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How can I know what cup size I will be after implants? July 11, 2012

Posted by bosshardt in Uncategorized.
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Many questions have a simple answer and a more complicated one. The simple answer to this question is: you can’t, at least not precisely. The more complicated answer has to do with all the variables that come into play when discussing breast implants and size.

Most women know that when they buy bras of the same cup size from different manufacturers, they may not fit the same way. Different cup sizes from different manufacturers may fit the same. The reason for this, and what makes discussions of breast size so difficult, is that there is no standard for what an A, B, C, D, or other cup size really is. In a vault somewhere, in the National Bureau of Standards, there is a 12 inch ruler that is the standard for what 12 inches means. All rulers are made to that exact standard so that all 12 inch rulers are of identical length. No comparable standard exists for bra cup size. All manufacturers make bras to their own particular standards, which is why a B cup bra from one manufacture may fit you the same as a C cup from another.Victoria’s Secret bras are consistently smaller than other bras. I think this is to make their customers feel good that they can wear a C or D cup, when bras purchased elsewhere are B or C cups, respectively.

There are also multiple methods for measuring women for bra size and these can yield different cup sizes for the same person, further adding to the confusion.

Patients frequently come in requesting a particular cup size that they wish to be after their implant surgery. There is no direct correlation between how many cc’s of fill an implant contains and what that implant will do to a specific patient’s cup size. I have seen the same implant not increase the cup size at all (the patient simply filled out her existing bras more fully) in one patient, increase cup size by one in another patient, and increase it by two cup sizes in yet a third. There is no formula or computer program that can precisely and consistently predict what cup a patient will wear after their surgery. Some women like to wear their bras tighter, others looser, and some like padded versus non-padded bras. The variations are endless.

Another challenge for the breast implant surgeon is to anticipate what will make the patient happy. This can be difficult to do. We cannot put ourselves into the patient’s mind to know with certainty what they are looking for. We listen to what patients tell us. Some patients are very concerned about being too big after surgery and in those, we will be a bit more conservative with our choice of implant. Others want to be very full, even “showy” , and for those we will choose a larger implant. Some patients want the biggest implant we can give them, regardless of whether they will look natural or not.

To “size” patients, I first listen to what they tell me their desires are. I ask questions and try to determine to the best of my ability what they are seeking. I examine the breasts to assess their natural size, shape, presence of asymmetry, looseness of the skin, quality of the breast tissue, and anatomy of the chest. I take measurements. Putting all of these together, I can come up with an educated guess, or at least a range, of sizes that might work. I do not make a final decision until surgery. There, I prepare the breasts for the implants then insert a breast sizer, a temporary implant that I can inflate to any size I wish. By doing this I can see and feel, exactly what the implant does to the breast. Knowing how the implants are likely to settle out, I can usually choose a nice size and one that the vast majority of patients will be happy with. There are always 3 other people in the room with me; two nurses and an anesthetist, and everyone has an opinion. I cannot recall that we have ever disagreed on what looked best for any patient.

Some women overlook the fact that what they give me to work with will determine, to a great extent, the best implant for them. Patients with smaller body builds, smaller breasts, tighter skin, etc. will obviously not be able to accommodate the same size implant as someone larger, with more, looser skin will. If I try to put too large an implant into a breast, I will stress the tissues more and there is a greater chance that the implant will not settle properly, that it may buckle or fold (which raises the risk of implant failure and leakage), that it may be too easily seen or felt, and/or that the breast will not look good years down the road.It is always risky to compare oneself with one’s friends who have had implants as their situation may have been very different. Ultimately, every patient is unique and cannot be fit exactly into the same mold as someone else.

Some young women, that have a very nice result from implant surgery, come in seeking larger implants because of everything from their own dissatisfaction, to peer pressure, to pressure from a partner. This poses a dilemma for the surgeon because going bigger is not as simple as changing out one implant for another. For one thing, the established implant pocket will have to be enlarged, which is more surgery. For another, the added size and weight of a larger implant may place very different dynamic forces on the tissues, affecting how the breast will look later. Bigger, heavier implants increase the risk of sagging later. Breasts that are too big  can create issues with back, neck, or shoulder pain; the types of problems we see in women seeking breast reduction surgery. They may limit women who wish to be physically active in engaging in athletic activities because of difficulty finding adequate support. Finally, exchanging implants subjects the patient to all the risks of an additional operation, including the risk of something happening that might ruin an otherwise great prior result. There is a saying in plastic surgery that applies: “the enemy of good is better”. From an aesthetic standpoint, implants that are too big just never look natural and some patients look odd, even bizarre with breasts that are too large.

The discussion of sizing and what to expect from implants is one of the most important aspects of preparing patients for what to expect and is something I spend a great deal of time on, from the very first consultation. Even so, it is not possible to anticipate ever contingency, which is why I tell patients that I cannot guarantee they will be satisfied with the size implants chosen. In my experience, patients who select their own implants are more often dissatisfied than not, usually because they choose too small a size. I suggest patients allow me to size them but I always allow for the possibility of some patients (less 1% in my experience) seeking different size implants later. I offer this type of revision at cost to cover my expenses and the cost of a new pair of implants. I do not charge for my time when doing this. I feel this is fair as both of us are picking up some of the cost of the revision.

Finally, never undergo breast implant surgery for anyone but yourself and don’t seek out larger implants unless it is for the same reason. If your partner wants bigger implants, let him get his own!

Breast sizing is part of the “art” of plastic surgery and as such, while the vast majority of patients are very happy, a few may find themselves seeking larger or smaller implants later.


Illuminating Lasers June 9, 2012

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If it involves a laser it must be better than a procedure without the laser, right? This is a common misconception which arises from our natural fascination with new technology. There is also an inherent desire in people ( or is it only Americans ) to be the first to experience the newest wrinkle, no pun intended, in plastic surgery. To understand laser resurfacing, one must know a little bit about lasers.

Laser. The word is an acronym and stands for Light Amplification by Stimulated Emission of Radiation . Laser light has several unique properties. It is monochromatic, that is, it contains only one color or wavelength of light. It is coherent, meaning that the light beam does not disperse with increasing distance from the source; the beam is focused, even at great distances. It is very powerful. The heat generated by some lasers is likened to that on the surface of the sun.

Lasers work by transmitting their energy to the material that they strike. If the material absorbs the laser light well, the laser light energy will transfer to the material which will heat up. The carbon dioxide (CO2) laser produces an invisible light which has a wavelength that is absorbed by water. When this light strikes a living cell, the laser energy is transferred to the water in the cell. If sufficient energy is transferred, the water in the cell will boil or vaporize, destroying the cell. In the past, CO2 lasers had limited usefulness in that a lot of their heat was transferred to areas around the target spot, producing too much collateral damage to tissues. The solution to this was pulsing. Pulsed lasers transmit an incredibly brief, incredibly powerful burst of laser light. On striking the skin, the first layer of cells is vaporized but before anymore underlying tissue can be damaged, the light has shut off. This allows the CO2 laser to resurface the skin, layer by layer, without producing a more extensive zone of injury, or burn. Although no longer a new technology, the pulsed CO2 laser is still the workhorse for skin resurfacing of the face and the results are the “gold standard” for this procedure. It does have the longest “down” time, leaves the skin quite pink for months, and is the most “invasive of the laser techniques.

The erbium laser heats water even more efficiently than CO2 and is very useful for resurfacing too. Both CO2 and erbium lasers have their place in the practice of plastic surgery for resurfacing needs. Contrary to claims of less postoperative redness with the erbium laser, both produce redness of the skin which is more dependent on the depth of the resurfacing than on the type of laser used.

A new technology is “fractionated” lasering. If you think of the standard laser as producing a single beam of light, fractionated lasers produce a pattern of many tiny beams. The area on the skin “hit” by the laser is smaller with intervals of undamaged skin between these. Think of multiple dots versus one big spot. This speeds healing considerably and fractionated laser procedures heal in half the time for the CO2 or older erbium lasers. The down side to this is that the results are correspondingly less impressive too. These work fine for skin with mild to moderate wrinkling but for severely wrinkled skin they may be inadequate.

Although most laser resurfacing removes some surface skin, requiring a period of healing with associated seepage and crusting of the skin, there is a non-ablative form of laser resurfacing. This uses a combination of fractionated technology with an erbium laser to penetrate the skin, without damaging it, yet producing an effect by stimulating collagen, the skin’s structural protein, to increase. The Palomar non-ablative laser handpiece is the only device at this time which is approved by the FDA for reducing the appearance of stretch marks. It is also used on acne scars and fresh surgical scars to help the fade and smooth out. I believe that this technology is in its infancy and the results tend to somewhat “hit and miss”. Some patients seem to respond great and others not at all.

Laser resurfacing is done to eliminate wrinkles, reverse some of the sun damage and aging changes in the skin, and produce a slight tightening of the skin. It is very effective. In some patients, a period of skin preparation may be beneficial to optimize the results. After 4 to 6 weeks of preparation, the resurfacing is done.

Laser resurfacing requires some anesthesia. In some procedures, we can sometimes use a topical cream applied to the skin to numb it. Local anesthesia can be used, along with intravenous sedation when necessary. Large areas, such as a full face resurfacing are often done with patients asleep under general anesthesia.

Post resurfacing discomfort, healing time, redness, and relative risks are a function of the depth of the resurfacing procedure. The deeper the resurfacing, the more effective it will be, but along with this will be greater discomfort, healing time, redness, and potential risks.

Just as pre resurfacing preparation of the skin is crucial, so is post resurfacing care. Patients need to be closely followed to be sure that everything is done to ensure optimal healing and the best possible results. Skin resurfacing of this type produces permanent results, unlike lighter salon type procedures. The skin will always look smoother and more youthful than it would have without the resurfacing.

Like all surgical procedures, laser procedures carry risks. Patients must be protected from inadvertent burns. The eyes need to be carefully shielded. Any burn, even a controlled laser burn, can produce scarring if the lasering is too aggressive. Lasers are notorious for activating the virus that cause cold sores on the lips and we pre-treat all patients to prevent this. Skin color changes can occur, both darkening and lightening, depending on the skin type and type of laser procedure. Darkening usually resolves in a few months. Lightening is usually permanent. Ultimately, one cannot guarantee the results of laser resurfacing as there are wide individual variations among patients in how they respond.

An online consultation for breast augmentation April 5, 2012

Posted by bosshardt in Uncategorized.
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Revised 04/05/12

Breast Augmentation- Information for Patients

The decision to have a breast augmentation is a major one with life-long consequences. Please be sure you understand this operation well and have all of your questions answered before proceeding. Once surgery is done, it can never be totally undone.

The only way to add meaningful volume or fullness to your breasts is to use breast implants. You cannot do exercises, take pills, use creams, or use “vacuum pumps” to accomplish this goal!! The following information is being provided to you in order to ensure that you are fully informed about breast augmentation. It is a comprehensive summary of this very popular plastic surgical procedure. Together with your consultation with me, the information contained herein should allow you to make an informed decision about whether or not this operation is for you.

Our facility-

The surgery is done in our office which includes a state-licensed ambulatory surgery center. Very few private offices in Florida have such a facility. The operating room is on par with those of hospitals and is subject to the same state inspection and credentialing. We have all the necessary staffing, equipment, and resources to perform surgery with the safety our patients deserve, and handle any emergencies. I recommend doing the surgery here because we can better preserve confidentiality, our staff are very familiar with the surgery since we do so many, and the facility costs are significantly lower than at other ASC’s or hospital operating rooms. I have admitting privileges at Florida Hospital Waterman, LeesburgRegionalMedicalCenter, and South Lake Hospital if you wish to go elsewhere for surgery, but the costs will be greater. In the event of a problem, we can transfer patients immediately across the street to the hospital. So far, I have never had to do this following a breast augmentation. Because this is a state licensed ambulatory facility, patients cannot be kept overnight. In over 23 years, none of my patients have ever been unable to go straight home after their surgery.


I perform breast augmentation under general anesthesia. Another option is using local anesthesia with heavy sedation but I do not recommend this. I do not believe sedation is any safer and it presents potential problems, such as patients feeling pain, becoming aware, or squirming while undergoing surgery, making the procedure more difficult to perform. Many practices that offer office-based breast augmentation perform this surgery under local anesthesia with sedation only because they are not accredited to do general anesthesia. We do not have this limitation. In 23 years of practice, I have never had a single patient experience any complication from anesthesia during, or after, a breast augmentation.


Several incisions are used for breast augmentation. They are along the edge of the areola (the colored skin around the nipple), in the crease under the breast, the axilla (armpit), and the umbilicus (belly button). The last one is known as the TUBA (Trans-Umbilical Breast Augmentation). I feel that it is a ridiculous approach and do not understand why anyone would choose this. It is not widely performed and only a tiny fraction of augmentations are done this way. I don’t feel that the axillary approach or TUBA have any significant advantages over the others and choose not to offer then at this time. Of the first two, I prefer an incision in the crease under the breast. My aesthetic sense is that the nipple and areola are the visual focal point of the female breast and our eyes are drawn to this area of the breast. I do not like to put a scar there. In the crease incision under the breast, no breast tissue has to be cut, in contrast to the areolar incision. In patients who make perfect scars, there really is no difference between the two. If the scar is less than perfect, it is less conspicuous underneath the breast.  My incision is an inch or less, the smallest possible, to insert a deflated, rolled saline implant. Scar revisions are almost never necessary from this incision. Gel implants require a larger incision, usually around 5-6 cm, because they are put in pre-filled.

Implant position

Once an incision is made, I have to create space for the implant. This space is called a “pocket” and can be placed either under or over your pectoralis muscle, a large, flat triangular muscle which sits under the breasts. When I examine you, I have you contract this muscle to assess its size, position, and degree of development. Most breast augmentations are done with the implant placed beneath this muscle. Advantages of this position are several. With more tissue over the implant, it less prone to be seen or felt through the skin. Under-the-muscle implants are less likely to experience tightening of the scar tissue that naturally forms around the implant. This is called capsular contracture and will be explained below. Under-the-muscle position makes it a little easier to obtain acceptable mammograms later. For some patients, such as those with very developed muscles or some breast sagging, above-the-muscle placement may be advantageous. The pectoralis muscle must be partially released from it’s attachments to the ribs in under-the-muscle placement. This should result in no appreciable loss of upper body strength or arm motion. With under muscle implants, breasts will usually demonstrate some change in shape when the muscle is contracted. This may be minimally to very noticeable. It does not cause any problem beyond this and only rarely justifies attempts at correction. Most breast implants done in theU.S.today are done under the muscle.

The Implants

On November 17, 2006, the FDA lifted the moratorium on the use of silicone gel implants for breast augmentation. This means that women now have the choice of silicone or saline implants for their surgery. I still feel that for the vast majority of women, saline implants (filled with sterile, salt water) provide a result that is on par with silicone gel implants and will for the forseeable future will continue to recommend them to my patients. They are excellent implants and provide wonderful results for most patients. One advantage to saline is that if the implants ever rupture or leak, the saline is harmlessly absorbed by your tissues and eliminated. Replacing a leaking implant is quite simple and easy to do. Women with unusually thin skin and minimal breast tissue, may benefit from the gel implants because they tend to produce less rippling. This fact may be more important when the implants are under thinner tissue. The new gel implants have a more viscous gel that will not run, so leaks should not be as messy as in the past. One of the potential problems with gel implants is difficulty detecting leaks and it is recommended that women get an MRI 3 years after implantation and every 2 years after that to check for leaks. The cost of an MRI is around $1000 and insurance will not cover this examination for the purpose of diagnosing a leak in a cosmetic implant. I do not feel that it is realistic to expect a breast implant to be in your body for decades without a significant chance of a leak at some time in the distant future.

Both saline and gel implants come in several styles. There are round/smooth, round/textured, anatomical/smooth, and anatomical/textured. Textured implants have a higher leakage rate and are more prone to show visible rippling through the skin than smooth implants. I don’t use them. Anatomical implants may move around inside the pocket. They can rotate, spin, flip, etc. and this can affect the contour of the breasts. Anatomical/textured implants can be useful in some patients but the majority of breast augmentations in the U.S.are done using round smooth implants because these produce the best results in most patients. For most of my patients, I recommend round, smooth implants.

The most important decision to be made, which will determine your results, and satisfaction, is the size of implant chosen for you. This is an inherently subjective process. There is no formula, computer program, or method outside of surgery which can precisely determine the best implant for you. Putting implants in your bra will not tell you what these will do for you inside your breasts. I believe that intra-operative sizing is the best way to decide the ideal implant size for my patients. I encourage you to tell me what your goals are. Unless, you wish otherwise, I try to produce a result that will look natural, look well proportioned to your body, have normal sensitivity, and feel as normal as possible. Sizing is done by putting a sizer into each breast and inflating these until the desired result is seen. I have sized nearly every patient I have done over 23 years and less than 1% have not been satisfied with the size chosen. When patients have chosen their own implants, they have almost invariably been disappointed. If you are unhappy with your implant size, I will recommend that you live with them for one year. Some patients simply take longer to adjust to their new appearance. If, at the end of that time, you still wish for a bigger, or smaller, implant, I will offer to exchange your implants for new ones at a discounted fee. This offer is good for one year from the date of your surgery.

Bra cup size

Please understand that there is no established standard for what is an A, B, C, or D cup bra. The cup size of one manufacturer’s bras is not identical to that of anothers. Patient preferences often determine what cup size they wear. This is why using cup size to describe breasts is very imprecise and I have not found it very useful. While I will do my best to get you the cup size you wish, my primary goal is not a specific cup but, rather, a happy patient. If you are happy with your results, then cup size is secondary. If you desire something more conservative, or “showy”, please let me know. As long as it is not medically inappropriate, or dangerous, I will do my utmost to help you achieve your goals.

Recovery and convalescence from surgery-

Some postoperative discomfort is to be expected from all surgery and breast augmentation is no exception. You will receive medications for pain and this will usually keep you fairly comfortable. Most patients are off of the prescription medications within a few days. A few may need a refill. You should remain sedentary and quiet for the first 5-6 days. After I see you for your first postoperative visit, if you are doing well, I will no longer restrict your activities. This means that you can resume doing whatever you can do comfortably. Just use common sense and don’t overdo things like exercise, etc. for a week or two. You should be back up to 100% within 4 weeks. The total recuperation  period is between 3 and 6 months and I always follow patients for at least 6 months before discharging them, to be sure everything has turned out well. I recommend my patients return for a brief check up every 2 years or so to verify that all is well with their breasts and implants. There is no charge for the visit, ever.


Photographs will be taken of your breasts before surgery and at your final visit. This is to help plan your surgery and assess the final results. They do not show your face and are not shown to anyone without your express, written permission. You are welcome to have copies of your before and after pictures if you wish. You may be asked for your permission to use your photographs in our practice and this would be greatly appreciated but you should feel no obligation to allow their use if this makes you uncomfortable.

Breast augmentation; the upside

Among operations in general, and cosmetic surgery in particular, breast augmentation has one of the highest satisfaction rates. In studies of patients who have had breast implants for over ten years, the satisfaction level is consistently greater than 90%. It is very uncommon for patients to be less than satisfied with the results of their surgery. Even those patients who have complications, or less than perfect results, tend to prefer their breasts with implants over how they were before surgery. My goal is that six months after your surgery, you will be able to say that you would do it over again if given this opportunity.

Breast augmentation; the downside or risks/complications/limitations

Breast augmentation, like all surgical procedures carries risks, and complications can occur. Every effort is made to prevent complications but no operation, and no surgeon, is perfect. Every procedure has limitations in what it can accomplish. Below is a listing of the more common risks and limitations.

 Capsular contracture– All breasts will form a layer of scar tissue around the implant. This scar is called a capsule. If the capsule shrinks (contracts), and/or thickens, it can begin to squeeze the implant and this can make the breast feel hard. Severe contracture can distort the breast shape or even be painful. No one knows exactly why a few patients do this. Contracture to some degree occurs in between 3 and 5 % of patients and it is not possible to predict who these will be. If a contracture occurs severe enough to produce an unacceptable outcome, correction will require revision surgery. There will be an additional cost for this revision which will cover the expenses of surgery. You may be asked to follow a program after your surgery to prevent contractures. This may include taking vitamin E orally, massaging your breasts, and wearing a compression bra or strap. Not all surgeons do all these things.  It is very important to follow my instructions carefully, but even diligent adherence to this program does not guarantee that a contracture will not occur. If you experience capsular contracture, undergo a revision attempt, and the contracture re-occurs, I will not do another revision, since I feel the chance of success at that point is very low. If the result is not acceptable, I will offer to remove your implants at no additional cost to you.

Capsule stretching– Less common than contracture, in some patients, the implant pocket may gradually stretch. This can result in too much visible movement of the implants. When you lay down, the implants may shift too far to the side. When you sit up, the implant may sit too low on the chest, making the nipple look too high on the breast. This problem is difficult to correct and requires surgery to tighten the implant pocket with stitches. There will be a fee for this type of corrective surgery just as for a revision as noted above.  Successful correction of this condition cannot be guaranteed.

Leakage– Saline implants have a risk of leaking of between 5 and 9% in the first 10 years. After that, the failure rate increases by 1% per year. Your implants carry a lifetime replacement warranty. If they leak or fail for any reason, you will be given 2 new implants by the manufacturer. For the first 10 years after surgery, the manufacturer will pay the costs of replacing one implant ($1200). You can obtain $2400 of coverage, for replacement of 2 implants by paying the manufacturer $125 within 30 days after your surgery (I strongly recommend this). You will receive a brochure explaining this. Leakage is harmless, as noted above. Some implants deflate overnight. Others may take weeks to become obvious. All leaks eventually become obvious. The presence of capsular contracture increases the risk of implant failure. Gel implants have a leak rate of between 0.5-2.7% over 3-4 years. As I explained earlier, gel implant leaks are much harder to detect.

Visible rippling and wrinkling– Implants cannot perfectly mimic the breast tissue that you do not have naturally. Saline implants, as they settle, can produce visible and/or palpable ripples and winkles in the skin of the breasts. This is more likely the larger the implant is relative to the natural breast. Contracture of the pocket makes implant rippling and failure more likely. You must understand that breast augmentation is an unnatural process that tries to produce a natural result. A few patients may get that perfect result which looks and feels entirely natural. Most patients get excellent results, albeit not perfect. Rippling and wrinkling only rarely cause dissatisfaction with the procedure.

Abnormal movement of the implants– because implants are not the same as your natural breast tissue, the way they move in your breasts will not exactly mimic breast tissue. You may see the implants shift as you change position. This is more likely in patients with very thin breast tissue and skin. If your implants are under the muscle, when you forcefully contract the muscle, the inner, lower area of the breasts will probably flatten and the implant will visibly move. This is only rarely objectionable. Correction requires additional surgery to move the implants to an above muscle position. I have not yet ever had to do this. There would be a fee to cover expenses.

Loss of nipple/areola sensitivity– 90% of women will not lose any of the natural sensitivity of the breast, especially the nipple/areola area. Most patients will have some numbness in the breast skin, most often in the lower half of the breast. This usually resolves in a couple of months. Hypersensitivity of the nipples can occur and this usually resolves more rapidly. In a few patients, loss of some degree of normal sensitivity may be permanent, and in a rare patient, the breasts may be quite numb. So far, no patient of mine has ever returned dissatisfied with the surgery because of loss of feeling. Removing the implants is not expected to reverse loss of sensitivity.

Calcifications in the breast tissue– over years, calcium deposits may form in the tissue around your implants and this can appear on a mammogram. The calcium deposits are harmless but can make interpretation of mammograms difficult. Rarely, clarifying the nature of calcium depostis may require a biopsy of the breast. Any surgery on your breasts carries the risk of harming the implants in some way.

Cancer and other illnesses– At this time, it is almost universally accepted that women with breast implants do not have an increased chance of developing breast cancer. Numerous studies over the past 20 years, of tens of thousands of women, have failed to demonstrate any link between breast implant surgery and increased risk of developing any disease, whether autoimmune or not. While this is not a guarantee that this cannot happen in some exceptionally rare circumstance, it should reassure patients that the chances are extremely remote. In January of 2011 the FDA  began a registry to look at a possible connection between breast implants and an extremely rare form of lymphoma of the breast- anaplastic large cell lymphoma (ALCL). To date, some 35 or so women with implants have developed this lymphoma. The numbers are too small to draw any conclusions. Most case seem to involve implants placed for reconstruction, implants older than 8 years, and textured implants. It may be 10 years or more before we will know if there is any connection here. The FDA has not felt this problem justifies any change in the status of breast implants as a medical device.

Interfering with mammograms– implants do block x-rays and produce a shadow on mammograms. To get around this, mammogram techniques are modified for women with implants. An Eklund, or displacement, technique is used to push the implants out of the way, and additional views are taken. Most, but not all, of the breast tissue can be seen. It is theoretically possible that a small lump might be missed, and if this lump were cancerous, this could result in a delay in diagnosis and treatment. Studies have compared breast cancer patients who had breast implant surgery with those who never had implants. No statistical difference has been found in the results of the cancer treatment between the two groups. Capsular contracture, by making the breasts difficult or impossible to compress can compromise mammography. Breasts that stay soft can be examined by mammography more effectively. This is why I feel compliance with the  program of breast massage, taking vitamin E, and using a compression garment to help keep your breasts soft is so important. I recommend adherence to the American Cancer Society guidelines for obtaining mammograms for my patients.

Complications common to all surgery– Breast augmentation also has many complications in common with other surgeries. These include, but are not limited to, such things as infection, bleeding, poor quality scars, delayed healing, injury to structures in or around the area of surgery, complications related to anesthesia, and complications which can be serious, or even life threatening, such as blood clots in the legs or lungs, heart attack, stroke, pneumonia, and more. The likelihood of any of these happening to you is less than 1%. There are many more potential complications of surgery, enough to fill a book, but most are exceedingly rare and will probably not be seen in a surgeon’s career.

Summary of complications– While complications from breast augmentation are rare, they can and do occur. The only way to completely eliminate the potential for complications is to avoid having breast implant surgery.

Future surgery

It is highly likely that at some time in the future you will need, or simply desire, another operation on your breasts as a result of implant surgery. The most likely would be to replace a leaking implant but you may also elect to remove them at some time, exchange them ( for something larger, smaller, or, perhaps, a newer, better implant than is available today), correct a late occurring contracture (this is rare but can happen), perform a breast lift for sagging, or some other procedure. Because breast augmentation is a cosmetic procedure, any surgery related to this will probably be regarded as cosmetic by most insurance companies and, therefore, not covered by insurance.

What will your breasts look like years from now?

Many things will affect your appearance over the years. Pregnancy (if applicable), weight loss or gain, health issues, habits (exercise, sleep, diet, smoking, drinking, etc.) the manner in which you age, and your genetic makeup, to name a few. It is therefore impossible to predict how your breasts will look years from now. After implant surgery, your breasts will be heavier and gravity will affect them more. I recommend that you not go braless routinely. Beyond your skin and some fine ligaments within the breasts, both of which will stretch with time, a bra is the only support your breasts have.

Smoking and breast augmentation

Besides being one of the worst things for your health, smoking can have very significant adverse effects on the results of breast augmentation. Patients exposed to cigarette smoke during the critical period before and after surgery are much more prone to developing capsular contracture, which I discussed above. This holds for those who smoke themselves, and those who inhale much second hand smoke. This serves as my disclaimer that states you will be responsible for any ill effects of smoking. If capsular contracture occurs in a smoker, the fee for revision surgery is higher than for non-smokers as an added inducement to quit.  Smoking should be stopped for 6 weeks before surgery and abstained from for a full 3 months afterwards. Ideally, you should stop altogether!


When I perform breast implant surgery, I can only guarantee one thing; that when I do the surgery, I will bring to bear all of my skill and experience on that day to provide you with the best result that I can. There are innumerable variables and intangible factors that can affect the outcome of any operation. Many of these are out of my control, and yours. You must understand, and accept, this small degree of uncertainty if you wish to undergo a breast augmentation. If you decide to move forward with the surgery, it is my hope that six months later, you will be very glad that you had the surgery. I will do my utmost to achieve that goal.  

I have read all of the  information in this handout and/or it has been explained to me. All of my questions have been answered to my satisfaction. I understand and accept the risks and limitations as explained to me and listed in this handout. I desire to proceed with breast augmentation as discussed.


___________________________     ___________

Patient signature                                 Date

___________________________      ___________

Witness signature                                Date

___________________________      ___________

Richard T. Bosshardt, MD, FACS     Date

Are you a candidate for a breast reduction and will insurance cover this? June 24, 2011

Posted by bosshardt in Uncategorized.
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Reduction mammaplasty, the medical term for a breast reduction, is one of the most common plastic surgery procedures. In my experience, it also has one of the highest rates of patient satisfaction of any procedure in the specialty. I think this is for two reasons: women with very large breasts are usually pretty miserable and appreciate the relief obtained and results are, aesthetically, usually pretty nice.

There is no “cookbook” formula for who is a candidate. If you have large, full breasts and are having symptoms from these, then you are probably a candidate. Cup size is not always helpful. While most women with problems with have bra cup size in the D and larger range, I have seen women with significant problems who wore a C cup.

I take a very comprehensive history when evaluating patients for breast reduction surgery. In addition to their cup size I want to know about any aches and pains in the back, neck, and shoulders. Problems with rashes under and between the breasts are common with large breasts. Some women complain of a “pulling” sensation on their chest and discomfort with laying down, as the large breasts spill to the sides. Numbness and tingling down the arms, into the hands and fingers, can be caused by large breasts. A physical examination, of course, will confirm that the breasts are large. I take detailed measurements and always document the size of the breasts with photographs. Very helpful is the presence of grooves in the shoulders where the bra straps dig in. This is an objective, tell tale sign of a problem.

Once I determine that a patient is a candidate for surgery, the next step is to obtain approval for the surgery from their insurance company. This can be interesting. Insurance companies are all over the place with their policies regarding this surgery. Some policies do not cover this surgery at all. Those that do often put all sorts of pre-conditions on their coverage, some of which make no sense at all. The most common requirement is that a minimum weight of breast tissue must be removed for the surgery to be covered. This amount may be so great as to be absurd. There is no accepted standard for how much a breast needs to be reduced for this to be therapeutic. Some policies require ridiculous things like some form of documentation that you have tried different bras (what woman hasn’t?) without really explaining how this is to be done, have had a trial of physical therapy (no evidence that this is the least bit effective in the long term), and have tried a course of pain medications (why should a woman be made to take pain medications for the rest of her life when an operation is nearly 100% effective in curing the problem!?).

After the consultation, I will contact your insurance company, provide them with your clinical information and a photograph of your breasts (required by all insurers before they will consider coverage), and wait to see how they respond. If the response is favorable, all that needs to be done is schedule a date. If coverage is denied, I will follow the necessary steps to appeal this, as far as I can. Sometimes, I can get an initial denial reversed.

If, after all is said and done, we cannot get you covered, or if you simply have no medical insurance, I can offer this procedure in our own, private ambulatory surgery center housed in our office. We can do these very safely and comfortably and our total fee for the entire surgery is very reasonable. Our patient coordinator will be happy to give you a quote for this surgery.

There are many misconceptions about breast reduction. Even many primary care physicians are misinformed about the surgery. Some men, including doctors and non-doctors, do not understand how uncomfortable large breasts can be and discourage women from seeking this surgery. Breast reduction surgery is quite safe with few complications and only very rare serious ones. Postoperative discomfort is very modest and most patients are surprised at how little pain there is. It is nearly 100% effective in relieving the symptoms of large breasts. Of all the operations I perform as a plastic surgeon, breast reduction has the closest to a perfect track record of satisfied patients.

After surgery, the breast will have scars on them and, as with all scars, the quality of these cannot be guaranteed. They are usually pretty good and more than justified by the results. The breasts may loose some sensitivity- larger breasts are more likely to do this. Conversely, very large breasts usually have less sensitivity to begin with. Various techniques exist to reduce large breasts. Some use limited incisions to minimize scars but these may also compromise getting the best shape and aesthetic result. A breast reduction will simultaneously lift a saggy breast, producing a more youthful, perky look. Breast feeding after a reduction can be problematic. Much depends on the technique used and preoperative size of the breasts. I have had some patients who successfully breast fed after surgery but I tell all patients to expect not to be able to do this. Breast reduction does not impair the ability to obtain a good mammogram. Some studies suggest that reducing a large breast may somewhat reduce the risk of breast cancer later but this has not been judged to be enough of a factor to warrant it being used as a justification for the surgery. 

You will need to anticipate about 2 weeks to recover from surgery but can probably resume routine, day-to-day activities sooner than that. Vigorous physical activity, such as sports, going to the gym, etc. can be resumed in 4 weeks. I follow patients for a full 6 months after surgery to be sure that everything goes as it should and the outcome is a good one.

For women with large breasts, who are having problems with them, breast reduction is a very successful procedure with a few complications. It produces the double benefit of relieving symptoms and making the breasts more “perky” and attractive; truly a “win-win” situation!

Dr. Millard June 24, 2011

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He was one of the two most influential men in my life; my father is the other. He was also one of the most influential men you never heard of. He passed away on Father’s Day. In a professional career spanning over 50 years, plastic surgeon D. Ralph Millard, Jr., MD, wrote or co-wrote 9 books, published 149 papers in peer-reviewed medical journals, and wrote 53 chapters in medical textbooks. He developed the operation used throughout the world today for the repair of cleft lips. He personally repaired thousands of cleft lips and palates.

A supremely innovative surgeon with a lifelong thirst for perfection of his craft, he also developed numerous procedures and surgical instruments. He was an acknowledged master of one of the most difficult procedures in the specialty- total nasal reconstruction and his results sometimes looked better than the patient’s original nose.

As impressive as these accomplishments were, perhaps his greatest professional legacy were the hundreds of residents and fellows that he trained in the science and art of plastic surgery over 28 years as head of the division of plastic surgery at the University of Miami/Jackson Memorial Hosptial. His list of students reads like a Who’s who of plastic surgery. Some have returned to their home countries to use what they learned to serve patients and, in turn, pass on this legacy to their own residents. In the U.S. many of Dr. Millard’s protégés have become heads of training programs and trained several generations of plastic surgeons. Anyone who has ever required the services of a plastic and reconstructive surgeon has benefited in some way from the influence of Dr. Millard.

In 2000 Dr. Millard was named one of the top 10 plastic surgeons of the millennium by the American Society of Plastic Surgeons and some would argue that he was at the top of that list. His influence is felt to this day.

One of his unique and lasting contributions, not only to plastic surgeons but to readers in any walk of life was the publication in 1987 of his landmark book, Principlization of Plastic Surgery. Nominated for a Pulitzer Prize, it was unlike any other medical textbook. Written in a narrative style and copiously illustrated, it had something for everyone from the most accomplished surgeon to the interested non-medical readers. The book innumerated 33 principles of plastic surgery which could be equally applied to life as to the specialty. By emphasizing principles, which do not change, over procedures which become obsolete as the next best thing comes along, he insured that his book would be as relevant decades later as the day it was published.

An imposing figure even in his 80’s, Dr. Millard had a steely gaze that could cause great discomfiture in any of his residents or patients who did not meet his lofty expectations for them. He demanded the absolute best of himself and those who trained under him. Stories about him are legion among those who knew. There was the applicant for a position in his program who arrived in the operating room only to be greeted by “the Chief” and instructed to go to the white board in the corner of the room and draw a horse!

Dr. Millard was one of those rare surgeons whose waiting list of patients extended not weeks, or months, but years. He eschewed celebrities and felt more at ease with a young couple bringing him their child with a cleft and praying for a miracle. With Dr. Millard, they often got it. His passing closes a glorious chapter in the history of plastic surgery in the U.S. and abroad.

Dr. Millard was my professor and mentor for 2 years. I have been grateful ever since.

What style breast implant should I choose June 8, 2011

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What implant style should I choose?

It seems most patients coming into for a consultation for breast augmentation these days are doing a lot of research online before seeing a plastic surgeon. Among the various decisions that have to be made about implants is what style of implant to choose. Choices in both saline and gel implants include round/smooth, round/textured, tear drop/smooth, and tear drop/textured. Round implants are broken down even further into moderate, moderate “plus”, and high profile implants. How is a person to choose among these?

Let me explain texturing first. A ‘textured’ implant has a surface that looks and feels rough or fuzzy. This surface texturing is intended to encourage the attachment of the tissues around the implant to the surface of the implant. Think of a Velcro-like adherence. The idea behind this is that the surface texturing and tissue adherence will reduce the likelihood that the pocket around the implant might contract, squeezing the implant and making the breast feel hard and/or distorting the shape. This condition is called capsular contracture and is one of the main reasons some women get a less than perfect result. There are several issues with textured implants.

One is that they are stiffer than non-textured implants and thus have a significantly higher failure rate over time. Another issue is that the texturing simply doesn’t do what it is intended in many cases (I would say in most cases, in my experience). I rarely remove textured implants where I see significant tissue adherence to the surface of the implant. Textured implants are much more prone to having collections of serum, called seromas, form around them so that in most cases, the use of a drain in each breast is advisable. Drains are, quite frankly, a nuisance for patients, and a potential source of introducing infection into the implant pocket, a disastrous occurrence. When tissue adherence does occur, combined with the added stiffness of the implant, visible and palpable rippling of the implants is more common.

Smooth implants do not have the above issues.

As to tear drop, also called “anatomically shaped” implants versus round implants it would seem that the former would work better. After all, a natural breast is not really round but has a natural tear drop shape, right? True, but it is an interesting fact that when women with round implants have x-rays taken of their breasts while sitting up, the round implants settle into a tear drop shape due to gravity. When they lay down, the implants change to a rounded shape, allowing the breasts to settle more naturally. Because tear drop shaped implants have this shape built into them, they maintain the same shape regardless of position so this natural change does not occur. In addition, they are prone to spinning, flipping, etc. and this can make the breast assume unusual contours. The only way to avoid this is to secure the implant in the pocket in some way, such as by using surface texturing but then, you have the issues with texturing that I mentioned above.

It is for these reasons that when plastic surgeons are polled as to their preference in implant style, nearly 85% primarily choose round/smooth implants. They have a lower failure rate, produce great results in most patients, can move around in the pocket without altering breast shape, and just happen to be less expensive than the textured and tear drop shaped implants, as well. I call this a win, win, win, and win situation!

As to moderate, moderate plus, and high profile implants, the choice of these relate in large part to the width of the chest and the patients stated goals. Do they want large implants but have a fairly narrow chest? Then high profile implants might work best. Are they an average size, with fairly typical moderately small breasts, and a little loose skin? A moderate plus profile implant will work well. Much of this is very subjective and determined by the patient’s stated goals, the situation they present with, and the surgeon’s aesthetic sense. There are no formulas or computer programs that can precisely predict the best implant size and style for each patient with reliability and consistency. That is part of the “art” of breast augmentation.

R. Bosshardt, MD, FACS
8 June 2011

A great commentary on liposuction April 10, 2011

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I am not above posting the comments of other plastic surgeons if I feel that they have something to say, and are saying it well. This post by Dr. Paul Howard, in Birmingham, Alabama, on liposuction is excellent, and very well written. I agree with everything in it. Dr. Howard is a board certified plastic surgeon and also an alumnus of the training program that I graduated from, in Miami, Florida, under Dr. D. Ralph Millard, Jr. Maybe great minds DO think alike! Just kidding…but, seriously, the post is well worth reading for anyone contemplating liposuction these days. It is so hard to separate the hype from the reality. Check it out: http://liposuctionbirminghamal.com/

Breast Implants and Cancer risk March 13, 2011

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When the movie “Jaws 2” came out, the tagline was “just when you thought it was safe to go back in the water….. After the breast implant scare that surfaced in 1990 with the “expose” by Connie Chung, it was over 10 years before enough data was gathered around the world to confirm, to a medical certainty, that breasts implants did not make women ill, and did not put them at risk for breast, or any other cancer. Women returned to plastic surgeons offices in droves to have the implants put in that they had desired, but postponed, during media hysteria.  Unfortunately, in a distressing nod to Jaws 2, it can be said: “just when you thought it was safe to get back into the plastic surgeon’s office….. Now, there is new data suggesting a possible association between implants and a very rare cancer. 

Medical certaintly is not the same as 100% sure. For one thing, it is not possible to prove a negative. No one can prove now and forever that breast implants do not cause cancer because there is always the hypothetical possibility that some woman, some where, under just the right set of circumstances, may experience just that. All it takes is one case to blow medical certainty out of the water.

Medical knowledge is not static. It is constantly changing as new information is discovered. Doctors can only practice according to what knowledge is available at the time. Until recently, there has been no connection observed between women having breast implants and increased risk of any cancer.

Recently, reports have begun to surface of a few women with implants developing a very rare form of cancer, anaplastic large cell lymphoma (ALCL). This is a cancer of the lymphatic system. In the United States, ALCL occurs in 1 out of 500,000 women. ALCL arising in the breast is much rarer still, with an incidence of 3 out of 100 million women.

Between January 1997 and May 2010 a total of 34 unique cases of ALCL arising in the breasts of women with implants has been reported to the Food and Drug Administration. Two thirds received implants for reconstruction following breast cancer treatment. Most of the others were for cosmetic breast augmentation with a few not specified. More than half of the implants were silicone gel filled versus saline. In only four cases was the implant type, smooth surface versus textured surface, noted and in those all were textured implants (This does not seem terribly surprising given that textured implants, which have a “fuzzy” surface, are more prone to seromas than the smooth style. It remains to be seen if this connection is borne out with more investigation).

Nearly all the women with ALCL  had their implants for 8 years or more. Most cases were diagnosed when the women underwent revision surgery for persistent fluid (seroma) around the implants and/or for hardening of the breasts. In all cases the cancer was confined to the space between the implant the capsule of scar surrounding it.

Because of past concerns regarding implants and their potential to cause illnesses or cancer, which led to a moratorium on silicone gel implants for cosmetic use for nearly 15 years, the FDA is moving very quickly on this. The FDA and the American Society of Plastic Surgeons have collaborated to establish a registry of patients with ALCL and breast implants and are asking that new cases be reported immediately. Because of the rare nature of ALCL, especially in breast patients, it may be as long as ten years, possibly more, before there are enough numbers of women to be able to draw conclusions.

In the FDA white paper published in January 2011 (http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239996.htm ) three key findings were noted. There may be an association between breast implants and ALCL. At this time it is not known what type of implant may be associated with a higher or lower risk of ALCL. The connection to textured implants is tenuous at best. The true cause of ALCL in women with breast implants is not known.

What are women with implants to do now? Because of the small numbers and the inability to make statistically valid conclusions, the FDA does not recommend that women with breast implants have these removed if they are not having any problems. At this time, the FDA does not feel that this issue is sufficient to warrant any change in the safety status of breast implants. As new information becomes available, this will be made public. One of the lessons learned with the implant controversy of the 1990’s- 2000’s was the importance of transparency in averting uninformed speculation and misinformation in the media.

Women who have noted hardening of their implants after years of being soft or who note swelling or fluid around their implants should have these checked. Routine breast surveillance for cancer is as important for women with implants as for those without them. It is important not to lose sight of the fact that women have a lifetime risk of breast cancer of between in 1 in 9 and 1 in 11, with or without implants, compared to the tiny risk of ALCL.

Finding a bra after your breast augmentation October 7, 2010

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Many patients ask me about bras after they have had breast augmentation surgery. As I tell every patient who comes in seeking this enhancement, breast augmentation is an inherently unnatural thing to do. Breast implants, while good, are not perfect in duplicating what is naturally missing so the final result will rarely look and/or feel 100%  “natural”, although very nice none-the-less. One aspect of this “unnaturalness” (is that a word?) will be how the augmented breasts fit into a bra. Fitting for bras normally can be a challenge. Trust me on this: there is no standard out there for cup size. If you buy the same cup size from ten different manufacturers, they will all fit you differently. I do not use bra cup size as a measure of breast size because there is so much variation. There are numerous formulas for fitting bras and they may give very different results. Victoria’s secret, for example, will size most women a full cup size large than anyone else. I think they feel this makes their customers feel better. When performing breast augmentation I try to use an implant size that will achieve a result that will satisfy my understanding of the patient’s desires, make them look as natural as possible, produce a visible increase in fullness, and, hopefully, avoid unnecessary problems for them, now and in the future. Women often don’t realize that the result will be with them for years, or even the rest of their lives, and I try to look down the road.  But, I am getting off track. Back to bras……..

My advice regarding post operative bras is to wear comfortable sports bras, without underwires or thick seams, for the first month or so after surgery. The breasts may be sensitive and the implants will not have fully settled, so fitted bras will probably not fit well, underwires may be uncomfortable, and sizing may be inaccurate. Once the implants have settled and the breasts assumed their final shape, that is the right time to get fitted. The bottom line is that the best bra for you is the one that fits you well and gives good support. This may require a little trial and error. Most large department stores and lingerie stores have people trained to fit customers for bras. Admittedly, some women just happen to have that combination of chest circumference and breast shape/size that makes them very difficult to fit after breast implant surgery.  There is one brand, Le Mystere (www.lemystere.com), that makes bras specifically for women with implants. The are a bit wider along the curve of the underwire and have some other modifications to better fit these individuals. They are available in many department stores, such as Macy’s and Neiman Marcus. They are not cheap at $76 each but if they are your best fit, they are worth it.

Sports bras are great but some don’t give enough support for women with larger breasts. One of my patients is a runner. A week after her augmentation, she ran 20 miles in a long distance relay! I don’t recommend this, but she was committed and did not have any problems. She searched extensively and came up with two sports bras that she felt were excellent. One is the Enell sports bra (www.enell.com) and the other is the “Tata Tamer” (no, I am not making this up) (www.lululemon.com). She states that both were extremely comfortable and gave “the girls” great support when she ran.

Many of my patients express a desire for superior fullness from their implant surgery. This is very difficult to produce on purpose and, usually, when there is superior fullness due to the implant, it does not look natural and can look a little strange. The best way to get that fullness is with a good “push-up” bra. The same thing applies to cleavage. Most small breasted women do not have much cleavage. I can try to enhance this by bringing the implant pockets closer together but I have to do this very carefully. Too close and I risk disrupting the skin attachment to the breast bone. This can produce what some call “bread loafing” and others call a “uni-breast”, where the implants are too close together and, again, look strange. This is VERY difficult to correct. Cleavage after breast augmentation has done what it can, is best produced with a good bra to push the breasts together.

I do recommend that my patients limit how much they go braless. The only support your breasts have is the skin and some fine ligaments that connect the skin to the muscle. The ligaments are called Coopers ligaments (in medical school, we called them “Coopers Droopers” because they stretch out with age and allow the breasts to sag). You will sag more over time if you go braless a lot. A comfortable, well fitted bra is your best defense against sagging.

If you discover any great bras out there please let me know  so I can pass this on to patients.

What can you tell me about the Lifestyle Lift? Do you do these? January 16, 2010

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It seems the Lifestyle Lift has become very popular and we get a lot of questions about this procedure. I can’t tell you much about this procedure specifically. The reason is that this is a proprietary surgical procedure. This means that the doctor who developed it, David Kent, D. O., an otolaryngologist, has registered the Lifestyle Lift as a trademark and the only way a physician can learn details about it is to pay him for the privilege. It costs several thousand dollars to take his course and learn how to perform the Lifestyle Lift. However, as a plastic surgeon with 21 years of experience I can tell you some things based on having seen patients who have had this procedure done. As a plastic surgeon, I perform facelifts frequently. I am familiar with the different types of facelifts and variations of this procedure, I know the anatomy well, and the changes that occur with aging which a facelift is intended to correct. I also know the limitations of the procedure.  

The Lifestyle Lift is a variation on a mini-facelift. Mini facelifts differ from full facelifts in that there is much less cutting and releasing of the skin from the underlying muscles. Less skin is removed. The surgery takes less time, carries fewer risks, and recovery is quicker. All good, right? The problem is that the results are less too. The surgeon who trained me, Dr. D. Ralph Millard, Jr., who performed many thousands of facelifts in his 40+ year career said it best: “Mini procedures give mini results”.  I think this is as true today as when I trained over 20 years ago.

The Lifestyle Lift brochures and web site are very impressive and show results that border on the unbelievable. It has been my experience that when something sounds too good to be true, it usually is. Looking at the Lifestyle Lift a little more closely there are some things that just don’t sound right. On the one hand, the procedure promises incredible results with an hour of surgery. This is pushing things even for a mini-facelift. The brochures and web site, however, also state that many of the patients underwent an additonal “neck firming” procedure. What was that? The brochures and ads don’t say. I can tell you from some former Lifestyle Lift patients that their surgery took a lot longer than an hour  and more than a week to recover from. None of the results that I have seen have been remotely as impressive as what I see on the brochures and several patients were very unhappy with their experience as the doctor did not spend much time with or explain the procedure well, and they did not get the results promised.

I seriously question the accuracy of the claims and results boasted by the Lifestyle Lift. I just know too much about facial surgery to believe that they can deliver these results as promised. One telling incident occurred in New York State where the Lifestyle Lift company was fined $300,000 for false and misleading use of the internet. It seems that employees of the Lifestyle Lift were passing themselves off as satisfied patients on the internet in order to lure prospective patients. New York Attorney General Andrew Cuomo called the company’s attempts to lure patients “devious, manipulative, and illegal”. If you know how infrequently false advertising charges are pursued, it gives you an idea how egregious this action of the Lifestyle Lift company was. The situation is ironic when you read the Lifestyle Lift Code of Internet Conduct and Assurance on their website.

The Lifestyle Lift boasts that all of its surgeons are “board certified”. That may well be true, but board certified in what? Any physician with an MD or a DO degree can lay claim to the title of facial plastic surgeon or plastic surgeon if they wish. When surgery is done in an office setting, as the Lifestyle Lift is, there is no law that prohibits any physician, even non-surgeons from performing surgery in their own facility.

We have seen many procedures come and go over the years and are always cautious about new procedures that promise amazing results with minimal effort. Remember the non-surgical facelift using barbed threads, the Feather Lift? Where is that today? Gone, because not only did it not work. There were too many patients with complications and visible bands under their skin from the threads. We predicted this at the beginning and refused to jump on that bandwagon. Remember laser facelifts and eye lifts? Also ineffective and abandoned after an initial flurry of interest.

There are other proprietary mini-facelifts out there. One that comes to mind is the Quick Lift. The advertising for this one is very similar to the Lifestyle Lift. There are probably some other procedures out there now whose names I don’t know. If you want to look into something like this for yourself, go ahead, but go in with your eyes wide open and ask a lot of questions. By all means get a second opinion from a board certified plastic surgeon who is not affiliated with the Lifestyle Lift. Beware of grandiose claims of incredible results with minimal surgery.

Two very important things to consider in approaching any cosmetic surgery. One is to be sure that the facility where your surgery will be done is accredited by an organization approved to certify ambulatory surgery facilities. These include the American Association for the Accreditation of Ambulatory Surgery Facilities (AAASF), Accreditation Association for Ambulatory Health Care (AAAHC), and the Joint Commission. Beware of bogus certifications. The second thing is to ask if your surgeon has privileges to perform the same procedures in a hospital that he or she performs in their office. Hospitals take great care to ensure that their doctors are properly trained and certified to be doing the operations they perform. Doctors are free to do pretty much whatever they wish in their office.