Part I – What three dimensional imaging systems are

I have always enjoyed technology. Since I was a teenager in the early 1970’s, I loved electronics (computing wasn’t even a hobby back then). For my pre-med major in college, I studied Biomedical and Electrical Engineering at Northwestern. It was there that I obtained a strong background in computers and emerging biomedical technologies. During the latter part of my plastic surgical fellowship training, I saw the advantage to know not only how to operate computers and run software programs, but to learn how to develop tem as well. Several of the software applications I developed over ten years ago, are still in use in my practice today.

When I was a surgical resident, I remember visiting a young plastic surgeon that had a computerized imaging system. It consisted of an inexpensive, low resolution video camera, a computer (one of those early PC’s) and a monitor. He took a photo of my face and showed me how the software could change the image. He deftly demonstrated how he could take my nose, remove it from my face and replace it back, this time upside down. Kind of a cool curiosity, but is it worth it? That was about twenty five years ago. Over the years, I have seen a couple of such imaging systems that could take a two dimensional image (two dimensional means a flat image with height and width, but no depth) and manipulate it somewhat. I was pretty unimpressed by what I saw, until recently.

I practice plastic surgery in the same office as dermatologist Dr. Elyse Rafal, who also is my spouse. Dr. Rafal has always been involved in clinical drug trials with various pharmaceutical companies. These studies rely on high quality, consistent, reproducible photographic imaging. Over the thirteen years I know my wife, I cannot remember a single drug study that required imaging that did not have customized photographic equipment developed by Canfield Scientific, in Fairfield, NJ.
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There are many things that we invest in. Most of the time when we think “invest” we envision a plan to take an initial financial commitment and place it somewhere so that it enhances in value. Although worthwhile, there are other great ways to invest your money. We do this all the time and not think about it. We invest money and time in our own education or that of our children so that we (they) can have an enhanced earning capacity to hopefully lead a more comfortable and secure life. We invest time to find the right home, car, vacation. We invest our emotions in finding the perfect spouse. I write this on the day of my eleventh anniversary, for instance. Investing all comes down to making oneself happier and more secure.

Cosmetic surgical procedures such as breast implants, breast lifts, tummy tucks, facelifts, rhinoplasty and liposuction are often seen as a luxury, maybe even frivolous. But when you think of it, it really isn’t. It may help you feel more secure and confident about yourself; more comfortable within your own skin, so to say. And unlike a vacation, a car, a boat, a new entertainment system, the results obtained with cosmetic surgery are longer lasting and appreciate with time. How do you place a value on feeling good about yourself, being more self-confident?

Let’s talk about Botox. An average treatment may run $600 for about 40 – 50 units of Botox. If the Botox treatment lasts, conservatively speaking 90 days (sometimes up to 120 days), the cost per day is about six dollars per day to look younger and more refreshed.

Cosmetic surgery is even more of a value. The most common cosmetic surgical procedure is breast augmentation. The approximate cost of breast implant surgery on Long Island is around $7300.00. Although you never need to change a perfectly good breast implant, device failure is about one percent per year. So at twenty years there is a twenty percent chance of needing to replace a breast implant. So let’s say the duration of the breast implant surgery procedure is twenty years. Twenty years is 7300 days. So for just one dollar per day, you can feel better about yourself. Isn’t that worth it?

Introduction – read this only if you are serious about breast augmentation and want to learn more…

Breast augmentation is probably the most common cosmetic surgical procedure performed today. There are many options to consider: type of implant (saline or silicone gel), shape (round or anatomic “teardrop”), surface texture (smooth or “textured”), placement of implant (above the muscle or below it), implant size, technique (dual plane type I, II or III), whether or not a breast lift (mastopexy) is also needed and should it be performed at the time of surgery or later.

Most women who desire breast augmentation are good candidates for it. There are some limitations; the surgeon can only work with the tissues he is given. Some patients have issues that may compromise the results, or make the surgery a little more difficult. This includes differences in breast size, shape and position on the chest, chest wall (rib cage) asymmetry, overstretched tissue from pregnancy or weight loss, drooping of the nipple (ptosis) and drooping (“bottoming out”) of the glandular tissue.

I define a successful outcome in breast augmentation surgery as one in which the patient goes into surgery with realistic expectations, and a surgical result is delivered which meets those expectations. Because the patient has been properly educated as to what is a likely outcome, and that outcome is met, then the patient (and the surgeon!) will be satisfied with the outcome.

The key to success is education and proper decision making. Proper decision making in plastic surgery is a joint effort between the surgeon and the patient. The patient is presented with many options and decisions to make. If the patient is not properly educated as to how to consider and make the necessary decisions, then there is no assurance of a good outcome.

The purpose of this rather lengthy, detailed Frequently Asked Questions (“FAQ”) for breast augmentation is not to “wet the prospective patients appetite” for breast augmentation, rather, it is for the patient who is serious about breast augmentation and wants to learn more. The more you, the patient, educates yourself, the more you will derive from your consultation, and the better your ability to make all the right decisions to ensure that you obtain the result that you so desire and deserve. All though not all inclusive, this set of FAQ’s should well prepare you for your initial consultation with the surgeon of your choice.

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by Mark D. Epstein, M.D., F.A.C.S.

Traditionally, breast augmentation is associated with a considerable amount of pain and down time, but this no longer needs to be the case.
Breast implants may be placed either below or above the pectoralis major muscle (a muscle located just beneath the breast). The advantage to placing the implant below the muscle is that there is much less interference with mammography, as well as more soft tissue to cover the implant, making it less palpable and visible.

Pregnancy/lactation causes stretching of the breast tissue with loss of fullness and bottoming-out of the breast. Often, a decision is made to place the implant above the muscle to better fill out the breast-skin envelope; however, in these cases there is less soft tissue coverage of the implant and less support for it. Using a specially created technique called dual-plane augmentation, women with such breasts can enjoy the benefits of a breast augmentation with implant placement below the muscle.

A breast implant consists of a silicone shell (bag) filled with either saline (salt water) or silicone gel. Silicone gel filled implants were re-released by the FDA in November 2006 after extensive study. They have become increasingly popular. Saline implants are available in either a round or teardrop shape. The advantage of a saline teardrop implant over a round saline implant is that the overall breast shape will be more natural in most cases. Use of saline teardrop implants requires greater attention to detail in placement than a saline round implant. The advantage of saline round implants are that they are easier to use and less expensive. Silicone gel implants are available in a round shape only. As silicone gel round implants are more flexible in shape than a saline round implant, in my experience, I believe that the overall shape of a breast augmented with a silicone gel round implant is more natural than that obtained with a saline round implant.

Breast implants may be placed through incisions in the armpit, around the nipple or under the breast. The advantage to an armpit incision is that the scar is well hidden and there is no scar on the breast itself. Although most surgeons perform this procedure blindly, minimally invasive endoscopic breast augmentation (similar to laparoscopic surgery) provides enhanced visualization of the surgical pocket on a large television monitor, affording greater precision during the surgery.
A periareolar scar (around the nipple) is usually inconspicuous. The disadvantage to the technique is that wound healing varies greatly according to the biology of the individual and thus some women have a more noticeable scar, which would now appear on the most conspicuous part of the breast.

The most common surgical approach to breast augmentation is an inframammary (breast crease) incision. This scar is barely noticeable as the lower portion of the breasts often covers the crease and scar. This surgical approach provides the surgeon with the greatest visualization of the surgical pocket, and the ability to make internal modifications as necessary in a breast that has drooped secondary to pregnancy/lactation. The techniques best suited for you will be discussed at your consultation.

Using techniques specifically designed to reduce post-operative discomfort, the post-operative experience has been dramatically improved. Many patients return to normal activities of living within 24 hours. During the past 3 1/2 years, nearly all our patients have been able to raise their arms up high over their head before they left the recovery room. Some patients have even put on makeup and brushed their own hair before going home. Occasionally, patients have felt good enough after surgery to go out shopping or to dinner later the same day! Rapid recovery after breast augmentation surgery is the culmination of proper preoperative planning, delicate and precise surgical technique, refinements in anesthetic management, and postoperative care designed to promote a quick recovery with minimal discomfort. Average return to work is about five days, and often less. Most patients experience some mild discomfort after surgery, but overall, the average amount of discomfort and downtime after surgery have been significantly reduced while the quality and consistency of the aesthetic results have been greatly improved.

Dr. Mark Epstein is a dual board certified plastic surgeon specializing in breast augmentation, with a special focus on improving the patient experience before and after surgery.

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by Mark D. Epstein, M.D., F.A.C.S.

In my busy aesthetic surgical practice, I see many patients desiring to rejuvenate their facial appearance, but they are not sure as to what they need. They ask me if they should get Botox or fillers which is less invasive than surgery, or go with surgery for a more long-lasting result. What I will share here is my approach, which is integrated from both plastic surgery and dermatology.

The key to a successful facial rejuvenation is no different that that for any medical problem; accurate assessment or diagnosis of the problem followed by correct treatment. I have defined six key areas to assess.

1. Skin quality – Years of chronic sun exposure as well as environmental and genetic factors can induce fine lines and wrinkles, pigment changes, loss of elasticity and overall complexion problems. Here the treatment is to address the skin with topical agents. Botox, fillers and surgery have really no role here. Our aesthetician can refresh the facial skin using various types of peels and other topical agents. This does require compliance, but the reward is fresher, more radiant and youthful skin. Think of it not as a short term treatment to fix a problem, but rather as ongoing maintenance just as is proper diet and exercise.

2. Dynamic lines – These are wrinkles produced in the skin as a direct result of the contraction of underlying facial muscles. Examples include horizontal forehead lines, vertical glabellar (the area of the lower forehead between the eyebrows) lines, crows-feet(the area just outside the eyes) and vertical lip lines. Treatment requires the muscles to be relaxed. Botox is the best way to achieve this. Thorough understanding of facial muscle anatomy and function is required to selectively relax these muscles to give a more youthful appearance without producing a mask-like or surprised appearance.

3. Static lines – These are lines produced not by facial muscles but by a combination of loss of facial fat with aging and also stretching of skin and sagging due to gravity over time. Examples of these lines include the nasolabial folds (the oblique lines between the cheeks and the upper lip extending all the way down from the nose to the corners of the mouth) and the marionette (puppet) lines, which are extensions of the nasolabial folds further down the face. Although surgery can be helpful here, a very popular and effective way to treat these lines is to restore the lost volume to the face. This is done with fillers. Examples of fillers include Collagen, Restylane, Juvederm, Perlane and Radiesse. The longevity of the result varies among the different types of fillers used. For a more complete discussion of Botox and fillers, please visit www.epsteinplasticsurgery.com.

4. Loss of facial volume – As we age, even as a small child, there is loss of fat under the skin which can become pronounced when we are in adulthood. The cheeks hollow and a “tear-trough”may develop under the eyes at the junction of the lower eyelids and cheeks. Fillers work very nicely here, but surgery can improve these areas as well.

5. Sagging of facial structures – Gravity, loss of facial skin and muscle tone result in the descent of important facial features such as the eyebrows, malar area (the prominent part of the cheeks under the eyes) and the development of jowls. In this case surgery is usually the best option (browlift, facelift) although Botox can do a nice job of elevating the tail of the eyebrow and fillers can sometimes reduce the depression between the jowls and chin, giving the “illusion” of a smoother, more unified jaw line.

6. Redundant skin – Loss of skin elasticity and gravity as well as genetic factors weigh heavily on the development of redundant or excess skin. This develops over the entire face. During surgery, the skin is re-draped over the deeper facial structures permitting removal of the excess skin. Although Botox and fillers have no role in correcting redundant skin, they may be useful adjuncts after surgery to restore lost facial volume and correct wrinkle lines due to facial muscle activity

Our practice offers the services of myself, a plastic surgeon, as well as that of Elyse S. Rafal, M.D., a dermatologist (both of us board-certfied) as well as Irene Maher, an aesthetician. All of us would love the opportunity to meet with you for a complimentary evaluation.

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by Mark D. Epstein, M.D., F.A.C.S.

So you’ve decided to take the first step towards surgical enhancement or rejuvenation. You want to arrange a consultation with a plastic surgeon. How do you begin? Plastic surgery has now become extremely popular and mainstream. How do you make sense of the frequent advertisements and recommendations of others? I would like to give the reader some guidelines as to how to proceed.

Board certification – The American Board of Medical Specialties (ABMS) recognizes 24 medical specialties, and the American Board of Plastic Surgery is one of them. All other boards with the words “plastic surgery” in its name are not boards recognized by ABMS. Some plastic surgeons, as I am, are certified by more than one (ABMS) board (i.e. general surgery) prior to receiving training in plastic surgery.

Specialty – Many physicians and other health care providers are performing cosmetic surgery with varying qualifications. There are weekend courses, preceptorships and other brief ways of “learning” cosmetic surgery. Only a physician trained in an accredited plastic surgery residency is formally trained in cosmetic surgery of the face, breast, body and extremities. If you choose a non-plastic surgeon for a cosmetic surgical procedure, inquire as to the qualifications of that individual to perform that particular type of procedure.

Recommendations – A recommendation from a friend or relative who has undergone a particular type of procedure can provide invaluable information. If possible, it is always helpful to take advantage of this recommendation. In our office, we often refer perspective patients to speak with our many happy patients.

Internet – Plastic surgery web sites contain a plethora of useful information. Spend time reading the factual content on the site. Is it relevant and useful? Also, good quality before and after color photographs provide a unique opportunity to survey the quality of the surgeon’s work. I am particularly proud of our website and I invite you to visit us at www.epsteinplasticsurgery.com.

The office and personnel – Is surgery performed in an office based surgical facility? Is the facility accredited? By what organization? We are very proud of the fact that we are accredited by JCAHO ,the same organization that provides accreditation to hospitals. How were you treated on the telephone? Were the office personnel friendly, courteous and helpful? Did they make you feel special? Were you greeted properly? Were you made to feel at home? In our office, we pride ourselves on treating patients the way we ourselves want to be treated.

The consultation – Was the surgeon warm and friendly? Did he/she spend adequate time with you? (A breast augmentation consultation in our office usually lasts at least 30 -45 minutes). Did the surgeon perform a comprehensive physical examination? Was he/she able to understand your concerns and desires as well as propose and explain an appropriate plan of treatment? Did he/she listen to your questions? Did the surgeon make you comfortable about undergoing cosmetic surgery? Ask if he or she has patients that would be willing to speak with you.

Please feel free to have a complimentary consultation at our office. I promise that you will not be disappointed. I am committed to delivering the best cosmetic outcome possible. Furthermore, safety is a prime concern. We pride ourselves on performing cosmetic surgery in a highly individualized fashion within a warm, caring and nurturing environment.

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