Welcome to our March Newsline.

As has become my custom, I am beginning this newsletter aboard an airliner crossing the ocean. Once again, we are on our way to Israel. The last time we made this journey, it was to participate in a training program in disaster medicine as part of an agreement I and a number of other doctors had made to serve as back up physicians in the hospital in Nahariya, in northern Israel, should we be needed in time of war. As many of you may know, this very hospital was hit by rockets during the Second Lebonese War in Israel. While prepared to return at any time, I was told that we were not needed and all was under control.

Tel Aviv
The Tobins in Jaffa with Tel Aviv in the background

This time, we are returning as tourists, although we will be returning to Naharyia where we will visit with friends we made during the last trip. Israel seems to put a hold on you, and once you visit, you are drawn back. On this trip, we are looking forward to seeing many of the sites that we did not get to visit before.

Yad Vashem

Yad Vashem – the Holocaust Museum in Jerusalem.


After 15 years, the Food and Drug Administration (FDA) has again released gel filled implants. Women now have the choice of continuing to use saline filled implants or opting for gel. While in favor of the decision, we are still encouraging the choice of saline. With over 15 years of experience with saline, following an equal experience with gel, I continue to feel that saline implants represent the better choice. Let’s evaluate the pros and cons of each.

All implants have the potential for problems. During our consultation, we always stress that women must be prepared to deal with these problems. Breast augmentation is a very satisfying operation for the great majority of women who choose this option. The high satisfaction is one of the problems we face, since women become so pleased with their new body image that they are unwilling to give up the implants even when problems arise. Having the implants removed is almost like a mastectomy. Fortunately, most women do not have major problems, but a very small minority do.

Most of the problems faced are related to a condition called capsular contracture. The capsule is a membrane of collagen, akin to scar tissue, that forms around any implant that is placed in the body. It represents the body’s attempt to wall off any object recognized as foreign. This is an entirely normal reaction. The reason that silicone is used for implants is partly because it is the least reactive material that can be put in the body. In other words, although it is foreign, it is less foreign than most materials. I guess it’s like Canada being a foreign country, but we don’t see Canadians as much different than ourselves.

At any rate, this membrane, or capsule, is usually very thin and compliant. It merely serves to hold the implant in place. Sometimes, however, it can either thicken or tighten. We really don’t have any idea of why this happens. We are aware of some factors. We know that patients who experience post operative bleeding are much more likely to experience capsular contracture, and so the blood that forms around the implant is probably one major factor. This is why we are so in favor of the endoscopic technique. It is almost always a bloodless operation.

For whatever reason, if the capsule contracts, it begins to compress the implant. This can cause any number of problems. It can cause pain or tenderness in the breast. It can distort the shape of the breast. It can push the implant out of position, usually in an upward direction toward the collar bone. It can simply make the implant feel firm and unnatural. If these problems are mild, patients usually accept them, but if severe, surgery is required. The endoscopic laser technique that we have developed is highly successful in correcting this problem, but it can recur, and in a very small percentage of patients, it keeps coming back in spite of all treatment.

Now what does this have to do with the decision as to whether a woman should choose gel or saline? The simple fact is that gel implants are much more likely to lead to capsular contracture than saline; perhaps three times as high. That’s a pretty significant difference.

Another major advantage of saline is safety. Sad but true is the fact that all implants have the potential to leak. Good as the technology is, it is not perfect. Breast implants, when placed in the body, are in almost constant motion. They are subject to shearing forces which can ultimately lead to leakage. Saline implants are somewhat more likely to leak since there is the potential for leakage from the filling valve. Nevertheless, a leaking saline implant poses no threat of danger and is simple to fix. We simply go in through the original incision, remove the deflated implant and replace it. Our patient is fully back to normal immediately.

With gel, the problem is more complex. First of all leakage can be hard to detect, and detection can be quite expensive. The FDA recommends that all patients who have gel implants undergo a breast MRI three years after surgery and every two years thereafter. An expense that can far exceed the cost of the original surgery. Even then, we have found that breast MRI is not entirely accurate. We have seen both false positive and false negative reports. In fact, we no longer recommend that exam to our patients, preferring to carry out breast endoscopy when there is suspicion of leakage. If a gel implant leaks, the liquid silicone may be confined to within the membrane or capsule, but it can extrude through the capsule where it can get into soft tissue, lymph nodes or even nerves. Replacement of gel implants may require a fairly complex surgery to remove not only the leaking implant, but also the surrounding capsule. This is a rather tedious and time consuming operation – far more complex than simple implant exchange.

What makes gel most attractive is the fact that many people feel that it produces a more natural feeling breast. To some extent, this is undeniable. The question is the degree of difference. All implants can produce surface waviness or rippling if there is not adequate soft tissue covering the implant. If there is, waviness is rarely a problem, especially if patients are conservative in their choice of implant size. Furthermore, by placing the implant beneath the muscle, waviness in the upper breast is much less likely.

Finally, saline implants can be inserted through a much smaller incision. In fact, with our endoscopic technique, the incision in the armpit need only be long enough to allow insertion of the endoscope.

What’s the bottom line? As always, we believe in offering our patients choices. For the present, we have not seen any interest in gel, but if our patient prefers it, we will be glad to accommodate them. If patients ask, and they usually do, our recommendation at present is to stay with saline.


This spring, I will be lecturing at a Facial Plastic Surgery meeting sponsored by the University of Tennessee, and held at Hilton Head, SC. One of the topics I was asked to address was the controversy over doing eyelid surgery, brow surgery or both. In researching the topic, I was reading a very popular text book on aesthetic surgery where the author suggested that it was the surgeon’s responsibility to recommend to the patient which of these procedures was indicated. He stated, that in his opinion, most of the time both should be done. I could not disagree more.

I realize that opinions vary, but my feeling is, and has always been, that we should primarily address problems that are of concern to our patients. I think that often we surgeons do too much analyzing and recommending, and not enough asking and listening. I always find it a bit disconcerting at meetings when surgeons talk about what their patients need.

I always tell my patients that there is nothing I do that anyone needs. Of course this is an exaggeration. When self esteem is at stake, there is certainly a strong indication for change. But if we are truly trying to help our patients, it is vital for us to determine what they are really seeking to change. Sometimes they want our opinion, but not always.

In regard to this issue of eyelid and brow surgery, I try to take time to explain what each will accomplish. By showing patients with slight manual brow elevation, this is usually quite easy. Surprisingly, at least in my practice, most patients are not seeking brow elevation but rather elimination of excess skin and fat in the upper eyelid.

The distinction is important. We have excellent techniques of brow elevation ranging from endoscopic brow lift to a major extended subperiosteal coronal lift. But these are much more complex operations than a blepharoplasty. Upper lid blepharoplasty, when performed with the surgical laser, is a relatively simple, safe operation that allows very rapid recovery. In addition, it is far less expensive than most brow procedures. For patients in whom we are concerned that blepharoplasty may pull down the brow, we have safe and simple brow stabilization procedures.

No doubt, a significant number of patients are concerned about brow position, and for these patients brow elevation can be considered either with our without blepharoplasty.

What’s the bottom line? Like so many issues in cosmetic surgery, decision making is a very important process. Sometimes it is not easy and requires considerable consultation and consideration. This aspect of cosmetic surgery – the consultation, is a vital part of your treatment program. It is an aspect that we do not take lightly. In fact, it is not uncommon for this to require more time than the surgery itself.

Heroic Israeli Paratrooper
“Heroic Israeli paratrooper originally from Milwaukee, WS who fought and was wounded in the Second Lebanese war.”

I’m finishing this as we return from Israel. It has been a remarkable trip. As I mentioned, our first trip to Israel was to study and learn medicine. This trip was to learn about Israel; and what a remarkable country it is. In spite of the need to defend itself from hostile and barbaric forces surrounding it, the country flourishes with construction all around. Their people are inspiring. We had an opportunity to talk with a paratrooper, originally from the US, who was wounded in the Second Lebanonese War. His story was remarkable. During the heat of the combat, he told us, he got frightened – almost to the point of panic. He said that one of his comrades gave him the support he needed to continue fighting, in spite of the fact that he had been shot several times in the arm. When they tried to evacuate him, he refused. He said he could not leave his comrades. It reminded me of the spirit of the US troops during World War II – a spirit that continues today in Iraq.

Western Wall in the Old City of Jerusalem
The Western Wall in the Old City of Jerusalem.

Additional visits to the Holocaust Museum, the Israeli Independence Hall, the Diaspora Museum not to mention sight seeing in Jerusalem, where we explored the recently excavated tunnels under the old city, visits to Masada, the Dead Sea, Tel Aviv and Jaffa made for a very active schedule.

We completed the trip in the North in the Galilee region, returning to Nahariya where we visited old friends from our previous trip which made this a very memorable visit.

That’s it for now. As always we welcome your comments and suggestions. And thanks to the many of you that have given your feedback. It really is appreciated. Let us know what topics you would like covered. Frankly, that’s the hardest part of planning this periodic Newsline.

Facial Plastic Surgery


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

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