Richard V. Dowden, M.D., C.M., F.A.C.S.

Certified by the American Board of Plastic Surgery

Cosmetic and Plastic Surgery, Inc.
6770 Mayfield Road, Suite 410
(Mayfield Heights) Cleveland, Ohio 44124
(440) 449-7470

Answers to Frequently Asked Questions about
breast enlargement through-the-navel ( TUBA ):

Why is there so much conflicting information from different surgeons?

Excellent question, and one to which an understanding of the answer is vital to anyone trying to make sense out of all the information in order to make some decisions. The first thing you must realize is that surgery is an art, not a clear-cut science. The second thing to realize is that surgeons differ in their training, their skill, their artistic ability, and their values. And the third thing to realize is that nearly all the surgeons sincerely believe what they are telling you. There are several categories of reasons for different surgeons giving different information.
    Causes of Conflicting Information:
  1. Differing skill levels lead to different conclusions.
  2. Some surgeons just recite what they were taught.
  3. Different techniques lead to varied results.
  4. Other hidden factors may be the real difference.
  5. Ignorance can lead to strong wrong opinions.
  6. Surgeons may have strong personal preferences.
  7. Surgeons may be speculating from other data.
  8. Opinions may be based on outdated information.
  9. Opinions may be based on anecdotes not studies.
  10. Different levels of conservatism lead to different opinions.
  11. Surgeons can't recommend what they are unable to do.

Differing skill levels lead to different conclusions:

 One's skills influence one's opinions. Imagine that surgeon A is not very good at performing transaxillary, but very skillful at doing peri-areolar, and that surgeon B is excellent at performing transaxillary, but has a difficult time getting periareolar to come out well. It is clear which procedure each surgeon will say works the best and produces the best result.

Some surgeons just recite what they were taught:

 We all start our learning by listening to those who went before us, and at first their opinions are taken as the ultimate truth. Only after time, we learn that some of those opinions are not really factual, or are outdated. Let's say that some of the things surgeons A and B were taught have been proven wrong, but surgeon A has kept up with the medical journals better than B has. Then B will be only repeating what was taught without thinking about it.

Different techniques lead to varied results:

 Surgeons A and B may think they are talking about the same thing, whereas in fact they are not. For example, lets say that A does procedure X using the endoscope to control and verify everything during the operation, but B does it just by feel. It is possible that B might say it is very difficult to get a good symmetrical implant placement with procedure X, yet surgeon A says it is no problem.

Other hidden factors may be the real difference:

 Sometimes what makes the difference between surgeons and between operations may be a different factor than what the surgeon thinks it is. One common example has to do with visibility of rippling/wrinkling. Surgeon A might believe that under-the-muscle implants display less wrinkling than over-the-muscle implants, yet B says it is the other way around. The explanation lies in the other variables. For example, it could be that surgeon A does not fill the implants to the optimum (which may require overfill), in which case it is true that the Unders show less wrinkling than Overs, but B fills the implants correctly and so doesn't see that factor. Similarly, the explanation for B's point of view may be that B uses only textured implants under the muscle, and smooth ones over the muscle, and so may be seeing the "Traction Wrinkling" that is a characteristic of textured implants, therefore sees more wrinkling with Unders than with Overs.

Ignorance can lead to strong, wrong, opinions:

 Surgeon A might know quite a lot about a technique, say the TUBA approach, and know from experience that it has a rapid recovery time and minimal pain, whereas surgeon B has not had the opportunity to learn about it, let alone to have any experience with it, and therefore B imagines that there would be a lot of pain in the abdominal area that would prolong recovery. Not having the actual facts available, B's ignorance of the procedure has led to an incorrect supposition.

Surgeons may have strong personal preferences:

 I have actually heard plastic surgeons at meetings say that they would never, under any circumstances, put in an implant larger than 275cc; others that they would never put an implant under the muscle; or that they would never make an incision around the areola. Why? Because they don't personally like the way it looks. Instead of leaving those decisions to the patient, they impose their own values and preferences. So it is easy to see why surgeon A might say that subpectoral transaxillary looks the best, and surgeon B that periareolar prepectoral gives the best result. Here, "best" means "what I myself like to look at".

Surgeons may be speculating from other data:

 Opinions should be based upon real data. But sometimes, there is a lack of data, and opinions can get based upon speculation from what limited data there is. A common example of this relates to mammograms after implants. It is a known fact that studies (of a limited number of patients) have indicated that there is more cross-sectional breast area visible on xray with Unders than Overs. Surgeon A might then speculate that breast cancer detection could be more difficult with Overs than Unders. But surgeon B could point out that perhaps the reasons that the women chose Overs in the first place were because they had lost a lot of breast tissue and wanted more correction of sagging. Or surgeon B might point out that it is a big jump from the question of cross-sectional breast area to detection of cancer, and that there has never been even one scientific study showing that Unders made detection of actual cancers easier than Overs, or that cancers were missed differentially with Overs.

Opinions may be based on outdated information:

 Medicine is constantly changing, techniques are improving all the time, and keeping up is not easy. Surgeons A and B might have read the same thing at one time, but B might not be aware that things had changed, and might be telling people the way things used to be. One real example of this related to the TUBA procedure. Years ago, in 1991, the TUBA procedure as it was first described was associated with a higher deflation rate in the hands of the only person in the world doing it - its inventor. After that fact was realized during the developmental phase, the manufacturers said they might not honor the warranty unless the procedure was changed to avoid any stress upon the implant. The inventor promptly improved the procedure, so that now the TUBA procedure actually has a lower deflation rate than any other method. But perhaps B doesn't know that, and might go around erroneously telling patients that the TUBA would void the warranty. (The manufacturers have confirmed in writing that the warranty is intact after TUBA. See http://www.drdowden.com/faqs/tubaguar.html)

Opinions may be based on anecdotes not studies:

 Again, well-controlled studies are the only valid way to reach conclusions, and the only valid thing upon which to base opinions. But when we plastic surgeons get together, we are eager to learn from each other's experiences. Sometimes, though, if there is no real study that pertains to a particular question, there is an understandable tendency to substitute anecdotal information. So Surgeon A stays home while B goes to a meeting, and there hears another surgeon report his bad experience with a certain shape of implant. Even though the problems were actually due to that surgeon's unfamiliarity with that shape of implant, it may affect B's opinion of that type.

Different levels of conservatism lead to different opinions:

 Some surgeons are more meticulous and conservative than others. Let's say that, for example, patients who are taking aspirin have a 1/200 chance of having to return to surgery for a small amount of blood accumulating around the implant, whereas those not taking aspirin the chance is lower at 1/300. Surgeon A might require the patients to avoid aspirin because the chance of bleeding is measurably higher, but B might say it doesn't matter because the difference between 1/200 and 1/300 is small. Different viewpoints and different levels of conservatism cause differing opinions!

Surgeons cannot recommend what they are unable to do:

 Some surgeons are not trained to do all the different options of types of procedures, and therefore are not in a position to recommend them. Unfortunately, this may even take the form of making disparaging remarks about a procedure if they themselves do not know how to do it. Of all the factors, this is the one about which we are the least proud to see exhibited by our colleagues, and although not widely prevalent, neither is it rare. If you hear such remarks, ask first where is the data in support of the opinion. If there is none, then ask where the surgeon received his training to perform the procedure in question, and how many cases has he personally done to form the basis for the opinion. You will have the explanation for bias soon enough!
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6770 Mayfield Road, Suite 410
(Mayfield Heights) Cleveland, Ohio 44124
(440) 449-7470

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