I Morphs I Breast Augmentation Procedure I Before and After Photos I Incision Choices I Dr. Shamoun's List of Precautions I
Typical Pre-Op Consultation  I  View Breast Augmentation Surgery

1. How do I choose the best Plastic Surgeon for me?

2. How do I compare surgeons?"

3. What is best for me?

4. What about tear drop or anatomic implants?

5. What about silicone?

6. What about size?

7. What is cup size and what does it mean?

8. What about drains and dressings?

9. How long until they fall and decrease in size with time?

10. Why Dr. Shamoun?

11. What determines the final result?

12. How long do the implants last?

13. What is responsible for most of the catastrophic events related to implants?

14. Your surgical experience?




Q: How do I choose the best Plastic Surgeon for me?

A: To protect yourself from complications arising from inadequately trained, incompetent, and unethical physicians, Dr. Shamoun recommends: ASK IF THE SURGEON IS BOARD CERTIFIED BY THE AMERICAN BOARD OF PLASTIC SURGERY. This is the only Board Certification that guarantees formalized training in both General Surgery and Plastic Surgery. Beware of "gimmicks" and misleading advertising from any other physician claiming Board Certification. Beware of those who tell you they are Board Certified but neglect to say in what discipline. Beware of the "bogus Boards." Such Boards are not recognized by the Board of Medical Specialties. Some of these Boards often simply require payment of a fee to join and provide no assurance of training. Always ask to see Certificates, verifying Board Certification by the American Board of Plastic Surgery (or call 1-888-425-2785, or download www.plasticsurgery.org). Ask if your surgeon has hospital privileges to perform the particular surgery you are considering and call the hospital to make sure.

Anyone can attempt to perform plastic surgery anywhere in the United States, but as a patient, you want someone qualified and competent to take care of you if something goes wrong. If you are not diligent and educated in your search, you may find you have had major plastic surgery performed by a dentist, oral surgeon, dermatologist, or ear, nose, and throat physician with no formalized plastic surgical training. I do not state the above to be critical of my non-plastic surgical colleagues, but only to assure yourself of adequately trained physicians who are competent and qualified to take care of you.

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Q: How do I compare surgeons?

A: In your search for a plastic surgeon, you must begin to find a surgeon who is Board Certified by the American Board of Plastic Surgery first. You must then consult with several surgeons and decide if you like that individual and feels he/she is competent enough to perform the procedure in question. Be careful and be critical. The more skills a surgeon develops, the more choices the surgeon can offer and the more surgical alternatives are available for optimizing the result for any given patient.

I have several rules that patients may utilize when making choices about breast augmentation:

A. Review breast augmentation before-and-after photographs carefully. Remember that all photographs are different. It is important for surgeons to show patients before-and-after photographs reflecting accurate breast tissue and chest wall characteristics that are similar to a particular patient. Patients must be matched for frame, age, height, and weight, as well as soft tissue and hard tissue characteristics in order to gain any knowledge from looking at before-and-after photos. In other words, patients must have similar breasts and chest wall dimensions in order to make comparisons.

B. Ask the surgeon to show you his more difficult cases. Ask to see many different types of breasts. This will help you gain knowledge as to his expertise in dealing with problems. Remember that patients with small, beautiful breasts often have large beautiful breasts afterwards. The more difficult cases are cases that involve patients with no breast tissue, severe asymmetries, droopy breasts, congenital deformities and breast reconstruction. It is paramount for patients to see particularly difficult cases in order to gain knowledge of a surgeon's expertise.

C. It is important to see if the post-operative and pre- operative photographs are of good quality and well controlled.

D. Ask the surgeon to show you close-up photography of all types of incisions. If pre and post-operative photographs are at different angles and different depths, with different Lighting, then attention to detail is lacking and one should look elsewhere.

One should also be sure and ask to see many different matched views of the same patients' before-and-after pictures. Sometimes, the side views may look great when the front views may not look so great, or vise versa. Be sure and visualize as many different views (of the same patient) as possible in order not to be fooled or misled. (usually see front, three-quarter, and side views of the same patient.

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Q: What is best for me?

A: It is important to find out what incisional approach, what type of implant, and what position the implants should be placed in, that serves your best interest as a patient.

Remember, it is the soft tissue and hard tissue characteristics relative to the size of the implant that determines where the implant is best positioned (that is, usually either submuscular or subglandular). It is also very important to ask your surgeon if he places implants above and below the muscle. It is my opinion that most senior plastic surgeons and non-plastic surgeons do not offer patients choices. Often the absence of choices usually dictates the result. It is my opinion that frequently surgeons cut corners in order to achieve a quick result without proper concern for the long term benefits of any individual patient. Some surgeons try to talk patients into the procedure they, as surgeons, feel more comfortable with (I believe this is wrong).

One must keep in mind that a submuscular breast augmentation procedure must be performed precisely using sharp dissection and must be performed by a true surgeon. If your surgeon always places an implant in one position, my recommendations are to look elsewhere. He/she is usually a cookie cutter surgeon who knows only one way to deal with one problem. It is my opinion that there is one best way for any particular patient, given pre-operative soft tissue characteristics and patient concerns. Remember that all choices of implant, all incisional approaches, all anatomic positions of the implant have advantages and disadvantages, and must be explained in detail in order for you to be well informed.

Most patients (70%) that present to my office for augmentation mammoplasty have very little breast tissue and benefit the most from partial retropectoral placement of either a saline or silicone implant. In most of these patients, the pectoral muscle is gently lifted and not cut.

Approximately 30% of patients in my practice benefit from a subglandular approach, given their soft tissue characteristics.

Just because your friend or relative had an implant placed in a certain position does not mean that you should have an implant also placed in this position.

A combination of factors: based on soft tissue and hard tissue characteristics, breast cancer risk, scarring, athleticism, sensory disturbances, as well as the ability to breast feed all impact on the choices and eventual decision concerning the correct position. I can assure you that there is one best approach for any given woman,depending on her needs, and it is the surgeons' responsibility to determine what combination of choices is best. The one best approach cannot be determined by looking at a photo- graph of a patient, without a close examination, or without discussing what is important to the patient.

Every choice one can make has both advantages and disadvantages. The only way to make informed decisions is to understand all the facts about all the choices. A competent Plastic Surgeon must be able to reliably give every patient, every incisional approach option, every currently manufactured breast implant option, and both pocket location options, in order to fulfill their needs and deliver a State of the Art breast augmentation procedure.

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Q: What about tear drop or anatomic implants?

A: Anatomic implants are tear drop shaped and are only available in a textured shell. It is my opinion that they look best in women who are tall and have a long torso. Women who have a stature of greater than 5'5" may be candidates for this implant. These implants are textured and, therefore, more palpable and somewhat firmer in consistency (they do not move very well). They are also taller than they are wide and more rectangular in shape. It is my opinion they do not look any more natural than a round implant for any given woman. Proponents who encourage tear drop or anatomic implants often receive royalties from implant companies and, thus, promote their products. In summary one cannot often tell from a photo whether the patient has round or anatomic implants, unless she is very small and very thin.


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Q: What about silicone?

A: Silicone implants are the most commonly available implants world wide. With the exception of Japan and the United States, they are widely used in Europe, South America and other major countries. Several major epidemiological, immunological, toxicological, and rheumatological studies have concluded that silicone breast implants do not cause any autoimmune disease, connective tissue disease, or immune system dysfunctions. A panel of unbiased experts unequivocally concluded that silicone breast implants do not cause any diseases. It is unfortunate that the FDA and Plaintiff lawyers have deprived the American women of their rights to valid information and valid choices with regard to breast implants. A full two-hundred page report by a select panel of medical experts is available through the Federal Breast Implant Multidistrict Litigation Web Site.

Silicone implants are available on an adjunct study protocol. I am an investigator and frequently perform silicone implants when needed. Remember, that saline vs silicone gel filler is a choice, like all other choices in augmentation. There is no such thing as any perfect option or set of options, but there is a best option that can be tailored for any given patient. Every option comes with a set of trade offs that patients must be willing to accept.

It is my opinion that the major draw back to silicone is the greater risk of capsular contracture that can develop, as well as the inability to know exactly when and if this implant leaks. Remember we as surgeons and healthcare providers do not know everything about anything. I also feel we will continue to learn more about silicone with time.

It is difficult to compare a 1970 silicone implant with a 1980 or 1990 implant. Through the years, these implants have changed in quality and their risk of rupture or leakage has also changed. Silicone and saline implants look the same and feel different. It is interesting that the slightly firmer feel of saline is usually of no concern to women who have never ever experienced silicone implants. Silicone implants can often be placed in a subglandular position due to their softness and less need for soft tissue coverage. Ideal patients for a silicone filler include those women with very little tissue and moderately droopy breasts who desire no scars from a lift (see patient #29 in breast augmentation photo gallery). If we could predict with accuracy who would form scar tissue around a silicone implant, we, as Plastic Surgeons, would choose silicone as our first choice for most all women. Unfortunately, the unpredictable nature of capsular contracture precludes the use of silicone for most women today.

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Q: What about size?

A: I cannot produce a breast of any size without untoward events occurring. It is my job to educate any given patient about the long term consequences of breast augmentation surgery. Sometimes patients do not fully realize the consequences of what they do for at least two to five years following the surgery. Remember that precise chest wall shapes and measurements, height and weight charts, and soft tissue characteristics relative to any given breast implant determine how large a woman can safely augment her breasts without great risk.

After revising numerous breast augmentations operated upon elsewhere, it is my opinion that the number one cause of complications related to breast implants (i.e., bottoming out, thinning out of tissues, rippling) is directly related to over- sized implants relative to a woman's frame, chest wall characteristics, and soft tissue envelope. Patients must use common sense when it comes to size. It is impossible to make a decision on what size you should be, based on a friend, a photo, or a chat room on the Internet. It is also virtually impossible for any given women to have a similar woman's exact breast tissue characteristics, even if they are the same height and weight. It is most important to consult with a physician who understands soft tissue principles in order to prevent future complications from developing.

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Q: What is cup size and what does it mean?

A: It is important for patients to understand what cup size really means. A 300 cc. implant for one patient may achieve a B cup, and for another patient a D cup. How is this possible? It is because the breast tissue characteristics relative to the chest wall characteristics are different for any given patient.

Cup size is determined by measuring the chest wall circumference and then the breast circumference. If the breast circumference is 5" greater than the chest wall circumference, then the patient has an A cup breast; 6" greater than the chest wall circumference, a B cup; 7" greater than the chest wall circumference, a C cup, and 8" greater than the chest wall circumference, a D cup. Chest wall circumference is measured from the bottom of the breast (at the inframammary crease) and breast circumference is measured at the most projecting point of the breast (over the nipple). Please see helpful links to determine your cup size:
www. braselect.co.uk/shoppingassistant.html
www. delawarewoman.com/june99/beauty.html

It is my personal belief that cup size is not important, and one should basically forget about it. It is the actual look that becomes important. My ultimate goal is for a women to look just as good nude as in clothing. It is my bias that patients who frequently have a round/hard ball/fake/"shock value" type look in clothing often look ridiculous in the absence of clothing. "If you can spot a womans' breast from the back, then they are too big and unattractive."

During the consultation, I will determine a size range for any given patient. The actual cc. volume is not important as I will tailor the operation for any given patient based on their soft tissue characteristics. At the time of surgery, I will use sizers and determine the exact volume necessary in order to achieve the look desired. It is important to realize the operation is tailored for any given patient, and no specific volume is determined pre-operatively (only a range is chosen before the procedure).

I feel very strongly that when a physician (regardless of the number of years in practice) decides on the exact volume of an implant prior to the surgery, he/she may over-estimate or under-estimate the exact implant that needs to be utilized by 20%. This would be like visiting a shoe store, finding your size, and buying the first pair. Of course, some fit better than others.

At the time of surgery, after the prostheses are inserted, you will be changed to a sitting position on the operating room table. I carefully inspect both sides to assure symmetry and make additional adjustments if necessary. Precise adjustments of the pocket size, implant size, and implant position will be made with any given patient in an upright position on the operating room table when they are asleep. I use several trial sizers before committing to a specific size implant, much like trying on a pair of shoes. This enables me to give a more exact look and assure the most accurate, refined and aesthetic result in all body positions.

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Q: What about drains and dressings?

A: Drainage tubes and compression dressings are unnecessary after the procedure. It is my personal philosophy that drains are utilized by surgeons who use blunt technique to create an implant pocket which, therefore, causes more tissue trauma and bleeding compared to other techniques. Drains are often necessary to remove fluid produced by the tissues in response to the tissue trauma of dissection when blunt dissection is utilized. It is my belief that utilization of a meticulous technique with precise control of all bleeding vessels is far superior to any blunt dissection. I find that drains are totally unnecessary in first time augmentation operations. I also feel that compression post-operative dressings are also unnecessary. .

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Q: How long until they fall and decrease in size with time?

A: It is unnecessary for implants to fall into a proper position over three weeks to three months post-operatively. In most routine breast augmentation procedures, the implants are placed in a proper position. This will result in an excellent position of the breast implants in an early post-operative time interval. It is usually unnecessary to use axillary straps or heavy Ace wraps in order to move the implants into a lower position. In only very unusual selected cases are implants placed in a relatively high position (on purpose) in order to prevent bottoming out. One must remember that a Plastic and Reconstructive Surgeon must be able to predict what will happen to the implant and the soft tissue over the first two to three weeks to years later for any given patient. This is determined by the chest wall and soft tissue characteristics, as well as experience in dealing with all types of breasts. This decision involves how much muscle to elevate or cut, what type of implant to utilize, and how much dissection is necessary. It is the ability to plan the procedure pre-operatively and fine tune the particulars intra-operatively that determine a far superior result from an average result.

When a particular size is chosen, the breast size should be compensated for swelling, atrophy of tissues, and weight changes in the post-operative period. In general, any given woman can expect a 10-15% smaller size in 6 months to one year after the procedure (especially if implants are placed in a submuscular position). Subglandular implants will change size less with time (5-10%). This is due to atrophy of the tissues and swelling. One should be aware, however, that any weight gain may enlarge the breasts and negate the decrease in size in the post-operative period. I encourage all women with large breasts after augmentation (greater than C cup) to wear support as much as possible to preserve the new look and soft tissue characteristics as long as possible. These decisions are of utmost importance and precisely why your choice of a surgeon becomes critical.

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Q: Why Dr. Shamoun?

A: I frequently use every implant made through every incision and in every location (above and below the muscle). I can also assure you that your breasts will absolutely look the best they can look. I will determine the best approach for you with the most advantages and least disadvantages to suit your needs and satisfy your goals long term. Some simple generalities based on my experience are as follows:

1. What are the choices? Augmentation mammoplasty procedures involve choices. The choices of incision approaches include inframammary, periareolar, axillary, or umbilical. The choices of currently manufactured breast implants include silicone or saline implants. The choices of the types of implants include textured surface implants vs smooth surfaced implants. The choices concerning the shape of the implant involve anatomical or tear drop vs round implants (round implants may be high profile, moderate profile, or low profile). The choices of the pocket locations are either partial retropectoral, total retropectoral or subglandular.

There appears to be anywhere from two to four hundred ways to perform the procedure given the above variables. Which is best depends on the type and thickness of tissues the patient brings the surgeon to work with. They all have trade offs. More are perfect. The most important thing is to provide adequate soft tissue cover over any implant so that implant edges are not visible. One must choose implant size carefully so that one does not progressively make tissues thinner, the coverage poorer and risk visible edges and wrinkling associated with other complications.

It is my opinion that the majority (70%) of patients that present to me requesting saline implants over silicone are better served with implants placed in a partial retropectoral position. The partial retropectoral placement of most saline implants is best suited for those patients who present with an A cup and very little breast tissue. The advantages of this approach include a lower risk of capsular contracture, lower risk of movement of the implant, and lower risk of ripples. In addition, more breast tissue is visualized on mammogram and more internal support exists to control the droop over time.

30% of my patients will benefit from implants placed in a sub- glandular position, and these are patients that have adequate soft tissue coverage (with thick fibrous breast tissue) or a slight droop to their breast appearance. Other candidates are patients who have very scant amounts of tissue but very dense tissue with thick skin. Saline implants in all of these patients can often be implanted in a subglandular position with excellent results.

It is important to realize that capsular contracture rates (the most common unpredictable complication) vary with the type of filler material in the implant, the location of the implant, characteristics of the implant shell (silicone is more likely to become encapsulated than saline), as well as your choice of surgeon.

With silicone gel-filled implants, smooth shell implants have a higher incidence of capsular contracture compared to textured surface implants. The risk of capsular contracture with saline implants is the same whether they are textured or smooth surfaced. Textured implants, however, are firmer and more palpable. Therefore, I do not believe that textured saline implants provide any benefit (except perhaps to prevent a teardrop implant from changing positions). (In short, texturizing the shell appears to offer an advantage against capsule contracture only for silicone implants).

Overall, submuscular placement of any implant appears to provide a lower risk of capsular contracture than above the muscle. Overall, my capsular contracture rates are less than 1% when implants are placed in a partial retropectoral position. I attribute this very low capsular contracture rate due to a meticulous bloodless technique, massage exercises, and appropriate implant choices. Remember, if you are thin, adequate soft tissue coverage should be your number one priority and your implant should be placed in a partial retropectoral, under the muscle position. Once again, there are no guarantees with any elective surgery, but I can assure you that your breast enhancement surgery will be a most pleasant experience and your new look will be the absolute best possible.

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Q: What determines the final result?

A: Outside of the experience and talent of the surgeon, it is the combination of choices available that determine the final result for any given woman.

There are four different incisions, two different types of implant fillers, two different types of shells, four to six different shapes of implants, and fifteen to twenty different volume sizes. It is the correct combination of these variables that determines the final result. The experience, judgment, and artistic ability of the surgeon using these combination of variables will determine the final result.

1. How does a surgeon use the different variables for any given patient?
I am often asked what incision and what implant is best for me? I feel very strongly that patients should not have a fixed idea of what they want prior to their consultation. There are indications and specific limitations of every approach and every style and shape of implant. Any given patient must realize that any 300cc. implant may look totally different, even in the same patient.

A 300cc. implant may be a high profile implant, moderate profile implant, low profile implant, smooth-walled implant, textured implant, anatomical or round implant, inflatable implant, or pre-filled implant. Individual breast implants may look totally different but have exactly the same fill volume (the shapes and profiles may be different when the volumes may be the same). How do we use these different variables as Plastic Surgeons? It is my opinion that the different shapes of implants should be utilized based on chest wall and breast tissue characteristics for any given woman. The location of the nipple areolar complex, skin and breast soft tissue characteristics as well as chest wall characteristics are of great importance in determining what type of implant to utilize:

A)    For example, a woman who presents with very high positioned breasts on her chest wall (nipple areolar complex is positioned very high near the collar bone and nipples are close to one another) frequently are difficult to augment with standard implants. These particular patients benefit from a high profile implant that has greater projection than base width. see patient #3 Standard low profile implants in these patients with small breasts, close together nipple areolar complexes and high positioned breasts, look ridiculous. The standard round implants (which are moderate or low profile) are as wide as they are tall and would have to be positioned too high, too low, or too wide in these particular patients. It is precisely this group of patients that need a high profile implant where most of the volume is projected anteriorly and the base is relatively small in order to successfully achieve an aesthetically pleasing augmentation of adequate size.

B)     Other choices involve which type of incision is best for any given woman? This may involve choices of preserving nipple sensation as much as possible or preserving the ability to breast feed. Frequently young patients, younger than twenty-one, would like to preserve the ability to breast feed over the appearance of any scar. Based on my experience and the mid wife literature, the incision should not be placed at the border of the areola if a woman wishes to preserve 100% the ability to breast feed (due the 10-20% risk of interfering with the ability to breast feed). The breast tissue ducts are violated as the approach goes through the breast tissue, resulting in interruption of ductal flow when attempting to breast feed. When pregnancy occurs and a patient desires to breast feed, the ducts frequently become engorged and are unable to empty milk due to ductal scar tissue developing. Approximately 10-20% of these women will have to resort to other means of breast feeding.

It is my personal philosophy that all of the risks and benefits need to be made available to any given woman in order for them to make educated decisions. One must remember the quality of life is different for different people, and, therefore, the incision choices, implant location, implant sizes, and styles must be different also. It is my job to determine what is important and help any woman choose the approach that offers the most advantages and least disadvantages for them. Remember this should be different for different patients.

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Q: How long do implants last?

One must remember that implants are mechanical devices that eventually will fail. Failure may become manifest as a capsular contracture or leakage. With silicone implants, it is difficult to determine if leakage occurs given the thickness of the implant gel. The only specific way to determine if a silicone implant is leaking is to obtain an MRI, ultrasound, or mammogram. Saline implants, on the other hand, are obvious when leaking, given the fact that the water is resorbed by the body. It is my philosophy to not adopt a routine standard of implant removal and replacement. I do not believe it is necessary to remove a standard saline implant just because it has been in place a number of years. Statistics prove that the saline within the shell of an implant can remain for years problem-free.

All women must realize that just as their face ages, their breast tissue will also age and their implants will not look the same in five years, ten years, or twenty years. Frequently the overall look of the breast will necessitate removal and replacement along with some other type of procedure if necessary. Remember that routine replacement of saline implants, in my opinion, is not necessary (even a deflated silicone shell could remain in the body long term with no problems if need be).

The removal and replacement of a saline implant that is ruptured or leaking is a very safe and straightforward procedure. The implant leak will become obvious over two-three weeks as the tissue reverts to its original size. The procedure is performed electively (and not as an emergency) and will take approximately twenty-five minutes to remove and replace. The implant pocket has already been dissected and the same original incision and approach is utilized. The recovery time is one day. Frequently all implant manufacturers will guarantee their product for five to ten years and they will reimburse the patient for some of the anesthesia and facility costs. It is my general policy to remove and replace any implant that I have implanted at a significantly reduced cost if it has leaked or deflated over any woman's life time.

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Q: What is responsible for most of the catastrophic events related to implants?

A: I am frequently asked by attorneys involved in litigation to review cases and serve as an Expert when breast implants have been utilized and unfavorable results develop. I have also specialized in restoring many womens breasts after multiple unsuccessful previous surgeries. It is my opinion that the most common cause of litigation related to breast implants involve incompetent/ untrained surgeons or poor judgment on behalf of the surgeon in utilizing the different choices available.

Patients frequently will shop price, creating a catastrophe with numerous long term problems in order to save $500-1,000. Problems related to implants include extrusion, malposition, bottoming out, synmastia, capsular contracture, double bubble phenomena, infection, and bleeding (see photo gallery: Breast Augmentation Revisions
). Many of the problems are predictable and unfortunately irreversible. Sadly, many of these patients who sought breast enhancement are now delegated to breast reconstruction candidates.

It is my opinion the most common incisional approaches resulting in litigation are the transumbilical approach and the transaxillary approach. Although I utilize these approaches, there are certain limitations of these approaches which must be recognized and discussed pre-operatively (I frequently compare the transumbilical approach for breast augmentation to changing one's oil in their car through the exhaust pipe. It doesn't make much sense). Problem patients with dents, malposition, implant failures, distortion of the abdomen, capsular contractures and asymmetry have all been referred to me with the transumbilical approach. The most common problems referred to me with the axillary approach include asymmetries, restricted pockets, and inframammary crease problems such as bottoming out and high riding implants.

Attention to detail usually results in excellent incisions regardless of the location, and, therefore, it is my prejudice that the shape, size, and overall appearance of the breast takes precedence over the scarring from the incision. I invite you to schedule an appointment and look at the scars up close, regardless of their location in any individual patient. I invite you to see the breast implant revision section of this Web site to see the difficult restorative nature of secondary breast surgery. REMEMBER: It is best to do it right the first time! Limiting reoperations requires optional decisions and precise surgery at the first procedure.

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Q: Your surgical experience?

A: Your surgery will more than likely be performed under general anesthesia. I feel that you should be relaxed and should remain pain-free throughout the procedure. This is accomplished by way of general anesthesia in an Accredited facility setting. I take pride in working with the very best healthcare professionals in order to provide excellent anesthesia and nursing care.

Your post-operative course, unlike what you have heard, will not be difficult at all. Patients frequently require a one to two day recovery for subglandular placement of implants and a three to four day recovery for submuscular placement of implants. Immediately after your surgery, you will be in a light bra with small steri-strips covering the incision location. NO heavy garments, Ace wraps or drains are utilized. I encourage you to resume your physical activity as you see fit.

It is my personal feelings that you will not damage anything by resuming activity early. You may be a bit uncomfortable, and, therefore, need to restrict your activity in the first one to two days after the surgery.

Meticulous technique with sharp dissection is utilized intra-operatively with coagulation of all small blood vessels. Only approximately one teaspoon or tablespoon of blood is lost throughout the surgery. I feel very strongly that this is why my patients frequently do not bruise, have minimal swelling after the procedure, and have less than a 1% risk of encapsulation.

Patients are followed twenty-four to forty-eight hours after the procedure, primarily for reassurance. Their small steri-strips are changed and it is perfectly acceptable to take a shower shortly after surgery. I encourage you to wear your bra to prevent swelling in the immediate post-operative period.

Your second visit will be approximately one week after surgery, at which time the sutures, if necessary, will be removed and specialized treatment in scar care will be given (in order to allow the scar to heal without noticeability). It is also at the one week visit that I will massage or displace your breast. It is my feeling that with smooth-walled saline implants placed either subglandular or submuscular, that massage and displacement may help your breast stay as soft as possible. The literature suggests that it may or may not help in maintaining the softness of the breast. It is my opinion that massage has no negative effect, and, therefore, should be utilized if possible. I do not recommend massage in the immediate post-operative period due to discomfort.

Many women may find that it takes approximately one to six weeks to develop a bond between their new breasts. Their implants will feel hard and artificial and one breast will always heal quicker than the other. After this bonding phase, you will feel that your implants are a part of you and you will enjoy them forever.

It is important for you to realize that I wish you the very best throughout this surgical procedure. I will spend an inordinate amount of time pre-operatively discussing the risks, benefits, alternatives, and complications and deciding on what is best for you. I will not push you into any given situation unless I feel very strongly about it. I will walk you through the procedure personally and will call you the evening of your surgery to check your condition. Please do not hesitate to ask anything pre- operatively or post-operatively regarding your breast implant surgery.

My office has, and always will, make accommodations for patients traveling a great distance from around the country and from international locations.

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I hope this information has been helpful. If any questions arise, please do not hesitate to e-mail Dr. Shamoun at JMShamoun@aol.com, or call 949-759-3077.

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