Fitness Model Revsion Aesthetic Breast Surgery

Revision breast augmentation in Fitness Models possess unique challenges to the surgeon. Aesthetic results are usually quite optimal after complete capsulectomy, but the thinning tissue often allows implant visibility or rippling. I often choose to perform complete capsulectomy to allow the breast to re-drape over the implant. It is important for the surgeon to have a thorough knowledge of the previous operations, as implants may have been in prior planes, or neosubpectoral pockets may have been created from prior capsules and have subsequently contracted. I have used the neosubpectoral pocket on many occasions for revision aesthetic breast surgery and have found it useful. However, in women who present with recurrent capsular contracture, it is important to remove the capsules to allow the breast to re-expand and produce an optimal aesthetic shape.

Often in patients who have undergone previous revision aesthetic breast surgery and who are competitive athletes, fitness models, or clothing models, the breast and surrounding subcutaneous tissue is thin. To prevent implant visibility or palpable rippling in this population, I have found Strattice to be quite useful.

The Roxbury Clinic & Surgery Center continues to grow as a center for capsular contracture as well as revision aesthetic breast surgery. An increasing number of women choose to undergo their mastopexy/augmentation, capsular contracture surgery, breast augmentation, removal and replacement, as well as second stage breast reconstruction surgery at the Roxbury Clinic & Surgery Center.

Brian P. Dickinson, M.D.

http://www.drbriandickinson.com/

Strattice for Revision Aesthetic Breast Augmentation

We are starting to see many patients come from out of state to have their revision augmentation procedures or capsulectomy surgeries performed at the Roxbury Clinic & Surgery Center. I have been using the Strattice in the manner as taught to me by Neal Handel, M.D. When working through small incisions, I have found the use of appropriately and carefully placed marionette sutures to align the Strattice in correct position while the remaining sutures are performed through the limited incision.

I have found Strattice to be very helpful in the revision breast augmentation patient who has rippling, implant palpability, synmastia, bottoming out, and fold asymmetry. I have also found Strattice to be helpful as a barrier between the nipple areola complex incision and the capsule of the breast implant.

I remember repeatedly, the lessons on tendon healing by one of my great mentors, Malcolm Lesavoy, M.D. He would always describe the "one wound/one scar" theory for tendon healing. I find that the same theory can apply to breast implant capsules.

Frequently, I see patients who present for capsular contracture surgery who have a thickened scar beneath their periareolar incision with a "scar rind" that is aggressively fixed to their underlying capsule. It is my belief that the interposed Strattice may prevent the "scar rind" that I frequently see beneath the periareolar incision that is firmly fixed to the capsule. I hope this has great implications for reducing capsular contracture.

Brian P. Dickinson, M.D.
www.drbriandickinson.com

Adipose Derived Stem Cell Fat Transfer for Breast Augmentation

Cell-Assisted Lipotransfer for Cosmetic Breast Augmentation: Supportive Use of Adipose-Derived Stem/Stromal Cells
Kotaro Yoshimura,1 Katsujiro Sato,2 Noriyuki Aoi,1 Masakazu Kurita,3 Toshitsugu Hirohi,4 and Kiyonori Harii3
Aesthetic Plast Surg. 2008 January; 32(1): 48–55.

I have had the great opportunity to reacquaint with a mentor who has sparked my interest in the use of autologous fat transfer for breast augmentation. As I read through the selected reading articles, I have found excellent results published by Japan and Korea on the use of adipose derived stem cells of autologous fat transfer for cosmetic breast augmentation.

My interest in this grows, as I continue to having a growing group of patients who are interested in a small to modest increase in breast size and who do not want an implant of either silicone or saline. In these patients, available fat can be harvested from the lower abdomen, buttocks, and thighs and transferred to the breast for augmentation.

I am very satisfied with the results we are achieving with silicone gel implants and find that there will always be a continued role for them in women who desire a larger augmentation or require replacement of significant breast volume following mastectomy. I believe that fat transfer will not replace silicone breast augmentation, but serves as an alternative for those women who do not want a large volume augmentation and who do not want an implant based augmentation.

Brian P. Dickinson, M.D.

Breast Augmentation: Testimonial

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Patient testimonials are one of the highest compliments I could ever receive. This happy patient writes in her testimonial:

"This experience couldn't possibly have been any better, and bless Dr. L for referring me to you! You're the best -- Dr L told me you were going to be the next big bev hills plastic surgeon, and I think he's right.... from the first visit I felt comfortable and am soooooo pleased with my results, you have NO idea!

Every visit has been a true delight, and actually fun and entertaining (not usually the case half naked in a dr office!).... I love that I found a Doc that I didn't feel all weird with, and that I NEVER felt judged, and was always treated with the utmost respect. Thanks!;"

No Touch Teqhnique Breast Implant Delivery

I have been using the Keller Funnel routinely for my periareolar and transaxillary breast augmentation cases. The Keller Funnel allows me to deliver larger implants through a smaller incision without traumatizing the breast implant, the skin, or having the breast implant come into contact with the skin.

I believe strongly that this "no touch technique delivery system" can help reduce the incidence of capsular contracture. It is of paramount importance to me that my patients receive great results and that I try to do everything possible to minimize complications.

Brian P. Dickinson, M.D.

http://www.drbriandickinson.com/

Revision Breast Augmentation Surgery for Saline Implant Deflation

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Breast implants are medical devices and over time, like all medical devices, are subject to fatigue. Over time, the development of a capsular contracture around a breast implant can cause folds in the shell of a saline implant. Repeated creasing in the fold of a saline implant can cause the shell to fatigue and allow the saline to leak.

The leak of saline into the body is not harmful to the patient, but is nonetheless, psycholocially distressing. These patients have been coming to our office with an increasing frequency and request the removal of their saline implants for silicone implants. Often patients who have a deflation of their saline implants have had their devices for over 8-10 years.

These patients who have undergone removal and replacement of their saline implants for silicone gel implants are starting to tell their friends how happy they are with the improvement in the shape and feel of their breasts. As a result, I am seeing an increase in the number of patients who present to the office requesting their saline implants to be exchanged for silicone implants.



Brian P. Dickinson, M.D.
www.drbriandickinson.com

Breast Implants. Saline Implant Valve Failure with Capsular Contracture

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I am seeing more and more women in consultation in my office with deflation of their saline breast implants. In fact, twice this month we had women who presented with the development of pain around their breast implant with an associated distortion of the breast shape secondary to breast implant valve failure.

It has been my experience that the development of a capsular contracture around the breast implant changes not only the shape of the breast implant capsule complex, but may incorporate around the valve of the saline implant (as shown in the image above).

Either continued contraction of the breast capsule resulting in a change in the surface area to volume ratio and/or ingrowth of the capsule to the valve disrupts the valve and allows the saline to extravasate. These women often present with continued pain and the apparent deflation of the implant can be distressing to the patient.

In these cases I recommend that women undergo removal and replacement of their breast implants and capsulectomy. Many women are opting now to exchange their saline implants for silicone gel breast implants.After these surgeries, patients are very happy with the new contour of their implants and their pain is often markedly improved.

Brian P. Dickinson, M.D.
www.drbriandickinson.com

The Keller Funnel for Silicone Gel Implant Delivery

Today was truly a great day of cases. As the breast augmentation, revision breast augmentation, and capsular contracture surgery practice grows, I continually look for ways to improve patient outcomes, reduce patient recovery time, reduce incision length, and prevent capsular contracture.

I have found that the Keller Funnel facilitates delivery of silicone gel implants through smaller incisions and allows me to employ a no-touch delivery technique whereby the gel implant does not come into contact with the nipple areola complex or the axillary skin when placing implants. I found that the Keller Funnel greatly facilitated today's cases and I will use it for the breast augmentation cases later in the week.

I anticipate that the no-touch delivery technique is one method to further reduce the prevalence and incidence of capsular contracture. I look forward to continued success with is device.

Brian P. Dickinson, M.D.

Breast Augmentation Porportion

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I find that the most important aspect of breast augmentation, is that the operative plan needs to be individualized for each patient. I have found that different breast implant profiles work very well and can produce a similar aesthetic look depending upon the anatomic dimensions of the patient and tissue characteristics.

It is important when operating on a patient with a short nipple to inframammary fold distance to select a breast implant that not only is proportionate to the base diameter, but also to the breast height. While it is important to maintain superior fullness of the breast it is important that the "take off" of the breast contour is not placed to superiorly or that the chest to breast angle is not too acute.

This patient is very happy with her breast augmentation as her breast/waist/hip ratio is in better proportion. Selection of appropriate breast implant size and dimension is paramount to an optimal outcome.

There are three different dimensions and profiles of breast implants. Mentor corporation makes a moderate, moderate plus, and high profile silicone gel breast implant. Allergan produces a style 10, style 15, and style 20 for their breast implants. These labels respectively correspond to breast implants with increasing projection to base diameter ratios.

Brian P. Dickinson, M.D.

www.drbriandickinson.com

Self-Study:Article Review

Review of "Breast Cancer Diagnosis and Prognosis in Augmented Women" Plastic & Reconstructive Surgery 118: 587-593, 2006 by Neal Handel & Melvin J. Silverstein."

Frequently in my practice I am asked by many women who desire breast augmentation or who have already had a breast augmentation and now want a lift, removal and replacement, or surgery for capsular contracture the following question:

Do breast implants impair my ability to detect breast cancer or increase my risk of getting breast cancer?

To answer this question and as part of my own self study, I read and reviewed an article in Plastic & Reconstructive Surgery 118: 587-593, 2006 by Neal Handel & Melvin J. Silverstein. I present here notes which are helpful for my own self study as well as for patient education during consultation:

Background:
--Breast enlargement surgery is popular. More than 334,000 women underwent elective breast augmentation in 2004.
--A woman in the United States has a 1 in 7 (13.4 percent) lifetime risk of developing breast cancer.
--There is no etiologic link between implants and breast tumors. Numerous studies show that the rate of breast cancer is not increased among augmented women, and some studies demonstrate lower than expected rates.
--However, because of the large number of women undergoing augmentation, there have been persistent concerns about possible adverse effects of implants on cancer detection and treatment.

Methods:
The authors reviewed their database of women with breast cancer and determined if there was a difference in breast cancer between augmented and non-augmented women.

Results:
--There was no statistically significant difference in stage of disease between augmented and non-augmented patients. The mean tumor size, recurrence rates, and breast cancer- specific survival were virtually identical in both groups.
--Augmented patients were more likely to present with palpable lesions.

Conclusion:
Augmented and nonaugmented patients are diagnosed at a similar stage of breast cancer and have a comparable diagnosis. While implants may impair mammography, they appear to facilitate detection of palpable breast cancers on physical examination.

Breast Augmentation in Runway & Clothing Models

The most personally rewarding part of my day is the expression of gratitude I receive from my patients. The highest compliment that I could ever receive is a patient testimonial.

One recent patient testimonial came in the form of before and after photographs from her recent photoshoot.

Breast augmentation in the runway model physique is particularly challenging as it is important to hide the appearance that a surgery was performed. Furthermore, it is a requirement for these models to “fit” their respective clothing line and often remain in the same cup size bra or within a cup. While the increase in cup size is usually modest in comparison to other breast augmentation populations, the difference is significant to the camera, the advertisement, the patient, and her family.

Breast Augmentation Consultation & Bra Sizing: The Challenges & The Basics

Breast augmentation consultations and procedures may be challenging when trying to determine post-operative bra size. I have found the bra-sizing system designed by Dr. Edward A. Pechter from Valencia, CA to be the most effective method for successful breast procedures.

The breast augmentation consultation can often bring anxiety to the patient as there are many questions to be addressed or discussed. These variables can range from topics pertaining to the patient (medical conditions, height & weight, bra size, pre-operative breast shape); surgeon (preference for above vs. below the muscle, incision choice); or implant (saline vs. silicone, smooth vs. textured, profile).

Determining bra size in breast procedure consultations creates a common frame of reference for the physician and patient to discuss post operative bra size. The first step in the physical examination is observation. In the observation step, both the patient and I stand in front of the mirror and with the same perspective identify any asymmetries between the breasts. Breasts are more often than not asymmetric with either a discrepancy in breast volume, breast fold position, nipple position, shoulder height, and chest wall asymmetry. After this step of the physical examination we proceed to pre-operative bra sizing.

Bra Sizing: The Basics

The size of a bra is determined by two factors: 1) The Band Size & 2) The Cup Size.

1) The Band Size

Step 1. The band size of the bra is relatively a fixed number determined by the circumference of a woman’s chest. This number can be measured with a measuring tape in inches, just beneath the breasts, in the crease where the band of the bra would be placed.
Step 2. Add five to the number of inches determined from this measurement. For example, if the measured number is 27” then if you add the number 5, the result is 32. Therefore the band size of the bra necessary is 32. If the measured number were 28” adding 5 would result in a 33 band. One quickly realizes when bra shopping that there are no odd number band sizes, so one would try on a 32 or 34 band bra to see which fit best. In this scenario, the 32 bra would be worn on the last of three clasps and a 34 bra would be worn on the first of three clasps.

The band size is relatively consistent in women of adult age as the bony ribcage has completed growing. This number will change to a small degree if a woman gains or looses weight around the chest where the band of the bra would normally be placed. The so called “bra fat”.

2) The Cup Size

I have found the “Size Me Up” system designed by Edward Pechter in Valencia, CA to be the best system for determining cup size. In the “Size Me Up” system, the dome of the breast is measured by starting the measurement from where the breast begins on the side of the chest, passing over the nipple and finishing towards the sternum where the breast ends. The resulting measurement is then compared on the “Size Me Up” chart to determine the cup and bra size.

One point I have learned is that the “cup volume” or “measured breast dome” increases depending upon the band width. That is, a “C” cup represents a smaller volume breast for a woman with a small ribcage (i.e.32 band size bra, C-cup) than a woman with a larger ribcage (i.e. 36 band size bra, C-cup).

In my experience, the best manner in which to predict the post-operative cup size is to determine the pre-operative bra size measurements and base diameter of the patient. The post-operative cup size can be predicted by using these measurements with the volume per base diameter of the breast implant.

While the prediction of post-operative cup size is not exact, I find this step to be helpful, as it facilitates a common frame of reference between the patient and surgeon.

Photograph: Revision breast augmentation. Bilateral Capsulectomy, Conversion of total submuscular saline breast augmentation to dual plane silicone breast augmentation.

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Revision Breast Augmentation: Correction of Capsular Contracture & The Double Bubble Deformity

While I enjoy all aspects of Aesthetic Surgery, correction of capsular contracture and revision breast surgery is particularly enjoyable to me. Not only do I enjoy anatomic and aesthetic challenges of these operations, but also the degree of patient satisfaction is high.

This patient had painful capsular contracture and left breast double-bubble deformity. Correction of this asymmetry was done with bilateral "en bloc" capsulectomy, re-set of the inframammary fold, and change of implant profile. I am very thankful to have had such excellent aesthetic surgery training from outstanding mentors in Beverly Hills, Sherman Oaks, Encino, and Valencia. I am truly fortunate.

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