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Monthly Archives: August 2012

Breast Augmentation Characteristics

The seven characteristics that go into breast augmentation

Sixth and most important to most patients is breast size!! By the way, what is bra size anyway? It’s just a relative relationship of breasts displaced size compared to the torso that the breast sits on, nothing more. That is “cup size” a 32D cup breast is a smaller breast by absolute volume than a 36C cup. Did you know that?

Bra manufacturers in recent years are pushing women to buy C and D cup bras because the connotation is that this is the desirable breast. Just like a dress manufacturer who wants to make a big marketing splash will change their size 6 dresses to fours and size fours to twos!! Women love them. They think that this dress maker is brilliant because they feel thinner!!

The idealized breast is somewhere between a C cup and a D cup for most women. A cup is filled by volume and skin envelope. So, saggy breasts that fill a cup are more skin and less volume. As I discuss this with patients in my office we discuss all these things.

But here’s the catch: there are about 200 different implants and four billion women!! You first have to match the proper base diameter to the chest, body, rib cage. Available volumes in profile projections next are evaluated. And there you are. We can arrive at a realistic goal outcome for size!! Seems easy but you’d be amazed at how many women come to see me with disappointing outcomes from surgery done elsewhere by others that I am asked to correct.

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Breast Augmentation Characteristics

The seven characteristics that go into breast augmentation

The fifth point to discuss is incision placement. By now you can guess I have strong feelings about this as well. We’ll talk about only simple augmentations and not implant augmentation combined with breast lift.  Essentially there are four options,infra-mammary fold approach, peri-areola approach, trans-axillary approach, and trans-umbilical approach.

The new device known as the Keller funnel  has allowed pre filled silicone implants to be placed now with incisions nearly the same size as those used for saline filled implants which are unfilled or partially filled when placed. See my you tube video ” Implant Magic” to see how large pre filled silicone breast implants can be placed thru tiny incisions — you’ll love it!

Peri-areola incisions are popular. The problem is that it increases the likelihood of nipple numbness. A bigger problem to me is that the incision goes thru breast tissue and directly down to implant space. I have always had a problem with this. It often triggers a local contracture response which can pucker the breast, tighten and alter the  urge of the lower breast and create unsightly shape issues. They are sometimes not completely correctable.

Trans-axillary augmentation sounds great in theory but the problem here is that this incision is the farthest away from the most critical area to precisely dissect internally to release muscle in order to get the best cosmetically shaped and aesthetically appealing breasts. In precision oriented surgery this is a problem. And this is why trans-axillary augmentation notoriously leads to implant malposition most commonly, high and widely positioned breasts and is known to have the highest reoperation rate. Unnatural!  And I don’t like it.

Trans-umbilical implant placement is a gimmicky approach used in marketing. Did you know that manufacturers will not warranty their implants placed that way? Interesting.

It is virtually impossible to get an anatomically correct sub muscular implant placement this way. Essentially all are subglandular and look like half grapefruits. No artistry here. Just because you can doesn’ t mean you should. Not good.

Finally, we get to infra-mammary approach. This allows for precision placement and artistry of implant space creation. It is the most versatile in dealing with the myriad of anatomical nuances our bodies present with. It is by far the best. So I favor this method. Look at my web site. I’ll bet you can’t find a single incision on any view of any breast augment patient!

 Click here to read about the 1st characteristic

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Breast Augmentation Characteristics

The seven characteristics that go into breast augmentation

Now on to number four: whether to place breast implants above the muscle or below the muscle. Above the muscle is also referred to as subglandular, or under the breast. Our anatomy is such that the pectoralis muscle is not very long.  In fact, the pectoralis muscle only goes down over the rib cage equal to as far as the bottom of the areola around the nipple.  This means that when the muscle is lifted up and implants are placed beneath the muscle, the muscle covers about two thirds to three quarters of the implant, or conversely, the entire pectoralis muscle is over the implant. I hope your following this.

The importance of this is that submuscular breast augmentation requires more skill.  Implants placed under the muscle tend to last longer and have fewer complications particularly regarding capsular contracture.  Additionally, patients with subglandular implants tend to have more implant rippling and more implant palpability. A little appreciated phenomenon of saline filled implants placed in the subglandular position is pressure atrophy of fat over time. This tends to thin out overlying breast which creates premature sag and increases rippling as well.

Also and very important is that breast cancer surveillance by diagnostic imaging, (mammography and ultrasound) may be compromised by subglandular implant placement. Diagnostic intervention such as core biopsy could damage the implants in this location. Sub muscular placed implants, however, should not interfere with imaging or intervention. In fact, in my practice I have never had a patient, radiologist, or gynecologist complain that any implant case I’ve done interfered with imaging or intervention!!

So overall, there is really no place for subglandular augmentation.  It still unfortunately accounts for nearly half of all breast implant augmentations.  It is untrue that you can’t work out with implants under muscle. I have countless patients who are personal trainers, fitness experts, triathletes and the like with implants under muscle.

Finally, from an aesthetic standpoint, submuscular implants done well look and feel far superior to subglandular implants.  It is also untrue that they can be placed close together to get cleavage when done under muscle. See my web site to see what I mean!

So categorically, I recommend only sub muscular placement of breast implants!!

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Best Docs in New Jersey

New Jersey Monthly Interviews Dr. Spiro for Best Doc

The following comes from an interview done by a magazine for a Top Doctor’s issue.   We will present 5 questions and answers each week for 3 weeks.  Enjoy.

1. How do you define success for yourself or for your practice?

Success is a measure of happiness.  If I have happy patients, then I’m successful and happy.

2. What is the most rewarding aspect of your work?

When patients are truly grateful for the efforts and outcomes I have worked so hard to achieve for them.

3. Any awards/distinctions/honors within the last five years that you’d like to mention?

–       5 times Top Docs – New Jersey Monthly

–       Excellence in leadership awarded to me from my Department of Plastic Surgery (56 surgeons), at the completion of my 4 years as Chairman of the department in 2011.

4. What are you most proud of with regard to your career?

I’ve worked nearly 20 years in plastic surgery and have performed more than 17,000 procedures.  Every patient, every single time, got my best effort! That’s what I am most proud of.

5. Is there anything philanthropic you wish to cite?

I’m too modest to cite specifics.  Let’s say that other than philanthropy what little free time I have, I donate to my art career in painting and to St. Barnabas Medical Center where I serve on the Board of Trustees.

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Click here to read the second set of 5 questions

 

Breast Augmentation Characteristics

The seven characteristics that go into breast augmentation

Ok you’re getting smarter.  Now on to characteristic number three.  Implants are either round shaped or shaped. How do we choose? Shaped implants sounds at first to be a good idea, but there are several problems to contend with.  Firstly, there are generally two breasts.  They don’t know each other and a three dimensional contrived shaped implant will look oddly shaped compared to its neighbor if one moves slightly.  All implants should be free to move.  An immobile implant is oddly firm, fixed and unnatural.  A moveable implant simulates a real breast right? I knew you’d agree.  A round implant placed under muscle where the implant space not the implant has been shaped always looks the same as the opposite breast.

The second problem with shaped implants is that their shell walls must be textured.  You’ve already learned my bias about that! Textured shaped implants are known to have a shorter life expectancy than round smooth implants. It’s all coming together now!!

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Regeneration
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