Transgender Breast Augmentation

Q: Dr. Eppley, I’m currently looking for a surgeon to do my transgender breast augmentation, I’ve done my research for a few years and now. Looking for a surgeon, a little about my profile: I’m a transgender girl with a small rib cage and an overall very small frame and build. I’ve been on hormones for about two years now and believe I’ve achieved all I can naturally. I definitely know that I want to do cohesive gel ( “gummy bear”) implants, if you offer them (I think I read that you do). And would love to hear back from you! 

I also would like to ask about removing ribs 11 12 and maybe 10, I know you’ve recently removed them from two women before and I’ve read your feedback on RealSelf.com about the procedure. I’d love to hear back from you on what you recommend! Much appreciated!

A: All silicone breast implants today are of the highly cohesive gel variety known as the urban term, gummy bear breast implants. All three existing breast implant manufacturers use the same silicone gel today. What implant size, shape and profile remain to be determined. (volume in ccs, round versus tear drop shaped and medium vs. high profiles) Such selections are based on what your breast augmentation goals are.

The role of lower rib removal is for narrowing of the anatomic waist. This is for patients who are unable to achieve a more hourglass shape or any inward indentation at the level of the waistline at the umbilical level. This is often a particular body contouring issue in male to female transgender patients whose ribcages are phenotypcally wider with greater outward rib flare.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Implant Profiles

Q: Dr. Eppley, I came in about a week ago to discuss breast augmentation. I am confused about breast implant profiles. I’m about five one and 100lbs. Right away I knew I wanted silicone due to them having a softer feel and I also was leaning towards moderate Plus due to the pictures that I have liked. They seem to look more natural well as natural as you can get with implants. Though right away you said high profile I’m sure it’s due to my small frame. My question is this afterwards will the high profile give me that two very round balls on my chest? Or will they hang a lil and have some side boob like real ones do? I just don’t want to look like I have balls on my chest though with my small frame will the high profile give me the boob look I’m looking for the noticeable though somewhat natural look. That the moderate Plus would give if I was a little wider? Could you help explain a little more the difference and looks please. I’m very interested I just want to be 100% with my decision. I understand with my small frame my options are limited. I believe I decided with 400cc round high profile silicone.. Thank you.

A: Your primary question about breast augmentation is in understanding the difference between high profile and moderate plus profile implants. To some degree, the size of 400cc in your body size is never going to look ‘natural’. Larger breast implants placed in smaller tight chested skin can not really avoid having a rounder/fuller look. That is more a function of the patient’s anatomy that it is being placed in and much less to do with the implant’s profile. There is also the very relevant issue of what happens with time (e.g., 6 months after surgery) as the tissues relax and settle after being so dramatically expanded in such a short time. Meaning implanted breasts that look high and round will always settle into a more natural shape over time. But the key issue is time and one has to be patient.

To better understand breast implant profiles, a high profile implant is less wide than the moderate plus. (even though they have similar 400cc volumes) This type of implant profile is often used in smaller women who are getting ‘bigger’ implants so the implant does end up too wide or too far to the side of the chest. (in the way of the swing of the arms) The tradeoff for that choice may be that they will slightly more round in the upper part of the breast. A moderate plus profile implant is more wide and slightly less high. It will have slightly less upper pole fullness but at the expense of more implant to the side. At the end of the day one has to choose which aesthetic tradeoff they prefer….a slightly rounder looking breast (high profile) or one that is a bit too far too the side. (moderate plus)

Dr. Barry Eppley
Indianapolis, Indiana

Breast Augmentation

Q: Dr. Eppley, I have an Inquiry regarding breast augmentation, I am wondering if my wife would be a candidate or should even consider a consultation.  She had ovarian cancer in 2005 and then in 2014 was diagnosed with Stage 4 head and throat cancer.  She is currently in remission. She has always wanted breast augmentation surgery but I wonder now if it would be too late.

A: Just because one has cancer, or even a lifespan that looks limited, does not preclude one from undergoing breast augmentation surgery. I did a lady some time ago who a stage 4 liver cancer. She had always waned to have breast implants and finally fulfilled her wish. She lived for two years after the procedure. It is all about making patients happy. Some people in having a cancer diagnosis may take that trip around the world or climb up Machu Picchu…others may want to have breast implants. There is no medical reason to not do so if her cancer doctors approve and she is not on any active chemotherapy or immunosuppression drugs. Breast augmentation surgery would be comparatively ‘easy’ to go through compared to any of her other cancer surgeries.

Dr. Barry Eppley
Indianapolis, Indiana

Breast Lift

Q: Dr. Eppley, What is the cost of start to finish with Breast Augmentation. I am concerned that I may need a breast lift as well but I see you have a before and after photo on your website when you click on the breast tab and below its says large breast implants there is a female on the left that is very comparable to my breast structure and looks like she just had implants and looks amazing. That’s what I am looking for. I am 27 years old with one child now with extra skin. Thanks

A: The critical question is whether you need a breast lift with your implants or not. That, of course, would impact the results as well as the cost of the surgery.if you could send some pictures of your breasts I could make that determination. The other issue that can tip the balance for or against the need for a breast lift is the final size of the breasts one desires. In some cases, large breast implants can overcome mild to moderate amounts of breast sagging with the considerable volumetric expansion. But that depends on the position of the nipple to the inframammary fold. Large volumetric expansion (large breast implants) works to create a breast lift IF the nipple is at the level of the inframammary fold or higher.

Dr. Barry Eppley

Indianapolis, Indiana

Silicone Breast Implants

Q: Dr. Eppley, I’ve been considering a breast augmentation but I have a few questions. I’m 21, and I’ve read that you cannot do silicone breast implants until you are 22. I’ve also read that it’s illegal to get silicone done under 22, but I’m not wanting to do saline. I’m curious if it’s possible to do silicone or not at my age. If it’s not how does that work. thank you for your time!

A: Let me provide clarification about age and the insertion of silicone breast implants. Because the long and extensive clinical trials for the silicone breast implants used today consisted largely of women between the ages of 22 and 65 years of age, the FDA listed that age range as the recommended ages of silicone breast augmentation. While that is the FDA guidelines for the use of silicone breast implants, it is completely up to the plastic surgeon to use them as he/she sees medically appropriate. Thus it is perfectly legal and medically appropriate to use silicone breast implants at any age below 22 years old. This is up to the decision and informed discussion between the plastic surgeon and the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Augmentation in Kidney Transplants

Q: Dr. Eppley, I am currently an A cup and would like to set up a consultation to review my eligibility for breast augmentation. I would like to consider a full B cup. Some information about me – 32 year old female, kidney transplant recipient five years ago and on dialysis for seven years prior to the transplant.I have wanted to have breast augmentation for many years and after a lot of research I have not been able to find anyone locally who has previously done this type of plastic surgery on a kidney transplant recipient. Please let me know your thoughts, I see that you do have previous experience in this specialized procedure.

A: I have done various types of cosmetic surgery in kidney transplant patients from breast augmentation, breast reconstruction, tummy tucks and facelifts. I have not seen any complications from any of these procedures despite the patients having a kidney transplant and being on immunosuppression. I think as long as your transplant doctors so not see a contraindication you should have an uncomplicated postoperative course.

In theory the elective placement of a synthetic device, like in breast augmentation, in a patient on immunosuppression seems one that would be fraught with peril but that has not been my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Augmentation

Q: Dr. Eppley, I am just finishing nursing our fourth baby and am looking into getting breast augmentation done. How long do I need to wait after finishing nursing? Also, we are military stationed overseas so would be flying in. How soon is the follow-up appointment? About how many nights should we plan to stay in a nearby hotel? Thank you! 

A: The first question after having nursed four babies is whether you just need implants alone? Do you have any sagging and is the nipple above the lower breast crease/fold. if sagging is present, as defined by the nipple being at or below the lower breast fold, then a lift will be needed with the implants. As a general rule it is good to wait three moths after nursing to have the breasts shrink back down to reveal the amount of true sagging, if any, and to have a good appreciation of the desired implant size needed for the desired breast size result.

Since the real time to judge the results of breast augmentation is that of months and no sutures are placed that would need to be removed. One could leave for home fairly quickly after the breast augmentation procedure when one feels comfortable traveling.

Dr. Barry Eppley

Indianapolis, Indiana

Are Textured Breast Implants Better?

Q: Dr. Eppley, I met with you for a breast augmentation consultation last week. Before I schedule my surgery, I have a few more questions about specific brands of implants. I believe you recommended Sientra, but I’ve been looking into Mentor implants. Specifically, the Mentor MemoryGel Siltex round implants. I’ m interested in the textured surface versus the smooth because the (perhaps dubious) Internet research done suggests textured surfaces lead to a lower rate of capsular contracture. And, Mentor appeals to me because of the enhanced warranty available for purchase. If my logic and/or research are wrong, please do correct me. If I did choose to go with Mentor, would there be a price difference from the original quote I received?

A: Thank you for the additional questions about breast augmentation and specifically about breast implants. Let me preface my comments with the understanding that it does not make any difference to me what brand of breast implants a patient uses. From my perspective, the three major breast implant manufacturers offer comparable devices for surgical implantation. The manufacturers, of course, see it differently and often promote and advertise relatively miniscule purported advantages to their devices.

When it comes to smooth and textured breast implants, it is important to understand what their advantages as well as their disadvantages are …as you will pay more to use them. (they are more expensive because it takes an extra step in their manufacture to add the textured surface onto the implant) Textured breast implants have only been shown to reduce the risk of capsular contracture when the implants are placed above the muscle. There has never been shown any differences in capsular contracture rates when they are placed below the muscle. The greatest reduction in capsular contracture, what was once a common breast augmentation problem, was the change in implant location from above to below the muscle. The type or surface of the implant is irrelevant when placed in the submuscular position. In my breast augmentation experience, which spans over 20 years and over 800 breast augmentations, I had yet to see a capsular contracture from a primary breast augmentation. In that time I have only performed a single above the muscle breast augmentation. All the surgeries have been done using smooth breast implant devices. This is a testament to the value and importance of the submuscular (technically the partial submuscuar or dual plane location.

It is also important to be aware that textured breast implants, besides costing more, require a slightly bigger incision to place and have a slightly higher risk of infection as any textured surfaced implant does. (the rough surface offers greater opportunity for bacterial adhesion than a smooth surface does) Due to their thicker shells they will feel more firm and will move less freely (due to tissue adhesion) than smooth breast implants.

Today, all breast implant manufacturers offer the identical warranty…lifelong implant replacement and a 10 year for surgery warranty of new implants plus $3500 towards the cost of surgery to replace them. (technically Sientra offers $3600 towards the surgery cost on the first ten years and also has a capaulat contarcture warranty so one could argue their warranty is better than Mentor and Allergan)

Again, it does not matter to me what breast implant manufacturer, style or size any patient desires. I will surgically place whatever they want. The only thing I do care about is that patients make an educated choice and that they understand the advantages and disadvantages of those choices.

Dr. Barry Eppley

Indianapolis, Indiana

Why Do Breast Implants Ride High Early After Surgery?

Q: Dr. Eppley, after breast augmentation why do women usually have high placement of their implants even when insertion of the implant is inframammary? Also, why do the implants drop? Why doesn’t the surgeon just place them where they belong? Is it due to the type of implant used? (e.g. size, textured vs smooth?) Maybe you can offer some clarity?

A: Your breast augmentation question is an excellent one and the phenomenon of ‘high riding’ breast implants early after surgery is common. In fact, the plastic surgeon does place the implant in the desired position during surgery. But it is important to remember that the implant places some degree of stretch on the overlying skin which is greatest in the new lower pole of the breast mound. (nipple down to lower breast fold) In getting larger breasts much of that effect (at least 50%) comes from increasing the size of the lower pole of the breast. Tissues in this area are much tighter than that above the nipple and often new skin is recruited form the abdomen to accomodate the effects of the immediate and often dramatic volume expansion. (lowering of the breast fold)

This lower pole expansion will create a rebound effect as it needs time to relax after surgery. Since the upper pole of the breast has much softer tissues, the breast implants will often naturally ride up for a while from this rebound effect. Thus the early high riding implant. Once the lower pole skin relaxes the implants can drop down into the original pocket for which it was created. (implant settling)

How significant this rebound effect is and how high and how long breast implants may be high riding is influenced by many factors. The quality and amount of breast skin, size of the implants, and whether they are smooth or textured all influence this postoperative healing process.

Dr. Barry Eppley

Indianapolis, Indiana

 

What Type Of Breast Implants Are Best?

Q: Dr. Eppley, I have been wanting breast implants for a long time and have been researching a lot of doctors and implants. I would like to speak about the augmentation with you. I have has one consult last year and I really liked the doctor but he only did saline implants and I think I am leaning more towards silicone implants but would like to discuss both with a doctor that does both.

Natural Breast Augmentation Dr Barry Eppley IndianapolisA: Saline and silicone filled implants are both FDA-approved options for breast augmentation. They do share certain similarities, they both create equally effective enlargements of the breasts and are equally safe. Looking at augmented breasts from the outside, it would be impossible to tell what type of breast implants was used. But beyond their external appearance, they do have several very distinct differences. Saline implants are associated eventually with palpable and visible ripples on the bottom and sides of the breasts which does not occur with silicone implants. Most women will say that silicone implants feel more natural as a gel-filled implant feels better than a bag of water. A dramatic difference between the two is in how hey will eventually fail. (they will not last a lifetime and will eventually need to be replaced) Saline implants fail by a dramatic loss of fullness like like that of a flat tire. Silicone implants never lose volume because the gel does not act like a liquid (like a gummy bear candy) and just stays in place and with same volume even if the bag sustains a tear or a hole. For this reason alone, silicone breast implants last longer than saline implants.

The concise version of this story is that there is one and only one reason to ever get saline breast implants….cost. They are the most economic form of breast augmentation because a pair of saline implants costs less to buy than a pair of silicone implants from the manufacturer.

Dr. Barry Eppley

Indianapolis, Indiana