Birmingham Breast Augmentation - Balancing risk for Implants over or under the muscle

One of the questions we get asked the most during consultations for breast augmentation is whether an implant should go over or under the chest (pectoralis major) muscle. There are wide variations in surgeon and patient preferance when you survery the world on this. In general, the American surgeon is much more likely to suggest an under the muscle placement as opposed to our colleagues in Europe, South America, or Asia.

Why the difference? It's a question of risk versus benefits.

The controversy over silicone implants in the United States in the 1980's led to a rapid conversion to saline filled implants. Saline implants perform poorly under thin tissue in terms of visability and wrinkling. To compensate for this, a bias for sub muscular placments emerged to conceal the devices more. There may or may not be some advantage in terms of less hardening of the implants over time, another purported benefit.

What's the downside of submuscular placement

• more pain post-operatively
• potential "animation" of the devies with movement or exercise
• gradual drift of the implant down and lateral from the contraction of the muscle
• sliding of the breast tissue down over the muscle with age producing the "Snoopy deformity"

When suggesting the proper implant position for a patient, the most important consideration is how thick the breast tissue coverage in the upper breast is. If  a pinch of the tissue suggest 2cm+ thickness, most people have enough tissue to consider either subglandular (over the muscle) or subfascial placement (over the muscle but under the muscle fascia). Other factor we assess are skin quality (thick or thin), amount of ptosis (droop), and how physically active the patient is.

If you're a prospective patient for this type of surgery and would like to come in for a consultation, please feel free to call us at (205) 298-8660.

Cheers!

Dr. Rob Oliver Jr.

The new mammogram and self exam guidelines set off a hornet's nest of controversy

The suggestions of the United States Preventive Services Task Force (USPSTF) regarding mammograms and breast self-exam have touched off a hornet's nest (to say the least) of controversy. The new guidelines recommend that women in their 40s no longer have annual mammograms and that women ages 50 to 74 have them only every other year instead of annually. After having the message drummed into American women that they HAVE to have a mammogram annually starting at age 40, why the change in advice?


The task force report explains that for every 1,000 women in their 40s who receive routine mammograms, only two cases of cancer are detected. Alongside this is the fact that 98 women will also have "false positives" mammograms which will detect something that possibly looks like cancer, but that further testing shows actually is not. The cost and morbidity of routine mammography of the population (and the subsequent workup of such lesions) therefore brings the issue of cost-effectiveness of the program into question.

Last month I wrote a post "The Return of the weregild" discussing how the cost of healthcare gets into the accounting practices of establishing how much a life is worth to society and how much we can afford in support of such a life. Although downplayed by the USPFTF, this actuarial view played some role in the decision. It is my opinion that this is actual the thoughtful way we'll have to address health care spending. Although no one wants the heath care curve "bent" at their expense, you have to look at cost/benefit of practices to the system to control spending and give yourself the biggest bang for the buck for your tax dollars.

If you step back from the hysteria, I don't particularly find the recommendations controversial. It actually reflects the world consensus re. mammograms that mammograms in younger women (<50) are a poor way to affect how many women actually die from breast cancer (the whole point of screening). No other western nation practices routine mammograms under 40 that I'm aware of (and hasn't for some time) looking at this same data. If you're going to screen younger women it needs to be done more selectively to those with strong family history or palpable abnormalities that require further workup. This is exactly what's endorsed by USPFTP and should be a model of thoughtful care for patients going forward.

My first though re. this report was actually that "I wonder how long it's going to be before insurers adopt this" and require certain guidelines be met for women less then 50 perscribed a mammogram. It didn't take long as some HMO's have said they're reviewing their policies in light of this. If you're interested there's a short article on that issue in today's New York Times.

Dr Rob Oliver

Birmingham Breast Implants - What's the role of textured implants versus smooth devices?

There are several distinct types of ways we classify breast implants.

1. silicone or saline filled
2. round or anatomic shaped
3. smooth surfaced or textured

For the material and shape issues, there clearly are performance characteristics that differ. As to the issue of the implant shell surface, it gets a little more confusing. The routine use of rough or textured surfaces on breast implants in the prevention of capsular contracture has been debated for nearly 20 years.

In the early 1980's we first read in the literature that the surface texture of an implant is an important variable in determining the soft-tissue response to an implant's capsule surface and experiments suggested that texturing resulted in tissue ingrowth and adherence to the implant surface.

These observations were first made with polyurethane-coated breast implants which had rough surfaces and almost no observed capsular contractures in patients with breast implants. Texturing was then quickly translated to contemporary silastic (silicone rubber) covered implants, but whether or not the same effect was maintained has been a little murky.

If (a big if) there's a protective effect from texturing, the best data I've seen suggests that it's gone as you get closer to a decade out during surgery. If I had to guess why that's so, I'd say that reflects the ruptures starting to show up in those 4th generation implants at a decade out.

It's kind of interesting to see the split between the United States and the rest of the world on this issue. Our singular experience with saline implants from 1990-2006 led many surgeons to abandon textured implants for smooth round devices as they're less likely to show visible wrinkles or ripples thru the skin. The "velcro-like" effect of the implant on it's surrounding tissue causes these ripples when the implant shifts. The rest of the world has a strong preference for textured devices as they never went through dealing with the limitations of saline implants. Philosophically, those doctors made the decision that they're willing to accept more rippling as a trade off for (possibly) less capsular contracture (implant hardening).

I personally am kind of ambivalent on this. Being an American-trained surgeon, I saw mostly round smooth implants placed partially under the pectoralis muscle during my residency. Over time, I've come to believe there's a role for "subfascial" implant techniques(over the muscle, but under the muscle fascia) with smooth implants. Looking ahead, I think we're poised to see a lot of plastic surgeons getting reacquainted with textured implants with the new shaped "gummy bear" implants which are all textured to help prevent rotation of the implant in the body.


Dr. Rob Oliver Jr.

Birmingham Breast Augmentation - Tips for minimizing complications and achieving long term results

Breast augmentation is a conceptually simple operation. You dissect a space for the implant and put in the device. viola! However, the medical literature that has studied this rigorously demonstrates some alarming numbers in terms of how frequently people require re operations. By parsing this outcome data, a number of trends have become obvious.

1. Large implants are associated with more complications
2. Reoperations are associated with more complications
3. Operations should be planned with an eye towards long term tissue-implant interaction

In general, the smallest volume and narrowest width implant required is the preferred implant choice due to the effects of gravity and the passive stretch of breast tissue over time. As silicone implants are slightly less heavy per volume then saline devices and have less of a "settling" of the weight on the lower breast, they would seem to be preferable over the long term.

Careful and precise dissection of the space (or "pocket") that the implant sits in has clearly been shown to be an improvement over traditional blunt dissection. There is little role for that type of surgery, and is one reason why transumbilical (TUBA) breast augmentations (which require blunt dissection) are a poor choice. Gentle handling and preparation of the implant prior to insertion also clearly seems to play a role in decreasing hardening and rupture of the devices in the years after implantation.

In forthcoming blog posts, I'll discuss some of these technical issues in greater detail.

If you wish to set up a visit to consult for breast augmentation surgery, please call our office at

(205) 298-8660
Dr. Rob Oliver

Welcome to The Birmingham Breast Blog

Welcome to the my project, "The Birmingham Breast Blog", a spin off of my other blog, Plastic Surgery 101. This blog will focus more strictly on my specialties of cosmetic and reconstructive breast surgery.

My practice, Plastic Surgery Specialists of Birmingham, seeks to utilize state of the art techniques and materials to raise the standard of care in cosmetic and reconstructive breast surgery. I'm a double board-certified plastic surgeon with advanced fellowship training in cosmetic and reconstructive breast surgery.

Some of the topics I have an interest in and intend to talk about in this blog in the near future include:

1. short scar breast reduction and breast lift surgery

2. advanced breast implant materials and techniques

3. fat grafting of the breast for reconstructive and cosmetic indications

4. nipple sparing mastectomy surgery

5. reoperative breast surgery in patients already having breast implants or previous breast reduction surgery

6. advanced breast reconstruction techniques using your own tissue



If you stumble onto this blog and would like to set up an appointment, feel free to call us at (205) 298-8660.

Dr. Rob Oliver Jr.