In 1992, the FDA issued a moratorium on silicone breast implants in this country amidst concerns on the safety of silicone breast implants. Fourteen years, countless studies and thousands of patients later, many of the safety concerns that prompted the silicone breast implant ban were never clinically realized. In 2006, the FDA reversed the prior moratorium and released silicone breast implants for cosmetic use. Five years later and after analysis of the post -market data, the FDA reaffirmed the safety of silicone breast implants. Today San Jose breast augmentation patients have a choice of both silicone and saline breast implants.

Despite the positive safety findings of silicone breast implants, the recent controversy of French implant manufacturer Poly Implant Prosthese (PIP) has created new fears on the safety of silicone breast implants. PIP implants underwent a worldwide recall of its silicone breast implants due to an exceedingly high rupture rate. It was later revealed that the company used lower grade industrial silicone (at 10% of the cost of medical grade silicone) in the manufacture of PIP implants. The result was an inferior quality prosthesis that developed higher leak rates. PIP implants were sold across Europe, Asia and South America and have been implanted in over 300,000 women worldwide.

Luckily for San Jose breast augmentation patients, PIP implants were never sold in the US. In the US there are only two implant companies: Mentor (a division of Johnson and Johnson) and Allergan. Both companies exhibit high manufacturer quality with low rupture rates. Six year follow-up studies by Mentor and Allergan show a low rupture rate, typically around 1% per year.  Drs. Jerome and Tom Liu have also completed certification for use of the Mentor Memory Gel and Allergan Natrelle silicone breast implants and important pre-requisite for breast augmentation. San Jose patients will be reassured that Drs. Jerome and Tom Liu are experienced in both brands of implants and all the models they carry.

Although PIP implants were never approved for use in the US, there are US residents who may have had PIP implants placed when they were traveling or living abroad. Mentor has launched a compassionate care program (valid 1/1/2012 through 12/31/2012) where Mentor will reimburse $250 for US residents with PIP implants who wish to have them exchanged with Mentor saline or silicone implants for their breast augmentation. San Jose or any patient with PIP implants should contact our office (408-418-0808) for more details on the Mentor Compassionate Care Program.

At Liu Plastic Surgery, we understand that patient safety is number one. Silicone breast implants have a long history of both safety and controversy in this country and abroad. Our goal is to be your physician advocate throughout the process. So which is better silicone or saline implants? Here are some of the things you may want to consider before YOU decide.

Feel (Advantage: Silicone)

When patients come into our office for a breast augmentation consultation, we will place a sample silicone and saline implant for them to feel. In this head to head comparison the silicone breast implant is unbeaten. Patients report that the silicone implant feels more “natural.” Patients often describe that the saline implant feels like a “bag of water.” When both implants are squeezed the silicone implant just feels softer because it is a gel while the saline implant is more fluid filled. When the saline implant is shaken you can sometimes hear a sloshing sound. Over time, the dissolved air can escape from the saline liquid and form air bubbles inside the shell further contributing the sloshing sound. This is the single most convincing reason why women choose silicone over saline implants.

Rippling (Advantage: Silicone)

Both silicone and saline implants have a silicone shell. The difference is what’s inside. When both implants are held upright the edges of the silicone implant are smooth while the edges of the saline implant are rippled. Many patients have described seeing rippling along the side of the breasts of women they know who have had saline implants. This becomes an issue especially in thin patients or when the implant is placed above the muscle (subglandular).

Leakage / Rupture Detection (Advantage: Saline)

When a saline implant ruptures it is obvious. Often times, women suddenly discover that one breast is slightly smaller than the other or completely deflated to the pre-augmentation size and shape. When a silicone implant ruptures it may or may not be clinically obvious or detectable. The latest generation of silicone implants is cohesive gels which mean that when the implant is cut the gel stays in one place (click to see video of a silicone implant cut in half). The same holds true if there is a leak or break in the silicone shell. As a result, the FDA has recommended that silicone breast implants be monitored for rupture with a breast MRI 3 years after surgery and every 2 years thereafter. As stated earlier, the rupture rate for Mentor Memory gel silicone implants is 1% at 6 years.

Risk of Rupture (Advantage: Silicone)

Mentor has published data from its Core Gel study and from its Saline Prospective Study. Six year data from the Core Gel study reveal a 1.1% rupture rate in primary augmentation patients. Five year data from the saline study reveals a 10% deflation rate.

Cost (Advantage: Saline)

Plain and simple silicone implants cost more. They are more expensive to manufacture and therefore cost more. Silicone implants cost roughly 40% more than saline implants.

Warranty (Advantage: Silicone)

All Mentor breast implants carry a lifetime warranty against rupture. Mentor will replace the ruptured implant and the other implant for free. During the first 10 years, Mentor will also pay for up to $3500 of the cost of the surgery for silicone implant ruptures. For saline breast implants Mentor will pay $1200 of the cost of surgery. Patients who have an enhanced saline warranty (paid $100 within 45 days of surgery for a warrant upgrade), Mentor will pay $2400 of the cost of surgery. For no additional cost, the warranty of silicone implants will reimburse more the cost of surgery should a rupture occur in the first 10 years.

Both Drs. Jerome and Tom Liu are passionate about breast augmentation but most importantly they are concerned for the safety of their patients in the San Jose. Breast augmentation surgery begins with an understanding of the patient’s goals and discussion of the risks and benefits of breast augmentation surgery. A thorough analysis of your chest and breast anatomy to determine which implant and size is right for you come with 17 years of collective training from the aesthetic fellowship trained plastic surgeons at LPS. Your visit starts with a consultation with one of our plastic surgeons in San Jose-Los Gatos who have advanced fellowship training in aesthetic breast procedures. During your consultation you will develop a customized breast augmentation package that is tailored to your body to include: implant type, position, incision and size. The plastic surgeons at LPS will give you a thorough and honest assessment to determine if you are a patient who would benefit from breast augmentation.

Contact Liu Plastic Surgery (San Jose – Los Gatos) at 408-418-0808 to discuss surgical your surgical options for breast augmentation surgery.

Volume is the new vogue in aesthetic (cosmetic) surgery. Injectable dermal fillers do just that….. they provide volume and/or stimulate the formation of collagen in the face. Since wrinkles are accentuated by uneven soft tissue volume distribution, restoration of that soft tissue volume will often improve the wrinkle topography of the face. Many patients have noticed that they looked younger when their weight is stable or even a bit on the heavier side. The popularity of injectable fillers have also extended to the young and wrinkle-less. Injectable fillers are used to enhance areas like the lips or improve the shape of the nose (so called “liquid rhinoplasty”).

The most common form of injectable dermal filler (Juvederm®, Restylane®, Perlane® and Prevelle®) are made of hyaluronic acid, a natural gel that is in our skin and joints. This compound is highly hydrophilic (attracts water) and will retain water and plump the tissue that it is injected in. Radiesse® is another class of filler that uses small microspheres of calcium crystals coated with collagen. Over time, the hyaluronic acid or calcium microspheres will break down and the results reverse. Sculptra® is in a class of its own. Unlike traditional “fillers” Sculptra® is not space occupying. This poly-L-lactic acid solution is injected and as it breaks down it stimulates new collagen formation. There is also evidence that repeat injections of hyaluronic acid and calcium microspheres also can stimulate new collagen formation for the plastic surgery patients in San Jose, Bay Area. Botox®, another popular injection is not a type of injectable filler and will be addressed in another article.

Whereas the majority of dermal fillers are manufactured, sterile and instantly available off the shelf, there is one type of filler that is 100% natural and is readily available from the patient….. FAT! Fat grafting is technique where a patient’s fat is removed from their body, cleaned and purified into injectable fat grafts. The fat is then reintroduced into the patient’s body in areas that are deficient of soft tissue. Common areas are the face, breast or buttock. San Jose plastic surgery patients are excited at the fact that they can get rid of fat from one part of the body and donate it to enhance another part of the body. Patients often call this “lite San Jose liposuction.”

But wait…. this sounds too good to be true. Although, fat grafting is a powerful tool in plastic surgery there are many reasons why injectable dermal fillers are superior when it comes to facial injections. Fat grafts require harvesting the fat cells from one area of the body, processing the fat and then re-introducing the cells to another part of the body. This requires a surgical procedure to harvest and process the fat. In addition, it is unclear what percentage of the fat cells will survive. Injectable dermal fillers are more predictable in their survival and are pre-packaged so there is no down time.

So injectable dermal fillers are better than fat grafts? Not quite. Injectable dermal fillers have an important role in the plastic surgeon’s armamentarium of procedures but they are not a panacea. Injectable dermal fillers have become so popular that some cosmetic practitioners will readily inject any patient anywhere. Performance of injectable fillers seems deceptively simple that patients are willing to accept these injections from any practitioner. Celebrities like Priscilla Presley have been fooled by allowing a “cosmetic surgeon” (turns out he isn’t a licensed physician in the US) to inject industrial grade silicone into her face! Therefore patients should abide by the adage “Caveat emptor (buyer beware).”

Regardless of what type of injectable dermal fillers you are interested in, it is important for you to be evaluated by a plastic surgeon to determine if you are a candidate for injectable dermal filler correction, plastic surgery or both. Facial aging is a combination of both anatomic changes and volumetric changes. Therefore any successful rejuvenation must incorporate and harmoniously balance components of both. Injectable fillers and aesthetic (cosmetic) plastic surgery are not substitutes but rather complementary procedures. A patient with thick neck bands and jawline laxity and jowls is not going to benefit from injectable dermal fillers but rather a facelift. Another patient with midface deflation and a clean neckline could benefit from injectable dermal fillers or surgical facial rejuvenation or both. Both injectable dermal fillers and plastic surgery have complementary roles in facial rejuvenation. A thorough facial analysis by a plastic surgeon specializing in aesthetic (cosmetic) plastic surgery will best determine which is best for you.

At Liu Plastic Surgery we believe successful aesthetic rejuvenation starts with listening to the patient’s aesthetic concerns and goals. A thorough facial analysis is then performed built on the training and understanding of facial aging and its effects on facial anatomy that comes with 17 years of collective training from the aesthetic fellowship trained plastic surgeons at LPS. Your visit starts with a consultation with one of our plastic surgeons in San Jose-Los Gatos who have advanced fellowship training in facial injectable procedures. Your plastic surgeon will listen to your concerns and analyze your face focusing on the facial anatomy that is causing the area of concern and providing you with an individualized aesthetic goal that may include injectable fillers, aesthetic (cosmetic) surgery or both. The plastic surgeons at LPS will give you a thorough and honest assessment to determine if you are a patient who would benefit from injectable dermal fillers. All injections are performed by the plastic surgeons themselves.

Contact Liu Plastic Surgery (San Jose – Los Gatos) at 408-418-0808 to see if you are a candidate for injectable dermal fillers.

This is a 50-year old San Jose-Los Gatos cosmetic surgery patient who has undergone injectable dermal filler for correction of her facial soft tissue deflation and aging. She has received three sessions of Sculptra® (6 vials). In addition, she has also received Restylane® (2 syringes) for soft tissue touch up and fine contouring. Shown is her 14 month result showing restoration of her facial soft tissue volume. She initially presented because she did not like her lower eyelid bags and wanted a lower eyelid surgery (blepharoplasty). With volume restoration her orbital-cheek junction is softened. Her lower eyelid fat bags look less pronounced. She did not get a lower eyelid blepharoplasty. Her face looks fuller, more youthful and rested.

Asian aesthetics is a field in aesthetic (cosmetic) plastic surgery that focuses on understanding the anatomic differences between Asians and non-Asians and how that impacts the respective ethnic perspective of beauty. The plastic surgeon performs procedures to improve the aesthetic appearance of the patient while maintaining the patient’s ethnic identity and respecting the cultural norms of beauty. There are structural anatomic differences between different ethnic groups from the skin down to the bone. Nowhere is this more evident than the differences between the Asian upper eyelid and the Western upper eyelid. One procedure that epitomizes Asian aesthetics is the Asian eyelid surgery (blepharoplasty) or “double eyelid surgery.” The goal of the surgery is the creation of an upper eyelid fold or the accentuation and elevation of a fold that is already there (Figure 1).

The incidence of single eyelid surgery in the US is similar to Asia. About 50% of San Jose Asian eyelid surgery patients lack the upper eyelid crease commonly seen in the majority of Western upper eyelids (Figure 2). There are many reasons why patients wish to have Asian double eyelid surgery. For those with a single eyelid, de novo creation of a double eyelid is a personal cosmetic preference. Some women feel that have a double eyelid makes the eyes look bigger and more attractive. The double upper eyelid also aids in eye makeup application. Other patients have an existing double eyelid but the crease is too low or too weak. These patients like their double eyelid eyes but want an enhancement of their existing eyelids (Figure 3). The third category of patients have pre-existing asymmetries between the two eyes (one single and one double) (Figure 4). Patients with asymmetries just want to look balanced. Since it is impossible to convert a double to a single eyelid and most patients find their double eyelid to be more attractive, the symmetry procedure will convert the single to a double eyelid. Whichever of these reasons applies to you, Asian blepharoplasty (Asian double eyelid surgery) is the most common surgical procedure performed in Asia and San Jose. Asian eyelid surgery is also the most common Asian aesthetic surgery procedure in the United States.

Figure 1

Figure 2

Figure 3

Figure 4

There are anatomic differences between the Asian eyelid and the Western eyelid. The main anatomic differences are 1) levator dermal attachments or adhesions 2) retroseptal fat quantity and inferior displacement 3) orbicularis oculi muscular hypertrophy and 4) presence of medial epicanthal fold. Each of these components is evaluated during the patient consultation to determine which component(s) needs to be surgical addressed to give the patient the desired end result.

Levator dermal attachments

In the Western eyelid, the levator-tarsal apparatus and the upper eyelid skin are connected by levator-dermal attachments or adhesion planes. Upward displacement of the levator muscle during eye opening pulls the upper eyelid skin down, resulting in a fold. The result is a gliding of the inferior skin beneath the upper skin creating a double fold. In Western eyelid, the number of attachments is greater and the insertion is over a longer distance (including higher up along the eyelid). In the Asian eyelid, the insertions are less and over a shorter distance (lower on the eyelid) or absent all together resulting in a thin double eyelid crease or a single eyelid, respectively. These levator-dermal attachments are precisely what we are surgically re-creating when we perform the double suture technique (DST) for our San Jose Asian eyelid surgery (blepharoplasty) patients.

Retroseptal fat quantity and inferior displacement

For some patients of San Jose, Asian eyelid surgery is not just about creating a new levator-dermal attachment (aka skin crease). Candidates who are not candidates for the double suture (DST) often have “heavy” or “puffy” eyes. These patients require an “open” or incisional technique because of excess tissue that needs to be removed. One component of the excess soft tissue is from the retroseptal fat (Figure 5). Unlike in the Western patient’s eyelids, the retroseptal fat of the Asian patient’s eyelid can be more prominent. This is also accentuated by the fact that the septum inserts lower on the tarso-levator complex. Instead of being higher on the eyelid, the inferiorly displaced fat sits lowers and makes the eyelid appear puffy. Whether the puffy eyelid is due to excess fat, lower positioned fat or both, the surgical correction must be tailored to the anatomy of the patient.

Figure 5

Orbicularis oculi muscular hypertrophy

Similar to the retroseptal fat, the orbicularis oculi muscle of the Asian eyelid can also be hypertrophic (enlarged) contributing to a “puffy” upper eyelid. In order to achieve a clean and crisp upper eyelid crease, the excess tissue that sits between the levator muscle and skin needs to be debulked. This includes the inferiorly displaced retroseptal fat and the preseptal orbicularis oculi muscle. The orbicularis oculi muscle is a natural sphincter (circular) muscle that helps our eyes close and squint (Figure 6, above). In many Asian patients, the orbicularis muscle over the upper eyelid is thickened (Figure 6, below). Debulking of this muscle does not alter the function of the upper eyelid.

Figure 6

Medial epicanthal fold

Lastly, the medial epicanthal fold is the extra medial eyelid skin often seen in Asian patients (Figure 7). The degree of the medial epicanthal fold can vary from a mild (small) fold to a severe (large) fold. The excess skin fold covers the medial part of the eye and can give the eye a more narrowed or pointed appearance. Whereas lack of a medial epicanthal fold in the Western eyelid produces a parallel crease, presence of a medial epicanthal fold can result in a tapering of the eyelid crease at it approaches the nose (nasal taper). This is a personal aesthetic opinion, as many of our patients are not bothered by their epicanthal fold and find the nasally tapered crease pleasing. Many Asian models and movie stars have a nasal-tapered crease. Preservation of the epicanthal fold can be important to maintain a patient’s ethnic identity. Release of the epicanthal fold is often criticized as a “Westernizing” procedure. Many Asian patients do not want to look “Western” but rather want an improvement if their underlying aesthetic appearance while preserving their ethnic identity. Unlike the other blepharoplasty incisions that are nicely hidden in the upper eyelid crease, correction of the medial epicanthal fold (medial epicanthoplasty) requires placement of a surgical incision in the center part of the face in a visible area. Though the scar is small and fades over time, many patients are reluctant to have a potentially visible scar.

Figure 7

From Korea to Japan to Taiwan to San Jose, Asian eyelid surgery has arrived to Liu Plastic Surgery. Both Drs. Jerome and Tom Liu are passionate about Asian double eyelid surgery (Asian blepharoplasty) for their patients in the San Jose- Bay Area. Asian eyelid surgery begins with a thorough analysis of your eyelid to evaluate your underlying anatomy and determine which procedure is right for you. At Liu Plastic Surgery we believe successful aesthetic rejuvenation starts with listening to the patient’s aesthetic concerns and goals. Your visit starts with a consultation with one of our plastic surgeons in San Jose-Los Gatos who have advanced fellowship training in facial aesthetic procedures. Your plastic surgeon will listen to your concerns and analyze your face focusing on the facial anatomy that is causing the area of concern and providing you with an individualized aesthetic goal. The plastic surgeons at Liu Plastic Surgery will give you a thorough and honest assessment to determine if you are a patient who would benefit from Asian eyelid surgery and whether a suture or incision technique is best for you.

Contact Liu Plastic Surgery (San Jose – Los Gatos) at 408-418-0808 to discuss surgical your surgical options for Asian eyelid surgery.

Figure 8

This is a 29-year old San Jose-Bay area Asian eyelid surgery patient. She was born with a single eyelid. She did not like the shape of her eyes and had problems with makeup application. She wanted to have a double fold but wanted a small fold width for a more natural and subtle look. She was not a candidate for suture blepharoplasty (DST) because of her puffy upper eyelid (muscle hypertrophy and excess fat). Shown is her postop result after open incisional upper eyelid surgery.

Figure 9

This is a 26-year old San Francisco-Bay area Asian eyelid surgery patient. She has an existing double crease but it is narrow and low. She would like a higher and wider eyelid crease. She does not have a puffy upper eyelid and is a good candidate for double suture technique blepharoplasty (DST). Fold width is determined by the patient’s preference. Shown is her postoperative result after double suture technique blepharoplasty (DST).