For many women, a Mommy Makeover is a logical step to take once they have completed their families. Although there’s no specific definition of what constitutes a Mommy Makeover, in general, they usually involve a tummy tuck and some kind of breast enhancement, which could be a breast augmentation, breast lift or reduction, depending on the woman.

How soon can a woman have a Mommy Makeover?
It is my opinion that a woman needs to stabilize emotionally and physically after childbirth prior to contemplating cosmetic surgery of any kind. If they have extra weight, it is best to lose it as soon as possible; if there are any medical problems resulting from the surgery, these need to be addressed, and if there are any emotional issues, such as postpartum depression, this too needs to be treated and resolved before making such an important decision as cosmetic surgery. It is absolutely normal for any woman who undergoes cosmetic surgery and makes a substantial change in their physical appearance to undergo emotional “ups and downs.” We warn all our cosmetic surgery patients about this well before the date of surgery. Emotional depression is a normal result of the surgery, both physiologically as well as emotionally. Fortunately, as long as there is no underlying depression, it is very short lived.

To answer the question as to when to time a mommy makeover, I would recommend not making any important decisions about surgery until any post-partum depression has lifted. That said, if the depression is a direct result of the changes in your body due to pregnancy that can be easily surgically corrected such as restoring fullness to your breasts or removing excess hanging skin from your abdomen, then in those cases it might be worthwhile to make the decision to make a physical change sooner.

To your health and 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

I occasionally meet with a patient who has concerns about anesthesia. Sometimes they are concerned about giving up control and being completely asleep without knowing what’s happening. Some of them have heard or read stories about people having bad experiences with anesthesia. I’d like to share with you my outlook on how to choose the right anesthesia for your procedure here in my plastic surgery in Stony Brook, and to review with you the safety features of today’s anesthesia choices.

When deciding what type of anesthesia to employ for cosmetic surgery, I believe it is a mistake to base my decision upon a goal to use the least amount of anesthesia to get the job done. With the current state-of-the-art, modern anesthesia techniques, anesthesia is extremely safe. It is my opinion that it is more important to give you, my patient, the best possible surgical experience in addition to the best surgical result. This necessitates putting you in a “mental and emotional place” that exists without anxiety and no perception of passing time. This requires either sedation or general anesthesia. Sometimes, the line dividing sedation and general is quite vague, so it is almost irrelevant what we call it.

For those concerned about the (albeit rare) mild sore throat that sometimes comes after a surgery, it’s important to know that not all surgeries require that a tube, called an endotracheal tube, be placed down the airway. Often, an LMA (short for laryngeal mask airway) is a better choice. The bottom line for me, as your surgeon, is, “what’s the safest choice for this patient and this procedure?”

For instance, if a patient requires complete muscle relaxation (paralysis) then I can’t just heavily sedate them, because they aren’t able to breathe on their own. The anesthesia machine does that for you. However, if it is OK for the patient to breathe on their own during surgery, then sedation without a breathing tube may be the way to go.

An important consideration when we’re talking about various anesthesia choices is this: one of the nice benefits of sedation and general anesthesia is the amnesia that follows. In other words, you wake from surgery with no recollection of the events you just experienced. It’s like falling asleep for a nap, and when you waken, the procedure is over.

In terms of local anesthesia, I believe that local anesthesia really should be limited to very minor procedures or, in the alternative, procedures done upon very select patients who have absolutely no anxiety and I can obtain an adequate degree of anesthesia in a safe manner.

To your health & beauty,
Dr. Mark Epstein

Patients often ask me if they can avoid a face lift and just focus on the neck. The question is also asked the other way around: is it possible to have a facelift without a neck lift? This is my response:

With the advent of techniques that permit greater facial rejuvenation with less operating time and less risk of nerve injury (such as with the MACS lift), I believe that the neck should be treated with the face for a variety of reasons.

Aesthetic reason: The neck ages with the face. For example, they are both exposed to the sun in equal amounts (this assumes you don’t wear a turtleneck every day of the year!). It is a very rare case indeed (I’ve actually never had one) where the neck couldn’t benefit from surgical rejuvenation at the same time as the face. As I am already there, why leave it out of the equation when there is benefit to be gained?

Technical reason: If you are having the face lifted, then you need the neck skin to come up and re-drape over the jawline. It takes only a few minutes to undermine (elevate) the neck skin (I like using power-assisted liposuction with or without suction as needed). When elevating the cheek skin (I prefer the MACS lift) it is a simple extension of the surgical plane to enter the neck. After lipo undermining, this is very easy and quick. As the MACS lift is a pure vertical lift, it is a natural extension to bring the neck skin up to the jawline and at the same time elevate and tighten the platysma (the thin, flat muscle in the neck). I see little to gain by treating the neck without the face and vice-versa. Doing them together gives a much more natural look, which is what you want, right?

Give a jingle to our Stony Brook plastic surgery office if you’re thinking it might be the right time for some neck and/or facial rejuvenation. I promise we’ll guide you to the right decision for you.

To your health and wellness,

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.