DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

Anesthesia – General, Sedation or Local?

When Is A Cheap Augmentation Not So Cheap?

These days, nearly everyone is cost conscious. All my patients would love to pay as little as possible for their surgery. This only makes sense and I wish I could offer my services for less than anyone else. We try to set our fees as fair as we can based upon the level of quality and service that we provide, notwithstanding the fact that we also offer what most other surgeons in this area do not offer: 3 D imaging with the Vectra system, One Day Recovery Breast Augmentation™ and one of the lowest reoperation rates around. If having the ability to visualize a computer simulation of your surgery,  experiencing a recovery consisting of dramatically less discomfort requiring no narcotics and the ability to go out the day of your surgery and drive the very next day, and a minimal chance of needing to pay for another surgery in the next few years is not enough of an incentive to seek consultation and surgery with our practice, let’s explore cost.

Here’s one way some surgeons cut corners to bring down cost: Use a nurse anesthetist rather than an anesthesiologist (physician) to provide anesthesia

Some surgeons who charge considerably less for their surgery use nurse anesthetists rather than anesthesiologists. What is the difference? A nurse anesthetist is a nurse who has critical care experience and undergoes additional training in anesthesia. They usually function in hospitals and ambulatory surgical centers under the supervision of a board certified anesthesiologist. An anesthesiologist, on the other hand, is a physician who undergoes several years of special training in anesthesia following graduation from medical school. With all due respect to my nurse anesthetist colleagues, whom I have the utmost respect and admiration for, you cannot compare the knowledge and skill set of a nurse with two years of anesthesia training to a physician who completed four years of medical school and three years of anesthesia residency training, not withstanding the fact that most nurse anesthetists work under the supervision of a physician anesthesiologist and not the other way around. My understanding of the law in most cases is that nurse anesthetists must function under the supervision of a physician, but this physician does not need to be an anesthesiologist. As such, a nurse anesthetist may work in an office based surgical facility like my own, and function under the supervision of the plastic surgeon! This is a kind of scary thought to me. These nurse anesthetists know more about anesthesia than I as a surgeon would ever hope to know, so why do I want to be their “supervisor”. This makes no sense from a safety point of view. It has always been my practice to take every possible precaution to make certain that I only select patients who are the healthiest and the lowest risk for complications during/following surgery in my facility. However, if an emergency in my office based surgical facility should arise, I want to make sure that I have the most experienced person possible responsible for my patient’s anesthetic management and that person is always going to be a board certified anesthesiologist.

Sometimes a breast augmentation ends up costing a lot more than you expected

So you book surgery for a breast augmentation. You are very excited. You meet with the surgeon and you go over implant size, and instructions after surgery. The surgeon discusses potential complications like bleeding, infection, needing to replace your implant one day. Sure, these are all reasonable things to talk about. Bleeding and infection are generally very infrequent complications in the very capable hands of most surgeons. Implants, as all mechanical devices, do not last forever and I tell my patients this. However, this issue is a constant factor, no matter who the surgeon is. Let’s talk about other issues resulting in a need for surgery that maybe your surgeon didn’t discuss with you. And remember, another trip to the operating room is usually associated with additional costs. Costs that in many cases, you, the patient, will be responsible for.

Reasons for reoperation:

  • Hematoma (collection of blood around the implant after surgery due to bleeding inside the breast pocket)
  • Infection with need to remove implant in some cases (very rare)
  • Implant malposition (this may be due to improper surgical creation of the pocket or tissue stretch after surgery which is not controllable by patient nor surgeon)
  • Capsule contracture (hardening of the scar tissue around the breast)
  • Request for size change (either increase or decrease)

The national statistics for breast augmentation re-operation in the first 3 years following surgery are surprising. 15% – 40% of women who undergo breast augmentation with silicone gel implants are looking at a second procedure in the first three years after surgery! Personally, I find that figure unacceptable. In my practice, approximately 2% of women who undergo breast augmentation with silicone gel implants undergo a second procedure in the first three years. Less than 1% of my patients have a second operation due to hematoma (although this is a very low number, I am always working to reduce it), leaving a fraction of a percent of my patients who undergo early re-operation for all the other reasons combined.

Why are my statistics so much better than the national averages? The technique that I use for breast augmentation has been studied and reported by Dr. Tebbetts in the plastic surgical literature as having the lowest re-operation rate. Precise selection of implant size based upon the existing breast size and breast tissue characteristics, a non-traumatic surgical dissection, special attention to the prevention of infection and a special postoperative set of instructions to facilitate recovery culminate in the ability to produce a 24 hour recovery and the lowest chance of re-operation possible. Just to give an example, current thinking on the cause for capsule contracture is the following: Whenever one places a foreign body (like a breast implant) into the body, the body reacts by surrounding it with a thin layer of pliable scar tissue called a “capsule”. This capsule normally does nothing and does not affect the surgical result. You can’t see if nor feel it. Now, if there is blood oozing around the implant after surgery is over and the wound is closed, a protective barrier called a “biofilm” is created around the implant. This biofilm protects bacteria of low virulence (ability to cause infection) from the bodie’s immune system defenses. These bacteria now have a safe harbor to multiply, setting up a low grade infection, not apparent to the patient, however the body then reacts by thickening of the scar tissue capsule from a thin filmy layer to a thickened, hard layer of tissue. The scar tissue capsule then contracts and causes the implant to feel hard. The implant isn’t any different, but it feels hard due to the strong forces of contraction of the capsule. This causes visible distortion of the breast and the breast then feels hard. Capsule contracture is one of the most common reasons for re-operation after breast augmentation. I began using silicone gel implants when they became available in 2006 and did not experience my first capsule contracture from these devices until 2012, for a capsule contracture rate of less than 1%!

The take-home message here is that a breast augmentation procedure performed using a technique that is associated with a lower chance of reoperation means less surgery and less cost to you, the patient. The corollary is, sometimes a cheap breast augmentation is not so cheap when you factor in the high rate of reoperation other surgeons’ patients experiences after breast augmentation surgery.

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