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BEFORE AND AFTER
PHOTOGRAPHS Whether
or not to show before and after pictures will always be debated. It has been my
practice to do this for all sorts of cosmetic surgery for twenty-five years. The
photographs are shown to those patients who would like to see them for the
purpose of giving them information. The pictures show the facts of what breast
implants have been able to do for other persons, and what they cannot do. Generally,
the size of the areola is slightly increased and the breasts appear considerably
larger. Basically, breast implants make the breasts larger and do not correct
other problems, such as large areola, sagging, or asymmetries other than size. As
the patients and their accompanying friends or relatives look at the pictures
together, they will find some they like better than others, and perhaps express
the desire to achieve that goal. The
doctor or his assistant who is counseling the patient can point out that the
patient with attractive breasts after augmentation, had attractive smaller
breasts before. In other words, whatever the patient has before surgery will
still be there, and the breasts will be made larger by the implants. This
seems obvious, but many patients have not realized this concept,
and go to the doctor because they saw a friend who now has a beautiful
bosom, done by the doctor, when most of the result was not actually within the
surgeon's control. And such an eager patient herself actually has considerable
sagging, large areola, asymmetries, and stretch marks, which cannot be
eliminated by augmentation. However, she may naively think that since the
surgeon made her friend's breasts beautiful, he can do it for her. Showing
photographs is a gentle and effective way of getting the point across that what
you will have after is what you had before, plus the volume of the implants.
Therefore, the patient is asked to find someone who looks very much like herself
in the before pictures, and then to look at the after pictures to see the result
in order to get an idea of what results the patient in question would probably
obtain. This
is especially helpful when the breasts are a little pendulous, and the patient
mostly would like them lifted. PENDULOUS BREASTS Pendulous
breasts are normal and may be as or more attractive as any others. For
discussion we will define the pendulous breasts as follows: Grade
I:
The skin of the breast touches the skin of the chest wall only when the
patient is lying supine or leaning backwards. With
the patient erect the breast skin does not touch the chest skin, and the breasts
will not support a pencil under the breasts at all. Grade
II: The skin of the breast touches
the skin of the chest with the patient in the erect position, and may support a
pencil under the breast. The nipple is above the level of the inframammary fold,
and the fold can be lowered. Grade
III: The breast skin touches the
chest skin. The breast holds a pencil or two easily. The nipple is above the
inframammary fold, or can be brought higher by lowering the fold. Grade
IV: The breast skin touches the chest
skin. The nipples are below the inframammary fold and cannot be brought above by
lowering the fold. This gives the appearance of more than half the breast volume
lying below the inframammary fold. Grades
I and II are good candidates for augmentation. In consideration of the patient
with Grade III, the important question is, “Will the nipples point out or
slightly up after augmentation?” We
often recommend quite large implants for the person with Grade III because there
is a considerable amount of loose skin, and we must smoothly fill it or risk
having a “ball-in-a-sock” type of phenomenon from too small an implant. The
patients with the characteristics of the Grade III have been some of our
happiest patients when they are fully informed of what results they will have
and what the surgery will and will not accomplish for them before they decide to
have it done. As
patients look at the before and after photographs of patients with pendulous
breasts in counseling, they can see some breasts that were small and pendulous
before surgery that are filled out and much less pendulous after. This
is accomplished by lowering the inframammary fold, and can move a Grade III up
to a Grade II or I when the breasts are small and the implants are relatively
large. There is also a slight pendulum lift that occurs. This is explained by
measuring the distance from the suprasternal notch to the nipple, as some
recommend doing in all cases, especially the pendulous breasts. It can be
explained to the patient that this measurement is not changed by the surgery,
but since the implants push the breasts out from the chest wall to a certain
extent, there is a slight lifting of the nipple as a pendulum would swing upward
as it swings outward. This
slight pendulum lift can be no more than about a centimeter, or at the most, a
half an inch. Patients with pendulous breasts frequently ask to be fuller up
high on the chest, above where their breast tissue is lying. Again, the before
and after photos of other augmented pendulous breasts allow us to explain that
the desired high fullness is impossible to attain (unless it is achieved by
pushing the breasts up with a bra after surgery), because the center of the
implants must be placed approximately behind the nipple. MASTOPEXY COUNSELING Patients
who want and need a lift may be counseled on mastopexy, whether or not the
surgeon actually does that surgery. It
is helpful to the patient to know what it is all about. I show them
augmentations and ask them to look for scars, and they will notice that there
are none. Then I show them the typical anchor scar in before and after photos of
mastopexies. Since
we don't want the patient to think that we are the only surgeon who leaves scars
with breast lifts, it is a good idea to show before and after photos of the best
work of other surgeons using books and articles. Finally,
we recommend to the patient that if they want a breast lift they ask to see as
many before and after photos as the surgeon will show them of the results
obtained, so they will be fully informed and not disappointed. The crescent
mastopexy leaves less of a scar and can sometimes be helpful. Many
surgeons who have performed augmentations for years do not do mastopexy and
breast reduction, and it is not necessary to do these operations in order to
perform breast implant surgery with very good results. 4.
INDICATIONS AND CONTRAINDICATIONS The
good candidate for breast augmentation is an adult female, in good general
health with small breasts and the desire to have them made larger. The
legal age of consent in most states is eighteen, but if the patient is living
with parents, it might be wise to have the approval and knowledge of a parent
unless the patient is over the age of twenty-one. The
patient considering cosmetic surgery should also have realistic expectations of
possible complications and the probable result of surgery. It is not enough to
simply provide information that may or may not be understood. It is advantageous
to ask the patient how she will handle a complication such as excessive
firmness, and to listen very carefully to her answer. The
person who would be very depressed by or unable to cope with a complication like
excessive firmness is not a good candidate. Contraindications to breast surgery
may be divided into the following types: PHYSICAL
CONTRAINDICATIONS 1. Poor health Poor
health of various sorts, such as bleeding tendencies, hypertension, heart
disease, chronic pulmonary, renal, and hepatic diseases, and acute/chronic skin,
ear or periodontal infections may be problems. Keloid and excessive scar formers
are not only more likely to have problems with the incision site scars, but are
also more prone to capsular contracture. A person with dermatographia may also
be more prone to capsules. 2. Chest wall deformities
Patients
with chest wall deformities (i.e. Poland's Syndrome, which occurs in males and
females and is associated with unilateral lack of the pectoralis major, mammary
hypoplasia, and other abnormalities of the upper extremities, such as
syndactyly) are advised against having breast augmentation surgery. The more
severe cases of pectus excavatum and markedly hypoplastic breasts can be
problems, especially when capsule contracture occurs and causes distortion. 3. Pendulous breasts As
described in the preoperative counseling section, the patient with pendulous
breasts presents a challenge. Only the grade IV type will clearly be made to
look worse by augmentation, and this is because the bulk of the implant will sit
above the nipple and increase the downward pointing tendency of the breast. The
Grade III with the nipple above the inframammary fold (or the small breast that
can have the inframammary fold lowered) may still be a good candidate if the
patient is fully informed and has realistic expectations of the results. In
other words, the patient with pendulous breasts who is planning to have
augmentation surgery is more likely to be pleased if she knows beforehand how
she will look after surgery. This information can best be conveyed to the
patient by allowing the patient to see clear photographs of the results of
patients with a similar amount of sagging. Another alternative is to take
photographs of the patient and sketch the expected appearance and change in
contours from surgery on copies of the photos. 4. Gross asymmetries The
patient with gross asymmetries such as different-sized areolae, nipples pointing
in different directions, having one inframammary fold higher than the other,
having one breast hypertrophied or more pendulous than the other, inversion of
one nipple, etc. should have these
aspects clearly documented on photographs. As well, she will preferably consent
in writing that she understands the surgeon cannot correct these pre-existing
problems or conditions. 5. Lactating breasts Very
often the patient seeking augmentation will have been pregnant and will wish for
implants to fill up the breasts to the size they were with pregnancy and
breast-feeding. This is a very reasonable request, and one with which the
surgery can comply. If,
however, the surgeon performs the operation while the patient is still lactating
(which is defined as the time when there is still more than a few drops of milk
that can be expressed by mild pressure on the breasts), then the pressure of the
implants (even with subpectoral placement) will cause milk to accumulate around
the implants. Frequently, this will lead to severe capsule contracture. Usually,
the patient who has been breast-feeding should wait for a month or more before
considering breast implant surgery. Sometimes the patient is very insistent
because she does not want to be small, flat and unattractive, even for a few
weeks. This insistence is a trap for the surgeon. It
is better to wait six months or more. The breast milk around the implant is
referred to as Galactorrhea. Severe capsule contracture is the usually result. 6. Other contradictions Other
than physical contraindications, the most common can be divided into mental and
financial. It is not necessary to be extremely wary of psychiatric problems in
patients seeking breast augmentation. Such psychiatric problems are certainly no
more common in breast augmentation patients than in those patients having any
other kind of cosmetic surgical procedure. Many
years ago there was a reasonable opinion that persons seeking cosmetic surgery
were mentally or emotionally unstable. Perhaps there was some truth to such an
opinion if the risks of the procedures were much greater and the results were
less satisfying and predictable. It certainly is not true today. The
patients seeking improvement in appearance by reasonable and tried and true
methods are among the most aware and intelligent of our society.
Some of our presidents and all of the president's wives (except for
Barbara Bush) since the Nixon administration have had cosmetic surgery. The
vast majority of persons seeking improvement in appearance through breast
augmentation and other procedures are as mentally stable as those who go to the
beauty shop or the cosmetics counter with the same motives. Occasionally though,
we see patients who are mentally ill, simply because a significant percentage of
the population falls into that category. We cannot discuss all of these cases
but some deserve special mention. Hopefully,
the physician will recognize the severely depressed and the psychotic patient
with a distorted sense of reality. Even these persons can recover and have their
surgery at a later time. The milder mental problems are more difficult to
recognize and may not really be mental illnesses at all, but can cause the
surgeon some anxieties if he doesn't deal with them properly. Some
of these “mental problems” are more like attitudes people have. For example,
very rarely a person will be seen who really doesn't want the operation for
herself, but is doing it to please someone else, or even worse, to accomplish a
specific goal, such as getting her husband back. This desire is easily uncovered
and recognized by the physician interviewing the patient by asking the simple
question, "Why do you want this operation?" The
simple answer, "To look better" is what we hope to hear. However, when
we hear other goals (i.e. secondary goals) that may not be achieved, it is
important that the patient understands that the surgery will not necessarily
accomplish secondary goals, even when it has been very successful in the primary
goal of making the breasts larger and more at attractive. The
patient with unrealistic expectations is the most common potential problem.
Normal and even very intelligent people expect not to have any problems. They
expect that if they pay a good doctor thousands of dollars for a breast
operation, they can reasonably expect to have beautiful breasts. This
is why the preoperative counseling and the informed consents are so important.
The judge and jury feel the same way, and will not accept any verbal assurances
from the doctor that he informed the patient. All information about serious and
common complications must be in writing and signed by the patient, preferably
under witness. The
last of the common contraindications to surgery that is not physical is the
patient with financial problems. You will learn (if you don't know already),
that cosmetic surgery must be paid for in advance. In today's world, as any
attorney will tell you, there is no way you can collect after the fact. When the
patient is apparently a deserving needy person who just can't afford much, we
are tempted to do the procedure for less. Really,
such a patient should be charged more. What if there is a complication requiring
hospitalization? Or, what if there is some reason a revision or capsulotomy is
needed in the future? Poorer patients are more likely to sue. Filing lawsuits is
like buying lottery tickets; attorneys are hoping and praying for a client who
was turned away by a physician when she developed a complication simply because
she couldn't afford the care she needed.
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