Breast Implant Massage to Prevent Hardening Contracture : When, Where and How?

On one of the forums at which I occasionally contribute the question came up of breast implant massage for textured implants as a preventative measure to avoid hardening (Capsular Contracture.) The question was under what circumstances does it make sense to massage textured implants within breasts to prevent hardening. As is frequently the case, the answer relates to the history of breast implants and hardening:

To make a long story short, one of the most frustrating issues when working with breast implants is the tendency over time for them to harden within the breast. To be more correct, the breast tends to harden around the implant. This is more often the case with silicone gel breast implants, implants with relatively little soft tissue coverage, in smokers, and in cases in which infection, radiation treatment or bleeding have been involved. Back in the seventies and eighties, there were studies with differing methods of decreasing these tendencies. The studies had varying results (unfortunately) showing loose associations with implants with textured surfaces and patients in whom breast massage was used showing inconsistently favorable results.

Surgeons do not all do things exactly the same and frequently a surgeon’s experience affects his or her practice. Breast implant surgery is no exception to the case. Some surgeons will tell you that there is no need to massage textured implants. Others will tell you the opposite. There is no consensus here.

Many surgeons will look at issues with a particular patient to determine what to advise. If patients have had more issues with capsular contracture, then massage and/or textured implants might be advised. Many of us rarely if ever use textured implants for other reasons (for example they are more often associated with rippling.) Suffice it to say following your surgeon’s advice and having follow-up visits with that surgeon is probably the best strategy to try to avoid capsular contracture. I tend to use more saline filled implants and moderate sizes and have had very low contracture rates over the years in my practice. If you are going to massage your implanted breasts, have your surgeon show you how he or she would like you to do it. The method is debatable as well.

Best Regards,

John Di Saia MD

Related:

Your Options With Capsular Contracture / Rock Hard Breasts

“I Have Hard 20 Year Old Breast Implants?”

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Plastic Surgery at Medi-Cal Rates – How Glamorous.

Plastic surgery is not always as glamorous as you see on television. Part of my practice has been the repair of wounds. Recently a wound care hospital at which I have seen patients called asking if I would see a patient. The patient’s HMO pays at Medi-Cal rates. For those of you who don’t know, Medi-Cal is California’s Medicaid program.

Medi-Cal rates amount to about half of Medicare rates which is essentially nothing. The practice barely squeaks through any profit on most Medicare business. I am always conflicted as to whether or not to see such a patient.

On one hand, I’d like to be of help. On the other hand, starting a trend at which doctors care for patients at less than overhead is part of what brought us to where we are today.

Best Regards,

John Di Saia MD

Originally posted 2011-04-27 07:30:57.

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Hospital Administrators Are Not Always Honest

I used to do emergency work at a hospital in a large chain. It was hardy profitable and became less so over time. When I moved an hour away I sought to limit my emergency exposure for obvious reasons. The hospital administration cited sections of the Bylaws and Rules and Regulations that mandated that surgical specialists take call. This was specified for Plastic Surgery and Orthopedics.

Later and entirely by accident, I found out that the Orthopedists were being paid to take this emergency call by the same administration that was citing those hospital documents. Essentially they were being paid to take call from 15 minutes away whereas I was required to take call for free from four times the distance. Needless to say I dropped that hospital after briefly entertaining legal action. So soon after my divorce I hardly wanted to enrich another attorney. They are much smarter about getting paid than physicians are. I did inform a contact at the local newspaper who passed on the story stating that the public doesn’t really care if a doctor gets screwed over. I found that a bit amusing.

As the story evolved I extended my practice up the street not so far away and something similar almost happened again. This time the administration in my new acute care hospital sought to get into an arrangement with me to take call. They were very quick to stipulate that this arrangement was to be secret. It was to involve some kind of payment from the hospital. The thought left a bad taste in my mouth. Emergency call is a loser. I just stopped taking it.

The moral of this story is that you should not expect hospital administrators to be honorable people. Entering into any kind of business arrangement with them especially a secret one is liable to be unfair, unjust or just plain illegal. You might want to avoid that.

[Originally written for and published on FreelanceMD.com:

http://freelancemd.com/blog/2012/5/28/hospital-administrators-are-not-always-honest.html]

Best Regards,

John Di Saia MD

Originally posted 2012-06-11 07:30:29.

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Ugly Plastic Surgery – Thigh Wound Skin Grafts

From my Instagram here is a series of images of a man’s thigh with wounds from drug abuse and infection over years.

“Skin popping” refers to the practice amongst drug users of “popping” the skin with needles filled with their drug of choice. The needles these people use are often not very clean and result in skin infections and at times open wounds. This man’s legs show years of wounds with poor quality healing resulting in scarring (white spots) mixed with newer open wounds from more recent injury.

Two wounds on the pictured leg were cleaned surgically (debridement) and grafted with shavings of the patient’s skin. In one image the grafts appear covered with foam dressings (stents) awaiting adherence before stent removal. The third image is of the newly adherent and healing grafts. Without graft surgery these wounds would have taken months if cared for properly under ideal conditions to heal. This is not pretty cosmetic plastic surgery, but is rather a needed and underpaid aspect of plastics that fewer and fewer plastic surgeons practice.

Best Regards,

John Di Saia MD

Originally posted 2012-08-17 07:30:12.

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Dr D in a Prius Poll?

Initial Post 11/3/11 7:30 AM -

Hello all,

I am thinking of changing my ride. The idea of driving a Prius appeals to me. I get to use less gas which makes me feel a bit better about not contributing so much to our pollution and gas industry problems. There are a few environmentalist quirks I picked up as a Berkeley undergrad. :) The nerd in me likes efficiency and with the miles I drive I might need to stop less frequently. Some of the docs around me have commented that they are not so sure my clients will take well to their plastic surgeon driving a more green machine however.

So you can vote on it:

<a href="http://www.sodahead.com/fun/should-a-plastic-surgeon-like-dr-d-drive-a-prius/question-2259327/" title="Should a Plastic Surgeon Like Dr D drive a Prius?">Should a Plastic Surgeon Like Dr D drive a Prius?</a>

Update 9/26/12 – I have had my Prius for nearly a year and really love it. It is not a really sexy ride but I have been over that for years. It has been reliable and not stopping for gasoline so much has been pretty cool. The AC could be a bit stronger, but otherwise I am happy.

Best Regards,

John Di Saia MD

Originally posted 2011-11-03 07:30:41.

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Talking to Your Plastic Surgeon

Once in a while I hear a patient complaining about her inability to communicate with her plastic surgeon. Not everyone can be a Dr D patient you know. :) The truth be told, I do not always have all the time in the World to talk either.

There are some facts that contribute to the tendency for surgeons not to always be so free with their “talking time:”

(1) We get paid to operate. Examining a patient is important, but talking over and above a certain amount is actually counter productive. I break this rule frequently which might explain why I am in solo practice. :)

(2) When we need to talk, the topics are not always so wonderful. I have had long conversations about how what a patient says she wants is actually risky and likely to fail. This is the ultimate in revenue negative when we talk about why you shouldn’t have surgery. Remember rule #1?

Life isn’t always dollars and cents, but remember I do cosmetic and reconstructive plastic surgery. In my latter capacity, I need to move around quite a bit to make it work.

It as absolutely true in modern medicine that the things that patients want pay much better than the things they need. And surgeons have more overhead to pay.

Best Regards,

John Di Saia MD

Originally posted 2012-09-12 07:30:15.

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Low Maintenance Breast Implants – Are They Doable?

Low Maintenance Breast Implant

Surgery – Is this achievable?

Reader Question:

I am looking into getting breast implants but want to keep redo surgeries to a minimum. Some of my friends have had 2-3 boob jobs in ten years, so I am not going to their doctor. I saw a few of your patients online saying that the implants you put in they kept for ten years. I want to get a worry-free boob job?

Thanks for the compliment.

There are several things you can do to reduce your risk for the need/desire for re-operation after breast implant surgery:

(1) Have surgery by a good qualified surgeon. In my book, that means a good ABPS board-certified plastic surgeon.

(2) Request guidance from your surgeon regarding the volume to which you can go safely. The leading cause of poor outcomes with implants that I see is the placement of implants too large for a woman’s available soft tissue coverage. Good surgeons know this although many fear “losing the case” if they share their concerns.

(3) Choose saline-filled implants and have them placed beneath your pectoral muscles. Silicone gel is another option but I feel the breast hardening rate (capsular contracture} is higher with them. Capsular contracture is also higher in some other cases that you may want to review before surgery.

(4) If you have any degree of breast sag, talk about breast lift surgery as an option before you have your operation.

Best Regards,

John Di Saia MD

Originally posted 2011-04-22 07:30:34.

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Dr D an Aging Athlete and the Statin Question – Statin Every Other Day? III

Statins are so positively heralded in the medical literature and had kept my LDL cholesterol low for eight years, it seemed that it made sense to try to stay on them. So one of my first manipulations to get rid of the muscle pain was to try to alternate a every other day Statin with an alternative drug:

So 20 mg of Atrovastatin every other day with alternative days on fenofibrate at 145 mg:

Total Cholesterol: 155
LDL Cholesterol: 86
Triglycerides: 140

HDL Cholesterol: 41

My Creatinine Kinase bumped to 222 (44-196) on this regimen though and my muscle pain was intermittent, but still present so the equation was not quite right yet.

Best Regards,

John Di Saia MD

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Reader Question: Help My Seroma Won’t Go Away!

I had a tummy tuck two months ago. Now I have a little water-filled “pouchie” above my couchie where the water waves move when I poke it. My surgeon says it is not a problem and will go away. Should I be worried?

A seroma is a lymph filled pocket in your soft tissues. We are most aware of them when they are just under the skin as they can demonstrate a “fluid wave” phenomenon when they are tapped. Larger scale surgery is more of a risk toward the formation of a seroma and tummy tuck surgery is included.

On the positive side, these things tend to resolve when small and wounds are newer. The longer they manage to persist, the greater the chance that they will not go away, but rather form a scarred in cavity that will tend to stay. In a worst case scenario they can require surgery to fix. Alternate treatments include draining them intermittently with a needle or with a drainage tube or injecting them with a chemical to encourage them to shrink or go away. Opinions as to how often or urgent treatment of a seroma is vary substantially. Left alone they can mar good tummy tuck results, so I like to deal with them quickly. My tummy tuck results have benefited by this policy by my way of thinking. I haven’t needed to re-operate to repair one in over ten years.

Seromas are best avoided. The best ways to do this involve the proper use of drains and compression garments after a large scale operation as well as tailoring that operation to be less risky.

Best Regards,

John Di Saia MD

Originally posted 2011-06-09 07:30:09.

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The Plastic Surgeon versus Cosmetic Surgeon Turf War

Most patients are comfortably oblivious to the wide open nature of cosmetic surgery and the doctors who perform it. There are no laws against doctors of any level or type of training in cosmetic surgery opening their private clinics to the masses and performing surgery. The question of what training is really needed to entitle a doctor to perform this kind of surgery is hotly argued in many cases by the same doctors who wish to garner your business.

Board certification often comes into play. The problem is that there are many boards and relatively little oversight. I have been criticized by those representing cosmetic doctors for my lack of respect for their prowess. It is often hard to respect a doctor with little if any verifiable training who purports to be my equal. Unfortunately for consumers their experiences often can be subject to trial and error as they wade through the marketplace.

My point of contention is and has been that doctors who have not completed residency training and have not been certified by verified ABMS (American Board of Medical Specialists) boards that include cosmetic work in their residencies are not good bets for their patients. Inspection of your prospective surgeon regarding qualifications before surgery is an absolute must if you want to maximize your potential for a good outcome. News stories that have run recently have reinforced this point a great deal.

Best Regards,

John Di Saia MD

Related:

Credentials in Plastic Surgery

Originally posted 2011-01-07 07:30:03.

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