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The 5 Steps of Breast Cancer Reconstruction


October is breast cancer awareness month as it continues to be one of the most common disorders affecting women. However, great strides have been made in both cancer diagnosis and treatment. In addition, many options exist for reconstruction following breast lumpectomy or mastectomy that allow these women to enjoy a greater quality of life.


There are several important and timely decisions for women to consider in achieving an optimal outcome. These choices can be overwhelming, though, so here are 5 steps to help women work through this difficult time.


Step 1: The Cancer Operation


Following the diagnosis of breast carcinoma a woman’s first consultation should be with a general surgeon experienced in all of the options for removal of the cancer. Together they should decide upon mastectomy or less radical surgery such as lumpectomy, as well as the role of adjuvant treatment such as chemotherapy and radiation. Based upon these plans a referral to a plastic surgeon with expertise in breast surgery is in order.


Step 2: Immediate vs. Delayed Reconstruction


The initial consultation with a plastic surgeon includes a thorough medical history and directed physical examination. The first decision will be whether to delay the breast reconstruction or begin at the time of mastectomy. The latter is regarded as an “immediate” reconstruction. Coordinated surgery offers the advantage of a single operation and fresh tissue planes for a cleaner and faster reconstruction, although delayed breast reconstruction can also be safely performed years after a mastectomy.


Step 3: Autologous Tissue vs. Prosthesis Reconstruction


The detailed plastic surgery discussion should include the types of reconstruction. There are several procedures available for creation of a new breast mound ranging from simple implant placement to microsurgery. The choice will depend upon several variables including the patient’s desires and body type. Autologous reconstruction is performed using the woman’s own body fat from the belly, back or buttocks. These can be lengthy and more complicated procedures. Breast implants, with or without expansion of the chest skin is called prosthesis reconstruction.


Step 4: The Other Breast


The opposite, healthy breast can be reshaped as well. Breast augmentation, lift or reduction for the purpose of achieving symmetry to the reconstructed breast may be necessary and should be included in the reconstructive planning.


Step 5: Nipple and Areolar Reconstruction


Once a new breast mound has been formed the final phase is the optional creation of a nipple and/or areola. Many procedures exist for this purpose. Although these are not mandatory, the results can be amazing.


Finally, and fortunately, laws exist to protect women from insurance companies during this vulnerable time. Florida law mandates coverage for both the reconstructed breast as well as the other healthy breast, if necessary, to achieve symmetry.


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. Dr. Perez 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. Our office aggressively advocates only on behalf of patients, not insurance plans. More information is available at or call (954) 351-2200. Visit our website blog to learn about The 10 Questions Every Plastic Surgery Should Ask.

Sientra: The New FDA-Approved Shaped Gel Breast Implant

Breast augmentation surgery is the most commonly performed surgical procedure in plastic surgery. Following the breast implant lawsuit crisis of the early 1990’s most silicone gel manufacturers fled the U.S. market. Only two companies, Allergan (formerly McGhan/Inamed) and Mentor/J&J, remained and have dominated the market for the past 20 years. One consequence of this implant duopoly is that the cost of breast implants increased from hundreds to thousands of dollars since the 1980’s.


Earlier this year the U.S. F.D.A. which regulates medical devices approved a third breast implant manufacturer. Santa Barbara based Sientra was approved to offer silicone gel prostheses for sale in the U.S.  Allergan and Mentor are also based in Santa Barbara, leading to the affectionate term of “Silicone Alley” for the Southern California region.


Dozens of breast implant companies exist throughout the world. Many of these brands are sold in Latin America. Sientra’s parent manufacturer has sold implants internationally, but of course U.S. approval is a highly coveted achievement.


A Good Thing…and a New Thing


The arrival of a third player to the U.S. breast implant market is expected to be a good thing for American women. In addition to providing greater competition, Sientra offers a unique line of shaped gel implants. These “teardrop” or “anatomical” breast prostheses are commonly used in Europe and Latin America. A saline-water filled version has been available for years in the U.S. However, Sientra is the only manufacturer granted F.D.A approval for the gel filled type.

Shaped implants offer greater options for both cosmetic and reconstructive breast surgery. The prostheses come in a variety of shapes, sizes, base diameters and projections giving both the patient and surgeon greater versatility in body contouring.


The augmentation procedure using shaped implants is different from the traditional round prosthesis insertion. Therefore it is advisable that patients choosing these implants consult with experienced breast plastic surgeons. As a corporate philosophy, Sientra will only sell and warranty implants placed by plastic surgeons recognized by the American Board of Plastic Surgery.


Editor’s Note: Dr. Perez can be seen on ABC News in Miami discussing the Sientra implant at:



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). Dr. Perez 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

May is Mommy Makeover Month (Original Article)

May is the month we dedicate to celebrate motherhood. It’s only fitting, therefore, that we also recognize the changes that motherhood brings.

Of course, becoming a mother alters the life of a woman in many ways, often running the gamut of emotional experiences. There are also changes to a woman’s body that accompany growing, carrying and bearing a child.

Pregnancy, and the weight gain that occur, create growth, not only of the baby, but also of the mom. Among the structures that grow to accommodate the new addition is mom’s belly skin. Sometimes the skin has difficulty expanding evenly so it cracks in areas. These cracks in the skin are what we identify as stretch marks.

Labor and delivery also create changes in the woman’s pelvis, allowing the hips to relax and widen during the birthing process. Multiple pregnancies multiply this effect on the woman’s body. These permanent changes are, however, well compensated by the joys of motherhood

The other parts of the woman’s body greatly affected by pregnancy are the breasts. The breasts grow and engorge in preparation for feeding the infant. Many women like the appearance of their breasts during pregnancy because the breasts become full and robust. Often women are disappointed after pregnancy when the breasts lose their fullness and begin to drift downward.

The good news is that many of the undesirable effects on the woman’s body from pregnancy can often be minimized before, or improved afterwards, through good perinatal care, as well as, the judicious and timely use of plastic surgery.


Let’s Start at the Top

            The breasts typically lose their fullness and descend to a lower position after pregnancy. Sometimes the areolae also stretch. The reasons for these changes are simple; gravity and skin tone.

The surgical treatment of post-pregnancy breast changes depends upon the condition. Lack of fullness requires placement of implants to restore volume. Nowadays many implant choices are available. Women who choose to breast feed should defer breast augmentation until the breasts revert back to their dry, pre-pregnancy state, usually 1-2 months after cessation of feeding.

Breast droopiness requires a lift procedure. Lift techniques vary but typically involve a greater degree of scarring than simple breast augmentation. Patients need to be ok with these scars and should have a thorough consultation to review them prior to surgery. Areolae can also be made smaller at the same time. Sometimes patients can benefit from both a breast lift and augmentation to restore position and fullness.


Then There’s the Baby Belly

            The abdomen does the heavy lifting in pregnancy. It’s no surprise therefore, that, after pregnancy, skin redundancy and stretch marks can remain. Another interesting effect of pregnancy is a separation of the paired rectus abdominus (i.e sit-up) muscles. The result is a gap between the muscles resembling a hernia. It is because of this anatomical separation of the muscles that abdominal exercises after pregnancy, such as sit-ups, although beneficial, are of limited value.

In cases of loose abdominal skin, stretch marks, and muscle separtation, the procedure of choice is an abdominoplasty, also known as a tummy tuck. Like the breast lift, tummy tuck surgery requires scars that need to be accepted by the patient. The tradeoff, however, is substantial removal of excess skin and stretch marks, as well as repositioning of the muscles. The result is a dramatic tightening of the belly with a very high degree of satisfaction. Tummy tuck patients are among the happiest in my practice.

Since both the breasts and the belly are affected by pregnancy, women often choose a combination of procedures. Sometimes even other areas, such as the love handles or the thighs also become part of the mommy makeover.

Combination procedures require additional safety considerations with respect to the operating facility and anesthesia. As with all plastic surgery a thorough and honest consultation with an experienced surgeon is key to a happy mommy. Happy Mother’s Day!



About the Author:


Jorge A. Perez, M.D., F.A.C.S. is a board certified plastic surgeon in Ft. Lauderdale. He 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 body contouring 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.

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)

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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.