Is It Important to Wear a Bra With Your Breast Implants?

I repeatedly emphasize to our patients that good bras are important or the breasts will sag. If they wear the bras and have support all the time, particularly for the first year when the scar is forming around the breast implant, often the breasts will be just as perky five years later as when the breast implant is placed. However, especially if the breast implant is a large one, the patient will have unpleasant, unnatural, and unsightly sagging of the breast. Here’s an example where the patient, in spite of all my admonitions, is wearing a very lightweight bra, at only two months after breast implant surgery. We recommended to her that she consider a heavier bra like the Bali Minimizer bra, and as always we told her to continue on her fish oil and Vitamin E indefinitely in order to keep her breasts soft.

Liposuction For Men - Six-Pack Abs

Did you know that you could have sculpted abdominal muscles from your liposuction procedure? There are new options available that can give you a chance to look your best. Dr. Yoho specializes in removing all the possible fat from this “six-pack” area of the abdomen and also injecting a little bit of fat in each square of your “six-pack.” This fat tends to be retained and creates a bulging muscular look. While the recovery takes a little longer than with ordinary liposuction, the results can be stunning. Additionally, we make a special effort to suction the fat from the creases of your abdominal muscles, thus creating more definition. Feel free to schedule a complimentary consultation about this exciting new procedure.

Information About Breast Surgery

We require patients to write out the following so they absolutely understand some of the complications of breast implant surgery: “There will be problems.” “We do not know what problems.” “I will feel the implant.” “I will have rippling.” “They will be unequal or asymmetrical.” “I will need to wear a bra to prevent sagging.” “Sometime in the future I may want or need a breast reduction or lift.”

After the patients write this, we discuss with them all the possible complications of breast surgery. Breast surgery has one of the highest satisfaction rates in our practice, and breast augmentation has been a mainstream procedure in America, with about 10% of women here having breast implants (at least in California). However, there are some problems. In the Allergan® implant study, a re-operation rate of 1 in 3 patients was found after 5 years for silicone implants. It is likely that the saline breast implants have a high re-operation rate also. The biggest problem is capsular contracture, which is a firming or hardening of the implants. This may occur in 5% to 10% of the patients who have breast implants. Fortunately, there are now some medical treatments for capsular contracture including fish oil, which I believe is an anti-inflammatory. We recommend a dose of 4 grams a day. Also, we have a medication called Accolate, which is FDA-approved for asthma. It is not FDA-approved for treatment of other conditions, and so this is an “off-label use of an on-label drug.” Doctors are allowed by law to use drugs that are approved for one disease to treat other conditions. Unfortunately, for Accolate, there have been a few reported instances of liver failure. The chance of liver failure seems to be one in several million per patient. By comparison, every person in America has approximately a one in 8,000 chance of dying in an automobile accident each year. In any case, we want our patients to understand that breast implants are not perfect.

One of the other complications we see, if the patients do not wear good bras, is a “rock in the sock” problem. That is when the skin envelope or the breast itself sags, and the implant sags down with it until you get a very saggy breast with an implant resting at the bottom of it. This can be prevented if a good bra is worn. We recommend wearing a bra at least during the day and, better yet, 24 hours a day for the first 7 to 8 months while the tissues are healing properly. We show our patients that a bra should put pressure on their shoulders and should lift their breasts. This is part of the advice we regularly provide during our complimentary consultation and during the postoperative process as well.


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Robert Yoho, M.D.

Advances in Breast Augmentation

Belly button breast augmentation or "TUBA" is one of the innovative techniques in breast augmentation surgery that has rendered obsolete many of the surgeries that leave scars on the breast, such as the through-the-areola approach. While some patients need to be treated by the through-the-areola approach because of odd-shaped breasts or other problems, the TUBA approach can put the implant in through the belly button without any scars anywhere near the breasts.

In experienced hands, this technique works wonders for many patients. It seems to have a lower rate of complications, such as capsular contracture, which is firming of the breasts. This complication accounts for the highest of all of the problem rates in breast augmentation surgery.

Dr. Peter Cheski pioneered and invented this technique, and Dr. Yoho learned his technique right from Dr. Cheski, working closely alongside him in his office over the years. Dr. Cheski was at the point where he could perform one of these surgeries in 10 to 15 minutes with virtually no help outside of a scrub tech and a sedation person who watched the monitor. He performed many tens of thousands of these surgeries over the years, and Dr. Cheski is regarded as one of the pioneers in breast augmentation.

Please come in for a look to see whether this procedure is appropriate for you. We love its results, but you must be evaluated before having the procedure.

Sculpting a Six-Pack

Did you know that there are new liposuction techniques that can get you more definition of your abdominal muscles than ever before? These new techniques include special aggressive suction of the fat in between the muscles, which can be done with ordinary liposuction or with other types of liposuction machines. Dr. Yoho’s belief is these new machines don’t yield any significant advantage. However, the real news is that a tiny bit of fat injected into the muscles of the abdominal area makes for greater definition and a much better result. This has to be done carefully and with experience, to ensure that the muscle squares are enhanced and improved. It helps to have good muscle tone before the procedure, but you don’t have to be slender. The liposuction itself can do that.

The Biggest Issue in Breast Implants Part 3: Breast Implantation Issues

Judy in Trinidad

How is capsular contracture or hardening of the breast implants treated?

First, as mentioned in the past essay, we attempt to prevent this by encouraging the consumption of fish oil and Vitamin E. These home remedies are not clearly established to prevent capsules, but there is a lot of circumstantial evidence suggesting that they do.

Second, if you have a capsule, there are various remedies, and one of the things that has been thought to work is a medicine for lung disease called Accolate, or another related medicine called Singulair. These brand-name medicines are commonly used by lung doctors to improve lung functioning in certain kinds of asthmatic and other conditions. They have a very small statistical rate of some serious problem, so be sure to talk to your doctor about these before taking the medicines. In any case, they're expensive and they need to be taken for four to six months in order to be effective. The earlier you catch your capsule, in other words, the softer the breast is before starting the medicine, the better chance you have of correcting the problem with a medication.

We also increase the fish oil to a higher dose, although as stated before, this is not clearly known to be effective. We have seen interesting cases in which a person who stops taking their Vitamin E or fish oil and develops a capsule within a month, but of course, this doesn't prove anything for sure.

Surgery for capsular contracture is problematic, because the chances of the problem coming back are very, very high after most any surgery. The traditional approaches include removal of the capsule, which sometimes is difficult, especially under the muscle, and replacement of the implant in a different plane. This means that if the implant was above the muscle, you put it below the muscle; and if it was below the muscle, you put it above the muscle in the secondary operation. The chances of a return of the hardening of the breast after these surgeries is a disappointing nearly 50 percent.

Unfortunately, the Allergan study, which encompassed many, many thousands of women with breast implants and silicone gel implants, had a secondary operation rate of about one in three after seven years. This means that you must not view these things as a permanent solution to small breasts unless you're lucky.

Judy, my wife, has had her implants for about 15 years and has never had any problem except for a slight firming on one side, so she might be the exception rather than the rule.

Best of luck, and if you get breast implants, be sure you have a good surgeon who will be happy to follow you for any problems afterwards.

The Biggest Issue in Breast Implants Part 2: The Advantages and Disadvantages of Various Breast Implant Techniques

Seattle Port at Night 2

Part 1 covered some of the aspects of above versus below-the-muscle implant placement. One more note about this issue: There was a large-scale study over 20 years ago that showed that with silicone implants that there was a higher capsule or hardening rate with over-the-muscle implants. Subsequent studies have not shown this to be true, so even though this remains as an urban legend, it probably has not been verified. It probably isn't the case.

This brings us to the subject of this essay, hardening or firming of the breast implants or "capsular contracture." Capsular contracture is the most likely complication after breast implantation, and many studies show that rates are about 5 percent or 1 in 20. When capsular contracture occurs, the breast implants become hard and sometimes progressively so, to such an extent that the women can't stand it and want them removed. Most capsules have no significant health impact, but they can be uncomfortable and be cosmetically unacceptable.

The things we try to do to avoid a capsule after the breast implant surgery are threefold.

First, we encourage the use of good-fitting bras (this also helps decrease problems with the implants descending).

Second, we encourage postoperative patients to take fish oil. Fish oil is an anti-inflammatory and we think that it decreases the capsule formation, although this has never been formally studied and may be another urban legend.

Third, Vitamin E at doses of 400/800 International Units a day also helps decrease the chance of a capsule formation.

No one really knows what causes these complications, but certainly if you have some inflammation or an infection or extra blood around the implant, these all typically do increase the risk of capsule formation. But most capsules are of unknown cause, and some women just seem to be capsule-formers. It's possible that the breast ducts which connect with the outside in some women are colonized or infected with bacteria and this may contribute to capsule formation, but this is unclear.

Certainly if you're lactating, your chances of a capsule are much higher, and so for this reason we recommend that you not consider breast implantation for a full three months after having your baby (if you do not breast feed) or after stopping breast-feeding.

The Biggest Issue in Breast Implants: A 3-Part Series

Pasadena's Natural Beauty

 Part 1: By far the most important choice you will make in your pursuit of bigger breasts is whether to put the implant above or below the muscle. The muscle is a wildcard that produces many effects, not all of them good. Understanding all of these options and possibilities is very important. 

We recently took the Sports Illustrated swimwear, swimsuit model edition, and analyzed the problems with the women's breast implants. Many of the under-the-muscle placements had resulted in the implant being pushed out toward the side and down. The girls in the Sports Illustrated photographs were often holding their breasts toward the middle, and many times the implant had dropped or been forced down lower than it might naturally have done so by the muscle action. 

Under-the-muscle implants are supposed to produce a more natural curve in the upper part of the breast area, and perhaps they do for a while. However, eventually most "under the muscle" implants get pushed down so the muscle is no longer really covering them. 

Of course, it's possible and even likely that over-the-muscle implants droop also, unless they're protected by a good-quality bra most of the time. These implants, however, tend to sag straight down. 

Efforts to repair problems like these are relatively hazardous compared to the initial implant surgery. The medical journals are full of reports of nipple areolar area death and a higher infection rate and other problems due to attempts to improve breast implants. 

One particular article I show the patients who want surgery because their breasts have stretched out, and this article shows in living color nipple areolar complex or nipple areolar area skin death and loss of the nipple and areola. 

Even though breast implants have problems, they are still the most popular and the highest satisfaction cosmetic surgery we have. Women who improve their bustline often feel much more confident and are able to perform at a higher level in many ways. 

Fish Oil Is Just Fantastic Stuff, or: Everything You Wanted To Know About Fish Oil but Were Afraid To Ask

Fish oil has been shown in studies to be an excellent anti-inflammatory. It actually has been used for rheumatoid arthritis to decrease inflammation and pain, and it really works as been proved by scientific study. We use it to attempt to decrease breast firmness after breast implantation, which is the most common complication. Capsular contracture or breast firmness occurs in at least 5% of all breast implants and it is a very aggravating problem for both surgeon and patient. It’s our belief that taking fish oil in reasonably large doses, perhaps a teaspoon a day or more of the liquid fish oil (the equivalent of five of those large 1g pills) can be very useful. The best fish oil is refined fish oil which has had the mercury removed. We recommend Nordic Naturals, Carlson, or Eskimo brand fish oil. Nordic Naturals has the biggest reputation, but it may be more expensive. Buy oils online because they are costly. Nordic Naturals is available in several grades. It is important to become knowledgeable about active components in the fish oil and consider buying the more expensive types. We use larger doses at times to combat capsular contracture.

Fish oil is also good for certain kinds of heart problems, and is heavily recommended for people with high triglycerides, which is part of the cholesterol problem. Dr. Yoho takes fish oil every day for an arthritic ankle and so he is certainly an advocate himself.

Am I A Surgical Candidate?

Dr. Yoho and friends in Argentina.

You are a surgical candidate if a number of things come together. First of all, you have to be psychologically ready for a surgery. Sometimes these things are stressful and sometimes they’re not, but you have to be willing to undergo the stresses of the possible complications for any of these given surgeries, however unlikely they are. Most cosmetic surgeries are comfortable and their post-operative recovery for most people is very modest, however. 

Second, you need to have good physical characteristics for the surgery that you desire. The doctor will help you understand just what kind of result you are likely to expect. For example, a woman with medium-sized breasts and a lot of breast tissue can get spectacular results with breast implants in most cases. A woman with long, skinny breasts sometimes needs reconstructive surgery and some of these surgeries come out better than others. Liposuction works very well for people with a lot of fat just under the skin surface, but doesn’t work at all for people with fat underneath the muscle wall. 

Of course, you need to be able to afford the procedure, and you need to be able to take the time off. If you are too busy to take the time off, many of the noninvasive procedures we do can, over time, make improvements that are as significant or nearly as significant as the invasive procedures. For example, our fractionated laser repeated several times can produce a fantastic result, and if you stay out of the sun and use Fallene sunscreen from drugstore.com (for example) and Retin-A over a year or two, you can get a fantastic result that rids you of wrinkles and really in many ways is as good as the invasive procedure which requires the two-week recovery and the possibility of more complications. 

Fillers can approximate a facelift for the right individual, replacing the fat and restoring the contours and form of the aging face to a younger contour, and when performed in conjunction with Botox and the resurfacing modalities, can be spectacular indeed. But the noninvasive procedures, remember, can be easily as expensive as the invasive procedures and require coming back to the office a lot.

SERIAL NUMBERS ON BREAST IMPLANTS: LOS ANGELES COSMETIC SURGERY

These are photos of three silicone breast implants: all the same volume, but different “profiles”. The “high profile” implants are generally the best, they do not ripple as much and usually are more natural for most patients.

There is a fairly recent story in the news about Los Angeles cosmetic surgery patient Jasmine Fiore’s body being identified from the serial numbers on her breast implants. The murderer apparently had destroyed the woman’s fingertips, so she could not be identified from this and otherwise she was mutilated beyond recognition and supposedly she had been identified by checking the numbers on her breast implants. This would work only for silicone breast implants, which have individual numbers on the implants.

There are no serial numbers on saline or salt water implant implants: there’s only a “lot” number. The number of saline implants manufactured together is about 10,000 and in this 10,000 group all of the implants are identical. Now if a woman was carrying her card, that she got from her doctor, in her pocket and there was a serial number on the card, even if the name was not on the card, she could be identified. The breast implant companies keep track of what is going on and if a certain group of breast implants was having a certain kind of failure pattern, or leakage pattern, this could be identified.

So we know that Jasmine Fiore, Los Angeles breast augmentation patient, allegedly murdered by her husband Ryan Jenkins (if the news story is true) most likely had silicone implants!

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.