Who Should You have Cosmetic Surgery for?

As my homepage came up on the computer today I noted an article on Slate.com concerning a college student who was worried about her summer at home because her mother has been nagging her to look better and pushing her to have cosmetic surgery to improve her life. Surely, this is the stuff of daytime television. The scenario was that of a “Dear Abby” sort of thing, with the young woman seeking advice about how to keep her summer at home pleasant and resist her mother’s need to “improve” her. Some how we see such posts and figure that this can’t be real, yet as a plastic surgeon I can assure you this is the world we live in today. When we see individuals in the consultation room to discuss a concern as to how cosmetic surgery will improve one’s life, it can be helpful to understand just whose life is in need of improvement.


Pressure to look good, or the need to defy aging, can be intertwined into our family relationships, those with a spouse, or even with those who we interact with at work, in very complicated ways. It can make perfect sense for a mother to want the best for her daughter and use persuasion to encourage her to fix a nose which is less than beautiful. Or perhaps, she might bring her daughter in to consider a breast reduction because she knows how difficult her daughter will find the unwanted looks she may get from others, or the clothing issues she will face in a fashionable workplace. The arguments can make perfect sense, a mother wants the very best for her daughter, knows what is right for her, and her daughter must consider what her mother is doing for her and the family, not to be ungrateful. The drama can be considerable in the consultation room, and as one familiar with drama, romance and life’s complexities, I recall the torment of Anne Elliot in Jane Austen’s novel Persuasion as she struggles to fit in with her blended family and turns away her first love, Frederick Wentworth.


Anne could tell us that the decisions are not so easy when so many others are involved. Just who should you have cosmetic surgery for? Should a young woman have her nose fixed to fit into the family photos? How about a woman I had seen, with her husband looking into breast implants to enlarge her breast as he considers what size she should be? That can be a scary one. Though the rhinoplasty might be the ‘right’ thing to do, or even the breast implants for that matter, I have come to the conclusion that cosmetic surgery is something we should do for ourselves. Like so many decisions in life, others you trust, or those who care, may have an opinion; yet cosmetic surgery is for you and about you alone. Seems rather selfish, though we live best following our own insights as to how we should look and feel.


The breast implants by the way, they decided on a D cup (unknowing to him it was her idea all along), and did, as far as we know today, live happily ever after. The young woman we knew did not have the rhinoplasty (as her mother did at her age) and did not look like the family in the group photo. She became engaged to a young man after graduation, just the way she was and the way she felt and looked her ‘best’, for better or worse, as all marriages are. As I always have known, Jane Austen had it right. And Anne, too, finally, after much persuasion did what was right for her and her alone. She and Frederic lived happily ever after. Thank you, Jane.

New Alternatives are Emerging for Breast Reconstruction

Currently about 250,000 women will face breast cancer each year. As our screening and detection have improved, our patients have become younger and fortunately, the breast cancers have become smaller. The early diagnosis with smaller cancers, many of which are noninvasive, has pushed the interest in reconstruction. The American Society of Plastic Surgeons (ASPS) data has shown that 96,000 seek breast reconstruction annually. Still, many who face the challenges of breast cancer diagnosis and treatment are not fully aware of all their options. Some states have even moved to ensuring women have the option to consult with a plastic surgeon before mastectomy.
In our own practice, we find patients are very active in pushing the discussion and taking an active role in understanding what their breast cancer journey will be like. Consider with early diagnosis at age forty, women have to look ahead to forty years of life without a breast, and today’s generation tells us they want to participate and make treatment decisions. They expect to have a full life and look as good as possible, and some wish to look even better than they did before mastectomy.
New alternatives our practice is investigating involve cohesive gel, or form stable implants which come in numerous shapes and sizes to match the natural breast shape. We began with the Allergan 153 implant trial which was a first evolution of a shaped implant. We found that mastectomy removed some the personality of the breast which was not as easily restored with current round breast implants, and the shaped implants gave us some very good results. This progressed into the current Allergan 410 or ‘gummy bear’ implant study which is still ongoing.
Tissue expanders may also take a new turn. A tissue expander is often needed to hold the space, and later expand the breast skin in preparation for an implant. The expander is filled over several office visits which can be time consuming for those eager to get back into a regular schedule. A newer expander being developed can be filled by the patient according to their own schedule and comfort level, and just might improve the whole process.
Finally, nipple reconstruction has always been the finishing touch to the perfect reconstruction, and something so simple can be a powerful and life changing event as the new breast comes to life. The nipple is so important to the essence of the normal breast that newer mastectomy techniques may be able to preserve the nipple for a fortunate group of patients. Sparing the nipple can allow an immediate implant placement and a one step process to restore a normal breast form and appearance.
Just as our ability to diagnose and cure breast cancer has greatly improved, so has our appreciation and ability to reconstruct the breast. Younger patients continue to push us beyond the pink ribbon as they demand the very best path to a full, active and beautiful life.

Springtime Renewal for your Skin

Spring is as important time to gear up for coming sun season. Most of us are in a habit to use UV protection, and when combined with antioxidants we get the best defense for our skin. But what about the damage that is already done? Accumulated UV exposure results in uneven skin tones and blemishes, and at worse skin cancers. The spring season can also be a time to introduce a renovation and repair for your skin. You don’t have to live with your past sunburns and problematic skin. It may be time to introduce your skin to retinol. Retinols are vitamin A derivatives which are clinically proven to nourish the skin and produce increased cell turnover, increased collagen production, and over time will reduce the UV damage of summers past. With regular use, retinols are one of the most powerful tools available to truly repair and correct blotchiness, age spots, fine lines, and wrinkles from both photo-aging and intrinsic aging of the skin. Few products can claim to turn back the clock on environmental skin aging. In addition to sun protection this spring, we hope to see you to discuss the addition of a Retinol to you skin care plan. We have found the SkinCeuticals Retinol 0.5 ideal for daily nighttime use. And for those who are preparing for a peel or laser procedure, the SkinCeuticals Retinol 1.0 is a great way to get you skin ready for a maximal result from your procedure. With continued regular use, retinols can help you to a lifetime of healthy young looking skin.

The U.S. is not the most “Nip and Tucked” Nation after all!

We often get a bad reputation for being a culture obsessed with youth and beauty, driven to stay competitive while at work and out and about. The U.S. is certainly the largest market for both surgical and non surgical cosmetic procedures. However, according to a recent survey by the International Society of Aesthetic Plastic Surgeons (ISAPS), the United States comes in a distant sixth in our quest to look the very best. An unscientific survey was circulated to ISAPS members, about 20,000 in all, and 698 responses were returned. The winner is: South Korea! Yes, the U.S. has been thoroughly out done by South Korea, where it is estimated that one out of every five women has had cosmetic surgery. The most popular procedures listed were liposuction, nasal reshaping, and double eyelid surgery to reduce and Asian influence and produce a more western lid shape. The second place finish goes to: Greece! Despite all the economic turmoil and austerity measures, Greece has drawn a line on looking good at all cost and it seems that breast augmentation has captured the hearts and minds of the Greek women who refuse to sacrifice cosmetic surgery as the economy struggles for a rebound. The third place country, Italy, is also a bit of a surprise, but the interest here appeared to be Botox treatments for a more subtle and conservative approach to cosmetic enhancements. Brazil is a country known for the importance of good looks, and there was a bit of contention as to why Brazil did not come in higher on the survey list. Remember, the poll was not scientific. Brazil takes its cosmetic surgery so seriously that the government allows tax deductions for those who invest in their looks. Beauty is a benefit to Brazilian culture and society, and their overall economy as well. And speaking of the economy of cosmetic surgery, Columbia, number five, has become a magnet for ‘medical tourism’, within reach of many seeking cosmetic procedures at an affordable cost, and a pleasant locale to recover. Is the U.S.A. really number six on the list of nations in the pursuit of beauty? We are, after all, the largest market and probably outspend the top five combined, but we are not as unique in our culture and interests as we might think. And just consider China, an emerging economy that did not even appear in the recent survey. Well, they just may be next poised to take number one spot away from everyone else.

Facts Grow about Fat Grafting and Lipo-Transfer

True, fat grafting into the breast is controversial. However, as we have gained experience, we find that some of the early concerns of calcifications and cysts can be minimized and the result from grafting or lipotransfer can be durable. The most important application at the present is filling contour deformities and improving the result of breast reconstruction. By layering in fat grafts, the breast can be filled and shaped with softer and more natural results. As yet, there is not a clear consensus on the best technique, the exact role of stem cells, or the correct amount to transfer at any one session. We find that layering the fat in smaller volumes is giving good results and is an idea gaining the most traction in the community. There is of course, the added benefit of body contouring elsewhere to obtain the fat needed. Breast enhancement with fat grafting still under investigation may benefit only those who wish a very modest increase in the breast size, or help those who have a modest breast asymmetry and wish to avoid a breast implant. We are not yet ready to consider fat grafting as a replacement for breast augmentation as our patients will often ask for an increase of one to two cup sizes, but liposuction candidates can put the fat to good use to provide fill in the upper breast or to improve a breast deflated after weight loss. Many studies will follow, however lipotransfer of fat grafting with care can be a durable and versatile tool for breast contouring and shaping. The bad fat can be turned into good fat in the right location!

The New “Gummy Bear” Breast Implants

The new line of breast implants which has come available will include a very cohesive gel implant, which maintains a stable shape, nicknamed the “gummy bear” breast implant. We have been interested in the “gummy bear” and have studied the Allergan 410 “gummy bear” for breast reconstruction for several years now, in anticipation of market approval. The form stable implant has been very important in reconstruction because the implant shape will put back some the personality of the breast that might have been lost after breast cancer removal. So just what is a “gummy bear”? We get images of the little, colored bear candy; soft, yet keeping bear shape after a good squeeze. Unlike a silicone gel implant that is more ‘runny’, the “gummy bear” will return to the breast shape after a good squeeze or hug. Because of this unique gel that sticks tightly to itself, the implant will also keep its shape even after a rupture and keep the gel in place with fewer leaks. With the new implants from Sientra, the “gummy bear” will become more widely available, and perhaps, Allergan, will too get market approval. This is a great relief for those who need a stable implant for breast reconstruction and may not qualify for the current studies. Also, some might consider the “gummy bear” for breast augmentation if the breast is denser, or perhaps for capsules that have caused implants to feel round and firm. Choice is always a win and we are glad the FDA has given us a go on the “gummy bears”.

The Dramatic Increase in Chin Implant Surgeries

By now, you have probably seen the “quoted” dramatic rise in the popularity of chin augmentation which has blanketed the internet -- noted everywhere from Fox News to WebMD. Although chin augmentation procedures have seen a 70% increase, the actual number of chin implants performed is roughly about 20,000. Compared to breast augmentation where 300,000 are performed annually, chin augmentation is still very selective. So why the interest in chin implants? Some have blamed the internet and social media for producing trends and exchanges of ideas at lightening speed. As true with fashion, cosmetic surgery can “go viral” as well. Chin implant surgery, also called genioplasty, has always been a means to balance facial features and profile. We like chin implants in individuals where excessive facial convexity is an issue because of a weak or receding chin. Chin augmentation, coupled with nasal refinement or rhinoplasty, can have a profound affect on your facial form and can create a ‘new you’. Recent articles show genioplasty as a means to stay in the game at work; strong chins look confident, and are popular with baby boomers. This procedure does make powerful improvements and is a strong statement about who you are. As we age, strong changes in facial form can also be harder to work into your ‘Facebook’ page without significant edits. Computer imaging should be a must to ‘try out’ the new look and avoid mistakes or regrets. We don’t know exactly how it happens, but yes, chin implants are on the rise, and to those who jump in on the trend . . . “see the new you on Facebook.”

Fifty Years with Silicone Gel Breast Implants. What’s on the Horizon in 2016? [Part 5 of 5]

As I began this series, we have come to a new chapter in the use of the silicone gel breast implant. The chapter actually began in 2006 when the FDA released silicone gel back into the U.S. market for breast augmentation. The silicone “crisis” never reached other countries in the world, only the U.S. with its very unique legal system. When implants were released, there were new product warnings, labeling, follow-up recommendations, age restrictions, and the requirement for an additional 10 years of post market studies to add to the already burgeoning implant research data. But what did we truly learn from the past experience? Breast augmentation remains a very popular procedure with very high satisfaction rates. Those who choose breast augmentation will most likely wear implants their entire life. Satisfaction is so high that most would prefer never to even think about their breast implants, and even forget to mention them when they have a mammogram. Herein lays the problem; all breast implants will wear out and need replacement. We repeat the need for implant maintenance, the value of MRI tests, importance of the ‘ten year’ check, though is everybody listening? Everyone wearing a silicone gel implant should keep the implant identification card, keep in touch with a surgeon for check ups, and know all good things come to an end, and for most, new implants and a new beginning. Implants will have a significant, though low leak rate at ten years of perhaps 8%, so I have marked my calendar for 2016; just ten years after silicone gel implants came back and hit the ground running. This could be critical year, if we have not learned from the past one. Remember, your breast implants will not make you sick, and do not cause cancer, and will not explode in your chest, but they will eventually leak, each and every one of them. When the news comes on in 2016 and newscasters break the story, remember you heard it here first. Let’s not panic, no shock and dismay, just out with the old ones and in with the new. Ten good years is, well, ten very good years. By then, the silicone gel implant will turn 54, and no doubt will still be the most studied medical device in the world.

The Silicone Gel Breast Implant, the Most Studied Device in the World [Part 4 of 5]

During the silicone breast implant moratorium, juries continued to grant large awards based on “junk science” and an unproven link to autoimmune illness, and the plaintiff’s bar and “experts” continued to reap huge fees for their efforts. Even before the historic bankruptcy of Dow Corning, the medical community responded with study after study failing to show any link to silicone implants and autoimmune or connective tissue disease. The Mayo Clinic published their findings in 1994, Harvard in 1995, the compiled work by the American College of Rheumatology in 1995, all finding no increased risk to women with silicone gel breast implants. Despite the data, over 400,000 women had filed for settlements. With continued U.S. and international studies, the turning point was reached in late 1996 when the federal court in Oregon ruled that plaintiff’s lawyers could no longer present evidence that was scientifically invalid. The National Cancer Institute later published their results refuting any link between breast implants and breast cancer. And in 1999, the National Academy of Sciences under the Institute of Medicine released its report refuting the claim that silicone breast implants are responsible for any major disease. As the decade of the 1990’s ended, the toll on American women was horrific with scares of cancer and illness, and the toll on the American worker and investor, with thousands of lost jobs, devastating. The “hoax” cost Dow Corning over 3 billion dollars, and destroyed many other companies altogether.

The Silicone Gel Implant Moratorium [Part 3 of 5]

In the spring of 1992, thirty years after the development of the silicone gel breast implant, Dr. David Kessler the head of the FDA placed a moratorium on the use of the silicone gel implant. This decision occurred despite the fact that FDA expert panels were unable to find any casual link to illness. Despite the ruling, silicone implants were released and allowed only for those women needing reconstruction after breast cancer. For all but two manufacturers, the decisions came too late. The firestorm of litigation and increasing awards based on vague “silicone induced” autoimmune disorders had caught hold. A jury in Texas where the silicone gel breast implant was born awarded over $55 million in damages in one single verdict. Just one year after the moratorium on the silicone gel breast implant was imposed; there were over 12,000 lawsuits against Dow Corning alone. By the spring of 1994, a group of companies tried to form a fund or global settlement to cover the multitude of suits regarding questions about the silicone gel breast implant in order to provide a settlement for individuals without question of any illness or cause. Despite all, the firestorm raged and by spring of 1995 Dow Corning filed for bankruptcy, with over 20,000 pending lawsuits. The human side to this tragedy is that many women believed that they had become ill from silicone gel implants. Vague flu like symptoms, aches, malaise, and fear complicated many women’s lives. There was no science which supported the relationship, but to very many the symptoms became real, and with the assistance of internists, rheumatologists, and others, plastic surgeons were left to guide and support their patients. Countless hours were spent discussing what was truly known, and many more removing implants for better or worse. The bonfire of litigation spread to the giant Dow Chemical, the parent company of Dow Corning, but as the legal battle raged, the medical community turned the silicone gel breast implant into the most studied medical device that the world has known.

Silicone Breast Implants on Trial and the Advent of ‘Junk Science’ [Part 2 of 5]

As we continue to look back at the amazing history of the silicone gel breast implant, it seemed that by the 1980’s we had the ideal solution at hand for augmentation and reconstruction of the breast. Though implant rupture might require a second surgery for removal, and implant hardening was a problem for some, there were few safely concerns. As the implants had now been on the market for nearly thirty years, it seemed an unnecessary effort to collect the scientific data that the FDA asked for in 1988. By 1990, there were several manufacturers with a wide choice of implant sizes and styles. However, companies and surgeons began to collect and submit the data and studies to the FDA by the hundreds. Over the past decades, the number of silent implant leaks and ruptures were growing and everything changed for plastic surgeons in December of 1990. Many of us have recollections of where we were the night when ‘Face to Face’ with Connie Chung aired, raising the fears about the dangers of silicone gel breast implants, exposing her own unhappy experience and those of others. The level of national awareness went to an all time high with images of leaking ‘goo’ in the media and rising health concerns. Still despite the data collected, we could find no health problems or cancer links to the silicone gel implants, though questions arose -- could the implants be proven to be safe? By the next year, the FDA assembled a panel of experts from all areas of medicine and material experts, including toxicology, immunology and oncology as well as plastic surgeons, to review all the data available. That same year what the FDA panel was not able to find, a link between silicone gel implants and any human illness, trial lawyers in Alabama did. According to plaintiffs’ experts, an individual with breast implants had developed an autoimmune condition caused by the implants. Actually this was the second such case where “experts” introduced a theory that silicone gel somehow affected the immune system causing illness. Thus “junk science” the ability to introduce scientific theory as fact in order to receive financial compensation was established in U.S. courtrooms. In short order, hundreds of lawsuits were filed against both surgeons and implant manufacturers, and by 1992 silicone gel breast implants were voluntarily withdrawn for use. Left with only saline breast implants, we held our breath and waited. And just when things looked very dark indeed, they became darker. More to come.