Breast surgery — what you need to know
An experienced plastic surgeon’s viewpoint by
Dwight V. Galloway M.D.
The female breast in our society has received much more attention than its function warrants. Many women are extremely involved with their size, shape and symmetry and will go to great lengths to correct what they perceive as imperfections, which are really normal changes from puberty to pregnancy to menopause. Plastic surgeons are very frequently requested to correct what are in reality just normal variations. The breast operations are our most requested surgery. However there are real significant abnormalities as well and many operations have been developed and text books written describing the various techniques in the last 50 years. The breast implants are by far the most common and I have placed over 5000 of these in over the last 45 years. Ivalon sponges and dermal fat grafts from the buttocks were the norm in 1965, to be replaced with silicone, followed with saline filled silastic bags and presently with silicone cohesive gels. The size has increased from 200cc to 400cc and various skin incisions used to try to hide evidence of the surgeon’s interference with nature. I use the old tried and true incision in the fold under the breast which gives the best access to do the really important part which is the creation of the “pocket” where the implant will sit for the next 40 or 50 years. Implant can be placed under the breast alone, under the pectoralis muscle and the breast, or under all the chest muscles, which is what I do in the vast preponderance of cases. I have used all 3 methods and will, on occasion, still vary my technique in carefully chosen situations. There are advantages and disadvantages to all the methods. The biggest problem with placing them under the breast only is long term hardness from scar contracture in about 35 per cent of breasts. This method is quick and can be done in an office setting under local anesthesia and so can be less expensive. Under the pectoralis is easier to perform and quicker and gives less hardness but over time the implant and breast sags down on the chest and abdomen and the operation usually requires general anesthesia as it is hard to get adequate local anesthesia under the muscle. The implant goes with the nipple and breast so looks more natural but may not be desirable if you want “cleavage”. Putting them under all 3 muscles is considerably harder for the surgeon and takes more time but has almost completely eliminated the hardness problem for me in the last 20 years. Cleavage and “upper fill” are excellent. However the breast itself can stretch and hang down over the “perky” breast and require a mastopexy either at the time of implant placement or later, after pregnancy, weight loss or just time. The serratus muscle holds the implant up forever so there is no sag but its contraction moves the breast up in an abnormal manner so that can be a distraction in certain situations such as at the exercise gymnasium.
There are essentially 3 types of mastopexy or breast lifts to place the nipple-areola up on the chest and over the implant. (1)The “donut” where the skin between the areola and the newly desire position is removed. This leaves only as scar around the areola, (2) the “lollipop” where a large wedge of skin is removed from the areola down to the fold under the breast and leaves an additional vertical scar, and (3) the Wise pattern, or the inverted anchor, where skin in removed vertically and transversely and results in both a vertical and transverse scar. It is the transverse scar that often gets thick. Numerous techniques of infolding the breast tissue and advancing the breast up on the chest wall and transferring tubes of breast under the breast to try to build upper fill have in general been disappointing in the long term and the really only good way to get upper fill (cleavage) is an implant.
Reduction mammaplasty to reduce the size of undesired big breast is one of the most rewarding plastic surgery operations. For many years the insurance companies would pay for this surgery as it relieved back and neck pain, but about 8 years ago they discovered that they could reduce the surgical fee from about $9000 to $800 and still claim they covered it in their policy. So now the surgery becomes “self pay” and in the classification of cosmetic surgery. Again there are many variations of these operations and the skin incisions are very like the mastopexy ones with the addition of the free nipple graft where the nipple areola is completely taken off the body and put back on as a skin graft. The symptoms of large breasts are just as severe from a psychological aspect as physical and are tremendously improved with the surgery. The costs for the entire operation as a cosmetic “pay in advance” case, including the required pathologist examination, the operating room, the surgeon and assistant is about the same as the old surgeon fee. i.e. less than half the total the insurance companies paid. What used to be a very common operation is now quite rare.