Celebrity Plastic Surgery, News, Gossip

By Patty Kovacs, Editor-at-Large, Makemeheal.com

Want to increase your breast size and slim down your mid-section at the same time?

After years of medical research, specialty trained plastic surgeons are successfully increasing a woman’s breast size using the patient’s own fat along with fat stem cells. This revolutionary plastic surgery procedure is opening a new frontier in breast augmentation and causing interested patients to look more closely at their options.

For years, saline and silicone implants have served as the most viable method for breast augmentation patients, but inserting saline or plastic into one’s body is considered by some women as a procedure that poses health concerns. While saline or silicone implants are ‘foreign objects’ placed into the body, innumerable studies and FDA approval declare both saline and silicone implants to be safe. Breast augmentation and liposuction were front runner plastic surgery procedures for 2008, and are proving to continue to be so in 2009.

The relatively uncommon fat grafting breast augmentation procedure has women everywhere buzzing about the benefits of this seemingly more natural breast enhancement option. So what’s a woman to do? First, decisions mean options and options are a good thing. Present clinical evidence does not conclude that fat grafting is safer or better than saline or silicone implants, but the idea of taking one’s own fat and repositioning it to augment the breasts is rapidly capturing the attention of medicine, consumers, and the media. I decided to take a more careful look into this procedure as the beauty buffet of breast augmentation procedures is likely to bring a feast of pros and cons and confusion is best converted to clarity.

Autologous fat grafting, also known as fat transfer (AFT), is a procedure in which fat cells are harvested from one part of the body and injected into another. It’s gaining acclaim rapidly. Proponents of fat grafting breast augmentation say it can be very effective in enhancing the size and appearance of the breasts using one’s own tissue. The procedure can also soften the appearance of existing implants and hide visible rippling which is particularly apparent in very thin women with a bony chest wall and little skin or fat with which to work.

The process typically increases breast size by one cup size. Recovery time is argued by opponents to be less than with traditional implants, as both the breast and donor site must heal. Also, patients need to have an adequate supply of excess fat for the procedure. Opponents claim it can take up to six months or more for breast shape results to complete post surgery as opposed to implants where recovery and results appear in six to eight weeks. But the surgeons with whom I spoke expressed short recovery following the fat transfer procedure claiming their patients could return to work in only a few days.

Methods for tissue harvest and tissue injection have been refined. Fat cells are carefully removed by a specialized liposuction procedure using numerous syringes and transferred to the breast via dozens of minutely small injections. This technique results in increased survival of the fat cells. There remains debate over how much of the transferred fat remains long-term, but the doctors with whom I spoke said it could possibly last a lifetime, unlike implants which are recommended to be replaced at least every ten years.

The procedure can be very effective in enhancing in enhancing the appearance of the breast for breast reconstruction. Fat grafting breast augmentation can also soften the appearance of existing implants, particularly in very thin women who experience visible rippling with their implants.

Augmenting the breast with the body’s own fat first became popular in the 1980s; however, both ASPS and ASAPS initially cautioned its members against the technique because of side effects such as oil cysts, calcification, and tissue scarring. The calcification in particular made it difficult for mammogram readings to distinguish between calcifications associated with breast cancer and calcifications associated with fat transfer.

A renewed clinical interest in fat grafting for both reconstructive and aesthetic purposes has emerged and surgical proponents of the procedure are calling it the wave of the future in aesthetic breast enhancement procedures.

I decided to go straight to the top and speak with Dr. Mel Bircoll, retired Board Certified Plastic Surgeon and Chief of Plastic Surgery at the former Beverly Hills Medical Center, a prestigious facility which catered to the upper crust of Beverly Hills, on the site of what is now the Peninsula Hotel. Dr. Bircoll, an icon of medicine and the first doctor to perform liposuction in North America in the latter 1970’s, now resides in Bel Air and remains active on advisory boards for fat transfer procedures and stem cell research.

“My esteemed clientele were so pleased with the progressive face lift procedures I performed in the 60’s, 70’s and 80’s, they kept asking me, ‘Dr. Bircoll, can you take it from here (thighs) and place it here (breasts)?’ To accommodate their pleas I introduced the first fat transfer procedures in the United States in 1984,” Dr. Bircoll declared.

How did he come up with the first successful fat transfer procedures in North America? Dr. Bircoll explained that fat transfer procedures were going on as early as 1890, but that the procedures did not produce tissue that could be oxygenated; thus, the fat transfer tissue would die. He figured if he could inject a small enough quantity into the center of vascularized tissue, each minutely small quantity would get its oxygen supply and survive. Breathing room meant survival of the fat cells and that meant success. His procedure is the very foundation of today’s multiple micro injections procedure for successful fat transfer. Each of the micro injections receives oxygen and the procedure, when done properly, brings outstanding results, he reports. Fat is successfully removed from the patient’s own body and placed into the patient’s breast, all using the person’s own fat, creating a naturally enhanced breast with no foreign implant.

One of Dr. Mercoll’s select students is Board Certified Dr. Todd Malan of Scottsdale, AZ, now a teacher of Dr. Bircoll’s method and Founder of the signature breast augmentation procedure, the “Natural Breast Augmentation.”

Dr. Malan explained to me, “The method for harvest and injection of the patient’s tissue is a highly refined approach. But we’ve achieved success unlike any other fat transfer breast augmentation procedures. Procedures previously performed in the 1980s provided only 50 per cent of fat cells surviving. The procedure we perform today maximizes fat stem cells to provide an 85-90 percent survival of the cell. We implement a method of harvesting the fat cells that places little to no trauma on the harvested fat and allows the aesthetic enhancement to last (potentially) a lifetime. Fat cells are carefully removed by liposuction using syringes and transferred to the breast via dozens of micro injections. The ‘Natural Breast Augmentation’ technique results in greatly increased survival of the fat cells, and though there remains debate over how much of the transferred fat remains long term, we see no reason to believe it is not for life.”

Dr. Malan has trained only six surgeons in the United States due to the precision and surgical expertise required to perform the procedure correctly. One of his elite students, Dr. August Accetta, of Huntington Beach, CA (www.accettamd.com) told me he is amazed regarding patient satisfaction and success with the procedure.

“Finally my patients who have long desired breast enhancement but did not wish to have implants due to their not wanting a foreign substance in their body nor on their breast wall, comment that the procedure has offered them a wonderful, full, all natural, utterly beautiful breast enhancement and they’re elated. It’s a tedious procedure requiring meticulous attention to every detail and should only be performed by a highly trained specialist, but the end results can be astonishingly natural and beautiful,” acclaims Dr. Accetta.

He says there are four primary reasons for patients to request Natural Breast Augmentation: First, general augmentation. Second, restoration to pre- pregnancy breast size, shape, and appearance. Natural Breast Augmentation is also performed to correct embarrassing size discrepancies, and, lastly, restoration following surgical lumpectomy procedures.

“As long as the fat is injected in the correct way, the patient will be overjoyed that her breasts look and feel 100% natural,” said Dr. Accetta. “This is the very first procedure to allow doctors to use everything nature gave us to help a woman obtain that perfect hourglass figure… naturally!”

In 2007, the highly respected medical association, American Society for Plastic Surgery (ASPS) , formed a Fat Graft Task Force to conduct an assessment regarding the safety and efficacy of autologous fat grafting (AFT). I spoke to Dr. Karol A. Gutowski, Chair for the ASPS review, about the results of the study.

“We looked at studies from around the world and concluded that while there are a lot of concerns, there’s much evidence showing positive results from this procedure. We actually couldn’t find strong evidence showing why not to perform this procedure for breast augmentation, but we also didn’t conclude this is the best technology there is for achieving certain specific goals, say for breast reconstruction. The standard now for breast augmentation is implants which has its pros and cons; same is true for fat grafting. Unfortunately, we have no formal studies comparing the two. Maybe in the near future as we could use more information and studies on this.”

While there is one registered prospective clinical trial (BRAVA, clinicaltrials.gov ID:NCT00466765) and other non-registered prospective trials involving fat grafting to the breast, no randomized controlled trials were identified during the literature search.

As the procedure continues to grow in demand, numerous surgeons are creating their own ‘signature’ or trademark procedure of the fat transfer breast augmentation. In reply to safety, proponents argue that sophisticated radiology and modern digital mammography equipment of today can better distinguish cancer cells from benign ones when examining dense breast tissue. Advocates state that fat grafting breast augmentation does not compromise accurate mammography readings any more than implants, and, in fact, most of them feel the procedure means far less mammographical compromise than implants. Opponents suggest more research is needed before concluding that the procedure’s benefits outweigh risks.

The process typically increases breast size by one cup size. Recovery time may be less than with traditional implants, as both the breast and donor site must heal. Patients need to have an adequate supply of excess fat for the procedure.

Opponents claim it can take longer for results to take shape after the procedure as opposed to implant procedures. There remains debate over how much of the transferred fat remains long term. Formal clinical trial evidence does not exist to suggest that fat grafting is safer or better than saline or silicone implants.

The American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) urge consumers to proceed carefully with any breast enhancement procedure.

As with all aesthetic surgical procedures, research the facts, I want to emphasize how important it is to consult only with a Board Certified Plastic Surgeon, compare the stratum of fat transfer breast augmentation procedures, and examine carefully all before and after procedure results.

Patty Kovacs, Editor-At-Large at Makemeheal.com, is a published author and beauty expert. Patty is the Executive Producer/Host of The Health and Beauty Revolution Show on wsRadio. Her 800+ interviews include over 450 New York Times best-selling authors. Patty

See Patty’s Websites: www.pattykovacevich.com

Patty Kovacs and Lois W. Stern are the co-founders of Coast to Coast - Eye on Beauty Newsletter. Check it out!

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February 6, 2009 - Los Angeles, CA

Make Me Heal (www.makemeheal.com), the world’s largest website for all things plastic surgery, cosmetic treatments, and anti-aging, has announced that over fifty top plastic surgeons have joined Makemeheal.com to answer questions live that are posted by consumers on the website’s Ask-An-Expert area. Launched in November of 2008, Ask-an-Expert is a free service that allows consumers to ask a question and get key answers from top doctors and experts about any procedure or topic within the fields of plastic surgery, dermatology, and skin care. Moreover, regular people from the Makemeheal.com community can also post responses to questions.

“Ask-an-Expert is rapidly becoming one of Makemeheal.com’s most popular areas of our portal, as it allows consumers to ask important questions and get answers from different leading doctors and experts at a click of a button — and for free,” says Ariel Perets, Founder & CEO of Makemeheal.com.

Aside from asking questions, users can simply use this incredible resource to do research numerous types of procedures, treatments, and products using sophisticated search functions on Ask-an-Expert.

Among the physicians answering questions on the Makemeheal.com site include Dr. Marcel Daniels, Dr. Brent Moelleken, Dr. Shervin Naderi, Dr. Alexander Rivkin, and other top plastic surgeons.

Check out Ask-An-Expert.

About Make Me Heal

Make Me Heal (www.makemeheal.com) is the world’s largest website for all things plastic surgery, beauty enhancement, and anti-aging.  With 1 million members and over 300,000 unique visitors per month, Make Me Heal is a one-stop portal for all the products, services, and information resources needed by the consumer.

Discover The Make Me Heal World…

• Find a great plastic surgeon on Makemeheal.com’s Plastic Surgeons Directory, check credentials, and read patient reviews of doctors.

• Chat, ask questions, and get advice from people on our Message Boards & Blogs.

• View or upload Before & After Plastic Surgery Pictures in the world’s largest photo library of women and men who’ve had plastic surgery.

• Ask top plastic surgeons questions & get answers live on Make Me Heal’s Ask-An-Expert area.
• Shop for Plastic Surgery Recovery & Preparation Products and Beauty & Skin Care Products.
  
• Read Plastic Surgery News & Gossip.

Visit the website: Make Me Heal

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By Dr. Jennifer Walden, MD, FACS

The History. The enhancement of the female breast has been a source of attention for centuries. In 1889, one of the first recorded breast augmentation procedures was performed by the Austrian surgeon Gersuny, who injected liquid paraffin directly into the breasts to enhance their shape and fullness. Since then numerous attempts including the placement of foam, sponge, and liquid silicone have been performed to surgically enlarge the breasts, often with devastating results.

In 1962, Houston plastic surgeons Cronin and Gerow began the clinical trials which led to the first silicone gel-filled implants by the manufacturer Dow Corning in 1963. Although various modifications have and continue to be made on the original prototype design, it was the silicone breast implant that was greatly responsible for reducing the serious problems associated with earlier injection techniques. In an ironic twist, public concerns regarding a possible link between silicone implants and autoimmune disease, as well as other health issues sparked a media frenzy which resulted in a moratorium on silicone gel-filled implants by the FDA in 1992. This ban left saline implants as the only option in the U.S. for surgical augmentation until 1998, when silicone was reintroduced in restricted clinical trials. By 2006, however, there had been no conclusive scientific data to support a correlation between silicone breast implants and any systemic disease. Silicone gel implants once again have become available for primary augmentation procedures and remain the prosthesis of choice worldwide with a well-established safety profile.

What Now? Problems with the earlier generation silicone gel implants were that they had a thick, unnaturally stiff shell, a high rate of gel bleed, and an unacceptably high incidence of capsular contracture (up to 70%). Third generation implants, from the mid-1980s forward until today, utilize a multi-layer barrier shell to decrease gel bleed and are filled with a thicker, more cohesive gel to reduce potential leakage. These implants, termed “responsive gels,” have proven high rates of safety and efficacy, and were re-approved for general use with conditions by the United States FDA in November 2006. Currently, third generation silicone gel-filled breast implants are approved for: (1) reconstruction in women of any age and (2) augmentation in women 22 years or older. In contrast, saline-filled breast implants are approved for women 18 years or older. The two main implant manufacturers which provide plastic surgeons and patients with well-studied, safe FDA-approved breast implants for their patients in the United States are Mentor (Santa Barbara, CA) and Allergan Corporation (Irvine, CA).

As a female plastic surgeon, breast augmentation is my most requested and performed procedure. In New York, my average patient is in her 20s or 30s, wants to do it for herself to improve the appearance of her breasts, may have one or two children, and has arrived at the decision to have it done independently and privately after conducting her own research. Besides me doing this procedure multiple times every week, breast augmentation has also been the most commonly performed cosmetic surgical procedure for women in the United States the past two years! I am using silicone implants about 85% of the time and saline implants about 15% of the time. I find that silicone implants more closely resemble the consistency and texture of normal breast tissue, and that the tactile and visual aesthetics are more pleasing. That being said, saline implants are still a nice option in women under 22 years of age for primary breast augmentation or when dealing with an asymmetry where it will be helpful to fill the implants different volumes intraoperatively. One of the benefits of saline filled implants is that they can be adjusted in the operating room, as opposed to pre-filled silicone implants which often require the use of sizers intraoperatively for cases of different sized breasts.

In the following preop and postop example, the patient is 5′4″ and 115 pounds. I used 300cc smooth round moderate plus profile under the muscle saline filled implants.

(Left: Before, Right: After)

The breast pocket may be created in either the subglandular (under the gland) or subpectoral (under the pectoralis major muscle) space. The subglandular technique is usually reserved for patients who have substantial breast tissue or a mild degree of ptosis, or breast droop, since greater projection may be obtained. Also, women who are avid bodybuilders may prefer subglandular implants for the reason that placing them under the muscle in some instances may produce breast animation and distortions when the pectoral muscles are flexed. Increased risks of capsular contracture, rippling and implant palpability are typically issues discouraging the routine use of subglandular placement.

In the vast majority of patients, I believe the under the muscle technique produces optimum results. The pectoralis major drapes the top 3/4 of the implant, softening the transition, and therefore creating a more anatomically shaped breast mound. This method also achieves a natural feel, which is especially desirable when using saline implants. In addition to improved aesthetic outcomes, there are advantages in regard to breast-feeding as well as cancer screening.

The proper selection if breast implant size is extremely important for minimizing complications and optimizing patient satisfaction. I consider the base diameter of the chest, along with tissue laxity and the amount of breast tissue a patient is starting with, as the most important factors in choosing implant size. Implants come in three types of profiles: moderate, moderate plus or midrange depending upon the implant manufacturer, or high profile. For a given width, or base diameter, of an implant the implant project lower or higher on the chest. So, for a base diameter of 12 centimeters (a measurement the surgeon takes across the width of your breast), a moderate profile implant will have less volume and projection than a moderate plus or high profile implant does for the same base diameter. I generally use moderate plus or midrange profile implants because the average base diameter I see is around 11.5 to 12.5 cm. This gives around 300 to 325 cc of volume (a very common size of implant—around a C cup if you were starting as an A cup, or with little breast tissue).

I tend to reserve moderate profile implants for women with very broad chests who don’t particularly want to look top-heavy, and I use high profile implants in women who are petite with a smaller base diameters (say 10.5 cm) who say they want to be a C cup or bigger…. I need the increased volume built into the higher projection of the implant to get them to the volume they want without the implant borders extending outside of the natural confines of their breasts. Ultra high profile implants are available and more popular in Europe and other countries due to the increased demand for greater projection and size. Implants that are too big for a woman’s individual chest dimensions lead to a higher likelihood of irreparable tissue stretch, bottoming out, and complications that may lead to reoperation.

In the following preop and postop example, the patient is 5′4″ and 115 pounds. I used 350cc smooth round high profile under the muscle silicone gel implants.

(Left: Before, Right: After)

What’s New? Evaluation of the highly-cohesive, form-stable fourth generation implants is well underway by the FDA in the United States, but these implants have been widely used since the mid-1990s in many other countries and are very popular in Europe. These teardrop-shaped (often called anatomic or “gummy bear”) implants are textured and contain a highly cross-linked form of silicone gel to minimize the possibility of silicone migration, as well as upper pole collapse and folds in the implant shell. Studies of these devices have shown significant promise in clinical trials with low rates of capsular contracture and rupture, and high rates of patient satisfaction. Both Mentor and Allergan Corporation have shaped anatomic gel implants that are being reviewed by the FDA but are available in Europe and other countries around the world. There are a matrix of different implants to chose from in these lines, with varying width, height, and projection for different body and breast types.

Allergan’s highly cohesive, shaped implant is called the Style 410, and the company is currently in discussions with the FDA and look forward to a decision regarding its approval, but cannot speculate on timing. A very similar situation exists with Mentor Corporation as well for their form stable shaped implant called Contour Profile Gel (CPG). The shaped cohesive gel implant represents a new option in the United States for women considering breast surgery for reconstruction and augmentation. In my opinion, the potential drawbacks are that they do feel a little firmer than the smooth round responsive gels, and the possibility exists that they could shift or turn in the pocket and not look or feel right if that were to happen (called malrotation). For this reason, very precise breast pocket dissection is needed for this type of implant. These implants do cost significantly more than saline, and likely will cost several hundred dollars more per pair than responsive silicone gel implants if and when they are approved by the FDA.

Since highly cohesive gel implants are not deformable, they cannot be squeezed through little incisions. Depending upon the size of the implant, incision length must be between 4.5-5.5 cm. It also can make insertion from around the areola difficult. Armpit, or transaxillary incision is possible, but exceedingly difficult. The reason at this point in time that I actually prefer smooth round gels is that they act and feel very much like normal breast tissue — when you lay down, normal breast tissue flattens and lateralizes, and so do the smooth round responsive gels. When you stand up, gravity takes effect and the gel situates within the implant at the base of the breast to give fullness in the lower pole and a smooth slope at the top. This can be illustrated in Figure 1a (Style 410) and Figure 1b (Smooth round responsive gel) with my nurse, Sarah, and the two types of implants in the photos. I also am able to fit smooth round silicone gel implants through relatively small incisions at the inframammery crease, areolar border (periareolar), or armpit.

(Left: Figure 1a, Right: Figure 1b)

In summary, pending FDA approval Mentor’s Contour Profile Gel and Allergan’s Style 410 will be the latest additions to the already wide selection of available implants; there are hundreds of breast implant combinations from type of filler, volume, base width and profile—all to help women and their surgeon find the fit that is appropriate for them.

The Future. Breast enhancement using fat grafts (lipoaugmentation) rather than silicone or saline implants employs fat suctioned from the patient’s buttocks, thighs or other fatty areas. This type of breast surgery can be used to increase the size of the breast or to fill in defects or abnormalities in existing breasts, including enhancing the appearance after breast reconstruction and softening the look of existing implants. Fat injections of the breasts may offer patients augmentation with a natural look and feel and the benefit of body contouring through liposuction—without the requirement for incisions or implants.

However, long-term safety and efficacy data as well as the effect of the procedure on breast cancer screening using mammography is still being evaluated in clinical studies. Concerns about fat grafting for breast enhancement include unpredictable or low survival rates of the transferred cells (which are frequently absorbed by the body), development of cysts, calcification and tissue scarring. Another major concern is long-term problems with breast cancer detection due to difficulties in telling the difference on mammograms between calcifications associated with breast cancer and calcifications associated with fat transfer.

This procedure does offer a modest opportunity for enhancement— specifically, about one cup size increase and the degree of enlargement will depend on the amount of spare fat that the patient has. But, numerous questions remain about this new technique: How much of the fat survives? Does the procedure have to be repeated? Are the breasts hard and uncomfortable for long periods after the procedure? And most importantly, what are the cancer implications of this technique? Research projects, funded by the Aesthetic Surgery Education and Research Foundation (ASERF) of the American Society for Aesthetic Plastic Surgery are being conducted to determine the safety and efficacy of breast enhancement with fat.

In the meantime, plastic surgeons will continue to study the intricate details of the procedure for the safety of our patients– namely, the techniques of harvesting, preparation, and placement of the fat tissue, who should receive fat transfer, when it is appropriate, and whether it is safe for the long term. Results of clinical studies this far seem promising—so maybe going up a cup size with the benefit of a little liposuction elsewhere will be common practice in 5 or 10 years! Anyone reading this should be aware that this procedure is very technique dependant and to avoid complications it must to be done correctly by a properly trained, board-certified plastic surgeon.

Let the Buyer Beware. Have you heard of dermal fillers? These materials are gel-like compounds that can be injected into the body and have been traditionally used in facial rejuvenation. They increase the volume of the area injected, and are either classified as permanent or semi-permanent. Restylane, Hylaform, and Juvederm are types of hyaluronic acid dermal fillers that are currently FDA approved for injection into the nasolabial folds, or laugh lines, of the face.

Swedish scientists have developed a dermal filler called Macrolane (made by Q-Med in Sweden) which is being marketed in Europe and is not approved by the FDA for use in the United States. Macrolane is composed of hyaluronic acid but in larger particles than those found in Restylane. This makes it more suitable for treatment of larger areas, and the body may absorb it more slowly given the larger particle size. Known on the internet and in the media as a “Boob Jab,” Macrolane is being touted for breast augmentation and shaping of the décolletage, as well as an adjunct after breast implant procedures and liposuction when there may be contour problems. Compared with treatment with Restylane, much greater volumes are used in an average treatment with Macrolane and the gel is injected deeper in the skin layer to add larger volumes.

But be aware that this procedure is not permanent - all dermal fillers are eventually absorbed and metabolized by the body! One round of Macrolane breast augmentation may last 1-2 years, but could resorb in less time than that. Controversy exists around this procedure as we don’t know exactly how this material will look on mammogram, if it will eventually cause permanent lumps and bumps, or if it could even obscure of confuse the diagnosis of a future breast cancer.

My associate recently met a woman from London who consulted with him about getting silicone breast implants. The patient reported that she had undergone breast injections with Macrolane for enhancement. The procedure was done by injecting the material through a cannula, or hollow tube, with incisions of 6-7mm on either sides of her breasts. The patient stated that the material was injected under the pectoralis major muscle and was indeed painful even though some local anesthesia was used. She went from a full A cup to a B cup…but all of the material was gone in 2 ½ to 3 months, and then she was right back down to an A-cup! Hence the consultation for real breast implants.

Other drawbacks of the “Boob Jab” procedure include that Macrolane is only available in the UK and Europe, costs an average $4,000 - $7,000 (similar to the cost of breast implants, which is a much longer lasting form of enhancement!), and we don’t know its long term effects on breast tissue and the overlying skin. Yes, this means the procedure and payment needs to be repeated every 1-2 years if you decide to enter into such a treatment plan; I would argue to save your money and think about augmentation with FDA approved breast implants if you are this serious about going forward with augmenting your breasts.

Can breast pumps be used for breast enlargement and how do they work? Breast pumps basically work through the physiological process known as tissue expansion. If you apply a gentle pressure to stretch skin or other soft tissues, they slowly stretch. If you’ve ever seen a person with oversized ear plugs or a native tribesman with a large ornament in his lip, you’ve seen tissue expansion at work. By applying relatively gentle vacuum (negative) pressure to the breasts, breast pumps encourage the process of tissue expansion. Over time this leads to a modest increase in breast size, but temporary breast pumps in my opinion are really not a viable permanent breast enlargement solution. In fact, overuse of this type of breast pump may cause broken blood vessels, skin irritation, and discomfort. The Brava system (Brava, LLC, Coconut Grove, FL) is one of the more popular branded devices for external breast enlargement by this method that has been studied in a well-controlled fashion. The Brava system has been shown to increase breast size after prolonged use, but there are some significant drawbacks including the following:

• Cost - the Brava device runs about $2500

• Time - the device must be worn 10 hours a day for 10 weeks, or 700 hours

• Discomfort - the device applies a rather strong suction to the chest, which many women find uncomfortable

• Amount of growth - on average, after 10 weeks, a woman may gain about 100 cc of breast volume, and that’s only about ½ of a cup size.

• Embarrassment - you don’t want to be seen outside the house in this contraption, and most women that I know (including myself) would not be game for wearing this apparatus on their breasts for 10 hours a day… it’s simply not feasible.

Cleavage enhancers like Rodial Boob Job (Rodial, UK) are creams that tout enlargement of the breasts as an end effect. Although these creams may tighten, soften and enhance the appearance of the skin of the breasts, there is no way that a topically applied cream can block internal fat deposition elsewhere in the body and focus it to the breasts, which is what the company’s website claims.

Mama Mio Boob Tube (Mama Mio, Huntington Beach, CA) is a nice product that has active ingredients including CoQ10 which is important for skin strength and elasticity, Shea Butter and Dandelion Root for restoring skin tone, Evening Primrose Oil, Avocado oil, and a rich blend of omega 3, 6, and 9. I have used this product before and has a very rich moisturizing quality, lovely scent…and the company sells a complement of products for the tummy, buttocks, breasts, etc, including “Bootcamp for Butts” and “Bootcamp for Boobs” creams! (LOL).

In summary, breast augmentation technology is changing fast, and but I seriously doubt implants themselves will ever become a thing of the past! Newer techniques involving the injection of substances into the breasts should be considered judiciously after doing proper research and consulting with a qualified plastic surgeon.

About Dr. Walden

Jennifer L. Walden, MD, FACS is a Plastic and Reconstructive Surgeon who is fellowship-trained in aesthetic surgery and board certified by the American Board of Plastic Surgery. She currently is an associate attending in Plastic Surgery at Manhattan Eye, Ear and Throat Hospital and Lenox Hill Hospital. She is also a member of the American Society of Plastic Surgeons and is a Fellow of the American College of Surgeons. Her office is located at in Manhattan at 50 East 71st Street (on the corner of Park Avenue and 71st Street).

Dr. Walden, a native Texan, received her undergraduate education at the University of Texas at Austin, graduating with Honors with a Bachelor of Arts in Biology. She continued her education at the University of Texas Medical Branch in Galveston where she received her Medical Doctorate with Highest Honors and numerous academic awards including graduating as the salutatorian of her medical school class. Dr. Walden received her formal training in plastic and reconstructive surgery at the University of Texas Medical Branch and completed an externship at the prestigious Plastic Surgery Associates in Miami under the direction of Dr’s. Baker and Stuzin. After completing her residency training, she moved from Texas to New York to pursue her special interest in aesthetic surgery during her fellowship at Manhattan Eye, Ear and Throat Hospital under the direction of Sherrell J. Aston, MD. During her fellowship, she benefited from the knowledge and expertise of many internationally known leaders in the field of aesthetic plastic surgery. Dr. Walden is currently the Program Director of the Manhattan Eye, Ear and Throat Hospital Aesthetic Surgery Fellowship, one of the foremost organized training programs of cosmetic surgery in the nation.

Dr. Walden has presented multiple research papers, published articles, and has enjoyed involvement in organized medicine and plastic surgery on both local and national levels. Learn More About Dr. Walden

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See Liz’s Before & After Plastic Surgery Pictures Album.

Since she was a teenager, 26-year-old Liz (friendname: lizNher2sisters) knew she would eventually get breast augmentation, but it wasn’t until 2 years ago that she started saving and researching for the procedure. After having trouble choosing her implant size, she finally chose 400cc Mentor silicone implants for her June 19^th surgery with Dr. Mark Zilmer in Washington. Additionally, she used the Make Me Heal Message Boards to connect with others having the same procedure for support and advice. Though she experienced a lot of pain right after the procedure, she was back to work after only 5 days. Now, at 4 months post op, she loves her new womanly figure but is experiencing a bit of “boob greed” and wishes she would have gone a bit bigger.

Liz’s advice for anyone contemplating plastic surgery is:

“Do what makes YOU happy and don’t listen to others. If you do it to give you self esteem, you won’t find it. Do it to help bring out what you know is inside of you. It is an enhancement of the beautiful person you already are.”

Please join us for an interview with Liz:

Make Me Heal: When did you first have the idea to have your procedure(s)?

Liz: In my teenage years I knew I would eventually do it, but seriously began the research and saving about 2 years prior.

Make Me Heal: What were your motivations (physical, emotional, social, etc.) behind your decision to have the procedure(s)?

Liz: Physically I felt inadequate and wanted to fill out a pretty lacy bra or bathing suit WITHOUT using inserts or push ups! Wanted my tall athletic frame to be more proportional.

Make Me Heal: How long did it take you to make a decision and was it an easy or difficult one to make?

Liz: Having the surgery was an easy choice. However, choosing the size was extremely stressful. I feared going too big for what was recommended but I wanted bigger than suggested by my first pre op PS. So I looked at many pictures and debated for over a month. Even still I wish I would’ve had more time and made a better decision as I would have chosen 450-475cc’s.

Make Me Heal: Did your family, friends, and any other people in your close circle give you support, opposition, or did you make this decision without considering them?

Liz: This decision was for ME 100%. My mother opposed it, my significant other supported me. However, I told them plain and simple that I was going to do it no matter what. At that point, the support was there from all areas.

Make Me Heal: How did you research the procedure and come to decide on this particular procedure?

Liz: I went on line and read a lot of facts and myths and looked at pictures constantly. I asked those I knew who had done it and posted on MMH for a month beforehand. I still wish i would’ve taken a little more time on MMH before the surgery but I was too excited that I didn’t plan it accordingly. Still no regrets on the surgery itself. Just size.

Make Me Heal: Please discuss if you used any of Make Me Heal’s resources such as the message boards, pictures library, doctor directory and doctor reviews, and any recovery and preparation products that you used.

Liz: I took full advantage of the message boards and pictures to help make my decisions and help me in my recovery. It was an extreme help.

Make Me Heal: How did you come to choose your doctor?

Liz: My doctor was the 2nd PS I met. The practice I chose was recommended by a friend. I was comfortable with my PS’s support and ease. He made me feel like this surgery was natural and normal, and whatever I wanted within reason he could make happen. That helped me push the CC’s slightly larger than recommended size my first consult PS recommended for my BWD. Glad I did.

Make Me Heal: Please discuss if you have any role in deciding the type of technique used for your surgery by the doctor, incision placements, implant brand, anesthesia type, etc.

Liz: No my practice typically does one certain types of incisions and anesthesia. However due to my lack of tissue, the placement was recommended and I agreed.

Make Me Heal: How did you prepare for the surgery?

Liz: I purchased comfortable clothing for the first post op days. Easy to eat foods. The prescribed meds and vitamins to help for a speedy recovery. Took them for 2 weeks prior and a few weeks after to help with healing. Did not engage in any alcoholic beverages or blood thinning agents listed in the paperwork provided by my Ps. Took 5 days off from work and prepared my team for my return and inability to lift or do excess activity. Purchased button front sports bras. Had plans for where my 4 year old would be taken care of in order for optimal outcomes for all involved.

Make Me Heal: How were you feeling the night before the surgery and on the moments before the surgery itself?

Liz: I experienced doubts and fear and insecurities of my decision. Did I go too big, will it look too small? Will I still feel my nipples? Will the scars be too big with silicone…should I change to saline? How will people react to them, will they even notice? Will I just look fat? Will they feel real or fake? Will they ripple because I have little tissue, or will I get CC? All these thoughts ran through my mind plus many more. I was VERY nervous the morning of. It was surreal and was excited to wake up and feel like a woman!

Make Me Heal: How was the recovery process? Please discuss what side effects you experienced? What were the worse parts of the recovery? Did anyone help you during the recovery?

Liz: Morning boob was HORRIBLE. I honestly felt it was worse than childbirth. I expected it to be much easier, but I was wrong. I have a high tolerance for pain but my pain meds seemed to simply put me to sleep rather then kill any pain. My boyfriend helped me for 3 days non stop. It was a nice help, but still very stressful as we both did not know what to expect.

Make Me Heal: Please discuss the pain or discomfort you experienced during the recovery?

Liz: Very painful to move. Painful To get up or down from the 45 degree angle in bed. I feared moving and it took much courage and determination to do it on my own. Even with help I cried in pain.

Make Me Heal: How well prepared were you for the recovery from physical, emotional, and mental respects? Did you do any research (i.e. online, books, message boards, etc.) to make your recovery smoother?

Liz: I relied mostly on the MMH boards. They were VERY helpful with all the weird feelings or sounds my new implants made or caused. However I was not prepared enough for the pain or decision of what size I should go.

Make Me Heal: What are your top recovery tips to other patients?

Liz: Stay on top of your pain meds!! Give it time before you start to worry! Two different breasts, two different recoveries.

Make Me Heal: How long did you take off from work? What did you tell your co-workers about taking this time off? Did anyone notice your cosmetic procedures at work and what did you tell them if they asked about it?

Liz: 5 days off from work and all of my employees knew what I was doing for the most part and I would be limited on my activity when returning. They hardly noticed since I wore a lot of padded push ups prior.

Make Me Heal: How happy are you with the results?

Liz: 1 to 5 … I would say I am a 4. Wish they were a tad larger, otherwise they look amazingly perfect!

Make Me Heal: How has your makeover impacted your life from personal, social, career, and other respects?

Liz: My personal life is much better as I more comfortable in the nude and confident showing myself. Socially I carry myself with my chin a little higher as i am proud that its ALL ME and no longer just a great bra. Career has not changed and I didn’t expect it to.

Make Me Heal: Would you have done anything differently if you had the chance?

Liz: Gone with more CC’s. More research would have gotten me to where I needed to be to be happier.

Make Me Heal: Was Make Me Heal beneficial to you along your journey?

Liz: It has been a tremendous help. I can share my crazy thoughts and worries that everyone else wouldn’t even begin to understand. I can see others progress and know it is different with everyone and I am NOT alone.

See Liz’s Before & After Plastic Surgery Pictures Album.

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By Andrew Wolfe, MD

Obesity and the constellation of diseases which result from obesity are among the most significant health problems in the United States today. In an effort to combat this epidemic, patients are increasingly turning to Bariatric Surgeons for massive weight loss surgery. Last year 200,000 Bariatric procedures were performed, representing a 10-fold increase over the previous decade. The benefits of the weight loss are profound and far-reaching. Physiologically, there are improvements in many weight-related conditions, such as diabetes, cardiovascular disease, and skeletal disorders. The psychological benefits include marked improvements in body image and social acceptance as well as decreases in depression and anxiety.

Although the weight loss is truly a life saving process, it is not without its negative side effects. Psychological challenges can include stressful changes in relationships with the patient’s spouse, friends, and the opposite sex. These changes can be so pronounced that patients may experience an identity crisis after weight loss, and psychological counseling and support groups are integral to the successful transition from obese to non-obese. Physically, the loss of fat results in disproportionately loose skin and underlying soft tissue, which can lead to both aesthetic and functional concerns.

For many massive weight loss (MWL) patients, Plastic Surgery is a vital step in their journey, and improves their physical and psychological well-being. More than 100,000 contouring procedures have been performed on MWL patients, and that number is growing exponentially. The goals of surgery are straightforward – improved function, hygiene and appearance, achieved through safe, predictable procedures. As straightforward as these goals may be, post-MWL Plastic Surgery is a rapidly-evolving specialty, and procedures are constantly evolving to offer patients better, safer results.

Prior to any elective surgery after MWL, preoperative considerations which must be taken into account include nutrition, weight stability, and smoking habits. Nutritional deficiencies are common after weight reduction surgery, although newer Bariatric procedures are less likely to affect patients adversely than were older techniques. Vitamin and protein levels are generally checked before surgery, and supplemented if necessary, in an effort to maximize the efficiency of wound healing. Weight stability prior to contouring procedures is beneficial, and most patients undergo Plastic Surgery 12 to 18 months after their Bariatric procedure. A minimum of 3 months at a stable weight is a typical benchmark, although 6 months of stability is preferred. Of note, some patients do find that contouring procedures lead to further weight reduction through increased activity levels postoperatively. All nicotine-containing products must be avoided around the time of surgery, as they significantly increase the risk of wound healing complications.

The types of procedures performed on MWL patients are different than those on non-weight-loss patients. Given the profound laxity that most patients exhibit, extensive excisional procedures are usually necessary, resulting in larger scars, longer recovery times, and greater risks. In addition to the increased amount of skin, the quality of the skin that remains after contouring procedures tends to be of poor quality – stretch marks, loss of elasticity, and atrophy of the skin are all to be expected. Because of this, secondary touch-ups and revisions are not unusual in this population, and should not be seen as failures of the original surgery. Fortunately, MWL patients tend to be very tolerant of scars, very motivated, and extremely satisfied with the dramatic improvements that these procedures can produce.

Procedure types are generally broken up into the lower body (abdomen, buttocks, and thighs), and the upper body (breast, back, and arms). MWL patients present with a wide variety of deformities, priorities, and expectations, and individualization of treatment is crucial to success. Many patients require more surgery than can safely be performed in one session, and a staged approach is usually necessary. The lower body is generally addressed first, as the abdomen is almost universally a priority for MWL patients. Second stage procedures address the upper body, while a third stage may be useful for thigh tightening and/or touch-ups. Facial procedures may also be performed.

Laxity of the skin and soft tissues of the abdomen can be pronounced after MWL, and virtually all patients require some type of abdominal tightening. An abdominoplasty, or “tummy tuck” corrects this laxity with a multi-layered approach that tightens skin and muscle while removing excess fat in the lower abdomen.

This diagrams illustrates the key steps of an abdominoplasty. The initial incisions are made around the umbilicus and in the lower abdomen, and the skin is lifted off of the underlying muscles up to the rib cage. The rectus muscles are then tightened. As shown, this tightening is generally done in a vertical fashion, although additional vectors of tightening may be added if significant laxity exists. The patient is flexed on the table, and excess skin is advanced down towards the pubis and excised. Finally, the umbilicus is brought up through the abdominoplasty flap and sculpted into position.

Photos of a 35-year-old woman who had lost 90 lbs, before and after an abdominoplasty.

Photos of a 44-year-old woman who lost 120 lbs after an open gastric bypass before and after an abdominoplasty. (She previously underwent an augmentation/mastopexy.)

Photos of 38-year-old woman who lost 180 lbs after a laparoscopic gastric bypass, before and after lower body lift with augmentation/mastopexy.

Surgical correction of the upper body includes the female breast, male chest, arms, and back. Female breast surgery is commonly performed after MWL with the goals of improving the breast shape, volume, and skin envelope. Given the loss of soft tissue integrity of the breast that comes with MWL, most patients will need some type of skin tightening, be it with a mastopexy, augmentation/mastopexy, or reduction. In some patients, this can be achieved with a vertical scar pattern, while others with more profound ptosis may need a Wise-pattern or “anchor” scar.

The preoperative breast volume may be ideal, in which case a mastopexy alone can be performed. In this operation, the breast gland is reshaped, and excess skin is removed. Although no volume is removed, the breast tends to appear smaller due to its more compact shape. Many patients present with breasts that remain too large even after weight loss, and a breast reduction is performed. Finally, patients may desire a breast that is larger and perkier than their current breast. A breast augmentation in conjunction with a mastopexy is then performed.

Photo of a 45-year-old patient before and after an augmentation/vertical mastopexy.

Arm laxity is an issue for many patients after MWL, and is corrected with an arm lift, or brachioplasty. A brachioplasty tightens loose arm skin, improves the contour of the axilla, and can be combined with liposuction of the arm if residual fullness exists. The degree of laxity often seen after MWL often requires a full brachioplasty as opposed to a more limited technique, and results in scars which extend to the inner elbow. These scars often heal very well but take years to fully mature, and are visible in a short-sleeved shirt.

MWL patients often experience premature aging of the facial soft issues in addition to those changes seen in other parts of the body. Loss of volume and elasticity in the face can be corrected with procedures that resuspend soft tissues and tighten the skin while maintaining or augmenting facial volume. Newer facelift techniques may afford patients shorter scars, a quicker recovery, and fewer complications. A popular technique is the “Short-scar Lateral SMAS-ectomy” facelift, developed by Dr. Daniel Baker. Also known as a “Mini-facelift”, this procedure offers significant improvement in facial shape with a surgery less aggressive than that commonly performed. Many patients choose to add other procedures such as eyelid surgery (”blepharoplasty”) or brow lift at the same time for a more complete facial rejuvenation.

The risks associated with these procedures vary widely. For many body contouring procedures, the scars are long and heal to varying degrees of fineness. Wound healing complications are more likely in smokers and those with poor nutrition. Secondary relaxation of tissues is certainly possible, even after an aggressive procedure, and revisions are common in this patient population. As previously stated, a revision should be seen as a fine-tuning or enhancement of a previous operation. Deep venous thrombosis, or DVT, is one of the most dreaded complications seen with this type of surgery. During surgery, or in the postoperative period, these clots can form in the deep veins of the legs and have the potential to migrate to the lungs as a pulmonary embolism, a potentially fatal complication. A key intraoperative step to prevent DVT’s is the use of pneumatic compression devices that are applied to the legs. Early ambulation after surgery is also important. The risk of DVT is increased in the obese, older patients, smokers, and patients taking birth control pills. If multiple risk factors are present, short-term treatment with an injectable anticoagulant such as Fragmin or Lovenox may be used.

The postoperative recovery after surgery can range from less than a week for some breast procedures to three weeks for a lower body lift. Most breast procedures require a week off from work, and result in postoperative discomfort that requires prescription pain medication for three or four days. Lighter exercise may be resumed in two weeks, while more vigorous activities such as yoga or Pilates should be avoided for three or four weeks. In contrast, abdominoplasties and body lifts often require two tow three weeks off of work, with lighter exercise resuming at three weeks. Strenuous activities should be avoided for six weeks to allow adequate healing of the lifted tissues. Facial procedures tend to result in relatively mild discomfort, but patient appearance may dictate a two-week avoidance of social activities.

In summary, the field of Plastic Surgery after MWL is rapidly advancing. For these patients, safety is first and foremost, and a systematic approach to presurgical, intraoperative, and postoperative care can reduce complications. Communication, patient education, and informed consent are crucial, and patients must have realistic expectations. Finally, individualization and timing of procedures should be based on patient anatomy and patient priorities. Despite the challenges MWL patients present, the rewards for both surgeon and patient can be great.

About the Author

Born and raised in New York, Dr. Andrew Wolfe operates his practice, “The Center for Cosmetic Surgery,” in Denver, Colorado. Dr. Wolfe is passionate about his work, and thoroughly enjoys both the personal and technical aspects of the specialty. He believes that the physician-patient relationship is truly a partnership. “I have to understand a patient’s history, desires, and physical status before I can recommend a course of action. At the same time,” Dr. Wolfe says, “the patient has to learn about the various options available for any given procedure before they can make an informed decision.” Patient education is a high priority at the Center for Cosmetic Surgery, and Dr. Wolfe spends a great deal of time with his patients, both before and after surgery, making sure that they understand their surgical options. At the Center for Cosmetic Surgery, Dr. Wolfe has created a blend of state-of-the-art techniques and more traditional approaches. “I’m not shy about adopting new techniques or procedures”, he says, “but I need to be sure that they are safe and effective first.” Above all, Dr. Wolfe feels privileged to be able to be able to perform the work he does. “Virtually everything I do is elective, and I consider it an honor to be chosen by a patient to perform their surgery.” Learn more about Dr. Wolfe.

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By Leonard M. Hochstein, MD

The perfect breast augmentation begins by choosing the right plastic surgeon. I think by now everyone understands board certification and some of the fake boards that are out so I will not dwell on these issues, but talk about more specifics as I have seen in my experience.

I believe that the perfect result is a surgeon’s combination of talent and experience. There is no question of some surgeons’ ability to make asymmetric breasts look beautiful while others falter. Much of this is as a result of experience while seeing every type of breast that there is. There is no question that my skill improved with my experience. This translates into few insights for the patient. It is hard to find a talented young surgeon, so go for the proven one with the necessary experience to get the job done. Unless you are in the major market, it is unlikely you will find a surgeon who does 500 breast augmentation surgeries annually like I do. So what number is considered good? I would say at least 150 breast augmentation procedures annually is sufficient. This means that the surgeon is doing about 3 breast augmentation procedures on a weekly basis. Make sure to see plenty of pictures of their results. There should be good consistency there. Be wary of surgeons who will only have a few pictures to show you. You should be able to look at books that include hundreds of patients.

The next factor to consider is the site of surgery and the anesthesia provider. There are four options for setting. I would suggest either a private, accredited surgical center which is my preference or an outpatient ambulatory surgery facility. The other two options are a non-accredited private facility or hospital. I would avoid the former because there is no quality control standards and the latter because hospitals are dirty environments with infection risk being unacceptable for my standards.

If there is a problem in the surgery, it is generally anesthesia-related, but it seems few patients asked me about who will be putting them to sleep. There are two options here. The first is a board-certified anesthesiologist and the next option is a CRNA or nurse anesthetist. I use Dr. Livschultz, a medical doctor who is a board-certified anesthesiologist. He has been working in my office for the last 2-1/2 years full time. This familiarity allows us to offer the safest experience for my patients. Most doctors, because of their inconsistency, book their anesthesia provider based on availability which puts you at the mercy of the anesthesiologist who is available on that day. This relationship fosters unfamiliarity and inconsistency. I have a very close relationship with my anesthesiologist where we are able to discuss any pitfalls and make adjustments. For example, we recently came up with a protocol of providing totally intravenous anesthesia or TIVA for first time patients thereby avoiding any risk of malignant hyperthermia. Using a nurse (CRNA) is also frequently used, but not in my practice. In this situation, the physician is overseeing the anesthesia and since I am not trained in this field, I do not believe I am qualified to do so. Be aware of this because it is a cost cutting maneuver; go for the physician anesthesiologist instead.

Now that you have picked your physician, it is time to decide on the type of implant, the incision, and the size. I am not going to talk too much about placement as implant should always be placed submuscularly and if you have chosen a competent surgeon I will assume that is their preferred placement. I am not aware of any experienced breast surgeon who would put the implants above the muscle or in a subglandular location. There are two types of implants available, saline or silicone. The shells in both are made of silicone. They only differ in that saline implants have a balance that they can be inflated once they are positioned. The shells are smooth or textured. Texturing is a process where smooth implants are given a rougher feel. The idea here is to decrease the risk of capsular contraction. The downside is that by making the shell thicker, it also raises the risk of rippling or wrinkling. I do not use textured implants unless there is a significant risk or history of contracture. In this situation, they are indispensable. The main difference is what the implants are filled with. One is filled with saline solution and the other with silicone gel. There are subcategories of each. They come in round or teardrop and the silicone also varies in level of cohesiveness. I prefer the round because they allow for better cleavage and more fullness superiority, but mainly because the teardrop implants tend to shift, which can create an unnatural appearance. I also prefer silicone as they feel much more like breast tissue and have much less wrinkling or rippling than do the saline counterparts. All silicone implants today are cohesive, meaning the silicone will maintain its shape even if there is a defect in the integrity of the shell. But there are now 2 levels of cohesiveness, namely Level 1 and Level 2. The Level 1 implants which are currently used in the United States are semi-liquid whereas level 2 (gummy bear) are semi-solid. The level 2 implants, which come in teardrop shape only are currently unavailable in the United States as the study is now over (there is a prominent plastic surgeon in the Los Angeles area who advertises that he is still using these implants which is not true, so do not be fooled). I have had the opportunity to work with some of these level 2 implants and have found them to be unsatisfactory for two reasons. The first is that they are too firm and also require a very large incision or scar to place as they are not malleable and cannot be bent to place requiring the opening to be almost as wide as the implant itself. This also limits access to the inframammary fold. I believe these implants may have a role for reconstruction in the future, but for aesthetic purposes, I prefer the level 1’s. I still see hesitance towards silicone implants due to safety issues or leak detention. But these concerns are unwarranted. Silicone implants were taken off from the market in 1991, not because they were found to be unsafe, but rather because the FDA deemed them to be inadequately studied. Since that time, there have been multiple studies which have unequivocally found them to be safe and without any links to autoimmune diseases. Simply, the women who developed these illnesses would have developed them whether they had implants or not. The other issue I regularly hear about is the risk of deflation and its treatment. Over the course of 7 years, the deflation rate for saline implants is 15% whereas for silicone it is only 2%; thus making silicone more durable. If there should be a leak, it is much easier to diagnose the saline implants as they simply go flat.

Silicone cannot be diagnosed by physical exam, but rather requires an MRI. The treatment for each is much different since the shape or volume of a silicone implant does not change, it is very easy to replace and could be done simply under local anesthesia. Saline implants are much more difficult to replace as the capsule begins to contract immediately after deflation. This is much harder and requires a general anesthetic with reconstruction of the pocket. I use Mentor implants, as I believe they are the best implant available in the market and currently they come with a lifetime warranty.

There are several access points for implant placement including transaxillary, periareolar, inframammary fold, and transumbilical. All these access points are available for saline implants but limited to periareolar or inframammary fold for silicone. I prefer the periareolar approach because the scars tend to heal better and are less visible when wearing a bathing suit. It also allows direct access to the inferior insertion of the pectoralis major muscle, the proper release of which is crucial to perfect placement.

The last discussion is the size of the implant and the profile, low, medium, or high. When I determine the implant size I begin by talking about the patient’s desired cup. I need to stress that this is only a starting point of the discussion as I do not create a cup size, but rather a look. We decide this by looking at some of my postoperative pictures, as well as having the patient bring in pictures of looks they like and then trying on an implant. Trying on an implant is more useful in smaller breasted women and less so in women who have more breast tissue or are in need of a lift as well. When the patient likes the look of an implant on her chest, I add 50 cc to it and that is the volume I use in the submuscular location. There is no perfect way of picking the size, but this has worked well for me. As a bit of final advice, if you are between 2 sizes, go for the larger one and do not listen to your friend’s advice. They are not you, do not know what you want, nor do they necessarily have your best interest at heart. If there is ever a regret it is that patients did not go bigger. I rarely hear that they are too big.

I choose the profile depending on the patient’s desired size and chest width. The three profiles are moderate(low), moderate plus(medium), and high(high). I typically use the moderate plus because it gives the best combination of projection, which gives a more defined cleavage, and enough width of diameter to avoid cleavage separation. For my patients who have narrow chests or wish to have a large cup size I choose the high profile implant. I rarely use the low profile implant as the only indication is for models who wish to have a very small augmentation and need the greatest diameter width as possible to avoid cleavage separation.

The recovery period is less than a week. Most of my patients are able to drive on the fifth day and return to work after one week as long as no heavy lifting is required. I allow my patients to reach above their head as long as they are not stretching to reach a distant object. I allow aerobic workouts as long as they limit to lower body after 4 weeks and full gym workouts after 6 weeks. I do have patients perform massaging exercises to stretch the muscle in the medial location by squeezing the implants together. This also helps for settling which is usually a 4-month process and rarely can take longer. I also recommend that a moisturizer be used on the incision after 3 weeks of healing and on the breast itself immediately after surgery. Scars do not create moisture on their own and they need help.

Breast implant maintenance is a topic which seems to be misunderstood. The biggest misconception is that implants should be replaced every ten years. This is simply not true and came about based on the data that the old (prior to 1991) silicone implants had a significant leak rate after 10 years. By mistake this has been extrapolated to the current saline and silicone implants used today. The current silicone implants made by Mentor are warrantied for life and require replacement only if a defect should develop. This is the same case for saline implants which are currently warrantied for 10 years (extended warranty is available for purchase from Mentor). Simply put, if there is no problem precautionary replacement is not required.

The horizon shows a few things of promise. Stem cells may one day be used for breast surgery. Their potential seems limitless. I am just beginning to work with them and will see what applications develop.

There is no question that I have some very strong opinions on breast augmentation. These opinions have been formed over many years and many augmentations. I sincerely hope my ideas will be of help to anyone interested in this wonderful operation.

Ask Dr. Leonard M. Hochstein Questions & Get Answers

Click here to ask Dr. Hochstein Questions Live & Get Answers

Dr. Hochstein has his own message board on Make Me Heal where he answers facial plastic surgery questions live from patients.

About Dr. Hochstein:

Dr. Hochstein, or Dr. H as he is known as, began his medical career when he applied to medical school as a merit scholar high school senior. He was able to surpass the customary four years of college and go directly from high school into medical school. The first in a long list of exceptional achievements to be obtained during his academic and surgical training. He attended the accelerated program at the Louisiana State University Medical Center where he graduated as Valedictorian of his class. It was during his time in medical school that Dr. H worked closely with the Department of Surgery and had his first scientific paper published. He received his M.D. in 1990.http://messageboards.makemeheal.com/viewtopic.php?t=89524

Learn More about Dr. Leonard Hochstein

Dr. Hochstein’s Website: http://www.lhochsteinmd.com

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By Dr. Michael C. Pickart, M.D., F.A.C.S.

Breast Implants: Should I Wait Until I’ve Completed All My Pregnancies?

It’s up to you.

Many young women are interested both in breast augmentation and in having children. They frequently wonder…

• Are breast implants dangerous for the baby?
• Do breast implants create issues when breast feeding?
• Will the implants still look good after pregnancies?

My short answers:

• Among mothers with implants, breast feeding is safe for the babies.
• On the other hand, breast implants may decrease the chance (by about 5-10%) that a mother can successfully breast feed.
• Breast implants may improve chest appearance both before and after pregnancies and breast feeding.
• Ultimately, a patient must decide for herself after she has had a chance to consider the facts….

Here are my long answers, with all the facts:

A woman who is interested in breast implants and in motherhood should weigh the plusses and minuses of both options.

One school of thought is to do the surgery when you want it. If you want a breast augmentation now, then do it now! You might not have your children for another 5-10 years. Why should you go without the implants for that relatively long period of time?

Moreover, breast implants are safe for children. They do not contaminate the breast milk.

And implants may actually improve breast appearance after pregnancies and lactation. Often, women lose fullness in the upper halves of their breasts after children and breast feeding. In recent mothers, I frequently place implants to increase upper pole volume, and sometimes I add breast lifts to position the nipple properly. If a patient has already had a breast augmentation, then I usually need to perform the lifts (called mastopexies) only.

Implants are not, however, without some risks. Large implants can stretch nerves, especially the nerves that provide sensation to the nipples and areolas. If those nerves are excessively stretched, then the nipples and areolas can become numb. If the nipples and areolas are numb, the breasts might not produce enough milk. Nipple-areolar numbness is uncommon but not rare; about 5-10% of patients do notice some degree of numbness.

Another way that breast implants affect lactation is incision location. One of my favorite incisions for breast augmentations is from 3 o’clock to 9 o’clock around the lower half of the areola. However, I never use this incision if a woman intends to breast feed. I want to avoid severing any milk ducts that might be important for lactation. Instead, I recommend an inframammary incision (in the fold under the breast).

(By the way, I no longer do armpit or bellybutton incisions. These were both novelty incisions, through which I have never seen perfect results—either in my own patients or in anybody else’s. I am very fussy, and I am only satisfied when the breasts are perfect. With armpit and bellybutton incisions, the results are just too unpredictable.)

So, the bottom line: a patient must decide for herself….

• If you’d feel better about your chest appearance with implants now, then let’s proceed.
• You shouldn’t worry that you are putting your baby at risk.
• I’d recommend an implant on the smaller side (that will be less likely to cause nipple numbness).
• And we should agree that an incision in the fold underneath the breast will be safest.
• However, if you really want to maximize the chance that you will be able to successfully breast feed, then I must admit that we should wait until after your pregnancies; you’ll probably have a 5-10% greater chance of being able to breast feed your baby.

Visit Dr. Michael C. Pickart’s Plastic Surgery Message Board on Make Me Heal, where you can ask him questions about liposuction and get answers.

An accomplished plastic surgeon with expertise in both cosmetic surgery and reconstructive surgery, Dr. Michael C. Pickart (http://www.pickartplasticsurgery.com)specializes in all breast surgery procedures (breast implants, reduction, lift), body contouring procedures such as liposuction and tummy tuck, and has extensive experience in facial plastic surgery (i.e. facelift, eyelid surgery, rhinoplasty). Certified by the American Board of Plastic Surgery, Dr. Pickart previously served as a Clinical Assistant Professor of Plastic Surgery at Loma Linda University, where he has taught students and residents the principles of plastic surgery. Graduating from Stanford University with honors, Dr. Pickart trained with renowned plastic surgeons Drs. John Grossman and Philippe Capraro, in Denver, Colorado. Dr. Pickart graduated in the top of his class from the School of Medicine at the University of California, San Francisco, one of the most selective medical schools in the country.

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The virtues of breast implants have been widely discussed in both words and pictures, with breast augmentation patients often citing not only an improved physical appearance, but also a greater self-confidence and body image, better love prospects and more marketability in the job market. But virtually no attention has been given to a common problem that plagues a wide number of plastic surgery patients who undergo breast augmentations. In a poll conducted by Make Me Heal (www.makemeheal.com), 45% of breast augmentation patients admitted that they wished they got bigger breasts than the size they ended up with following surgery, while 14% wanted smaller implants than the actual size they got. Of the respondents, 41% said the breast size they received was the one they wanted.

Speaking about the problem of getting the right size breast implants, one patient nicknamed “domesticgoddess“ wrote on the Make Me Heal message boards, “I have moderate profiles and I wish I would have pushed for the high profiles in a larger cc volume. I thought I wanted that natural look but now I just want that perky upper pole fullness without having to wear a bra.“

A second patient with a username “connies“ said, “I went from a b to a double dd and now I am used to them. After 9 weeks I think I could have gone bigger!“

The problem of patients getting their breasts augmented to a size that they wished was bigger or smaller stems from the very fact that one cannot actually measure accurately the breast size they want to be. Moreover, breast implants are not like clothing, as one cannot actually “try on” an implant before deciding which size to get. While doctors will do everything to help patients better communicate the breast size they want by having patients bring in photos of women with breasts they desire, using digital imaging software to show patients the size they can be, or by having the patient put bags of rice in their bras at home, these methods do not lead to an accurate determination of what breast size the patient actually desires. As a result of these rough methods, women often find themselves getting breast implants that are smaller than the size they wanted. The only way to rectify this problem is to go under the knife a second time, remove the existing implants, and have bigger implants re-inserted. But the idea of having to get plastic surgery again is not appealing to most patients, who settle for their new breast size, despite it not being the ideal one they wanted.

Breast Implant Sizer Helps Women Get The Breast Size & Look They Desire

But there is hope apparently for women about to undergo a breast augmentation. In light of so many women with breast implants ending up having breasts that are not the size they wanted, Make Me Heal began offering this month the Breast Implants Sizer, a simple, yet powerful tool that enables women seeking to get breast implants to better visualize the breast size that they desire and to determine more accurately how many cubic centimeters (also known as “cc’s”, which are the measurement of implants) their implants should be. As over 50% of women today who have breast augmentations either have difficulty in figuring out exactly the size they should be or after having surgery wish they chose a different size than they got, Make Me Heal’s Breast Implant Sizer helps ensure that a woman will be able to get the right size that she desires with no regrets.

The Breast Implant Sizer comes with two implants that are filled by a syringe with water. The syringe has millimeter measurements, and 1 millimeter is equal to 1 cubic centimeter (this is the measurement used for determining breast implant size). As one fills the implant with the syringe multiple times, the patient simply needs to write down on paper how many cc’s one is adding each time. When a desired size is achieved, the implant is inserted inside the bra and the patient is able to visualize how the implant fits. The patient can walk around with the implant all day and get a more accurate visualization of how they would look and feel at that size. As the implant can go up to 600 cc’s, one can adjust the implant to visualize their new look in different sizes.

See the Breast Implants Sizer.

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Women looking for a minimally invasive, virtually scarless breast augmentation may find hope in a new and innovative procedure called Celution that has just gained approval in the European Union. The new plastic surgery technique achieves breast enlargement by injecting a supercharged fat mixture into the patient’s breast. Fat is taken from a woman’s stomach area, buttocks, or thighs using a minor liposuction-like procedure under local anesthetic.

Celution is not yet available in the United States, but it has been approved by the European Union for 2008. The technique will first focus on breast reconstruction for women who have had breast cancer and have undergone a partial mastectomy (breast removal) or lumpectomy. However, breast augmentation through the Celution techinque may be a possibility in the future.

Fat taken from the patient is placed in the Celution system, a device which separates out and concentrates stem cells and regenerative cells. About an hour later, a prescribed dose of regenerative cells are injected into the patient’s breast tissue. “It works by ’supercharging’ the fat cells, which makes them stay where they are injected”, explained Dr. Eric Daniels, senior director of business development for Cytori Therapeutics in San Diego, which developed the Celution technique.

Following the Celution procedure, breasts may enlarge up to two cup sizes over about six months, while also appearing more natural than with traditional breast augmentation procedures. One day, women seeking to increase their bust may be able to go in and have this procedure done during their lunch break, and of course, the bonus is that fat would also be taken from the stomach or thighs while one’s breasts are enlarged. Who could complain about that?

The use of fat injections in reconstructive procedures is not a new breakthrough, as it is commonly used in different cosmetic procedures for many years. Dr. Brian Kinney, a plastic surgeon from Beverly Hills, California and clinical assistant professor of plastic surgery at the University of Southern California, said that, “It’s become common practice for plastic surgeons to use [the patient’s own] fat in filling in defects such as around the eyes, in the nasolabial (nose to mouth) folds, and in the body, especially after liposuction that leads to irregular contours.”

However, breast reconstructions using fat injections have failed in the past because the patient’s body often reabsorbed the fat. With Celution, however, mixing fat-derived stem cells from the Celution system with the patient’s fat has apparently minimized this problem of fat reabsorbing in the body. “The supercharged fat graft survives really well and fills in the volume defect left by partial mastectomy,“ says Kai Pinkernel, Cytori’s Head of Research & Development.

Kinney, who is also past president of the Plastic Surgery Educational Foundation of the American Society of Plastic Surgeons stated that a procedure like Celution could be of benefit to women wanting a regular breast augmentation.

“It would not be surprising in the future — with refinement in technique — that this could be of benefit to women who need augmentation or reconstruction. But it may be many years, and it’s far too early to know before large, well-controlled case-control clinical trials are done and peer-reviewed by other experts,” says Kinney.

While Celution and stem-cell fat techniques of the like hold considerable promise for women seeking a minimally invasive breast augmentation that would not require the insertion of implants, the prospect of a one-hour procedure to achieve an aesthetically pleasing result that rivals a traditional breast enlargement surgery seems unlikely. Doctors believe such a procedure will likely need to take longer than one-hour to achieve desirable breast enhancement results. “Just a few years ago, lots of attention focused on the weekend face lift”, Kinney said. “A lunchtime breast augmentation is equally implausible.” Similary, Mac Hedrick, president of Cytori Therapeutics, said “No one is going to leave for lunch, have the procedure and go back to work like it’s no problem.” Hedrick expects the procedure to take two hours under general anesthesia. Additionally, the Celution technique has the limitation of not being able to increase one’s bust by more than two cup sizes.

Yet even if the procedure would take longer than lunch to perform, many prospective candidates seeking a moderate breast enlargement would likely flock to have a virtually scarless and silicone-free breast augmentation.

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Before	After One Month

Stem cells are becoming more widely used in plastic surgery for breast augmentations, as fillers for wrinkles, and to enlarge any body part where more fullness is sought. With the European Union and Britain having just approved the use of stem cells for cosmetic surgery this month, this move is likely to make the use of stem cells more and more popular worldwide and ultimately in the United States.

Stem Cells In Breast Augmentation

Stem cells have been used in breast augmentations since 2003, as Japanese scientists have pioneered a treatment that offers a natural breast augmentation that uses stem cells and fat derived from the patient’s own body to create soft and naturally augmented breasts. As no implants are needed and only self-extracted stem cells and fat are used, the patient’s enhanced breasts are essentially “real.” This procedure has been performed on 54 patients (for breast enhancement and facial rejuvenation procedures) thus far without any patients reporting any major problems. Already approved in the European Union and Britain, stem cell-assisted breast enhancement may soon become a reality in the United States.

One stem cell-assisted treatment can successfully increase breast volume by 120-160 ml (1 ml equals 1 cc), which is the rough equivalent of two bra-cup sizes (5 to 7 cm). For patients seeking to augment their breasts by 300 ml, the treatment needs to be performed twice. In both cases, no implant is used. For augmentations exceeding 300 ml, a combination of an implant and the stem cell technique is used to achieve the desired results.

Pioneered in Japan by plastic surgeon Dr. Kotaro Yoshimura (read Make Me Heal’s one-on-one interview with Dr. Yoshimura), the Cell-Assisted Lipotransfer (CAL) soft tissue augmentation technique claims to result in breasts that look and feel more natural and smoother without implants and the larger scars that accompany traditional breast augmentations using implants. The technique is performed by suctioning fat from the abdomen or thigh and then injecting the fat together with adipose-derived stem cells obtained from the patient back into the breast. The liposuctioned fat mixture, which now contains a high level of stem cells, is then transplanted layer by layer back into each breast to ensure an even distribution of the fatty mixture. What then occurs is that the stem cells enable the fat to grow its own blood supply, which leads to the fat becoming a part of the breast as opposed to a foreign mass. Some of the cells produce more fat and other cells change into a living blood supply for new breast tissue that grows into the treated breast. Unlike traditional breast augmentations, there are no incisions involved, as only small needle punctures are made on each breast that lead to tiny imperceptible marks (a detailed description of the procedure follows the interview at the bottom). Furthermore, enhancing one’s breast through the stem cell technique eliminates the risks associated with implants including deflation and leakage, capsular contracture (hardness and deformity), autoimmune disease (neurological problems), infection (skin redness and fever), and displacement (asymmetry and dislocation). Because the patient uses one’s own stem cells and fat, the CAL technique carries no risk of the tissue being rejected by the body.

The main drawback to the procedure is that breast volume can only increase 120-160 ml per treatment, with a maximum breast enlargement of 300 ml through two treatments. Additionally, very thin patients may lack an adequate supply of adipose fat.

Stem Cells In Facial Rejuvenation Procedures

Before	After

Stem cells are also being used to reduce and fill in wrinkles, repair damaged tissues, and help the skin regenerate itself and become more healthy and radiant. When stem cells are placed next to mature adult tissue, they can naturally repair the tissue and help it regenerate itself into new, youthful tissue. Dr. Richard Ellenbogen, who is among America’s leading face lift surgeons, has been using a patient’s own fat to restore volume and youthfulness to the face for over 25 years. Dr. Ellenbogen recently made the discovery that not only does fat help restore volume to aging and weak facial structures, but the fat also rejuvenates the skin because it contains stem cells.

“I first started using fat during my Volumetric Facelift to restore volume in patients’ faces over 25 years ago,” says Dr. Ellenbogen. “After years of working with fat, science has now revealed that the stem cells in fat reduce wrinkles and give patients radiant, glowing skin as well.”

Patients of Dr. Ellenbogen who had the Volumetric Facelift often said that their skin looked healthier and that wrinkles and pigmentation spots they had disappeared after the procedure. Since a face lift is not meant to erase wrinkles but rather treat the underlying structures, this added benefit was a welcomed surprise. Dr. Ellenbogen attributes the disappearance of wrinkles and the improvement in the skin appearance to the presence of the very rich stem cells found in the fat that has been injected into the face during the Volumetric Facelift.

Dr. Karl-Georg Heinrich in Germany has also been using stem cells for plastic surgery procedures. Dr. Heinrich says that “with stem cells we not only get 100% natural results - these will also last a lifetime.” Being that the stem cells are obtained from fat that is liposuctioned from the patient’s body, the patient is able to both lose fat and improve their skin at the same time.

With more surgeons finding that stem cells can be used to augment breasts and other body areas as well as act as fillers for wrinkles, the future holds great promise to patients who are seeking more natural ways to enhance themselves.

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