But just how does a plastic surgeon insert breast implants through a belly button?

First, the patient is placed under a general anesthesia; the whole procedure goes better if she lies still like a statue. Local anesthetics are injected into the umbilicus (the belly button) and breast.

Then, the plastic surgeon makes an inch and one-half long incision in the umbilicus and creates two tunnels just under the skin, one apiece leading to a breast. The surgeon has the choice of ending the tunnels above or below the chest muscle to make an implant pocket.

A tiny light and camera inside the tunnels then checks the pockets’ position.

After that,  empty breast implants are rolled up like a cigar, inserted through the tunnels and placed in the pockets. They are then filled with saline to expand the pockets. (The expander filler tubes hang out of the belly button incision.)

After removing the expander, yet another long instrument checks the position of the pockets to make sure the new, enhanced breasts will be balanced and symmetrical.

The next-to-last step is placing the permanent breast implant through the tunnels and filling them to the size the patient wants.

Only saline breast implants are used; silicone implants are already, permanently filled and won’t fit through the tunnels.

Last item?  Closing the incision and applying a dressing.

While recovering, the patient will notice some pain in her stomach near the tunnels and more discomfort if the implant has been placed below the chest muscle. However, adherents say there is less bleeding during a TUBA procedure and a quicker recovery with less risk to breast and nipple nerves.

As in all plastic surgery procedures, a practitioner who does the procedure often – once or twice weekly  – is more likely to produce the best results.

Despite all that, many plastic surgeons writing in RealSelf.com don’t recommend TUBA because the procedure is difficult unless the surgeon is highly skilled and experienced.

One way to check: the surgeon should have many, many breast augmentation before and after pictures of his past TUBA patients.

But a good guess is that the implant picks up a stray germ or three from the skin of the patient as the implant is worked through the incision and down into a previously prepared pocket, usually under the chest muscles.

Now, a plastic surgeon has come up with a way to place an implant through the skin, down and under the breast without the implant touching the patient’s skin.

It works like this: the tip of a nylon funnel is placed through the incision into the breast pocket. The surgeon puts the implant into the funnel and squeezes the implant into place.

The device (pictured) looks like a pastry bag used by bakers and chiefs.

Known as the Keller Funnel, somewhere around 400 U.S. plastic surgeons are said to be using it in breast enlargements. The funnel can be used when incisions are made in the:

• Armpit, an area known to surgeons as the axilla
• Areola, the brown area surrounding the nipple
• Inframammary fold, the area under the breast where the chest wall meets the breast

Normally, a surgeon uses his fingers to squeeze, poke and prod the implant into place. It’s harder to put a silicone implant into place because it is already filled. Saline implants, however, can be inserted empty and then filled after placement.

More women and their partners often report they prefer the soft, natural feel of silicone.

The funnel’s makers say placement is easier — and more sterile — because the nylon funnel has a slippery coating which allows the implant to slide easily along the length of the funnel.

Without the device, some plastic surgeons say their fingers have become fatigued while pushing and prodding the implants into place.

One expert even did a study and found a 95 percent reduction in force surgeons must apply to get the implant into the breast pocket!

Other benefits claimed include:

• Smaller scars
• Faster and more gentle surgery
• Quicker healing
• Easier on the patients’ breasts

According to the manufacturer, about 1000 breast enhancement procedures have a used the funnel.

So your bff goes in for breast augmentation or your other gf has a nose job. Of course, you notice, but exactly what do you say? A proper response can be awkward so why not let the professionals say it for you and send a plastic surgery greeting card?

Leading the way several years ago was the aptly named Lift Me Up Cards with greetings for gal pals who had:

• Breast augmentation (Congratulations on the Twins!)
• Breast lift (“I Thought You Needed a Little Lift. But it looks like your plastic surgeon already took care of you!”
• Rhinoplasty (“Your Nose Looks Great! You picked a great one!)
• Liposuction (“I Thought We Could Sit Around and Chew the Fat. But since you had liposuction, that’s not a good idea!”)
• Tummy Tuck (“Congratulations on Your Tuck! Now, no more Roll!)
• Face lifts (“You Look like a Million Bucks! I hope it did not cost that much to look so great!”)
• Sclerotherapy (“You’re So Vein. You probably think this card is about you!”)

And because imitation is the most sincere form of flattery, other plastic surgery greeting cards have entered the fray. Greeting Card Universe, for instance, offers congratulation cards for:

• Cosmetic Surgery
• Your Boob Job
• Your Breast Reduction
• Your Face Lift.

One card for breast augmentation patients shows a puzzled youngster on the front saying, “Gee whiz…I always heard of people making mountains out of molehills.” When you open the card, it says: “I just never knew anybody could really make it happen!”

Yet another card obviously intended only for woman-to-woman mailings says on the cover: “So you got some new Boobies, eh?”

Open the card and it says inside: “Can I have your old ones? Wait, I already have old ones!”

(Browse other plastic surgery greeting cards.)

But save a life?

It actually happened when a mother of four little children was trapped under her massive N-size cup breasts for half a year.

The strange case happened in a remote area of Northern Peru when a five-foot tall woman, Julia Manihuari, 29, found her breasts continued growing after the birth of her third son.

According to news reports, Julia’s breasts caused her to faint if she tried to get out of bed; Julia, who admitted to having always had a small body build, said the stress of the breasts caused her absolute agony.

“My breasts were growing daily,” said Julia Peru. “My skin had sores and I had trouble breathing.”

By comparison, the Guinness world record holder for largest breasts ever belongs to a Florida exotic dancer who claims to have triple M breasts.

In Peru, Julia’s doctors at the Loayza Archbishop Hospital in Iquitos – in the Peruvian rain forest —  had more serious concerns. First, they announced that the diagnosis was an extreme form of bilateral gynecomastia. But that was probably an error in translation because gynecomastia only occurs in males.

Julia’s doctors probably meant gigantomastia, which is the rapid growth of the breasts usually concurrent with pregnancy, according to Dorland’s Medical Dictionary.

Naturally the doctors were worried that the huge weight would crush her lungs.

Such a condition is VERY rare and only happens in about one in every 28,000 women.

After six months of being bed bound, word about Julia’s plight eventually got out, donations poured in and a trip to the nearest hospital was organized.

During a six-hour operation, doctors found the breast reduction was more complex than most because they had to work around many extra blood vessels which had sprouted in the breasts.

(Learn more about the unusual breast surgery.)

Eventually, they removed 35 pounds of flesh, fat and tissue, leaving Julia with much more manageable 34B breasts and freeing her from entrapment in her bed.

It started with a study of 10,000 mammograms taken at a surgeon-run breast health center in South Africa.

Both South Africa and the United States have known shortages of radiologists who are trained to interpret the breast images so that a diagnosis is spot-on.

To test just how well breast surgeons could analyze a mammogram, Justus Apffelstaedt, MD, an associate professor of surgery and head of the University of Stellenbosch’s Breast Clinic and colleagues, created a database of mammograms done between January, 2003 and June, 2009.

A separate data base contained the patients’ vital data, including:

• Age
• Previous breast surgery
• Confirmed cancer cases
• Therapy records

Each mammogram was then read by two breast surgeons and his answers jotted down.

Results: The surgeons’ readings were equivalent to the results of screening programs run by specialized breast radiologists in Europe and in Australia.

But the breast surgeons scored even higher than dedicated radiologists in the United States.

The finding could be useful because valuable time can be saved.

One important measurement of the skill of the person reading and interpreting mammograms is known as the “recall rate.”

That means the patient must go back for another mammogram because the first was inconclusive. Physicians who needlessly send patients back for another mammogram waste precious time if indeed a case of cancer is present.

But the breast surgeons “bounce back” rate was about the same as European and Aussie radiologists and a little better than American radiologist.

Adds Dr. Apffelstaedt: “Breast surgeons are a highly qualified source for second opinions….women should take advantage of this.”

(Read more about the breast surgeon study.)

Added Deanna Attai, M.D., chair for the Communications Committee for the American Society of Breast Surgeons (ABBrS), and director of the Center for Breast Care in Burbank, California: “There are countless examples of a surgeon finding something on a mammogram that might have been missed by their radiologist.”

What does all this mean for you, the patient? Just ask your breast surgeon what experience he or she had reading mammograms.

The struggle to require all insurance policies to cover breast reconstruction with breast plastic surgery after mastectomy was a big deal and literally required an act of Congress a little over a decade ago.

So you could call it the law of the land.

But Alicia Holt MD, a surgical fellow at the Hope Medical Center in Duarte, California, started counting heads of how many breast cancer patients in California choose breast reconstruction after their breast surgery to remove them via mastectomy.

Dr. Holt studied reconstruction rates after breast cancer surgery in California from 2003 to 2007. She saw a slight improvement, with 21.4 percent of women choosing reconstruction in ’07 while ’08 saw 29.3 percent of breast cancer patients going back under the knife for breast augmentation.

Reporting on her study at the annual meeting of the American Society of Breast Surgeons (ASBS) in Las Vegas, Dr. Holt found some limiting factors that influence a woman’s decision including:

• Insurance type
• Ethnicity
• Hospital type

Not surprisingly, Dr. Holt found women under 40 had the highest rates of breast reconstruction.

However, African-Americans were half as likely as Anglo background women to opt for breast rebuilding right away.

Patients with private insurance go in for plastic surgery breast reconstruction before women with Medi-Cal, the California health insurance program for low-income women.

Finally, patients at teaching or National Cancer Institute-qualified facilities were more likely to have breast surgery reconstruction.

According to Dr. Holt, breast cancer patients were just not getting the word that reconstruction is a right afforded them by national legislation.

One participant in the study, a breast cancer surgeon, says she  requires her patients to see a plastic surgeon, even if they have decided to forego breast reconstruction.

But Deanna Attai, MD, director of Burbank’s Center for Breast Care said another difficulty could be getting trained plastic surgeons – who normally work on a cash upfront basis – to do the procedure and accept insurance payments.

Concluded the doctors: “We need to get more information out, not only to patients but to the providers of plastic surgery.

Amen to THAT!

Until now, women who wanted breast augmentation or breast reconstruction after cancer had the choices of:

• Saline and silicone implants
• Flaps of fat and skin from the tummy or the sides

Some surgeons, reconstructing breasts for cancer patients have also taken large flaps of skin and fat from the patient’s buttocks to use as breasts.

But that causes a scooped out, flat appearance on the haunches and, usually, the need for yet another plastic surgery to create more rounded buttocks.

During one surgery, Ariel Rad, M.D., an assistant professor of plastic surgery at Johns Hopkins University School of Medicine noticed during one operation a blood vessel that would make the surgery to transplant love handles to breasts and recovery easier.

Any time plastic surgeons transplant fat, they must place it close to an existing blood supply — or else create a new blood supply. Without blood, the transplanted fat will die. Because dead fat tends to calcify, mammograms readings are blocked and may hide evidence of returning cancer in the future.

Professor Rad and his colleagues then decided to find out if everybody had that particular blood vessel. So they studied corpses and performed CT scans on living patients and found it present in 60 percent of patients.

The next step was using the method on 12 slim, athletic women who had lost their breasts to cancer. The surgeons were also thrilled to find the critical blood vessel needed to connect the blood supply in the mammary area was twice as long as the one used in buttocks grafts.

The new surgery was performed on the dozen patients from February, 2008 to one year later. All had good cosmetic results, according to Dr. Rad

The operation is performed with a microscope to connect blood vessels and provides a bonus in addition to reconstructed breasts, including:

• An improved contour of the waist
•  An improved contour of the hips

(Read more about the love handle breast augmentation procedure in ScienceBlog.com)

A recent survey revealed that some patients have very active imaginations and can come up with some, well, very unusual questions.

Here are the top 5 off-the-wall questions that patients have asked:

1.) If I ski or camp in the snow, can breast implants freeze?

In a word, no. That is, unless the rest of your freezes, too!

Breast implants are in a very warm, comfy environment. Even if your whole body, your silicone implants – being oil based – would not freeze. Your saline implants – being largely salt water – would only freeze if you succumbed while sleeping outside in below zero weather.

2.)  If my husband gets, ah….excited during, ah, intimate moments and squeezes my breasts hard, can the implants break or take a different shape?

Again, no way, unless your hubby’s name is Superman. Provided the implant has been put in under the pectoral, or chest, muscle, your main man feels your natural breast tissue.

3.) I only see women in your office, doctor. Has a man ever had breast implants?

A professional gambler once took a $100,000 bet that he could not survive one year with size 38C breast implants in his chest. He took the bet, collected the 100K and then wrote a book, The Man with the $100,000 Breasts. The gambler/author said women were fascinated.

4.) Can a guy tell if I’ve had breast enhancement? Will he care?

He will be able to tell if:

• Each nipple points to the closest armpit
• Ripples show through the skin
• The breasts are two different sizes
• You have no cleavage
• Scar tissue forms around the implants, making the breasts hard

According to a woman’s magazine survey, 83 percent of guys don’t like breast enhancements.

5.) How can guys tell if I’ve had breast enlargement?

When a breast implant patient moves around or reaches up, her breasts keep the same shape. Natural, unaugmented breasts will flatten when you put the arms over your head or fall forward when you lean over. Not-so-good implants look round and hard like a grapefruit halves. Undoctored breasts hang, more like water balloons.

That means people find uses for products the manufacturers completely missed. Any New Yorker  knows right how valuable kitty litter is for getting a grip on icy sidewalks.

The latest law of unintended uses? Breast implants as body armor.

Back in 2006, Israel was undergoing rocket attacks. Emergency surgeons at Nahariya Hospital reported they found shrapnel from an exploded rocked imbedded in the silicone breast implants of a 24-year-old. “The fragments were just inches from her heart so the implants saved her life,” said a spokesman. (Read a blog about shrapnel-catching breast implants.)

Our take: silicone is very thick, most shrapnel fragments are jagged but flat and don’t penetrate the body very deeply. Mostly likely true.

Another instance happened in Bulgaria, also in 2006, when a woman had a head on collision with another car. A policeman reported her double D implants absorbed most of the impact, protecting the driver’s ribs and vital organs.

Our take: Probably true. (We sure wish a doctor had backed up the police report.) Read the breast implants as airbags story.

The most current implant-as-body-armor instance happened when an L.A. woman was shot point blank by a crazed gunman who attacked a dental office where his wife was working. Another victim was shot in the arm and then played dead. But the gunman allegedly aimed directly at her heart and fired. A cosmetic surgeon later reported the implants saved the woman’s life.

Our take: it probably did not happen like that. Most assault rifles fire a high velocity bullet that, at close range, would zip through any implant, through the victim and then into and through yet another person.

What probably happened: The hospital spokesman where the victim was treated reported spotting bullet fragments only millimeters from her heart in a CT scan. So she was probably hit by a ricochet bullet that had lost most of its energy. Or the bullet struck the victim’s necklace and broke up. (Read the size D Implants article.)

Nonetheless, she should consider herself very, very lucky.

Adding to her luck was a kindly Beverly Hills cosmetic surgeon who offered to do for  no, or low, fees a reconstructive surgery when the victim healed.

Morale? Nobody should ever get saline implants or silicone implants with the idea of acquiring an internal bulletproof vest!

Jana, a former two-time world champ in the 2003 and 2007 400 meter hurdles, only had the implants for 14 months before, in her own words, “I’m  back to being as flat as a pancake.”

Dancers are another group of athletes that feel large breasts only get in their way.

Other celebrities have opted to go through explant surgery, the procedure to remove or replace breast implants.

For instance, former Spice girl, Victoria Beckham, had her large implants downsized during the summer of 2009. Victoria has a tiny frame and her implants just did not compliment her body.

O.C. Real Housewife Tamara Barney found she was having back pains due to her large implants so she had them replaced with a smaller set which also proved to be a pain in the back. At one point, Tamara was thinking she would lose the implants altogether.

New York City Real Housewife Jill Zarin reduced her implants from a 32 G to a 32D.

Some women having explant surgery, the procedure to remove implants, opt to have a breast lift (or mastopexy) at the same time.

According to the American Society of Plastic Surgeons (ASPS), the average cost of implant removal in the U.S. is $2435. With 20,967 breast augmentation patients having explant surgery in 2008, about $51,044,485 was spent.

 (2008 is the most recent year for which statistics have been compiled. 2009 statistics will be released in March, 2010.)

The three most common reasons for breast implant removal include:

• A change in size or shape
• Implant leak
• Capsular contracture, a type of internal scarring that hardens the implant and breast

Other famous women who had their breast implants removed or had a considerable reduction in implant size include:

• Britney Spears
• Demi Moore
• Jenny McCartney
• Courtney Love
• Jenna Jameson
• MTV’s Kacey Long
• Denise Richards

(Read our previous post about how Denise Richards first got uncomfortably large breast implants, and then received even larger implants – due to bad communication with the plastic surgeon — before going just right for her size.)