A Conversation with Dr. Mark Epstein
Dr. Mark Epstein has been performing breast augmentation for more than thirty years at his practice in Hauppauge, New York. Over that time, he has watched the operation change almost beyond recognition, from saline implants and long, painful recoveries to the minimally invasive, same day recovery techniques he uses today.
We sat down with Dr. Epstein to talk about that evolution: the implants he has worked with, the surgical instruments he designed himself, his enhanced recovery philosophy, his years participating in the FDA study for Motiva implants, and his current approach, Preservé minimally invasive breast augmentation.
Part 1: Three Decades of Perspective
You’ve been performing breast augmentation for more than three decades. How dramatically has breast augmentation changed?
Almost unrecognizably. When I started, we were working with saline implants that rippled easily and felt hard and unnatural under the skin. Today’s implants feel like natural breast tissue. That alone changes the conversation with every patient who sits down across from me.
The surgery itself changed just as much as the device. Early on, placement was under the muscle, and it was a genuinely painful operation with a long recovery. Now I can do it minimally invasively, above the muscle, and patients have almost no real downtime. If you told me thirty years ago that this would be routine, I would not have believed you.
What were the important milestones, and which changes actually translated into meaningful benefits for patients?
Nearly every generation of implant brought a real, meaningful benefit. The one exception was the macrotextured implants, which turned out to be associated with a rare lymphoma called ALCL. That was an important lesson for the whole field.
For me personally, the Allergan Natrelle Soft Touch implants were the first true breakthrough. But even those do not compare to where we are now with the Motiva Round and Ergonomix implants. That is a different level entirely.
You’ve worked with implants from Mentor, Sientra, Allergan, and now Motiva. What have you learned comparing them?
Having worked directly with so many systems gives you a perspective you cannot get any other way. Honestly, I did not see much real difference among the fifth generation implants, Allergan, Sientra, and Mentor. If you look at the rheology, meaning how the silicone gel actually behaves biomechanically, they are fairly similar to one another.
The sixth generation Motiva gel implants are a different story. The gel rheology, the surface characteristics, and the shell mechanics are all built differently, along with several other advances in the technology. In my experience, they simply perform better. They have the lowest rate of complications I have seen, including rupture, capsular contracture, and the need for revision surgery.
That matches the published data too. A six year study in the Aesthetic Surgery Journal followed more than a thousand patients with Motiva implants and found a rupture rate of just 0.2 percent, a capsular contracture rate of 0.4 percent, and no cases of ALCL at all (Randquist et al., 2023). That kind of evidence is a big part of why I made the switch.
Part 2: Technique Changed Too
The operation itself has evolved too. How has your approach to creating the implant pocket and placing the implant changed?
In the past, I used electrocautery, which creates heat in the tissue, to build the pocket under the muscle. Now I use a minimally invasive technique that preserves the breast ligaments and creates the pocket above the muscle, with far less inflammation than cautery ever allowed.
I am seeing better breast contours, fewer complications, and overall happier patients.
Surgeons have debated subglandular, subfascial, partial submuscular, and dual plane techniques for years. How has your thinking about implant position evolved?
None of those older techniques give the implant a truly stable anatomical home. I much prefer working above the muscle now that we have the Motiva implants available. In the past I dealt with animation and waterfall deformities, and I had a hard time achieving good cleavage because I was hesitant to place fifth generation implants above the muscle. That has all changed.
With Preservé, I do not see inferior or lateral malposition of the implant anymore. I can use a smaller implant and selectively add volume to the upper, inner part of the breast, which is where patients need it most. A smaller implant also means less stress on the breast tissue over time from gravity.
Why do you believe the way a surgeon handles the tissue during an augmentation can be just as important as the implant being placed?
Surgery is a controlled form of trauma. The less trauma I create, the faster my patients recover and return to their normal activities. Less trauma also means less bleeding, and less bleeding means a lower risk of hematoma and capsular contracture.
Part 3: You Became an Instrument Designer
At some point you designed your own surgical instrumentation. What problem were you trying to solve?
The instrumentation available at the time was not designed with good ergonomics in mind. The instruments did not grasp the tissue well, so I needed more force to hold everything in place during dissection. The lengths were not right either, which put a lot of stress on my shoulder.
After a few procedures in a single morning, my shoulder would genuinely hurt, to the point that I eventually needed steroid injections. Designing my own instruments solved that. It improved the ergonomics of the entire procedure and took the stress off my shoulder completely.
How did developing your own instruments change the way you perform the operation, and how did it change your thinking as a surgeon?
I have a background in electrical and biomedical engineering, so the way I think is built around solving problems. When something in surgery is harder than it should be, I look at whether a change in instrument design, or an entirely new concept, can simplify it.
That process taught me to approach problems with a simple rule: keep it simple. Some of the best designs I have come up with are also the simplest.
Part 4: Rethinking Recovery
Breast augmentation used to have a reputation for a painful recovery. You’ve developed an enhanced recovery approach that avoids narcotics. What changed?
I learned this approach from my mentor in breast augmentation, Dr. John Tebbetts. He challenged the standard of the time and proved that even with submuscular breast augmentation, a one day recovery without narcotics was reliable and repeatable. I adopted this immediately, well before most of my colleagues did.
Even now, more than twenty years after my first one day recovery breast augmentation, patients are still skeptical that it is possible. With Preservé, recovery is even faster. Many patients return to normal activity the same day.
Walk me through your enhanced recovery philosophy. What happens in the operating room?
It starts with the patient believing that this kind of recovery is actually achievable. In the operating room, minimizing tissue trauma and blood loss is essential. Narcotics and nerve blocks are no longer necessary.
Your philosophy is almost the opposite of giving stronger medication: perform the operation in a way that produces less pain in the first place. How do you accomplish that?
An enhanced recovery starts before surgery even begins, with the patient understanding that it is achievable. In the operating room, minimizing trauma is the priority. After surgery, an early return to physical activity is not just safe, it is essential to getting patients back to their daily lives as quickly as possible.
Part 5: Motiva and the FDA Study
Motiva entered the U.S. market following its FDA clinical study. What interested you enough about the technology to become involved?
When Motiva first approached me, I had never heard of them. I went to their website and did a deep dive into the technology behind their implants, and I was genuinely blown away by what I saw. I knew right then that these implants would eventually earn FDA approval, and that they would change breast augmentation for women in the United States.
For a patient who hears phrases like progressive gel, implant ergonomics, or advanced shell technology, what is genuinely different about Motiva implants?
Not all silicone gels are the same. The mechanical properties differ widely between brands. Motiva gels are the softest, most natural feeling gel I have worked with. The way the gel and shell move together produces less rippling than any implant I have seen.
The Ergonomix implant behaves like a teardrop shaped implant, but unlike older shaped devices, that teardrop shape forms naturally as gravity acts on the gel rather than being molded into a fixed shape. Lying flat, the implant is round. Standing up, it settles into a teardrop. That means as the implant naturally rotates inside the breast, the shape stays oriented correctly. And unlike older shaped devices, it does not need a macrotextured surface to stay attached to the breast and chest wall.
Participating in an FDA study is very different from adopting a device after approval. What did that process teach you?
I entered the FDA study in 2018, and the implant was not approved until September of 2024. That gave me six years of annual evaluations on my patients before approval, and I am continuing to follow many of these patients today as part of a ten year total follow-up commitment built into the study.
That gave me a depth of understanding about how these implants behave over the long term, not just in the first year. By the time the implants became commercially available in 2024, I was already comfortable using them and knew how to select the right option for each patient.
Have your clinical results matched what you expected going into the study?
My results exceeded what I expected going in. The breasts stay remarkably soft and natural, and I see less bottoming out and lower malposition than with any other implant I have used.
I believed in this technology so strongly that my girlfriend, now my wife, became one of my study patients.
Part 6: From Smaller Incisions to Minimally Invasive Augmentation
What does minimally invasive breast augmentation actually mean to you? Is it simply a smaller incision?
Minimally invasive means a smaller incision, yes, but just as important, it means less internal trauma to the breast tissue.
That brings us to Preservé. What is it, and how does it differ from the breast augmentation operation you’ve performed for most of your career?
Preservé is a minimally invasive technique with several real benefits. My patients tend to focus on the fact that it does not require general anesthesia, it can be done wide awake, it uses a small incision, and it comes with a faster recovery. All of that is true.
But for me, the most important thing, and what really separates it from every other breast augmentation technique I have used, above or below the muscle, is that Preservé has the lowest complication rate I have seen for hematoma, infection, capsular contracture, reoperation, and inferior or lateral malposition of the implant. It also consistently produces the most natural results I have ever achieved.
What structures are you trying to preserve with this approach, and why does that matter?
With Preservé, the circummammary ligament and Cooper’s ligaments stay intact, which keeps the implant in a stable pocket. Because there is no cutting inside the breast itself, the nerves that give the nipple its sensation are left unharmed, so loss of nipple sensation is essentially a thing of the past.
The technique also allows for a smaller implant, placed to selectively add volume to the upper and inner portion of the breast. Less implant weight means less long term stress on the breast tissue from gravity, so the shape holds up better over time. All of that adds up to a lower reoperation rate.
There’s always a danger that minimally invasive becomes a marketing term. What objective criteria should patients use to tell the difference?
If there is genuinely less trauma to the tissue, and that translates into a faster recovery, then the operation is truly minimally invasive. That is the test I use.
Part 7: The Perspective Only Time Gives You
What are you doing today that the younger version of you would have found difficult to believe?
My younger self would never have believed you could place a breast implant through such a small incision, in half the time of a traditional surgery, with no cutting inside the breast itself, a faster recovery, and better aesthetic results overall.
What did surgeons, including you, believe about breast augmentation 20 or 30 years ago that you now think was wrong?
We all believed there was essentially no reason to ever place an implant above the muscle. I now say the opposite. Time, advances in technology and surgical technique, and the data supporting this shift made that change possible.
When you evaluate a new technology today, how do you distinguish a genuine advance from something that is simply new and well marketed?
It can be difficult in the moment, but it usually does not take very long. The differences become apparent pretty quickly.
If the ideal breast augmentation means the least trauma, the least pain, the fastest recovery, the most natural result, and the lowest long term reoperation burden, how close are we today?
We are there now. My patients go out to lunch right after surgery. They get on a treadmill or stationary bike and resume sexual activity. If there was no sedation involved, some are cleared to drive again later that same day, but only once they are already home. I never let a patient drive herself home from the office after surgery. I cannot imagine a faster recovery than that, although I am sure that in time, it will happen.
You recently performed your 200th Preservé procedure. What have you learned, and what do you do differently today than when you first began?
In the very beginning, I was not sure what Preservé was capable of, and I could not predict the results. I knew they would be good, but I did not yet have enough experience with the procedure to know exactly what they would look like. I only used it on simple cases I knew would give great results, not on massive weight loss patients or anyone with significant drooping, and I certainly did not consider it for revision cases.
Today I use Preservé on virtually all of my primary augmentations, along with revision cases where the original implants were placed below the muscle. I have recently expanded to revision cases where the previous implants were above the muscle as well. I now use ultrasound on one hundred percent of cases, to make sure the fluid goes into exactly the right plane and that the dissection stays in the correct plane throughout. I have also added a few checkpoints to the procedure as a quality control measure, to make sure every step is being done properly.
After two hundred cases, I can say that Preservé has given me the best aesthetic results I have ever seen, with the happiest patients and the fewest complications. I have not had a single case of inferior or lateral malposition, capsular contracture, or infection so far. I believe Preservé represents a new era in breast augmentation, and I am thrilled to be part of it.
What do you think the next major evolution in breast augmentation will be?
I think the next major evolution will be in reoperative surgery. I have already been using Preservé successfully as a revision procedure for patients who previously had breast augmentation below the muscle and are now dealing with malposition, capsular contracture, wanting to go smaller, or an unsatisfying contour.
Revision surgery for patients who had their original augmentation above the muscle is a bigger challenge, though it is possible. I believe that will improve with time as well.
After more than three decades performing breast augmentation, are you more excited about the implant itself, or about how much less invasive the operation is becoming?
That is a fantastic question. When Motiva earned FDA approval in 2024, I was thrilled. But now, combining that implant technology with Preservé minimally invasive breast augmentation represents the most powerful advance in breast augmentation I have seen in my entire career.
It gives me a level of excitement about this field that I have genuinely never felt before.
Learn More
If you are considering breast augmentation and want to learn more about Preservé minimally invasive breast augmentation or Motiva implants, our team at Epstein Plastic Surgery in Hauppauge, New York is happy to answer your questions. Follow along on Instagram at dr.markepstein, on Facebook and Instagram at @epsteinplasticsurgery, and on TikTok at @epsteinplasticsurgery.
To learn more about Preservé minimally invasive breast augmentation or Motiva implants, call 631.689.1100 to schedule a consultation with us today.
