Breast Implants: Consideration #5: Location of Incision

There are four commonly used incisions for breast augmentations.

1. Inframammary fold - a gently curved incision in the fold beneath the breast
2. Periareolar - a semicircular incision around the lower half of the areola
3. Transaxillary - a straight incision in an armpit crease
4. Transumbilical - a curved incision in the upper half of the umblicus

According to a recent study published in the Aesthetic Surgery Journal, Board Certified Plastic Surgeons in the USA prefer the inframammary fold and periareolar approaches.  The actual percentages of Board Certified Plastic Surgeons who prefer a particular approach...

1. Inframammary fold - 64%
2. Periareolar - 25%
3. Transaxillary - 8.7%
4. Transumbilical - 0.4%

Why is the inframammary approach most popular?

• Most versatile:  Any type of implant (saline or silicone, round or tear drop, smooth or textured, small or large) can be placed through this incision.  The inframammary approach allows access into either of the available pockets (under the breast or under the breast + muscle).
• Useful for secondary surgery:  Hopefully, you will not need a second (or third) surgery.  However, most implants will not last the lifetime of a women undergoing primary breast augmentations in her 30s.  She should plan on additional procedures.  The inframammary incision can be reused again and again for replacements of implants, corrections of problems, etc.
• Excellent precision:  Because the incision is directly beneath the breast, the surgeon can see what he is doing.  Any bleeding can be immediately stopped.  The pocket domain can be precisely controlled.  There is no need for guesswork.
• Distant from nerves and milk ducts:  Because the inframammary incision is away from nerves and milk ducts, there should (theoretically) be a decreased incidence of nipple numbness and fewer difficulties with subsequent breast feeding.  Moreover, since milk ducts may contain bacteria, remaining distant to bacteria may reduce a patient's risk of infection.
• Good aesthetics:  Inframammary scars tend to heal well; scars rarely hypertrophy (become thick and raised).  Moreover, since an attractive breast has a subtle "hang," the mound should itself obscure the resultant scar.  At the minimum, the inframammary scar should fall within the shadow of the breast.
• Limitations:  Very, very few.
• • Rare patients may have so little natural breast tissue that they don't really have folds; these patients may benefit from another approach.
  • Constricted breasts may be better treated with periareolar incisions.  (Constricted breasts are tight breasts with little tissue other than immediately behind the areolae.)
  • Others may object to the scar, but they must remember that the other scars (periareolar, transaxillary, and transumbilical) may be more advantageous only in the short term.  If those patients need secondary surgery, they are probably going to end up with inframammary incisions anyway.  Then, they have two sets of scars. 

Why is the periareolar incision also frequently used?

• Somewhat versatile:  Many types of implants can be placed through this incision; however, large silicone implants cannot always be placed through small areolae.  Tear-drop-shaped implants may be difficult to maneuver through small areolae too.  Both the subglandular and subpectoral pockets can be created through this incision.
• Particularly useful for constricted/tubular breasts:  The areola can be reduced in size at the same time.
• Can be useful for some secondary surgeries:  Some secondary surgeries can be performed through this approach.  However, on other occasions, the surgeon must convert to an inframammary technique.
• Excellent precision:  Like the inframammary incision, the periareolar approach allows for great control and precision.
• Good aesthetics:  Periareolar scars may be somewhat invisible.  For maximum camouflage, some plastic surgeons advocate tattooing any visible scars with ink similar in color to the patient's natural areolae.
• Limitations:  Some.  But this is still a useful technique.
• • If the patient has small areolae, then the periareolar incisions may not allow for placements of large silicone implants or tear-drop-shaped implants.
  • Some secondary surgeries may still require an inframammary approach.
  • Periareolar incisions may be more likely to damage the nerves that supply nipple sensation.  If erogenous nipple sensitivity is important to the patient, this may not be the best approach.
  • Periareolar incision may be more likely to damage milk ducts.  If the patient might breast feed in the future, then this may not be the best choice.

What are the problems with the transaxillary approach?

• Only somewhat versatile:  Saline implants can be easily placed through the armpit.  However, it is difficult to place even moderate-sized silicone implants through the transaxillary incision.  It would be very difficult (if not impossible) to place tear-drop-shaped implants through this approach.  Both the subglandular and subpectoral pockets can be created through this incision.
• Not useful for most secondary surgeries:  Most of these patients will end up requiring a second set of incisions (probably at the inframammary folds.  Then, they are stuck with four incisions, rather than just two.)
• Reduced precision:  Unless complex endoscopic equipment is used to improve visualization, precision is markedly reduced.
• Usually, good aesthetics:  If the scar heals nicely, then the breast itself has no scars (until the secondary procedures).  However, some of these incisions heal thick.  Then, the patient is stuck with scars that other people will see when she wears routine clothes, such as tank tops.
• Limitations:  Many.  I don't use this technique anymore.
• • While some surgeons claim that they can place small silicone implants through transaxillary incisions, they certainly cannot get medium or large silicone implants through this approach.
  • It would be very difficult to orient tear-drop-shaped implants via the armpits.
  • Secondary surgeries can only very infrequently be performed through the under arms.  Usually, these patients will require inframammary incisions.
  • Without complex endoscopic equipment, visualization is impaired.  Could there be a greater likelihood for bleeding complications and for malpositioned implants?

Why is the transumbilical breast augmentation (TUBA) condemned?

• This is a novelty technique.  Most Board Certified Plastic Surgeons think that it is foolish.
• No versatility regarding implant type:  Only round, saline implants are possible with the TUBA.  It would be impossible to place a silicone implant or a tear-drop-shaped implant with this technique.
• No subpectoral placement:  Only subglandular placement is possible.
• Not at all useful for secondary surgeries, under any circumstances.
• Poor precision:  Most of the patients complain that at least one of the two breasts is "off to the side" or "too close to the middle."
• The scar may be invisible.  However, a secondary procedure would necessitate inframammary or periareolar scars.
• This technique is officially condemned by implant manufacturers.  Use of the TUBA approach invalidates device warranties.

Bottom lines: 

• Like my colleagues around the country, I advocate incisions at the inframammary folds and around the areolae.
• For most patients, the fold will be best, especially since silicone is becoming so much more popular than saline.
• In the unusual patient who either has constricted breasts or poorly defined folds, periareolar incisions may be better.

Breast Implants: Consideration #4: Smooth v. Textured

The shell of a breast implant can be smooth (as shown on the left) or textured (as on the right).

Biophysicists first developed texturing in their attempt to decrease capsular contractures.

• All foreign materials (whether knee replacements, artificial heart valves, or metal rods for stabilizing bones) stimulate inflammation and surrounding scar.
• • The body thinks, "What the hell is this thing?!  I need to protect myself."
  • The resultant inflammation produces the scar.
• Capsular contracture is the specific term for the scar around breast implants.
• While all breast implant patients have some degree of capsule, in 7-9% of patients the scar can be excessive. 
• • The breasts can be too firm;
  • they can be distorted;
  • they can even be painful.
• Below is a patient from Hawaii who presented to my Ventura office with severe capsular contractures.  Ouch.

Textured shells were supposed to decrease the incidence of capsules and to minimize their extent when they did form.  The rationale was that any scar formed around textured implants would be irregularly oriented, and thus less likely to become hard, firm, or distorting.

Most studies, however, have not supported this theory.  Textured implants become hard ("contracted") as often as smooth implants.

Moreover,...

• Textured implants have thicker shells.  Thus, to begin with, textured implants are a bit firmer.
• Textured implants tend to produce more rippling.

Now you know why 92% of Board Certified Plastic Surgeons in the USA use smooth implants rather than textured implants.

So, why do we ever use texturing?

• Rarely, some patients benefit from tear-drop-shaped implants.  The texturing helps to stabilize the implants so that they maintain their orientation.  (Please read my post from 3 days ago.)
• Tissue expanders used in breast reconstruction also have an "anatomic" shape.  Whenever I am treating a mastectomy patient who is interested in a prosthetic breast reconstruction, I always use textured devices to create a pocket for a permanent implant.

(By the way, the Hawaiian patient had a happy ending--albeit after a corrective surgery....)

Breast Implants: Consideration #3: Round v. Tear Drop

Breast implants can be shaped in two common configurations:

• Round (on the left)
• Tear drop (also known as, anatomical) (on the right)

Ideally, a breast itself is shaped like a tear drop...

• Its upper half is full but not protuberant.  The upper profile is straight, not round.
• Its lower half contains the bulk of the breast volume, but is not droopy.  Its profile is round but tight.
• The nipple should point parallel to the floor.  It is located at the peak of the fullness.

If the ideal breast is shaped like a tear drop, why do 96% of Board Certified Plastic Surgeons (including me) prefer round implants?

Is it that we and our patients have grown to prefer Pamela Anderson's "Baywatch breasts," which are...

• round, both in the upper and in the lower halves.
• look more like cantaloupes than tear drops.

I should hope NOT!

We prefer round implants (in the vast majority of patients) because they tend to augment the upper pole proportionately more.  The upper breast is what deflates after pregnancies, breast feeding, and menopause.  Check out Kate Winslet, who has had a couple of kids, and who acted nude in The Reader...

Not that I am pushing breast implants on Ms. Winslet, but using a non-anatomically-shaped implant would restore youthful contours more effectively.

There are at least four other major problems with shaped implants:

1. Bigger incisions:  Placing a tear-drop-shaped implant obviously requires that the upper, less protuberant part is on top, and the lower, fuller half is at the bottom.  To ensure this proper orientation, a surgeon needs a bigger incision.  Mini incisions (just 3-4 centimeters) are usually not possible; 6 cm is more typical.
2. Possibility of rotation:  If a round implant rotates around, so what?  It's round.  If a shaped implant rotates, trouble.  The protuberant part might not be at the bottom of the breast.  The resultant breast could look bizarre.  But you're thinking, "If my surgeon is good, this won't happen."  Well, that's usually true, but no guarantee.  Rotation can happen to even the most compliant patient with the best surgeon.
3. Shaped implants are always textured:  Because of the risk of rotation, the manufacturers have textured the implants, so that the tissue sticks to the implants better.  Thus, texturing does minimize rotation.  Unfortunately, texturing leads to more rippling relative to smooth surfaces.  (I will discuss the smooth v. texture issue in a few days.)
4. Shaped silicone implants are not available in the USA:  Currently, the FDA has approved tear-drop-shaped saline implants, as well as round saline and round silicone.  Tear-drop silicone implants are not available.  If you agree that silicone are superior in most cases (as I did a few days ago), then you must use round.

Breast Implants: Consideration #2: Silicone v. Saline

Breast implants are composed of...

• a shell (made from a silicone elastomer)
• filled with either...
• • saline or
  • silicone gel

Saline literally means salt water.  It is sterile water with physiological amounts of sodium and chloride.  Saline is what's in most hospital IVs.  If a saline implant were to rupture, the woman's body would absorb the saline--just as if she had been given a bolus of IV fluid.  There is 100% safety.

Silicone is a complex polymer with varying degrees of cohesiveness.  Old silicone filler was minimally cohesive; it had the consistency of molasses.  In contrast, the newest silicone fillers are more like gummy bears.  The contained silicone is a liquid but is very cohesive.  Even if the shell were to rupture, the filler would not "spill" inside a woman's body.  It is so viscous that even a split silicone implant retains its general shape...

 

Nowadays, I generally prefer silicone; however, I use both products.  Certainly, there are advantages and disadvantages to the each of the two filler materials.

Proponents of saline implants will argue...

• Saline implants are cheaper:  The two American implant manufacturer's sell saline implants for about $500 a piece.
• • Silicone is $900 per implant.  
• Saline implants are adjustable:  Saline implants can be filled to a range of volumes in the operating room.  Fine adjustments are, therefore, possible.
• • For example, a particular implant could be filled between 300 and 350 cc.
  • Since many woman have one breast which is slightly larger than the other,
  • the implant for the larger breast could filled less--to just 325 cc,
  • while the implant for the smaller breast could be filled more--to 350 cc.
  • Optimal symmetry is thus obtained.
  • Customized adjustments in sizing may be important to those patients who are particularly concerned about their preoperative asymmetry.
  • On the other hand, silicone implants are sealed at the factory.  There is no way to make fine adjustments to any individual implant.
• I can use a smaller incision for a saline implant:  Incisions for saline implants are generally smaller than for silicone implants.
• • Saline implants do not come pre-filled.  On the contrary, they arrive without any fillers.  They are just shells.
  • These shells can be rolled up like cigars and placed through very tiny incisions (each perhaps only 3 cm in length).
  • The shell can then be filled (via sterile IV tubing) after it is already in position beneath the patient's breasts.
  • Since silicone implants are pre-filled at the factory, the incision must be large enough to accommodate the full volume of the implant.  Incisions for all but the smallest silicone implants must then be 4-6 cm in length.
• Peace of mind:  Some patients don't believe that silicone implants (even the newest versions) are safe.  (More on this hysteria later.)  At least with saline, there is no concern for safety.

Proponents of silicone implants will argue...

• Silicone implants have a more natural feel:  Unquestionably, silicone implants feel more like natural breasts.
• • Do a "squeeze test" at your plastic surgeon's office.
  • Saline implants feel like water balloons (which, of course, is what they are). 
• Silicone implants exhibit less rippling:  Have you ever been bothered by the sight of rippling Hollywood breasts?  These women probably underwent saline breast augmentations, like this patient....

• Silicone tends to ripple less than saline.  If you are thin, and if the above picture bothers you, strongly consider silicone.
• There are other ways to minimize rippling in thin patients (such as placing implants beneath the chest wall muscles).
• Silicone implants (probably) produce a more natural appearance:  Most patients do agree that silicone implants look more natural,
• • especially, if they are thin, and if they are small-chested to begin with.
  • Undoubtedly, silicone implants look better when bouncing.  After you do the squeeze test at your plastic surgeon's office, do the "jiggle test."  Silicone implants sway like real breasts.  Saline implants move like water balloons.
• I bet that silicone implants are more durable:  While long-term data on durability are not available, I suspect that silicone implants will last longer than saline.
• • The fill valve on a saline implant is a point of potential failure.
  • There is no "fill valve" on a silicone implant.  It was pre-filled at the factory.

Breast Implants: Consideration #1: How to Find the Right Doctor

Finding the right doctor can be tricky.  By some estimates, there may be as many as 60,000 doctors in the United States who perform some type of cosmetic surgery.  However, there are only 6,000 Board Certified Plastic Surgeons!  Therefore, 90% of cosmetic physicians do not have formal training in plastic surgery.

I have blogged about this topic before:  http://www.pickartplasticsurgeryblog.com/2008/03/10-questions-to.html#more.  At a minimum, you should ask your physician the following questions:

1. Are you certified by the American Board of Plastic Surgery?

2. What training did you have after medical school?  Was it actually plastic surgery?

3. How many breast implant surgeries do you perform each year?

4. What hospitals do you work in?  Where do you admit your patients?

5. If you prefer to operate in your office or ambulatory health care facility, is it accredited?

6. Who administers the anesthesia?  Is this person a Board Certified Anesthesiologist?

7. What do you do if there is a complication?

8. What's your financial policy for complications?

9. Are you academically affiliated?

10. Is the state medical board investigating you for any complaints or malpractice suits?

But sometimes, even the right credentials are not enough....

Breast Implants: 9 Considerations to Ensure the Best Results

Contrary to the common stereotype, the typical patient requesting breast enhancement is not a Hollywood teen queen.  She does not make her living by showing off her body.  She does not have a domineering boyfriend who has been browbeating her into looking like Dolly Parton.

On the contrary, the typical breast enhancement patient is a regular person....

• She has been thinking about a breast augmentation ever since puberty--when her breasts never developed to her satisfaction
• She may be in her early 20s, but she may also be in her 70s or 80s.
• Usually she liked the increased breast fullness that came with her pregnancies.
• But she tends not to like the droopiness that occurred after she stopped breast feeding.
• Her husband or boyfriend is, to be honest, a bit bewildered.  He loves her as she is, but he is willing to support her decision--whatever it may be.

Does this woman sound like you?

Breast Reductions Reduce Pain...In 16 Year Olds

I'm almost 16 and I have a 36DD breast size.  Do I need to wait to have a breast reduction?

- Carla

No!  But there are caveats....

Breast reductions are fantastic operations.  Of all the surgeries and procedures that I routinely perform, breast reductions have the highest rate of satisfaction.  Not only are breasts reconstructed to be higher and cuter, but also the patient receives significant symptom relief.

Carla, what are your goals?  Are you interested in...?

• decreasing pain in your neck, upper back, and shoulders
• minimizing sweating and rashes in the folds beneath your breasts
• feeling more confident around your peers, especially in a bathing suit

If yes, then breast reductions are a great option--regardless of age.

The big issue with breast surgery at 16 years old, Carla, is that your breasts will continue to change.  (Of course, breasts are going to change from any age.  Ask any 45-year-old woman who has had kids!  She probably wished that her breasts had not changed!)  Nevertheless, 16-year-old women will probably experience more change than 25 year olds.

I have performed breast reductions on 16 year olds, and they have been thrilled.  But, in a few cases, the breasts continued to grow.  Then, I had to perform a second breast reduction on those patients (even though the patients and their mothers thought that the breasts had been fully developed before the first surgery).

Also, you must realize that your smaller breasts will have scars and that you will be having a major surgery.  I am not trying to dissuade you, but just want you to be fully informed.

Check out these before and after pics of a recent patient--in her early 20s--who underwent breast reductions.  She couldn't be happier:  less neck and back pain, less shoulder grooving and discomfort, less sweating and rashes, and more self-confidence.

 

Evolence Discontinued

The economic downturn continues to particularly hurt "cosmoceutical" companies.  Evolence is the latest victim.  Ortho Dermatologics (a division of Ortho-McNeil-Janssen Pharmaceuticals, which is itself a division of Johnson & Johnson) has discontinued Evolence.

What is (was) Evolence?

• A soft-tissue filler based upon porcine collagen (from a pig)
• Excellent safety record:  Unlike bovine collagen (from a cow) which caused multiple allergies, Evolence was never associated with a single allergy.
• FDA approved on June 30, 2008:  The federal government was satisfied with its safety and efficacy.
• It has been used similarly to Juvederm and Restylane, especially at the nasolabial folds (connecting the nostrils to the corners of the mouth).
• Less swelling and bruising than Juvederm and Restylane
• Similar longevity as Juvederm and Restylane

If Evolence was similar to Juvederm and Restylane (and with less bruising), why wasn't it more popular?

Lumpiness.  A number of my patients noted that Evolence was not as soft or smooth at its competitors.  While the lumps were never visible, they were palpable (and apparently annoying).

My mother loved Evolence.  Women in their 60s and 70s have thinner skin, which tends to bruise significantly (with all of the injectable products).  When my mother had requested Juvederm, Restylane, Elevess/Hydrelle, or Radiesse, the subsequent bruising had persisted as long as two weeks.  However, with Evolence, the black-and-blue marks were smaller and resolved within a few days.

Evolence has filled a niche in my practice:  It is useful in patients who would like to minimize bruising...

• because they have a big event tonight!
• because they are older.
• because they naturally have thin blood.
• because they are on blood thinners (like Coumadin, Plavix, or aspirin).

What will be the new anti-bruising injectable filler?  In this economy, I don't know.  I certainly hope that Evolence is soon replaced.

Whatever Happened to LipoZap?

Bankrupt.

LipoZap went by many names:

• Lipostabil
• Flabjab
• Lipomelt
• Lipodissolve
• Fat-Away

All contained some quantity of phosphatidylcholine, a bile acid found naturally in our gall bladders.  German researchers recognized that intravenous phosphatidylcholine may prevent and treat blood vessel blockages caused by fat particles (known as fat emboli).  Other Europeans thought, "If it melts fat in the blood vessels, shouldn't it melt fat under the skin?"  The hope was that subcutaneous phosphotidylcholine injections would be a non-surgical alternative to liposuction.

However, LipoZap was never approved for cosmetic use (in any country).  Its efficacy was never proven.  And its safety was never established for subcutaneous injections.

Nevertheless, that didn't stop unscrupulous physicians from promoting and administering this product--even right here in the USA.

For $3000-5000, many patients underwent injections in their doctors' offices, in the hope that their stubborn fat deposits would melt away.  Their wishes almost uniformly went unanswered.  Most received no benefit.  Others developed irregularities.  Worst of all, a few patients suffered allergic reactions, hypersensitivities, and infections.

The satisfaction rate was abysmal.  Check out http://www.realself.com/LipoZap/reviews.  Zero out of 9 respondents would recommend LipoZap.

The unkindest cut of all:  The patients were swindled.  After the LipoZappers closed their doors, many patients were still owed money; they had not yet received all of the treatments paid for up front.  A number of class action lawsuits are pending.  I hope that the patients get their money back.