To answer your questions...

Reader's questions addressed, vol XI

Question #1:

An Answer:

The condition of a male having abnormally large breasts is referred to as "Gynecomastia." There are a number of different operations for this problem. Most commonly it is addressed through small incisions below the pigmented areas around the nipple. Some insurance companies cover the operation. It can be done as an outpatient.
Thanks for the Question,
John Di Saia, M.D.

Question #2:

>Hello Doctor,
>I am oriental and interested in nasal implant, I would like to have more bridge on my nose, and also I like to have the tip of the nose fixed because it's too rounded. My questions are what kind of implant is made out of? How can I make sure that my nose will take the implant and there won't be infection around the implant?

An Answer:

Why do you feel you need an implant to do this? Cartilage is the best implant, which can be obtained from inside the nose (septum), the ear or potentially a rib. Artificial implants are available but they can get infected (it is rare) or extrude from the nose.
Thanks for the Question,
John Di Saia, M.D.

Question #3: >I am currently seeking a plastic surgeon to remove "skin and fat" hanging from my stomach. I have had four children, the first at 10 pounds, the last two being twins who weighed 8 pounds and 7 pounds. I have lost 50 pounds over the last year with a combination of watching what I eat and regular exercise (exercise bike/walking). I have been heavy all of my life, but I have never had a stomach like this before my pregnancies. It is definitely a deformity, out of proportion to my body! When I run down the stairs in my home, you can hear my stomach "flapping". I cannot wear any pants that are not elastic banded. I also have hygiene problems because of the "flap".

>I am going to try to get this covered by my insurance company. I don't want this procedure done to give me a "washboard stomach", I just want to look normal again. I am currently 218 pounds at 5'6". When I graduated from high school I was 180 pounds (I am currently 34 years old). Is a procedure like this done on people who are overweight already? I don't know if I will ever lose another pound - I like to think I will but as I said, I will always be a big girl. As I said before, I don't want this done to look good, just normal.

An Answer:

If you are asking whether or not insurance comapnies are going to cover this , I don't know. I can tell you that they have been getting less and less prone to do so as of late paying so little to the surgeons that we cannot afford to do it. They reimbursement they propose on some procedures at present doesn't even cover overhead expenses. Incidentally, most people after having an abdominoplasty don't get a "washboard stomach." This would be an unreasonable expectation for all but the most mildly affected patients.
Thanks for the Question,
John Di Saia, M.D.

Question #4:

>I received breast implants below the muscle on three weeks ago. I went to my surgeon on the 9th post-operative day for a follow up and told him I was upset because my right breast was bigger than my left one. After looking he said it was not a problem yet. My left one had just not settled in yet. When would it be a problem and is there anything I can do to help it settle into place.

An Answer:

Was your right breast larger than your left to start? In performing the operation more often than not implants of the same size are placed. As breasts (like any other paired organ) display slight differences when compared with one another, post-operatively a difference can be seen. In fact, the pre-operative difference can seem more obvious on occasion. You may want to review your pre-operative pictures. As swelling can also be evident at this early post-operative state, waiting for a few weeks may make the difference less obvious as well.
Thanks for the Question,
John Di Saia, M.D

Question #5:

>Hi, I have to thank you for the information you provided me on breast augmenation. I am seriously considering this procedure. I would appreciate your advise on some pondering questions that I have: 1. does making the incision at the areola(?nipple) make them less sensative. I definately do not want to loose this. 2. What are the advantages/disadvanatage of having the incision made under the arm. Someone told me that the implant sits higher because it's harder to place & has to travel further. I'm trying to decide what the best result w/the less noticable scars is. 3. I'm an aerobic instructor & work w/weights 3 times a week. Is there anything I should be concerned about placing the implant behind or in front of the pec muscle? Thanks again and I look forward to your response. P.S. so far your site has offered the best advise, information and expamples (I've been browsing about 5-6 times.

An Answer:

(1) The different approaches (at least the Armpit, Under the breast, and at the Areola) surprisingly have similar patterns of sensory loss. All patients will have some sensory changes at the time of the procedure. Only 15% of these patients will not regain all of their sensation. The remainder will have some residual loss. If you wish to have no risk of sensory loss, I would encourage you to re-consider the operation.

(2) The "Armpit" approach is more difficult as the surgeon is operating through a tunnel. I personally am not pleased with the shape of the breast that results. I have far more control through either of the other approaches.

(3) The decision whether to place the implant behind the pectoralis or not rests upon the type of implant (now saline) and the amount of breast tissue to start. I prefer to place the implant behind the muscle (particularly with saline filled implants) as the risk of visible wrinkling at the implant surface is decreased (for the area in which the implant is below muscle). There will be some loss of strength of the Pectoralis major muscle which most patients do not appreciate. You may wish to not have as large an implant to potentially disturb the muscle less. The only patient of which I have heard that wished to have her implants reduced in size was an avid gym-goer. She said that they were impairing her activity. This is in striking contrast to well over 90% of those patients that complain who wish to go larger.
Thanks for the Question,
John Di Saia, M.D.

Question #6:

>Dear Dr. Di Saia:
>My wife has had breast implants for some 2 1/2 years now. She is 5'6" tall and weighs about 120 lbs, of medium build (bone structure). She made her own decision to have breast augmentation to enlarge her breasts, and had 780cc and 800cc breast implants on that augmentation, which enlarged her 34-C cup bustline to 34-DDD cup/34-EE cup. Although she was very satisfied with the results initially, I notice of late that she is no longer so pleased. She had mild ptosis prior to augmentation, and still has some now, though to a lesser degree. The reason I am mentioning this ptosis, is that she approached me last weekend about having another breast augmentation procedure to further enlarge her breasts. She went on to do some experimenting (with ziploc bags/water balloons,etc.), and has decided that removing her current implants and replacing them with breast implants of the size 2500 cc's each will give her the look she desires. She is in her mid-twenties, and I suspect she is interested in performing at a local gentlemen's club, which is of course her prerogative as well.

>Her (four) questions:
>Given her mild ptosis now with her current 780/800cc implants, will she be able to accept implants as large as 2500 cc's? (Even if it will result in an 'unnatural' look)
>We have heard of 'custom-order' implants - are sizes as large as 2500cc's available?
>Would you recommend an 'inflatable' -type implant, that will allow her to be enlarged to this size over time (or perhaps to an even larger size in the future if she is so inclined)
>What would you speculate to be some of the complications she might have with implants of this size, that are different from the normal complications that can occur with implants of her current size or smaller?

An Answer:

I cannot say that I would recommend such a large implant. I don't honestly know if implants of this size are available. The potential consequences of placing such an implant are really a function of the small amount of soft tissue cover that will be available for the prosthetic. The potential for such a large implant to erode through the skin and cause large unsightly stretch marks will be large. Similarly the possibility of long term back pain or advanced arthritis may arise. As your wife is young, I would suggest you think of the long term picture. Depending upon the amount of ptosis, a smaller implant with a minimal breast lift may improve her appearance. Everything really depends however upon what she considers a good appearance.

Variable inflatable prosthetics have not impressed me, therefore I wouldn't recommend them. Besides, the maximum inflation will be limiting I would predict in your case.
Thanks for the Question,
John Di Saia, M.D.

Question #7:

>I am 17 and I have small (A cup) breast and I want to know if I medically speaking, I am too young to get implants? Is there an age I should wait?

An Answer:

This is really a controversial question. Young people often spend little time thinking about things that have life-long implications. I know I was this way. The breast also changes as women get older.

These two items (not to mention the issue of legal consent) make it reasonable for young people (under 21 or so) to wait to consider the operation. The youngest patient I have operated at present for breast augmentation is 23 years old.
Thanks for the Question,
John Di Saia, M.D.

Question #8:

>Hi, I am a 22 year old female with quite saggy breasts. I wear a 38C and do not need implants just a lift to firm them up so they do not sag. Is this something done without having to get any implants.

An Answer:

It can be if the patient desires not to have an implant but often projection is better with a small implant after a lift.
Thanks for the Question,
John Di Saia

Question #9:

>Dear Dr. John,
>1) I have inverted nipples and would like them to be normal, is there a procedure that would make them respond in the normal fashion?

An Answer:

There are several procedures for correcting the inverted nipple. Just performing your augmentation through a periareolar approach may be enough though. Most involve an incision in the perioareolar skin with a dissection under the nipple. This may impair sensitivity more than a simple periareolar incision for a breast augmentation.

Thanks for the Question,
John Di Saia, M.D.

Question #10:

>I understand there is a new [liposuction] prosedure that melts the fat away rather than using suction. My qusestion is, I have call many doctors in the Bay Area and most say that this procedure is not legal nor FDA approved. Is this true and if so how can the Doctor I have my consult with be preforming it?

An Answer:

You are referring to "Ultrasound-assisted" liposuction. This is currently under investigation by the American Society Of Plastic And Reconstructive Surgeons (ASPRS). The procedure uses sound waves to break up fat and allow easier suction. Suction is still used to remove the fat. Some surgeons have access to the equiptment and others do not. As it is not yet FDA approved I believe that they are required to inform patients of this fact. There is no ban on the procedure however. It is just new and finding its place in the surgeon's armamentarium.

Thanks for the Question,
John Di Saia, M.D.

Please note that this information (as well as that on all my pages) is offered freely to individuals considering cosmetic surgery. No rights are granted and it is not to be reprinted or copied without the author's prior written consent. Beware that although efforts have been made to assure accuracy, many of the issues discussed here are a matter of professional opinion. Consultation with a qualified Plastic Surgeon should be obtained to answer more detailed and potentially personal questions.