Breast Procedures

Breast Augmentation

Breast enhancement surgery using saline or gel-filled implants remains extremely popular after over half a century of clinical practice. It is the most popular aesthetic procedure carried out on women in the United States today.

Concerns over the potential for silicone to produce autoimmune disease have now been laid to rest and gel-filled implants are back on the market with the blessing of the FDA.

Women request breast enhancement for the same reasons as most people who seek aesthetic surgery: to improve their self-image and attractiveness to others. However, it has been shown that patients register an increase in self-esteem and a greater self-confidence in the workplace following breast augmentation.

The operation, usually carried out under general anesthesia as a day case, is relatively simple. A space is created either behind the breast itself (sub mammary) or behind the pectoralis muscle (subpectoral). Don't be confused about which is better: they both have their proponents and detractors. There is something to be said for each. In most people, sub mammary implants look more natural. However, when the patient is very thin or where there is little or no breast development, the lack of 'padding' over the implant can lead to the implant becoming too obvious with visible wrinkling and an unduly sharp peripheral border. In such cases, subpectoral placement is preferred.

The incisions made for the introduction of the implant vary. The most popular route is via a 4-5cm incision in the fold just under the breast. The implant can also be placed through a 'periareolar' incision - one that follows the lower border of the areola - or through the armpit (transaxillary). Inflatable implants have even been inserted through the belly-button using special instrumentation (TUBA). For reasons I would be happy to discuss, I do not favor this last modality.

When considering a breast augmentation, it is important to consider that you will be entering a long term relationship with your plastic surgeon. Maintenance of your investment is vital to minimize complications and keep you looking your best. Annual checkups are mandatory, so it is vital to select a surgeon who recognizes this and is prepared to carry it out.

At your initial consultation, I will take a detailed history and perform a thorough examination with the object of finding out your aims, determining what size, style and type of implant would best satisfy them, and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. We will discuss implant placement and select the most appropriate method of placement. You will have ample time to ask questions and discuss your options in a professional yet friendly setting. The surgery itself will be carried out in a safe environment (a hospital or an accredited ambulatory surgery center) and you will have a board certified anesthesiologist giving the anesthetic. You should be able to return to work in about a week.

Breast Lift, Breast Reduction

I've grouped breast lift and reduction mammoplasty together because to the plastic surgeon they are closely related and, indeed, similar procedures: in both operations the nipple areola complex (NAC) is repositioned at a higher level; the breast is tightened from below; the resulting scars are the same (anchor or lollypop), and in both operations some tissue is always removed. The minimum tissue removal in a breast lift is a skin whereas in a reduction, breast tissue, fat and skin are extensively resected. There is a wide spectrum in between.

An important difference between the two operations is that reduction mammoplasties are performed to alleviate symptoms such as backache, neck ache, shoulder grooving (from bra straps), persistent sweat rash and severe asymmetries. Breast lifts are performed for purely aesthetic reasons. Insurance will frequently cover breast reduction, although the policy will often demand that a certain weight (e.g. 500gm) be removed from each side. If less is removed, the operation will be considered cosmetic and may not be covered.

Both lifts and reductions are usually performed under a general anesthetic as day surgeries. However if either is combined with another procedure - for example with abdominoplasty as in the so-called 'mommy makeover' - then an overnight stay is recommended. Both breast operations can be performed with either the 'Wise' pattern - which produces an anchor-shaped scar or as a 'vertical' reduction where a lollypop scar results (like the anchor but without the transverse component). The method selected depends somewhat on the size of the reduction, the necessity for large skin resection and on previous scarring

Many patients ask whether their nipple will retain normal erotic sensation after breast surgery. It has been shown that in the vast majority of cases it will either be retained or will return within six months. Others enquire about the possibility of breast feeding after surgery. While there is no guarantee that anyone can breast feed - even without surgery - there is no reduction in the proportion who can, as a result of it. It should be stated, however, that the larger the resection, the more the potential damage to the nerves and ducts that make both of these things possible.

At your initial consultation, I shall take a detailed history and perform a thorough examination with the object of elucidating your symptoms, establishing your goals, and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. It is important to know whether you have a personal or family history of breast cancer and to order appropriate screening if you do. We will discuss the method to be used and the position of the scar you may expect. In the case of a reduction, we will discuss the amount of tissue to be removed, the expected cup size after the operation and the likelihood of the surgery being a benefit of your insurance. You will have ample time to ask questions and discuss your options in a professional yet friendly setting. The surgery itself will be carried out in a safe environment (a hospital or an accredited ambulatory surgery center) and you will have a board certified anesthesiologist giving the anesthetic. You should be able to return to work in about a two weeks or even sooner of no active shoulder motion is involved.

Breast Reconstruction

Most women who undergo mastectomy are offered the possibility of immediate breast reconstruction under the same anesthetic. I strongly believe that it is a woman's right to have her body restored to as close to normal as possible following the removal of breast cancer. The requirement for health insurance to cover not only breast reconstruction, but also balancing procedures and nipple reconstruction, is mandated by statute in most states.

To women who have not had reconstruction at the time of their original mastectomy, and who have perhaps already undergone radiotherapy and/or chemotherapy I would offer 'delayed' reconstruction. Occasionally, delayed reconstruction is planned ahead, particularly when post-operative radiotherapy is contemplated.

The method of reconstruction is individualized to each patient. It is highly desirable that surgery be tailored to the individual's requirements. To make this feasible, it is essential for the surgeon to be not only familiar but skilled in all the modalities of breast reconstruction. It is a sad fact that when your only tool is a hammer, the whole world looks like a nail! Factors that influence the choice of procedure must be fully discussed with the patient. These include:

• Age
• Type of cancer
• General medical condition
• History of smoking and diabetes
• Size and shape of the normal breast
• Radiotherapy
• Abdominal scars
• General adiposity
• Recreational activities and sports
• Extent of disease
• Extent of surgery
• Patient's wishes (last but not least)

Basically, there are two types of breast reconstruction: those involving the patient's own tissue (autogenous) and those utilizing implants (alloplastic).

Use of the patient's own tissue involves the harvesting of a large section of skin and fat from a donor area and transplanting it to the chest. Such procedures are known as free tissue transfers. Circulation to the tissue is reestablished by microvascular anastomosis (the joining together of small blood vessels under a microscope). Functional impairment at the donor site is eliminated by the use of 'Perforator Flaps' such as DIEP, SIEA and SGAP flaps, in which the muscle is spared and only fat and skin are taken. The donor sites for these perforator flaps include: the lower abdomen ('DIEP' and 'SIEA' flaps, where, as a bonus, the patient gets a tummy tuck); the buttock ('GAP' flaps), the inner thigh (TUG flaps) and the back ('TDAP' flap). Whatever the donor site, the surgeon takes particular care to eliminate or at least minimize the amount of muscle taken with the flap, so as to maintain normal function both in day to day living and in recreational activities. Perforator flaps are technically demanding and they are only performed regularly in a few centers in the United States and abroad. Older methods of free tissue transfer such as free or pedicled TRAM flaps require the sacrifice of muscle and sometimes the tunneling of tissue, with a greater risk of hernia and functional loss. It is therefore important for the patient to know the kind of free tissue transfer that is being offered and be educated in the specific advantages offered by perforator flaps.

Implants may be saline or gel-filled. They are often used after the initial placement of a tissue expander at the time of mastectomy. A tissue expander is like an empty implant with a metal valve on the front. Over a few weeks, the tissue expander is inflated at the doctor's office by his injecting saline into the valve. The expander gets larger and gradually stretches the skin in preparation for placement of the definitive implant. This takes place at a second procedure. The increasing use of 'skin sparing' mastectomies reduce the need for expansion so that implants may be inserted immediately. Often I use a human-derived collagen product such as Alloderm in conjunction with the patient's own pectoral muscle to create a well protected pocket to accurately protect and position the expander or prosthesis.

Nipple reconstruction is likewise offered to all patients. This may be performed as day surgery - often under local anesthetic - usually about four months after the initial reconstruction. When this is combined with a 'skin-sparing' mastectomy, the scarring is mostly hidden and the resulting appearance is virtually normal. I frequently perform balancing procedures and scar revisions at the same time as nipple reconstruction to obtain the best result humanly possible for the patient involved.

At your initial consultation, I shall take a detailed history and perform a thorough examination with the object of establishing the options available, formulating a treatment plan and ensuring that any pre-existing medical conditions may be appropriately managed to minimize risk at the time of surgery. You will have ample time to ask questions and discuss your options in a professional yet friendly setting. The surgery itself will be carried out in a safe hospital environment and you will have a board certified anesthesiologist giving the anesthetic. Your time off work will depend on the method used and the physical activity required in your occupation. I will discuss this with you on an individual basis.

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