As far as return to work is concerned,   most of my patients can return to work within 48-72 hours of their surgery, provided of course they are not involved in some type of  job in which physical labor is involved (such as overhead use of the arms as in warehouse workers or construction work. Seriously, I have had  patients  who work on road crews and in the construction industry). I tell my patients that as soon as they no longer require narcotic pain medications there is no reason why they can not return to work.  9 out of 10  of my patients use over the counter Tylenol and Motrin  after the first post operative day to control post operative discomfort and use narcotics only at night before bedtime.  I utilize long acting local anesthetics in the operating room so that each patient is pain free upon  completion of their surgery.  This technique  in conjunction with a comprehensive post operative recovery  regime  minimizes  pain  management .  I discuss what all this entails with my patients at their initial consult. I used the “pain pump” after surgeries when they were first brought out on the market years ago, but after extensive experience with both the pain pump and my own post operative pain management regime, my regime is vastly superior to the pain pump. Hundreds of patients can attest to that. In fact I still have several unused, unopened pain pumps in my inventory at my surgical facility.  If a patient is some how sold on the idea of a pain pump after their surgery  I can provide that option.

Regarding return to unrestricted physical activity, the time frame for this  is generally 3 – 6 weeks depending on whether the implant was placed above the muscle or below the muscle. Anything which will elevated the blood pressure or heart rate after surgery will increase blood flow through the area which is trying to heal. This will induce more swelling. More swelling is counter productive to  long term outcome. This is especially true if the implant is placed under the muscle. The muscle swells quite a bit after surgery on its own just by the nature of the procedure;  patients shouldn’t do anything which amplifies this response.  I will allow patients to resume light activity after the second week and see how each patient responds. After three weeks I generally allow for any type of physical activity for submammary augmentation patients and six weeks for submuscular. Also, by six weeks the muscle has healed to the point that strenuous  physical activity can not cause any injury to the muscle which could cause internal bleeding and produce a hematoma (blood collection) around the implant.  Physical intimacy can be resumed as soon as the individual feels comfortable doing so. ( But no “rough stuff” for a couple of weeks! ).  I am perhaps slightly more conservative than some surgeons, but I feel my extremely low re-operation/complication rate speaks for itself.

The last aspect of the recovery phase is how long until the final  results. By final results I mean complete healing and also the appearance of the breast contour. Let me address breast contour first.  Once again this time frame is shorter for submammary augmentation patients than for submuscular because the role the pectoral muscle plays in the post operative breast shape. In both types of surgery patients will experience what is known as “upper pole ” swelling or fullness. ( upper pole  refers to the region of the breast above the nipple areolar complex, the inferior pole is the area below).  The breast tissue itself recovers relatively quickly and it is not uncommon for my submammary breast augmentation patients to have their final shape within  two or three weeks of their surgery. This time frame is longer in those patients who started off with tighter breast tissue and experience what is known as “soft tissue” stretch due to the implant. The more the soft tissue has to stretch to accommodate the implant, the more swelling there may be, hence a slightly longer recovery period. (this is one reason why it is not a good idea to have  an implant which is too larger for your individual breast characteristics. This should be determined and thoroughly discussed with each patient  when  deciding implant shape and size).  The inferior pole often times has to expand somewhat in order to accommodate the implant and this can take a couple of weeks as well. This response to the surgery and placement of the implant is amplified when the implant is placed under the muscle. For submuscular augmentation patients it maybe as long as two or three months before the upper pole swelling resolves completely and the breasts accommodates to  the implant. By six weeks most of the swelling has resolved and the great majority of patients do not appreciate any residual swelling and are extremely happy with their new size and shape. It is when you look at side by side comparisons of pictures taken at 6 weeks versus 12 weeks when these subtle nuances can be seen. And for the most part the differences are quite subtle.

The other aspect of final healing is how long until the numbness from the surgery resolves and the scars fade.  Sensation returns somewhat in the first or second post operative week  and  returns completely by six to twelve weeks. The more soft tissue stretch the longer this may take. Residual numbness can take as long as a year to completely resolve but this is very unusual. Scars tend to be red for  a couple of  months and gradually fade over a year or so. The  blonde,  blue eyed patients tend to have redder scars initially but also tend to fade to the whitest given time. Darker colored individuals tend to develop darker scars which take a year or so to completely fade. Thick or raised/wide scars  are exceedingly rare in my practice for several reasons which I discuss with each patient during their consult.  There are several post operative scar management regimes I discuss with each patient throughout their recovery based on their needs which will maximize the quality of their scars and minimize the visibility. Remember: there is no such thing as a “scarless scar” in the adult patient.  But by and large the long term scars from breast augmentation surgery heal very nicely and inconspicuously.

The last aspect regarding recovery from breast augmentation surgery which I stress with each patient is the need to be vigilant about good support garments to maintain the newly acquired breast contour and the need for pocket exercises to keep  the breasts soft and feeling natural.  If patients are committed to these post operative breast augmentation recommendations they can expect to  achieve the best possible long term outcome  and avoid problems.

First there is the surgeon’s fee. Each surgeon’s fee will be   different  and this may be based on his or her experience ,  the time involved and how the followup visits are handled.  The number of follow up visits and for how long (how many weeks or months) vary from surgeon to surgeon as does who actually sees the follow up patients.  Sometimes the doctor spends only  a few minutes with a patient in follow up and delegates most of the follow up visit responsibilities to  his or her nurses. Also the surgeon’s  technique is an important consideration. A transaxillary endoscopic breast augmentation takes more time  because the equipment set up time is much more involved, and it is technically more involved than other techniques.  Expect to pay a  more for this particular technique.  The facility may also ask for slightly more if this technique is used because of the expense  of the equipment and the time and effort involved with the cleaning and care of this equipment.. At my facility the additional cost is usually on the order of an additional $1000.That covers all additional expenses for transaxillary endoscopic breast augmentation. For patients who are adamant about  having no scarring on the breast, this is worth the premium cost.

Next is the  Facility /Operating Room (OR) fees  and anesthesia services  which are another major cost  factor. Facility fees and anesthesia services are generally separate fees incurred by the patient, but every once in awhile they are rolled into a single  “facility” fee.  These fees can vary  between facilities as to how they charge for their time and services.  Generally hospitals are more expensive than free standing  ambulatory surgery facilities and office based  surgical facility being the least expensive, but  this may not always be the case. Many facilities charge a basic rate for  breast augmentation surgery, say for an hour or so of O.R. time  with  the recovery room being included.  Same is usually true for anesthesia services.  Anesthesia services may be slightly more if you undergo a general anesthesia versus local with IV sedation. However, if your surgeon goes over  the allotted block of time he or she has set aside for you or you are slow to recover from the anesthesia , then the patient is frequently made responsible for these  additional charge. So beware of this  “add-on” cost which you, the patient can get stuck with. Often times I hear patients tell me how they are told  by other physician’s office staff  “not to worry”, “that hardly ever happens” etc.  The fact is that  these “overage” fees can AND do occur.

In fact my own patients have had this unpleasant experience before I built my own facility. This scenario absolutely never occurs at my facility;  I guarantee it , so there are no surprises when it comes to  the  facility  and/or anesthesia costs. Surgery is stressful enough for the patient,  so there will be NO  stressing over this issue.

The last cost factor are the implants themselves. Depending on what type of implant the patient selects (silicone or saline) the cost of the implants can vary from around $1000.00 for saline and about twice that for silicone.  Implant manufacturers have  their own  costs as well, so not all saline  or silicone implants will be identical in cost. I do not not charge a premium for silicone augmentation surgery above the actual costs I incur by the manufacturers for the implants themselves. Some practices do charge more for silicone augmentation surgery because of the additional time and effort to close the slightly longer incisions utilized for the silicone implants.

One thing which I stress to patients who are considering breast augmentation, or any type of cosmetic surgery for that matter is that while cost is an important consideration, it should be about the last thing on your list when choosing who performs your surgery  or  where. The most important consideration is whether or not your surgery will be done #1 safely, and #2 effectively. Then you must have a good overall feel for the surgeon and his staff. Are they highly experienced, do you share them same sense of aesthetics regarding size and shape, do you like the results  this particular surgeon obtains, are you comfortable in the presence of the surgeon and staff. All these factors should come into play when making your choice.  Whether  or not you got your surgery for a discount or for ” a really good deal” will mean nothing if you are not happy  and  healthy  afterwards….food for thought.

Laser technoolgy has been out for years, but most recently some companies have applied this technology for applications in liposuction and have aggressively marketed as being superior to other technologies.The advertising states laser liposuction can be done without general anesthesia, can create better skin retraction, causes less bleeding and therefore less post operative bruising, uses small(er) incisions and can be used on any part of the body. The very same results  occurs with Ultrasonic Assisted Liposuction (UAL), which has been a technology used by many surgeons for liposuction for more than a decade. And some of these claims can be said for any type of liposuction technology if done properly and in the properly selected patient.

Any type of liposuction can be done without general anesthesia, however do not be lead to believe that laser liposuction is somehow painless and therefore no type of anesthesia is required.  Once again I am talking about surgical liposuction procedures.  A local anesthesia  can be utilized for virtually any type of liposuction procedure , as long as the area being treated is small enough to be completely anesthetized safely by local injection of the anesthetic solution. The “tumescent”  anesthesia technique popularized liposuction to a great degree by allowing liposuction to be done without general anesthesia and without  a marked amount of post operative bruising.  This technique utilizes significant amounts of fluid with varying amounts of local anesthetic and epinepherine. This fluid is injected into the area to be treated with liposuction. The local anesthetic numbs the patient to allow for the liposuction procedure to be done painlessly and without the use of general anesthesia. The large amount of fluid allows for the extraction of fat without damage to other structures within the soft tissue. The epinepherine causes the blood vessels to marked constrict which decreases bleeding to a great degree and therefore there is minimal post operative bleeding.  This technique is great when small areas are treated  and limited amounts of fat are to be removed. It can be used in a fully awake patient. Some surgeons will actually have the patient standing up while  performing the liposuction procedure  utilizing the tumescent anesthesia technique.  When large volumes and greater areas are treated at a single setting, then general anesthesia  may be the safer alternative. It is when surgeons inject too much volume of anesthetic solution at one time that  complications occur  which we have all read about. The ideal candidate for local anesthetic techniques are generally within 20 – 30 pounds of their ideal body weight and are trying to improve the contour of specific smaller sites such as love handle or outer thighs. If a large abdomen or multiple  large areas are treated at a single setting then general anesthesia may be the safer alternative. Also general anesthesia maybe a safer choice even if many  smaller ares are treated at a single setting. A qualified and experienced surgeon will be able to make this decision.

Laser liposuction can create superior skin retraction over SAL (Suction Assisted Liposuction) alone, but Ultrasonic Assisted Liposuction (UAL) can create the same type of soft tissue changes that allow for superior skin retraction. Both laser and ultrasonic energy heat the fatty tissue to allow  for its extraction. The technologies differ in how the fatty tissue is heated, but the end result is basically the same. The heat positively affected the deep tissues to allow for better skin retraction. Patients who may be marginal candidates because of their skin characteristics can be suitable candidates if ultrasonic or laser assisted liposuction techniques are utilized. Patients who have poor quality skin may not be  suitable candidates for any type of liposuction procedure regardless of the technology being utilized. Once again a qualified and experienced surgeon should be able to make this determination.

The ultrasonic or laser energy which heats the fatty tissue also allows for  less intraoperative bleeding and therefore less post operative bruising. Once again, the technologies differ in how the fatty tissue is heated, but the end result is basically the same. Even SAL alone does not necessarily create a lot of bruising post operatively if the correct type and proper amounts of fluid is injected into the fatty tissue prior to treatment.

The incision length used to be larger when UAL was first being utilized in the early stages of its use and was widely accepted as a major disadvantage with UAL. This was due to the use of “skin protectors” at the incision sites. The cannula used in UAL  are not necessarily  of a larger diameter than other technologies, but they are made of titanium which can  cause more friction at the incision site and also can become hot with extended use  during the procedure. With experience surgeons found alternative techniques to reduce and eliminate these  downsides of UAL.  Now with improved techniques and experience, these complications can be avoided and the incision length is no longer than with any other technique .

Any type of liposuction technique can be utilized on virtually any body part. There is nothing unique with the use of laser technology which lends this specific technique to one body part over another. With that being said, both laser and ultrasonic technologies make treating more fibrous areas much easier, such as the flank regions and the upper abdomen. Also redo liposuction procedures are much easier and there is less intraoperative bleeding with both laser and ultrasonic technologies over standard SAL.

Do not be mislead into thinking that laser assisted liposuction techniques are superior to all others just because laser is used in the name of the technique.  Always remember that the most important variable in successful and safe liposuction procedures is NOT the type of cannula or technology being used;   what is at the end of the cannula  makes the biggest difference: the surgeon. Be sure that the surgeon you chose for your liposuction procedure is qualified, well trained and just as importantly, well experienced.  Hope this has shed some light on the topic of liposuction and will help you in the future.

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Generally the most important consideration in deciding if a breast implant should be placed above the muscle, referred to as a submammary breast augmentation,              ( click here or click here to view before/after submammary breast augmentation) or under/below the muscle,  referred to as a submuscular or subpectoralpectoral breast augmenatation  (click here to view before/after submuscular breast augmentation) is how much breast tissue is present and the quality of the that breast tissue. The only accurate method of determining the quality and quantity of each patient’s breast tissue  as it relates to  optimal implant position is by a thorough physical examination.  Pictures can not convey these important  physical characteristics.

Another factor in determining  optimal implant position is the activity or lifestyle of each patient. Sometimes compromises must be made in order to meet an individual patient’s needs. For example, placing an implant above the muscle in a female bodybuilder may lead to more implant visibility post operatively, but that may be less important than not having the implant move with muscle contraction as would be the case if the implant was under the muscle.

If there is not much  breast tissue present ,  an implant placed on top of the muscle has a  greater tendency to be visible. Being able to see the edge  of a breast implant is not a natural look .  Some patients actually want to have the pronounced appearance of the implant, the so called ” Pamela Lee Anderson” or ” Victoria Secret” model look. This generally refers to the roundness of the upper portion of the breast, but it the visibility of the edge of the implant which imparts this look. Also, sometimes an implant can wrinkle at some  point post operatively, usually months after the surgery. Placing the implant under the muscle allows for an extra layer of soft tissue coverage in order to  hide the implant  and therefore lessen the chance of visible wrinkling.  If the implant is placed under the muscle a slightly larger implant  may be utilized all other factors being equal. This is because along the medial border of the breast  (medial border being over the breast bone side versus the lateral border which is the arm pit side of the breast) there is considerably  less tissue.   Placing the implant  under the muscle  provides additional soft tissue coverage over the medial aspect of the breast and this can lessen the  chance of implant visibility post op.

An implant placed under the muscle may move with muscle contraction. There are  implant selection considerations and surgical techniques which can lessen the tendency for this to occur, but there is no getting around the fact that a submuscular implant may be prone to movement with muscle contraction.  If this does occur post operatively it is   generally minimal and well tolerated in most patients.

Also, if the patients tissue characteristics are poor (a lot of stretch marks, laxity of the skin) an implant placed on top of the muscle may not have the support as if it was placed under the muscle. In the long term , the skin can stretch and the implant drops significantly. This is known as a “ball in sock deformity”.  Imagine placing a cue ball in a tube sock…not a very pleasant visual; and very difficult to correct. Best to avoid this complication.

Also, in selected patients who need a breast lift with breast augmentation, placing the implant under the muscle can be safer in that the blood supply to the nipple area is preserved. If a more extensive mastopexy (breast lift)  procedure needs to be done to produce the most aesthetically pleasing outcome, this is an important consideration in order to avoid the potential complication of skin loss around the nipple region of the breast. Click here to view before/after mastopexy breast augmentation.

Placing the breast implant underneath the muscle also affords slightly more visualization of the breast tissue during mammogragphy. This might be a consideration in those patients who have a family history of breast cancer.

Are there down sides to having a subpectoral breast augmentation which have not been discussed?? of course…there is no free lunch so to speak.  Some of the other  downsides of having subpectoral breast augmentation include the following :  generally somewhat more painful post operatively, requires more time of restricted activity to allow for healing,  has  more swelling and  takes longer to achieve the end results of a naturally appearing breast than a submammary augmentation. All of the “down sides” are well worth it if the patient’s individual characteristic require subpectoral implant placement to avoid complications and undesirable outcomes.

So how do you know whether you should have your breast augmentation surgery utilizing the submammary or the subpectoral route? Start with a thorough examination and consultation by a qualified plastic surgeon who has extensive training and experience in breast augmentation surgery who understands  your needs and desires for breast augmentation which will maximize  your  individual  outcome.  Hope this has shed some light on submammary versus subpectoral breast augmentation. In the end,  the best route for breast augmentation is the one that will maximize your outcome.

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In select patients, the upper abdomen (referred to as the epigastrium) demonstrates excessive laxity on physical examination which can be corrected by pulling the tissue upwards, in contradistinction to a formal abdominoplasty in which   the excessive  skin of the  abdominal wall tissue is tightened by a downward pull.

In patients who undergo a simultaneous abdominplasty with breast augmentation, this can provide the ultimate in abdominal contouring  while minimizing visible abdominal post operative scarring.  The incisional scars of a reverse abdominoplasty are well hidden within the inframammary crease beneath the breasts and are  just slightly longer than the standard incisional scars used to perform a silicone implant  breast augmentation .

In many individuals, the epigastric area of the abdominal wall is too lax to allow for consistent and reliable skin retraction following a standard abdominoplasty or liposuction procedure. By performing a reverse abdominoplasty, these types of  patients have  the best potential to avoid the dreaded “epigastric bulge” following standard abdominoplasty or liposuction  procedures.

The reverse component of the abdominoplasty procedure does not substitute for lower abdominal scar all together in those individuals who require more extensive surgery to address abdominal wall contour deformities.  If the abdominal wall  muscles are lax or there is excessive skin and fat in the lower abdomen,  the surgeon still has to tighten the abdominal muscles  and/or remove this excessive tissue through a lower abominal incision.

So how do you know if you would benefit from a reverse abdominoplasty procedure? A thorough consultation by a plastic surgeon who has the specific training and experience in this specific type of body contouring surgery  can decide the optimal surgical intervention  required to address each patient’s unique  needs.

Thanks Mar for the question. I hope this sheds some light on the topic of “Reverse Abdominoplasty”  for hugh.  Au revoir.

First of all, silicone implants are safe. The  Institute of Medicine, a branch of the CDC (Center for Disease Control) wrote a position paper in which the safety of silicone breast implants were affirmed. The paper reviewed the research data on the topic, specifically two large studies, one out of Canada and another from the United States in which 10,000 and 15,000 women were followed for years to determine if there were long term health risks to women in whom silicone breast implants were used.  These studies were in progress well before the  alleged health  issues were raised in the infamous class action law  suit .  Silicone  breast implants were found NOT to be associated with any of these health  issues raised in the law suit, specifically auto-immune disorders. The federal judge involved in the litigation chose not to allow these studies to be brought into evidence .  The end result of the law suit was over 3 billion  dolloars  being  awarded against Dow-Corning , a huge chunk of which went to the  plaintiff lawyers.  It has been estimated by the legal community that the attorneys involved averaged $90,000/hour for their time.  Also, after the dust settled so to speak, the FDA got involved and placed a moratorium on the use of silicone breast implants for patients undergoing  breast augmentation strictly for cosmetic reasons (known as primary augmentation). Women undergoing any type of reconstructive procedure, including a breast lift (mastopexy) were allowed to chose silicone implants for their surgery.  My facility had an IRB  to use silicone implants since 1999. (IRB is special permission for  use of silicone implants for data gathering purposes). My patients and  I have seen first hand the remarkable benefits using silicone implants over saline for breast surgery. Not until the fall of 2006, after many years of gathering data did the FDA change their position and allow the use of silicone implants for strictly cosmetic reasons. At that time surgeons had to stress  to patients that the FDA wanted all patients using silicone implants to get an MRI scan three years after their breast augmentation surgery then every two years thereafter in order to determine exactly how long a silicone breast implant would last before they ruptured.  The FDA could not obtain adequate information in this regard and as of August 2011, the FDA has dropped this request with the use of silicone implants. Now woman have the freedom to chose silicone or saline for the breast augmentation surgery  knowing the facts regarding  silicone implant  safety. Science and not political hype and hysteria have won the day so to speak (finally!).

Now that the safety issue has been addressed, I can discuss the benefits as well as the downside of silicone  versus saline implants as they relate to to patient outcome  and  satisfaction.

Regarding the outcome, there is no debating the point that all things considered, silicone filled implants will provide a superior outcome compared to saline.  This is not to say that saline implants do not  do a very nice job  in enhancing the size and contour of  a woman’s breast  ( click here to view saline implant breast augmentation before/after), but saline implants fall short of silicone implants in subtle, but tangible  aspects.  First and foremost, silicone implants   provide  a more realistic and pleasing  feel  compared to saline and  silicone gel filled implants do not wrinkle as much as saline filled implants. (Click here to view silicone implant breast augmentation before/after)

Being able to feel (or more precisely, not being  able to feel)   the  implant post operatively is one of the major advantages of silicone filled breast implant over a saline filled breast implant.  Saline filled breast implants feel like a water balloon (exact words from many of my patients who have had revisional surgery to replace their saline filled breast implants with silicone filled breast implants).  Silicone gel just feels more like breast tissue. This is especially true with patients who have enough native breast tissue to cover the entire breast implant.  Post operatively a breast should feel and move  like a breast. This is much more readily achieved with a silicone filled breast implant than with a saline filled breast implant.

Silicone implants tend not to wrinkle as much as saline implants post operatively. Silicone gel is what is known as a cohesive fill material…the gel “sticks to itself” so to speak. In other words, when the implant is held in a position against gravity, all the gel will not run to the bottom of the implant as is the case for saline.   This  can be a significant difference between the two types of implants  for  patients who have  very little  native breast tissue  .  Generally if you can’t  “pinch an inch” of breast tissue then a silicone implant may be a better option.  Ideally there should be enough breast tissue to sufficiently cover the implant in its entirety. Patients  do not want to see the wrinkled edge of the implant six months post operatively when  she leans forward or along the sides of the breast, which is often the case with saline implants. This is not to say that silicone implants never demonstrate  visible wrinkling, but the incidence of this occurring is reduced with silicone implants.

Because of  silicone implants  decreased tendency not to show wrinkling, silicone implants may  be be placed in the submammary position instead of underneath the muscle in some patients who demonstrate minimal native breast tissue. Saline implants require more breast tissue to be adequately  covered than do silicone implants. Implant position (or placement)  is a whole discussion in of itself which is discussed fully in another blog, but placing the implant on top of the muscle  may allow for  less post operative pain, swelling, and decreases the recovery period.

Both types of implants are prone to failure (leakage or rupture) given sufficient time  after surgery. Implants,  like anything else do not last forever. If saline implants develop a leak, the saline will eventually leak out of the implant and be absorbed by the body.  The saline used to fill the implant is exactly what a patient receives intravenously so it is utilized by the body as fluid.. The breast will become flat or lose its prior shape and volume.   Data suggests 0.7% rupture rate for silicone implants at four years post operatively. It is difficult to quote an exact figure for silicone implant rupture rate over its lifetime, but it is thought to be under 10%.   I use to tell patients  saline implants have a 1-2% per year life of the implant rupture rate. In other words, if you have a saline implant for 10 years, then your implant has a 10 – 20% chance of failing. That seems to be more tangible, but now the manufacturers state  7-9% rupture rate for the lifetime of the saline implant.  If  a ruptured or leaking  saline implant is replaced before the capsule around the implant shrinks, it is a simple matter of replacing the saline implant under a local anesthetic. There is none of the original post operative swelling and discomfort. It is only a matter of caring for a fresh incision for a couple of weeks. If a silicone implant leaks or ruptures, because of the cohesive nature of the fill material  not all of the silicone gel will necessarily come out of the implant shell.  Also,  the silicone gel will not be absorbed by the body like saline.  The silicone gel which leaks out of the implant shell is contained within the scar tissue which normally forms around any breast implant( this scar tissue is known as a capsule). The breast may not deflate and shrink in size as would be the case with a leaking saline implant. Replacing the implant is still recommended, but the bottom line is that there is not urgency as in a saline implant. Some patients chose not to have anything done until problems arise. An MRI is the definitive method of diagnosing  silicone implant rupture, unfortunately 11% of MRI results will be read as a rupture when no rupture exists. This is what is referred to a a “false positive” result and is one reason why the FDA  backed away from recommending MRI followup in patients with silicone  filled breast implants. Patients sometime ask which implant lasts longer. The answer is: no one really  knows. Theoretically the silicone gel acts as a better lubricant inside the implant shell as compared to saline. This property of silicone gel is thought to prevent or at least prolong the occurrence  of  “fold flaw” leaks. A fold flaw in an implant is analogous to what happens if you take a soda can and repetitively  fold it back and forth upon itself. After  several times of doing this the can develops a tear along the crease or fold.  Hence the term “fold flaw”.

Both of the primary United States breast implant  manufacturers  (Allergan and Mentor)  offer comprehensive warranties on their products.  A pair of s aline or silicone implants are considered a single item so that is one implant  fails, the manufacturer will replace both implants free of charge  as lifetime warranties. Within 10 years of surgery, they offer $1200 to the patient to help reduce saline implant replacement surgery costs.  Both  offer additional  warranty in which they will provide an extra $1200 if the patient pays $100 insurance within thirty days of their initial surgery. These surgery costs are only covered for tens years, but the saline implant replacement warranty is for lifetime. Silicone implants will be replaced free of charge as a pair for lifetime just as saline. Both manufacturers have identical surgery cost coverage of $3400 for replacing their silicone implants in case of rupture. This is a lifetime coverage, unlike saline which is only for ten years.

It has  been my experience that if you follow a patient long enough,  some patients appear to  see a change in volume or be able to feel the  saline implant  compared to that of a of the silicone filled implant. This does not occur in all patients but I have had several patients over the years in which the patient and I  both thought that her saline filled implant was leaking or deflating only to find an intact implant at the time of re-operation. For some reason the saline filled implant seems to lose volume even though when I remove the fluid and measure it in the OR, the volume is exactly what I put in it several years before.

Both types of implants obscure mammogram visualization of the breast post operatively to the same degree.  The shell of the implants are identical.   It is the shell of the  implants which interferes with mammographic visualization of the breast. Whether the implant is saline or silicone filled is not relevant.  Whether the implant is above or below the muscle has more influence on how much breast tissue can be visualized on mammogram. Generally an implant below the muscle allows about 20% more mammographic visualization of breast tissue than if the implant is above the muscle.

Silicone filled implants come pre-filled and therefore require a slightly larger incision to place compared to a saline implant.  This slightly longer incision length can be looked at as a down side of silicone implants, but the additional length of the incision is so  inconsequential that this aspect of choosing  one type of implant over the other should really not be a deciding factor.   The larger incision length required for silicone implants  may be a factor however  if a patient is absolutely set on having her breast augmentation surgery via  the periareolar incisional approach. If a patient has a very small areola,  a large silicone filled implant may not be able to squeeze through  such a small opening.  Saline implants are empty and rolled up like as soft tortilla during placement. Once they are in proper position, the saline is added to the correct volume through a removable filler tube. This allows for a smaller length incision when utilizing saline filled implants.

Saline filled implants are adjustable in the OR in that the surgeon can  over fill the saline implant at the time of implantation.  Under  filling is never recommended by implant manufacturers  nor  is over filling by more than 30 cc’s (about an once).  The  adjust-ability of a saline filled implant may seem advantageous   in of  itself, but I do not think it  should not be a reason why a patient should choose  saline implants, all things considered. Silicone implants are pre-filled, but with the variety of widths, volumes and projections available your surgeon can choose an implant that is right for your specific needs.

Both silicone and saline implants come in different profiles (projection) for the same base width of any given implant. This allows for customizing outcome without having to resort to using an excessively wide implant. These implant profiles are demonstrated to each patient during their initial consult so each patient can visualize the difference. Saline high profile implants impart too much of a “ball” effect post operatively and I have stopped using high profile saline implants in my practice. Silicone high profile implants , on the other hand are fantastic options in the properly selected patient and are used extensively in my practice.

My practice experience has been consistent with the world wide plastic surgery literature in that there is no increased incidence of abnormal capsule formation with silicone filled breast implants compared to saline filled breast implants.  Many years ago this was an issue, but the current  manufacturing technology is so superior with  silicone gel filled implants that the issues of gel leakage causing abnormally hard, painful breast months to years after implantation is no longer a valid argument.

The final word on whether silicone filled breast implants are superior to saline filled implants come from the patients who have had the experience with both types of breast implants. I have  dozens and dozens of patients who have had saline filled implants initially but were  later exchanged for silicone filled breast implants. In each one of these patients the response was identical: my patients preferred silicone over saline. They made comments like “they (the silicone implants) feel like me, ” I can sleep on my stomach and I don’t feel like I’m on water balloons”, “my gynecologist couldn’t even tell I had implants” and the comments go on and on. Not one patient has ever voiced regret in changing from saline to silicone filled breast implants.

If there is a down side to silicone  breast implants it would be that they do cost more than saline, and this cost is universally passed onto the patient; sorry. Generally silicone implants cost about $1,000 more than their saline counter parts.

My  responsibility as your surgeon  is to fully inform  each patient of the risks and benefits of each type of implant and to make recommendations as to which type of  implant will provide the patient with the best outcome. The final decision  to use saline or silicone implants is always left up to patient.

I just saw a patient in follow up who lost over 7 inches from a single UAL (Ultrasonic Assisted Liposuction) procedure.  This individual was frustrated at prior attempts to lose the “love handles and “pooch”  of the lower anterior abdomen.   In addition, this individual had to reduce the waist circumference by four inches because of occupational requirements. Based on the well localized areas of fat deposits, I was quite certain I could attain this degree of improvement utilizing  Ultrasonic Assisted Liposuction.  Although I do not guarantee or promise a certain amount of circumference loss when performing a liposuction procedure, experience has taught me who can expect the most improvement  We were both pleasantly surprised with the measurements at three months post op.

Ultrasonic Assisted Liposuction (UAL) is especially useful in removing  fat from the flank region of the waist. This area is quite fibrous and the fat is not as easily or consistently removed with conventional Suction Assisted Liposuction (SAL) techniques.  Also,  UAL has the added benefit of potentially increasing the amount of skin retraction, thus improving the final contour of the treated area post operatively.  This individual went from the typical convex deformity of the flank region before the UAL procedure to having a youthful concave curvature to the flank region post operatively. The anterior lower abdomen responds just as favorably to SAL (Suction Assisted Liposuction) as it does to UAL  (Ultrasonic Assisted Liposuction) procedures. This is because this area is not fibrous.  UAL may be more beneficial in this region if there is poorer skin tone or some stretch marks on the skin. This is due to the increased potential to cause a more pronounced skin retraction utilizing Ultrasonic Assisted Liposuction

What liposuction will NOT do is provide an individual with a “six pack”  of the abdomen or increase muscle definition.  It does not matter which liposuction technique is utilized. It is false advertising when you see a before and after photo where an individual goes from being a “fatty” pre op to having  a “Mr. Universe”  physique post op. The same can be said for “Lipo Dissolve” and the other non invasive “laser” techniques  which so often  promises results which simply can not be attained. Remember:  if it sounds too good to be true, it probably isn’t.

Liposuction procedures are not methods of weight reduction!  I often am asked “how much weight will I lose?”.  I have no idea how to answer that question and I have done literally a thousand liposuction procedures over the last fourteen years.  I tell my patients who pose that question the same thing : I can reduce the thickness of the area treated  so that you can only “pinch an inch” post op,  but I can not tell an individual how that will correlate to weight loss.

So how do you know if you can expect to decrease your waist circumference with a liposuction procedure? Only a thorough  examination  and consultation will tell.   There are many factors to be considered and a qualified plastic surgeon who is well trained and thoroughly experienced in the use of liposuction can make those types of determinations.

I have seen many men who present with the classic “pot belly” or “beer belly” who thought that they could “lose their gut”  with a liposuction procedure only to be told “not so”.  In some individuals this type of  deformity is due to fat accumulation inside the abdomen and not an accumulation of fat beneath the skin. Only subcutaneous fat (the fat beneath the skin) can be removed with liposuction procedures.

Other patients have poor skin tone which makes them poor candidates for liposuction. The skin has to be able to retract post operatively for liposuction to be a viable option. Other individuals simply have too much skin and fat to be addressed with  only liposuction  and would be better served with an abdominoplasty procedure,  sometimes with  concurrent liposuction .  Abdominoplasty surgery in conjunction with  liposuction can absolutely do wonders to improve the contour of an individual’s waist.

Of course, no discussion regarding cosmetic surgery  would be complete without stressing the importance of patient safety. You must be in good physical condition to undergo liposuction surgery. Once again, a well qualified plastic surgeon can make that determination.

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Many women  are  naturally larger on one side compared to the other.  Based on each patient’s individual characteristics, a surgeon has the option of picking implants to address each patient’s  asymmetry  based on the implants base width, volume, and projection.  Various  profile implants  are now available which can successfully correct breast asymmetry.

Profile refers to the projection of  an implant.  An implant can have vastly different shape given  identical volume based on whether the implant is a low profile, moderate profile or a high profile.  One of the breast implant manufacturers which I routinely use  offers   three different profiles for any given width of an implant.  For instance, an 11.7 centimeter base width silicone  implant  in low profile option has a volume of 240 cc’s,  in moderate profile a volume of 287 cc’s,  and in high profile 375 cc’s.  With this type of direct comparison it is easier  for a patient to visualize how important implant profile is when choosing an implant based on each patient’s individual characteristics.  I routinely demonstrate this comparison of implant profiles and dimensions to patients during their initial consult  so that they have a firm understanding that implant volume is not the most important factor when choosing an implant.  Projection of the implant is very important  to the overall outcome and final shape of the breast after surgery, especially if asymmetry is an issue. An implant of a greater projection can make up for the discrepancy  of native breast tissue from side to side, thereby correcting  pre-existing breast asymmetry.

Sometimes the base width of one breast is greater than the other.  If the patient demonstrates roughly similar or equal amount of native breast tissue, the surgeon can choose appropriate implants to make up for this discrepancy.

Many times it is a combination of breast base width as well as breast native tissue which accounts for the  apparent breast asymmetry. In these cases, it is somewhat more challenging for the surgeon to choose the  implants. In these instances,  breast implant sizers  can be utilized. Click here for before/after

A sizer is a temporary implant, either saline filled or silicone filled, which the surgeon can  use at the time of surgery to  determine the best implant for each patient’s particular needs.  This adds to the time, work, and therefore overall cost of breast augmentation surgery. This additional cost is well worth the effort if you have a discernible  breast size difference from side to side.

I just operated on a patient last week in which asymmetrical sized implants were utilized based on the use of sizers  in the operating room. Her outcome was almost perfect symmetry post operatively.

Breast implant size and shape  is just one of the many factors a surgeon should consider when performing breast augmentation surgery, especially if breast asymmetry is an issue. If you are considering breast augmentation surgery, be sure  that your surgeon has the experience and training to explain  to you all of your options based on your individual needs. This is especially true if breast asymmetry is one of your major concerns in considering breast augmentation surgery.

Ultrasonic Assisted Liposuction utilizes a specialized cannula which vibrates at 22,500 Hz which emulsifies fat allowing the subcuataneous fat to be removed with far less bleeding than which can be achieved with standard Suction Assisted Liposuction (SAL).  The reduction in post operative bruising is very much appreciated by my patients. This is especially true in my UAL patients who had  undergone standard Suction Assisted Liposuction (SAL) in the past by other surgeons.  These patients consistently remark about the great contour improvement after UAL but without the extensive bruising they experienced with their prior SAL procedure.

Another great benefit of Ultrasound Assisted Liposuction is that the ultrasonic energy actually creates more of a stimulus for skin retraction post operatively.  Skin retraction  is a very important consideration for the patient considering any type of liposuction or body contouring procedure. This benefit is obvious when considering the needs of a patient wanting to reduce the size of the breast and hoping to avoid post operative scarring which can occur if the skin must be surgically removed versus allowing the skin to retract by itself following an Ultrasound Assisted Liposuction procedure. As with all cosmetic procedures, patient selection is the key to a safe and successful outcome.

I have used UAL extensively in my body contouring practice for the last 14 years. I have found Ultrasonic Assisted Liposuction to be a very safe and  effective adjunct to abdominoplasty, thigh lift, neck lift,  and virtually all of my liposuction surgeries, but it can also be used for the reduction of breast tissue in both males as well as females. I utilize  UAL for both male and female breast reduction procedures because of the unique advantages offered by Ultrasound Assisted Liposuction which are not associated with standard SAL (Suction Assisted Liposuction).

Gynecomastia  (male breast enlargement) affects up to 15% of the male population, but the good news is that it can be effectively and safely treated with Ultrasonic Assisted Liposuction (UAL) in a large percentage of cases, thereby reducing the post operative scarring associated with excisional breast reduction surgery.

Last week I was able to utilize Ultrasound Assisted Liposuction in a male patient  for gynecomastia reduction . This patient  required a very limited excisional incision on one side  to remove a marble sized piece of breast tissue which was  not completely removed by UAL alone. This results in far less post operative scarring which I think all patients are hoping for in any type of cosmetic surgery procedure. This patient has seen a remarkable improvement in his chest region  while avoiding  the more extensive scarring which would be inevitable without the use of UAL.

I continuously utilize Ultrasonic Assisted Liposuction (UAL) in conjunction with other excisional type of body contouring procedures such as abdominoplasty, lower body lifts, and thigh lifts because it reduces blood lost, thus making these combination procedures safer to do together.

The only way to know your options for   body contouring purposes and if UAL is a valuable adjunct to your needs, whether it be for reducing unwanted excessive breast tissue, ( male or female),  or to improve the contour of your waist or other problem areas, is to have a consultation with a well trained Plastic Surgeon who has extensive training and experience in all aspects of body contouring surgery. No one technique  or technology is best suited for all patients. The use of newer technologies and techniques allows for a custom tailored approach which is uniquely chosen for each individual patient based on that patient’s particular needs, desires and expectations. This is the approach I use for every one of my patients

Once again, thanks for your time. Tim Bradley, MD