1. SEROMA: As with most other surgeries, it is possible to overdo it and create problems with your own healing. Following abdominoplasty, this can lead to a complication called a seroma. A seroma is a fluid collection under the skin which can require additional treatment.

When a tummy tuck is performed, loose skin and fat are removed between the pubic area and the belly button. In order for the skin above the belly button to stretch out enough to pull down and close the gap, the skin and fat above the belly button must be peeled up and away from the underlying muscles. This also allows exposure to tighten your abdominal musculature which is standard with almost every abdominoplasty. After the skin is lifted up, it is stretched and advanced down to the groin and pubic region and sutured together. You have to take it easy after surgery to allow these sutures to hold and for the skin to heal. Part of the healing process requires the advanced skin to fuse or stick back to the underlying muscles. Too much activity (especially twisting or stretching) will delay this critical part of the healing process. This is especially important during the first week.

In order to keep body fluid from collecting under the skin, a drainage tube (or two) is placed during surgery in the space between the skin and muscle and connected to a small suction reservoir on the outside. We can usually determine if you are being too active because the surgical drain continues to collect a great deal of fluid instead of decreasing every day. Normally it takes about eight days for the tissues to stick together and the drainage tubes to stop draining so that they can be removed. It can take much longer if you are too active. Even more concerning, this can lead to areas which fail to stick back down, and an area like that will fill with fluid after the drain tubes are removed resulting in a seroma. A seroma must be treated using a needle through the skin to try to aspirate or drain the fluid. Sometimes seromas must be aspirated with a needle repeatedly and rarely they may reoccur so persistently that surgery must be performed to place a new drainage tube. If a seroma does require surgery, Dr. Stagnone would not charge you a surgeon’s fee but you would be required to pay the anesthesiologist and the operating room fees to cover the expenses of the operating room supplies and staff. Seroma is preventable and extremely uncommon if you do your part and maintain a sensible activity level after your surgery.

2. DVT: Deep vein thrombosis is the medical term for a blood clot in the veins, occurring most frequently in the legs. The risk of DVT after abdominoplasty is published at about 1 in 300. This risk increases with obesity, diabetes and many other conditions of poor health. It also increases with longer surgery times. When abdominoplasty is combined with additional procedures, the risk can increase statistically to about three and one half percent or more. DVT is not unique to abdominoplasty, it is a risk of prolonged inactivity which can occur following many surgical procedures, childbirth and even occur spontaneously such as during a long flight. This is one of the most important reasons why patients are told to get up and walk after major surgery. DVT is not caused by the surgery itself, it is caused by inactivity during and after your procedure. Like a seroma, DVT is preventable if you do your part.

At the Plastic Surgery Center of Dallas we use a safety device known as an SCD (sequential compression device) during surgery to prevent DVT. An SCD squeezes your legs rhythmically during the entire procedure, pumping the blood out of your legs and back towards the heart. After the surgery, you must take responsibility to maintain your own circulation and keep the blood in your legs from pooling. It’s amazing how simple this is. Yet if you don’t understand this and do your part, you are at a greater risk of DVT. Walking causes the calf muscles to contract which squeezes the blood upstream through a series of one-way valves. Walking can minimize your risk of DVT. Only you can assure that this is done. Unlike the hospital setting in which the nursing staff encourages you to get up and walk, abdominoplasty is done as an outpatient procedure, so the responsibility falls on you and your caretaker. It is important that you get up out of bed and walk every few hours after abdominoplasty for several minutes. It also helps to have your caretaker raise your legs while in bed and massage your calves. Rhythmically flexing your feet at the ankles can also keep the circulation from pooling in your lower legs.

If you get a DVT, the most likely presentation is swelling in one leg. It is extremely rare for both legs to get a DVT at the same time. If this occurs after your abdominoplasty you’d be directed to proceed at once to the emergency room. DVT is a true emergency since it can sometimes break free and travel to your heart and lungs, called a pulmonary embolism, which can be life threatening. These conditions are treated in the hospital by a medical specialist. Admission for DVT is not a “warranty” item after cosmetic surgery. It is a rare but recognized medical complication from inactivity. It is extremely unlikely to occur if you do your part and follow our guidelines regarding post-op activity.

3. SCARS: The scar from a tummy tuck typically extends from one hip region to the other. Dr. Stagnone draws the incisions on the skin for each patient during the initial consultation to be sure it is clear where the incisions will be and what tissues will be removed. The final position of the scar cannot be determined precisely. Because of laxity in the pubic area and upper thighs, the skin below the incision can rise when it is sewn together. Dr. Stagnone tries to get the scar as low as possible but in some individuals it ends up higher than others. We will show you many post-operative pictures to demonstrate the range of abdominoplasty scar position. Dr. Stagnone also tries to show the range of location on you by stretching up on the skin after drawing his proposed incisions during the consultation.

The quality of the final scar also varies from person to person. Dr. Stagnone always sutures the tissues together using only internal buried sutures along the lower scar, which gives everyone a chance to have a fine “hairline” scar. Staples are never used. Nonetheless some of the final scar quality is also determined by your heredity and a small percentage of patients will develop a red thick scar called a hypertrophic scar or even a keloid, which is like a tumor of scar tissue. Others develop a darker color to their scar called hyperpigmentation. These types of poor scars are not caused by surgical technique. Poor scars are a known risk of all surgeries. Dr. Stagnone will perform the most meticulous repair possible and if you follow our instructions after surgery we will teach you the proper ways to manage your scar to get your own best possible result.

In summary, abdominoplasty can be an amazing surgery with dramatic results. It is a major surgery which we perform routinely with a very high level of safety. We believe that detailed education will help you increase the likelihood of a smooth recovery. Our goal is to help you get through all of the steps of your aftercare, leading to a full return of activity within 6 weeks.

Our system has evolved over the years to account for the fact that people are all different and we respect that and want to be sure our patients have the best, most comfortable experience possible. All of the patients at The Plastic Surgery Center of Dallas are given prescriptions in advance to be sure that all the bases are covered in the event of need. These meds don’t have to be used, and in fact the prescriptions don’t even have to be filled but we have found that some people are more comfortable with a muscle relaxer after breast augmentation under the muscle, some do need medication for nausea or upset stomach and many do in fact want to take some pain medication to be more comfortable. These are all provided in advance along with Valium to help calm the nerves if desired the night before surgery as well as the morning of the procedure.

In summary, the 24 hour recovery is possible for many patients but not for everyone. Techniques have evolved to minimize discomfort and greatly speed up recovery, but as with ALL surgeries, breast augmentation is real surgery. Skin, breast tissue and muscle are all involved in the creation of the space for the breast implant and some degree of pain is impossible to avoid. Our goal is to use the most advanced techniques, but also be liberal in providing the best options and medications for each individuals unique recovery and return to activity!

TECHNIQUE

Rhinoplasty (“Nose job”) is most commonly performed today as an open rhinoplasty which includes an incision across the columella, the thin bridge of skin separating the nostrils. The rest of the incisions are inside the nose, allowing the skin to be precisely lifted off the bone and cartilage so the internal structures can be visualized and the nose more accurately reshaped. Most rhinoplasties are done to make a large nose smaller, smoother and in better proportion to the face. 

In the most common rhinoplasty, the cartilages that  shape and support the tip are sculpted then  reshaped with sutures to control the width and position of the tip of the nose.  The hump, if present, is “sanded down” with a rasp which is used like a nail file to reduce the prominence and correct the profile. There are two nasal bones that meet in the middle like the roof of a house and when they are “shaved down” with the rasp, often a gap results between them, similar to the roof of a house if the top foot or two was removed.  In order to close that gap (“open roof”) the bone must usually be broken free from their rigid attachment to the adjacent facial bones.  This allows them to be “pinched together”, closing the open roof and narrowing the nose.  The nasal bones are broken free with a type of chisel called an osteotome.

The skin is placed back over the newly shaped bone and cartilage and a splint is applied after all of the incisions inside and out are closed with stitches.  The splint protects the delicately repositioned bones while they heal.  All of the internal stitches dissolve but any stitches in the exposed skin are idealy removed within six days to minimize visible scarring.

VARIABLES AND REALISTIC EXPECTATIONS

There is a limit to how much smaller the new nose can be, based on its starting size. The skin “envelope” can only shrink within a certain range to fit the newly reduced bone and cartilage framework. If the nose is reduced in size excessively, the skin can “bunch up” and leave an unattractive fullness to the tip of the nose. Removing skin would require visible scars which can be very unfavorable. In addition, the tip cartilages can only be reduced and reshaped within certain limits since there is a minimum which must be left to adequately support the tip of the nose.  Thus, in a sense, there is a certain non-negotiable degree to which the nose can be reduced in size. We try to demonstrate this using computer imaging to modify your nose and demonstrate realistic outcomes.

Certain aspects of the healing process vary from individual to individual and are not entirely  in the control of the surgeon. When the bones heal back together they can thicken (called a bony “callus”) and result in slight bump which can show as a minor imperfection in a nose that is still beautiful.  Also, scar tissue forms under the skin as part of the normal healing process that fuses the skin back to the reshaped bone and cartilage. If the individual forms thin, delicate scar, the nose will be slightly more refined and smaller.  If the scar tissue is somewhat thicker (say the thickness of a slice of lunch meat instead of a tissue) the tip of the nose will be slightly rounder, fuller and less defined, although the nose is still typically nicely improved. Because of these physi0logic variables, we like to use computer imaging to show a subtle range of outcomes that must be accepted to be a good candidate for rhinoplasty. If an individual is excessively picky with the computer imaging when realistic results are shown, they are usually not considered a good candidate for surgery since that type of patient has been shown by studies to be unhappy a very high percentage of the time even with an appropriate improvement in appearance. 

We will always strive to demonstrate honestly what can and cannot be achieved and show a realistic range of outcomes and before and after pictures of our patients to help you decide if rhinoplasty is a good choice for you.

RIPPLING: Rippling describes visible ripples in the breast following breast augmentation. This is far more common with saline filled implants and relatively uncommon with silicone gel implants. The reason for rippling is that all implants are compressible, not rigid spheres and because of this they all have folds on the surface of the implant. With saline implants, since they contain just salt water inside, the implant folds are much sharper. They are easier to feel and see through the skin in patients with small breasts, very thin skin or in those who choose larger implants, exerting more pressure on the overlying skin. Silicone gel is much thicker and, while there are folds in a silicone gel implant, they are much more gradual and therefore rippling is less common. Rippling is a function of the amount of tissue you have to cover or hide the implant, not any kind of defect in the implant.

CAPSULAR CONTRACTURE: Once the implant is placed inside the body the healing process results in a thin layer of scar tissue surrounding the implant much like a cocoon forming around a caterpillar. This layer of scar tissue is called a capsule and in some individuals the healing process is more aggressive than others. If an individual’s scar capsule begins to tighten around the implant it can make the implant feel firmer, appear more round in shape and even begin to cause the implant to rise upwards as the implant is shifted in position within its normal pocket. The capsule of scar tissue can also thicken over time, which makes the capsular contracture even more uncomfortable and visible. There are many precautions with breast augmentation, which can minimize the risk of capsular contracture and we use all of these, including specific cleansing of the patient’s skin and the surgeon’s gloves prior to handling of the implant and the use of a triple antibiotic irrigation within the pocket. Using all of the current techniques to minimize this risk, it can be decreased to about 2% overall. Roughly half of the individuals who develop some capsular contracture will respond to an oral medication, which is intended for asthma. As a side effect, this medication seems to modify the cells which create scar tissue, causing the scar capsule to begin to soften. About half of the patients with early capsular contracture will achieve resolution with this medication. This leaves a small number of individuals who have enough unfavorable scar formation that they may benefit from surgery. There is no warrantee for capsular contracture since the implant company is very clear that it is the individual’s tissue response, not the implant becoming firm. When the implant is removed it can be seen to be perfectly normal. It is the scar tissue inside caused by the individual’s “overly aggressive” healing which results in capsular contracture. This is a risk that cannot be blamed on the surgeon or the implant manufacturer and one that every individual who wishes to undergo breast augmentation must accept.

HEMATOMA: Postoperative bleeding is a risk with nearly all surgeries. When the pocket for the implant is surgically created it is sculpted using a cautery. The cautery is a device that delivers an energy charge, which splits through tissues and seals them off, including muscle fibers, nerve fibers and blood vessels, as the implant pocket is formed. Any bleeding is visualized clearly using a brilliantly lighted fiberoptic retractor, allowing the cautery to be used accurately to stop all active bleeding. The pocket is flushed out with an irrigation solution and suctioned so that any bleeding can be visualized and stopped before the implant is placed. Nonetheless, after the surgery, if the tissues are traumatized in any way from over activity or if the blood pressure rises from emotions, pain or even just bad luck, bleeding can begin. Blood can collect around the implant causing the breast to enlarge and become somewhat sore and perhaps appear bruised; however because it is a closed space, the bleeding typically stops and is not an emergency situation. If you present to the clinic with an enlarged, tender, slightly bruised breast and we make the diagnosis of hematoma, it is best that you have surgery to remove the clot of blood around the implant or you will likely develop a deformity. Dr. Stagnone never charges any surgeon’s fee for the operation to treat a hematoma and performs this surgery at no charge. The anesthesiologist however, will charge you to go back under anesthesia for the surgery and you will be responsible for that fee as well as the operating room fee, covering all of the equipment, supplies and staff necessary to perform this operation. Dr. Stagnone feels very strongly that a surgeon should never charge or profit from surgery such as this but that the patient should also assume responsibility for their own activity after surgery. Most hematomas, when discussed truthfully, follow some type of “event” by the patient. The overall risk is very low and in our practice is approximately one-half of one percent.

SENSORY CHANGES:

• Loss of sensation or numbness: When the space or “pocket” is created for the breast implant, tissues which are adherent or stuck together are split apart in order to create that space. Among the tissues which will be split free are some nerve fibers. It is common to have numbness or decreased sensation around the incision and sometimes in other areas on the breast. Occasionally the nipple itself may lose sensation. This is more common when the patient chooses very large breast implants since more tissues must be split apart to create the necessarily larger “pocket”. Also, the larger implant may exert more pressure on the adjacent nerves which causes the numbness in some cases. Many cases of numbness resolve spontaneously since the nerve fibers are stretched or cauterized but not irreversibly injured. Nonetheless, some cases of sensory loss are permanent. This is a non-negotiable risk of breast augmentation and must be accepted to be a candidate for this operation.

• B. Hypersensitivity: In some cases sensation is elevated and the breast becomes hypersensitive. Even the pressure and temperature of showering can be uncomfortable and this too is an inherent risk which cannot be eliminated. This generally passes with time as the swelling and healing processes evolve. Although uncommon, there are reported cases of permanent hypersensitivity.

SAGGING: There is no technology to secure the breast implant internally to a rigid structure such as a rib. The pocket which is created for breast implants typically follows the shape of the normal breast fold and is designed to mimic the shape of the breast once the implant is placed inside. The implant however is not “wired down” or fixed to anything internally. It simply sits inside that pocket similar to putting your cell phone in your shirt pocket. The breast implant sits on the breast fold which acts as the shelf supporting the implant. If your tissues are lax and loose, the implant may stretch your tissues and settle lower.  It is important to understand this and to accept that you cannot always select any type of breast you wish with augmentation and why augmented breasts must be supported just like real breasts. When you lie on your back, the implants can move to the side under the force of gravity almost like a ball on a hill. Thus over time, the space between the breasts can widen as sagging occurs in that direction. There is no way for the doctor to prevent this so we emphasize that support is typically necessary with breast implants just as it is with natural breasts. This is most important in patients with very loose, lax tissues or those who select very large implants, which exert more weight or pressure on your skin. Implants over 350-400cc are considered to be in that category by many plastic surgeons.

DEFLATION OR RUPTURE:

• Saline implants can develop cracks in the surface over time or failure of the valve used to fill them with saline. Even the tiniest pinhole in a saline implant will result in leakage causing the implant to go flat. This creates, in some sense, a social emergency due to the sudden mismatch of an augmented breast on one side and a flat breast on the other. The material, which leaks out is just salt water and therefore there are no issues or concerns regarding safety. However, the potential to deflate or go flat suddenly is certainly a disadvantage of saline filled implants.

• Silicone gel implants are now currently a fourth generation device which has been modified over the years to decrease the risk of failure or rupture. Fourth generation implants have thicker more resilient rubber surfaces. Also, the silicone gel on the inside is now thick enough that if the implant is sliced in two, it maintains its form and cannot “flow away”. Thus if there is a tiny crack in a current silicone gel implant it will not go flat. It will typically maintain its shape and size and will often be undetectable. There is no pain or deformity or disease from exposure to silicone. In fact silicone is already present in the body in concentrations much higher than the concentrations caused by an implant. Many products such as lipstick, underarm deodorant, hair spray, Mylanta, etc. contain silicone and it is a substance, which exists in everyone’s body in a measurable amount. Numerous scientific studies relating to silicone gel have confirmed that it does not cause any type of disease. Interestingly, if a puncture is made in a breast implant even with something substantial, and the implant is compressed, the gel will bulge out, but when it is released the gel is drawn back into the implant, behaving more like Jell-O than any type of liquid. Given the fact that there is no medical consequence of such minute exposure to silicone gel, and the implant maintains its shape, it is difficult for me to strongly advise the need for frequent MRI studies to look at the surface of the implant. When the FDA removed their restrictions on silicone gel implants in 2006, one of its recommendations was that women consider monitoring the implant with MRI scans to look at the implant through the body at intervals of every two years. Besides the evidence showing that silicone is harmless and already present in the body from other products, my biggest concern over this recommendation is that the MRI scan itself is not perfect. A certain percentage of MRI scans are “false positive”. What this means is that the MRI scan may be inconclusive or may suggest to the radiologist that there is a problem with the implant even though it is intact. This is certainly problematic if the patient becomes concerned enough to want to have surgery for reassurance. If an operation is performed and the implant is normal there will be no warrantee coverage whatsoever. Thus the patient assumes the financial responsibility for exploratory surgery in the event that the MRI scan looks suspicious but the implant is not defective. It is my opinion that, particularly early on, if the breast is soft and ideal and unchanged in its shape, appearance and feel and has no symptoms of discomfort, it is very difficult for me to defend the choice of having costly MRI scans in such an asymptomatic breast. I personally have seen a patient who presented with MRI “confirmed” ruptures of both silicone gel implants and the operation revealed two absolutely normal and intact implants. If I were advising my own family member I would advise her to only consider an MRI scan in the event that there was something abnormal with her breasts. If everything was perfectly normal, I still might consider a prophylactic or investigative MRI at nine and a half years or so, shortly before the 10 year warrantee expires. This is a choice for each individual to make and I certainly do not discourage patients from getting MRI scans as recommended by the FDA. I do however have concerns about the cost and the relatively low yield for the study, particularly since it has been shown that silicone does not cause any disease. Current data show that in ten years, the failure rate following primary breast augmentation for these implants is less than 6%. Routine mammography is still necessary to screen for breast cancer.

The above information summarizes what we consider to be the most commonly encountered risks of breast augmentation surgery. It is not an exhaustive list of all of the risks of this procedure. Although most of these are either minor or relatively infrequent, they do occur from time to time and everyone must accept these risks and give their informed consent in order to proceed with surgery.

Gregory J Stagnone, M.D., P.A.

Saline implants are inserted empty and filled by the surgeon during the procedure. This allows a slightly smaller incision and somewhat greater accuracy in correcting asymmetry in breast size since the surgeon can choose to fill one more than the other. Saline implants are less expensive, too, approximately $1000.00 per pair less than silicone gel filled implants. If a saline implants leaks, it deflates and that breast loses volume, creating a sense of urgency for surgical replacement. Some patients enjoy the peace of mind knowing that it contains only sterile salt water and is quickly absorbed by the body. Others are distressed that a leak in the implant creates a situation of necessity to have replacement surgery. Saline implants feel stiffer in patients with very little breast tissue and the folds in the implant can more frequently be felt or seen, a condition called rippling. Also, saline implants look less natural in some patients, especially those with very small breasts before surgery. This is considered an advantage for patients who prefer a tighter, rounder, less “natural” augmentation. Although most of my patients request results that look natural and proportional, those who prefer a more spherical and visibly augmented look are often better served with saline implants. In my experience this is a more frequent request in younger patients, which is fortunate, since the FDA (without explanation) restricts silicone gel to individuals age 22 or older.

Silicone gel breast implants have changed dramatically since their introduction in the 1960s. Silicone can be manipulated chemically to be a liquid or solid rubber or anything in between. Earlier versions of the contained silicone gel were less formed and could flow out of a tiny crack in the implant. The earliest models could even “seep” through the intact rubber shell, a process called gel bleed. The newer implants, which are a fourth generation device, have gel so thick that, like Jell-O, it maintains its shape for a prolonged period, even if cut in half. The silicone rubber shell is far more durable too, further decreasing the risk of leakage. Current data show that over 94% of today’s gel implants are still intact at 10 years. Studies also show conclusively that silicone has no relationship to the development of any known disease or illness, one of the main factors leading to the FDA’s approval. The advantages of silicone gel breast implants include a more tissue-like quality which feels more like breast tissue, and a lower risk of feeling the implant folds or seeing them through the skin (rippling). Many patients feel that gel filled implants result in a more natural shape since they settle and move more like breast tissue than saline implants. Gel implants do require a slightly larger incision since they are pre-filled. Routine mammograms are still necessary for breast cancer screening and in addition, when the FDA removed their restrictions on silicone gel breast implants, they suggested that women with these devices consider an MRI scan after 3 years and again every two years to evaluate the surface of the implant. The importance of this in terms of patient health is debatable however, since the fourth generation silicone gel is so thick it would be unlikely for it to flow out of a small crack in the implant shell. Additionally, the MRI scan is not infallible, and there is the possibility of an inconclusive result and even the known risk of a false positive MRI scan which could create unnecessary confusion. It is my feeling that an MRI scan is warranted when there are unexpected or suspicious changes in the breast but that it is debatable as to the need for regular or frequent MRI scans as a method of surveillance. Additionally, as mentioned, current data show that there is no known illness or disease caused by silicone. Since it appears harmless, many physicians feel that it is of questionable value to obtain MRI scans in a problem free augmented breast. This may be a decision best left to a woman and her plastic surgeon, but the FDA’s position is to consider an MRI scan after 3 years, then every 2 years thereafter.

In summary, saline implants are less expensive, adjustable in volume and provide good results in most women with a reasonable amount of breast tissue to minimize rippling. Silicone gel implants feel more natural and appear to decrease the risk of surface rippling and in many instances appear, feel, and move more like actual breast tissue. It is my feeling that silicone gel provides the most “real” or “natural” breast augmentation. Saline implants go flat when they leak and replacement may be psychologically urgent. Silicone gel may require an MRI scan to detect failure.

Each woman must weigh these pros and cons to determine the choice of implant which is right for her.

Liposuction

Everyone’s heard about liposuction. Simply speaking, pesky areas of fat can be removed through a nearly invisible incision by softening the fat and drawing it out through tiny tubes called cannulas.

Liposuction is not for everyone. The two biggest limitations are in the amount of fat which can be safely removed and the quality of skin over the fat deposits. If the skin is too loose, it may bunch up or show surface irregularities after the fat is evacuated, since loose skin may not be tighten up adequately after the fat is removed. In addition, there is a safe limit to the amount of fat which can be removed at one time. Removing too much fat can cause shifting of body fluid into the empty spaces, which can affect the circulation and blood pressure. Most problems with liposuction surgery are due to trying to remove too much fat at one time or poor patient selection.
The best situations for liposuction are in individuals with good, firm skin and localized bulges. Liposuction works best on localized areas of fat that don’t seem to fit the rest of the body, like inner and outer thigh bulges, hips, and the abdomen. Fat looking knees and arms can be improved too. Men usually do best with the “spare tire” area (love handles and lower abdomen) as well as breast areas, which can be fatty and sometimes look feminine.

The perfect candidate for liposuction alone is near normal body weight with good skin tone and very localized bulges of fat. If expectations are set realistically, liposuction can also be successful if the skin is a little loose or the individual is a little overweight. Liposuctions should not be considered a way to lose weight. I like to use both ultrasonic liposuction and “superwet” liposuction, which is a safer, more predictable variation of the tumescent technique. The results of liposuction are related to proper patient selection and your surgeons skill much more than they are to which device is used.

Tummy Tuck

If the skin is too loose for liposuction, great results can often be obtained with abdominoplasty, also called tummy tuck surgery. Liposuction cannot tighten loose skin or stretched out muscles, which follow pregnancy or obesity. Abdominoplasty can remove and tighten unwanted loose skin, reshape and rejuvenate the belly button and tighten and flatten loose abdominal muscles.

There are actually three types of tummy tucks, depending on the individual situation. The simplest variation, called a mini-abdominoplasty just tightens the muscles below the belly button through a small incision over the pubic hairline. This is perfect for the thin person with a “pot belly” due to the stretching and relaxation of the abdominal muscles that often follows pregnancy. If the muscle is stretched out and there is also loose, rippled skin below the belly button, an extended mini abdominoplasty is ideal. The extended mini abdominoplasty not only tightens lax and bulging lower abdominal muscles but also removes skin and excessive fat below the belly button. If the abdomen also has loose skin or fat rolls above the belly button, a full abdominoplasty works best. Full abdominoplasty removes almost all of the skin between the belly button and the pubic area and tightens the upper abdomen too as well as reshaping and tightening the belly button and skin around it.  With each type of tummy tuck, the scar is progressively longer but there is more dramatic improvement.  Each individuals scar is slightly different based on their body shape, but we try to get the scar as low as possible. I like to draw the tummy tuck pattern on each patient during the consultation to show approximately where their scar will end up. We have extensive before and after photos of all types of tummy tucks, which help decide if abdominoplasty is right for you.

Body Lifts

Although most people have heard of tummy tucks, most don’t know that we can lift and tighten other areas of the body too. The most common areas are the outer thighs, the bottom and the arms. These procedures aren’t for everyone since the scars tend to be more difficult to hide and recovery is often longer and more uncomfortable. Nonetheless, if the skin is really loose and saggy in those areas, body lifting procedures are the best options and dramatic changes are possible.

Putting It All Together

Most of the techniques to reshape the body can be done together. It’s usually possible to analyze all of the trouble spots and develop a plan that allows considerable body reshaping with one procedure and one “down time” for recovery. This has been called “The Mommy Makeover” or Total Body Contouring. It’s especially popular to combine one or more of these options with breast surgery, since the loss of breast volume or tone often goes hand in hand with the other changes of age and pregnancy. There are several different breast implants and different types of breast lifting so that most people have good choices.

Gregory Stagnone, M.D., F.A.C.S., is the owner and director of the Plastic Surgery Center of Dallas.

He is a specialist in cosmetic surgery limiting his practice to cosmetic enhancement and rejuvenation of the face and body. Individuals interested in obtaining specific information regarding cosmetic surgery may call (972) 661-5077 in Dallas.

Why do women get breast implants?

Surprisingly, it is usually not to attract men or primarily for the appearance e of the exposed breast.  Most women want breast implants to create a better body proportion and look good in their outfits.  A lot of my patients answer that question by saying they just want to look normal.  Relatively few outfits “off the rack” will properly fit a woman with very minimal breast tissue.  An equal number want implants to restore the breast volume and shape they lost following pregnancy.  Interestingly, husbands and boyfriends sometimes put up resistance because they completely misunderstand and assume their mate wants to be more attractive to other men.  For many women, this is not even an issue.  As a rule, breast implants are chosen for proportional and relatively natural-looking in the vast majority of my patients.

Can a woman choose any size or shape she wants?

Every woman has her own unique starting point.  Occasionally someone comes in with goals that simply are not possible with their tissues.  I spend a lot of time with my patients teaching them about their own anatomy and their own range of possible results.  The compliance  or (elasticity) or each woman’s skin and the size of her rib cage establish the limits in the size of implants she can accommodate.  When you try to exceed those limits the result is often a tight, unnaturally round breast which I think is a poor trade-off for greater size.  On the other hand, if the tissues are loose,  deterioration in shape and sagging can occur with overly aggressive augmentation.  We have a really effective system of sizing in which I precisely measure each patient’s ideal breast diameter and match it up what a range of appropriate implants, using reference charts.  The most commonly used implant comes in 16 sizes.  Usually two or three different sizes are available to most women to offer a range of possibilities that will look right on their body.  We then help our parients try on each of her choices with pre-filled sizing implants in an unpadded bra and she can choose the size she likes best.  This step is done by one of four members of my staff, and all of them have breast augmentations which I have performed.  This is usually a lot of fun for the patient.  She can try the sizers with different outfits.  Patients often bring their husband or boyfriend for their “vote!”  Once the size is selected we try to show results that are realistic for that individual using hundreds of “before and after” pictures of my patients .

Why are there so many different breast implants?

In an attempt to create the ideal breast, a number of different implants have been developed.  Anatomically shaped or “teardrop” implants were devised to try to create a more naturally shaped breast, but many plastic surgeons don’t consider this successful.  Anatomically shaped implants have a rough textured surface which keeps them from shifting position by adhering to the adjacent tissues, but the texturizing process requires a thicker implant, which can feel stiffer and move less naturally.  Many plastic surgeons have abandoned anatomically shaped implants completely.  I have found that a naturally shaped and softer feeling breast can usually be created using smooth-surfaced implants which are thinner and more pliable.  Smooth implants are round in shape but different breast contours can be created by adjusting the fill volumeof saline implants or choosing from 3 different “profiles” using silicone gel. Each individual has their own starting shape which defines and limits their choice. We will spend time during your consultation listeninmg to your hopes but before you leave we will work to be sure your expectations are realistic in term of what is possible with your starting anatomy.

Silicone gel implants are generally softer and more natural feeling that saline implants. This is especially important in women with minimal breast tissue. Round silicone implants appear to shift in shape more like real breast tissue too. In my practice over 90 of our patients choose silicone gel implants over saline. Sometimes women with saline implants will have subtle rippling, which can be felt through the skin and occasionally is even visible.  Silicone gel implants will often prevent or minimize this rippling.

Do you use the same method of breast augmentation on all of your patients?

Absolutely not.  There are number of choices and it is very important to consider each individual’s unique starting anatomy, their specific goals and their history.  Implants can be placed below or on top of the pectoral muscle.  Every patient has her choice.  Occasionally better shape can be obtained with implants placed on top of the muscle. Most patients select placement under the muscle, however, because the mammogram us usually more accurate and the additional layer of tissue covering the implants decreases the likelihood of seeing of feeling implant ripples.  I also believe that with submuscular implants the upper pole contour is better, especially in thin women with very little breast tissue.  I still use some anatomically shaped implants for certain breast shapes but more commonly prefer low, medium or high profile round implants to offer a wider variety of options.  High profile implants may be a good choice for someone with a narrow chest who wants larger breasts.  I also still use surface textured implants occasionally is I’m performing corrective surgery for capsular contracture, which is unnatural hardening of a previously augmented breast by the patient’s own excessive formation of scar tissue.  It’s important to be able to vary your technique and to have a good understanding of each of the available implants, especially when performing corrective surgery.

Do you see many patients for secondary or corrective breast augmentations?

Yes I do, and it has become an area of special interest to me.  We have so few laws regulating our specialty that any physician can legally perform these procedures with no formal training in plastic surgery. Gynecologists are now doing them in the Dallas area.  Insufficient training can result in a lot of avoidable problems.  One way to be more confident about your choice is to confirm that your doctor is a plastic surgeon who is certified by the American Board of Plastic Surgery.  Nonetheless, even with proper training, if a breast augmentation is rushed or performed without meticulous attention to detail there are many potential problems with final shape or symmetry.  Many of the corrective surgeries I have performed appear to be very dramatic, but technically, only involve refining or finishing up underdone operations and placing correctly sized implants.  Others are more technically challenging and involve reshaping the breast tissues using a variety of breast lift procedures in addition to corrective augmentation.  I especially love these challenges because they are artistically interesting and no two are the same.

What is The Mommy Makeover and how does it complement breast augmentation?

It’s pretty common to see patients with multiple areas they’d like improved.  A lot of the breast changes we see following pregnancy are accompanied by unwanted changes in the abdomen, hips, and thighs.  It’s very common in my practice to perform abdominoplasty (or tummy tuck) at the same time as breast enhancement.  Even before pregnancy, fat accumulation in those same areas can often be improved by sculpting away the bulges with liposuction.  Total body contouring or “Mommy Makeover” are terms we use to describe the process of analyzing the relationship between different areas and developing a plan to improve overall proportion which enhances the entire body.  Interestingly, I even combine breast surgery with facial cosmetic surgery, especially enhancement of the nose, eye and lips.  After 12 years in practice, one of the things that keeps it fun and challenging is this variety.  Every individual is different and requires a unique approach.  That’s the art of plastic surgery.

In short, breast implants placed on top of the muscle usually result in only minor discomfort and have a very rapid recovery. Those whose priority is the avoidance of pain or who only have time to take a day or two off will often select this option. Also, in women whose priority is dramatic cleavage, placing the implants on top of the muscle may better deliver the desired result.

There are compromises, however, and each woman must carefully weigh this decision since implants placed on top of the muscle may have a higher likelihood of becoming firm from the body’s production of scar tissue around the implant. This risk may be minimized by selecting a breast implant with a rough textured surface, but again, there are tradeoffs. Texturizing requires a thicker implant, which may feel slightly less realistic than a smooth implant and there also appears to be a higher likelihood of visible ripples on the breast surface with textured implants in very small-breasted women.

If one is willing to accept the higher likelihood of firm scar formation (contracture), advantages of the smooth surfaced implant include a softer feel due to the thinner implant shell, a more natural movement of the breast since the implant slides around more freely, less swelling early after surgery (the breasts appear to take shape more quickly) and some data suggesting a lower likelihood of implant deflation.

More of my patients choose the option of placing the implants under the muscle. The recovery varies but tends to be a little longer since some of the muscle fibers must be cut to properly shape the breasts. We can control this with muscle relaxers and pain medication and, although every individual is unique, most of our patients are really comfortable and resume many activities in a day or two and return to sedentary jobs within 3 or 4 days. Advantages of breast augmentation under the muscle are numerous and include a lower likelihood of visible surface ripples, less chance of the breast drooping with time (more a problem with very large implants), an apparent lower likelihood of developing breast firmness due to scar formation around the implant and greater breast visibility with mammograms, which may be an important issue if there is a strong family history of breast cancer. The tradeoffs of breast augmentation under the muscle include unnatural movement of the breast when the muscle is forcibly contracted and sometimes a slightly wider space between the breasts resulting in less cleavage in some women.

The final variable involves the use of anatomically contoured implants which can be placed above or below the pectoralis muscle. Rather than a round shape, these implants are sloped so that the upper portion of the breast is not so full. Anatomically shaped implants are not very popular today as they can shift position and generally don’t feel as soft and natural as smooth surfaced implants which are always round in shape. Round implants can be filled conservatively and also give a very naturally sloped shape. Nonetheless, anatomically shaped implants are useful in women with certain starting breast shapes to create a specific look. For a woman who wants a very round looking breast, we may use the high profile implant which offers more aggressive enlargement and is more spherical in shape.

There is no single perfect option in breast augmentation for everyone. Often, two very similar women will select entirely different options due to their completely different goals. With proper education, most patients will choose the right option for them. Breast size is selected based on careful measurement to achieve proper and realistic breast dimensions as well as the patient’s specific desires. Patients are encouraged to bring in pictures of models they find aesthetically appealing.

I often place implants in the patient’s bra during the consultation to confirm that we are in agreement regarding the appropriate size selected. We also have extensive catalogues of before and after photos to demonstrate the many options and possibilities.

Psychologically there are few procedures in cosmetic surgery which can so dramatically and positively affect a woman’s self-image as breast augmentation. Clothes fit better, proportion is normalized, and social confidence often soars. The careful selection of the proper breast augmentation can be a time consuming but rewarding process, and ensures the best possible results.