as an A, B, C, D, or even DD cup. This is a place where you need to really look at the photos. Every plastic surgeon has a photo book. If they don’t, particularly for a common procedure like a breast augmentation, then don’t go to them. You need to see what their eye is like. I like natural. I love it when a patient comes in, telling me of how they were naked in front of a friend and the friend, “couldn’t believe how good I looked after breastfeeding three kids.” It is a high compliment to me when my patients forget these were not the breasts they were born with.
3. Photos don’t work. Many patients surf the internet for photos. Some target someone their same height and weight to pick out what volume breast implant they want. Every woman is uniquely fantastically different. Are you curvy? tall? short? broad? muscular? how much natural tissue do you have? do you have full hips and bottom? I can see short women with 400cc implants look salt of the earth natural, but a tall woman with a 400cc breast implant look like she needs a new day job. Again, every woman is different. You must try on the sizing implants.
So, how do you pick?
Try on sizing implants. In the office at your consultation I have you try on sizing implants. You won’t know what you like unless you SEE yourself, so bring in your favorite work out gear, bikini top, saturday-night on-the -town tops. Form fitting crew necks or turtlenecks are the ones to make you look the most busty. You should feel comfortable in all of your clothes. We women wear many hats: we are mothers, wives, teachers, lawyers, girls on a the town, atheletes…. You need to find the size to fit you in all aspects of your life. And I always remind my patients, there is no law against wearing a push up bra if you need a little extra sometimes.
The cardinal rule of implants is “you always wish you would have gone bigger.” I never believed the rule when I first heard it. But it is true. One of my patients said “breast implants are like diamond rings, they shrink with time”. They don’t really shrink (neither do the diamonds), but what shocks you at first won’t shock you after a while. Try out your new size prior to surgery. Stuff your bra. Wear it everywhere. You will get used to seeing yourself with breasts, so if you want to upsize a little, you will figure it out prior to surgery. Also everyone else will get used to seeing you with breasts, so 1. they won’t notice a change when you do surgery, and 2. you’ll see what kind of attention you get- wanted (or unwanted).
After having said the cardinal rule is everyone wishes they went a bit bigger, I have to say bigger is not always better. You want to go to a size where you feel like you did this. “If I’m going to go through surgery, I want to feel like I see a difference.” Bigger volume also means bigger weight. It can droop over time, thin the skin, etc. So if you are athletic, particularly running, have thin skin, have poor skin tone, or are young and want babies in the future, consider the pros and cons of size.
Size is an important aspect of breast augmentation. Take your time to decide. This is one area I will not choose for my patients, but I will educate you to make your best decision.
Posted on September 29, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast augmentation, breast implant, interesting & new
If only we could take fat from where we DON’T want it and put it where we do.
This is the premise behind fat grafting to the breast. Lipoaugmentation, fat transfer to the breast, fat grafting are all terms you will hear. Your own fat is a wonderful substance. It is soft, part of you, not a foreign object with issues of body rejection. So what is the story? Why do we do breast augmentations with silicone and saline implants at all?
Fat grafting is not a new technique. We plastic surgeons have been doing fat grafting for years. The techniques have been refined over the years to try to increase fat survival. When you move fat from one area (your inner thigh) and put it in another area (your buttock, breast, etc), the fat must recruit a new blood supply to live. Fat cells are living cells. They need blood to bring oxygen and nutrients so they can live. The newer fat grafting techniques involve harvesting the fat with less trauma, to preserve the health of the fat cell, and placing the fat cells in the new area by smaller injection sizes to improve the blood flow to the newly moved fat cell.
Imagine you are laying new grass in your backyard. You created a fertile, rich soil bed. It is moist. But there is no lawn sprinkler system yet. You have to wait a week until that will hook up to feed your new grass. If you lay down grass by rolls of sod in a low water environment, it will have a hard time surviving. If instead you tried to grow the grass in a low water state with individual seeds, you will have more of your product survive.
What does fat do if it dies? Ahhh. Here’s the rub. If fat dies, it does two things which are not good for breasts. First, the fat can harden. Second, the fat can calcify. The second point is the one which prevents most plastic surgeons from doing large scale fat grafting to the breast: what do we do about calcifications? Mammograms are based on finding clusters of calcifications to detect breast cancer early. What do we do for a 40 year old patient who had breast augmentation with fat years ago who now has calcifications throughout the breast?
There is also the issue of how much fat survives. If the fat does not get a blood supply, in addition to turning hard (fat necrosis) and calcifying, it can just melt away. This is the “take” of the fat graft. To compensate for this, many will fat graft more fat than they think they need, assuming some will melt away. Others will do a series of grafting to add more as needed. And even if the fat has good take, it is not unusual to see the fat gradually lessen in volume over time.
I am a natural girl. I have had three kids and know firsthand how fat goes from where you do want it (breast) to where you don’t want it (everywhere else). I think fat is a wonderful graft substance in other areas of the body: cheek, lip, back of the hands, indents and divets on the body. But the breasts are a unique place. Breast cancer rates used to be quoted as 1 in 11 when I was in med school. Now they quote 1 in 6.
This is a hot topic for us plastic surgeons. We want to use natural substances to do breast augmentation. There are currently studies being done to specifically look at our issues: how much fat can be grafted at a time? Will we be able to increase breast size by one cup ? more? What are the changes seen after fat grafting to the breast on serial mammograms? Does the breast hold the change in volume?
Until these are better studied, hold onto that fat and don’t put it in your breast quite yet.
Posted on in Breast, Post Pregnancy Breast
Stretch marks are essentially a tear in the skin.
Breast implants can cause stretch marks. This is not common, but it is a risk. I see it most often in a young patient with thicker skin (think Asian, Latina, Phillipino). When this skin needs to stretch quickly to accept the new implant, it can cause a “tear” in the skin. Again, I must repeat, this is not common.
Will it stretch marks happen to me?
If you got stretch marks on your thighs when growing or have bad stretch marks from a pregnancy, these may indicate a higher risk. There was a recent study showing a genetic component to stretch marks. The finding was the dermal fibroblasts in these patients were the issue, producing less elastin and collagen than expected. There was also a study finding stretch marks could be made without stretching the skin, just using a steroid cream. This may support a multifactorial cause which also includes hormonal changes.
Regardless, we see a correlation with rapid change in size and strech marks. Therefore breast implant size is also a factor. The bigger you go with your breast implants, the more you stretch your skin. In general women who have babies and breastfed have essentially “pre-stretched” their skin. I find the occurence of new stretch marks for these patients is less.
How to prevent stretch marks? You can’t totally prevent them. Genetics you can’t change. You can watch what size you are doing with your breast augmentation, but that doesn’t guarantee you won’t get stretch marks. I see women who go to large sizes with no stretch marks, and women with small implants form strech marks.
I do believe in hydration and massaging of the breasts. Studies are unclear if there is a specific lotion which is better. Start massaging the skin before your surgery date, and continue after for about a month.
There is a lot of buzz about nutrition: Vitamin C, Vitamin A, Zinc, avoiding caffeine. I don’t know of any particular studies which support this, but it likely won’t hurt.
