September 2009

Implants come in all shapes and sizes just like we women do.

It gets confusing when you surf the internet and see photos of websites and patients.  How do you choose?  This is a place where your surgeon really will guide you.  Every surgeon has their method of choosing an implant for a patient.  This includes size, profile (width, projection), and type of implant. 

I see many women come in confused by what implant to get.  There is so much information out there, and you cannot become an expert by reading.  You can pick a surgeon who is right for you.  I repeat myself often on this point, but the two most important decisions when you decide to do breast augmentation: find a board certified plastic surgeon (by the Board of Plastic Surgery), and like the aesthetic

What does “the aesthetic” mean? Look at the photos. Do they look pretty to you? Do you like the shape? Do you want to look natural or augmented?  Every doctor has what in their mind’s eye looks like a “pretty breast.”  You and your plastic surgeon should have the same eye.  At my practice in Palo Alto, and throughout the Bay Area, most patients seek what I would call a natural look.  They want it to look like nothing was done, these are the breasts they were born with.

Major categories of implants:

  • fill:    gel / silicone  or saline
  • profile:    low, medium, or high
  • shape:  round or anatomic / shaped
  • shell:   smooth or textured
  • volume

Profile has to do with the width and projection for a given volume.  In general, the low profile implants are flatter and wider than the high profile implants.  I have some patients who think to have a natural result you must have a low profile implant.  This is not true.  The profile of the implant varies depending on the patient: how broad are they? how much natural breast tissue do they have?  how big are they going? If you look at my photos, you will see all three profiles of breast implant. 

In general, if you are between two profiles, the lower profile implant will give more of a salt of the earth natural look, the higher profile a little more perky look.  Width is important.  If you go with too narrow of a breast implant, you will look fake and have a wider gulley between your breasts.  If you pick too wide of an implant, you will be fuller into your armpit, a particular problem if you are a tennis player or golfer.

My general rule of thumb is to have the patient pick volume first, profile then follows.  If you are at an extreme: a very small size or very large size, then your breast implant width may not be ideal.  This is something I review with patients during their consultation.

If you have further questions, please email me through my website:

Okay. So you have decided you are going to do a breast augmentation.  One of the choices you need to make is what size?

I often hear “I want it to look natural.”  “I want to be proportional.”  “I want to be a full B / C / I don’t know.”  Great.   You have started to think about it.

My girlfriend guide to plastic surgery for breast implants (ie what I tell my girlfriends):

1. Don’t pick out a cup size.  I am amazed at how women come in wanting a letter cup size.  There is no standard to bra sizing.  What is a 34C at Victoria’s Secret, is not at La Perla, Olga, Maidenform, etc etc.  What you think is a 34C may not be what I think is one.   Focus on what you like when you see it in the mirror.  I am stunned some women go to doctors who tell them they, the doctor, will pick the size.  Given how many times I have found women totally off on what cup size they think they want, I would strongly discourage this.

2. Photos don’t work.  Seeing a photo of a woman who had 300cc implants does not tell you what you will look like.  Every woman is different.  Lovely, unique, fantastic, and different.  Even for a woman of the same height and weight, how broad are your shoulders? Do you have hips? How broad is your chest? Are you muscular? curvy? I have seen a short woman with a 400cc implant look totally proportional, and a taller woman with the same implant look like she needs a new day job.

3. Natural is not a size.  I can make a woman look natural and proportional as an A, B, C, D, or even DD cup.  Natural has to do with the shape of the breast, how it sits, how it moves.  Every surgeon has an aesthetic.  I am natural.  I have patients who, naked in front of their friends, find their friends can’t tell they have implants.  “How do you look so good after 3 kids?”

So, how do you pick?

Try on sizing implants.  The only way  you know what you like is to SEE it on you.  I make all my patients try on sizers with their clothing in the office.  Bring in tons of tight tops, particularly high necked ones (nothing makes you as busty as those form fitting turtlenecks).  If you work out a lot, or swim, bring in those too.  You need to feel comfortable in all of your looks.  Most of us are multi-faceted women – we are atheletes, mothers, girls on a Saturday night, and yes, even surgeons.  You have to feel comfortable in all areas of your world.  And there is no law against wearing a push up bra after you get breast implants if you need a little extra.

The cardinal rule of implants is “you always wish you would have gone bigger.”  I never believed that rule when I first heard it.  But it is true.  One of my patients said “breast implants are like diamond rings, they shrink with time”.   They don’t really shrink (neither do the diamonds), but what shocks you at first won’t shock you after a while. I recommend you try out your new size for a while.  Stuff your bra prior to surgery.  You will get used to seeing yourself with breasts, so if you want to upsize you will do so prior to picking your final size before surgery.  Also, others will get used to seeing you with breasts, so they won’t notice the change, and you’ll see if it stirs up any good (or unwanted)attention.

Bigger is not always better.  If  you have thin skin, are an athelte (particulary the higher impact sports like running), have poor skin tone, are young  and want pregnancies/breast feeding in the future, then consider the pros and cons of size.  This is an area where your surgeon can help guide you.

Size is an important aspect of breast augmentation.  Take your time to decide.  This is one area I will not choose for my patients, but I will educate you to make your best decision.

My typical patient never thought they would have a plastic surgeon.

I am a plastic surgeon in Palo Alto, California.  When I started my practice, I thought most breast augmentation patients would be 25 year olds who want to look good in a bikini.

I was wrong.

I have done hundreds of breast augmentations, and my biggest patient population is women after children.  The mommy makeover. After baby tune up.  Call it what you will.   My patients are educated, assured.  They have great self esteem. They are in shape and take pride in having a healthy body. They are not being pushed by a husband.  They do not want hootchie mama breasts; in fact, they don’t want anyone to know they have done a thing.  They are surprised they are in my office.  They never thought they would do plastic surgery.  They think no one they know would do this. (Though most of my patients come from a 10 mile radius, so they likely have a friend with breast implants.)

Breast feeding and pregnancy take a larger toll on us than it did our mothers.  We tend to have our children later; we are having multiple children; and we breastfeed.  Here in Northern California support for breastfeeding is everywhere.  My mother had three kids.  She started at age 24 and was done by 28.  Her whole generation was one who thought formula and “science” was better for the baby than breastfeeding.  Her post baby breasts fared better than mine .

A typical story, ” I was fine with what I had.  I wasn’t large, but I was happy.  Then I had kids. ____(insert number) And I breastfed for ________ months. (insert number)  And now I have nothing left / my bikini rides up / I have to wear a push up bra or padding everywhere / I can’t put on a swimsuit / my breasts look like they are on the cover of National Geographic / I can’t stand to see my breasts.”

You never want to feel like you are common.  I love the uniqueness of my patients.  I love the strength of women.  But there are trends we women fall into after having kids.  Most of us are in a fog for the first couple years after children.  And you don’t really know what is going to look like what.  Most of us had more time with our pre baby bodies.  It is hard to go through pregnancy and watch your body change.  The generation of baby boomer women caused an increase in accepatance of plastic surgery.  So you get done with kids, you are 40 and vital, and you think, why do I have to accept my breasts will look like this?

I see patients usually 2 -3 years after their last baby.  It is at this point you are out of the fog, you have worked out and had time pass, and you can finally assess what your post baby body will look like.  I always feel like I should hand out those iconic flags they stuck on the moon.  This is MY body.  I am not a milk truck.  A jungle gym.  A baby carrier.  I am a woman.  I am ME.  And my patients reclaim their body and sexuality again.

Breast implants are not for everyone.  There are risks, some patients are better candidates than others, some really need a lift, you have to accept you will outlive your first pair of implants… But for the right women, an implant can reconstruct the breast.  Implants can be small or large and be made to look natural at either volume.  Every doctor has an aesthetic.  Look at photos to see if you and your doctor will click.  Look for a doctor who is a true plastic surgeon, Board Certified by the Board of Plastic Surgery.

I will have more posts later on breast implant nuance: profiles of implant, gel or saline, in front or behind the muscle, biplanar or total muscle coverage. It is too much for this post.  Please email me with questions.

What happened to your breasts? (read, for most women who have had kids and breastfed, WHERE DID MY BREASTS GO?)  Please remember with this I am a HUGE FAN of breastfeeding.  I can’t imagine having the ability to help your child in all areas, particularly the bonding, intelligence, and immunity, and not do it.  I breastfed all three of my children for 9 months to over a year. But pregnancy and breastfeeding do affect your breasts.

General rules of thumb with the breasts:

As you age your breasts change.  Breasts are primarily a mix of breast tissue (a kind of fibrous substance with breast glands, ducts, and milk when you are breastfeeding) and fat.  When you are young, more of your breast is breast tissue.  This tissue tends to be dense.  Part of the reason we don’t mammogram younger women, in addition to the fact their cancer rates are low, is we can’t see much on the film due to the denseness of the breast tissue.  As you get older, your breast composition becomes fattier.  With this change in composition, the breast volume changes more with weight change.

In general I see trends in women who have breastfed.  The longer you breastfeed, the more change you have.  So a woman who has breastfed for 3 months has fewer changes than one who has fed for a year.  The more kids you have, the more change.  And again, read my breastfeeding tips on my blog, and try to feed evenly on each breast. (yes yes, I know.  Your baby likes one better, one makes more, yadda yadda.  But trust me.)

We as a generation do not look the same as our mothers.  Overall, particularly here in the Bay Area, we had our children at an older age.  Many of us had multiple children.  And here in Palo Alto there is signficant, good support to breastfeed.  Hence the larger changes to our breasts than our mother’s.

If you were small breasted to begin with, the babies may have left you with nothing.  Welcome to why breast implants are so popular.

If you were large breasted to begin with, welcome to why your breasts now touch your knees, you are short waisted (or long breasted as I like to call it), and you have to wear a bra 24 hours a day. Welcome to why breast reductions and lifts are so popular.

So you are going to take the plunge. I think it is fantastic.  There is nothing I have done as moving and rewarding as having children.  Pregnancy is hard on the body.  Common changes occur.  Here is a brief overview of some things to do before you get knocked up.

1. Exercise.  A healthy body does better with pregnancy.  A lot of the women I see with great figures after pregnancy had them before pregnancy.  So improve your muscle tone, particularly your core muscles (especially the rectus muscles and oblique muscles which you use to do pilates/the plank/sit ups).

2. Healthy skin.  The “rosy skin” of pregnancy sounds great. And many women do get it.  They also get a lot of pigmentation.  The sun spots, age spots, freckling- call it what you will- worsens with pregnancy.  So prior to pregnancy, try to reverse any skin pigmentation you have.  Hydroquinone and Retin A are great for pigmentation, but they are NOT baby safe.  There are products with Vitamin C and E which are okay while pregnant and breast feeding.  And the key to pigment? SUNSCREEN and the big floppy sun hat. You should apply sunscreen daily.  Try to find a moisturizer or makeup base with sunscreen in it.  When doing activities in the sun, apply sunscreen 20 minutes before going outside, reapply every 45 minutes in water, reapply every 2 hours regardless, and use sunscreen less than a year old.  I am a fan of the clear zinc based sunscreens.  They are mechanical blockers, not chemical, so they are likely less absorbed in the skin.  Very effective and thought to be a little more baby safe.

3. Ideal weight.  You will gain weight with pregnancy.  (Oh my!? shocking.) The amount of weight you gain varies, but the usual recommendation is 25 pounds.  There is a correlation with weight gain and body changes- stretch marks, loose skin, diastasis, and higher post pregnancy weight.  There are studies which link obese children to mothers who were obese before pregnancy.  (The amount of weight gain has been revised to 11-20 pounds for women with a BMI of 30 or more.)

4. Stop smoking.  I could go on for ages on this one.  It affects every body system; increases your chance of heart attacks, stroke, and cancer; along with sun exposure it is the biggest ager of the skin, and does things I can’t fix with products and peels; no surgeon will do a tummy tuck or a breast lift on a smoker, so you might as well stop now; it is expensive; you can’t do it in restaurants; it yellows your teeth.

The health effects on the baby: it lowers the amount of oxygen they get in utero, increases heart rate, and increases rate of miscarriage and low birth weight.  There are other studies indicating after birth these babies have issues with asthma, behaviorial issues, and higher SIDS. For more information go to:

5. Surgeries. The one surgery I like before pregnancy is liposuction.  If you have a discrete problem area, like “my outer thighs,” or are an exaggerated pear or apple shape, your shape will not improve with pregnancy.  Particularly for those women who are teeny tiny up top and carry all their weight in their thighs/hips, when you put on baby weight it will all go there.  Fast forward: you are now 10 years older and have stretched that skin more, for a longer time, and your skin is older- it won’t bounce back after liposuction like it would at age 25. Skin tone is key to liposuction, and young skin is better.

I do not like to do abdominoplasty (tummy tuck) or breast surgery right before babies.  If your breasts really bother you and you will not have babies for 5-10 years, then it may be worth it to do now. But pregnancy and breast feeding affect the belly and the breast the most.  If you can, wait to fix up those areas until after you have kids.


Exercise. Wear sunscreen. Eat well/be your ideal weight. Don’t smoke.  Sounds simple, eh?

Now go get practicing to have that baby.


So that age old question: “How does that giant baby fit into my belly?”  It does so by moving the other things around and stretching your muscles and skin.  Your abdominal muscles are the rectus muscles (the “six pack”) and oblique muscles.  The muscles of the abdomen do not cross the midline.  This central line is called the linea alba.  It is made of a leathery substance called fascia.  When you are pregnant, your muscles separate in the middle.  This separation between the muscles is the diastasis.  Everyone who has had a pregnancy has some separation.  This is the reason you can’t “suck it in” as tightly as you did before pregnancy.  This is also part of why your waist gets wider.

The amount of separation varies.  Some people have a small amount, some a wide.  It tends to get worse with the number of pregnancies and the amount of weight you gain.  (Another reason that large babies should give their moms large presents on mother’s day.) Some women have poor genetics though and get a lot of loosening with their first child.  If your diastasis is bad, you will have a flat belly lying down, and then look pregnant when you stand up.  When your abdominal muscles are loose, you may have back pain due to weak abdominal strength.

Since no muscles cross this midline, you can’t tighten it up again with exercise. (To many a husband’s chagrin. So tell him that his “honey you just need to do more sit ups” will not work.) A diastasis is fixed with a tummy tuck.

A tummy tuck is two parts.  That bottom part is internal and fixes the diastasis separation.  You can’t see it.  It is a corset which brings those muscles back together.  I use a two layer muscle tightening approach; both layers are permenant sutures.  This will tighten your core again as it brings the muscles together.

The second layer to a tummy tuck is removing excess skin. 

A hernia is a true hole in the abdominal wall.  This commonly occurs at the belly button, and is why some women are no longer an “innie” after pregnancy.  Sometimes people will call a diastasis a “ventral hernia.”  Most women have a simple separation where the sheet of tissue keeping the “insides in” is still intact, not a hole.

I am a huge fan of breast feeding.  The benefits are well known.  For the baby, there is reduced otitis media, respiratory infections, gastroenteritis, rates of SIDS, childhood obesity, type 2 diabetes, and childhood leukemia.  For the mother, there are lower rates of breast and ovarian cancer and type 2 diabetes.  There have even been studies that breastfed children deal better with stress later in life.

It is recommended you breastfeed exclusively for 6 months.  I breastfed all of my children.  Particularly with the dangers in the world of swine flu and other diseases, it is one of the best gifts you can give your child.

Breastfeeding can take a toll on your breasts.  So here are some recommendations:

1. Alternate breasts.  Everyone has one side which is easier to feed on, produces more milk, the baby likes it better, etc etc. Breasts are not symmetric.  They are different sizes and different producers.  Try to use both breasts evenly.  Use a timer and switch to the other side.  Personally, I tried to feed from both breasts with each feed.  When I have patients who exclusively breastfeed on one side, there is a marked difference between their breasts at the end.  The key to breasts is symmetry.  Whatever you do, you want your breasts to look as alike as they can.

2. Support.  Breasts are not a muscle. The infamous ”we must, we must, we must increase our bust” exercises don’t work.  The pectoral muscle lies beneath the breast tissue.  The breast itself is composed of breast tissue, ligaments, and fat.  When the tissue has stretched, there is no way to “firm” it up again with exercises, creams, or lasers.  So wear a bra.  Make sure it fits well and is really supporting you.  Sleep in the bra.  To see if the bra is giving good support, jump up and down in front of the mirror and see how well you are supported.  Everyone has seen a woman jogging who does not have enough support.  A good bra has a defined size, 2-3 rows of hooks in the back, and adjustable straps to transfer the weight of the breast to the shoulder.