DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

Anesthesia – General, Sedation or Local?

What Is Different About The One-Day Recovery Breast Augmentation

I am often asked by my patients during the initial consultation "What is different about the way you perform the surgery?", "Why doesn't everyone else do the surgery this way?". These are excellent questions. It only makes sense. I put forth a surgical procedure that gives excellent results with minimal post operative discomfort and little downtime, and the lowest rate of re-operation. So, why doesn't all the other plastic surgeons perform breast augmentation this way?

I answer it very simply. I can't explain why a surgeon performs a surgery one way or another. As my former chief of surgery during my general surgery residency training (more years ago than I care to think about) once said, a surgeon is an internist who operates. What that means is that as surgeons, we need to understand all about physiology and anatomy. We need to understand blood flow to tissues and wound healing. Add to this that as plastic surgeons, we need to be artists as well. We need to understand the relationship between aesthetics and tissue dynamics. However, aside from all this understanding, we perform a technical exercise. We plan, we cut, move and sew tissues. Some maneuvers are technically easy to perform, some are not. Anatomy varies somewhat, tissues vary in quality and consistency, and lets face it, not everyone can take something apart and put it back together with the same technical finesse. The bottom line is that every surgeon must operate within their own degree of comfort. What works for one surgeon may not work as well in the hands of another. Not every surgeon can duplicate what another surgeon can do. That does not mean that the surgeon is not skilled or qualified, it just means that a particular procedure might not be right for them to perform, so they perform the surgery in a way such that they can achieve the end result they want, albeit maybe with more downtime, postoperative pain or a higher revision rate.

I would love to say that I developed all this myself and this is my contribution to plastic surgery. However, I am going to be very honest here. Back in 2002, I was at a national plastic surgery meeting in San Antonio, Texas and I heard my friend John Tebbetts, a Dallas, Texas plastic surgeon give a riveting lecture on  a new way to perform breast augmentation where the patient can go to dinner the same day and recover in 24 hours. I know Dr. Tebbetts well and he is one of the most painfully honest, methodical and thoughtful plastic surgeons I know. I knew that he wasn't stretching the truth one iota. So I made it a point to visit him and learn how all this is possible. In 2004 I made that trip to Dallas and my breast augmentation practice changed forever. Dr. Tebbetts and his wife, Terrye, wrote a book The Best Breast 2 which explains in detail the rationale for this procedure. It is written primarily for women interested in having breast augmentation surgery. It is a wonderful resource and I recommend it highly.

So what is different about the way I perform the surgery? There are many factors that are important in achieving a recovery from breast augmentation in just 24 hours. I will focus on the technical aspect of the surgery. The way I learned to do breast augmentation when I was a resident in plastic surgery is much the way it is still done today, about (again its hard to say) thirty years later. An incision is made in the skin, lets say for example, in the crease under the breast. The incision is deepened until the lower edge of the muscle is identified. Now the muscle is lifted off the chest wall and the space between the muscle and the ribs is opened, creating a space for the implant. After the implant is inserted, the wound is closed by a variety of techniques, according to surgeon preference. Ok, so if I did that then, and I still do that now, why do my patients recover so much more easily? Ever hear the expression "It's all in the wrist?". Well, its not in the wrist. it is in how you handle the tissues.

During my surgical training, I completed a full five year general surgery residency including a year as chief resident. I completed a two year residency in plastic surgery, also including a year as chief resident. I completed a year of hand surgery and another year of reconstructive microsurgery, all at some of the finest institutions in the world (University of Cincinnati, Penn State University - Hershey Medical Center, Curtis Hand Center of Union Memorial Hospital, Brigham and Women's Hospital/Boston Children's Hospital - Harvard Medical). I even did a year of research, but that doesn't count for what I'm going to say, I just wanted to mention this because it all adds up to ten years of post surgical training after medical school which sounds more impressive than just saying nine years. During all those years I worked with scores of really excellent surgeons. Surgical training is like an apprenticeship, with a period of graduated responsibility and supervision. When operating, it is the attending surgeon's duty to make sure you are performing the surgery correctly and to offer appropriate tips, tricks as well as criticisms during the performance of that procedure. That said, I can't recall, not even once, during all those years of training, when an attending surgeon said to me "watch how you handle that tissue because the patient is going to feel it after surgery and they will have more postoperative pain."

Why is this? Simple. The thinking then, as it is today, is that surgery causes pain and pain requires narcotic pain medicine, at least for the first several days. The patient is under anesthesia, so what difference does it make so long as the patient is asleep during surgery (thus not feeling any pain), we know when they wake up they will get pain medicine anyway, so why do I have to be mindful of the way I handle the tissues?

Wrong. Wrong. Wrong. The fact is, surgery can be performed in many cases (not all types of procedures) with very little bleeding and postoperative pain, and very minimal need for postoperative pain medicine and frequently with no need for any narcotics after surgery. How do I know it's true? Simple, because that is my credo. Gentle handling of tissues has made all the difference in the world in the recovery of my patients following not only breast augmentation, but breast reduction, breast lift, tummy tuck, liposuction, rhinoplasty ("nose job"), etc. Now, back to breast augmentation. The way the pocket is typically made involves inserting a blunt dissector, which looks like a cross between a crow bar and a golf club, into the space between the chest wall (the ribs) and the muscle above, and pushing it in and out, banging the ribs in the process, until the muscle has been avulsed (a nice word meaning "ripped and torn") from the ribs. Not much precision in creating the pocket. And talk about the bleeding. And the bruising. And the swelling. Yikes! I can't believe I used to do this.

So what do I do now? Very gentle tissue handling. Use of an electrocautery which looks like a fine tipped pencil that uses concentrated electrical energy to divide the tissues without tearing the tissues is the major difference. I have made some further refinements as well. A few years ago, I developed a series of retractors (Epstein Breast Retractors) that allow me to elevate the tissues and see deep inside the breast pocket with the least amount of physical force needed to pull upward on the delicate breast tissues. I also recently developed another instrument (Epstein Sub-muscular retractor) which allows me to delicately sweep the pocket to visually inspect and make sure there is no bleeding before inserting the implant. In my humble opinion, residual blood within the pocket is an irritant and will lead to more postoperative discomfort. The retractor greatly facilitates  insertion of the implant into the proper position during dual plane procedures. I studied biomedical and electrical engineering at Northwestern University in the 1970's. I am an engineer and a techie at heart. I love improving my tools and creating solutions for problems and making things work better. So for me, instrument design and creation is a natural progression. I record data on my patient's recoveries, so when I quote my statistics, they are based upon real patient data. When I began using the techniques I learned from Dr. Tebbetts, in my hands, I was achieving an 80% 24 hour recovery, which means the patient can do most all of their normal activities of daily living except strenuous exercise within 24 hours. That was terrific, but not good enough. After I developed the Epstein Breast Retractors, 98% of my patients were now experiencing a one day recovery. Was it the retractor or just having more practice and experience? Hard to know for sure. However, the key thing is I am achieving these recoveries and have been doing so since 2004.

The below video demonstrates how I perform breast augmentation surgery in a gentle, atraumatic fashion. Note: the breast is barely disturbed during the entire process.

This next video is a compilation of four different surgeons performing breast augmentation surgery on YouTube. Note the use of a finger and other devices to rip, tear and pull the breast from the chest wall.

Look at the video below to learn more about the instrumentation that I developed for breast augmentation:


So why are breast augmentations still being performed the old way? You have to ask the individual surgeons...

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