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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 requests 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.

Here’s what you can expect from me. First, 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’ve always wanted 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 a dramatically enhanced understanding of how an augmentation could change how you look.

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 up to date with medical advances, and am proud to have my own state-of-the-art surgical facility. 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 based on my own clinical studies.

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

Breast Augmentation Expert

Dr. Teitelbaum is an internationally recognized board-certified plastic surgeon known for his specific 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 is frequently asked to teach plastic surgeons around the world about the differences between various cohesive gel implants, as well as the advantages and disadvantages for each in different patient profiles.

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, Israel, Mexico, Morocco, and Sweden. He is also recognized locally, as one of just a few Los Angeles cosmetic surgeons to have been asked to join the esteemed teaching faculty of UCLA Medical School, where he is Assistant Clinical Professor of Plastic Surgery.

Dr. Teitelbaum has published several recent articles on breast augmentation in the prestigious journal Plastic and Reconstructive Surgery—including, among others, a landmark paper on reducing the need for patients to have multiple operations, and a roundtable discussion on breast augmentation he led with the most elite names in cosmetic surgery. 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, as well as a lead instructor in the breast augmentation course offered to plastic surgeons at the annual meeting of the American Society of Aesthetic Plastic Surgery—the largest aesthetic plastic surgery meeting in the world.

• Patients. Dr. Teitelbaum is cosmetic surgeon to a number of influential people, models, and celebrities, but he is most proud of the fact that he is often chosen by other physicians for their own surgeries or those of their family members. 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. Keep making the world a more beautiful place.”

Getting the Best Results

The natural, beautiful results Dr. Teitelbaum is known for are no accident—they are a direct result of the principles that have guided him since he opened his practice in 1995, and have made him one of the country’s premier breast surgeons. Here, he shares his advice for making smart decisions that will yield the best possible outcome.

It’s critical that you select an implant size and shape that fits your breasts. If an implant is too big, the breast looks round, shiny, and bulging on top in the short term. In the long term, the skin will stretch, the tissue will compress and thin, and the breast will sag. If an implant is too small, it will fail to proportionally fill out the breast. There is a narrow range of ideal sizes for each woman’s breast, and your surgeon will help you to understand what is realistic for you.

When considering the choice of incision, the resulting scar isn’t the only factor to consider. It seems like the most important thing before surgery, but no matter where the incision is, it is usually inconspicuous. What ends up being more important are issues such as pain, recovery time, sensation, ability to breast feed, accuracy, symmetry, avoiding implant hardening (capsular contracture), and putting off any revision surgery as far into the future as possible. Keep an open mind, and listen carefully to the logic behind any incision suggested to you.

If you are thin and can see your breastbone and ribs, don’t expect augmentation to correct a wide gap between your breasts. Some patients and plastic surgeons have the mistaken assumption that larger implants will fill in that space: They will not. Placing an implant under the extremely thin skin close to the sternum will result in fake-looking breasts that could migrate so close together that they form what is commonly referred to as a “uniboob.” (The medical term for this is symmastia.) A breast augmentation only augments the breast itself; it will not add tissue over a bony upper chest. And since your implants are obviously in front of your ribs, if you can see them, you most likely will be able to see your breast implant.

All breasts are a little asymmetrical—even after augmentation. Dr. Teitelbaum will do everything he can to make sure both breasts are as even as possible, and can adjust the implant size to correct major asymmetry when necessary. But it’s important to be realistic and accept that a tiny amount of variation will always be present—and almost never be noticeable to anyone but you.

Remember that skin stretches. If your tissue is thin, the implant will be visible no matter what the size. And, just as we have all seen with natural breasts, the larger they are, the more all breasts fall with age. It should come as no surprise that the additional weight of augmented breasts will similarly cause the skin to stretch and sag over time. A good cosmetic surgeon will help you assess what implant will best fit your natural breast pocket as well as examine your skin quality.

Don’t automatically dismiss the idea of a breast lift. If your skin is thinned, sun-damaged, or already stretched, adding additional weight can often cause the breasts to sag more quickly. This seems to be especially common in women who have stretch marks on their breasts, have had babies, or lost a lot of weight. Your surgeon will take measurements of your breast skin under maximal stretch. If the measurements are greater than a certain amount, your surgeon may recommend a breast lift. Heed his or her advice—or do no surgery at all. Proceeding with an augmentation in breasts that really need a lift rarely produces the results desired, and may ultimately just postpone the inevitable and necessitate an even more extensive lift down the road.

Once you’ve taken the above factors into consideration, weighed your options, and heard what your surgeon recommends, you should find yourself in an excellent position to make the critical surgical decisions that will determine the outcome of your breast augmentation surgery.

What to Expect at Your Consultation

There are four steps to your breast consultation with Dr. Teitelbaum:

1. Communicate to Dr. Teitelbaum exactly how you want to look. Think about overall size, shape, and proportion. Natural or fake? Large, balanced, or small relative to your shoulders and hips? Do you want the implant to be visible through your skin or do you want it to blend imperceptibly into your body? Do you like an upper bulge or do you prefer a straight or even empty upper breast? A look that’s just enough to fill out your breast so you look womanly and feminine or something that even without a bra “pops” and is eye-catching? Whatever it is you want, don’t hesitate to tell Dr. Teitelbaum your wishes—there are no wrong wishes.


2. Dr. Teitelbaum will examine and measure you in order to determine if your wishes can be fulfilled exactly as you hope. Every woman’s breast skin has a certain volume that it can hold. If you fill it up beyond that point, the edges of the implant will be visible through your skin and the top will bulge. In time, the pressure will stretch your skin and may cause sagging. If you underfill the breasts, they will not look full, the upper part may be concave, and they may not be proportionally shaped. A breast that is already full, firm, and tight will have less capacity to be enlarged without looking augmented. A breast that is loose, empty, and soft has a greater capacity to be augmented while still looking natural. The thinner you are, the more likely it is that your implant could be seen or felt, while the thicker your tissue, the more your body will hide the implant.


3. This is the critical step, in which together you and Dr. Teitelbaum reconcile your “wishes” with your “tissues.” Most of the time, women intuitively know what will work on their body. But sometimes there are conflicts: there are patients that want to be a lot bigger and still look natural, yet an implant large enough to achieve that breast size would overfill their tight breasts, rendering them looking round and fake. They must choose: they can go larger and look less natural, or go smaller and look more natural. So too are there patients that just want to be full and only a little larger, yet an implant of adequate size to fill their loose breasts would make them much larger than they hoped to be. These women must choose between being the size they want and accepting being less filled, or being filled but larger than they ideally want. Dr. Teitelbaum has very specific expertise in this type of evaluation, and he excels at helping patients wade through these difficult decisions. He will never mislead you about your outcome; he will always tell you the truth about what your tissues will allow you to achieve.


4. In the final step, he will help you to visualize what you will look like after surgery. Dr. Teitelbaum wants you to know ahead of time how you will look with the implants you have selected; he doesn’t want a patient to ever wake up bigger or smaller than they were expecting. The doctor will take a 3D photo of you, then use his state-of-the-art breast-imaging system to simulate the size that you’ve decided on—so you can see on a computer screen how it would look in your body. (You can do this undressed or with a bra on.) Second, he will give you a “sizer implant’ to put inside an unpadded bra—so you can assess how your new breast size will appear under different clothes. Third, he will show you photos of patients of similar size and weight to yourself. None of these methods is precise, but taken in combination, they will help to give you some indication of how various implant sizes will look on your body.

In The Media

View Dr. Teitelbaum In The Media

Articles featuring Dr. Teitelbaum!

More of Dr. Teitelbaum's articles include: McGhan Style 410 Implant Study The Cohesive Gel Implant Study

Click Here to Read the Articles Below

Cohesive Implant Expert

Many of Dr. Teitelbaum’s patients choose him to be their surgeon specifically 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). Widely popular in Europe because of their natural-looking and -feeling results, these implants are now available from just a few surgeons in the United States. Dr. Teitelbaum has been using them in studies since 2000 and is one of the most experienced providers in the country. He is the only surgeon in the state of California who was asked to participate in the clinical trials of all three cohesive implant manufacturers. And because of his extensive, excellent results, 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.

Cohesive gel implants offer a soft and supple feel with the added benefit of being relatively leak-free due to the nature of the silicone. It is this consistency that allows the implants to maintain the commonly requested teardrop shape. While the edges of the implant blend gradually into the surrounding tissue, the thinner top of the implant slopes gently down to a fuller bottom half, creating the most natural possible breast contour. Plus, clinical studies have demonstrated that cohesive implants have the lowest rate of capsular contracture (hardening of the breasts) and leakage of any implant ever studied.


Dr. Teitelbaum is an enthusiastic supporter of this new technology, and is developing the educational material that one implant manufacturer will use to credential surgeons who wish to use them following FDA approval. 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.

Additional Information on Participating in Cohesive “Gummy Bear” Implant Studies

Allergan Style 410 Implant Study

Frequently Asked Questions about Cohesive “Gummy Bear” Breast Implants

What Are Cohesive Gel Breast Implants?

The standard implant in the United States has been saline filled, ever since the FDA moratorium on silicone gel filled breast implants in 1992. The type of implants that were available before the ban are available today as part of an "adjunct study," which is open to patients with congenital deformities or having a revision for particular reasons. (refer to section on this in website.)

What distinguishes cohesive implants is that the silicone gel is firmer, essentially a soft solid. If a cohesive implant is cut in half, there is no gross movement of gel, and the implant maintains its shape.

The way these are made is that the company uses more "crosslinker" in the making of the implant. The ingredients are the same, but with more crosslinker added, it makes the gel firmer. The term "cohesive" has been bastardized in recent years. Cohesive breast implants implies form stability, or form retention. That means that in any position, the implant maintains its shape. That is an important distinction, because it means that the shell should not fold, and that it will maintain a particular shape.

Unfortunately, given the recent media attention to cohesive implants, many are using the term to describe "regular" silicone gel implants. Technically, they are correct; all silicone gel is cohesive to some degree. But the term cohesive has always meant form stability, and when patients ask for cohesive gel, it is because they are looking for an implant with those particular characteristics of durability and shape retention. Hopefully, the terminology will be clarified in the coming years.

Which Surgeons Can Use Cohesive Gel Implants In The United States?

Each of the three studies has a group of only several dozen surgeons that are allowed to order the implants and implant them. Surgical expertise and a commitment to careful patient follow-up were the criteria the manufacturers used to select the surgeons that they would have implant their implants. Dr. Teitelbaum is the only surgeon in California (and if not the only, one of the very few in the entire nation) to have been asked by all three manufacturers to participate in their clinical trials.

Which Patients Can Receive Cohesive Gel Implants In The United States?

The trials are open to patients seeking a first time augmentation, a revision of a breast augmentation, or breast reconstruction following mastectomy. Patients with certain medical problems cannot participate. Please see the enrollment specifications for each of the implants listed below. In addition to the objective medical issues, patients must be committed and willing to participate for a full ten years of follow-up to be considered for the study. Patients must be in the immediate geographic vicinity of the implanting surgeon in order to facilitate this follow-up.

What Are The Main Advantages Of Cohesive Gel Implants?

The main advantages of cohesive gel implants are longevity and shape. Longevity, because they do not develop folds, and it is along folds that implants ultimately fail. And if, somehow, the shell does fail, since the gel is so thick, it hopefully will not migrate anywhere in any significant quantity. Shape is enhanced because, from the point of view of a surgeon, there is only control of breast shape if there is control of distribution of fill in an augmentation. If the fill cannot be controlled, then the shape cannot be controlled. And to control distribution of fill in the breast, fill distribution must be controlled in the breast implant. All fillers other than cohesive silicone gel - saline or regular silicone gel -can migrate around within the shell of an implant, which means that there is not control over breast shape. Looking at results from breast augmentation objectively, these implants appear to have the most aesthetically natural and beautiful results.

Why Are Cohesive Gel Implants Anatomically Shaped?

A breast projects more at the bottom than at the top. Therefore, it makes sense for an implant to be shaped that way. And the thinner an implant is at the top, the more gradually and naturally it will feather into the upper chest, making itself less conspicuous. Without a cohesive, form stable filler, there is little point in making shape into an implant, as the implant will ultimately lose the shape. But with a form stable filler, the shape will be maintained.


Are There Round Cohesive Gel Implants?

Form stable round cohesive gel implants are available in Europe, but not in the United States. There is actually very little use for them. If you look at an implant lying on its side on a table, it looks much like an M&M. But when it is held upright, the upper pole gradually collapses. It is that upper collapse that allows those implants to look natural (though it is doing so at the risk of folds on the implant shell.) A true cohesive round does not do that. By maintaining that M&M shape when vertical, it creates a dome-like, relatively top-protruding shape.

However, cohesivity is not a black and white issue; there is an endless continuum in cohesive gel from very liquidy to very solid. On Silimed's cohesive clinical trial, there are 4 different round gel options. These are more cohesive than implants made in the past, and can be considered cohesive, but they are not as cohesive as their anatomically shaped cohesive gel implants or the anatomic cohesive implants by Mentor or Inamed. They fold less than gel implants of the past, but they are not quite form stable, in terms of their ability to resist folds or predictably maintain a shape.

Do Cohesive Gel Implants Come With A Smooth And A Textured Surface?

All anatomic (a.k.a. teardrop) shaped implants are textured, as the texturing increases friction and helps keep them from rotating. Since a teardrop implant is different at the bottom than the top, it is important that it maintains its position.

The Silimed round implants come in both smooth and textured surface, but remember that while relatively more cohesive than most other silicone gel implants, they are not form stable like their anatomically shaped cousins.

What Happens If A Cohesive Gel Implant Ruptures?

We do not really know, because there is so little experience with this. At the time of writing this, there is report of a single rupture in a series of several thousand in Sweden. If it did happen, however, one would imagine that the gel, being relatively stiff and solid, would not migrate in any significant amount. Since it has the consistency of a gummy bear, the gel would presumably stay in place. Microscopic migration of gel would presumably occur, and this can even happen to some extent through an intact shell. This is a subject of ongoing investigation, and more research will be needed to answer this question.


How Would You Know If A Cohesive Gel Implant Has Leaked?

Given the gummy bear nature of the filler of these implants, it is likely that it would be difficult to tell if they ruptured. Perhaps it might be detected by mammogram or MRI. When any implant is placed in the body, the body forms a capsule around the implant. If a cohesive implant were to leak, it would probably just stay within the capsule. The capsule might thicken, and a patient may notice a difference in the feel of the breast. But it is also possible that there might be no change at all. The important point, however, is that silicone gel has not been linked with any health problem, so even if there were a shell disruption, it should not prove to be of any medical problem.

History of Cohesive Gel “Gummy Bear” Implants

The rationale of cohesive gel implants can best be understood by tracing the development of these implants.

It all began with the successes and failures of an implant that was popular in the 1980s, the Replicon. This was an anatomically shaped, polyurethane coated, silicone gel filled implant. Many surgeons felt that the initial results were very beautiful.

But these results were short-lived. The polyurethane that was bonded to the surface of the shell helped to maintain the anatomic shape of the implant. But the body eventually degraded the polyurethane, and once it was absorbed off of the shell, the remaining thin and pliable shell could not hold the silicone gel in place, and so its shape was lost. It ended up looking like an under-filled round implant. Gravity forced the gel to the bottom of the shell, collapsing the upper breast, and expanding the lower breast. Folds developed in the collapsed upper pole. These could sometimes be seen or felt. The shell was very thin, and with time, the shell weakened along those folds, and eventually could break, allowing the relatively liquid-like contents of the implant to leak outside of the shell. In addition to the effects of gravity, the forces of the breast acted upon the implant, deforming its initial anatomical shape. The implant accommodated to the shape of the breast, rather than the breast taking on the shape of the implant.

How could an implant be made that could maintain these initial excellent results over the long term? Dr. John Tebbetts of Dallas, working with Dan Carlysle of McGhan (now called Inamed), are credited for trying to solve this problem. Though what follows is a simplification of a very long and highly technical process, the core theme is that they realized that the shell could not be solely responsible for maintaining shape; the contents had to hold a shape as well. So they experimented with making different silicone gel fillers. Silicone can be made in virtually any firmness, from a liquid lubricant to almost a rock-hard solid, depending upon how much "cross-linker" is added to the formula. Through experimentation, they were able to create an implant filler that was adequately soft, yet would maintain the shape that was molded into it. If the filler were form stable, then the gel could not fall to the bottom, leading to collapse of the upper pole, which is what led to folds and ultimately shell failures in other implants. And by being form stable, it would maintain the particular shape in which it was made, thereby allowing the surgeon to control breast shape.

With past implants, shape was of only moderate importance, as with non-form stable contents, the forces of the body and of gravity would shape the implant. But with this filler, the actual shape became a very important issue. They experimented with various ratios of widths, heights, and projections. They looked to create an implant that would create and maintain an optimum aesthetic balance to the breast.

The culmination of their efforts was the McGhan Style 410. Unfortunately, this was right in the middle of the breast implant crisis in this country, so the climate was not right politically to ask the FDA for approval of a new silicone implant. However, the implant was taken to Europe in 1993, and it has remained one of the largest selling implants in the world. For the United States, McGhan subtly redesigned the shell, and marketed a saline-filled version of the 410, called the 468.

Clinical Trials of the 410 began in the United States in 2001. Because of the similarity between the 410 and the 468, surgeons with significant experience were chosen to do the initial 410 study. Three year data has now matured, and Inamed will present this to the FDA late in 2004.

Subsequently, Mentor and Silimed developed their own version of the 410. Mentor's is called the CPG (Contour Profile Gel), and Silimed's is called.

Click Here to visit a website devoted to Cohesive “Gummy Bear” Implants

24 Hour Recovery

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, drive the next day, and need no more than a few days off work.

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 state-of-the-art 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 hundreds of patients as well as many surgeons; feel free to ask as many questions as you like about how he can do the same for you.

Allure Article

Beautiful and Natural Breasts

Patients come to Dr. Teitelbaum from around the world for breast augmentation. Some come because of a satisfied friend, a magazine article, his reputation, or perhaps interest in a pain-free recovery.

But they often say this: Dr. Teitelbaum’s photo book shows the best results they have seen anywhere. When you come in for your personalized consultation, you will be able to peruse literally hundreds of photos of women at all different stages of their recovery, and with literally every possible body type and implant choice. You will be stunned by the diversity of beautiful results!

Why does Dr. Teitelbaum have this reputation? While all surgeons give lip-service to creating natural results, Dr. Teitelbaum really means it. He pays attention to the many factors which contribute to creating a beautiful and natural result.

The single most important factor is the size and shape of the implant: too big looks bulgy and round and too small looks empty and bottom-heavy. Many surgeons determine implant size by having patients put rice or water in a bra. But doing so totally ignores the shape of your breasts! Dr. Teitelbaum takes multiple meticulous measurements that enable him to tell you the ideal size and shape for your breasts.

Patients who have gone on other consultations, often remark about the detailed analysis Dr. Teitelbaum makes of their breasts, noting subtle asymmetries, thickness of their tissues, and ratios of different measurements of their breasts. It is through this thoughtful analysis that he is able to make recommendations to make your breasts as beautiful as they can be.

In fact, he even is patenting a device to help other surgeons make the proper implant selection based upon each woman’s breast.

He then discusses with you whether the implant that ideally fills your breast tissue creates a breast of the size that you want. He has a beautiful aesthetic eye, and he will discuss with you how well the ideal implant for your breast will fit in proportion to your body.

For a result to be beautiful, the breast implant must not sit too high or too low, and both sides must be even. Symmetry is a very important property of beauty. No matter what incision he uses, Dr. Teitelbaum always operates “under direct vision,” so that he is precise and accurate in the placement of breast implants. Believe it or not, many surgeons still perform this operation “blindly,” slipping a finger or an instrument through an incision to blindly create the pocket for the implant.

The appearance of a breast can be marred by a conspicuous scar. For that reason, Dr. Teitelbaum uses incisions that are well-hidden and inconspicuous, but that still allow for the creation of an accurate pocket and an easy recovery.

Revision of Breast Implant Problems

If you are considering breast augmentation for the first time, you want to be sure that you do it right. You obviously want to avoid the emotional distress, inconvenience, and expense of having to have an early revision. And doing it right the first time is the best chance to set you up for having a result that will be as long lasting and beautiful as possible.

There are many women with serious and even permanent problems because of errors made with their first breast augmentation. Dr. Teitelbaum has learned from these women which choices in the first surgery can set a patient up for problems later. Using these principles, he was asked by an implant manufacturer to create an educational curriculum to teach other surgeons how to reduce their revision rates. And he is coauthor on a landmark paper that sets guidelines for surgeons to reduce the number of operations a patient will have in her lifetime.

Many surgeons approach this surgery with a very short-sighted view of their outcomes. Dr Teitelbaum recognizes the importance of achieving beautiful results not just for a year or two after the surgery, but for a patient’s entire life. While a surgeon that operates on a patient today is not technically responsible for a patient five years from now, Dr. Teitelbaum nonetheless recognizes that decisions made today will have effects years from now, and therefore counsels patients to make decisions that take this into account. He will always discuss with patients not just the short term effects of their choices, but what will happen to their breasts over time.

Other plastic surgeons refer Dr. Teitelbaum the most challenging cases that need revision. Having done so many of these revisions, Dr. Teitelbaum was asked to write a textbook chapter for an upcoming plastic surgery textbook entitled “Revision of Breast Augmentation.”

As complex as first-time breast augmentation is, revision is substantially more difficult. Patients’ anatomy may have been distorted with the past surgery, old records may have been lost, and tissues may have been thinned, stretched, or in other ways damaged. Worst, patients are frustrated, angry, and fearful after having spent a large sum of money and undergone one or more operations for a result that is totally unacceptable.

Dr. Teitelbaum understands these issues, and is aware of the spectrum of options to handle these problems, both “tried and true” and the new or experimental. For instance, he has a large experience using the cohesive or gummy bear implants, which can be helpful in many types of revisions because of their low likelihood of developing any visible folds or ripples. He is on the advisory board of a company named Lifecell which makes a special material derived from human or pig skin, working to find the optimal way to solve the most difficult augmentation problems. He is one of the pioneers of a new technique called the “neo retropectoral pocket,” which is a powerful and very effective technique that can be frequently applied in breast augmentation revision. He has coauthored a paper on using it to correct symmastia (the so-called “uni-boob,”) one of the most difficult problems to correct.

Synmastia
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.

Implant Malposition
The most beautiful women in the world all have asymmetry of their breasts. But sometimes an implant ends up so misplaced that it makes the asymmetry unacceptable and even causes deformities. The most common asymmetry is when one implant is too low. But they can be too close together, essentially joining in the center. This is known as symmastia (aka the uniboob deformity.) Or the implants can lay to far to the sides, widening cleavage and distressing patients by how far they fall out when they lay down. Treatment for all of these problems can be done by creating a new pocket. For instance, if an implant is in front of the muscle, a more even new pocket can be made behind the muscle, and vice versa. But if the pocket is already behind the muscle and there is good reason to stay behind the muscle, for instance to maintain good coverage over the implant, then one either closes off the lowered pocket with a technique called capsulorraphy or with something called a capsular flap. The newest way to handle this is with a technique called the neosubpectoral pocket, which creates a new pocket between the scar tissue and the muscle, using the strength of the scar tissue to correct the pocket malposition.

Droopiness
Sometimes an implant stays fixed in place and the breast can slide off it, drooping as a result of gravity. At other times, the implant itself falls down, stretching out the lower skin of the breast, which is known as “bottoming out.” These problems most frequently occur in women who had large implants and/or pre-existing stretched skin and perhaps droopy breasts before they even had their implants. That could have been the result of their own development, weight fluctuations, or pregnancies. Very often, these patients will recall being told that they needed a lift when they first had their augmentation, but decided against it because they didn’t want the scar. Each of these cases is very different, and care needs to be individualized.

Rippling/Visibility
Many patients complain that they can see or feel folds, ripples, or knuckles of implants. This happens mostly with saline, but it can even happen with silicone implants. If tissue is thin enough, this can even happen with the cohesive gel gummy bear implants, though that happens less frequently. Since he is an expert with the cohesive implants, many patients with this problem seek out Dr. Teitelbaum. While these implants do have an advantage over other implants for this situation, the underlying problem for most of these women is the thinness of their soft tissue over the implants. All of the patients with the worst rippling problems are extremely thin. The cornerstone of improving patients in this category is trying to get as much tissue coverage as possible, such as switching implants to behind the muscle if they are in front. Oftentimes, these patients have been behind the muscle, but they have stretched in the lower part of their breast, and by lifting the lower part of their breast, more of the implant can be kept under the muscle. Other techniques, such as using Strattice or Alloderm tissue implants can be very helpful in these challenging cases.

Size Change
This is an unfortunate reason for surgery. If there is adequate preoperative discussion and planning, this should be largely unavoidable, but it can still happen. Dr. Teitelbaum believes that implants should be sized at the first surgery according to what fits a patient’s particular breasts. Too big will look unnatural and stretch the breast, and too small will leave the upper breast underfilled and the breast looking empty and disproportional. So, if the implant chosen for the first surgery is that which was suggested – on these objective terms – then to change the size later would be illogical. That being said, sometimes patients go larger or smaller than was suggested to them initially, or other patients change their mind about what they want. This operation is not always as simple as just removing one and replacing with a bigger or smaller size. It can require some work to increase or decrease the size of the pocket, depending upon your tissues and the change in size. The most important thing to recognize is that if you are wanting bigger and bigger implants because your skin has a tendency to stretch, you need to stop and consider whether you should stop and have a lift, rather than progressively going larger, which inevitably will mean more stretch and emptiness later…one step forward and two steps back.

Saline Problems
With the end of the 14 year moratorium on silicone in the United States ending in November of 2006, there are hundreds of thousands of saline patients in the United States who at one time or another will come in to have their implants replaced. Despite evidence demonstrating that the fears that lead to the moratorium in 1992 were unfounded, some women nonetheless are suspicious of silicone. But most of the patients Dr. Teitelbaum sees want to have silicone. Some saline patients are bothered by firmness and roundness if their saline implants were highly filled, while others are bothered by upper pole emptiness, sloshiness, and ripples if their implants were underfilled. With saline, there was no perfect fill, and switching to silicone frequently fixes these problems. Other women have a saline deflation, and come in after one breast “disappeared” over a few days, and have both implants switched, either to saline or to silicone. Many are coming in now years after their saline, asking now to either replace their saline implants or get silicone implants so that a deflation does not occur at a time that is inconvenient for them. Some women asking to switch to silicone have nothing really wrong, except perhaps wanting a little softer and more natural of a feel, and something that is less perceptible to their intimate partners.

AXIS THREE

3D 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 is known for his skill in intuiting exactly what volume will satisfy his patient’s wishes and look most balanced on her body, it’s understandable that you will want to visualize precisely how different options will look on you. It’s for this reason that Dr. Teitelbaum became the first aesthetic surgeon in the country to use the Axis Three digital breast imaging system. He has now used this state-of-the-art technology to help hundreds of satisfied patients forecast how they will look after their procedure.

After taking three-dimensional digital images of the breasts, the Axis Three software then calculates precise measurements and determines the exact volume of the breast tissue present. The system can then be used to simulate what various sizes of implants would look like when placed in your existing frame. 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 and Dr. Teitelbaum to more precisely select the implant that is right for you.

Of course, like any simulation, Axis Three 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 surgical consultations with Dr. Teitelbaum include a visual imaging session using the Axis Three at no additional charge.

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