Breast Augmentation

Breast augmentation continues to be one of the most popular procedures for women with almost 300,000 performed in the United States.  According to the American Society of Plastic Surgery, 72% of breast augmentations were performed with silicone gel implants versus 28% with saline implants.

Breast augmentation is a cosmetic procedure with the aim of increasing the size, changing the shape or fullness of a woman’s breasts. Breast implants are placed in the breast pocket under the breast tissue or under the muscle during the surgery.

Who is a candidate?

Any healthy woman who is able to undergo breast augmentation. Breast augmentation is available to any female over the age of 18 years old without the consent of an adult. A female’s growth should be complete and stable. If choosing silicone gel implants and you are less than 22 years of age it would be considered an off label use.

That being said, we recommend a thorough understanding of the risks, alternatives and benefits of undergoing a breast implant augmentation and possess the maturity to make the right decision.

How is it performed?

An incision is made in the fold of the (inframammary) or along the areola of the nipple (peri-areolar) most frequently. Some surgeons will also make an incision in the axilla (trans-axillary). The implant is then placed in a pocket that is dissected underneath the breast tissue (subglandular) or the pectoralis major muscle (submuscular).

Dr. Koumanis will discuss incision options with you and the advantages and disadvantages associated with the different methods. The biggest advantage of putting them under the muscle is that there is less chance of a capsular contracture (hardening of the breast capsule around the implant).

The surgery usually takes 1.5 to 2 hours and is performed most frequently under general anesthesia but sometimes under intravenous conscious sedation where the patient does not require a breathing tube and is given medication to make them very drowsy.

Where is the incision made?

The most common place for the incision is hidden just under the breast fold. The incision is usually under 2 inches. Another common place is a small incision around the areola if the patient is a candidate. The implants are then introduced through this small space in a safe and sterile manner.

Mastopexy, Breast Lift

Breast lift surgery also called mastopexy is used for drooping or sagging breasts (“ptosis” in medical terms). Drooping or saggy breasts usually occur with advanced age, after breastfeeding and pregnancies. Women usually come to our practice seeking an improvement in the way their breasts look and feel.

Who is a good candidate?

All healthy women are candidates for breast lift surgery if they have sagging ptotic breasts. The following situations are seen frequently in women who desire breast lift surgery:

• sagging breasts after significant weight loss
• lifting of the breasts after aging, post-pregnancy or breast-feeding
• repositioning of nipples that have dropped to give a more perky appearance

Do you sometimes combine other procedures with breast lift surgery?

Yes, sometimes breast augmentation with an implant is needed if significant volume has been lost and need to be regained at the same procedure as a breast lift. Additionally, some women desire mommy makeover procedures which can combined breast surgery with liposuction, tummy tuck or torso lift and possibly a thigh lift. This is not an exhaustive list but a combination of any of these procedures is sometimes performed at the same time as your breast lift surgery.

How is breast lift surgery or mastopexy performed?

A circular incision around the nipple is carried out along with different patterns in order to lift the nipple-areola complex, skin, and breast tissue up. The pattern and length of the incisions are varied depending on the type of procedure needed and how much of a breast lift is required. Dr. Koumanis will go over all the options with you during your appointment and consultation.

What are the results like for breast lift surgery?

Most women are very pleased with their breast lift surgery. However, results are never guaranteed. That being said breast lift surgery is a common and frequently performed surgery with true and tried results for the most part. The results usually last for a significant period of time but again every case varies depending on age skin quality etc. Dr. Koumanis strives for all his patients to be happy with their results.

What are some of the complications?

As in any procedure complications sometimes occur. It is not common in surgery. However, infection bleeding, scarring, sensation issues have been known to occur. Dr. Koumanis prides himself on low complication rates and will discuss all of these issues during your consultation.

What are the costs of the surgery?

In our practice, breast lift surgery costs approximately $6500- $7500.  If the procedure is combined with a breast augmentation using an implant it can cost between $8200-$10,200.

What is the recovery time?

Most candidates will experience some discomfort for the first few days to about a week.  This is usually tolerable and pain control prescriptions are used to help with postoperative pain.  The pain is not usually significant with this procedure but everyone is different.

Patients are usually okay to begin some activities within 48 hours. Walking, sitting can occur the next morning.  Some light exercise can usually begin at around four weeks and unrestricted activities usually at six weeks. That being said, patients are different and so Dr. Koumanis will discuss each postoperative step in person with you.

Breast Reconstruction
Dr. Koumanis is an expert at breast reconstruction with over 14 years of experience performing advanced techniques to restore the female breast after mastectomy. In the following section, frequently asked questions will be answered involving breast reconstruction using implants and also your own tissue.

What is breast reconstruction?
Breast reconstruction is the use of autologous tissue (i.e. your own tissue), breast implants or a combination of the two in order to restore the shape of ones’ breasts.

How many surgeries does it take to achieve final results?
It takes approximately 2-3 surgeries to achieve the final results. It depends if your mastectomy surgeon will be performing a nipple sparing approach or whether the tumor is close to the nipple ducts and therefore must be taken. The third and final step in reconstruction is to make nipple flaps. If a nipple sparing approach is used nipple flaps are not needed.

What happens in each step?
The first step involves the mastectomy. After the mastectomy and at the same anesthesia setting Dr. Koumanis will take a tissue expander first and wrap it with Alloderm (cadaveric acellular dermal skin) and place it either behind the pectoralis muscle of the chest or above it, wrapping the front/anterior surface of the tissue expander. Then 2 drains are put in each breast pocket to help drain fluid in the postoperative period. The drains stay in between 1-2 weeks usually.

1. Inferior Skin flap of Breast
2. Alloderm™ sling cradling the implant

Then 3 weeks later expansion starts in the office. The skin is prepped with betadine and alcohol and sterile normal saline is injected into the expander once weekly until the desired size has been attained.

Once the expansion is completed, the second stage involves removing the tissue expander and replacing it with a permanent silicone cohesive gel implant and some flap revisions by excision of the skin envelope is sometimes needed.
The third stage involves creation of nipple flaps if the nipples and areolas were excised during the mastectomy.

What is the advantage of putting the implant above the pectoralis muscle?

When does one perform a unilateral (one side) versus a bilateral (two-sided) breast reconstruction?

A unilateral breast reconstruction is performed when a one-sided mastectomy due to cancer is performed. A bilateral procedure is performed when there is cancer on both sides. A bilateral procedure is sometimes performed due to patient desire to reduce her risk of cancer on the opposite breast although. Bilateral procedures whereby by the opposite breast is removed prophylactically are common due to strong family history of breast cancer, genetic risk (BRCA1 and BRCA2 genes), in ability to properly monitor the opposite breast, or patient anxiety of having to undergo a possible future cancer procedure or mastectomy.

If one side is performed, then the other breast sometimes needs a reduction or a mastopexy (i.e. lift) in a future procedure. Bilateral reconstruction procedures have one advantage that they offer better symmetry as both breasts will consist of implants. If there is no strong family history, or genetic predisposition, or bilateral disease, then a prophylactic mastectomy provides little advantage in relation to oncological risks and survival. With that being said, we perform bilateral procedures with one side being prophylactic quite frequently

How long does the whole process take?

As discussed above, implant breast reconstruction requires a minimum of 2 operations (tissue expander first, then exchange of tissue expander to silicone gel implant once fully expanded), and a third small operation is only needed if nipple flap reconstruction is required. If no radiation or chemotherapy is required in your breast cancer treatment plan, then things go fairly quickly. In this case most breast reconstructions are completed within 4 months. If radiation and/or chemotherapy is required, then the process takes longer. Please see below.

Where are the incisions made?

Incisions are made in accordance to where the tumor is located. If the mastectomy is being performed prophylactically due to BRCA1 or BRACA2 genetic predisposition, then a nipple sparing approach can be used if the nipples are in a decent position. Then the incision is made laterally along the inferior breast fold, to hide the scar as much as possible. If the nipple needs to be raised than a peri-areolar incision is used to enter the breast. In most cases a skin sparing approach is used whereby as much of the breast skin is retained during the mastectomy.

Figure: Various incisions used in mastectomy and breast reconstruction surgery

1. Inframammary incision (hidden scar *NS approach)
2. Inferior peri-areolar incision (*NS with lateral extension if needed)
3. Superior peri-areolar incision (*NS with lateral extension if needed)
4. Classical elliptical incision (horizontal across breast when closed)
*NS=nipple-sparing

What if I need radiation or chemotherapy?

In the chance that you require chemotherapy and/or radiation then this is usually done after the first surgery (i.e. mastectomy and tissue expander). By the time you begin your therapy, which is within 6 weeks of surgery usually, we will usually have you fully expanded. Needing chemotherapy and radiation will obviously delay completion of your breast reconstruction. With chemotherapy only, the second stage surgery can commence within 4-6 weeks after your last treatment to allow for your immune system to return to its normal state.

If you require radiotherapy, then the exchange of the tissue expander to the silicone gel implant will take place 6 months after your final radiotherapy session. The tissues require time to heal from the radiation damage and fibrosis. Sometimes Dr. Koumanis will perform a fat grafting procedure at 3 months after radiation to help heal the radiated tissue around the implant and soften the tissues and decrease the effects of radiation fibrosis.

Radiotherapy can cause loss of the implant through infection or extrusion. If this occurs, then an autologous reconstruction (i.e your own tissue from elsewhere) may be needed. A latissimus muscle flap with a new implant or a DIEP flap (i.e. skin and fat tissue from the abdomen) the may be required for a successful outcome.

Are silicone implants safe?

ilicone gel implants are safe. They have been FDA approved in the setting of a breast augmentation or breast reconstruction. They do not cause cancer and there is no evidence that they cause any autoimmune disorders. Almost all of our patients tolerate them very well. There is the recent issue of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) associated with breast implants. BIA-ALCL is a rare but treatable type of lymphoma that has been linked to certain breast implants. It is more frequently associated with older textured implants.

Dr. Koumanis generally uses smooth gel implants except in certain circumstances. Dr. Koumanis to this date has not experienced BIA-ALCL in any of his patients. He will discuss the symptoms in detail during your consultation. Symptoms usually include an enlarged breast with seroma fluid contained within the breast pocket. No all enlarged breasts with fluid after implant reconstruction is due to BIA-ALCL so a fluid sample is usually taken to rule out the diagnosis.

How long do the silicone implants last?

In general, silicone cohesive gel implants last approximately 10 years, although we have seen many last even longer.

Do I need frequent follow-up and monitoring?

It is best to be followed up yearly for the first few years then bi-yearly after that. If a rupture does occur, this is not life-threatening. If a rupture of an implant is suspected, an ultrasound is the first line to detect the rupture. If this is inconclusive, an MRI will be ordered which is more sensitive to detecting a rupture.

Breast reduction

Are yoju unsatisfied with the look and feel of your breasts because they are overly large or sagging?  If yes, then breast reduction surgery can be a rewarding procedure to help correct the debilitating and often embarrassing issues associated with large breasts.

Not only does breast reduction surgery decrease the size of the breasts so they are more comfortable but it also helps lift the breasts such as one would find in a mastopexy which is a breast lift procedure.

In essence, you are getting a breast reduction and a breast lift in one surgery. Dr.Koumanis specializes in breast surgery and has performed numerous breast reconstructions procedures. Dr.Koumanis at Capital Area Plastic Surgery will help you obtain the desired size and look of your breasts in a comfortable setting.

The aim is to lift and reduce the breasts and make them more proportional to one’s body. You will be made to feel safe and comfortable with Dr. Koumanis and his professional team at Capital Area Plastic Surgery.

Who is a candidate for breast reduction surgery?

If one or several of the following signs and symptoms exist you may be a candidate for breast reduction (aka reduction mammoplasty) surgery:

• Breasts  that are very large or disproportionate to one’s body size 
• Disproportionate size between left and right breasts 
• Significantly poor posture due to overly enlarged breasts 
• Heavy breasts that sag or droop
• Back neck or shoulder pain or discomfort caused by large and heavy weighted breasts 
• Bra strap grooves in the shoulders caused by heavy breasts
•  Heavy large breasts with sagging nipples and areolas (thy may be  downward pointing)
• Feelings of embarrassment or being self-consciousness 
• Rashes or infections found under the fold of the breasts
•  Breast discomfort when walking or lying down
• Difficulty in athletic or physical exercise due to large breasts

If you’ve experienced one or more of the above conditions or symptoms then breast reduction may provide relief and satisfaction.

How is breast reduction surgery performed?

There are several techniques that Dr. Koumanis uses to perform breast reduction surgery depending on the needs and presentation of the patient. Some of the techniques use a shorter  scar reduction which only uses an incision around each nipple and then a vertical incision going down to the breast fold.

If there is a lot of excess skin sometimes horizontal  incisions along the inframammary breast fold are needed in order to remove excess skin on the horizontal axis.  Both of these techniques are true and tried procedures that Dr. Koumanis has used throughout his years of practice.

Once the incisions are made the skin and breast flaps are lifted and then a specific pattern is used to reduce the amount of breast tissue for each breast.  Sometimes more glandular and breast tissue will be taken from one breast over another for correction of asymmetry and an attempt to correct this mismatch in size between the left and right breasts.

The nipple and aereola complex is then lifted into a keyhole pattern at a higher position on both sides.  The areola can be reduced during this part of the operation to make it more proportional to the breast mound.  During the procedure

Dr. Koumanis will then tighten the skin envelope around the nipple and areola of the breast. The procedure is usually performed in an outpatient or ambulatory surgery setting taking anywhere between 2- 4 hours to perform  depending on the size of the breasts and the amount needed to be removed.

Rarely does the patient have to stay overnight.  Dr. Koumanis will then be put on your sterile dressings and gauze. A sterile bra is also fitted to help with comfort and support for the breasts while they are healing.  Most of the sutures that are used are dissolvable thereby avoiding the need for stitch removal.

The complications that can arise from the surgery are usually minimal but Dr. Koumanis will discuss these in detail during her consultation.

What is the recovery time for breast rate reduction surgery?

The average recovery time associated with breast reduction surgery is between 7 and 10 days.  Postoperative pain is usually minimal and is well controlled with oral pain medications.

Patients are able to take a shower normally after 2 days.  Most women return to work and go about her daily normal routines in about 10 days to 2 weeks.  After 4 weeks they’re usually no restrictions even for heavy exercise and activity.

If you are from the Capital Area District or anywhere in upstate New York or traveling from abroad please feel free to make an appointment for a free consultation with Dr. Koumanis.