COHESIVE IMPLANT EXPERT
BREAST IMPLANT REVISION EXPERT
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Dr. Steven Teitelbaum
Dr. Teitelbaum is an internationally recognized board-certified plastic surgeon known for his expertise in breast augmentation. He has extensive experience working with both saline and silicone implants, having helped design and test the most current models, and he lectures and teaches other surgeons how to perform breast augmentation surgery and achieve the best results with minimal pain and recovery time.
• Expertise. Dr. Teitelbaum is the only surgeon in the state of California, and perhaps the only in the United States to have participated in the clinical studies of the newest generation of breast implants (also known as “cohesive”, “gummy-bear”, or “form-stable” implants) for all three implant manufacturers—Mentor, McGhan (now Allergan), and Silimed (now Sientra.) He also testified at the FDA hearings on silicone gel breast implants. As a result, he has among the most clinical research experience of any physician in the U.S. with these implants, and he has taught plastic surgeons in the U.S. and overseas how to use these implants.
In the past few years, Dr. Teitelbaum has given over fifty lectures to other plastic surgeons on breast augmentation and breast implant revision surgery—including talks across the U.S. and in Brazil, England, Malaysia, Israel, Mexico, Morocco, and Sweden. He also teaches plastic surgery to residents at the UCLA Medical School.
Dr. Teitelbaum has published several recent articles on breast augmentation in the most prestigious plastic surgery journal Plastic and Reconstructive Surgery—including, among others, a landmark paper on reducing the need for patients to have multiple operations, and analyzing how breasts can be damaged by improperly sized breast implants. He has written recent textbook chapters on both initial and revision breast augmentation surgery.
Dr. Teitelbaum is a principal figure in creating the curricula used to teach other surgeons how to select the proper implants for each patient and achieve the most-natural results. He invented a device to aid surgeons in implant selection and was awarded a US Patent in 2010. He is a lead instructor in the breast augmentation course offered to plastic surgeons at the annual meeting of the American Society of Aesthetic Plastic Surgery.
• Patients. Dr. Teitelbaum is cosmetic surgeon to a number of influential people, models, and celebrities, but he is most proud to often be chosen by other physicians for themselves or their families. Dr. Teitelbaum is also frequently referred difficult cases from other top surgeons in the U.S. and around the world. Finally, Dr. Teitelbaum is often chosen by employees of breast-implant manufacturers—people who observe many plastic surgeons and have access to the results achieved with their products. Following a 2007 review of his clinical trial results by a two-person evaluation team that travels countrywide to review all surgical results for a particular implant—Dr. Teitelbaum received this note: “Jennifer is not given to false praise—what she told you about your work was truly from the heart, and I agree with her. You have that very unique gift which enables you to produce spectacular results over and over again.”
Philosophy of Breast Augmentation
Dr. Teitelbaum’s approach to breast augmentation is a direct result of years of studying, writing, and lecturing on the subject. He’d like to share with you a few of the points that distinguish him from other aesthetic surgeons:
“Augmentation affects your breasts for the rest of your life—a responsibility I take very seriously. Every surgical decision we make together—from the incision site to the pocket location to the type and size of implant—should further the goal of making your breasts look their absolute best, in the safest way possible. We should make choices that give you a beautiful breast not just this year and next, but for many years beyond that.
My personal aesthetic gravitates toward breasts that are beautiful and natural, and my patients generally share this approach. Most of them specifically say that they do not want to look “fake”; unless a patient specifically insists otherwise, this is always my goal. I tell patients what I believe will look best for them and be best for their bodies, but ultimately you – the patient – is the one who decides what will be done. I will work hard to make sure that I understand what you want before proceeding with any surgery.
You can expect an unparalleled consultation experience. Many plastic surgeons actually pass you off to a patient coordinator, or they may spend only a few moments with you. I schedule a large block of time for each prospective patient, and will take as much time as you need to discuss how you want your breasts to look, and any concerns you may have. Whether you have the surgery done by me, by someone else, or not at all, you will be sure to leave my office with an enhanced understanding of the specific issues surrounding breast augmentation in you.
This dialogue will continue throughout our entire relationship as doctor and patient. Far too often I hear other surgeons’ patients complain that their augmentation didn’t give them the results they wanted or expected. This is unacceptable to me, which is why I will explain the implications and consequences of each decision we make together, and stay in constant contact to make sure you know exactly what to expect.
I put an enormous amount of effort into keeping myself and my surgical facility up to date with advances in technology. And while I don’t rush to embrace every innovation, through my own research I have been able to improve upon breast augmentation techniques. In fact, I instruct other surgeons in how to minimize recovery time and pain in initial breast augmentation. And I do every part of your operation.
I use only MD board-certified anesthesiologists. We have hand-picked the best group of nurses, and the same team works together day after day, which provides you with an additional level of safety, comfort, and experience.
Finally, I think it is important to stay in close contact with a patient after surgery. No matter how busy our office gets, you can expect regular follow-ups and the kind of top-notch postoperative care I consider necessary to ensure the best possible results, and I give out my cell phone number to all surgical patients so that I am easily within reach. I’m honored when any patient chooses me to be her surgeon, and I strive to make sure my conduct always reflects that feeling.”
Steven Teitelbaum MD FACS
Read Carefully Before Your Consultation
Decisions about implant type, size, incision, and pocket location will have a permanent effect on your breasts. Too often these decisions are based upon “patient choice” or “surgeon preference,” rather than the conclusions of the best scientific articles. As an astute observer of the unfortunate decisions that contributed to the problems he sees in revision augmentation patients, Dr. Teitelbaum will counsel you to make the decisions that will help you achieve the most beautiful result in both the short and long term.
Three implant types are available: saline filled, silicone filled, and the so-called gummy bear. The natural feel of silicone filled implants has made them the most commonly used of all. Saline implants are available for patients who remain fearful of silicone (though the concerns of the 1990’s have been put to rest.) The highly cohesive or “gummy bear” implants are not FDA approved and patients wanting them are required to be a part of an investigational trial. Dr. Teitelbaum is a participant in all of the cohesive implant trials and will discuss with you whether these implants will be good for you (see additional sheet about these implants.)
Deciding upon implant size is often difficult for patients and surgeons, but it actually should be very straightforward. Each breast has an ideal implant size if the goal is to make the breast look full and beautifully shaped. If a much smaller implant is used, the breast will not be full and the upper part will look empty. If a much larger implant is selected, the breast will look stuffed, round, bulgy on top, and less natural. This is true regardless of implant type and surgery technique.
If you want a natural look, or if you selected Dr. Teitelbaum because you were impressed with his beautiful results, allow him to size you based upon your measurements. Dr. Teitelbaum has taught sizing to many surgeons and received a patent in 2010 for an implant sizing device, so you can trust that his analysis will create the most beautiful breast possible. Some patients accept Dr. Teitelbaum’s suggestion because they realize he knows what will be the prettiest for their breasts. If patients are concerned that they could end up larger or smaller than they wish, he has them try on implants and see a 3D simulation of their results.
If you want to be larger than what the measurements determined is best for you, you must understand that to do so means that you will look more stuffed and round. If you want to be smaller, you must understand you will look less full. Going larger than ideal does not just mean that you will look less natural; it will lead to more skin stretch and thinning of your breast tissue from pressure, leading to problems years from now that can be impossible to correct. Dr. Teitelbaum has published articles on this topic and makes it a priority to help his patients avoid these sorts of problems.
The significance of the incision is far more than the resulting scar. Each incision involves different risks, recoveries, and long term results. Data has emerged demonstrating a substantial advantage for the underneath the breast (inframammary) incision. There is a better chance the implants will be accurately placed; there is a lower chance of the breasts becoming hard; there is a lower chance of needing another operation; the scar can be reused for any revision in the future; and the scar is often the most inconspicuous. He has experience with and can offer you all the incisions, but because the preponderance of data now favors the inframammary incision, he will probably suggest that to you.
Dr. Teitelbaum will usually suggest the “dual plane” pocket, in which the implant is partially behind your muscle. This is one of the latest developments in breast augmentation surgery and Dr. Teitelbaum has written about it and taught other surgeons how to control the extent of muscle coverage to optimize shape. It allows maximization of coverage where necessary and enhancement of shape where desired, thereby realizing the benefits of both the in front and the behind the pockets. This optimizes breast shape, minimizes implant visibility, helps with mammograms, and reduces the chance of capsular contracture.
Highly Cohesive Implants
Many of Dr. Teitelbaum's patients choose him to be their surgeon because of his expertise with cohesive gel implants (also known as "gummy-bear implants" because the gel has a consistency similar to that of the candy). These have been widely used in Europe since 1993. US clinical trials began in 2001 and until now the implants were only available to patients and a select group of surgeons participating in clinical trials. These implants received FDA approval in February of 2013.
Dr. Teitelbaum is the only surgeon in the state of California who participated in the clinical trials of all three cohesive implant manufacturers. He has over a decade of experience and has implanted more than 1300 such implants. Because of his excellent results in a wide variety of breast types, Dr. Teitelbaum is one of the most frequently requested lecturers on this topic in the United States, and he has traveled to places as far away as Asia, Europe and Africa to share his cohesive breast implant expertise with other surgeons.
These implants have several advantages and disadvantages. While beautiful and natural results can be achieved with any breast implant, Dr. Teitelbaum believes he has greater control to create a more beautiful shape with these implants. They are more resistant to developing folds that can be either seen or felt. Studies show a lower rate of scar tissue formation, leakage, and chance of needing another operation than standard silicone gel implants. While many patients perceive these implants as "leak-free", in fact it is possible for them to break, though the gel is so stiff that it does not appear to migrate.
They are slightly firmer than standard silicone implants, but it is that characteristic which allows them to maintain a shape and to have possibly enhanced durability. Since they are thin at the top and thick at the bottom, they must maintain their orientation. If a round implant rotates, then there is no change in appearance, but if a teardrop rotates then it can create a distortion. This is a risk that exists with these cohesive implants that does not exist with the round implants.
They work best in patients who wish to have a proportional augmentation, because they do not look as good when sized much above or below what is ideal for the breast. In loose and highly mobile breasts, they tend to feel more firm than they do in breasts that are already very firm.
Dr. Teitelbaum is an enthusiastic supporter of this new technology, and developed the educational material that one implant manufacturer will use to credential surgeons who wish to use them. In fact, he was even videotaped performing surgery to demonstrate to other surgeons the ideal way of using these implants. As excited as he is about these implants, he does not believe they are ideal for everyone. He always works with each patient to determine exactly what size and type of implant is right for her, and would never automatically recommend cohesive implants. When you come in for your consultation, you and Dr. Teitelbaum can explore if they might be right for you. In the meantime, we encourage you to visit Dr. Teitelbaum's special website, www.cohesiveimplants.com, to learn more about this exciting new technology and all it has to offer.
Does the idea of a virtually pain-free breast augmentation seem too good to be true?
As remarkable as it sounds, recent developments have allowed over 90 percent of our breast augmentation patients to return to normal activities within 24 hours, without the need for narcotics, bed rest, or special bandages or bras. Bruising is minimal or nonexistent, and pain is controlled with ordinary Advil. In fact, Dr. Teitelbaum’s patients routinely go out to dinner the night of surgery, usually drive within several days, and need to take just a few days off of work. They can help with their children and go for a walk the day of surgery.
This is no exaggeration—and it’s also no accident. Your easy recovery will be the result of Dr. Teitelbaum’s commitment to meticulous preoperative planning, state-of-the-art anesthesia procedures, and the surgeon’s detailed understanding of finer points of anatomy, which allows each operation to proceed smoothly and with a minimum of trauma. His modern surgery suite also offers the latest advances in anesthesia protocols, which significantly minimizes postoperative nausea.
Because of rough or imprecise technique, some surgeons tightly bandage patients or make them wear a special bra in the hopes of forcing the implant into a particular position or to act as a tourniquet to prevent bleeding. Dr. Teitelbaum’s precise and gentle surgical technique, conversely, allows his patients to move their arms in the recovery room right after surgery—and the result is less pain, a shorter recovery, and a lower chance of hardening of the breasts.
There’s a reason why Dr. Teitelbaum has been asked to teach other doctors how to achieve this kind of pain-free recovery at the largest annual plastic surgery meeting in the world. He’s made a believer out of many patients and surgeons; ask as many questions as you like about how he can do the same for you.
3-D Computer Simulation of Augmentation Results
Every woman considering breast augmentation shares the same concern: How do I choose an implant that’s the right size for me?
While Dr. Teitelbaum has a patent for a device that determines the best implant size for a breast and he is extremely experienced in helping patients find an implant that is best for them, it’s understandable that you will want to get some sense of how different options will look on you. It’s for this reason that Dr. Teitelbaum uses a state of the art digital breast imaging system. The Precision Light technology has helped hundreds of satisfied patients forecast how they will look after their procedure.
This device is new and not available to the public. While there are other 3-D devices on the market, none have the same sophisticated software engine that actually does a simulation rather than just a “morph,” thereby creating what seem to be much more realistic images. While the images are excellent and generally reliable, patients should understand that this is a new technology and only time will determine the accuracy of these images.
After taking three-dimensional digital images of the breasts, the Precision Light software then calculates precise measurements and determines the exact volume of the breast tissue present. The system can then be used to simulate how various implant sizes and types will look on you. Because any size implant can be simulated on your body, the machine presents you with an unprecedented opportunity to visualize approximately how you will look ahead of time, allowing you to get an idea of whether the implant Dr. Teitelbaum calculated for your breast gives you the overall size and balance that you wish.
Of course, like any simulation, Precision Light can’t give a 100 percent precise prediction of the outcome. But Dr. Teitelbaum has found it to be far and away the most helpful forecasting tool available—and his patients agree. Many say that the digital imaging played a big role in reducing their concerns about their implant size, and gave them more confidence that they would be happy with their outcome.
All breast augmentation consultations that are candidates for digital imaging include a Precision Light session at no additional charge. If you have breasts that are droopy and hang over the crease under your breasts, realize that the camera cannot get a picture of the bottom part of your breasts and therefore a simulation will not be possible for you. It also cannot simulate a lift or revision of a previous augmentation.
READ DR. TEITELBAUM'S NEW ARTICLE ABOUT BREAST CANCER
READ DR. TEITELBAUM'S ARTICLE ABOUT HIGHLY COHESIVE IMPLANTS
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Synmastia, by Dr. Steven Teitelbaum
Synmastia (also known as symmastia) is a condition that occurs when breast implants sit too close to the middle of the patient’s chest. Some women refer to it as ‘breadloafing” and extreme cases can even lead to the “uniboob” look. The problem can be corrected through breast augmentation revision surgery. This presentation by Dr. Steven Teitelbaum, M.D., F.A.C.S. explains in detail how to detect and repair synmastia. The pictures give you visual guidance while the text explains what you are looking at and how the repair is performed.
Dr. Teitelbaum is a plastic surgeon practicing near Los Angeles, California. He has extensive experience with both primary breast augmentation and with breast augmentation revision. He has compiled this presentation from actual cases of synmastia that he has revised recently.
||This variety of patients with synmastia (symmastia) demonstrates the underlying problem: the implant is sitting too far towards the center rather than behind the breast itself. The markings indicate where the implant should sit; correction involves closing off the overly large space so that the implant remains where it looks best|
||There are cases in which the breast only crosses the center of the body when it is forcibly pushed over; this is still synmastia (symmastia,) albeit a more mild case.|
||Notice how her implants are so close that they are even touching! The implants should not have been allowed to migrate into the area of the hatched red line. The problem can be due to inadvertent overdissection by the surgeon, the shape of the patient’s rib cage, the size of the implants, or weakness of the patient’s tissues.|
||In addition to the implant pocket being open too far towards the center, it is often too low in many cases of severe symmastia (synmastia.) |
||Laying on her back prior to surgery, it is apparent how the implants come too close to the center and the skin over the breastbone is tented up into the air. The red hatch marks represent the area of her old implant pocket that needs to be closed off.|
||Many symmastia (synmastia) patients have somewhat of a depressed breast bone area; gravity can then pull an implant down the slope towards the center.|
||This patient has the opposite type of a breast bone: it is protuberant (the medical term for it is “pectus carinatum.”) Note that gravity has pulled this patient’s implants down towards her sides.|
||Correction requires closing off the hatched areas so that the implant just remains within the inner solid line. This can be done with sutures (capsulorraphy), placing a patch of material, or with the newest technique, creation of a new space called a neosubpectoral pocket.|
||With correction using the neosubpectoral pocket, the symmastia is totally corrected and looks smooth on the table at the end of the case. Note the wide gap between the new pocket and the line indicating where the old implant used to sit.|
||Immediately before and immediately after correction, still in the operating room. The implants now have a normal distance between them and the skin over the breast bone no longer “tents” from the pressure of the implants. It is often important to switch to a smaller implant in order for the symmastia repair to heal and for the problem not to recur. Imagine if the implant in the after photo below were a lot larger; it is easy to visualize how that would stress the repair and if large enough, may cause the skin to tent again over the breast bone.|
||Everyone wants cleavage but it must be smooth and even. As in this case, sometimes it is important to leave the breasts just a little wider than ideal in order to be sure that there is ample tissue to prevent recurrence of the problem.|
||Symmastia (synmastia) should be judged in a variety of positions. With the arms raised preop in the upper left, the joining of the breasts creates a “uniboob” type of a look which is shown corrected in the upper right photograph. While cleavage is good, note in the lower left how odd it looks when the skin pulls off of the breast bone. This is corrected as shown in the postop in the lower right photo.|
||Note how much deeper and more attractive the cleave is on the left. In the middle photos, note the severe extent of the tenting of the skin off of the breast bone. In the upper right, look how far the implant can be moved across the center, but how the implant is restricted to its side in the photo beneath it following repair.|
||In this severe case of synmastia (symmastia), the patient literally had a single pocket in which the implants were touching. Not all synmastia repairs turn out this excellent. Sometimes the tissue gets stretched from longstanding synmastia and other times it may have been damaged at the time of the first operation.|
||Her underlying problem is that her implants were way too wide for her body and crossed the centerline of her chest. The right was also too low. By raising them, moving them out, and making them a bit smaller, she enjoyed a significant improvement not just to the appearance of her breasts, but to their feel as well.|
||When implants are too close to the center, the nipples point out; when they are too low, the nipples point up. It is fascinating to note in symmastia (synmastia) patients how implants in the wrong place can so dramatically change the appearance of the nipples.|
||Note in the frontal view how much more even the implants are, and how they are no longer touching in the center. Cleavage is good, but the skin over this patients breastbone pulled away from her body when she would lean forward. Note that in the sideways view, her upper bulge is reduced but not eliminated. This was by the patient’s own choice; had she selected a smaller implant, there would be less of an upper bulge and the nipple would not tip down.|
||In severe cases of symmastia with large implants that have been neglected for years, there is often stretch of the skin in the lower inner part of the breast towards the breast bone, leaving the folds that are seen. These could be improved with a lift, but the patient preferred leaving it as it is to having scars of a lift. It is also fascinating to look at the sideways photos and note how the nipple no longer points out to the side when the implant is properly positioned in three dimensions.|
||This is another example of a patient with severe, long term stretching of the skin over her lower breast bone. Such folds are usually only seen in thin patients with very large implants who have lived with their symmastia for years. She would need to have a lift if she would like to improve these. Note how an implant sitting too far towards the center doesn’t just distort the center; the breasts in the preop photos are too narrow, they do not fill the width of her chest, and the result makes her whole torso look unbalanced.|
||This patient has successful correction of her symmastia, but no doubt some asymmetries still remain. The thinner the patient and the larger the implant, the more likely there is to be some residual deformities. But other than looking straight into a mirror or camera, her shortcomings are not noticeable. Large implants definitely contribute to causing symmastia, and placing large implants back in after correcting symmastia – as in this case, can still lead to implants that look more round than natural.|
||It is obvious not just that her implants did not sit symmetrically, but they are simply too big for her body. One of the most frequent causes for problematic outcomes after breast augmentation is selecting implants for which a patient simply does not have the room on her chest for them to be! Any patient considering an augmentation for the first time - as well as getting a revision – would be wise to choose an implant no larger than fits their body.|
||This is the same patient as shown in slide 11. Although her symmastia seems subtle when standing, it was actually quite severe and deforming in clothing. By creating symmetrical pockets within which the implants can sit, the breasts become noticeably more attractive for her torso.|