Traditional Breast Lifts/reduction versus the new “Vertical Mastopexy/Ice Cream Cone” Breast Lift (with or without implant or reduction)

When you are unhappy with your breasts, there may be three reasons:
1) volume
2) shape
3) positioning

Positioning really refers to how saggy the breasts are. If your only concern is volume, and you don’t have a problem with the shape or positioning or , breast liposuction or an implant may be the best choice. Most patients can achieve a one to two cup size reduction with liposuction, and a 1 to 2 inch nipple elevation with liposuction alone.

If you are concerned with the shape but you generally like the size of your breasts, then the “Ice Cream Cone/Vertical Mastopexy” may be the procedure of choice for you. This procedure can provide a volume reduction if necessary but it’s primary function is to shape the breast and re-position the nipple areolar area. If for some reason after this procedudre, you decide you want a bit more volume, it’s not a problem to place an implant 4 to 6 months later. About 50 per cent of patients choose to put an implant and 50 per cent are happy with the lift only without implant.

Note that the traditional “anchor” scar procedure is generally regarded as not as satisfactory as the vertical mastopexy. This older procedure needs a scar all around the bottom of your breasts plus a scar up the middle plus a scar around the areola as well. It does not hold up as well as the vertical mastopexy, and tends to sag sooner. Also, the newer procedure needs only a scar down the middle of the front of the breast and around the areolae.

Remember whatever choice you make, if you need an implant, it’s always better to do this procedure in two surgeries. This is because if you have the implant put in and reduce the breast as well, the forces on the breast tend to pull the scars apart. When you do the lift first, then put the implant in later, the breast tissues hold up better and there’s less risk of sag and other unsatisfactory results. .

Note: Dr. Yoho does not usually perform the anchor-type scar procedure, the traditional breast lift. However photographs of the other procedure both with and without implants are available at DrYoho.com.

CALIFORNIA LIPOSUCTION LEGAL STANDARDS

Weight Loss with Liposuction: Some patients get drama! This is 6 weeks after surgery.

I’ve reprinted the law regarding liposuction standards in California, below. I was involved in developing these standards. I testified several times before the California Medical Board and supplied them with materials and documentation to aid them in their decision-making process. I believe that these rules are important and necessary for safety. I want to make several points.
1) If you are seeing someone who does not start an intravenous line, they are violating the surgeon’s “standard of care” and also California law.
2) The other requirements that are seen below include blood oxygen and blood pressure monitoring, which are simple, modern devices to see how well you are breathing and how well your heart is working.
3) Modern liposuction is a very, very safe procedure in experienced hands. However, there are risks and if you find someone who says that it is risk free, you should look elsewhere. Common surgical complications such as infection are unlikely but possible.
4) If your surgeon uses no relaxation medicines at all, some sort of liposuction may be performed and the risks may be lower. However, like anything in life, there are trade-offs, in other words you have to accept possibly a lower standard of results—in particular less fat removal--in exchange for not going to sleep. Additionally, we have found that many of our patients find the option of having nothing but local anesthetic frightening and sometimes quite uncomfortable. This is not to say that I approve of general anesthesia for liposuction, I don’t. I think this compounds the risk.
5) For individuals who need significant amounts of fat removed, California law requires a certified surgical center, such as a hospital would have. Ask to see the certificate if this is the case.



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Dr. Yoho's Chapter published in a Breast Augmentation Book

See

(link)
for a large sample of this book. Dr. Yoho's article was about how to alter the implant pocket without going into the implant space. The ideas it contained were originated by Dan Metcalf and Roy Morgan MDs. The technique consists of suturing the skin to the underlying tissues to make a breast implant pocket smaller.

Complications of Breast Implant Surgery: Hematoma

The photo above is of my son having his first haircut and has nothing to do with the article below.

One of the common problems with breast implant surgery is bleeding around the implant right after the surgery. When the pocket for the breast implant is placed, it’s sometimes impossible to do this in a way that produces no bleeding, though we try as hard as we can. Additionally, after the surgery, a compressive wrap is often placed in the hope that this will help. Sometimes however the area surrounding the implant will end up with significant blood in it within a few hours and other times it will even fill up with blood. This space is closed and sealed, so the pressure that develops in the cavity will generally stop any bleeding before it becomes dangerous to your health but it can be uncomfortable. The tip-off is usually that one breast becomes much bigger, more swollen, and more bruised than the other one. We can look at the breasts with a bright light in a dark room and this can help distinguish whether the area is just swollen or contains blood.

The blood should be taken out by returning the patient to surgery, opening the incision, taking the implant out, washing the area with a few quarts of sterile salt water solution, putting the implant back, and then sewing up the incision. Sometimes if bleeding vessels are found, they are “cauterized” or burned with the special device used for this purpose. This procedure is usually done at 24 to 48 hours after the original surgery. Only rarely does bleeding become apparent after this time.

Why is this important, and why can’t we just depend on the body to clean up the blood on it’s own? Well, “capsular contraction” or firm to hard scarring around the implant (later) is much more common when there’s blood surrounding the implant initially that the body has to remove. Recovery time is also much longer when there’s a “hematoma” or blood in this area. This complication happens in perhaps a few percent of all breast cases, and is probably more common in secondary cases, in other words in cases where the breast has been operated on before.

See also link for a discussion of other breast implant risks and second link for a general discussion of complications in cosmetic surgery risks.

Dr. Yoho used to be a real climber

Photo above was taken during an ascent by Dr. Yoho of El Capitan's Nose route in Yosemite. An article was published in Alpinist magazine (April 18, 2007) about Dr. Yoho's "first ascent" in Zion National Park, which he did in 1987 with his friend Dave Jones. This climb has recently been climbed "free" by another set of climbers. This means that at no point was it necessary to use gear placed in the rock to advance up the climb. There are some photos and a nice story. See link for photos and article.

Dr. Yoho has climbed the Nose Route of El Capitan in less than 24 hours, see chart. See Biography for Dr. Yoho's personal biography.

Perfection and Cosmetic Surgery

The above photo is of another surgeon's breast implant which was coming out through the incision that it was placed through. This implant had to be removed a week later after watching and waiting for the hole to close by itself. The lady was to wait for 4 months then have the implant replaced when the healing was complete. Many such problems occur in cosmetic surgery, and this is nothing unusual.

Nothing is perfect! Every face and body is different. Every result depends on the preexisting state of the patient’s skin and underlying structures, and their nutrition as well as the skill of the surgeon. We see imperfections and complications all the time. If we were just to operate on people who looked great and were in perfect health, our results would be nearly perfect too. The following is one “Evaluation” from one of our patients at just a week after the liposuction surgery. Everyone isn’t this happy however. Perfection just doesn’t exist in life or cosmetic surgery…

“Dr. Yoho’s staff is wonderful. They were on top of things. I got a call from his staff every day after my surgery to ensure I was doing well. I felt very comfortable and important. Both Dr. Yoho and Jeremy were wonderful as well. They made me feel relaxed and worry free. I already can see results from my surgery and can’t wait till all the healing process is over to see everything. Thanks you Dr. Yoho and staff for making me feel great and helping me bring my sexy back!!!”

Clint Eastwood is said to have stated, “If you want a guarantee, get a toaster.” We always say there are no guarantees. Our reputation is our guarantee. We promise to do our absolute best to give you the nicest cosmetic result in the safest way we can. For a more definitive article about cosmetic surgery expectations and complications see link. There's a photo here of skin death after liposuction.

The latest on our Fractionated CO2 Laser: the Smart Xide Dot.

As you may know, a CO2 laser is a stronger laser (see laser results for results)that has to potential in the right patients to erase wrinkles and improve discoloration dramatically. The older CO2 lasers sometimes produced undesirable permanent decrease in pigmentation. This problem has been solved if the new CO2 fractional lasers are used carefully. Patients with the proper (lighter) skin type can be treated more aggressively, and get good results right away. We do treat darker skin types, but it has to be a careful, slow process, over several sessions. The new Smart Xide Dot laser sprays thousands of tiny treated areas on the face or neck and leaves intact bridges of skin that allow for rapid healing.

Where the new laser has come into its own seems to be the neck area. This was formerly impossible to treat without over or under doing it. Now, we seem to often have 50 per cent improvements with just one treatment. We can use just enough treatment power without using too much. Those brown, sun exposed necks that many women in our Pasadena / Los Angeles / or Central Valley / Fresno area have can be successfully and carefully lightened with this laser. And it’s really not painful. If our patients want to take the numbing cream home, they can apply it an hour before they come in to see us and they generally have very little discomfort. Or, if you would rather not have any sensation at all, we offer sedation inexpensively if you have a friend to drive you home. See Lasers at DrYoho.com for more information.

Breast implants: over versus under the muscle?

The left implant is a saline implant which is deflated. The right implant is a silicone implant.

When breast implants were first invented, silicone fill was always used. During this era, the implants were placed over the muscle. Later, saline implants were developed, but they never felt as natural and they tended to ripple (or scallop along the edges). It was around this time that someone started putting the implants under the muscle, so there would be more body tissue between the implant and the outside, hopefully to make the look and feel of the enlarged breast more natural. The standard practice now is to place just the top part of the implant under the muscle and the lower part of the implant under just the breast tissue and skin. The lowest 20 per cent of the muscle is cut, in order to allow this.

Remember that for a time, there was thinking by regulators in the USA that silicone implants were dangerous, and they were banned from general use for about a decade. Sub-muscular implant placement really gained popularity during this period for the saline implants that were used.

Now, there’s a third way to place the implant, and that’s under the “skin” or “fascia” of the muscle, above the muscle and below the breast tissue. This has some of the advantages of both approaches. This technique has been popularized by one of the busiest breast surgeons in the USA: Dan Metcalf, MD, who frequently performs over 600 breast implant cases a year. Most sub fascial implants are performed through an armpit incision, where the "skin" of the muscle is thick and easily identifiable by the surgeon. Many of these implants were placed as described.

There are surgeons who have been trained that only sub-muscular implants are right and there are surgeons who mostly do sub-glandular (above the muscle) implants and others who believe that sub-muscular implants lead to lots of problems ten years after surgery. Do not believe anyone who tells you that there’s one best way to do this surgery for every patient. Here are some photos of breast implants placed under the muscle.

What does Dr. Yoho do for his Pasadena / Fresno / Visalia cosmetic surgery breast patients? We individualize the approach for each person. The questions we ask are: what do their breasts look like, can they afford and do they want silicone implants, and what sort of incision is desired. For patients who have relatively perky well formed breasts with normal shape and lots of breast tissue, they may get very nice results with a sub-fascial or above the muscle approach with a saline implant and have just as good a result as with a silicone implant. For patients who have odd breasts, such as “tubular” breasts, often a silicone implant above the muscle is recommended because of the surgery needed and the skin stretching that may be needed. If you have very little breast tissue, you likely are a better candidate for sub-muscular implants. These can be silicone or saline depending on the preference. See DrYoho.com for more on silicone versus saline and the style of implants available. We absolutely have to have a look at your breasts and speak to you about your individual preferences to give you the best idea of what is right for you.