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Breast

Breast

Arguably, the female breast has been historically and is still today the symbol of femininity.  Without question its size, shape, and loss from cancer can have a dramatic impact on how a woman feels about herself.

This page describes the four common plastic surgery operations dealing with the breast.  Be sure and see the before and after photos for examples.

Breast Augmentation

Breast size is a “beauty in the eye of the beholder” concept.  Some women enjoy their breasts being small.  However others desire volume they never have had, or volume they lost due to pregnancy, nursing, or weight loss.

The surgery involves inserting an implant under the breast and usually under the muscle beneath the breast.  ALL breast implants are essentially a silicone “balloon” filled either with saline (salt water) or silicone gel.  Testing was reviewed by the Food and Drug Administration that showed them to be safe, and the gel version was re-released back on the market in 2006.  They are more popular than the saline implants because they feel more natural and have less rippling.

I feel strongly that every woman needs to be aware of the negative aspects of breast implants.

The first issue is leakage.  Much as in the same way you can wear out a paperclip by bending it repeatedly, the shell or envelope of the breast implant repeatedly bends and over time, wears out and develops a hole.  It may take 10, 15, 20 years, or more for this to happen.  This is true with saline or gel.  If the saline leaks, the body absorbs it and the implant goes flat on that side.  If it is a gel implant, the scar around the implant traps the leaking gel.  While you may not know if it has leaked, the gel is trapped by the scar and does NOT go to other places in the body.

The second issue is cancer screening. The implant device takes up space and can interfere with mammograms making the need for ultrasound or MRI more likely.

While I customize the procedure to the individual woman, most of the time I recommend an incision at the lower edge of the breast and suggest the top of the implant be under the muscle and the bottom edge of the implant be under the gland to help in hiding the top edge of the implant while giving a natural profile to the bottom of the breast.

The major question for most women is the size of the implant.  Internet photos are helpful, but a woman’s height, weight, and frame make a difference.  Size selection was difficult for both surgeon and patient.  Historically we tried stuffing implants in the patient’s bra or  having her do homework by measuring rice in plastic bags and stuffing them into her bra. In either case, you could not see the breast shape change and everyone agreed it was not very accurate.

I was equally dissatisfied with this sizing process and therefore invested in the Vectra 3D imaging system in Feb 2009.  This device takes 6 pictures of you simultaneously and then the computer draws a 3D reconstruction of your breast from shoulders to waist.  The computer can simulate the placement of the implants.  More importantly, the computer knows the dimensions of implants of all sizes so we can “try them on” and view estimates of how YOU would look with that size!  Check out the Vectra page for more details on this technology. 

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Breast lift or Mastopexy

Sometimes after pregnancy, major weight loss, or with routine aging, the volume of the breast may remain acceptable, but the shape becomes too elongated, saggy, or droopy.  A way to think about this is that the “container” (the skin) is too large for the “contents” (the breast tissue itself).

One solution is to add volume by having a breast augmentation and “fill the container”.  However, if the nipple is below the bottom edge of the breast, filling the breast with an implant tends to push the nipple even lower and gives a poor result. A better choice is to remove skin and reduce the size of the container and at the same time reposition the nipple to the front of the breast.

There are numerous breast-lifting procedures (crescent mastopexy, doughnut mastopexy, lollipop mastopexy, vertical mastopexy, and inverted T or anchor) and they all have a role depending on the degree of drooping.  As a general rule, mastopexy is a trade of getting scars in return for better shape.  The more improvement needed to improve the shape, the more scars it will take to get the improvement desired.

Smaller mastopexies can be done in the office with local (Novocain) anesthesia while the larger ones require general anesthesia in the operating room. 

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Breast Reduction

Some women have large heavy breasts, which puts a strain on their shoulders, neck, and back.  For many of these women, a supportive bra is not sufficient and reducing the weight of their breasts is a consideration.

Conceptually a breast reduction is two operations at the same time.  One is to go into the breast and remove tissue to reduce the weight (and at the same time the volume).  With this lower volume, there is a excess of skin creating a skin / volume mismatch identical to the conditions which need a mastopexy, so a skin reduction is the second part of a breast reduction.

With appropriate documentation from my office and particularly your primary care doctor, insurance can often cover the procedure when the amount removed is in excess of 500 grams (a bit more than 1 pound) [ Note- Medicare requires more: 700 grams]. 

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Breast Reconstruction

It is impossible in a website article to do justice to the important and complex topic of breast reconstruction.  Nevertheless, I will try and give an overview of the topic.

Two groups of woman come in to be educated about breast reconstruction.  The first are women who have had a mastectomy in the past.   The second are the women who have a diagnosis of cancer now and are going to require surgery either a lumpectomy or a mastectomy and want to consider starting their reconstruction at the same time as their cancer surgery.

The first group are considered delayed reconstruction and commonly seek reconstruction for one of three reasons: 1) they dislike their bra riding up their chest with no breast to hold it in place, 2) they fear or have experienced their breast prosthesis falling out, or 3) they feel they have lost their “wholeness” as a woman.

For the second group, I emphasis that while reconstruction is important, the priority is to have a good and appropriate cancer plan including surgery, perhaps chemotherapy and / or radiation therapy.

As a generality, there are 2 operations to treat breast cancer:  Mastectomy and lumpectomy (or partial mastectomy depending on amount of tissue removed).  The decision about which choice is best is made by the woman and her breast cancer surgeon.

If a mastectomy is required, nationally 80% of the reconstructions use some type of breast implant.  This leaves 20% to be some tissue rearrangement operation using tummy tissue, back tissue, or removing a piece of tissue completely from the woman, moving it to the chest area and then reconnecting the blood vessels with the operating microscope.  This disconnect and reconnect procedure involves microsurgery and is categorized as a free tissue transfer.  A common type of this surgery for breast reconstruction uses the lower abdominal skin and is called the DIEP flap.  Currently no one does microsurgical free flap breast reconstruction here in the Valley.

The other breast needs to be considered as well.  Depending on its size, shape, and cancer risk some woman choose a preventative prophylactic mastectomy and therefore need bilateral reconstruction.  Others women may need a lift or a reduction on the other breast to create a balance between the reconstructed breast and the natural remaining breast.

Reconstruction for lumpectomy or partial mastectomy can range from doing nothing, some intra-breast stitches, an implant,  a breast lift or a breast reduction. 

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