I try to answer this question by explaining the purpose of implants with different “profiles”, and why this is a confusing and badly named system. I prefer the descriptions moderate, narrower and narrow base…read on…

important dimensions for breast augmentation

Post op 11 years

Most plastic surgeons today use an approach to size that takes into account more than volume (cc’s). But most patients ultimately think  volume=size after hearing and reading about everything else.  (“My friend had 350cc’s and I like her’s”).

Implant volume is only one factor. How much breast tissue  you have before surgery is very important. The shape of your breasts before surgery is the most important factor determining the shape of your breasts after surgery.

Beyond implant volume and your natural breast shape and volume there are the dimensions of your chest. We try to fill the space between the edge of your armpit and the side of your breastbone to give as natural/ beautiful a look as possible.

Here is where moderate profile, moderate plus profile and hi profile (Mentor Medical’s terms) plays a role. If your chest is relatively narrow, and you ask for a relatively large volume, to fit that volume onto the space available, we need to use a higher profile  ie narrower base implant.

On the other hand, if you want a modest implant size and your chest has a greater width, you will need a standard “moderate profile” implant to fill the space out and not have too narrow an implant with too much mobility when you lie down.

During the initial consultation I take  certain measurements that are useful in the sizing process. We look especially at the distance from the nipple to the crease under the breast (NAC – IMF) and the base diameter (distance from breast bone to armpit edge), as well as how far the nipple is from the top of the breast bone (SN – NAC)

When my staff and I size my patients for breast augmentation, we want to fulfill an idea each  woman has in her mind, of her ideal. Sometimes this isn’t possible because her desires aren’t realistic, but usually we come pretty close.

Generally speaking, we try to get an idea of what size you have in mind first, by putting you into a standard bra of the band width and cup size you desire. The band width is what you  should be wearing now, though many women wear the wrong size according to professional bra fitters. Your natural breast occupies some of the bra cup, but the cup is partly empty. Then we fill the bra cup  to the degree of fullness you desire using an inflatable device and measure the volume we have added. Most of the time we add enough volume so you feel it is too much and then reduce this slightly. For some women, who fear being too large we add only enough to make her feel comfortable.

If the volume you desire is high, so that a moderate profile (ie. normal diameter) implant wouldn’t have enough room, we use a narrower base/ diameter implant. I may choose a mod plus or a high profile implant, depending on the volume and base diameter as well as the nipple-to-crease dimension.

While all this sounds terribly complicated, it really comes down to a matter of balance. We balance the volume desires with the physical dimensions and come up with the best possible combination of those factors. Sometimes this may mean adjusting the volume of the implant up or down a little, and the final decision on  exactly what implant needs to be used will be one I will need to make. Ultimately, it will be with the aim of giving you the greatest chance of satisfaction.

For years I have encouraged both him and his parents to switch to Apple products (after numerous visits trying to help with their struggles to integrate their photos, music and other files on their home PC). Why do people who will spend tens of thousands of dollars on expensive cars hesitate to  spend a few hundred extra on a computer that will make their lives easier than the alternative (and last longer, ultimately costing less)?

A few of our Apple devices, from the old SE( top left) through MacBook pro, ipod, Ipad, IPhone 4

I told my nephew, Sam, how twenty two years ago, after a six month struggle with an Olivetti word processor, an accountant friend sold me a used MAC SE 6800 computer and changed my life.   Reading Walter Isaacson’s biography “Steve Jobs” over the Xmas holiday,http://authors.simonandschuster.com/Walter-Isaacson/697650   I was profoundly struck by how the advances in the Mac since that first SE paralleled the rapid development of my practice. First with the sheer ease of use that first computer introduced, then in 1992 with a MAC CI and a video capture device and Photoshop we gained the ability to do videoimaging (digital cameras were then over $16000 and only used by professional news photogs).

Later, it was on the old SE that I wrote the first edition of my book: Cosmetic Plastic Surgery, A Patient’s Guide, usually with my black lab KD at my feet, and often with one child in my lap. There were the “think different” ads in the late 90′s, which appealed to any innovative person. We bought the very first iMac for our front desk in the old office (they looked like an extreme speed skier’s helmet). We insisted on a Mac- only office when everyone was telling us the brand was dead.

When the first iPod came out and I saw the ads featuring a classic image of Hendrix, I said ” I want one of those”. Though I practiced self denial on that one, for a while, a few months later someone I love dearly gave me a 10gig Ipod for my birthday. I still have the original with the wheel, which actually rotates. The other day I booted it up…still works. What really struck me (and I am far from alone, which is why my nephew says one out of three people was reading the Isaacson biography around the pool where he was vacationing during the holiday season) was the most arresting visual of the keynote address Jobs gave to introduce the iPad in 2010. Apple, he said (and I now know he was paraphrasing Edward Land, inventor of the instant “Polaroid” camera) has always been at the junction of  Liberal Arts and Technology. Behind him was a visual  showing street signs  labelled “Arts” and “Technology”.

Jobs at the intersection of Liberal Arts and Technology "streets"

In my application to medical school in 1973, I had written (we had to write a short essay as to why we wanted to be doctors)  something uncannily similar. I saw medicine as a way of combining my interests in both Arts and Sciences.  I had done my pre-medical requisite courses while enrolled in the UBC faculty of Arts, and while also studying Philosophy, History,  Sociology and “majoring” in English.

Plastic Surgery, when I finally encountered it during my first post-medical school year as an intern, struck me suddenly, as the ultimate junction of arts (humanities) and  science. Until I heard Jobs speak, and realized he was truly at that nexus. Everything in the “Apple universe” was infused with his idea of beauty , grace, and an effortlessly integrated user experience. This was an ideal which could only come from someone with deep insight into both the liberal arts and technology.

As Walter Isaacson says, the commencement address Jobs gave to Stanford University’s graduating class in 2005 is one of the most profound and inspirational addresses ever given. If you haven’t seen it, get  it on youtube or however you can. http://www.youtube.com/watch?v=D1R-jKKp3NA I am late in writing something of a tribute to Jobs, with this blog coming months after his tragically early death. I was profoundly affected, reading his biography.

The world is a lesser place without him and we are all affected in ways we will appreciate more  as the years go by.

Any responsible professional or business today wants to know the answer to the important question, “How are we doing?”

This is especially true when we serve the public, and  that is why we are frequently interrupted at dinner by telephone surveys wanting to know about our “recent customer experience”.

In my practice of cosmetic  plastic surgery, I serve the needs of my patients, in many ways, attempting to fulfill their dreams of looking and feeling their best, while attending to the need for safety and consistency as much as possible.

For years, we have surveyed our patients after their surgery in our surgical facility. Our reception area has a large  book filled with cards expressing appreciation, not just for my surgical  results, but also for the kind and attentive manner my staff have given to the thousands of patients who have been under our care.

The British Columbia College of Physicians and Surgeons no longer allows any form of advertising, including websites, to contain testimonials from patients.

The Internet does provide a forum for exchange of ideas, and we are all familiar with reviews of hotels, restaurants, and other service industry businesses. Medicine is subject to the same kind of online discussions on various sites.

Some of these sites are reputable, but one in particular, is not, and has been found to be engaging in destructive and unscrupulous practices.

RateMds.com

While I support the idea of online reviews, what has been occurring on “RateMDs.com”  is unethical and does not contribute to the purpose of the internet: exchange of information in a free and unfettered fashion.

Many of our patients who were thrilled with the care we delivered and wrote reviews on this site have had their postings removed, most recently with the note “as SPAM” attached, while negative reviews are left posted.

Until recently I thought I might have been the first to have been affected, or the first to notice this, but the following link made me aware there are other doctors affected similarly:

Rate MDs and Manipulation of Review Status

The owners of RateMDs do not respond to email inquiries and clearly have an interest in what used to be called “muckraking” and reputation destruction.

We are not the first to raise this as an issue. A quick Google search reveals dozens of angry doctors and patients, and digging a little deeper reveals whole message boards filled with people who feel that RateMDs.com is not providing fair information:

Fortunately, most patients are more intelligent and recognize when they have been recommended to a certain surgeon by many friends, the online reviews posted on this site are biased.

Alternative Review Sites

If you are looking for Canadian plastic surgeons I would suggest you look at

plasticsurgeryinfo.ca

and

canadaba.ca

( specifically for breast augmentation )

Google reviews are also less likely to be tampered with.

I would also add I have heard some of the sites devoted to restaurant reviews and hotel reviews are notoriously corrupt and subject to manipulation.

What are the consequences of implant leaks?

I have heard I need to change my implants every ten years. Is this true?

I have been asked these questions ever since I started in practice and my answer has never varied.
It is not unusual for patients to consult with me and ask me if they need to have their implants changed at regular intervals. Usually a time of ten years is cited but I have heard every eight years and even as often as every five years.
Until recently I did not know why this was such a common question but I now know there are surgeons practicing even within my community who tell patients they need to have them changed at routine intervals.
I am far from alone in believing this is utterly false and misleading. A quick search for answers on this question reveals many surgeons blogs and commentary, all of which is generally in agreement with my views.

I believe the chances of implant leakage is very low for many years, only rises gradually over time, and that operating on otherwise well patients without a reason when they have an other wise satisfactory result, exposes them to risk, and expenses which are entirely unnecessary. The only benefits are to the plastic surgeon.

There is no scientific literature to support regular implant exchange, nor does the manufacturers’ product literature suggest this.

This is in spite of the fact we never suggest implants will last a “lifetime”. The risk of leakage in the first ten years is very low probably less than 5%, and only rises gradually over time. A leak in a saline implant results in saline being quickly absorbed; the body is 70% composed to begin with, and the resulting loss of volume( size) makes a leak obvious, without any special tests.

Leaking silicone implants are no longer even suspected of causing diseases as they were accused in the late 1980′s and early 1990s.

But the diagnosis of a leaked silicone implant is more difficult to make than saline. Generally there will be little or no external sign of a leak, and it is for this reason in the USA the FDA requires all patients with silicone containing implants to undergo regular MRI exams to screen for leakage ( mammograms and breast ultrasound are of limited value in screenings for leaks). However Canada, like Britain, France, Germany, Australia , New Zealand and other countries with similarly advanced medical systems like ours, do not feel this kind of screening for leaks is needed. I generally suggest an MRI be considered at about 8 – 10 years after surgery although in the future advances in technology will likely make some other less costly technique satisfactory.

If the implants are intact…leave them alone. Unless you have another good reason for surgery.

Below are links to the two approved manufacturers of implants. From their sites you can download their product brochures which give extensive information.

http://www.mentorwwllc.com/global-us/FDATraining.aspx
http://www.allergan.ca/products/natrelle.htm

At times over the past 15 years, I have had patients ask me about comments they have heard from other plastic surgeons suggesting this was an unsatisfactory approach to the operation for a variety of reasons. One reason they have been given was that secondary surgery, if needed, must to be done through  a traditional incision under the breast. This is just not true, in most cases.

This argument is usually put forth by those who have no desire to use the armpit approach, and does not recognize the advantages it has to the patient. The first flaw is that secondary surgery today, in breast augmentation, is far less frequent than it used to be. If you can be augmented without leaving scars on the breast at all, there is a clear benefit. The second flaw is that even if secondary surgery is needed it may be possible to do so through the original armpit incision.

We have had enough experience with  secondary surgery to increase implant size to consider it a first choice in patients who have undergone prior augmentation from this incision.

Capsular contracture has fortunately become a relatively rare event, since  the mid 1990’s when the placement of implants in the “partial submuscular” location became routine. However, we still need to treat the occasional patient for capsular contracture Fortunately, we are usually able to successfully do so through the armpit, and usually with the implant left in place while manipulating the telescope and instruments around in the implant space.

The following case is just such an example:

Pre-Op

Post-Op

Several months after surgery, she developed capsular contracture. The second image shows the unfortunate development of a contracture with the implant displaced upwards several months after her initial procedure.

Final Result

After endoscopic capsulotomy ( expansion of the space) there is dramatic release and improvement of her shape ( and the degree of softness). Still without any incisions or scars on the breasts.

Like arthroscopic knee surgery, trans-axillary breast augmentation was a significant refinement when it was introduced in the mid-1990s. While,  when conditions require, I continue to do traditional breast augmentation through the incisions under the breast , the armpit approach continues to be my preferred route. At the same time, I tell all my patients there is no perfect way of doing any operation, and my colleagues using traditional incisions are also doing excellent work.
Ultimately the choice of incision in up to you, the patient. I can only give you the best advice possible, including an experienced opinion about the trans-axillary route.

One of the most common questions in my practice is often asked the day after surgery:
“How soon can I go back to the gym?” or “how soon can I …(play tennis/ski/swim/run/etc)?”

The answer to this, like most things, is “that depends”. It depends on how smooth a post-operative course you have, and also, what you will be doing. If you are like the vast majority of breast augmentation patients and experience a routine recovery, we usually let you start gently and ease back into your routine of sports and exercise over a period lasting weeks to several months.

Most of our patients are fit and involved in many activities involving upper body movement, from water skiing to mountain biking and from vigorous gym workouts to fitness competitions.

As a general rule, we suggest a light aerobic workout without raising your pulse over 100bpm and without flushing in your face at 7-10 days (stair master, stationary bike or treadmill, brisk walking). You can add light isolated biceps exercise at three weeks. Crunches and other basic core activities can be done at four weeks.

When to start upper-body exercises

I suggest waiting until six weeks to begin pec major actions such as chest presses, lat pulldowns and push-up like activities. These should begin light, and build gradually.

Pushups should be done first off the knees, and reps built up to three sets of 20; once this is achieved you may go to off the toes, beginning with fewer reps and again building them up. Similarly, chest presses should be done at first with very light weights.

Any development of pain where the pec major muscle joins the breast bone should be treated like any overuse injury: back off on the exercise, rest, ice if needed,and re-introduce the activity gradually.
You can interpret the above guidelines to help guide you for your favorite sport.
If you have any specific questions, please do not hesitate to ask us.

Another Approach to Exercise after Breast Augmentation

The following video taken from YouTube shows a series of exercises recommended by Chicago-based Cosmetic Plastic Surgeon Otto Placik. Please contact us to see if these types of exercises will be right for you.

Otto Placik MD. a board certified Chicago Illinois based plastic surgeon presents Post breast augmentation enhancement enlargement implant surgery arm range of motion exercises to passively stretch the pectoralis muscle and minimize muscle spasm and pain.

Here is the chemistry… A pound weighs 454grams. (I’m going to get a little complicated here) A gram of fat contains nine calories of energy( a calorie is a chemists measure of energy). Each pound, therefore, contains 9×454= 4086 calories. Most aerobic activities consume 200-500 calories per hour. The most demanding, such as skipping rope, and the skate type of cross country skiing might use 600-800 calories per hour, but swimming, running, stair master, rowing machines etc. are less. At 200 calories per hour you would need 20 hours in the gym to lose a pound!!!!!!! By contrast if you take in too much you will put on weight rapidly. If you only consume 200 calories daily more than your energy requirements you will put a pound on every three weeks (21×200=4200calories). http://www.nutristrategy.com/caloriesburned.htm

Alcohol consumption influences your weight, but not in the manner most people think. Though there are (carbohydrate) calories in alcohol (derived from fermentation of sugar) and the caloric content varies from one type to another (beer, wine, spirits) the actual caloric content of the drink is less important than what the alcohol does to your metabolism. Beer contains about 150 cal/serving, wine about 100 and spirits about 200 calories per serving, but this is increased in mixed drinks by the “ mixer” which will have varying amounts of sugar and other sources of calories. Your brain runs on glucose, the elemental sugar. This sugar comes from immediate blood glucose( what you have floating around in your blood), sugar stored as liver and muscle starch (glycogen), and protein/fat conversion to sugar through intermediate metabolic routes, mostly done in the liver. When your liver is busy metabolizing alcohol, it can’t do much in the way of providing sugar for your brain. You get hungry!!! This is why cocktails are traditionally used to stimulate appetite before dinner. While your liver is occupied with its “load” of alcohol, most of your food intake is routed to storage (fat) for later conversion. It is not a very efficient way to run the body. Drinking makes you consume far more than the actual calories in the drink.

The third key point I like to make about diet is that people who eat breakfast consistently tend to have better weight control. Though you may say you don’t feel hungry in the morning this is likely because you are consuming too many calories at night, which are incompletely digested by morning. If you then skip breakfast by mid-morning and after coffee ( which jump starts you metabolism and increases the effects of adrenaline) you are in starvation mode and you spend the rest of the day trying to catch-up…a vicious cycle has begun!
For a very good discussion about the issue of weight control and exercise read Leslie Beck’ s column from the Globe and Mail, April 19 2011: http://www.theglobeandmail.com/life/health/new-health/health-nutrition/leslie-beck/cant-lose-weight-these-diet-blunders-may-be-to-blame/article1991153/

BMI A relationship between height and weight is widely used as an index of normal vs abnormal weight. You can be just as unhealthy by being underweight as you can from being overweight. BMI is a calculated value based on weight (pounds)x4.88 divided by height (feet) squared Normal is considered to be 18.5-25, underweight below 18.5; overweight 25-29; obese 30-35; and morbidly obese 35 and over. By the way, the old saying “<em>you can never be too rich or too thin</em>” isn’t true either. Being too thin can lead to health problems as well.
In 2006 Spain banned “waifs” from runway modeling Because of the rising risk of major complications of surgery with BMI greater than 30, I do not operate on patients with a BMI over 30. This sometimes is upsetting to patients who really would like surgery to be part of the solution to their weight problems, but I feel it is my responsibility to do what I consider to be safe surgery and ignoring the increasing probability of serious problems over a BMI of 30 is like driving considerably over the speed limits. Sure, the chance of a major accident aren’t much higher driving 120 kph on a straight stretch of highway in good weather conditions and daylight. At 140kph the increased risk starts to feel real. At 160, it is palpable and passengers will be truly scared. Etc. I have operated on many patients over the years who have seen me with borderline or even well established obesity initially and have, after a discussion about nutrition and exercise gone home developed better eating habits, gradually reduced their weight, and returned for surgery as better prepared and healthier patients several months or a year later.
You might want to look at this page on Divine.ca regarding BMI as well http://www.divine.ca/en/fitness-and-nutrition/body-mass-index/c_28/
Both of the following links may also be helpful
http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm
and:
http://www.hc-sc.gc.ca/fn-an/nutrition/weights-poids/guide-ld-adult/cg_quick_ref-ldc_rapide_ref-table1-eng.php

In the morning they would have been fasted since midnight the night before, and were taken by stretcher down long corridors and tunnels and up elevators to the Operating Room suite, where they would inevitably wait, cold and scared, on the stretcher for their time to be taken into the room where their surgery was to occur. Often there were scowls of disapproval from nurses and doctors who were there for “necessary surgery”

But esthetic surgery patients at the public hospitals were increasingly given lower priority both by the administration, resulting in difficulties in scheduling and by the hospital staff, who were busy dealing with increasingly sicker patients. Today, most surgery is done on an out–patient basis, and nearly all esthetic surgery is done in private clinics. Non-hospital facilities have grown in popularity because of reduced cost, more efficient service, and specialization in the care of the ambulatory patient.

But to carry out safe surgery without all the massive backup a hospital provides requires meticulous planning and screening, because once the day of surgery arrives, it is difficult if not impossible to get blood tests and other reports.

With the move away from the hospital, came a new need for standards. In the U.S.A., the American Association for Accreditation of Ambulatory Surgical Facilities and in Canada, the Canadian Association for Accreditation of Ambulatory Surgical Facilities were formed to ensure quality and patient safety. In British Columbia, the College of Physicians and Surgeons began an accreditation programme in the late 1980’s which continues to work towards high level inspection and accreditation standards.

https://www.cpsbc.ca/about/accreditation-programs/nhmsf/public-information

In the mid-1990’s, similar accreditation was begun in California; but most states and provinces still did not have such standards. Later, with the lack of regulation in some jurisdictions, numerous catastrophic complications occurred, necessitating tighter regulation which has followed gradually. Today, all members of the American Society of Plastic Surgeons must only operate in certified facilities. This does not mean the standards for accreditation are everywhere equal. In Canada, British Columbia and Alberta have led the way in establishing standards which are the equal or exceed those in public hospital institutions, and Ontario is finally rapidly closing the gap subsequent to a widely publicized and  an unfortunate liposuction associated death, at the hands of a general practitioner ( see How to choose a surgeon) and the inquest which followed.  but in some parts of the patient should check to ensure the facility is certified by a provincial certifying body,  the CAAASPF, or, in the USA, by the AAAASPF, the AAAHC, or the JCAHQ or a State facility accreditation body.
See: http://www.plasticsurgery.org/Articles-and-Galleries/Patient-and-Consumer-Information.html

Regardless of whether the surgery is done under general anaesthesia (the patient completely unaware of the surroundings) or local anesthesia with sedation (“twilight” anaesthesia in which the patient is less aware of the surroundings but able to respond to spoken orders), the patient will be asked to eat and drink nothing, except, perhaps, approved medications, for several hours prior to surgery. (Usually  nothing to eat or drink after midnight the night before.) In some cases of twilight anaesthesia, the sedation is given by nurses under the surgeon’s direction and no anesthesiologist is present. Whenever a general anaesthetic is given, an anaesthetist is present, although in the U.S.A., certified nursing anesthesia technicians may be used.

All patients need to spend at least  the first night, in the care of a responsible adult. I like my major body contour patients ( tummy tuck and body lift) as well as facelift patients to spend the first night in the clinic. I strongly believe they get started on a quicker and less anxiety filled recovery under these circumstances.   I usually see patients the first working day after surgery and check for any problems, discuss how the patient is feeling, and review any concerns. Stitches are removed at subsequent visits, according to the particular surgery.