The Best Breast

By Terrye Tebbetts

As expected,  the season has begun.  The kids are back in school, and all the schedules are settling down and now we are starting to plan our holidays and winter vacations.  And now the phones are ringing with the same sentiment…….”I am going on a cruise in 4 weeks – I want to have my BA done now!”  Or “We are going to the Bahamas for Christmas, I need to have surgery as soon as possible!”  We love that you are thinking about breast augmentation and planning trips – we just want to help you with your planning so that  the surgery and recovery and the trip all go well.  So I posted this Time line piece in September – - but I think it needs to go up again to help you research, plan, execute and enjoy your BA!

~  A Time line for planning your breast augmentation surgery for Spring 2010 ~

Often, once the kids go back to school and the fall schedules settle down or in, we tend to start thinking about ourselves again.  We start to plan and think about things we might just want to do for us – but when it comes to breast augmentation, often we don’t allow ourselves enough time.  Optimal planning is the key.

Our patients have been predictably up and out to dinner the day of surgery for over 10 years now – 24 Hour Recovery is a reality for Dr. Tebbetts, our practice and our patients.  But sometimes in the excitement of getting up and out and going again, patients forget that it takes time to realize optimal healing and acceptance of the implants – it’s a process.

First, there is education.  You have to know and understand what your choices and options are – pocket location, incision location, how to determine size, which implant (shaped or round, saline or silicone, smooth or textured) and then how in the world do you find the right surgeon?  Why is it important to learn about your recovery ahead of time?  The Internet is helpful but really can only be as good as your knowledge – since anyone can put anything on a website – whether it is personal opinion or science – if you don’t educate yourself – how can you tell the difference?  The Best Breast 2 is an incredible resource for every woman considering this operation.  Yes – it’s a big 500 page plus book – but you can read it for what you need to get out of it – it is worth the time and effort you will put into getting facts – not just opinions from friends and message boards (not that those aren’t valuable resources too – but they have to be tempered with fact, science and objectivity).  Plus – you can tell a lot about the plastic surgeons you call – just by how much the staff really knows and shares with you and what kind of written information they send to you.  You don’t want to use a surgeon that does not specialize in this procedure – there is too much at stake.  So to get ready for spring, you need to start learning about breast implants and breast augmentation now!

Second, interviewing and consulting with surgeons.  This process can take up to 6- 8 weeks – so once again, if you are planning to look good pool side in the spring of 2010, consulting in the fall of 2009 is key.

Third, scheduling surgery – Most plastic surgeons will require a 4-6 week lead time to get your procedure on the surgeon’s schedule and assist you with all the preoperative requirements.

Fourth, Recovery – I cannot stress to you how important it is to learn about this preoperatively – even before your consults.  Why waste your time on a consult with a ps who’s routine recovery is 3 weeks long in a strap with drains and pain pills if you can use a ps who can have you up and out and returning to normal activity in a matter of days (let alone 24 Hours!)?  We know now, that true 24 Hour Recovery yields lower incidence of developing Capsular Contracture – so it’s not just about feeling good right away, but reducing risk of reop and revision long term (there are TWO chapters on Recovery in the The Best Breast 2 that fully explain all the ramifications of a better post op experience).  Ask the hard recovery questions right off the bat – to save time in the end. 

                Standard 24 Hour Recovery time line ~

arms up and showered and out to dinner or shopping the night of surgery (no bras, bandages, drains, straps, pain pills or bruising)

approximately 2 days before full energy level returns

 if surgery on Friday, back to work on Monday

no cardio for 2 weeks, no lifting more than 35 lbs for three weeks

no SOAKING in still water for 6 weeks (Planning for spring and summer – this has to be factored in your time line!  Getting in still water too soon increases your risk of infection!)

Fifth, The Stages of Recovery – often referred to as “dropping and fluffing” or “settling” – generally you have about 4-6 weeks where your implants will feel permanently pushed up, 3 months before you can really try to buy bras, 6-9 months when sensation is normalizing and 9-12 months for the incision to be considered “healed” – your greatest risk period for developing capsular contracture is within the first 12 months.  You will have nuisances during all of these periods – explained in detail in the book.  I have had so many patients tell me they refer to the book even more post op than preop  – it is so nice to reassure yourself that what you are feeling and experiencing is normal and that the “story” you were told to begin with did not change – very comforting!

In order to be ready to debut your new additions in the spring of 2010, start your breast augmentation journey NOW!  Educate yourself, go on your consults, find your surgeon, make your choices – have surgery by mid – to late January at the very latest to be fully ready with no restrictions on your outdoor activities or travels to places tropical in early spring (March). 

Just remember, we can have you feeling great in 24 Hours, but for the implants to soften and settle and for you to feel good about being in lighter, more revealing clothing and bathing suits and to be in the water safely, a good 3 month lead time is your best time line for the best result!

by Terrye Tebbetts

I cannot thank you all so much for your prayers and thoughts that have come our way over the last 2 weeks.  Trust me, we feel them and appreciate them more than we will ever be able to share with you ~ it means so much to us.

What has happened to me - my eye – my family – is totally preventable by removing the game of darts and balloons from the midway – its not just the Texas State Fair  – think about how many school carnivals and county fairs continue to offer this game year round.  This balloon/dart game is dangerous and parents need to understand the dangers that lurk around this activity.

My family and I chose to talk with the local media today  – Fox 4 News  – and they went to the Fair and spoke with their representatives – you have to see it to believe it……. http://www.myfoxdfw.com/dpp/news/Dart_Hits_Womans_Eye_at_Stat

Some of the most dangerous risks to our children are things we never even dreamed could happen.  If I can just make more people aware of the dangers associated with these dart and balloon games, I am positive more parents will protect their children.

by Terrye Tebbetts

This has absolutely nothing to do with breast augmentation or breast implants but I wanted to share what I have discovered about this really cool organization – The Lollipop Theater.  Our daughter is in charge of her 6th grade class’ community service project and this is the group they chose to help.  The Today Show did a really nice piece on them a couple of weeks ago – you can check that out on their website too.

The 6^th Graders Community Service Project ~ Putting Smiles on the Faces of Hospitalized Kids!

We have chosen The Lollipop Theater (www.lollipoptheater.org) as the target of our fundraiser this year and what better way to raise money for The Lollipop Theater than to sell lollipops!  The Lollipop Theater takes new movies (not on DVD yet) into children’s hospitals and sets up a Premier Showing for children and their families who cannot leave the hospital ~ and if the kids are too sick to come down to the showing, they try to have extra copies that can be taken into that child’s hospital room.  It is something we all take for granted, being able to go see a movie, but for these kids and their families an afternoon escape to Hogwarts or a sky full of Meatballs ….. it means the world!

During the week of October 5^th – 9^th – please send a couple of extra dollars with your kids so they can buy some lollipops and help sick children be able to go to a movie just like your kids get to go to a movie.

Even if you hit a matinee or have a coupon, taking your family to the movies means spending at least $10.00 – so please, send a few of those dollars our way so we can help kids and their families who can’t leave the hospital to go see a movie – if we can help them forget the hardships of their illness even for an afternoon and put a smile on a few faces that haven’t had a reason to smile in a long time – isn’t it worth a couple of dollars????

So please look for us at lunch on October 6^th and 8^th and after school all week long by the play ground – send a couple of dollars with your child and put a smile directly onto another child’s face!

Thank you for your help!

The 6^th Grade Class

After a very (very, very) long two week absence, the best patient coordinator in the world of plastic surgery returns to our office tomorrow as Mrs. Karen Elizabeth Taylor.  

On Saturday, April 11, 2009, Karen and Scott tied the knot in one of the most beautiful settings I have ever seen.  They choose to marry in there home town area of Southern Maryland and now I definitley know why. 

The quaintness, the colonial history, the beauty of the water all made for a perfect setting for about 200 of their closest friends and family to witness this very special event in their lives. 

Congratulations Karen and Scott and Welcome Back to Texas!!!

Some of life’s most interesting and rewarding opportunities to learn and improve are the result of other people’s commitment and their willingness to share. 

Jean Keene was that kind of person.  Jean, known to nature lovers and photographers worldwide as the “Eagle Lady”, was born in Minnesota, grew up on a dairy farm in Minnesota, and first worked as a rodeo trick rider.  Following a riding injury, she worked as a professional truck driver hauling cattle, and in 1977, drove a motor home from Minnesota to Alaska.  She parked her motor home near  the end of the Homer Spit in Homer, Alaska, and worked as a foreman in a fish processing plant.

Soon after arriving in Homer, Jean noticed bald eagles on the beach of Kachemak Bay adjacent to the Homer Spit Campground.  Having fed songbirds for years, Jean began bringing fish parts from the processing facility, and began feeding bald eagles near her motor home.  For three decades, Jean fed up to 200 eagles daily an estimated 500 lbs. of fish daily during the late winter and early spring until the eagles departed with the influx of tourists to the area.

Jean’s eagle feeding was not without controversy.  Some environmentalists felt that eagles were harmed as a result of their proximity to people.  Some believed that other bird populations in the area suffered as a result of the eagles, and others including some Homer residents, claimed that the eagles caused car accidents, and even were a threat to their small animal pets.  Although many of these claims were undocumented, the Homer City Council ultimately passed an ordinance banning the feeding of eagles within the city limits, but granted Jean rights to continue feeding until 2010.  Jean passed away in her house adjacent to her motor home on January 13, 2009  with her eagles nearby.  The house and her truck were funded largely by donations from a group of photographers who Jean had befriended and who made frequent pilgrimages to photograph the eagles.

Read more about Jean’s life and her challenges here.

How does Jean Keene’s story relate to us?  Beginning during  my teenage years, I developed an avid interest in photography.  Due to a lack of financial resources, my photography equipment was extremely limited during my medical school, residency, and early years in practice, but my interest in visual images has grown progressively.   My love of all things outdoors and critters of all kinds that live there made wildlife photography something I couldn’t do without.  Fortunately, I am blessed with a wife and daughter who share my love of animals, and support my indulgences.

When I learned that Jean had passed away, and knew of her story, I made a short notice trip to Homer to have one last chance to photograph one of the world’s largest concentrations of bald eagles.  The images in this video of Homer, the Homer Spit, the Grewingk Glacier directly across Kachemak Bay (visible from Homer), and the eagles were taken over a two day period that I’ll never forget.  I have worked diligently for many years to improve my photographic skills, helped by many committed photographers who despite their own priorities, were willing to spend time to share their knowledge to help me learn.

The opportunity to see and photograph these magnificent birds in a close up and personal setting would likely have never happened were it not for Jean Keene.  Despite any objections by groups or individuals (in my opinion often based on unproved or self-serving motives that I nevertheless respect), I am grateful to Jean and those who have supported her for this unique opportunity.  For many years, I have photographed eagles in the wild, and despite my best efforts, I have never been able to be close enough to fully appreciate the beauty of bald eagles and the magnificent mechanics of their flight.  As I sat on the beach in 20 degree weather with a 25 knot howling wind and blowing snow photographing the eagles on the Homer spit, it occurred to me that the things I respect most about Jean are things that Terrye and I believe in strongly–commitment, sharing, and facing challenges head on in order to advance.

Like Jean–we don’t focus on objectors and detractors.  Our focus is all about patients.  Every priority begins with our patients–assuring every patient the best opportunity for knowledge, good decisions, the most state-of-the-art surgery, the most rapid and carefree recovery, and the least risk of reoperations or risks to their tissue in the future.  An unblinking commitment to those priorities, regardless of the challenges, has enabled us to deliver a completely redefined experience for breast augmentation patients.  Our track record is open for comparison to any other surgeon worldwide.

We are committed to continually develop new techniques to deliver better for patients, and committed to sharing what we’ve learned and developed with our colleagues for the benefit of all patients.  We have published and shared scientifically verified, peer reviewed data and processes in the most respected professional journal in our specialty, and have demonstrated unequivocally that specific processes of patient education, tissue based implant selection, and surgical techniques can routinely deliver out to dinner augmentation, 24-hour recovery, and the lowest  reoperation rates ever published from an FDA PMA study–objectors and detractors persist.

Challenges are unavoidable, but they not distract us from patient priorities.  We have and will continue to deal aggressively with challenges to assure what’s best for patients.  Commitment, sharing, and dealing with challenges is what has enabled us to deliver an unparalleled level of recovery and outcomes for our patients.  The same approach enabled Jean Keene to realize her priorities and provide a path for others, like me, to learn and grow.

Rest in peace, Jean.  Many of us will think of you every time they see an eagle.  It’s not about the naysayers; it’s about the eagles.

Chapter 2- Looking at breast augmentation surgery in new ways, and the first hidden prize

by John B. Tebbetts, M.D.

Back to the pig (if you don’t get it, check out my previous post, Chapter 1 of the 24 hour recovery story).  I wasn’t at all confident that acorns (pig prizes) were to be found, but I figured (again, in case you missed it the first time, “figured” is Texican lingo for “I thought”) that at worst, I could get some good video footage of breast augmentation surgery.  Three inexpensive video cameras later (one over my shoulder, one looking at the folks around the operating table, and a third viewing the entire room), and we had a setup that could record the movements of everyone in the surgical suite as I performed a breast augmentation.

My surgical team thought I had lost it (nothing new to my group).  Most later admitted feeling a bit threatened by my intent to micro analyze every move each of us made.  But I’m blessed with a committed group who’ll do anything to make things better for patients…and for me.  Several operations later, we had piles of videotape that documented every move.  Frank Gilbreth would have been proud.  Now the fun (translated….butt busting hard work) began.

I never imagined the time required to analyze every motion in a breast augmentation.  I love visual images, video, and if I could choose another life, I’d come back as a clone of Speilberg.  But this isn’t creative imaging.  This is stuff I’ve seen thousands of times, thought I could do with my eyes closed (just kidding) and I’m supposed to look at it in a different way?  It was incredibly boring at first.  Uncomfortable.  Repetitive.  Where is the prize?

More than 300 working hours into analyzing the video, I still didn’t get the picture (no pun intended).   I felt like a donkey trying to climb Mt. Everest.   Three minutes of video required more than 90 minutes to just document the motions, much less try to figure out what it all meant, and I had 20 hours of video.  It wasn’t fun…..until suddenly it became incredibly fun.

One day…long into the day when dead tired usually means not very productive or observant, I was looking at a video segment and dutifully logging motions.  BAM!  Damn.  Look what I just did on that video!  I cut that blood vessel, and it was clearly visible an instant before I cut it–but I cut it anyway.  WHY?  If there was one turning point in the story, this is it.  You never see what you don’t look for.  Sometimes, because of how surgeons are trained, your eyes work a programmed way, yada, yada, yada…all lame excuses…you just didn’t see.  It happened because I was thinking the same way I’d always been thinking…seeing what I’d always been seeing….no surprise.  Even Einstein recognized that insanity is doing the same thing over and over again and expecting different results (sorry if I paraphrased you Al, we still buds?).  I needed to change.

Back to the blood vessel spewing on the video.  Worst thing, it’s zoomed video.  That tiny blood vessel looked like Mt. Vesuvius when the blood erupted.  In reality, it was only a few drops of blood, something no surgeon blinks at…do what you need to do, let it bleed, and then stop the bleeding.  But zoomed and magnified, that small blood vessel’s eruption spilling a couple of drops of blood onto adjacent tissues looked like bloody diarrhea hitting a sponge (yes, I know, not pleasant). The tissues adjacent to that tiny blood vessel were soaked…red..yuck…compared to the beauty of human tissue that’s not stained by blood (I know most of you don’t really want to go there either).  I wouldn’t go there if it were not important to the story.  The visual image hit me, and it changed the way I think about the most basic of my surgical techniques.  Tiny areas of bleeding, never even noticed by most surgeons, become huge when they soak into millions of cells in adjacent tissues.  Blood cells, outside of a normal blood vessel, are like white phosphorus (that’s some seriously burnin’ stuff) to normal tissues.  Blood soaked into tissues, even a little bit, promotes unbelievable inflammation and pain.  Stay tuned for later pictures of the differences between a blood stained implant pocket and a “bloodless” one (for some that may be a reason to exit now).

Because I was looking at a hugely magnified view of what I see every day, I say something I see every day from a different perspective.  Not until much later did I understand the significance of what I saw (remember the pig….), but finally I did recognize that..  Small things make big differences.  Small amounts of blood soaked into tissues can cause big time discomfort.  I was taught during my surgical training that blood is no big deal.  Cut what you need to cut to do what you need to do, and then stop the bleeding.  I can tell you right now, that ain’t so if you want to get the prize.

So Prize 1 was recognizing that it was possible to recognize small blood vessels before cutting them, and if I could control those small blood vessels before they bled into adjacent tissue, that could reduce pain.  Bingo- while trying to become more efficient, I found the first prize of reducing bleeding to reduce pain.  Small thing, everyone said…until later when they saw how it impacts patient comfort and recovery.

Then the rib thing happened. While I was working on this project, I took a little time off and made one of my twice a year pilgrimages to Moab, Utah to ride dirt bikes (yes, I admit that I’ve always loved throttles and air).  Poison Spider got me.  Poison Spider is a 23 mile ride, and if you start from the south end, you ascend from a canyon to the top of the mesa very rapidly, straight up a series of very large boulder jump-ups (steps 2-4 feet high each).  I wheelied successfully to the last jump up, and relaxed just for an instant as the front wheel came down on a small rock less than a foot in diameter that should have been nothing.  It wasn’t nothing.  Flipped the bike, I’m on the ground, and the bike with hot pipes and muffler comes down directly on top of my chest, creating a bike-Bubba-red rock club sandwich.

Didn’t notice the popping sounds very much, but after getting up, found it a bit hard to breathe as I kicked and kicked on the bike starter to get going.  Five miles further on, I tried to walk 1/2 mile to an overlook to photograph, but had to stop because I couldn’t get enough air (and I don’t mean air in the jumping a dirt bike sense).  I couldn’t breathe worth a damn, but being a doctor and not wanting to whine around my studly buddies, I ignored it.  Rode the rest of the 23 miles out, but every time I tried to inhale, it felt like some bad dude jabbing  knives into my chest…and the bumps, rock jumps, and descents didn’t help a bit.  Life sucked, and the last thing I was thinking about was efficiency.

Five broken ribs, a punctured lung, and two separations of the ribs from the breastbone (sternum)- oh well.  Not fun.  Ended the riding, despite highly technical treatment of lots of Motrin and adult beverages at night.  Got back to Dallas, and for about 3 months, the bad dude with the jabbing knife stayed around.  But what in the world does the rib thing have to do with 24 hour recovery?

Back at the video workstations, I was logging steps and motions, now inside the pocket for the implant.  The back wall of the pocket is the rib cage.  A retractor is an instrument that lifts the overlying tissues to allow the surgeon to see between the tissue planes and develop a pocket for the implant.  As I was inserting a retractor on the video,  I noticed that the tip of the retractor and the tip of the attached fiber optic bundle used to light the inside of the pocket….struck a rib (picture below).  Just a tap, but instantly, the white, glistening surface of the rib began to develop a red splotch that was spreading beneath a clear layer of tissue that covers the rib–the periosteum.  Another light went on.  The periosteum is a very sensitive layer of tissue, and blood beneath the periosteum (periosteal hematoma) causes significant pain.  What blew my mind was the thought that earlier in my career, I was taught to create the pocket for the implant with a blunt instrument that banged on every rib over the entire chest wall and ripped tissues to create a pocket.           No wonder patients have pain after augmentation when surgeons create the pocket for the implant using blunt dissection .  Well meaning surgeons ripping tissue to create a pocket, blunt instruments banging on ribs, and blood soaking into tissues and beneath rib periosteum.  Take a look.

This is a picture inside the implant pocket that shows a close up of a rib with tiny blood vessels coursing over the rib.  The yellow arrow shows the tip of a retractor just barely touching the rib, and beneath the retractor, the broken blood vessel and blood flowing under the rib lining (periosteum).  This small, but very significant detail can cause significant pain for patients.  It’s called a subperiosteal hematoma (throw that term around at your next cocktail party).

Now I could imagine how the usual breast augmentation patient felt after surgery- that bad dude that got me after the dirt bike rib thing not only was sticking a knife in various places, but he was lighting that fire of inflammation inside the tissues as the blood that soaked in created inflammation.  While looking to improve efficiency, I had stumbled onto a couple of very simple but significant pearls–problems recognized–blunt trauma to ribs and blood soaked into tissues.  Like the pig, just by continuing to look, and look, and look, good things were beginning to happen.

Recognizing problems is a key first step.  Developing solutions is usually more difficult.  But not this time.  The initial solutions were straightforward:  1) Find a way to create the pocket for the implant that stopped bleeding before it started, preventing blood soaking into tissues, and 2) change my surgical techniques and instruments to develop a strict no-touch technique for ribs and rib periosteum.

Enter the electrocautery.  An electrocautery is an electrical generator (sophisticated) that sends a programmable electric current to a surgical instrument.  When the instrument is activated, the current can do two things: a) cut through tissue and seal small blood vessels in the process to prevent bleeding, and b) when encountering larger blood vessels, applying current using pinch forceps can seal the ends of vessels and stop bleeding.  For surgeons, an electrocautery is not magic.  But how a surgeon uses electrocautery instruments can be magic.  We hear from surgeons routinely that “I use the electrocautery, but I don’t get the results you get.”  My reply is always the same, “It’s not that you use it, it’s how you use it. I used electrocautery instruments for 15 years before I realized specific ways to use them more effectively.”

Surgeons use two basic types of electrocautery instruments routinely- a handswitching electrocautery pencil, and various types of electocautery forceps (see pics below).  Traditionally, surgeons are taught to use the pencil instrument to cut tissue and control smaller blood vessels,  and taught to use the forceps type instrument to coagulate (close and seal) blood vessels after cutting the vessel–to stop the bleeding.  The problem with that approach is that it allows blood to soak into tissues before the bleeding is stopped.  Blood in tissues…fire….inflammation.

Another problem was apparent on the videos’ analysis.  In slow motion, I noticed that when the electrocautery pencil cut through a larger blood vessel that was unseen, the pencil was not capable of quickly and predictably stopping the bleeding.  Follow this sequence:  I cut the unseen vessel with the electrocautery pencil…bleeding starts….I turn, put down the pencil instrument….the instrument nurse places electrocautery forceps in my hand…I look down to find the foot switch to activate the forceps…I look back into the pocket–more blood….I take a gauze sponge on another instrument to soak up the blood…and then switch instruments again, back to the electrocautery forceps…and control the bleeding.  Eight steps….five miles of unnecessary motions (well, not quite, but on analysis it appears that way), and by the time the vessel is controlled, the tissues lining the pocket look like the Red Sea (except redder) with blood soaked into every adjacent tissue (I decided not to reiterate the sponge analogy).

Now the Gilbreth principles really kick in, and I begin to realize how dramatically different all this could be if I could do a couple of things.  What if I could develop a very sharp tipped electrocautery forcep that could cut tissue as effectively as the pencil instrument, and use the same instrument to stop bleeding either before it starts (prospective hemostasis)?  If I cut a blood vessel that I simply couldn’t see, I’d have the forceps already in hand and could stop the bleeding before blood soaked into adjacent tissues.  And if I designed an instrument with a hand switch on the forceps that activated the current, I’d never have to look down to find a foot switch.  Eight motions would be reduced to one–now we’re talking efficiency!  And in the process, I’ve addressed one of the main causes of pain….blood soaked into tissues.

Tools are great, but remember, I mentioned that it’s all about how you use them.  To optimize the concept of prospective hemostasis, I needed to stop bleeding before it starts.  That meant relearning surgical anatomy on a new level–by mapping the locations of much smaller blood vessels that are not illustrated in any anatomy text, and by sequencing my thoughts during surgery to prioritize searching for those smaller vessels as I dissect a pocket and using the electrocautery forceps to seal at least two spots along the vessel before cutting between the sealed locations.

The photograph below shows the locations of the larger blood vessels that surgeons must control before cutting in order to prevent tissue staining and minimize inflammation and pain for the patient.  In addition to these major vessels, surgeons must also know and anticipate the locations of many smaller blood vessels throughout the pocket.  I had always focused on the fancy dials and current settings on the electrocautery, but while going through video, I noticed that despite all the fancy settings, the speed at which I moved the tip of the electrocautery instrument made a huge difference.  Different pace in different tissue types…way too much detail…but it was just another acorn.

The ribs solution (avoiding touching ribs with any instrument) was a simpler problem, but more difficult to address.  Changing habits is tough for anyone.  For a surgeon, it’s near impossible.  It sounds incredibly simple to just keep the tissues elevated off the ribs at all times, and never touch the ribs when inserting or removing a retractor.  The concepts are primitive.  Implementing them 100% of the time requires constant attention to detail–the old habits of ignoring the ribs don’t ever go away.  Some retractor design changes and other instrument changes helped, but end of the day, I was learning that I was having to change how I think and focus on details I’d never focused on before.

Visual proof.  The three pictures above show (left) inside a pocket dissected by blunt instrument dissection (note the red staining), (center) a pocket dissected on the right with blunt techniques and on the left using our electrocautery instruments; and (right) a pocket dissected entirely using electrocautery instruments and avoiding all contact with the ribs seen on the right.  The absence of blood staining in the pocket in the right picture is dramatic, and means that the patient will have a much more rapid recovery with much less pain.

Several very simple observations, a modification of instrument designs, a checklist of steps to locate and control even the smallest blood vessels before blood could soak into tissue, and changing longstanding habits to prevent instruments from ever touching the ribs–over a few months it all happened, and surgery started to change dramatically.

The pig had found a couple of prizes–in unexpected places.  Simple things that I had always believed were routine and not important became very important.  Things I thought I was good at, I realized that I was strictly average, and that’s why I was seeing average efficiency in surgery and average recovery with my patients.  But as the pig would have it, as I was focusing on improving efficiency, I stumbled onto small surgical details that were beginning to dramatically change our surgery and our patient’s experience.

How we put it all together and the prize for us and our patients is the subject of Chapter 3 of the 24-hour recovery story.  Stay tuned for the rest of the story–and what happened to the pig.

I hear a lot of questions and talk about how long will it take for implants to settle or drop ~ and a lot fear when one drops faster or more than the other one following breast augmentation. 

Although we all have to wait for the implants to settle into the bottom portion of the breast envelope and that wait period varies from patient to patient, I think we must also consider what the breast envelope was like before surgery.

This is another reason I love the High Five System of measurements that Dr. Tebbetts uses to evaluate a breast during consult with a patient.  When we measure a patient preoperatively, we can show them and document all the measurements of the breast.  Inevitably, the breasts are different.  No two breasts are exactly alike before surgery – -so they won’t be the same after surgery either.  Nor will they heal/settle the same.  So if your right breast envelope was smaller and tighter to begin with, then it will certainly be the straggler in the settling game but it may also always be a little different than the left because it was smaller to begin with.  Does that make sense?

Most women know that their breasts are different ~ not all, but most do.  So when you can objectively measure the breast and show the patient the difference preoperatively then they know the differences that exist and what they surgeon is dealing with then post operatively there are no surprises.  I have always found, that if it is a surprise, it is a problem!  Honesty, once again, is the best policy and the best way to have happy patients!

By the way, Dr. Tebbetts feels like the implants aren’t really where they are going to be for at least six months.  It’s hard, because you like what you see so quickly after surgery – but they are still changing, softening and settling for a long time.  Remember, they don’t get bigger or smaller – - they just keep getting better!

In our practice, we decided many years ago that it was not productive to try to plan a patient’s operation based on something that either did not exist or something that had nothing to do with the patient’s body!  Think about it – most women talk about their breasts in terms of cup size, right?  But there is no standard definition for cup size in fashion – they are different depending on the designer or the store or whether it is strapless or underwire, whether it came from Target or Victoria’s Secret.  Not to mention that there is NO, not one, clinical, scientific definition for cup size!  So how can surgeons and patients communicate effectively and plan an operation based on something that has no true standard measurment?  On the same note, how can you take a photo of another woman into a surgeon and say, “Here, this is what I like.  This is what I want my breasts to look like?”  Have you ever tried that with your hair dresser?  How’d that turn out?  It just floors me that surgeons and patients are changing bodies with out taking the body that they are changing into account!

Thus the evolution of measurements.  Dr. Tebbetts started developing a system of measurements that would quantify the void in a breast, telling us what that breast envelope will hold safely within the limits of the patients tissue.  The definitive system is called the High Five System.  It is very simple, but extremely accurate.  By being objective and putting numbers on the operative plan, the surgeon and the patient are working together with each other to augment the breast while respecting the tissue.  In doing so, you limit weight and by limiting weight, hopefully allow the result to last longer and look beautiful as it ages gracefully with the patient.

The High Five System is something patient can even do at home on their own to get an idea of what implant size they will need.  The system is detailed in The Best Breast 2 and I have worksheet that I often email to patients so that they can try it for themselves.

It just makes sense – having breast implants is still having surgery.  So if it is surgery, the planning should be clinical and objective.  If you walk into the ER with a ton of terrible symptoms, they don’t hold up photos of other people who kind of had the same symptoms to figure out what you need, do they?  Last time I checked, they run tests and do things like MEASURE your temperature and your blood pressure – - science – objectivity.  If we can all get comfortable applying a peer reviewed and published measurement system, High Five,  to breast implants  – perhaps we can eliminate shades of grey and expectations like -”I’d like to be a Full C/Small D, doctor.”

The High Five System was published in Plastic and Reconstructive Surgery Journal and is visible on The Best Breast 2 website under News and then Scientifc Articles.