The Best Breast

Subplots:  1)History repeats itself, 2)why would any patient want to have tubes coming out of her breasts following a breast augmentation when she could go to dinner the same evening without the tubes, and 3) why would surgeons want to burden patients with unnecessary tubes if better alternatives exist?

If you’re considering breast augmentation, at some point you’ll probably wonder, “How painful is it?  How long does it take to recover?”  And if you’re normal, anything that sounds as if it could decrease the pain and shorten recovery should sound pretty good….until you know (thank you Paul Harvey)…the rest of the story.

A colleague forwarded me a link to a recent news release about a surgeon who just completed a 12-year study (read the release here) advocating the use of tubes left in the breasts following augmentation for pain control.  The study concluded that by leaving tubes in the breast following surgery and injecting local anesthetic for control of pain following breast augmentation, the method was “as effective as narcotics”.  As I read the news release, I couldn’t help wondering, “Am I living on the same planet, in the same millenium?”  Tubes following augmentation?  Narcotics?  Not in our world.

The idea of putting local anesthetic into the body or the pocket that contains the implant is not “new” news.  These techniques were in use in 1977, 32 years ago, when I began my plastic surgery residency.  But we discontinued those practices more than 25 years ago in our practice for 4 simple reasons:

1)  Every tube going into or coming out of the breast following augmentation a) is uncomfortable and disconcerting to every patient, 2) tubes into the body create a continuous tract or connection from the outside skin which harbors bacteria to the inside of the pocket containing the implant, thereby increasing risks of contamination or infection around the implant–a very large foreign body; 3) whether or not a pain pump is connected or the patient performs self-injections, tubes exiting the body increase costs, increase risks, make patients feel sick, are unsightly, require bandaging and special dress, and inevitably slow a patient’s recovery, and 4) there are scientifically proved methods that make tubes totally unnecessary in first time breast augmentation while allowing patients to be out to dinner the evening of augmentation.

But what about the pain?  What about the recovery?  Wouldn’t any patient want less pain and a faster recovery?  Of course they would, and they can–without tubes.  Therein lies the rest of the story.

What if every patient could have a 96% chance of returning to full normal activity within 24 hours (read the technical, scientific proof here and here, and much more comprehensive, straight talk explanation here)–without any tubes–and even without any bandages, no narcotic pain pills, no pain pumps, no special bras, no increased risks of infection, and NO TUBES COMING OUT OF THE BREASTS?  With a 96% chance of returning to full, normal activities within 24 hours, what if every patient could have an 85% chance of going out to dinner, shopping, or a movie on the same evening that she had her breast augmentation–again- WITHOUT ANY TUBES, BANDAGES, OR NARCOTICS?

Fairy tale?  Not at all.  Instead, this type of recovery, all without tubes or other burdensome, costly, and risky adjuncts, has been available to surgeons and patients worldwide since 2002–all techniques and processes peer reviewed and published in the most respected professional journal in plastic surgery.  For the past decade in our practice and in other surgeons’ practices, this level of recovery is routine and predictable– without the necessity of tubes of any kind coming out of the body.

The obvious questions are:

1) With these scientifically proved techniques readily available, why would any patient want tubes coming out of her body?

2) With these scientifically proved techniques readily available, why would any surgeon want to burden patients with the increased costs, potential risks, hassles, and prolonged recovery associated with unnecessary drains and tubes?

We ask ourselves these same questions every day, and marvel (not) at how three decade old techniques and methods somehow resurface as something “new.”  Indwelling tubes for drainage or pain relief?  State-of-the-art breast augmentation has advanced far past those unnecessary adjuncts that impede patient recovery, increase costs, and increase potential risks.

“What is, is.”  Any type of tube or catheter exiting the body after a routine, first time breast augmentation IS disconcerting to the patient, a nuisance, a distraction, an additional cost, can present additional risks of implant infection, and it IS unnecessary in first time breast augmentations if surgeons implement state-of-the art, scientifically proved processes.

An improved, redefined patient experience and recovery IS having an 85% chance of going out to dinner the evening of her augmentation, a 96% chance of returning to full normal activities within 24 hours, and a 3% or less chance of having a reoperation within 3-7 years- without the necessity of any types of tubes coming out of her body.

The peer reviewed and published scientific data that supports these comments is available here.

A postscript for perspective:  All of the comments above apply to primary or first time breast augmentations.  Drainage tubes or other adjuncts may be reasonable and indicated in reoperations following augmentation, and in breast reconstruction procedures.

I am so happy to have a guest blogger today!  I asked Tebbetts to weigh in with his thoughts and experience on High Profile implants.  I see a lot of comments from women about all the implant profiles ~ but not alot of education or information specifically about what it means or what effect it will have on tissue long term.  So here’s a tale of two implants……

The plot:  What you may think you want, and what you may get…

It’s a simple story, but with a sad twist.  Certain patients want more projecting breast–forward thrusting, perky, “lifted”, or even Dagmar-like (definition:  missile or artillery shell-like, named after a famous cleavage, and used for the design of front bumper grill decorations in 50’s cars–find out more here: http://en.wikipedia.org/wiki/Dagmar_bumpers.)   What patients want, surgeons historically provide.  Simple demand and supply, but in this case, a story with a twist.

The story begins something like this–patient wants, surgeon supplies, patient pays, patient has new breasts, patient is happy.  Then the twist; the story doesn’t stop with “patient is happy”.  Patient thought she knew what she wanted–she just never dreamed what she might get.  Happy for a while, but then later…where did the projection go?  “Perky? I don’t think so.  Now they’re more like “rock in a sock?”  “I nursed my first child; why can’t I nurse now?”  And “why can I see the edges of my implant; why are these big ripples in my cleavage area; and why does my surgeon say these things can’t be corrected?”  Like the movie Easy Rider (yes I know that dates me), a story with a great beginning, but with twists and a sad ending.

High and extra high projection breast implants seem like a good idea for first-time breast augmentation patients who want them–until the story changes with a twist and sad ending.  Can a high projecting implant create a high projecting breast that hits the aesthetic mark for what the patient wants?  No question, and that’s why many surgeons implant them when patients ask.  The problem is making choices without knowing the potential story endings.

The more highly projecting (front-to-back dimension) of a breast implant, the harder the implant pushes on what’s in front of it–particularly breast tissue (the milk producing tissue that covers the implant and makes the breast feel like a breast) and the skin envelope (the skin that contains the implant and breast tissue, and supports the breast). What’s wrong with the story so far?  Don’t we need a more projecting implant to push harder and create a more projecting breast?  Yes, we do.  Patient and surgeon have decided what they want, and they have selected the type of implant that will force the tissues to the desired result.  But then comes the twist: forcing tissues to a desired result has consequences that patient and/or surgeon may not have considered when choosing an implant, changing a happy story to a sad ending.

The twists and the sad ending are predictable.  Excessive pressure from excessive implant size or projection compresses (squashes is a simpler term) the breast tissue against the overlying skin.  Over time, two bad things happen.  The breast tissue simply fades away or shrinks over time (medical term: parenchymal atrophy), and it’s gone–for good.  No breast tissue, no milk, no nursing, and no coverage over the breast implant, so implant edges become visible.   Excessive pressure from overly projecting implants overly stretches the skin of the lower breast.  Like a blown bubble with chewing gum, as the bubble gets larger, it gets thinner.  Larger bubble in the lower breast means emptying of the upper breast and a fuller lower breast–rock in a sock.  Thinner bubble with less breast tissue covering the implant allows implant edges to become visible (yes, it’s ugly).  As the weight of the implant pulls on the thin bubble (the skin evelope), the skin wrinkles and ripples in the areas where the skin is thinnest, often in the cleavage area where it’s most noticeable.

Sad ending is, once the tissue is gone, it’s gone.  Once the skin envelope is too thin–it’s forever.  No surgical procedure can restore tissues irreversibly damaged by excessively projecting or excessively large imlants.  What started out as a well-intended but poorly thought out story, often ends up as a sad ending with uncorrectable tissue deformities.

Morals of the story?  Decisions and choices without thorough knowledge can produce irreversible and uncorrectable deformities.  Be certain that you balance what you think you want with what you are likely to get.

You may know what you think you want, but you need to know what you may get before making a choice of implant projection and size.  Keeping the happy story happy requires the right choices up front, because life (and breast augmentation) are about choices, and patients and surgeons are responsible for the choices they make.  Avoiding the twist requires recognizing and avoiding choices that put a sad ending on a happy story.   There is little or no place for highly projecting breast implants for primary (first time) augmentation if safety and preservation of patient tissues are priorities.

Postscript:  Breast reconstruction after mastectomy is very different compared to breast augmentation.  The breast (or large portions of it) is gone.  In carefully considered situations, more highly projecting implants sometimes have a place in breast reconstruction.

I had the pleasure of visiting with a really nice, new patient yesterday who was very well informed – had done her own research and had read our book, The Best Breast 2.  I love working with women who have really and truly done their homework and are looking for the best result and experience they can have in breast augmentation.  It makes my job so easy – when they know what I know, we can really have some detailed and constructive discussions.  Yesterday, our discussion went to another level. 

Once I had finished covering all the points I needed to cover for her patient education consult, it was time for her questions.  After sitting in my chair for 20 years, I have pretty much heard it all ~ but this patient took an innovative route to discover more information about us and how we approach this operation.  She asked me to address all the criticisms and negative things she could find on the web about us ~ wow ~ now that is a little hard to hear!

We know that not every surgeon or patient will agree with our methods or processes.  We know that when we do something really different and can truly produce a result and recovery that is almost too good to be true, that there will be those who say it can’t be done.  If you can achieve results that few can replicate – there are those that will want to impede progress for patients.

But when you live in our world of plastic surgery, specifically breast augmentation, I know what we do is truly better for patients.  When you can take the national re operation and revision rate of 25 % and drop it to 3% in Dr. Tebbetts’ practice - – there is no question that that is better for patients.  When you can involve patients in the decisions and return them to full normal activity in 24 hours – again no question that this is better for patients.  

 It was good for me to address things people say about us and our practice that might have seemed like a criticism on the surface, because as I addressed them I realized that all of the issues and comments arise from how different what we do for patients really is.  And that they really aren’t negative at all.  Answering these questions made me realize how what we have done for patients in breast augmentation has truly redefined the patient’s experience ~ 24 Hour Recovery is a reality and Dr. Tebbetts made that happen and has shared all of that knowledge and the how to’s  with his colleagues!  

The more we question, the more we challenge, the more we learn and the better off patients will be.  So bring on the tough questions and criticisms, because now that I think about it, they were really compliments in disguise.