Welcome to our September email update.

I am beginning the edition of our email newsletter as Gail and I are enroute to Iceland. We are on the second leg of the journey flying between Dallas and Boston. Later this evening we will be on Iceland Air arriving in Iceland early tomorrow morning.

Map shows the route of our iceland adventure.
Glacier lagoon, Jökulsárlón on the
east coast of Iceland.
Gail and I at Gulfoss (golden falls) – A huge, multi-level waterfall rivaling any in the world.


Breast augmentation is certainly gaining in popularity and, for the most part, causes little difficulty that can’t be corrected with secondary surgery. The use of saline filled implants has further enhanced the safety of the operation. Certainly the results of the surgery depend to a large extent on the skill and experience of the surgeon. Nevertheless, there are occasions when an adverse outcome defies even the most skillful surgeon.

No matter how hard we try to counsel our patients about the risks of surgery it seems that most patients simply assume that problems will occur in someone else and not them. Add to this the unpleasant fact that complications inevitably involve added expense and it is not difficult to understand the frustration of patients who are in this situation. For this very reason, we always stress to patients the importance of clearer understanding that when implants are placed in the body, there is always the possibility that additional surgery may be required.

Of the problems that occur two are most common: deflation and firmness. Our experience indicates that saline filled implants have about a one percent risk of failure each year. Surprising to us has been the observation that the risks of deflation has not increased as time goes on. In other words, a ten year old implant seems no more likely to leak than a two year old implant. At this point, we really have no idea how long saline filled implants will last, but probably much longer than we had originally anticipated.

Fortunately, when an implant does deflate, replacement is quite simple if it is carried out promptly. In most cases, the financial burden is also lessened as the manufacturer’s warrantee will usually be in effect. The key to success, of course, is prompt correction. We consider replacement of a deflated implant to be urgent. The reason is that when the implant deflates, the surrounding tissue capsule begins to contract. If this condition is allowed to progress, the implant pocket becomes constricted and when the replacement implant is inserted, it will feel unnaturally firm or distorted. This requires additional surgery to release the capsule.

This is the reason why, when patients call, describing deflation, we always inquire as to when the first signs of deflation occurred. We are also concerned as to whether the implant felt soft and natural before the deflation. If it was not, this is a good time to correct any preexisting capsular contracture.

We have previously reported on our endoscopic laser technique of treating firm capsules surrounding breast implants. Our success with this technique convinces us that it is the procedure of choice. While the operation enjoys a high likelihood of success, it does not, of course, guarantee that the condition will not reoccur. If it does, patients face a difficult choice. Very often, a second laser endoscopic procedure is requested, and at times, may provide a longer lasting result than the first.

Aside from the endoscopic procedure, some patients opt for a capsulectomy. This is an operation that involves a surgical removal of the capsule. Rather than opening up the constricting tissue, it removes it. The surgery, which is quite tedious, results in a fresh start since the body forms an entirely new, and hopefully softer, capsule around the implant. Fortunately, this is not often required.

The question as to how far one should go is always an individual decision. Some patients simply will not give up. Others might eventually decide to live with the firmness. Finally, there is a small group that ultimately decides to have the implants removed. The important thing to realize is that, at the end of the day, it is the patient’s choice based on a thorough understanding of the available alternatives. Thankfully, most patients will never be faced with that difficult decision. Hopefully, we will have done our job of adequately explaining risks and alternatives so that our patients understand their choices!

It is now eight days since I began this newsletter. Once again we are on Iceland Air returning to Boston en route home. What a trip and what a beautiful country. If you ever have the opportunity, I would definitely suggest a visit.


One of the topics I spoke about at the Newport Beach Facial Plastic Surgery Symposium in August related to the techniques that we utilize to avoid the need for drains and bulky dressings after facelift surgery. Other than a light elastic neck wrap which our patients wear about half the time for a few weeks after surgery, we do not believe in the use of either dressings or surgical drains after facelift surgery.

The secrets to avoiding the need for drains and dressings lie in techniques that avoid significant bleeding. First of all, attention must be paid to maintaining the proper surgical plane of dissection. This is largely due to the individual skill and experience of the surgeon, but there are some tricks of the trade that can help. We find that magnification in the form of lighted optical magnification greatly adds to our precision. It also helps us to recognize small nerve fibers. This in turn minimizes the risk of nerve injury during surgery.

Another helpful adjunct is the use of a surgical laser as a dissecting tool. Not only is this a very precise method of dissection, but it also minimizes bleeding since it seals small vessels as it cuts.

While these techniques are important, equally vital is proper preparation of the tissues before the initial incision is made. To accomplish this, we inject into the tissues a very dilute solution of epinephrine. This drug, which is diluted into a larger amount of saline, a balanced salt solution, has the effect of constricting blood vessels to the point where bleeding is reduced to almost nothing. Additionally, the volume of the saline swells the tissues temporarily which improves our ability to properly work in well defined surgical planes.

That’s about all for now. I’m now back home having also made a quick weekend trip on my motorcycle to Tulsa, OK, where I spoke at a surgical symposium being put on by one of my former Fellows, Dr. Angelo Cuzalina. Another former Fellow, Dr. Jacob Hiavay, was also speaking at the meeting. It is always a pleasure to see former Fellows achieving recognition in their own right. It was a great trip stopping over for a delightful dinner in Wichita Falls and riding up to Tulsa the next morning. The weather was good although I got a little wet on the way home. All in all a great weekend!


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

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