One Surgery or Two? Demystifying Staged Breast Lift and Augmentation

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:11):
Hey, Dr. Koehler.

Dr. Koehler (00:13):
Hey, Kirstin.

Kirstin (00:13):
Would you like to know what we're talking about today?

Dr. Koehler (00:19):
Sure.

Kirstin (00:20):
We're talking about to stage or not to stage. Has this been on your mind lately?

Dr. Koehler (00:27):
No. Well, maybe, I dunno, what are we talking about? Staging or not staging what? Breast surgery?

Kirstin (00:32):
Breast surgery, yep. Whether some patients can do like a simultaneous lift augmentation or sometimes you have to split it up.

Dr. Koehler (00:41):
Actually, that's a good subject. I guess first of all, I would just back up and say we get a lot of women that come in after either weight loss or kids for various reasons and they want a breast lift. And so I guess the first thing that we have to do is educate people what a breast lift will and won't do. Of course, I always tell people, I'd rather call it a de-sagging procedure because that more accurately describes what's going to happen. Basically with a lift, you're relocating the nipple back where it's supposed to be, and then removing the sagging breast tissue that hangs below the crease of the breast, but it doesn't really give you any more fullness in the upper part of the breast. And so a lot of times when people come in for a breast lift, they're not coming in with even the thought of an implant, but we have to talk to them about that because if they're wanting to restore that fullness in the upper part of the breast, that usually requires an implant.

(01:28):
And there's been a lot of techniques to try to do that without an implant. And I think there's some ways that you can do that. But the most predictable and successful way is with an implant. And so then there comes the issue of, well, can you do it at the same time or do they have to separate it? There was a good study done years ago that looked at the revision rate of doing breast lifts and augmentations at the same time. And in that paper, which a lot of people quote as part of their informed consent process is that about 25% of people that undergo a simultaneous breast lift and augmentation procedure are going to need some type of a revision. Now that could range from something minor as like a scar revision to something more involved like repositioning an implant. But 25% is kind of a high rate, and it's by far the most complex breast procedure that cosmetic surgeons do when you're doing an implant and a lift and somebody's laying down and it looks completely different than when they're standing up. To get everything all lined up and perfectly matched is quite a challenge actually. There's a lot of surgeons that won't even do, just flat out will not do a lift and an augmentation at the same time because of the higher reported revision rate. But I would say a lot of doctors do them at the same time. But there are reasons when we don't.

Kirstin (02:47):
What are some reasons why you would do a lift in augmentation separately? Or are there benefits to either approach?

Dr. Koehler (02:55):
Well, I would say if we can do it at the same time, we certainly like to do at the same time as one anesthetic, one recovery. So that's what everybody wants. And I'd say probably 80% of the time we can do that. The subset of patients that I, and even when I give you this list of people in my head that I kind of think these are the ones that I tend to stage, some of these can be done at the same time. It depends. But typically the ones that I'm going to recommend staging are massive weight loss patients. And the reason those patients sometimes need to be staged is because a lot of times we're going to be doing a really significant lift and I'm moving their nipple a really significant distance. I also want to remove as much tissue as I possibly can to get that breast perky in the skin envelope a little tighter.

(03:39):
And so then I'll come back later and do the implant. But there are cases where I do them at the same time. Another big reason for staging it is women who have significant asymmetries, and I'm not talking just a little bit of difference, but women who've got one breast might be a couple cup sizes bigger than the other side, and in those cases, we're going to be doing a reduction on one side and a lift on the other. Sometimes those patients benefit from staging it because we may not get it a hundred percent perfect with the reduction and the lift, and then it gives us a second opportunity to kind of make adjustments with implant volume or whatever to get them as close as we can. So that would be another reason. Another pretty common reason where I separate it is in women that have tuberous breasts.

(04:24):
So in those women, their breasts have a tubular type of shape and they oftentimes have a asymmetries that go along with them. First thing I want to do is correct the tuberous deformity. If that's not corrected properly and you put an implant in, then you've got an implant with this sort of tuberous mound on top of it and it doesn't look good. Again, these are just a few of the reasons why we might want to separate it. And then I guess one other reason is the most obvious, which is patient choice. I'll tell people there's a higher associated revision rate with doing a simultaneous procedure. And some people are very worried about scars, and of course scars always heal better when they're not under tension. And if you've got an implant in there that's putting a lot of tension on your incisions, that there's a possibility that that could create widening of your scars.

(05:13):
If they're really worried about it, they may want to elect to do it as two different procedures, but I'd say most people, it's not the case. They don't want to pay for two anesthesias, two facilities. They don't want to have two recoveries. And so as a surgeon, we kind of would like to get the procedure done as one if we can as well. So that's really the optimal thing is if we can do it all at once. But I definitely think if your doctor's recommending that you separate them, you should definitely pause before kind of going ahead. Ultimately, you can probably find somebody that's willing to do what you want, and some people will do that in doctor shop and get the answer they're looking for rather than maybe what's best for them. But if you have somebody that's recommending separating it out, make sure you fully understand why they're recommending that.

Kirstin (05:58):
So in the stage approach, which procedure is usually done first?

Dr. Koehler (06:04):
The lift for sure. I would never do it the other way around. I mean, I'm not saying you couldn't do it the other way around, but if you've got, let's say, droopy breasts and we put the implants in and now you've got implant with breasts hanging over the top of the implant, if they decide not to go ahead with the second part, it's kind of not a good look for you. But if you do the lift and you choose not to do an implant, which we see sometimes, right? Sometimes people get a breast lift and they really weren't maybe keen on an implant in the first place, which is another reason why you might stage it. So some people are like, well, do I really need an implant? And the answer is, well, you don't need one. Nobody needs it ever, but you might benefit from it and you might want one. So if you stage it, you've got the opportunity, let's get the breast lift, and if you like it, great, we're done. No more surgery. But if you don't and you want more fullness, then you put the implant in. So the lift is always done as a first time procedure.

Kirstin (06:56):
So if you stage the procedures, how much time do you normally wait in between the two surgeries?

Dr. Koehler (07:01):
Yeah, the minimum amount of time is three months. So I've had people that had a breast lift and waited a whole year or longer for various reasons, whether it's financial, recovery time, family issues, whatever. So there's not a maximum time you can do it whenever, but the minimum is typically three months because we want to allow those incisions to mature enough to where when we do put the implant in that they're not going to widen the scars and all that kind of stuff.

Kirstin (07:28):
It's been discussed possibly in some of our other podcasts that if somebody needs a staged lift augmentation, you will not budge on that decision.

Dr. Koehler (07:43):
Well.

Kirstin (07:43):
It's not true?

Dr. Koehler (07:44):
I'm getting harder and harder to convince. The problem is, listen, as this doctor or the surgeon taking care of the patient, we want our patients to be happy. We want to give them the result they want, and we want to give them the recovery they want and all of these things. But sometimes you can't have what you want. Well I say talked into, I mean people don't talk you into it, but if you're on the fence of like, and in your gut you're like, no, this really needs to be staged. I've been down this road, we're going to get a predictable result. Question is, well, can you? Well, yes you can, but if your past experience says we're going to have probably a 30% chance of a revision here or whatever, maybe then the best thing to do is to say, let's do it staged. I've been doing this long enough now that if they don't like what I have to say and they go somewhere else, my feelings aren't hurt. Find who you want. I generally try to be respectful of what patients are wanting in terms of recovery and all that sort of thing. So usually if I'm saying no, I've got a good reason, so it's not just caught me on a bad day and I'm like, yeah, no, you got to have two surgeries.

Kirstin (08:51):
Well, so what are some risks of combining the two surgeries if you would rather do it staged, and this person just absolutely only wants one surgery. What are some risks of that?

Dr. Koehler (09:03):
Well, I mean, if the tissue envelope is too tight, for instance, sometimes if there's like a tuberous breast, I mean it's going to be a skin might be really tight by the time you've done that. And if they want an implant, you might have to go with a smaller implant just to get one in. Or if you do put the implant in that they want, incisions may just be under too much tension and it may just open up. You could have an implant exposed, you could have healing issues. That can happen. It's not common, but those kinds of things can happen. Or widening of scars or the implants, because I mentioned it's a little more complicated. Maybe the implant doesn't settle and you have to go back and reposition the implant, which for some people, in fact, there was an editorial or a comment I think on that article that I was referencing earlier.

(09:48):
Somebody said, well, although the revision rate of 25% is pretty high, it's still lower than the a hundred percent re-operation rate if you do two surgeries. Yeah, okay, that's true. If you say, well, we're going to do two that's committing a hundred percent to two surgeries, versus, oh, there's 25% revision rate, I still have a 75% chance of doing one surgery. But you can't look at it that way because sometimes that 25% is maybe it's not just a simple revision, and then maybe it's two surgeries or maybe it's like now you didn't get the result you wanted, and it's very hard to go back and get you that because we didn't do it the way we should have. So anyhow, you got to be careful how you look at those numbers.

Kirstin (10:31):
Is recovery, I guess I want to say better for a lift versus an augmentation or vice versa?

Dr. Koehler (10:40):
A breast augmentation, typically, we tell people, oh, you'll be off pain medicine three to five days. It's not a bad recovery, but in a way, I think a breast augmentation is a more painful recovery than a breast lift. The incisions are more extensive with a breast lift, but we're not lifting up your muscle. We're not putting anything up under the muscle. It's really just skin incisions and removing some breast tissue. So I'd say both of them are not big recoveries individually. Each one of them is less than a week of recovery. You'll be off pain medicine for sure in a week.

Kirstin (11:12):
I've heard that from patients that their recovery from their lift was a little bit easier than their augmentation.

Dr. Koehler (11:17):
It usually is. And a breast augmentation is not a big recovery.

Kirstin (11:22):
Does the size of your implants matter as far as recovery goes? If a person gets a 250 cc implant versus somebody who gets a 600, will they have a difference in recovery, do you think?

Dr. Koehler (11:33):
Possibly, but I've not noticed a correlation. I think some people are tougher than others. You can put a small implant in somebody and they can be varied, uncomfortable, and I have people that get the biggest implant you can get, and they're like, they're fine as can be. They're happy, happy and they're not hurting. So I don't know. I mean, I think obviously it could probably have an impact, but I don't think there's a direct correlation.

Kirstin (11:58):
In terms of cost, is there a benefit to doing both procedures at the same time?

Dr. Koehler (12:03):
Yeah, there is. It's not a huge amount, but there's a difference. In the cases where we are purposely staging it, we've kind of discounted the second procedure to where we're like, okay, well, it's not exactly the same as doing it at the same time, but we don't want you making the decision purely based off of price. So we try to do our best. There is added cost than doing it once. I mean, there's two surgical setups, two everything, so it is a little bit more expensive, but we try to at least accommodate that to a certain extent.

Kirstin (12:33):
Right. Because not their fault that their anatomy causes them to have two separate surgeries.

Dr. Koehler (12:37):
And it's not our fault either. So it's kind of like we try to split the difference and go, okay, we're going to cover our cost and it's going to be a little bit more, but we're not charging it out like two identical separate surgeries.

Kirstin (12:48):
Do you customize plans based on each individual person's anatomy and goals?

Dr. Koehler (12:54):
Always. I mean, that should be the number one for everybody. I mean, nothing is cookie cutter.

Kirstin (12:58):
Not even just with not augmentations or lifts or anything. I mean, you do that with everything.

Dr. Koehler (13:03):
A lot of the procedures we do are very, very similar. I think that where you tend to recognize this the most is with your staff because you'll do something the same way, maybe 95 times out of a hundred, and then five times out of a hundred it's done differently. And it's because of your years of experience and training and everybody's going, why are we doing this different? And it's because people are not the same. And recognizing those little differences and also your years of experience are what tell you this is a case, and that's where you are getting paid is for being able to recognize when this something falls outside of the, this is the way we always do it. And so yeah, a lot of cases are very similar, but absolutely, we always go into it with this, what is different about this patient and do we have to do anything differently or not?

Kirstin (13:56):
You talked a little bit about scarring, and part of the reason of staging surgeries is to hopefully limit scarring. Are you able to elaborate a little bit on that?

Dr. Koehler (14:06):
Not really. I'll tell you why. Because I have had patients that have gone with actually pretty big implants and did a simultaneous breast lift and augmentation and have perfect scars, and I have patients that have separated it where they're like, oh, I don't want to have the tension on the scars. And yes, in theory that is correct, but we also know people heal differently. And so some people just tend to heal better regardless of the circumstances. And so some of it is patient, some of it is surgical technique, and there can be other factors that come into play too. But the point is it's not predictable, but I can tell people factors that allow for better healing and definitely incisions that not under excessive tension will heal better typically than those that aren't. But then you've got the patient factors, and then some people have more reaction to suture, and so they end up with more redness and prolonged redness. And some people are prone to keloids, although we don't see that often. We see some people with keloids or hypertrophic scars, a lot of different factors, and that's why there's no way of, you could never look somebody in the eyes and say, well, definitely if you stage it, you're going to have perfect scars versus if you separate it or do it together, you can't say that. But I can tell you that if you're asking me things that will potentially improve it, that's one.

Kirstin (15:31):
Let's talk about the importance of realistic expectations and thorough consultations and pre-op appointments.

Dr. Koehler (15:40):
Yeah, realistic expectations is very important for all surgeries, and I think that comes from looking at the doctors before and after photos, trying to pick people that look similar to you, showing the doctor pictures maybe of what your expectations are because your doctor may look at it and go, yeah, no, we cannot get that. That's just not possible. Or they might be, yeah, absolutely, we can get that. Discussion back and forth, building realistic expectations for all procedures is very important because nobody's got a magic wand we just talked about. There are things that are within the doctor's realm, like their experience, their technique, all of those things. That's the things the doctor control, but I can't control your body's inflammatory response. I can't control how your tissues tend to heal because you make the same incision, just an incision, nothing else. You make on 10 different people, and it can heal very different than 10 different people. So what was your other question? The expectations and

Kirstin (16:38):
Thorough consults and pre-ops.

Dr. Koehler (16:40):
Oh, well, yeah. I mean, I think at our practice we try to be pretty thorough, especially at the preoperative appointment, and that's partly with just trying to make sure that you understand what your role in taking care of things. Give you an example. I think we've mentioned it before in one of our podcasts, but I had a patient that had a tummy tuck and was in a hot tub, I don't know, several weeks after surgery and got a bad infection and ended up being fine. But you can't get in a hot tub two weeks after surgery. You can't do that. That's what the importance of the preoperative appointment is to kind of go through the do's and don'ts of things that you can control as part of your healing process. And so we try to be thorough with that so that there's no misunderstandings there, and that again, you end up with the best possible chance of a good result.

Kirstin (17:27):
Exactly. Do you want to add anything?

Dr. Koehler (17:30):
No, I'm all done.

Kirstin (17:32):
You're all done.

Dr. Koehler (17:33):
I've been talking for, it seems like a while here. I did too much talking. I'm done.

Kirstin (17:39):
That's unusual for you.

Dr. Koehler (17:40):
Yeah.

Kirstin (17:41):
Okay. All right. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at AlabamatheBeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (17:56):
Thanks, Kirstin.

Kirstin (17:56):
Go back to making Alabama beautiful.

Dr. Koehler (17:59):
Alright.

Kirstin (17:59):
Got a question for Dr. Koehler? Leave us a voicemail at AlabamatheBeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you'd like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.