Danielle Regis (DR): Can you elaborate on your educational background?
Dr. David Barall (DB) : I graduated from the University of Pennsylvania, then I went to Brown University Medical School. I graduated from there, and was a general surgery resident for five years at Rhode Island Hospital. I was a plastic surgery resident for two years there. I became a plastic surgery fellow at Bringham and Women's Hospital in Boston, MA. After my tenure there, I established my practice in Providence, RI, where I have practiced for the past ten years.

DR: Who are the best candidates for breast augmentation?
DB: They are generally healthy women, whose breast has not developed to their satisfaction, in terms of size. The skin of their breast is elastic. Typically, their skin is not stretched out and the nipple is above the inferior fold of the breast. If for one reason or another, the skin has stretched and the nipple has decended to the level of the fold or even below that, then a woman would need a mastopexy, or breast lift to tighten the skin. Once this has been accomplished, a breast augmentation could be performed. Initially, I tightened the skin and placed in the implants in the patient. I found that one is asking the body to do quite a bit. A great deal of tension is being placed on skin that has been recently sutured. Then, I reverted back to two separate procedures, where someone would first come in and have their breasts lifted and tightened, and let that heal for a couple of months. Then, once the nipple is in the proper position, the breast at this point, being the normal anatomical shape can be augmented. Splitting the surgery into two separate episodes has worked out well for me.

DR: What is the profile of your typical patient?
DB: I would say we have two age groups. One is the younger women, maybe early twenties, who find that their clothes don't fit well, or are physically fit but are embarrassed about the size of their breasts, or for some reason, are not happy with the size of their breast. Then, I have women in their late thirties, early forties where this is something they've always wanted to do, but put it off. Some women in this group have actually lost volume in their breast after they breastfed. Others in this category have experienced lost elasticity in the skin of their breasts. What women would need in either case is to have the skin tightened, and then, they could have their breasts enlarged. I occasionally a dancer will come to me seeking a cup size that is way too big. I refer them out, because I am not interested in operating on individuals that want to look abnormal.

DR: Are any of your clients concerned about the possibility of an adverse reaction to the implants?
DB: They always ask if they will be able to breastfeed and are concerned about any changes in nipple sensation. The procedures that are being done now involve placing the implant underneath the pectoralis muscle, which is not really near the breast. The breast sits on top of the muscle. So yes, they will be able to breastfeed. Some women who have never had surgery cannot breastfeed. In terms of nipple sensation, the incicion is pretty far away from the nerves.

DR: Do they express concern as to the possibility of their implants rupturing?
DB: Oh yeah, they will always ask questions about the risks to having surgery. There are a number of things we will go over with the patient. The saline breast implant could leak. It could rupture. It is not certain as to how long they will last.

DR: How long do the implants last? I've read five years, seven years, ten years....
DB: I've been taking silicone breast implants out of women twenty years later. Some are intact. Some have ruptured. I just took some silicone implants out of a patient I had operated on ten years ago, which looked like they were just put in. They were still intact. The silicone on the inside was clear. The life of the implants are unpredictable.

DR: What size do most of your clients want to be?
DB: Most of clients want to be a generous C. They tend to think that the D range is out of proportion. Women that are an A cup think that being a B would be acceptable, but would feel better if they were a C - they want to look good but not overdo it.

DR: How long does it take to recover?
DB: The scar tissue will soften in about a year's time. It will take at least six months for the swelling to go down. By that time, the women have incorporated that new dress size into their daily routine.

DR: I know there is a capsule that forms around the implant. Will that ever degenerate?
DB: Anytime there is a foreign substance in the body, the body will try to wall it off. The capsule, or scar tissue that forms for most people is very fine. However, in some individuals, especially those that have silicone breast implants, a rock hard scar or capsule develops. Generally the capsule that forms around the saline implant has not caused too many problems. Studies have shown that when the implant is placed under the muscle, the chance of hard capsules forming is much less. Everybody will have some type of a capsule.

DR: Do ethnic groups scar differently?
DB: For some reason, African-Americans, Asians, and some Caucasians, tend to form too much scar tissue. There are varying degrees of too much scar tissue. Most people form a very thin scar. If the scar becomes thickened and reddened it is termed a hypertrophic scar. If the scar tissue then goes outside the boundary of wherever the incision is made, it is known as a keloid. The areas most prone to developing a keloid are the middle of the chest, lateral shoulder area, and the earlobes. The problems that surgeons tend to run into with people that have darker complexions, is that too much pigment is produced as the body heals the wound. Of course, everybody is different, but I'd say more often than not, someone who has darker pigment in their skin will form darker scars. Occasionally, the scar will lighten. I haven't really seen this phenomenon after breast augmentation. The incision in that case is usually underneath the breast. But, I have seen keloid scars on the lateral portions of the breasts of African-American or Asian patients after a breast reduction has been performed.

DR: What is the effect of chemotherapy on the success of the implants?
DB: I haven't had any problems with someone just having chemotherapy. When we have a patient that has had a mastectomy, we usually do a two-stage breast reconstruction. First, the patient undergoes surgery where tissue is inserted underneath the muscle. After the body has healed, we then insert saline through the skin, so essentially, you have a balloon underneath the skin that we are blowing up. I , myself, will not stick a needle through someone's skin while they have a low white blood count. The white cells are the cells that fight infection - I'd like their white cells to be normal.

DR: How often do you have to perform corrective surgery on patients that have had their breasts augmented by you?
DB: Fortunately, it has not been that often. During the years I have been in practice, three patients have had their saline implants deflate. I've had one patient whose implant had risen up on one side. I then had to go back in and lower it. I usually have patients wear a bra right after surgery to prevent such an occurance. In general, the surgery is very successful.

DR: Are there any adverse conditions that aren't reparable? I had seen a picture of a woman whose breasts fused together after surgery. She underwent corrective surgery, but her breasts fused together again...
DB: That's where as you are making your dissection pockets you go across the midline, so you've raised up all that tissue and sealed it down. Most surgeons, generally try to keep the pockets generous, but not go across the midline. General complications are infection, hematoma (bleeding under the skin), malposition of the implant, rupture of the implant. I suppose if there was an infection around the implant, one would have to go back in there. That's what happened to me on one occassion, I had to go back and actually take the implant out so that the wound could heal and so she could get rid of the infection. I later put the implant back in.

DR: How long did you wait to put the implant back in?
DB: One month.

DR: In your opinion, which are better - anatomical or round implants?
DB: I've been through the spectrum of both. I actually started with the round implants. When the anatomics came out, I thought that they would give my patients a breast which closely resembled the normal breast shape. I used those for awhile, again, those were saline. What I found was that when a woman stood up, occassionally the water would go out of them and especially if they were thin, you could feel the top of the implant. Also, when I used them, I felt there was too much fullness in the upper aspect of the breast. I have gone back over the last five or eight years, at least, to using the round implants again. I think they yield a nice, natural look, at least for me.

DR: What is your opinion of the PIP (pre-filled) saline implants?
DB: I haven't used those. I saw some that were made in France, or something, or at one of the meetings, but I haven't used them. It seems like it would be a good idea to not have to fill the implants up. Again, you're running into a problem if the company is not one of the two major suppliers of implants. Of course we've had problems in the past with implant companies going out of business, or leaving the business. That might be one of my reservations. None of my colleagues use them. Also, the implants that require filling allow me to add or substract fluid as needed.

DR: In your opinion, which is better - over or under the muscle?
DB: With the silicone implants, one seems to have good results over the muscle - just under the breast tissue. The problem is that the risk of capsular contracture increases when the implant is positioned there. If the implant is placed under the muscle, the patient is less aware of it. Also, the under-the-muscle option is better because the implant does not get in the way of examining the breast tissue for signs of cancer during a mammogram.

DR: Where do you think the incision should be made? I had read somewhere that an incision can be made in the belly button...
DB: Yeah, some people make it in the belly button. I do not perform surgery in that manner, nor do I know of anyone who does. The common areas are around the nipple, in the auxilla (armpit), and underneath the breast. Some people have good luck with endoscopic breast augmentation through the armpit. I personally haven't done it. One of the problems associated with this approach is that the implant is not lowered enough to prevent it from riding high. Other problems include poor visibility when placing the implant, and the ability to stop any bleeding that may occur. In my opinion, the best area to make the incision is under thebreast. With saline implants, one only has to make a small incision, about two centimeters long and I have had pretty good results in terms of hiding the scar in the fold (underneath the breast). Dancers may be concerned with having a scar in that area and may prefer an incision in the auxilla. I would then suggest an incision around the nipple.

DR: In your opinion, are silicone breast implants safe?
DB: From what I've read, the illnesses alleged to have been caused by silicone breast implants have never been proven. In fact, the FDA has allowed silicone breast implants back on the market for breast reconstruction, or if a woman has had problems with saline implants. We are not allowed to use them for fresh breast augmentation. I guess, they're still researching that. The patients that I have implanted with silicone, have not had any significant problems with them. Some people did form hard scars or capsules around their silicone implants, and when we got in there, it looked just like an eggshell - the body formed calcium around it. These weren't any of my own patients, but patients I had taken implants out that had had them in for ten or twenty years. Except for the problem of capsular contracture, rupture, or calcium deposition, I have to believe based on studies that have been done that they are safe. Will I use them again? Probably not, because I achieve reasonably good results with the saline implants. Less issues can come up with the saline implants. The patient also has to feel confident about what they have and feel good about what they have. I haven't had women requesting silicone.

DR: How would you react if your daughter expressed a desire to have breast implants?
DB: I think it has to be an individual reason as to why she would be doing it. If she obviously wasn't proportional and normal, and the implants gave her confidence I say she should go for it. If she is getting implants even though she is already proportional - it's her decision, but I would tend to dissuade someone from undergoing surgery who looks proportional. If having larger breasts would make someone feel more confident, or better around their peers, then they should have it done.

DR: What are the attitudes of the men that come in with their girlfriends or wives?
DB: Most of the attitudes are that they just want the person to be happy, from what I see. Occasionally, you'll have a boyfriend or fiancee that comes in, and makes you wonder who the surgery is really for.

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