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Perez Plastic Surgery

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It’s Spring. Time for a Lift? Face, that is. (Original Article)

· Eyelids, Face and Neck · No Comments

Spring is that time when we like to freshen things up. The options to freshen our appearance seem endless and often confusing. Lasers, peels, fillers and other “non-surgical” choices often compete with the more traditional surgical procedures. However, just like an artist chooses the right colors for his canvas, the plastic surgeon must guide the patient to choose the right treatment for the desired effect.

The last decade has seen an explosion of fillers used to treat facial wrinkles. In addition, it seems every day we hear another slick “lift” procedure advertised that promises dramatic results with minimal down time. It is more important now than ever for patients to seek honest, competent advice from multiple practitioners versed in the whole array of treatment options.

I like to evaluate the facial rejuvenation patient by dividing the face into thirds. We start at the top by examining the forehead and eyebrows. If the brows are below the rim of the bone, or if the patient is bothered by significant forehead wrinkles, a forehead/brow lift procedure may be indicated. I have a high threshold for recommending this procedure however, since these patients can look overdone and surprised. Botox offers a simple alternative for forehead wrinkles. It works well but is temporary and expensive.

The middle third of the face are the eyelids. If the eyes are the windows of the soul, then the eyelids are the curtains that allow us enjoy the view. They are truly the most expressive part of the face and the first place we notice our age. Usually by age 40 most of us have aging changes around the eyes. The upper lids develop excess skin causing hooding.  The puffy bags on the lower lids create a tired look.

The procedure of choice to correct tired eyelids is the eyelid tuck or blepharoplasty. It is a commonly performed surgery with a very high degree of patient satisfaction. It is one of my personal favorites to perform and is the most commonly performed aging procedure for men. The procedure takes 45 minutes and patients soon enjoy a refreshed and less tired look.

The lower third of the face includes the area of the cheeks, jawline and neck. As we age the skin and other tissues sag from the underlying bony structures. In addition, wrinkles in the skin, often affected by smoking and sun exposure, contribute to the facial aging changes. The two problems should be treated differently. Facial laxity is treated by surgical face and neck lift procedures, while skin changes are best addressed by injectable fillers or topical treatments such as peels and lasers.

Although highly advertised under many catchy terms, surgical facelift procedures generally fall into two categories, mini and full. A mini-facelift is best suited for patients in their 40’s or younger who just want to freshen the cheek and jawline. The advantage is that it is quick procedure with a rapid recovery. My preference for isolated mild neck fullness is a less invasive, unique ultrasonic liposuction tightening procedure.

The patient for traditional face and necklift is in her late 40’s and older with laxity of the jawline and neck, often with turkey-like banding. Combined with eyelid surgery, the procedure often produces dramatic results and can reduce the aging appearance by decades. It is another one of my favorite procedures to perform.

As with all procedures, an honest consultation with a reputable and experienced physician is the best place to customize an individual treatment plan.

June is Dad’s Turn: Men and Plastic Surgery (Original Article)

June is the month we honor our dads so it’s fitting that it should be the issue where we discuss plastic surgery for men. Although men are more discrete about plastic surgery they do represent about 10-20% of all cosmetic surgery patients. There are certain surgical procedures that are particularly common among men. Here are the most popular:


Eyelids — Eyelid rejuvenation, or blepharoplasty, is among the most common cosmetic procedures performed on men. Usually by age forty we start to notice the signs of aging. The eyelids are the first place where those telltale facial features appear. The upper eyelids develop excess skin. In severe cases even blocking peripheral vision. The treatment involves removing the extra skin and usually a small amount of fat.


The lower eyelid “bags” are usually caused by excess fat pockets or thickened muscle. Other conditions can contribute to lower eyelid puffiness, including salt intake and allergies, but these are not corrected by surgery. Nevertheless, upper and lower eyelid blepharoplasty is a common procedure with a very high degree of satisfaction. It creates a refreshed, rested and more youthful overall appearance to the face.


Face & Neck — The face and neck are also areas of interest to aging men. Neck laxity in particular is a common complaint among men. It’s that occasional profile photo that prompts men to grab the wattle under the chin and head to the plastic surgeon.


Rejuvenation of the face and neck can range from limited incision ultrasonic neck lift lipoplasty to mini-lift to conventional full face and neck lift. The choice of procedures depends upon the patient’s individual skin tone, goals and tolerance of scars.


Body Contouring — Liposuction and other body contouring procedures are also not the exclusive domain of women. Men seek improvement in their shape as well, although typically in different areas of the body.


There are two common areas for body contouring in men. These are the abdomen and flanks, affectionately known as the “love handles,” and the male breast. Diet and exercise are great ways to maintain weight and stay well toned. However, sometimes stubborn areas of fat accumulation remain. In men it’s usually around the waistline.


Gynecomastia, a unique condition of abnormal breast tissue growth can also affect men, both young and old. Liposuction, especially ultrasonic lipoplasty, is a well suited treatment for these areas.

Procedures, including post-bariatric weight loss surgery, Botox, injectables, hair replacement and others are also increasingly common among men.

Breast Implants: Is it time for a Change? (Original Article)

· Breast · No Comments

Breast augmentation continues to be the most common cosmetic procedure performed by plastic surgeons. Although breast implants have been popularized by celebrities such as Pamela Anderson and Britney Spears, the history of these controversial devices began five decades ago.

Initially women’s breasts were enlarged using surgically placed sponges. The procedure was crude and fraught with complications. Modern augmentation took hold in the 1970’s with the use of silicone gel implants. The benefits of breast implants were even touted in the song “Dance 10, Looks 3”from the hit Broadway musical “A Chorus Line”.

The Controversy Years


            The 1980’s brought the largest surge in breast augmentation procedures. A variety of implant types were available from multiple manufacturers. Most devices were filled with silicone gel or saline, salt water solutions. In the late 1980’s and early 90’s reports of arthritic-type diseases associated began to surface. Citing a lack of safety data for the implant devices, the Food and Drug Administration withdrew silicone gel implants from Most of the existing companies left the implant market, leaving only twoU.S.manufacturers. California-based Mentor Medical and McGhan Medical (later Inamed/Allergan) remained as the onlyU.S.producers of breast implants.

Limitations were placed in 1991 on the availability of silicone gel implants. Saline filled became the only devices available for primary cosmetic breast augmentation. With rare exception, in theU.S., gel devices were approved only for reconstruction following mastectomy. However, throughout the 1990’s, the implants continued to be the most popular devices for augmentation outside theU.S.andCanada. Ironically, the cosmetic gel implants produced by the U.S. manufacturers were available only for export to women outside the U.S.

Saline Implants Rule

The 1990’s and first half of this decade were defined by a growth in breast augmentation surgery using saline implants. They are silicone rubber bags filled with a salt water solution. Vocal celebrities, reality TV shows and a growing image-conscious society combined for a boom in plastic surgery procedures, led by saline implants.

The implant is placed empty into the pocket and folded like a taco, so the scar is only slightly larger than an inch. The smaller scars allow for greater flexibility, including the incision around the areola or even the belly button. It is filled to the actual size with the saline solution on the operating table. More water can be added to one side, if necessary, to correct a size disparity. The implants can be placed in front, or behind the pectoralis chest muscle.

The implants are not without occasional problems, though. A thick scar tissue shell, termed a capsular contracture, may occur causing hardness or distortion to the breast. Deflation of the implant with loss of the water solution is also possible. Both of these problems may require additional surgery. Patients sometimes can feel, or even see, the rippling edges of the implant. In some cases this is very bothersome. In addition, in patients with very large implant pockets the cleavage can be unpleasantly wide. Despite the occasional complications, however, the procedure carries a very high degree of satisfaction.

They’re Baaaack…

            Saline implants ruled in theU.S.until late in 2006, when the F.D.A. approved silicone gel implants for primary cosmetic augmentation. The twoU.S.manufacturers partnered with selected plastic surgeons with expertise in breast augmentation. The National Council of Leaders in Breast Aesthetics was formed to provide feedback on the new prostheses.

The new gel implants, sold internationally for years, are different from the prostheses of the 1980’s. The gel is not as liquid as before making leakage less problematic. The new implants are often called “gummy bears” because of their cohesive, firmer filling. The new gels are the most natural feeling implants to date. They are also lighter than the saline implants, a feature especially valuable for women with looser breast skin.

The gels have some disadvantages too, however. The implant is prefilled and sealed so the incision required is slightly larger and adjustment of minor asymmetries is not possible. In addition, the F.D.A. attached a few strings to their approval. Patients must be 22 years old and M.R.I. examination of the breasts is recommended to detect leaks. The new gel implants are also more expensive than saline.


What’s Next

            The past two years have seen a transition from saline implants to the new silicone gels. In our practice most new patients are choosing gel implants because of their softer, more natural feel and lighter weight. In addition, many patients with existing saline implants, especially those with hardness, rippling or deflation, are opting for a change to silicone. In cases of malposition or unpleasantly wide cleavage, reshaping the implant pocket is also possible.

The newest breast implant on the horizon is a combination of silicone gel with an inner saline chamber. This exciting new prosthesis allows for the soft feel of silicone with the adjustability of saline. The water can even be added weeks after the surgery allowing the patient to choose her final size. Although it is produced by a U.S. manufacturer, the implants are not yet available here.

Finally, women considering breast augmentation should have multiple consultations with board certified plastic surgeons experienced in the procedure.


About the Author:


Jorge A. Perez, M.D., F.A.C.S. is a member of the NOVO National Council of Leaders in Breast Aesthetics. He has served as a consultant for both Mentor (J&J) and Inamed (Allergan), leading breast implant manufacturers.

He has lectured internationally on the subject of breast surgery and has been selected among the Castle Connolly (U.S. News & World Report) America’s Top Doctors. More information is available at or or call (954) 351-2200.

Natural vs. Fake: The Dilemma of Breast Implants (Original Article)

· Breast · No Comments

breast augmentation for women seeking fuller figures has been around since the 1960’s. The original operation involved the insertion of surgical sponges. It was fraught with problems.


The 1997 movie Breast Men is a semibiographical depiction of the pioneers of breast implants who first used silicone prostheses. Since that time implants, and the surgical procedures to insert them, have evolved in many ways. However, the original goal is still the same; achieving a natural look.


Although the definition of “natural” can vary significantly, I’ll try to outline the variables I work through with patients for breast augmentation. It is important that patients be informed of the various options because there are several decisions in which they should participate.


Size Matters

            The most common question I’m asked during breast augmentation consultation is “What would be a good size?” My first response is to remind the patient that implants are not breasts. They are basically bags of water (saline) or gel (silicone) that are placed to enhance the woman’s own breast tissue.


A simple formula is that the greater the patient’s own breast tissue, and the smaller the prosthesis, the more natural the result. The converse is also true: the less tissue and larger prosthesis, the less natural, or more fake the appearance.


Size is, by far, the most important variable in achieving a natural result. If there is any doubt just take a walk along South Beach. In my opinion, there is nothing worse than an attractive woman with distractingly large breast implants.


Breast size is also influenced by cultural factors. I’ve had the privilege of lecturing in many countries. When I survey plastic surgeons I find that average implant size increases from Asia to Europe to Latin America to the U.S. I tell my colleagues that here we suffer from what I call the “Pamela Anderson Syndrome”. Interestingly, surgeons everywhere, even in Vietnam, seem to be familiar with the Baywatch star.


The problem with choosing an implant size is that there is no precise language that the patient and doctor can speak. Women identify breast dimension by cup size of their bra. Unfortunately, as most women know, bra size can vary tremendously. In addition, implants don’t come in cup size. Manufacturers create implants in sizes based upon the volume, in cubic centimeters (cc’s) of the bags. However, the numbers (250, 300, 350…) are usually meaningless to the patient.


Each surgeon develops his or her own technique for choosing the right breast implant size. Sometimes patients will bring in photos or try on sample prostheses in the office. I like to ask patients what their goals are. Do they want to be understated? Proportionate to their build? Or do they plan to dance on tables? It’s not an exact formula but I perform many augmentations and this method has worked well for me over the years.


I also point out to patients that breast implants are not like a pair of shoes, where one size fits perfectly, but a size above or below won’t. The correct choice of implant falls into a range of potential sizes.


Shapes and Styles

            Breast implants come in various shapes and styles. These choices will also impact the aesthetic result of surgery. The first choice is between saline and silicone prostheses. Saline implants are silicone-shell water bags. Silicone gel implants have a filling similar to gummy bear candy. Gel implants are softer. They feel and look more natural and are lighter than the equivalent saline sizes.


Gel implants are the most commonly used breast prostheses throughout the world. They are more expensive that saline and have some restrictions which should be discussed at the time of consultation.


Saline and silicone implants come with either a smooth or textured cover and in round or teardrop shapes. The concern of the latter is that they can tilt and cause an uneven bulge.


Textured implant covering feels similar to Velcro. It tends to make the implant stiffer and more likely to cause unnatural rippling of the breast skin. In the U.S., the smooth, round implants are most common. However, patients should feel all the implant types at the time of consultation and then decide for themselves.


Surgical Technique: It’s All About the Cleavage!

There are several surgical incisions and approaches to breast augmentation surgery. The technique often will vary based upon the surgeon’s preference and experience. The patient’s goals are important here too. These choices include placement of the scar and the implant pocket. The specifics of these decisions should be discussed with the surgeon during the consultation.


One very important variable however, is the position of the implant pocket. All too often implants are placed too far apart and fail to close the cleavage gap. However, women certainly understand, it’s all about the cleavage!


Even though every woman presents with a different preoperative cleavage gap, the surgeon should focus on helping the patient achieve her personal best. With few exceptions, the gap should be narrower in almost all cases.


We’ve revised cases where the gap was so wide that when the patient laid down the implants would roll into the armpits. One patient even affectionately referred to herself as the “table top chest”. In my opinion, proper cleavage is second to size in achieving a natural result.


So what goes into a “natural” breast implant result? The answer is all of the above; size, shape, style, technique and cleavage. Obviously, these will vary by patient and her personal goals. They should all be discussed thoroughly at the time of consultation.


About the Author:

Dr. Perez is a member of the NOVO National Council of Leaders in Breast Aesthetics. He has served as a consultant for both Mentor (J&J) and Inamed (Allergan), leading breast implant manufacturers.

He has lectured internationally on the subject of breast surgery and has been selected among the Castle Connolly (U.S. News & World Report) America’s Top Doctors. More information is available at or or call (954) 351-2200.

The French Breast Implant Crisis (Original Article)

· Breast · No Comments

A breast implant scandal in Europe has drawn the attention of women throughout the world, including here in the United States. Poly Implant Prothese (P.I.P.), a French breast implant company was shut down in April 2010 after it was revealed that the manufacturer was using sub-standard, industrial grade, silicone in its’ gel prostheses. In January 2012 the former head of the company and other principals were arrested in France and charged with involuntary injury.
The P.I.P. implants were also found to have a significantly high rupture rate. The combination of rupture and non-medical grade silicone are of concern because of the risk of severe inflammatory reaction within the breast. European health authorities have recommended that women with these implants have them removed.
P.I.P. has sold over 300,000 implants in 65 countries throughout the world. Most of the implants were exported. Latin American countries were among the largest purchasers of these defective implants. Central America, Mexico, Argentina, Venezuela, Colombia and others have used the French implants since the early 1990s. Brazilian plastic surgeons purchased 25,000 P.I.P. implants.
The U.S. has very strict standards for the sale of breast implants. Currently only two manufacturers, Mentor/J&J and Inamed/Allergan, have F.D.A. approval for the sale of breast implants here. However, the landscape in Latin America is very different. In excess of 10 breast implant manufacturers, from countries such as China, Brazil and France, offer their products for sale there.
The American French Connection

Although only the two U.S. manufacturers are permitted by the F.D.A. to sell implants in the U.S., French implants have appeared in South Florida because of the number of patients who travel to Central and South America for breast augmentation.
Typically these women travel to cities in Venezuela, Colombia, the Dominican Republic, Costa Rica, and others seeking implant surgery at a lower cost. Often the cost savings is in the implants themselves, since the U.S. implants can cost up to $1,000. each. French, Chinese and Brazilian implants typically cost hundreds of dollars less.
Most recently, health authorities from several countries in Latin America have recommended that women with P.I.P. implants return for consultation with their plastic surgeon. It is also advisable that patients planning surgery outside the U.S. obtain detailed information about their prostheses, as well as the plastic surgeon and the surgical facility.

Jorge A. Perez, M.D., F.A.C.S. is a member of the NOVO, National Council of Leaders in Breast Aesthetics. He has served as a consultant for Mentor (J&J) and Inamed (Allergan), both leading U.S. breast implant manufacturers. He has lectured internationally to plastic surgeons on the subject of breast surgery and has been selected among Castle Connolly’s (U.S. News & World Report) list of America’s Top Doctors. More information is available at or call (954) 351-2200.