Category: Breast Augmentation


silicone-vs-saline-breast-implantwebThe American Society of Plastic Surgeons released its 2013 statistics in February. Breast augmentation was again the most frequently performed surgery and 72% of augmentations were with silicone implants compared to only 28% saline. The preference for silicone over saline is a reversal of trends from a decade ago. In the early 1990’s the US had a brewing controversy over the reliability of silicone, and the Food and Drug Association responded with a ban on their use except when part of a safety study. The implants remained available and widely used in Europe and South America. The FDA pre-approval study gathered data for fourteen years before returning the silicone implant to the list of approved medical devices. 2006 was the time of their return to the market, but the product had been modified to address the concerns that were raised. They have come a long way from where they started.    

Silicone implants are generally considered superior today because of their natural feel and durability.  The evolution of the modern Silicone Implant can be summarized:

  • First Generation: (1962) the original implant had a thick shell (0.25mm on average) filled with a thick viscous silicone gel. A Dacron patch was on the back. Implants were controversial when they first came out, but they rapidly became popular.
    Mark Twain once said, “A man with a new idea is a crank until the idea succeeds.”
  • Second Generation: (1970’s) About 10 years later the wall thinned out to 0.13mm and thinner gel was used on the inside. This change was undertaken to create a softer feel.
  • Third Generation: (1980s) A thick, silica-reinforced shell was developed for the silicone implant, to improve the strength of the outer envelope. This generation had much thinner gel content, compared to the thickness of syrup. The gel was more likely to travel when the shell was compromised. These are the implants that generated the controversy of twenty years ago.
  • Fourth Generation: (1992) The shell was made stronger and the gel was more cohesive in response to the problems that had been identified. The cohesive gel sticks to itself and is not likely to “ooze” out if the shell has a break down. 
  • Fifth Generation: (2012) The most recent modification to be approved by the FDA is the “gummy bear” or form stable implant. It has a much denser gel inside and is shaped with greater fullness at the bottom and texturing on the surface. This latest adaptation is being incorporated into practice in special circumstances. It allows more choices to personalize implant selection for each patient.

Twenty years ago silicone implants were held in suspicion. Careful clinical trials were undertaken to confirm their safety. Ten years ago, while the controversy was still brewing, most women chose saline implants for their augmentation.  Our thinking has evolved in response to the scientific data as well as patients’ experiences. The community of Plastic Surgeons will continue to evolve its thinking as new science and technology becomes available.

If ten years from now we are thinking the same as today, it is likely we are not thinking at all

Beauty, Body Contouring, Breast Augmentation, Breast health, Breast Implants, Doctor-Patient Relationship, Mommy Makeover

Combining an International “Vacation” with Plastic Surgery: Is Price More Important than Quality?

Womaninhammock“Medical tourism” is a modern reality. It is estimated that there may be as many as 15 million Americans a year receiving some form of care outside of the country. Those that are seeking plastic surgery are lured by combining their desire for cosmetic improvement with their desire for a vacation abroad. The consumer that puts a premium on cost over quality may not be aware of what they are giving up.

Here are some points to consider before booking the trip:

  1. What are the qualifications of the person performing your surgery abroad?  Does the country have any regulation of who is allowed to perform cosmetic surgery?
  2. Will a language barrier make it difficult to communicate with your caregivers, about your medical history, your informed consent, and your after care instructions? Will they know all they need to know about you and will you learn what you need to know from them?
  3. How can you verify the safety and sterility of the operating room where your surgery will take place? The United States has high, likely the strictest standards, for accrediting its medical facilities.
  4. Recovery from surgery is usually a time where rest is needed to heal. Fatigue is likely to interfere with the “vacation” part of the trip.
  5. Who will take care of potential complications? What if you need care beyond the time allotted for the trip?
  6. If the result is unsatisfactory who will revise your surgery? Will you have any follow up?

The American Society for Aesthetic Plastic Surgery has a set of guidelines for those consider international plastic surgery. You can access this checklist here.

Anti-aging, Beauty, Body Contouring, Breast Augmentation, Breast Implants, Discount cosmetic surgery, Doctor-Patient Relationship, Mommy Makeover

After the Weight Loss

scaleOne of the good things about our nation’s obesity epidemic is that there are so many people affected by it learning to reverse the weight gain. I often ask people what made them ready for change.  In my practice about half of the massive weight loss patients I see had bariatric surgery and half used diet and exercise alone. Make no mistake. Both are hard work.

The US population has obesity levels that are sky rocketing compared to our parent’s generation.  Theories abound about the cause of this unprecedented rise, but there is no doubt that it has become a serious public health problem. Health benefits of massive weight loss are large, but people often endure aesthetic and functional impairments that do not go away with weight loss alone.

Studies show that people are pleased with the changes in their appearance after massive weight loss, but their body image satisfaction decreases after 2-3 years.

The change comes from quality of life limitations created by the deflated hanging skin. They experience functional impairments including limited mobility from excess inner thigh skin, postural instability from abdominal skin excess, and increased hygiene demands from areas where the overhanging skin rubs.  16% report sores, rash and skin breakdown. 60% are dissatisfied with the appearance of their thighs.  Many continue to feel uncomfortable about their appearance which can have an impact on sexual and social interactions. The removal of excess skin by body contouring plastic surgery can contribute to better, physical, psychological, and social function. 

Studies have shown that 75-85% of those who have sustained massive weight loss desire body contouring surgery. The desire for plastic surgery after weight loss is twice as frequent in women and inversely related to age.

For more information refer to the December 2012 issue of Annals of Plastic Surgery.

Beauty, Body Contouring, Breast Augmentation, Breast health, Breast Implants, Breast Reduction, Cellulite, Mommy Makeover, Uncategorized, Weight loss

Easing Recovery After Breast Augmentation

Most women that choose breast implant surgery have been considering it for a long time and are highly motivated. They are happy about their anticipated body change. As the day approaches, it is not uncommon to have concerns about putting up with post-operative discomfort. Here are a few of the ways that postoperative pain can be lessened and use of narcotics can be decreased:

  1. Nerve Blocks Just like the dentist injects the nerves to your teeth to make a procedure comfortable, it is possible to block nerves to the chest wall before breast augmentation. The nerves that bring sensation to the breast area run just below each rib on the chest wall. Injecting these nerves with a long acting local anesthetic, blocks painful impulses. I like to place a lot of local anesthetic in the tissues at the beginning of the procedure. I use “intercostal nerve blocks,” and I put additional local around the incision, beneath the muscle and along the breast fold to get the areas as pain free as possible. If the pain is blocked early in recovery the overall pain response appears to be diminished. These local anesthetic blocks do not eliminate the need for pain pills, but they do reduce the amount of narcotic that is required during recovery. 
  2. on-Q_pump“Pain Pump” Most women find their post augmentation discomfort is manageable, but for those that are particularly worried about dealing with it, I use a device called the On Q Pain Buster. This pain pump technology is an elastic ball filled with local anesthetic that continually delivers the medication to the surgical site through two tiny catheters. It provides good pain relief for three days following the procedure. For more information on the Pain Buster go to
  3. Exparel Exparel is a new formulation of an old local anesthetic. The medication bupivacaine has long been used for long acting block of pain impulses. It has been created in a slow release form by wrapping the medication in a “liposome.” A liposome is a fat coating that allows a 72 hour sustained release. This medication adds expense comparable to the pain pump, but it can be placed in the surgical area to help numb the discomfort. It provides one more tool to make recovery manageable. Basic information about Exparel can be found on

I am happy to discuss these options with you when you come in for a consultation about breast enlargement to make your recovery as comfortable as possible.



Breast Augmentation, Breast health, Breast Implants, Doctor-Patient Relationship, Mommy Makeover

Current Trends Show Fat Grafting the Breast Is Popular

Breast Fat TransferA recent survey of board certified Plastic Surgeons confirms that plastic surgeons are using fat transfer with increasing frequency and success.
80% reported using fat in parts of the body other than breast.
70 % actively perform fat grafting to the breast.
62% used fat transfer as a good choice for improving breast shape and
contour in reconstructive breast surgeries.
28% of the surveyed surgeons employ this technique for cosmetic purposes.



Here are some of the ways this valuable technique is being used:

  1. Breast implants in thin women can show wrinkling or visible borders. Fat can provide a thicker soft tissue cover to hide implant characteristics.
  2. Fat grafts can cover prominent ribs or an irregular chest wall.
  3. Congenital breast problems, such as tubular breasts or lack of growth of one breast can be reshaped with fat transfer as part of the procedure.
  4. In breast reconstruction after mastectomy, fat can help camouflage the borders of an implant, or fill in a deficit in a flap contour or after a lumpectomy defect. Fat can treat irradiated tissue and seems to improve skin quality. 

There were nearly 72,000 fat grafting procedures reported by US board certified surgeons for 2012, according to the American Society for Aesthetic Surgery. 

For more detail visit the July 2013 issue if Plastic and Reconstructive Surgery,

Anti-aging, Blepharoplasty, Body Contouring, Breast Augmentation, Breast health, Breast Implants, Breast Reduction, Fat Transfer / Fat Grafting, Mommy Makeover, Tubular Breasts


WomanRedheadAccording to the American Society of Plastic Surgery there were 286,000 breast augmentations in the United States last year, an increase of over 200% since 1997. In my last blog, I reported on evidence that shows a high degree of satisfaction with the choice to have breast implants. We know that breast implants do not last a lifetime, but women want the satisfaction with their procedure to last a very long time. The US implant manufacturers advise that implants will need to be removed or replaced eventually. So what are some of the reasons for revising breast surgery?

A study (published last month in Aesthetic Surgery Journal) looked at 110 consecutive women that underwent revision of their breast implants between the years 2004 and 2009. The reoperation rate in this study was 16.3% with an average time from first surgery to revision of 8.9 years.

Here are the reasons for re-operation in this surgeon’s practice:

1. 42%developed sagging (ptosis) of their breast, a natural progression of biological change.

2. 29% had capsular contracture (scar tissue around the implant resulting in firmness).

3. 19% were re-operated for a high riding implant.

4. 14% indicated implant position was not where it belonged (malposition).

5. 7% had infection.

6. 5% developed breast cancer.

7. 4% objected to rippling of implant.

8. 4% had synmastia (implant pocket lifting up over the sternum).

9. 3% had a “double-bubble” where implant and breast did not merge in a smooth transition.

10. 2% deflation.

As humans age their skin thins, loosing elasticity. As breast volume fluctuates with weight changes and pregnancy, there is a natural sagging of the breast. Implant placement can accelerate these natural changes. This report shows that the majority of revisionary breast implant surgery is to improve appearance and reverse changes of aging, rather than for medical necessity. That is a good thing if you are the patient, because you can choose the time when it matters to you.

Anti-aging, Beauty, Body Contouring, Breast Augmentation, Breast Implants, Breast Reduction, Mommy Makeover, Personal Fitness, Uncategorized

Studies Confirm Patient Satisfaction with Choosing Breast Augmentation

The purpose of aesthetic plastic surgery is to improve quality of life by enhancing one’s body confidence and comfort. A recent study published in the Aesthetic Surgery Journal looks at the satisfaction and well-being of a group of 155 women that had breast augmentation in 2008 and 2009. The data confirms that women report a significant improvement in their satisfaction with breast appearance, psychosocial well-being, and sense of sexual well-being after surgery. The anonymous survey was administered before and six weeks after their breast implant procedure. The scores were tabulated on a 1-100 point basis.

Here are some of the outcomes reported:

  1. Satisfaction with breast appearance improved from a score of 26 to 82.
  2. 79% were satisfied with the size of their breasts post operatively.
  3. Sense of wellbeing increased from a score of 52 to 85. 
  4. 97% reported they felt attractive, up from 51%.
  5. 96% felt more self-assured, up from 51%.
  6. 94% reported that they felt confident most or all the time, improved from 53% prior to surgery.
  7. 91% answered that they felt confident sexually after their augmentation, up from 46% preoperatively.

The research did not examine those women that did not report improved quality of life after the procedure. This group was small but it would be valuable to gain insight on why they did not achieve the same satisfaction. 

The questionnaire that was used is called the BREAST –Q. It was developed to meet national and international standards of outcomes assessment for evidence based medicine. For a closer look check out the Aesthetic Surgery Journal 33(2)245-251, 2013.

Anti-aging, Beauty, Body Contouring, Breast Augmentation, Breast health, Breast Implants, Personal Fitness

Latest Research on Breast Implant Sizing

WomanwithpinkbraBreast augmentation ranks first in frequently performed plastic surgery procedures. Perhaps the most important factors in assuring satisfaction with the outcome is having the surgeon and patient agree on an implant size that is suitable.  Reoperation for size change of implant happens about 8-9% of the time and can be avoided with careful decision making in advance. The December 2012 edition of the Journal of Plastic and Reconstructive Surgery has a new study published on ways plastic surgeons select implant sizes for their breast augmentation patients. 

“Surgeons that rated breast diameter as the most important variable in size selection had the lowest reoperation rate for size change”

“Choosing a breast implant for a prospective patient is not a straightforward task.”

A survey was sent to 3000 members of the American Society of Plastic Surgeons inviting them to report how they selected implant size prior to surgery and what their reoperation rate was for size change.  Surgeons ranked variables in the following order:

  1. Woman’s desired size
  2. Breast Base Diameter
  3. Amount of skin/breast to cover the implant
  4. Distance from the fold beneath the breast to the nipple, unstretched
  5. Stretched skin distance from fold to nipple
  6. Skin “pinch” thickness
  7. Sterna l notch to nipple distance
  8. Distance between nipples
  9. Diameter of areola
  10. Nipple projection

The variable that could be related to a decrease in reoperation rate for size change was the measurement of base diameter. In the event of a conflict between patient’s desired volume and implant width, surgeons who re-educated their patients about the reasons for  different size choice had a lower repeat surgery rate than those who compromised with their patients in the event of a conflict.


Body Contouring, Breast Augmentation, Breast health, Breast Implants, Doctor-Patient Relationship, Mommy Makeover

Nipple Sensitivity After Breast Augmentation: What Are the Facts?

Nipple sensitivityBREAST AUGMENTATION surgery remains the most frequently performed cosmetic surgery in the United States. The demand for BREAST IMPLANT SURGERY increased 4% in 2011 to 307,000 women according to the American Society of Plastic Surgeons. 

As its popularity grows, women are becoming more proactive about educating themselves about their decision. One of the most significant concerns is about sensitivity to the nipple post operatively. Women want to know the statistics, not just “opinions” not backed up by any evidence. They want to make fully informed decisions.

An excellent study on this subject was published in the October 2011 issue of Plastic and Reconstructive Surgery. A plastic surgeon from Rome collaborating with a British colleague published data on 1222 patients (that is 2444 breasts!) examining nerve function after breast enlargement surgery. They reported the following:

  1. Half of all patients experienced a TEMPORARY change in sensitivity that goes away by itself in 6-8 weeks. 
  2. At six months, 94.8% of women had normal sensation, unchanged from before surgery.
  3. Large breast implants did not increase the incidence of sensory change.
  4. Patient age did not factor into sensory change.
  5. Placing the implant above or below the pectoral muscle did not make a difference in sensation.
  6. A decrease in feeling was present in 2.7% of women post op. Discomfort was noted for 3.5%.
  7. The only risk factor identified for altering nerve sensation was use of the periareolar incision.

In fact the periareolar  incision resulted in more than double the number of women with altered sensation.  Fortunately this sensory change affected only a small number of women. If a scar around the areola is what you prefer, it is good to know the facts up front.

Breast Augmentation, Breast health, Breast Implants, Mommy Makeover

What Does the Future Hold for Silicone Breast Implant Imaging?

MRI findings

Diagrams of MR imaging findings in implant rupture. At left, intracapsular rupture where silicone is contained by the surrounding fibrous scar tissue (black arrows). The collaped outer shell (curved arrow) and often fluid droplets are seen within the gel. At righ, an extracapsular rupture, where silicone gel extends beyond the fibrous scar or capsule.

Silicone breast implants are one of the most extensively researched medical devices in the US. They have a high safety profile and are being used increasingly with good product performance. Breast implant shell failure is one of the concerns many women express when investigating choice of implant type. If the shell of a saline implant develops a break the fluid spills out and deflation occurs within days. If a silicone implant experiences a break in the shell, it generally requires an imaging study to confirm.

The implants currently marketed in the United States are referred to as “Fourth Generation Responsive Gel.” These implants have a silicone center that is thicker than earlier implants. Because of the viscosity, if there is a break in the envelope, shell failure, the gel tends to stick to itself, rather than oozing out of the sac like syrup.

Detecting a leak involves some form of an imaging study. Mammograms give a certain amount of information about the status of an implant, but are not sensitive enough to pick up every rupture. A negative study can give false reassurance that the implant is intact.

An MRI, magnetic resonance imaging, is considered the Gold Standard. The FDA has recommended a post operative MRI at year three and every two years thereafter. There is no scientific evidence that backs the timing of this recommendation, and most plastic surgeons believe the recommendation is overly cautious. Both the cost and the inconvenience of MRI exams are barriers to women using this for follow up. Additionally, MRI exams can over read, meaning give the appearance of a rupture where none exists. This can lead to unnecessary surgery.

Technology advances in some areas with mind boggling speed. Medical imaging is a field of rapid technological expansion. As predicted, there is an emerging technology that is not yet market ready that promises to vastly improve post operative imaging of silicone implants.

High resolution ultrasound is being studied for its ability to give accurate information about the shell of silicone breast implants. Preliminary research is published in the Aesthetic Surgery Journal, February 2012, p.157. The authors report that as they refine this ultrasound technique, it may provide relative affordability, accessibility, and availability. It’s good news for the future of monitoring the shells of silicone breast implants.

Beauty, Breast Augmentation, Breast health, Breast Implants

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