Benefits of Breast Reduction Surgery

 

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Introduction

The size of the breasts differs from women to women depending on the sensitivity of the breasts to the hormonal stimulation that occurs during adolescence. Some women develop huge breasts as a result and opt to go in for breast reduction surgery which has several benefits. Let us now have a look into some of the benefits of breast reduction surgery.

 

Reduction in Neck Pain

Because of the huge size of the breasts, the neck is concomitantly pulled into a relatively downward position making the neck muscles taut and putting strain on the ligaments thereby causing neck pain. A breast reduction surgery causes a decrease in the size of the breasts and thereby releases tension on the neck and this relaxation causes a concomitant decrease in neck pain. The long term result of this is immense.

 

Advantage of a Breast Lift

In patients with huge breasts one can usually see the nipple-areolar complex drooping down and even pointing downwards which makes it very unaesthetic. By repositioning the breast tissue during the reduction process the nipple-areola is pulled up into a more anatomical position thereby achieving a breast lift. This makes the look of the breasts extremely aesthetic which is of advantage especially in young patients.

 

Reduction in areolar size

As the breast size increases so does the size of the areola. Huge areola look extremely unaesthetic. Fortunately, in breast reduction surgery, the areolar size is tailored to a more accurate fit for the breasts which makes the final size pleasurable. This areolar size can be modified according to the wishes of the patient.

 

Avoidance of skin infections

Patients who have huge breasts might have problems in cleaning the under surface of their breasts owing to the huge weight of their breasts. This makes the prevalence of skin infections especially fungal infections quite high in these patients as sweat and dirt accumulates. The breast reduction procedure helps in decreasing the weight of the breasts thereby facilitating easy cleansing of the breasts thereby decreasing the incidence of these infections.

 

Resolving social problems

Huge breasts might create a social problem with many patients preferring to stay indoors because of fear of ridicule and continuous staring by others. With a breast reduction surgery the breasts are made more aesthetic thereby resolving this problem of avoidance.

 

Enhancement of cleavage

As the breast enlarges in size these also tend to droop down because of the weight of the breasts thereby emptying the upper poles of the breasts which takes a toll on the cleavage which loses its attractiveness. With a breast reduction surgery the breast parenchyma is shifted to the upper pole enhancing the natural beauty of the cleavage.

 

Decreased incidence of breast cancer

Multiple studies have shown that the actual risk of developing breast cancer decreases in patients going through a breast reduction surgery. This might be as a result of the decrease in breast parenchyma that occurs during breast reduction surgery or to some other causes.

 

Conclusion

These are only some of the benefits of breast reduction surgery. There are numerous other benefits and therefore women should not be hesitant when contemplating a breast reduction surgery.

Is Cosmetic Surgery Scar-Less?

Introduction

Scarring over forehead from poor operative technique

Scarring over forehead from poor operative technique

There is a general idea among the people that cosmetic surgery is “scar less”. I frequently have patients asking me “So this procedure will be scar less, right?” or “I have a scar in my forehead, you’ll make that disappear, right?” This notion about cosmetic surgery is inherited from the movies where actors frequently get a plastic surgery done to their faces resulting in a complete change in their faces without leaving any forms of scars! Let us now look into the reality.

Scars

Scars are marks left over the skin when the skin is injured. Practically speaking, scars cannot form once the baby is inside the womb: if the skin is injured then the healing is scar less! After birth, any form of trauma (including surgery) leads to the development of scars. Therefore, surgeries without scars do not exist at this point of time! Do not be fooled by advertisements labelling a procedure as “scar less”: if the surgery requires a skin breach, then scarring is inevitable. That being said, there are a variety of procedures adopted by cosmetic surgeons which lead to barely visible scars which is the beauty of cosmetic surgery.

Surgical Technique

Surgical technique is sometimes over exaggerated in cosmetic surgery. However, there are some basic principles which need to be followed when performing a cosmetic surgery like the resting skin tension lines, method of closure and so on. Frequently one might see ugly scars over the face of individuals: this is the result of poor technique and can be addressed successfully by scar revision techniques in many cases. Therefore, ugly scars can be made to convert into good scars.

Skin Color

Skin color is one aspect which can modulate scars in many ways. People who are fair usually have scars after surgery which can be very difficult to discern. On the other hand, as the skin color darkens the scars become more and more prominent. This fact should be explained to such people coming in for cosmetic surgery. In dark skinned individuals even hypertrophic scars and keloids can form which can be very unsightly and might require other forms of management.

Treatment of Scarring

An astute cosmetic surgeon will have multiple options of scar revision in his hand. Not every procedure is suited for everyone and he should be the best judge in this regard. Patients should understand that although scarring is inevitable there are now multiple options to make the scar appear lighter so that the final result should be excellent in trained hands.

Conclusion

“Scar less” surgery does not exist. Do not be deceived by “scar less surgery” or “scar less hair transplants” as you would then be ultimately disappointed. Patients should therefore choose a cosmetic surgeon who would highlight them this reality and would strive for less visible scarring and would also offer them multiple procedures to ensure that unsightly scars do not occur.

Management of Stretch Marks (Striae)

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Introduction

Skin has a certain degree of elasticity in that when it is stretched it expands. However, when the degree of expansion is rapid such that it is not able to withstand the effect of tensile forces, it tends to break down leaving behind scars which are seen as stretch marks.

Types of stretch marks

In the early stages, there is a linear break in the skin. Gradually this expands to form the classical stretch marks which are red in color to begin with (striae rubra). As these scars mature they tend to become atrophic and assume a pale whitish color (striae alba). These are the basic stretch marks which confound people.

Management of Striae rubra

All topical treatments which have some propensity to improve stretch marks work on striae rubra. Topical treatment can comprise of retinoids, Vitamin C and fruit acids with the idea of moisturizing these lesions. A variety of lasers including the flashlamp pulsed dye laser at low intensities as well as the long pulsed Nd:YAG laser have been shown to improve the quality of stretch marks. Similar effect has been obtained with Intense Pulsed Light (IPL) devices. However, complete disappearance of these marks does not usually occur.

Management of Striae alba

This is the most difficult part! A variety of treatment modalities have been experimented but the results have been disappointing. Lasers do not usually work, even the fractional CO2 laser has been shown to have unpredictable results. Ultimately, if the patient can accept a limited scar for a wide area of scars then surgical excision is the best management. The best example is exemplified by an abdominoplasty for striae gravidarum which results in a scar hidden under the undergarments instead of multiple scars distributed all over the lower abdomen.

Conclusion

Stretch marks can be difficult to treat and patient satisfaction even more difficult to achieve. Topical therapy may be tried but if the results are disappointing then surgical excision should be offered to the patient for best results.

Nose Surgery to Elevate your Nose

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Introduction

Nose occupies the central part of the face and therefore it is not surprising that nose surgery continues to increase to provide a better cosmetic appearance to the nose. It is important to mention in this regard that the ethnic variations of the nose should be taken into account when going in for a cosmetic nose surgery. A Caucasian nose on an Afro-American would look no good and would in fact look horrible! Therefore, plastic surgeons should be cautious when approaching patients for rhinoplasty.

Nasal Elevation: Options of Nose Surgery

Nasal elevation is primarily asked for in the Asian population as also the Afro-American and Indian population. In these patients, the dorsum of the nose is quite depressed which makes the overall facial appearance very unaesthetic. Other patients would also seek nose surgery following a previous nose surgery where the results were imperfect or botched up. Elevation of the nose can be performed by open or closed techniques but the open technique is most recommended because the whole nasal anatomy is beautifully discernible and appropriate corrections made.

Materials used in Nose elevation

There are a variety of materials available for elevating the nose. Silicone implants are quite common and are an easy way to elevate the nose but just like any foreign body elsewhere in the human body, there is a real risk of extrusion which can make matters horrible. Cartilage obtained from the nose, ear and chest are also used for nasal elevation as also bone harvested from different parts of the body. Such autogenous materials are preferable to many surgeons because these have minimal chances of extrusion like silicone.

What you should choose

Discuss with your plastic surgeon what exactly you want, accordingly the surgeon would advise you of the best material. Surgeons also might have preferences which you can discuss. If you are afraid of scars then silicone might be the best thing for you, however, remember the real risk of extrusion. If you are okay with scars and want to play safe then go in for autogenous cartilage or bone, these would give excellent results.

Conclusion

Nose surgery involves extensive discussion between the patient and the plastic surgeon to achieve the best outcome possible. Proper education of the patient is extremely important so that the decision can be taken jointly by the patient and the surgeon keeping the patient requirements cardinal.

 

Lip Reduction Surgery: What patients should know

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Introduction

A lot of patients visit plastic surgeons because they are concerned about the appearance of their lips. While many are concerned that they have hypertrophic lips, others would say that they feel that either the upper or lower lip is hypertrophied. Some people present with grotesque lips following a lip enhancement procedure while others may present with functional issues desiring lip reduction surgery.

Relevant Anatomy

What is considered “normal” is actually an enigma and varies widely among cultures! Regarding the lips, the most commonly accepted anatomy pertaining to lip reduction surgery is that the upper lip should project only slightly forward than the lower lip. The lips should be slightly parted in normal profile and an excessive protrusion of the upper lip compared to the lower is consider unaesthetic. The upper lip ideally covers around two-thirds of the upper incisors. Also, slightly more lower lip vermillion is exposed in normal profile compared to the upper one. These facts should be kept in mind by the patient who is contemplating lip reduction.

Lip reduction surgery

Lip reduction surgery is done on an outpatient basis. It is done for patients who feel that their lips are heavy compared to their faces. According to patient choice, surgery can be performed in both lips or in only one. There were a lot of procedures described earlier but in 2007, a “bikini” excision of the lips was advocated which involved excising the upper lip as per the design of the upper part of a bikini while the lower lip was excised according to the lower part of a bikini in the form of a triangle.

The Brazilian modification of the bikini design came up in later years which advocated more conservative excision of the upper lip and a more curved excision of the lower lip rather than a triangular excision.

The above procedures are suitable for those who desire a correction of both lips, however, for patients who desire a correction of a single lip only, other procedures tailored to the needs of the patient are more suitable.

Conclusion

Lip reduction surgery is individualized according to what a patient wants. Patients must first develop a basic understanding of what the “normal” appearance of lips should be and then contemplate surgery because it might be difficult if not impossible to restore their earlier condition in case they feel that the surgery did not meet their expectations.

Weight Loss and the HCG Diet

Introduction

People who are obese visit innumerable clinics and plastic surgeons to get a solution to their weight loss program which can be quite difficult and frustrating at times. Weight loss is attempted by people for physical reasons or for health purposes and additionally it improves their appearance and instils confidence. A variety of weight loss programs are advocated by people including the use of machines, diets, exercise plans and lastly surgery in the form of bariatric surgery or liposuction (which should NEVER be done with the aim of weight loss).

Importance of Diet

Why do people become obese? The simple answer is intake of more calories than you can spend leading to a positive calorie balance which the body tends to store, mostly in the form of fat. That is why weight loss regimens focus mainly on 2 things: intake less calories by modifying your diet and at the same time burn those stored calories by doing exercise. Both of these lead to a negative energy balance which leads to weight loss.

A variety of weight loss diets have been advocated by people many of whom do not know anything about the physiology of the body and thus tend to harm the body. Therefore, a correct diet plan is most important in ensuring that you get continued weight loss with the lowest complication rate.

HCG Diet

So, what is so special about the HCG diet? HCG diet incorporates the use of the hormone HCG which is produced during pregnancy in association with severe calorie restriction. This was initiated on the premise that HCG causes severe appetite suppression which therefore makes intake of a near starvation diet possible. Generally HCG drops or injections are given in collaboration with a 500-800 Calorie diet. Supporters claim that this causes immense weight loss ranging from 10-15 kg per month. Therefore, this diet regimen is now advocated by many centers to achieve faster weight loss in individuals because everyone wants results fast!

Is HCG diet effective?

Contrary to all claims, there is no solid evidence that HCG diet actually works! The real reason that weight loss occurs is because of the intake of so few calories. In fact, it is not considered to be safe at all. Intake of so few calories without medical supervision can lead to problems like formation of gallstones, irregularity in the heartbeat and an imbalance in electrolytes which can derange body functions severely.

People who have resorted to this diet have been shown to be more irritable, are more fatigued, restless and depressed. Many of them tend to develop edema from electrolyte imbalance and male boobs or gynecomastia from hormonal imbalance. Thromboembolism or the formation of blood clots in the legs and their subsequent migration with disastrous effects is also a possibility. Therefore, do NOT resort to such dietary plans in order to achieve faster weight loss.

Conclusion

A variety of dietary plans can be provided to you by qualified medical practitioners and dieticians who would cater to your body needs. Resorting to experimental and unproven dietary plans can be catastrophic and are definitely not recommended.

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Frequently Asked Questions in Breast Reduction Surgery

1. Who should go in for this surgery?

If you are having heavy breasts and feel uncomfortable then breast reduction surgery is meant for you. Many women with enlarged breasts encounter neck, shoulder and back pain: in these patients the pain is drastically improved after this surgery and the posture also improves.

2. How is the surgery conducted?

Prior to the surgery your doctor would advise you some tests to check your operative fitness. Depending on your age, you would also need to undergo wither an ultrasound of your breasts or a mammography. If all of these reports are normal, you can be taken up for surgery. The surgery is conducted under general anesthesia. Your surgeon would mark your breasts and then you would be put to sleep. You would be informed about the type of surgery that would be done and the scars to expect. In big reductions, it is also likely that drains would be inserted which would be removed after 3-4 days.

3. Is stitch removal going to hurt?

Some surgeons use absorbable sutures while others would use sutures that would need to be removed. If non-absorbable sutures are used then these would need to be removed usually 10-14 days after surgery. Since quite a few sutures are applied, stitch removal might hurt because frequently some patients find the nipple area hypersensitive after surgery. Therefore, it is better to resort to some pain medications prior to stitch removal for comfort.

4. What is the scar management protocol?

Scars can be a problem following breast reduction surgery. The best way to deal with scars is to manage them as early as possible. When the wounds have healed you can apply Silicone gel over the same as an idea to prevent the formation of hypertrophic scars. The skin of your breasts might be dry so it is a good idea to massage the same with some skin oil as well as moisturizers. Massaging is of immense benefit although it might hurt initially.

5. How do I avoid discomfort after surgery?

A bumpy way back home can hurt! It is best to avoid sudden, jerky movements after surgery because that is going to hurt. Take your pain medications regularly and wear the sports bra as advised by your surgeon: this is going to support your breasts and would be extremely comfortable. Light stretching can also be done and would help you to recover faster after surgery.

6. When should I determine the final bra size?

Don’t make an idea of what your final bra size would be prior to your surgery. Immediately after surgery, the breasts are swollen therefore this is not your final size. The swelling would take long to resolve so buy your bra only after you reach your final size a couple of weeks after surgery. Till then keep wearing the sports bra for comfort.

7. What should my husband expect after surgery?

Husbands should be counseled that the breasts might look quite scary in the beginning! It is only after the stitches are removed and the breasts settle down that they would regain their natural shape. So, they need to be patient during all this time. This is one thing that is frequently over looked because husbands need to actively participate in their wives’ surgeries in order to make it a success.

8. What would be the appearance of my breasts immediately after surgery?

Immediately after surgery your breasts are going to look boxy and misshapen. Don’t worry, this is not your final shape! The upper poles of the breasts are usually exaggerated after surgery and would look awkward in the beginning since patients going in for this surgery have an empty upper pole. This settles down in a few weeks’ time giving an elegant and natural shape to the breasts.

9. When can I join the gym after surgery?

Patients can usually go back to the gym 3-4 weeks after surgery, however, it is imperative that they wear a surgical bra during all times in the gym. Lifting heavy weights is prohibited for the first month after surgery. It is recommended to follow a light schedule in the initial few days and gradually progress to more intensive workout depending on how much you can tolerate.

10. Will I have normal nipple sensitivity?

Nipple sensation is usually preserved unless you have a breast amputation with free nipple grafting when it is devoid of sensation. However, many women would have decreased or increased sensitivity in their nipples following surgery which would improve with time. Do not scratch your nipples as this might be quite uncomfortable. Remember, all of these are temporary and would keep on improving with time.

11. How long do I need to wear surgical bras?

Get 2-3 surgical bras because you might need them for a long time. It is essential to support your breasts as they adapt to their natural shape. Therefore, keep wearing surgical bras for a period of 4-5 months for increased comfort. After that time you can buy your new bras based on your final breast size.

12. How do I sleep after surgery?

It is best to keep your head elevated over a pillow during sleep. Also, keep a pillow under each arm for support. Do not try to sleep on your tummy till all the pain has gone away which might take quite a few weeks. Sleeping by the sides is possible with a pillow support at the sides. Wear a surgical bra even during sleep.

 

Hugely enlarged breasts

Hugely enlarged breasts

ACNE SCARS: CLASSIFICATION & ITS IMPLICATION

ACNE SCARS: CLASSIFICATION & ITS IMPLICATION

Introduction

Acne is extremely common among the adolescent population and inadequate management as well as persistent infection and inflammation can lead to the development of scars in the areas of these lesions. Scars following acne lesions can be of various types and some can be so much disfiguring that patients can be quite depressed psychologically. So, let us see what the types of acne scars are because not every scar type can be managed by the same form of treatment. In a separate article I will then highlight the treatment of acne scars.

Types of Acne Scars

Acne Scars are broadly classified into 2 types: Atrophic and Hypertrophic. In atrophic scarring the base of the scar is flattened or indented leaving a visible depression on the surface of the skin. The opposite happens in hypertrophic scarring in which the scar projects beyond the margin of the skin. Atrophic and hypertrophic acne scars can be again sub classified into many types.

Atrophic Scars

Atrophic scars outnumber hypertrophic acne scars by 3 times. The most common type of atrophic scar is the ice-pick scar which accounts for around 70% of total scars followed by the boxcar in around 20% of patients and finally the rolling scars in around 10%.

Ice-pick Scars
These are narrow, typically less than 2 mm scars appearing as small punched out defects multiple in nature. The base is narrower than the topmost part of the scar making it appear like a V. These scars are quite deep in nature and extend to the deep layer of the dermis and sometimes also to the subcutaneous tissue below the dermis.

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Rolling Scars
In these scars there is adherence of the dermal layer to the subcuticular layer giving a wavy appearance to the skin. These scars are much wider than the ice-pick scars with diameters in the range of 4-5 mm. The skin overlying the scars appears essentially normal.

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Boxcar scars
These are usually circular or oval in shape with a wider base and top as compared to ice-pick scars leading to prominent vertical margins and a U-shape. These can resemble the scars of chicken pox. They may be shallow or deep in nature.

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Mixed Scars
Sometimes, all the above 3 types of scars are mixed together and then it becomes extremely difficult to categorize those scars into 1 particular section. These are then labelled as mixed scars.

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Hypertrophic acne scars

Hypertrophic acne scars are of 2 types: hypertrophic and keloidal. These more commonly occur in dark-skinned individuals.

Hypertrophic scars
These scars are elevated above the surface of the skin but these remain restricted to the margins of the original lesions.

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Keloidal acne scars
Keloidal acne scars are those which spread well beyond the original margins of the acne lesions giving a nodular appearance to the scars.

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Conclusion

Proper treatment of acne in the initial stages results in less scar formation. Acne scars once formed need to be properly evaluated and classified by an experienced plastic surgeon because treatment needs to be individualized based on the characteristics of the scars.

The Strive for Beauty

The Strive for Beauty

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From time immemorial mankind has been fascinated with beauty! The strive for beauty and beautiful people has led to wars, destruction, creativity and so many other things. Accordingly, most people if not all desire for beauty. So, what is beauty in its true sense? In today’s world, beauty is defined as the physical appearance of a person which incites strong desires in the opposite sex and which is considered as extremely pleasing to the eyes! In the same sex this incites a sense of jealousy in many cases.

Consider the fashion models for instance: both men and women would love to emulate models. So, what is so fascinating and beautiful about models that they are considered as role models? The answer lies in the epitome of beauty. Beauty is therefore a perfect combination of facial features and a well proportionate body that is so desired by others. Of course, the concept of beauty varies amongst cultures but in general there are certain aspects that are considered more attractive than others. For example, no one likes an aging face with wrinkles or a drooping brow. Similarly, a perfectly proportionate body with well-shaped breasts combined with perfect distribution of fat elsewhere is considered to be sexually attractive. Men, on the other hand, flaunt their perfect 6 pack abs and a well proportionate and toned body.

Most people actually deviate from these so called aesthetic standards which sometimes can lead to severe depression, a sense of rejection from the opposite sex and a loss in confidence. Therefore, in today’s world what can be the solution of such a problem? The answer fortunately lies in cosmetic surgery!

Cosmetic surgery is a branch of plastic surgery that deals with the aesthetic appearance of a person. Cosmetic surgeons strive their level best to bring their patients more close to the aesthetic ideal. This improves their self-confidence and also instills a sense of well-being. From eliminating wrinkles in the face to aesthetically improving nose and ears and reshaping the body by liposuction and abdominoplasty, cosmetic surgeons can achieve the unthinkable. The size and shape of the breasts can be altered so also the appearance of the genitalia which was unthinkable even a couple of years back as the field is rapidly expanding.

Cosmetic surgery is, however, not free of complications! Complications can occur with any surgical procedure and therefore there is a certain element of risk when a person goes in for this form of surgery. Moreover, because of the increasing demand of cosmetic surgery, even people from other disciplines as well as people who are not adequately trained in this form of surgery attract patients with huge advertisements ultimately leading to disastrous results in many cases which might be even impossible for a well-trained surgeon to correct!

Therefore, if you are contemplating cosmetic surgery, please gather some background knowledge of the surgery you are considering. Next, search for some well-trained surgeons in your area and have a talk with them regarding what you desire. Do not have unrealistic expectations! After you are satisfied that the surgeon would be able to deliver his best, commit yourself to surgery.

Breast Augmentation by Implant/Fat: Do you need it?

Breasts are a hallmark of femininity and a decreased breast size contributes to lack of confidence in many women. The size of the breasts might be small as a genetic trait and there can also be a decrease in size after pregnancy or weight reduction as also with aging (typically the breasts appear deflated in these cases). So, what can modern plastic and cosmetic surgery do for these people to build up their confidence and restore femininity?

The answer is a type of surgery known as augmentation mammoplasty which increases the size of the breasts. The breast size is increased in most cases with the help of an implant (made usually of silicone) or with the help of fat taken from the patient’s body. Increase in breast size with fat transfer is done in only a few centers.

It is important that a preoperative evaluation of the breasts be made with a mammography (if you are over 35 years of age) or with an ultrasound in women less than 35 years to note any abnormalities thereof and to compare with postoperative repeat investigations. This is especially important in cases of fat injections because in the postoperative period abnormal calcifications might appear which need to be compared with the preoperative reports.

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Basically, in breast augmentation, you would be having a consultation with your surgeon in which the various implant options would be discussed along with the volume of the implant that would suit you best. The markings would then be done and you would be put to sleep during the procedure. Depending on your choice of incision which again would be discussed with you preoperatively, the incision would be made and dissection done. The site for the implant whether under the breast or under the muscle that lies under the breast would again be discussed with you before the surgery along with their advantages and disadvantages and the same would be accomplished during the surgery. The incision lines would then be closed.

The recovery period is a few days following the procedure. Risks include those associated with the general anesthetic which would be explained to you in details as also the prospect of unfavorable scarring, poor healing, changes in breast or nipple sensation, capsular contracture characterized by the development of a firm scar tissue around an implant, rupture of implant and many others. It must be noted however that most women do not develop any complications following the surgery and are quite satisfied with the results. The most dreaded result is implant extrusion as a result of infection in which case the affected implant needs to be removed. A repeat insertion can be performed after a period of stabilization usually after 6 months.

Breast augmentation by injection of fat on the other hand can be performed under either local or general anesthesia. Fat is aspirated from the abdomen or hips and then injected into the breasts after processing. However, the body tends to absorb fat at a rapid rate so that much of the injected fat might be absorbed. A vacuum device known as BRAVA is applied to the breasts for a couple of weeks prior to surgery and then this is followed by fat injections in many cases; this procedure has shown to provide better results than simple fat injections. Since the degree of breast augmentation with fat injection is limited, the process needs to be repeated at regular intervals for best results. Please note that only a moderate degree of breast augmentation is possible with fat injections.

At Cosmetic Surgery Kolkata, your needs would be personally addressed by Dr. Adhikari through a thorough discussion which would highlight any deformities you might be having, the implant size that would be required and the choice of incision and the site for placement of implant. If you would like to go in for breast augmentation using fat transfer you would be informed that the procedure might need to be repeated because much of the transferred fat might be absorbed. Your doctor might also require you to get a preoperative mammogram before the procedure which is a form of X-ray of your breasts. Finally, the potential risks of the surgery would be highlighted to you.

Breast augmentation can be an expensive surgery because of the cost of the implants so you should discuss the options of financing your surgery with your surgeon. However, in the end, I would like to impress upon you that the results of surgery are usually extraordinary and you would leave the hospital a transformed person!