by Mark D. Epstein, M.D., F.A.C.S.

Traditionally, breast augmentation is associated with a considerable amount of pain and down time, but this no longer needs to be the case.
Breast implants may be placed either below or above the pectoralis major muscle (a muscle located just beneath the breast). The advantage to placing the implant below the muscle is that there is much less interference with mammography, as well as more soft tissue to cover the implant, making it less palpable and visible.

Pregnancy/lactation causes stretching of the breast tissue with loss of fullness and bottoming-out of the breast. Often, a decision is made to place the implant above the muscle to better fill out the breast-skin envelope; however, in these cases there is less soft tissue coverage of the implant and less support for it. Using a specially created technique called dual-plane augmentation, women with such breasts can enjoy the benefits of a breast augmentation with implant placement below the muscle.

A breast implant consists of a silicone shell (bag) filled with either saline (salt water) or silicone gel. Silicone gel filled implants were re-released by the FDA in November 2006 after extensive study. They have become increasingly popular. Saline implants are available in either a round or teardrop shape. The advantage of a saline teardrop implant over a round saline implant is that the overall breast shape will be more natural in most cases. Use of saline teardrop implants requires greater attention to detail in placement than a saline round implant. The advantage of saline round implants are that they are easier to use and less expensive. Silicone gel implants are available in a round shape only. As silicone gel round implants are more flexible in shape than a saline round implant, in my experience, I believe that the overall shape of a breast augmented with a silicone gel round implant is more natural than that obtained with a saline round implant.

Breast implants may be placed through incisions in the armpit, around the nipple or under the breast. The advantage to an armpit incision is that the scar is well hidden and there is no scar on the breast itself. Although most surgeons perform this procedure blindly, minimally invasive endoscopic breast augmentation (similar to laparoscopic surgery) provides enhanced visualization of the surgical pocket on a large television monitor, affording greater precision during the surgery.
A periareolar scar (around the nipple) is usually inconspicuous. The disadvantage to the technique is that wound healing varies greatly according to the biology of the individual and thus some women have a more noticeable scar, which would now appear on the most conspicuous part of the breast.

The most common surgical approach to breast augmentation is an inframammary (breast crease) incision. This scar is barely noticeable as the lower portion of the breasts often covers the crease and scar. This surgical approach provides the surgeon with the greatest visualization of the surgical pocket, and the ability to make internal modifications as necessary in a breast that has drooped secondary to pregnancy/lactation. The techniques best suited for you will be discussed at your consultation.

Using techniques specifically designed to reduce post-operative discomfort, the post-operative experience has been dramatically improved. Many patients return to normal activities of living within 24 hours. During the past 3 1/2 years, nearly all our patients have been able to raise their arms up high over their head before they left the recovery room. Some patients have even put on makeup and brushed their own hair before going home. Occasionally, patients have felt good enough after surgery to go out shopping or to dinner later the same day! Rapid recovery after breast augmentation surgery is the culmination of proper preoperative planning, delicate and precise surgical technique, refinements in anesthetic management, and postoperative care designed to promote a quick recovery with minimal discomfort. Average return to work is about five days, and often less. Most patients experience some mild discomfort after surgery, but overall, the average amount of discomfort and downtime after surgery have been significantly reduced while the quality and consistency of the aesthetic results have been greatly improved.

Dr. Mark Epstein is a dual board certified plastic surgeon specializing in breast augmentation, with a special focus on improving the patient experience before and after surgery.

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Investing in yourself – Cosmetic surgery and Botox in Stony Brook, Long Island

There are many things that we invest in. Most of the time when we think “invest” we envision a plan to take an initial financial commitment and place it somewhere so that it enhances in value. Although worthwhile, there are other great ways to invest your money. We do this all the time and not think about it. We invest money and time in our own education or that of our children so that we (they) can have an enhanced earning capacity to hopefully lead a more comfortable and secure life. We invest time to find the right home, car, vacation. We invest our emotions in finding the perfect spouse. I write this on the day of my eleventh anniversary, for instance. Investing all comes down to making oneself happier and more secure.

Cosmetic surgical procedures such as breast implants, breast lifts, tummy tucks, facelifts, rhinoplasty and liposuction are often seen as a luxury, maybe even frivolous. But when you think of it, it really isn’t. It may help you feel more secure and confident about yourself; more comfortable within your own skin, so to say. And unlike a vacation, a car, a boat, a new entertainment system, the results obtained with cosmetic surgery are longer lasting and appreciate with time. How do you place a value on feeling good about yourself, being more self-confident?

Let’s talk about Botox. An average treatment may run $600 for about 40 – 50 units of Botox. If the Botox treatment lasts, conservatively speaking 90 days (sometimes up to 120 days), the cost per day is about six dollars per day to look younger and more refreshed.

Cosmetic surgery is even more of a value. The most common cosmetic surgical procedure is breast augmentation. The approximate cost of breast implant surgery on Long Island is around $7300.00. Although you never need to change a perfectly good breast implant, device failure is about one percent per year. So at twenty years there is a twenty percent chance of needing to replace a breast implant. So let’s say the duration of the breast implant surgery procedure is twenty years. Twenty years is 7300 days. So for just one dollar per day, you can feel better about yourself. Isn’t that worth it?

I began my surgical residency training in 1984. Many of the plastic surgery operations performed when I began my training are still current today. It is the very nature of plastic surgery to improve and re-design surgical procedures, always looking for a way to perform a procedure with greater safety, achieve better, more natural, longer-lasting results with less downtime. How has breast augmentation improved over time?

Breast implants have been around since the 1960’s. Breast implants consist of a solid silicone shell, filled with either saline (salt water) or silicone gel. For decades, surgeons have been able to achieve wonderful, natural results with breast implants. Unfortunately, the postoperative period was marred by pain, often described as feeling like a truck ran over your chest. Ugh! Quite frankly, with a recovery like this, it is simply amazing to me that breast augmentation has consistently been the most common cosmetic surgical procedure performed in this country! I think that the willingness to undergo a procedure that causes so much agony is a testament to the emotional fortitude of today’s woman in the quest for a more beautiful, balanced and sensual shape: a desire to feel more confident within one’s own skin.

Let me digress a little about my experience with surgical training. I completed a five year general surgical residency with an additional year of surgical research, a two year residency in plastic surgery, a one year fellowship in hand surgery and a one year fellowship in microsurgery. Pretty good training, and I am very proud of it. This totaled ten years of training after graduation from medical school until I returned to my native Long Island to begin my practice (the average plastic surgeon trains 5 – 7 years). And through all this training, literally thousands of operations performed, the majority under the tutelage of master surgeons, I cannot remember one single discussion, either in the operating room or out, relating to how to perform an operation in such a way that a patient will feel less pain, recover with less downtime. Unbelievable! We were just taught that during anesthesia the patient will perceive no pain, so you can handle the tissues any way you want, because the patient will not feel it.. We learn about how to give post-operative pain medicine to our patients, how to put in local anesthesia in the wound at the end of surgery to give a few extra hours of pain relief. The drug reps would show us literature that their little pain pill works better and longer than the competition’s pain pill. We could not have missed the point any more!

I went into practice in Stony Brook, Long Island in 1994, and began performing breast augmentations then. I would say that my patients experienced pain and downtime about average to those of my colleagues. Unfortunately, for the majority of those that perform breast augmentation, little has changed today. Some surgeons inject local anesthesia in the wound for a few hours of pain relief, some perform nerve blocks, implant thin tubes called catheters to inject pain medicine into the implant pocket, place electromagnetic coils around the breasts, and the like. The local anesthesia wears off in a few hours. The catheters and coils add another encumbrance to wear and make the patient uncomfortable. How can you recover when you are sent home with gadgets and gizmos all over your chest? Elastic bandages and wraps? Whew!

Fortunately, there is a better way. If surgeons would only learn how to perform an operation without causing so much tissue trauma as to result in all that postoperative pain, recovery would be so much better. If the surgeon could look at an operation and understand which maneuvers are not associated with significant pain after surgery (i.e. the incision) and which maneuvers are associated with pain after surgery (the dissection of the pocket for the implant), and then determine how to perform the maneuvers associated with pain in such a way as to not result in as much pain and downtime after surgery..

That is exactly what I have accomplished. I have to give credit where credit is due. In breast augmentation, these principles were pioneered by Dr. John Tebbetts in Dallas. I was most fortunate to be a direct benefactor of the wealth of his wisdom, having been taught these techniques by him personally several years ago. My augmentation practice on Long Island was literally transformed overnight. Via the internet, I also get many out of town referrals as well. I will give you opinion and I will give you fact. My opinion is that I think my augmentation results are very natural and my patients are very pleased with their results. Now for the facts. Whereas the three year revision rate for breast augmentation is around 25%, mine is just a few percent, mostly due to issues out of my direct control such as an occasional saline implant deflation or a capsule contracture. The best part is the recovery! My patients awaken from surgery with far less discomfort than I previously saw. Since changing my surgical technique in 2004, I have not seen a single patient who could not put her hands up high over her head while still on the stretcher in the recovery room. 92% of my patients take nothing stronger than ibuprofen (Advil) for discomfort, if anything at all! 86% resume normal activities of daily living, including driving (no strenuous exercise!) the next day, with many going out the same day as their augmentation to dinner, shopping and the movies, just to name a few things they do. I just love hearing from the patients on their first post op visit about all the things they were able to do right after their surgery.

You can read more about this on my web site http://www.epsteinplasticsurgery.com/breast_augmentation_information.htm and see before and after photographs of our patients at http://www.epsteinplasticsurgery.com/procedures-breast.htm#baug