Keloids are benign tumor growths of scar tissue. Common areas include the earlobes, beard area, and groin. Treatment options for keloids center on the cause of keloids -> unregulated inflammatory response to trauma. This is why steroids, radiation, pressure, and inflammatory modulation (interferon, 5-FU)  therapies are advocated. Surgery alone has a recurrence rate of around 85%, and is not recommended in isolation without adjuvant therapies.

The beard area is a very difficult place to treat. Although steroid injections may help with a developing keloid, they usually only soften an established keloid. Interferon and 5-FU treatment has very mixed results, but most data points to a less than effective treatment. For this area, I usually recommend a trial therapy of surgical excision of a small area of the keloid combined with immediate steroid injection and a pressure garment (similar to a chin strap) with or without adjuvant radiation. If you have resolution in the treated area, I would proceed with the same therapy for the remainder of the keloid. If you have a recurrence of the keloid, you may need more aggressive treatment.

Recently, some surgeons have been reporting good results using different types of dermal matrix replacements (such as Alloderm or Integra) followed by very thin split thickness skin grafting. Having been used for years in burn scar reconstruction, there is some belief that by providing a scaffold for wound repair, one can alleviate the abnormal scar response in a keloid. These reports are currently anecdotal, however may be an option for you. I would recommend a thorough discussion with a plastic surgeon in regards to your keloids.

Your question really deal with two separate issues: 1. Where to get cohesive gel implants (which, I believe you are referring to the “form stable” anatomic implants) 2. And the cost of cheaper surgery in another country.

Because this is a confusing topic for most readers, I’ll share a bit of the background on the implants. The form stable cohesive gel implants (Mentor CPG or Inamed 410) are essentially anatomically shaped silicone gel implants where the gel itself retains the manufactured shape. The obvious advantages of this implant are the improved feel from using silicone over saline and the ability to augment the lower pole of the breast more than the upper pole. An additional advantage is the lower migration rate of silicone in the case of a rupture due to it’s higher cohesive nature. As of right now, I believe that the study groups are closed to new patients meaning that you cannot get these implants in the US. The reason for this is quite simple: these devices are not FDA approved and are considered study only. In other words, we don’t have the data to determine if these devices are safe for general use. I don’t know your reasons for wanting onlythese devices, but if you do choose to have them, you need to either travel abroad or wait until they are approved in the US.

This leads to the question of having surgery in another country. In Brazil, there are many wonderful plastic surgeons. If you have the time to take stay during your postoperative recovery period and you have support (family/friends), then this sounds like a good option for you. The risks are obviously dealing with any complications from surgery or long-term affects on your breasts (sagging, asymmetries, etc.) years later. If you can stay for a few weeks, this is advisable. The corollary of your situation is the person who takes a “plastic surgery vacation” to a foreign country and has surgery by someone they don’t know and without proper follow up. In those cases, I am very concerned because there is no regulation or certification of these surgeons and the facilities they operate in. This type of “discount” plastic surgery is much more common in Europe and is to be cautioned against.

The bottom line is that if you are going to have plastic surgery, make sure your plastic surgeon is Board Certified by the American Board of Plastic Surgery and that they operate in an accredited facility. If you choose to have surgery in another country, obtain that country’s information on that surgeon and their qualifications. I’ve listed the website for the American Board of Plastic Surgery to help you and our readers when looking for a board certified plastic surgeon.

Breast implants (either saline or silicone) are not lifetime devices. Over time, the constant folding and movement of the implants can cause small holes in the shell of the implant.

In saline devices, this leads to a slow leakage of the saline which becomes absorbed by the body. This results in obvious deflation of the implant.

In a silicone gel implant, it depends a lot more on the make of the implant. Older implants tended to have more liquid silicone and thinner shells leading to higher rupture rates and a phenomenon known as “gel bleed.” Gel bleed is the passage of the liquid silicone through the shell of the implant without an actual hole in the shell. It can be very difficult to detect this simply by exam, although an MRI may help with the identification of silicone outside the shell. The current gel implants are more “cohesive” meaning the gel itself is less likely to bleed through the shell or exit through a small hole in the implant. Regardless, the FDA recommends recurrent MRIs to detect silicone gel implant ruptures.

Many patients ask whether they need to have their implants replaced after a given amount of time. If they are saline implants and they have not changed in shape or size and you are happy with them, my recommendation is to leave them be. For silicone gel implants it is more a matter of personal choice. If you have concerns over the implants and/or have noticed changes in the size or shape of the breast, you may consider an MRI to evaluate the state of the implants. If they show signs of rupture or silicone bleed, I recommend replacement of the implants.  

A great question, and a very difficult one to answer. Simply stated, the outcomes from a breast reconstruction range from simple breast “mounds” to breasts that are aesthetically better than what the patient had before surgery. Of course, there are many factors which influence how a breast reconstruction turns out. I’ll review the benefits of different types of reconstruction and what factors positively or negatively impact them.

The most common type of breast reconstruction in the US is an implant reconstruction. Usually done in at least two stages with an expander placed first, followed by an exchange of the expander for either a saline or silicone implant. The ideal patient for implant reconstruction typically has the following characteristics:

1. Small to moderate size breasts with minimal droopiness

2. A bilateral reconstruction – it is easier to achieve symmetry

3. No history of radiation

4. Good skin tone

In addition, for women who are candidates for nipple sparing mastectomies, this type of breast reconstruction can have the appearance of a breast augmentation and are some of the most impressive reconstructions performed.

Another large number of reconstructions are performed with autologous tissue (tissue from somewhere else on your body). These include pedicled flaps from the back or abdomen as well as free flaps (microsurgical flaps) from the abdomen, buttocks, or thighs. Usually, these procedures obviate the need for an implant. The tissue is composed of skin, fat, and sometimes muscle which gives a very natural “feel” to the reconstructed breast. The ideal candidates for these types of reconstructions include:

1. Women with larger breasts and larger body types

2. Unilateral or one-sided reconstructions – a flap reconstruction has the ability to mimic natural breast ptosis or sagginess

3. A history of radiation therapy to a breast (usually from a previous lumpectomy and radiation)

The patient’s medical history including smoking history, diabetes, obesity, previous surgery, etc. have a large impact on the quality of the result. Also, the surgeon’s experience with a particular type of reconstruction is very important as well. Many hospitals and cancer centers have breast cancer support groups where women can talk to other women about their experiences and satisfaction with breast reconstruction. Also, your plastic surgeon is likely to have a portfolio of reconstruction pictures to give you an idea of what to expect throughout the reconstructive process.

Typically, this is a 1.5 – 2 hour discussion with patients in my office. Hopefully, I’ve been able to clarify some of the confusing points of breast reconstruction. Overall, I believe that most patients who undergo breast reconstruction are happy with their results.

In my practice, I view facial rejuvenation as a stepwise approach to correcting the signs of aging as they occur. Early on, simple treatment of the facial skin using appropriate skin products (toners, peptide serums, etc.) and sunscreens can slow and reverse the early signs of aging. As skin loses it’s elasticity and wrinkles become more prominent, Botox and fillers (such as Juvederm) are more appropriate. A facelift is reserved for more significant changes. Typically, this involves deep wrinkles around the mouth and chin, jowling, hollowness under the eyes, and laxity of the skin in front of the ears.

In performing a facelift, the long term correction relies on tightening the deep tissues of the face (SMAS) and not relying on simply pulling the already inelastic skin. Other adjunctive procedures including eye lifts (blepharoplasty), midface correction, fat injections, and neck lifting all help to address individual problem areas. To find what options are right for you, I recommend seeing a Board Certified Plastic Surgeon.