Breast Augmentation: About the Procedure, Risks & Recovery

INTRODUCTION
If you are thinking about breast augmentation, you are not alone. Last year more than 125,000 women chose to enhance their looks through a procedure that is now the second most popular of all cosmetic plastic surgeries. In fact, doctors have been performing—and perfecting—the procedure for thirty years.

Breast augmentation (also called mammaplasty) is a surgery to contour and enlarge breasts using implants. Many women choose the procedure because they feel their breasts are too small for their body. Some women lose breast size after childbirth or breastfeeding. For others, nature was not overly generous to begin with. And there are other women who are bothered by uneven breasts and would like a more naturally balanced look.

Is It Vain to Consider a Surgical Procedure That Can Change Your Appearance?
Certainly not. To want to look good, to have an appearance that is inviting to others, and to look attractive in clothing is only natural. Nothing is wrong with a heightened sense of self-esteem, and breast augmentation has given many women a greater confidence and better feeling about their own femininity and body.

Do They Look Natural?
Implanted breasts tend to be rounder and firmer than breasts that have not been augmented—characteristics that some people think are actually improvements on mother nature. What breast size is your ideal? We usually think “cup size” when we think breasts. After all, that’s how we choose our bras and bathing suits. If you tell your doctor you want a “C” cup, he or she will understand the general size you wish to be after breast augmentation. But in reality, implants don’t come in cup measurements—they come in “cc's” (cubic centimeters, a measurement of volume) as well as a few different shapes. There are some things you can do to more clearly convey the breast size you wish to be, although your body size and proportions will be a determining factor in the breast size and shape that is right for you.

Most often breast augmentation takes place in an outpatient surgical clinic or hospital under general anesthesia. In some cases, the surgery is done using a local anesthesia combined with sedation so you are awake but drowsy and relaxed. You and your doctor will discuss these options. The surgery usually takes from one to two hours. After surgery, you’ll be taken to the recovery room for several hours before you are able to go home. Plan to have someone accompany you; you’ll be drowsy and feel discomfort. Pain medication will be prescribed which you will probably want to take for a few days.

The Implant
A soft, pliable implant—(imagine a clear plastic pillow filled with Jell-O or salt water) is placed in a pocket the surgeon has formed in your tissue either behind the pectoral muscle or in front of the muscle wall.

Placement of the Implant
Your own anatomy helps determine what placement position is right for you. As a rule, implants behind the muscle are less likely to form a hardening called capsular contracture and less likely to show a rippling on the skin. They usually result in a more natural, softer looking bosom, and this placement is often preferable because it can allow for a better mammogram. Most implants are placed behind the chest muscle.

On the other hand, women with very droopy breasts may have better results when the implant is placed on top of the muscle because that can give their bust a rounder and firmer appearance where the chest was once flattened out.

The Incision
In order to place the implant in your breast tissue, the surgeon will need to make a surgical incision. The incision can be made around the areola (periareolar )— the darker skin that surrounds your nipple; in the armpit; or directly under your breast.

When the incision is made in the areola, usually the scar is barely noticeable, the tiny line blends into the surrounding skin. An incision made under the breast (inframammary) can be inconspicuous as well because the breast itself will hide the scar. Armpit (axillary) incisions may be noticed when the arm is raised, and some surgeons find that it is more difficult to accurately form the pocket that the implant is tucked into from this entry point. Some surgeons use an endoscope, a surgical instrument consisting of a long, thin, lighted tube, to aid them in the insertion of breast implants.

TUBA Method
Some newer endoscopic procedures involve making an incision in the navel (“TUBA” or “transumbilical” or periumbilical method). One tiny half-moon incision is made in the navel and the surgeon then creates a tunnel to the breast area. A "pocket" in the breast tissue is formed that will hold the saline implant. (Endoscopically-assisted surgery allows the surgeon to see on a video screen the pathway and placement site.)

When the pocket is ready, the surgeon will guide the implants-which at this point are empty thin sacs that are rolled up like a cigar-into place. The implants are filled with sterile saline solution; when the surgeon removes the filling tube, the saline implant port self-seals.

"The big advantage is there is no visible scar and it appears that patients have less pain. They seem to recover rapidly," reports Dr. Robert Gerson, a board-certified plastic surgeon who practices in Illinois and Wisconsin and is one of the few doctors in the US trained to perform the procedure. He believes that the TUBA method results in less chance of damaging nerves that can lead to loss of feeling in the breasts.

With this technique, breast implants are most successfully placed on top of the muscle wall. That may be a drawback for some: Many women, including very flat-chested patients, have better, more natural-looking results when their implants are placed behind the pectoralis muscle. But for the patient who is very concerned about any visible scarring-TUBA might be a technique to investigate and consider.

Who Is a Candidate?
Women who want an improvement to the way they look, but have realistic expectations, are the best candidates for breast augmentation.

If you are looking for a nicer appearance, but not an unattainable one, the procedure might be for you. Most women who have had the surgery say they feel more attractive and self-confident. That's not surprising-when you look good, you feel good. Breast augmentation is not without risks and some discomfort, but many women decide that the long-term benefits of more shapely, enhanced breasts are well worth it.

Of course your physician will want to make sure you are in good physical health if you are considering breast augmentation. A pre-op physical, health history and blood work-up will be done before you go in for surgery. Age is not a limiting factor as long as your general health is good.

If you are a serious candidate for this type of plastic surgery, make sure the doctor you choose is board certified. Discuss procedure, risks, benefits and treatment options. "Use this opportunity to determine whether or not you are comfortable with the surgeon and whether or not you want him or her to do the surgery," advises Gregory Mesna, M.D.

In most cases the procedure is considered elective or "cosmetic" and means you will probably have to pay for it yourself. Costs vary in different regions of the country, but average between $5,000 and $6,000.

Preparing for Surgery
Breast augmentation, as with any other surgical procedure, requires you to be in good health. Discuss any health concerns and problems that you may have with your doctor.

Before your surgery, routine laboratory tests including blood counts and blood chemistries, as well as an electrocardiogram if you are over 40 years old, will be performed.

Here are a few general guidelines that you should follow:

• Don't take aspirin or any drugs containing aspirin for at least two weeks before surgery. Aspirin can interfere with normal blood clotting.
• Don't eat or drink anything after midnight the night before surgery. Your stomach needs to be completely empty when undergoing anesthesia or sedation.
• Avoid drinking alcohol a few days prior to surgery.
• If you smoke, stop smoking before your procedure and for some time afterward. Smoking reduces the rate of healing.
• Shower or bathe the evening before surgery, but don't shave your underarms for at least 12 hours before surgery.
• The morning of surgery you may brush your teeth, but don't swallow any water.
• Wear something loose that opens in the front. You don't want to put on anything that goes over your head after surgery.
• Arrange for someone to drive you home. Arrange for a friend or relative to stay with you for 24 hours after surgery.

Pain
You will experience pain, swelling, tenderness and some bruising after surgery, but your doctor will prescribe pain medication to ease you through this time. If the implants have been positioned behind the chest pectoral muscle, expect the kind of pain you would experience with a pulled muscle—because that’s exactly what the surgeon has to do to fit the implant in its pocket. If the implant has been placed in front of the muscle, pain is often minimal.

Prescription pain medications can be used for 4 to 7 days. Take only when needed, don’t take more than prescribed, and don’t take them for more than a week. After several days, most women find that acetaminophen is all they need.

You may be prescribed an antibiotic to fight infection.

Ice packs will help reduce swelling and soothe the incision.

If at any time following surgery you experience fever, bleeding or other symptoms of infection, let your doctor know right away.

Recovery
How will I feel? When can I get back to work? When can I get back to my normal routine? Recovery time is individual, depending upon the patient, the placement and type of the implant, and the surgical technique.

However, here are some general guidelines:

• You’ll feel tired and tender for the first 24 to 48 hours. Plan to take it easy.
• You’ll probably be able to go back to work in several days if your job is not too physically demanding. If your work requires physical energy and stamina, you’ll need to allow more time for your recovery.
• Avoid vigorous exercise for six weeks.
• Your stitches will be removed in a week to 10 days. The incision scars will be firm and pink for at least six weeks, and then will begin to fade. Your breasts will remain swollen for three to four weeks following surgery. They will be tender to touch and exercise.
• No lifting for two weeks and no heavy lifting for four weeks.
• Allow about two months for “complete” recovery from breast augmentation surgery.

Following surgery, your surgeon will apply gauze bandages to your incision sites and you will be placed in a surgical bra which you will wear for about two days. You will receive instructions about changing the gauze and keeping the incision clean; positions for sleep and rest; raising your arms, breathing exercises and breast massage.

Call your doctor if:

• There is an increase in pain, swelling, redness, drainage or bleeding in the surgical area;
• You develop headache, muscle aches, dizziness or a general ill feeling and fever, nausea or vomiting.

Usual follow up after surgery is at one week, one month, three and/or six months and thereafter at annual exams.

Risks
Breast augmentation is a relatively straightforward procedure, but as with any surgery, there are risks and uncertainties.

These are not common, but you should be aware of the possible complications that include:

• Bleeding following the operation. If it continues, another operation may be needed to control the bleeding and remove the accumulated blood.
• Postoperative infection. A small percentage of women develop an infection around the implant. If the body does not respond to antibiotics, the implant may need to be removed for several months until the infection is cleared, and then a new implant is inserted.
• Changes in nipple or breast sensation. Nipple numbness may be temporary or permanent.
• Capsular contracture. If the scar or capsule around the implant begins to tighten, the breast will feel hard and sometimes result in a baseball-like appearance. The implant may need to be removed or replaced, or the scar tissue may need to be surgically removed.
• Rippling or wave-like appearance on breast that look like indentations. In most cases the ripple occurs as the implant moves.
• Shifting of the implant. The device can move from its original placement and/or push through layers of tissue and become visible at the surface of the breast. (Placing the implant beneath the muscle may help to minimize this problem.)
• Implant leaking or rupture. An injury from a blow to the chest, a compression during mammogram, or even normal movement could cause the implant casing to leak. If a saline-filled implant breaks, the implant will deflate in a few hours and the salt water will be harmlessly absorbed by the body. A ruptured or leaking implant must be replaced which requires a second surgery.

Costs
In most cases, breast augmentation is considered elective or "cosmetic" surgery, which means you will probably have to pay for it yourself. Total costs vary in different regions of the country, but average between $5,000 and $6,000.

According to the American Society of Plastic Surgeons (ASPS), in 1998, the average fee charged by the surgeon for breast augmentation was $3,077. (That does not cover anesthesia, hospital/surgical center charges, or the cost of the implant, which adds $1,500 to $2,000.)

The ASPS reports the following state-by-state averages of fees charged by plastic surgeons in 1998: California, $3,234; New York, $4,417; Florida, $2,616; Texas, $2,851.

More to Know
How will your life change after breast augmentation? Aside from the fact that there is a good likelihood that you'll be happier with your new shape, you'll find few restrictions or big changes. But here are a few things to keep in mind.

• Breast cancer screening and mammography. As for all women, you will need regular mammography exams after a certain age to detect breast cancer. Both saline and silicone implants can obscure the tissue in which a tumor may be present, making detection more difficult. However, breast implants that have been positioned under the muscle are less likely to interfere. When you book your mammogram, tell them you have implants and that you want a technician who has been specially trained. At your appointment, remind them again. Breast implants can rupture with improper mammogram handling.
• Breast-feeding. You should be able to breast-feed successfully after breast augmentation. According to La Leche League, many women with silicone breast implants have successfully nursed with no apparent harmful effect to themselves or their children.
• Implants don't last forever. Most likely you will need to replace the implants at some point down the road, which means you'll need another surgery. Discuss implant product warranty with your doctor so you are clear about what is and isn't covered in the cost of the surgery.

Types of Breast Implants
A breast implant is a silicone shell filled with either a saline (salt water) solution or silicone gel. The implant most often used today is saline-filled. Under some conditions, silicone gel implants can be used, but these are mostly used for reconstructive surgery. Because saline is similar in composition to other body fluids, if a saline implant should rupture and leak, the saline solution, which is harmless, is absorbed by the body.

There are round implants and anatomic implants. The anatomic implants may also be described as "teardrop", "anatomical",or "tapered" implants. The tapered implant is sometimes suggested for thinner women because it may result in a more natural-looking upper chest.

The rounded implant gives a fuller upper chest and cleavage. Implants of either type placed behind the muscle may provide a similar appearance.

The outer surface of the implant may be either textured or smooth. Textured implants may help reduce capsule formation around the implant. The evidence is not conclusive. Some surgeons have found that textured implants have more of a tendency to ripple. Advocates of smooth implants claim that they are less likely to cause visible rippling (especially if placed below the pectoral muscle) and are more natural to the touch.

Because there is a lack of evidence supporting the safety of silicone gel-filled implants, the Food & Drug Administration (FDA) restricted their use to primarily reconstructive procedures in approved clinical studies. Some women requiring replacement of existing gel implants may also be eligible to participate in the study. Saline-filled implants are currently under review for both reconstructive and elective purposes.

Adjustable-fill implants allow the implant size to be adjusted after the initial surgery. A self-sealing tube and valve allow the surgeon to add or remove additional fluid to increase or decrease the size, respectively. The valve is often removed surgically and the implants remain at their adjusted size.

An alternative implant filled with a purified form of soybean oil is also being evaluated and it is not known if it will be available for general use.

Liposuction - Safe or Unsafe?

Liposuction, or liposculpture is the most common cosmetic surgical procedure in the United States. Traditionally, liposuction was associated with an outpatient surgical setting, where excess fat was removed and patients experienced rapid recovery and gratifying results.

In recent years, procedures have become more ambitious with larger amounts of fat being removed. Though this progress frequently allows for more dramatic results, it has unfortunately been associated with serious complications, including death. Because liposuction remains an attractive cosmetic procedure, patients want to know if liposuction is fundamentally safe and, if so, how they can make sure their particular procedure is done safely.

Liposuction is conceptually simple. A healthy patient with areas of excess fat has these areas reduced by vacuuming the fat through small metal tubes called cannulas. This procedure is frequently done on an outpatient basis under general anesthesia in the hospital or accredited surgical facility.

Most liposuction begins with the surgeon infiltrating a special solution into the fatty tissues to be suctioned. This solution is mostly salt water, but also contains adrenaline to reduce blood loss and may contain a local anesthetic to reduce pain. Following the injection of this "tumescent" fluid, fat removal begins. In certain cases, the initial phase of liposuction involves ultrasound cannulas that loosen the fat to be removed. This is followed by standard liposuction, where a vacuum is employed to remove the excess fat.

At the end of the procedure, the patient is placed in a compression garment to reduce postoperative swelling. In most cases, the patient is discharged home the same day and returns to work in a few days. When more significant fat removal is performed (greater than 10 pounds), patients are usually observed overnight.

It sounds so simple, so how could anything go wrong? Easy – each factor in liposuction can be critical to a safe outcome. For instance, if the patient is not healthy, even liposuction can result in significant problems, such as a heart attack or trouble breathing. If the surgeon is overly aggressive in fat removal, excessive blood loss can occur. If the anesthesia is not administered properly, too much fluid can be given with serious consequences. If the surgical facility is poorly maintained, infections can be more frequent and lifesaving equipment might not be available in an emergency.

There Are a Few General Factors that Influence the Safety of Liposuction:

Patient: Liposuction is for healthy patients who are within about 40% or their ideal body weight. Liposuction is not intended to be a strategy for weight loss. Obese patients should be considered only rarely. Patients with significant heart or lung disease are not candidates.

Doctor: Ideally, liposuction should be done by surgeons familiar with all facets of liposuction, including the tumescent technique and ultrasound-assisted liposuction. Board certification, preferably by the American Board of Plastic Surgery, is mandatory. This ensures that a national organization feels this surgeon is competent and safe. Additionally, and equally as important, the surgeon should have privileges to perform the procedure in a local hospital. Such privileges mean the surgeon has demonstrated to his or her peers locally that he or she is capable of performing the procedure safely.

Anesthesiologist: Whether general anesthesia is being used or not, all patients undergoing liposuction should be monitored by someone other than their surgeon. This is preferably done by a board-certified anesthesiologist, but can also be done by an experienced, certified registered nurse anesthetist. Experience is essential as it can be difficult to manage liposuction patients, especially during a large volume liposuction.

Facility: Liposuction should always be performed in a hospital or accredited surgery center. The surgery center should be approved by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). This certifies that the facility is of the highest quality. Frequently, I hear of patients who have undergone liposuction done under local anesthesia without proper monitoring, who have done well. I try to point out that just because the surgery was successful, it does not mean it was performed safely. Since liposuction is a real operation with real risks, the conditions for the procedure should be the same as those for any other surgical procedure such as a hysterectomy. Accepting anything less is simply making liposuction more risky than it needs to be.

Liposuction is like any operation in cosmetic surgery in that it can have unsatisfactory results. Specifically, too much or too little fat can be removed, contour irregularities can develop and swelling can be prolonged. However, when adequate precautions as outlined above are taken, life-threatening complications should be exceptionally rare. When done properly by an experienced surgeon in an accredited facility, liposuction remains an extremely safe and effective way to improve one’s shape by fat removal.

Liposuction is real surgery and involves risks such as bleeding, infection and scarring. Results will vary.

Hair transplantation: The Pluck and Sew Technique

Summary
A novel and simple approach to single hair follicle transplantation for alopecia is a hair threaded on a curved needle with the follicle attached. It is the best aesthetically acceptable means of doing so in certain circumstances. These are the eyebrow, the sideburn, the hair margin, areas requiring precise grafting following facelift procedures and the eyelash. The presented technique simplifies the precise, oriented placement of single hair grafts and has been time-tested by the senior author for the last 20 years.

Introduction
Surgical techniques of hair restoration have generally fallen far short of normalcy. Current techniques of composite tissue grafting and flap restoration often lead to hair or browlines which appear quite peculiar. Punch graft growth patterns are uneven, resembling the distortions seen in doll's hair. The hair of locally transposed flaps angle in the wrong direction and have too even a margin with an apparent perimeter scar. Tissue expander reconstruction leaves central defects with hair, usually, again growing in the wrong direction. Microvascular transfer, in skilled hands, offers a meaningful alternative although few surgeons have the experience and expertise required to assure a good result. Strip grafts 1 and square scalp grafts 2 have been advocated as solutions to the hairline problems in selected patients but can often lead to an abnormal appearing hairline. Since the senior author presented this novel approach of individual hair transplantation in 1980, the techniques of mini and micro grafting 3 and the development of specific punches 4 for the harvesting of grafts have been developed which improve the aesthetic outcome of alopecia correction.

In small, defined areas, the technique which gives best aesthetic result is individual hair placement. This is particularly true in the reconstruction of the eyelash for which there is no good currently available reconstructive option. Marritt 5 advocated single hair transplantation for such areas, using one or two hairs from standard 4mm punch grafts inserted with a 16-gauge angiocath as a punch.

We offer a delicate, simplified technique for individual hair transplantation, leading to minimal (if any) scarring, with the ability to control the direction of hair growth. The current technique has been used by the senior author for over twenty years in hairline, eyebrow and eyelash reconstruction. In selected areas and for selected patients this technique allows a precise placement and angulation of individual hair follicles.

Technique
The accurate and atraumatic placement of individual hairs in the proper orientation and without the production of scars in the recipient bed is difficult but simplified by our technique. The first step is the harvesting of the hair follicle. A donor graft is harvested from an area of the scalp distant to the traumatic defect and/or one unlikely to be affected by male pattern baldness. The hair is left long in the area to be harvested. A strip 2 to 3mm in width is ideal for harvesting. The graft should have a generous amount of subcutaneous tissue adherent to the underside in an effort to ensure complete inclusion of the hair follicle. 7X loupe magnification makes the harvesting easy. Retrograde dissection of the hair is accomplished with micro or very fine iris scissors leaving a generous cuff of subcutaneous tissue around the follicle and bulb. This tissue appears translucent in the scalp. The follicle is liberated up into the dermis where a Jeweler's forceps with, filed-down, blunted edges are used to "pluck" the follicle gently from the scalp in the direction opposite its growth; carrying the hair along with it.

If the transplants are to be numerous, harvesting of individual hairs may take place on the day prior to the recipient bed grafting with storage of the hair grafts in moistened gauze at 4 degrees C. This allows the tedious procedure of individual hair follicle harvesting to occur in a sterile area without the detainment of either the patient or operating room staff. The survival of the hair follicles is not significantly altered by such storage overnight. We have however noted that survival does diminish significantly after 24 to 36 hours of storage.

Placement of the individual hair follicles in the skin at the recipient site has been successfully performed using several tools. Initially a trocar was used followed by a specially constructed grasping forceps to pull the hair into the recipient site in a retrograde manner. These techniques resulted in more donor site scarring and more difficulty in achieving the exact direction of hair growth desired than the technique currently used. The current technique is also much gentler and allows less manipulation of the hair, particularly at the follicular end. Currently, we use a number 5, French-eye, cutting edge needle (Anchor Products Co., Addison, Ill.). As a general rule, the smallest free needle manufactured is usually the perfect size. It allows the snug introduction of follicle and minimal surrounding adipose tissue to slide comfortably into its tract. Leaving too much surrounding bulb attached to the follicle can force the hair from its follicular sheath, loosing the bulb and the potential for regrowth. The needle may be either 1/2 or 3/8 circle depending upon the needed direction of hair growth and recipient site skin thickness. The hair end loops through the eye of the needle and follows the needle through the skin and into the subcutaneous tissue exiting in the desired direction at a precise location with precise angulation. Accuracy can be enhanced with loupe magnification. The hair is then cut slightly above the level of the skin so that it is not removed by entrapment in dressings or otherwise inadvertently removed. A coating of antibiotic ointment is applied to minimize drying of the recipient bed surface.

Results and Discussion
This technique is exceptionally useful for small, localized areas of alopecia and is particularly suited to hair margin, the brow and lost sideburn aesthetic reconstruction. It is also the only workable reconstructive option available in eyelash reconstruction known to the authors. It has previously been suggested that single hair micrografts would be the most natural in eyebrow repair, for sideburn reconstruction in women after facelift and for the softening of border hypopigmentation in the transplanted hairlines of blond, fair-skinned patients. We agree with and extend these uses of single hair grafts.

The only limitation to the technique is its tedious nature and its current inappropriateness for large areas needing grafting. It does, however, lend itself well to "streamlining" with harvesting performed by technicians. Causes of graft failure are bulb transection during the harvesting procedure and inadvertent loss of the sheath, as described earlier, usually due to too much bulb being left on the follicle. Graft failure from drying of the follicles and use of transplants which are too old rarely occurs. Unlike most grafts, fresh follicles which have been carefully harvested and kept moist may grow without first exfoliating.

The senior author presented this technique 13 years ago following perfecting its use in the decade preceding its presentation. It has been used in over 25 patients with good results (space limitations disallow extensive presentation of results in a techniques paper). The intended publication after its initial presentation was delayed due to an overwhelming referral of patients which the senior author was unable to accept. The technique is now offered knowing that it will be streamlined by those especially interested in hair replacement surgery.

Bibliography
1. Vallis, C. Surgical treatment of the receding hairline. Plast. Reconstr. Surg. 44: 271, 1969.

2. Coiffman, F. Use of square scalp grafts for male pattern baldness. Plast. Reconstr. Surg. 60: 228, 1977.

3. Frechet, P. Micro and mini hair grafting using the standard hair implantation procedure. J. Dermatol. Surg. Oncol. 15: 533, 1989.

4. Arouete, J. Correction of baldness by grafts. Ann. Chir. Plast. Esthet. 35: 19, 1990.

5. Marritt, E. Single-hair transplantation for hairline refinement: A practical solution. J. Dermatol. Surg. Oncol. 10: 962, 1984.

Published in 1994. Previously presented at the May 1980 meeting of the American Society of Aesthetic Plastic Surgeons, Orlando, Florida.

Breast Augmentation from a Surgeon's Perspective

By Franklin D. Richards, MD Bethesda, MD

Breast augmentation is a surgical procedure to enhance the size and shape of a woman's breast for a number of reasons. Most often a woman seeks breast augmentation to enhance the body contour, who, for personal reasons, feels her breast size is too small or to correct a reduction in breast volume after pregnancy. Some desire to improve an imbalance in breast size. By inserting an implant behind each breast, surgeons are able to increase a woman's bustline by one or more bra cup sizes.

Breast augmentation can enhance your appearance and your self-confidence. Before you decide to have surgery, think carefully about your expectations and discuss them with your surgeon. If you're physically healthy and realistic in your expectations, you may be a good candidate.

Possible Complications
A breast implant is a silastic shell filled with a saltwater solution known as saline. Breast augmentation is relatively straightforward. But, as with any operation, there are risks associated with surgery and specific complications associated with this procedure.

The most common problem, capsular contracture, occurs if the scar or capsule around the implant begins to tighten. If this occurs it can make the breast feel firm or even hard. Capsular contracture can be treated by removal or scoring of the scar tissue.

Complications with this procedure are possible, but fortunately, unusual. They include bleeding, infection, nipple numbness and implant leaking. Sporadically, breast implants may break or leak. Rupture can occur as a result of injury or even from normal compression and movement of your breast and implant, causing the shell to leak. If a saline implant breaks, the implant will deflate in a few hours and the salt water will be harmlessly absorbed by the body. However, the ruptured or leaking implant must be replaced. This involves opening the original incision and inserting a new implant.

While there is no evidence that breast implants cause breast cancer, they may change the way mammography is done to detect cancer. When you request a routine mammogram, be sure to notify the center that you have breast implants. Often this will mean that additional oblique mammographic views are performed. Ultrasound examinations may be of benefit in some women with implants to detect breast lumps or to evaluate the implant.

While the majority of women do not experience the above complications, you should discuss each of them with your physician to make sure you understand the risks and consequences of breast augmentation.

The Surgical Procedure
Breast augmentation is most commonly performed in an outpatient facility using general anesthesia, so you'll sleep through the entire operation. Some surgeons may use local anesthesia, combined with a sedative to make you drowsy, so you'll be relaxed but awake, and may feel some discomfort.

The method of inserting and positioning your implant will depend on your anatomy and your surgeon's recommendation. The incision can be made either in the crease where the breast meets the chest, around the areola or in the armpit. Usually the incision around the areola is less conspicuous, however, the incision under the breast is frequently hidden by the breast itself. The armpit incision often heals well, but it may be noticeable with a raised arm, and it is difficult to create an accurately placed pocket with this incision.

The implant may be placed in a pocket under the pectoralis muscle or directly on top of it. Generally, saline implants are placed behind the muscle as there is often better breast form, less chance of capsular contracture (hardening) and it helps to prevent any waviness‚ of the implant from being noticed. If you have any significant breast droopiness (ptosis), the implant pocket may need to be placed on top of the muscle. This allows the implant to fill out the breast skin and results in a better correction of the droopy breast.

Shape of the Implant
Several considerations are made in choosing a breast implant. There are round implants and also tapered sometimes called contoured or anatomical implants. Generally, for a very thin individual, a tapered implant will result in a more natural, less rounded appearance to the upper portion of the breast. However, if the implant is placed behind the muscle, the appearance is very similar.

Additionally, implants may have a smooth or textured surface. The textured implant was developed to help reduce the incidence of capsular contracture (hardening). Again, if the implant is placed behind the muscle, there does not appear to be significant differences between the implant surfaces.

You’ll want to discuss the pros and cons of these alternatives with your doctor before surgery to make sure you fully understand the implications of the procedure. The surgery usually takes one to two hours to complete. There is often a wrapped gauze dressing around the breasts for one or two days.

After the Surgery
You should be able to return to work within a few days, depending on the level of activity required for your job. Follow your surgeon's advice on when to begin exercises and normal activities. Your breasts will probably be sensitive to exercise and direct stimulation for two to three weeks.

Your scars will be firm and pink for at least six weeks. Then they may remain the same size for several months, or even appear widened. After several months, the scars will begin to fade, although they will never disappear completely.

It's Your Own Decision
For may women, the result of breast augmentation can be satisfying, even exhilarating, as they learn to appreciate their fuller appearance. Your decision to have breast augmentation is a highly personal one that not everyone will understand. The important thing is how you feel about it.

Lasers: New Technology for Skin Conditions & Tattoo Removal

We’ve all heard about the many uses of lasers in medicine. Lasers are used in surgery to destroy cancerous and precancerous tissue, to remove tissues such as tonsils with much less pain and swelling than with conventional surgery, and to remove tumors which contain many blood vessels that otherwise might be difficult or dangerous to remove.

Earlier lasers such as the C02 and Argon Lasers were also used to treat certain skin conditions such as birthmarks, tattoos, and warts. These earlier lasers had the disadvantage of leaving more scars after the treatment of certain skin lesions especially if the tissue to be removed extended deeper into the skin, as in many tattoos. The patients generally preferred the scar to the tattoo; however, since the scar had less social stigma than the tattoo. As a plastic surgeon in the military, I had abundant experience removing tattoos with these early lasers, but I was not satisfied with the scars that resulted.

Fortunately technology came to the rescue. A second generation of lasers was developed for treatment of these superficial skin lesions. Depending on the color and depth of the skin lesion, we are now able to select from a number of lasers that differ in the wavelength of light that the laser produces. When the laser light hits the brown or red skin discoloration or tattoo pigment, it is selectively absorbed. The rapid absorption of the light energy causes the tattoo ink or the pigmented cells in the skin brown spot to destruct or burst apart. The body’s natural filtering system then removes the debris. Because the surrounding normal tissue does not absorb the laser energy, the treated area is less likely to scar.

Superficial skin spots such as brown age spots, "liver spots", and freckles are usually removed with one to two treatments. Common areas that develop brown spots are the sun exposed areas of the face and back of the hands. Occasionally after laser treatments, some brown birthmarks may return after several months to a year. Elevated brown spots such as moles or lesions that may be cancerous should not be treated with the laser, but should be removed surgically so that they may be sent to a pathologist for a definitive diagnosis, as further treatment may be needed.

Red skin spots and superficial blood vessels especially on the face may be treated with the laser, which is selectively absorbed by the red blood cell hemoglobin. The overlying skin is usually left undamaged, but the superficial vessels and/or spots are destroyed. Small spider veins of the legs may be treated with the laser but generally respond better to other treatment methods, such as injection of sclerosing solutions.

Tattoo Removal
The most exciting use of the new lasers are in the treatment of tattoos. Decorative tattoos have been in vogue for at least 5,000 years and a multitude of tattoo removal techniques have been used throughout history including sanding of the skin, chemical treatment of the skin, and laser removal of the skin containing the tattoo. All treatments lead to the same problem; a scar similar to a burn scar, since most tattoos extend deeper into the skin. With the advent of this new generation of lasers that selectively send energy only into the tattoo pigment, we have seen a marked decrease in the scarring. Tattoos are either professional, where a large amount of pigment is placed using a tattoo machine, or non-professional where a small amount of pigment is placed usually using a needle. Non-professional tattoos require fewer laser treatments than professional tattoos as they have less pigment to be destroyed. On the average, non-professional tattoos required three to four treatments and professional tattoos require six to eight treatments. Usually the treatments are spaced at one to two month intervals to allow the body’s filtering mechanisms to clear out the tattoo pigment debris. Not all colors respond equally well with all lasers, but fortunately several different types of lasers are available so that most pigments will respond to one of the available lasers.

Laser treatment is usually performed in the office, requires no anesthesia, and takes only ten to twenty minutes. The impact of the laser light hitting the skin produces a sensation similar to the snap of a thin rubber band. After treatment the area will feel similar to a mild sunburn.

For treatment of brown spots the area remains reddened for two to four weeks then gradually returns to its normal coloring and texture. For red skin spots, the area typically bruises, but does not leave an open wound. For tattoos which are deeper, there may be pinpoint bleeding and an antibacterial ointment and dressing is applied to the area. A small amount of lighter discoloration and texture change is evident, which gradually improves over time. Permanent scarring is rare.

Laser treatments are usually less expensive than conventional surgery. Costs range from $300 - $600 per treatment session and are usually dependent on the amount of time the laser is in use and on the type of laser used. Insurance usually does not cover the cost of laser surgery for tattoo removal, but may cover the removal of other skin lesions depending on the particular policy.

So the next time you have to cover up those brown discolorations with make-up or conceal that tattoo that you got in your twenties, think about taking advantage of this latest development of laser technology to create healthier and more attractive skin.

Laser Resurfacing for the Treatment of Facial Imperfections

Did you ever look in the mirror only to see your facial imperfections, such as wrinkles, dark spots, blemishes and acne scars staring back at you?

We now have a new laser technology that removes the outermost layer of the facial skin very selectively. When the new skin grows back, in five to fourteen days, this skin is smoother and less likely to have such prominent surface irregularities.

The areas that are most effectively treated with this technology are wrinkles, pigment irregularities and acne scars. Other blemishes such as raised moles, broken vessels and large pores are better treated with surgery, other laser technology or skin care programs utilizing Retin A and glycolic acid. Usually a skin care evaluation by the plastic surgeon can effectively identify which techniques are best to correct the problem areas that are of most concern to you.

If laser resurfacing is recommended then often Retin A is applied to the facial skin each evening after removal of makeup, if worn, for several weeks prior to treatment.

Areas of the face to be treated are identified. Choices include the entire face, the cheeks, the area around the mouth and the area around the eyes. Treating large areas often requires anesthesia to sedate the patient. Local areas may be done without anesthesia in select patients.

After treatment, a tape dressing is applied and remains in place for three to seven days. Discomfort is minimal as long as this tape remains in place. Healing is usually complete in five to fourteen days although the skin must be protected from ultraviolet rays for several months after surgery. At first the new skin is more delicate and often reddish in color for two weeks to two months after treatment. Occasionally, this reddish tint may last up to six months usually with more extensive treatment in certain patients with skin types susceptible to this redness.

Laser resurfacing is safest in patients with fair skin and is more likely to have prolonged redness in patients with deep wrinkles. Creams can be used to decrease the redness and makeup can be used to camouflage the redness. Patients with olive or pigmented skin have a risk of discoloration of the skin that is resurfacing the face.

After the new skin heals and has time to mature, the surface is smoother and often has less pigment variations.

With the use of an effective skin care program to help maintain this improved skin surface and of course sun blocks to help prevent further sun damage to the skin, you can now face the mirror with a more vibrant and youthful appearance.

Avoiding End Hits In Ultrasound-Assisted Lipoplasty

A potential disadvantage of ultrasound-assisted lipoplasty is tissue burns. These may occur when the tip of the probe hits the undersurface of the skin. These "end hits" occur when the tip of the probe is vertically oriented to the skin surface, and they are more likely to happen when the surgeon is trying to go around the sides of the patient from centrally located access incisions.

To help avoid hitting the skin’s undersurface around the lateral aspect of an area being treated, a lateral meridian is drawn before surgery with the patient standing. The surgeon should not cross this lateral meridian when working in an anterior direction from the central access incisions with the patient in a prone position or when working in a posterior direction with the patient in a supine position. The prone position displaces this lateral line posteriorly, whereas the supine position displaces it anteriorly because the operating room table pushes up against the patient’s body.

The surgeon’s non-dominant hand assists by rolling tissue toward the probe so that its tip does not approach the skin in a vertical orientation. Early in my experience, I would sometimes push the probe too far around a contour. The surface orientation provided by the lateral line has helped prevent that problem so the tip of the probe is not perpendicular to the skin.

I limit access incisions to well-concealed sites. One or two incisions at the superior border of the escutcheon or umbilicus for the anterior abdomen and lateral flanks, and one at each of the lower lateral borders of the escutcheon for the inner and outer thighs have been adequate when the patient is in the supine position. Incisions on either side of the spine and in each buttock crease have sufficed to treat flanks and thighs with the patient in the prone position.