Update: Safe Medical Cosmetic Surgery

Dr Goldman’s professional opinion on this very serious and dangerous situation

The recent case of a young woman who had a cardiac arrest in a Sydney clinic while undergoing a cosmetic procedure (breast augmentation) once again highlights the fact that safety is paramount. All else is secondary.

The operation was performed under local anaesthetic with intravenous sedation. According to the published article, a specialist anaesthetist was not present. The assumption is that the doctor performing the surgery also administered the sedation and local anaesthetic. Doctors regularly give local anaesthetic but can also give the intravenous sedation as well as performing the surgery. This should not be performed if a significant surgical procedure is being done. The correct medication at the correct dose is essential for a safe level of sedation and anaesthetic to enable an operation of this nature can be performed. It also requires appropriate monitoring of the patient’s breathing, heart and circulation. This is impossible to do safely if the doctor is also performing the surgery with the required level of concentration.

Local anaesthetics are schedule 4 drugs with significant potential risks and side effects. In addition, they often also contain a drug called adrenaline, which has a potent effect on the heart and circulation. Adrenaline is also a natural hormone. All these local anaesthetics have a maximum safe dose that cannot be exceeded. The effects of excessive doses of local anaesthetic administered to a person will often cause generalised seizures of the type that occurs in a patient with epilepsy. However, more dangerously, excessive doses of local anaesthetic can initially cause irregularities of heart beat but also a cardiac arrest.

Although it is possible that a particular person has an unknown sensitivity to a particular local anaesthetic drug or even adrenaline, or has an unknown medical condition that can contribute to such a sensitivity, it is far more likely that the maximum safe dose was exceeded in the case in question, without the appropriate monitoring. The reason for this opinion is that the first side augmentation had already been completed and the cardiac arrest occurred during the surgery on the other side. If appropriate monitoring was in place, alarms would have alerted the doctor (better still, the anaesthetist if present) to the fact that the heart rhythm had become irregular. Further, in these situations, there can often be a fall in the blood pressure which would have triggered alarms on the monitoring equipment if present.

None of this occurred according to the published report.

Credentials and accreditation requirements for clinics in Australia

There are a number of cosmetic operations that are often performed in “clinics” that are not subject to the same level of credentialing and accreditation that mainstream hospital are.

The Australian Council of Healthcare Standards (ACHS) is the national organisation that maintains standards in Australian hospitals. Hospitals with IVF and laboratory facilities have to comply with other credentialing organisations in addition.

The philosophy of ACHS is as follows:

“We’re an independent, not-for-profit organisation dedicated to improving quality in health care.  Our Council represents governments, consumers and peak health bodies from throughout Australia.

We are Australia’s leading health care assessment and accreditation provider.

Our mission is to improve the quality and safety of health care.

We develop performance measures with industry and deliver quality improvement programs.”

– Last Review Date 27 May 2014

Hospitals are compulsorily part of this system. It is imperative to apply this same credentialing authority to ALL facilities that perform significant and invasive medical and especially surgical procedures in Australia in order to ensure the safety and quality of healthcare (and procedures) across all segments of the healthcare industry in Australia.

It is inconceivable and illogical to apply these standards to one segment of the healthcare system but allow a large, unregulated alternative set of facilities to provide invasive medical/surgical procedures completely without standards/levels of compliance/quality and safety of healthcare to be assessed and measured.

It is well known that there are a litany of procedures that occur in unregulated facilities in terms of the administration of various forms of anaesthesia from local anaesthetic to local and intravenous anaesthetic all the way through to general anaesthetics.

The performance of a variety of surgical procedures ranging from mainstream surgery (vasectomy, termination of pregnancy, excision of various benign and malignant skin lesions), various cosmetic surgical procedures (for example breast augmentation, liposuction plus others) and various dental procedures.

There are ample reports in the press and other media (coronial inquests) regarding very serious life threatening complications such as seizures, cardiac irregularities even cardiac arrest, catastrophic bleeding, severe and life threatening infections, and DEATH.

These extreme events have occurred in ALL the procedures mentioned above. The most recent event was reported as recently as Friday January 27th 2015 in the Sydney Morning Herald. There have been liposuction deaths in “unregulated” clinics in Australia in the recent past few years. Other complications were a death in a dental clinic related to unexpected and uncontrolled bleeding in a woman after a simple dental extraction. This woman had a particular bleeding disorder and was on blood thinning medication.

There have also been three reported liposuction-related deaths over a three year period in the recent past in Australia. Two of the three were from unrecognised bleeding after the surgery while the patient was in the recovery area. The third was from unrecognised perforation of the abdominal muscle wall following liposuction within the abdominal cavity, resulting in multiple intestinal perforations.

Preventable complications with greater regulation

These are dramatic and catastrophic complications that were ALL preventable if better, closer monitoring and more regulated healthcare facilities and services were in place across all levels of facility.

Unfortunately, this is not the case in the Australian healthcare system overall. Certain aspects of the Australian healthcare system are very well and adequately regulated (examples are the mainstream hospitals, all aged-care facilities, which also have federal healthcare regulations, general practitioners, all specialists, dentists and dental specialist nurses, allied healthcare professions). This is NOT an exhaustive list.

The crux of the problem at hand is the following:

Various levels of surgery are performed out of the mainstream regulated healthcare facilities. On occasion, these clinics and facilities will have other quality designations that DO NOT comply with the currently accepted healthcare regulatory requirements. These are used to allay the fears of the uninformed public.

Every surgical procedure and every form of anaesthetic carries risk, these risks can be life threatening and must never be underplayed. The common complications relating to anaesthesia all relate to overdose of these drugs with toxic effects on the brain (seizures), the heart (irregularities of heart rhythm and cardiac arrest in advanced and unmonitored/inadequately monitored cases), a fall in blood pressure/low blood pressure which contribute to the heart effect as well. In addition, the same drugs can inhibit the breathing mechanisms. There are extremely rare cases of allergic reactions to anaesthetic drugs that can be completely unpredictable. These are far less common than the administration of far too much local anaesthetic.

Further, a number of these clinics will also use intravenous sedation drugs in addition to the local anaesthetic. These drugs all also cause depression of the respiratory (breathing) mechanisms and can cause breathing to stop (respiratory arrest).

Some of these clinics and facilities will employ the services of a registered anaesthetic specialist. This will often negate the above mentioned anaesthetic complications. Unfortunately, the majority of such facilities do not employ specialist anaesthetic services for a number of reasons including attempts to reduce the cost of these procedures.

Lastly, the surgical procedures like breast augmentation, liposuction (in almost all forms), vasectomy, skin lesion removal to name a few are often performed by medical practitioners (doctors) with qualifications, training and experience that is inadequately regulated and poorly controlled. A significant number of these doctors are not registered specialists. Some are GP’s with a “cosmetic training”. Some are registered as GP’s in Australia but may be specialists from their country of origin but not registered specialists in Australia. Some of these “non-specialist” doctors are working under the training and supervision of Australian trained, registered and practicing specialists who only loosely supervise these doctors under their control.

The basic medical degree and qualification is called a Batchelor of Medicine and a Batchelor of Surgery (MB.BS) depending on the country of origin. We have inherited a version of the British medical system. This has led to the current situation and difficulty because it means an individual who is a licensed medical practitioner (a doctor) has a degree that “qualifies” the individual to practice medicine and surgery without meaningful registration.

It is now time for  all the Australian Healthcare jurisdictions to come together with important stakeholders ( limited, important and workable) to regulate the entire healthcare industry including cosmetic, dental, allied, alternative, ancillary and mainstream (medical and nursing). If this does not occur, more young, fit and healthy, unexpected and preventable deaths WILL occur.

It has to be about public safety first and above all else. Better compliance must become mandatory to protect the health and wellbeing of Australians undergoing medical and surgical procedures in all segments of society.

Dr Goldman’s Cosmetic Clinics: Safety Practices & Accreditation

Dr Goldman will only perform surgery in fully accredited hospitals with a specialist anaesthetist providing the anaesthetic (general anaesthetic or local anaesthetic with intravenous sedation). All of Dr Goldman’s cosmetic procedures are done in a certified hospital operating room with ALL the appropriate safety and monitoring in place. In addition, this safety and monitoring continues after the anaesthetic, in the post-surgery recovery area and out into the ward until it is safe for discharge home. Learn more about Dr Goldman’s professional accreditation.

What is the Most Effective Hair Removal Treatment? Laser, IPL & Others

Shaving, waxing, hair removal creams (aka depilatory creams), electrolysis, IPL (Intense Pulsed Light) and laser are all used to get rid of unwanted hair.

Those who shave, wax, use creams or electrolysis to keep up with hair removal maintenance are all too familiar with the need to keep repeating these techniques as the hair grows back – a time consuming process that is also rather expensive over-time.

Permanent Hair Reduction / Removal

To remove the hassle of repeated maintenance, it is becoming more and more popular for people to opt for permanent hair reduction treatments – the best of which are IPL and laser. When talking about these treatments it can be a little misleading to use the term ‘permanent hair removal’ as this implies that hair can never grow back. It is impossible to give the guarantee that a hair removal technique (at this time) is permanent. Permanent hair reduction is achievable however, and the process is so advanced that the hair reduction is so significant that any further maintenance or upkeep is substantially reduced.

hair removal wax

Old fashion hair removal wax

IPL is best, but all IPL Treatments are not equal

IPL is currently viewed as the best technique for the removal of unwanted hair, and in certain circumstances, can result in permanent hair reduction. However, a word of caution is essential: there are MANY different types of IPL systems and machines available today, and they are not all created equal!

They all claim to offer ‘Intense Pulsed Light’ technology, but some take the ‘intense’ part of this term loosely, and so are not particularly effective. Professional IPL systems and machines are highly powerful and require professional training to use safely and effectively, but it also possible to purchase ‘home IPL devices’ in a large range of retail outlets, and the effectiveness of these machines is rather questionable – many using ‘intense pulsed light’ without the required physical light characteristics that actually makes IPL treatment effective.

Characteristics of a safe & effective IPL treatment

What characterises an effective light based therapy for the permanent reduction of unwanted hair is the following:

Focused on the follicle with no surrounding damage: The light used must be of a particular characteristic (wavelength and power), that will be absorbed by the pigment in the hair follicle (root of the hair) without damaging the surrounding structures such as nerve endings, small blood vessels and oil and sweat glands.

No wasted light: A good IPL platform that is capable of delivering a light filtering system that can effectively ‘narrow down’ the wavelength of the light beam and remove the other light wavelengths that are not effective in being absorbed by and therefore target the hair follicles. Most IPL based systems do not have these filtering systems and although may have the required power output, have a number of wavelengths that are of no use and therefore not effective in being absorbed by the hair follicle (i.e. ‘wasted light’).

Effective on all skin & hair types: An effective IPL treatment must be capable of treating all skin types and all hair types. The less effective IPL systems are not powerful enough and the light wavelengths are not narrow enough to be useful in permanent hair reduction. It is important to note here, however, that grey hair cannot be treated by any system as grey hair has no pigment to absorb the light and therefore, no light based system is effective for people with grey hair).

Power + Focused Wavelength for minimum sessions: The IPL system and professional you go with must use the correct power together with the correct and narrow wavelength to get you the most effective hair reduction result per treatment session in order to achieve permanent hair reduction in the minimum number of treatments.

Why we use the Alma Laser Harmony XL IPL Platform

Dr Goldman uses the Alma Laser Harmony XL platform for IPL Hair Removal (with the SHR Pro hand-piece) that fulfils all the above criteria. The light pulse from the Harmony XL is filtered to a very specific and narrow wavelength (light beam) by a complex system trademarked by Alma Lasers. As this is an actual laser platform, the filtering system removes the ineffective wavelengths from the light beam generated by the machine and only allows through the particular light that is most effective in hair follicle destruction. In addition, as this is an actual powerful laser system, it is capable of generating the required power output for the most effective hair reduction system in Dr Goldman’s opinion.

As this particular form of permanent hair reduction is delivered by a laser and not an IPL machine, this is called Advanced Fluorescence Therapy (AFT).

It is not the same as any ordinary IPL treatment; it is far more effective in permanently reducing unwanted hair.

There are a number of other very special and trademarked features that enable the Alma Lasers Harmony XL Laser to achieve the very high degree of success in permanent hair reduction, including:

  • The ‘In MotionTM’ technology that allows the therapist to use the machine in a continuous ‘in motionTM’ technique. This is in contrast to all the other IPL systems that use a ‘point and shoot’ technique. The result is that the treatment time using Alma Lasers system is much shorter so each treatment is quicker and thus far more comfortable
  • An in-built cooling system that also makes the treatments more comfortable
  • Far fewer treatment sessions required to achieve the desirable outcome of permanent hair reduction
  • Due to the above 3 points, the overall cost is usually lower than a number of other IPL hair reduction systems.

Feel free to contact Dr Robert Goldman for hair removal treatment that works.

Breastfeeding & Breast Surgery

During pregnancy, the hormone changes that women undergo are designed to prepare for the expansion of certain parts of the body – mainly the hips, abdomen and breasts.

This results in the loosening or softening of skin, muscles, ligaments and certain joints, preparing the woman for the pregnancy and subsequent childbirth.

In the next series of blogs, I will address many of the issues that women wish to explore related to body changes and pregnancy. I will focus particularly on the breasts and abdomen, as these are the two most common areas that women tend to feel unhappy about and come to discuss with me following pregnancy.

In this, the first article in the Cosmetic Surgery & Pregnancy Series I will focus on cosmetic breast surgery and pregnancy. The next will be about the changes to your abdomen, and finally an article about general body changes during pregnancy and some non-cosmetic procedures that can often help.

Breast Augmentation (Implants) and Pregnancy

There are a number of aspects regarding breast augmentation and pregnancy that women often ask me about – mainly the ideal timeframe between the surgery and pregnancy and vice versa, as well as what can be done to repair sagging breasts after having children.

pregnant mother

My advice is always the same: it’s important to have all the information that will allow you to make a decision about what is best for you. During a breast augmentation consultation meeting I usually discuss all the changes that occur during pregnancy and give you my opinion about what I think is best for you depending on when or if you have had or intend to have children. Once you are educated with all the necessary information I will ask you to think about what’s best for your situation, and if you still want to go ahead I’m happy to book an operation.

Need to Know: Changes to the Breast During Pregnancy & Breastfeeding

The non-pregnant breast consists mainly of fat with a much lesser breast gland component. This is regardless of whether your breasts are small, average or large. With the hormonal changes during pregnancy, the breast gland component dramatically expands (in preparation for lactation) at the expense of the breast fat. So by the end of pregnancy the breasts are usually very enlarged, heavy and often painful.

After delivery and once breast feeding has ceased, the hormonal profile returns to your pre-pregnancy state. This results in the breast gland once again reducing in size. Unfortunately, however, the breast fat does not return to its previous state. Coupled with this, the breast skin has expanded to accommodate the enlarged breasts during pregnancy, and now that the gland has reduced in size and the breast has lost some fat volume, the breasts tend to droop.

Should I have a breast augmentation even if I plan on having children soon?

These changes to your breasts do become worse and more pronounced the longer you breast feed for and the more children you have. Therefore, it is important to be aware that if you do have a breast augmentation prior to falling pregnant, you will still likely experience similar problems with drooping after the breast gland has expanded, stretched the skin and then contracted.

This is unfortunate, especially if you have just gone through the expense and risk of a breast augmentation.  Ideally, in my opinion, the timeframe between your augmentation and pregnancy should be around 2 or more years.

I have just had a baby, when can I have a breast augmentation?

The next issue is the timeframe between delivering your baby and having an augmentation. Ideally, you need to wait until your baby is 6 months old. This is the time it takes for the increased blood supply that occurs to prepare for lactation to reduce to the pre-pregnancy state. A breast augmentation performed too early increases your risk of bleeding and, on rare occasions, may result in milk leakage out of the surgery wound.

Will I be able to breastfeed if I have a breast augmentation?

A breast augmentation does not in itself result in a woman not being able to breastfeed. Research shows that about 50% of women who have had a breast lift or reduction are unable to breastfeed. This may be because these procedures involve cutting into the breast gland structures. However, what many people don’t take into account is that there are a significant number of women who are naturally unable to breastfeed. If a woman hasn’t had a child before having a breast augmentation, then it is unknown whether she had the ability to breastfeed to begin with.

The bottom line is, if you have a breast augmentation before having your first child, only time will tell if you will be able to successfully breastfeed or not.

Breast Lift (Mastopexy) and/or Augmentation After Pregnancy

The changes to the breasts during pregnancy (discussed above) almost always result in the breasts losing volume and becoming ‘droopy’, so a common question from women who have already had a number of children is what can be done to return the youthful and perky appearance of their breasts.

The most popular option is a breast lift – either with or without an accompanying augmentation (implants). The choice between a lift with or without implants will depend on the result you want. A simple breast lift (simple mastopexy) will rearrange the breast gland structure – moving it higher up the chest – and reduce the excess skin on the breast. This results in small but shapely and perky breasts. If a fuller look is desired, a breast lift can be performed with implants simultaneously.

Unfortunately, this operation does not always result in a long-term solution. Breast droop is a natural phenomenon with time/age/gravity. It is not preventable. Some women are fortunate in that the breasts’ supporting structures and ligaments delay droop while with other less fortunate women, droop occurs early and easily. This applies to both the natural state of the breasts as well as after a lift. It is estimated that droop after a lift procedure can occur as early as 3 years after the surgery (with the lesser “donut” lift) or 5 to 7 years after the “classic” breast lift.

Breast Reduction (Reduction Mammoplasty) after Pregnancy

A breast reduction is a much more durable operation than a breast lift, often lasting in excess of 10 years before droop sets in again. Depending on the desired results, a breast reduction can involve the removal of minimal breast gland tissue or a large amount of breast tissue, as well as a removal of excess skin.

It is actually also possible to perform a breast reduction with implants simultaneously – the implants here of course are more for shape than size. Ultimately, a breast reduction may be considered as the “perfect lift”.

The incision and scarring pattern with a this procedure (breast reduction with implants) is the same as that involved in a breast lift or a breast reduction. It is known as a “lollipop” scar – with an incision made around the areolar (pigmented) skin and down the front of the breast into the crease under the breast.

To further discuss your options feel free to get in touch with us or book a consultation with Dr. Goldman.

Labiaplasty: The What, Why & How

An operation to reduce the size and conspicuousness of the labia minora or inner labia.

This is the operation that will result in the inner lips not protruding from the “outers”. An overall more “tidy” appearance is the result with improved personal wellbeing and confidence.

Labiaplasty has suddenly exploded on the scene. This procedure is rapidly becoming one of the most commonly sought after surgical procedures for women. Social anthropologists are studying the reasons why this should be. I think the following issues are contributing to this demand. Firstly, the popularity of the Brazilian wax has resulted in women visualizing their labia. Prior to this, “things” we’re hidden and not easily seen. The next issue was the widespread access to certain “genres” of website where women could, for the first time, see images of potentially thousands of other women who were ” neat and tidy”. Result: I want to look like that!

Young women

On a serious note, labialasty in its modern form has been around for some 30 years. Experts who write on this subject initially recommended certain criteria be fulfilled before this surgery could be recommended. Firstly, the maximum length if the labia minora should be more than 4 cm. Next, the labia minora should be inhibiting certain aspects of daily living for example, the discomfort associated with certain physical activities and sporting pursuits. These include exercise, bicycle or horse riding, exercising in a gym, going to the beach, the inability to wear tight jeans, discomfort with intercourse and worst of all, the labia ” getting in the way of the urinary stream” with resulting “spraying”. So, these were the traditional indications for the surgery.

New Procedures

In modern times, I believe that if a woman attends a consultation and requests this surgery, this is sufficient indication provided certain criteria are met. For example, there must be no underlying gynaecological conditions that would preclude this surgery, it must be the appropriate surgery for the appropriate reasons typically the labia minora protrude significantly beyond the labia majora or outers and that the expectations are appropriate.

More recently, additional surgical procedures are being requested at the same time as the labiaplasty. Commonly, clitoral hood reduction where the clitoral hood is surgically trimmed back, typically only around 1 to 1.5 mm to slightly increase the clitoral exposure so as to enhance the sexual experience.

This surgery is being requested by both young and middle aged women. In my practice, this ranges currently from age 18 to 54. The motivations are always the same. However, in the slightly older group, other rejuvenation techniques are becoming popular. It is worthwhile considering that the “skin and other tissues” of both labia majora and minora( outers and inners) are subject to the same degenerative processes as the rest of the body and that as part of a labialasty assessment, Dr Goldman and Keris Gordon, cosmetic nurse, will assess the potential issues of volume loss of both labia majora and minora structures. It is now possible to consider the administration of hyaluronic acid products (so called facial and lip fillers) to rejuvenate the labial structures to result in a more youthful appearance with resulting enhanced personal confidence as well as sexual experience.

The Future: Designer Vaginas

Currently in Beverley Hills, the concept of the “designer vagina” has appeared. This is combination surgery that  involves labiaplasty, clitoral hood reduction, G-spot enhancement vaginal “tightening” and rejuvenation using fillers. This vaginal tightening  procedure is nothing more than a refinement of the classic operations for prolapse. The difference is that the tightening operation as well as the other components are performed with laser as opposed to traditional surgery.

As with a number of issues, Australia lags behind the United states by a number of years. We at catching up rapidly.  Currently, Dr Robert Goldman performs a large number of labiaplasty operations and is now combining this with other rejuvenation techniques to enhance the youthfulness of this anatomy. We only perform the “wedge” operation.

Interested in labiaplasty or vaginal rejuvenation procedures or simply want more info to make a better decision then feel free to contact Dr Robert Goldman.

Cosmetic Surgery Tourism Disadvantages

The growing trend to undergo cosmetic surgery in places such as Thailand, the Philippines and Malaysia is based on cost saving mainly but also the “promise” of a holiday.

The truth is that people who go overseas are subjecting themselves to various risks. The risk of DVT (deep vein thrombosis) is increased for 6 weeks after any surgical procedure and so the flight back to Australia carries a real risk of DVT or worse, pulmonary embolus – lung clots, which can be life threatening. Yet another reason not to go to Thailand! Martial Law was declared in Thailand on 20th May 2014. Do you want to have surgery in a country with such political instability and riots. Think again.

There is minimal or no consent process; women undergoing a breast augmentation may undergo a breast lift at the same time, with the resultant scarring, without this having been discussed properly. There is no follow up unless clients go back overseas; Australian Specialists are reluctant to take on clients who have had their surgery overseas.

holiday pool woman

Especially related to breast augmentations, Asian surgeons tend to undersize western women mainly for cultural reasons but the more important aspects are that women are rarely involved in the choice of implant including size,shape and style. Finally, the surgeons almost universally place implants in the subpectoral plane or behind the pectoral major muscle. This is not natural as the implant is placed into the incorrect body plane. Further, it is destructive as far as the pecs are concerned.

The end result of under the muscle breast augmentations is that the breast droops off the implant as it cannot move with the breast (held in a fixed position by the overlying muscle).

As a high number of women will require corrective surgery, there obviously will be significant costs over and above the costs of the initial surgery: If you cannot afford to undergo the surgery in Australia, how are you going to afford the revision ( corrective ) operation that will often be necessary. If you needed a heart bypass or a cancer operation,would you choose to go to one of these overseas venues because it is a cheaper option?

Dr Goldman will be setting up an alternative destination (Australian) to the overseas “ medical tourist “ destinations and industry. We are not offering a discount service, rather a high quality Australian Specialist Surgical Service with all the appropriate assessment, licensing, consent, surgery and follow-up processes that one would expect from an Australasian College of Surgeons specialist.

There are going to be women as well as men who are very happy with the outcome of their surgery overseas. However, as a specialist in Australia, I see a very significant number of unhappy clients.

Breast Implants: Under vs Over Muscle

Why I do not place breast implants under the muscle!

I explain why I do not place breast implants behind the pectoral muscles in terms of how the breast develops, the anatomy of the breast, muscles, muscle nerve supply, breast changes over time and some of the surgery.

Breast development and Anatomy

By placing breast implants behind the pectoral muscles the surgeon is failing to take into consideration the origin, development and structure of the (female) breast.

The breast is a modified skin gland. It has it’s origins in a layer called the “ectoderm” this is one of the 3 primary layers that the developing human embryo develops from. It is the layer that forms all skin based structures including the breast, skin, sweat glands, hair, nails but to name some. The developing bodies muscle layer arises from the “mesoderm” or developing muscle layer. It is a separate structural and functional body layer.

Many surgeons both here in Australia as well as overseas perform submuscular breast augmentations. Unfortunately, the Thailand surgeons almost exclusively perform submuscular breast augmentations.

The pectoral muscles of the chest have two components: the outer big pectoral muscles (pectoralis major) and the inner smaller (pectoralis minor). Submuscular breast implants are placed either behind the pectoralis major muscle or worse, behind both muscles. There is a variant of this technique what is called; “The Dual Plane” placement.

Disadvantages of submuscular breast augmentation

Some surgeons will use an incision in the armpit ( axillary incision) while others will use an incision in the crease underneath the breast ( infra-mammary). Either way, when a surgeon intends on performing a submuscular breast augmentation, a pocket must be created for the implant BEHIND the pectoral muscles. If the surgeon is using an infra-mammary incision, the lowermost attachment of the pectoral muscles to the ribs must be cut to enter the natural tissue plane under the muscles.

The muscle is then lifted off the ribs to create the pocket. If the surgeon uses the armpit approach, the lowermost attachment of the muscles are left undisturbed but the implants will sit too high on the chest as the breast implants are “pushed up” by the strong attachment of the pectoral muscles as well as the ligaments of the infra-mammary crease.

Busting the 7 Biggest Bust Myths

Running out of the chest, from between the rib space, are the two nerves that supply the pectoral muscles, called the medial and lateral pectoral nerves. These are either stretched as they are moved sideways to accommodate the implant or worse, these two nerves are even cut as part of the pocket creation.

This together with the need to cut the lowermost attachment of the muscle itself results in a process called atrophy. This means thinning, weakening and wasting of the pectoralis major muscle. Women may often notice this effect as a degree of upper body weakness.

Now, the pectoral major muscle also has an attachment to the collar bone at the top and the edge/side of the breastbone (sternum). The anatomy of these muscle have more significant effects on the result and outcome of breast enhancement /augmentation.

A pocket for breast implants behind the muscles lifts up this muscle and because it has its uppermost attachment to the collarbone, the “breast” looks too high on the chest. Next, as the pocket is behind the muscle and this then is attached to the side of the breastbone, the breasts look “too wide apart” this results in an undesirable and un-natural looking cleavage.

On occasion, with the incision underneath the breast and a submuscular implant placement, the bottom cut edge of the muscle can become visible. On contracting the pectoral muscles, the contraction pulls the implants and the breast up and outwards.

All these issues are very far from natural and the appearance and functionality of the breast are very unnatural. Despite all of this, the single and most important reason why submuscular breast augmentations are not the natural and desired procedure, is that all women’s breasts will, over time, droop off the implants as the implants are held in a fixed and unmovable position by the pectoral muscles. It is essential that the implant is part of the breast, moves and behaves exactly as the breast does, an impossibility with submuscular breast augmentations.

Lastly and specifically related to the surgery, the overall risks and complications are greater, the re-operation rate (need for corrective surgery) is almost universal and finally, the postoperative pain levels with a muscle-cutting operation are severe necessitating possibly up to 5 days of bed rest, very strong analgesics ( pain killers) and a prolonged downtime.

Advantages of submuscular breast augmentation

Almost none! However, the under the muscle operation was developed some 30 or more years ago when the quality of breast implants was very poor compared to the high quality, soft, natural feeling breast implants used today.

With the older style breast implants, particularly in petite, flat chested women, it was far more natural to place these implants behind the pectoral muscles so that the breast implant could not be seen or felt. With today’s modern, soft, very naturally feeling breast implants, this is no longer the case.

The anatomical, developmental and functional aspects of the breast as discussed above form the basis  of why Dr Robert Goldman almost never will perform a submuscular Augmentation Mammoplasty (breast augmentation).

Need more information regarding breast implants, augmentations or reductions? Contact Dr Robert Goldman for a discussion of your needs and circumstances.