Please visit my dedicated breast augmentation web site www.breastimplantslongisland.com .

I have maintained a this plastic surgery web site www.epsteinplasticsurgery.com since 1999. The purpose of my web sites is to provide information to the viewer about the plastic surgical procedures that I perform. A web site without useful information of benefit to patients is nothing more than an advertisement. I have always believed in patient education and involving the patient in the decision making process. In order to do that, there has to be a concerted effort to make available useful educational material on the web site.

Breast augmentation is different than most plastic surgical operations because two foreign bodies are inserted into the body. There are many choices to make regarding this surgery: round or teardrop, smooth or textured, saline or silicone, above the muscle or below the muscle, low-medium-high or extra high profile, incision below the breast or around the nipple or in the armpit or through the navel are just some of the choices to be made.

I have yet to identify a web site as comprehensive as I felt necessary to give the viewer one good resource to use in preparation for making the right choices in breast augmentation surgery.

My new web site, www.breastimplantslongisland.com is dedicated to topics that relate only to breast augmentation surgery. The core of the web site is a tutorial I call “Breast Implants 101” that uses not only descriptive text but also illustrations as well as case material from my breast augmentation practice.

I am very proud of this web site and hope that it will be of value to all who visit.

While doing some grocery shopping tonight (yes, plastic surgeons do grocery shopping – my spouse is a dermatologist so we split the household chores) I saw this month’s Life & Style cover story “Heidi’s New Surgery Disaster.” Being a cosmetic plastic surgeon this naturally piqued my curiosity so I bought the magazine and read it when I got home.

The essence of the article is a story about how Heidi regrets all the surgery she had, about ten or so operations performed at once, at a cost of over $100,000. There is an extensive pictorial showing her multitude of scars, which are portrayed as horrific. I am not writing this blog to defend what was done, but rather to make a few comments on my observations and offer my opinion.

1. No one “needs” cosmetic surgery. Sure, we may see someone with a large hump on their nose and say they “need” to have it fixed, but they really don’t. The purpose of cosmetic surgery, as I see it, is to make a person feel better about the way they look, that is, to make them more comfortable in their own skin. There is other reason to have cosmetic surgery than to make you feel better. Never do it for someone else.

2. Do not let your surgeon “talk” you into having anything done that you are not in agreement with. Heidi discussed having liposuction on her legs, but later expressed remorse that the scars did not justify the results and that her surgeon talked her into it. As her surgeon recently and very unfortunately met a tragic end, we will never know the truth about that.

3. Surgery does not happen without scars. All humans form permanent visible scars when their flesh is wounded. Some scars are less apparent than others. As plastic surgeons, we learn how to plan our incisions, close wounds, perform surgery and handle tissues so as to minimize scarring, but we cannot eliminate it. Some patients will form scars more visible than other patients. As surgeons, we have no control over patients biologic wound healing properties. I inform all of my patients of this fact many times over before surgery is performed.

4. Surgery is stressful. Altering your physical appearance, even for the better is stressful. Combining the two can produce stress as well as emotional ups and downs in the immediate period after surgery. This is all normal, and again, I advise all of my patients about this. I even have a cute little diagram that we give them before surgery to explain this. Some patients undergo two or three procedures in a single sitting. With advances in surgical and anesthetic technique, this is rarely an issue. However, where do you draw the line? I am not sure just what the limit should be, but I do believe that ten procedures at once is probably a bit much.

5. With the exception of Heidi Montag’s breast augmentation, I think that most of her results look good. Maybe not perfect, but plastic surgery is rarely perfect. Let’s face it, our tissues are rarely perfect and the surgeon can only work with what he is given, but that doesn’t mean he can’t still deliver exceptional results. My suspicion is that Heidi was not adequately counseled before her surgery about what to expect in terms of results and scars after the surgery. As far as her breast augmentation, I think that that alone can be the subject of another blog, but suffice it to say that it is ill advised to go from an A or B cup to a G cup. The destruction to the breast tissues is irreversible and uncorrectable. A properly performed augmentation based on the natural characteristics of the breasts yields excellent, natural results with minimal risk of problems, both in the short term as well as the long term.

My advice for those interested in plastic surgery is to not be put off by Heidi’s unusual story. Her story is one of a woman with perhaps unrealistic expectations, a long list of features about her body that she wishes to correct, a surgeon who more than pushed the envelope on what in my humble opinion is reasonable and a lack of appropriate preoperative counseling and preparation.

I recommend those interested in cosmetic surgery to do your research. Spend time on the Internet looking at lots of plastic surgery websites. Learn as much about the procedure that you are interested in. Visit several surgeons. Ask lots of questions. Speak to patients who have had the surgery that you are interested in. IF you personally know people who have undergone the surgery that you wish, visit their doctor as well. An informed patient, as with any other consumer, will in the end be the happiest patient.

To your health & beauty,
Dr. Mark Epstein

Occasionally, during a breast augmentation consultation with me in our Stony Brook plastic surgery practice, a woman expresses concerns about her ability to breastfeed later on, should she wish to do so. With so many women committed to breastfeeding their infants, I want to be certain you have the facts about breast enhancements and future nursing.

Successful breastfeeding, with or without implants, is based on the ability of the breast to create milk, the ducts to carry that milk to the nipple and, lastly, the nipple to release milk to the child. That said, my personal belief is that there is potentially (although not necessarily) more risk of interference with the ducts that carry the milk from the breast gland to the nipple with a nipple incision, areolar revision, etc., than with breast implants. As I personally prefer placing the implant under the muscle, interference with breastfeeding has not been a concern at all for my patients. I cannot think of a single instance in my career when a woman told me after breast augmentation surgery that she was no longer able to breast feed, whereas she had successfully done so prior to surgery. Even in patients who have had placement of the implant above the muscle, theoretically there should be no interference with the ability of the milk to pass from deep within the breast through the ducts to the nipples.

However, in my experience with women coming in for breast reduction, I’ve seen women who said they had been unable to breast feed. Whether this is size related is unknown, but this was not due to an implant.

If you have questions about breast enhancements, be sure to call our office for information.

To your health and beauty,
Dr. Mark Epstein

Silicone is material that has a rubbery texture. A breast implant consists of a solid silicone shell (bag) filled with either saline (salt water) or silicone gel. All breast implants are made by spraying a mold with or dipping a mold into liquid silicone. When the silicone dries, the implant is then peeled off the mold. When the implant is removed from the mold, there is a small opening on the back (underside) of the implant where the mold was attached to its supporting pole. A silicone patch is then applied to seal the implant. To make a silicone gel filled implant, a needle is inserted through the patch to inject the silicone gel. To make a saline implant, a separate valve is attached to the front of the implant. Silicone gel filled implants are inserted pre-filled with silicone gel, but saline implants are inserted deflated. First, a fill tube is attached to the implant and then the implant is rolled up like a cigar. Once inside the breast, saline is inserted into the implant via the fill tube. The fill tube is then removed when the implant is fully inflated, and the valve plug is pressed into the valve to seal it.

Silicone gel filled implants were re-released by the FDA in November 2006 after fifteen years of extensive study. Silicone implants have become extremely popular.

THE FILLER: Silicone gel is “cohesive” filler where saline is not. This means that the silicone gel holds together and does not disperse should there be a disruption in the silicone envelope that contains the gel filler. The more “cross-linking” of the silicone, the more the gel tends to retain its shape, a term called “form-stable”.

SHAPE: Saline implants are available in either a round or a teardrop shape. The advantage to a saline teardrop implant is that the overall breast shape is more natural in most cases. Use of saline teardrop implants requires greater attention to detail in placement than a round implant. A common criticism of teardrop implants from my colleagues is that they turn once inside the breast (not true for a first time augmentation) and that later on they look the same as round implants. When I look at my own results with saline teardrop versus round implants, I believe that the shape of the breasts with the teardrop saline implants is clearly superior to those with the round saline implants. If you view the cases on my web site, www.epsteinplasticsurgery.com, I think that you will come to the same conclusion.

Silicone gel filled implants are available in a round shape only. However, due to the cohesive nature of the gel filler, the round implant tends to give a more natural appearance of the breast than a round saline implant. When reviewing my own cases, (again, you can see them on my website), I think that you will agree that the appearance of the round silicone gel implants is similar to those of the teardrop saline implants.

EASE OF USE: The advantage of saline round implants are that they are much easier to use and less expensive than teardrop saline implants. There is a definite “learning curve” to using teardrop implants. If you are placing saline implants, I do agree that the teardrop implants should be highly considered. As of this writing, silicone gel implants are only available in a round shape, and thus easy to place, but because they are prefilled and cannot be rolled up, require a slightly longer incision than saline implants do, but not enough to warrant a choice of one or the other.

FEEL: Due to the cohesive nature of the silicone gel filled implants, in my experience (and my patients agree) the breasts augmented with silicone gel implants feel much softer and more natural than those with saline implants do. Breasts with saline implants feel much more firm and unnatural. The more soft tissue that you have to cover the implant (muscle and particularly breast tissue, the less palpable a saline implant will be. However, understand that as the breast ages, and then undergoes changes caused by pregnancy and lactation, it will atrophy (the tissue thins out). As atrophy occurs, a previously less palpable saline implant may not be noticeably visible and easily palpable. I have seen this happen in a few patients who underwent augmentation prior to pregnancy and then returning a year or so after childbirth.

RIPPLING/WRINKING: There is far less visible and palpable rippling and wrinkling with silicone gel implants over saline implants (14 times less!).

SAFETY: Silicone gel implants were used for many years in this country, as well as in many countries around the world, until 1991 when the FDA enacted a moratorium on their use, pending the results of several studies designed to examine the safety of the device. On November 17, 2006, the FDA approved the use of silicone breast implants for breast augmentation and reconstruction. Breast implants are the most studied medical devices in history.

Silicone is biologically inert. This means that there is no reaction between silicone and the body. You cannot reject silicone nor be allergic to it. There is absolutely no connection between breast cancer and breast implants. Studies have shown that the incidence of breast cancer is the same in women with breast implants as those who do not have them. Furthermore, in those that do develop breast cancer, the stage of breast cancer at detection is the same for within with and without breast implants.

The safety of silicone-filled breast implants is supported by extensive pre-clinical device testing, their use in approximately 1,000,000 women worldwide and nearly a decade of U.S. clinical experience involving more than 80,000 women. These carefully designed medical studies have proven that there is no connection between breast implants and any other disease processes.

LEAKAGE/TEARS: Both saline and silicone gel filled implants are safe. Should a saline implant develop a tear or even a pinhole leak, the implant will deflate in about 48 hours. Leaks can also occur at the fill valve, which is not an issue with silicone gel implants which do not have a fill valve. When the implant deflates, the breast will be noticeably smaller and feel much different than it was a few days before. Should a silicone implant develop a pinhole, the gel will most likely stay inside the implant due to the cohesive nature of the gel? Should a larger tear occur, there may be some movement of the gel out of the implant. However, the gel would be contained by the normal scar tissue “capsule” that forms around all breast implants shortly after implantation. If a problem occurs with a gel implant, you may notice a change in the shape or feel of the breast, or experience some mild discomfort. An ultrasound of the breast is an excellent way to detect the presence of a problem with a breast implant. Actual rupture rates are extremely low, approximately 1% per year.

PATIENT SATISFACTION: Based on the research collected in the US and the practical experience gained outside of the US for the past 25 years in over 60 countries, where both silicone and saline have been available to women and 90% of the markets prefer silicone, women generally find silicone breast implants to look and feel more natural than saline implants.

RESTRICTIONS: Saline implants are approved by the FDA for use in women 18 years and older. Silicone gel filled implants are approved for women age 22 years and older.

COST: Silicone gel implants do cost a little more than saline implants, but it is my opinion that the difference should not be enough to be a factor in selecting which type of implant you which to have.

The FDA’s decision confirms that silicone gel-filled breast implants are a safe and effective option for women seeking breast implant surgery. Now, with the FDA approval of Silicone-Filled Breast Implants, I am able to offer a broader range of options to all of my patients, many of whom desire to rejuvenate their breasts after child bearing, or enjoy a fuller shape for which nature has otherwise denied them.

Breast implants are placed into a pocket under the breast. The terms “above the muscle” and “below the muscle” are frequently bandied about. Which is better? Patients have opinions, surgeons have opinions. Certainly, I, a plastic surgeon who has performed a fair number of breast augmentations, have an opinion. Before I render than opinion, let’s review the pertinent anatomy.

Below the breast is the pectoralis major muscle. It is attached to the chest wall along the lower, inner portion of the breast, then along the entire side of the breast bone. The muscle spans across the chest like a triangle, and attached to the upper arm bone called the humerus. Below the muscle lies the chest wall, essentially the rib cage.

To place the implant under the muscle, a pocket is created by lifting the muscle off the underlying rib cage. The attachment of the muscle to the overlying breast remains undisturbed. To place the implant above the muscle, the breast is lifted off the underlying muscle. The attachment of the muscle to the underlying rib cage is undisturbed.

So, which is better? In either case, you have a pocket, and in that pocket you increase the size of the breast by inserting an implant. Theoretically, it should not make much difference. Theoretically yes, but in practice, quite the opposite. Consider the following:

1. The more soft tissue (breast and muscle are both examples of “soft tissue”) that is placed over the implant, the less visible and palpable the implant will be. If the patient has nice, thick, firm breast tissue, then it may not make too much difference which route you take. Certainly, if the tissue is naturally thin, or thinned out by atrophy after pregnancy and lactation, if will matter greatly which route of placement is utilized. Also, consider that with time, everyone (unfortunately) ages and that results in thinning (atrophy) of tissue.

2. The muscle is subject to less stretching that the skin and breast tissue. It acts like a stabilizer to prevent overstretching of the breast pocket (to some extent).

3. There is (according to my friends who are radiologists specializing in breast imaging) less interference with interpreting mammography when the implant is below the muscle. This statement is purely anecdotal and not based on any personal experience as I do not interpret mammograms.

4. It is no easier to place the implant above the muscle than below it, and probably requires a little more surgical effort, although not enough to make any difference to persuade the surgeon to choose below the muscle placement.

5. Despite the fact that the muscle is being partially cut with placement below the muscle, I do not believe that there is any more discomfort or downtime in using below the muscle placement. I utilize a rapid recovery method with below the muscle placement and my patients require no more than Advil for discomfort and are driving the next day.

So then, what is the reason surgeons choose to place implants above the muscle? There are a few reasons. The first may seem silly, but is in fact a reason surgeons choose to do what they do. The answer is “because that is what I was taught to do”, or “because that is how I have always done it and it works for me”. That is fine, but you cannot advance as a surgeon if you don’t keep yourself open to advances. Personally, I am always on the lookout for better ways to do things. It may take some getting used to when changing up to another technique, but if it is for the betterment of my patients, then why not? If I wasn’t progressive, then I would still be writing prescriptions for narcotics like Vicodin instead of just Advil after surgery, wrapping my patients is straps and bandages instead of just a small paper Steri-Strip and telling my patients they cannot raise their arms or drive for days or weeks instead of raising their arms high above their head while still on the recovery room stretcher and driving to their first follow up visit in my office the next day. That is a whole different story; my point is that a surgeon must be up to date on the latest techniques and methods.

There is one compelling reason why many surgeons place implants above the muscle. If you have a breast that has lactated, lost fullness in the upper portion and the glandular tissue is bottoming out (some of the breast tissue lies below the lower crease of the breast), then you have a special situation, one which is also very common. If you place an implant below the muscle, then the breast mound from the implant will lie up high, but the breast tissue will slide off the front of the implant and sag over the implant. From the side, this resembles the side view of the dog “Snoopy” from the Charlie Brown cartoons. The reason for this is that the muscle is preventing the implant from moving lower into the breast where there is some sagging. If you place the implant on top of the muscle, then you no longer have this problem. However, placing the implant above the muscle will result in some other potential problems: there is now much thinner tissue over the implant, so the implant will be more palpable and visible. Also, there will be less support of the shape of the breast without the muscle. Lastly, mammography may be more difficult.

A better solution is to place the implant under the muscle using a dual plane technique. In this technique, the muscle is repositioned superiorly in the breast pocket. There is a little less muscle coverage of the implant, but there still is muscle coverage of the upper portion of the implant nonetheless. The implant can now move into the lower pole (portion) of the breast and fill it out properly. All this with no need for a breast lift.

The dual plane technique will be the subject of a future blog on this website.