Breast Augmentation: What Happens During a Consultation?

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There are many reasons why women seek breast augmentation. Some women feel that increasing their breast size will give them greater self-confidence. Others would like to feel more proportional between their top and bottom so they fit better into their clothing. Mothers frequently seek breast augmentation to restore what was lost with breastfeeding and ageing. Supporting loose skin and giving upper breast fullness are also common reasons for choosing breast enlargement.

Good communication with patients in breast augmentation is key. There’s a need to review their medical histories and ask patients what their goals are for breast augmentation. In some cases, it is a modest increase in size to fit better in their clothing. Other times it’s a significant increase in volume to change their look. A patient may desire an improved breast shape or, possibly, better symmetry is their goal. Still others may want to restore their pre-pregnancy figure and may choose to combine their augmentation with a breast lift or other procedures.

On examining the patient, one needs to consider many features including breast volume, width, height, nipple position, areola size, ribcage curvature, skin tone, droopiness, asymmetry, and crease position. Breasts are highly variable, and I help the patient understand what their best options are based on their physical characteristics. We then come to a common agreement about what our goal will be. Remember, that “breast are sisters, not twins” so more often than not there is quite some variation between the two breasts so you can’t expect a perfect match following breast augmentation.

When the patient returns for their pre-operative visit, typically 1-3 weeks before surgery, I have them look through many digital photographs of breasts to show me their desired result. If there is a discrepancy between what we have discussed and what the patient is showing me with pictures, I’ll identify the difference and sort out what they really want, often using the 3D VECTRA which can simulate what the breasts may look like after augmentation. At the end of our meeting, I’m fairly confident that I understand what the patient desires. Likewise, the patient feels comfortable with our communication and our plan.

The photographs are then brought with me to the operating room. When the patient is asleep, I create the pockets for the implants on each of the breasts, and I occasionally use implant sizers to confirm the volume and shape of the optimal breast implants for the patient. Most patients are back to work and most of their usual routine in several days or up to a week. Strenuous exercise should be avoided for several weeks.

To learn more about breast augmentations, request a consultation by contacting us at 13000DRTIM or emailing us at info@drtim.com.au 

Breast Implants & Anaplastic Large Cell Lymphoma (ALCL)- No Cause For Alarm

Breast Implant & ALCL

Only recently described, breast implant–associated anaplastic large cell lymphoma (ALCL) usually presents as an effusion-associated fibrous capsule surrounding the implant and less frequently as a mass. Little is known about the natural history and long-term outcomes of such disease. It is estimated that between 5 and 10 million women have breast implants. Due to the rarity of a diagnosis of ALCL (3 in 100 million per year in the USA diagnosed with ALCL in the breast) a worldwide collaboration is required to provide robust data to investigate this possible link.

ALCL is a lymphoma and not cancer of the breast tissue. When breast implants are placed in the body, they are inserted behind the breast tissue or under the chest muscle. Over time, a fibrous scar called a capsule develops around the implant, separating it from the rest of the breast. In women with breast implants, the ALCL was generally found adjacent to the implant itself and contained within the fibrous capsule. ALCL is a lymphoma which is a type of cancer involving cells of the immune system. It is not cancer of the breast tissue.

The most recent clinical studies state that it is not possible to confirm with any certainty whether breast implants have any relation to an increased likelihood of developing ALCL, and particularly whether any one type of implant can create a higher or lower risk than another of developing the disease. It should be noted that ALCL is extremely rare and treatable. This is evidenced in particular by three recent papers:

  1. A Danish nationwide study – ‘Breast implants and anaplastic large-cell lymphoma: a Danish population-based cohort study’– concluded that in a nationwide cohort of 19,885 women who underwent breast implant surgery between 1973 and 2010, no cases of ALCL were identified
  2. A review of cases within another recent comprehensive article, ‘Breast implant-associated anaplastic large-cell lymphoma: long-term follow-up of 60 patients’ concluded that: “most patients with breast implant-associated ALCL who had disease confined within the fibrous capsule achieved complete remission. Proper management for these patients may be limited to capsulectomy and implant removal. Patients who present with a mass have a more aggressive clinical course that may be fatal, justifying cytotoxic chemotherapy in addition to removal of implants.”
  3. In a study reported in the Journal of Clinical Oncology, Roberto N. Miranda, MD, Associate Professor in the Department of Hematopathology at The University of Texas MD Anderson Cancer Center, and colleagues assessed disease characteristics, treatment, and outcomes in 60 cases. They found that outcomes are better in women with effusion confined by the fibrous capsule, whereas disease presenting as a mass has a more aggressive clinical course.Patients should be advised that ALCL is a very rare condition and until any further evidence is presented there is no need to remove breast implants as a matter of course.

 

These data suggest that there are two patient subsets. Most patients who present with an effusion around the implant, without a tumour mass, achieve complete remission and excellent disease-free survival. A smaller subset of patients presents with a tumour mass associated with the fibrous capsule and are more likely to have clinically aggressive disease. We suggest that patients without a mass may benefit from a conservative therapeutic approach, perhaps removal of the implant with capsulectomy alone, whereas patients with a tumour mass may need removal of the implants and systemic therapy that still needs to be defined.

 

We continue to advise that any women with breast implants who experience any sudden unexplained changes, lumps or swelling should speak to their GP or their surgeon.

Can Breast Implants Raise a Low Nipple Areola Complex?

A youthful, cosmetically ideal breast has a nipple areola complex diameter of about 38-42mm.  Some breasts have large areolas from the time that they develop during puberty, and some enlarge later in life with pregnancy and breastfeeding. A large areola tends to make a breast look ’matronly’ even if it is not sagging. Nipple-areola complex diameter can definitely be reduced or enlarged, and this can be performed as a stand-alone procedure or as part of any breast enhancement procedure such as a lift, augmentation or reduction.

An attractive, well-positioned, and proportionate nipple areola complex is an important goal for many women looking to achieve a beautiful breast appearance. This small area of a woman’s anatomy can have a big impact on her satisfaction with her breasts. Women who are unhappy with the appearance of their nipple areola complexes, can have them corrected either alone or in combination with any breast enhancement procedure.

Breast augmentation with breast implants will not necessarily raise the nipple areola complex position in sagging breasts and in fact in some cases may make the areola larger. There are techniques to allow the implant to fall into the lower pole of the breast to create the illusion of lifting with more of the breast volume sitting lower on the chest. This is where using a tear drop (anatomical) breast implant can help as it creates a” bucket-handle” effect on the nipple areola complex.

The submuscular (below the muscle) breast implants are” innocent bystanders” to whatever happens to the breasts, as they are really chest wall implants that simply push the breasts forward. The submuscular breast implants are supported by the overlying pectoralis major muscles. In contrast, subglandular (above the muscle) breast implants are more likely to fall with pregnancy or weight loss, as they are supported only by the overlying breast tissues.

A periareolar (around the areola) or circumvertical (lollipop type) breast lifts are reasonable choices to reduce the nipple areola complex size and raise its position on the breast. These techniques reliably elevate the breast while keeping scars to a minimum. These breast lifts are desirable because of the nipple position (usually at or below the breast fold) and because of breast sagging. Neither nipple areola complex position nor breast sagging would be corrected with breast implants alone. “Blowing up the balloon” with larger breast implants will only create excessively large, still very saggy breasts. Reshaping the breast and elevating the nipple areola complex and breast back up onto the chest will play an important role in helping one achieve a cosmetically pleasing result.

Most plastic surgeons have a clear policy defining the financial responsibility of the surgeon and the patient in case of complications involving breast lifts, both short and long term. The policy should be made clear to each patient before surgery. It may differ from surgeon to surgeon with the majority of surgeons not charging their fee for reoperating on the patient but the patient having to pay the facility and anaesthesia costs.

Many women feel uncomfortable with their breasts their whole life because they had ’droopy’ or enlarged nipples or areolas that looked abnormal. A small surgical procedure to enhance the nipple areola complex can be extremely important for a woman’s self-esteem and self-image.

Question: Does it matter to you whether the nipple areola complex is proportionate to the remaining breast? You can leave a comment below.

Breast Lift and Augmentation: The facts you need to know!

The goals of breast lift with or without breast augmentation are to restore shape, volume, and nipple-areola position. However, simultaneous breast lift and augmentation present multiple problems, specifically because it becomes harder to control all of the variables affecting the outcome when combining the two procedures. No single method is best to treat all types of sagging (ptosis), and maintaining a good blood supply to the nipple-areola complex is of paramount importance, so a staged procedure may be necessary at times.

Why is combining a breast lift and breast augmentation the most difficult of all cosmetic breast surgery procedures? The surgery involves manoeuvres that can be counterproductive to each other since the skin is being removed and when closed back up again, pushes the breast in and upwards, whilst an implant stretches the skin in an out and in a downwards direction. These conflicting tensions can adversely affect the blood supply to the breast and skin which may affect wound healing, scar quality etc. Positioning of both the nipple and breast fold also becomes more challenging during simultaneous lift and augmentation. Secondly, no two breasts are the same, and each patient is seeking a different endpoint, sometimes with unrealistic expectations.

The first thing that I do when evaluating a patient for a breast lift is to ask them if they are happy with their present breast volume. You can simply do this by pinching the skin below the breast and pushing it up where it belongs. Most women are amazed at how little of breast volume they actually have. If that is the case, then volume enhancement, usually with an implant, is necessary along with a lift. If the volume is satisfactory, then a breast lift will suffice.

The second thing to do is grade the amount of breast sagging. This is done by using Regnault’s classification which looks at the position of the nipple as follows:

1)  Grade 1 (minor): nipple at breast fold
2)  Grade 2 (moderate): nipple is below the fold but above the lower breast contour
3)  Grade 3 (major): nipple is below the fold and below breast contour
4)  Pseudoptosis (“false sagging”): nipple lies above the fold, there is little breast volume, some of which lies below the fold

Other characteristics that one looks out for are:

1) Skin: elasticity and excess;
2)  Breast tissue:  firm and fibrous or soft and fatty; and
3)  Skin-breast tissue relationship: firm and adherent or loosely adherent and is the breast full or empty. Skin quality and the skin-breast tissue relationship are the key factors in determining the breast lift procedure and the quality and longevity of the final result.

As a general rule, if the skin elasticity is normal, the breast envelope is full, and the skin is adherent to the underlying breast tissue, then the scars would be limited, and vice versa. In other words, one progresses from limited scars such as periareolar scars (scars around the nipple-areola complex) to periareolar-vertical scars (scars that run down the front of the breast below the nipple-areola complex) to more extensive, full-length inverted-T or anchor scars.

For the patient with “pseudoptosis,” inserting a breast implant alone, usually tear-dropped shaped, is typically all that is needed. For Grade I sagging, an implant alone or a lift plus an implant may be required.

Depending on a number of factors, the lift may be performed via a crescent, periareolar, or vertical approach. A vertical approach is preferred if there is significant looseness below the nipple. However, the periareolar incision is generally used in just a few specific situations. Since this skin-only incision is unable to lift much weight, it is an option in women with small breasts who need only a small amount of nipple repositioning, usually < 2 cm.

In addition, it is considered advantageous in women with pointed, conical or tubular breasts, because it causes areolar flattening and eliminates the tubular nature. The main issue I have with performing a periareolar breast lift is its tendency to cause areolar flattening and leave the areola more prone to stretching.

In Grade 2 sagging, especially where the breasts are large and heavy, a vertical breast lift is often required because it will effectively lift the breast tissue to achieve increased projection. However, a periareolar incision may still be considered for women with light breasts. When performing a vertical breast lift, the procedure may be converted into a short inverted-T lift if a difficulty is encountered controlling the nipple-to-breast fold distance.

With Grade 3 sagging, the lift technique depends on the nipple-to-breast fold distance. If it is > 10 cm, most surgeons perform an inverted-T breast lift. Otherwise, vertical breast lift remains an option that will enable control of the nipple-to-breast fold distance, as the vertical scar tends to shorten in the post-operative period with scar contraction.

Thanks for reading!

Dr. Tim – Sydney Cosmetic Plastic Surgeon

www.cosmeticculture.com.au
www.drtim.com.au

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The two main categories of breast implants are silicone gel or saline-filled implants. Silicone gel implants have been popular since the early 1960s, and they have gone through multiple generations of improvements since that time. Silicone gel implants have undergone rigorous studies which have shown they are safe and do not cause breast cancer nor connective tissue disorders.

The main advantage of silicone implants is that they feel more natural than saline implants. Gel implants are less prone to rippling than saline, which makes them particularly advantageous for thin patients. The current 5th generation of silicone implants are cohesive, meaning that the gel is viscous enough that even if the implant ruptures the gel tends to remain in the same place, a little like jelly. Previous generations, the silicone was more like thick maple syrup.

Saline (ie. saltwater) implants have a long record of safety too and are less expensive than silicone gel implants. They are generally placed when they are empty and filled once they are inside the breast pocket, so that the access incisions may be even smaller. When a saline implant leaks, most of the saline from the implant is rapidly and harmlessly absorbed by the body. The deflation is usually obvious, and the patient returns for removal and replacement of the saline implant. This may be done under local anaesthesia if the patient is an appropriate candidate. The primary disadvantage of saline implants is that they don’t look or feel as natural as the silicone gel implants. This is a particularly important issue for women who are thin or have decreased elasticity of their skin.

 To learn more about breast augmentation, request a consultation by contacting us at 13000DRTIM or emailing us at info@drtim.com.au 

Breast Augmentation Part 4 of 4: The Surgical Facility

Your safety is of paramount importance when undergoing breast augmentation. Always have your surgery in an accredited hospital or day surgery facility. If you are young and healthy, then a day surgery facility is fine. If you are older and have health problems, then a hospital would be a better place to have the procedure performed because of the availability and back-up of an intensive care unit and other highly specialised healthcare professionals.

Accredited means that the surgical facility has passed a set of rigorous examinations to assure that the equipment and procedures meet standards for optimal safety. The hospital or day surgery facility should be fully accredited by the Australian Council on Healthcare Standards (ACHS) or a set of ISO standards that provide the highest standards of service. Patient health, safety, and comfort should be the surgical facilities main concerns and they should continually monitor and evaluate their performance to achieve these outcomes. Another requirement of accreditation is to assure that personnel is trained, experienced, and skilled healthcare professionals and procedures and equipment are in place to deal with any emergency from a power outage to cardiac arrest.

Sometimes it’s reassuring to visit the accredited facility yourself. If you’re not comfortable with a surgical facility, don’t have the breast augmentation surgery there. What you want to see is modern and comfortable surroundings, as well as caring and warm personnel. The operating room should appear state-of-the-art, spotlessly clean, and equipped with the most up-to-date equipment. The recovery area should be immediately adjacent to the operating rooms. Some surgical facilities provide overnight accommodations with one-on-one nursing care especially for patients who need overnight care for more extensive procedures.

The following checklist should help you “tie things up” when organising your breast augmentation:

1)  Check the date of surgery and pay scheduling deposit if required

2)  Review surgeon’s financial policies and policies for refunds

3)  Sign informed consent and operative consent forms for breast augmentation

4)  Schedule laboratory tests and mammography/ultrasound if required

5)  Review medications to avoid and ones to take before surgery

6)  Review post-operative instructions the night before surgery

7)  On the day of surgery wear comfortable clothes, get someone to drive you home and be with you overnight, wear no make-up, and leave your jewellery and valuables at home

Question: What things do you consider important in the surgical facility when having a breast augmentation? You can leave a comment below

Breast Augmentation revisions: 3 facts you must know!

Designing a surgical plan that can deliver a satisfactory result for women seeking surgical revision after breast augmentation can be quite difficult.  It still requires the plastic surgeon to obtain a good history, perform a careful clinical examination and identify the woman’s concerns and goals.

Revisional surgery after breast augmentation is typically more complex, because of the diversity of presentations and the interval elapsed since their primary surgery.  Additional surgery may be required because of anatomical changes caused by the previous procedure or that have occurred over me.  This information must be explained to and understood by women who may be expecting an easy fix. Furthermore, plastic surgeons may face the challenge of communicating with a dissatisfied and angry patient and therefore, in-depth and honest discussions outlining the risks, benefits, and costs of the various options remain paramount for achieving success.

There are 3 key facts women seeking revisional surgery after breast augmentation need to consider:

1)  Your plastic surgeon needs to listen carefully to what you’re saying.  They must find out what’s motivating you in order to satisfy your goals.  If your problem, however, is imperceptible to them, or you’re seeking an outcome they consider unattainable, they may not be able to help you reach your goals.

2)  Use visuals to enhance your consultation.  Visuals are extremely useful in helping you to understand all your options.  Your plastic surgeon should draw schematic diagrams to explain the various techniques and present you with lots of pictures of previous patients, which should be catalogued by physical attributes, rather than by implant volume or bra size.

3)  Make sure all your options are given to you in detail.  Your plastic surgeon should take a systematic approach to counseling you about your surgical options, beginning by describing the simplest, least-expensive procedure and moving up in terms of complexity and cost. Outlining all of the information so that you understand the basis for your recommendations and the likely outcomes should help you reach an informed decision and choose an operation that will deliver a satisfactory result.

If you have cost in mind and are dissatisfied after your recent primary surgery, then try and rectify the situation by returning to your previous surgeon. If this is not an option because of poor surgeon-patient communication, then you should seek another surgeon.

Thanks for reading!

 

Dr Tim – Sydney Cosmetic Plastic Surgeon

www.cosmeticculture.com.au
www.drtim.com.au

 

What Is a Mummy Makeover?

Many of today’s mums don’t feel they should sacrifice the way they look just because they’ve had children. After multiple pregnancies and breastfeeding, many women find it impossible for diet and exercise alone to restore their figures. These women usually want their tummies and breasts back the way they looked before pregnancy.

These so-called “Mummy Makeovers” are usually performed on women in their 30s or early 40s. There are multiple variations of the Mummy Makeover, of course, and I individualise the plan for each patient depending on their needs. Many women will not need or desire all of these procedures. Each patient determines what her personal Mummy Makeover will involve after we discuss her concerns and options in a thorough consultation.

A Mummy Makeover may be performed in one or more stages. Age, health, needs, and desires are all considered carefully when I formulate a plan for each patient. The majority of my patients choose to do more than one procedure at a time. I’ve had a great deal of experience performing these combined surgeries over the past decade. We take many steps to assure both minimal pain and maximum safety during our procedures:

  1. TUMMY TUCK: The tummy tends to experience the greatest change following pregnancy with stretch marks, loose skin and lower tummy fat being the most common complaints. The tummy muscles may also be stretched to the point that they remain separated in the midline, accentuating the patient’s lower tummy bulge. To treat these problems, I perform a tummy tuck where I remove the excess skin and fat from the tummy and tighten the muscles. Whenever we do a tummy tuck as part of the Mummy Makeover, we perform liposuction and pay special on to the belly button to help create a nice looking midriff.
  2. LIPOSUCTION: After having children, fat tends to redistribute to new areas on the body where it may be unwanted. This is frequently true even if women are successful at losing their baby weight. Most often, bulges of fat accumulated around the waist and on the thighs. On these areas, I frequently perform liposuction as part of a Mummy Makeover.
  3. BREAST SURGERY: The breasts go through dramatic changes with pregnancy and breastfeeding. Patient concerns about their breasts vary greatly, but the most common breast procedures I perform as part of a Mummy Makeover include:

Many of our patients for the Mummy Makeover travel from places outside of Sydney. Our staff can help with the planning of these sorts of trips through our CosmeticCulture Makeover Vacation Program, which makes travel for cosmetic surgery quite easy. More information is available on our website www.cosmeticculture.com.au, including descriptions of tummy tuck and breast augmentation or breast lifts as well as liposuction. You can also email us for more information at info@drtim.com.au or call us at 13000DRTIM.

Question:  Which parts of your post-childbirth body would you like to change with a Mummy Makeover? You can leave a comment below.

Breast Implants: Things to Know Before Getting Them

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There are two main reasons why women get breast implants. The first one is for reconstructive purposes. This is to bring the breast back to its original form after it has been damaged by an injury or by a disease such as cancer.

The second reason has to do with cosmetic or aesthetic reasons. They may want to have fuller breast or breasts that are more symmetrical with one another. It is also a way to boost confidence in their bodies.

The cost of doing such a procedure will vary. Depending on the location, the doctor who will be doing the operation and the type of implant used the cost can run to a couple of thousand dollars.

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Most plastic surgeons favour the infra-mammary incision location for most breast implants. The peri-areolar incision is made as a semicircle at the lower border of the pigmented areola. It does heal beautifully in most cases and uses the interface of the darker and lighter pigmented skin to camouflage the incision. For patients with small areolae, it may be preferable to use the infra-mammary incision, located underneath the breast. This incision also heals very well, and is especially useful for women with well defined creases under their breasts.

The axillary incision (in the armpit) is another option, but it’s better suited for saline implants than silicone gel. Because this access incision is a greater distance from the implant pocket, it’s less precise than the peri-areolar and infra-mammary approaches. Studies have confirmed that there is a higher implant revision rate using the axillary approach. Usually the axillary scars heal well, but they may still be visible when the patient wears sleeveless outfits. There is also a higher rate of breast implant infections with the peri-areolar and axillary approaches.

Patients frequently ask what effect the incision location has on maintaining nipple sensation after surgery. The answer is that the access incision usually has little effect on nipple sensation. Rather, it’s the size of the implant pocket that has the largest impact on nipple sensation. Large implants may require a pocket that stretches the nerves to the point that they do not function well, increasing the odds of impaired nipple sensation. Even so, the vast majority of my patients maintain normal nipple sensation.

Breast implants may be placed over or under the pectoralis major muscle. In the early days of breast augmentation, all implants were placed on top of the muscle. However, in recent decades, it has become more common to place implants underneath the pectoralis major muscle. The muscle covers the top half of the implant, providing additional thickness of coverage over the implant in the critical cleavage area. This makes it less likely that the implant edges or ripples will be visible when wearing a bra or swimsuit. Studies have also shown that the rate of capsular contracture is lower when the implants are placed under the muscle. Breast imaging to screen for breast cancer is more accurate when the implants are placed behind the muscle. For these reasons, I prefer to place implants underneath the muscle for most of my breast implant patients.

 

To learn more about breast augmentations, request a consultation by contacting us at 13000DRTIM or emailing us at info@drtim.com.au