4/23/14

The Surge in Breast Lifts! A clarification of the “In-Depth Report”.  

The conflict of breast lifts vs breast augmentation became obvious when the phones of our offices in Louisiana blew up with women inquiring about breast augmentation prices and the type of breast lift procedure I perform. I kind of liked it, but the reason for the frenzy was from a KTBS ABC Channel 3 Evening News segment called “In-Depth Reports with Jessica Crandall”, the night before. The topic related to a finding in the American Society of Plastic Surgeon’s (ASPS) yearly survey. The excitement was about the dramatic increase in women undergoing breast lifts. She sought an opinion related to these astounding statistics and the subject of breast lifts from plastic surgeons, Dr. Simeon Wall, Jr. and Dr. Holley Casey. The news cast was very professional and I believe that informing the general population about the facts of cosmetic procedures is extremely important. That is why I participate in KTBS ABC’s Channel 3’s Healthline at noon every second Thursday of the month where facts related to cosmetic surgery are clarified.   The “In-Depth Report” video can be viewed at http://www.ktbs.com/video and under a segment called “Breast Lifts outpace growth of Breast Implants”. For the public and those women thinking about a breast lift procedure I’d like to clarify my position on the ASPS statistics and types of breast lift I prefer to perform.  I greatly respect each of my colleagues opinions even though sometimes my opinion will differ.

 About the Statistics

Astounding conclusions from statistics on breast lifts vs. breast augmentations in Louisiana should probably raise a red flag in the mind’s of reasonable people. Statistics should be carefully examined before believing they are credible news “sound bites”. The American Society of Plastic Surgeons revealed recently an astounding 70% increase in breast lifts from 2000 to 2013. Wow that’s amazing, but since I’m not into sensationalism and I’m not sure why the ASPS felt this year’s 70% increase was news worthy when last years 74% increase was not. I didn’t find either statistic from either year news worthy. The question that has to be asked is, “Why does there appear to be an 70% an increase from 2000 to 2013 when on a year to year basis the increases are only between 1 to 3% per year from 2006 to 2013 in breast lifts.  There must have been a dramatic increase in breast lift from 2000 to 2006 or the number of well established plastics surgeon reporting data from 2006 to 2013 increased. Either of these possibilities would explain the numbers.) The explanation by Ms. Crandall was simply the fact that more baby boomers are electing to do cosmetic breast surgery, which is true, but this explanation simply does not come close to accounting for the “dramatic” statistical increase.   A more accurate and significant reason for the dramatic percentage increase is a “statistical error” brought about by data collection over the last 13 years.  This error comes from the fact that the reporting of cosmetic surgery procedures by experienced practicing surgeon was deplorable in the late 1990’s and early 2000’s and the data was primarily from recent graduates of plastic surgery residency whose practice in cosmetic surgery was not fully developed. Their practices were primarily reconstructive cases, but they were required to report all their case to complete their board certification. Naturally, breast lifts would be under reported because data from more mature practices where not included.   Older plastic surgeon were not required to report their cases in ordered to be re-certified and early one it was a bit of a pain to collect the data and submit it.  Fortunately over the last 8 years the reporting participation rate of established plastic surgeons has greatly improved.  This error in data collection can account for the “news worthy” statistics, which is not news worthy at all.  I didn’t care to mention this “incredible finding” on my monthly news presentation this month, even though the announcement was at least 2 weeks old.  The statistical information can be found at the ASPS website. Plastic Surgery Procedural Statistics | American Society of Plastic Surgeons (ASPS) Ms. Crandall is a very good reporter and I realize actual dissection of a subject is difficult due to her demanding schedule and lack of resources to verify information.  This is a common problem with national and local news reporting. Heck, Fox News reported the findings on April 1st.  Their excitement about the finding must have been an “April Fool’s Joke”. Unfortunately, sound bite are not true bites.

Breast Lifts

As related to types of breast lifts and whether one is preferable or more advance than the another; my opinion differs from Simeon’s and Holly’s. I rarely recommend a “Lollipop” breast lift in Louisiana to my patient population.  I don’t find many of my patients are good candidates for a “Lollipop Lift”.  If one is then it would be the right operation to do. To me the “Lollipop Technique is often sold with the “advantage” of having less incisions than the “old”  Wise-Pattern (Anchor) Lift as well as the “illusion” that the “Lollipop” lift is a “new technique” and therefore must be better than an old technique.  This was a theme that ran throughout the news segment. Addressing the Lollipop’s most common sales pitch which is “less incisions” you need to dissect the reason people find it appealing.  They believe there will be less “visible” scars. It is true there are less incision with a “Lollipop Lift”, but a distinction should be made between “total incisions” and “total visible incisions”.  It’s the total visible incision that matter to most patients.   If you look carefully, both techniques have the same “visible” incisions from a frontal view once the incisions have matured.  The incision around the nipple and the vertical limb, the stick of the Lollipop lift and the Anchor lift are both visible.  With the Anchor Technique the incision at the bra line is rarely visible because of the breast above.  Essentially, the bra line incision is out of sight out of mind.  I don’t see a distinct advantage of having less incisions when the visible incisions are the same.  To me it is not a great selling point.

Historically and aesthetically I have a different view of the “Lollipop” Lift verse the “Anchor” lift. 

In my opinion, Ms. Candall’s commentary about “new advances” in breast lift techniques needs some serious clarification.  In a patient’s mind “new” means better and more advanced.  But as they say, “There is nothing new under the sun.”  The vertical lift incision was first introduced to the cosmetic surgery world in 1964 for breast reduction (although the first report in the literature was in the early 1970’s) by Dr. Claude Lassus and it was quickly modified for breast lift.  So the technique is not new and therefore not advanced.  (In all fairness to the program’s participants, since the Anchor Lift was first reported by Dr. Robert Wise in 1956, I guess you could call the “Lollipop” lift “new”, even though they both are 5 decades old.  In most plastic surgeon’s mind “new” is not necessarily better.  Since the technique has been around for decades it is curious that the majority of plastic surgeon rarely use the technique or use it solely at the patients request.  I feel the Wise-Pattern mastopexy is still the gold standard related to breast lifts.  It is true that the Lollipop Lift is quicker to do, simple to do and probably a little less uncomfortable than a Wise Pattern Lift, but I believe patients get a better short and long term result because higher surgical and aesthetic skills are required to perform the more complex and technically pure procedure. See this for history: Lejour Breast Reduction

My Opinion Why the Bra Line Incision in an Anchor Lift is critically important. 

Actually having the bra line incision is very important for two good reasons. First to prevent the upward displacement of the nipple and second to reduce a “bottomed out” appearance to the breast.  Related to the first, twenty-five years ago by a patient / friend taught this to me. Her complaint, after a breast lift, was that when she bent over while wearing a bathing suit her nipples were exposed above the upper edge of the suit.  At the consultation, I did the appropriate measurements from the nipple to the sternum and from the base of the neck to the nipple region and the numbers were perfect, the lower pole did appear to be a little bottomed out, but I told her I couldn’t see how it was possible.  In her determination she showed me.  She laid down on the floor, flat on her back, and sure enough the nipple appeared at the upper edge of her bra.  I realized then that the distance from the nipple to the bra line was too long.  Why is this important?  Well, you have to think of the nipple region as a “dog on a leash”.  That leash is the length between the nipple and the bra line.  If it is to long that “dog” can run and peer out over the top of bathing suits and bras with certain movements.  (This is more common if implant are used at the time of the lift and the patient has a substantial amount of breast tissue.) You can’t control or shorten the length of the leash with a lollipop lift.  You can only control it with the bra line incision of an Anchor Lift.   Also over time both the length of the leash in the lollipop and anchor lift elongate, but in anchor lift, if the leash or vertical limb is kept very short at the time of the operation, the elongation rarely becomes as long as the one in the lollipop lift.  (I have seen some patients elongate the length of the leash even in an Anchor Lift but it certainly is not common.) In addition, as in my patient, if the length of the leash were shorter this would have reduced the “bottomed out” look of the lower breast.  Bottoming out of the lower pole of the breast initially begins right after surgery as the swelling stretches on the skin.  Subsequently gravity, and the fact breast live off the edge of a cliff all their lives, facilitates further bottoming out.   (This was actually demonstrated in the 1972 when Dr. Paul McKissock, an innovator in plastic surgery, elongated the vertical limb of an Anchor Lift  thinking that it would improve the results but it caused excessive bottoming out.  Again controlling and shortening the vertical limb of any lift is extremely important for the shape of the breast long term.  This can’t be done with a “Lollipop Lift”. (Again this is totally my opinion which has been molded over the  the last 30 years with very long term patient follow-ups. Younger plastic surgeons generally don’t have the benefit of such follow up.)

My Opinion on Pain Control After Breast Surgery

In the news cast the local plastic surgeon was absolutely right as to a new local anesthetic used to control pain in their “Rapid Recovery Program” after breast surgery. (It actually is a new formulation of a 30 year old local anesthetic but it was approve by the FDA about two years ago for longer term local pain control, about 2 days.) It is not a bad technique it just increases the cost of the procedure by about $250 to $350. For 30 years, I have routinely used long acting anesthetics in the tissues around a breast lift or breast augmentation in Louisiana. This usually gives the patient 4 to 6 hours of no pain and get them past the most uncomfortable part of the surgery. If they take their pain medication before the anesthetic wears off then pain control is very good. The most uncomfortable part is right after the surgery when the tissues are letting you know they did not enjoy anything I did. (You have to realize as a surgeon “I just beat up on people for a living, as far as your body is concerned”. All surgery is a calculated trauma. Just think about it, your body is sitting there minding its own business when someone takes a knife to it. Its either a mugging or a surgery and the body can’t distinguish the difference between the two.) If you like the concept of not having to take many pain meds after a surgery and you are willing to incur the added expense, then I will inject the area with the longer lasting local anesthetic. This is discussed with my patients prior to surgery, but I haven’t had anyone agree to use the injection.

Aesthetic Procedure pricing

Ms. Candall’s reporting of the cost of a breast augmentation and a mastopexy unfortunately was misleading to everyone watching the segment. The quoted prices were the prices of the surgeons fees alone and not the cost of implants, anesthesia or facility fees. Those prices in no way reflect the true cost of the procedures. I recommend asking for total expenses prior to scheduling. All in all Tuesday’s “In-Depth Report” was a thought provoking segment but it was far from what would be called an “In-Depth Report”. If you have any question or rebuttal to my opinion on choosing a breast lift vs. breast augmentation, I would appreciate you comments. Send them to info@bridgestobeauty.com

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