My general advice for implants is if “it ain’t broke don’t fix it.”  If you have a small issue- one side looks a hair different than the other, one nipple is a hair different- those are difficult things to fix.  Implants are tricky things and your body is even trickier.  No one is symmetric.  The forces on your implants and healing are not symmetric.  (Do you carry your purse/baby/backpack always on one side? Do you sleep on one side? Are you right handed? Left? Do you sleep on your tummy? How good are your bras? Do you golf? play tennis? jog?)

So let’s say you have a medium to bigger issue.  What would that be? Asymmetry, bottoming out, implant migration, capsular contracture, size issue, or droop.  Then a breast revision makes more sense.

When you replace breast implants, what you do varies.  Things you need to think about:

Do you want to

• change the fill of the implant (gel or saline)
• change the plane of the implant (above or below muscle)
• change size
• change width and projection (profile of implant)
• change shape (round or anatomic)
• change shell surface (textured or smooth)
• do pocket work to move where the implant sits (particularly useful if too high, bottomed out, or has migrated into your armpit)
• do breast lift if needed.
• try to fix capsular contractures or other issues?

Usually breast revision surgery and/ or implant exchange is one procedure.  We remove the old implants, do what we need to do, and then place new implants.

SO

• If you are going to do a revision breast surgery, get a copy of your operation report and implant card.  If your surgeon has retired, the operating center may have it.  It is very useful to know exactly what was done and what you have.
• Take the time to be exact in what you want changed. Make a “dream wish list.”  (Changes all have pros and cons and risks- we may not be able to do it all.)  But it is good to really analyze your breasts and try to improve where you can.
• If you are happy with your implants, do not do anything.  I don’t recommend exchanging implants just to change them out.  Every time you do surgery it is a little like rolling the dice in Vegas.  Being a girl from Reno, I have never liked the odds of gambling.  Remember when you “fix” one thing, you run the risk of creating something else, surgery risks, cost, recovery, etc.

Breast implant removal and leaving them out (ie you don’t put new implants in) is a rare thing.  I have done them, but maybe one patient a year (And only one of my breast aug patients had them removed.  These patients I have seen are from other doctors.).  The reasons are multiple: they are too big, persistent capsular contracture, droop, they just don’t want them anymore… but again it is a rare thing.

How did I answer this patient? 

Short answer:  For you at age 24 (I’m assuming no pregnancies/kids) with small breast implants placed only 2 months ago, you’ll likely look close to your pre surgery state. BUT if you had a constricted or tubular breast, the shape may be different.  I don’t know what your shape was, your skin tone, etc.

Longer answer: Breasts change over time when you DON’T have implants in, so of course they will change when you do have implants in.  How much they change is all over the map.

• how old are you?
• what is your skin tone?
• have you had kids? breastfed? for how long? how many kids?
• weight changes?
• how big are the implants?
• are they in front of or behind the muscle?
• how long have they been in?
• are you droopy with them in?

Very likely they will NOT LOOK LIKE THEY DID BEFORE you did anything.  In their mind patients want to do a “reset” button.  But you have aged since you had them placed, so again, even if you had never done a breast augmentation at all, your breast at age 35 after two kids wouldn’t look like your breast did at age 25. (I know, I know. This aging thing sucks.)

The poorer your skin tone, the older you are, the more stretchy your natural skin, the bigger and longer the implants have been in, yadda yadda, the more change you will have.  The more change, the less likely they will look like the breasts you are remembering prior to implants.  And don’t forget how we idealize what we had in the past. The memory in the mind is very kind- we tend to be thinner, prettier, more fit.

My advice to women who are on the fence about doing breast implants is not to do them.  For women with implants, it is rare not to replace them if there is an issue.

Breast implants do have a weight.  In general, the number of cc’s is equal to the number of grams.  So a 400 cc implant weighs about 400 grams.  Since we live in the San Francisco Bay Area and not Europe, how many pounds is this? 1000 grams = 2.2 pounds.  So you can do the math. 

Saline or gel implants are measured in cc’s.  It is the volume, not the type of implant, which determines weight.

Interestingly, my breast implant rep sent me an article once asking about the specific gravity of silicone.  Why would this matter? (and what is specific gravity?) Well, one of her doctors said patients with silicone breast implants told him the gel breast implants feel lighter than saline. The manufacturer answer was, “The specific gravity of silicone is .98 grams/cc so gel is slightly less dense than saline.  However the shell contributes to the overall weight, and the saline shell weighs about 25 g. So if you add 400cc, then the total final weight would be 425 grams.”

They went on to answer, for silicone implants they fill by weight on the manufacturing floor.  They zero out the weight of the shell.  They estimated the weight of a 400cc gel is actually about 410 grams. 

So, there you have it.  Even if you put in large implants,  your weight is not changing much.  One to two pounds max.  If you put on 10 pounds after surgery, it isn’t the implants.  Must be from all the bon bons you ate while luxuriating and recovering. (Yes, this is said with tongue in cheek. Almost all of my patients are moms, so I know you don’t get more than a day or two off from the grind.)

And as an afterthought, on these last few days of August, good luck to all you women acclamating back to kids in school.  May the force be with you, and may your calendars be organized.

Anatomic implants have been talked about a lot recently at our meetings.  The style 410 gummy bear implant is not available in the US.  Even when it does become available (which I have stopped holding my breath for… it is now 3 years and counting), I don’t know it will be the workhorse of breast augmentation.

Why do I like round implants? For a multitude of reasons: I get a great shape; round implants move (which I feel makes them look and feel more natural); I saw a lot of issues with the textured shaped implants during my residency (shaped implants were all the rage in the mid 90s) with wrinkles and fold failure causing leakage; and a MRI study showed when placed behind the muscle there is little to no shape advantage of the shaped implant versus round implant. 

The last issue? Rotation.

A study came out in July issue of PRS about the style 510 (the next generation after the 410) and the investigators found an 8% malrotation rate.  As they say, “anatomic prostheses are asymmetrically shaped, which can lead to a severe deformity of the breast profile when rotation around one of the axes occurs.”  In English, that means when a shaped implant rotates, it doesn’t look pretty.

Theories about why malposition occurs?

• The implant surface (more texturing is better),
• the pocket.  (type of pocket? width?),
• the tissue (thin skin can stretch out the pocket and allow lateral migration and then rotation),
• excessive movement, particularly when healing
• no friction (caused by fluid or double capsule)
• capsular contracture. 

Some of the issues may be surgery related.  You can’t overdissect the lateral pocket, and want a pocket to be taller than it is wide.  Large implants, particularly in thin patients with poor cover, rotate more.

Bottom line: Anatomic implants have issues.  This study was done in the Netherlands.  Europeans have access to the style 410 gummy bear and have used it for years.  Plastic surgeons fall on both sides of the fence when it comes to shaped versus round implants.  My mentor for my breast fellowship really likes the 410, but he as an investigator is one of the only guys who can use them, and his practice is almost all difficult revisions of prior breast augmentations, where he is making neopockets, using dermal matrix products, and using shaped implants.  Before restrictions occurred, some of my colleagues doing uncomplicated first time breast augmentation patients were able to use the 410.  Many of these colleagues didn’t like them and went back to using round implants.  So you will find much controversy on this subject. 

I think, as with all things plastic surgical, you will find the anatomic implant is the “right” choice for a certain patient population.  But which patients are those patients? I don’t know yet.  Perhaps rib cage shape? migration issues? no tissue cover? capsular contracture issues? breast cancer?  Regardless, until the 410 is available in the US, I will stick with my current recommendations.  I get great results with the round smooth gels. And the result, your happiness with a pretty breast, is what matters.

So why did she come in?

She came in because that 10 year number stuck in her mind.  “Don’t I have to redo these every 10 years?”

Nope.

Ten years sticks in people’s minds because the implant warranty against deflation is good for 10 years.  As we all know from multitudes of electronic gadgets and cars, warranties tend to be well researched things.  Things don’t tend to break down until AFTER the warranty expires.  For breast implants, I see women who have had breast implants for 20 – 30 years with no issues with their implants.  

It is true the shell of the breast implant degrades over time.  It would be easier to “switch them out” when there is no leakage from the implant.  But surgery is not without risk.  Every time you do a surgery, you run the risk of infection, capsular contracture, malposition, bleeding, anesthesia complications, more scar, etc.  This does not factor in the issues of cost and recovery.  I did a surgery today where the patient had over 20 year old gel implants which were pristine.  Had she done a revision at every 10 year mark, she would have had 2 unnecessary surgeries. 

So my advice?

Wait until you have an issue.  What kind of issue? Capsular contracture, implant malposition, you look different after kids, you want gels but you have saline, wrinkling, you want to be bigger/smaller/something…  Have another goal.  I don’t think implants last forever.  You will need to redo them.

So my advice to this patient? She is 28 now and going to graduate school.  She wants kids in the future.  I told her to wait.  She has no issues now, so there is no advantage to doing a surgery.  Have fun, enjoy them.  Have her kids.  Breasts change significantly after pregnancy and breast feeding.  When she is done with all that, 5-10 years from now, then tinker with them. 

If it ain’t broke, don’t fix it.

I got an email today from a patient looking for breast augmentation using fat. I DO think this will be a good, viable way to augment the breast in the future. (Except for you super skinny athletic Bay Area women- You don’t have any fat to harvest.  Start eating ice cream.) 

The successful doctors who have good results and have been doing fat transfer to the breast for years, do a lot of prep work prior to the procedure. This entails usually the Brava system (a suction cup thing you put on your breast) for a month prior to the procedure and a month afterwards. !!!!!  Why would they do this? Why would you subject yourself to suction cups on the breast nightly? Are we auditioning for a Lady Gaga video?  No. 

Fat must survive when you move it. 

We call this fat “take.”  If  I transfer 500cc of fat, how much will be alive when I look at it later? 400cc? 300cc?  And that “later” needs to be a point months down the road, otherwise you can’t tell what is swelling and nonviable fat.

What happens if the fat does not “take’?  Oooh.  This is where it will do bad things.

• calcify (BAD in breasts. that is what we monitor to look for breast cancer!)
• oil cysts
• lumps
• hardening
• melt away

This whole topic just is a thorn in my side.  I am concerned and dismayed by marketing gone amuk.  I was invited to go to a “revolutionary new water assisted liposuction fat transfer workshop.”  They are being featured on every news program out there.  When I saw the promotional photo, I immediately did not want to go.  Why?  Because in their promo , their best photo to promote their workshop, the woman has swelling and bruise still there. 

This tells me this woman is only weeks out from surgery.  This tells me that months out from surgery the results don’t look as good, otherwise they would show me that photo. 

So AAARGH.  I went to the water lipo website, where they touted how there was no anesthesia, no downtime, no pain, blah blah blah.  I am mad.  I feel they are deceiving women.  Where is their medical integrity? Where are their photos of mammograms on these women? Where are their one year follow ups? Why are they marketing to non plastic surgeons? To non surgeons? 

I speak of this from a position of knowledge.  I DID go to a fat grafting workshop, put on by my colleagues, Board Certified Plastic Surgeons from all over the world.  These doctors have been refining their techniques and doing massive studies, following the patients for years afterwards including with MRI and mammograms.  I think they are close to a protocol of how best to do fat grafting.

Please be wary.  I am not doing fat grafting to the breast yet because I want to see the final data on HOW to do it safely, predictably, and effectively.  I want the studies to come out first to make sure it is safe, particularly with the rates of breast cancer. 

Be wary of those with big promises and little integrity.

People worry a lot about change in nipple sensation after surgery.  I would love to say, “No no! don’t worry.  You’ll be exactly like you are now.”  But I can’t say that. 

Why? Because I don’t know.

Don’t go freaking out about this.  Most women end up with about the same sensation as they started with.  Trust me, if there were big changes in the majority of women, breast augmentation would not be the number one procedure we do.  Nerves are tricky little things.  The sensation to the nipple comes up from the sides of the breast.  All surgery causes some sensation change immediately after surgery.   What can you expect? Usually the skin starts out numb, then it turns tingly/ itchy/ small jabs or shooting pains/ soreness, and then it settles out.  Most women end up pretty much where they started. 

How can we  help preserve nipple sensation? (Now there is a cause we can all rally behind!)

We know nerves are challenged when they are stretched.  It is the reason when you are pregnant or breastfeed and the milk comes in your breasts are tingly, hypersensitive (sorry guys- don’t touch), or itchy.  But just like it did after a week or two when breastfeeding, it settles out.  And the breasts feel normal.  So we know when we do an augmentation, the bigger you go, the more you stretch your skin, the higher the chance of sensory change.

The incision.  Ah, the incision.  Does that affect sensation?  Seems like if you cut at the areola, it should affect sensation more.  There was a study in our literature looking at that.  See link.  They found no correlation with where you cut, but they did with how big you go.

So it is rolling the dice a bit.  I can’t promise you what you will have after surgery.  I suspect it will be close to where you are now, but we won’t know until we do surgery and see.  For those patients focused on a guarantee, beware of the doctor who promises you no change.  No honest doctor can make that promise.

This is not a shock.  Makes sense if you try on sizing implants and look at yourself in the mirror, you will be better able to pick what you are comfortable with.  Maybe I am biased- their technique is exactly what I have found successful- which is to have women try on gel sizing implants twice (or more) before surgery.  I also send my patients home with the rice test, so they can preview and wear around their new size for a while before picking their final size.

What I really find shocking is the doctors who just “pick a size” for their patient.  More shockingly, I can’t imagine any of my Palo Alto Bay Area moms allowing someone to pick a size for them. I thought the “honey I know what you need” era was long gone.

My recommendations (which they echo in the paper):

• don’t focus on a specific cup size
• every patient is different. (body type, hips/curves, shoulders, muscle, height, weight)
• be comfortable in all of your looks (dropping kids off at school to going out on a saturday night)

Interestingly, the patient population of the investigator mimics my patient population- women seeking more conservative breast augmentations, particularly to restore what was lost after child rearing.  Of those who chose their size preoperatively, the average size was lower than for those women who did not pick their implant size.

“Most patients today conduct considerable research, much of it Internet based…Many have fixed notions of size …based on cup size, celebrity or internet photographs, the experience of friends (both good and bad), or their personality…Verbal communication alone between the patient and physician, even if supplemented, is an unreliable method for determining implant size.”

I agree.  You are smart, intelligent women (particularly if you are reading my blog).  This is your body.  Your body, your breast, your choice.  I am here to help guide you- gel vs. saline, widths, projections, profiles of implant… But you are the one best at making the choice of size.  You just need to see it.

Tissue expander and implant reconstruction is the most common reconstruction done.  A big issue, particularly for my ultra thin Bay Area women, is poor coverage over the implant.  These women are thin: they have no fat, thin skin, and no breast tissue after mastectomy.  Many won’t expand well in the lower portion of the breast, which is where we’d love to see you expand more to get a natural breast look.

Along came acellular dermal matrix.  What is that in English?  It is dermis, essentially an extra layer of skin.  It is great to help “thicken” tissue which is too thin, help implant position, and give better coverage over the implant.  It has become more popular in the past few years, and has helped some patients avoid a larger surgery involving muscle flaps.

Is it better?

A recent study came out in PRS (our big plastic surgery journal) in Feb 2010 looking at 415 immediate breast reconstructions.  They compared those which used the acellular dermal matrix versus those which did not.  The study wished to assess the “risk of postoperative complications associated with the use of acellular dermal matrix assisted implant based reconstruction.” The two patient groups were matched for age, cormorbidities, smoking, radiation, cancer stage.

Findings?

Acellular dermal matrix was statistically significant risk factor for developing postoperative seroma and for infection.  There was a 4x seroma rate, and 5 x the infection rate.

There are many variables, as with all things.  This study should be taken with a grain of salt.  But I think their final thought is a good one:  “The selection criteria for acellular dermal matrix utilization in breast reconstruction should be more carefully determined by critically assessing the potential benefits.”  “Routine use of acellular dermal matrix in every implant based breast reconstruction seems unwarranted.”

I agree.

A new study in the May 1, 2010 issue of the International Journal of Cancer says implants may hinder the early detection of breast malignancies, but they do not affect patient survival.

This sounds like a lightening rod in the world of breast implants.  What did they find?

The study analyzed 24,000+ women who had breast augmentation in Canada between 1974 and 1989.  Cancers and mortality were looked at through 1997.

Breast cancer was found in 182 patients of the implant group and 202 in the control group.

• Implants delayed the diagnosis in augmented patients
• No statistical differences were seen in age at diagnosis, tumor size, histology type.
• The delay in diagnosis did not affect overall prognosis.
• Breast cancer survival was similar in both groups.

What does this mean?

I have not been able to read the whole article.  Due to the timing of the original breast augmentations, I suspect most of these women had first or second generation noncoehsive gel implants in front of the muscle.  Many likely had capsular contracture.  I don’t know in Canada what the breast cancer screening process is, when it is done, when it starts, how often it is done, if they use techniques like Ecklund, etc.

What I do believe:

• There is some impairment of mammograms when you put in breast implants.
• The impairment is significantly less when you go under the muscle (which is one of the big reasons I prefer submuscular.  One study quotes 39% impairment in front of the muscle vs. 9% behind the muscle relative to nonaugmented women.)
• Hard breasts / capsular contracture makes it more difficult to view the breast tissue (another reason to go submuscular, as the capsular contracture rates are lower behind the muscle)
• If you use the Ecklund technique and take more films (two additional CC and MLO views, with a fifth lateral view if needed), and use other modalities (such as ultrasound if needed) you can further reduce the risk.
• If you have implants, you should go to a mammogram center which does these techniques and is well versed in evaluating women with implants.
• Ecklund and others (published in radiology journals in the late 80s) argued implants help thin the overlying glandular breast tissue and give you a smooth backdrop, thereby enhancing the physical breast exam.

So I will tell you what I tell all my patients.  Breast implants will reduce your ability to visualize the breast.  This reduction is lower when behind the muscle.  If you have a strong family history of breast cancer, you need to strongly consider this risk.  If doing gel implants where the risk of capsular contracture is higher, particularly if you have a strong family history of breast cancer, consider a preoperative MRI so you can see your baseline prior to augmentation.  Anyone over the age of 35 should get a good baseline mammogram prior to any breast surgery.  And don’t forget your self exams (or ask a spouse/friend).  Just don’t forget.