Welcome to our May email Update.

Aloha! This month’s email Newsline is being written on the Big Island of Hawaii.


Gail and I are here for a few days of rest and relaxation, not to mention a Mother’s Day celebration. Our Condo on the Kona coast is in the lovely Keauhou Gardens development. We have been very busy at work the past few weeks, and the rest is most welcome. Shortly after returning to Abilene later this week, we will be leaving for Ixtapa Mexico where I will be lecturing for a few days.

The Extended Subperiosteal Coronal Lift Revisited

It’s been quite a while since we updated our readers on one of my favorite operations, the Extended Subperiosteal Coronal Lift. Most women who seek facial rejuvenation are primarily concerned about the neck and jowl area. For these patients, the traditional or lower facelift is the procedure of choice. But for those who are primarily concerned about the mid and upper face, nothing seems to work out quite as well as the subperiosteal lift. Years ago, we often combined the subperiosteal lift with the lower lift in a single operation. It worked well but represented a rather formidable procedure for most patients.

Our current preference for those seeking rejuvenation of both the upper and lower face is to combine the traditional facelift with the endoscopic approach to the brow and forehead. Why not combine the subperiosteal with the traditional lower? Well the answer is simply that the combination requires longer time for recovery, while combining the endoscopic approach does not. Besides that, the combination of lower lift with endoscopic brow lift comes close to matching the results of the more extensive combination.

Who, then, is the best candidate for the subperiosteal approach to the forehead, brow and midface? It is usually the relatively younger patients who are not yet showing significant ageing in the neck but are mainly concerned about mid or upper face ageing. While the subperiosteal lift is a rather formidable operation, when carried out without the lower lift, recovery is usually rather prompt – actually on par with the lower traditional facelift. One big advantage of the subperiosteal coronal approach is that there are no visible scars since the incision is limited to a scalp incision. The entire operation is carried out through this single incision, along with two tiny incisions in the mouth.

For the proper patient, the Extended Subperiosteal Coronal Lift remains our recommended procedure of choice and it continues to be a very popular option for our patients. Additional information can be found on our website under the section: Facts for Patients Considering Cosmetic Surgery, or by contacting us directly by phone, email or through a personal consultation.

Injectable Fillers

We continue to get many inquiries about the status of new injectable fillers for facial augmentation and for the treatment of skin lines and depressions. Our advice to patients remains rather skeptical about these new products. Nearly all of them are temporary and the newer permanent preparations such as Artecol have not been used long enough to satisfy us of their long term safety. We remain convinced that when properly used, silicone is still the method of choice for soft tissue augmentation. Increasing numbers of patients continue to choose this method and we are pleased to note the high satisfaction that is provides. While most of our patients choose silicone for lip enhancement, we also have a great deal of experience using it for other types of augmentation.

Breast Augmentation and Implant Size

This is the time of year when we see increasing numbers of patients interested in breast enlargement and the most common question among our patients relates to choice of size. Unfortunately, this is a question that is most difficult to answer. The primary goal of breast enlargement surgery is to provide our patient with enhanced self-esteem. There is no correct or ideal breast size for all individuals. Our long experience with this operation has convinced us that the decision of size is one that is best made by the patient.

Of course there are often situations that compel us to make specific recommendations or limitations, but in the majority of cases, we depend upon the patient to make a decision about size, based on sizing exercises that are reviewed during the consultation. It must work, because we find that nearly all of our patients are satisfied with the resulting size after surgery.

There are some general considerations that must be made in deciding about size. First of all, it may be necessary to pick a size large enough to fill the breast. This is especially true in patients who have some sag or laxity in their breast. Implant diameter is related to size, and a patient with a large frame may not do well with a very small diameter implant. On the other hand, we know that very large implants are associated with a higher risk of surface irregularity because of the increased stretching of the skin. Additionally, there does seem to be a somewhat higher risk of firmness or capsular contracture with very large implants.
All of these issues must be fully considered during the pre-surgical consultation, but still, in the long run, it is usually a matter of patients deciding on size through diligent sizing exercises. While we will do all we can to help make the decision the right one, there is no one right answer for all patients.

Male Chest Enhancement

A final word while on this subject. While we normally think of breast enlargement for women, men also are interested in chest enhancement. While the operations are somewhat similar, there are significant differences. In men, the goal of surgery is to give fullness and definition in the upper chest. While we still approach the operation with an endoscopic technique through a small armpit incision, the implants used are different. In men, a soft, but solid silicone implant is used. While it is somewhat more difficult to insert, it does eliminate the risk of leakage and is rarely complicated by shifting position or development of firmness. In fact, while there is always risk to surgery, it turns out that complications are fewer in male chest enhancement than in breast enlargement for women.

That’s it for this month. As always, we appreciate your input and suggestions for future updates. Any comments are always appreciated.

That’s it for this month. Please keep your questions and comments coming. We want this to be as informative as possible and your input surely helps.


Howard A. Tobin, M.D., F. A. C. S.

For general information: askdena@newlook.org or n41gt@newlook.org