Wrinkle Fillers

Products like Restylane, Juvederm, Perlane and Radiesse allow for quick correction of moderate wrinkles with minimal downtime. They are all dermal fillers, and as the name implies, they are used to fill in unwanted wrinkles and folds. The correction can be increased with increased volume, and the downtime is about 24 hours of mild redness and sometimes longer for resolution of the occasional bruise. The improvement is immediate, and continues to improve for the first month. They can be used anywhere on the face. Since fillers do not inhibit muscle motion, they excel in the correction of lines around the mouth and in the lower face.

Neuromodulators

Products like BOTOX Cosmetic, Dysport and Xeomin are neuromodulators. They relax the muscles that cause wrinkles, like the frown lines found between the eyebrows. These take a few days to relax the muscle, and gradual improvement is seen as the skin is no longer folding from the muscle motion. Since neuromodulators reduce, or even stop, muscle motion, they are used mostly in the upper face. Use around the mouth needs to minimal and requires advanced techniques and good judgement.

Facial Wrinkle Correction Video

Today’s video is about how to use minimally invasive procedures to achieve maximum results. It is from a recent appearance on KRON‘s Body Beautiful. The (415) number in this video was for viewers to call during the live broadcast. If you have questions about dermal fillers or botox, please a call us at (925) 943-6353.

Facial Wrinkle Correction Video Contents

This Facial Wrinkle Correction Video includes:

• Liquid Facelifts and Facial Wrinkle Reduction
• Why have a Plastic Surgeon do your non-surgical wrinkle treatments.
• Is Wrinkle Reduction Art or Science?
• What happened to Collagen?
• What are the problems with dermal fillers?
• What is Hyaluronic Acid?
• How does Hyaluronic Acid improve wrinkles?
• Can you get Botulism from Botox?
• Viewer Question – How can a scar beneath the eye be improved?
• What can be done at home to improve scars?
• Does massage or using topical silicone improve scars?

Who Am I?

I am a Board Certified Plastic Surgeon in private practice in the San Francisco Bay Area city of Walnut Creek, California, for almost 15 years. My practice includes a wide range of plastic surgery, with specialization in cosmetic plastic surgery. To learn more about my practice visit the Meet Dr. Mele page.

Why see a Plastic Surgeon for Non-Surgical Wrinkle Correction?

While I specialize in Cosmetic Plastic Surgery, the development of injectable therapies has revolutionized the way I approach facial rejuvenation. Dermal Fillers and Wrinkle Relaxers are no substitute for real plastic surgery; however, they do allow for real improvement in the appearance of facial lines and wrinkles, in ways that were just not possible before. The advantage of seeing a Board Certified Plastic Surgeon for your non-surgical wrinkle correction is two-fold. You get the immediate advantage of a trained plastic surgeon’s advanced knowledge of facial anatomy, and the future advantage having a trusted relationship with that plastic surgeon should longer lasting, surgical correction be desired.

More Wrinkle Correction Information

Information on facial wrinkle reduction is available in English and Español. Please follow the links below:

• Wrinkle filler & wrinkle relaxer information, including Before and After Pictures, on Dr. Mele’s main web site.
• Reducción de Arrugas y Cuidado de la Piel
• Five part series on Lip Augmentation

More Wrinkle Correction Videos

This is part 3 of 4. Below are links to the rest of the series:

• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 1
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 2
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 3 (You are here)
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 4 (Coming soon)

Plastic surgery is extremely personal, and I depend on you to help me know what the best course of treatment will be. Sometimes plastic surgery is the best answer, and sometimes less is more appropriate.

Many plastic surgeons use Botox and Restylane in their practices. While non-surgical, these products are complementary to what we Plastic Surgeons do. For example:

Forehead Wrinkles and Frown Lines

Relaxing the frown lines and forehead wrinkles has always been a part of the Brow Lift procedure. If you have droopy eyebrows that are pushing skin onto your upper eyelids, deep wrinkles running across your forehead, or vertical lines between the eyebrows that make you look angry (frown lines), a brown lift might be for you. On the other hand, if you have the frown lines the forehead wrinkles, but the eyebrows and eyelids are fine, Botox, Dysport and Xeomin, may provide you with an equally attractive result.

Lower Face Wrinkles

Lower facial wrinkles include the Naso-Labial Folds (NLF’s), Marionette Lines (ML’s), lip lines and other wrinkles found on the lower face. These areas can be treated with a Facelift, when coexisting with lower facial skin laxity, but when found in isolation, a face lift is more than what is needed. Dermal fillers like Restylane, Juvederm, Perlane and Radiesse can pinpoint the treatment to exactly where it is needed, without the downtime associated with surgery.

Naso-Labial Folds (NLF’s)

The Naso-Labial Folds are the lines that extend from the sides of the nose down to the lips. They are the result of muscle attachments to the skin, and are deepened when we smile. The more firmly the muscle is attached, the deeper the resulting fold. Filling the NLF’s with Restylane, Juvederm, Perlane or Radiesse can reduce the appearance of folds without affecting the ability to smile. Unlike botox, dermal fillers do not inhibit motion.

Marionette Lines (ML’s)

The Marionette Lines are a continuation of the NLF’s, extending from the corners of the mouth down to the jaw line. These too are reinforced when we talk and smile broadly. Like the Naso-Labial Folds, the Marionette Lines respond well to fillers. The ML’s often require more volume than the NLF’s for what would seem to be wrinkles of similar depth.

Lip Lines

Lip lines are the fine lines that radiate out from the lips. Often referred to as Smoker’s Lines, the lines are formed when we pucker our lips. Lip lines allow lipstick to bleed, and can make maintaining a clean line at the edge of the lip difficult. By carefully filling in the edge of the lip, a smoothed contour can be formed, and less lipstick bleed occurs. This can be done with or without Lip Augmentation, or purposefully adding volume to the lips.

Facial Wrinkle Correction Before and After Photos

This segment focusses on dermal fillers, and shows numerous before and after pictures illustrating the areas more commonly treated with fillers like Restylane, Juvederm, Perlane and Radiesse. Wrinkle relaxers, like Botox, Dysport and Xeomin can complement results in facial wrinkle reduction, but were not used for the areas shown in these before and after pictures.

Facial Wrinkle Correction Video

Today’s video is from a recent appearance on KRON‘s Body Beautiful during which I discuss how to use minimally invasive procedures to achieve maximum results. The (415) number in this video was for viewers to call during the live broadcast. If you have questions about dermal fillers or botox, give us a call at (925) 943-6353.

Facial Wrinkle Correction Video Contents

This Facial Wrinkle Correction Video includes:

• Liquid Facelifts or Facial Wrinkle Reduction
• The effects of gravity and aging on the face.
• Who is a good candidate for wrinkle reduction treatments?
• Before and After Pictures of Dermal filler treatments
  • Before and After Pictures of Howdy Doody Line treatment
  • Before and After Pictures of Naso-Labial Fold treatment
  • Before and After Pictures of Facial Wrinkle treatment
  • Before and After Pictures of Acne Scar treatment
  • Before and After Pictures of Lip Augmentation
  • Before and After Pictures of Non-Surgical Rhinoplasty
• Dermal fillers used include
  • Restylane
  • Juvederm
  • Perlane
  • Radiesse
• Neuromodulators can also enhance the results of fillers. For example:
  • BOTOX Cosmetic
  • Dyport
  • Xeomin
• The best areas to treat with fillers
• Temporary vs. “Permanent” Correction

Who Am I?

I am a Board Certified Plastic Surgeon in private practice in the San Francisco Bay Area city of Walnut Creek, California, for almost 15 years. The development of injectable therapies has revolutionized the way facial rejuvenation is approached. While no substitute for real plastic surgery, they do allow for real improvement in appearance of facial lines and wrinkles, in ways that were just not possible before.

More Wrinkle Correction Information

Information on facial wrinkle reduction is available in English and Español. Please follow the links below:

• Wrinkle filler & wrinkle relaxer information, including Before and After Pictures, on Dr. Mele’s main web site.
• Reducción de Arrugas y Cuidado de la Piel
• Five part series on Lip Augmentation

More Wrinkle Correction Videos

This is part 2 of 4. Below are links to the rest of the series:

• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 1
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 2 (You are here)
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 3 (Coming soon)
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 4 (Coming soon)

San Francisco Bay Area – Leaders in Wrinkle Reduction

San Francisco Bay Area Plastic Surgery patients have always been at the forefront of facial wrinkle correction with fillers. It began in the 70′s with the local development of Collagen, and carries on today with its replacement, hyaluronic acid or HA.

Wrinkle Fillers – Restylane, Juvederm, Perlane & Radiesse

Like collagen, HA is a normal component of the skin, and is also found in our joints. HA dermal fillers are sold under many brands names, with the most popular being Restylane, Juvederm and Perlane. These clear gels allow for the correction of moderate to deep facial rhytids (lines) with minimal down time and quick improvement.

Wrinkle Relaxers – Botox, Dysport & Xeomin

Botulinum toxins have been used for years for the treatment of blepharospasm, a disabling chronic spasm of the muscles around the eyes causing functional blindness. For many years it was the plastic surgeons “secret” weapon, and used off-label, but a few years ago Allergan received approval for a new indication – the cosmetic treatment of frown lines. BOTOX Cosmetic was born. Others have followed with similar approval and results including Dysport and Xeomin.

Facial Wrinkle Correction Video

Today’s video is from a recent appearance on KRON‘s Body Beautiful during which I discuss how to use minimally invasive procedures to achieve maximum results. The discussion includes the use of fillers like Restylane, Juvederm, Perlane and Radiesse, and wrinkle relaxers, like Botox, Dysport and Xeomin. The (415) number in this video was for viewers to call during the live broadcast. If you have questions about dermal fillers or botox, give us a call at (925) 943-6353.

This Facial Wrinkle Correction Video includes:

• Liquid Facelifts
• Freshening up for special occasions
• Dermal fillers
  • Restylane
  • Juvederm
  • Perlane
  • Radiesse
• Neuromodulators
  • BOTOX Cosmetic
  • Dyport
  • Xeomin
• The best areas to treat with fillers
• The best areas to treat with neuromodulators
• Who is a good candidate for wrinkle reduction treatments?

As a Board Certified Plastic Surgeon in private practice in the San Francisco Bay Area city of Walnut Creek, California, for almost 15 years, the development of these injectable therapies has revolutionized the way facial rejuvenation is approached. While no substitute for real plastic surgery, they allow for real improvement in appearance of facial lines and wrinkles, in ways that were just not possible before.

More Wrinkle Correction Information

Information on facial wrinkle reduction is available in English and Español. Please follow the links below:

• Wrinkle filler & wrinkle relaxer information, including Before and After Pictures, on Dr. Mele’s main web site.
• Reducción de Arrugas y Cuidado de la Piel
• Five part series on Lip Augmentation

More Wrinkle Correction Videos

This is part 1 of 4. Below are links to the rest of the series:

• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 1 (You are here)
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 2
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 3 (Coming soon)
• Wrinkle Correction – Fillers, Botox and Plastic Surgery – Part 4 (Coming soon)

It made headlines in 2004 when New Jersey, in a misguided effort to raise state taxes, levied a 6% excise tax on Cosmetic Surgery. Now the nip-tuck tax is getting the axe.

Read My Lips … No Cosmetic Taxes

Today, New Jersey Governor Chris Christie signed legislation calling for the elimination of the state’s 6 percent tax on cosmetic surgery procedures. Medical procedures, like food, have always been tax free, but in 2004, New Jersey enacted the New Jersey Cosmetic Medical Procedures Gross Receipts Tax. A 6% gross receipts tax was required on all cosmetic surgery, hair transplants, cosmetic injections, cosmetic soft tissue fillers, dermabrasion and chemical peels, laser hair removal, laser skin resurfacing, laser treatment of leg veins, sclerotherapy, and cosmetic dentistry. All providers were required to register, report gross receipts and pay the tax quarterly.

This type of tax is called an excise tax. Excise taxes are taxes paid when purchases are made on a specific good. Excise taxes are often included in the price of the product, such as gasoline, alcohol and tobacco. There are also excise taxes on certain activities, such as taxes on wagering or taxes on highway usage by trucks.

Inefficient Taxation

Excise taxes are indirect, because the government does not collect the tax. Instead, and intermediary, like the producer or the merchant, is charged and they in turn pay the government. These types of taxes are inefficient and costly to regulate, and this is likely the reason the tax is being withdrawn. In the case of New Jersey, the annual tax collected was half of what was expected, about 10 million dollars. Furthermore, this was more than offset by an annual loss to the state of about 34 million dollars. This, among other facts, lead Joseph Cryan, the sponsor of the 2004 bill, to lead the repeal.

Who Decides What is Cosmetic Surgery?

There is not always a clear division between cosmetic and reconstructive surgery, and this makes this type of tax arbitrary and difficult to administer. The decision of medical necessity was left to those collecting the tax. This led to the taxation of cosmetic surgeries like those used to improve appearance after disfiguring accidents, port wine stain removal and even keloid scar removal.

A Tax on the Middle Class

With cosmetic procedures becoming more acceptable, it is no longer the exclusive realm of the rich and famous. Research by the American Society of Plastic Surgery found that 71 percent of plastic surgeries were for individuals earning less than $60,000 a year; moreover, only 10 percent of respondents reported household income over $90,000.

A Tax on Women

Research from the American Society for Dermatologic Surgery finds that 83 percent of its members’ minimally invasive cosmetic medical procedure patients are women. The percentage of women accounting for cosmetic surgery procedures approaches 90% in the yearly surgical statistics published by the American Society of Plastic Surgery.

Connecticut’s Cosmetic Taxes

Six months ago, Connecticut passed a 6.35% sales tax on all cosmetic medical procedures. Time will tell if the state suffers the same fate as New Jersey. It seems likely. With Connecticut being a small state, it is estimated that as many as half of Connecticut’s cosmetic patients will seek their care out of state to avoid the tax. This will have a significant negative impact on the state’s corporate tax revenue.

California’s Cosmetic Taxes

California considered a cosmetic tax a few years back, but with a greater appreciation of the complexities involved, the bill was withdrawn and exchanged for a 10% tax on tanning salons. This tax revenue should be reduced a little more this year thanks to a bill signed by Governor Jerry Brown that went into effect on Jan. 1, that bans indoor tanning for anyone under 18.

How does the "best" breast measure up?

Breast Augmentation with Breast Implants remains one of the most popular cosmetic plastic surgery procedures in the San Francisco Bay Area, but breast enhancement comes in all shapes and sizes. As a Board Certified Plastic Surgeon in the East San Francisco Bay Area City of Walnut Creek, a large part of my private practice is dedicated to the numerous aspects of breast enhancement, including:

• Breast Augmentation with Saline and Silicone Breast Implants
• Breast Augmentation Revision
• Breast Augmentation with Breast Lift (Mastopexy)
• Breast Lift (Mastopexy)
• Breast Reduction (Reduction Mammoplasty)

Breast Enhancement

The simplest way to decide what to do to achieve the optimal results in Breast Enhancement Surgery is to independently evaluate what needs to be done to the size of the breast and what needs to be done to the shape of the breast. While intimately related, size and shape often need to be addressed separately.

The Best Breast Size

The best size for your breasts depends on you. The best breast size will vary, and depends on the size of your body (preoperative breast size, the dimensions of the chest wall, height, weight); your level of activity (couch potato, gym enthusiast, serious athlete, Olympian); and most importantly, your comfort level with your desired cup size. This is a simplification, but a good sampling of what I am considering during every breast enhancement consultation. Whether increasing the size of the breasts with breast augmentation or decreasing the size of the breast with Breast Reduction, there is a range of aesthetic outcomes determined by physical parameters. In the vast majority of cases, this range includes what my patient has pictured in her own mind. On the other hand, the imagination has no bounds, and occasionally it outstrips what is possible.

The Best Breast Shape

The ideal breast is perky, with the nipple centered over the most projecting aspect of the breast. Changes in shape solely due to absent or lost volume, like that seen after pregnancy or weight loss, can often be improved with breast implants alone. Changes in shape due to increasing breast volume, whether due to genetics, pregnancy or weight gain, are addressed with breast reduction.

It may seem like breast reduction is the opposite of Breast Augmentation. If you are considering only breast size, it is. However, when we consider breast shape, just removing volume is not sufficient. The result would be a deflated, saggy breast. Breast reduction surgery includes a breast lift as an integral part of the procedure.

The Best Breast Lift

Breast Lifts, like breasts themselves, come in different sizes. Small breast lifts are effective for small amounts of sagging, while big breast lifts are necessary to correct large amounts of sagging. The topic is too large to cover in a paragraph, or even a web page, but more general information is available on San Francisco Breast.

The important part about breast lifts is that they help enhance the shape of the breast. Whether you are born with tubular breasts, have breast asymmetry or your breasts are ptotic (saggy), a breast lift can reshape the breasts into a more attractive form. Unlike breast augmentation, which simply magnifies the existing shape of the breast, a breast lift can remove excess skin and elevate the nipple’s position on the breast mound.

Breast Enhancement Consultations

If you are considering breast augmentation, breast lift or breast reduction surgery, be certain to find a qualified Board Certified Plastic Surgeon. It is important to remember that while there may be several ways to accomplish your desired goals, the method is not as important as the person you choose to do your surgery. Choose a Board Certified Plastic Surgeon, who is an active member of the American Society of Plastic Surgeons (ASPS). If you are considering cosmetic plastic surgery, members of the American Society for Aesthetic Plastic Surgery (ASAPS) are ASPS members who have shown a special interest in the cosmetic side of plastic surgery. For those truly dedicated to Cosmetic Plastic Surgery, the ASAPS also offers a Certificate of Advanced Education in Cosmetic Surgery. Mine is pictured below, as evidence that I am dedicated to providing you with the best that Cosmetic Plastic Surgery has to offer.

Dr. Mele's Certificate of Advanced Education in Cosmetic Surgery

If you are in the Greater San Francisco Bay Area, and would like to take the next step and schedule a personalized consultation appointment, please give us a call at (925) 943-6353, or use the contact form to the left.

Tummy Tuck, Abdominoplasty, Panniculectomy, it doesn't matter what you want to call it, the result is a flatter, firmer stomach.

What Does a Tummy Tuck (Abdominoplasty) Do?

Tummy tucks are designed to fix abdominal wall laxity. Abdominoplasty can repair stretched abdominal wall muscles. The tummy tuck removes the excess skin and fat that accumulates on the lower belly. This part of the abdominoplasty is sometimes called a Panniculectomy. Whatever the name, the result is a firmer, flatter abdominal wall.

Tummy Tuck Timing – When to Get Your Abdominoplasty

There are several reasons for abdominal wall laxity, but having children tops the list. Pregnancy stretches the abdominal muscles and skin. Often the stretching is irreversible, and the skin and muscle remain loose, despite weight loss and working out. It may take several months for your abdomen to recover from child birth. Normally, maximum shrinkage is seen by your newborns first birthday. The best time to get a tummy tuck is after your are done having children. For more information about abdominoplasty, click on San Francisco Tummy Tucks

Another common reason for a tummy tuck is a history of being overweight. Weight gain, like pregnancy, stretches the abdominal wall. When the weight is lost, loose skin and stretched muscle may continue to be a problem. This occurs in more areas than the abdomen. Loose skin may affect the breasts, face, arms and thighs too. The best time to have a tummy tuck after Weight Loss, is when you have reached your goal weight. If you have had bariatric surgery for weight loss, it is recommended to wait one year after your weight loss surgery. This allows you to reach a stable weight, and gives your body time to adjust to its new physiology. For more information on plastic surgery that can help improve your appearance after weight loss, click on Post-Bariatric Plastic Surgery.

Mommy Makeovers

The Mommy Makeover is a combination of Tummy Tuck and Breast Enhancement. Since pregnancy affects the breast and abdomen, the mommy makeover is one of the most common combination surgeries I perform. Most commonly, Breast Augmentation, with or without a Breast Lift, is added to the tummy tuck. But sometimes, just a breast lift (mastopexy) or even breast reduction is needed. A mommy makeover may involve a smaller abdominal procedure when appropriate, so liposuction and mini tummy tucks (mini abdominoplasty) are always considered. For more information on Mommy Makeovers, click on San Francisco Mommy Makeover.

If you would like more information about the mommy makeover, tummy tuck, mini tummy tuck, liposuction, Breast Augmentation, breast lift, breast reduction or post-bariatric plastic surgery, make an appointment for a personal, private plastic surgery consultation. Give us a call at (925) 943-6353, or use the contact form on this page.

The Liquid Facelift - Wrinkle Fillers: Restylane, Perlane, Juvederm, Radiesse; and Neuromodulators: BOTOX Cosmetic, Dysport and Xeomin.

The Liquid Facelift is a quick way to reduce the signs of facial aging. Technically not a facelift, the term liquid facelift refers to use of volume restoring injectables like Restylane, Perlane, Juvederm and Radiesse. These products can fill unwanted wrinkles and enhance facial features that are desired.

Filling Unwanted Wrinkles

Dermal Fillers are a class of pharmaceuticals designed to plump sagging skin. Unwanted facial wrinkles, like those found around the mouth, can be carefully filled to significantly reduce their appearance. The treatments are performed right in the office, and the downtime is minimal.

Dermal Fillers are administered with a fine needle, and come complete with local anesthetic inside. The most common unwanted side-effects are temporary and include swelling and bruising. Icing after treatments can help reduce both. A few days prior to your treatment, it is important to avoid medication that thins the blood like: aspirin, ibuprofen, naprosyn, vitamin E, fish oil and many natural supplements. This will reduce your risk of bruising. If you are planning to do some wrinkle reduction for a special occasion, do not delay. Ideally you should have the treatment done several weeks in advance. If you bruise, you will have plenty of time to recover, but your results will last for months.

Enhance Facial Features

Sometimes the goal is not to disguise, but to augment. Restylane, Perlane, Juvederm and Radiesse can be used to increase the size of some of the face’s most desirable features. Hyaluronic based fillers like Restylane, Perlane, Juvederm, can be used to enhance the lips. While Radiesse can be used to enhance the cheek bones and chin. If you are considering facial augmentation with cheek or chin implants, dermal fillers can provide a way to try it out on a temporary basis.

Maintaining the Result You Want

If you want to maintain the results, it is necessary to touch up the areas from time to time. For most patients, touch-ups require less volume than the initial treatment. This is because we are adding volume before the previous correction has completely resorbed, and because these product promote your face to produce collagen in the areas of injection. Even after treatment, the face continues to age. Dermal fillers cannot provide permanent results. The amount of wrinkle reduction, and the time it will last for you, may vary.

2011 Holiday Discounts on Selected Dermal Fillers and Neuromodulators

For the month of December several promotional specials are being offered in our San Francisco Bay Area, Walnut Creek plastic surgery office:

• Any HA filler, buy two get one free includes: Restylane, Juvederm, and Perlane. All product must be administered by December 31, 2011.
• Up to $65 rebate with each syringe purchased. (May be combined with above!)
  • Perlane – $65 rebate on each 1.0 cc syringe (maximum of 6 cc’s)
  • Restylane – $50 rebate on each 1.0 cc syringe (minimum of 2 cc’s & maximum of 6 cc’s)
• $50 rebate on BOTOX Cosmetic and Dysport treatments of $200 or more.

Liquid Facelift Appointments

If you are interested in learning more about the liquid facelift and facial wrinkle fillers, or you want to know more about neuromodulators like Botox, Dysport and Xeomin, please give our San Francisco Bay Area Plastic Surgery office a call at (925) 943-6353, and schedule a personal consultation appointment. More information is also available on our web site under face: facial wrinkles (minimally invasive) or on DrMele.com under skin.

Breast Implants Have Come a Long Way in 50 Years

Saline Breast Implants

You might be surprised to find out that saline filled implants did not appear until the French company, Laboratoires Arion, began manufacturing them in 1964. Filled with 0.9% saline, water that is the same saltiness as your body, these implants are filled in the operating room after insertion, allowing for a smaller incision compared to the incision needed for pre-filled silicone gel breast implants. While early models were fragile, contemporary saline breast implants have a stronger silicone elastomer shell. These implants became the most frequently used in the US during the 1990′s, when silicone gel filled breast implants where restricted to reconstructive use only.

Silicone Breast Implants

While saline filled breast implants have changed relatively little over their lifetime, silicone filled breast implants have gone through five distinct generations.

First Generation Silicone Breast Implants

The first generation was tear-dropped shaped. Yes, that’s correct, the first breast implants were silicone filled and tear dropped shaped. These implants have a smooth surface, so to keep them from rotating, a Dacron patch was attached to the back. It had the texture of the soft side of Velco, and allowed the body a point of attachment to prevent rotation. The shell was thick, as was the gel inside. This helped prevent deflation and tearing at the point of fixation. The thicker gel also made it easier to take care of any leaks, as the thicker the gel, the less it migrates.

Second Generation Silicone Breast Implants

In the 1970′s, in an attempt to improve the look and feel after breast augmentation, the shell and the gel inside the implant was made thinner. Unfortunately, new technology doesn’t always mean improved. With these changes came more complications. The thinner shells broke more frequently and the thinner gel could migrate farther after a leak. Even without a leak, silicone gel could “bleed” through the intact shell like Helium through a balloon. This resulted in a class action lawsuit against Dow Corning and other breast implant manufacturers. Other “improvements” which arrived in the 70′s were polyurethane foam coating for the implant shell and double lumen implants.

Polyurethane foam coating reduced the incidence of capsular contracture, but a concern that a breakdown product of the coating (TDA) might cause cancer stopped sales. The FDA later stated the risk was infinitesimally small, but no breast implant manufacturer has sought FDA approval for sale in the US. These implants remain available in Europe and South America.

Double lumen implants have two sections, an inner chamber pre-filled with silicone gel and an outer chamber that can be filled with a varying amount of saline. Double lumen implants were used mostly for breast reconstruction. Unfortunately, the increased complexity of dual chamber breast implants led to increased device failure, and eventual withdrawal from the market.

Third Generation Silicone Breast Implants

Around 1985, breast implants where manufactured with elastomer coated shells. This significantly reduced the number of implant failures and also the problem with gel “bleed”. Since that time the rate of capsular contracture has dropped. Coincidence? Maybe. At the same time the changes in the shell were made, additional improvements in manufacturing and quality control also occurred.

Fourth Generation Silicone Breast Implants

Fourth generation implants are defined by a return to a thicker, cohesive silicone gel filler. Back to the future is the theme for the third and fourth generation breast implants. Like the original breast implants, with thicker tougher shells and thicker less runny filler, the safety and predictability of fourth generation, cohesive gel breast implants has improved. Fourth generation silicone gel filled implants are currently the only FDA approved silicone breast implants currently available in the US.

Fifth Generation Silicone Breast Implants

The next incarnation of silicone breast implants are the gummi-bears. They are filled with a soft, semi-solid silicone with the consistency of gummi-bear candy. They are soft enough to give when compressed, but firm enough to return to their original shape when the pressure is released. Since they are essentially a solid, these implants do not experience problems with leakage or gel migration. Most are made with an anatomical shape. To prevent rotation, the implants surface is textured to allow the capsule to attach to the shell. This works most the time, but implant malposition from rotation can be a problem (not seen with smooth round implants). Overall, the form-stable implants are more firm, but still soft. Somewhat surprisingly, they can still ripple (wrinkle).

Allergan Natrelle Style 410 (gummi-bear) breast implants come in 12 shapes and many sizes.

Since they are solid, gummi-bear breast implants require a larger incision for placement. This can be a deterrent when a simple breast augmentation is being considered. The mastectomy incision used for breast reconstruction and the breast lift incisions allow for the insertion of solid implants without additional incision length.

Soft-solid breast implants are figuratively sitting on the shelf at the FDA. Despite some advantages, the approval process has ground to halt over the last several years. The FDA has all the information it has requested, and no new requests for information are forthcoming. Despite this, no vote has been taken. It is increasingly unclear to industry, plastic surgeons and patients alike what the reason is. These fifth generation breast implants have a good record in Europe, where they have been used since 1995, and they have been available since 2000 to our northern neighbor, Canada. Dear FDA, how about approving silicone implants that can’t leak this year?

Anaplastic Large Cell Lymphoma

Demographics of all Known Reported Cases

Demographics of the cases are as follows:

• Age: Median 51 years old, Range 28-87 years old
• Implant Type: Silicone 24, Saline 7, Not specified 3
• Time from implant to ALCL diagnosis: Median 8 years, Range 1-23 years
• Reason for Breast Implant: Reconstruction 11, Cosmetic 19, Not Specified 4

The American Society of Plastic Surgery (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) have partnered with other international plastic surgery societies like the International Society for Aesthetic Plastic Surgery (ISAPS), to provide an organized way to report, and characterize the diagnosis and treatment of ALCL since its discovery.

ALCL is Not Breast Cancer

Breast cancer dwarfs ALCL in both numbers of cases and lethality. Breast cancer has an incidence of 1 in 9 women. This means for a group of nine randomly selected women, one woman would be expected to develop breast cancer in her lifetime. The actual breast cancer rate is a little higher, and this is why routine mammograms after age 40 are so important for early detection. The risk of getting breast cancer is about 700 times higher than the risk of getting struck by lightning.

No Increased Rate of Breast Cancer for Women with Breast Implants

While the association between ALCL and breast implants is still being worked out, there is no increased risk of breast cancer in women with breast implants. In fact, the results of more than seven long-term follow-up studies show that women with implants have a lower rate of breast cancer than is expected in the general population, and higher survival rates, perhaps due to enhanced breast awareness and early detection.

Looks Like ALCL, but Doesn’t Act Like ALCL

ALCL associated with breast implants is not as aggressive as other types of ALCL. It acts more like cutaneous lymphomas than the more systemic form of ALCL. ALCL associated with breast implants has been characterized as a rarely occurring, low-grade lymphoma, that seems to grow slowly and locally. While the risk of breast cancer is 1 in 9, the risk of ALCL is less than 1 in 300,000, and most resources quote ranges of 1 in 500,000 to 1 in a million. The risk of getting ALCL associated with breast implants is 50 to 150 times lower than the risk of getting stuck by lightning.

Last week, news of the first reported death from ALCL associated with breast implants hit the French news. The details are not known at this time, and unfortunately, the case is further complicated by the use of fraudulent breast implants that were filled with industrial grade silicone instead of the required medical grade silicone. The implants were manufactured by Poly Implant Prothèses (PIP) at La Seybe-sur-Mer in the Var. The company was forced to close in March of 2010, after it was determined that the implants were filled with non-medical grade silicone gel. These implants have more gel bleed, and are ten times more likely to break. Even though the company was forced to withdraw its products from the market when the discovery was made, thousands of French women are known to still have the defective implants. These implants have never been FDA approved in the US. Only Allergan’s Natrelle and Mentor’s Memory Gel breast implants are currently FDA approved.

The Latest ALCL News

The best information currently available on the topic is a review of opinions by a panel of experts from RAND Health, UCLA’s department of medicine’s division of hematology-oncology, the University of Michigan Health System’s department of surgery’s division of plastic surgery and others. The article has been accepted by ASPS’s Plastic and Reconstructive Surgery Journal, but has not yet been published. The results are based on the small number of cases known to exist, represent the opinions of the seven panel members and are not based on prospective randomized evidence. A copy of the article can be found here. The article’s disclaimer reads: Support for this study was provided by the Plastic Surgery Educational Foundation (PSEF) and the Aesthetic Surgery Education and Research Foundation (ASERF) through unrestricted grants from Allergan, L.L.C.; Mentor Worldwide, L.L.C.; and Sientra, Inc. Neither the study sponsors nor the listed companies had roles in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

As more information becomes available, I will post more updates. It is important to remember that this is an extremely rare problem. It is a sensational story though, so it is sure to hit the mainstream media soon. The ASPS, ASAPS and ISAPS are actively seeking all known cases of ALCL found around breast implants to determine what, if any association exists, if there is a causal relationship and how best to treat the disease when discovered. If you have, or know someone who has, ALCL associated with breast implants, please contact one of these plastic surgery societies and the FDA.

More Information About ALCL

A current summery of ALCL cases appeared in the June issue of Plastic and Reconstructive Surgery. The abstract can be read here.

The FDA has an ALCL and breast implants FAQ page here. Moreover, all confirmed cases of ALCL in women with breast implants should be reported to Medwatch, the FDA’s safety information and adverse event reporting program. Report online here or by calling 1-800-332-1088.

How to Detect ALCL Associated with Breast Implants

The chances of getting breast implant associated ALCL are extremely remote. I have thousands of patients with breast implants, and chances are that I will go my entire career without seeing one case. This, however, will not keep me from looking for it.

Most cases of ALCL in patients with breast implants have presented with a seroma (fluid collection) around the breast implant more than six months after the initial surgery. To try and detect ALCL as soon as possible, experts are recommending aspirating (draining) seromas around breast implants when they occur later than six months after breast augmentation or breast augmentation revision surgery, and also sending the fluid for cytologic analysis to check for abnormal cells. If you feel you have a problem with your breast implants, do not delay; seek the advice of a Board Certified Plastic Surgeon in your area.

This month, Sparkah.com has named the Top 100 Cosmetic Surgeons / Plastic Surgeons in San Francisco of 2012 and Beyond, and I am happy to share with you my inclusion in the top 10. The San Francisco Bay Area is home to some of the best trained plastic surgeons in the nation, and a big Thank You goes out to all my patients who placed me among the very best, and or course to Sparkah for including my private plastic surgery practice at the top of its list.

As mentioned last week, talking about non surgical plastic surgery in the san francisco bay area, the San Francisco Bay Area is my home.

It’s certainly not the cheapest place to live, but like plastic surgery, you get what you pay for: great weather, great culture, beautiful scenery and a large variety of what makes life worth living. From beaches to mountains, sports to the arts, there is something for everybody. It’s a great place to live, work and play. I am glad that my Walnut Creek Plastic Surgery practice has been included as a part of what is great in our San Francisco Bay Area neighborhood.

Thank you for the opportunity to continue to contribute. Whether you are looking for facial plastic surgery like a facelift, eyelid lift or rhinoplasty, or body work like a breast augmentation, tummy tuck or liposuction, Joseph A. Mele, III, MD, Inc., will be here for you in 2012 and beyond.

Inclusion in the Top Plastic Surgeons in San Francisco to See In 2012 is based on:

• Years of Experience
• Online Reviews
• How Easy it is to Reach Them on Twitter
• School Background
• Popularity Online

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