"Interview Conducted By Breast Implants 411"

BI411: What originally interested you in plastic surgery?

Dr. Rigano: The guys I first worked with in Toledo, Ohio, as a medical student, were a pretty interesting group. They pretty well performed every aspect of plastic surgery, from major hand reconstruction and reattachment, major facial trauma, burn care, breast cancer treatment, skin cancer treatment, as well as all the cosmetic procedures. It opened my eyes to the actual breadth of the specialty and what you could actually accomplish. It was broader than anything else I looked at and really caught my attention.

BI411: Some doctors say the artistic aspect of it really grabs them.

Dr. Rigano: It does and it takes time to better understand that and appreciate that, I've been able to do that more in the last 5 or 6 years. In the first 5 or 6 that you work, you're doing ER work, major reconstruction, you're putting limbs on, and that's a little bit different. It's not so artistic sometimes, so that appreciation does come with time.

BI411: Under what circumstances should a woman not have breast augmentation?

Dr. Rigano: I feel that you need to be careful about emotional issues. I certainly think they need to be quite stable and realistic in the first place to undergo the operation. If they're not realistic, no procedure will make them happy. I want to make sure that the operation is for the woman, not for other reasons - not so she can gain a husband, or do other secondary things like that. Would I do a dancer? Sure, I would, because I still think that's for the lady. Women need to be stable, realistic, well grounded - they need to make sure that this is what they want and they're trying to look more natural and add a more youthful aspect to their breasts than what they've had after pregnancy changes. Those are common things and very good indications, and I like to keep those general ideas in mind for them. It's the secondary reasons you have to be very careful with.

BI411: On the subject of exotic dancers, they come in all shapes and sizes, of course. I would imagine a dancer might have a very slight frame, but want a much larger breast. On a typical woman, I imagine you'd advise her to not to go through with anything too "showy". Would you do the same thing with a dancer in that situation, or would you recognize that some exotic dancers see large breasts as a kind of uniform for their job?

Dr. Rigano: I would do that universally, across the board. You have to show them what the risk/benefit ratio is. The overall risk of having breast implants is a capsular contracture, which is a scar around the implant. That is a number one, long-term risk that is significant. It can give pain, distortion to the breast and then secondary problems from that. To minimize that, not only do we place them under the muscle, you also want to be careful with the actual balance of soft tissue to implant. If you have a lady who's a 32A who wants to be a 32H, certainly that's going to upset that balance and they're going to be 90% implant and 10% them. I would expect them to not only look disproportionate, but the implant would be likely visible and down the road, the capsule and scar around it will likely get firmer and harder. If you take that patient and make them a 32B to B+, you're probably in a very nice ratio of their own soft tissue with their breast tissue and the pectoral muscle and you're in a 50/50 type arrangement, where it's half soft tissue and half implant, therefore, they stay more natural, they look more natural and they feel better long term.

Fortunately, I have not been pushed by too many patients to go much larger. Certainly many ladies who have a very nice augmentation come in and what do they wish? "Oh, I wish I just went a little bit larger". When I see them three of four months out, it's like a half cup - it's not like they want to go one or two more cups - it's a very subtle change. That's why I like them to talk to women who have had this done. The beauty of this is, if you let the ladies help with their own decision, they become much happier patients, which is true for anyone you do surgery on.

BI411: One aspect of your website (www.abcsurg.com) I like is that you have phone numbers of your previous patients that they can call.

Dr. Rigano: Part of what I need to do is to make sure they understand what their own soft tissue limits impose on the procedure, so they get a good benefit with a low risk. They can talk to patients with similar anatomy and develop a better understanding of proportions and procedures.

BI411: What should a woman expect during her first consultation with you?

Dr. Rigano: First, before they even come in here, they've been sent information from the office regarding the procedures they're interested in, as well as being referred to the website to get information about the staff, so they're a little bit more at ease. During that time we tell them what is going to happen and most of the time, up front, they'll get a phone call from me.

When they get here, the first thing we do is, my assistant or my nurse will go in and take a thorough medical history and they'll put that on the consultation sheet. Once that's happened, I will go in and review that with the patient and ask any relevant medical questions to make sure I understand their medical history. Then I will ask them, point blank, exactly what they would like to see in a perfect world. Once we do that, I give them some general information about procedures, about implants, answer some quick, general questions, try to limit that to a few minutes and get them to tell me all the things they would like. Once they do that, I let them slip into a robe and I'll come back to do an exam. Part of the exam involves chest wall and cup size. That means carefully looking at them and not just having them say they're a 34C and they want to be a D. When I measure them, they might be a 36B. We go through a good breast exam at that time - I make them understand about their skin, their breast tissue, the muscle, what pregnancy changes or what other changes have occurred, whether it's an asymmetry or not. Then we will talk about the options of a surgical approach and during that time I will mark on them a little bit, to help them understand that. I bring in a selection of silicone as well as saline implants and we discuss implant selection. We let them put those in their bra and do measurements again to give them a rough idea of what they may look like and what new volume and size to expect.

Once we've done all that, I will make sure I examine everything they want me to and I will step out of the room and let them get dressed again. We'll then summarize things, I'll give them more information and at that time I will have a general idea of size, I'll have a good idea of the approach I would use and I would show them some anatomy - textbooks and pictures of how we do all this, so that they really understand the procedure. Then I'll give them some patients to talk to if they haven't already done that and I'll give them some information that the FDA has prepared for women who are considering implants. At that time I ask them if they're really interested and want to schedule some time, they can do that - it's a low-pressure situation. If it's more informational, I'll give them more patients to talk to and phone numbers and then I'll let them go.

BI411: In the course of interviewing them, do you prepare them for the potential emotional roller coaster they may face before and after surgery?

Dr. Rigano: There are a couple general things I try to do when I see that - those are the patients where you really want their input. If I see that they need a little bit more control, then I want them to decide the size and the approach. I want them to do that and as long as I feel I can achieve what they want, without adding any unnecessary risks or problems, I will let them play a major role in the decisions, even though it may be exactly what I think. If you let them feel that way, then they're more involved and they're happier people versus if I'm the ultimate controller and I do things - if it's not just the way they want it, it becomes my problem. My consultation is an hour. In that hour, I can really learn a lot about someone. If I have that uneasy sense, I don't even talk about scheduling anything. I make sure they get information and I want to see them again. I see everyone a minimum of two times before any surgery.

BI411: What should a woman look for and be leery of in a plastic surgeon?

Dr. Rigano: Number one, good credentials. If you're going to see someone, you want to make sure that they're not only well trained for the procedures that you're considering, you also want to know that they have good experience - that they've done this procedure numerous times. Most importantly, you want to see someone who's going to spend time with you and understand exactly what you want. In this managed-care world, where people are trying to churn out a ton of things at high volume, if you're not going to spend time and make sure you educate people well, you're going to have some unhappy people. Someone who's willing to devote that time and is able to educate them carefully about the procedure, whether its risk to benefits, anatomy, surgical technique, follow up, whatever it is, ends up with happier patients. On top of those things, it's important that you have a staff that is well trained as well. The staff needs to be able to answer questions for patients; even the nurses will give a bit of patient care. All those things are important to keep in mind to help find a good surgeon.

BI411: One thing doctors have brought up in the course of these interviews is that they're getting scared by some of the younger doctors who come out of medical school and want to go straight to breast augmentation - where the fast money is - and ignore some of the other plastic surgeries, as well as ignoring the more standard doctoring that goes with the certification.

Dr. Rigano: I do see some younger guys really trying to do more cosmetics, they advertise that they do some in the office, they do them under IV sedation and because of that it's an easier procedure, which is a bunch of malarkey! I've seen patients fall for that trap - There are surgeons who work in their offices and he have done surgery there with just the surgeon and the receptionist with IV sedation. I've seen some pretty unhappy people, because they didn't have an adequate staff, they're trying to lower costs and do things in the office without appropriate...without appropriate ANYthing. So yes, I do see that, and you want to be leery of anything that sounds too good. You want to be leery of any surgeon that glosses over patient safety issues and of any surgeon who belittles the risks - every procedure has minor or major risks. And that comes back to education. If a surgeon isn't willing to carefully educate and communicate with a patient, I would be very leery of that doctor.

BI411: What do you think of the Internet as a form of referral in place of the more common word of mouth?

Dr. Rigano: What got me onto the Internet was that it's a way for me to get information to patients even before they come in here. I consider my website as an informational, educational guide. I never thought of it as a big marketing tool. Plus, for 11 years, I have been the busiest surgeon for breast cancer and breast reconstruction in the city by far. There was a need and I filled that need and still do. I use just as many implants for reconstruction as I do for augmentation.

BI411: We've learned from the ASPS website that immediate breast reconstruction surgeries are growing in popularity faster that augmentation. Are you noticing this same trend in your practice?

Dr. Rigano: Most patients who call are interested in short scar techniques. Which I do commonly, since many women prefer a more youthful shape without implants. I've done them for years, so it's always a big portion of my practice. A day doesn't go by where I don't see a new patient consultation for breast cancer. People know I do breast cancer reconstruction - I do a ton of it. I see people all over the state because of that. I don't think anyone really knew that I do that I do all the other types of plastic surgeries. So the website became a way that I could communicate to patients and other people that I do these other things as well. If you can take tissue from the abdominal wall with the muscle, bring it under the skin and close it up like a tummy-tuck and rebuild a breast from that tissue, then you can pretty well do a lot of abdominal contour surgery, you can do breast surgery, you can do al lot of things because you're highly trained and highly skilled.

Some ladies come in with small breasts that have breast cancer and they want to be larger. So we build a larger breast for reconstruction and then we come in and do an opposite implant to match the reconstructed breast. So I see a good number of ladies that I augment that way to help balance them at their request.

BI411: Where do you see plastic surgery heading in the future?

Dr. Rigano: The bar for plastic surgery is going up. Not only are the procedures more common, but I feel that in the last 10, 15 years the training is better, the society itself is more uniform and we are all committed to our specialty - our educational seminars are top notch. Our board is pushing the bar high for plastic surgeons. I have a very nice surgical suite, I do very careful cases in here, I bring in an anesthesiologists for IV sedation - your mother or wife would be fine right here - but that's not enough. We're fully accredited this July because our society wants us to be. That means more safety issues - if you're not committed to this and not going to push for these new standards, for example dermatologists doing liposuction, then there's no way anyone can measure up to the bar for our specialty. As education becomes more widespread through sources like your company, myself and through other patients, everyone will understand that you need to go to this group to be evaluated and consulted, maybe even see another surgeon and get another thorough consultation and then make a decision.

Dr. Rigano understands the concerns a woman feels and he doesn't trivialize them. In fact, he wants a woman to know this operation is not to be treated lightly. He is an expert surgeon - his candor and humanity is an appealing side sometimes lacking in other plastic surgeons. He sums himself up better than we can:

"Our specialty is trying to raise the standard. What your company is doing
educationally is a great thing. It ties into what I like, which is making people understand what they're getting into. That's understanding all the risks and realizing we can't gloss over things. Not every result is perfect and doctors are mere mortals."

You can reach Dr. Rigano at (937) 293-3800, or visit his website at www.abcsurg.com - as you can imagine from this brief interview, his schedule is very crowded with referrals from happy patients, so call early.