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Plano TX Plastic Surgery - Flower Mound TX Plastic Surgery

Breast Augmentation

“I am so happy with my breast augmentation results! Dr. Friedman is so knowledgeable and meticulous, and he did a great job. You’ll miss out if you don’t go to him.”

- Cassie Actual Patient

Breast augmentation provides improved volume, cleavage, and upper breast fullness in women with naturally small breasts or volume loss from pregnancy, weight loss, or aging. Breast augmentation can also provide improved self-image, clothing choices, and confidence.

With 30 years of experience as a wood and marble sculptor, Dr. Friedman finds that breast enhancement surgery comes naturally. The average plastic surgeon completes about 35 breast augmentations per year. In contrast, Dr. Friedman performs about 130 augmentations annually. Since 1996, he has placed over 5000 breast implants.

All About Breast Implants


Silicone gel vs. saline

Silicone gel implants were approved by the FDA in 2006 following many years of study. The FDA temporarily restricted their use in 1992 due to concern regarding possible side effects. There remains no conclusive evidence of a link between silicone gel and any autoimmune disease. Approximately 85% of breast implants currently placed in the U.S. are silicone gel.

Saline-filled breast implants are filled with the salt water solution used in I.V. fluids. If a saline implant leaks, the harmless salt water contents are released and absorbed by the body. Saline implants are covered with a plastic shell made of solid silicone.

Unfortunately, there is no perfect breast implant.

implants

Advantages of silicone gel:

  1. More natural feel. Think jelly, instead of water.
  2. More natural look. In thin women, silicone gel implants are less likely to produce a visible silhouette along the upper and inner breast.
  3. Reduced rippling. If you put water in a sandwich bag, you will notice ripples in the bag, just as you will in saline implants.
  4. Greater durability. Silicone gel implants, on average, have a longer implant lifespan than saline.

Advantages of saline:

  1. Reduced cost. Saline implants are $1300 less expensive than silicone.
  2. Smaller incisions. Dr. Friedman places saline implants through a 3 cm (just over an inch) incision and places silicone gel implants through an approximately 5 cm (2 inch) incision.
  3. Reduced risk of capsular contracture (scar tissue causing excessive implant firmness).
  4. Public perception that it is a “safer” implant. Because ruptures of silicone gel implants may be difficult to detect, the FDA recommends MRI evaluation of silicone implants at regular intervals (every other year) following surgery.

The bottom line: From a purely cosmetic standpoint, silicone gel is probably a better implant than saline. From a medical standpoint, it is difficult to argue with the safety of a bag of salt water. In women with a reasonable amount of breast tissue and subcutaneous fat, Dr. Friedman feels that either saline or silicone gel is a good choice. In women with minimal breast tissue, poor breast tone, and/or minimal subcutaneous fat (and therefore a greater risk for significant rippling with saline implants), silicone gel may be a better choice.

Breast implant size

Determining the "right" breast implant size can be a major challenge.

Let's discuss the most frequent methods and their pitfalls.

1. Going by bra cup size: "I’m an A cup, and I want to be a full C cup."

The problem: There is no standardization of cup size among bra manufacturers. A Playtex B is frequently a Victoria’s Secret C. A woman who fits a 34 D cup may also fit a 36 C. So cup size is imprecise, at best, and sometimes closer to a guess.

implant-size
2. Relying on a surgeon’s determination of the "correct" size based solely on breast measurements.

It has become popular among breast implant surgeons to measure the width of the base of the breast, find an implant with the same diameter (based on a chart provided the implant manufacturers), and then tell the patient that this is the magical "right size."

The problem: Although this is reasonable anatomically, your desires regarding breast size are much more important than the manufacturer’s or the surgeon’s. While a surgeon can and should provide guidance regarding implant size, the ultimate choice should be yours. If your “right” size is different from his, your surgeon should be flexible (rather than mindlessly following his breast diameter chart).

implant-size
3. Stuffing your bra with different implant sizes until you find the right one.

This is great for marketing purposes. You get to "try on" different implants until you find the right size.

The problem: The actual implants go under the breast tissues, not over them. Superimposing the implants on top of your breasts creates a snowman effect (one sphere stacked on top of the other), which exaggerates the projection of the breasts relative to what will actually happen in the operating room. Women commonly choose implants that are smaller than they actually wanted.

correct-size
4. So how do you and Dr. Friedman determine the right implant size?

Dr. Friedman thinks in terms of implant volumes: 330 cc, 360 cc, 390 cc, etc. You think in terms of cup sizes. Neither of these allows effective communication. So Dr. Friedman uses the one thing that both you and he can see: photos. Although no sizing method works perfectly, photos work better than anything else we have tried.

before-after

You can choose among the before and after photos of breast augmentations on our website, among the hundreds of photos in our office photo albums, or among any photos from any magazine or internet site. Although you might not know the cup size of the women you choose or the number of cc's, it really doesn't matter. You simply look through breast photos and categorize them as "too big," "too small," or "about right." We will analyze the photos with you. Dr. Friedman believes that there is a range of acceptable sizes, rather than a specific “correct” size.

As long as your photo choices are reasonable for your frame, the choice of breast implant size is yours.

Above or below muscle

Implants can be placed either above (subglandular) or below (submuscular) the pectoralis major muscles.

AboveBelowMuscle-placement

ADVANTAGES OF SUBMUSCULAR (BELOW MUSCLE) POSITION:

  1. Reduced risk of interference with mammography. The muscle separates the implants (below muscle) from the breast tissue (above muscle).
  2. Reduced risk of capsular contracture (scar tissue causing excessive implant firmness).
  3. Reduced risk of long-term sagging of the implants. Muscle is more effective than skin in supporting the weight of the implants.
  4. Reduced rippling of implants. The additional implant coverage provided by the muscle reduces the extent of rippling along the upper and inner breast, particularly with saline implants.
  5. Reduced risk of a distinct implant silhouette along the upper and inner breasts. The pectoralis major muscle blunts the junction of the upper and inner implant edges and the chest wall.

ADVANTAGES OF SUBGLANDULAR (ABOVE MUSCLE) POSITION:

  1. Reduced surgical time, effort, and skill required.
  2. Reduced discomfort immediately after surgery.
  3. No risk of weakening the pectoralis major muscles in athletes.
  4. No implant movement with forceful chest exercise.

The bottom line: Dr. Friedman places nearly all breast implants beneath the pectoralis major muscles. He feels strongly that this leads to better long term results in most women. He even published an article about this in Plastic Surgery Practice, a national plastic surgery journal: plasticsurgerydallas.com/one-surgeons-opinion.php#news

Profile, shape, & surface

Beyond implant size and contents (saline or silicone gel), multiple other variables affect breast implants.

Breast implant profile

The profile of a breast implant describes the ratio of the projection of the implant (how far it sticks out) to the diameter of the implant (how wide it is).

implant-profile

Implant Profile

• Low Profile
• Moderate Profile
• High Profile

Implant projection

• Small
• Moderate
• Large

Implant diameter

• Wide
• Moderate
• Narrow

In most women seeking augmentation, a moderate or moderate-plus profile breast implant (moderate projection, moderate diameter) provides the most natural look. This is Dr. Friedman’s preference in the vast majority of breast augmentations.

However, in women with narrow chests who desire very large implants, a high profile breast implant (large projection, narrow diameter) may be a reasonable choice, though it may project enough to look a little artificial.

In rare patients who have a wide chest wall and desire a small implant, a low profile breast implant (small projection, large diameter) may be worth consideration.

Breast implant shape

Dr. Friedman exclusively uses round breast implants. They accentuate the fullness of the upper breast by equally augmenting the upper and lower breast.

Teardrop or anatomical breast implants preferentially enlarge the lower breast, providing less volume along the upper breast. If a teardrop implant rotates, it distorts the shape of the breast. (If a round implant rotates, breast shape remains unchanged.)

implant-shape

Breast implant surface

All saline and silicone gel breast implants have an outer shell that is made from solid silicone. As the name implies, smooth implants have a smooth, slick surface. Textured implants have a rough, clingy surface.

Right after breast augmentation surgery, almost all breast implants look too high and too tight. Smooth breast implants are "slippery," and their weight will cause them to settle after surgery. This is desirable when the implants are below muscle, assuming the pectoralis major muscles have adequate bulk to hold up the implants. Textured breast implants tend to cling to the surrounding tissues,. As a result, textured implant are more likely than smooth implants to remain too high and tight on a long term basis. Dr. Friedman limits their use to women whose tissues provide inadequate implant support.

Recent FDA data suggest an association between textured implants and the development of a rare cancer, called breast-implant associated anaplastic large cell lymphoma (BIA-ALCL). No such association has been definitively established for smooth implants.

For these reasons, Dr. Friedman uses smooth breast implants in approximately 97% of his breast augmentation patients.

implant-surface
Actual Patient

Why choose Dr. Friedman for your breast augmentation?

Dr. Friedman performs an average of 130 breast augmentations annually (vs. about 35 for the average plastic surgeon), and he has been in practice for well over 20 years. He has placed over 5000 breast implants.

Beyond his decades of experience as a plastic surgeon and wood and marble sculptor, before-and-after results, and outstanding patient reviews, here are some important reasons to choose Dr. Friedman for your breast augmentation:

Surgical technique

  1. Most surgeons perform breast augmentation using a technique called “blunt dissection.” They use a blunt instrument or a gloved finger to tear the pectoralis major muscle off the ribs. Then they put in your breast implants. Blunt dissection is fast. (Some surgeons can complete your procedure in less than 30 minutes.) Unfortunately, it causes significant tissue trauma and bleeding and may lead to increased complication rates and reoperations. To reduce bleeding, many surgeons use surgical drainage tubes, compression bras, and/or ACE bandages following surgery.

    In contrast, Dr. Friedman uses electrocautery to perform your surgery. This involves use of a thin, long, matchstick-shaped instrument that heat-seals the tissues as they are elevated. This reduces bleeding (Dr. Friedman’s average blood loss is under an ounce), virtually eliminates bruising, and makes drainage tubes, ACE bandages, and compression bras unnecessary.

  2. Most surgeons “release” the pectoralis major muscles by cutting the entire lower portions in half to accommodate the implants. This frequently results in excessive descent or “bottoming out” of the breast implants in the months and years following surgery.

    In contrast, Dr. Friedman releases little or none of the pectoralis major muscles in most women. A largely intact pectoralis major provides better implant support and “perkier” long-term results.

  3. Most surgeons choose implant size based on dimensional charts from implant manufacturers or based on women “trying on” sample breast implants. Neither of these methods works particularly well.

    In contrast, Dr. Friedman encourages you to choose photos of women with the breast size you desire. After creating “pockets” for your implants, Dr. Friedman places “sizers,” which are sterile sample implants, and temporarily sits you up on the operating table (while you are asleep under anesthesia). This enables him to preview and adjust your results before selecting the implants that best match your anatomy and the photos of desired size that you have chosen.

These technical modifications add time to the surgery. But they provide improved results and reduced complication and reoperation rates. Dr. Friedman looks at it this way: “It may be a couple hours out of my life, but it’s the rest of yours.”

Safety

Your safety is our highest priority.

  1. Your outpatient surgery will be performed under general anesthesia at the West Plano Plastic Surgery Center, which has been nationally accredited by the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF) since the year 2000. Dr. Friedman is the Founder and Director of the Center. AAAASF has stringent accreditation standards and requires regular inspections and annual recertification.
  2. The West Plano Plastic Surgery Center is located immediately adjacent to Dr. Friedman’s office in Professional Medical Building 3 at Texas Health Presbyterian Hospital of Plano. You will not be in a freestanding surgery center miles from a hospital; you will be on the campus of one of the premier hospitals in North Texas.
  3. Unlike most plastic surgeons, Dr. Friedman exclusively uses physician anesthesiologists---not nurses or technicians---to administer your anesthesia. He believes that their superior training provides a safer patient experience.

Artistry

Unlike the vast majority of surgeons who claim that they can “sculpt” your breasts, Dr. Friedman is actually an experienced and respected wood and marble sculptor whose work has been displayed in galleries and is part of many private collections. He was an accomplished artist well before he attended medical school. For Dr. Friedman, breast and body contouring surgery represents the synthesis of his talents as an artist and a plastic surgeon.

Before approach-wood-before

After approach-wood-after

Torso carved from Nepalese rosewood
by Ronald M. Friedman, M.D.

Please click here to view photos of Dr. Friedman’s wood and marble sculptures.

When you visit our office, we will be happy to show you a variety of “before and after” photos of breast enlargements performed by Dr. Friedman. You will also be able to see and feel the differences between saline and silicone gel implants. If you wish to speak to other women who have undergone breast augmentation, we will be happy to provide phone numbers.

Q & A: Breast Augmentation


Approximately 85% of breast implants currently placed in the United States are silicone gel. Saline implants remain a reasonable alternative, particularly in women with a significant amount of breast tissue and subcutaneous fat.
The FDA has restricted the use of silicone gel implants to women ages 22 and greater except in the case of severe breast developmental deformities. For women ages 18 to 21, saline implants remain a viable alternative.
Your implants will probably not last as long as you do. It is likely that one or both of your implants will require replacement at some point in your lifetime due to deflation (saline) or rupture (silicone gel). Most saline implants will last at least 10 years; most silicone gel implants will last at least 15 years. In the absence of an implant-related problem, there is no need to "change out" your implants (i.e. if it isn’t broken, don’t fix it).
Saline implants are filled with sterile saltwater. Upon deflation, the saline is absorbed harmlessly. There is no known health risk associated with deflated saline implants. The FDA has determined that intact silicone gel implants are safe. However, they have not made a determination regarding the safety of ruptured silicone gel implants. Therefore, the FDA currently recommends that any ruptured silicone gel implant be removed.
Dr. Friedman performs breast augmentation through an inframammary approach, using incisions located near the creases beneath the breasts. Typical incisions are 3 cm (just over an inch) for saline and approximately 5 cm (2 inches) for silicone gel. Incisions around the nipple-areolae (periareolar approach) are associated with a greater risk of infection, capsular contracture, and interference with breastfeeding. Incisions in the armpits (axillary approach) are associated with a high risk of capsular contracture and an increased risk of implant malposition.
Your cleavage after surgery is determined by the following factors:
  1. Your anatomy. Regardless of your breast size, you can probably look at your breasts in the mirror and see whether they are close together (figure 1) or far apart (figure 2). The distance between your breasts before surgery strongly influences the distance between your breasts after surgery.

    clevage-1

    Figure 1: More cleavage before surgery--and after surgery.

    clevage-2

    Figure 2: Less cleavage before surgery--and after surgery.

  2. Implant size. In general, larger implants create more cleavage than smaller implants. More specifically, implants with a larger diameter extend closer to the midline than those with a smaller diameter. If cleavage is a major priority, then use the largest implant with which you feel comfortable.
  3. Surgical technique. Dr. Friedman routinely places breast implants under the pectoralis major muscles (see above). Having done this operation thousands of times, he has noticed that the pectoralis muscles have an outer leaflet (further from the midline) and an inner leaflet (closer to the midline). Dr. Friedman frequently divides the outer leaflet to maximize cleavage—while preserving the integrity of the inner leaflet.
All silicone gel implants are “cohesive,” meaning that silicone is a viscous material (like molasses). Some implants are more cohesive than others. Highly cohesive implants have informally been called “gummy bears.” Their advantages include reduced implant rippling (particularly in thin women with minimal breast tissue who are undergoing revision augmentation surgery) and reduced implant gel dispersion with rupture. Their disadvantages include mildly longer incisions and significantly increased cost.
Implants may reduce the sensitivity of mammograms. This is a greater concern for implants placed above muscle than those placed below muscle. In order to better visualize the breast tissues, additional mammography views (such as the Eklund displacement view) are recommended. Of interest, implants may actually make it easier to detect breast lumps on physical exam.
Approximately 20% of the roughly 140 breast augmentations performed by Dr. Friedman annually are breast implant revisions. Many of these women are referred by other physicians. Dr. Friedman performs revisions to increase or decrease implant size, remove and replace deflated or ruptured implants, soften breasts that have become hard (capsular contracture), or improve breast implant position and shape.
Dr. Friedman frequently performs breast augmentation with breast lift in women who desire improvement in breast sagging from pregnancy, weight loss, or aging. He also performs a large number of mommy makeover procedures, combining breast augmentation with liposuction and/or tummy tuck.
Actual Patient

Preparing for Breast Augmentation


One week before surgery

  1. Do NOT take aspirin-containing products or anti-inflammatories (Motrin, Ibuprofen, Excedrin, Aleve, Naprosyn), as these may increase your risk of bleeding. Use extra-strength Tylenol for any headaches or other minor pains. Do not take supplements.
  2. Please notify Dr. Friedman's staff if you become sick with a fever, significant cough, etc. If necessary, your surgery can be rescheduled to a time when you are feeling better.
  3. Do NOT smoke at all or use any nicotine products for at least 4 weeks (and preferably 6 weeks) prior to surgery and 4 weeks after surgery. Smoking interferes with wound healing and increases your risk for anesthetic and surgical complications.
  4. Arrange to have a relative or friend drive you home after surgery and stay with you for the evening. You cannot drive yourself home.

The evening before surgery

  1. Do not eat or drink anything for at least 8 hours prior to your scheduled surgery time.
  2. Make some jello and/or soup for after surgery. Have some juice in your refrigerator.
  3. The anesthesiologist will contact you by phone to discuss your medical history and to answer any questions.

Day of surgery: before you leave home

  1. Remember not to eat, drink, or smoke. This includes no chewing gum, mints, etc.
  2. Make sure someone is available to drive you home. Put a pillow and blanket in the car.
  3. Wear loose, comfortable clothing. Avoid heavy make-up, jewelry, or contact lenses. Please do not use any lotion, baby oil, perfume or powder. LEAVE ALL VALUABLES AT HOME!

Day of surgery: at the facility before surgery

  1. Dr. Friedman will talk to you before surgery to answer any last-minute questions. He will place drawings on your chest to help him accurately plan your surgery.
  2. You will meet the anesthesiologist and surgical nurses.

Day of surgery: at the facility after surgery

  1. You will be taken to the recovery area to wake up after surgery. Dr. Friedman will speak to your family/friends.
  2. Approximately 1 hour later, your family can visit you. Once you are feeling well enough, you may go home.

At home after surgery

  1. Have someone stay with you for the first night. You may be weak and drowsy.
  2. Take the antibiotics, pain medication (as needed), and anti-nausea medicine (if needed) that Dr. Friedman has prescribed for you.
  3. Sleep with your head elevated. Sleep on your back (not your stomach or side).
  4. Keep your dressings (gauze and tape) clean and dry. Do not remove the dressings. You may shower only from the waist down. You may wish to sponge bathe.
  5. You may remove the gauze and tape over the incisions and begin light showers four days after surgery. Avoid immersing the breasts under water.
  6. Take at least 10 deep breaths every hour. This will help keep your lungs expanded.
  7. Do not be a couch potato. To reduce the risk of blood clots in the legs, get up and walk anytime you eat or need the bathroom. While you are in bed, repeatedly flex your ankles (moving your toes up and then down) and/or have your family massage your calves.
  8. If you experience a prolonged fever (oral temperature greater than 101), contact Dr. Friedman. Please feel free to call our office or page Dr. Friedman for any other problems or concerns.

Activity level

  • 1 week after surgery: You may resume casual walking but must not engage in vigorous exercise that increases your blood pressure or heart rate. You may resume driving once you are off of your pain medication. Avoid freeways until you are comfortable with city driving.
  • 3 weeks after surgery: You may resume light jogging (with a jog bra) or an elliptical trainer but must avoid vigorous use of your chest or arms.
  • 6 weeks after surgery: You may gradually resume exercise involving the chest and arms. Only now you may lift more than 5 pounds.
  • 6 months after surgery: You may resume chest exercise, including pushups, bench pressing, and planks.

Sleeping position

Please sleep on your back (flat or elevated) or part way over (pillow under your shoulder and hip). Do not sleep on your side until at least 3 weeks after surgery. Unless otherwise instructed by Dr. Friedman, do not sleep on your stomach until about 6 months after surgery.

Incision care

You have a layer of tissue glue to seal your incision. After this peels off (about 3 to 4 weeks after surgery), begin scar massage twice daily with Prosil (available at our front desk) or Recedo (available by prescription). Continue scar massage for about 3 months.

Breast exercises and bra usage

Your implants are high and tight, as expected. Dr. Friedman will instruct you on exercises to mobilize the implants (usually up and in) until they have softened and settled to some degree. Final settling will take about six months. Once you feel that the implants are no longer "way too high," you begin use of a bra to reduce further downward settling of the implants. Please avoid an underwire bra for at least 3 months, as it may irritate your incisions. Even after the implants have settled, you should push them up and in about 2 minutes per week (for the rest of your life) to help keep them soft.

Water exposure

You may begin light showers but should avoid scrubbing your incisions. Do not immerse your breasts under water in a bathtub for 4 weeks. Avoid immersing your breasts in a pool, lake, or ocean for 6 weeks.

Medications

One week after surgery, you may resume use of any medications or supplements that you discontinued prior to surgery. However, for at least 3 weeks, you should avoid Motrin, aspirin, and any other product that may thin your blood.

Smoking

Do not smoke for at least one month (and preferably much longer) after surgery. Smoking may increase your risk of infection, wound healing problems, breathing problems following anesthesia, and blood clots.

Tanning

You may tan your breasts whenever you like. However, you should avoid tanning directly over your incisions for at least 6 months. Premature tanning of the incisions may cause them to darken permanently.

Sex

You may resume intercourse in a non-weight bearing position (i.e. on your side) about 3 weeks after surgery. You may not bear any weight on your chest for at least 6 weeks and should avoid full weight bearing on the chest for 6 months.

Dental visits

Avoid dental cleanings/fillings for 6 weeks, as bacteria in your gums can be transmitted to your implants via your bloodstream.

Please feel free to ask Dr. Friedman or his staff about any additional questions or concerns.

Please click here for more information about Dr. Friedman.

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© 2018 Ronald M. Friedman, M.D., P.A.

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