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Dr Daniel Fleming PERFORMS more BREAST implant operations than any other doctor in australia. He has performed thousands in the last 13 years. HE EXPLAINS THE CONSTANT IMPROVEMENT AND REFINEMENT OF SURGICAL TECHNIQUES.

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ll potential breast implant patients find the prospect both exciting and a little daunting. You wouldn’t be normal if you weren’t a bit nervous about it. Also most patients share a similar set of goals for their surgery: • Achieving the best result possible given the shape and size of their existing breasts • Minimising the risks of complications and the need for re-operation • Reducing recovery down time and discomfort.

Achieving optimal results given the shape and size of their existing breasts Most patients who come to see me for breast implants have done a lot of research. They have, quite rightly, read magazines, surfed the internet and spoken to friends who have had implants. However, sometimes this research has an unintended effect: it can create unrealistic expectations of what is possible to achieve. If a patient has unrealistic expectations before surgery then inevitably they will be disappointed afterwards. Not surprisingly, in promotional material the majority of surgeons usually use photographs of patients with very attractive breasts as the result of implants. Some surgeons now also use beautiful ‘artistic’ photographs. These do not help to develop realistic expectations for the majority of patients and may sometimes tell you more about the photographer’s abilities than those of the surgeon. It is not often understood that these results are typically achieved in patients whose existing breasts were ‘technically straightforward’ for implant surgery. These patients generally have attractive breasts to start with, do not have much breast tissue, have no sag, have nipples well above the breast crease, have little

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asymmetry and usually have not had children! An example of this can be found at the bottom of page 76. Most patients do not have all of these features and, if this is you, then you are normal. However, you will probably get a different result from the patients in the adverts. The key to achieving the best possible result you can, given the breasts you already have, is to develop an operative plan with a surgeon very experienced in breast implants. Your surgeon will be able to help you make the right choices and show you realistic results of what you are likely to achieve. The elements of the operative plan are: A Breast lift or no breast lift needed? B Shape of implants – round or teardrop shaped? C Implant profile (sticky-out-ness) – low, medium, high or ultra-high? D Position of implant – behind or in front of the muscle or dual plane? E Surface of implant – textured, smooth or polyurethane foam (Brazilian)? F Size of implant? Although the biggest factor determining your final result is what your breasts look like now, and therefore this must influence your expectations, each element of the operative plan will also affect your result. I believe the development of the operative plan with my patients is as important as the surgery itself. This is one of the reasons why I feel all consultations should be directly with the doctor performing the surgery and not delegated to a nurse or consultant.


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The following checklist can help you achieve the best result possible. 1. Choose a surgeon who is prepared to consult with you personally right from the start and has sufficient breast implant experience to have seen the results of implants in all types of breasts. Your surgeon should have performed breast augmentation surgery hundreds or preferably thousands of times. Do not be afraid to ask. 2. Make sure your surgeon offers and has discussed with you all of the different options that make up the operative plan (A-F above). Again, don’t be afraid to ask, and you may wish to take the list with you to the consultation. For example, if your surgeon does not put any implants behind the muscle, they won’t be able to offer you this choice. If you are a patient who would be better suited to have implants behind the muscle you will not get the best possible result. 3. Ensure you are informed about and offered the option of Brazilian implants. These implants greatly reduce the risk of the commonest complication and commonest reason for re-operation so you need to know about them. (See the next section for further information about this). 4. Ask to see ‘non-artistic’ before and after photos of the surgeon’s own patients who have breasts similar to your own. This will help you develop realistic expectations. 5. Once the operative plan is finalised, go over it again with your surgeon to make sure you understand why the choice of each element has been made. Remember that not all women can have beautiful breasts even after surgery, but most women wanting implants can have better breasts. By understanding the importance of both the operative plan and of the unavoidable limitations of your existing breasts, and by following the above checklist, you should be able to maximise the chances of being happy with your implants.

Minimising the risks of complications and the need for re-operation

First of all, ensure you have followed the checklist of points. Additionally, you can reduce your risks by insisting your surgery is performed in a licensed day surgery. This is different to an accredited facility, which does not have to meet the same standard as a licensed day hospital, so be careful not to confuse the two. Also ensure your anaesthetic is given by an anaesthetist and not by a nurse under the direction of the surgeon. If a complication does occur, you do not want there to be only one doctor responsible for the operation and the anaesthetic at the same time. If you are comparing costs between surgeons make sure you are comparing apples with apples – the extra safety of an anaesthetist in a licensed day hospital may be the reason for a price difference.

In Australia there are now implants available which can reduce the problem of capsular contracture dramatically. Manufactured in Brazil by Silimed, these implants are soft cohesive silicone gel implants covered with a layer of polyurethane foam.

Capsular contracture Everyone considering breast implant surgery soon discovers that the commonest complication is capsular contracture. This is where the membrane that grows around all implants and, which normally cannot be seen or felt, behaves like shrink wrap, compressing the implant and causing it to feel firm or hard, often distorting its shape. It is not known what causes most contractures although there are many theories. What we do know is this

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complication is by far the commonest cause of dissatisfaction and the need for further surgery. Capsules are rated according to four grades.

Grade 1 The breast is soft and you cannot tell an implant is present.

Grade 2 The breast is firmer than normal but this does not bother the patient nor change the appearance of the breast.

Grade 3 The breast is obviously firmer than it should be, the patient is aware of this and there may be some change in shape of the breast.

Grade 4 The breast is hard and distorted and may be painful. Only Grades 3 and 4 are considered to be capsular contractures. So if a study says it found a 9 percent rate of capsular contracture, it means 9 percent of the patients had Grade 3 or 4 capsules. Obviously every surgeon wants to have a low contracture rate so they are hoping to have Grades 1 and 2 capsules, which are not counted as contractures, and not Grades 3 or 4, which are. You will see that because of the definitions the decision whether to grade a capsule 2 or 3 is very subjective. Also remember because contractures develop progressively, every Grade 3 was previously a Grade 2. With the best will in the world a doctor will tend to ‘look on the bright side’ and favour categorising a capsule Grade 2 rather than Grade 3 if there is any doubt. Thus a Grade 2 will not show up in his contracture rate, while a Grade 3 will. If a doctor only performs 50 implant operations a year, then it only takes one patient with a contracture not to return to see him and a Grade 3 to be mistakenly called a Grade 2 for his percentage contracture rate to be 4 percent less than it really is. So you can see that you can’t necessarily rely on a claimed capsular contracture rate without knowing how accurately it has been calculated. Interestingly studies in which independent assessments of a doctor’s patients have been made show very significant increases in the rate of contractures Grade 3 or worse compared with the rate the doctor thought he had when assessing his own patients. This is not because the doctors are dishonest but because of the phenomenon of observer bias. This bias can even occur in independently controlled studies due to the subjective nature of grading

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capsules. The best guide to true contracture rates is the data submitted to the United States regulatory body, the Food and Drug Administration, by the implant companies when silicone implants were reapproved in 2006. These were well designed studies of large numbers of patients spread across many doctors, so we can be pretty confident in the accuracy of the results. The bottom line is capsular contracture is common and occurs in at least 10 percent of all women having had implants. One published study showed that teardropshaped implants had a lower rate of capsular contracture – about 5 percent – so you may be told this is an advantage of teardrop implants. The problem here is that all the teardrop implants in the study contained super thick cohesive silicone gel, which is firmer and more resistant to shape change than other cohesive gels. This means Grade 3 contractures were less noticeable and more likely to be called a Grade 2 and therefore not counted in the 5 percent. You might think this is a good thing until you realise the patients were less likely to complain about contracture only because their breasts were more firm in the first place! Because of their very firm gel these implants rarely feel like a Grade 1 capsule, which is the best outcome and the one you should be aiming for. I avoid using firm gel implants unless my patient has a very difficult shape to her breasts. The firm gel has a greater ability to re-shape the breasts in these patients. An example of such a patient can be found in the first set of photos on page 75.

Implants In Australia there are now implants available which can reduce the problem of capsular contracture dramatically. Manufactured in Brazil by Silimed, these implants are soft cohesive silicone gel implants covered with a layer of polyurethane foam. They have recently received approval from Australia’s regulatory body, the Therapeutic Goods Administration (TGA). This means Australian doctors can now offer them to all their patients. Many years of use overseas has shown that covering silicone gel implants with a polyurethane foam surface reduces the risk of capsular contracture to between 1 and 2 percent. The foam covering feels like suede or fur so they are known as ‘super-furry Brazilians’! Once you understand how these implants work you will understand why neither smooth nor textured implants achieve the same low rates of contracture. Remember all implants form a capsule around them – think of it as membrane walling the implant off from the breast tissue. It is only a problem when it contracts


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Traditional versus state-of-the-art Advice after traditional techniques:

Advice for state-of-the-art 24 hour recovery technique:

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• Take at least a week off work – longer if your job involves physical activity • Take it very easy for the first few days • Expect to have quite a bit of pain • Strong painkillers and muscle relaxants will be provided • Don’t raise your hands above your head in the first week • Don’t drive a car for a week • Avoid physical exercise for six weeks • Drains are often needed for the first 48 hours • Wear a special bra or bandages ‘to keep the implants in place’

• You can return to your normal routine after 24 hours with the exception of gym, aerobics, contact sports and lifting abnormally heavy objects • Expect the sensation of tightness in the chest area • Mild painkillers such as Panadol are usually all that is needed to manage discomfort • You can and should raise your hands above your head before you leave the hospital • You may drive after 24 hours if you wish • No special bras or bandaging is required

like shrink wrap compressing the implant. Unfortunately, as we’ve seen, this occurs in about 10 percent of patients. The capsule is made of collagen, a protein we all have in our skin. Collagen fibres are microscopic tubes and in the capsules of smooth and textured implants these are lined up end on end, running in the same direction and surrounding the implant. This means if a stimulus to contraction occurs, the fibres can slide over one another, shortening and causing the shrink-wrap effect of the capsule around the implant. When the Brazilian implants are used, the foam covering actually becomes part of the capsule. It acts as scaffolding or a lattice, which the collagen fibres wrap themselves around. The fibres are now disjointed and not lined up end on end and are much less likely to slide over one another so the capsule is much less likely to contract. This type of implant is not new. They were first used as long ago as 1969, so we have almost 40 years of experience confirming their safety. Since 1970 there have been more than 90 papers published around the world about their use, which have confirmed their safety and the reduced rate of capsular contracture. Dr Neal Handel, an assistant clinical professor of plastic surgery at the University of California Los Angeles, reviewed all of the breast implant patients at his practice from 1981 to 2004 and found that 345 smooth implants, 618 textured and 568 polyurethane foam-covered implants were used. He wrote this conclusion in an article in the Aesthetic Surgery Journal 26, 2006: ‘Based on analysis of our data, we conclude that the contracture rate after all types of breast surgery is dramatically lower with polyurethane foam-covered implants than with smooth or textured implants.’ ‘There is nothing to suggest that polyurethane foam,

or its in vivo breakdown products, pose a threat to the health or safety of patients. Polyurethane implants have measurable advantages over smooth and mechanically textured gelfilled prostheses and do not appear to be associated with an increased risk of complications or morbidity.’ Argentinian Dr Guillermo Vazquez, a plastic surgeon from Buenos Aires, reported his experience in 2007 using these implants in 1,287 patients over an 18-year period. In Aesthetic Plastic Surgery 37, he concluded: ‘Currently, given our wide experience with the use of polyurethane-coated silicone gel implants, we may state they are the best option for augmentation mammoplasty, and have the lowest incidence of fibrous capsular contraction.’ Writing in Clinics in Plastic Surgery 28, 2001 Drs Roderick Hester, John Tebbetts and Patrick Maxwell from Georgia, Dallas and Nashville respectively, reviewed the literature on and their experience with polyurethane foam-covered breast implants and concluded: ‘During the span of this author’s practice, he has never been able to match the number and quality of superior results exemplified by these patients when using other devices.’ Round Brazilian implants cost about $350 per pair more than existing round implants, but Brazilian teardrop implants are in fact cheaper than other similarly shaped products. These implants require different techniques for insertion if they are to be positioned correctly, so it is important that you ensure your surgeon has plenty of experience in their use. Prior to the unrestricted TGA approval I used Brazilian implants for four years in selected patients with individual TGA approval. My experience has confirmed the international findings on these implants – very low rates of capsular contracture combined with excellent softness and appearance. Now these implants have been approved

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for unrestricted use by the TGA, I offer all my patients the Brazilian implants and find that 95 percent choose them.

Reducing recovery down time and discomfort With the exception of drains, bras and bandaging, I had given the traditional advice to my patients for many years (see table on page 73). I did often wonder, however, if I was just giving the same advice simply because it was what I had been taught and because it was standard practice. I then read an article written by Texas plastic surgeon Dr John Tebbetts. He claimed he could achieve a predictable 24-hour return to normal activities, with the exception of gym, aerobics, contact sports and lifting of abnormally heavy objects, in more than 90 percent of his patients. He surveyed his patients after surgery and found that nine out of 10 could go shopping or out for a meal, return to a non-physical job, drive a car, perform light domestic duties and lift regular-sized objects 24 hours after having breast implant surgery. He also claimed it made no difference to their recovery if the implants were placed in front of or behind the muscle. Dr Tebbetts didn’t use drains or straps or bandaging and stated that complication rates were lower using his techniques. In fact, patients were encouraged to put their arms above their heads before they even left the day surgery. When I first read this article I simply did not believe it. However, I knew my patients really wanted to reduce recovery times, so I further investigated Dr Tebbetts’ technique and started using it myself. The critical element of the technique is a method of dissection of the implant pocket that aims to reduce blood loss to only 1 millilitre or less per side. If this is achieved, there is no blood staining of the pocket. This reduces post-operative inflammation and therefore pain. Dr Tebbetts claims it also will reduce the incidence of capsular contracture. Although in theory this is reasonable, it has not yet been proved. A dry operating field is necessary and local anaesthetic is only used for the skin incision or not at all. Therefore ‘twilight sedation’ which relies on large volumes of local anaesthetic solution, cannot be used. Light general anaesthesia keeps the patient asleep and also allows the anaesthetist to relax the chest muscles if the implant is to be placed behind the muscle. Special instruments and operating techniques are used to dramatically reduce the amount of bleeding in most cases. Because there is less pain, fewer medications are needed postoperatively. This also contributes to a quicker recovery as all painkillers stronger than Panadol can cause side

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effects, especially nausea. Having now used this technique for more than a year on more than 350 patients, I know that blood loss is significantly less and there is a definite and substantial reduction in recovery times. Although no patient can be promised a 24-hour recovery time, many do experience this. Patients are advised that, apart from gym, aerobics, contact sports and lifting abnormally heavy objects after 24 hours they can perform any activity unless it causes pain. We have surveyed our patients and many do only need Panadol to manage any discomfort. The typical patient can go shopping, out to dinner and drive a car after 48 hours. I now use this technique on all my patients. Patients considering breast implant surgery who want to reduce their recovery time should be aware of the technique and should ask their surgeon what experience he or she has in using it.

Case study Former deputy editor of Australian Cosmetic Surgery Magazine Elise Eggleton spoke with one of Dr Fleming’s patients who underwent breast implant surgery using the ‘24-hour recovery’ technique. Dr Fleming’s patient, Nikki had implants placed behind the muscle and says she experienced a remarkably short recovery period. Nikki took two Panadol four times a day for about a week after the operation, supplemented by one dose of an anti-inflammatory drug when she felt particularly tight across the chest. The day after the operation, Nikki rested and went for a walk in the park and drove her car. ‘I was also able to wash my hair and put my hands above my head without any problems,’ she says. Nikki, who works as a beauty therapist, had been prepared to take two weeks off work. ‘However, I was back at work two days after the operation – although it was a light workload. Five days later I was right back into it – I even gave someone a massage!’ Four weeks later Nikki says she was playing competitive hockey again.

Conclusions To sum up how to ensure you get state-of-the-art breast implant surgery, I believe every patient should: • Choose a very experienced surgeon – preferably with a history of thousands of procedures. • Work with him or her to develop an individual operative plan based on the factors explained above. • Make sure the 24-hour recovery technique is used with an anaesthetist in a licensed day hospital. • Carefully consider the option of super furry Brazilian implants and if you do not choose them make sure you know why you are not doing so.


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Asymmetry, some sag and a tight crease made this patient’s breasts difficult. A firm gel, high profile teardrop implant of 270cc was put in a dual plane position to obtain a pleasing result.

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AFTER breast implants by Dr Fleming

This patient’s pointy, tubular breasts required careful planning and operative technique to optimise her result.

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AFTER breast implants by Dr Fleming

Widely spaced breasts are common and need sophisticated operative planning to minimise the gap.

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AFTER breast implants by Dr Fleming

Please remember every patient will have her own unique result depending on what she looked like before implants.

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This patient in her late 30s after bearing children, had some breast sag and asymmetry.

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AFTER high profile 340g dual plane breast implant augmentation with by Dr Fleming

This sequence shows how muscle spasm in the upper part of the breast in patients who have implants under the muscle initially gives a high, boxy look which settles as the muscle relaxes.

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4 weeks AFTER medium profile 260g breast implant augmentation by Dr Fleming

12 weeks AFTER the operation by Dr Fleming

Please remember every patient will have her own unique result depending on what she looked like before implants.

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BREAST IMPLANTS – THE DVD

Don’t go to your consultation without it. From Dr Daniel Fleming, the doctor more Australian women choose for their implant surgery than any other, and Dr David Topchian, who together with Dr Fleming, has Australia’s most experience using the P-URE Brazilian implants which are proven to reduce complications. Both doctors use the rapid recovery technique which Dr Fleming introduced to Australia. This complimentary DVD is specifically designed as a resource to provide all women who are considering breast augmentation with comprehensive, up-to-date and understandable information so they can make fully informed choices. There is no sugar-coating, no ‘artistic’ photographs – just the facts so you can decide if implant surgery is right for you. The information in this DVD will help you work with your surgeon to formulate a personalised operation plan most likely to give the best result you can get.

To obtain your FREE DVD without any obligation or for more information please call

1800 682 220 Cosmetic Surgery Institute of Australia Brisbane, Melbourne and NSW www.breastimplantsaustralia.com

Initial phone/internet consultations available for country, interstate and overseas patients


Cosmetic Surgery Institute of Australia