She was told by her prior surgeon that she did not need a lift for her ptotic breasts. He advised her to have larger implants placed in the subglandular space and that it "would fill up the tissue envelope." Six months after her initial surgery, she stated that she never wanted breasts that large, and now her breasts are even saggier than before she had the original breast surgery. A COMMON CASE HISTORY A large portion of my practice is devoted to revisionary breast surgery, and i see this scenario on a regular basis.Over the years, I have never seen this approach actually yield a good long-term result. More often than not, I see a patient who is dissatisfied with the size of her breast and degree of ptosis. I think it's very easy to convince a patient who is not sophisticated about breast surgery into having a larger breast implant rather than having a mastopexy or scar placed on her breasts. I think it's important for us, as plastic surgeons, to realize that this is generally not good practice. It's certainly something very easy to sell to the patient. However, when you think about disconnecting the attachments of the breast tissues to the pectoralis major muscle, taking a breast that is already ptotic or prone to ptosis, and placing a heavy implant in the subglandular space, it's predictable that the end result is going to be a large ptotic breast. THE ROLE OF ADVOCATE It's poor practice for surgeons to continue to do this, and the excuse of "that's what the patient wanted" or "if i don't do it, someone else will" is unacceptable. We have to be better advocates for the patient, and it's our responsibility to educate the patient to have appropriate surgery. Our aesthetic judgment comes from years of training and experience, and our surgical expertise should not be influenced by unrealistic patient desires or short-term gains. In closing, I make a plea to all plastic surgeons to practice more responsible breast surgery and think in terms of the long-term result for each patient. I believe that placing a larger subglandular implant for ptosis is bad practice in most instances. Paul E. Chasan, M.D., F.A.C.S., is a board-certified member of the American Society of Plastic and Reconstructive Surgeons and a diplomate of the American College of Surgeons. Dr. Chasan is on staff at Scripps Memorial Hospital in La Jolla where he serves on the credential committee. In addition, Dr. Chasan is an assistant clinical professor, Department of Surgery, at University of California, San Diego.
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