BREAST PROCEDURES

BREAST AUGMENTATION

Can I have silicone gel implants instead of saline filled implants?

As of November 17, 2006, the FDA has approved the use of silicone gel implants for patients that desire a breast augmentation. Patients have to be at least 22 years old to receive the gel implants for primary breast augmentation. So now along with the saline-filled implants, there are even more implant choices for patients desiring a breast augmentation.

What incision can be used to place the breast implants?

There are many different ways to perform breast augmentation. The incision can be placed in the armpit (transaxillary), under the breast (inframammary), at the border of the areola and breast skin (periareolar), through the umbilicus (transumbilical), and even through an abdominoplasty incision when performing an abdominoplasty (transabdominal). Each location has its pros and cons.

Will I have normal nipple sensation after the surgery?

Many patients will have some change in sensation after the surgery; this is often due to swelling that usually resolves after 4-6 weeks. However, about 15% of patients will have a change in sensation that persists after 1 year.

Does the choice of incision location affect nipple sensation?

There have been no scientific studies to prove that incision location affects sensation. However, many plastic surgeons postulate that sensory changes may be related to the size of the implant used. That is, the larger the implant the more likely sensation will change. This may be due to the stretching of the tissues in the pocket that needs to accommodate the larger implants, and therefore stretching the sensory nerves may affect the function of these nerves.

Will I be able to breast feed?

It is difficult to predict whether or not an individual will be able to breast feed after augmentation. Some women who are very small breasted to begin with can produce a lot of milk, while some very large breasted women cannot. Inevitably during surgery some of the parenchyma is divided to create the pocket for implant placement. However, there are many patients who can breast feed. Again, this depends upon the individual patient.

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BREAST LIFT

Why do my breasts sag?

As a patient grows older, the breasts begin to sag. They will sag more with large weight fluctuations. Similarly hormonal changes during pregnancy cause the breast to become engorged. After childbirth is complete, the breasts deflate. This is analogous to a balloon that is blown up to capacity. The air slowly leaks out of the balloon and the skin of the balloon becomes weaker.

If I have a breast lift operation will I have a lot of scars?

It really depends upon what the breasts look like and what the patient desires from the surgery. If the patient wants more volume and the breasts do not sag too much, then a breast implant through a small incision may be all that is required to make the breasts look better. On the other hand, if the patient wants a lift and no increase in volume, then a limited incision breast lift technique can be employed. This includes vertical breast lift operations, which limit the incisions to a lollipop appearance (a circle around the border of the areola and a vertical line from the lower border of the areola to the inframammary fold). Sometimes the incision can be limited to the area just around the areola.

What if I decide to have more children? Can I still have this surgery?

I usually instruct patients to delay having a breast lift until they have completed their child bearing. The breasts will go through the same changes as they did with other pregnancies. The breasts may or may not stay "lifted," so it is probably best to wait.

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BREAST REDUCTION

I have bra strap grooving, neck and back pain. Will my symptoms go away with a breast reduction?

Patients with very large breasts often have symptoms of neck and back pain and bra strap grooving. Many times these symptoms will improve after a breast reduction.

Most people I know that have had a breast reduction have an "anchor" type incision. Are there techniques to limit the amount of incisions?

For many patients I have been using a limited incision approach that creates a "lollipop" type of closure (a circle around the border of the areola and a vertical line from the lower border of the areola to the inframammary fold). In other words, the entire inframammary incision of the "anchor" type of wound closure is eliminated! This can be done for most patients except for those with excessively large breasts requiring more than 2-3 pounds of tissue to be removed from each breast.

Will I be able to breast feed after surgery?

It is difficult to predict whether or not an individual will be able to breast feed after breast reduction surgery. Some women who are very small breasted before surgery can produce a lot of milk, while some very large breasted women cannot. Inevitably during surgery some of the parenchyma is removed. There are many patients who can still breast feed. Again, this depends upon the individual patient.

Will I have normal sensation in my nipples after the surgery?

Many patients will have some change in sensation after the surgery. Some patients with excessively large breasts do not have sensation in their nipples before surgery. In fact after breast reduction surgery some of these patients recover nipple sensation although the etiology is not well defined. However, there are a percentage of patients who will have diminished sensation that persists after 1 year.

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BREAST RECONSTRUCTION

What is a TRAM flap?

A transverse rectus abdominis myocutaneous flap, or TRAM flap, is derived from the lower abdomen. It consists of the skin and underlying fat of the lower abdomen, usually from just below the umbilicus to the pubic region, the same tissue that is normally discarded during a "tummy tuck." This is a pedicled flap; the lower skin and fat have attachments to the underlying rectus muscle and its accompanying blood supply. The blood supply is not cut and reattached elsewhere on the body as with a free flap. The TRAM flap is placed onto the chest to reconstruct the breast. This is often a very natural feeling mound of tissue that is molded into a breast. At the same time, the patient has the benefit of having a "tummy tuck" as well.

Am I a candidate for a TRAM flap?

A good candidate for a TRAM flap has a mound of lower abdominal fat that can be raised to create a breast. If the patient is very thin and has no subcutaneous fat on the lower abdomen then there will not be enough tissue to create a breast. In addition if there is a large discrepancy between the size of the breast on the non-operated side to the amount of available abdominal tissue, decisions have to be made to either recruit more tissue from the abdomen or make the non-operated breast smaller at a later time. Some medical conditions also affect the ability to perform this surgery. Therefore, patients with unregulated high blood pressure, poorly controlled diabetes, and obesity may not be good candidates. In addition, smokers are poor candidates unless they stop smoking for several weeks prior to surgery.

What about a free flap?

Free flaps are tissue mounds that are detached from their original blood supply and reattached to another blood supply somewhere else on the body. There are many types of free flaps that can be used for breast reconstruction including the free TRAM, the deep inferior epigastric artery (DIEP)perforator flap, superior gluteal artery perforator (SGAP) flap to name a few. These flaps usually bring in more tissue to the chest than those brought in as pedicled flaps, or flaps that are still attached to its original blood supply.

What is a Perforator flap?

A perforator flap is a free flap that incorporates the overlying skin and subcutaneous fat with the perforating or piercing artery and veins. Traditionally, free flaps that were used for reconstruction included the skin, the subcutaneous fat, the underlying fascia, and muscle. Perforator flaps require a greater expertise in harvesting and provide a more specialized tissue reconstruction usually without incorporating any muscle in the flap.

What is a DIEP flap?

A deep inferior epigastric artery perforator (DIEP) flap is a free flap that is similar to a free TRAM flap without taking any muscle. So for breast reconstruction, this means that the tissue that is normally removed in a tummy tuck (the lower abdominal fat and skin) is carefully harvested from the lower abdomen along with its perforating vessels and re-attached to vessels in the chest to perform breast reconstruction. The beauty of this operation is that the underlying rectus muscle is not removed. Therefore, it has been shown to decrease the incidence of lower abdominal bulges that have plagued some of the other breast reconstructions using the lower abdominal tissue. Furthermore, some studies have shown that abdominal muscle function has been better maintained with this operation than with some of the others (i.e. free TRAM, or pedicled TRAM). In addition, there have been some studies that have shown that these patients also have less post-operative pain. The resulting donor site scar is similar to a tummy tuck scar.

What if I do not have enough tissue in my lower abdomen to perform a DIEP flap?

The superior gluteal artery perforator (SGAP) flap and the inferior gluteal artery perforator (IGAP) flap are two possible alternatives to the DIEP flap if there is not enough tissue on the abdomen to use for breast reconstruction. The tissue used for these flaps comes from either the upper lateral buttock roll or from the lower lateral buttock roll. The beauty of these two flaps is that again muscle is not usually taken with the harvesting, and the resulting buttock scar usually heals extremely well and is often hidden within the underwear or bathing suit line.


Can't I just have breast implants?

Yes, in fact sometimes this is the best option. Patients who are not good candidates for a TRAM flap or free flap are usually still candidates for an implant reconstruction. Commonly a tissue expander has to be placed first to expand the chest pocket. This is a balloon that needs to be filled periodically with sterile salt water. After several months of stretching the tissue with an expander, the expander is then replaced with a permanent breast implant.

What if I need radiation treatment after surgery?

Recent articles in the plastic surgical literature suggest that reconstruction should be delayed in this case. However, it is not always known if radiation will be necessary until after the surgery is completed and the final pathology is known. If a reconstruction is performed and then the patient requires radiation, there is an increase risk of changes to the reconstructed breast that may require revision.