Florida Breast Surgery
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What could I expect from the experience?

Patient 1: 

If you're ready to do this, don't go looking at others' experiences online. Don't watch YouTube videos because everybody is so different. 

One that I watched, the girls were saying that they were in excruciating pain for three days. One girl slept for three days, um.  

They kinda made it sound really scary and for me, it was like the complete opposite. I mean, I woke up kinda groggy, like it was never a throbbing pain. It was just very dull, kinda achy when you work out, so, I made a mistake of looking up other’s experiences. I think that's what freaked me out beforehand,  pre-operatively. 


Patient 2: 

From my perspective, I am so happy. I was so scared. I mean, I trust Dr. Goldberg 100%, but I, it, I just wouldn't have picked it any bigger, any smaller. She totally captured the look that I wanted to go for. I showed her pictures of what I wanted, but at the same time, you don't really know what you want, and she just hit the nail right on the head. I couldn't be any happier with the way that they look, yeah.


Patient 3: 

With my pre-op visit with Dr. Goldberg, tried on all the different sizes, and it gave me a really good idea of the look that I wanted to go for. I had a number set in my head before I went in, but trying on all the sizes made me really what size was really more appropriate for my body type and how active I am. I was both  nervous and excited. I couldn't sleep much the night before, I was just anxious to see the outcome, and I was ready to get it done.

The surgery went pretty well, and I was just a little bit tender. It was a little bit hard to breathe in, but I kinda psyched myself out by looking at YouTube videos and all the girls were like freaking out. I'm surprised I actually felt pretty good. 

The first thing I tried to do was try to peek at them, but that was a bad idea. But other than that, everybody here, including Dr. Goldberg, has been amazing. They made me feel really at ease, so I'm happy. 

Also, I couldn’t sleep much. I slept awesome at the beginning of the night and then when I woke up, it's just so uncomfortable to sit up for maybe 9 hours

How can I assure the best experience?

The ASPS stands for the American Society of Plastic Surgeons. It's a professional organization and you have to be a board-certified plastic surgeon to become a member of the ASPS, and that's where the stringency comes in. To become board certified, you have to have at least five to six years of surgical training with specifically two to three years in plastic surgery. You also have to pass a two-day written examination followed by an oral examination a year later, where all of your first year's surgical cases are analyzed by a committee and you have to defend your results. 

Women have been obsessed with breast size for hundreds of years and breast implants have actually been around since the 1960s. Over two million women in the United States alone have breast implants, and nearly 300,000 more join them each year. But with so many women considering breast enhancement surgery, I've often wondered if there was a better way to prepare women for what to expect.

Is there discomfort after the procedure?

After surgery, we give you a patch to wear to help with any nausea you might have from the pain medication

T’ll make your mouth's really dry. You can take it off, you know, whenever you want, but we recommend that you keep it on for a day so it'll help with the nausea from any pain medication you're taking. When you take it off, wash your hands so you don't get it in your eyes.

People are kind of in a post-surgery stupor and you're taking pain meds and the nerve blocks (which is medication along each of the ribs) are still in place right after surgery. That only lasts 6 to 8 hours after surgery.

You’ll also wear a special bra after the procedure, which can be itchy. 

What other things should I be aware of after the procedure?

Right after surgery, it's best to limit lifting and arm movement for the first two weeks.  

You also want to limit any cardiovascular activity for the first two weeks because anything that will raise your heart rate or blood pressure can increase the risk of bleeding and swelling after surgery.

The best way to recover is to do what you can to reduce inflammation after surgery. There's a mnemonic that physicians have long used for strains and sprains called RICE. This is rest, ice, elevation and compression.  

Rest means that although you can move your arms within a normal comfortable range, and even lift them over your head if you're comfortable, you should avoid overuse of the arms by doing things like emptying the dishwasher and vacuuming.  This should be done for the first 2 to 3 weeks after surgery.

Ice and cold compresses can be used on top of the breasts to reduce pain and to reduce inflammation, as well as minimize swelling in the first 24 to 48 hours. A compressive garment is generally worn for two to three weeks after surgery to minimize swelling and to help add support and comfort for the breasts.

Most patients find that within a few months after breast augmentation, they're able to get back to all the activities they were able to do before.

Can I still breast feed after the procedure? 

Some women are able to breastfeed exclusively and some women are not. That doesn’t change with breast augmentation.  

Avoiding an incision around the areola does give the best chance for preserving the ability to breastfeed, but it's definitely an individual factor.

Some things you can do to give yourself the best chance of being able to breastfeed in the future are avoid an incision around the areola and avoid an implant that's too large for your chest since this can cause nerve damage and potential atrophy of breast tissue.

When did silicone implants stop being used? 

Silicon implants were taken off the market for cosmetic patients for about a decade since there was very little research to prove that they were safe. 

In the years leading up to the moratorium, several women successfully sued Dow Corning based upon fears that silicone implants caused auto-immune disease.  Implant manufacturers only settled these lawsuits instead of fighting them because it was the easiest option at the time. The reality is that the risk of silicon poisoning is much higher for a diabetic using insulin needles than it is for someone with breast implants.

During that moratorium on implants for cosmetic use, silicone implants were still used for breast reconstruction and studied very extensively. The eventual result was that the ban on breast implants was finally lifted in 2002.

Are there any risks? 

With nearly 300,000 breast augmentations performed in 2012, according to the ASPS, 62% of patients used silicone implants and 38% used saline implants. 

There are many myths about breast implants that simply aren't true. There are claims all over the internet about breast implants causing cancer, making it harder to detect breast cancer, needing to be replaced every 10 years, or even that the body may reject them. However, breast implants are very safe medical devices for the most part.

French police are continuing to question the head of a firm that supplied non-medical grade silicone breast implants to hundreds of thousands of women around the world. Seventy-two-year old Jean Claude Mas and another executive of the now-defunct PIP company was arrested in mid 2017 at his home in Six-Fours-les-Plages on France's southern coast. They're facing charges of involuntary manslaughter and causing bodily harm.

How safe is the anesthesia?

Generally, anesthesia is very safe.  

I tell patients it's much more likely that you'll die in a car accident on the way to anesthesia instead of the actual anesthesia. Many of the risks are genetic and if your family hasn't had problems with anesthesia, it's very unlikely that you will.

So saline implants are the way to go?

Saline implants are available for all patients who want breast augmentation. They also are slightly less expensive than the other implants.  

Many patients feel more safe with saline implants since it's IV fluid there instead of silicone gel, however, saline implants have a higher rupture rate and rupture is very noticeable since the breast will deflate. Also, rippling of the shell can be visible through the skin, especially in thin patients or patients with stretched out breast tissue.

Although many patients have excellent results with saline, silicone implants look and feel more natural. The advantage of smooth, round silicone implants is that there is such a large variety of sizes and shapes that they come in. Most patients can find a size and a shape that will fit their tissues and give them the result that they want.

The first generation of silicone implants in the 1960s had a very liquidy silicone, kind of like honey. Further generations of silicone implants were developed that behaved a little more like a solid, but the silicone was still allowed to flow within the silicone implant which meant that after many years, a lot of times the silicone settled to the bottom when the patient was in a standing position, and created less fullness at the top of the breast.

What about the shape of the implants How much does that matter?

Breast implants come in two shapes, round and anatomic or tear-drop shape.  Round implants generally assume a pretty anatomical shape when it comes to patients in an upright position, but the anatomic breast implants will always be fuller at the bottom than the top, which is a natural breast shape.

The whole idea behind the form stable implant is that because of a stiffer gel and an anatomic shape, which is more full at the bottom, more stable cleavage is created over time. Even though the gel in smooth round implants has gotten thicker over time, it is still allowed to flow within the implant which can lead to loss of upper fullness or cleavage over time, and can even lead to visible rippling in some patients.

Because form stable implants are textured, the main purpose of which is to prevent rotation, there actually is a slightly lower risk of capsular contracture.  Also, form stable implants are slightly less likely to rupture than regular silicone implants.

The main disadvantage is, since they're anatomically shaped, if the implant rotates, the more full part of the breast could end up at the top. 

The other disadvantage is that because they're stiffer devices, they often require a slightly larger incision and because the device acts more like a solid than a liquid, it is possible to actually fracture the gel through too small of an incision.

A good candidate for form stable implants is someone who wants a very natural looking result. The sizes that are available in the U.S. so far aren't going to give you a D-cup breast, but they're going to give you a very nice natural full B or small C result.

I’ve heard that the “texture” of the implant matters. Why is that

Implants come with two textures. 

Smooth implants are actually the most common implants in the United States and these are free to move about within the scar tissue pocket that develops around the implant. Textured implants have a more rough surface and they adhere to the tissues. They're generally used for anatomic shaped implants to keep them from rotating. 

There are lower rates of capsular contracture and there is less settling of the breast down and out to the side over time, but some patients require a drain after surgery and textured implants may show more rippling.

I’ve heard of “gummy bear” implants. What are those?

Form stable implants are anatomically shaped implants with a thicker gel than is traditionally used in normal silicone implants. They're called gummy bear implants because the texture basically feels like a gummy bear. Over the years, scientists have cross linked the silicone to make it more solid and the form stable silicone has even more cross linking than regular silicone.

What should I look out for when considering implants?

Low-priced surgery is very popular right now, especially with the recent economy, and believe it or not, it is actually legal for an anesthesiologist or emergency room physician to place breast implants, and surgery could be done in an operating room that doesn't meet state standards.  

Medical tourism offers low prices, but patients expose themselves to possibly substandard or expired implants, poor sterility and lack of post-op monitoring. Not only do patients risk their health and risk a poor result, but dealing with these complications can be way more costly than just choosing a slightly more expensive board-certified plastic surgeon here in the U.S. to begin with.

What implants do you use?

I use both Allergan and Mentor breast implants. There are subtle differences in the shell thickness and implant dimensions and for some patients, I do prefer one brand over the other. They are both, however, excellent implant companies and for most patients, it really makes no difference which implant brand is chosen.

Are there any issues with implants looking uneven?

Plastic surgeons can absolutely help with asymmetry. Most patients naturally have slightly asymmetric breasts. 

Most of the time, they don't notice these things ahead of time. When I'm measuring carefully during the consultation, most patients are surprised to find that the measurements are slightly off from breast to breast, even if they don't notice it in clothing. We always like to say that breasts are sisters, not twins because they really are not identical most of the time.

That said, if there are significant asymmetry issues, we can often use two different sized or sometimes even two different shaped implants to help improve those symmetry issues.

How do you know what implant size to use?

Implants don't actually come in cup sizes. Although I have a lot of patients that tell me their surgeon put a C-cup breast in, for example, cup size is relative to body size and is actually determined by measuring around the rib cage and then comparing that to the measurement around the fullest part of the breast.  

Bra makers are also very different, that it's really difficult to guarantee any specific cup size, even if the patient has a specific desire before surgery.

A lot of doctors just assume that patients want the largest, most full breast possible. Many patients do, however, want a natural result so I think it's most important to communicate with your surgeon about the clothing styles you like to wear and how obvious you want the breast augmentation to be to other people before you start thinking about size.

Can I pick my own implant size?

A lot of surgeons will let patients choose their own implant and I don't necessarily think this does the patients any favor. Choosing too large an implant can lead to problems like stretch marks, nerve damage, lowering of the breast on the chest wall, and implant displacement out to the sides. Choosing an implant based on the width of your breast as well as the quality of your breast skin and current breast tissue can mean a better and long-lasting result.

To choose the right implant for a patient, I measure the width of the breast. For that same width, there are generally several different sizes of implants, some which are very natural in projection and some which project more.  

Based on the size the patient wants, we can choose either a larger or smaller size within that range, but all of them will fit on the patient's chest and give them a natural looking result.

Also, some patients want large breasts so they can look like they have a smaller waist. 

Again, going too large can lower the fold, create too much fullness on top, and actually make you look heavier and more short-waisted.  Size is by far the most common regret when it comes to breast augmentation. There's a myth that every patient wishes that they went bigger, but honestly, I've noticed an equal number of patients that wish they'd chosen a smaller implant, especially once they get into their 30s and 40s.

Most patients get used to the swelling and artificial fullness on the top of the breast that's present for the first three months or so until the implant settles. That means that going larger won't necessarily make you happier.

I want a good cleavage. How can I get that?

Cleavage is determined by your anatomy. 

Implants are placed under the muscle and some patients' muscle inserts very close together on the breast bone; some patients' muscle inserts far apart. Trying to put the implants too close together can risk something called somastia where there's actually no normal separation between the breasts anymore.

There are certain implant styles and certainly larger sizes that can help enhance cleavage, but mostly it begins with what you have to start with. So the different profiles or shapes of the implants can impact this as well. There's something called a moderate profile of implant which is fairly wide and flat. This is different from the higher profile implants which are a little less in diameter, but project more off of the chest.

Sizers are a way to try on implants in the office to give you an idea of what a certain size implant might look like inside your bra. This is one way of patients communicating with surgeons about potential sizes for after surgery. 

Many women want breast augmentation to become more proportionate in clothing since they wear a smaller size on top than on bottom. Too large an implant can create new problems, like not being able to button the blouses you already own. Carefully consider this before going larger just to get your money's worth, or so you don't regret going too small.

How well are the incisions hidden?

The inframammary incision is my preferred incision since it is hidden in the breast crease and allows good exposure during surgery. 

The periareolar incision can be very well hidden, but there is a slightly higher risk of infection and capsular contracture since the breast ducts contain bacteria and are often cut during surgery.

Scars are on average about 4 centimeters. They can be slightly smaller for saline implants and they're slightly larger for the form stable implants. Most of the time, these scars heal very well on their own. For patients who are interested in doing something more, silicone-based scar creams and even silicone scar strips can be used, but they need to be used on a very regular basis for at least three months after surgery to get the full benefit.

Will I lose feeling in my nipples?

Also, patients who are very concerned about nipple sensation or future breastfeeding may want to avoid an incision around the areola.  

The axillary incision is off the breast, but it's only useful for saline or small silicone implants and it generally isn't used for second surgeries, so you'll need another incision if you ever need revision surgery or implant replacement.

Do the implants go over or under the muscle? 

The most common place for implants to be placed is under the muscle. This is done to reduce the rates of capsular contracture and to provide a more natural look and feel to the breast as well as minimizing rippling.  

Placing the implant on top of the muscle is sometimes done for professional bodybuilders or for women who have a fair amount of breast tissue already and just want to fill out a little bit of looseness after childbirth.

Is a breast lift ever a medical necessity?

The most common reason that patients would need a breast lift is if a lot of the breast tissue and especially the nipple is below the breast fold.  If you find yourself standing in front of the mirror lifting up your breasts to get the look you want, you almost certainly need a breast lift.

At home, one quick test to see if you need a breast lift is to actually place a pencil underneath your breast. If it stays there and doesn't drop immediately to the floor, there's a chance you need a breast lift.

Most of the time, if an appropriately sized implant is chosen, there will be some temporary swelling in the areola and nipple, but the size [00:26:00] will go completely back to normal.  One of the risks of choosing too large an implant is that there can be damage to the muscle fibers of the areola which can cause spreading and potentially stretching of the breast itself which could cause increase in size.

If you choose an appropriate sized implant, stretch marks are very uncommon after surgery.  That said, it is genetic and some patients are more prone than others.

Generally implants take between 1 and 3 months to settle, but it can take even longer for large implants or for patients who have very tight skin and very strong muscle.  In order to reject something, your body has to be able to make antibodies towards it.  Silicone is a very non-reactive chemical and doesn't have anything your body can create an antibody towards.

Would that be covered by insurance?

Generally, insurance doesn't cover breast augmentation unless there's a very significant congenital abnormality.  

Most patients don't have a congenital abnormality. This requires a lot of documentation by pediatricians over the course of many years and so, for most patients, it's just not going to work out.

Is there insurance available for this procedure? 

Cosmetassure is a cosmetic insurance that kicks in after you have your breast augmentation.  

For most patients, they've saved up a lot of money before surgery and so it's very difficult to think about having to pay for a complication if it happens. Fortunately, they're rare, but if it does happen to you, Cosmetassure will cover anything that happens within the first 30 days, so it gives a lot of assurance that you won't have to stress additionally if that happens.