Q&A one-on-one with Dr. Ratliff

Although nothing can take the place of talking with a physician about breast augmentation, Dr. Greg Ratliff would like to share some of the questions he commonly hears from patients when they are considering breast enhancement surgery.

Dr. Ratliff has divided the information into three categories: Before Surgery, During Surgery, and After Surgery. You may access each of these sections of the Q&A by clicking on the links below, or you may start at the beginning and read all of the questions and answers.

Before Surgery ♦ During Surgery ♦ After Surgery

Before Surgery

Q: What size implant is the "right" one, so I won't be too big or too small?

A: Sizing implants is actually a complex problem. Different surgeons use different algorithms for arriving at the final size, but the common decision points are these:

Patient desire. If you want to be a DD size, by all means say so. During your consultation, the more precise you are, the better your surgeon can understand what your goal is.
Chest dimensions. To get to the same bra cup size, a tall narrow chest will require a different implant size than a short wide chest. The shape of the ribs also is important in how the implants project, or stick out (straight ahead or more toward the side).
The diameter (width) of the actual breast tissue. This is one of the main determining factors of appropriate size. As an example, if your breast measures 12 centimeters(cm) wide, implants from 11.5 to 12.5 cm wide would probably be appropriate. The diameter determines the amount of fluid the implant will hold.
The volume of the existing natural breast. If you are starting at a C cup, getting to a D cup takes less implant than if you are starting at an A cup.

All of these factors are weighed together to arrive at the "right" implant for a more predictable result for any given body. Beware of the surgeon who takes a quick glance at you and says, " Oh, I think a 450cc implant will work fine," without measuring or talking to you. The doctor is either an idiot or a genius, and we all know which there are more of in the world.

Q: I don't want a really wide (or really tight) cleavage. How do I avoid that?

A: Unfortunately, the distance between the breasts before implants is the same as the distance after implants. This is mainly determined by the width of the breast bone (sternum). If you push your breasts gently together and look at where they are attached to your chest wall in the middle, you can get an approximation of how far apart they will be after surgery.

Q: I want the really round implant look. How do I get that?

A: Usually one or all of three factors accomplishes this:

Large implants placed on top of the muscle under very thin or small breasts, leaving little or no coverage of the implant by anything but skin.
Very large implants placed under the muscle, also stretching the coverage so that it its very thin.
Capsular contracture. This is the most common complication of breast implant surgery and is basically a tight bag of scar tissue forming around the implant and squeezing it into a ball.

Q: I want a really natural look, not a round implant look. How do I get that?

A: See the question above.

Use moderate or small size implants that do not overstretch the tissue.
Place them over or under the muscle as needed to get good tissue coverage over the implant.
Do not be one of the 2-6% of people who get a capsular contracture.

Q: Should I put the implants over the muscle or under the muscle?

A: This has a complex answer. Basically, there are two main points to consider:

Coverage. If there is little or no breast tissue in the upper half of the breast (above the nipple), it is usually best to put the implant under the muscle tissue to maximize the tissue covering it. This also helps make the "entry" from the collarbone downward into the breast smoother and more natural, like a teardrop. For women with a significant amount of natural breast tissue, however, it is sometimes better to place the implant on top of the muscle so that it will drop with the breast over time and continue to look natural.
Breast cancer. Most Radiologists agree that it is easier to do mammograms with implants under the muscle. If you have a family history of breast cancer (first degree female relative on your mother's side with breast cancer), you have a personal increased risk. Implants under the muscle are probably the wise choice, even if it compromises the cosmetic result slightly.

During Surgery

Q: How long does the surgery take?

A: This varies depending on the surgeon and the anesthesia provider. You can expect to be in the operating room from 45-90 minutes total. The actual surgery takes about 35-55 minutes; the rest of the time is spent getting monitors on, putting you to sleep or getting you numb and putting on dressings after the surgery.

Q: What kind of anesthesia is best?

A: This procedure can be done under local (numbing injections), twilight sedation (IV drugs) or general anesthesia (totally asleep). Your surgeon will have a preference and it is usually best to go along with this as it decreases the tension level in the OR. Personally, I prefer general anesthesia using a mask because it avoids any pain and the sore throat associated with a breathing tube. However, my operating time is somewhat faster than most (25-30 minutes), so this works well in my OR.

Q: How much blood will I lose?

A: Usually around 20-30cc, which is about half of a shot glass full. (And no, I am not a vampire)

Q: What if I'm on my period?

A: Makes no difference to the surgical procedure or the results. In addition, the stress of surgery may throw you "off cycle" for a month or two, causing you to start early or late. Doing a pregnancy test before surgery may help you with worries after surgery if this happens.

After Surgery

Q: Will it hurt?

A: Yes. This is surgery.

Q: How much will it hurt?

A: Changes in operative technique have drastically improved the post-op pain level in the last three to four years. I used to tell patients this was a 12 on the 1-to-10 scale, but now it's more like a 2-3 if the newer procedures are used.

Q: How soon will I look "normal"?

A: Your breasts will be swollen for 6-8 weeks, and they will feel tight for 6-9 months before dropping into place. The process is faster for over the muscle than it is for under the muscle placement.

Q: Will I need a special bra?

A: Your surgeon will usually put you in whatever garment or dressing is best for the first week after surgery. After that, the choice varies widely, from nothing at all (to encourage settling) all the way to specially constructed and reinforced surgical bras (think Madonna's golden cones). Most of the time there is a specific reason for the choice, but ask your surgeon why. This is one area that can be explained or negotiated.

Q: What about bathing?

A: Usually a shower only for the first week, since bath water has high concentrations of bacteria and can cause wound infections. The first shower is usually allowed after 48 hours, to give the incision time to seal. Avoiding long, hot showers early on (first 1-2 weeks) helps decrease the swelling and the risk of post-op bleeding.

Q: What about complications?

A: There are many potential problems, but only three major surgically related problems: Bleeding (hematoma), infection and implant malposition. Later complications during the healing process include capsular contracture (scar tightening around the implant), rippling and implant deflation. Please note that a "complication" is not necessarily a surgeon's mistake; all of these problems are known risks of the surgery and can occur no matter how well the surgery is done. Your surgeon should inform you of these and other risks and the percentage of times they occur.

Q: What kind of pain medicine will I get?

A: Most of the time, you will get a narcotic level drug (meperidine, morphine, oxycodone) for the first few days, a transition drug (hydrocodone, propoxyphene) for the next week and then anti-inflammatory drugs (ibuprofen, acetominophen) for another week if necessary. Some surgeons also give a muscle relaxer if the implants are under the muscle and some give an antibiotic for the first few days post-op.