Alamo Plastic Surgery!

2019 Breast Enhancement Surgery Guide

Hello and Welcome to Alamo Plastic Surgery! My name is Dr. William Albright and I want to personally thank you for taking the time to educate yourself about cosmetic breast surgery. Really. Whether it’s your first breast surgery or your fourth, I want this Surgery Guide to help you to make the best possible decisions. This information is condensed from my own personal practice, and, as such, reflects one (*humble*) surgeons’ opinion. Although not specific personalized medical advice, this guide should help frame concepts in a way that is easy to understand and may stimulate further self inquiry. Why here and why now? As a Board Certified Plastic Surgeon specializing in breast and body cosmetic surgery, I wanted to bring my world class training and expertise to Central Texas and my hometown of San Antonio! So I designed Alamo Plastic Surgery to be a unique practice that provides exceptional value to patients. How do we provide value? This e-Book is a great example. Information and its application to medical decision making is empowering! Empowered and informed patients make better choices and (I strongly believe) are more likely to achieve incredible and long-lasting results. With this e-Book, you should have a great foundation to making these important health decisions. 2

Why does cosmetic breast surgery matter? As I routinely say, plastic surgery has an image problem. In the US, most people have preconceived notions about plastic surgery: what it involves and who seeks it. These opinions are often informed by our popular culture which tends to highlight the outliers. Risky, over-the-top or bizarre surgeries (Cat boy, Bat boy, or whatever) performed to drive social media attention, TV ratings, YouTube views, or Instagram followers dominate our media. With these limited fringe examples, people naturally ascribe certain motivations to and pass judgement on those who seek plastic surgery. Oh, plastic surgery is… An especially dangerous attention-seeking behavior involving inherently broken, weak, or exceptionally vain people. A moral failing. Or perhaps, it’s just a foolish decision by people who have too much free time, or too little financial sense. More boobs, than brains... Thankfully, however, having treated patients from across the country and all age groups, these stereotypes do not fit with my experience. Many patients may initially seek breast rejuvenation as simply a means to obtain a more visually-appealing feature, like perkier breasts. But, is that visual feature (perkier breasts) really what makes you more attractive in most situations? What about when you are fully clothed and no one can really see your breasts? Or you wear that bra that lifts the breasts just so, without surgery? How come my heterosexual female patients care more about how they look in the eyes of their same-sex peers rather than their sexual partners (boyfriends/husbands)? The answer is… Confidence! Confidence is an attractive feature and communicates (verbally and nonverbally) to everyone around you that you feel comfortable in your own skin. This is one of the important byproducts of breast rejuvenation (as well as any number of other self-improvement activities like physical exercise). Although I enhance the appearance of the breasts, it’s the confidence boost that other people recognize and value. For the vast majority of patients, the person who most often sees your breasts out-of-clothes is YOU. When YOU think you look good, it changes your behavior, and other people take notice. Some of us forget what it's like to feel beautiful and have this self acceptance. We get too busy with our lives, our family and our work. Is this just vanity? Would it be better to just slug through life unnecessarily suffering just to cling to some sense of moral superiority? As a wise and influential person once said, “Bad breath is natural, normal and authentic”. And yet (gingival disease not withstading) most of us do not believe fixing your bad breath is a moral failing! Are there times when patients have unrealistic requests or expectations? When it is too much risk for too little reward? When life’s circumstances are such that it is wiser to avoid an expensive purchase? Yes, of course. I do not run a car dealership (no offense Murphy!). I am a physician and a confidant. At Alamo Plastic Surgery, we treat patients how we would want to be treated, which is to say, with honesty and respect. And our patients recognize this, value this and appreciate this. We wouldn’t have it any other way. So, welcome to Alamo Plastic Surgery, and good luck on your plastic surgery journey. Sincerely, William Albright 3

Our Team Alamo Plastic Surgery Mission - To provide exceptional value through patient education, empowerment, and incredible surgical results. 4

Dr. William Albright As a leading board certified plastic surgeon in central Texas, Dr. Albright consistently delivers life-changing surgical results and an exceptional plastic surgery experience for his patients. After training with plastic surgeons from around the world, Dr. Albright wanted to bring his expertise back to his hometown of San Antonio. After he graduated from UT Austin and UTMB in Galveston with Highest Honors, he was selected for an integrated plastic surgery residency. Plastic surgery goes beyond basic function by optimizing both aesthetics and function. While plastic surgery alters the body, it can also restore the spirit by better aligning one’s appearance with their internal self-image and vice versa. This duality of plastic surgery is what initially hooked Dr. Albright and continues to drive him to this day. After intense training at Penn State as well as advanced aesthetic training in Brazil, he sought to further improve his results by working as a clinical professor at the University of Iowa. By teaching fellow surgeons and his patients, he realized the incredible value of education, which has become an integral part and major focus of Dr. Albright’s unique approach to plastic surgery. Dr. Albright has the passion and expertise to help you achieve your plastic surgery goals. He looks forward to working with you to develop your individualized plan and give you the confidence needed to make your dreams a reality! Franchesca Espinosa As our dedicated Office Manager, Franchesca Espinosa works tirelessly to ensure every member of our care team upholds the Alamo Plastic Surgery Mission to provide an incredible plastic surgery experience and treat our patients with respect and honesty. She brings decades of experience in the medical field to our Team, and we are lucky to have her! Favorite aspect of her job: Giving patients the confidence to “take the plunge” and commit to improving their lives. Juli Albright Juli is one of our Patient Care Coordinators and marketing guru. She helps navigate patients through their office visits and surgical journey. She is passionate about improving the patient experience and helping Alamo Plastic Surgery deliver the highest level of quality care. Favorite aspect of her job: Chatting with patients who are “THRILLED” with their results, and making new connections with future satisfied patients. Christina Reyes Christina is one of our Medical Assistant who brings joy and a healthy work-ethic to our back office. She enjoys helping patients achieve their goals. She is compassionate and nurturing which may come from her previous years of working with cancer patients in medical oncology. Favorite aspect of her job: Participating in patient education and seeing patients through the entire process from consultation to finished product. 5

Planning your consultation? Our staff is here to make you feel comfortable and answer your questions. Our staff recommends these helpful tips for getting the most out of your consultation: 1. Bring a Friend - We find that it is helpful to have a trusted family member or friend come with you to your initial consultation. Having an extra set of eyes and ears can be invaluable. As many people may feel a little overwhelmed during the consultation itself, it is nice to have someone else there to ask questions and remember the answers. This person can then be a resource for discussion after the visit and when comparing different surgeons or surgical plans. 2. Intake Paperwork - Completing paperwork ahead of time makes your appointment more efficient, and more ENJOYABLE. Similar to most doctor’s office, we request you complete a medical history, a procedure specific intake form and various other legally required consent forms. 3. Photo consent form - Just as many of our surgical patients found Before and After photos helpful in their decision making, we ask these patients to “pay it forward”, so future patients will also have this important educational tool when they are trying to make their decision. However, your privacy is critically important to us, and we never use your name or your face with our body photos, unless you specifically and explicitly agree to it. At any time after giving consent, you can change your mind. Whether you opt-in or opt-out, we are here to help you in your journey. 4. Know the Process - During the physical exam, our amazing and friendly staff will review your paperwork and take your vital signs. You will then be asked to change for the examination (which will depend on what procedures you are interested in). Dr. Albright will then come in to speak with you about your medical history and plastic surgery goals. For the exam, he will take several measurements and assess the quality of your skin and soft tissue. Photographs may be taken for surgical planning and to help visualize surgical outcomes. After the consultation, you may visit with our office manager to review Before and After photos, discuss surgery details/recovery and surgery cost/financing. And… then you are finished with the initial consultation! 6

Preparing for Surgery: There and Back Again At Alamo Plastic Surgery, we want every patient to get the best surgical outcome possible. That’s why we discuss and provide detailed postoperative written and verbal instructions. Our guidelines are designed to promote the healing process and to prevent the occurrence of anything that could interfere with your recovery. Since it is impossible to discuss every conceivable scenario or situation that may arise, we try to focus on the most common issues that you may face after your surgery. If you have questions or concerns, please ask Dr. Albright or a team member. There are no silly questions! You are a partner in this process and we ask you to follow the instructions as closely as possible. These instructions are based on broad experience and are designed to give you the best opportunity for healing without delay or unwelcome surprises. 7

PREOP CHECKLIST To do as soon as surgery is scheduled: • If required, call surgical facility to pre-register: Specific facility and phone number is located on your cosmetic quote. One Month to Two Weeks prior to surgery: • The following items may need to be completed and reports submitted to Alamo Plastic Surgery at least 2 weeks prior to procedure:  Call surgical facility to pre-register, if not yet completed.  Get Mammogram (if over age 35 and has not been done within 6 months of scheduled surgery date; Not sure, ask Dr. Albright). Check with our office for help scheduling and notify us of date and facility performed.  Get EKG done (if over age 45). Check with our office for help scheduling and notify us of date and facility performed.  Any required labs, if needed.  Pay for the procedure (Surgery Facility, Anesthesia and Alamo Plastic Surgery), if required. Or, finalize financing option. Two Weeks prior to surgery: • STOP all aspirin-like products (aspirin/Aleve/Advil/Motrin) and any blood thinners, as directed by Dr. Albright. Unsure? Call us to confirm. • Call our office if you develop any of the following issues:  a cold or fever a productive cough  rash/acne outbreak on your chest  any kind of infection or are started on an antibiotic • Select a caregiver who will stay with you throughout the surgery day, that evening, and can bring you to your first post-op visit. • Have caregiver read post-op instructions. • Make sure payments have been made. 8

One Week prior to surgery: • Call the office if you develop a pimples or pustules on your body where the surgery will be performed (the chest or torso). If you have active acne where we are planning to operate on the day of your surgery, the surgery may need to be rescheduled. • Make sure any pre-op test results (mammogram/ EKG) have been received by Dr. Albright’s office. • Call Dr. Albright’s office if there are any changes in your health status (fever, cough, etc). • Pick up supplies (Gatorade, soups, etc.). SEE BELOW. • Pick up prescriptions from the pharmacy. • Make sure you have arranged for someone to be with you the day of surgery and the day after. Go over post-op instructions with caregiver. • Notify our office if you need assistance booking a hotel reservation, if needed. • Any questions? Call the office. Day of Surgery: • Don’t Freak Out. • Wear loose fitting clothes, button down front top. • Bring pain/nausea medications with you to the facility. • Bring a couple pillows for the car ride home. Day After Surgery: • Try to take it easy. • Wear loose fitting clothes with button/zip front top. • No pushing, pulling, or lifting over 10 pounds (check your purse). 9

RECOMMENDED SUPPLIES: Must Have Items: • Peace and Quiet • Caregiver: responsible for your care after surgery and the night after your surgery. • Postoperative Garments: Recovery bras or compression garments as discussed with our team. • For primary breast augmentation only: Cool compresses: at least one large reusable cold compress per breast. • Beverages: Water, Juice, Gatorade and/or carbonated soda (Sprite/7- Up) • Food: crackers, soup, Jell-O • Over-the-Counter Meds: Tylenol, and stool softeners. • Miscellaneous: straws that bend, and extra pillows. Optional Items: • Throat lozenges / Chloraseptic Spray for sore throat. • Premade / Frozen meals. 10

THE BIG DAY What should I wear/ bring? 1. Wear comfortable, loosely-fitted clothes. 3. Pants/shorts should have elastic or drawstring waist. 5. Shirt should be button front, or extremely oversized. 7. Bring a firm pillow (or folded firm blanket) and leave it in the car. You will use it on the ride home. When should I arrive? 1. You must arrive on time. If you arrive late for your operation, there may not be enough time to do the necessary preparatory work for your operation. Your operation may be delayed or even canceled. Please, be on time! What happens when I arrive? 1. You will be changed into a surgical gown and given foot and head covers. They may apply leg squeezing devices at this time. 3. An IV will be started and you will be given antibiotics. 5. Your caregiver may be with you until you are taken to the operating room. Who will I see before my surgery? 1. You will be assigned a Pre-Surgical Nurse who will explain much of what will happen to you. 3. Dr. Albright will mark the operative site(s) prior to going back to the OR. Be sure to ask him any remaining questions. 5. The anesthesiologist will talk to you about anesthesia and answer any questions that you may have. 11

Will my caregiver see Dr. Albright after the operation? 1. After you go back to the operating room, the procedure usually will take approximately 1-2 hours for breast augmentation, 2-4 hrs for breast lift, and 3-5 hours for breast reduction. Once completed, Dr. Albright will discuss your operation with your caregiver. 2. We ask that your caregiver stay at the Surgery Facility throughout your operation. When can my caregiver be with me after my operation? 1. Approximately 30-45 minutes following your operation, your caregiver will be taken into the recovery area to be with you. 2. Your caregiver will be given additional instructions at this time. What happens next? 1. At some point, a nurse will tell you it is time to leave the recovery area. You will still be in some pain but it will occur at a time that the nurse feels you are best able to tolerate the ride to your home or hotel. 2. Do not feel as if you are being pushed out. There is a window of time when you may leave while the medications are working at the maximum to reduce pain and nausea for the car ride. 4. Remember that even when you leave the Surgery Facility, help and answers to questions are only a phone call away. How long will we be at the Surgery Facility? 1. Total time at the Surgery Facility varies because some patients will require more time to recover after their operation than others. 2. Typical postoperative recovery time can vary between 1 hour to several hours. Should I wear a seat belt in the car ride? 1. Wear your seat belt while going home as you normally would. 2. The seat belt will not harm your breasts. If your driver is involved in a car accident, you will be grateful you wore your seatbelt. 4. If it feels more comfortable, you can hold the pillow (or folded blanket) against your chest for support during the car ride. Remember to limit reaching and pulling with your arms. 12

Breast Augmentation 101 saline implants breast volume breast reconstruction weight loss type of implant breast cancer general anesthesia breast augmentations procedures drainage tubes increase the size breast augmentation surgery surgical procedure size and shape augmentation mammoplasty breast tissue breast lift chest muscle restore breast plastic surgery pectoral muscle 13

Introduction to Breast Augmentation Women seek breast augmentation (augmentation mammoplasty) for a variety of reasons. For many women, it is not just to increase the size of their breasts, but may be to feel more comfortable in a swimsuit or confident out of clothes. It may be to return to their pre-pregnancy shape and volume. Some aim to correct an asymmetry or abnormal breast development that has plagued them since adolescence. Whether a woman wants people to know they’ve had a “boob job” or prefers a more reserved natural look, Dr. Albright will assist you in achieving your specific aesthetic goals. Breast augmentation is the most popular cosmetic surgery according to American Society of Plastic Surgery with over 300,000 procedures a year. Silicone implants were used in 88% of cases and 12% were saline. Given the variety of goals and body shapes, breast augmentation may seem a bit overwhelming. Relax! Dr. Albright has the skills and experience to walk you through the options that are best for you. He will explain breast implants and augmentation techniques in a way that makes sense. Breast augmentation combined with a breast lift or breast fat transfer might be another option for you. Dr. Albright takes the time to explain the relative risks and benefits of different augmentation techniques so you can make the best decision for you. 14

Who is a good breast augmentation candidate? We recommend checking out our incredible before and after photo gallery to see real life examples of breast augmentation. Most women who elect to do breast augmentation surgery have at least one of the following issues that must be addressed in the surgical plan: 1. Volume: Your breasts are too small, either from puberty or after pregnancy/weight loss. 2. Shape: Your breast shape has changed (after pregnancy, weight loss or with aging), and are too saggy, lacking firmness or cleavage. 3. Symmetry: Your breasts are asymmetric in volume, shape, feel, nipple position, position of the breast on the chest, etc. 4. Developmental anomalies: Your breasts failed to develop normally from the beginning. Patients must be physically healthy enough to undergo a procedure and are not actively using nicotine containing products. As breast augmentation is an elective surgery and the best chance for the ideal result is during the first surgery, we try to set all of our patients up for success before surgery. 15

What type of implant is right for you? During your consultation, Dr. Albright will discuss the differences between salt- water (saline) filled versus silicone gel filled breast implants. For most patients the choice will boil down to the overall comfort level with risks/benefits of the implant fill material. Here is a brief comparison of saline versus silicone breast implants: 16

1. Breast Implants and Rupture For saline implants, if the implant were to rupture, your body would slowly absorb the salt-water and you would notice a “deflation” or loss of volume in the affected breast. Conversely and especially with newer cohesive silicone implants, implant ruptures are often “silent”, meaning you may not be able to see or feel a difference in the implant after a rupture. The FDA recommends scheduled MRI surveillance of silicone implants to help detect these silent ruptures. If your silicone implant ruptures, the FDA recommends having it removed with or without replacement as a precaution. The recommended MRI’s are not covered by insurance and will have to be paid out of pocket. 2. Breast Implant Cost Saline implants are typically less expensive to purchase than silicone implants (typically several hundred dollars) but may have less extensive warranty coverage. An exception to the cheaper initial cost for saline-filled implants is the new “Ideal Implant”, which is a “structured”saline-filled implant that is purported to feel more like a silicone implant and has a similar overall cost to silicone implants. Implant warranties are also always evolving between implant types and implant brands. Although complications from primary breast augmentation are thankfully rare, we still strongly recommend purchasing increased warranty coverage for your implants from the implant manufacturer, if it is available. If you have questions, let us help! 3. Breast Implant Feel Silicone implants, including gummy bear breast implants, are widely accepted as feeling more “natural” or “breast-like” particularly when squeezed or poked/prodded. However, this is likely an over-simplification. The overall implant feel is also affected by implant pocket selection, implant fill characteristics (over-filled vs under-filled saline and more or less cohesive silicone gel), and overall soft tissue coverage. Dr. Albright typically reserves traditional single-lumen saline-filled implants for use below the muscle (total submuscular) to help minimize any unnatural feel. Furthermore, he discourages using these saline implants in a dual-plane pocket as the implants may migrate more quickly due to a water hammer effect from the saline fluid on the surrounding soft tissue. 4. Breast Implant Weight The implant fill density (typically grams of weight per cc of volume) is very similar between 0.9% Normal Saline, and cohesive silicone gel. Both approximate 1g per cc. Since saline implants come deflated and are filled with salt water during the procedure, they have a range of fill volumes that can be used and are therefore more adjustable than silicone implants which come pre-filled and have a fixed volume. But even with these variables, differences between implant weight (at least within the range of most implant sizes) are negligible. 5. Implant Rippling Every breast implant has the risk for rippling/scalloping/waviness/folding in its shell. This is why ensuring adequate soft tissue coverage to “hide” the implant is so important. There are certainly differences in overall risk of seeing or feeling these ripples or folds. Underfilled-saline implants are at greater risk than over-filled saline implants. Less cohesive silicone gel filled implants are at greater risk than more cohesive silicone gel implants. 17

Implant pocket: The critical first step... Implant pocket is the most important determinant of outcome and is described by the relationship of the implant to the pectoralis muscle on the chest. [We highly encourage you to reference our video series on our website (www.alamoplasticsurgery.com) to find an even better explanation with patient examples.] The “pec” muscle is a flat fan- shaped chest muscle connected to the front of the chest on three sides (collar bone, outside border of the breast bone, and along the ribs near the lower part of the breast). The muscle is not connected to the chest wall on the side toward your armpit (you can pinch the muscle between your fingers on the side) as it spans over the armpit to connect the chest to your upper arm. Placing the implant above this muscle is called subglandular or prepectoral. Placing the implant below the muscle is called submuscular or subpectoral, and can be further differentiated by being completely under the muscle (total submuscular), or partly under the muscle (dual-plane). When an implant is placed below the muscle, the procedure is more painful and you may need more pain medication. However, for most women, the pain is temporary and there is no difference in pain long term. By changing the pocket, you can change the overall breast look as well as the relative short and long term risks and benefits of the procedure. During your consultation, Dr. Albright will help you decide which implant pocket is best for you. For your convenience, he also put together this chart. 18

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Where will the scars be located? There are a variety of access incisions used for breast augmentation. Dr. Albright prefers an incision placed along the “new” lower breast crease/fold, called the inframammary fold or IMF incision. This incision may prevent seeding the implant with bacteria (which may be harbored in milk ducts that travel toward the nipple or deep hair follicles and sweat producing glands in the armpit). By avoiding bacteria around the implant, you decrease your chance of developing a capsular contracture. Dr. Albright also finds that this access incision provides the best access to the implant pocket for access, dissection and implant placement. Alternative access incisions exist, and these include periareolar, axillary and umbilical. A “periareolar” incision (either placed at the junction of the areola and normal skin; or placed through the center of the areola curving around the base of the nipple) is quite popular, as it hides the scar very well. However, there is a theoretical risk of implant contamination, as well as some scarring and tethering that can occur as the surgeon must either dissect through the breast tissue or around the breast tissue. Dr. Albright typically reserves this approach for patients who need a small lift to the areola/nipple and require incisions around the areola anyway. An incision in the armpit or axillary incision is also a popular scar location as it too tends to hide the scar in an area that is not often seen and has natural folds. However, again there is concern about implant contamination. Additionally, the dissection is more difficult especially near the lower breast fold and in dual plane augmentations. Finally, a saline implant may be placed through a small incision around the umbilicus, called a transumbilical breast augmentation or TUBA. The benefit of this technique is hiding a breast implant scar in a place where most people would not think to look. However, it makes the implant pocket dissection dramatically more difficult, and the technique has been criticized for poor implant position. 20

How long are the breast augmentation incisions? Your incision will vary depending on the type of implant fill, the size of the silicone implant, the access incision selected, and whether or not a mesh product is also being used. Since saline implants are typically inserted in a deflated state, and inflated with salt water while they are inside your body, the access incision is typically smaller (about 3-4 cm). Silicone filled implants are pre-filled and must be “squeezed” through a smaller incision. This usually necessitates a longer incision than saline filled implants, and will depend on how big the implant is (typically 4-6 cm). Many surgeons utilize a funnel (Keller Funnel II is an example) that helps squeeze the implant past the incision, similar to a cake frosting funnel. Some surgeons claim to use a much shorter incision with silicone implants by forcing the implant through a smaller opening using an implant funnel and applying more force to the implant. With newer cohesive gel filling, the gel structure is more like a semi-solid than a liquid, and can be “fractured”. Don’t believe us? Take a cohesive silicone gel implant and squeeze it as hard as you can with your fingers… You will find that permanent indentations have been created where your fingers were located, and these indentations remain over time. Dr. Albright recommends just extending the incision another ½ to 1 cm to avoid damaging the implants. If mesh is being used (a novel concept in primary breast augmentation), a longer incision may be needed particularly for saline implants so as to allow more working space for placing and anchoring the mesh prior to implant insertion. This is more common for revision breast augmentation. 21

Breast Augmentation Recovery 22

What is the recovery time and activity restrictions after breast implants? Dr. Albright wants all of his patients to get the best result possible. What we do after breast augmentation surgery is just as important as the surgery itself. Although there are slight variations in breast augmentation techniques, patients will have 2 weeks with minimal reaching/pulling with the arms, and less than 20 pounds lifting of weight. This is followed by 2 more weeks of less than 45 pounds lifting, but during this time you may reach and pull with the arms. In total, there will be 4 weeks of no intense exercise and you will be in a bra 24/7 except for showering. After these 4 weeks, most patients may begin regular exercise as tolerated. Worried about drainage tubes after your breast cosmetic surgery...? Don’t be. Dr. Albright rarely uses drains with this procedure. When will I see results from my Breast Augmentation? For most patients there will be initial swelling from surgery followed by gradual resolution of the swelling with a resulting loss of volume. Around 2 months, most of the swelling has resolved and you will be at your approximate breast size. At this point you can go out and purchase your new wardrobe (bras, bikinis, etc)! However, even at this point, you may not have your final breast SHAPE out-of-clothes (how the breast will look when standing naked). This is because the overlying soft tissues are still adjusting to the implant which takes about 2-3 months for above- the-muscle implants to about 4-6 months for below-the-muscle implants. Depending on your goals, this may help you figure out when to schedule your i. How can I maintain my results from breast augmentation? Understanding that the biology of aging can’t be reversed with a scalpel, there are some common sense precautions you can take to prolong the longevity of your result. Breast tissue and breast implants have weight. In fact, breast implants are typically heavier than native breast tissue for the same volume. Gravity and activities will move this weight over time, and eventually overpower the soft tissue support creating droopiness and a poorly positioned implant. For this reason, Dr. Albright recommends wearing breast support as much as possible, including at night, for life. Related to this concept of soft tissue strain, one should avoid significant weight fluctuations either up or down. Finally, we can avoid unnecessary damage to the soft tissue by limiting nicotine exposure and tanning. 23

Breast Augmentation Costs At Alamo Plastic Surgery, breast augmentation costs between $3800 - $5200. The main cost variable is the implant cost, whereas the other costs are relatively stable and fixed (facility fee, anesthesia fee, surgeon’s fee). Alamo Plastic Surgery offers many convenient financing options, including options with interest free periods. Options are always changing, so call us today to find out more. 24

Fat Transfer to the Breasts What is breast fat transfer? Fat transfer or grafting to the breast is one of the most exciting techniques in breast surgery. Fat grafting involves obtaining or harvesting fat cells from one part of the body (typically abdomen or thighs) by liposuction, and then the fat is injected into the breast tissue. The fat will then be able to provide bulk for breast enlargement, like augmentation with fat! A natural breast shape can also be created depending on the amount of fat transferred. Not only can fat transfer be used in primary breast augmentation, it can also be used in implant revision surgery, for instance, to help mask or camouflage an existing implant. Depending on the volume of fat moved, implant rippling and breast feel can improve. The procedure can be repeated as many times as necessary as long as there are adequate donor sites. Better still, the recovery for 'autologous fat grafting' is fairly straight-forward, and is essentially the same as cosmetic liposuction. Many patients see fat transfer breast augmentation as two surgeries in one: improving the look and feel of their breasts while also contouring their bellies or thighs! Dr. Albright notes very high patient satisfaction when combining fat grafting with other cosmetic procedures. Another benefit is relatively smaller incisions on the breasts. Fat grafting is an excellent stand-alone or adjunct procedure for cosmetic breast surgery, such as breast augmentation, breast implant adjustment, and breast lifts. With fat grafting, we are using your own tissue to provide breast volume and increase cup size. For breast lifts, the grafted fat can provide more volume to the top of the breast and help with overall breast shape/contour. Current technology denotes breast size can double with breast fat transfer. The fat when strategically placed can help improve implant step offs and visible implant rippling. Breast reconstruction patients also benefit from fat grafting. By increasing the soft tissue coverage in the reconstructed breast, fat grafting helps create a more natural feeling and looking breast. It can be used to help achieve better symmetry when trying to match your other nonreconstructed ‘native’ breast. Furthermore, many surgeons believe fat grafting can also improve the quality of the breast skin after radiation treatment, although this is still being studied. 25

Who is a good breast fat transfer candidate? Patients who are good breast augmentation candidates are likely good fat transfer patients. However there are a couple of considerations. First, patients must have a realistic expectation of what injected fat can and can’t do. We will get into this later, but, in short, grafted fat does not maintain the breast shape like an implant can. Second, you must have enough fat to harvest from some other part of your body. In other words, you can’t be too skinny. Related to this concept, is if you tend to be very thin or lose weight easily, the grafted fat that has survived will behave like your normal fat. Therefore, if you were to lose weight after surgery, you would expect that the breasts would also get smaller. Conversely, if you were to gain significant weight, your breasts could get bigger. This must be taken into account prior to surgery. We recommend checking out our incredible before and after photo gallery to see real life examples of breast fat transfer. 26

So, can fat replace a breast implant?!? Yes and no... The transferred fat is adding to the overall volume of the breast, but does not quite maintain its shape like a traditional breast implant. This is best seen at the top of the fat grafted breast. This will still have a more natural smooth transition whereas, depending on the implant, a traditional breast augmentation can have more projection and rounding of the top of the breast. Also different is the degree of volume change that can occur in one surgery. With the breast implant, you are assured of how much volume is being put into the breast versus fat grafting which has some fat volume loss after the surgery (fat that did not survive the relocation). 27

How long does it take to see my results? Although variable between patients, most patients will notice what fat graft has taken and what has not by about 3-4 months after the procedure. Further clouding the picture is the fact that patients also have normal postoperative swelling in the tissues, which can change the perceived volume of the breasts. This is also why Dr. Albright recommends waiting between fat grafting surgeries to make sure the patient has achieved a stable result before committing to additional surgery. 28

What about Some plastic surgeons will apply a suction-cup-like device Brava to the breasts before surgery in an effort to increase the system? blood flow into the tissues. It is thought that this may increase fat graft survival, and increase how much fat can be grafted into the breasts at one surgery. This is still somewhat controversial. Dr. Albright finds that patient’s are not interested in wearing these preoperative devices due to inconvenience and cost. Additionally, Dr. Albright finds that his patients have less fat graft survival with high volume fat transfers to the breasts. Finally, if you were to transfer truly large volumes of fat to the breast, the breast will behave more like a large fatty breast... Which is to say, that the breast will likely hang over time. This is because fat does not maintain its shape like an implant. 29

Where does the fat come from? Dr. Albright prefers areas on the body that are easily accessible in one position. For example, taking fat from the upper back would require your body to be repositioned during the procedure, and this will add to the time of the procedure. Increased time can increase your risk and potentially decrease the viability of the fat, if it spends too much time out of the body before re-injecting. For these reasons, Dr. Albright does not recommend taking it from the back, unless that is the only place on your body with adequate supply. Most commonly patients will have adequate and bothersome fat deposits that are more safely accessed, like the belly or the thighs. Still have questions, come see us today to discuss. 30

Risks of Breast Fat Transfer Is fat grafting safe in the breast? Studies have shown cancer safety of fat grafting even in the setting of patients with previous breast cancers or family history of breast cancer. Dr. Albright recommends obtaining breast imaging (mammogram/ultrasound/MRI) before surgery to ensure there is not currently a problem with the breast, and to act as a baseline for radiologists to compare future images against. The FDA and the American Society of Plastic Surgery continue to study the safety of fat-transferring procedures. Other downsides of fat grafting to the breast? A significant downside of fat grafting is the occasionally unpredictable survival of the grafted fat. Studies have shown and Dr. Albright’s experience supports the assertion that about one-half to two- thirds of the transferred fat will survive at one year after surgery. There are many factors that are involved with fat graft survival including thickness and quality of blood supply in the recipient breast tissue. The technique is dependent on well vascularized tissues, therefore patients with significant previous breast scars or those who actively use nicotine are not ideal candidates. Grafted fat that does not survive will be broken down over time, and can create areas of ‘fat necrosis’ or oil cysts. As a board certified plastic surgeon, Dr. Albright will discuss these issues with you and attempt to answer all of your questions so that you feel comfortable with this powerful technique. Wait, I’ve heard there have been deaths from fat grafting? When fat grafting to the buttocks (brazilian butt lift), there have been several high profile deaths. This seems to be related to both surgeon technique AND inherently higher risk area based on anatomy. When fat grafting to the buttocks, there are very large veins that can be injured and then allow grafted fat to enter the circulation. This can create fatal fat emboli. Unlike the buttock/pelvis, the vessels of the breast are smaller and less likely to be injured with the smaller blunt tip injecting cannulas used for the breast. This is another reason Dr. Albright does not perform high-volume fat transfer to the breast, so as to limit the risk of vessel injury and fat emoblization. 31

Breast Fat Transfer Cost At Alamo Plastic Surgery, breast fat transfer costs vary between $3000 - $5000 and up. The main cost variable is the amount of liposuction to be performed and the amount of fat to be injected into the breasts, which will vary between patients. The facility fee will also vary depending on how many body areas are to be contoured with the liposuction. Anesthesia and Dr. Albright’s fees are time based, and therefore will be adjusted by how long the overall procedure will take. Alamo Plastic Surgery offers many convenient financing options, including options with interest free periods. Options are always changing, so call us today to find out more. 32

Breast Lift Many women are quite satisfied with their breast volume in a bra, but are a little less comfortable with the shape of the breast when the bra comes off. Whether your breast is just too droopy or your nipples are pointing at the floor, Dr. Albright has a solution! With a breast lift, he can reposition the droopy breast tissue back up on the chest while also centering the nipple on the mound. Need the areola (pigmented skin around the nipple) to be smaller? He can do that too during the same surgery. For patients who may want slightly more fullness but not enough to warrant a breast implant or who don’t want to worry about future issues with breast implants, Dr. Albright can frequently add your own fat (removed with liposuction from another location on your body) to the breast to add some volume and improve overall contour. Fat grafting is a more natural filler for your breasts than silicone. The one limitation for this technique is that it does not maintain a full round upper pole of the breast out of clothes like an implant can. Dr Albright will be able to discuss this with you during your consultation. 33

Introduction If you are contemplating a breast lift, it can be intimidating to meet with a plastic surgeon to discuss something so personal. At Alamo Plastic Surgery our mission is fully educate patients so they are empowered to make great decisions for themselves. In this blog article, we strive to walk you through the process and different options. Please contact us at [email protected] or 210-670- 5302 if you have additional questions or comments. Initial Consultation First we will obtain a past medical history and surgical history. As a breast lift is a cosmetic procedure, it is important to make sure there are no medical risks associated with the surgery and we can meet your cosmetic goals. All of these things we will discuss in depth when you come for a visit. In addition, we will conduct a physical exam which will include several measurements to assess the skin quality and the breast tissue volume. These will dictate which procedures are best for you. 34

Breast Lift Surgery Explained For a traditional breast lift, we strive to correct two issues: 1. Excess skin and potentially low nipple position 2. Breast tissue that has slid off the chest 1. Skin - To address the excess skin and low nipple, the most common skin incision pattern in the US is a Wise pattern, also called an 'inverted T' or 'Anchor scar'. During this procedure, I will also cut into the areola (pigmented skin around the nipple) to make it smaller, if it has become stretched. Immediately after surgery, the areola will appear to be a little too small but, don't worry, it will stretch out over time like it did the first time. Utilizing this pattern, the nipple is raised and inset into position at the center of the repositioned breast mound. The skin below the new nipple position is then sewn together to create a nice straight vertical line. The side to side scar at the bottom fold of the breast is variable in length depending on the magnitude of extra breast skin (a smaller lift will result in a shorter scar as less skin needs to be removed). As you can see from the diagram, the scar pattern looks like an upside down letter 'T' or anchor. 2. Breast Tissue - Now to address the sagging breast mound. This has to do with what is being changed on the inside (under the skin). I utilize a \"superomedial pedicle with a caudally based 'auto augmentation' flap technique\". To start, you can think of it as cleaving the breast in two. This sounds dramatic, but just below the nipple and areola there is an incision through the breast. The nipple is going to stay attached from a blood supply from upper inner part of the breast or 'superomedial' (definition is above and towards the sternum). This is going to supply blood to nipple and areola. The nipple will move upward and rotate slightly into its new position. The lower portion of the breast (not attached to the nipple) is analogous to an inferior pedicle. But, in this case, the lower part of the breast is only used to provide additional bulk and function like an implant; it will be moved up to the new mound position underneath the new nipple. Thus, \"auto augmentation\" flap just means using your own breast tissue like an implant. However, it is not an implant as the shape produced is a teardrop shape, not round like most breast implants. A full profile implant associated with a breast augmentation creates superior pole fullness (rounded at top of the breast). To have more superior pole fullness with a breast lift, breast fat grafting can improve the contour and volume. Many patients are happy with this approach to avoid a breast implant. For a breast lift, I try to keep as much of your breast tissue as possible. With a breast reduction, I would remove some breast tissue to reduce the overall size and weight of the breast. For breast lifts, the immediate result after surgery, the breast shape may look a little like a breast augmentation (round full top), but this is temporary and due to postop swelling. Also immediatly after surgery, the nipple position will look artificially low and maybe even pointing down. As the breast ultimately settles lower, the nipple will be in an ideal position. 35

Breast Lift Risks Immediate Risks • Bleeding - Could lead to a hematoma (collection of blood) or an expanding hematoma (ongoing bleeding) which could limit blood flow to the skin and nipple which may require a return to the operating room. An expanded hematoma is very rare. • Poor Blood Flow to the Nipple - As mentioned in the previous section, the blood flow to and from (venous outflow) the nipple in order for the tissue to survive. If either of these break down (blood flow in or out), the tissue may ultimately heal poorly. If there is compromised blood flow, there are certain things Dr. Albright will do in the operating room to try and improve the flow. However, if these do not work, then a free nipple graft may need to be done. A free nipple graft involves physically removing the nipple and then suturing it back on like a skin graft. When this happens, we cut the nerves and milk ducts. Therefore, the major consequences of free nipple graft are loss of sensation, and inability to breastfeed. This is extremely rare and I have never had to do this for a breast lift. Intermediate Risks • Wound Healing - The most common area of wound healing is at the T point (bottom of the anchor where the scars meet). \"T\" also stand for tension. Tension decreases blood flow and any tissue without blood flow creates dead tissue so it can result in a small area of skin necrosis resulting in a small scab (typically <1 cm^2). Only about a third of patients will have this occur and most commonly only on one breast. This is not a serious issue, and we treat these wounds with regular dressing changes. It may result in a slightly larger scar but this is typically hidden by the breast. • Infection - Rare with breast lift. • Seroma - Rare with breast lift. 36

Long Term Consequences Scars (8-12 months to mature) after Breast Lift Scars may widen and stretch over time. There is potential for hypertrophic scars (thickened, wide, often raised scar that develops where skin is injured) to develop if you are predisposed to them. These may be treated with steroid injections and they are only a cosmetic issue. If you have a family history of keloid scarring or know you develop keloid scars (enlarging raised scars). During the initial consultation, we will discuss any concerns you may have about scarring. Nipple Sensation after Breast Lift For some women, this is very important. About a third of my patients will have some decreased sensation in one nipple. It is very rare to have it in both nipples. Breast Feeding after Breast Lift Usually women interested in breast lift have already had children so this is not a concern. There is no guarantee you will be able to breast feed, but most women who want to breastfeed can. Impermanence The result that you see after surgery will not last a lifetime. I recommend bra support all the time and avoiding activities that prematurely age the skin like tanning and smoking. This will help improve the longevity of the breast lift. Still the breast will undergo the normal aging process and is subject to gravity and genetics. 37

Breast Lift Recovery For a specific event, please allow 4 - 6 months after surgery before breasts are settled out-of-clothes. First Four Weeks Wear a bra all the time, no intense exercise, sleeping on your side, and any big travel plans. • 1-2 weeks - No lifting more than 20 pounds, and avoid reaching and pulling with your arms as this might put undue tension on your breasts. Most patients will return to work after 1-2 weeks from surgery. • 3-4 weeks - Light lifting (<45 lbs) and you may start reaching and pulling with your arms. 2 Months after Breast Lift Most of the swelling should disappear by 2 months after the surgery. At this time, you may buy new bras (even with underwire) and new clothing for your new breast shape. 3 - 4 Months after Breast Lift Breast lift shape should be well established with potential for minor changes up to six months. 8 - 12 Months after Breast Lift Scars should stabilize and heal by around 8 - 12 months. After this, options to tattoo or laser the scars to reduce their visibility are available. 38

Breast Lift Cost Breast lifts cost between $4700 - $7500. The main cost variables are duration of the procedure (larger breasts may take slightly more time) and whether or not fat grafting (fat transfer) is also being performed. Alamo Plastic Surgery offers PatientFi financing with 6 months interest free (if paid off within 6 months) or low fixed monthly payments. 39

Breast Augmentation with Breast Lift Women who desire both lifting of sagging breasts and more breast fullness particularly at the top of the breasts, may be most interested in a breast augmentation with a breast lift at the same time, also known as an augmentation mastopexy. The goals of this cosmetic surgery are to balance removal of too much stretched and damaged saggy skin with filling up the remaining skin with volume from an implant. This will produce a more aesthetically pleasing, and youthful breast contour, especially out-of-clothing. When performed well, the results can be incredible. However, with so many variables involved, it is critical to design an individualized surgical plan that matches your specific goals with your specific body. Although this technique has a higher need for revision surgery (as high as 1 in 4 patients!), splitting up the lift and the augmentation would ensure that 100% of patients need another surgery. Dr. Albright will discuss the pros and cons of different techniques so that you can make the best decision for your body. 40

What is the right size breast implant for my body with a breast augmentation with breast lift? A great question, as this will also help determine what skin excision pattern (scar pattern) is needed. The issues with implants are inherently similar to those of breast augmentation alone (please see the breast augmentation surgery tab above for more information on implants). Whereas with augmentation alone, augmentation mastopexy more commonly places the implant completely under the pectoralis muscle when possible, as the implant will be better supported by the muscle itself instead of the skin. Dr. Albright will have a more specific plan after a detailed breast exam and discussion of your surgical goals. 41

What scars are required for a breast augmentation with breast lift (augmentation mastopexy)? Typically seen as the main drawback to performing breast lift surgery, placing incisions, and the resulting scars, on the breast itself are a necessary part of achieving a better more youthful breast shape. Getting the best breast shape particularly out-of-clothes will usually outweigh the downsides of visible scars on the breast. Most commonly the scars will fade to a less noticeable whitish color, even if they widened slightly as they matured. The placement of the scars will be determined by how much excess skin is on the breast (the skin envelope) and how much volume is desired with the implant. Dr. Albright will offer his insight to help you choose the best options available to you and your type of breast. For women who only need a short nipple lift, a periareolar mastopexy may be adequate and has the fewest visible breast scars. This limits the scars to just around the areola (pigmented skin around the nipple), with or without an incision at the breast crease. For maximum excess skin removal and nipple lifting, a full Wise pattern or anchor scar may be used. This will leave a scar around the areola and a short vertical scar that connects the areola to a side-to-side scar located along the lower breast fold. 42

What about nipple sensation after breast augmentation with breast lift (augmentation mastopexy)? Another deterrent for women seeking to reclaim their more youthful breasts is the possibility of compromising sensation to the nipples. For women whose nipple sensation is an integral part of their erogenous experience, breast lift surgery with incisions placed around the areola (darker skin around the nipple) may not be worth the risk of decreased sensation. However, the risk of losing sensation in BOTH nipples is extremely low. Furthermore, in Dr Albright’s experience, most women are willing to trade a small risk of decreased sensation in one nipple for much more attractive breast shape when naked. 43

Breast implants with breast lift after bariatric surgery or massive weight loss... What's right for me? Congratulations on your weight loss! It is a difficult thing to achieve and you should be proud! Now that you have achieved a stable weight near your ideal or goal weight, it may be time to rejuvenate your breasts. For many women in this situation, it is easy to become disheartened. They say \"I always had big breasts, but, now after weight loss, I have deflated breasts that do not match my figure.\" Well these patients may be ideal candidates for an augmentation mastopexy. Typically to remove excess skin, an anchor type scar is needed. An implant will then provide the missing volume. Differences to consider for the massive weight loss patient are considering staging the procedure; doing a lift first then recovering from surgery and allowing the breast to settle before performing a breast augmentation later. Additionally, excess skin and residual fullness may exist around the sides of the breast toward the back (bra line). This may require additional surgery including excision (leaving a scar) and/or liposuction. Although this does increase the surgery time, complication risk, and overall cost, it may be necessary to give you the results you are looking for. Finally and perhaps most critically, where will breast rejuvenation fit in with your other cosmetic surgery goals (belly, arms, thighs, face, etc)? This requires a thorough assessment and discussion of your goals to fully answer. Dr. Albright will help you come up with a plan that works for you, your goals and your budget. 44

Are there any The short answer is yes. An augmentation specific risks mastopexy combines two very different breast to breast surgeries into one combined procedure which augmentation increases the complexity and thus the risk for with a complications. General anesthesia is usually breast lift required for this aesthetic plastic surgery (augmentation procedure. In addition to the individual risks mastopexy)? involved with breast augmentation and breast lift surgery, augmentation mastopexy has a higher revision rate. This means that there is a greater chance you may need or want a second “touch-up” surgery to improve the result. Although only a minority of women will undergo a second revision surgery, if you were to instead separate the surgeries (for example, perform a breast lift, wait 4-6 months, and then perform a breast augmentation) you would have a 100% chance of needing two surgeries. Also, when separating, or staging, the two procedures, 100% of patients will incur greater overall financial cost, and will have to undergo two postoperative recovery periods with activity restrictions. Rarely, however, Dr. Albright may still recommend separating the procedures for you, if your risk of having a bad result is too high. Still not sure? Come in today to get your questions answered and feel confident with your breast rejuvenation plan. 45

Patient Testimonials 5 star reviews on Google, Realself and Healthgrades All of my life I have been small chested, and when I became a mommy, it only went downhill from there. I didn’t know that the smallest “A” could sag and really deflate my confidence. I began working out, and became a Beach Body Coach. I strive to help others feel as confident as possible with exercise and eating right on a daily basis. This became very hard for me to continue to do, when I myself was lacking confidence in one area. The more chest and arm exercises I did, the more my breasts began to look like ‘pecks’. “I came to Dr. Albright for a simple consultation, and left feeling more motivated than ever. His staff was so professional, and despite my want for ‘cosmetic’ surgery, they were very welcoming!! I was in and out at my consult, and also at my second appointment. We scheduled surgery for two weeks later. Everything went great, and I saw Dr. Albright the next day for my follow up. All of the decisions that we made about my breast augmentation were spot on. My recovery time was four to six weeks, and I didn’t have much pain at all. At four weeks, I was cleared to begin working out again, very slowly. This was a quick recovery, and life got back to normal. I would have this surgery all over again, and have already recommended Dr. Albright and his staff to everyone I know!! This was the most convenient and wonderful experience I could have had with a surgery!!!” RealSelf Review from Beach Body Coach – 5 Stars “StacyRae916” 46

I had two singleton pregnancies and my last pregnancy was twins measuring at 47 weeks. I pumped for 43 months total. I am beyond happy with my results. He did an AMAZING job and I am still in shock!!” RealSelf Review – 5 Stars “Supermomx5” Dr. Albright performed a breast reduction and lift for me in June 2018. To say I am happy with the results would be an understatement. Dr. Albright and his staff answered all my questions, even the ones I thought were silly. Never felt like I was being rushed out of the office. Thank you, Dr. Albright.” Healthgrades – 5 Stars Q&A 1. Financing options? – Financing available through Care Credit 2. 3. 47