A Conversation About Breast Augmentation, Implants, and More With Dr. Paul Loewenstein

Doctor Paul Loewenstein practices in Brookfield, a suburb of Milwaukee, Wisconsin. With over 34 years of experience in the plastic surgery industry, Dr. Loewenstein’s current practice is devoted mostly to aesthetic surgery, including but not limited to face lifts, nose jobs, eye lifts, breast augmentation, breast lifts, breast reduction, tummy tucks and liposuction. Here, we discuss his practice, breast augmentation, and all the breast implant options available.

What are the advantages of your practice over the other options women might have in your area?

“I have a broad training in plastic surgery. I had six years of training in general surgery and plastic surgery combined. At our office, we don’t specialize in one part of the body, so if a woman comes in and she wants to have a breast augmentation and a nose job, we can do both. We have the flexibility of being able to approach different parts of the body all at once, which is something that my patients find convenient.”

Over your 34 years of practice, what trends or changes have you seen in breast enhancement and with silicone gel-filled implants in particular?

“Breast implants over the years have undergone a lot of changes. Silicone gel-filled implants have undergone three or maybe even four or five generations of shell and filler material. In the early 1990s the FDA put a moratorium on the use of silicone gel implants for breast enhancement. This was based on some claims patients made (mostly in the state of Texas) that the silicone gel implants were causing them to have diseases such a rheumatoid arthritis, scleroderma, lupus, or what we call connective tissue diseases.

“After thorough research was completed using large populations of women and extensive analysis, those studies showed there was no statistical association between silicone gel-filled implants and those diseases. So the silicone gel implant came back on the market and the companies have improved those implants over the years. The current generation has a little bit thicker shell, a more cohesive gel, but they still haven’t been able to get around the fact that the body builds a shell around the implant. If there’s a break in the silicone shell it’s going to be contained by the bodies’ scar tissue layer, so women don’t know if they have a leaking silicone implant. They have to get an MRI to detect a leak.”

How have saline implants changed over the years?

“Traditional saline implants haven’t really changed much at all in 30 plus years, with the exception of the IDEAL IMPLANT. The old saline implants were basically a bag of salt water, and they sloshed around like a bag of salt water. Now, once it was in the body, there wasn’t as much of a problem with that, but you could still tell the difference in most patients. The IDEAL IMPLANT is made up of baffled shells nested inside of each other so that the saline doesn’t slosh, it sort of flows more gradually, similar to what a silicone gel-filled implant does. So the one big change with saline has been the advance of the IDEAL IMPLANT.”

Do women come in to see you already aware of the different types of implants?

“Women are a little bit more health conscious overall than maybe they were 30 years ago when I started. They’re certainly more educated, they spend time on the internet doing their research. They know a lot more about what is available, what is out there, and the pros and cons of each type of implant. So they come in much better educated, but yet they know enough to know that sometimes the Internet isn’t 100% accurate, and almost all the time they’ll say, ‘well, what’s your opinion, Doctor?’  They may have a preconceived notion of what they want when they come in, but they’re willing to listen in spite of the fact that they’re much better educated than they were 20, 30 years ago. They’re still willing to get a professional opinion.”

Have women’s preferences shifted when it comes to breast size?

“When a patient comes in for a breast augmentation consultation, we take measurements of the patients’ chest width, the base diameter of the breast, the amount of skin elasticity, and we determine how much the skin will stretch. We look at the overall shape of the breast. Is it a little bit droopy? Is it perky to begin with, but small? All these different measurements and parameters are put into our computer and help us make the decision as to what size implant would work best. I think in the last 5 to 10 years I’ve seen a shift from women coming in saying, ‘I want 500 or 600cc implants’ to, ‘What do you think would work for me, Doctor?’

“There are anatomic limitations as to how big you can go, and I think again women appreciate a professional who has experience and knowledge and can give them advice. I think size preferences are also somewhat regional in terms of the United States. Maybe even worldwide, where it’s said in South America men prefer small breasts, and large rear ends. Different parts of the country where women are going to be wearing swimsuits more during the year may put an emphasis on a larger size. In some of the conservative North Eastern states, the overall implant size tends to be less from what I’ve heard, while the Midwest tends to be somewhat conservative. In California, Texas, or Florida the sizes may average a little bit higher.”

How can a woman know if she is or is not a good candidate for breast implants?

“The people who are not good candidates are generally the ones that have unrealistic expectations. If a patient comes in and they want to have a 600cc implant and they’re five feet, 100 pounds, that is probably not a good option for them. If they’re insistent on that, I will tell them, ‘I can’t give you that kind of a result just because of the limitations of your anatomy.’ Someone who has an active infection is also not a good candidate.”

Should a woman be finished with her childbearing and nursing years before she has a breast augmentation?

“Not necessarily. I see women who are single, young, and flat-chested, and want to enhance what they have. I think they’re perfectly good candidates for breast augmentation, and there’s no reason to tell them to wait 15 years before doing it. Then there are the women I see who are done having children. Some of them have nursed and what they used to have in the chest area has been deflated. So they’re another group of people who are very good candidates for breast augmentation.”

What would you tell a woman who is worried about scars from her breast enhancement surgery?

“Certainly it’s a cosmetic operation and both the patient and I myself are concerned about the scars. There are three different areas of the body where breast implants are usually inserted. There’s the inframammary crease under the breast, there is the areola or nipple approach, and then there’s the armpit, the axillary approach. Of those three options, I do about 80% of my incisions in the crease, 15% in the armpit and about 5% around the areola.

“If the patient is really concerned about having a visible scar, or a scar on the breast I will recommend the axillary approach. That is done endoscopically. The axillary approach got a bad reputation before the advent of the endoscope because it was a blind operation and it was generally done under the muscle. With endoscopy, you can look to see the extent of your dissection and make sure that you have done an adequate job so that the implant rests low enough and it doesn’t look too high. Having said that, there is a noticeable scar for a period of time while it’s red, and if you’re wearing a sleeveless top or a tank top, and you raise your arm up that’s going to be noticeable. On the other hand when it’s all said and done, that scar is very imperceptible, it looks just like a wrinkle in the armpit.

“The one around the areola seems to be popular in some parts of the country. I certainly will do that if that’s what the patient wants. Sometimes those scars depending on the pigmentation of the areola can be even more noticeable. They are on the front part of the breast. I have never had to do a revision of an inframammary crease incision in all my 34 years. They tend to heal with a very fine line. So the inframammary crease under the breast gives you the most flexibility if you have to go back down the road 10, 15, 20 years later and do something else.”

Should implants go in over or under the muscle? Do you have a personal preference?

“I find it’s very difficult to do on top of the muscle unless you make a large incision, which then sort of defeats the purpose of going through the axilla and having a very small, inch long scar. So when I go through the armpit, I virtually always go under the muscle. However, there are a lot of factors that come into play when you’re trying to decide to go over versus under the muscle. If a person has a really physical job, or if they’re really into weight lifting and bodybuilding, going under the muscle may not be the best approach. I’ve done some placements on top of the muscle in those situations. For a person who’s really thin, the edges of the implant may be more visible going over the muscle, so it may be better to go under the muscle in those situations.

“If I’m seeing a patient with a family history of breast cancer, I’d prefer to go under the muscle because it should be easier to perform a good mammogram with the implant under the muscle. The majority of the implants I put in are done under the muscle.”

What is your advice to help women ensure that they have the results that they want?

“In order to ensure a successful operation, patients should have in mind what their goals are. I don’t mind having a patient bring in pictures of other people, of what they think looks good. It may be unrealistic, but at least I can have a visual sense what they’re looking to accomplish. I’m in the MidWest and some women say, ‘I don’t want to look like Dolly Parton. I don’t want to look like a Barbie doll. I just want to restore what was there before I got pregnant and had children.’ while other women have different goals in mind.”

What should a woman do to ensure she’s getting a great plastic surgeon?

“I think communication is all important. If you don’t feel comfortable with your plastic surgeon, no matter what their credentials, see someone else! If you don’t feel like you’re communicating on the same page, see someone else! Of course a woman should seek out a board-certified plastic surgeon, preferably one who does a fair number of breast augmentations in their practice. He or she should have an open approach to different types of implants. I know some of my colleagues tend to steer their patient in one direction or the other because of deals they may have with certain companies.

“Doctors need to be forthright about what each implant can and can’t do for the patient. They should present it in an honest and open fashion. In some cases, if the patient feels like they’re being steered one way they should say, ‘Is there a reason you’re trying to talk me into this? I came in asking for one implant and you’re trying to talk me into a different implant.’ If you don’t feel comfortable with that situation, get another opinion from another plastic surgeon.”

What kind of complications should women be aware of when it comes to breast enhancement surgery?

“Capsular contracture (or the buildup of scar tissue around an implant) has bothered us plastic surgeons over the years, because no one has been able to figure out a true solution to it. There are a lot of theories as to why it happens. Those theories change about every five or ten years. The current theory is that there is a biofilm formation of bacterial slime around the implant. So some doctors irrigate the pocket with antibiotic solutions and put the patient on antibiotics for a period of time. Most surgeons try a “no-touch” technique where there’s only one person that contacts the implant and that’s the surgeon.

“I use, for example, a barrier film over the skin called IOBAN, which is impregnated with iodine that prevents bacteria from being dragged in the pocket. Having said that, capsular contraction still exists. It’s graded one, two, three, and four. One and two are mild, and probably aren’t going to require additional surgery, but the three and four capsular contractures may cause visible distortion of the breasts to the point where additional surgery is necessary.

“There’s another problem called BIA ALCL, which is Breast Implant Associated Anaplastic Large-Cell Lymphoma, because it is associated with and occurs around a breast implant. It’s a type of lymphoma or blood cancer that can occur around breast implants. To my knowledge, that has been described and confirmed only with textured implants. With so-called “fuzzy” implants, or implants that don’t have a smooth surface. IDEAL IMPLANT, for example, has a smooth surface. With most silicone gel-filled implants you can choose between a smooth or textured surface depending on the shape. The tear drop shapes are pretty much all textured, and the round tend to be smooth. The incidence is extremely low, maybe as low as one in a million, but it is a real entity, something to be aware of.

“Probably the most common complication would be a hematoma, or a bleeding issue that occurs after the surgery is over. I find that my incidence is extremely low, especially since we’ve been emphasizing avoiding medications that can contribute to bleeding. For example, I tell all my patients, no aspirin for two weeks, no ibuprofen, Aleve, etc., for at least a week. Also things like fish oil and vitamin E and many of the herbal supplements can cause prolonged bleeding. A lot of people don’t consider those drugs I listed as medications, but they are. They have side effects, known side effects that can cause problems with bleeding or even prolong the effects of anesthesia.

“It’s important to communicate to your plastic surgeon what medications you’re taking in all regards, not just prescriptions. I would say my hematomas have gone down significantly since emphasizing the importance of avoiding certain medications. If an infection occurs around the breast implant, the body’s immune system can’t function properly without having to remove the implant. I, for one, have never had to do that in my 34 years of practice, but infections do happen and they have been reported.

What should women do to avoid any complications post-surgery?

“Your plastic surgeon should give you a definite set of printed instructions on what to do after the surgery. Pay attention to that. Don’t ask your girlfriend, ‘What do you think I should do in this situation?’ Your girlfriend hasn’t done hundreds and hundreds of breast augmentations, she’s maybe had one herself, but every person’s experience is different. I just can’t emphasize enough that women should listen to the advice of their plastic surgeon. They are the best person to tell you what you should and shouldn’t be doing.

“Activity does have to be restricted afterwards, particularly if you go under the muscle. There are certain exercises like push ups and bench presses that I don’t want my patients doing for at least three months after the surgery. If your surgeon has a longer period of time where they restrict your activities, there’s probably a reason for that. So listen to your doctor, they’ve got the experience, they’ve got the knowledge.”

How long have you been using the IDEAL IMPLANT?

“I was first introduced to the IDEAL IMPLANT at one of our national meetings by the inventor, Dr. Hamas, and I had no knowledge of it prior to that time. He lined up an IDEAL IMPLANT next to a traditional saline implant and a silicone gel-filled implant and covered them with a cloth, and had me feel each implant through a cloth. I could tell an obvious difference between the traditional saline and silicone-gel implants. Then when I felt the third implant, which was the IDEAL IMPLANT, I thought it felt very similar to silicone gel. I could tell a little bit of a difference but it felt very, very close. So I started using IDEAL IMPLANT as soon as it became available to the general plastic surgery community around 2014.”

Have you noticed more women asking specifically for the IDEAL IMPLANT?

“As time has gone on and women have heard about it, more and more people come in requesting it. In the beginning I would present all the different types of implants to my patients and sort of let them decide. When patients would ask my opinion I tried not to say, ‘Go with this one for sure,’ but I would try to present the pluses and minuses and ask them what their concern was. If their concern was silent rupture and having to get MRIs to determine if they had a rupture, I would steer them more toward the IDEAL IMPLANT or the traditional saline implant. But after showing them the difference physically by having them examine each with their own hands, 100% choose IDEAL IMPLANT over traditional saline implants. Some patients and some husbands actually thought IDEAL IMPLANT felt more natural than a silicone implant. Not everybody chooses it, but a larger and larger percentage of my practice has been devoted to inserting IDEAL IMPLANT as time goes on.

What can you tell us about IDEAL IMPLANT and silent ruptures?

I’ve used IDEAL IMPLANT in my practice for at least three and a half years. I see people coming in with silicone gel-filled implants and something may have happened. Maybe they got into a car accident. They’re worried if they have a leak or not. If they have silicone gel, you may have to tell them, ‘The only way to know for sure is to have an MRI.’ But with my IDEAL IMPLANT patients, you can tell whether you have a leak or not by just looking in the mirror. I don’t have to send them for additional x-rays or studies. I can tell when they walk in the office if they have a leak or not. Women who want to have peace of mind about knowing whether they have a silent rupture are not stressed after surgery when they choose the IDEAL IMPLANT.”

What else do you like about the IDEAL IMPLANT?

“It has a very natural look and feel. The rippling that you sometimes see with the traditional saline implants just hasn’t been an issue. There are a lot of advantages. So far I haven’t seen capsular contracture as a major problem. Now that may change 15 years from now, but for now, the incidents of capsular contracture are extremely low. It’s lowest among all the different types of implants available. I just find that there’s a lot of reasons to have peace of mind when using the IDEAL IMPLANT.”

Do you feel like your IDEAL IMPLANT patients are satisfied with their results?

“Yes, our IDEAL IMPLANT patients are very happy, very satisfied. It really is, I think, the ideal implant.”

Considering breast implants in Brookfield, WI? Contact Dr. Paul Loewenstein today to discuss your options. Simply call 262-717-4000 or visit www.drloewenstein.com. Dr. Loewenstein’s office is located at 13800 West North Avenue, Suite 110, Brookfield, WI 53005. Call today for more information on IDEAL IMPLANT® Structured Breast Implants.