A. WHAT THE SURGERY WILL DO

Basically breast implants will make small breasts larger. To help our patient understand what this will do for her, the breasts are visually examined. At this time, with the patient partially disrobed, the patient may be asked what it is she would like to accomplish, and it is wise to listen carefully and make a note of what is said; the responses differ. Also the patient can be shown with a red felt tip pen where the incisions can be placed and which site in the doctor's opinion might be best for her (the incision that would provide the best result and leave the least noticeable scar).

The patient is told that we have a lot more information for them about the operation, and a booklet is given to them. We then offer to show the patient and whoever is accompanying them many before and after photographs.

Web site information is provided at www.ascbs.org to help determine what patients would gain in appearance from the operation, and a videotape can be shown which explains many pros and cons of the operation, such as the common complications of the procedure and how to manage them.

Patient choices

23 May, 2002

The seven choices we give our patients are:

 1. Size of implant 

 2. Site of incision

 3. Type of implant  

 4. Hospital or Office  

 5. General or Local Anesthesia

 6. Subpectoral or Subglandular   

 7. Shape

Giving the patient these choices allows them to have more control. A patient who is fully informed and makes a reasonable choice is less likely to be unhappy than a person who has no opportunity to choose.

Each of these choices may be explained to the patient, though the choice is generally in agreement with what the doctor recommends. The size of implant and site of incision are easy to explain and understand.

For the type of implant, of anesthesia, and whether to place the implant above or below the muscle, most will follow the surgeon’s advice. The patient has very little to rely on except the information they are given.

Allowing the patient to choose or to participate fully in the choices is recommended for a more pleased and happy patient.  It is advantageous if someone such as a friend or relative can also participate and offer the patient advice and support in discussion of the options and pros and cons.  It can be very helpful both to the patient and the surgeon.  Listening very carefully to the patient's remarks and expressed desires, writing them down as she speaks, and going over them again for a full understanding is a good technique.  These notes can then be reviewed again with the patient the morning of surgery.

The better informed patient is less afraid, feels more in control of her destiny, knows what to expect, and is easier to manage.

1.   Size

Very frequently, a few months after surgery the patient wishes the implants were larger, and yet before surgery the same patient was afraid they would be too big. The same patient may wish they were smaller for some occasions, such as jogging and participating in athletics, and would like them larger at other times, such as for evening wear or to fill out a bathing suit. Let us recognize that cosmetic patients are the type of persons who are displeased with their appearance, and though the surgery may improve the appearance, it does not alter the personality type. They still wish to be better, which is a healthy, wholesome attitude so long as they are not inclined to take excessive risks to achieve tiny, unnoticeable, vague, and ill-defined gains.

The most common question regarding size patients ask is "What size would I need to be to fill a C or D cup bra?"  Or the patient may simply say, "Make me just large enough to fill a C cup with a little fullness."  This request sounds simple and direct enough, but not only will it require a different size implant for each person, but may require a different size for each breast on the same patient.

The answer to the question of how many cc’s (cubic centimeters) of implant size are required depends upon how much breast tissue the patient already has. This may be different for each breast, and the two breasts may already be unequal in size, shape, and position of areola and inframammary folds.  The patient also may genuinely and truly be unaware of the differences in the breast until they are pointed out to her, even though she may realize one is a little smaller than the other. Also, the different bras and manufacturers have different dimensions for a C or D cup.

The best answer to size is the sandwich baggy technique.

If the patient will go and purchase an inexpensive bra with the cup size she desires to fill, then she can easily determine how much additional volume will be needed to fill the cup of the bra in cc's with a sandwich baggy filled with water.

If the patient takes some socks in her handbag to the store with her, she can fill the bra with the socks while trying it on to see that it is the one she wants to make her look good.

Then when she gets home with the bra she has selected, she fills a sandwich baggy with water until she has the size that produces the most desirable appearance. She does this simply by placing the filled sandwich baggy in the bra.  

Once she has determined what sandwich baggy volume makes her look the best, all she needs to do is measure the water in the sandwich baggies by pouring it in a kitchen graduate marked in cc's or milliliters. We demonstrate this and show the patient how to do this on her first visit to the office. We have her place sandwich baggies filled with 250 to 350 cc's of water in her bra in the privacy of an exam room with an assistant to help her. She can do this in front of a large mirror, so that she may understand the idea and see how she will look with her top on and off using different volumes of water.

With this SANDWICH BAGGY TECHNIQUE, the patient can determine as exactly as anyone what size will be best for her. It should be pointed out to the patient that there is almost no detectable difference in 10% more or less, and we ask our patients to grant us a variation of at least that amount, depending on what looks best at the time of surgery.

The water-filled sandwich bag sits out in the bra and does not fill all the areas that need to be filled to provide the forward bra cup filling projection and shape.  In other words, the sandwich baggy technique usually underestimates the volume required to produce the expected result, and this is especially true if the implants are placed in the submuscular position. As a general rule for the above muscle position, we recommend adding 10% to the estimated volume, and for below the muscle, 20%.

Should there be problems with the implants in the future - capsules, sagging, stretching of the breast skin due to pregnancy, breast cancer, etc. - one may find that the problems with the implants are less severe if the implants are smaller.  Larger implants may cause some pressure atrophy and thinning of muscle, subcutaneous fat, and breast tissue, or possibly even affect the ribs if placed in the submuscular position.

Occasionally the patient will choose implants that are too large, and have to be told that if an attempt were made to over stretch the skin, stretch marks could develop. Also, the smaller the implant, the chance of capsule contraction occurring will be smaller. This is because relatively more breast tissue will be covering the small implant, and therefore there will be less of a noticeable feeling of firmness, as well as less possibility of distortion with the same amount of capsule formation if the implants are small.

The patient who appears to be choosing too small a size should be informed of the nicer appearance larger breasts may have, and the before and after pictures are helpful in explaining this. As soon as you have done 10 cases you will have a nice collection of before and after photos to show patients.

The most common error in all of the choices made by patients is having chosen too small in choosing the size of the implant. Allowing the patient to have as much choice and play as much of a role in choosing every part of the operation leads to greater patient satisfaction and decreases the possibility of regret or remorse from not having the most desirable result.

Showing the patient a book of before and after photographs allows the doctor or his assistant to ask which ones the patient would like most for herself. It also helps the patient understand what she will obtain from the procedure if she sees someone who looks like she did before surgery, then to see what the patient looks like after.

At this point it wise to explain to the patient that while there are some choices the patient may have, the exact shape of the breasts, the areola and the nipples cannot be chosen with any certainty with surgery limited to placement of breast implants.  Implants control the size or volume of the breasts but not the shape (except to a limited degree), and they do not mitigate the sagging, drooping, size or shape of the areolae or nipples, or the symmetry in position or shape.

Asymmetry in volume can be adequately corrected, and occasionally this, combined with a change in the position of the inframammary fold on the smaller side, can do a lot to make the breasts look more alike. Other asymmetries, such as an inverted nipple on one side, a large areola on one side, a unilateral ptosis, etc., can be corrected by various techniques, but not by breast implants alone.

Asking the patient to bring in pictures from Playboy or other topless photos can be helpful on a preoperative visit. This can allow the surgeon and his staff to see if the patient's expectations are realistic.

A very clearly worded disclaimer (such as the one our surgery consent provides) is needed, which states that the patient will not look exactly like any certain photographs, drawings, or other persons.

Finally, it is not a good idea to see the patient's desires in photos she has chosen on the morning of surgery for the first time. They may be a long way from what can be accomplished.

2. Site of incision

Allowing the patient to choose the site of the incision may sound like an unsettling idea to some surgeons, but more than 98% of the patients will accept the doctor's recommendation anyway, so why not allow the patient to have as much say in the matter as possible?

In the patient whose breasts droop enough that the skin of the breast is touching the skin of the chest wall when the patient is standing erect, the inframammary incision placed slightly up on the breast just 1/2 to 1 cm above the new inframammary fold should be almost completely hidden, and may be the preferable and most recommended site.

In the patient with very small areolae, the areola incision may be nearly impossible. It is preferable to have this incision at least 2 cm long, and if it is to be less than1.5 cm, and the patient really insists on not having it under the arm, we may insist on permission to extend it laterally as much as 1/2 to 1 cm in each direction because it may not be possible to get an implant of over 200 cc volume through it.

 Ordinarily we tell our patients the following: 1.) The areola incision made in the wrinkles of the brown skin of the areola heals with the least scar, 2.) The inframammary incision is most visible, except in pendulous breasts, and 3.) The axillary incision is the least visible of all, unless the patient is a ballet dancer or for some other reason has her arms in the air with the axillae exposed very frequently.

 The techniques of the different approaches and associated problems will be discussed in detail in further chapters, but the patient may wish to know that the areola approach is the only one of the three that invades the breast tissue. Yet, in performing this incision technique in hundreds of women (and knowing others who have also done hundreds of women with this approach), I have yet to see or hear of breast nodules or cysts developing in the lower portion of the breast because of this approach. Many patients I have done with this approach have subsequently become pregnant and were able to breast-feed.

Also with the areolar approach, there has been no greater incidence of hypaesthesia of the nipple or lower breast skin than with the other incisions in my experience with more than 500 surgeries using this approach.

There is an article in the literature that states that patients who have the areolar approach have more difficulty breast-feeding than those with the axillary or inframammary incision. This is a retrospective study and is unreliable, but still the suggestion may be correct.

3. Type of implant

Almost always the patient will accept the doctor's recommendation for the type of implant. There were seven implant manufacturers before 1992 and the FDA. Now there are only three - McGhan, Mentor and PIP. Their names, addresses and phone numbers are listed together on a separate page in your workbook. The choice of implants for the surgeon is discussed in chapter twelve.

At times these companies will have videotapes on how to do the surgery. Wells Johnson supplies endoscopic equipment for the umbilical approach and has videotapes of that approach.

 What the patient wants is the best possible result, with no future problems. Many of the reasons for choosing a saline over a gel, or a combination, or the Meme is because of the rationale each one has for reducing the chance of or preventing the capsule contracture problem. The Meme was the best. But since it was covered with polyurethane foam, it was removed from the market and will probably never return. It was this interface of texturing that led to the textured silicone implants.

In the beginning, after it was discovered that silicone injections could lead to unacceptable complications and silicone was first placed in a silicone bag, the first implants in the early 1960s were silicone gel and they were firm and teardrop shaped. The capsule contracture rate was greater than 90%, with most being as hard as your elbow, except for whatever breast tissue was overlying them. So, softer implants were developed in the late 1960s.

These softer implants would assume a teardrop shape in the upright position, and so the teardrop shape was no longer necessary. Dacron patches then were popular to hold the implants up, and while they do this to a certain extent, the capsule contracture rate again approached 100% due to reaction to the Dacron. Also, the breast tissue continued to sag over the implants even when the implants stayed firmly fixed to the chest wall, resulting in distortion.  Dacron patches are very rarely used now.

In the early 1970s saline filled implants were introduced and were softer than the gel implant in the same patient when one side to the other was compared by independent observers. The problem with the saline implants is the leakage and deflation rate (which seems to be about 50% over a period of 10 years in my experience with about 100 pure saline and around 500 combination gel and saline patients). Yet many of the pure saline and many of the combination saline/silicone gel implants that I used 15 to 20 years ago are still intact.

The deflation often necessitates an additional operation, and since there is no doubt that some capsule contraction occurs with saline implants, why should a woman have to suffer an additional problem of deflation? For example I took out some saline implants that had been put in elsewhere, and had already required one revision because of deflation, and one side was completely collapsed and the other had a capsule. The implants were small, and the patient could have tolerated the firm side but was chagrined to have the asymmetry of a complete collapse of the other, so we replaced them both with gels. So gels had more and harder capsules, but were more popular than saline because of the deflation problem. Not because the result was more natural or softer. The saline, in fact, were softer.

When considering gel bleed as a cause of capsule contraction, please note that many patients have a capsule develop only on one side, and usually the capsule firmness and thickness is unequal on the two sides. Not only are a few capsules unilateral, but most patients have unequal firmness, and often it is markedly unequal with a soft breast on one side and spherical contracture and deformity on the other. These well known findings must be considered for any theory of capsule contracture. Gel bleed would occur almost equally and could not cause such asymmetry in capsule formation.

The choices in 1997 were all saline - textured or smooth and to be filled with a valve or pre-filled.

Textured shells have thicker walls and ripple more. The McGhan textured is deeper and the implant will not move or flow in the pocket. This appears less natural. But this deeply textured implant is less likely to have distortion and capsule contracture. It ripples more and feels firmer, and is more palpable below the nipple where the tissues are thinner. The 468 implant is a shaped, overfilled, fairly firm implant, but it does not allow much of a stuck on appearance. Because it is overfilled and less mobile, it does not seem as natural as the softer, slick salines.

The smooth implants have less rippling, are less palpable and are less firm than the McGhan 468. But they are subject to more capsule contracture.

As noted by the FDA, August 1991 BG pp2, "Since the saline filled implants do not have the silicone gel, they are probably even less likely to increase the risk of autoimmune diseases or cancer.  But since both types of implants have the silicone rubber envelope, such effects cannot be totally ruled out, even for the saline filled implants."

So the FDA presumption is that the silicone gel is more likely to cause autoimmune disease or cancer than solid silicone. Yet these reactions on the immune level are microscopic and the difference in the gel and the solid silicone chemically on the level of the molecular structure is analogous to the difference in ice and water. And if the chemistry is the same, the molecular reaction should be approximately the same.

Other factors for the choice of implants will be discussed further in chapter 12. Even if gel were to return, many probably would continue to use saline because of possibly decreased liability, being accustomed to them, reduced incidence of capsule contracture, smaller incisions being required, and an overall reputation of greater safety from all the unproven but suspicious problems associated with gel. 

This is page #2.

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