bodypostbaby's blog

When I started my practice a decade ago, most of my breast reductions were covered by insurance.  I think they are a great surgery, improving posture, neck pain, back pain, shoulder notching, and the ability to go jogging.

Things have changed.

Now almost none of my reductions can get covered. It is frustrating for me and my patients, as I see many large breasted women who can’t get covered.  What changed?

First, I now do a short scar breast reduction technique, called a vertical breast reduction.  I “cut out” less breast tissue with this technique.  Why did I change?  First and foremost: much shorter scar.  Also, I find this breast reduction better at shaping, with a longer lasting result.  I love it.  But with this technique I do liposuction of the lateral breast in the armpit area.  Insurance won’t include this fat as part of my “breast tissue removed” total.

Second, the amounts they require have gotten higher.  Not a good combo with my short scar technique where the amounts I directly cut out went down anyway. 

The Schnur scale came out of a study in the plastic surgery literature.  They did the study to prove breast reductions objectively, medically IMPROVE symptoms. During the 1980s plastic surgeons started to see insurance companies refusing to pay for breast reductions, calling them “cosmetic.”  So multiple studies followed, documenting scientifically that back pain, neck pain, and breast pain had about an 80% improvement after surgery.  (And patient satisfaction was around 90%.  Pretty fantastic, particularly given those were the days of the longer anchor scar.)

The Schnur study came up with a scale used to show the volume which needed to be removed for breast reductions done for medical reasons only.  The issue is the Schnur study had a mean height of patients being 5′4″, 163 pounds, and a mean total amount of breast tissue being removed was 1515g. (That is over 3 pounds per breast.)

Ug.  When I started my practice, if a woman was going down about 2 cup sizes, they would get covered.  I used to have to remove about 300g for insurance coverage.  Now it is adjusted to the body surface area, and the required amounts have gone up.  With current recommendations, a 5′6″ woman who weighs 140 pounds needs a reduction of 370-400 grams per breast to be covered.  If she weighs 160, she would need about 450 grams per breast.  Liposuctioned fat cannot be applied to this total.  In my office I can show you visually what “volume” (using an implant sizer) this would be.  Many times the amount looks like the total of the entire breast, essentially being a mastectomy.

You don’t need to convince me a breast reduction and lift is a good idea. Insurance is another story though.

BODY SURFACE AREA CALCULATOR at http://www.bcbst.com/providers/calculator.asp

SCHNUR SLIDING SCALE at http://www.bcbst.com/mpmanual/The_Schnur_Sliding_Scale_chart.htm 

I was recently the featured interview for an online magazine for busy moms to talk about the mommy makeover.

http://bizymoms.com/palo-alto/surgery/mommy-makeover-palo-alto.php

 I received a question today asking if there was a natural, nonsurgical way to lift the breast.  Ah… If only I were magic. 

The breast is not a muscle.  Doing pectoral muscle exercises will not lift the breast.  You can be as toned as possible in your underlying muscle, but it won’t lift the breast tissue, firm the ligaments, or tighten the skin. (or make your breasts larger. sigh.)

Skin tone is like a bathing suit.  When your skin is new, it has great elasticity.  It bounces back well, and doesn’t stretch out, wrinkle, or sag.  As we age, our swimsuit ages as well; and the tone isn’t as good.  We all have different qualities of skin tone based on our age, ethnicity, sun damage, smoking, what we have put it through (major weight changes, pregnancy, etc) and genetics. 

 Once your skin is stretched out, it is stretched.  There is no proven skin cream, exercise, or laser to improve it.  Many products will claim they firm and lift.  But I think these products prey on our dreams- none of them really work.  I always ask them to show me the science.  Show me the improved skin biopsy; show me the photos of the lift. 

 Watch out for trickery.  Many cosmetic lasers will show only photos at 1-2 months out.  This is misleading. When you have a little bit of swelling, the skin looks prettier, plumper, and more youthful.  What does it look like at 6 months? A year?  Some of the lasers will take the first photo without flash (always shows more wrinkles and aging) and the second photo with flash.  Or they will take the photos from different angles.  Watch out for this.  I love marketing.  I had a woman who was going to do a “laser bra” in which the laser lifted the breast.  Trust me, I have breastfed three kids.  If there were a simple laser treatment which firmed and lifted, I would be the first to sign up.

So, alas, I am here to tell you there is no magic answer, no pot of gold at the end of the rainbow.

The only way to really lift and reshape the breast is with a surgery.

Where to cut? 

When you choose to do a breast augmentation, we must get the breast implant inside. (Unfortuantely, it is not magic.)  This is the scar you will see when you are done.  There are pros and cons to each incision. 

There are three basic common incisions:

• Armpit (also known as axilla)
• Periareolar (at the bottom of the areola, the colored portion of the breast skin)
• Inframammary fold (also called IMF, the under part of your breast where an underwire goes)

There are other incisions  you hear about such as through the umbilicus (TUBA), through an abdominoplasty incision, and through the base of the  nipple. These are not as common (for real reasons).

IMF:  This is the most common incision used.  The scar can go in the crease of the underwire or just above the crease on the bottom curve of the breast.  PROS: On the breast, so only someone seeing you naked will see it.  Preserves ability to breastfeed.  Can use as an open door- when you need a revision surgery due to deflation or capsular contracture, you can fix it through the old scar.  CONS: If you wear a bikini which doesn’t hug your underwire, you may see the scar.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

AXILLA:  Scar goes into the armpit.  PROS: Preserves ability to breastfeed.  No scar on the breast.  CONS:  Scar in a place visible when you wear tank tops or bathing suits.  Usually more of the pocket is done by blunt dissection, so may get more bruise.  More difficult pocket dissection, may lead to implant malposition and upward migration of implant.  Difficult to place gel implants.  Usually need to make a second incision when you need revision surgery for implant replacement.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

PERIAREOLAR:  Scar is at the transition between the areola and the breast skin.  It does NOT go all the way around the areola.  It is at the bottom of the semicircle.  If you see a scar going 360 around the areola, then a breast lift was done.  PROS: I find this incision hides the scar the best, particularly in my patients with darker skin tones: Asian, Phillipino,  Latina,  and Black.  If your scar turns darker / brown, then it tends to blend with the areola.  It is an open door- you can reuse the old scar for any revision surgery.  It does NOT interfere with sensation. (Will go into sensation details below.) The scar is on the breast, so only someone seeing you naked will see it.  It gives the best access to making an accurate pocket dissection, important for smaller implant sizes, which is important for my natural aesthetic in my Bay Area patients.  It allows access to have meticulous bleeding control, important to limit bruising and potentially capsular contracture.  This is my favorite incision as I find the scar fades in most patients to nothingness.  I like it particularly for women who are done with pregnancy and breastfeeding, women with constricted or tubular breasts, and women who may need a lift down the road, so you limit future scars.  CONS: It does cut through some of the breast ducts, so for women who have not had children yet and want to breastfeed, it may impair breastfeeding.

The biggest issue women bring up when discussing breast augmentation incisions, tends to be sensation.  Will my breast sensation change? What affects it?  There is a common perception that cutting at the areola will cause more sensory change.  This is not true.  Funny.  It seems like if you cut at the areola then the nipple sensation should change more than if you cut at the armpit, eh?  A study published in our white journal (the plastic and reconstructive surgery journal- a big deal in my world) showed there was no difference in sensation based on where you cut, but there was a difference based on how big you go.  The sensory nerves come up from the sides.  As you stretch the skin the nerves stretch.  This is what causes the sensory change.  Think about how your breasts feel when you are pregnant- or better yet -when your milk comes in.  That tingly, numb, or hypersensitive-don’t-touch-my-breasts sensation.  Many women report right after augmentation feeling like they did when their milk came in.  This feeling goes away, though your final sensation may be the same, less, or more than prior to surgery. I tend to find sensory change is less for women after having kids, and my thought is they have essentially “prestretched” their breast skin.

SO. Bottom line on sensation? The bigger you go, particularly if you are stretching the skin, the more sensory change you will get.   

For photos, check out my gallery.  Most of the incisions you see are periareolar, and most photos are 6 weeks out.

Some plastic surgeons seem more focused on marketing than on their patients.

I guess I am an old fashioned girl. I like honest and real.  I don’t try to sell my patients a rainbow.  I don’t try to lure them into my office with promises of scarless surgeries, only to tell them it isn’t possible for them.  (Kind of reminds me of those teaser car lease rates.  In the fine fine print you’ll see only one is available at the special advertised rate, and oh yes, we forgot to mention the thousands of dollars down for registration and drive off…)

Anyhow, I recently saw an article by two young plastic surgeons advocating a single incision, single scar mommy makeover. (Forgetting all tummy tucks have two scars, so the name is misleading from the start…) But love it. Sign me up! What is it?

It basically is for women who need

1. Breast augmentation, in front of the muscle.
2. Tummy tuck.

Now I have many patients who benefit from a tummy tuck and breast augmentation.  It is a common combination for mommy makeover.  I find these dual surgeries safe in most of my Bay Area healthy patients. Most of my Palo Alto moms don’t have time to do two surgeries, the cost is lower, and it is one recovery. And I am all for reducing the number of scars.  Plastic surgery is about innovation.  What I do today is not what I did a decade ago.  And with new advances and refinements, I expect what I do in the future will be different as well.

My issue is with this procedure is it  has been tried before, with some poor results.  It is tough to position the implant well when going from the abdomen.  You create an opening which connects the breast pocket with the abdominal pocket.  There are many many issues with placing the implant in front of the muscle, particularly in thin women.  (Please see my page on breast augmentation for more information.)  And with implants my greatest concern is always what happens down the road.  Does it move? infection? hardening? And if you put it through the abdominal incision how are these addressed?

This is being spearheaded by two young guys just out of residency.  I don’t know how many they have done, what they look like (no photos were shown in the article, or on their website), or what the technique really is.

But it is a great marketing play.  It has gotten them an article written about them which I read, and I am sure it will attract patients to their new practice.  They have many sayings which could apply here: Buyer beware.  If it seems too good to be true, it usually is.  Show me, don’t tell me.

Until then, I will continue to keep my breast implants separate from my abdominal incision.  The breast augmentation scar at the areola on most of my patients fades to nothingness, I like the submuscular placement of the implant, and I like knowing I did everything I could to insure they have a beautiful, natural, soft result.  Unfortunately for me, good solid plastic surgery technique isn’t catchy.  Alas, no splashy article about me today.

So you decided you will do implants.  Now where to put them? (Yes, yes. other than the obvious “on the chest” or “one on each side” answer).

You will see doctors put breast implants in front of the muscle OR behind the muscle.  The muscle we are talking about is your pectoralis major muscle.  It is the one you do push ups with (or for you moms out there, the one you use to hold your baby while you try to cook dinner).  The muscle inserts along your sternum (the middle part) and along where your underwire goes (the inferior part).

The traditional teaching is putting the implant in front of the muscle gives more lift.  So when you have kids, breastfed, etc etc and your breasts appear deflated, you will get more lift and perkiness from the implant if you go in front of the muscle.  There is also less pain (bonus), and your breast implant won’t sometimes do a funny jump when you use your muscle (great!).  The issue I find with putting breast implants in front of the muscle is rippling and wrinkling in the upper part of the breast and cleavage area.  This is icky and tough to fix.  It tends to happen slowly over time, as your tissue thins. 

You are looking on this site because you don’t have much breast tissue, hence your need for implants. 

Nothing substitutes for soft tissue coverage over the implant to get a good result.

That soft tissue is skin, breast tissue (you don’t have much), and fat (again, you likely don’t have much of that either).  The only other cover is muscle.  I like going under the muscle for many reasons. 

1. Lower rate of capsular contracture / turning hard. 

2. More tissue covering your implant in the cleavage and upper area.  So when you wear a low cut dress or strapless top, you don’t worry about wrinkles, ripples, or implant edges.

3. Easier to do a mammogram.  Behind the muscle lets you see more of the breast on mammogram than in front of the muscle.  Very important, especially with a family history of breast cancer.

4.  I think a more natural look.

Putting a breast implant behind the muscle does not lift as much as in front of the muscle.  To get around this, many doctors do what is called a biplanar approach.  Sounds fancy.  What it means is we keep the implant under the muscle up top, and the implant is on top of the muscle on the bottom.  For women in that droopy-i-might-need-a-lift category, I like to do this technique.  I also use more release along the inferior border of the muscle for women with tubular and constricted breasts.

Personally, I never release the muscle along the sternum (the medial, cleavage area).  I hate how it looks- I think it gives a fake, round look.  Sometimes the breasts get too close or too far apart with this as well.  Overall, I tend to favor more muscle coverage.  It gives better soft tissue coverage over the implant. (Remember: soft tissue over implant=makes look pretty.)  And I think it helps keep the breast from bottoming out.

So, what should you take away from this?

I favor under the muscle.  All doctors do not do “under the muscle” the same way.  Some cut the muscle more than others. 

So how do you choose?

Look at the photos. And talk to your doctor about what technique is best for you and why.

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: http://laurengreenbergmd.com

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.

www.laurengreenbergmd.com

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.