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.