DR. HOCHSTEIN’S BREAST AUGMENTATION EVOLUTION
Before I get into the specifics I would like to state my qualifications to be able to make some comments and have credibility doing it. More than half of my practice is dedicated to primary and revisional breast augmentation. From an experience standpoint I perform more silicone breast augmentations than 99% of surgeons who perform the operation. Statistically speaking the average surgeon performs 25 augmentations annually. I perform over 750. There are two companies who provide silicone breast implants in the USA. They are Mentor and Allergan. I had previously used Mentor implants and was given an award for being in the top 2% in the nation for using their implants. They would not let me see the exact ranking. I now use Allergan implants as I prefer their shape and I believe they pretty much share the market equally. I was able to see the ranking and although they will not allow me to say I am the top surgeon in the nation using silicone breast implants they will allow me to say that I am in the top 5 surgeons. I do certainly understand that quantity does not always equate to quality but I want to offer that save for my website I do not do any kind of advertising. You will never see me in a radio, TV, or print ad. Quite simply my practice is based on the loyalty and support of my patients who have been happy with my work and I cherish their support deeply. I have not said it enough but thank you so much….now let’s talk about the surgery.
Let me first state that there is no perfect technique. The technique I use now has evolved over the past 15 years of doing the operation and the things that work best for me would not necessarily work for another surgeon or vice versa but I would like to dispel some of the myths that I have heard over the years. I first learned how to perform the surgery under the tutelage of the great Dr. D. Ralph Millard. Dr. Millard did not teach me how to do the operation as breast surgery was not his specialty but he taught me how to be a plastic surgeon and to always be critical of my results and always strive to “do it better”. I was very fortunate to perform my plastic surgery training at the University of Miami where the residents had a pretty busy cosmetic surgery clinic where we actually got to perform the surgeries. This is very rare in most training programs as the only cosmetic experience is watching the attending do it. When I graduated I had already performed 25 breast augmentations. This may not sound like much but it was about 25 more than most plastic surgeons coming out of a training program and gave me a big head start from which to build. Interestingly when I began my practice I never planned on becoming the “Boob God” as I have been called in the press but rather wanted to do the best job I could for every patient with every surgery.
The surgery that I began with was considered the complete submuscular augmentation which is a bit of a misnomer. There are two muscles which are used to cover the implant which are the pectorals major and the serratus anterior and they thin at the lower aspect of where the implant would lay. Essentially the bottom of the implant would be covered only by a thin level of connective tissue with very few muscle fibers but I believed this was the best technique because at the time we only had saline implants to use and rippling (wrinkling) of the implants was a big issue. The thing that bothered me most about the results with this technique was that since the muscle was not cut at the lower portion of the insertion into the sternum the implants moved or jumped too much whenever the pec muscle contracted, sometimes by very simple motions such as the act of simply wiping down a counter and patients did not like it. The other issue was that the lower fibers would not adequately stretch and the bottom of the implant would have some flattening and sometimes the implants would not adequately drop and would sit too high. It was also almost impossible to adjust asymmetric breast folds and to create a better cleavage at the lower aspect of the breast which is extremely common problems. I was not very happy with these issues and started to research how I could improve the results and began speaking to other surgeons about these issues to see how they handled it.
Shockingly most of the surgeons I spoke to would not offer me any real advice so I was left to learn most through trial and error. It was around this time I went to Los Angeles for a vacation. On this visit I happened to run into a now very famous plastic surgeon that was having lunch at the same restaurant. I was with someone that knew him so we were invited to sit down for lunch and we ended up talking about plastic surgery for 3 hours. This was great because other then in medical school no other doctor had spoken so freely with me about their experience with plastic surgery. I also felt like he was sharing his trademark secrets that most other doctors would never have shared with another young plastic surgeon. We were talking about breast augmentation when he told me that he liked to split the muscle at the lowermost portion. When I heard this simple concept I got so excited I think I stopped listening about anything else. Right away I knew I could potentially correct all of the issues I had with my current technique. I could not wait to get back to Miami and try it out. I have never told anyone this true story before nor have I thanked the surgeon that gave me this knowledge but it changed the way I perform surgery even to this day.
When I returned home I saw that I had a difficult augmentation that week. It was a patient with mild ptosis (droopiness) with asymmetric lower folds. This type of anatomy had me losing sleep before but I felt I was ready for it. In the surgery I split the muscle just above the fold location and internally pushed down the higher fold to match the other side. I was able to perform this surgery much quicker than ever before and when I sat the patient up it looked great. I still had some concerns. Would this increase the risk of rippling at the bottom of the implant and would there be a higher risk of a double bubble or the implants traveling too low? I anxiously waited for the follow up visits. When I saw the results I could not believe it. They were perfect! The folds were symmetric, there was an inherent lift to the breast I had not seen before and the bottom of the breast had a soft beautiful curve which I was able to get to fill in the lower cleavage. This was by far the best result I had ever performed on a very difficult case. There was a little increase in rippling but it was minimal. Interestingly my patients also seemed to have less pain and recover quicker from the operation. Turns out all of the pain from this surgery was stretching of the muscle and this cut at the bottom seemed to relieve a lot of the pressure. I had found my basic technique and boy did my practice take off at that point. I quickly went from doing one or two augmentations a month to at least one or two every week. This was a huge success for a guy only in his second year of practice.
The only area of my concern now was the rippling at the bottom of the breast. My early concerns of double bubble and settling too low were unfounded. No primary augmentation of mine had ever suffered this complication. Fortunately silicone implants were making a comeback and I found the cure for my rippling problems. At the time they were used under a study protocol and patients had to qualify for them and I loved using them. They were softer, had almost no rippling and had a beautiful shape but only about a third of my patients qualified for them and wanted to use them…people were still a little afraid of them. When the FDA finally did the right thing and started thinking about women and not the fringe fear mongers and approved them for use for everyone in 2006 it was a great victory. Now over 95% of my patients were choosing these breast implants in Miami and everyone was happy about it.
The basics were set and I was quickly being recognized as the “go to guy” for Miami breast augmentation but I was not satisfied. I knew there was something I could do more and so I began experimenting with what I call breast shaping. You see it is rare to see the breasts being completely symmetric in shape and size and implants were a very poor option to correct these issues as different implant sizes came with different shapes with projections and diameters and so we were often trading one type of asymmetry for another. I thought what if I remove some breast tissue from very specific locations? I could improve small to moderate size asymmetries and also influence the breast shape as well! I found that I could actually raise a droopy breast without any additional scarring in small droops and enhance my results in those that needed additional skin removal/scarring. These were results that no other type of technique could approximate and this is the technique I currently use.
I have added a few more adjuncts to my surgery. They address armpit fat and pain. Many women have armpit fat which detracts from the upper portion of the breast but I was always afraid to do anything about it. You see when I was a resident I was always taught that you could never do liposuction in the armpit because of all of the important nerves and blood vessels that course in this area. We were taught that only direct excision, with the resultant nasty scar, was an option. When you lack experience you have to trust your professors and I did but as I gained experience with the procedure and the anatomy I thought it could be done safely. I did it and have done so on approximately 200 such patients who suffered from this anatomy with nothing more than a minimal bruise as the drawback. I had also learned that the old adage of “those who can’t do it teach it”. The other adjunct of adding a long acting anesthetic into the muscle at the time of surgery was suggested by my anesthesiologist. I do this now on every augmentation and the results have shown that my patients require less pain medication in the recovery room and when I see them on the second postoperative day for dressing removal they feel great and are able to move around comfortably.
I would like to stress again that the techniques I use will not work for others. I take a great deal of experience to perform the shaping procedures which I perform. I am also not so arrogant as to believe that my way is the best way. It just works best for me. Simply it is the way that I perform the operation while trying to decrease the risk of complications.