August 22nd, 2011 drtim 
Breast augmentation and the high demand for beautiful breasts remains one of the most popular plastic surgery procedures in Beverly Hills. With so many breast augmentations, breast augmentation revisions also becomes commonplace. Breast revision surgery may include any number of things ranging from removal and replacement for bigger (or smaller size), capsular contracture (see prior blog for details of this problem), breast asymmetry, removal of saline implants for silicone, rippling, bottoming out, and deflation. Of these, capsular contracture is probably the most common reason for a breast augmentation revision. In cities where bigger is generally deemed as better in the breast worlds (Houston, Dallas, southern California), bottoming out is a rather unpleasant prevalent sequel of large implants. Basically, this is when the weight of the implant causes the implant to migrate down and give an illusion of a nipple to high on the breast. While bottoming out is usually related to larger implants, it can happen to anyone at any age, and a lot of it is related to natural tissue elasticity properties of the individual. That is, smaller implants in a thin girl with poor elastic properties of her skin can also develop this phenomenon. To correct this, one may just wear wired bras for a prolonged period of time if the bottoming out is quick and after surgery, or, may need revisional breast surgery to resuspend the implant above a recreated breast fold. In fact, many of the complications one sees with breast augmentation can be corrected without surgery with good follow up care and compliance. So, every time I plan on performing a breast augmentation on a patient, I stress that THEIR post op care and compliance heavily influences the ultimate cosmetic result. Massaging and attention to post op care by your physician, particularly in the first 6 weeks of surgery is crucial!
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August 7th, 2011 drtim 
In Los Angeles California, beautiful breasts are a high priority among many young women. In my last blog, I discussed some of the measurements that have been developed to describe ideal aesthetic, beautiful breasts. But how do we achieve them surgically if one is not fortunate enough to own them naturally? Well, for one we can do nothing. Cosmetic breast surgery is elective, and unless one has a gross deformity or defect (like mastectomy, radical asymmetry or tubular breast deformity), then one can simply chose to live with their breasts and avoid potential problems with breast augmentation (like capsular contracture, bottoming out, asymmetry, etc.). If the goal is simply to enlarge the breasts, therapies range from the rare use of the BRAVO system which uses constant negative pressure for months to gain breast tissue, to breast enlargement with breast implant or fat grafting. Please refer to my prior blog about fat grafting to breasts. Implants, like breasts, come in many shapes or sizes. With breast measurements, a plastic surgeon can decide which ‘style’ of implant may fit your body best. In addition, over and under muscle placement is not an typically arbitrary decision. I will put silicone OVER the muscle in particular circumstances. Saline over the muscle is a bit more risky as saline implants more often lead to rippling than there silicone cousins. For instance, when there is ample breast tissue (like a B cup or more), and the patient is over 22 years of age (FDA recommendation is for all patients receiving silicone breast implants for primary augmentation be at least age of 22). Other strong indications include pseudoptosis (when there is a slight bottoming-out of breast tissue), or if a woman with B cup breasts or more desires a more natural look. This is a point of contention as to which position looks more natural. However, consider that the more anatomically correct position is certainly not under the muscle where there is never any native tissue. Furthermore, under the muscle can lead to animation deformities with flexion of the pectoralis major muscle. That is, the implant can move around when a woman uses her chest wall muscles. Other reasons for putting implants OVER the muscle include capsular contracture in the sub-muscular position. This is called pocket-switching, and it puts the new implant on a revision in a virgin territory.
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July 27th, 2011 drtim Once upon a time in Beve
rly Hills there was a woman named Mary who had perfect C cup breasts. They were perky, symmetrical, and looked wonderful with or without a bra. Then, she had a few children, and she gained and lost some weight. Time went by, and before she knew it her older bras were no just too large. For Mary’s 30th birthday, she decided to get her breasts enhanced with a breast augmentation. Although her breasts weren’t truly “saggy”, or “ptotic”, they appeared deflated, particularly in the upper pole. She underwent an uneventful breast augmentation with 325 cc silicone implants placed over the muscle (subglandular). This positioning of the implant as opposed to under the muscle gives a but more nipple elevation. And, voila! Her breasts were once again stunning with or without a bra. However, over the course of 3 years, her left breast hardened. She developed what is called a capsular contracture. This is when the tissues around the breast implant (called capsule) harden from exaggerated scarring inside the body. It generally happens 3 percent per year, and the solution may require excision of the capsule. How did this happen? Well, it isnt totally understood how capsular contractures develop. Certainly, frequent massaging and maybe placement under the muscle can help reduce this incidence. Other risk factors include infection of the breast or hematoma (bleeding into the implant pocket). And of course, genetics probably plays a role too. So, Mary had a breast revision surgery where the capsule (internal scar) was removed, and lived happily ever after. The moral of the story is, capsular contracture can happen. But it can be fixed by a skilled plastic surgeon. The End.
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