Essential Information

Dr. Fisher has outlined some very important information to help you better understand the process of cosmetic and reconstructive surgery.

Augmentation Mammoplasty “Breast Implants”

Two different circumstances most frequently create an interest in surgical breast enlargement. The first involves congenital underdevelopment of or an imbalance in the amount of naturally existing breast tissue relative to the other body measurements such as hip circumference and height. In this instance, there may be problems with breast asymmetry or shape deformities. The second situation is caused by a natural loss of breast volume which follows a large weight loss or the child-bearing years. The breast often takes on a collapsed or deflated appearance and clothing no longer fits as nicely through the chest.

Surgical augmentation of the breast is accomplished by using an artificial implant that is placed beneath the breast tissues. The implant varies in size according to the wishes of the patient. The implant itself contains a jacket and a “filler” of a saline (salt-water) solution identical to that used intravenously in hospitals.

While the once popular silicone gel is no longer used as a filler, silicone in its more solid “rubberlike” form is still used to create the implant’s jacket, which maintains the volume of the saline filler. In recent years, some patients have raised concerns about the potential for implanted silicone to cause diseases. To date, however, these claims have not been substantiated by carefully performed scientific studies that have examined the health of thousands of previously augmented patients. Saline implants wrapped in a silicone jacket are currently allowed for breast augmentation by the Food and Drug Administration (FDA). The number of breast augmentation procedures performed annually at the Mayo Clinic is once again increasing.

During the consultation for breast augmentation, the physician and patient use simulation to decide the amount of breast augmentation that best meets the patient’s needs. During the actual surgery, the implant is placed under the existing breast tissue or under the chest muscle, depending on the patient’s pre-existing breast shape and size. The procedure can be done with local anesthetic and sedation or under general anesthesia.

Scars are an unavoidable result of the incisions required to place breast implants, but they generally are small and can be placed inconspicuously. In some cases, the implants can be placed with the aid of a lighted rod called an endoscope, which permits even smaller incisions and scars. Incision placement is influenced by such factors as apparel preferences and implant placement. The surgery is generally performed on an outpatient basis.

Some discomfort arises from the stretching of the breast tissues, but it largely resolves within two to three days and is well-controlled with medications. Patients should not wear blouses or brassieres until the sutures are removed seven to 10 days postoperatively. Patients generally return to work within one week, but should avoid exertional activities over the three to four weeks required for bruising and swelling to resolve.

Postoperative complications include blood accumulation or infection adjacent to the implant. Both problems occur infrequently, but can necessitate a second operation or temporary removal of the implant. Because implants are a medical device, they can fail at any point after implantation. This is uncommon, but it would require implant replacement surgery because leaking would cause the involved breast to shrink to the preoperative size. Some patients develop a firm layer of scar tissue around their implants which can make the breast hard to the touch or painful. Called “capsular contracture,” this can cause the breast contour to be asymmetrical and may require secondary procedures for improvement. Nipple sensation can be increased or decreased by the procedure. Although this is almost always temporary, it can be permanent. Most patients are able to breast-feed following augmentation.

Breast implants do cause some interference with the ability of mammography to detect early breast cancers. This is an important consideration that patients should discuss with a physician, particularly patients with a first-degree relative who has had breast cancer. All augmented patients need to inform their radiologists of their implants so the screening technique can be favorably modified.

Despite these limitations, approximately two million women are estimated to have undergone breast enlargement surgery. The overwhelming majority are satisfied with the results.

Mastopexy “Breast Lift”

Breast sagging (ptosis) is a common problem following pregnancies, weight loss or aging. Sagging occurs when breast skin stretches, and breast tissue and fat degenerate over time. This results in a less youthful appearance of the breasts.

Breast sagging can be corrected with a breast lift (mastopexy). If the breast sagging is minimal and the breasts are small, ptosis can be corrected with augmentation mammoplasty. This method causes fewer scars on the breast than mastopexy.

The mastopexy procedure may be performed under either local anesthesia with intravenous sedation or general anesthesia. The operation takes about two hours, and patients often return home the same day.

During mastopexy, surgeons reposition the nipple and areola to a higher position and remove excess skin from beneath the breast. Closing the remaining skin lifts the breast mound to a higher position and recontours the breast to give it a more projected and youthful appearance. If there is inadequate breast tissue to fill the skin and achieve the desired size, a saline-filled breast implant may be placed beneath the breast at the same time, achieving both the desired size, shape and projection. Patients may resume limited activities the day after surgery and normal activities in three to four weeks. Pain usually can be controlled with oral pain medication. Sutures are removed one to two weeks after surgery.

When there is marked sagging, the incisions required and resulting scars are similar to those resulting from a breast reduction . In cases of less breast sagging, mastopexy can often be accomplished with smaller scars.

Potential complications of mastopexy include bleeding, infection and healing problems. Patients may experience some decrease in sensation in the nipple. In addition, some patients may notice minor irregularities in the size and shape of the breasts, and in the position of the areola and nipple. Occasionally, infection or healing problems can cause scars to widen and a portion of the nipple and areola to be lost. On rare occasions, scars may become thick and red and require revision.

Following mastopexy, patients may be able to breast-feed because the nipple usually is not separated from the milk glands. If an implant is used, however, problems with the implant can occur.

Following the surgery and healing period, the breast will have a more attractive and youthful appearance. With time, however, there may be further sagging that could necessitate a revisional procedure.

Reduction Mammoplasty “Breast Reduction”

Women with large, heavy breasts may experience several health concerns related to their breasts: back pain, neck pain, grooves in the shoulders from bra straps, pain in the breasts, and rashes under the breasts. Women with arthritis of the spine and shoulders may have more symptoms than usual because of the added weight of heavy breasts. Some women are bothered by the psychological embarrassment of large breasts. In other situations, athletic, active women and women who are trying to lose weight are inhibited by the size of their breasts. Often, it is difficult and expensive to find clothes that fit.

Breast reduction can minimize or eliminate these problems. During the procedure, excess skin and breast tissue are removed and the breasts reshaped to be smaller and more attractive. The procedure is performed at the hospital under general anesthesia. When only a small amount of tissue is removed, the procedure can be performed under local anesthesia with intravenous sedation as an outpatient procedure.

During the procedure, the surgeon makes incisions so that scars form around the areola, vertically below the areola, and in the crease beneath the breast. Scars are an unavoidable drawback to the procedure, but typically quite acceptable to most patients. The incisions are designed so that the scars will not be visible while wearing normal clothing. Then the surgeon repositions the nipple and areola to a higher position on the breast, and removes excess breast tissue and skin. A drain may be left in place at the time of surgery and removed several days later. The patient can be up and about the day after surgery, and can go home in a few days. Sutures are removed within the first two weeks following surgery.

Potential complications of breast reduction include postoperative bleeding, infection and healing problems. These complications may result in more conspicuous scars. When the nipple and areola are transferred to their new position, it may not “take” or heal, and a portion or all of it may be lost. This is uncommon. Smoking immediately before and after surgery may contribute to this problem.

Although every attempt is made to obtain symmetry and a natural shape, there may be some irregularities in the final size and shape of the breasts or in the positioning of the areola and nipple. Because separating the nipple from the breast tissue during the procedure disturbs the superficial nerves of the nipple, patients may experience a decrease in sensation. Patients also may experience a permanent inability to breast-feed after having the surgery. Because these symptoms are normal side effects of breast reduction surgery, patients should consider these factors seriously before deciding to undergo the procedure.

Since reduction mammoplasty is often performed for the relief of physical symptoms, some insurance companies may pay for the surgery. However, insurance companies differ widely in their policy of payment for this procedure. Patients should check with their carriers about coverage before having the surgery.

Following surgery, most women report that their back and neck pain are reduced. Typical scars are a well accepted trade-off for most patients. Patients also have fewer problems finding suitable clothes and are able to become more involved in sports.

Selection of Your Surgeon

The process used to select your surgeon should be as thorough as your selection of your spouse. This selection is a process of choice. Choosing whom will perform your surgery is perhaps the single most important factor in determining a successful outcome to your surgery.

Successful outcomes in plastic or cosmetic surgery are quite different from other surgical procedures because while the surgical performance may be adequate, the result may not meet the expectations of the patient.

Certainly complications may initially spoil the “result.” Infections, bleeding, scar formation, immunity and psychology all have a component in the equation of the “result.”

Other factors may play a role in cosmetic surgery giving it an aura of unpredictability. The psychology of cosmetic surgery is not well understood, nor is it well documented.

Psychological factors which give cosmetic surgery a mystical tinge also make the patient and surgeon selection process most important in determining the adequacy of the result, as it pertains to you, and hopefully to your surgeon. Remember, cosmetic surgery is purely for appearance and the improvement in appearance may result in a successful experience, if all of the conditions are met.

Your relationship with your surgeon involves many factors such as trust, mutual respect, openness, honesty and personal commitment, just to name a few. Perhaps cosmetic surgery will prove to be the last medical/surgical specialty where the doctor-patient relationship may survive the onslaught of the HMO’s and Medicare and ideally last a lifetime!

Surgeons, particularly, cosmetic or plastic surgeons are quite different from other specialists. Confusion remains as to what they are and what they are qualified to do. Plastic surgeons are certainly the most qualified to perform cosmetic surgery, since they have the most training and are certified by a specialty board which is world recognized and they know it. Cosmetic surgery arose from the need of a small select group of society who could afford it and needed to look their best. Obviously, this group was highly selective and money was not an object. This included actresses and actors and the wealthy who wanted to rid themselves of obvious racial or developmental characteristics. With the invention of motion pictures and close-ups, changes in nasal profiles and facial characteristics were essential to success, as Hollywood defined it. In those days, cosmetic surgery was secretive and available only to a few, but as anesthetic and surgical risk was minimized and greater technical prowess was achieved, cosmetic surgery began to flourish, although in a quiet sort of way.

Now, cosmetic surgery is the most rapidly growing medical field, commanding the greatest portion of the public’s attention. With the elimination of private insurance and the socialization of other fields of medicine, many other specialists are trying to portray themselves as qualified even though they may not have any prior experience in this seemingly simple but highly complex field.

Finding the right surgeon may be as easy as getting a referral from a friend or as difficult as interviewing several surgeons so you can make an informed decision that is right for you.

Professional competency, training which substantiates their ability to perform the surgery, personal stability, and a willingness to devote their personal time and energy to the positive outcome of your surgery, are some of the key factors in determining the “success” of your surgery.


Pre-Operative Guide

Introduction:
Cosmetic Surgery unlike other surgical specialties, involves the application of surgical procedures in order to change our appearance and thereby improve our self-image. The improvement in self-image, more accurately termed Body Image, does not always follow after a technically successful operative procedure. The lack of understanding of, and the predictability of how and why cosmetic surgery works or does not work is a testimonial to the complexity of the psychological change preceding and following surgical intervention. Most often, good feelings follow technically good results. But feelings are difficult to define and manage particularly if the patient experiences undesirable negativity after the procedure, when the healing processes are incomplete and visual appearances may be temporarily distorted.

Cosmetic Surgery is only successful if the patient feels that he or she has had an improvement of the self-consciousness experienced in their lives. Studies have shown that 60 % of the patients seeking cosmetic surgery wish to improve their mirror or photographic image, in order to be socially more acceptable. Thus, unlike functional surgery aesthetic surgery has to surpass function and produce a psychological gain all at the risk of functional loss, disfigurement, pain and disruption of our pre-surgical lives. This is a task that almost defies logical understanding yet, on a daily basis in any experienced plastic surgeon’s office, patients who have been carefully prepared for surgery and have a clear understanding of what can and cannot be achieved, are a testimonial to the almost miraculous change which cosmetic surgery can produce.

While the most dramatic part of surgical therapy is the operation itself, it is only a part of the entire process known as the peri-operative period.

Often, details of the surgical procedure itself, legal consents, and financial issues cloud the nebulous period before or after your surgery, however attention to these “details” is most important to a good surgical outcome. Every operation, in addition to the to the procedure itself, entails local as well as total body physiologic changes, subjecting the patient to continuous strain before, during, and after the operation.

Part of the decision-making process should include a detailed discussion of the pre-operative and post-operative procedures for your care.


Pre-Operative Preparation:

Schedule an ample amount of time to adequately prepare for your surgery. The amount of preparation usually varies with the complexity of the procedure, but any operation requires some planning.

• Is this the appropriate time for me to have surgery?

• Am I psychologically “ready” for a cosmetic change?

• Am I physically fit to undergo the stress of surgery?

• Can I stop bad habits in enough time before the operation so that I won’t
have to deal with them after the procedure?

• Am I medically “cleared” to undergo surgery?

• Have I taken aspirin, anti-inflammatory medications, or herbal/vitamins
(i.e. garlic) which may increase my chances of excessive bleeding?

• Do I have any respiratory problems (i.e. asthma, bronchitis, difficulty
breathing,shortness of breath) which may increase my risk of anesthesia?

• Do I have any heart problems (i.e. lack of exercise tolerance,
chest tightness or pain, chronic fatigue, valvular heart disease, rapid or
slow heart rates, swelling in the ankles or feet)

• Did any member of my family expire during anesthesia, if so why?
(abnormal reactions to anesthesia can be inherited)

• Did I ever have hepatitis, jaundice (yellow eyes), irritable bowel
syndrome, ulcers, or chronic abdominal pain.

• Did I ever have a seizure, chronic headaches, loss of consciousness,
weakness or loss of sensation in the arms, legs or feet?

• Do I have any skin problems (rashes, boils, acne, etc.) which may affect
my surgery?

• Do I have any blood problems, bruising, bleeding from cuts which may
increase the chances of bleeding during surgery?

• Are there any bladder problems, difficulty in passing water, fluid
retention, or kidney disease ?

• Have I been disappointed, displeased, or upset with any previous
healthcare issues and why?

• Do I have unrealistic expectations and have I expressed myself openly
with my surgeon as to my expectations of the outcome of the surgery?

• Can I go on with my life if the result is not what I wanted?

• If I have a complication, will it be devastating to me or will I be able to
“work it out” with my surgeon until the problem can be resolved?

• Will my surgeon be supportive if a complication does arise and does my
surgeon have “escape” plans at the ready just in case I may need them?

The above list of questions represents a general outline of potential issues which may have to be addressed during or after the surgical procedure. Remember, failure to fully appreciate the necessity of evaluating your health issues prior to your surgery may adversely affect your results.

Medicine aside, the psychological issues which play before, during and after surgery may be intense. Do not be afraid to ask your surgeon for medications to calm or relax you prior to your surgery. A calm and relaxed (as much as can be expected) body and mind require much less medication during surgery than an excited, overly tired or stressed physiology.

Remember, cosmetic surgery is elective, therefore it can be postponed until your body, your mind, your finances, your family or most importantly YOU are completely ready.


The Early Pre-Operative Phase

While some surgeons merely operate without pre-operative care, several issues need to be controlled in the days preceding the surgery.

• Prepare an environment that will not be disruptive to your recovery.

• Often work pressures accumulate prior to vacation or time off for recovery. It is essential that work partners, employers, and staff be supportive, without necessarily informing them that you are going to have cosmetic surgery. Tell your employer, etc. that you will need some time off (at least a week or two) to have elective surgery. It is not necessary that everyone in your workplace know that you may be having a personal improvement.

• Family pressures need to be decompressed and family members need to show active support. If a family member or friend expresses negativity toward your decision to have surgery, tell them politely that you will not need their help and enlist someone who will support you when you are recovering. The last thing any patient needs is someone telling them they look bad, they should not have done the surgery, or that the surgery was all for vanity’s sake. These negative remarks, especially in the early post-operative period can have a surprisingly devastating effect on a great surgical outcome, producing a long-lasting negativity which may be permanent.

• Child care duties especially for the young (ages 0-8) need to be transferred to another responsible adult, other than the person who will be responsible for your care. Make sure that you will not have to worry about your children during the early post-operative period so you can rest comfortably for the first 48-72 hours or until adequate healing has taken place.

• Be sure that there is extra money on hand for additional medications, nursing care and your budget.

• Check with your insurance company to inform them that you are having elective surgery and to ensure that you will have coverage for emergency hospitalization. HMO is not insurance. Private carriers often say: “We will not cover complications from cosmetic surgery; however, pre-approval for emergency admission after elective surgery may be a different matter.

• Clean your home, bed and bed linens at least 2-3 days prior to surgery but not the night before. Exposure to excessive dust or dirt just before surgery and in the early post-operative period will definitely increase your rate of complications.

• 2-3 Days prior to surgery begin to decrease your dietary intake, gently clean your bowels, and try to regulate your bowel movements. Constipation usually follows most surgical procedures.

• Do hydrate yourself well. Check with your surgeon about dietary restrictions 12 hours prior to surgery (never eat garlic or heavily the night before your surgery).

• Check with your surgeon about special medications for increasing coagulation (Vitamin K), antibiotics, special surgical soaps for decontamination of the skin and hair, shaving, hair and skin care. (Surgery should not be performed in the midst of a skin infection or rash).

• Pay attention and understand the operative site. Where will the surgeon operate? How can I assist in preparing that site for the surgeon?

• Never eat or drink anything (unless specifically directed to do so) after midnight, the night before your surgery. (Retained stomach contents may block your airway, if you vomit during or after the surgery. Treatment for this condition called “aspiration” is not always effective and the acid from the stomach may produce a “lung burn” which often cannot be reversed. Food contents which block the airway cannot be easily removed, if they go beyond the vocal cords).

• Eat lightly bland foods. If you have excess stomach acid notify your surgeon and treat it before you have your operation.

• If you have trouble sleeping, ask your surgeon for a sleeping medication or something calming. (Never take medications unless they are prescribed by your surgeon).

• Never smoke prior to surgery. (Carbon monoxide binds irreversibly to the red blood cell decreasing the availability of other red cells to carry oxygen and this cannot be reversed, even with 100% oxygen).

• All other medical issues need to be completely stabilized and controlled to the best degree possible in order for your surgery to go well. (It is best to have your surgeon’s attention directed to your procedure, rather than correcting your medical problems during the surgery).

• If you have doubt or a premonition (an extremely bad “gut” reaction) prior to your surgery, postpone it!


Day of Surgery

• Arrive at your surgeon’s office at least thirty minutes or an hour prior to your surgical time, or as instructed.

• Notify the office staff of any changes in your medical or psychological condition. Do not be afraid to inform them of any changes, even if you do not think they are important. Let your surgical team decide if these will affect your surgery.

• Shower thoroughly as directed using an anti-bacterial soap.

• Do not wear make-up, false eyelashes, wigs, jewelry, hair pins, or anything which can easily be removed.

• Long hair should be placed in a pony tail or a braid away from the back of the head where your head will rest. If you are having surgery which involves the hair-bearing areas, check with your surgeon.

• Dress simply: Loose fitting clothing, with openings in the front and loose shoes. Underwear should be cotton and bring an extra pair. Also bring something extra to warm yourself on your ride home.

• Minors must always have a legal guardian or parent with them at all times.

• Have a responsible adult accompany you to the office and pick you up.

• Driving after receiving medications may be considered “driving under the influence.” Also, it is more important AFTER the surgery to have your caregiver with you to receive special instructions directly from the surgical team, to avoid misunderstandings about your aftercare.

• Never smoke, drink alcohol, or use any other “substances” for at least a week prior to surgery. Dangerous interactions can occur during surgery which may result in cardiac arrest or inability to recover from the anesthesia and other problems. If you cannot stop your habits, tell your doctor and they can assist you. Never sneak or hide your bad habits, they will only come back to “haunt” you at your weakest moment, when you are recovering from your surgery.


Post-Surgical Care

Post-operative care varies according to the procedure performed and the surgeon who performed it.

• Before leaving the surgery center make sure the surgical team members have your phone number where you can be reached that night and make sure that you are accessible by phone after the surgery to maintain contact at all times.

• Always have someone with you who can assist you with your aftercare. That means going to the bathroom, cleaning up if you vomit, emptying bloody drainage, awakening you for the next 24 hours on a schedule, assisting with dressing and undressing, being able to change blood-stained bandages and functioning as a nursing assistant.

• Have towels and plastic bowls in the car in case you vomit on the way home.

• Have a blanket in the car to keep warm.

• Medications: as directed by your surgeon. Never take pain medication on an empty stomach as this will always produce nausea and vomiting.

• Always have help going to the bathroom and while you are in the bathroom. In hospitals, patients often faint and injure themselves when they are left on the toilet alone because straining directs the blood away from the brain.

• Have an alarm clock at the bedside to awaken you for medications, fluid intake, food, and wound care during the night.

• Never smoke

• Never drink alcohol

• Expect to be in some discomfort. Excessive pain or swelling may be a danger sign warning you to call your surgeon.

• Progressive discoloration, blueness, continued bleeding, blackness of the wound or anywhere, rashes, fever, unusual symptoms of any kind, pain away from the operative site may require immediate attention. Notify your surgeon that there may be a serious change in your condition requiring immediate attention.

• If your lungs seem congested, try to cough and deep breathe every two hours for the next 12 hours after the surgery.

• Position yourself comfortably. Elevation decreases edema (swelling).

• Never sleep on your operative site.

• Never fall on your operative site.

• Never “pick” at the surgical site.

• Never sleep with animals or in soiled bed clothing.

• Always wash your hands after going to the bathroom.

• Never get your operative site wet.

• Never remove a dressing, garment, or device.

• Never take aspirin, or other medications, herbs, unless directed by your physician.

• Don’t exert, strain, bend over, or engage in sexual activity.

• Do not bathe or shower until you are told to do so.

• Do not exercise

Once the early post-operative period has passed, care needs to be directed to preserving the operative result. Normal activity cannot usually be resumed until the surgical site has healed sufficiently to withstand the stresses of everyday life.

Excessive concern in the early postoperative stage is not productive to healing. Ask for anti-anxiety medication if you cannot sleep or if you cannot control your fears and work with the surgeon’s staff to alleviate your concerns. Fortunately, most injuries heal uneventfully even without treatment unless it is a surgical emergency such as excessive collection of blood, infection which is characterized by progressive swelling, pain, warmth, and redness, fever, air hunger or shortness of breath, wheezing, chest pain, uncontrolled pain, or any other symptom which is not improving.

Baring all of this, gradually within two to five days you will begin to improve. Usually your office visits will depend upon the complexity and risk of the surgical procedure. If complications arise, try to be patient and work to resolve your problems with your surgeon. Remind yourself that changing horses in midstream is not a good idea, unless continued deterioration of your condition warrants a second opinion.

Analysis of the final result should occur in the next three to twelve months following the procedure. Emergency corrections rarely ever result in anything other than increasing scarring and making it more difficult to revise the surgery later on.

Follow the directions of your surgeon regarding exercises, massage, resumption of normal activity, restrictions, and the use of post-surgical garments. Never assume that post-operative care is unimportant.

Sometimes patients have difficulty resuming normal activities. Sleep cycles can change along with appearance. Significant others may become unsupportive. Fellow workers may reinforce your own insecurities lend them a deaf ear. Psychological gains may be delayed.

Unlike functional surgery in which pre-operative pain is often relieved by the surgical process, cosmetic surgery inflicts pain and discomfort which may persist beyond the early postoperative period. Rather than relief from psychological stress, patients experience increased anxiety and agitation after awakening and viewing their distorted image in the mirror. Never judge your surgical result from your early post-operative appearance. It takes years of experience by a seasoned operator to evaluate and treat early post-operative issues. Swelling is not symmetrical and can obscure even the best results; however, if you feel excessively concerned then have your surgeon take a look. Remember, you and your surgeon are a team, working together to achieve a common goal,the best possible result for both of you.


Glossary of Terms

Brassieres and Corsets
Old fashioned body contortion devices.

Clothiers
Fashion designers.

Conical
Cone shaped.

Enigma
Mystery.

Elongated
Stretched due to loss of tensile strength.

Foreign Body Effects
The effect of the body’s reaction to something perceived as being inorganic or non-systemic (to its own organism).

Foreign Body Reaction
The body’s reaction to something perceived as being inorganic or non-systemic (to its own organism).

Functional Organ
Vital body part.

Perspective
Life-like view point including aspects of depth of field and vanishing point.

Saline
Salt water.

Side Effect
An effect not intended by the original procedure.

Silicon Gel
SiO2 in a gelatin-type format. Submuscular Breast Augmentation
Augmentation performed below (underneath) the supporting muscle tissue.

Suture
Thread used in stitches. Most commonly made from sterile material.