Breast Procedures | Billings Plastic Surgery

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Breast Procedures

Mommy Makeover

Pregnancy can take a toll on our bodies, affecting our breasts, tummies, legs and more. After nine months—or more, if nursing—you are probably longing for your pre-baby body. Whether you choose a healthy regimen of diet and exercise, minimally invasive cosmetic treatments, cosmetic procedures or all of the above, you might also consider a Mommy Makeover to get back in shape. The Mommy Makeover, which addresses a woman’s post-pregnancy body issues in a single-session surgery that typically combines the following:

Breast Augmentation

Simply put, breast augmentation increases the volume of the breast. Many of our patients have very little breast volume, having never developed much breast tissue, and are lacking proportion to their figure. Others find that pregnancy expanded their breasts, and later left them without the volume but with plenty of extra skin. Addition of volume to the breast can improve the proportion of a figure and also rejuvenate a sagging breast.

What do I need to know?
We’ve found the happiest patients are the best informed patients. We will carefully examine you and explain to you all the factors that go into successful augmentation. We will show you how the shape of your chest wall, the width of your chest, the fold under your breast, the amount of skin you have, and the position of your breast all play into the decisions we make. Our approach is to carefully listen to your wants and needs, and thoroughly educate you in the entire process. We have a very detailed sizing procedure we go through with you to choose the size you want.

How is the operation done?
The operation is done under general anesthesia, and it lasts around an hour. You will stay 2 or 3 hours after the operation for recovery. Incisions are made under the breast or around the areola. We are not currently doing the axillary (armpit) procedure because we have seen too many problems from other practices with this approach. The transumbilical (TUBA) approach is advertised a lot, but it requires saline implants only and most of our patients are choosing gel implants. There are also problems with this approach in terms of the precision of the implant placement. After incision, a pocket is created under the pectoralis muscle. Implants placed under this muscle have fewer complications such as scar tissue formation or visible rippling. We check the size and position of the implant in the operating room prior to closing the incisions with dissolvable stitches and a layer of skin glue. We are currently using a medication called  Exparel to improve postoperative comfort. This is a local anesthesia medication that is injected into the are where implants are placed during the operation while you are  still asleep.  The medication is slowly released over the following 72 hours, and has dramatically improved the comfort of our patients during their early recovery. We will place you in a surgical bra to hold the implants in shape as you are healing.

What is recovery like?
You may return to work and normal activity as soon as you feel like it. If something is comfortable, it is probably OK. Vigorous upper body activity is probably best avoided for a month or so. Walking or jogging is fine when it is comfortable. You may shower right away. Sexual activity can be resumed when comfortable. Implants usually take a few months to settle and become more natural looking, and may appear high at first. Scars take about 6 months to a year to fade. Silicone tape can help with scar maturation.

What about saline vs. silicone?
We’ve studied this, read all the articles, given talks on it, and have generally worked this issue to exhaustion. The bottom line is that all implants have their issues. They are not a lifetime device for most people, and we figure a range of 15-30 years for their longevity. Some patients have them forever, and some will fail early. Saline and gel implants have a similar incidence of problems. Saline implants can get a hole and deflate. Silicone implants can break down and get hard when the body reacts to them. Neither implant has been shown to cause illnesses such as arthritis, connective tissue disorders, or autoimmune diseases.

Saline implants have the advantages of lower cost and a smaller incision. They can be placed through remote incisions. Most patients feel they are harder, show more ripples, and are less natural. That said, we did saline implants exclusively for a number of years and patients were okay with that.

Gel implants cost more, require a larger incision (by a half inch or so), and can’t be placed through remote incisions like the belly button. Most patients, however, feel they are more natural and softer. During your consultation, you will examine and handle both types of implants to make up your own mind.

What are the risks?
Infection and bleeding can occur but are uncommon. In rare cases, the implants may have to be removed. There may be temporary, and very rarely, permanent numbness of the nipple. Scars may be visible even after time. There may be some degree of asymmetry (sides not the same), which usually reflects differences in the native breasts, magnified by the increase in volume. Later complications can include capsular contracture, which is when scar tissue forms around the implant and makes it hard. The implants may leak and either deflate or get hard. Despite all this, problems are remarkably few and satisfaction high. We believe that with meticulous examination, planning, and education the problems are minimized. Billings Plastic Surgery is not an augmentation factory, doing as many procedures as fast as we can to make the most money. We are serious surgeons, highly trained, who are very thoughtful and careful. This is your body and your life, and you should have the best.

Breast Reduction

This has to be one of our most satisfying operations. Patients who have struggled with neck, back, and shoulder pain due to breast enlargement are thrilled not only with their pain relief, but with the smaller and more shapely breast that has resulted. The deep shoulder grooves from heavy bras resolve, and patients just look smaller as well.

Am I a candidate?
The above symptoms, with the addition of some headaches, are the typical presentation of someone with excessive breast size. Patients often find that elevating the breasts or lying down help with the symptoms. Deep bra strap grooves and the presence of rashes under the breasts are often associated as well. Patients often have to seek help at specialty bra shops as clothing stores won’t have garments large enough.

What about insurance?
This is quite variable from company to company. Generally, if you have neck, back, and shoulder pain due to breast enlargement, and you have rashes or deep grooves, you are a likely a candidate. Usually a referral from a primary care physician or chiropractor to us is required, so it’s good to have that lined up ahead of time. The insurance company often requires a certain amount of breast tissue be removed, and we will help you with this estimate. We then send a letter requesting authorization from the insurance company.

How is the procedure done?
This is an outpatient procedure with a general anesthetic. Markings are performed before surgery to get the precise pattern we want. Incisions are made around the areolar, and from the areola to the fold under the breast. Usually there is an incision under the breast as well if you have a lot of extra skin. Be wary of surgeons who advertise breast reduction with small incisions, because frequently those breasts end up drooping again soon. We are comfortable with all the techniques, and will educate you about your best option.

What are the risks?
Healing problems, mostly small ones, can occur after breast reduction. Infections and bleeding are uncommon but not impossible. Changes in nipple sensation are usually temporary, but can be permanent. Very rarely a nipple can be lost to a blood supply problem. The breasts may not be the exact same size, or the nipples in the exact same location. Scars might be permanently visible or get thick. For the most part, the patients who have this procedure are so happy with the way they feel that they have remarkably few complaints.

Breast Reconstruction

We consider breast reconstruction one of the most important things we do. The chance to meaningfully help someone at one of the most difficult times in their lives is the reason we went into medicine. The possibility of a mastectomy for cancer or other breast disease, or the deformity that has some after a lumpectomy, is daunting for most women. We feel we provide a highly supportive, caring, and warm environment for those facing this challenge.

Where do I start?
After the detection of a lump, and the visits with your primary care physician and likely a general surgeon, it may be appropriate for you to see a plastic surgeon. They, and you, may have determined that mastectomy is right for you, or at least a possibility. We can then educate you about breast reconstruction and its possible role in your situation. We will also coordinate your care with the other providers, so that everyone understands the plan and the reasons for it. We will show pictures and drawings, examine you carefully for all the options available, and even put you in touch with our other patients if you wish.

What are the options?
This is a highly customized situation, depending on your tumor, your body, your preferences regarding the extent of the surgery, and many other factors. Your consultation will help you with these decisions.

The most common method of reconstruction in this country is the expander/implant method. At the time of the mastectomy, a shaped envelope is placed under the pectoral muscle of the chest. We also use a piece of bio engineered skin to cover this envelope, which is called a tissue expander. Over the next several weeks after surgery, the expander can be filled with saline through the skin, and gradually the skin and muscle are expanded so that a permanent implant, usually a silicone gel implant, can be placed at a second, outpatient surgery. The advantage to this method is that it involves no additional incisions beyond that of the mastectomy, it is relatively simple, and most patients are satisfied with it. The disadvantages are that the implants are not your own tissue, they may not feel as natural, and there may be visible rippling of the implant. They are also not desirable if you are going to have radiation, as they can get quite hard.

Breast Lift (Mastopexy)

A saggy or droopy breast is the result of an excess of skin for the available breast tissue. Pregnancy can cause the breast to grow and swell, stretching the skin, but when the breast returns to its normal size after the conclusion of breast feeding, the excess skin left behind can lead to a droopy breast. Weight loss or normal aging can do the same thing. Basically a sagging breast is one in which there is too much skin and not enough breast.

The solution is to add breast volume or to reduce the amount of excess skin, or both. There isn’t a procedure where we move the breast up and tie it down, unfortunately (although many have tried).

The procedure is usually done under general anesthesia, although smaller lifts can be done with a local anesthetic. The doctor will perform precise drawings on you prior to the operation, which takes about an hour and a half to two hours. The appearance of the breast may appear tight and unnatural at first, but this quickly “ripens” into a nice shape. The scars fade over a 6-12 month period.

Male Breast Reduction

It goes without saying that male breast enlargement is upsetting. This condition may be from birth (congenital), obesity, some types of drugs, or rarely, a hormonal problem.

The doctor will do a careful history and examination to make sure there are no medical causes that require treatment. The extent of the procedure depends on how much excess tissue and skin you have. It may include only a liposuction procedure, a small incision with a lighted scope retractor to remove breast tissue, or a procedure that involves removal of skin and visible scars. We will educate you about all the alternatives.

How is it done?
Usually general anesthesia is required. Markings are performed before surgery. The procedure takes from 45 minutes to 2 hours, and is an outpatient procedure. We don’t usually use drains or tubes.

Recovery?
We’ll have you wear some type of compression garment for a month, and watch the vigorous upper body activity for a while depending on the extent of the procedure. Most types of work are OK right away, maybe reduced activity if you have a very physical job.

Risks?
Scars are a possibility, although most guys think they are worth it. Changes in nipple sensation are not uncommon, not usually permanent. Infections and wound problems are rare.

Breast Asymmetry Surgery

Many women are born with breasts that are uneven in size and shape, which may or may not be noticeable to others. These differences in breasts are often undetectable to patients themselves, causing no problems at all, while other women can have obvious asymmetry, which can cause both an unbalanced appearance and emotional distress.

Asymmetric breasts can be corrected through surgery that either enlarges the smaller breast or reduces the larger one. Implants can be placed in smaller breasts or a breast reduction can be performed on larger breasts. If the nipples appear at different heights, surgery can relocate one or both of the nipples.

All of these options produce breasts that are more similar in appearance, working with each woman’s unique body to achieve the best possible results. Creating a more balanced appearance can help improve physical balance, self-confidence and body image.

Congenital Breast Abnormalities

Congenital breast abnormalities are defects in the breast that are present from birth. The most common types are extra, or accessory, nipples and breast tissue. Between two and six percent of people are estimated to have these deformities. Most people with accessory nipples have more than one and they can occur from the underarm to the groin. Sometimes patients are not even aware of their existence because they may be mistaken for moles. Accessory breast tissue is most often found in the underarm area.

Poland’s syndrome is a congenital cause of breast asymmetry in which there are underdeveloped or absent chest muscles and breast bone on one side of the body. In milder cases, Poland’s syndrome might not be noticeable until a child reaches puberty, when breast and chest development make missing muscle mass apparent. It occurs much more frequently in males than in females.

Other types of congenital abnormalities that are relatively uncommon are severe underdevelopment or absence of one or both breasts or nipples. When the breast tissue is missing, it usually occurs in tandem with abnormalities of the underlying muscles and rib cage. Plastic surgical correction can remedy these deficits and offer a significantly better quality of life.