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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.

Your Breast Surgery Questions Answered by Dr. Jed Horowitz

Dr. Jed Horowitz is a board-certified plastic surgeon at Pacific Center for Plastic Surgery in Newport Beach California. Dr. Horowitz has been practicing since 1985 and has expertise in many different areas of plastic surgery. We recently asked him about his experience in plastic surgery, what he thinks about the IDEAL IMPLANT® Structured Breast Implant, his breast enhancement recommendations, and more. Read below for his expert answers then visit his website to schedule a consultation.

How many breast enhancements do you perform and what is the breakdown of breast implant types?

“Breast enhancement has always been a big part of plastic and cosmetic surgery in general and, in our practice, it’s always been a large part. Along with breast enhancement, which is basically breast enlargement and breast augmentation, we also do breast lifts and breast reductions.

“Our practice probably 50% revision or secondary breast surgery because we have patients who have breast implants for 10, 15, 20, 30 years. Their bodies have gone through changes, their breasts have responded through their lives to all of these changes. Now maybe their breasts are sagging a little bit. Maybe they’re emptying in their upper part. Maybe the implants are too large, maybe they’ve gained weight and their breasts are just too large. Or they’ve had their breast implants for 20 years and it’s time for a change. Implants still play a large part in those changes.

“When I started doing the surgery a long time ago, the only implants that are available were silicone gel implants and traditional saline implants. We have silicone gel that’s more cohesive, more gummy bear or like jello, and some that are more liquidy. Then we have the IDEAL IMPLANT® Structured Breast Implant. The IDEAL IMPLANT is a structured implant filled with saline as opposed to silicone gel. It feels more like a traditional silicone gel implant because of the way it’s structured.

“The company spent more than ten years in developing and testing this implant. The idea was that if you put in inner layers into this outer silicone shell, it would slow down the flow of saline when you would touch the implant. It’s the way the saline flows through the implant that makes it feel more like a silicone gel implant. The saline doesn’t just slosh through the implant as in a more typical saline implant. It has a much more natural feel. It feels more like breast tissue. It feels more like silicone gel. It’s a great option for the women who has concerns about a silicone gel implant that still wants to have a breast implant. It’s just a great alternative for those reasons and several other reasons.”

How does IDEAL IMPLANT® Structured Breast Implant compare to traditional saline implants? Do incisions play a role in determining which implant you recommend?

“In my practice, I’ve been doing this long enough that I’ve used pretty much every implant that’s available and has been developed. We’ve used all the different incisions that are available. That includes incisions under the breast (inframammary), incisions around the nipple (periareolar incision), and incisions in the armpit (transaxillary). For many patients, we used to do a TUBA or transumbilical breast augmentation. The only scar is in the belly button. That’s the only time that we’ll use a standard traditional saline implant. The saline implants roll up very thin so can roll them up like a cigar when you insert them. You can make a small incision in the belly button, roll this up, make a small tunnel from the belly button to the bottom of the breast and then insert the implant in that matter. Currently the most commonly requested incision is actually under the breast. If I’m making an incision under the breast, there’s no benefit of using a traditional saline implant. It doesn’t feel as natural as breast tissue.

“The IDEAL IMPLANT® Structured Breast Implant is just a much better implant. We have now more than ten years of follow up. The complication rate for IDEAL IMPLANT® Structured Breast Implants is very, very low. When I say complication, in particular we’re talking about deflation of the implant where the saline just leaks out, and capsular contracture where you develop firmness around the implant. IDEAL IMPLANT has better statistics right now in their six year follow up then traditional saline implants and even traditional silicone gel implants. Those are other reasons why the IDEAL IMPLANT is just a better choice for many patients.”

How does the IDEAL IMPLANT® Structured Breast Implant compare to silicone gel options available?

“Even with a silicone gel implant, it’s still possible to see some of these same problems of rippling, wrinkling, waviness of the implant. And there are some women that still have concerns about silicone gel. Some women have had silicone gel implants for many years and have had what’s called “silent rupture” where the implant can actually leak and break and you don’t know it until you have a mammogram or an MRI. The recommendations are to remove all of the silicone gel, remove the capsule, and start fresh. A woman who has experienced that and now needs to have a new implant frequently will be concerned about having another silicone gel implant. That’s one group of women that frequently will switch to the IDEAL IMPLANT® Structured Breast Implant. Another group of women are women who know women who’ve had that problem and are concerned because their best friend had to have repeated breast implant surgeries because of problems with their silicone gel implant. They feel more comfortable having saline. When an IDEAL IMPLANT® Structured Breast Implant leaks, it doesn’t happen frequently and it happens less than silicone gel. But when it does, our bodies just absorb the saline, which is a natural part of our body. There’s nothing that’s fearful about that.”

How do you help patients who are trying to determine the best implant size for them?

“I think I’ve done pretty well on sizing over the years because I haven’t had anybody request a change in size for a long time. The number one cause for a secondary breast operation is for a women to change the size of her implant.

“The conversation starts off with education. I have to explain the difference between cup size and bra size and patient size. Their height and their weight and their size. A zero size versus a six or eight and what that all means relative to cc’s of volume of the implant. For some reason, this is just not intuitive to many patients when they come in. That’s a long discussion as part of the consult.

“Another part of the consult may involve a patient bringing in photos taken usually from a website of what she would like to look like. Then we have to look at the photos and see if her before photo looks anything like the patient. You need to look at the patient’s height and weight and see if they’re similar. If the patient brings in an image of a patient who is 5 foot ten and 145 pounds and she’s 105 pounds, the implant is going to be very different. We have to digest all of that information, then have a long discussion with a patient so she understands why we’re choosing a certain size. It’s confusing for the patients because the patients will go to three different doctors and they’ll come and see me. They’ll say, ‘I just saw doctor so-and-so down the street and they say I need 450cc.’ I say, “That’s great. That’s gonna make you a 32F cup. If that’s what you would like to be, that’s fine. That’s not what I think you want.’ It’s difficult for the patients sometimes. They get a lot of different information and it’s not always correct.”

What advice do you give to patients who are concerned about scarring?

“Most patients coming in for cosmetic surgery are concerned about the incisions or placement of the incisions. I always ask the patient what they’ve been thinking of because they’ve absorbed a lot of information from social media, the Internet, previous consults, what their friends have told them, so I always ask if they have ideas in mind.

“I spoke a little bit earlier about the incisions that are available. Most typically now, we’re not using the belly button incision. They’re through the armpit, around the nipple and under the breast. Some women are fearful now about the incision around the nipple or the areola because there’s some information saying there’s more bacteria and a higher risk of encapsulation. There’s some literature available to that, but I’m not sure it’s concrete. My personal experience, I think my rate of capsular contracture has been the same, regardless of the incision that we use. I personally think that there are good options for each patient.

“A patient who has a very small areola . . . they’re not a good candidate for an areola incision at all, it’s just too small. If we try to make the incision under the breast, if they’re very small and they’re very flat chested, they don’t have a good fold, and that scar will be more visible. For that patient, a transaxillary incision is a great option. Doctors who don’t do a transaxillary incision will frequently have bad things to say about it. They’ll say, ‘You can have bleeding, you can have nerve damage. You can’t place the implant correctly,’ and that’s all nonsense. Any doctor who has done that operation consistently knows you can get the same result with any of the incisions that I spoke about.

“For another woman that comes in and already has had children, maybe she has some laxity of her skin, she already has a well-defined fold under her breast, an incision under the breast is great. It’s going to be hidden no matter what, we don’t have to cut any of the breast tissue. When we do a periareolar incision, usually we’ll cut through the lower part of the breast tissue to get to the muscle or to go under the breast, so you’re disrupting a little bit more of the glands of the breast. When you make the incision under the breast in the fold, you’re immediately under everything. If a woman has more breast tissue, more gland, then going underneath the breast in the fold might be a better operation for her.”

How do you advise patients who aren’t sure which implant type to pick?

“Every woman is different, their breasts are different, their needs are different. I try to educate my patients and tell them what I think is best for them given all of the options. In my practice, silicone gel implants are still probably 85% of the implants that I use, but every year we’re putting in more of the IDEAL IMPLANT® Structured Breast Implants. Because patients now are becoming more aware of IDEAL IMPLANT and they are more readily available.

“When patients come in, before they just sit down and we start talking about silicone gel implants, I will give them a sheet of paper that discusses IDEAL IMPLANT, because they may not be familiar with it. It will outline why the IDEAL IMPLANT® Structured Breast Implant might be a better choice for them compared to the silicone gel implant, so at least it’s in their mind. They’ve had the ability to at least read about it and know that that’s an option. Then we’ll continue with the rest of the consult I’ve just discussed. At that point we’ll say, ‘What do you think about the IDEAL IMPLANT? Are you set on having a silicone gel implant? Is this of interest to you? Do you want more information?’ Then we’ll go from there. I like for my patients to make educated choices, to make their choices for good reasons.

“If they say, ‘I want this silicone gel implant,’ I ask, ‘Well, why are you choosing that?’ They’ll say, ‘I’ve been told that it’s this and this and this. I’ve felt them, I’ve read about it. I just think it’s a good choice for me.’ That’s great. Then if a patient is just reading about the IDEAL IMPLANT® Structured Breast Implant for the first time, I’ll say, ‘How do you feel about the IDEAL IMPLANT?’ They’ll say, ‘It’s the first I’ve heard about it.’ I’ll say, ‘Good. Why don’t you take home the information, here’s a website. Think about it. We’re not doing the surgery for six weeks. See if this is a good option for you and we’ll go from there.’

How long can women expect their breast implants to last?

“The longevity of an implant is something we’ll discuss at a consult. It’s an important discussion because the party line right now for most implants has been that implants will last about 10 years. That’s just all implants across the board, different companies, different styles of implants. Now there are doctors who’ve told patients, ‘You need to come in and replace your silicone gel implants at 10 years, you have to do that.’ Again, there’s no statistic, there’s no literature that supports that. I tell my patients that implants become weaker over time and at 10 years, you need to think about possibly having to replace them and it would be a good time at that point, if you haven’t already had mammograms and ultrasounds, to at least get that as a starting point, and if there’s any concern, to get an MRI, which is recommended by the FDA for a silicone gel implant.

“Now our own bodies don’t last a lifetime. We get arthritis, our knees give out, our shoulders give out, we get neck pain or back pain, so our bodies don’t last a lifetime. There’s no man-made device that lasts a lifetime. It would be great if our cars would last forever but they don’t. Man-made devices wear out. When you put a breast implant into a woman’s body, her heart is beating, she’s breathing. If she’s athletic she’s moving, her breasts are moving, there’s constant motion. If you think about taking a paperclip and bend that paperclip back and forth and back and forth and back and forth, you develop a weak spot in that paperclip, and at some point, it just breaks. Implants are no different, just like every other device, so over time, they will wear. Now some of the companies have been really good about warranting their implant, at least for 10 years, as IDEAL IMPLANT does. They will replace the implant if they become defective before that 10 year period.

“I have patients coming in that have implants that are 30 years old. I have patients coming in for their light lift facelifts and I’ll go through their medical history and they’ll say they had breast implant surgery 25 years ago. I’ll say, ‘Oh, that’s great. When did you replace them?’ They’ll say, ‘I haven’t replaced them.’ I’ll say, ‘Have you thought about it?’ They’ll say, ‘They’re fine.’ We’ll talk a little bit about that and why it might be a good idea to do a little bit of research on that and think about it, but there are a lot of patients, they just come in, they’ve had their implants for 10, 15, 20, 30 years and they’re good, they’re fine.”

Through your years in practice have you seen any trends in cosmetic surgery?

“I’ve been in practice for a while now and I’ve seen all the changes that have occurred with breast implants, breast sizing, types of surgery. Breast implants initially were pretty much mostly silicone gel. We had traditional saline implants then, but almost everybody had silicone gel placed. There were all almost always placed through an incision in the mammary fold. In the United States, they were almost always placed under the muscle. Since that time, we’ve gone through smooth implants, we’ve gone through textured implants. We’ve had textured implants with different types of texturing. Minimal texturing, coarse texturing, and all of that was focused at cutting down on scar tissue or the rate of encapsulation. We’ve gone through shaped implants, we had saline shaped implants, we’ve had silicone gel shaped implants.

“Those are trends with implants and now we have the IDEAL IMPLANT, of course, a much better structured saline implant, so it’s rare to use a traditional saline implant at all. I’ll just go to the IDEAL IMPLANT, and it’s a great name. It’s the ideal implant for that patient. The other big change, the other really big change in breast surgery has been, again, it’s called hybrid or composite breast surgery, there may be some other names that doctors use. It’s using a combination of your own tissue, your own body fat, and an implant or no implant.

“The hybrid operations are usually a combination of an implant, whether it’s an IDEAL IMPLANT® Structured Breast Implant or a silicone gel implant, and, again, the body’s own fat. You put the implant in and, if it’s just a breast augmentation, we may decide the patient needs a little bit more fullness in one part of the breast or the other, and because the implants are a fixed shape, they can’t take a customization of the contours. Most women have breasts that are unequal, they’re asymmetric, so the ability to correct small asymmetries by adding their own fat is a great advance. That’s a big change.”

Have size requests changed much over time?

“Size requests for implants go a little bit like fashion. When I started, Twiggy was really popular. Twiggy was a model back in the early ’70s and she was very young and she must have been like a size double zero, very flat chested, and that was the image of a model at that point in time. Women just wanted a little bit of breast enhancement. I mean, a typical breast implant volume in the late ’70s was probably 240cc for an average size woman. Then we got into the 1980s and 1990s, and everything got bigger, the world got bigger, breasts got bigger. We got to a point where the average size implant probably went up to about 375cc, 390cc.

“The average cup size, the average bra size sold was a 36C. If you went to clothing manufacturers, I think that’s what they would gear most of their clothing towards. Either a 34 or 36C was the average size. Along with that, that became the average size breast implant, and there were always extremes. Most women did not want smaller, larger sometimes.

“Now I think it’s going backwards. I think women now are coming in, some women are having their implants removed. A lot of those women are having a small lift, maybe they’ve had children. Maybe their bodies have changed a little bit. Maybe they’ve gained a little bit of weight. They’re now in their 40s or 50s. They’re beyond having that 375cc implant.

“Smaller implants also have less complications. Smaller implants have less problems of stretching of the skin, stretch marks, dropping into a low position below the fold. I think in general, smaller implants, they’re more modest, you’re placing less of a demand on the woman’s body. I think they heal better, longevity is probably better. Bigger breasts sag, whether you have implants or natural breasts. More weight and gravity is a bad combination, so it’s not just implants.”

As a surgeon, what do you like about the IDEAL IMPLANT® Structured Breast Implant? Why should women be aware of this option?

“First of all, I want to give my patients options, so it’s good having choices for my patients when they come in. For the patients that are concerned about silicone gel, and they’re concerned about the safety of silicone gel, I am happy to give them an alternative. And the only alternative I had before was the standard saline implant. And the standard saline implant doesn’t feel as natural as breast tissue or as natural as silicone gel, and has greater problems with rippling, wrinkling, or waviness for many patients. So for me as a surgeon, I like having the IDEAL IMPLANT as an option for all those patients, particularly the ones that have safety concerns.”

What is your advice for women who aren’t in Newport Beach to find the right plastic surgeon?

“For the few patients that just don’t want to travel and want to go to somebody local I think board-certification is always at the top of the list. At least it’s a starting point to make sure your doctor has had appropriate training and has gone through appropriate testing to make sure that they have the correct information, the ability and the skill sets to do the correct operation. The next thing of course is experience because you have young doctors. That’s great, when I was a young doctor, I felt I knew everything, and I knew a lot and I was good then. But with time and experience, most doctors get better at what they do. Also, I think the experience of the doctor who has used different types of implants, different incisions, different type of breast enhancement, I think it’s important because they’re not just choosing the one operation that they’ve learned how to do well.

“Because every patient is different. And one incision may be great in one patient, but the other incision might be better for the next patient. So to go to a doctor who has experience in doing the different techniques, the different placement of implants. Who has used the different types of implants. I think if you can get to a surgeon who has that experience, that’s a plus for that patient. It’s not always possible if you live in a geographic area where you have limited number of doctors. But that’s when it pays sometimes to travel.”

What information do women need for a successful outcome?

“We give our patients maybe too much information. There’s a lot of information that they get to prepare for surgery. And then a lot of information about what they can expect after surgery and the things they need to do. For a breast augmentation, it may be as simple as wearing a tape over the incision. All the stitching is always done underneath the skin, so there are never any stitch marks. But we want to support that initially, so we may use tapes.

“Now, full on activity, if we’re going underneath the muscle for a lift or an augmentation, we want to let that pectoralis muscle mend a little bit. So I may start to increase their activity over two to six weeks for full on activity. At six weeks we cut them free to do whatever they want. But again, things that they can do: taking care of the incisions with the products that we give them, wearing their sports bra or whichever bra that we feel is necessary for them for their particular operation, sometimes we use a support strap that goes over the top of the breast, if we need the bottom parts of the breasts to stretch a little bit. And that goes on over about two or three months. And those are most of the things we ask our patients to do.”

Why should women choose Pacific Center Plastic Surgery in Newport Beach?

“I think Newport Beach has many, many plastic surgeons. They have many well-trained plastic surgeons. I think what’s different about our practice, Dr. Nichter and I have performed surgery for many years now. We’ve done these operations every way they could be done, used every implant. And I think our experience is very important to patients coming to visit us. I think right now there are not many doctors in this area that have that level of experience with all the incisions, all the devices, different types of anesthesia, different operating room settings. Outpatient, inpatient, you know, we’ve done this surgery pretty much every way it could be done.

“Dr. Nichter and I also spend a lot of time researching products that are available to our patients. We were on the first group of people to start using IDEAL IMPLANT® Structured Breast Implants. We won’t do anything that is not safe, anything that we don’t believe in, anything that we feel has not been researched and studied. But as soon as we get to that point, we will get that device, that product, and make it available to our patients, if we think it’s something our patients will benefit from. Like the IDEAL IMPLANT® Structured Breast Implant. IDEAL IMPLANT and Sientra are the only two implant companies that will sell implants only to board-certified plastic surgeons. And I think that speaks volumes to the integrity of both of those companies. And it speaks volumes to our practice. Because a lot of doctors will continue to use the other implants because for whatever reason, they’re part of a buying program. If you buy Allergan products, use their Botox, get their implants, you have a better arrangement with that company. But we told that company, unless you sell only to board-certified surgeons, we will stop using your product. And now that we have two alternatives, that’s what we’ve done.”

Considering breast implants in Newport Beach? Contact Dr. Horowitz today to discuss your options. Simply call  949-720-3888 or visit www.PacificCenterPlasticSurgery.com. Dr. Horowitz’s office is located at 3991 MacArthur Boulevard, Suite 320/340, Newport Beach, CA 92660. Call today for more information on IDEAL IMPLANT® Structured Breast Implants.

Dr. Larry Nichter on the Benefits of the IDEAL IMPLANT® Structured Breast Implant

Dr. Larry Nichter is a board-certified plastic surgeon in Newport Beach, California. A formerly tenured professor at the University of Southern California, Dr. Nichter now runs a successful private practice, Pacific Center Plastic Surgery in Newport Beach, with fellow surgeon Dr. Jed Horowitz. Dr. Nichter is a lead FDA investigator for IDEAL IMPLANT and has presented reports on the success of this new technology to the American Society for Aesthetic Plastic Surgery and American Society of Plastic Surgery. After nine years and over 100 cases using the IDEAL IMPLANT® Structured Breast Implant, Dr. Nichter has a unique point of view. We asked Dr. Nichter about his thoughts and experience with breast implants. Read below for his expert opinions.

What are the benefits of using the IDEAL IMPLANT® Structured Breast Implants?

“Well from a surgeon’s perspective, the best thing involved is you don’t really have to worry about silent ruptures. So silicone gel implants have a rupture rate that’s pretty high from 9% – 24% at 10 years. If silicone gel implants are ruptured, it’s not simply removing the silicone gel, you usually have to remove the capsule around the gel, the lining around the gel, called a capsulotomy. And that takes extra time, that can take half an hour to an hour per breast to do that.

“That’s in comparison to the IDEAL IMPLANT® Structured Breast Implant where if it leaks, you just simply remove it. Because of the high rupture rates, I tell my patients for silicone gel implants, just plan on removing them every 10-12 years, because after that the rupture rate is so high. You don’t have to do that with IDEAL IMPLANT® Structured Breast Implants. You can just leave them in until there’s a leak because it’s just simple saline, the stuff that’s in an IV solution. It’s incredibly safe and so there’s far fewer lifetime surgeries with an IDEAL IMPLANT® Structured Breast Implant, compared to traditional silicone gel implants.

“There are also many uses for the IDEAL IMPLANT® Structured Breast Implant. For example, it’s not just for primary augmentations, you can also use it for revision work, especially if the patient has had problems in the past with capsular contracture. In fact, the IDEAL IMPLANT® Structured Breast Implant has this incredible guarantee that they will give you in terms of replacing implant and helping the patients should a complication occur. It can be used not just in revisional surgery but at the same time as we do a breast lift.

“And lastly, although it’s not FDA approved for reconstruction during mastectomy, I do think in the future, once it’s FDA approved, this will be a great addition to our arsenal for reconstruction after breast cancer.”

Have you had to deal with many ruptured silicone gel implants in your career? What other complications could lead to a revision surgery?

“Oh yes. Ruptured silicone gel implants are just part and parcel, what we call bread and butter surgery for a plastic surgeon because of the high rupture rate. The other reason we operate on patients with silicone gel implants, and saline implants for that matter, is capsular contracture, that is, the hardening of the implant. The implant actually is soft, but the membrane around it, called the capsule, gets very thick and can actually squeeze the implant, distorting the way the breasts look, so making it quite hard.

“We were very surprised, in the FDA study looking at more than 500 woman, how low the capsular contracture rate was for IDEAL IMPLANT. In fact, it was significantly lower than silicone gel implants, which in the past had some of the lowest rates. So, that’s a huge advantage, another advantage of the IDEAL IMPLANT® Structured Breast Implant.”

How is patient satisfaction with the IDEAL IMPLANT® Structured Breast Implant?

“Part of the FDA study is looking at satisfaction. The women’s satisfaction is somewhere between 92- 94%, almost identical to what the surgeon’s satisfaction rate is. So they’re extremely thrilled with the results.

“My patients in general are thrilled about IDEAL IMPLANT. In fact, they tell their friends and their friends come in for it and so on. It’s very interesting that two studies were done last year. One of which looked at a very large volume of woman, more than like 930 woman. And they did a study and wanted to know, ‘Would you be concerned if there was a silent rupture of an implant, say a silicone gel implant? Or any type of implant. But if so, would you want it removed?’ Overwhelmingly, more than 90% said absolutely we would want it removed.

“I’m not sure if you’re aware of this, but the FDA has guidelines for silicone implants, their guidelines are very specific. They would like you to have an MRI scan at three years, and then every two years to see if you have a rupture because if you have a rupture of silicone gel implant, typically you don’t see any difference with your breasts so you would not know this. Women are very concerned about that fact. They don’t like having it and this survey, done by a third party, show that over 90% of the women, if it was a silent rupture, they wanted the implant removed.

“With an IDEAL IMPLANT® Structured Breast Implant, since it’s just saline that fills it, it’s wonderful. Instead of an MRI scan, you just simply use a mirror. But you can keep your implant not just 10-12 years, which is what I recommend for silicone gel implants, but for 20 years, 25 years. As long as it’s intact and okay. If there are no silent ruptures, that’s a huge advantage.”

Have you noticed any recent trends in plastic surgery?

“Well certainly the time is right to consider a more advanced breast implant. Women are health conscious, they’re looking for things that are natural and very healthy. There’s nothing more natural or healthy than saline. That’s what your body is filled of. So, that’s one of the reasons why I think the IDEAL IMPLANT appeals to many people.

“Many people are looking for organic foods and things, again, that have very low health risks. They don’t want to have to have lots of studies, like the MRI scan. For example, you have to make an appointment. It’s expensive. It’s not covered by insurance. You have to take time out of your life. And there’s worry. What are the results? What happens if it’s ruptured? The peace of mind factor is huge for patients, for women in particular. And here you have a natural product that’s just saline. If it ruptures, it’s just like getting an IV, you’re hydrated.

“But the bottom line is, it fits all the criteria of a more natural, healthy alternative to a silicone gel implant. And I see that as a huge trend.”

Have you noticed a change in the size breast implant women are requesting?

“Yes. So I’ve been doing breast augmentation surgery, using breast implants for reconstruction, lifts with reconstruction, mommy makeovers, for 30 years. During my first 10 years, every year implant size seemed to get larger and larger and larger in terms of requests by my patients. The middle 10 years, it seems like they mostly, slowly got a little larger. But the last 10 years, clearly women are moving towards smaller implants.

“They want something that’s proportionate. They either want to dress up and look very sexy or they would like to get in business clothes and be taken very seriously. They’re more athletic, again, health conscious and they want something that will fit many different aspects of their life. Again, the IDEAL IMPLANT is great because one advantage of the IDEAL IMPLANT, for example, is you can adjust the volume. So if you have breast asymmetry, you can get more symmetrical breasts. You can affect the profile.

“So you could have a more aggressive, more sexy looking sort of profile if you wanted to. Or you can have a very natural appearance. You have all the advantages of this, unlike silicone gel implants where you have to be very specific on which implant you pick. So you have the options on the operating table of changing the characteristic slightly to both match in size and shape, and also patient’s desires.”

Do your patients have any concerns about scarring after surgery?

“One advantage of the IDEAL IMPLANT® Structured Breast Implant is the implant is placed into the body deflated and then once it’s in the pocket, it’s inflated and filled. Because it’s deflated, you can use a much smaller incision, so therefore, there’s less scarring involved with the IDEAL IMPLANT. A silicone gel implant, in comparison, is factory-filled without seams and so in order to have an implant that’s sizeable, unfortunately, we need to make an incision that will accommodate it. So that’s a big advantage, there’s far less scarring with the IDEAL IMPLANT.”

What are your views on implant placement (above or below the muscle)?

“We take every patient on an individual basis. We ask them a lot of detailed questions. We have them bring in pictures of what they would like to look like. So a lot of women that have very little breast tissue, for example, and would like to be subtly improved, or to increase the fullness on the upper part of their breasts, which in general is the place where you lose volume with aging and, especially after pregnancy, we oftentimes will put it beneath the muscle.

“But there are other reasons. If someone has a little bit of sag and does not want a lift, putting the implant above the muscle or splitting the difference in what’s called a dual plane, where it’s partially under the muscle and partially over, can help augment and lift the breast a little bit. So there are many nuances and that’s why it’s really critical that you got a board-certified plastic surgeon such as myself, that has this experience and all the nuances in order to do the best job.

“The IDEAL IMPLANT company, I have to give them tremendous credit. The IDEAL IMPLANT company is [one of] the only implant companies that will sell to only board-certified plastic surgeons. So you know if you’re choosing IDEAL IMPLANT, just by choosing it, you know you’re at least going to someone with significant training and experience to get the results you want. And they will spend a lot of time with you and, hopefully, as we do, to make sure that you know all the choices, nuances of where to place the implant. Above or below the muscle and so on. Where scars will be. Whether you need a lift at the same time. And so forth.”

What complications do women need to be aware of before getting breast implants?

“So, when we’re looking at implants and you’re comparing different types of implants, in particular, let’s compare IDEAL IMPLANT® Structured Breast Implants to silicone gel implants. First of all, if you’re under the age of 22, only saline implants are FDA approved, so that would limit it to IDEAL IMPLANT. Virtually no one uses the traditional, old fashioned saline implants because the waviness or rippling and so on.

“But in terms of risks we already went through, there’s two to four times less risk of rupture and again, at least a two-fold decreased risk of capsular contracture with the IDEAL IMPLANT. Those are the two main complications.

“There are some rare, or I should say uncommon complications that are making the news. One of which is ALCL: Anaplastic Large Cell Lymphoma. It’s a cancer that’s not very aggressive, but the point is, although it’s been linked to several types of implants, it’s my understanding that approximately 80% or more are only found in textured implants. There’s a rough surface around the implant and that’s of interest. It’s the most common implant used outside the United States, especially in Europe, South America, and Central America. This form of cancer, especially with certain brands of implants can be significantly high. As much as 1 in 5,000, or less as time goes on, because it takes many years, at least eight to ten years or so, for most of these to develop.

“But the IDEAL IMPLANT® Structured Breast Implant is a smooth implant, so that would put you at the least possible risk. To my knowledge, there’s never been a report of ALCL with any implant by the IDEAL IMPLANT Company. We’re now up to year nine in our study, which will end at 10 years. So it’d be the lowest of all the rates in developing this unusual type of problem.”

How do you help women choose the right breast implant?

“Choosing implants is a difficult choice and we understand that. We’ve made a pretty simple chart comparing, on one side, silicone gel implants, and saline implants, particularly the IDEAL IMPLANT® Structured Breast Implant, on another. So, for example, incisions are smaller with the IDEAL IMPLANT® Structured Breast Implant. There is less risk of capsular contracture (that’s the hardening of the implant). And less risk of rupture, significantly between the two. There’s no silent rupture. You don’t have to worry about, ‘Is it ruptured or not?’ You know immediately. Therefore, we don’t recommend that the IDEAL IMPLANT® Structured Breast Implant is replaced 10-12 years, unlike a silicone gel implant. You can keep them in as long as you want. So therefore, there’s less lifetime surgeries.

“Then lastly, again, we just let them know that the contents are just saline. It just leaks out. If there was a rupture with a silicone gel implant, chances are you would need to remove the outer lining around it, which is a much larger procedure and may require drains and so on. That’s just not required with the IDEAL IMPLANT® Structured Breast Implant.

“But it used to be that about 90% of my patients, up to 95%, would pick silicone gel implants, and maybe only 5% saline. Now, it’s easily the majority of my patients pick IDEAL IMPLANT® Structured Breast Implants after I present that information and allow them to read about it. And I’m thrilled.

“Here you have something with all the advantages of a silicone gel implant, without the disadvantages. So, it’s a win-win situation. My patients usually are very well educated. Many of them find me because I have some of the largest experience in the country placing these. And they come to me with that specific reason. If they haven’t heard about them I just mention, ‘why don’t you do some research? Here’s some scientific articles reviewing it.’ They make the decision really quickly and they’re in a very informed way. Invariably, the majority now pick IDEAL IMPLANT® Structured Breast Implants.”

Do you have any advice for women who are considering breast enhancement surgery?

“Well first of all, the most important decision you can make is to pick your surgeon. The second most important choice you can make is to pick the safest product to use, or one that matches your wishes, goals, and ideals.

“So one, you have to pick a board-certified plastic surgeon. But I have to tell you, I work in Newport Beach, Orange County, Southern California. And I would think that at least half of the implants placed in my area are placed by non-board-certified plastic surgeons. What do I mean by that? Ear, nose, and throat doctors are doing it in this area. OBGYNs are doing it. General surgeons are doing it.

“And doctors don’t know. They say very truthfully, ‘I am a board-certified surgeon, doing plastic surgery.’ Dermatologists are even starting to do these. A plastic surgeon trains longer than just about every speciality out there with the exception of a few, like neurosurgery, cardiothoracic surgery. They train about the same length of time.

“So you really want someone who is skilled with both the anatomy and function, and all the potential problems that could go wrong, which fortunately are very few. But in terms of getting a result that’s excellent, you just need to pick that right person.

“The second thing is that many surgeons feel comfortable with what they trained with. The IDEAL IMPLANT has only been around for just under five years. So although there is a very large experience which is growing significantly and dramatically, sometimes surgeons are set in their ways. So it behooves patients to sometimes even educate their doctors. Say, ‘I’ve been reading about this implant. I think I would like to use it.’ And to encourage their doctors if they don’t know about it, to find out about it. It’s very simple to use. But I think that I can just see the rate of which the growth is happening with the IDEAL IMPLANT, and my personal prediction is within the next 5-10 years, it’ll be one of the more popular implants in the U.S. and Canada.”

What can you tell us about your plastic surgery practice?

“I’m part of a two plastic surgeon practice in Newport Beach, California, called Pacific Center for Plastic Surgery. In this office, we place more IDEAL IMPLANT® Structured Breast Implants than, I believe, just about any practice in the United States. As one of the lead FDA investigators, I’ve read through most of all the peer reviewed journal articles on the IDEAL IMPLANT, and that takes everyone’s experience, all the 45 investigators of all the women patients across the country, and I have access to the data that’s been published. I’m just thrilled with the results.

“I think that going to someone who has lots of experience is always one of the best choices you can make. Fortunately there are plastic surgeons across the entire United States that have that experience. We of course would welcome anyone to our practice, to educate them about their choices, and in particular about the IDEAL IMPLANT.”

Considering breast implants in Newport Beach? Contact Dr. Larry Nichter today to discuss your options. Simply call 949-720-3888 or visit www.PacificCenterPlasticSurgery.com. Dr. Nichter’s office is located at 3991 MacArthur Boulevard, Suite 320/340, Newport Beach, CA 92660. Call today for more information on IDEAL IMPLANT® Structured Breast Implants.

The Feel of Silicone Gel, the Safety of Saline: IDEAL IMPLANT with Dr. Jonathan Heistein

As a plastic surgeon certified by the American Board of Plastic Surgery, Fort Worth worth plastic surgeon Jonathan Heistein is part of an exclusive group of surgeons eligible to offer the IDEAL IMPLANT® Structured Breast Implant to his patients pursuing a breast augmentation. In a recent interview, he discussed the benefits of this new, innovative structured implant.

What are the different breast implant options available?

“Over the years, breast implant technology has changed a little bit. The choice for many, many years was either the standard saline implants or the newer silicone gel implants. Now we have a third option, which bridges the gap and has some of the best properties of both worlds. The IDEAL IMPLANT is a structured implant and so it offers the ability for the implant to maintain its shape a little bit better than a saline implant would, yet has some of the better qualities of silicone gel in terms of it being softer and more natural feeling.”

How do you help your patients decide what type of implant is right for them?

“When a woman comes in for a breast augmentation consultation, in addition to discussing all of the pros and cons of each of the styles of implants, I allow them to feel each one, see each one, and see how each one looks on them. They are able to try them on. I present the data in an unbiased way, so that they can see what the literature says about the implants in terms of the rupture rate and contracture rate. It gives people who want to have that information a better understanding of what they are choosing.

“Many women come in unsure of the kind of implant that they want. Some have heard good things about silicone gel, and some have heard bad things about silicone gel. They may have preconceived notions about one of the other. But if I present them an unbiased opinion and give them the facts about each one of those, many women are now choosing the IDEAL IMPLANT as a viable option, which can give them some of the properties of a saline that make it better and some of the properties in silicone gel that make it better.”

What happens when a woman with silicone gel implants experiences a “silent rupture” and wants to change her implant type?

“In general, when a silicone gel implant ruptures, it can be problematic. But for women who don’t want to deal with the problem of not knowing that they’re ruptured, then a saline or a ‘structured implant’ might be a better choice. When there’s a ruptured implant and an exchange is planned, I don’t think that the style of implant going back in really has much of a change of the outcome. The majority of the operation, the hard part of operation, is making sure that all the implant, implant material, and sometimes scar tissue, is removed appropriately. But once that groundwork has been laid, the process of putting in that new implant is pretty straightforward.”

How do you help women determine the cup size that will best fit their body?

“Determining size is one of the most important things we do at the consultation for a breast augmentation, because that is ultimately what determines the outcome. First, I find out what each patient’s goals are. So if they’re a B cup bra, and they want to end up something like a D or a C, that can give me a basic idea of where we should start. The first thing I do is take some measurements. That’s important to understand the dimensionality of the implants, and how they’re going to look and function. It also allows me to help decide which implant might look most natural based on those dimensions. Once we’ve determined the dimensions and what would fit and what wouldn’t, I allow patients to try on the different sizes in a bra that we provide for them. They look in the mirror and see what they look like and feel what they look like. This way they can really see what they are getting into with each volume.”

Why do you like the IDEAL IMPLANT® Structured Breast Implant?

“As a surgeon, the IDEAL IMPLANT offers some advantages over both saline and silicone gel. The biggest advantage is that it’s useful for women who worry about having a ‘silent rupture’ with a silicone gel implant. So the IDEAL IMPLANT, like saline implants, if there’s a rupture, it will deflate and you will know it right away. The other thing that’s very nice about the IDEAL IMPLANT is that it maintains the shape of the implant like a silicone gel implant would due to the structure that’s inside the implants. It combines the best of both worlds because there’s no risk of ‘silent rupture’ and there is no need for frequent MRIs. That’s also another added benefit that women like in choosing the IDEAL IMPLANT.”

What kind of response do you get from your patients that choose the IDEAL IMPLANT?

“I think that my patients that have come to the conclusion that the IDEAL IMPLANT is the right implant for them, are usually very comfortable and happy in their decision. Most of my patients, no matter what type of implant they use, are usually very happy with their breast augmentation outcome because I’ve involved them in the process of helping them decide how big they are and where the incision sites are going be. They have almost full control over deciding the outcome. My IDEAL IMPLANT patients seem to be very well informed and very happy with both their physical outcome and also their mental outcome as well.”

What is the recovery process after receiving a breast augmentation?

“The recovery process is fairly straightforward. If you take it easy and don’t try to over exert yourself or do more activity than is recommended, most often you will heal just fine. Problems can occur if you go back to activities too quickly or you pull or push something too heavy, then it might displace the implant or cause bleeding. The best advice is just to follow the directions that your surgeon gives you. Most of the time that’s going to be to limit your activity, use a compression bra or a sports bra, and to sometimes do some massage techniques which are shown to you usually at the first or second postoperative visit.”

What if a woman wants a breast lift and a breast augmentation?

“Some women come in and they have breasts sagging in addition to the fact that they want more volume. In those situations, I offer a breast lift at the same time as an augmentation. It does increase the complexity of the procedure a little bit, but it is convenient to be able to accomplish both of those goals at the same time. And so most often we do it that way. It changes the approach a little bit. The scarring is a little bit different, but it all depends on how much sagging and how much rejuvenation is necessary to determine the course of that. The surgery, when a breast lift is combined with an augmentation, is a little bit more complex than just having breast augmentation by itself. The cost is a little bit higher. The recovery is a little bit longer. But for most young, healthy patients without any other medical problems, the recovery period is quite simple and uncomplicated. It generally goes along without any hiccups.”

How do you address concerns about placement of the breast implant and potential scarring?

“In terms of whether I put the implants on top of the muscle or under the muscle, almost 100% of the time I recommend that women put an implant underneath the muscle. I think it offers some significant advantages and very, very few women are candidates for the other approach. Initially, in terms of some women who have already had implants put in on top of the muscle, if they come in for an exchange, for a new implant, many times in those situations, I’ll keep them in the position that they are. But for a primary breast augmentation, almost always I recommend that they go under the muscle.

“With relation to the approach and what scars to use to get that implant in, there are three main options. The underneath breast or the inframammary fold approach, that’s my most preferred and most common approach. Also the incision can be put around the areola on the underside of the areola, and that’s a viable approach. It has some advantages and some disadvantages, but certainly a useful technique when I’m already making an incision around the areola for another purpose. Then a third approach is in the armpit. It’s an option, but seemingly one that I probably use least often.”

What should women consider when searching out a plastic surgeon?

“I think it’s hard sometimes for patients to understand what doctor to go to. The first and most important thing I think women should look at is if their doctor or their intended doctor is board-certified by the American Board of Plastic Surgery. That is very easy to find out by going to the American Board of Plastic Surgery website. Once that piece is covered, I think that there are ways to find a doctor that you can trust. Word of mouth of friends or family members that have also used a doctor for a similar reason, or else somebody in the healthcare field that knows which plastic surgeons are better than the others. I think asking for advice from people that have been down the same route is a great way to start. If you don’t have any of those options available, then looking at various websites like realself.com can give you some insights into the doctors in your area that are worth seeing.

“I think that many of my patients are referred to me by word of mouth from other patients of mine that have had good outcomes. I believe that’s a really good way to find out if your surgeon is reasonable, acceptable, and willing to work with you to achieve the goals and outcomes that you desire. My patients are typically very happy with their outcomes, mostly because I start off by educating them about the options, allowing them to help in the decision-making, and then giving them the operation that they are requesting. I’m lucky enough to have a great support staff that really helps our patients both before and after surgery, and become a valuable resource in that process to be able to answer questions and help with anything that might go on.”

Considering breast implants in Fort Worth, TX? Contact Dr. Jonathan Heistein today to discuss your options. Simply call 817-820-0000 or visit www.drheistein.com. Dr. Heistein’s office is located at 521 West Southlake Boulevard, Suite 175, Southlake, TX 76092. Call today for more information on IDEAL IMPLANT® Structured Breast Implants.

What is a Structured Breast Implant? Dr. Steven Ringler Explains the IDEAL IMPLANT

If you are considering a breast augmentation, it is important to know all your options. Dr. Steven Ringler, a board-certified plastic surgeon, helps his patients understand the different types of breast implants available. In a recent interview, Dr. Ringler outlined how the new IDEAL IMPLANT® Structured Breast Implants are different from saline or silicone gel implants.

Describe your practice and work experience as a plastic surgeon.

“My practice is totally dedicated to cosmetic or aesthetic surgery. I have been in plastic surgery for over 33 years. My practice is divided about a third facial cosmetic surgery, a third breast and cosmetic, and body contouring the remaining third. I see patients from our local community, but I also see patients from out of town. We have a beautiful facility, very private, with a great team of employees and staff to help patients make decisions about what’s best for them. My cosmetic practice patients are happy. They’re treated with respect. We’re good at listening and learning what patient’s goals and expectations are, and trying to meet those with procedures and treatments we have to offer.

“Many years ago, a patient asked me what I would do if it was my wife, and at that time, it was saline or silicone gel. I said saline without hesitating. I made a decision at that time, that I would specialize in saline breast augmentation because I thought it was a better option for women, and I don’t regret that decision. I’ve always done saline and silicone gel, because I’ve always made it a patient’s option. I think that it is important that the patients have options, and that’s why I like to offer options to patients – saline, silicone gel, and now the IDEAL IMPLANT. I think these are three great options for patients. I don’t think any patient that I see now can’t come up with a decision given those options.”

How do you help your patients achieve their goals?

“I try and manage expectations by getting a really clear understanding about what the patient’s goal is, and what their expectation is. Size is a big factor. We use computer imaging to help with that. We also use external sizers and clinical photographs to help with that. Patients will occasionally bring in photos that they think look good, that they’ve downloaded, and I’ll review those with them. I think the most important thing is that the patient has a pretty good understanding about what the size and shape of the breast is going to look like, and if they need a lift or they don’t need a lift. It’s really important that they understand that. I think that if you’re really good at communicating those points with the patient, and have a long conversation about it, they’re going to be happy with the result. I have a very high level of satisfaction in my patients. Very rarely do I have a patient coming back asking for something to be revised, unless they’ve had an issue with scar tissue or implant position, which is a risk of the surgery.”

How do you help women decide between traditional saline implants, silicone gel implants, and IDEAL IMPLANT® Structured Breast Implants?

“I think it’s really important, as a physician, to educate the patient. That’s part of the informed consent process. I think patients need to understand what their options are. It’s their body. They need to make the decision. That being said, I don’t feel that a ‘gummy bear’ implant is a good option really for anybody anymore, especially with the issues that are coming up with the ‘textured’ implants. I don’t use any ‘textured’ implants, and many of my colleagues have stopped using ‘textured’ implants because of concerns over long-term safety.

“If someone comes in asking for a silicone gel, and I think their physical dimensions are a good fit for the IDEAL IMPLANT, then I generally tell them why I think the IDEAL IMPLANT is as good. I let them feel the implant. I show them the differences between the implants, even the same size IDEAL IMPLANT sitting next to a silicone gel implant has a different shape. I explain to them why I think the shape is better, and then I show them clinical photos of patients with standard implants and the IDEAL IMPLANT. The uniform response is, ‘I like the IDEAL IMPLANT results better. Those look better.’ So it’s fairly easy for me to convince patients. They know I think it’s better. I tell them I have a very strong bias that way. But most patients, by the time I’m through discussing the differences, they pretty much agree with me.

“I still have patients that will end up choosing a traditional saline implant. I had one patient with a very broad chest, and as a result, I thought it would be a better fit for her. She wanted a very large implant. I was concerned that the IDEAL IMPLANT might have too narrow a base diameter. But then there are also patients who I recommend the IDEAL IMPLANT, and they make the decision. A lot of patients come in and they say, ‘Well, if you’ve been getting great results with traditional saline, and my girlfriends have saline, I’m good with that. I don’t see the advantages.’ I have others that say, ‘I want the latest, the greatest thing.’ They want the IDEAL IMPLANT. And I do get good results with both. So it’s a little bit of a unique situation for me to come up with a reason why I should switch. But now that I’ve seen the clinical results, I tend to recommend the IDEAL IMPLANT over traditional saline, if all other things are equal.”

Why do you like IDEAL IMPLANT® Structured Breast Implants?

“As soon as the IDEAL IMPLANT became commercially available, I began using the product. It’s a great advancement because it’s really the best design change that I’ve seen in implants throughout my entire career, especially being a big fan of saline implants.

“I’ve done a little over 50 patients with the IDEAL IMPLANT. When I first started using them, my staff that uploads my photos, they started telling me I was getting better results. I always thought I had pretty good results all along, so to find out from my employees that the IDEAL IMPLANT results were better, I started looking at them, comparing them to my saline breast augmentation that I thought were pretty good. But I think what I’ve really noticed with the IDEAL IMPLANT, is I think the shape of the breast is quite a bit better. Patients have had a very high level of satisfaction. I’ve not had anybody come back saying that they weren’t happy with the IDEAL IMPLANT. And now, I’m getting many patients coming in who have heard about the IDEAL IMPLANT. They’ve seen them online. They’ve heard from other patients. They’re starting to ask for the IDEAL IMPLANT by name.

“I like the shape of the IDEAL IMPLANT. I think the clinical results are better, especially in women who have very little breast tissue and have lost a lot of breast volume. Even with a silicone gel or traditional saline, I don’t think I get as good a shape in those patients as I’ve been seeing with the IDEAL IMPLANT. So that’s been very important to me.”

How do you educate women about the advantages and disadvantages between a saline implant and a silicone gel implant?

“When I’m talking to patients about implants, I always talk about silicone gel also. If it’s a silicone gel implant, I tell them that many surgeons are recommending replacement every 10 to 15 years. I also tell them the issues about requiring an MRI. With a traditional saline or the IDEAL IMPLANT, I tell them my 20-year data is 1.8% deflation rate. [Note: For the IDEAL IMPLANT, the seven-year data shows a 1.8% deflation rate.] So I’m an optimist, 98% don’t leak. If the implant doesn’t leak, and they’re not having problems with implant position, there’s no reason to replace the implant. Nobody can guarantee that the implants are going to last their whole life, but I have patients who’ve had saline implants in for 30 years and are doing just fine. At that point, there’s no reason to replace them, unless they’re having an issue. Maybe later in life their breast volume will change, they’ll want a smaller implant or a bigger implant. That’s a possibility. There’s not a long-term necessity to change the saline implant if they’re not having problems.

“Clearly I like the advantages of saline over silicone gel. I like the safety of saline over silicone gel. I don’t think that women are going to get MRI’s every three or four years to monitor their silicone gel implants. I’ve taken out hundreds of ruptured silicone gel implants during my career. It’s a big operation, removing the silicone gel. If I never see another silicone gel implant related problem, I’d be very happy.

“With the saline implant, if it leaks, it’s a very easy thing to change. There’s minimal downtime, and it’s minimal inconvenience to the patient. A saline implant is not subject to monitoring. They come in for an exam, they look at themselves in the mirror, and they can tell if their implant is leaking. I do think that the double-lumen of the IDEAL IMPLANT is nice because it’s never going to totally deflate. Patients don’t have to worry about that. It’s still going to maintain roughly 60% of its volume, even if the outer shell leaks. That seems to be reassuring to some patients. Overall, I’ve just been very happy and find myself more enthusiastic about the IDEAL IMPLANT. As I use the IDEAL IMPLANT, the long-term results I’ve been seeing, they feel natural. I can’t tell the difference between the IDEAL IMPLANT and a silicone gel implant when I examine the patient. I have to look at their chart to know what they have in.”

How do you help your patients determine an incision location and the placement of the implant?

“I see a lot of patients specifically because they want a transaxillary approach. I feel that I can get an optimal result, without a breast scar. This is a cosmetic operation. I don’t see why we should ever put a scar on the breast if we don’t have to. I see patients back for other procedures or for long-term follow up, and I can’t even find their axillary scar. They’re thrilled with that.

“There are some situations, due to the patient’s anatomy or personal preference, where they want an incision in the breast fold. I’m certainly qualified to do it that way, but I just don’t see any advantage, for the majority of patients, to have a scar on their breast. With the IDEAL IMPLANT, I’ve not had any issues using them through the armpit. I know there are some other surgeons in the country that are doing it that way. I actually find it goes really smoothly.

“For patients who need a lift, and we’re talking about an implant, and I’m going to use the IDEAL IMPLANT, I still as a general rule put the implant in from underneath the arm because I feel like I get better muscle coverage of the implant, and I don’t expose the implant to the breast tissue. Many surgeons believe that this is somehow protective, whether it’s low-grade bacteria or what’s called biofilm that might be from exposing the implant by inserting it through a breast incision. That may be reduced. I looked at my long-term data with saline implants, and have had extremely low incidence of capsular contracture. I’ve always attributed that to the transaxillary approach. I can’t prove that because I don’t have a double blind study, but I think many surgeons in the community feel that that does protect the implant, so I still use that approach, even when I’m doing a lift.

“Also, I almost always put an implant underneath muscle. I do only in a very rare situation where the patient insists that it be in front of the muscle, and then it’s a much longer conversation because it’s a higher rate of capsular contracture. I don’t think the results look as natural. I’ve never put the IDEAL IMPLANT or saline implant in front of the muscle. I’ve only used silicone gel in front of the muscle, and that goes back to my earlier career. I don’t really look forward to doing that again, unless a patient really had a unique situation. I think in the last 10 years, I’ve done that once where the patient had insisted on it.”

What should women consider when they are researching plastic surgeons?

“I think the most important thing that any woman can do that is interested in breast augmentation, start by seeing a board-certified plastic surgeon that has extensive experience in aesthetic breast surgery and offers patients options, whether it’s silicone gel, traditional saline, or the IDEAL IMPLANT. They have options and experience to really address patients concerns and meet their needs. That’s the best way to have a good outcome for the surgery, and minimize any risks.”

Considering breast implants in Grand Rapids? Contact Dr. Steven Ringler today to discuss your options. Simply call 616-328-8800 or visit  www.stevenringlermd.com. Dr. Ringler’s office is located at 1151 East Paris Avenue SE, #200, Grand Rapids, MI 49546. Call today for more information on IDEAL IMPLANT® Structured Breast Implants.

Breast Implants: Silicone Gel Concerns and How to Avoid Scars