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.

The 20th Anniversary Komen San Francisco Race for the Cure!
Sunday, September 26, 2010
Along the Beautiful Embarcadero, starting and finishing by the Ferry Building.
5K Run/Walk & 1 Mile Fun Walk

Up to 75 percent of the net income from each domestic Affiliate Race stays in the local community to fund breast health education and breast cancer screening and treatment projects. So get off your bottoms and enjoy our beautiful northern california fall. Not only will it be good for breast cancer, it will benefit your heart as well.

Cost is $30.  Your kids ages 6-12 can enter as well for $10 (includes a tshirt).

Not a runner? For $35, you can join the “sleep in for a cure” and get a t shirt as well. (I love that they have this feature too.)

https://secure.info-komen.org/site/TRR/RacefortheCure/SFO_SanFranciscoAffiliate/1943285177?pg=ptype&fr_id=1813

I have been around medicine my whole life.  My father was a plastic surgeon as well.  Back in his day 30 years ago when a patient had insurance, he billed insurance for x amount, and they paid x amount.

What a concept.

When I started my practice I got on to as many insurance plans as I could.  It was a way to network with patients and grow my practice.  But I noticed the older doctors were trying to get off insurance plans.  You’ll see a lot of the great internal medicine doctors don’t take any insurance anymore- they have become “concierge” doctors.  Why?

• Because most insurance does not pay doctors well.
• They will only pay a portion of the billed amount.  I could charge $100,000 for a surgery.  But insurance plans have what is “allowed” for each CPT code.  This is the maximum I can get paid.  And it is a small number.
• This has caused doctors to need to increase volume to make a living.  Doctors don’t want to slam a gazillion patients into a day.  They have been forced to do that to make ends meet.  Particularly in Silicon Valley, rents are high. Costs of employees are high.  Don’t forget malpractice, office supplies, medical supplies, etc etc.  Most medical offices have at least one employee dedicated just to billing insurance.
• When you are a solo practicioner like I am, your reimbursement by insurance is even lower.  The large groups like Stanford and the Palo Alto clinic have better negotiating power with insurance plans to get better reimbursement.
• When I am on an insurance plan, I am not allowed to balance bill the patient.  Let’s say I do a long breast cancer reconstruction case.   Bilateral.  As a surgeon, my surgery code with insurance includes ALL of your visits pertaining to that surgery for 3 months.  My visit to the hospital for the next day or two after surgery.  All of your follow ups in my office.  When I do a tissue expander I see you every 2-3 weeks.  I use supplies: saline, syringes, needles, local anesthetic.  I am not allowed to bill for any of those costs.
• You have to submit, and frequently resubmit claims to get paid.

You can still go to any doctor you want if you are on a PPO plan.  Even if they are not “on” your plan, they will be covered, though usually at a lower percentage.  We are considered “out of network.”

I know you pay high monthly fees and deductibles and copays for your health insurance.  We must for our family.  But insurance is not passing that money on to the doctors.  Most general surgeons make about $400-500 for a hernia repair.  I just did a bilateral breast cancer reconstruction case.  I saw her for a preop for an hour. The surgery took about four hours with mastectomies.  I saw her multiple times in the hospital.  Then I saw her in clinic to expand her every 2-3 weeks, for a total of 8 post op visits I can’t bill for.  My supplies were not reimbursed.  I was paid $700.  For my skin cancer excisions, I am paid almost the costs of the sutures and supplies I use.  My ER call visits I frequently don’t get paid at all.  It is pro bono work. 

All doctors pay to go to medical school, which takes four years after college.  All residencies are a minimum of three years.  All surgery residencies are a minimum of five years.  Plastic surgery is an additional fellowship, so we train even longer.  We give up the decade of our 20s to living in a hospital to learn our craft.   I trained in the days of 100+  hour work weeks, living in the hospital.  We delayed our lives- marriage, buying a home, kids.

It is tragic to see what is happening.  Older seasoned doctors retire early, when they are at the height of their career, due to poor reimbursement.  Doctors do things out of their specialty, to try to get into the cash pay areas. 

Please see the link under.  This is a group of general surgeons discussing hernia insurance reimbursement.  http://www.generalsurgerynews.com/index.asp?section_id=67&show=dept&issue_id=109&article_id=4089

So why do we not take insurance plans?  Because we can’t if we are to survive with a shred of our ideals intact.  I need to pay my overhead.  I don’t want to become a patient mill.  I want to give my patients the “concierge” medicine they deserve.  Surgery is a scary thing, particularly when recently diagnosed with cancer.  These patients should not be rushed.

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.

Breast reductions reduce the size of breasts.  For men, this would be the area they consider “chest.”  When a man comes to me for liposuction, I almost always end up liposuctioning the chest area.  Sometimes what men think is prominent pectoral muscles is fat over the muscle.  (Though not all of it.  If you have been working out, you likely have a lot of muscle there too.)

Men are very different than women.

• Their breast is mostly fat
• It doesn’t tend to droop as much
• They have better skin tone
• Their chest is visible in a bathing suit and other clothes

For men, gynecomastia, moob job- whatever you call it- is done primarily by liposuction, with a small direct excision of breast tissue (if present) using an incision around the areola.  Most men I see though have little to no real breast tissue.  And I almost never need to cut out skin.

Women are different.

• Breast tissue and fat throughout the breast
• The breast droops, especially if your breast is large, you’ve had pregnancies and breastfed, you are a runner…
• Poor skin tone
• You can hide scars better than men

For most women, a huge issue in a large breast is the DROOP.  I think the profound part of a reduction is the LIFT.  In order to do this, you must cut out skin.  That results in a larger scar.  But for most patients it is worth it.  I do a shorter scar vertical lift, which I love for shape and lesser scar.  People talk about liposuction only for women with large breasts.  The issue is the women with the good skin tone, where there is some hope of the breast skin shrinking and lifting, are the young women- and a lot of them have dense breast tissue, which you can’t liposuction.  For the older women, who have a lot of softer fat, they are droopy.  Again, I think 80% of the benefit of a reduction is the lift.

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.