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Breast cancer continues to be a major health issue for women, averaging just under 200,000 new cases per year. It is the second leading cause of cancer-related deaths in women. From a plastic surgery standpoint, cosmetic breast surgery cases well exceed this number with over 500,000 procedures being performed per year. The crossing of these two breast treatments places plastic surgeons in a position to help improve breast cancer screening. Because all forms of cosmetic breast surgery produce irreversible changes to the breast parenchyma, the importance of presurgical screening is even more important.
In the November 2009 issue of Plastic and Reconstructive Surgery, Drs. Selber, Wu and colleagues looked at this very issue. Their study looked primarily at the behavior of plastic surgeons in knowledge and adherence to the American Cancer Society (ACS) Breast Cancer screening guidelines. The greatest relevance of their report, however, is to create awareness as to what preoperative breast screening should be done when cosmetic changes are anticipated to be done.
As a review of the ACS guidelines, women at average risk should begin self-breast examinations at least every 3 years for women in their 20s and 30s and yearly for woman over 40. Mammogram screening begins at age 40. This means that any woman undergoing cosmetic breast surgery under 40 should at least have a breast examination. Once over 40, all should have a mammogram as well.
These guidelines change for women at increased risk. A more aggressive screening program which may include MRIs should be done for women who are BRCA mutation carriers, a first degree relative of BRCA carrier and radiation exposure between the ages of 10 and 30 years of age. Women at increased breast cancer risk include two or more relatives with breast or ovarian cancer, breast cancer occurring before age 50 in an affected relative, one or more relatives with two cancers, male relatives with breast cancer, or a family history of breast or ovarian cancer with Ashkenazi Jewish heritage.
Because of the frequency in which cosmetic breast surgery (breast augmentation, breast lift, breast reduction) is done, plastic surgeons are in a unique position to screen women for breast cancer. Often, this would be the first and in some cases the only breast cancer screening that they may receive. Taking a family history, performing a breast examination, and referral for a preoperative mammogram if indicated are in the patient’s best interest. Women over age 40 should not undergo any form of cosmetic breast surgery unless they have been baseline screened regardless of their risk factor. Women under age 40 with moderate to high risk should have the same baseline breast information obtained prior to surgery.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Breast augmentation is an operation that is essentially about enlarging the breast mounds. Where and how the implant is placed can affect not only the shape of the breast mounds but their symmetry to each other. The change in the breast mound, however, will not make a difference in the position of one’s nipples. This is an extremely important point for patients to realize and appreciate before undergoing the procedure.
Breast augmentation will usually make a small change in the size or diameter of the nipple. It may also affect how the nipple is viewed in the vertical dimension on the breast mound or how it sits relative to the newly enlarged and shaped breast mound.
But enlarging the breast mound will NOT change the horizontal position of the nipples relative to each other. In other words, if you have a difference in the position of the nipples between the two breasts (by drawing a level horizontal line between the two nipples), this will not improve as a result of placing breast implants. Most often the difference in nipple position is a direct reflection of the size and shape of the breast mound. Those breasts that have more skin or loose skin may have a nipple that sits lower.
Recognizing that the nipple position is different before surgery is extremely important. Unhappiness or criticism of breast augmentation results is often from either some mound or nipple asymmetry. Recognizing that horizontal asymmetry exists before surgery gives one the opportunity to consider a nipple lift or adjustment during the breast augmentation procedure. While a nipple lift can always be done after, the patient should be given a choice as to how to manage nipple asymmetry beforehand. Pointing it out after the fact is usually viewed as the plastic surgeon’s fault more than as a result of one’s preoperative anatomy.
Nipple lifts are very simple removals of crescent-shaped pieces of skin that move the areola in the direction of the skin removal. Most commonly, this is going to be upward for a nipple that sits lower. (also known as a superior crescent mastopexy) But in my Indianapolis plastic surgery practice, I have done them for nipples that were too far to the side to move them inward (towards the sternum) as well. They result in a change of about one to two centimeters based on the tightness of one’s skin and how large of a breast augmentation has been done. They do leave a very scar but it usually is quite fine and not a concern to most patients.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Breast augmentation is a very successful cosmetic procedure that, fortunately, is associated with a low risk of medical complications such as bleeding or infection. When talking to my Indianapolis plastic surgery patients about breast augmentation, I try to cover the most likely complications which can occur. Most of these will center on issues relating to having an implant and the short and long terms problems that may develop.
One of the very uncommon medical problems that can occur after breast augmentation (actually any form of breast surgery) is a condition known as Mondor’s syndrome. It is so rare that it is not one of the potential complications that is even discussed. It is when temporary cords develop extending from below the breast towards the abdomen. These cords are thought to be due to inflammation of the superficial veins below the breast. This is a blood vessel condition known as superficial thrombophlebitis and is well known to occur in other parts of the body, particularly the arms and legs. These cords become more prominent when the breast is pulled upwards and can be one sided or both sided. They appear weeks after surgery, last a few months, and then usually go away.
First described by Dr. Henri Mondor, a French surgeon, in 1939, this condition is a rare entity of the subcutaneous veins of the anterior chest wall. The trauma of raising the pectoralis muscle or disturbing the glandular tissue of the breast causes blood to stagnate in some of the draining veins. The sudden appearance of a vertical cord on and below the breast extending into the abdomen is classic. It is initially red and tender and subsequently becomes a painless, tough, fibrous band that is accompanied by tightness and pulling on the skin. It may be difficult to fully raise one’s arm. This band remains for varying periods up to several months. The condition is not harmful and will eventually subside. No specific treatment is needed although it can be very tender and painful. Anti-inflammatory and pain medications can be helpful in this regard. Antibiotics have not been shown to be helpful nor would they be expected to be given that blood clotting and inflammation is the problem, not bacterial infection.
To the woman undergoing breast augmentation, the development of Mondor’s syndrome after surgery is unexpected and disturbing. One may wonder why we didn’t talk about it before surgery but it is just so rare that it doesn’t fall into what we should be most concerned about. It should be comforting to know that it is a self-solving problem that will have no long-term negative effects on the breast result.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Breast augmentation is an operation that makes an immediate and dramatic change. Because of the implant’s expansive effect, there are certain alterations in the overlying skin of the breast mound that most patients don’t think about or aren’t aware of. These changes frequently result in phone calls and concern during the first month after surgery.
The first thing that one will notice right after surgery is the breasts are very firm and stiff. They will feel unnatural and not what you expected breast implants to feel like. This is the result of swelling and immediate expansion of the skin by the underlying implant. The skin will simply need some time to relax. It will take at least a month before the skin starts to relax and feel softer. It will likely take up to three months after surgery until the breasts feel normal and you forget about the fact that you have implants. What once felt like ‘rocks’ on your chest will eventually become a naturally feeling and looking breast.
As part of this immediate skin expansion effect is that the shape of the breasts will initially look very round like balls on your chest. They will usually also look somewhat high with a very full upper pole of the breast. This is less so if you had some sagging before surgery and will be particularly so if you had fairly tight chest skin before. While some patients want a more rounded breast look, this is exactly what many other patients do not want and fear. As the swelling subsides and the skin begins to relax, this round look will start to become less so. It takes the skin on the bottom side of the breast to relax and stretch out for the implant to settle into a more natural lower position. The use of banding (strap across the top of the breast), implant massage, and sleeping on one’s stomach can all help this process move along sooner.
Nipple sensation after surgery is often temporarily altered. Usually the nipple will feel hypersensitive and may cause undesireable sensations even if lightly brushed or touched. This too sensitive nipple almost always settles down in the first month after surgery and returns to normal feeling. Less commonly, the nipple may feel completely or partially numb and it may take up to several months for full feeling to return.
Occasionally, patients report the sensation of fluid or sloshing around the breasts in the first seven to ten days after surgery. This is normal as is the result of residual irrigation fluid used to wash out the breast pockets prior to incision closure. As the fluid is absorbed, this sensation will go away.
As I tell my Indianapolis breast augmentation patients, it is important to remember that the chest skin and tissues will take some time to adapt to the new implant. Since the implant is synthetic and can not relax or give over time, the overlying skin must eventually do so. Tiny nerves that control the feeling on the bottom side of the implant are temporarily severed and must ‘regrow’ after which all your breast feeling will go back to normal. This adaptation and healing process takes time and one must not judge the results of breast augmentation surgery until this phase of recovery is complete.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
One of the primary goals of breast augmentation is to give the patient their desired size through the selection of the implant that can achieve that goal. While there are many methods prior to surgery to help with that selection process, none are an exact method and the final implant placed in surgery is still as much of an art form as it is science. Postoperatively, some women may be ultimately disappointed with their reluctance to go bigger or they may become accustomed to their current breast size. In all of the aforementioned circumstances, a patient may desire to change their current implant size for a larger one.
One of the advantages of removing and replacing an existing breast implant is that one has a good idea of the impact a certain volume has on one’s breast size. It should therefore be easier to know how much bigger in size (volume) to go. On the one hand, this is certainly true. On the other hand, however, one can still be fooled unless one has an appreciation of incremental volume changes by percentage.
When a patient asks me to go bigger with a breast implant, I ask them how much bigger….by percentage. In other words, do you want to be 25%, 50%, 75% or 100% bigger. Going less than 25% bigger hardly justifies the expense of the operation so I start at that amount. To put that into perspective, let us take for example that one has a current breast implant size of 350cc. Moving up to 400ccs, while that seems a good improvement, is really only a 15% increase in size. A 100cc implant size (450cc) increase is a 25% enlargement which begins to be visible. This 100cc minimum rule of breast implant size increase in exchanges is a good one in my Indianapolis plastic surgery experience. While in larger implants, the percentage volume increase must be proportionately bigger. (e.g., 625cc from a 500cc implant) Conversely, a smaller starting implant (300cc for example) will need only 75cc to get a 25% volume increase.
It is easy to see that using the percentage volume increase method will often run contrary to what one might have otherwise selected. Going up 25 or 50ccs in breast implant size will not make much of a difference. Patient’s usually have a misunderstanding of the impact of volume change and often believe these small increases will result in much bigger changes than they actually will.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Understanding the Risks and Potential Complications in Breast Augmentation
Author: barryeppley
Breast augmentation continues to be popular amongst patients and plastic surgeons alike due to its immediate and highly successful results for most patients. As the operation is widely satisfying and associated with a fairly rapid recovery, patients can begin to enjoy the benefits of breast augmentation quite quickly.
Despite the tremendous benefits of breast augmentation, it is important to remember that it is an operation that involves an implant. As such, there are some risks and potential complications that do exist and no one is immune from them. While not to throw cold water on a hot fire, so to speak, it is important that potential patients understand that risks exist and not every result is perfect. Some of that is due to the fact that many women’s breasts are not perfect to start out with in terms of symmetry and other differences between them. In addition, the surgery involves two sites that are right next to each other for comparison.
In appreciating potential complications after breast augmentation, a recent paper was published in the September 2009 issue of Plastic and Reconstructive Surgery on this very subject by Drs. Hvilsom and others from Denmark. Looking at over 5,000 women over an 8 year period that had breast augmentation, they looked at the incidence of complications at different time periods (0 to 30 days, 0 to 3 years, and 0 to 5 years) focusing on issues of infection, hematoma, asymmetry, and capsular contracture. They report a 17% incidence of an adverse event and a near 5% rate of surgery-requiring complications. The following complications rates were reported: hematoma 1.2%, infection 1.2%, asymmetry 5.2% and significant capsular contracture of 5.2%. Displacement and/or asymmetry and capsular contracture were the most frequent indications for reoperation.
While this report was from a different country with multiple surgeons (including slightly different techniques and implants) and all types of patients being treated (not an homogenous population), the data is from a registry which is very common in these smaller Scandinavian countries. (Some would argue that Denmark is not part of Scandinavia but that is a different discussion) As a result, this is good pooled data from which to draw some conclusions. It does address the important patient concern of….what are my chances of needing further surgery from a complication?
These reported breast augmentation outcomes correspond fairly well with what is reported in other studies. It is also almost exactly what I tell my Indianapolis breast augmentation patients. The risk of hematoma and infection are very low (1%) and will occur almost within the first 30 days after surgery. The most common complication thereafter is one of an aesthetic nature which is breast asymmetry or some malpositioning of the implant (s) which is around 5% to 7%. (in essence it is not common but it is not rare either) Todays rates of capsular contracture, in the short term (less than 10 years which is short compared to a lifetime) are very low with submuscular implant placement and are around 1%. Over 10 years or longer, they may likely be somewhat higher.
Breast augmentation is a tremendous psychologically uplifting operation for women who want it. In this state of sometimes near euphoria, however, it is important to remember that there are some complications which can occur. None of them ‘ruin’ the final outcome and most of the time they are completely solveable without significant long-term adverse outcomes.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The Sagging Breast - Breast Augmentation, Breast Lift or Both?
Author: barryeppley
The breast that has a moderate to a significant amount of sag is commonly seen by plastic surgeons. Often such a patient is seen who is seeking breast augmentation. It is commonly perceived, although largely erroneous, that a breast implant will lift a sagging breast. Despite the wonders that an implant can do to reshape and rejuvenate a breast, it does not have the ability to move a nipple or the breast mound higher up on the chest wall.
Breast sagging, also known in plastic surgery terms as ptosis, is defined by where the nipple sits in relation to where the lower breast fold (inframammary crease) is. There is a ptosis classification system with four types which precisely defines the nipple-fold relationship. From a patient’s perspective however, what matters is…at what point will an implant alone not work well and I have to consider some form of a breast lift? The simplistic answer is when your nipple is at or just below the level of the fold. At this nipple position on the mound, a breast implant alone is not going to lift the breast. While it will make the breast much fuller and give the mound a nice shape, the nipple will still be located on the lower pole of the breast pointing downward.
Many wonder about the use of no implant and a breast lift alone in the sagging breast. While a lift will move the nipple up higher and provide breast reshaping, it will not in most cases make the breast look bigger. This is another erroneous perception. In fact, in some patients it may even make the breast look smaller due to less of a breast skin sleeve.
The consideration of the need for a breast lift with an implant is often a painful discovery when one is seeking breast augmentation. Scars on the breast create a new cosmetic deformity that must be balanced against the sagging that it is replacing. For some, that trade-off is an easy one. For others, it is a more difficult decision. Often times, a breast augmentation simply can not be satisfactorily done without a concomitant breast lift.
Combined breast augmentation and breast lifts can be done several ways. The degree of lift that can or should be done is controlled by the amount of scarring that a patient can tolerate. The scar burden must be balanced against how severe the sagging is. The use of a breast implant definitely helps a sagging breast and often may lessen the degree of breast lift that may be needed. Larger breast implants help fill out loose skin but will still not lift the nipple any appreciable amount. The stark reality about breast lifts is that the more scar that is created, the greater amount the nipple is lifted upwards,
With a breast augmentation some patients may find that some sagging is more acceptable than any type of breast scar. For others, the scars are more acceptable and the desire to improve the sagging supercedes any scar concerns. Looking at photographs of both fresh and mature breast lift scars can really help a patient better appreciate what degree of scarring that is involved.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Breast augmentation, due to its near instant gratification, is what I call a ‘euphoric’ plastic surgery operation. Most women are immensely excited about the prospects of the results and they have painted themselves into that role by envisioning how clothes and other attire will look afterwards. In the wake of this enthusiasm, it is easy to overlook or not hear or read about any possible undesireable outcomes that may result.
Breast augmentation, like all surgery, has inherent risks and complications like bleeding and infection. But any operation that involves the placement of a synthetic implant or material is inherently prone to a higher than traditional rate of surgical complications. An implant introduces a whole new set of potential issues, particularly when the appearance of the outcome is how the operation is graded on the success scale. Breasts compound this issue further because there are two of them…and they are side by side.
If you look at any of the manufacturer’s rates of reoperation, which they know well due to FDA requirements and clinical trials and are published, you will discover an almost shockingly high rate of revisional or secondary breast implant surgeries. One must remember that this collection of data is a very mixed population of surgeons and patients of all ages and types of breast problems. Nonetheless, the manufacturer reported revision rates of primary breast augmentation surgeries is in the range of up to 30%…in the first three years after surgery! These reported revision rates were for every conceivable breast implant problem including infection, bleeding, breast asymmetry, capsular contracture, implant rupture or failure, and unhappiness with the breast size or breast shape.
I don’t present these reported rates to scare or put fear into any potential breast augmentation patients. But some patients do need a reality check in their otherwise enthusiastic but often oblivious psychological state before surgery. I do not experience this high rate of revision rates in my Indianapolis plastic surgery practice, but it is also clear that low risk factors of 1% or 2% revisional needs is not accurate either. A more accurate number is in the range of 3% to 5%. A fairly low risk for sure but not a rare occurrence either.
The pertinent message is that breast augmentation surgery has higher risks than other types of breast surgeries such as reductions and lifts. This is primarily due to the use of an implant to create the result and the highly critical nature of many cosmetic breast patients. Most complications and the need for revisional surgery are, fortunately, usually cosmetic in nature. Most often the issue is of implant positioning and asymmetry as well as breast shape and nipple positioning.
It is important to remember that breast implants can only take what you naturally have and make it larger. They can not really give you completely different breasts even if it appears that they do. It is important to be aware of your presurgical breast shape and any asymmetries. What may appear to be a small difference before surgery can turn into a much bigger difference after.
Because of the not rare need for revisional surgery after breast augmentation, one should have a clear idea as to what one’s financial obligations may be should that need arise.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Breast augmentation is the relatively simple procedure of placing an implant underneath one’s existing breast mound. By so doing, the existing breast mound is changed by enlargement. What is not obvious to most patients is that although the breast becomes larger, many of its pre-surgical features remain.
An implant can change breast size and to some degree its shape but certain things they can not do. One of these unchangeable features is the spacing between the breasts or how far apart they are. Women are often bothered by a big gap between their breast mounds or how wide apart they are. When the breast mound sits way to the side of the chest wall and the nipples do not point forward, these are widely spaced breasts.
One of the common questions that I get in my Indianapolis plastic surgery practice from breast augmentation patients is that they do not like the gap between their breasts. They often feel that breast implants will correct that problem. Unfortunately, this is often not the case. The breasts will become larger but they will still be very much to the side or the interbreast gap will still exist.
A breast gap can be reduced by positioning the implants as close as possible. This is easier to do when the implant is above the muscle than below it due to the sternal attachments of the pectoralis muscle. A larger implant makes this more possible than a smaller one. But the closeness of the breast mounds after augmentation is as much a function of one’s natural anatomy than surgical technique.
I often point out to patients that cleavage is a function of wearing a bra and not caused directly by breast implants. Trying to create cleavage by implants alone runs the risk of what is known as synmastia, where the implants actually touch across the sternum. This is a difficult problem to correct and is best avoided.
While most prospective breast augmentation patients have seen photos of implanted women with great cleavage, such results are not possible for many women. Their naturally wide-spaced breasts do not permit such outcomes. One has to have realistic expectations given what one has to work with.
Wide-spaced breasts can have nipples that are oriented or point to the side. I call this wall-eyed breasts. Once implanted, this nipple orientation can be exaggerated even if the implants are well placed and symmetrical. One small procedure that can help this problem is a medial or inward nipple lift. By removing a small crescent of skin on the inside of the nipple, the nipple is moved further inward. This small procedure can help provide some nipple re-orientation.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Breast augmentation today is easier than ever before!….That is certainly the marketing hype and there is a lot of truth to it. But to call the recovery after breast augmentation as….no recovery….easy….or painless as some advertisements suggest is to not be completely truthful. All surgery induces some pain, swelling, and bruising. Breast augmentation is not different.
Breast augmentation is most commonly done today by placing the implant under the pectoralis muscle. (although there is a recent trend back to above the muscle for some plastic surgeons) By putting the implant submuscular, the muscle is stretched, traumatized, and even some fibers are cut. This makes the muscle sore, swollen and difficult to stretch. This also makes the upper arm hard to lift up very far. In essence, submuscular breast augmentation requires physical therapy for recovery.
While breast augmentation can not be recovery free, its recovery can be shortened. This is made possible by early and aggressive physical therapy. Breast augmentation physical therapy starts the night of surgery and consists of range of motion exercises of the arm. By early stretching of the arm in circles and by raising the arm from one’s side to the level of the shoulder and above, the pectoralis muscle is mobilized. Stretching helps loosen up the injured muscle fibers and prevent restrictive scar formation.
This form of pectoralis physical therapy, combined with anti-inflammatory drugs such as Alleve and Ibuprofen, allows one to get moving very early. While swelling, a little bruising, and some pain can be expected, early physical therapy can lessen its effects to just a few days. Even in the worst-case scenario, one should have a significant recovery by one week.
One other helpful recovery aid I use in my Indianapolis plastic surgery practice is the ActiPatch or ActiLoop. This is a small battery-operated battery device that emits pulsed electromagnetic fields that penetrate the breast tissue and help reduce swelling and inflammation. I have my patients wear it as a loop over the breasts for the first 36 hours. It is easy to wear it inside one’s bra as the loop fits over much of the breast mound.
Rapid recovery breast augmentation is a reality through a combination of early physical therapy, anyi-inflammatory medications, and the ActiPatch device. Significant recovery should be a matter of days not weeks.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis