James L. Pertsch, MD

 

Questions and Answers

 

Emailed questions along with Dr. Pertsch's answers are presented for your general information. Each person's desired result, anatomy, and expectation vary a great deal. Medical advice cannot be given without an 'in person' discussion and examination by a qualified physician.

 

Additional comments not in the origin correspondence are place within brackets [ ]. Duplicate material was deleted and may make some responses seem overly abbreviated. Patients identified as **. Patient questions have not been otherwise edited or had spelling corrected.

 

 

Abdominoplasty (Tummy Tuck): Before Surgery

Breast Augmentation: Before Surgery

Breast Augmentation: After Surgery

Breast Augmentation: Considering Further Refinements

Breast Reduction

Liposuction

Prominent Ear Reduction, Pinning, or Setback

Q&A For Thinner Looking Faces

Q&A For a Combinations of Procedures

   » Liposuction and other procedures at the same time

   » Breast lift and abdominoplasty: before surgery

 

 

Choosing a Plastic Surgeon

 

Date: Fri, 21 Apr 2000 17:46

Dear Dr. Pertsch,

Thank you for answering my email [initial mail: see patients first email QA.] I do have an appointment for consultation for breast augmentation this coming Tuesday. But I would also like to ask you about the recent abdominal surgery that I had. I know my gynecologist is not a plastic surgeon like you, but I really think that either my incision hasn't completely healed yet or it might just stay the way it looks right now. There's a big flab hanging out on top of the stitches. I had a c-section when I had my baby 10 yrs. ago. But it didn't look like this then. Do you mind if you check it out when I see you on Tuesday. It's really not a pretty sight at all. I hope we can talk about it even if it has nothing to do with the breast augmentation that I'm planning on having. Thank you for your time. I shall see you soon. Thanks for mailing again. I look forward to meeting you.

 

Answer: Dear ** Your complaint about some overhang over the top of your c-section incision is very common. Most commonly this occurs when deeper tissues get stuck to the skin without enough of the normal fatty layer in between. Since you recently had the c-section there could be a degree of lymph edema (see below) i.e. the skin above the scar could be more swollen than the skin just below giving a pouching effect. Other factors to consider: now you've had another child your abdominal skin may be more lax. The second time through the same incision increases the chance of imperfect healing.

This indentation could probably have been avoided BUT I would spend more time just closing your wound than your gynecologist spent on the entire operation. In all fairness it's not expected that a gynecologist spend this much time on the skin.

This overhang problem can usually be markedly improved with scar revision surgery. Occasionally a full abdominoplasty (tummy tuck) is what will give the best result. If indicated the revision or abdominoplasty surgery could be performed at the same operation as the breast augmentation.

Aside on lymph edema: lymph edema is a bit hard to explain briefly: beside the arteries and veins there is a separate system of tiny tubes in your body to deal with the constant, small volume of fluid that gets outside the blood vessels: the lymphatic system. In your lower stomach (abdomen) these tubes drain toward your groin/mons pubis/pubic area. When there is a new incision these channels get interrupted and take many months to grow back.

 

To get pricing quotes please contact our office.

James L. Pertsch, M.D.

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Hello my name is **. I am interested in having a tummy tuck done. I am currently exercising, but have had two children and now have a pouch. Please email me with information and pricing.

 

Dear ** [2/11/00]:

Thank you for your mail.

Tummy tuck (Abdominoplasty) is on of my favorite procedures as it is such a body transforming/ patient transforming operation. Many of my patients come without tan lines and I see them months later with 2 piece tan lines.

There are two procedures that can make your stomach (abdomen) look better. If there is only fat excess with good skin -> liposuction. If there is a skin excess, or skin and fat excess -> tummy tuck (abdominoplasty).

If the abdominal skin has good tone (i.e. remains elastic with minimal stretch marks, not loosened by weight gain or pregnancy) then liposuction alone may give considerable improvement. Liposuction removes the fatty tissue provided the skin can snap back into place.

If abdominal skin is in excess i.e. skin feels looser, there is a little pooch or overhang when standing that worsens when sitting, indented scar or the stomach bulges significantly when viewed from the side then skin and fat problems exist. Skin and fat will need to be removed. An abdominoplasty rejuvenates the abdomen by removing most of the skin and fat between the navel and the pubic area. The covering of the underlying muscle is tightened to give a flatter stomach when viewed from the side. The remaining skin is then stretched to give a tighter, youthful look. Often, liposuction to 'fine tune' other areas is be performed at the same time. Fortunately you'll be sleeping through all of this!

The recovery from an abdominoplasty may be up to 2 weeks before returning to a desk type job. Driving will be up to you but feel your abdominal muscles tense as you quickly step on the brakes. These abdominal muscles will be sore for 2-6 weeks. It may be approximately 2 weeks before you could catch a 3 year old child making a dash for the street. Although aerobic exercise may be started 2 weeks after this procedure plan to wait 6 weeks before heavy lifting or stomach exercises. Although most patients go home the evening of their procedure, we help with arrangements for our out of town guests. Air travel is not recommended for 3 days.

Tammy can help provide more information 650-342-1511. Consider a visit to our office. We will show you videotapes on your options and many more 'before and after' photographs. After an examination I can discuss your options and help choose what is best to achieve the improvements you seek.

 

To get pricing quotes please contact our office.

I look forward to meeting you.

James L. Pertsch, M.D.

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Breast Augmentation: Before Surgery

 

Breast augmentation is a very successful procedure and therefore is very popular. The success rate is high in that it can boost confidence, improve clothing fit and selection, and improve choice of bathing suit attire, etc. Of course no operation is 'perfect' but most patients are very happy they had it done.

Breast augmentation has been our most frequent procedure for the last 4 years.

The procedure takes about two hours and is usually performed in our own, private, accredited office operating room/ recovery room facility. Recovery is a minimum of 2 days before returning to desk type work but usually a 4-5 day extra long weekend is best. You may need coverage for a few days if you have young children. Exercise is permitted 2 weeks after surgery.

All procedures entail some risk: infection, bleeding, maintenance... A fairly complete outline of these is available from the implant manufacturers in a brochure required by the FDA (Food and Drug Administration): please see instructions on my 'question and answer' page.

It is important that you not only find the right doctor but also consider their staff. The doctor's staff is who you will be dealing with quite a lot.

If you are interested in more information please call Tammy and come see us 650-342-1511. It is not to early to start getting information. We'll show you videos about the procedure, before and after of other patients, and after an exam you will know whether you are a candidate. Please call the office for pricing quotes.

We do maintain a short list of patients that can 'drop everything and come'. Such patients help us in case of a last minute surgery postponement that would otherwise leave our operating room idle and we help them with a considerable financial break.

Please call Tammy 650-342-1511 if we can provide additional information for you or you'd like to come see us.

 

To get pricing quotes please contact our office.

I look forward to meeting you.

James L. Pertsch, M.D.

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Notice from Dr. Pertsch 6/12/00:
[FDA (Federal Drug Administration) has been investigating saline implants and recently required implant manufacturers to provide information to each prospective patient. The information (for companies with implants approved for use in the United States ) can be found here: http://www.fda.gov/cdrh/breastimplants/ (you will leave Dr. Pertsch's site: touch your 'back' button to return)

Be aware:
1. Current information is found under "Patient Informed Decision Labeling for Saline Filled Breast Implants" by companies Mentor or McGhan. Some aspects are controversial. A widely used and proven way to reduce chance of infection using an Iodine based solution Betadine during surgery is 'contraindicated' by the FDA . Plastic surgeons have not been allowed complete access to the data that caused them to make this decision.

2. Outdated information that may be misleading and therefore not recommended is offered under "Breast Implant Consumer Handbook November 1998".]

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I'm interested in possibly getting breast implants.I'm takins a scuba diving class and was curious if getting implants would effect my involevment in the sport any. Please e-mail me with information. Date: Thu, 21 Dec 2000 19:59:51 -0800 (PST)

 

Dear scuba diver in training,

Breast augmentation and scuba diving would not affect each other once you had recovered from the operation. The implants are filled with saline solution (a water and salt mixture). There is no air to be compressed or expand as you dive or ascend. As detailed further below [actually above] you may begin to use your arms immediately after surgery. I would recommend delaying SCUBA lessons for about 6 weeks after surgery when full arm strength might have returned. Dr. P.

[The same applies to flying and higher altitudes]

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Dear Dr. Pertsch, Date: Fri, 9 Jun 2000 00:17:13 EDT

I AM INTERESTED IN A BREAST ENLARGEMENT, AND I WAS WANTING TO KNOW IF THERE IS A WAY THAT YOU CAN MAKE THEM LOOK MORE NATURAL? THE PHOTOS THAT I HAVE VIEWED IN THE PREVIEWS LOOK TO ROUNDED. THEY JUST DON'T LOOK NATURAL, TO ME THEY ARE JUST TO ROUND. AND I WAS ALSO WANTING TO KNOW IF YOU'RE PRICES ARE REASONABLE?PLEASE WRITE ME BACK , AND SEND SOME PHOTOS OF SOME WORK THAT LOOKS MORE NATURAL THAT I CAN VIEW. THANK YOU FOR YOU'RE TIME.

 

Thank you for your mail. Breast augmentation is a procedure to make up for a natural process that fell short: left you smaller than you envisioned being. Breast augmentation is just the next best thing to a naturally developed breast.

In general the more breast tissue you have to start with and the smaller the size implant chosen the more likely the breast will appear like a naturally developed breast. The less breast tissue you have and the larger the implant size chosen more aspects of the result will be less like a naturally developed breast.

[related info from another email: "Having had a child and breast feeding stretches the skin and increases the chance of a very natural looking breast after augmentation. Another factor that gives a more natural look is when there is some of your own breast tissue present."]

I have all patients bring me photographs of chest proportion and appearance that best demonstrates what they expect to look like after their breast augmentation. After such a review with you I could estimate your chances of achieving the look you seek. [This would be a critical review for this patient to determine whether or not to perform surgery. She may be critical enough to become one of the rare patients after surgery that was sorry she had it done at all.]

For before and after photographs please see my web site: www.SanMateoPlasticSurgery.com The patients chosen are those that came to my office summer of '99 while the site was being constructed and first gave permission for use. Although many happened to have chosen larger implants they represent a random spectrum of results after breast augmentation.

If you are interested please call and come see us 650-342-1511. We'll show you videos about the procedure, before and after of other patients, and after an exam [and review of her pictures of the results sought] you will know whether you are a candidate.

 

To get pricing quotes please contact our office.

If you send us your address we can send more info. I look forward to meeting you.

James L. Pertsch, M.D.

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Dear Dr. Pertsch:

I was looking on the Internet for surgeons in my area and I came across your name. I am interested in getting breast implants and I was wondering if you do the Spectrum Implants (where you leave the tube in to adjust the size after the surgery) and if you can have them filled with Saline. Another question is about how much would you say this surgery would cost. Date: Mon, 8 May 2000 23:53:47 EDT

 

Thank you for your mail. Breast augmentation has been our most common procedure for over over three years.

I have not found the need to use the Spectrum implants [yet]. The only reason to have an adjustable implant would be to make it larger after the surgery. The decision would have to be made relatively soon as the natural healing process may make adding volume difficult months later. Then there is the extra hardware, expense and increased risk of infection when you go to adjust it later with a needle. I believe the maximum that can be added is 5 tablespoonfuls (75 cc). I have had patients come to me disappointed with their size after breast augmentation elsewhere. When asked how their size was selected typical response is 'the doctor chose what is proportionate for me'.

I developed a sizing technique over 11 years ago and have used it successfully in hundreds of patients: a sizing technique that allows you to select the look you want with my help. This reduces the chance of any wish to adjust afterwards. Here it is:

At the initial consultation we meet, review videotapes, before and after pictures and after an examination discuss recommended procedure and costs. [For patients not sure what procedure they need it is best to bring in some pictures at the initial consultation. Dr. Pertsch will be able to recommend the best procedure to achieve the breast appearance desired. Options to achieve the desired breast might include: implant only vs. breast lift only vs. lift with implant vs. breast reduction only vs.breast reduction with lift and add implants.]

Before any surgery you will return to the office for a comprehensive1.5-2.0 hours to review our extensive breast augmentation information, what to do before and after for the best results,an overall check of your health, and for implant sizing. (Before the time scheduled for this extensive, second consultation you will need to have found your "sizing pictures" as described below:)

After we get all this 'work' done my nurse and I will review pictures you found beforehand, in and out of clothing, of women whose proportion you like. (As you may have experienced some challenge finding the proper cup size for yourself so it is difficult for me to estimate cup size after surgery.) Obviously, I want you to be the proportion you wish to be after surgery. The best way I have found to accomplish this is for you to find pictures with the upper body look (proportion) you seek. Find pictures with and without clothes. The most helpful view is the oblique or 45 degree view i.e. half way between front view and side view. ] It gives me the best idea of how it is you want to look afterwards. Then, using a stretchy brassiere we have in the office you will try on the various implant sizers (between 155 to 600 cc) in front of the mirror. I check to be sure what you like in the pictures and in front of the mirror are consistent. Only then can I recommend an implant (size, style, manufacturer) for each side that will best accomplish what you want. Sizing doesn't end here however. Before the end of your surgery, after the implants are in, I sit you up and compare how you look with the pictures you brought to make final sizing adjustment decisions. Most women have a broad range of size their anatomy can comfortably handle and remain in proportion.

[There are some magazine photographs of models without clothes available in our office for your use. All sizing photographs must be selected before the actual scheduled time of your extensive preoperative appointment.]

Having said all this you will be the one having these implants for a long time. I have used just about all the implants out there in one situation or another. If you really like the idea of adjustability after your surgery the Spectrum implant could be used.

Please contact our office for pricing information.

If you send us your address we can send more info.

I look forward to meeting you.

James L. Pertsch, M.D.

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Dear Dr. Pertsch, Fri, 9 Jun 2000 15:36:29 EDT

I'm recently turned 16 and was wondering if @ my age should I get breast implants? I'm 5'2 110 lb. and a 34B but sometimes I fit into 34 A's. Do you think it's a good idea to get breast implants @ my age and with my weight and height. My grandmother thinks I'll grow but I don't think so she told me to look into it more and find out if it's safe to get them?

 

Thank you for your mail.

Dr. Pertsch answers: Although your grandmother might be right the odds are probably against a marked change in your breast size in the next couple years. From a strictly physical standpoint given your weight and height you could be a candidate for breast augmentation.

From an emotional standpoint there may be reasons to wait. A personal perspective: I had admired all the senior guys with their varsity jackets and cheerleaders hanging all over them in the hall. I worked hard to earn my own varsity jacket by the time I was a Junior. I distinctly remember one of the most unhappy days of my high school years was the first day I wore it: Life was just the same! No swooning anybody! Just a lot of disappointment that this accomplishment didn't catapult me anywhere! This jacket is still hanging with barely a wrinkle as I didn't wear it much.

In general I would recommend waiting at least 2 to 3 years. Why? Just to let some life time go by. I think it will improve the chances your new breast size might be an embellishment and not a crutch.

[update 9/22/00: the FDA has recently recommended not performing breast augmentation under age 18. Although physicians are allowed to do what is felt to be in the patient's best interest (regardless of chronological age) there could be some wisdom in this recommendation. I feel the FDA would best serve the public good by restricting its recommendations to those based on firm, scientific basis. I don't believe there is firm, scientific support for this age recommendation.]

James L. Pertsch, M.D.

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Dear Doctor Pertsch:

Date: Tue, 18 Apr 2000 01:10:19

I just had an ovary removed with a c-section, and I want to have a breast augmentation. How long do I have to wait before I can have the procedure done? [i.e. What to consider before deciding how long to wait between one surgery and another?] I'm not sure if I can have surgeries right after another. Please email me back.

 

Dear **, Thank you for your mail.

There is a range of acceptable timing between abdominal and breast augmentation surgery: from minutes to weeks. Here are some considerations:

Frequently patients have abdominal surgery at the same operation as breast augmentation (ex. tummy tuck with breast augmentation).

The human body recovers relatively quickly from the anesthesia medications. Just due to medications alone you might wait approximately 2 days.

Some patients are taking time off work and want to minimize their down time. The breast augmentation could be performed 1-2 weeks before the planned return to work.

Breast augmentation can make it uncomfortable to use your arms you may want to wait until you are no longer using your arms to assist you from getting up from a sitting position (approximately 1- 2 weeks).

Certain medical conditions (severe diabetes or conditions requiring steroid medicine taken by mouth) might make it best to recover until the risk of infection is completely over (~ 3 weeks).

If a cancer was unexpectedly found during the first surgery it might be best to recover from that shock before the stress of another operation.

If you wish to have your surgery in a period of weeks please schedule an initial consultation with your surgeon of choice (or better still reserve time on the surgery schedule) right away! Spring is traditionally plastic surgeons' busiest time. Scheduling considerations might be the rate limiting step in the process for you.

In summary, the human body can safely stand both surgeries under the same anesthetic. Other timing considerations are basically up to you.

Please let me know if you have any other questions. Tammy, my office scheduling coordinator, has helped many patients with timing concerns about breast augmentation and would be happy to talk with you 650-342-1511 (Tammy's direct voice line). James L. Pertsch, M.D.

[Patient emailed further question about an unsightly pouching of skin above c-section scar.]

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To: jpertsch@jpertsch.com Subject: questions Date: Tue, 4 Apr 2000 00:54:54 EDT

Do you also do anatomical shaped implants? How much does it cost? If you do the under the armpit surgery, what is the recovery time. I am 28, I have a child which I breast fed, I am not sure what size I am an A or a b, but either way, I would like to be a C. I don't want the difference to be too noticeable, so I have been wearing inserts in my bra for at least a couple of years now, but they are awkward, and of course, unfortunately removable.....so could you please help me? Thank you.

 

Dear ** Thank you for your mail. I apologize for my delayed response but the Spring is our busiest time.

I use anatomical shaped breast implants but usually recommend them in certain patient situations. Most commonly I have recommended round smooth implants to give my patients the look they wish achieve. Of course, if a patient has done their research and concluded anatomical implants will give them the look they want then that is what could be done. There is a higher risk of rotational problems inserting anatomical implants through the armpit (axilla) that using either the areolar or inframammary approach minimizes. Round implants do not have any risk of rotation / orientation problem.

Having had a child and breast feeding stretches the skin and increases the chance of a very natural looking breast after augmentation. Another factor that gives a more natural look is when there is some of your own breast tissue present. So, it sounds as though you have two factors that tend to give a very natural looking result after breast augmentation surgery.

As you may have experienced some challenge finding the proper cup size for yourself so it is difficult for me to estimate cup size after surgery. Obviously, I want you to be the proportion you wish to be after surgery. The best way I have found to accomplish this is for you to find pictures with the upper body look you seek. Find pictures with and without clothes. The most helpful view is the oblique or 45 degree view i.e. half way between front view and side view. Bring these photos in and after we review what proportion you like in these photos 'sizer sizing' will be completed. For sizer sizing you will put on one of our stretchy brassieres and try the various silicone gel sizer implants in front of our exam room mirror. In this way I can be sure the proportion you like in the pictures is best achieved with which sizer. We then select the best volume implant for each side to best accomplish your goal.

The cost : The manufacturer charges us 300 more for anatomical implants. If these are recommended or requested we ask our patient to cover this additional expense. [Other up to date cost info above.]

Total cost for our 'Fall Into the Gap' program is even less. These patients are all ready in advance then have the procedure date set with 7 days or less notice. Since these patients help us out when another patient's surgery is postponed last minute and take that otherwise unused time slot we offer further reduction in cost.

Recovery time depends not on where on the incision is but the large space created for the implant. Although I recommend allowing a week to recover patients have returned to desk/ computer type work after a weekend. Work involving strenuous upper arm usage may take 2 weeks

After years of wearing sizers it sounds as though you are psychologically ready for the breast augmentation procedure. Please call Tammy at 650-342-1511 if you would like to see our informational video, meet, and discuss the options in greater detail.

I look forward to meeting you. James L. Pertsch, M.D.

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To: "'jpertsch@jpertsch.com'" <jpertsch@jpertsch.com> [3/28/00]

Subject: lift and implants: What is the average expected costs/fees for this? Do you take installment payments. Thank you.

 

Answer: Breast lift and implants (augmentation mastopexy) may be the best procedure to transform deflated, sagging breasts to a more youthful, perky appearance. Many patients initially come seeking a lift with implants but settle for the improvement possible with implants alone to avoid the extra scarring that the lifting requires.

A breast lift (mastopexy) alone may leave the upper portion of the breast without much fullness. For larger, drooping breasts it is sometimes necessary to reduce the volume of breast tissue to minimize early reoccurrence of drooping, add an implant to give upper breast fullness, as well as performing the breast lift to restore lower breast shape and proper nipple/areolar position. [nipple projects from the breast, areola is the flat, colored part of the breast skin around the nipple]

Please contact our office for pricing information.

Please call Tammy if we can provide additional information: 650-342-1511 is Tammy's direct line. If you come visit us we have videotapes on the options. Seeing other patients' before and after photographs may make the procedure most suitable for you more apparent.

James L. Pertsch, M.D.

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[A patient emails concerned about bleeding after breast augmentation surgery 3/12/00]

A I WILL BE GOING IN FOR BREAST ENLARGEMENTS MARCH 14, 2000. MY FRIEND HAD THIS PROCEDURE ON THE 27TH OF FEBRUARY, SHE EXPERIENCED BLOOD CLOTTING AND THE DOCTOR HAD TO GO BACK IN AND REMOVE THE IMPLANT AND TAKE OUT THE CLOT. DOES THIS OCCUR OFTEN? CAN IT BE LIFE THREATING?

 

Dear **,

The bleeding you referred to sounds like the excessive bleeding that rarely occurs around the implant after surgery and then clots. It is usually not life threatening. (This type of bleeding is different from the blood clots that can form in your legs, break off, travel to your lungs and cause severe problems. Although anything is theoretically possible, I've never heard of this leg type of blood clot after breast augmentation. However, this [leg clot] type of problem is why you shouldn't lay in bed without moving for days after any operation!)

If bleeding around the implant happens you would experience one side being markedly tighter than the other, possible difficulty breathing because it is so tight, and pain medicines wouldn't seem to be of much help. No doubt this would prompt you to call your surgeon. Your surgeon would need to go back in that side only and remove the extra blood. Most of the time the surgeon wouldn't be able to tell exactly where the extra blood came from.

Although there would be more bruising on that side, ultimately, the result would not be much, if any, different than if the extra bleeding had not occurred.

The bleeding after surgery problem is infrequent. I have had it only 4 times in hundreds of patients over 12 years. The last time was 6-7 years ago.

The odds are in your favor on Thursday. James L. Pertsch, M.D.

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Hi Dr. Pertsch, [2/1/00 Questions are followed immediately by the answers.]

My name is ** and I too am considering implants. I am in the research phase and have a few questions.

1. I am 35 years old. I went from 110 - 194 lb. with my first child. That was 15 years ago. I now weight 156 and trying to lose weight be for my May Wedding. Do I have to lose all my weight before I have the surgery? Yes I do gain and lose weight in my breast.

 

Answer Question #1: In general it is best to lose what weight you can before having any cosmetic surgery performed. Breast augmentation could be performed now just that your 'after further weight loss breast size' will be somewhat unpredictable.

 

2. I would love to have this done before I get married. However, I am a firefighter and am not offer light duty at work. So am I asking for miracles to get them done 4 weeks(took vacation) prior to my Wedding?

 

Answer Question #2: Four weeks before your wedding should be adequate. I have had patients have breast augmentation only 2 weeks before their wedding but 4 weeks is better. I would be sure that final adjustments to your wedding attire can be made three weeks before your wedding. Also four weeks will give you enough time before returning to your potentially vigorous work.

 

3. I worry about sensation. Will I lose feeling? Do I have to have a lift since I 've had too children?

 

Answer Question #3: There is always a risk of losing some sensation in the nipple, areola (flat colored part around the nipple), or skin of the breast. The reason is that the nerves get to your breast skin as follows: brain -> spinal cord-> around the chest just under each rib-> up through breast to skin. During breast augmentation room under the breast needs to be made and some of the nerves may be stretched and still work, stretched such that they stop working, or need to be cut to make room for the implant. The biggest nerve to the breast skin is usually just lateral (i.e. away to the outside) to where the implant goes and thus most patients retain most sensation. Loss of sensation is always a major concern to patients going in for breast augmentation but rapidly becomes a 'non-issue' for my patients after surgery even if some sensation is lost.

 

4.I too have the need for a tummy tuck. How sore will I be if I get them both done together?
* Thank you for your time. I hope to hear from you soon. Sincerely, **

 

Answer Question #4: The tummy tuck operation is the more uncomfortable part of breast augmentation/ abdominoplasty (tummy tuck) combination. It would be best to get as close to your ideal weight as you can before a tummy tuck. Weighing less usually allows me to make a shorter incision and take off more skin. As you have seen from my web site the breast augmentation/ abdominoplasty (tummy tuck) combination makes a dramatic change in appearance and is therefore one of my favorite operations to perform.

Additional comments:

Regarding weight loss: If diet and exercise are going slowly we do offer a medication assisted weight loss program at our office. My wedding preparation patients are among the most highly motivated and usually do quite well. Although my weight loss practice is currently closed to new patients [as of 1/30/00 in anticipation of our busy late winter/ early springtime], please contact my wife, Suzanne Pertsch, M.D. internal medicine, at 650-344-5509 as she is still taking new weight loss patients.

Regarding spring surgery scheduling: Late winter and spring are characteristically our busiest times. Consider coming into the office soon for more information and to be sure you are a candidate for these procedures.

I look forward to meeting you. James L. Pertsch, M.D.

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Hi there! I would like to find out if there is a consultation fee for the first visit. If so what is the cost? I am very interested in breast augmentation and possible liposuction. Thanks! **

 

Dear **1/7/00 Thank you for your message.

The consultation includes viewing our videotapes for the procedures of interest to you and a meeting/examination with me for approximately 30 minutes. At the end of this initial visit you will have a better understanding of the procedure, had your specific questions answered, know whether you are a candidate to have your goals accomplished, the degree of improvement anticipated, and know your financial options. The staff or I will give you a tour of our private, in office outpatient surgery facility.

Please contact Tammy or Joy if you would like to come meet us 650-342-1511 and to get pricing quotes. I look forward to meeting you.



James L. Pertsch, M.D.

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Dear Dr. Pertsch,

I am a thirty-three year old woman considering breast augmentation secondary to loss of volume from breast feeding two children. Having researched the subject thoroughly I am concerned about the time period necessary for recovery from surgery. I am a RN in a very busy [nursing] Unit and would appreciate it if you could advise me on how long I would need to schedule myself absent from work. I have reviewed the qualifications of many Plastic Surgeons and I am very impressed by your resume. I look forward to hearing from you and hope in the near future to make an appointment for a preliminary consultation. Thank you for your time.

 

Dear **11/28/99 [re: Recovery time] It may be best to allow yourself a two week recovery from breast augmentation before your first day back to work. Even then you will still be sore but probably able to get through the day.

Generally I recommend most patients take about a week off work. The 'record setters' go back to secretarial work in 2 days.

The age of your children may make a difference. Most of my patients wouldn't be able to stop a three year old making a flat out run for the street for 2-4 days. It is best to not have breast fed for at least 6 months before surgery.

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Dear Dr. Pertsch: [re: finances]

 

Dear ** on 9/20/99,

Thank you for your inquiry about breast augmentation. Breast augmentation has been our most frequent procedure for the last 3 years. Please call and come see us 650-342-1511. We'll show you videos about the procedure, before and after of other patients, and after an exam you will know whether you area candidate.

The cost below includes virtually everything: implants, our accredited surgery facility, IV local anesthesia, the preoperative check of your health and lab test (except mammogram recommended if you are over 35 yr.) and all visits before and after surgery including long term yearly follow-up visits as well. Not included are the medicines for after surgery: antibiotics, muscle relaxants and for discomfort.

We do maintain a short list of patients that can 'drop everything and come'. Such patients help us in case of a last minute surgery postponement that would otherwise leave our operating room idle and we help them with a considerable financial break.

We ask that financial arrangements be completed about three weeks before surgery so we can focus on the medical issues, your sizing, etc.

San Mateo is about 5 miles south of the San Francisco International Airport. We have many patients come from quite a distance. We can condense your two preoperative visits into on 1.5 hour long visit if you come about 1 month before your prearranged surgery date. Beside the actual surgery day there are two follow up visits I request then I am happy to see you as often as you can come.

If you send me your address we can send more info. I look forward to meeting you.

 

To get pricing quotes please contact our office.

James L. Pertsch, M.D.

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Dr. Pertsch: [re: implant placement above or below the pectoralis major muscle]

 

Dear ** on 10/11/99,

There are many options and they need to be tailored to your specific anatomy, wishes, etc. In general I prefer to place the implant behind the pectoralis major muscle as it give the best appearance and has other advantages. [other advantages: better ability to perform mammography, less visibility of the implant where the breast shows most: upper and/or inner surface, less palpability of the implant especially in a slender patients]

Please contact me if I can provide additional information.

James L. Pertsch, M.D.

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Breast Augmentation: After Surgery

 

Hi Dr. Pertsch, [Tue, Oct 5, 1999, 8:30 PM] Everything is going great and the aches and pains are minimal. I love the work that you did. I am turning out to be very happy with the size that my breasts are and I am not subscribing to that belief that most augmentation patients seem to have, that we all should have gone bigger and bigger...we have to draw the line somewhere!

I have, of course, a question for you. I still from time to time read stuff on the Internet about saline implants and I come across web sites that have a negative view about them. A common problem I have read about is fungus or bacteria growing inside saline implants. One woman on one of these web sites said she had double lumen implants for three months and had to have them removed. Once they were removed, it was discovered that there was enough fungus inside her implants that, if the saline would have leaked inside her body, she would have died. First of all, how much truth is there in that? How possible is it for fungus to grow inside the implants and how dangerous is it if those organisms are released into the body? If the saline is sterile when it is placed into the implant shells, shouldn't it stay sterile? I'm not panicking but somewhat concerned.

Just as a side note, I emailed a woman that created one of the negative, anti-saline implant web sites I spoke about. I think because she had a bad experience (she had the double lumen implants that had to be removed) she believes all women are at risk. She told me that if I had implants, I was just another medical experiment because saline implants are not approved by the FDA. She said there is not enough information about saline implants available as far as their real risks, long and short term. This is what provoked me to write to you.

Thanks, **

 

Dear **,

I have never personally known of a case where there was a problem with the saline in a ruptured or intact implant. I know all the oil filled implants are running into trouble as they cause a tremendous inflammatory response when they break or leak.

Some physicians use saline poured into a bowl that is exposed to the operating room air for a varying period of time before drawing it up into a syringe and then filling the implants. Contamination with blood might make matters worse. Some doctors put antibiotics (a potential protein food source) in implants. Yours were done differently and filled using the most sterile technique possible: a fresh bag of saline with a special tubing with a one way valve (Braun Medical MAT-4100) [your surgeon can order these from: McGaw 800-523-9695] placed so the solution went via a closed circuit directly into the implant without air exposure, additives or contamination. Implant fill solution would remain sterile provided no leakage.

The concern of something growing in a pure electrolyte solution seems remote.

Saline implants have been used for about thirty years. Once a valve was designed that didn't leak, about 18-20 years ago they have not changed much.

Breast implants are still classed by the FDA as 'class 3: experimental' Because of all the negative press about gel they are now in the process of evaluating data which will probably result in them being moved to 'class 2: devices of benefit with some known risks'. (be aware that silicone implants are not available for use in breast augmentation today because the FDA perceives no health benefit to cosmetic breast augmentation) By the way aspirin is not FDA approved to be taken as a blood thinner but it is a general recommendation by many doctors to take one a day after age 50 to reduce chance of heart attack and stroke.

An anecdotal or personal negative experience can be a very powerful motivating force that might overcome the voice of reason.

James L. Pertsch, M.D.

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Breast Augmentation: Considering Further Refinements

 

Subject: Breast Augmentation Revision Date: Mon, 08 Jan 2001 05:46:41 -0000

Dear Dr. Pertsch,

I was browsing your website recently and found it to be of great interest. I currently have breast implants but suffer from encapsulation and I'm looking for information and a surgeon who might be best suited to help me. I currently have them over the muscle, was a 34AA, they're 350cc, textured, silicone. I was wondering what method you might favour in my situation, under or over, textured or smooth and any other recommendations you could make. Do you know anything about the double lumen implants and whether they might be helpful and would you recommend the steroid and anti-bacterial solution be used to try to help reduce the incidence. How are these administered and in what doses. Also, would you recommend creating a slightly larger pocket for the implant and then practicing the massage displacement technique that quite a few surgeons seem to practice. You seem to be quite knowledgeable about this surgery and I'm looking for advice from surgeons who seem to have more experience in this area. There seems to be so much conflicting opinions, that the whole area is a little confusing.Thank you for your time in reading this and I hope you can give me some suggestions. Look forward to hearing from you.

 


Dear Ms.** Thank you for your email.

From your description I think your breast situation can be improved. There are many options. To narrow the options down to the specific ones best for you I need more information. The best way for me to get this information is for you to come for a consultation at my office 650-344-8700. Next best would be to email photos (as .jpeg file attachments) of yourself front view, side view, and halfway in between showing from chin to just below your umbilicus (navel or belly button). I would need to know about your age, height, present weight and usual fluctuation, any children already or planned, your specific goals as to what aspect you want improved, date of breast surgeries and incision location, and photos of others (models or internet) in and out of clothing that demonstrate the proportion and appearance you wish to obtain. Then I could better estimate what needs be done to get you from where you are to where you want to be.

It was once felt that medications added to the space between the two shells of double lumen implants might be of some patient benefit in reducing the chance of capsular contracture (excessive breast firmness). However, no real benefit could ever be conclusively demonstrated. The FDA does not approve the implant to be used as a 'drug delivery system'. Also, what if you became allergic to the substance added and later the outer shell broke? Its felt best to add nothing but saline from a closed system into saline implants, nothing is added to silicone gel implants.

Some physicians recommend that patients with implants massage them (breast displacement exercises) for a minute or two each day: first pushing up, then down, right then left. This recommendation is an attempt to keep the pocket open so the breast will feel less firm.There is little, if any, scientific evidence that this really works. Generally, I ask my patients to do only those things for which there seems to be a scientific basis. However there is essentially no risk of causing harm so massage can be done if you would like to.

Other options for you beside textured or not: gel vs. saline, larger or smaller implants, putting implants under muscle instead of on top, and whether or not you need a breast lift in addition to loosening your tight breast capsule (capsulotomy: loosen and spread capsule or capsulectomy: remove tight capsule) achieve your goal.

 

To get pricing quotes please contact our office.

Regarding your getting confusing information: There may not be 'one best operation' for you. There could be several options that would successfully improve your situation and make you happier with your breasts.

James L. Pertsch, M.D.

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Hello. I had a breast augmentation done this past June [surgery: 6/00 this email: 1/01] and am very pleased. [Dr. Pertsch's patient: 5'6" 120 lb. 36A and had submuscular smooth 480 cc implants filled to 510 cc via the axillary (armpit)) incision now 38?C or D]

I had a few questions though. First, I do have a small dent that is very visible (on the top of my right breast) when I wear anything push-up, second, when I bend over, I do have rippling and even when I move around I can still see some. I assume this is because I have thin skin and very little body fat. My question is this: if I were to go a bit bigger do you think that these things may lessen? I know you can't give me a guarantee, but because my skin is stretched already, I thought going a bit bigger would take away some of the space that seems to be there now. I am on the east coast now and would be happy to send you a picture over the email if you need one.

I am also considering going a little bit bigger just to be larger. Could you give me an idea of the cost and how long this procedure would take? Thank you Dr. Pertsch. I really love the way I look now and you do great work. Thanks for your time.

 

Date: Fri, 5 Jan 2001 06:04:04 -0800 (PST)

 

Dear **,

I retrieved your record before responding to your mail. I am glad to hear of your overall satisfaction with your appearance.

It is recalled you are about 5'6" 120 lb. and had submuscular smooth 480 cc implants filled to 510 cc via the axillary (armpit)) incision.

In general going to a larger size would not make dents and ripples smaller but could magnify them. The larger weight implant may cause more pulling or folding and dents & ripples could become more visible. I do not have any mention in my 8/9/00 record about the dent on the right side but a picture would probably not alter these considerations. In general you will increase your chance of greater implant palpability/ visibility and increase the chances of dimples and asymmetry with larger implant placement and a second surgery, especially because you are so slender.

Replacing the saline implants with silicone gel implants may reduce palpable/ visible rippling. The FDA leaves it to the discretion of the patient/physician to determine what constitutes a severe enough problem to warrant their use (obviously, this determination could not be made without an examination).

The second breast surgery to insert still larger implants is often more challenging than the first operation. (Challenging for the surgeon to get an equally symetrical, smooth result without additional dents or contour irregulairties) As the second operation can take longer than the first and require new implants the price is fairly close to the initial cost. Your recovery will be 'kids stuff' compared to the first operation as most of the space has already been created. Find pictures that demonstrate the ideal proportion and look you would like to achieve to help your surgeon appreciate what you mean by a 'little' bigger.

[Patient had initial surgery through the armpit (axilla)] Going larger will probably require a periareolar or inframammary incision to get the best results: Even though your implants are soft and mobile there is a tough, thin capsule that would need to be precisely and evenly released under direct vision. An occaisional patient with a very generous capsule could have slightly larger implants placed via the original axillary (armpit) incision.

It is good that you are overall pleased after your surgery. The observations you make about palpability and a small dent are not uncommon [after breast augmentation], especially with your low body weight for height [ie. a very thin patient].

I would be honored to reevaluate you upon return to the bay area. If not returning soon you may wish to consult **** or seek his recommendation as to who to see. He was on of my mentors while I trained at Brown and Harvard.

 

To get pricing quotes please contact our office.

James L. Pertsch, M.D.

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[A patient emails multiple questions regarding bubbles felt after breast augmentation, implants dropping, possible revision to lower implants, incisions needed 2/22/00 7:31 PM Dr. Pertsch responds 2/22/00 9:48 PM:

 

Answer: These answers are 'generic' i.e. These answers can't be personalized for you as I have obviously not had a chance to examine you and there were no photos attached to your email. Medical advice can only properly be given after an examination, etc...

 

Q1: Is it normal to feel an air bubble in the implant? My PS said that the air bubble was in the implant itself and there isn't anything I can do about it. The air bubble feels horrible. You can feel it at the top of my breast and when you push it, where it dents in its awful!! It's like feeling a water balloon that is not quite full?! Should I contact my implant manufacturer?

 

Answer Q1: The 'bubble' may well be a slight pucker in the implant that pops in and out as you feel it. These bubble like areas can be the normal feel of the implant. (most everyone can feel their implant). They are usually not air in the implant but actually a little knuckle of implant shell that you may be feeling. If by 'thin skin' you are very slender with minimal fatty layer you will feel your implants more than someone with more covering over the implant. Silicone gel implants might have less of this feel but can only be used in certain situations.

 

Q2: I am only 5 months posts and am still waiting for my implants to "drop." I'm confused. I have anatomicals, unders, 285 ccs, slight case of ptosis, transax incision.......I also have thin skin...........My PS said he wasn't happy that my implants hadn't dropped yet but he was still waiting. He also said something about going back in and moving them down 1cm....AND that he has to use a new incision site? I mean for me that was the point in the transax scar was so I wouldn't have to have any visible scars on my breasts!! I'm getting stressed out! Please help!

 

Answer Q2: It may be best to wait for a while to see if the implants drop by themselves. Saline implants do have a tendency to drop or settle to a lower position over time. There can be changes for up to a year with more of the change earlier and less change later. The textured surface of the anatomicals may tend to keep them where they are.

Fine tuning type operations are usually best done though an incision where the surgeon can see perfectly well and thus best assure success. The best incisions for secondary surgeries are through the areola (the flat , colored part of the breast) or inframammary (the undersurface of the breast). So lowering the implants 1 cm. would best be accomplished through on of these two incisions regardless of where the first incision was. In other words the axillary (armpit), TUBA (navel), or via tummy tuck are not the best way to perform fine tune corrections with or without an endoscope.

I've answered this question assuming you really need your implants lowered 1 cm. You mentioned 'a little' ptosis or breast drooping. Be sure that what you don't really need is to have your existing breast tissue raised (breast lift or mastopexy) as is sometimes necessary with some forms of drooping breasts with loose skin. It could be the implants are in the correct position but the breast tissue is sagging too much. Be sure excessive breast drooping isn't the problem as lowering the implant may not fix the appearance you don't like.

 

'Q3': Thank you in advance.......I would just like another PS' opinion....I hope that you can help or offer me suggestions!

 

Answer Q3: I'm sorry if these responses have triggered more concern than relief. Your surgeon, ultimately, will not be able to duplicate all the wonder of a perfectly natural breast with plastic and water. Please be patient and understanding as possible as we try to do the best we can with what we have to work with.

James L. Pertsch, M.D.

 

'Q3' continues[Patient responds: 1/23/00 12:35 AM] Thank you for taking the time to respond to my e~mail. I am going to try to be a little more patient and see how the next few months go with my implants. Since I am only 5 months, I guess I ought to be more patient. I know its probably hard to dispense any advice without seeing ANY pictures of me, so I think I am going to take some pics and maybe send them out to you. I guess I'm a worry wart.

Maybe I should have given you more information about me and also sent along pics. I can say that I am 5'5," 103 lb. and I'm a bikini model and have practically no body fat. The "air" bubble that I feel in my left implant does NOT feel natural to me. But then how would I really know since this is my one and only BA?! However, I can say that I don't have THAT particular problem in my right implant.

I think that my implants look great in a bra and bikini top. And it is wonderful NOT to have to worry about a padded bra. But I certainly didn't foresee the "air" bubble. I know that isn't very specific to my problem but I don't know how else to describe it. its just that when I am naked, I can see that my nipples sit slightly lower on my implants rather than be centered. I am going to send you pictures as soon as I have new ones taken. I haven't taken any nude implant shots because I don't quite like the naked looks of them. I have expressed this opinion to my own PS.

Anyway, thank you for taking the time to respond and for listening!

 

Answer to 'Q3 continues': All issues as addressed above. JP

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Subject: more questions: Hi Dr. Pertsch, [Correcting breast asymmetry and/or going larger]

I had a question for you and though I will probably not follow through with this, it is something I've been thinking about. The last time I saw you (a couple of weeks ago), I mentioned that my right breast seemed considerably smaller than the left after my implants had settled. I am now over four months post op. While I realize that I should probably consider myself very lucky that my surgery went so well and I had such a quick recovery, it does bother me that my breasts vary so much in size. I've considered having the right side enlarged so they "match". My question to you is how much would it cost to redo my right breast? If the cost is close to what it would be to redo both breasts, I may as well just start over and go with larger implants at some point.

What is involved in the procedure of removing the implant and replacing it with a new one? Does McGhan cover anything like this (I doubt it but I thought I'd ask)? Lastly, will the pain of a second surgery be as severe as the first? I would think that since my muscles have stretched to accommodate the implants I have now that a second surgery would not hurt AS MUCH. Please email me back when you have a chance. Thanks.**

 

Dear ** 1/27/00,

I am composing this letter based on my recollection without your clinical record.

The manufacturers don't cover implant costs, etc. for the correcting 'minor' size discrepancy type of procedures. They do give a replacement implant if one has deflated. Also they cover the cost of surgeon/ facility if you sign a waiver that that amount absolves the manufacturer of any further liability, etc.

You have done most of your 'lifetime suffering' to have your breasts the way you want them. The discomfort associated with the first breast augmentation procedure is because a significant space is made where there was none before. Going larger, even considerably larger, correcting asymmetry, or replacement after deflation would be about 1/5th the recovery as the first time. After a second breast augmentation related surgery most patients return to full work or play the next day.

Implant size change surgery usually involves loosening the capsule (even a loose capsule) that the body always forms around an implant. Thus a second breast augmentation can involve almost more surgeon effort/ time than the first time. For a patient initially coming to me for a second breast procedure the cost for everything (surgeon, implants, IV local anesthesia, our in office operating room, lab, not mammogram > 35 yr. or take home meds) is in full 6280, or if cash or money order 5400 for both sides [as of 1/26/00]. For my own breast augmentation patients it is usually 10% to 60% less depending on time estimate/ difficulty factor, etc. (the last thing I want is having my existing patients trying to find another plastic surgeon!)

My recollection is that with your degree of asymmetry I would not be too anxious to re-operate on one side only to make it better. There will always be some 'apparent' asymmetry or visible difference even if breast tissue + implant volume were exactly the same on both sides. [i.e. Dr. Pertsch perceives the difference from side to side this patient is aware of but considers this to be 'within the normal range of naturally occurring breast asymmetry']

One cannot forget 'perfection est l'enemi de bien' or perfection is the enemy of good. Knowing what good can be made better and what good is good enough is a risk to benefit decision that should be carefully considered.

 

To get pricing quotes please contact our office.

James L. Pertsch, M.D.

 

Dear Dr. Pertsch [same patient responds later on 1/27],

Thank you for taking the time to provide this information for me. Your response has inspired me to end this misguided obsession of mine regarding the size of my breasts.

I have thought often of how I should have listened to you when we were choosing implant sizes but I didn't and now I wish of course that I had. So this time I will listen to you and take your advice.

You are quite right when you say "perfection is the enemy of good", and I can see how easy it is for one to fall into a cycle of undergoing many unnecessary surgeries in the pursuit of perfection. I think I'll do the simplest, most pain free and inexpensive thing there is for me to do: accept the way I am now and be happy with that.

Thank you Dr. Pertsch.

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Dear ** 12/30/99, [Multiple questions after a patient came from a considerable distance for a consultation with Dr. Pertsch. Questions are followed immediately by the answer.

 

Thank you for your mail. I was honored that you came to me for a consultation. I am sorry I could not promise you the perfect result sought but I think the odds are your situation could be improved. Answers are based on my recollection of your situation as your chart is at the office. I've addressed your questions one by one within the text of your note:

 

My name is **. I have met with you for a breast revision consultation on Dec. 22. [This patient had breast augmentation via armpit (axillary) approach with implants place above the muscle with some firmness, asymmetry, some palpable rippling, greater gap than desired between the breasts and was 5' 6" tall and weighed 155 lb.] We had discussed many of my goals and concerns and since then I have come up with some questions that I would like to ask you. If you can please either e-mail me back at ** or call me home at **, I would appreciated it very much. Here are some of the questions.

Question 1) Since you are going to cut through the areola will this effect my nipple sensitivity? Have you had any patients who have lost sensation? Is this a major concern?

 

Answer question 1. I have had patients that experienced reduced and increased nipple sensitivity after all the incisions used for breast augmentation surgery. With revision surgery there may be an increased chance of some reduced sensation, regardless of the incision, as small nerves that may have been swept out of the way earlier are now sitting next to the capsule and might be more easily injured.

The closer the incision to the areola the higher the chance of some reduction in nipple or areolar sensation.

The nipple sensation is a major issue for most all my patients before their surgery. Afterwards, patients seem much less concerned than they were beforehand even if sensation is reduced. Between some gradual return of sensation and my patients getting used to it it seems to become a 'non issue' for them afterwards.

 

Question 2) The implant that I have in now are McGhan smooth 360 cc filled to 420 cc. We have discussed that I do not want to be any larger and you suggested maybe going with a 390 cc implant filled to 400 cc. I am not quite sure of the reason for going with a 390 cc implant. Is it for softness because you are not filling it as much as the 360 cc implant or for other reasons? [Why not fill implants more than the manufacturer recommends?]

 

Answer question 2. Two reasons for going with an implant within the manufacturers recommended filling range. First: If I recall correctly the visibility/palpability of your implants was an issue for you. Less tensely filled implant may reduce the palpability of the margin of the implant. Second: The manufacturer has guaranteed your implants (replacement cost plus replacement implants) for 10 years. I have some concerns that in the future (5-10 years ) when all the implants are 'popping like soap bubbles in the wind' the manufacturer will be scrambling about scrutinizing claims to find reasons to not pay out on their promise (like all insurance companies do). One reason they may exclude coverage in the future is not following the manufactures guidelines i.e. filling implants more than manufacturer recommended. It is common for physicians to overfill or underfill implants if they believe it is in their patient's best interest for one reason or another.

 

Question 3) If we do go with the 390 cc implant will it only be filled up to 400 cc and also since the implant's diameter is a bit bigger than a 360 cc, will that make my breast look bigger on my chest wall?

 

Answer question 3. The diameter increase is a couple of millimeters (exact detail available at my office) I would put these few millimeters to work reducing the gap between your breasts rather than allowing the implants to move further to the outer side. [This patient has implants on top of the muscle now: the plan is to put the implants under the muscle which will help reduce a relatively wide space now present between the breasts.

 

Question 4) Also we have discussed the result that I am looking for in appearance I gave you a picture of one of your patients that I think had a very good result. That is the result I am looking for. In your opinion do you think that is a realistic goal and if it is how close do you think you can come to achieving that goal?

 

Answer question 4. You are about 10-15 % underweight for your height. The patient you liked was 10-15% overweight at that time (she has since lost about 30 pounds and gone into modeling as sideline work). (I wish I had pictures at her present weight to show you but I haven't seen her in since last summer as she lives at a distance). So... your result will be limited by this. I.e. consider the difference of looking at a pile of books covered by a heavy blanket as opposed to a thinner blanket?

Overall, I think your situation could be improved enough to go forward. My opinion is based on the fact that you are reasonably happy with your present appearance and I think you will look better afterwards. Your happiness after surgery and my willingness to perform the surgery for you depends on your ability to accept 'better' rather than 'perfect' as acceptable. Please understand I will strive with all my ability to seek 'perfect' for you. [Everybody is different: amount of breast tissue you have, skin elasticity, and amount of subcutaneous tissue (normal fatty layer) and will affect results obtained.]

 

Question 5) My left breast is soft but my right breast is a bit more firm. From what I know, I think there is a bit of scar tissue build up. It also feels a bit tighter, the implant sits a little higher on my chest than my left breast and is a little uncomfortable at times. Will you be able to fix it so that it would soften up like my left breast?

 

Answer question 5. Yes. But realize that any time surgery is performed to correct a firmness issue there may be as high as a 33% chance (one out of three) that the firmness may return.

 

Question 6) I do not want my breast to sit any lower on my chest wall. Will the surgery change that at all?

Answer question 6. In question # 5 you indicate firmness is an issue. Step on an orange to change it from a sphere to an ellipsoidal shape. What happened will also happen to your breast to some degree. There will be slightly less projection and an increase in diameter of the breast. i.e. there will be some slight lowering of your breast.

 

Question 7) Since you will be cutting through the areola, will this effect my milk glands for nursing?

 

Answer question 7. Probably not. There is no article published that I have seen or know of with statistics on this. Realize about one out of three women can't breast feed for one reason or another even without surgery on their breasts!

**Please forgive if my attempt to earnestly answer your questions comes across as 'brutally honest' From my perspective 'my life is too short' to have my waiting room filled with angry, misinformed patients. I want you to know and hear everything there is to know now rather than be surprised after a surgery.

James L. Pertsch, M.D.

 

These are all the questions I have now. I am sure that I will have more to ask you later on. I appreciate your time very much and look forward to hearing from you.

Thank You.

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Breast Reduction

 

QUESTION: I JUST HAD A BABY 9 MONTHS AGO, MY BREAST ARE VERY DROOPY, AND LARGE, HOW MUCH WOULD IT BE TO GET THEM TO A SIZE C, PERKY (RIGHT NOW I'M 38 DD) ? Date: Tue, 26 Dec 2000 15:58:26 -0500

 

Congratulations on your little one.

Breast reduction can not only reduce your breast size, relieve any back, neck or shoulder discomfort due to large breasts but also increase the ease with which you can participate in physical activities. In addition the breast will assume a more lifted, perky look after the procedure. Most patients are very happy they had this procedure done and frequently wonder why they waited so long to do so. Most have an experience of freedom and relief following the procedure. I have had patients that wanted more children but wanted their breasts reduced to make future pregnancies and the associated breast size change more tolerable.

Often insurance will cover breast reduction surgery if certain criteria are met. The best way to check for insurance coverage is to come to our office for a consultation. After review of your symptoms, a brief examination , Polaroid photos along with a letter to your insurance will request they 'pre-approve' your procedure. Once insurance has approved we can detail your approximate 'out of pocket' cost. Please call Tammy to schedule a time to come and see us 650-344-8700. We will show you a video tape on the procedure, show you before and after photographs of previous patients and gather the information for the pre-authorization.

The procedure itself takes between 2.5 to 4.5 hours. Often patients come to our office operating room, have the procedure and go home the same day. You will be return the next day for a quick check and drain tube removal (if any needed). Most of the time the sutures (stitches) are all inside so none need to be removed. Recovery takes about a week before returning to desk type work but it may take until the second week that you feel relatively comfortable lifting your nine + month old. With any procedure there are risks and possible complications: infection, bleeding, drainage, etc. but these occur infrequently. The main tradeoff is the necessary scarring: around the areola (flat, colored part of the breast), down towards the crease under the breast, and hidden in the crease. All marks improve slowly and look their best after 2-3 years. So far none of my patients have minded these marks because of the freedom they experience once all the excess breast is gone.

Its best to have stopped breast feeding about 6 months before the surgery. Its usually best to be sure the breast milk has dried up before the actual operation to reduce the chance of an infection. You must not smoke for a minimum of one month before and after the surgery (not even one cigarette) to reduce the chances of healing problems. Vitamin E and Aspirin must not be taken for two weeks before or two seeks after the procedure.

Breast reduction can be done without insurance involvement. These financial issues are detailed here:

The cost if insurance not involved includes virtually everything: our in office surgery facility, general anesthesia, the preoperative check of your health and lab test (except mammogram and this is recommended as you are over 35 yr.), pathologist check of the reduced tissue, and all visits before and after surgery including long term yearly follow-up visits as well. Not included are the medicines for after surgery: antibiotics, muscle relaxants and for discomfort .

We ask that financial arrangments be completed three weeks before surgery.

We do maintain a short list of patients that can 'drop everything and come'. Such patients help us in case of a last minute surgery postponement that would otherwise leave our operating room idle and we help them with a considerable financial break. Please call Tammy for more detail 650-342-1511.

It is important that you not only find the right doctor but also consider their staff. The doctor's staff is who you will be dealing with quite a lot.

Please call Tammy 650-342-1511 if we can provide additional information for you or you'd like to come see us.

 

To get pricing quotes please contact our office.

I look forward to meeting you.

James L. Pertsch, M.D.

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Liposuction

 

[Thanks for replying to my [other] email.] I am confused about twilight anesthesia. I was told by several anesthesiologists that while under heavy sedation, the patient is asleep and is not aware of what is going on. Why wouldn't that be the best option? I would think that it is safer than general, and just as comfortable. Unless, you do not give heavy sedation and just light sedation. Can you please clarify? Anesthesia, rather than the procedure per se is the biggest concern for me.Thanks again! 10/15/00

 

Dear **[The thought of anesthesia can be frightening: realize it is just a way of making you comfortable and not recall anything unpleasant. the deeper the anesthetic the less your chance of remembering anything around the time of your procedure. The deeper the anesthetic needed the better it may be to have an anesthesiologist present. there is a limit to the amount of local anesthetic that can be safely given. So, longer procedures or procedures on multiple area of the body may need to be done under general anesthetic.]

I have performed liposuction all the different ways with different types of anesthesia: straight local, conscious sedation light and heavy (twilight anesthesia), epidural and general anesthesia.

Regarding anesthesia: There are different levels of anesthesia representing a spectrum without sharp boundaries:

  • local only (patient awake)
  • local plus oral medications (patient awake)
  • local plus intravenous medication (some patient recollection probable or possible)
  • local plus heavy intravenous medication (no patient recollection, no special airway control)
  • local plus heavy intravenous medication (no patient recollection, with special airway control)
  • general anesthesia with airway control, patient breathing on their own with special airway control
  • general anesthesia with airway control, ventilator breathing for the patient

 

Also, there are regional blocks: epidural (or less commonly performed spinal) anesthesia

 

Then there is the issue of who is giving the medicines and what personnel are in the operating room with you:

  • surgeon with RN giving medicines at surgeon's direction
  • surgeon with CRNA (Certified Registered Nurse Anesthetist) giving medicines at RN's discretion
  • surgeon with anesthesiologist (M.D.)

 

Anesthesiologist may be present for all levels of anesthesia. CRNA or anesthesiologist must be present for anesthesia with special airway control or general anesthesia.

Any time someone says 'twilight anesthesia' they could be referring to any of the 'local plus' options above with or without an anesthesiologist present. You need to ask more questions about exactly what they mean by twilight.

I get the best results for my patients along with the least stress for all using general anesthesia with MD anesthesiologist present and the patient breathing on their own. It may be safer to have both the surgeon and and anesthesiologist present: one physician concerned about your looks and one about your blood pressure, etc.

Even under heavy sedation patients may grown and complain: although the patient will probably not remember anything unpleasant it increases the stress on me and my staff. With general anesthesia I am free to continue the procedure until I get the maximum improvement possible. Otherwise I may have to stop before achieving the best possible improvement due to apparent patient discomfort.

James L. Pertsch, M.D.

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Dear Dr. Pertsch [Sat, 12 Aug 2000 07:24:50 -0700] I think I'd be interested in receiving a liposuction. My gut has gotten quite large. I've been controlling my diet and running periodically for about a year and have only lost about 10 pounds. I need to make a big change. At that point I think the running will be even easier. Right now I weigh about 270 and I'm 76" tall. I'm expecting that my weight would drop to around 250.

I'm a 43 male with no allergies and I'm not on any medication. I'd prefer a Friday procedure on the hopes that I'd be ready to go back to work (a sedentary job) the following Monday. I would want this done in early September. I live in San Jose.

I'd appreciate some feedback. The best feedback would deal with the number of procedures you do in a typical month, how long you've been performing this procedure and your availability.

 

Dear **, Thank you for your mail.

As you know liposuction is not really a way to control weight. Patients expecting liposuction will solve weight problems are uniformly disappointed. Liposuction will help you look like you weigh less. However, patients with unresolved weight control issues could quickly gain enough back to have it look like they never had surgery. Seeing yourself with such an improved look after surgery can stimulate you to take even better care of themselves after liposuction. A recent patient, who previously had liposuction of the abdomen and hips, came back to do liposuction of other areas. Afterwards she was really excited: "I've really been motivated to exercise even more regularly [She had great shape and muscle tone]. And its much easier to decide against the second scoop of ice cream for fear of going back to the body I've paid over $7000 to improve!"

At 6' 4" tall your ideal body weight, according to insurance charts, is about 202 lb. (to calculate your theoretical ideal weight Men: 106 lb. for first 5' plus 6 lb. for each additional inch of height. Women 100 lb. first 5' and 5 lb. for each additional inch). I find it best to have my patients within 30% of their ideal body weight to obtain the best results from cosmetic surgery (your 30% over ~260?). Enough theory as their are always exceptions. Also I don't have patients torture themselves over losing the last few pounds before surgery.

Men, more often than women, sometimes carry their extra stomach fullness inside rather than outside their abdominal muscles. Liposuction can only address the fat the is outside the abdominal muscles.

I recommend the safest, most reliable liposuction technique that gives the best results for my patients. Thus far the technique is a super wet (almost tumescent) technique with Mercedes tip liposuction cannulae. Although it is exciting to use the 'latest and greatest' technologies (ultrasonic , external ultrasound, reciprocating cannulae) there are some increased risks for the patient with no real chance of a better result in the areas you specified.

I have performed the procedure many times with all types of anesthesia: straight local, local with sedation, epidural, and general anesthesia. Patients have had the most comfortable experience with our technique of general or epidural anesthesia that minimizes nausea. An anesthesiologist is always present. Comfort of my patients is very important to me.

These procedures can be done in the privacy of our own office operating room/recovery facility. We do most of our liposuction on Fridays as many patients can get back to work in a long weekend. Recovery time to 'public bathing suit viewing' is about two weeks. You can return to most activities in clothing earlier. Strenuous, aerobic exercise is avoided for 2 weeks.

Costs quoted below includes virtually everything: our accredited in office surgery facility, anesthesiologist, the preoperative check of your health, and lab test, post-operative garment, and all visits before and after surgery including long term yearly follow-up visits. Not included are the medicines for home after surgery: antibiotics and for discomfort.

I completed my Harvard plastic surgery residency 12 years ago and have been in practice in San Mateo County since then. I perform liposuction on average about 3 per month. These are usually big cases with multiple areas. As [liposuction] is very physically demanding for me to get the best results we try not to schedule more than one liposuction per day or more than 2 per week.

Please call Tammy if we can provide additional information or to schedule a consultation: 650-342-1511 If you come visit us we have videotapes on the options. Seeing other patients' before and after photographs can make the procedure most suitable for you more apparent. After an examination I can give you an idea of how much improvement can be expected so you can decide if it is worth pursuing. Please contact us as soon as possible if one particular date for surgery is best so we can reserve this time for you.

 

To get pricing quotes please contact our office.

I look forward to meeting you.

James L. Pertsch, M.D.

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To: jpertsch@jpertsch.com Subject: Prelim Questions [Date: Wed, 12 Apr 2000 10:56:15 EDT]

For a 35 y/o F within 10% of ideal body weight seeking lipo on abdomen, inner and outer thighs and flanks:
1. What method of lipo do you use? a. with or w/o reciprocating cannula;
2. What method of anesthesia do you recommend?
3. If possible, can you please give a very rough non-binding $ estimate.

Thank you.

 

Dear **

Thank you for your mail.

I recommend the safest, most reliable liposuction technique that gives the best results for my patients. Thus far the technique is a wet/tumescent technique with Mercedes tip liposuction cannulae. Although it is exciting to use the 'latest and greatest' technologies (ultrasonic , external ultrasound, reciprocating cannulae) there are some increased risks with no real chance of a better result in the areas you specified.

I have performed the procedure many times with all types of anesthesia: straight local, local with sedation, epidural, and general anesthesia. Patients have had the most comfortable experience with our technique of general or epidural anesthesia that minimizes nausea. An anesthesiologist is always present. Comfort of my patients is very important to me.

These procedures can be done in the privacy of our own office operating room/recovery facility. Recovery time to 'public viewing' is about one week but you can return to most activities, except strenuous exercise, earlier.

Liposuction of the abdomen, inner thighs, outer thighs and hips (flanks) is considered a 4 area liposuction.

Costs quoted below includes virtually everything: our accredited in office surgery facility, anesthesiologist, the preoperative check of your health, and lab test, postoperative garment, and all visits before and after surgery including long term yearly follow-up visits. Not included are the medicines for home after surgery: antibiotics and for discomfort.

Please call Tammy if we can provide additional information: 650-342-1511 is Tammy's direct line. If you come visit us we have videotapes on the options. Seeing other patients' before and after photographs can make the procedure most suitable for you more apparent. Please contact us as soon as possible if one particular date is best so we can reserve this time for you.

 

To get pricing quotes please contact our office.

I look forward to meeting you sometime. James L. Pertsch, M.D.

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Prominent Ear Reduction, Pinning, or Setback

 

Hello, I would like to know how much it'll cost ( total ) for your otoplasty procedure. I have done my research, seen a surgeon, and am currently looking at prices. I would also be interested in the "Fall into the gap" schedule; what type of discounts are available for the my procedure? Any info would be greatly appreciated. Date: Tue, 5 Dec 2000 13:25:47 -0800 (PST)

 

Dear **, Thank you for your mail. Otoplasty is the medical term for the correction of prominent ears.

Otoplasty is a very successful in that ears can be set-back and permanently eliminate concerns about their prominence. Of course no operation is 'perfect' but most patients are very happy they had it done.

The procedure takes about three to four hours hours and is usually performed in our own, private, accredited office operating room/ recovery room facility. I take my time during surgery but you remain very comfortable and remember nothing uncomfortable with conscious sedation. The incision is all behind the ear. I combine three separate techniques to assure adequate and permanent correction.

A head bandage is recommended for at least two days. Although you could read the next day recovery is a minimum of 2 days before returning to desk type work but usually a 4-5 day extra long weekend is best. It could be as long as 2 weeks before bruising, if any, resolves. Exercise is permitted 2 weeks after surgery. Its a procedure I enjoy performing because my patients (and I) are so satisfied with the results.

It is important that you not only find the right doctor but also consider their staff. The doctor's staff is who you will be dealing with quite a lot.

If you are interested in more information please call Tammy and come see us 650-342-1511. It is not to early to start getting information. We'll show you videos about the procedure, before and after of other patients, and after an exam you will know whether you are a candidate.

We ask that financial arrangments be completed three weeks before surgery.

We do maintain a short list of patients that can 'drop everything and come' [our 'fall into the gap' option]. Such patients help us in case of a last minute surgery postponement that would otherwise leave our operating room idle and we help them with a considerable financial break. Please call Tammy for more detail 650-342-1511.

Please call Tammy 650-342-1511 if we can provide additional information for you or you'd like to come see us.

 

To get pricing quotes please contact our office.

I look forward to meeting you.

James L. Pertsch, M.D.

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Q&A For Thinner Looking Faces

 

* Dear Dr. Pertsch: I read about a procedure called "Buccal Fat Removal" Do you do this...is it similar to a Facial Liposuction?

 

Thank you for your mail.

Buccal fat pad removal and liposuction are both similar in that they both remove fat.

Removal of the buccal fat pad results in a thinner looking face. After I have removed the buccal fat pad every patient (thus far) has received multiple compliments: "Have you lost weight?". Its removal makes a round or full face look much thinner and more angular. This fat pad is about the size of the last part of your thumb. The buccal fat is a special packet of fat in the middle of your cheek. To demonstrate where it is on yourself: clench your jaws, start at the corners of your mouth and inch your fingers toward your earlobes. When your index finger strikes a hard edge (the anterior part of the masseter muscle) stop! Your long finger is now over the center of the buccal fat pad. You can mimic the look of buccal fat pad removal by sucking your cheeks in a little bit. The fat pad can easily be removed under IV local anesthesia with the access inside your mouth. There is minimal down time after surgery of 1-2 days. Buccal fat pad removal can be performed alone or in combination with other procedures that make round/ full face look thinner and more angular: chin augmentation, rhinoplasty, and liposuction under the chin and/or the face. I perform this procedure frequently as is is relatively simple, little recovery time, and patients are pleased with the subtle but definite facial enhancement.

Liposuction can thin the entire cheek and area under the chin. Liposuction uses a very thin tubular instrument to sneak fat out of a broad area via a very tiny access point. Although many patients request thinner faces I perform facial liposuction less often than the procedures mentioned above.

Please do not hesitate to call Tammy 650-342-1511 if you want to come see photos of other patients that have had this done. After an examination I could propose which of these procedures would best achieve your goals.

James L. Pertsch, M.D.

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Q&A For a Combinations of Procedures

 

Questions re liposuction and other procedures at the same time

 

Subject: a few questions: Dr. Pertsch, I am planning to have liposuction and a minor rhinoplasty in July or August. The areas I want to lipo are inner thighs, tummy and chin. My nose needs to have just the tip worked on. My question for you is can I have all of this done at once? I work full time and go to grad school so I do not have the luxury of taking two "vacations" a year.

I am 29 and in good health- not overweight- just not liking the extra bulges. I have had a breast aug. and have been extremely happy with the results. Can you give me an approximate cost for the lipo and rhino?

Thank you for your time, Sincerely **

 

Dear ** [3/31/00]

The procedures you mentioned can be performed at one surgery thus making for only one recovery period for you.

The total cost can vary considerably depending on the extent of the nose (rhinoplasty) surgery necessary. Although it is only your tip that you wish to improve in some cases additional work is necessary to maintain facial balance. Planning nasal surgery can be likened to touching the first domino in a line of dominoes: once your adjust one area just a little bit, it is necessary to keep adjusting the next area just a little bit, etc. to maintain/improve facial aesthetic balance and beauty. So even though the tip of your nose is your primary concern you should not be surprised if a full rhinoplasty operation is recommended to achieve your goal. Tip only rhinoplasties are also performed.

Liposuction of the chin (submental), inner thighs, and tummy (abdomen) is considered a 3 area liposuction.

These procedures can be done in the privacy of our own office operating room/recovery facility. Recovery time to 'public viewing' is about one week.

Costs quoted below includes virtually everything: our accredited in office surgery facility, anesthesiologist, the preoperative check of your health, and lab test, postoperative garment, and all visits before and after surgery including long term yearly follow-up visits. Not included are the medicines for home after surgery: antibiotics and for discomfort.

Please call Tammy if we can provide additional information: 650-342-1511 is Tammy's direct line. If you come visit us we have videotapes on the options. Seeing other patients' before and after photographs can make the procedure most suitable for you more apparent. Please contact us as soon as possible if one particular date is best so we can reserve this time for you.

 

To get pricing quotes please contact our office.

I look forward to meeting you sometime. James L. Pertsch, M.D.

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Questions re: breast lift and abdominoplasty: before surgery

 

* Dear Dr. Pertsch: I am very interested in the tummy tuck liposuction and breast lift. I was wondering around the cost. I live in Oklahoma . Please let me know . I know you can't sum it to a round amount without seeing me first, but would like to know round figures and such.

Thank You [Date: Fri, 22 Sep 2000 02:25:46 -0500]

 

Dear **: Tummy tuck (Abdominoplasty) is on of my favorite procedures as it is such a body transforming/ patient transforming operation. Many of my patients come without tan lines and I see them months later with 2 piece tan lines.

As you are aware there are two procedures that can make your stomach (abdomen) look better. If there is only fat excess with good skin -> liposuction. If there is a skin excess, or skin and fat excess -> tummy tuck (abdominoplasty).

If the abdominal skin has good tone (i.e. remains elastic with minimal stretch marks, not loosened by weight gain or pregnancies) then liposuction alone may give considerable improvement. Liposuction removes the fatty tissue provided the skin can snap back into place.

If abdominal skin is in excess i.e. skin feels looser, there is a little pooch or overhang when standing that worsens when sitting, indented scar or the stomach bulges significantly when viewed from the side then skin and fat problems exist. Skin and fat will need to be removed. An abdominoplasty rejuvenates the abdomen by removing most of the skin and fat between the navel and the pubic area. The covering of the underlying muscle is tightened to give a flatter stomach when viewed from the side. The remaining skin is then stretched to give a tighter, youthful look. Often, liposuction to 'fine tune' other areas is be performed at the same time. Fortunately you'll be sleeping through all of this!

The recovery from an abdominoplasty may be up to 2 weeks before returning to a desk type job. Driving will be up to you but feel your abdominal muscles tense as you quickly step on the brakes. These abdominal muscles will be sore for 2-6 weeks. It may be approximately 2 weeks before you could catch a young child making a dash for the street. A five year old you won't catch for a month (of course you may not be able to catch him/her now!) Although aerobic exercise may be started 2 weeks after this procedure plan to wait 6 weeks before heavy lifting or stomach exercises. Although most patients go home the evening of their procedure, we help with arrangements for our out of town guests. Air travel is not recommended for at least 3 days.

We do maintain a short list of patients that can 'drop everything and come'. Such patients help us in case of a last minute surgery postponement that would otherwise leave our operating room idle and we help them with a considerable financial break.

We ask that financial arrangements be completed about three weeks before surgery so we can focus on the medical issues, etc.

A breast lift (mastopexy) alone may leave the upper portion of the breast without much fullness. For larger, drooping breasts it is sometimes necessary to reduce the volume of breast tissue to minimize early reoccurrence of drooping.

Breast lift and implants (augmentation mastopexy) may be the best procedure to transform deflated, sagging breast to a more youthful, perky appearance. Adding a small implant, even if you're relatively happy with your present breast volume, will give [lasting] upper breast fullness. The breast lift restores lower breast shape and proper nipple/areolar position.

Many patients initially come seeking a lift or a lift with implants but settle for the improvement possible with implants alone to avoid the extra scarring the lifting requires.

As with the abdominoplasty the cost quoted below include virtually everything: saline implants if needed, our accredited in office surgery facility, anesthesiologist (if general anesthesia selected), the preoperative check of your health and lab test (except mammogram recommended over 35 yr.) and all visits before and after surgery including long term yearly follow-up visits. Not included are the medicines for after surgery: antibiotics, muscle relaxants and for discomfort.

It is most important to figure out what procedure will get the breasts you now have to those you wish to have. There is a wide range of issues to discuss for each of the above options; risks and complications vary considerably depending on the option chosen. It might be best to send digital photos of yourself attached to an email (front, side and 45 degree angle showing from your neck to your navel). also, it would be helpful [actually its critical] to see photos of of how you want to look after the surgery (find photos in magazines, 45 degrees, in and out of clothing; scan them into your computer and send them as an email attachment)

It is important that you not only find the right doctor but also their staff. The doctor's staff is who you will be dealing with quite a lot.

If you are interested in more information please call Tammy and come see us 650-342-1511. We'll show you videos about the procedure, before and after of other patients, and after an exam you will know whether you are a candidate.

My best advice is to find a local plastic surgeon with whom you are comfortable [for this combination of abdominoplasty and simultaneous breast surgery]. Of course if you're between jobs, can leave the kids with your ex-husband, and can exercise stock options to finance two weeks recovering in San Francisco I'd be honored to take care of you. Forgive any potentially offensive assumptions in these comments but you get the idea. Tammy has plenty of information to smooth the way for our out of town guests.

Tammy can help provide more information 650-342-1511. Consider a visit to our office. We will show you videotapes on your options and many more 'before and after' photographs. After an examination I can discuss your options and help choose what is best to achieve the improvements you seek.

 

To get pricing quotes please contact our office.

Good luck. I look forward to meeting you if appropriate

James L. Pertsch, M.D.

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