Philadelphia -- There is no single answer to the question of the best approach to breast augmentation and mastoplexy breast lifts, according to the moderator of a panel discussion at the Symposium on Body Augmentation and Contouring, held here recently and sponsored by the American Academy of Cosmetic Surgery.
Philip C. Bonanno, M.D., professor of surgery and director of the Institute of Aesthetic Surgery and Medicine at Northern Westchester Hospital in Mt. Kisco, N.Y., said the discussion, which included surgeons E. Antonio Mangubat, M.D.; Richard T. Caleel, D.O.; E. Gregory Smith, M.D., D.D.S.; and Robert Shumway, M.D., highlighted a spectrum of experience with multiple approaches to breast augmentation.
The combination of the augmentation mammoplasty and mastopexy--and whether this was a procedure that should be staged, or combined--generated a lot of discussion.
"There was no unanimity of opinion, which is good," Dr. Bonanno said. "That means there are judgmental aspects of this surgery. You can't say there is only one way to go.
"The variety of approaches included some of the more standard ones: infra mammary, transaxillary, and peri-areolar, but with a fair amount of interest in the TUBA--the transumbilical breast augmentation. Everyone of these procedures is designed to have the surgical scar be the least conspicuous, and there is a great deal of emphasis on the TUBA."
The surgeons did find common ground on other issues, however:
- The presenters agreed on the importance of avoiding trying to satisfy unrealistic requirements on a patient's part, vis a vis the size.
"It's the physician's responsibility to tell a patient when her expectation on size is unrealistic," said Dr. Bonanno.
"If the patient discussion is--and I think this is rare--'I want to be big, I don't care how grotesque I look,'--I don't think that's a usual request. I think most people will say, 'I want to be big, but I want to be natural,'--and the surgeon has to say, 'This is how big you can be within these bounds, and still look natural.'"
- A patient who smokes is one factor that should raise red flags when it comes to doing surgery, the surgeons agreed.
Dr. Bonanno said most everyone thinks smoking is one criterion that needs to be considered strongly before surgery, because of its interference with wound healing.
"Some surgeons will ask the patient to stop smoking, and some patients will. If the surgeon chooses to operate on a patient who refuses to stop smoking, careful consideration should be given whether to do two procedures at once--primarily because of the wound healing problem."
- According to Dr. Bonanno, there is a consensus of opinion among most physicians--and he thinks most patients--who would prefer to see the silicone prosthesis available for breast augmentation surgery.
"The studies that have been done since silicone was removed from general use for breast implants showed that the concerns that were so widespread during the silicone prosthesis debacle fortunately have been unrealized on a scientific basis."
Dr. Bonanno thinks those studies be able to stand up to the types of lawsuits that were filed in the past.
"Those lawsuits were not based on science. Many, many lawsuits are based on junk science or no science, There is no arguing that some people are ill from something, but if one looks for a causal relationship between the illnesses and the prosthesis, to the best of my knowledge--and what is available to us as plastic surgeons--there has not been any conclusive evidence that there is even a hint of a causal relationship.
"Things happen. People get scleroderma or collagen disease, but the occurrence in the population that has silicone breast implants just doesn't seem to be a statistically significant difference from the public at large."
Despite the evidence, many of the doctors are reluctant to predict approval of silicone for cosmetic use. As Dr. Bonanno said, they're afraid it has become more of a political issue than a medical issue.
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