James H. Schmidt, MD (retired)

An antithrombin III deficiency is a medical condition where the clotting process is not controlled properly and can lead to unwanted clots. Obviously, if a blood clot occurs in a vital organ, or a clot breaks off an travels to a vital organ, serious injury or death can occur. Blood clots are often treated or prevented with blood thinners.

Breast augmentation is an elective procedure. Since it is elective and not necessary, we don't want to take unnecessary risks.  One of the risks associated with any surgery is bleeding.  If blood thinners are used around the time of surgery, this can greatly increase your risk of bleeding.

As you can see, there's a fine line between too much clotting and not enough.  The balance can be tipped in either direction. Even under the close surpervision of you plastic surgeon and hematologist, you're taking an unnecessary risk.  It looks like the four plastic surgeons you saw felt the same way. Breast augmentaion is a real surgical procedure with surgical risks.

  This question and answer format is for general information and the answer is based on the limited information provided in the question. The correct course of action can only be determined by you and your physician(s) after a thorough evaluation of your history and medical condition.  

Breast hanging, (breast ptosis), is classified as class I, class II or class III.  The class is determined by the position of the nipple/areolar complex in relation to the crease under the breast.  If someone has a class I ptosis, (where the nipple is at or above the crease), breast augmentation alone may correct the loose skin and hanging.  For classes II and III, breast lifting combined with an implant it usually required. 

If the skin is too loose and you just have a breast augmentation, the remaining skin can hang down from the breast giving you a long vertical shaped breast sometimes referred to as a "snoopy breast" like the nose on the cartoon character.

Some people try to avoid the breast lift, and scars by going to a larger implant.  However, very large implants will weigh more and over time can lead to more drooping especially if you skin and tissues are thin.

Looking at your photo only, you appear to have a class II ptosis and a combination augmentation mastopexy seems to be the best procedure for you. Obviously, I cannot assess the quality of your tissues from the photo.  Your plastic surgeon can assess this.  Discuss the above thoroughly with your doctor.  Also make sure that your doctor is well qualified and is experienced in this type of surgery. 

From your description, you are a very petite woman of medium height.  Although size of the implant is important, it is only one of several factors to be considered before surgery.  Your surgeon will assess the amount of breast tissue, the quality of the chest muscles, the elasticity of your skin among others.  All of these combined will determine your final result and your surgeon can help you determine the best size for you and help you anticipate the final result for your particular case.

Therefore, it is important to discuss this carefully with your doctor.  Try to describe the result you are seeking. 
Bring in some pictures of the type of breast you find attractive.  Ask you doctor if you can achieve this type of result. Communication is the key.  Your communication and the physical exam will allow your doctor to make the best recommendation for you.

During the consultation with my patients, the woman tries on different sized implants.  I find this helps many patients visualize the end result.  You are correct about the size of the breast becoming smaller after the surgery.  This is mostly due to the swelling that subsides over several weeks.  Keeping this in mind, if a woman is considering two different implant sizes, I usually recommend using the bigger implant assuming the tissues will accommodate this size.  This is where you need the advice of your surgeon.

Finally, make sure your surgeon is board certified by the American Board of Plastic Surgery and performs frequent breast implant surgery.

425 cc implants may be fine for you.  You state that you are 5'9" and 140 lbs.  You are a relatively tall woman.  As a general rule, taller women have broader shoulders and a wider chest and usually can use a larger implant than a woman with a smaller frame. The most common implant sizes in my practice are between 325 and 375cc but most of the women I see are shorter than 5'9".  There are other things to consider such as the amount of breast tissue you have and how tight you skin and muscles are.

During my consultations, I let women try on different sized implants.  I think this helps the patient see what type of result to expect with different sizes.

Most importantly, discuss these things with you doctor and express your expectations.  Make sure you see an experienced doctor who you can communicate with and who is board certified by the American Board of Plastic Surgery. 

Based upon your photo, you do have a fair amount of loose skin.  A breast augmentation will add volume to the breast and tighten the skin slightly. Unless you choose a huge implant, I suspect the skin will still have some laxity and remaining ptosis, (hanging).  Most patients with your type of skin and breast require both enlargement and lifting to provide the best result. 

More information is needed to help determine the best size implant for you.  This information will be collected by your PS and it may be helpful to have this available at the time of your consultation.

• What  type of result are you looking for? Some women what a small size change to look more proportional, others may want to correct changes that have occurred over time or with pregancy and still others what to be as large as possible.  Defining your goals can help you and your plastic surgeon determine the breast size for you.
• What are your body dimentions? Your height, weight, chest width and other dimensions will help determine the proper sized implant for you.  A petite woman will have a smaller chest and breast base diameter, whereas a larger woman with larger dimensions can carry a larger implant.
• Are you considering other surgerys? I see from your photo that the left breast is noticeably smaller than the right side.  You also have ptosis, (hanging), of the breasts.  This can be corrected at the time of breast augmentation if you choose. Your doctor may recommend combining breast augmentaion with a breast lift or other surgery.

The above information can help you and your doctor determine if 450cc implants are appropriate for you. During my consultation I let my patients try on different sizes.  This can also help you visualize the the look of various sized implants.  My patient tell me that this is very helpful.

All of my patients who have smooth implants are told to massage them twice a day.  I instruct them to take their open hand and first compress the implant with their palm.  The implant is compressed flat against the ribs and held for about 1 or 2 seconds.  The patient should then move the implant up towards the top of the implant pocket, in towards the breast bone, down towards the bottom of the breast and finally outward toward the side of the breast. Each compression is held for 1 or 2 seconds so the entire massage process takes only about 10 seconds.  Any easy way to remember the technique is to "push in, and then push North, South, East and West".

Breast massage is recommended to prevent capsule contractures, ( the development of firm scar tissue around the breast implants). Capsule contractures can occur many years after a woman has had breast augmentation.  Therefore, I tell my patients to massage "forever" since we have no way of knowing who may develop a capsule contracture or when it may occur.

I mentioned that I tell my patients to massage smooth implants.  They are designed to move freely in the implant pocket so we want the pocket to stay open so the implants move naturally.  Textured implants have a rough surface  and the tissue adheres to the implant. We do not massage this type of implant.

I is not unusual for one breast to soften and the implant to settle faster than the opposite breast.  Based on the info you provide, the left breast was the smaller breast and required an implant with a larger filling volume.  In essence the left, smaller breast was stretched more and was tighter than the right side. The breast with the tighter skin often will take more time to settle. I have seen this numerous times in my practice and in most cases the two breast do even out.  It is not unusual for an implant to take 1 or 2 months to settle. I instruct my patients to massage smooth saline implants which helps the implant pocket remain open and facilitates the implant to settle.

Your mentioned a hematoma.  Is this documented and if so what was done to correct this?  A hematoma can delay the recovery. This must be discussed with your plastic surgeon.  Did you indeed have a hematoma? Did it require drainage? Are you developing a firm breast consistent with a capsule contracture?

You are still early in your recovery period and you may do just fine as the healing process progresses.  However, you should relay your concerns to you plastic surgeon.  Ask him/her if things are progressing normally. Ask hem/her if you did have a hematoma or other problem that may be affecting you recovery and final result. You should get honest answers.  If you feel this is not the case, then consider a second opinion.  Always seek out a board certified plastic surgeon who is experienced in these procedures.

I think you can achieve the results you describe.  As you mentioned, no two people are alike and the final result depends on several factors. 

1. Keep in mind that the size of your breast after surgery is primarily determined by the amount of breast tissue you have added to the size of the implant used.  
2. The shape of your breast is determined by you own anatomy and the tightness of the skin on the breasts.

From your photos we can see that the breasts are pretty flat in the upper portion of the breast mound and you seem to have loose skin. I suspect that the best result can be achieved by combining implants and performing a lift.  Your skin seems to be loose in both the horizontal and vertical dimensions so you may need a full lift rather than a mini-lift.

When I see patients in consultation, we use a bra to help position the breasts upward and then use different implant sizes to see what gives the patient the result she is seeking. I found this to be very helpful for the patient trying to anticipate the surgical result.

You've provided some good information and seem to have a good idea of what you are trying to achieve. Make sure you see an experienced and board certified plastic surgeon and discuss these things thoroughly with him/her.  You and your doctor should agree on size and technique before proceeding with surgery.

Mondors bands are relatively common after breast augmentation.  They are caused by the tissues tightening beneath the breasts after breast surgery.  They are usually noticed when a woman raises her hands over her head thus lifting and tightening the tissues under the breasts. This condition is self limiting which means that it goes away by itself.

When a woman develops Mondors bands, several things can be done to help them go away quicker.  One is to massage the bands to soften the tight tissues. It sound like your doctor did this.  Other treatments include applying warm compresses to relax and soften the tissues.  A wash cloth warmed up with warm water can be used to do this--be careful not to use hot water and burn yourself.  Other people recommend using anti-inflammatory agents such as Motrin or Alleve  since this helps reduce the inflammation in the tissues leading to the banding.

Your Mondors band might come back shortly after your doctor visit, and then you can try the above treatments.  Eventually they will go away and won't return.