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tate-of-the-art
Dr Daniel Fleming PERFORMS more BREAST implant operations than
any other doctor in australia. He has performed thousands in
the last 13 years. HE EXPLAINS THE CONSTANT IMPROVEMENT AND
REFINEMENT OF SURGICAL TECHNIQUES.
A
ll potential breast implant patients find the
prospect both exciting and a little daunting.
You wouldn’t be normal if you weren’t a bit
nervous about it. Also most patients share a
similar set of goals for their surgery:
• Achieving the best result possible given the shape and
size of their existing breasts
• Minimising the risks of complications and the need
for re-operation
• Reducing recovery down time and discomfort.
Achieving optimal results
given the shape and size
of their existing breasts
Most patients who come to see me for breast implants
have done a lot of research. They have, quite rightly, read
magazines, surfed the internet and spoken to friends who
have had implants. However, sometimes this research has
an unintended effect: it can create unrealistic expectations
of what is possible to achieve. If a patient has unrealistic
expectations before surgery then inevitably they will be
disappointed afterwards.
Not surprisingly, in promotional material the majority
of surgeons usually use photographs of patients with very
attractive breasts as the result of implants. Some surgeons
now also use beautiful ‘artistic’ photographs. These do
not help to develop realistic expectations for the majority
of patients and may sometimes tell you more about the
photographer’s abilities than those of the surgeon.
It is not often understood that these results are
typically achieved in patients whose existing breasts were
‘technically straightforward’ for implant surgery.
These patients generally have attractive breasts to
start with, do not have much breast tissue, have no sag,
have nipples well above the breast crease, have little
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asymmetry and usually have not had children! An example
of this can be found at the bottom of page 76.
Most patients do not have all of these features and, if
this is you, then you are normal. However, you will probably
get a different result from the patients in the adverts. The
key to achieving the best possible result you can, given the
breasts you already have, is to develop an operative plan
with a surgeon very experienced in breast implants. Your
surgeon will be able to help you make the right choices and
show you realistic results of what you are likely to achieve.
The elements of the operative plan are:
A Breast lift or no breast lift needed?
B Shape of implants – round or teardrop shaped?
C Implant profile (sticky-out-ness) – low, medium, high or
ultra-high?
D Position of implant – behind or in front of the muscle or
dual plane?
E Surface of implant – textured, smooth or polyurethane
foam (Brazilian)?
F Size of implant?
Although the biggest factor determining your final
result is what your breasts look like now, and therefore
this must influence your expectations, each element of
the operative plan will also affect your result. I believe the
development of the operative plan with my patients is as
important as the surgery itself. This is one of the reasons
why I feel all consultations should be directly with the
doctor performing the surgery and not delegated to a
nurse or consultant.
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fleming promotion
breast augmentation
The following checklist can help you achieve the best
result possible.
1. Choose a surgeon who is prepared to consult with you
personally right from the start and has sufficient breast
implant experience to have seen the results of implants
in all types of breasts. Your surgeon should have
performed breast augmentation surgery hundreds or
preferably thousands of times. Do not be afraid to ask.
2. Make sure your surgeon offers and has discussed
with you all of the different options that make up the
operative plan (A-F above). Again, don’t be afraid
to ask, and you may wish to take the list with you
to the consultation. For example, if your surgeon
does not put any implants behind the muscle, they
won’t be able to offer you this choice. If you are a patient
who would be better suited to have implants behind
the muscle you will not get the best possible result.
3. Ensure you are informed about and offered the option
of Brazilian implants. These implants greatly reduce
the risk of the commonest complication and commonest
reason for re-operation so you need to know about
them. (See the next section for further information
about this).
4. Ask to see ‘non-artistic’ before and after photos of the
surgeon’s own patients who have breasts similar to your
own. This will help you develop realistic expectations.
5. Once the operative plan is finalised, go over it again
with your surgeon to make sure you understand why
the choice of each element has been made.
Remember that not all women can have beautiful
breasts even after surgery, but most women wanting
implants can have better breasts. By understanding
the importance of both the operative plan and of the
unavoidable limitations of your existing breasts, and
by following the above checklist, you should be able to
maximise the chances of being happy with your implants.
Minimising the risks of
complications and the
need for re-operation
First of all, ensure you have followed the checklist of
points. Additionally, you can reduce your risks by insisting
your surgery is performed in a licensed day surgery.
This is different to an accredited facility, which does
not have to meet the same standard as a licensed day
hospital, so be careful not to confuse the two. Also ensure
your anaesthetic is given by an anaesthetist and not by a
nurse under the direction of the surgeon. If a complication
does occur, you do not want there to be only one doctor
responsible for the operation and the anaesthetic at the
same time. If you are comparing costs between surgeons
make sure you are comparing apples with apples – the extra
safety of an anaesthetist in a licensed day hospital may
be the reason for a price difference.
In Australia there are now implants available which
can reduce the problem of capsular contracture
dramatically. Manufactured in Brazil by Silimed, these
implants are soft cohesive silicone gel implants covered
with a layer of polyurethane foam.
Capsular contracture
Everyone considering breast implant surgery soon
discovers that the commonest complication is capsular
contracture. This is where the membrane that grows around
all implants and, which normally cannot be seen or felt,
behaves like shrink wrap, compressing the implant and
causing it to feel firm or hard, often distorting its shape.
It is not known what causes most contractures
although there are many theories. What we do know is this
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complication is by far the commonest cause of dissatisfaction
and the need for further surgery.
Capsules are rated according to four grades.
Grade 1
The breast is soft and you cannot tell an implant is present.
Grade 2
The breast is firmer than normal but this does not bother
the patient nor change the appearance of the breast.
Grade 3
The breast is obviously firmer than it should be, the patient
is aware of this and there may be some change in shape of
the breast.
Grade 4
The breast is hard and distorted and may be painful.
Only Grades 3 and 4 are considered to be capsular
contractures. So if a study says it found a 9 percent rate of
capsular contracture, it means 9 percent of the patients had
Grade 3 or 4 capsules.
Obviously every surgeon wants to have a low
contracture rate so they are hoping to have Grades 1 and
2 capsules, which are not counted as contractures, and not
Grades 3 or 4, which are. You will see that because of the
definitions the decision whether to grade a capsule 2 or
3 is very subjective. Also remember because contractures
develop progressively, every Grade 3 was previously a
Grade 2. With the best will in the world a doctor will
tend to ‘look on the bright side’ and favour categorising a
capsule Grade 2 rather than Grade 3 if there is any
doubt. Thus a Grade 2 will not show up in his
contracture rate, while a Grade 3 will. If a doctor only
performs 50 implant operations a year, then it only
takes one patient with a contracture not to return to
see him and a Grade 3 to be mistakenly called a Grade 2
for his percentage contracture rate to be 4 percent less
than it really is. So you can see that you can’t necessarily
rely on a claimed capsular contracture rate without
knowing how accurately it has been calculated.
Interestingly studies in which independent assessments
of a doctor’s patients have been made show very
significant increases in the rate of contractures Grade 3 or
worse compared with the rate the doctor thought he had
when assessing his own patients. This is not because the
doctors are dishonest but because of the phenomenon of
observer bias. This bias can even occur in independently
controlled studies due to the subjective nature of grading
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capsules. The best guide to true contracture rates is the
data submitted to the United States regulatory body, the
Food and Drug Administration, by the implant companies
when silicone implants were reapproved in 2006. These
were well designed studies of large numbers of patients
spread across many doctors, so we can be pretty confident
in the accuracy of the results.
The bottom line is capsular contracture is common
and occurs in at least 10 percent of all women having had
implants. One published study showed that teardropshaped implants had a lower rate of capsular contracture
– about 5 percent – so you may be told this is an advantage
of teardrop implants. The problem here is that all the
teardrop implants in the study contained super thick
cohesive silicone gel, which is firmer and more resistant
to shape change than other cohesive gels. This means
Grade 3 contractures were less noticeable and more likely
to be called a Grade 2 and therefore not counted in the
5 percent. You might think this is a good thing until you
realise the patients were less likely to complain about
contracture only because their breasts were more firm
in the first place! Because of their very firm gel these
implants rarely feel like a Grade 1 capsule, which is the
best outcome and the one you should be aiming for.
I avoid using firm gel implants unless my patient has
a very difficult shape to her breasts. The firm gel has a
greater ability to re-shape the breasts in these patients.
An example of such a patient can be found in the first
set of photos on page 75.
Implants
In Australia there are now implants available which can
reduce the problem of capsular contracture dramatically.
Manufactured in Brazil by Silimed, these implants are
soft cohesive silicone gel implants covered with a layer of
polyurethane foam. They have recently received approval
from Australia’s regulatory body, the Therapeutic Goods
Administration (TGA). This means Australian doctors can
now offer them to all their patients. Many years of use
overseas has shown that covering silicone gel implants
with a polyurethane foam surface reduces the risk of
capsular contracture to between 1 and 2 percent. The
foam covering feels like suede or fur so they are known
as ‘super-furry Brazilians’! Once you understand how
these implants work you will understand why neither
smooth nor textured implants achieve the same low
rates of contracture.
Remember all implants form a capsule around them
– think of it as membrane walling the implant off from
the breast tissue. It is only a problem when it contracts
fleming promotion
Traditional versus state-of-the-art
Advice after traditional
techniques:
Advice for state-of-the-art
24 hour recovery technique:
old
new
• Take at least a week off work – longer if your job involves
physical activity
• Take it very easy for the first few days
• Expect to have quite a bit of pain
• Strong painkillers and muscle relaxants will be provided
• Don’t raise your hands above your head in the first week
• Don’t drive a car for a week
• Avoid physical exercise for six weeks
• Drains are often needed for the first 48 hours
• Wear a special bra or bandages ‘to keep the implants
in place’
• You can return to your normal routine after 24 hours
with the exception of gym, aerobics, contact sports
and lifting abnormally heavy objects
• Expect the sensation of tightness in the chest area
• Mild painkillers such as Panadol are usually all that is
needed to manage discomfort
• You can and should raise your hands above your head
before you leave the hospital
• You may drive after 24 hours if you wish
• No special bras or bandaging is required
like shrink wrap compressing the implant. Unfortunately,
as we’ve seen, this occurs in about 10 percent of patients.
The capsule is made of collagen, a protein we all have in
our skin. Collagen fibres are microscopic tubes and in
the capsules of smooth and textured implants these are
lined up end on end, running in the same direction and
surrounding the implant. This means if a stimulus to
contraction occurs, the fibres can slide over one another,
shortening and causing the shrink-wrap effect of the
capsule around the implant.
When the Brazilian implants are used, the foam
covering actually becomes part of the capsule. It acts as
scaffolding or a lattice, which the collagen fibres wrap
themselves around. The fibres are now disjointed and not
lined up end on end and are much less likely to slide over
one another so the capsule is much less likely to contract.
This type of implant is not new. They were first used
as long ago as 1969, so we have almost 40 years of
experience confirming their safety. Since 1970 there
have been more than 90 papers published around the
world about their use, which have confirmed their safety
and the reduced rate of capsular contracture.
Dr Neal Handel, an assistant clinical professor of
plastic surgery at the University of California Los
Angeles, reviewed all of the breast implant patients at his
practice from 1981 to 2004 and found that 345 smooth
implants, 618 textured and 568 polyurethane foam-covered
implants were used. He wrote this conclusion in an
article in the Aesthetic Surgery Journal 26, 2006:
‘Based on analysis of our data, we conclude that the
contracture rate after all types of breast surgery is dramatically
lower with polyurethane foam-covered implants than with
smooth or textured implants.’
‘There is nothing to suggest that polyurethane foam,
or its in vivo breakdown products, pose a threat to the health
or safety of patients. Polyurethane implants have measurable
advantages over smooth and mechanically textured gelfilled prostheses and do not appear to be associated
with an increased risk of complications or morbidity.’
Argentinian Dr Guillermo Vazquez, a plastic surgeon
from Buenos Aires, reported his experience in 2007 using
these implants in 1,287 patients over an 18-year period. In
Aesthetic Plastic Surgery 37, he concluded:
‘Currently, given our wide experience with the use of
polyurethane-coated silicone gel implants, we may state they
are the best option for augmentation mammoplasty, and
have the lowest incidence of fibrous capsular contraction.’
Writing in Clinics in Plastic Surgery 28, 2001 Drs Roderick
Hester, John Tebbetts and Patrick Maxwell from Georgia,
Dallas and Nashville respectively, reviewed the literature
on and their experience with polyurethane foam-covered
breast implants and concluded:
‘During the span of this author’s practice, he has never
been able to match the number and quality of superior results
exemplified by these patients when using other devices.’
Round Brazilian implants cost about $350 per pair
more than existing round implants, but Brazilian teardrop
implants are in fact cheaper than other similarly shaped
products. These implants require different techniques
for insertion if they are to be positioned correctly, so it is
important that you ensure your surgeon has plenty of
experience in their use.
Prior to the unrestricted TGA approval I used
Brazilian implants for four years in selected patients with
individual TGA approval. My experience has confirmed the
international findings on these implants – very low rates
of capsular contracture combined with excellent softness
and appearance. Now these implants have been approved
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for unrestricted use by the TGA, I offer all my patients the
Brazilian implants and find that 95 percent choose them.
Reducing recovery down
time and discomfort
With the exception of drains, bras and bandaging, I had
given the traditional advice to my patients for many years
(see table on page 73). I did often wonder, however, if I was
just giving the same advice simply because it was what I had
been taught and because it was standard practice.
I then read an article written by Texas plastic surgeon
Dr John Tebbetts. He claimed he could achieve a
predictable 24-hour return to normal activities, with the
exception of gym, aerobics, contact sports and lifting of
abnormally heavy objects, in more than 90 percent of
his patients. He surveyed his patients after surgery and
found that nine out of 10 could go shopping or out for
a meal, return to a non-physical job, drive a car, perform
light domestic duties and lift regular-sized objects 24
hours after having breast implant surgery. He also claimed
it made no difference to their recovery if the implants
were placed in front of or behind the muscle. Dr Tebbetts
didn’t use drains or straps or bandaging and stated that
complication rates were lower using his techniques. In
fact, patients were encouraged to put their arms above
their heads before they even left the day surgery.
When I first read this article I simply did not believe
it. However, I knew my patients really wanted to reduce
recovery times, so I further investigated Dr Tebbetts’
technique and started using it myself.
The critical element of the technique is a method of
dissection of the implant pocket that aims to reduce blood
loss to only 1 millilitre or less per side. If this is achieved,
there is no blood staining of the pocket. This reduces
post-operative inflammation and therefore pain. Dr
Tebbetts claims it also will reduce the incidence of
capsular contracture. Although in theory this is reasonable,
it has not yet been proved.
A dry operating field is necessary and local anaesthetic
is only used for the skin incision or not at all. Therefore
‘twilight sedation’ which relies on large volumes of local
anaesthetic solution, cannot be used. Light general
anaesthesia keeps the patient asleep and also allows
the anaesthetist to relax the chest muscles if the implant
is to be placed behind the muscle. Special instruments
and operating techniques are used to dramatically
reduce the amount of bleeding in most cases. Because
there is less pain, fewer medications are needed postoperatively. This also contributes to a quicker recovery
as all painkillers stronger than Panadol can cause side
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effects, especially nausea.
Having now used this technique for more than a
year on more than 350 patients, I know that blood loss is
significantly less and there is a definite and substantial
reduction in recovery times. Although no patient can
be promised a 24-hour recovery time, many do
experience this. Patients are advised that, apart from
gym, aerobics, contact sports and lifting abnormally
heavy objects after 24 hours they can perform any
activity unless it causes pain. We have surveyed our
patients and many do only need Panadol to manage any
discomfort. The typical patient can go shopping, out to
dinner and drive a car after 48 hours. I now use this
technique on all my patients. Patients considering breast
implant surgery who want to reduce their recovery time
should be aware of the technique and should ask their
surgeon what experience he or she has in using it.
Case study
Former deputy editor of Australian Cosmetic Surgery
Magazine Elise Eggleton spoke with one of Dr Fleming’s
patients who underwent breast implant surgery using the
‘24-hour recovery’ technique.
Dr Fleming’s patient, Nikki had implants placed
behind the muscle and says she experienced a remarkably
short recovery period. Nikki took two Panadol four times
a day for about a week after the operation, supplemented
by one dose of an anti-inflammatory drug when she
felt particularly tight across the chest. The day after the
operation, Nikki rested and went for a walk in the park and
drove her car. ‘I was also able to wash my hair and put my
hands above my head without any problems,’ she says.
Nikki, who works as a beauty therapist, had been
prepared to take two weeks off work. ‘However, I was back
at work two days after the operation – although it was a
light workload. Five days later I was right back into it – I
even gave someone a massage!’ Four weeks later Nikki says
she was playing competitive hockey again.
Conclusions
To sum up how to ensure you get state-of-the-art breast
implant surgery, I believe every patient should:
• Choose a very experienced surgeon – preferably with a
history of thousands of procedures.
• Work with him or her to develop an individual operative
plan based on the factors explained above.
• Make sure the 24-hour recovery technique is used with an
anaesthetist in a licensed day hospital.
• Carefully consider the option of super furry Brazilian
implants and if you do not choose them make sure you
know why you are not doing so.
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Asymmetry, some sag and a tight crease made this patient’s breasts difficult. A firm
gel, high profile teardrop implant of 270cc was put in a dual plane position to obtain
a pleasing result.
BEFORE
AFTER breast implants by Dr Fleming
This patient’s pointy, tubular breasts required careful planning and operative technique to
optimise her result.
BEFORE
AFTER breast implants by Dr Fleming
Widely spaced breasts are common and need sophisticated operative planning to minimise
the gap.
BEFORE
AFTER breast implants by Dr Fleming
Please remember every patient will have her own unique result depending on what she looked like before implants.
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B
This patient in her late 30s after bearing children, had some breast sag and asymmetry.
BEFORE
AFTER high profile 340g dual plane breast
implant augmentation with by Dr Fleming
This sequence shows how muscle spasm in the upper part of the breast in patients who have implants under the muscle initially gives a high,
boxy look which settles as the muscle relaxes.
BEFORE
4 weeks AFTER medium profile 260g breast
implant augmentation by Dr Fleming
12 weeks AFTER the operation
by Dr Fleming
Please remember every patient will have her own unique result depending on what she looked like before implants.
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