So many of my patients are full time students; some have the further pressures of athletic commitments. Finding the right time for an elective cosmetic procedure such as breast augmentation (breast enhancement), rhinoplasty (nose surgery), reduction of excess breast tissue (“man boobs” or gynecomastia), or ear reduction surgery (otoplasty) can be challenging. 

We know that your time and budgets are tight! Student Special! 

To respond to your special needs, Dr. Zwiebel has initiated a special summer time program to assist you to make affordable and find the time in your busy lives for the procedures that boost self-image and self confidence.

Call or e-mail today to learn more about this limited opportunity.

ALCL is very rare affecting approximately 1 in 500,000 people.  ALCL of  the breast is even less common affecting 3 in100 million people.

More recently the FDA  identified 36-60 women out of an estimated 10 million women with breast implants worldwide with either silicone  or saline-filled breast implants who have developed ALCL.

When associated with breast implants the ALCL tumor seems less aggressive and appears to be resolved by removing the breast implant capsule and replacing the implant. 

The cases have presented with sudden onset of painful swelling of the breast due to accumulation of fluid around the implant.  A lump may be felt or can be seen with a mammogram or scan.  It is important to stress this is not a form of breast cancer; in all cases the lump was attached to the implant capsule.  The occurrence has averaged between 8-24 years after the initial breast augmentation surgery. 

A registry is being set up in cooperation between the FDA and plastic surgeons working together with epidemiologists, toxicologists, and pathologists to diligently gather accurate information. 

The FDA continues to consider breast implants safe and effective.  There is no need for women with breast implants to change their routine care and follow-up.  It is recommended that women continue to perform self-examination, check their implants, and obtain routine mammograms. 

[Editor’s Note: This new information was obtained from an official FDA news release  and white paper, and information presented at a plastic surgery conference in Las Vegas, Friday, January 28, 2011]

# # #

There is no need for women with breast implants to change their routine care and follow-up. 

The FDA published its literature review in a document posted on FDA’s website today titled “Anaplastic Large Cell Lymphoma (ALCL) In Women with Breast Implants:  Preliminary FDA Findings and Analyses.”

If you have any questions or concerns, please call me at 303/470.3400.

For an augmented breast to have a natural appearance, it must move with the woman’s natural breast.  If the implant is in a fixed position, it creates “an obvious augmented look.”

At the time of breast augmentation, I create a space for the implant behind the breast tissue (subglandular or prepectoral) or behind the chest muscle (subpectoral). The space I create must be big enough for the size ands shape of the implant.  The size and shape of the space must be sufficient to allow the implant to follow the motion of the breast as the woman moves.

Imagine lying back next to the pool on a hot summer day: your breast will flatten and move up on the chest, and a little to the side, as a result of the change in your position.  Now imagine lying back after your breast augmentation: if the implants stay fixed on the chest and don’t move well, they will remain too round and point at the sky.  This abnormal shape will be obvious to even a casual observer.  You may well have already seen exactly what I’ve described in someone who has had poor results from breast enhancement.

On the other hand, if the space for the implant is too big, the implants may flop too far to the side of the chest!

Either situation is bound to make a woman feel self-conscious, rather than feel good about the way she looks.

So, the correct motion of a breast implant is important to get an attractive and natural appearing result from your breast augmentation Denver procedure.

In my previous blogs, I have written about the importance of size and shape in achieving a natural appearance with breast implants. In this blog, I will write about the importance of breast implant position to getting attractive results from breast augmentation.

Most women undergoing breast augmentation will benefit from placing the implant underneath the chest muscle (subpectoral), rather than on top of the muscle (prepectoral) and beneath the breast tissue. This technique produces softer breast contours (see Blog: Breast Implants: Looking Real, Part 2: Shape), and the subpectoral implant position results in significantly fewer capsule contractures, the hardening of the breast from scarring or tightness of the space for the implant.

The implant position must be centered behind the nipple. If the implant is too far to the center, the nipple will appear to point too far to the side. If the implant is placed too high on the chest, the nipple appears to point downward; if the implant is placed too low behind the breast, the nipple will point too high.

Here, symmetry becomes very important: the nipples must point the same way on each side.

Further, if the implants are placed too high on the chest, there will be excessive fullness and roundness to the top of the chest, like an exaggerated push-up bra, creating a fake appearance to the breast enhancement.

A common misconception is that implants will lift or support drooping breasts. This is not the case. If a woman is seeing drooping, a breast lift may be desirable, perhaps adding implants for size and enhanced shape. On the other hand, we commonly place breast implants to correct the deflation of the breast or loss of volume after pregnancy.

Perhaps the most noticeable characteristic of “the fake look” is a noticeable edge of the upper breast. A natural breast slopes gently from the chest wall, without a distinct demarcation from the curve of the upper chest. This upper part of the breast normally slopes gently, with a soft transition from the rib cage in the upper chest.

Because it isn’t normal to see a distinct line or edge to the top of the breast, our eye is distracted by seeing a line where it shouldn’t be. When we notice an edge to the top of the breast we conclude it must be “fake.”

The presence of an edge and too full or too round a breast makes the breasts look “hard,” like “pasted-on boobs,” or “grapefruits (substitute your favorite fruit here!) under the skin.”

How do you avoid the “paste-on look?”

First, the breast implant itself makes a big difference: if it is too large in size in proportion to your natural breast tissue, or if it is the wrong shape, the edge may be noticeable.

Your skin tone and thickness affects how well the edge of the implant is covered and camouflaged. Very thin skin in a slender woman will not hide the edges of the implant well.

The surgical technique can make a difference. Placing the implant beneath the pectoralis muscle provides more tissue coverage over the implant and the drape of the muscle over the implant smoothens the transition onto the implant in the upper part of the breast.

Capsule contracture can distort the shape of the breast: the tightening of the capsule around the implant can cause the “hard look” with the edges of the implant becoming too noticeable. (Please see my blog on avoiding capsule contracture).

How can you avoid an unnatural appearing result from breast implants? That guidance has to come from consultation with an experienced plastic surgeon in Denver. Breast implants need a specialist’s consideration—particularly from someone with a reputation for producing natural results.

The causes of a fake appearance after breast augmentation relate to size, shape, position and motion.

If the implant size is too big for a woman’s frame, she will have a result that will look disproportionately large and distort a woman’s figure, rather than enhance it. This can cause too much fullness in the upper and lateral chest and create an unnatural appearance, as well as difficulty in getting clothes to fit and drape attractively.

Too larger a breast augmentation can draw too much attention to a woman’s breasts and leave a woman feeling self-conscious rather than attractive.

How, then, to avoid the costly mistake of too large an augmentation, but still get the results you want?

Fitting the implant to the person is a key part of a breast augmentation consultation with an experienced breast implant specialist. Careful consideration of each woman’s goals, as well as her particular physique, are critical to achieving successful results.

In my practice in Denver, breast augmentation consultations begin by discussing your goals: understanding your vision is basic to getting you the result you seek. Each woman’s sense of self, sense of aesthetic balance is personal and unique, particularly in her sense of her own body.

Next we perform an examination which includes measurements that inform us what will fit your particular body, taking into account the size and shape of your breasts and your chest, as well as other important factors like skin tone and elasticity.

Then in our imaging studio, we use our state of the art Axis Three Dimensional Breast Simulator. We’ll digitally capture your own image to simulate images of you with implants of different size (and shape) so you can see what your results can look like, and together we can fine-tune your surgery plan to optimize your results.

Your best assurance for getting great results from breast augmentation come form good communication with your plastic surgeon, careful planning and choosing an experienced breast implant specialist with a reputation for producing natural results.

“I am a surgical R.N. and I have seen the procedure on TV, ” The Doctors”. A plastic surgeon is one of the hosts. He practices in L.A. A series of tiny incisions are made under the chin (maybe eight) from ear to ear. An “I guide” (a lighted cannula type device) is weaved in and out of the incisions with a suture shoestring resemblence. It goes under the chin and is pulled tight, just like tying your shoes. Very good results for a less invasive procedure that takes minutes to perform with an experienced surgeon. Less costly and recovery is fast. Everyone wins! Just check on the website “doctorstv.com”, it was on Wednesdays show I think. Wish someone would bring this here! Keep me informed please. I have also seen this on another show, but I didn’t catch the name. I just remember hearing it is fairly new and clever. I will volunteer to be a learning patient if you need. Thanks!”

“Surgical R.N.”(Actual Name Withheld for Privacy)

My reply:

Dear “Surgical R.N.”,

Many thanks for the follow-up note.

I found and reviewed the video of the procedure you mentioned here: http://www.thedoctorstv.com/main/procedure_list/1344.

The Doctors TV link gave me enough information to further research the procedure on the Internet.

There is nothing published about this technique in our respected refereed medical journals, nor has there been a presentation at one of our scientific meetings.
The IGuide technique is a variation on the Thread Lift which was a bit of a hype 5-7 years ago and has fallen out of view, if not into disrepute because it turned out to have too many unsatisfactory results and did not hold up well for most patients.
One problem is that the cost of the special sutures is so high that the procedures cost as much as more conventional techniques.
I also have some questions as to the validity of the technique conceptually, knowing what we know about essential plastic surgical technical principles. For example, experience has shown us that without some actual surgical re-draping of the tissues, suture suspension alone (like the Thread Lift and the similar appearing IGuide) fails to hold up over time (6-12 months).

There have also been problems with skin pleating: if you pull the loose or redundant skin up with a thread and don’t remove/cut-out the excess, where does the extra skin go? I have seen numerous patients who have tried the thread lift and ended up with wrinkles and pleats of the neck and cheek skin.

As a surgical nurse, you have probably seen various surgical techniques come and go, and can appreciate the importance of good medical reports including long-term outcomes that instruct us regarding validity of the procedures, satisfactory results and complication rates.

As a Plastic Surgeon, I would not do a procedure on a patient that I wouldn’t do on my own wife: Besides my doubting the conceptual validity of this technique, in my assessment, the IGuide face- and neck lift and techniques do not yet have the track record to merit one volunteering to be a guinea pig.

“Caveat Emptor!” (Let the buyer beware!)

Having said that, I do not know of anyone in Denver who is trying or offering the IGuide technique, but I am certain someone will be, in the near future, and it will be prominently advertised in our media, offering “more for less.” As I mentioned in my previous e-mail, cosmetic surgery is subject to a lot of marketing hype; The IGuide is a perfect fit for that sort of thing, with a catchy name and a promise of fewer incisions, less invasiveness (Are 8 stab incisions along the jawline better than the 1-inch incision in the crease under the chin of a conventional neck lift?) and as good results.

Thanks again for your inquiry and follow-up note.
Paul C. Zwiebel, M.D., D.M.D.

Although I anticipate the answer, speaking with them through an interpreter, I ask what they want me to do for their child. Rather than reply verbally through the interpreter, the answer is almost always made by pointing to the obvious cleft of the lip, or by opening the child’s mouth to point to the gaping opening of the roof of the mouth, a cleft palate.

It is so easy to feel a bond with the patients. Even though we do not speak the same language, the instinctual parental sense of attraction and desire to protect and nurture is irresistible. This seems common among my fellow American teammates who continually comment “how cute” the children are and the nurses are quick to want to hold the babies and play with them. These seem unusual, even extraordinary and unexpected reactions to a child with such an obvious facial deformity.

Later, I notice those same feelings manifest in how the crew is playful and caring for the baby as we bring the baby into the operating room and prepare to begin the surgery. My mind shifts to focus on the steps of preparation, administration of anesthesia and the technicalities of the reconstructive procedure. With cleft lip surgery, the challenge is in the planning. I wear magnifying lenses as I measure and mark with needle and ink the relevant anatomic points that are crucial to the precision of the ensuing incisions and surgical rearrangements of the repair. It is a unique sort of puzzle: finding the hidden pieces and moving them to complete the aesthetic solution.

An hour passes without my notice, my consciousness engulfed in the conceptual and technical challenge before me. Finally, we place the last stitch and pull back the drapes.

Then, I see the cute little baby, again.

Only now, without deformity the cute baby can be seen by every one.

Pingliang is almost exactly in the middle of the map of China, right.

I had a chance to visit Kongtong Mountain, which is a short taxi ride from our accommodations in Pinliang. It is interesting to note that traffic regulations are quite different here. It appears that the lines in the road are merely “suggestions.” Cars do not hesitate to drive on the “wrong side” of the road, if it is convenient for the driver. This adds interest and excitement to the trip, like watching a national tournament of vehicular “chicken.”

The landscape is terraced for agriculture, and sandstone rock faces are perforated with thousands of man-made caves, used for centuries as dwellings, now mostly for storage – typically of grain and other agri-products grown here. The Chinese consider the area “desolate and dry,” but it feels humid to a Coloradoan. Things do grow here, but it is hardly lush, as the sandstone and conglomerate soil is not very fertile. This accounts for this being a poor province, since agriculture is the main industry here.

The road curves to the left and we are abruptly in a more verdant landscape bordering a remarkably green lake above which is the steeply rising 2200 meter Kongtong Mountain. The immediate impulse is to get to the top of this natural tower that dominates the Gansu plateau.

The sharply ascending cable car ride over the lake is accompanied by rapidly clicking camera shutters. I join in taking pictures, knowing these photos fail to capture the beauty and feelings I am experiencing today, but I hope the photographs can serve to remind me even a little about how it feels to be in this place.

Even before the cable car arrives at its station, we see many temples perched on the mountain’s tiers of rocky projections. I have a moment of recognition that I am actually in one of those exotic places I have seen in ancient works of Chinese art; I feel I recognize the dragon- and gargoyle-adorned, pointy-roofed temples at the edges of thousand-foot precipices from some movie or travelogue. Only now, I am actually here, they are real, and not just an exotic image or artist’s creative machination.

After a bit of walking over the rocky landscape among great centuries-old temples, I have broken away from the group distracted by the fortune-tellers, souvenir booths and beer garden of the Tourist Center. The thousand stairs that very steeply rise to the next peek beckon and intimidate, but the view through the trees to the temple looming above is irresistible. The irregular stone steps are very tall and dotted with pilgrims pausing to rest and scan the panorama. Intermittently, a small path directs me to ancient Tao alters like “Temple of the Clouds,” each on its own particular perch, with its unique view.

My senses are further filled by incense, intermittent prayer gongs, and the chanting of robed monks.

High up in “Heaven City,” I happen to meet up with one of our crew; Barry is a bright Anesthesiologist from Beijing. He is cheerful and physically very fit. He is surprised to see me at this remote altitude, smiles and asks, “Should we go to the top?” By now, “the top” seems illusory, unreachable, like a mirage; as soon as I think I have gotten there, I see another temple through the trees above. Of course and without hesitation, I answer, “Yes!”

Some stairs are cut into the mountain with a temple carved around them. The views, altitude, and climbing steep narrow rocky paths on precipices with drops measured in hundreds of meters can all be described as “breath-taking.” One of the most thrilling is the narrow cable-suspended, “Bridge to Heaven,” the only tenuously thin attachment traversing to an isolated, needle like tall spire rising many hundreds of meters from the valley and crowned with its own small temple.

Barry and I reach the very top of Kongtong. The top temple is heralded by an archway before which Barry immediately poses, instructing me to photograph him being certain to clearly include the three Chinese characters painted on the arch which frames the temple behind. I comply. Barry takes the camera to ascertain adequacy of my photo-documentation. Sure that we are standing at an ancient and sacred spot, paramount in significance to the lore and history of Taoism, I ask Barry what the sacred calligraphy means. He points to the words and interprets for me: “This is the top.”