Choosing the right size breast implant. You can’t come in the office and say, “My friend Mary has 375s, so I want 375s.” We do probably 10 measurements of your chest and torso and nipple position and breast width to really determine what size implant is right for you, and we palpate and feel your soft tissue to feel how much laxity, how much stretch you have in your tissue. You can’t just stick the same size implant in everybody.

So we use these, what we call bio-dimensional profile of each individual to determine what implant best suits their frame. And once we have those measurements taken, what we do is we look at the implants that we have available, whether they’re silicone or saline. Implants come in, we call it, different profiles. So they have different widths and different amounts of projection. So, we can choose something that’s kind of more like a pancake or very flat, and that’s okay for somebody who wants a very, very small breast. Or we can choose something that’s more like a beach ball, that really sticks out and has a lot of prominence. And for some people, that’s exactly what they want. So by choosing the proper profile to what the patient’s desires are, we really can meet everyone’s individual needs.

Let’s talk about silicone implants, why we use them, who are the great candidates for silicone implants, and we’ll start out by saying many patients come in saying they just want silicone implants. Their friends have had silicone implants, and that’s all they know, and that’s all they want. But there are other options. But when we talk about silicone implants, what we really want to talk about is the level of cohesiveness, whether they’re more liquid or more stiffer. The stiffer implants are called gummy bears, and the more liquid implants are the traditional silicone implants. They’re just a little bit more fluid. They feel very good, but if they’re too fluid, if the liquid inside is too thin, they show more ripple and wrinkles.

When we talk about who is a great candidate for silicone implants, those are usually candidates who have a very thin amount of soft tissue. Again, most all the implants placed in my office are placed below the muscle, we call subpectoral breast augmentation. Occasionally, we do put them above the muscle for very specific indications, very specific reasons, such as a bodybuilder, someone who competes in the athletic bodybuilding competition. They can’t have that implant under the muscle.

There are traditionally three different incisions. The most common is the inframammary fold in the breast fold region which is hidden when you stand up. It’s in the shadow of the breast and heals very nicely in most skin types.

The second is what we call the periareolar, which is on the lower typically edge of the pigmented nipple areola skin junction. It’s usually a crescent smiley face incision and that heals very well too.

The third which is one that I really like, I think its great, is called the trans axillary or the armpit incision. And it’s again about one and a half inch incision in the armpit and use a special camera system to make a pocket under lighted magnification. The benefit of that in my hands are that we use a camera system, a bright light and everything is magnified and we use very precise instruments and can create a very nice pocket in a very nice position to implant with no visible scar on the breast.

Some of the concerns about each individual scar are really as follows. The periareolar scar has the highest rate of losing nipple sensation and it has a higher rate of what we call capsular contraction, which is the hardness or firmness of the implant which you really don’t want. Periareolar has a highest risk of that and for that reason it’s low on my list of selected incisions.

The inframammary or the breast fold really is the go to for larger silicone implants or patients that have complex anatomy because it really gives you the best visualization of the pocket and lets you really manipulate the tissue the most. So it’s really the gold standard.

The trans axillary or armpit is not offered by a lot of surgeons because the equipment is more technologically advanced, it’s fairly expensive and it is a more, really a more difficult procedure to perform so most surgeons don’t learn it and don’t offer it. It is something that I’ve done for literally almost 20 years now, so it’s something that when somebody comes to my office and says, “Oh, everyone in town says you can’t have a trans axillary incision.” It’s really because the doctor doesn’t know how to do it, but it really is an excellent, superb procedure for the right patient.

We’re going to talk about above the muscle or subglandular breast augmentation, versus below the muscle or subpectoral breast augmentation. In the United States, and in my practice, probably 95% of the patients have a subpectoral or below the muscle augmentation. There are some people though, that are good candidates for an above the muscle approach. Typically, the patient who wants an above the muscle implant is someone who’s very fitness oriented. They’re a bodybuilder, they don’t want what we call an animation deformity, which is showing the breast implant flexing when you move, when it’s below the muscle. For most patients, this is not a problem, even if you’re a heavy duty workout person, but there are some people who just had been online, and they don’t want it.

So we can go above the muscle. The key elements are you have to have enough soft tissue to cover the implant, because if you don’t, you’re going to see the edges, and you’re going to see rippling and wrinkling. It’s really a fallacy for some women who come in and say, “I read online that I might not need a breast lift if you just put the implant above my muscle.” I think that’s a fallacy, I don’t think that’s a real procedure, and I think it really is doing something inappropriate for the patient, because as soon as you load that soft tissue with an implant, which is more weight, it’s just going to stretch that skin, and it’s going to, what we call bottom out, where you’re going to have a very bottom heavy breast, it’s going to be a poor shape.

And we know factually, that whether it’s subglandular, or now, some people try to say, you can put an implant subfascial, really, really hard to do, not a very good operation, and it still has the same problems, and for many patients that much, much, much higher rate of capsular contracture. And if you have a really hard, painful, misshapen breast, you’re going to need a revision, and I always tell people, you’d rather do it right the first time, then to have to come back and try to fix something a second, or third, or fourth time.

Let’s talk a little bit about my practice and the name of my practice.

My practice is called Richmond Surgical Arts. Again, a little bit about my background. I went to dental school, and part of dentistry is very artistic. It’s sculpting. It’s manipulating materials. It’s having an eye for colors and shades. So I really think of myself as an artist.

When I switched professions and ended up in plastic surgery, it’s really ideal because we’re sculpting it and manipulating all areas of the body. And I really love the fact that I can manipulate tissue and manipulate patient’s appearance and do so with a very artistic eye. It really is something that really makes me happy every day.

Okay. Today we’re going to talk a little bit about breast symmetry. What really should we talk about is breast asymmetry, because all breasts are different. I’d like to say, “They’re sisters, not twins,” and so when we look at someone’s breasts, we know that they’re going to be different. Most patients don’t know this. They’re unaware of this, and when I measure them and I say, “Well, you’re five millimeters off here or a centimeter off here,” they kind of freak out and like, “Oh my gosh, I didn’t, I never knew this.” It’s normal. It’s absolutely normal. But what this means when we look at your breasts, we feel them and we look at the volume of breast tissue. I also look at your hand dominance. Sometimes it’s right, but sometimes it’s left, and sometimes that muscle is so much bigger that that’s going to come into play, that somebody just has a really dominant muscle.

And sometimes the chest wall itself is slanted or crooked, and that’s because some people have scoliosis. Some people, I joke, just have a big heart and their left side of the chest is just pushed out a little bit more. So there’s so many things that we can look at, and I measure it and evaluate. And what that means is that I’m going to adjust things as I see fit, to try to improve your symmetry. And that means that we sometimes don’t use the same implants. Sometimes we’ll use a 325 on one side, and a 350 on the other side. Sometimes if we’re using a saline implant, we’ll have a fill of 350 on one, and 365 on the other. And we’ll manipulate those volumes, and sometimes implants, to help improve your symmetry.

And I think that’s really a key important thing because some docs just say, “Hey, we’re throwing in 350s,” and you get one on each side. And the problem with that is that breast augmentation will magnify a breast asymmetry. So I’d like to try to improve it from the start, not try to explain something later to a patient, “Oh, oh, we should have done this, we should have done that,” because really, you have one chance to do it right. So let’s plan accordingly.

A huge concern patients have is in the post-op period, the bruising, the scarring. We’re going to talk a little about that, because we use some special things to help decrease it. We use medicines called arnica montana. It’s a natural product, helps decrease bruising and swelling. We also use a product called bromelain, which is a pineapple stem extract, and again, that helps decrease bruising and swelling.

When it comes to incisions, I mean, the closure of the incision is not something I take lightly. We do it very precisely. All of your sutures are tucked underneath the skin. In fact, we actually use three to four layers of sutures. So there’s not just one layer, but they’re all underneath the skin. We usually have some special material placed over your incision line, it’s an antibacterial product. You’ll remove that after 24 hours, and then we actually start you on typically a silicone scar gel, which helps improve the quality of your scar in the long run.

So now that textured implants have been voluntarily taken off the market by Allergan, the bio cell textured implant. What do you do? And while there is a disease process, we’ve all heard about breast implant associated lymphoma. We don’t want to cause a panic. We don’t want to yell fire in a crowded movie theater. But we do want to educate our patients that these implants are associated with this process. And the real key is patient comfort and patient peace of mind.

All implants fail eventually, so all implants need to be replaced eventually. So if you’ve had your implants for three years or seven years or 10 years, we know they start to fail. And so it might be something you now say, “Okay, this information’s out there. I’ve had my implants for 10 years and I want to replace them.” And this can be a very straightforward, simple process. We can replace same size, a little bigger. We can do some other things that if you want them done at the same time. Maybe a little lift if you now feel you need a little bit of a lift. But it can be done safely, effectively, and in a controlled manner. And we don’t want anyone to panic. But it is something that if you have these textured implants, you may be considering replacing them at this point in time.

We’re going to briefly talk about capsular contracture, or CC. People read about it online and want to know what they can do to help prevent it, and I think the biggest thing to prevention of capsule contracture is having a good surgeon. What you want is a very bloodless technique. The surgery must be performed very, very precisely. You want to select an implant that doesn’t overwhelm your frame, and implant selection is definitely part of it. I think it’s definitely important where you place the implant. Below the muscle, we know, has a tremendously lower rate of caps contracture.

And then we’re going to talk about other ways to place the implant. I am a huge fan of a device called the Keller Funnel. It was developed by Dr. Keller, plastic surgeon, and it’s basically a sterilized single use, slippery… It’s a slip-and-slide for breast implants. You put it in the big end, like a cake icing bag, you put the small end in, squirt it in, so no one touches your implant, the implant has no trauma to it, it doesn’t… It just slides right in. And there are several studies that are good studies showing a decreased risk of capsule contracture with the Keller Funnel.

The other thing is what we irrigate, or what we wash out your breast pocket with, prior to implant insertion. There’s several different formulas. There’s some really new exciting materials that I’m working with that are very safe, and I’m really excited to tell people that caps contracture can really be decreased by using appropriate surgical technique, appropriate implant placement, and then washing the pocket out with specific materials that we know are super safe and work fantastic.

Occasionally, we do have someone who does bruise more than usual. Sometimes the patient may have taken some aspirin or Motrin, and that just causes the body to bleed a little more at the time of surgery. All of your surgery is done meticulously, with essentially an electric knife, so there really is almost no bleeding during your operation. I often would say there are literally four or five drops of blood during the whole operation. Sometimes someone goes home, they come in the next day or two or three days later, and they’re pretty bruised. And that’s because a little bit of muscle edge from the subpectoral breast augmentation oozed and bruised them. The nice thing is, is that we have some treatments. We have some topical arnica gel, and most patients, in about seven to 10 days, that bruising can be all gone away with a little special additional medication.

You may have seen or heard that textured breast implants, specifically one made by Allergan, the BIOCELL textured implant, was voluntarily removed from the market very recently. What this means is that it’s no longer going to be available for use. Personally, I tell my patients that luckily I never really used textured implants. I never found them to offer the benefits that they were supposed to offer. In fact, they had, in my opinion, more complications than a smooth, round implant. There is a process and a disease process called breast implant associated lymphoma, and it is real, but it’s very rare. It really has only been shown to be associated with a textured implant. So, I think it was very wise for these implants to be removed from the market, because we know that if you have a smooth implant, saline or silicone, you’re really not at risk for this process. So, that’s the only implants I’ve ever used have been smooth implants. I do think that’s something that is great to hear, that these implants are not going to be used anymore in the US market or worldwide.

We’re going to chat a little about avoiding complications. Bigger is not always better. There is a limit to what we can do safely, and when someone comes in and says, “I want 800 CC implants, and I want them above the muscle,” more than likely, I’m going to say, “I’m not the doctor for you.” Really, what we want to do is limit rippling. We want to limit rippling, wrinkling, poor scar formation, thinning of the tissue, so there really is a limit to what we can do safely. We’re going to take a bunch of measurements of your breasts. We’re going to discuss the different profiles and shapes of implants we can use. But the best way to eliminate things like rippling and wrinkling are to follow safe guidelines and not push the envelope of safety.