What's the best breast implant incision? [Lee B. Daniel, MD, Eugene]

Eva Sheie (00:00):
Let's talk about incisions and techniques.

Dr. Daniel (00:03):
The main incision that I virtually always use is an inframammary incision, so that's under the fold under the breast. I feel like that's the best hidden incision, the best healing incision. It provides the best exposure, and so it kind of hits all the important factors for me with regards to access. There are incisions around the areola that I used a little bit in training. There's axillary incisions that provide some different pluses, but I think more minuses than pluses by far. One of the things with implants and the development of capsular contracture, which is excess scar tissue forming around the implant, and I'm sure we'll talk about that in a little bit more in the future, but with regards to potential bacterial colonization of an implant, I feel that some of those other access incisions may put people at a little bit more risk depending on the study that may or may not be borne out in some of the statistics. But if one is a better visualization and a better healing incision, I'm going to use that a hundred percent of the time. With revision surgeries, if somebody has come from elsewhere and has an incision around the areola for how their previous implants were placed, I'm going to still go inframammary because I can just do the revision, whatever may be necessary a whole lot more predictably through that access.

Eva Sheie (01:27):
How long does it take these incisions to heal and what do we have to do to kind of take care of them so that they heal quickly?

Dr. Daniel (01:34):
So incisions in my practice in the torso, I always cover with Steri strips in the operating room. So a one inch wide Steri strip, all dissolvable sutures under the surface of the skin, whether it's a tummy tuck or a breast augmentation. And those Steri strips with the extra sticky stuff, either benzoin or mastisol, all those stair strips stay on typically until they're one month post-op. At one month, we take the stair strip off start people on a scar gel that they'll use for the next couple of months. The time course for full healing of any incision in a human on average is about 12 months. And there's a lot of different stages of the healing process, but we continue to follow people out to at least eight or nine months just to make sure that they're not having any healing issues. But the normal physiology is what I end up having to talk to patients a lot about because any incision, especially in the torso, is going to be reddish for months six or eight months, sometimes maybe even longer.

(02:34):
Some of the other parts of the wound healing process, our bodies make scar tissue for about a month and a half as a response to any injury or surgery. Scar tissue is swollen, scar tissue is firm. And then on average, if you look at the wound healing literature between the third and six months post-op is when the body really starts to realize, oh, we don't need all that scar tissue. We're going to start to remove it. So there are dynamic things that happen throughout the healing process, particularly in that first six to eight months. So we continue to follow people through that whole time period. But for the most part, many augmentation patients I let get in the shower three or four days. I do make sure that they're not doing any aggressive activities. But with regards to incision integrity, the skin typically seals to water in 48 to 72 hours, and with that steri strip protective cover on the outside, it's just nice. I mean, for anybody that's had surgery or anybody that's been camping out without a shower for four days, that first shower is amazing. So I try to let patients feel a little bit more like themselves in the immediate post-op period.

Eva Sheie (03:42):
In terms of techniques, it's always a big social media and internet discussion is above the muscle, below the muscle, dual plane, and there's a lot of confusion about this. Can you make it not confusing for us?

Dr. Daniel (03:55):
I agree. It is confusing in the lay literature out there. I think there's a couple of things that I look at in my practice, and with traditional silicone gel implants, a very thin patient who maybe hasn't had a child, typically that's going to be better behind the muscle just because the thickness and slope of the muscle give a little more natural result. And I use this as an example too. I talk about natural this, natural that, and I was talking to a patient years ago about that, and she goes, Dr. Daniel, I'm paying for fake boobs, I want them to look like fake boobs. So that's part of the pre-op evaluation. You've got to figure out what patient's goals and wishes are, but behind the muscle tends to be really the most common way to do this. But in my practice, a lot of patients that have maybe had pregnancy, maybe had weight loss, they've lost a lot of upper pole fullness, and if they have a little bit of settling to their breast, that little bit can be termed pseudo ptosis.

(04:57):
That's when the nipple is above the fold under the breast. But some of the lower part of the breast gland tissue has settled below the fold. I just did this two days ago. The patient had a little bit of pseudo ptosis and we did a tummy tuck and a pre-pectoral breast augmentation. So without the kind of slope or tethering of the breast gland tissue, I can get a little more forward and up posture to the breast, and it almost looks like they've had a breast lift when I do the implants in front of the muscle and then it fills in that upper pole a little bit better as well.

(05:33):
I think I pick and choose those patients. There's another intermediate way where you go, sub facial, so there's a fascial covering over the pectoralis muscle, and that gives you a little extra cover around the edges of the implant. So maybe for the slightly thinner patient that wants a little bigger augmentation, that might be an option because it does tend to give a natural upper pole slope. But the key for me is to never recommend a technique where they're going to have that half a grapefruit or half a coconut look on their chest. I truly never see that and never want to see that in my post-op patients. So I think the decision for going in front of or behind the muscle is a very important one, and with some of the newer technology implants, that's going to open up different options for many patients.

Eva Sheie (06:25):
Okay. Give us your Instagram handle and your website.

Dr. Daniel (06:28):
Drleebdaniel.com. We have a couple of other sites, but that'll direct you. And then Instagram handle is pretty easy to remember: Best Plastic surgeon.

Eva Sheie (06:36):
That's you?

Dr. Daniel (06:39):
That's me.

Eva Sheie (06:40):
I finally found him.