Dr. Donn Hickman

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« on: November 14, 2008, 02:41:15 AM »
Dear Ms. :
     Thank you for your interest in breast augmentation upon the kind mention of our practice by Ms. (     )
As a result of the recent FDA approval of silicone for standard use in breast implants on November 17, 2006,  consumers and physicians  can once again, decide what implant ingredient is most suitable.  While at your present body size and breast volume, you may be pleased with either saline or silicone implants, I believe the chance of long term softness is far greater with saline-filled implants.  By placing all implants behind the muscle in our experience, overall success is better for each type of implant.  Often if a patient presents with a B cup or larger and desires some filling and lifting with implants, some surgeons may recommend placement of silicone (or even saline) over the muscles since the amount of available breast tissue will properly conceal the edges of the implant shell.  In time, using an over-muscle method, some patients get a higher percentage of firmness and rock-in-a-sock look especially with silicone implants.  When any implant system remains soft and pliable soft over the years, it is this feature that pleases consumers more than anything else.
     When the FDA released its report in 2006 it was clear that the firmness rate of advanced new design silicone gel implants was 11 to 21 % at 4 years, and this is very troubling.  Even the national rate of firmness for saline implants is reported to be 5 % at 4 years.     Our softness rate with saline implants over 15 years is over 99%.  The only patients with some elements of firmness are those with previous surgery and scar tissue, and slender patients who had the high projecting contour anatomic implants which, by design, are a little firmer.   The results with saline implants are usually seen at 3 to 6 weeks, while, in some cases, the silicone implants can smooth out in weeks only to encapsulate on one side in 6 months or sooner.  I am certainly favoring  saline, but do feel comfortable offering silicone gel if the patient would consider the under muscle approach, and use of  drains, and agree to a breast exercise regimen at home to counter the tendency for scarring by silicone gel filler.
The versatility of saline is as follows:
1.  the implants can be inserted through any incision, even through slender areolar borders.
2.  adjustability at surgery is a plus since many patients can have a portion of a cup difference between one side and another, and it is not uncommon to have a 10 to 30cc difference on the operating table.  Even using implant sizers to check for silicone gel implant symmetry, it is not always possible to get perfect symmetry.  With saline implants it is possible to get a bit closer in balance and harmony.
3. While the implants can deflate signaling the breakage of the device,  the rupture of a silicone implant may go undetected, even on a mammogram or MRI, and can cause consternation down the line.   To be sure, silicone has been shown thus far to cause -------no ill effects-------.  It is the possibility of free silicone migrating to lymph glands undetected, and confusing a patient or doctor examining the breast, and leading to x-rays and surgery, that makes silicone implants a bit more potentially problematic.
     We would recommend insertion of Mentor Style 1600 moderate profile saline implants most likely in your case, at a size of perhaps 300-400cc to obtain a full C or small D configuration, and this would be a behind-the-muscle approach. I would use a periareolar incision approach which is along the border of the areola on each side.  This approach is not likely to cause nipple sensation problems, and in fact there is no one procedure that is better than another in terms of best nipple sensation.   One can occasionally have nerve irritation, but this is truly the exception.  It can be seen in the exceedingly slender consumer who wishes a large augmentation, in one who has already undergone one or more previous surgeries, and in some patients who need a considerable lift to the breasts. The operation takes about an hour or so under general anesthesia as an outpatient. We use Community Hospital of Long Beach where several other plastic surgeons also bring their patients, and for whom there is an experienced Board-Certified Anesthesia Department well versed in plastic surgery patients and outpatient care.   I do place small linguini-size drain tubes in the implant pocket and have been doing so since 1991,  since I believe the removal of operative fluids keeps the scar tissue from forming.  The common approach is to use no drains and wrap the patient tightly.  With a remarkable softness rate to date, I believe it is combination of making a generous pocket, freeing up the muscle properly, use of saline which has a fixed hydrostatic water pressure that resists scarring, and keeping any blood and serum drained away from the foreign
is the key to a successful outcome in our Practice.    Recovery is usually a few days for basic activities, getting around, and driving, and return to work.  Some soreness and instability in the implant settling will be present for 4 weeks or so, thus requiring one to limit heavy aerobics and personal activities for that period.
The costs of surgery can range from  $6000 to $8000 for breast augmentation depending upon the type of implant style and ingredient selected.   Saline implant augmentation is at the lower end of the scale.  
We appreciate the opportunity to provide you with some information to better make an informed choice. Each surgeon will have a passion, philosophy, and experience from which to recommend their approach to Breast Augmentation and other Services.   Our endpoint is an attempt to obtain a happy consumer.    
Please see our main website  BEFORE AND AFTER  breast augmentation, lift, and reduction,  and our site devoted only to breast procedures, SERVICES, breast augmentation.
From our sister site and our interactive bulletin board
As a surgeon gains greater experience with breast enlargement surgery it clear that the operation is not routine, and the patient population is as varied as with any area of Plastic Surgery. The prospective woman seeking this surgery is in search of a long-lasting, natural, soft result, and in many cases would like to exceed a size commensurate with her frame. Women in this category have a particular focus on their physical appearance and may feel less feminine with smaller breasts. The best candidates are those who want the operation as something they are doing for themselves and have considered it quite a long time. They will have the highest satisfaction rate compared to someone who is trying to please significant others, or somehow feel the operation will improve lead to more attention and a life change. The average age of patients undergoing the operation is 25 to 45 years.

A patient will ordinarily be concerned about breast shape and breast size. The surgeon must listen carefully in order to best meet expectations after surgery. A hesitation by the patient pausing to remind the surgeon not to go too large may be a reflection of modesty. This must this must be explored to help the patient overcome any embarrassment over the subject, since misconceptions about why the patient is there, to have large breasts, can result in disappointment in the postoperative period. The patient is placed in two bras, one of a moderately large cup, and a bra with a smaller cup is placed over that. Our preference is to insert implants to a volume and size that is preferred by the patient while wearing the double bras. The smaller bra on top simulates the compression by the pectoral muscles, and seems to correlate beautifully with the postoperative look in a bra following surgery. This Practice places all implants behind the muscles due to the distinct advantages of this method following many years of experience. A natural and soft result similar to full natural breasts can be achieved with new methods of breast pocket development and internal tailoring performed at the time of implant insertion. Saline implants in the moderate projecting round smooth-shell design, have been compared with anatomic and tear-drop styles. The results in patients and on x-ray examination finds that the round implants look tear-shaped over time, but give better upper breast enhancement. The texture-surface implant shells while initially produced as a hedge against implant firmness have not proven to work in this way, but instead the texture might lead to a shortened life of the implant shell. Final data on these issues is being studied.

Augmented breasts that look and feel natural and leave no telltale scars are the next most important issues for patients. It is important to discuss advantages and disadvantages of implant shapes and styles, saline versus silicone, and how each may look on a particular frame. The use of photographs of case histories is important to properly inform the patient how their breasts may look once augmented and how they may compare to some ideal shape provided by a picture of a model or celebrity. Patients who display mild forms of breast sag and slope to their small breasts (described as minimal ptosis, moderate ptosis, pseudoptosis, and glandular ptosis) (See Classification of Ptosis under Breast Lift (Mastopexy)) may expect to have a result with a bit more slope of the breasts rather than the highest firmest look expected when the breasts are small but firm before surgery.

Sensation ordinarily is unimpaired by breast augmentation. With large implants, following difficult secondary breast procedures, or use of sharp methods of pocket creation, the incidence of diminished sensation may be a bit higher. Rarely there can be a temporary neuralgia of one of several tiny nerve branches that innervate the skin of the breast, areola, and nipple, but usually resolves in a few weeks. At first the breasts may appear to have diminished sensation but this rapidly improves 2 weeks following surgery. Sometimes the skin just below the areolae can be less sensitive for a while. For patients who develop the rare painful breast there are agents based on the medication Neurontin and others which can be quite helpful over a period of a few weeks to a few months. These agents are used in patients with pain disorders, and for the short-lived and rare episodes of nerve discomfort from breast operations, they can be highly affective.

It is best to remind a woman seeking breast augmentation that breast surveillance is important since breast cancer can occur in as many as 1 in 9 women. Patients with high risk of breast cancer by family history, or who may have had breast lumps from time to time, must be screened by physical examination, ultrasound, and even mammography, prior to consideration for surgery. Special breast compression mammograms have been available for many years to best image breasts containing prosthetic devices. Implants have no association with an increased risk of developing breast cancer, nor is the stage at diagnosis delayed due to late recognition of a breast lump. Several long terms studies following patients with breast implants revealed their incidence of breast cancer was the same as the general population, although the Los Angeles study of over 33000 women with breast implants demonstrated a slight decrease in the normal onset of breast cancer by a few percentage points.

Breast feeding following breast implantation should not be impaired, although there may be a slight decrease by 15% when periareolar incisions for placement are used, or when the implants are placed behind the breasts and above the muscles. Following pregnancy, breast augmentation should be deferred until milk has production has dried up, and some gynecologists feel that this may be 6 weeks to 2 months, although some authorities recommend waiting up to 6 months.  

06/22/07 at 23:05:21    
See our website at which now features some video case results of the face, breast, and body, using professionally made morphing technology.  These are not renditions but actual results from BEFORE to AFTER.
Note that the  some of the breast lift  reduction videos on youtube feature the WISE PATTERN method of scar placement.  
 FEB 2007 Silicone Implant Controversies
02/02/07 at 16:41:16    FEB 2007 Silicone Implants PRO AND CON
The fact that silicone-gel containing implants are back on the market still raises controversial points about their implantation and management.  COSMETIC SURGERY TIMES PUBLICATION TAKES ISSUE WITH SILICONE BREAST IMPLANTS.
Dr. Rod Rohrich, former President of the American Society of Plastic Surgeons (2005) comments: ....he'll offer siliicone breast implants only to patients with no breast tissue who have failed other implants. And he'll tell them that, with silicone, "The incision will be much larger," and the incidence of implant hardening is significantly higher - five per cent for saline, 20 per cent to 30 per cent for silicone. He adds that, although both silicone and saline implants last 13 to 15 years, "one doesn't know" when silicone implants have ruptured..... "Another thing we've learned is that patient satisfaction rate for saline implant breast augmentation exceeds 95%......Accordingly, as a scientist....very difficult to drop saline, which has served U.S. patients and physicians well for 15 years."
Cosmetic surgeons in other specialties are performing breast augmentation and have similar concerns but state  Dr. Michael Rosenberg of New York  "Availability was never intended to mean silicone implants will suit all patients, he adds. ...the availability of silicone implants "empowers women to make well-educated choices and keeps the decision between patient and physician."  SILICONE GEL IMPLANTS  
11/18/06 at 14:54:22   The FDA, in November 2006, after careful study of silicone gel implants since 1992 (when they were withdrawn for routine use to meet new standards of manufacture and safety)  approved two US companies to market and sell ADVANCED SILICONE GEL BREAST IMPLANTS.  
Mentor Corporation and Allergan Medical (owners of Inamed Corporation), both based in Southern California, meet orders by Plastic Surgeons, for patients interested in having breast enlargement with the stronger shell and thicker silicone-gel containing implants.  
The investigational status has been lifted for silicone gel-filled prostheses used for breast enhancement.  There are requirements for patients to be followed carefully, and an MRI scan is recommended every three years to exclude silent silicone gel implant rupture.
Free silicone injections to the breasts should never be considered.  
Each practice will complete a new device COURSE AND CERTIFICATION to be granted authority to insert these prostheses.  
WE HAVE COMPLETED NECESSARY CERTIFICATION REQUIREMENTS and may begin to use silicone gel implants on a routin basis for interested consumers.  Call us at 1 800 427 4714.  The paperwork required by the FDA and each manufacturer is a bit lengthy but this is to insure good long term follow-up on operated patients.  
The advanced silicone-gel implants are more expensive than saline-filled devices.  Choice of incisions for placement is limited when using silicone gel implants. The size of the incision will be larger for silicone implants. Incidence of scar tissue and implant hardening is higher for silicone gel impants.  Large silicone gel implant insertions are more challenging.  Long term warranties for both saline and silicone gel implants are much improved.
Please feel free to contact us .
Donn M. Hickman MD, FACS, and staff