This will be the first in a line of blogs about this topic.

Let me start first with an email I received from a patient,  “I just want let you know that I have had no problem breastfeeding.  I am grateful that nothing was damaged during my breast lift surgery.  Nice job to you!!  We had a beautiful girl.  I was worried about breastfeeding but it is going great.  I have a ton of milk supply on both breasts.   I just wanted to let you know. “

All breast surgery affects the breast.  Seems like a simple concept, but we forget it sometimes.  A 20 year old woman who wants a breast reduction may be more focused on getting her breasts smaller and somewhere above her waist, not the bonding and nutrition she may give with breastfeeding 10 years down the road when she decides to have kids. 

So I discuss it. 

Any woman who has not had children and wants to do any surgery of the breast needs to consider the effect surgery will have on the breast and your ability to breastfeed.  Thankfully, for most women, they are able to make milk.  The studies show there may be a decreased amount of milk, but I have had many patients who have had breast augmentation or breast reductions and lifts who have successfully gone on to breastfeed.

If you are a decade away from thinking about kids or you have a lot of issues with your breasts (backpain, droop, asymmetry, etc), then know there are techniques which help maximize your future ability to breastfeed.  If you are on the verge of having kids, wait to do the surgery.   It will totally preserve your ability to breastfeed among other advantages:
Anectode:  I had a friend who was 38, newly married, who wanted a breast augmentation.  I am a straight shooter, so I told her, “You are older.  You can’t wait to have kids.  Have your kids.  You’ll need to have them in the next year or two.  Your breasts will get bigger with pregnancy.  Your breasts will get bigger while breastfeeding.  When you know you are done, then do the surgery.  Pregnancy and breastfeeding changes the breasts a lot- shape, volume, symmetry.”  She did not listen, and went to someone else for surgery.  She has now had two surgeries within 3 years.  Had she waited until done with kids, she might have had just one surgery, and the results could have been better. 
 
I am a huge fan of breastfeeding.  I am not saying to do surgery or not do surgery.  I am not dictating the timing of your surgery.  This is all about educating you to make the right choices for you.

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

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.

Is plastic surgery a right choice for you?

As I said earlier, there is a price you pay for plastic surgery.  The price is scar, time off work and exercise, healing, getting someone to watch your kids for a week so you can do this, and the risks of surgery.  What price are you willing to pay? How much are you bothered? How easy is it to fix?

Some people scar well.  For these women, when they have a scar, it will start as a red scar, then turn purple, and then fade away into nothingness.  I have seen some of my patients come back, and I can’t find their scar.  I know where it is, but it faded away.  They pay a lower price than someone who may hyperpigment  (fancy way of saying scar turns darker, black, or brown) or keloid (fancy term for a condition where you form an elevated, itchy, ropey scar).

Some surgeries have small scars and potentially large changes.  Breast augmentation, eyelifts, and liposuction tend to have big changes with small scars.   Small price.  But now let’s say you come in, you were a 34D prior to kids and now you are more like a B, and your breasts droop.  Hmmmm. Tougher choice.  Breast lift with an implant is a bigger surgery, more scar, more potential for sensory change, etc etc.  What price are you willing to pay?  Would you rather have a small scar and the ideal sized breast implant for you, but still be a little droopy? Would you rather go to a larger volume breast implant if it meant you could be perkier and avoid doing a lift? How much larger? If you think, “no way! If I am going to go through surgery and get a breast implant, I want them to look perky and fantastic. I need the breasts up!”, then you might need a breast augmentation with a lift, with the larger length of surgery, recovery, and scar it entails.

Most of my photos I show are women 6 to 8 weeks after surgery.  I am reprimanded for it a lot.  Why do you show red scars? Why don’t you show scars when they are farther out? Why don’t you put underwear on your tummy tuck patients so we don’t see the scar?

I have photos of patients a year out with beautiful scars.  Most have beautiful scars. I don’t think that is helpful. You will see the scar the photos hide under the underwear. Anyone can look at a photo of a wrinkled, strech marked, hanging belly and think “of course they should do a tummy tuck.”  But you, the patient, will need to do the surgery.   You will feel the changes. You will see the scar while you heal.

So, find an honest surgeon.  I don’t candy coat.  I show my large surgery scars on purpose when they are new. Red. Raw. Visible.  New.  I discuss the risks and complications in detail.  When you do surgery there are elements we can’t control as plastic surgeons.  How will you heal? How will you scar?  When we say there is a 1% chance of something, will you be that person?  Education can be scary.  When choosing to do elective cosmetic surgery, you need to know what you are choosing.  I do hundreds of surgeries a year.  For these women, the “price” of surgery was worth it.  Only you can make the decision of what is right for you.

There is a price for plastic surgery.   (yes. yes. I am a plastic surgeon who will not give you a hard sell to do surgery do surgery do surgery.)  Because plastic surgery, the yummy mummy, mommy makeover is not for everyone.

When you get done having your beautiful babies, you wait a bit.  I strongly recommend you wait a bit.  What will your post baby body be like? Will your breasts stay full or will they deflate? Will they be anywhere near your neck or will they touch your waist? Will your belly look like you are permanently 4 months pregnant or will it get back into an okay territory?  How bad does it look when you sit down? And most importantly, does it bother you?

We all have these thoughts.  No woman goes through labor and gets done and doesn’t think UGGH when they see their belly skin flop over when they lie on their side that first day. Thank heavens we are ramped up on adrenaline looking at the beautiful new baby next to us, and then sleep deprived and can’t see straight for the next few months.  When women show up in my office, they have thought about doing surgery for months, sometimes years.  They are not happy.  On a frequent basis some thought haunts them.  “I can’t buy a bathing suit.”  “I was dancing and my bra padding migrated down my dress.”  “I look like a boy.”  “I look four months pregnant all the time.”  “I can’t do sit ups.”  “I have to always take in my jeans at the waist, because when I buy pants to fit my thighs the waist is too big.”  “I look like I hopped out of National Geographic.”

If you are happy with your body, don’t do anything.

Seeking advice from a plastic surgeon is the next step.  You have thought about it, talked to your friends perhaps, and read too much on the internet.  You need a doctor to evaluate you.  Please here take my advice:

  • See a Board Certified Plastic Surgeon.  Anyone can call themselves a plastic surgeon.  True plastic surgeons are trained as general surgeons first.  We are well trained to do all breast and body surgery.  I keep seeing women who have the wrong surgery done (especially liposuction when they needed a tummy tuck) because the doctor is not a real plastic surgeon.
  • See more than one doctor.  I joke if you see three plastic surgeons, you’ll get at least two different answers on how to do something.  Many patients fall into what I call a grey area: no surgery is perfect, but all will improve the situation.  An example:  You have lost breast volume and are mildly droopy.  Do you do a breast implant alone? Do you do an implant with a lift?  Do you just do a breast lift? Every woman is unique in what they look like and what they want to look like.  My Palo Alto patients are smart women.  They know their body, they know what amount of scar is okay, they know what look is okay.  I educate them, so they can make the right choice for them.

So, getting back to my original point, you pay a price for surgery. The price is not actual money (though yes, you do need to pay actual money too).  There are some procedures where the “price” is low: the surgery is easy, short, fast recovery, little downtime, small scar, scars heal well.  There are other surgeries where the price is higher: longer, bigger surgery, longer recovery, larger scar, higher chance of other things.

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