Spring Specials 2010

Yes...they're here!! Plastic Surgery specials for Spring 2010 (Feb - Apr).

You can find all the details on our website (link)

Included are discounts on breast augmentation, Botox, Juvederm, microdermabrasion and laser hair removal.

Now you can get the best - for a little less! Yay!!

Dr. Fiala tests the "Keller Funnel"

Ever see a product and go, "I wish I had thought of that"? Today, I tested a new surgical product called the Keller funnel, named after its inventor, also a plastic surgeon - and I had that very same sentiment.

Essentially, the Keller funnel looks like a high-tech cake decorator's funnel, the triangular bag with which cake icing would be squeezed onto a cake - except that this one is made of fancy materials, is sterile, and has an inner surface which is coated with a slippery space-age coating. Dr. Keller devised it to help plastic surgeons place silicone gel breast implants more easily during surgery, through smaller incisions, and with potentially less contamination or chance of implant damage.

While these other possible benefits haven't yet been scientifically proven, the gadget certainly does work for its primary purpose - the implant slides into the surgical pocket, easy as can be.

If the company can produce these at a reasonable price, I think they'll have a winner.

Ten reasons to consider a breast lift

You might need a breast lift (mastopexy) if one or more of these ten reasons sounds familiar to you:

1. You prefer the breast shape you get when you lift your breasts upwards with your hands.
2. You want your breasts to be “perkier”.
3. Your breast size is good, but they are "too low".
4. When standing, one or both of your nipples point towards the ground.
5. When standing, one or both of your nipples are at or below the level of your breast crease.
6. You can't go braless in any kind of top.
7. Your breast skin is loose, very stretchy, hangs or sags, because of weight fluctuations, pregnancy or breast feeding.
8. You like your breast shape when you stretch your arms above your head.
9. You look short-waisted because your breasts are covering your upper abdomen.
10. If you want your nipples to be positioned higher on the breasts.

Breast implants, by contrast, do not lift the breast. They can add volume, increase roundness, give more upper pole volume, increase projection and fill up loose breast skin - but implants do not lift.

If you have one of these 10 reasons, and want the breast to be larger as well - a combination of breast augmentation and lift may be an option for you.

Choosing the right breast implant shape

Back in the dark ages, plastic surgeons recommended breast implants based only on their total volume.

Now, most modern surgeons realize that it is important to measure the patient's rib cage width, and match the width of the implant to the width of the patient, in order to obtain a result that looks attractive, proportional, and avoids an overly wide cleavage gap or excessive lateral (side) fullness.

In addition to picking the right size, there are several choices of implant shapes available. These are called "profiles" by the manufacturers. Choosing the right profile makes a major difference in the final appearance of the breast shape.

Many patients are unaware of these possible choices before their consultation with us, and have only thought about the number of cc's in the implant or the cup size they want. A useful question to consider is "How much fullness do you like in the upper part of the breast?" Someone who want a lot of fullness will pick a different implant than someone who just wants a little.

The most popular profile (implant shape) in our practice, whether it be silicone or saline filled, is a medium profile implant. About 70% of our patients choose this shape. It gives an attractive fullness in the upper part of the breast, but not "too much" for most people's taste. I call this the "Victoria's Secret catalogue model" look, and the proportions work well for most average frame patients.

The second most popular profile is the "high profile" implant. It gives more roundness and fullness in the upper part of the breast. For women that have a narrow ribcage and still want a generous implant volume, the high profile shape is worth considering. For women that want a larger, fuller implant without going to a wider implant, sometimes switching from a medium profile to a high profile implant is also a useful option. About 20%-25% of our patients choose this shape. But it's a "love-it-or-hate-it shape"; some women think it looks a little too overdone or obvious, especially in the larger sizes, while some women find it sexy and attractive. It's all personal taste.

The low profile implant is the third choice. It works for women that have a broad ribcage, but for whom the other profiles would give an implant volume that would be excessively big. It's a more conservative and "natural" look, and gives less projection or upper pole fullness compared to the other two profiles.

While some surgeons strongly recommend high profile implants for women considering a combination breast augmentation / breast lift surgery, I do not insist that women make that particular choice. It is true that a higher profile implant has a greater arc length over its highly curved surface, and so it fills up more loose skin compared to the lower profile implants. However, the patient may not want the size or shape that a properly selected high profile implant gives. I think its more important to the final result to pick the implant size and shape that the patient wants first, and then tailor the mastopexy around that as needed. In my opinion, this is much more likely to make the patient happy in the long run.

In our experience, there's no substitute for proper measuring, followed by trying on actual implant sizers in a sports bra and T-shirt. Once women see how it looks in the mirror, it's amazing how rapidly they are able to sort out the many different choices. Once they see the look they prefer, most women know it almost immediately! It's kind of like trying on shoes: you know if they fit or not.

Breast Augmentation & Surgical Drains

Recently, a patient asked me if I used surgical drains as part of my routine when performing breast augmentation surgery. It's a thoughtful question - as there are a few surgeons locally who do use drains during breast augmentation surgery, removing them at the first or second postoperative visit. Drains, by the way, are small diameter, soft plastic tubes, which are used to remove fluid from a surgical area. They commonly have a bulb-type collection reservoir at one end of the tubing, while the other end has a perforated segment placed beneath the skin, near the involved surgical area.

I don't think they are necessary for the routine, first-time breast augmentation patient. In my opinion, drains are uncomfortable, they leave a small additional scar at their exit site, slow down the speed of the patient's return to everyday activities, and complicate a straightforward post-operative recovery process. In general, I only use drains if their benefit outweighs their drawbacks.

Here's the science: In a recent review, published in Aesthetic Plastic Surgery, a retrospective study of over 3000 breast augmentation patients in the United Kingdom showed that the use of surgical drains actually increased the risk of postoperative infections fivefold! No benefits of drains were seen in this study.

I do use drains in breast cases where there is a significant chance of a postoperative seroma, such as following capsulectomies, some forms of complex revisional breast surgery, large volume breast reductions, and explantations.

"Sisters, not identical twins": breast asymmetry

As one of the busiest breast surgery practices in Central Florida, I see many patients who would like a breast augmentation performed. As part of our routine, we carefully examine the patient, and during our examination, it's very common to find several differences or asymmetries between the two sides.

Most patients have no idea about these minor asymmetries of the breast until we show them...and then they see them. The reason we do this, of course, is to explain that these asymmetries will still be there post-operatively after a standard breast augmentation operation, since they were present pre-operatively.

There are several interesting studies about pre-operative asymmetry in patients undergoing breast augmentation.

Rohrich, Hartley & Brown, in their 2003 review of 100 patients, published in Plastic and Reconstructive Surgery found:
- 88% of women had natural breast asymmetries when critically examined,
- 72% of these women had more than more asymmetric feature.

In other words, nearly nine out of ten women have some degree of breast asymmetry. We commonly say "Think of the two breasts as sisters, not identical twins!"

Common asymmetries in this study included:
- nipple / areola position differences in 53%
- breast volume differences in 44%
- infra-mammary fold position differences in 30%
- chest wall (bony) differences in 9%

Similar findings were seen in 2009 study by de Chardon and associates, who examined 200 breast augmentation patients. They found a higher incidence of chest wall asymmetries, at 17%, which was most commonly caused by scoliosis of the spine with secondary changes in the rib shape.

Perhaps the most interesting finding from this French study was, of the patients that complained about breast asymmetry after surgery, 83.3% (five out of six) of them had the same asymmetry pre-operatively.

This finding certainly indicates the need to explain to patients what is present prior to the implant surgery, and help the patients to understand which features can or can not be corrected by implants alone.

Ripples and breast augmentation

One of the frustrating problems that can sometimes occur after breast implant surgery is known as "rippling" - an irregular wavy look or feel to the breast. This is caused by a combination of factors, related to the physical properties of the implant, the patient's own soft tissue and how it may have changed over time, and the choice of implant pocket design ("over vs. under").

Plastic surgeons generally divide these problems into 2 main categories, based on why they've happened.
1. Shell rippling
2. Traction rippling

Shell rippling is the most common problem of this kind I see, and is the topic for today. (I'll discuss traction ripples in a later blog.) The classic scenario is with a subglandular ("over") saline-filled implant in a slender woman who doesn't have very much tissue coverage over the implant. Typically, the breasts looked OK for a period of time, and then, ripples started to show up later.

The usual way to improve this situation is to operate, and get more tissue coverage over the implant, by converting it to a sub-pectoral position. This move significantly improves ripples in the upper portion of the breast - which is the area most exposed by low neckline fashions. The other solution is to change the saline implant to a silicone gel implant, which has been shown in studies to have a ripple rate of approximately 1%, as opposed to the ripple rate of saline implants, at about 10%. I usually prefer to use both methods - getting muscle coverage over a gel implant. It works well to fix this problem.

Shell ripples occur for several reasons: they have to do with the tendency of the elastomeric implant shell to want to fold in on itself, the amount of fill in the implant, the viscosity of the fill material in the implant, and the pressure applied by the surrounding soft tissue. They are disguised by the amount of soft tissue thickness over the implant. Often, with the passage of time, there is thinning out of the breast tissue adjacent to the implant, and implants that were adequately covered early post-op may become more obviously rippled over time.

Saline implants, having the lowest viscosity filler, will ripple the most. Currently available silicone gel implants, having a moderate viscosity filler, ripple a lot less. The "form stable" gummy bear implants, with their high viscosity silicone filler, should ripple even less than the current generation of gel implants. Early data from Europe seems to support this concept.

Women interested in saline implants often ask about the concept of "over-filling", which is just adding more saline solution in the implant bag, beyond the manufacturer's recommended range. There are pro's and con's to this approach. Certainly, more fluid will reduce some of the emptiness and collapse of the implant shell seen when the saline implant is in the vertical position. It also makes the implant larger, rounder, less natural looking, and a little more firm. It also potentially voids the manufacturer's warranty. If you over-do the over-filling, you start to see a new type of wrinkling - tension bands around the equator of the implant. So overfilling is only partially helpful- and as we've discussed, it only addresses one of the multiple factors that are involved with ripple formation.

The soft tissue pocket is also important. If there is a significant amount of capsular contracture, the soft tissue envelope may actually distort the shape of the implant, and cause it to fold on itself. This can cause a knuckle-like point to occur in the implant, which patients may be able to feel through the skin. Implant folds can lead to early implant failure. So, when you are fixing ripple issues, any capsule issues will need to be addressed surgically as well.

Take home message: ripples are related to the combination of thin soft tissue coverage, combined with the engineering limitations of the current generation of breast implant devices. If you are slender up top, and can feel or see your ribs on the side of your rib cage, you should give some thought to sub-pectoral implant placement of a gel implant, if you want to do everything currently possible to minimize your risk of ripple issues post-op.

For some ultra-skinny women, even sub-pectoral gel implants will have some ripples. While weight gain would help, very few women want to hear that they should gain a few pounds! Here, our treatment options are limited - placement of a layer of alloderm or strattice (very expensive), fat grafting to the breast (technically difficult), or perhaps injections of commercially available fillers. It remains to be seen whether the new generation of form-stable breast implants will be a good answer or not for this group of patients.

ASAPS 2009: breast implants & biofilms

One of the big topics of discussion at ASAPS this year was biofilms. Biofilms are a type of bacterial contamination that loves to form on solid, implanted devices like man-made heart valves, contact lenses, orthopedic implants, and yes...breast implants. There is a growing body of research that suggests that these biofilms are linked to the #1 unsolved problem of breast implants - capsular contracture.

Implant-associated biofilms don't cause fevers, redness or typical infection issues. They are difficult to detect without specialized testing. They are resistant to standard antibiotic treatment, and are virtually impossible to clean off from the implanted device. But when the sepcialized tests are done, there is a much higher incidence of these bacterial biofilms in women who have capsular contracture, compared to the tissue around soft, "normal" breast implants. Most commonly, the bacteria involved is Staph. epidermidis - the common bacteria that lives on our skin, and is also found inside the normal breast gland.

So, what does this mean? Well, taking this concept to its logical conclusion would suggest:

1. At the time of the initial surgery, take steps to reduce the chance of implant contamination. This can be done through technical measures such as using an antibiotic irrigation (or betadine) to rinse the implant and the implant pocket. Consider using the infra-mammary incision (more direct) rather than the peri-areolar incision (more contact with breast tissue).

2. At the time of a capsulectomy operation, consider using a brand-new implant (no biofilm), rather than re-using the old implant. Perform total capsulectomy (removing all of the capsule) rather than capsulotomy (cutting the capsule, but leaving it in place.)

3. After surgery, treat the breast implant just like a artificial heart valve, and take antibiotics whenever you have a procedure that might cause bacteria in the bloodstream, like dental cleanings, endoscopy, or minor surgery.

4. Researchers are investigating anti-bacterial coatings for implants, and other longer-lasting antibacterial delivery systems. One promising method involves a compound called Ageliferin, which disperses biofilm, and re-sensitizes the bacteria to antibiotics.

So far, most of the research is lab stuff. There haven't yet been large clinical studies giving us the answers that we need to make day-to-day decisions. But, it's hopeful that we're getting closer to finding an answer for the problem of capsular contracture.

Saline breast implants: pros and cons

Today's chapter is about saline breast implants.

Prior to 2006, saline implants were the most commonly used implant in the U.S. Now, with FDA re-approval of the silicone gel implants, that figure has fallen significantly, down to about 20% in our practice.

Here are the more common reasons that my patients give for picking a saline-filled breast implant.

1. Cost. Saline implants aren't as expensive.

2. Adjustability. For women with major breast asymmetry issues, the adjustability of the size of a saline implant at the time of surgery can be helpful to fine-tune the correction of volume differences between the two breasts. Essentially, we can "put a little more" on the smaller side. With silicone gel implants, the implants are not adjustable - so one has to go to the next size implant, a difference of 25-30 cc.

3. No need for follow-up scans. When a saline implant leaks, the saline is simply absorbed by the body. The implant deflates quickly - and making the diagnosis of an implant deflation is easy, without requiring fancy diagnostic tests. There are no recommendations for follow-up MRI scans, as there are with the gel filled implants.

4. Lingering anxiety about silicone gel. Despite the large number of carefully performed, large-scale scientific studies disproving many of the "urban legends" about health issues and silicone, some women are just more psychologically comfortable with the saline option.

5. Age. If you are younger than 22 years old, silicone gel implants may not be available under the FDA guidelines, unless you happen to have other issues, like rib cage asymmetry, scoliosis, and so forth.

6. Wanting the "very rounded" look. This can be achieved, if desired, by over-inflation of a saline implant, creating a more spherical shape and increased upper breast fullness.


Disadvantages of saline implants:

These were discussed in the previous blog chapter, during the discussion of silicone gel implants. The main issues are:
- a less realistic "feel" to the breast

- higher percentage of ripple / wrinkle issues, particularly in slender women.

While some surgeons will try to over-fill the implant in an attempt to reduce ripples, that may cause a different set of problems, such as creating excessive roundness of the upper breast, causing excessive firmness, or creating tension bands around the edge of the implant. Over-filling also potentially voids the manufacturer's warranty.

The choice of implant - the size, the shape, and the type of fill - are all issues that we discuss at the time of a consultation. Hopefully, the information in this blog will help you to become a more "informed patient" prior to your consultation and surgery, and will answer some preliminary questions for you.

Silicone breast implants: pros and cons

A very common question during augmentation consultations is about the various advantages and disadvantages of silicone breast implants and saline breast implants.

In this chapter of PSB- the Plastic Surgery Blog, we'll talk about silicone breast implants. The next installment will discuss saline breast implants.

Currently, about 80% of our patients select the silicone gel implants.

Safety data:

The FDA thoroughly looked at the scientific data, prior to allowing silicone breast implants back on the market for general cosmetic uses in 2006. The "blue-ribbon" panel of experts from multiple different fields of medicine agreed that, based on current scientific studies:

a) there is no increase in the risk of breast cancer due to the use of silicone breast implants, and

b) there is no increase in the rate of developing "auto-immune" or connective-tissue diseases like scleroderma, lupus or rheumatoid arthritis due to the use of silicone breast implants.


That being said, no implant is perfect.

Just like any man-made device, the implant, whether it is saline-filled or silicone gel filled, will eventually get old, become brittle, develop a small crack in the flexible outer shell, and leak. Implants don't last forever. At some point, a second surgery will be required to swap out the implants for a new pair.

Also, implants (both saline and silicone) do get in the way of seeing tissue clearly with a mammogram, as the implant hides some of the breast tissue. This problem is worse when the implants are above the muscle, and somewhat better when they are behind the pectoral muscle.

Lastly, an implant can become firmer than desired, due to the development of capsular contracture. This may require more surgery to fix, and currently, it's impossible to predict ahead of time whether this problem will happen for a particular patient, or not.

Advantages of silicone breast implants:

1. "the feel" - Most of my patients like the way the silicone breast implants feel. Simply put, they feel very similar to real breast tissue, and do not have the "water balloon" feel that the saline implants have. This, for most patients, is the deciding factor.

2. Less chance of ripples & wrinkles - Particularly in slender women, one of the main drawbacks of saline implants is that any wrinkling in the implant may show through the skin, causing visible ripples, particularly with leaning forward. This can happen even with the implants behind the muscle, and even if the implants are filled to the correct volume. Studies show that rippling occurs in about 10% of patients with saline implants, but only about 1% of silicone breast implants. Patients who are thin enough to feel their ribcage on the side of their chest are particularly prone to rippling problems. Switching to silicone implants often fixes the problem for patients with ripples in their saline implant (unless you are super-skinny!)

3. Works better for women with rib cage irregularities - Silicone gel implants seem to drape more smoothly over rib cage asymmetries due to scoliosis or pectus excavatum (sunken chest).

4. Less tissue stretch - Over time, the saline implants seem to have a slightly higher rate of stretching out the skin and soft tissues of the breast, compared to gel implants. This can result in pocket expansion, bottoming out, or ptosis (droop) of the breast.


Disadvantages of silicone breast implants:

1. More expensive than salines.

2. FDA recommendations for follow-up MRI's - As we discussed in an earlier blog chapter, MRI's are recommended at years 3, 5, 7 and so on. This can get expensive.

3. Trickier to tell if you have a deflation - Unlike saline implants in which a deflation is very obvious in a few days, it's more difficult to tell if there s a leak in a gel implant by simply looking at the breast. Usually, some sort of scan - like a breast ultrasound or MRI - is needed in order to make the diagnosis.

4. In the event of a leak, additional surgery is needed - Current recommendations call for a capsulectomy to be performed for most patients with a leaking gel implant. While this is a routine operation for most plastic surgeons, it does represent more surgery than the simple "switch-out" procedure that would be performed for a deflation in a saline implant.

5. May need a somewhat longer incision that the saline implant. Saline implants can be rolled up while still deflated, and placed into the breast through a small incision, and inflated after positioning. This drawback will become even more significant when the new generation "form-stable" or 'Gummy Bear" silicone implants are introduced to the U.S. market, as these require a 5-6 cm. incision.


Overall, patients are very satisfied with breast augmentation, regardless of whether saline or silicone breast implants are used. They recommend it to their friends, co-workers and family. It's the #1 most popular surgical procedure both in our practice, and nationwide. While you can usually get a good result with both kinds of implants, certain individual situations may make the choice of a particular type of implant better than the other.

The SoCal "Boobie Bandit"

And now, one of those "News of the Weird" stories...

Allegedly, a woman in Huntington Beach, CA, recently used a stolen identity to open a line of credit, which was then used to finance a breast implant exchange and liposuction surgery, worth $12,000. The woman lied to her doctor and the staff of the surgery center about her name and personal information, but when she didn't show up for any of the post-operative appointments, the staff became suspicious.

The shapely criminal might have gotten away with this theft - except for one minor detail. Her old breast implants had a registered tracking number, as many implanted devices do. This was used to track down her true identity...

The woman turned herself into custody last week, one day after the story and her photo were made public on the national news and internet.

No news yet on whether the upcoming trial will be televised, or if the stolen property will be repossessed!

Do breast implants prevent breast cancer?

It sounds hard to believe...but a new study published in the January issue of International Journal of Cancer found a 27% reduction in the number of breast cancers in women who have breast implants. The researchers compared the incidence rates of breast cancers in 6,200 Scandinavian women with breast implants, compared to the number of breast cancers that would be expected in the normal population. The women with implants had fewer breast cancers, over the 16 year time period of the study. The difference of 27% less in the implant group was statistically significant.

Is this a fluke? It could be. But this is not the first study to find this surprising finding.

In 1997, a study from Los Angeles published in Plastic and Reconstructive Surgery showed a similar finding, with a 37% reduction in the incidence of breast cancer in a group of 3182 women with implants followed over a 14 year period.

In 1992, a report from Alberta, Canada, published in the New England Journal of Medicine found a 53% decrease in the expected breast cancer incidence, over a 10 year follow-up period.

There are several other reports as well.

So why does this happen? Well, I don't think it's because that breast implants have some sort of special protective properties when it comes to breast cancer, although some investigators are looking into this possibility. It's more likely that the women who get breast implants are drawn from a low-risk population. Most plastic surgeons, for example, wouldn't put implants in a patient with a strong family history of breast cancer....but this only partially explains the findings of these studies. Further research is needed to come up with the full explanation.

It's good to know, that at the very least, breast implants do not increase your risk of developing a breast cancer.

Another myth "busted" (no pun intended!)

Do the FDA recommendations for MRI's after breast augmentation make sense?

When the FDA re-approved the general use of silicone breast implants in 2006, there were some "strings" attached. One of these was the recommendation for follow-up testing of the breast, using an MRI scan, at years 3, 5, 7 (and so on) to look for clinically "silent" implant leakage.

This was a new recommendation - and a change from the earlier FDA policy of 1992, which had not recommended any screening tests at all for asymptomatic women with silicone implants.

So, does this new FDA recommendation make sense?

Well, let's look at the science, shall we? It really breaks down into two different questions:
1) Is an MRI scan a good way to look at the breast - or would a breast ultrasound be a reasonable, inexpensive first-line alternative?
2) What are the odds of having a leaking silicone implant at 3 years, or 5 years?

This is going to get a little technical, but please, bear with me.

Question one: MRI or not.

Prior to the 2006 ruling, MRI was not in routine use as a "screening" exam for women with silicone breast implants - it was used if there was a specific reason, such as a mammogram or ultrasound that was indeterminate, or a clinical situation that required investigation.

An excellent paper published in 1998 by Chung and associates, from the University of Michigan, actually developed an algorithm for decision-making for women with suspected silicone breast implant rupture, based on a statistical method called Bayes' theorem.

They found that in asymptomatic women, if they had a "normal" result on a screening ultrasound test (i.e. no rupture reported), the probability of an actual rupture was low - 2.2%. If the ultrasound reported a rupture, and this was confirmed by MRI, the likelihood of a true rupture rose to 86% - a reasonable threshold to operate.

So, Chung et al. recommended breast ultrasound as their first-line test, since ultrasound is widely available, relatively cheap, and doesn't involve radiation. They only used the expensive MRI if the ultrasound was abnormal. Makes sense to me - I like this idea because the patient saves money, and is more likely to actually get the test done, because of the lower financial barrier.

In a separate paper published in 2001, Cher and associates did a meta-analysis of MRI results in 1039 women. They found that when the MRI was used for women with specific complaints like breast hardness, shape change, etc., that it was reasonably accurate in detecting rupture - >80%. In women without these issues, the positive predictive value of an MRI was "insufficient to warrant use as a screening tool". They also recommended using the MRI to confirm the results of a screening ultrasound.

The Royal College of Radiologists (UK) echoed these views in their recently published guidelines on breast imaging. A normal ultrasound examination was highly predictive (91%) for an intact implant. Ultrasound was recommended as an initial investigation. According to the RCR, patients with an abnormal ultrasound examination should then proceed to an MRI examination, provided the more powerful 1.5 Tesla MRI machines are used with the specialized "breast coil" imaging device. Lower power MRI machines or those that don't have the breast coil are not nearly as reliable.



Question two: how often does leakage really happen?

The best way to determine whether there is implant leakage is to perform surgery, and look at the implant directly. But, as you might imagine, it's pretty darn difficult to convince a women who is feeling perfectly fine, without any symptoms at all, to undergo surgery - just so we can open her up to look and see whether her implants are OK!!

So, this data is hard to come by. Instead, we use MRI scans - to estimate the deflation rate. In Mentor's Core study, at 3 years out, just 0.5% of the 420 patients had a rupture in the primary augmentation group.

In other words, at the three year point, 199 women will have to pay to have an MRI that is completely normal, for one woman to find a rupture. That's probably not the best utilization of health-care dollars.

In the study by Sharpe and Collis (UK), no ruptures were noted until 7 years postoperatively.

Data like this really make me wonder whether it makes sense to insist on a scan at years 3 and 5, when not much is happening.

In summary: the screening recommendations of the FDA are certainly controversial. I feel that they are scientifically questionable, financially imposing, and a bit of a "CYA" move by the FDA, particularly at years 3 and 5. However, they are the "official party line", so I tell all my patients about them. The FDA rules were probably written more with political expediency in mind. I hope that, in time, they will be modified to better reflect the actual science!

Silicone breast implants and breast feeding

Breast-feeding is known to be nutritionally superior to commercial infant formulas. Breast milk also has immune-boosting properties, and seems to reduce the chance of the baby developing common childhood conditions, such as eczema, otitis media, and iron-deficiency anemia. In other words, it's good for the baby.

Women who are considering breast augmentation with silicone gel implants often ask me whether their breast milk would somehow get "contaminated" from their implants, making the milk potentially harmful for their baby.

Well, let's look at the science. Quite a bit of research has been done on this topic at the Women's College Hospital in Toronto, Canada. The researchers there measured silicon levels in the breast milk of lactating women with silicone gel implants, and also in women who didn't have any breast implants. They also analyzed the silicon levels in cow's milk, and in 26 commercial infant formulas.

Silicon levels are used, since there is no satisfactory method of analysis of silicones. Silicon assays also include silica and silicate compounds, and are felt to be a reliable estimate of silicone levels. The samples were prepared in an "ultraclean" laboratory and analyzed using atomic absorption spectrophotometry.

Here are the results, in descending order:

Commercial infant formulas:..... 4402.5 parts per billion (average)
Cow's milk:......................... 708.9 parts per billion

Blood levels - no implants:...... 103.7 parts per billion
Blood levels - with implants:.... 79.29 parts per billion

Breast milk - with implants:..... 55.4 parts per billion
Breast milk - no implants:....... 51.0 parts per billion


Comparing women with breast implants to those without implants, the average silicon levels were not statistically different in either the breast milk, or in the blood.

Since lactating women with silicone breast implants are similar to women without implants in terms of levels of silicon in their breast milk, this would strongly suggest that women with silicone breast implants can go ahead and safely breast-feed their babies without any worries about having "contaminated" milk.

Silicon levels are actually 10 times higher in cow's milk and even higher in infant formulas, compared to breast milk. So, maybe it's time to avoid using commercial formulas, if you're worried about silicone !!

Does breast augmentation affect pectoral muscle strength?

Recently, a number of patients have asked me during their breast augmentation consultations whether the strength of the pectoral muscle is reduced after a sub-pectoral breast augmentation ("unders").

I can certainly answer from my patients' experience - very active patients (weight lifters, personal trainers, police women, wakeboarders and others) have not reported any problems to me whatsoever. The best way to answer the question, however, is to double-check the science. Has pectoral muscle strength been tested scientifically after surgery, and what did these tests show?

It turns out that there are two excellent studies on this very issue.

The first, published in 2003 in the Aesthetic Surgery Journal, tested strength performance on a computerized Biodex 3 isokinetic muscle-testing system. Twenty patients were tested preoperatively, and at 2 and 6 weeks postoperatively. At two weeks postop, 50% of the patients were back to pre-op measurements. At six weeks postop, 70% of patients were back to pre-op measurements. Long-term follow up measurements on 9 of the patients who agreed to return for a follow-up comparison showed full recovery in all 9 patients.

The second study, published in 2004 in the Plastic and Reconstructive Surgery Journal, tested both breast sensation and pectoralis muscle function. Again, a computerized system was used to acquire the strength testing data. There was no significant decrease in pectoral muscle strength at 3 months or at 6 months postoperatively in any of the tested movements (flexion, extension and adduction). Implant size did not have any adverse effect on pectoral strength, either.

So there you have it - two good scientific studies that show no permanent changes in pectoral muscle strength related to breast augmentation surgery, once the initial recovery period has been completed.

Another "urban legend" dispensed with!! :)

Fat grafting to the breast

Recently, there has been a resurgence of interest in the idea of using a person's own fatty tissue to enhance the breast. It seems like the ideal combination: "take a little off there, and put a little bit more up here".

The truth is: it's still a work-in-progress. Until recently, fat grafting to the breast had been considered a bad idea. Lumpy breasts, with oil-filled cysts, could occur. And worse, the scar tissue which sometimes formed after fat injections could exactly mimic the appearance of a breast cancer on a mammogram, leading to needless anxiety and additional biopsies.

Lately though, there has been a re-appraisal of this idea, both here in the USA and abroad. A breakthrough study from Japan found that the key factor to making the fat injections work in the breast seems to be the addition of stem cells.

By "turbo-charging" the injected fat with the person's own adult stem cells (also found in fatty tissue), the combination of fat cells and stem cells worked much better, successfully surviving the move from the donor site to the new location in the breast without the problems listed earlier.

Some pretty clever machinery is used to harvest, centrifuge, and purify the stem cells from liposuctioned fat. Some far-sighted biotech companies have already submitted automated versions of this machinery for FDA approval.

The Japanese group made fairly modest changes in the patient's breast size - averaging about 200 cc, which is small compared to the typical breast implants that we use here (commonly 300 - 500 cc), but their results show that the technique is promising. The fat-grafting surgery also takes much longer than a typical breast augmentation: about 6 hours of anesthesia time, compared to about 1 hour when implants are used.

Nevertheless, it's an exciting surgical innovation that someday (I hope) will be in common use. Currently, the technique is not FDA-approved, and is still in the "experimental" stage.

Trends in Breast Augmentation in Orlando

With a practice that is about 50% breast surgery, we are well-versed on the current trends in breast augmentation. Here are some of the patterns that we've noted.

1. Return of silicone gel: Three years ago, 90% of the implants we used were saline-filled. With the FDA re-approval of silicone gel breast implants, we've been offering our patients a choice of saline or silicone gel. Now, easily 75% of the implants that the patients want are silicone gel ones, due to their "more natural" feel and their lower rate of post-operative rippling in slender patients. The remaining 25% of our patients select saline implants due to their adjustability, their lower cost, or their desire to avoid anxieties about silicone gel altogether.

2. Credit crunch: Prior to September 2008, many younger patients were using third party financing to pay for their surgery. With the meltdown in the credit markets, these loans are more difficult to get, especially for people with marginal credit. Some are taking advantage of our cash-only discounts, but many are holding off on surgery for the moment.

3. Lack of interest in the "gummy bear" implants: Despite the buzz in the American plastic surgery societies about the impending FDA approval of form-stable silicone gel implants (commonly known as "gummy bears" due to their thick gel formulation) patients seem unimpressed. Once I describe the significantly bigger surgical incision required for their placement, patients seem to rule out that choice, despite their potential advantages. Our patients also don't seem to care for the tear-drop shape, either - the majority of our patients specifically ask for some fullness in the upper portion of the breast. This reflects the American sensibility for breast shape, which interestingly, is different than what is popular in Europe or South America. (More on than later!!)

Do I need a lift, Doctor?

A common question from patients who are considering a breast augmentation is whether they would need a breast lift or not.

There are several methods that plastic surgeons use to decide whether or not there is significant droop of the breast, known as "breast ptosis". Essentially, it all has to do with the position of the nipple, compared to the position of the crease underneath the breast, known as the "infra-mammary fold".

If the nipple is positioned above the horizontal level of the infra-mammary fold when you are standing up - then any ptosis you may have is considered "mild". If the nipple has descended below the level of the crease, then the breast droop is more significant, and you may indeed benefit from a breast lift, in addition to any augmentation you might be considering.

Another easy method to check for breast ptosis involves clasping your hands on top of your head, and looking at what happens to the nipple position in the mirror. If the nipple position is still too low for your liking, then a lift operation might be beneficial.

When the amount of droop is mild, often we can use a short-scar technique for the lift, avoiding the long anchor-shaped incisions used in the classic breast lift. The benelli or "donut" lift, for example, allows us to can use one circular incision around the nipple - and get three benefits with it: use it to place the implants, make the areola smaller in size, and get a little bit of a breast lift all at the same time.

Implants & lifts - part one

One area of confusion I see frequently in our practice is the difference between when we should use a breast augmentation, and when we should use a breast lift, otherwise known as a "mastopexy". Many people think that a breast implant will lift a significantly droopy (ptotic) breast - sadly, this is not the case.

Adding an implant to a droopy breast most commonly converts it to a bigger, but still droopy breast. Some surgeons will try to "fill up" a droopy breast with a big implant. While sometimes this works, for most people, the effect is temporary - and the additional implant weight on the stretchy breast skin tends to make the droop worse as time goes by. And now, it's a much more complicated thing to fix...

For some women, who just have just a relatively minor degree of breast ptosis (droop) - an implant may work, especially if it is combined with one of our smaller breast lifts, like the "donut lift" - which involves an incision around just the areolar area. But only use an implant if you've decided you want to have a larger breast size. You can't count on them to act as an "internal bra".

Breast implants - choosing the right size

Breast augmentation is the most popular procedure in our practice - we help several hundred women with this each year. In order to have a happy patient, one of the most important choices we make together is figuring out exactly the right size for the implant. The three of us - the patient, my nurse and I work together on this, until we've found "just the right one".

Most of my patients request something that looks "proportional" for their frame. Most of them want something in the mid-C to small-D cup size.

In the old days, implants were chosen by volume - if you wanted to be 2 cup sizes bigger, you needed a 300-400 cc implant. Unfortunately, that calculation didn't take into account the patient's height, size of their ribcage, or other parameters that vary widely from one person to another.

I think the key factor is to get the implant width right. After all, most women who are signing up for breast surgery want a nice cleavage - and want to avoid a big gap in the center. Most augmentation patients also want to fill up the width of the breast nicely, but avoid looking excessively broad in the chest, with the implant being so wide that it ends up sticking way out the sides, under their armpits.

While other doctors may have different opinions, here's a quick summary of what I do:

1) Start by measuring the width of each breast with a tape measure - going straight across from the area of the cleavage, to the outside of the breast. This will give you a number which varies from 11-12 cm in a petite patient, to 15-16 cm in someone with broad shoulders.

2) Next, subtract a little depending on the amount of breast tissue the patient already has. I estimate this by measuring the "pinch thickness" of the breast laterally.

3) Now that we've determined the approximate "base width" - the footprint - of the implant, we can have the patient try on implants of this particular width in a sports bra and T-shirt, and see what she likes in the mirror. We know that these implants are going to be the right width for the patient's frame.

Of course, the look of the implant in the sports bra isn't identical to what we're going to see post-operatively, but it is a good approximation of the size and weight, and it's probably more accurate than computer imaging is at the present time. If anything, the implant in the sports bra looks a little bigger than it will once the surgery is done.

This try-on process takes a good bit of time with the patient, so that's the reason that many other surgeons don't do it - but it really makes a huge difference in the quality of the results and in overall patient satisfaction.


Tom Fiala