Breast Augmentation / Breast Implants : An Informed Consent Presentation

Breast Augmentation:
Making an informed decision

W. Thomas McClellan, MD FACS
Board Certiﬁed, American Board of Plastic Surgery

www.mtpsa.com

Copyright © 2012 W. Thomas McClellan, MD FACS All rights reserved.

Tuesday, February 19, 13

Why is this presentation important?

• I want you to be an informed consumer.
• Create an outline to discuss procedure with
your plastic surgeon.
• Better understand the surgery, implants, risks,
complications, and post-op care.
• Help you to generate questions.



Introduction

• Statistics
• 316,948 breast augmentations in 2011
• #1 cosmetic procedure performed for
women between 22 and 40
•

American Society of Aesthetic Plastic Surgery 2011 Statistics www.surgery.org



Discussion Points

• Choosing a Plastic Surgeon
• Selecting an Implant Size
• Type of Implant (Memory Gel or Saline)
• Breast Cancer and Implants
• Incision Location



Discussion Points

• Above / Below Muscle
• Surgical Facility and Anesthesia
• Intra-Op Technical Caveats
• Post-Op Care
• Your Medical History / Risks / Complications



Choosing a Plastic Surgeon

• Board Certiﬁed in Plastic Surgery
• Look for the ASPS logo
- Minimum 6 years of focused Surgical Training after
Medical School
- Unparalleled written and oral examinations
- Extensive experience with breast augmentation
evaluation, surgery, post-op care, and complications.
- Operate in accredited surgical facilities.
• Don’t permit an Ob/GYN, ENT, or other non-
qualiﬁed doctor perform your breast
augmentation.


Choosing a Plastic Surgeon

• Questions to consider:
- How many does your plastic surgeon perform yearly?
- Photo Examples?
- Does a PA, Nurse, or Trainee operate on you during
surgery?
- Can you talk to a few of their former patients?
- Complications?

• Make sure you feel comfortable with the physician
and staff.



Selecting Implant Size

• Choosing proper size important for a lasting result.
• Review pictures of similar sized women.
• Try on the implants with a sports bra.
• Bring a friend or partner to offer advice.
• Multiple visits help make best decision.
• Size chosen is size you receive in OR.

Hvilsom, Gitte B. et al. Local Complications after Cosmetic Breast Augmentation Plastic & Reconstructive Surgery. 124(3):919-925, September 2009.
Araco, A et al. Sesitivity of the Nipple Areola Complex Following Breast Augmentation. Plastic & Reconstructive Surgery. 128(4):984-989, October 2011.
Adams, W. Breast Augmentation. Plastic and Reconstructive Surgery. 130(4):597e-611e, October 2012



Selecting Implant Size

• Important Anatomy
- Width of the breast and distance between breast
- Current breast size
- Tissue thickness and elasticity
- Sternal notch to nipple distance
- Patient height, weight, hip shape
- Your current breast asymmetry




Selecting Implant Type

Memory Gel Saline
Age minimum >22 18+
Size fixed (pre-filled silicone) adjustable (saltwater)
Feel softer firmer
Visibility less rippling more rippling
Weight lighter heavier
Incision length 4.5 3cm
Rupture silent (MRI to detect) immediate deflation
Capsular Contracture greater less
Cost $$ $

Every patient is different. Please consult with your surgeon to determine the best implant choice for you.



Breast Cancer and Implants

• Risk of breast cancer is not increased with implant
• Can’t see all breast tissue on mammogram
- requires extra view (Eklund displacement technique) to improve
visualization
• Palpable tumors are more easily detected with implant
• Implant doesn’t delay diagnosis of breast cancer
• If diagnosed with breast cancer survival rate is the same

Handel, N, The Effect of Silicone Implants on the Diagnosis, Prognosis, and Treatment of Breast Cancer. Plastic & Reconstructive Surgery. 120(7);81s-93s, December 2007.
Wood, Spear. What do women need to know and when do they need to know it. Plastic & Reconstructive Surgery. 120(7);135s-139s, December 2007



Incision
• Inframammary
- hidden in the lateral breast fold
- 4.5 - 5cm long
- 9x less capsular contracture = longer lasting result
- > retained nipple sensation
- < bleeding
- precise + gentler on the tissue
- incision used in future to exchange implants
Weiner, TC Relationship of Incision Choice to Capsular Contracture. Aesthetic Plastic Surgery. 2008 Mar; 32 (2): 303-6.
McClellan WT. et Al. The Inframammary Crease. Breast Augmentation Principles and Practice. Ch 5; 2009: 51-6.
*I prefer the inframammary incision when appropriate. Please consult your plastic surgeon for the best incision for you.



Inframammary incision @ 3 months
Text

Text well hidden in lateral breast fold
Scar



Above or Below Muscle (+/-)

Sub-Glandular Sub-Muscular
Capsular Contracture higher lower
Impact on mammography more less
Implant Visibility more rippling less rippling
Implant Palpability greater palpability less palpability of edges
Implant Location lower higher
Pain of Procedure same same
Implant Movement no movement + with activity

Every patient is different. Please consult with your surgeon to determine the best position for your implant.



Surgical Facility and Anesthesia

• Hospital or Certified Surgery Center
- Board Certified Anesthesiologist
• General anesthesia with LMA (laryngeal mask airway)
- Protected airway with easier recovery
- Stable blood pressure reduces hematoma risk
- Medications help prevent PNOV and reduce post-op pain
- If intra-op difficult, drug reaction, or event arises you are
already in the safest setting possible.

McClellan, W. et. al. Peri-Operative Blood Pressure Changes Associated with Hematoma and Mammaplasty. Presented ASAPS 2006.



Intra-operative Technical Caveats

• Attention to detail makes the difference
• Surgeon does entire procedure. (no PA or student)
• Pre-operative antibiotics
• Nipple-Areola covered
• Precise tissue dissection
• Strict Hemostasis (normotensive anesthesia)




Intra-operative Technical Caveats

• Implant and Pocket washed with antibiotic ﬂuid
• “No Touch Technique” for the implant + glove change
• Sit up to examine size, shape, and symmetry
• Three layered closure + Dermabond™
• Early removal of airway (prevents coughing)




Post Operative Care
• Follow-up Schedule
- Post-Op day 1, 5, 3 weeks, 3 months
• Breast Massage
- Important to maintain soft, natural, long lasting result
- Start Post Operative Day 1
- Up, In, Down (hold for 5 sec) 5x daily for one week
- 3x day for 2 weeks
- 1x day for life

*This is my preferred postoperative visit schedule and massage regimen.Your treatment plan may vary.



Post Operative Care

• Post-Operative Bra
- Cotton Support Bra (hooks in front) - 5 days
- No Bra - 1-2 week (patient dependent)
- Underwire Bra - Once implant descent is optimal
• Activity Level
- No lifting > 10 lbs for one week
- No working out for 4 weeks

*Individual treatment plans varies based on surgery. Make sure to discuss your care plan with your plastic surgeon.



Your Medical History

• Smoking
- increased infection and diminished wound healing
- quit 2 months prior to surgery and 1 month following
• Weight
- should be a stable base weight prior to augmentation
• Medications
- no aspirin, ibuprofen, NSAID, herbal supplements one
week before



Your Medical History

• Delayed candidate:
- UTI, sinus infection, breast feeding (in last 10 months),
weight changes

• Not a candidate: (in my practice)
- diabetes, heart disease, vascular insufﬁciency, prior
radiation, clotting disorder, autoimmune disease,
psychological illness, unrealistic expectations, or other
major medical condition



Risks and Considerations

• A small % of women can’t breastfeed after pregnancy
• As with any surgery, there is a very small general risk
such as: blood clot, heart attack, stroke, and death.
- your risk for blood clot is higher if taking birth control
pills and/or smoking.
• Implants don’t last forever. In time implants will
harden, and may become asymmetric; requiring
removal or exchange.
- change or removal at some point is necessary and
another cost.



Risks and Considerations

• If you have a complication related to cosmetic surgery,
who would pay for facility charges?
• Traditional insurance is unlikely to provide coverage.
• CosmetAssure is a cosmetic insurance included in your
surgical quote.
• Make sure your plastic surgeon offers this option in the
very small chance you may need it.



Possible Complications @ 5 years

Capsular Contracture 5.9%
Asymmetry 5.2%
Sensation Changes 2.7%
Infection 1.9%
Hematoma 1.5%
Palpable Folds 1.3%
Rupture 0.5%
Others <1%




Questions?
www.mtpsa.com



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