Q: Where in the body are stem cells found?
A: You may have watched a medical drama on TV, or known someone who had a “bone marrow transplant” for the treatment of certain types of cancer. The purpose of the transplant is to restore the stem cells of the bone marrow, so that new healthy blood and white cells can be made by the recipient. In a nutshell, the purpose of the treatment is to replace the patient’s regenerative cells with new healthy ones. The stem cells that are transplanted will then be able to make new blood cells for the patient forever. Stem cells are also found in very large numbers within fat tissue. You may wonder what they are doing there. But, when you think of it, fat happens to be just about everywhere in the body at sites where injury may occur, for example. This is a nice setup, since where ever you happen to be injured, stem cells are near by, ready to step into action.

Q: What about stem cell grafting for anti-aging?
A: As of May, 2012, there are no methods for accurately harvesting and replacing stem cells alone. Most of the ads regarding stem cells are a bit premature, to say the least- BUYER BEWARE. It is true that small parcel fat grafting does transfer some stem cells along with the fat cells. It has yet to be established whether enriching a fat graft with stem cells will improve outcomes. There are a few devices under investigation which allow doctors to harvest the stem cell portion of the graft and then add this part to a prepared fat graft, creating a ‘stem cell enriched fat graft’, but thus far there are no good clinical studies to show benefit from this process over routine fat grafting. I do not think that there is any doubt about the efficacy of fat grafting on its own, although other doctors will disagree with this. Despite a wide variety of nay-Sayers, fat grafting has been shown to be a safe and effective treatment for many problems that are commonly encountered in clinical practice. Italian researcher Dr. Gino Rigotti has shown that fat grafting in patients with post-radiation skin breakdown on their chests will heal their wounds after fat-graft treatment, an amazing result. He took patients who had failed to heal using conventional therapies and performed his fat grafting technique on them. As a result, they healed their chronic wounds.

Q: Does fat grafting work to enlarge breasts?
A: The short answer is yes, it works, but only to a point. Most women who desire breast enhancement want, on average, about one to one and one-half cup size enhancement. This usually means about 200 to 300 cc in the average sized patient. The average amount of enhancement that is safely achievable with fat grafting is only about a half cup size. The final word on this is that although it works, it can’t give women the total amount of enhancement that they want in a single procedure. However, for women who have a problem area of fat on their tummy or hips, this can be a great way to improve the figure, by removing the fat from where it is found in excess, and moving it to where it can do some good. It is a great way to improve the figure after giving birth, and an excellent addition to tummy tuck surgery. The excess fatty tissue from the tummy and sides (the ‘muffin top’) can be removed at surgery, and the fat added to the upper part of the breast which usually deflates following childbirth. Because no implants were used, the surgery never has to be repeated, and the results are permanent. The breasts remain soft and natural. Not everyone is a candidate however, and you should discuss this with your surgeon. I reported my results from my patients at several international meetings a few years ago, including the American Society for Aesthetic Plastic Surgery annual meeting.

Q: What about fat grafting for the breasts and breast cancer?
A: Fat grafting for the breasts is somewhat controversial. That is because there is some evidence to suggest that stem cells can, in certain circumstances, stimulate active cancer cells to multiply. If there are no active cancer cells however, it is not clear if stem cells will have any effect on causing cancer to develop if none was present before, but the evidence suggests that it does not. Italian researchers looked at women who had been treated for cancer and who had been treated with fat grafting and they found no increase in the number of patients with a recurrence, indicating that fat grafting probably does not cause cancer to develop, even in highly prone individuals (these patients, remember, already had been treated for cancer, so they were high risk by definition).

Q: What does fat grafting do for the face?
A: The new paradigm is to consider the three dimensional shape of the face when considering the effects of aging. Pulling the tissues of the face (ie the old way of face lifting) would flatten the cheeks and although it could change the shape of the face, it would not restore the most important features of a youthful face. The new techniques take the three dimensional volume deficits and treat them with fat or fillers. These 3-D techniques restore the missing volume of the upper face, as well are remove the excess volume of the lower face, creating a better balanced result that is more natural looking, and better approximates the youthful face.
I have been performing fat grafting and laser resurfacing as well as other advanced methods of face lifting procedures for over 20 years, and I can tell you without reservation that these methods do result in healthier looking skin and more natural looking results. The theory of stem cells may explain the results, but it has not been proven yet by clinical studies. That is not unusual in surgery, that a technique or procedure works but we can’t explain why it works. It is only a matter of time, as far as I am concerned.

Um, you look nice today!

Why is someone attractive? Why is someone beautiful? Why do infants in special corneal tracking studies spend a longer time looking at a photograph of a beautiful woman rather than a plain-Jane woman? Other studies show that infants and children prefer to play with dolls that are beautiful rather than dolls that look plain, even before they can talk! Remember, this happens before the age where socialization and societal norms have had any significant effect on the subjects. This is an inborn tendency, something that is hardwired into the way our brains work!! Why would this be? How could this be possibly explained? The study of evolutionary genetics provides some interesting answers to these fundamental questions….

Baby plays with pretty doll for longer period of time.

The most beautiful people will have the greatest possibility of mating, as well as the greatest number of options for choosing another mate. When groups of subjects were asked to sort men and women into the ‘correct’ couples, they showed a remarkable ability to sort out who was actually married to whom. Beautiful people tend to marry beautiful people. Beautiful people also end up in leadership positions, have more authority, have better jobs, and earn more money. And they tend to have way more sex! There are always some anomalies here, such as when you see the iconic beautiful bombshell model type with the old short bald fat guy (examples abound, look up Silvio Berlusconi)! Yes, money is an important factor, and I will reserve that discussion for another essay. The bottom line is that beauty is a sign of health, vitality, and wellness. Beauty signals to potential mates that the beautiful person has a ‘good’ set of genes, and will be highly likely to provide the necessary good genes to create a beautiful healthy baby. Carrying our genes into the future is one of our most fundamental drives, one that governs almost all of our activities.

Studies of paternity show that a remarkable number of infants are born to married couples where the actual father is not the man whose name is on the birth certificate. Women have urges, just like men, and it turns out that women are attracted to different types of men depending on the state of their fertility. During their most fertile period, at the time of ovulation, women are more attracted to rugged, virile, muscular types of men, whereas at other parts of the cycle, they are more likely to be attracted to stable, hardworking “good provider” types of men. Studies show that a surprisingly large number of these women have acted on their impulses, and many men have been thus cuckolded, since genetic studies have shown that the real husband cannot be the biological father of the child. I am not saying that this is good or bad, I am only reporting the results of these clinical studies.

A fundamental need...

There are elements of beauty that are ephemeral and very difficult to define in words, yet we know it when we see it. The most important interminable elements of beauty that are (relatively) easy to define include:

Symmetry -the left and right sides should be a good match, but are never identical mirror images. If you use photoshop to divide a photo in half and display a photo that is two rights or two lefts (after flipping the appropriate side over digitally), the two people always look like brothers or sisters, and the closer the photos look to twins, the better. The same is true of our hands, breasts, and everything else that is paired.

Shape- In youth, we have a triangular facial outline, with quite a bit of fullness in the upper face, and very little or no excess fullness in the lower face. In old age, our upper face looses much of its fullness in the forehead and temples. If you think about your grandparents, you may realize that you can almost see the skull shape under the skin of their scalp (the so called “peanut head”), and often the temples will be sunken in. In comparison, your children will have a full upper face, and the temple area will be full, round, and smooth. Older people will have some fullness under their chin, and they may have jowls that make the face a rectangular shape. Children on the other hand will have a slim chin and neck area and their shape will be triangular, with most of the fullness at the top. Similarly, the shape of the body has importance in signalling our health and ability to procreate. Fat is really beautiful. It is padding, it is storage, it is soft, and we really, really need it, despite the bad rap that fat gets. The shape of your face is primarily due to the shape, size, and position of the fat pads over the bony skeleton. The human breast is primarily made of fatty tissue, and we all know how much time and money is devoted to shaping, firming, and displaying them. Mind you, the very same amount of fat, positioned about 10 inches lower in the tummy is considered ugly! Shapely breasts and buttocks are in this category, signalling good health and nutrition.

Your shape signals your potential mates about...your potential to procreate!

Texture, Tone, and Colour- Smooth, evenly coloured skin, is a sign of good health, good nutrition, and vigor. These are signals to potential mates that the individual has good genes and will make good babies. Tone refers to the firmness and healthy quality of the body, both muscles and skin. Skin starts off as a smooth, evenly coloured, tight covering. As we age, we start to notice some changes in the pigment. Small brown spots develop in white skin. These are called solar lentigo, or solar lentigines. These are small accumulations of too much pigment within the skin. Another important component of skin, the elastic fibers (primarily elastin) also undergoes changes mainly due to exposure to ultraviolet light. If you leave a pair of Spandex tights sitting in sunlight for a prolonged period of time, the elastic fibers will break down and the tights will no longer be tight. Similarly, when we stay out in the sun, our body will make more pigment called melanin, which absorbs the light waves in the ultraviolet range to protect the important skin structures (including the DNA) from the harmful effects of UV light. Melanin is like a tiny built-in umbrella, protecting the delicate molecular DNA bonds from damage by UV radiation. That is why your body tans- to protect your body from UV radiation damage!

Personality- Although personality is difficult to define, it does play a critical role in attraction, but for the purposes of this essay, I am only considering physical attributes here. Athough ‘Beauty and The Beast’ and ‘Phantom of the Opera’ type stories abound, they are mostly found in story books, not real life.

Beauty and Surgery
If beauty is so important for attraction, how does surgery fit into the equation? How do you feel when you see someone who has “obviously had something done”? It probably makes you think “Ew, something is definitely wrong with that person”, so the natural response is to reject that person because they would not make ideal mates for procreation. That is why natural results are critical in cosmetic surgery! Any signal that your beauty is not genuine, signals to potential mates that your genes are defective, and even worse, that you are trying to hide your defect!

Whenever you consider surgery, make certain that the plan is not to “over-do” anything. The ideal result is the one that looks natural. The best results in cosmetic surgery are NEVER noticed, thank you, thank you very much. You only notice the surgery that was done poorly. A good result is “an undetectable result”.

Beauty is all biology, after all!

Claudio DeLorenzi MD FRCS
Copyright 2012

I spent far more than the usual time with these patients, explaining the various treatment options carefully. To one, I also explained the risks and benefits of surgical vs nonsurgical treatments, and how the nonsurgical options had some real benefits for her since her appearance would be significantly improved with non-surgical management, and that some things were simply not possible with surgery, but could be done with the non-surgical management. To the other patient, I was trying to explain the details of the surgery, but it became apparent that she simply was not ‘getting it’ and was asking for a treatment that could, in all likelihood, not only result in an unsatisfactory result, but had the real risk of causing serious harm, and that I would not do it. I finally told the patient that she was not a good listener, and did not understand the risks that she was going to undertake, and refused to treat her.

Both of these patients were quite unhappy with me, despite me doing my best to help them get what they wanted. One was unhappy with the risks that I outlined, basically telling me that I was being far too negative, and that other doctors advertised the operation that she wanted. ( I cannot divulge the treatments, nor can I divulge the actual conversations that took place, since that contradicts the principles that I swore to uphold.)

What is remarkable to me, is that both of these young patients left negative comments about me on various doctor rating websites, despite the fact that I refunded the money that one patient paid for treatment (a complete refund, despite the very significant costs that I undertook to provide the patient with the materials that were needed to provide care). The actual content of their negative ratings does not really matter, they were dissatisfied with my consultation, and they let others know that. That’s OK, I can handle the negative comments, because I know that what I do is serious work, and I always try to do the best job possible for my patients, in a very honest and straightforward way, whether they understand that or not. These young patients did not understand me, nor did they understand the limitations of the type of work that can be done.

The young patient who is somewhat immature and expects everything without risk is a problem in modern plastic surgery practice. With life experience, it becomes clear that you usually get what you pay for, and that sometimes, you really can’t have something that you want. Unfortunately, biology and randomness will always conspire to catch up with you eventually, and a procedure or product that you read about on a marketing-driven website is really not always in your best interests. When an experienced surgeon tells you honestly that you should not consider a particular treatment, he or she is not trying to be mean or cruel, or to prevent you from achieving something. They are trying to protect you from dangers that you may not be aware of.

This kind of miscommunication problem almost never happens with mature patients over thirty, and absolutely never with patients over 50. By that age, most people have experienced some of the routine hardships of life, and they really ‘get it’.

The young patient, on the other hand, has been taught almost from infancy that they can have whatever they desire, whenever they want, at any time of the day or night. No need to wait for something, because you can have it all right now, and it can be even be ‘free’. Real life is just not that way, at least with surgery, anyways. Real surgery has real risks, and unfortunately, modern plastic surgery advertising has created some very unrealistic expectations. Part of my job is to make sure that you understand what the risks are, what is safe and what is the best course of action in your particular circumstances. I am an honest person, and I always tell you the truth, whether you like the truth or not. I have never lost a patient, and I plan to keep it that way. I like to sleep in peace, knowing I do the right thing for my patients.

Claudio DeLorenzi
Copyright 2012

One of the most common things I see are extra nipples. These may occur anywhere along a line from the axilla (armpit) to the groin, along what is known as the ‘milk line’. Usually these are shaped just like a normal nipple-areolar complex (what we surgeons call the nipple and the surrounding pigmented skin), only smaller, sometimes miniature. Just as you may see multiple nipples on your pet cat, we are more or less built the same way, except that we lost the ability to have multiple breasts somewhere along the evolutionary chain. However, some people still occasionally have one or more supernumerary (extra) nipples, and rarely, some of these actually function (with actual milk producing breast mounds under them, and I once had a patient with a functioning breast in her groin that secreted milk while she was lactating, and a different patient who had an extra breast in her arm pit area- unfortunately, I have not been able to find those old photos to post here). This is a photo of what an extra nipple looks like (below).

Extra Nipple, typical appearance and location.

The nipple areaolar complex will tend to get darker with pregnancy and lactation, sometimes causing concern about malignant melanoma because the small extra nipple will also change colour.

These are relatively simple things to have removed, and if you are embarrassed about these, rest assured that they are very simple to treat. These are typically removed under local anaesthesia (as you might have during a visit to your dentist). A short visit to the office surgery center will have you rid of these in no time at all. Usually a couple of stitches will have to be used, so plan on coming back to the office within a week or two to have these taken out. Usually scarring is not a problem, and we have special scar treatment programs to prevent this problem anyway.

The basic mechanism is that ultraviolet light (aka UV radiation) causes damage to your skin’s DNA. I have already posted previously on the dangers of using tanning salons that promote UV exposure, and that this artificial UV light is a risk factor in melanoma(1) (a very serious type of cancer, sometimes lethal), as well as non-melanoma skin cancers(2). This is especially a problem in young people, who are at greater risk.

Your body does have a DNA repair process, that scans for and repairs errors, much like a disc checking program might check your hard disc for errors. The problem is that our bodies do not work at peak efficiency during the entire day: our repair system is optimal in the morning, and slacks off in the afternoon. So, if you are tempted to go out without any sun protection (listen up all you men out there- we know you just don’t get it(3)), you should do it in the morning. That way, you can time your greatest risk with your maximum preparedness. In other words, your cellular repair mechanisms will be at their maximal efficiency, and you stand a better chance of getting away with it.

1. Dore, J. F., Chignol, M. C. Tanning salons and skin cancer. Photochem. Photobiol. Sci. 11: 30-37, 2012.
2. Pfeifer, G. P., Besaratinia, A. UV wavelength-dependent DNA damage and human non-melanoma and melanoma skin cancer. Photochem. Photobiol. Sci. 11: 90-97, 2012.
3. Devos, S. A., Van der Endt, J. D., Broeckx, W., et al. Sunscreen use and skin protection behaviour on the Belgian beach: a comparison 9 years later. Eur. J. Cancer Prev., 2012.

A: Hi there: What you are describing is called “scleral show”, and it is a sign of an poor result from eyelid surgery.
‘Scleral show’ occurs when lower eyelids have been treated with traditional lower eyelid surgery, often seen with ‘lateral bowing’. What does that all mean?

Lower eyelid bags, ASAPS

The traditional (read “old way”) of doing eyelid tucks (blepharoplasty) was to cut away some skin from the lower eyelid, just below the eyelashes, and also to remove the fat bags from the lower eyelid.

When the eyelid has been operated on with these traditional techniques, the following results are common: The lower eyelid is smoother, but the lid no longer covers the lower part of the iris (the colored part around the pupil), and the shape of the edge of the lower lid is altered so that the lower lid dips downward towards the outer corner of the eye. The first part, where more of the ‘whites of the eye’ is revealed is called ‘scleral show’, and the second part where the outer part of the lower lid dips downwards is called ‘lateral bowing’ (think of the curve of a bow, as in bow and arrows). Both of these features are really bad, and do not look good at all. These results should be avoided at all costs.

These problems are best prevented by not damaging the essential supporting layers of the lower eyelid. The best techniques, in my opinion, avoid cutting through all the supporting layers of the lower eyelid. It is best to redistribute the fat from the lower eyelid rather than cutting it all out, and it is best to remove minimal or no skin separately while increasing the support of the lower eyelid at the same time. These problems can be fixed, depending on how badly damaged the supporting structures are, but it is much easier just avoiding the whole problem in the first place. Go to an experienced boarded plastic surgeon and ask about transconjunctival surgery and canthopexy (altering the fat from the inside of the eyelid, and supporting the lower eyelid). This type of operation avoids these problems entirely, and there is no scar on the lower eyelid at all. The ‘canthopexy’ refers to tightening the supporting layers of the lower eyelid so that they cannot droop downward. I have been doing this type of eyelid surgery for at least 18 years, and I find it to be a very reliable and successful technique that has very few problems or complications. The groove in the lower eyelid between the eyelid and the cheek bone can be nicely filled in by moving some of the fat bags into the groove. This has been called fat repositioning, and it works well, but sometimes a bit of fat has to also be cut away if there is too much of it. In fact, a clinical research study showed in 2008 that the main cause of large lower eyelid bags was an actual increase in the amount of fat (1), rather than just herniation (pouching out) of the existing fat. However, because the fat in the cheeks has been shown clinically to not only decrease in amount, but also drop downwards with increasing laxity of the ligaments and fibers holding it in place. Therefore, transferring some of the excess fat downwards into the groove from the eyelid makes sense from a clinical standpoint, since it is supported by research evidence. Treating the wrinkled skin with special lasers is also very effective in smoothing out the skin when using these techniques.

Claudio DeLorenzi MD FRCS copyright 2012

References
1: Darcy SJ et al, Magnetic resonance imaging characterization of orbital changes with age and associated contributions to lower eyelid prominence. Plast Reconstr Surg. 2008 Sep;122(3):921-9

Apparently, quite a number of people! Some of them have even died! Although these illegal injectors have been charged with all sorts of crimes, it does not magically bring their victims back. Some of these victims will have ill effects for life, and suffer the horrible deformities from years of chronic wounds and open draining sores on their bodies. But hey, they got a bargain, right?

Here are some examples:
Police in Philadelphia arrested Padge Victoria Windslowe on Feb 29-2012. She allegedly administered illegal “butt-enlarging” injections which may have caused the death of a 20 year old British woman (Claudia Aderotimi). In a separate case, Oneal Ron Morris was arrested in Florida for injecting cement, glue, and tire sealant.

Wait, there are more… Whalesca Castillo was arrested for injecting liquid silicone into the breasts and buttocks of her clients in New York. And meanwhile, in Miami, Ana Josefa Sevilla was charged with a similar crime after one her victims ended up in Emergency with complications from a similar scheme. There are more, but you get the idea.

This is surreal. Tire sealant? Bathtub caulk? Superglue? OMG, people, really?

It is easy to be a real specialist. Just go to university for 14 years and you’re done.

Or, you could go to the hardware store and pick up some “medical” supplies and do it yourself, right? Who needs to go to school for such simple stuff?

What ever happened to common sense? Ok, that is the end of my rant. But if anyone whisper’s to you, “Psst, hey, want a real bargain on fillers?”, hopefully you will now have enough sense to keep walking…

From a common sense standpoint, it is clear that facial cosmetic surgery does work to reduce your apparent age. As I have outlined in numerous previous blogs, the goals of surgery are different for each patient, but there is much common ground. The signs of youth include the overall shape of the face, with more volume in the upper face, less loose skin around the upper and lower eyelids, and a tighter neckline. Although we can fill up some of these areas with so-called ‘minimally invasive’ techniques, such as with dermal fillers, and we can slightly tighten the skin with different forms of light or electrical energy or even ultrasound, surgery is the mainstay and the gold standard to which all results are compared.
With surgery, we can reposition fat and restore tone, and remove some skin excess, where present. When combined with volume replacement, either with dermal fillers or your own natural fat, the results are good to very good. Restoring the youthful tone to the skin, and removing sun damage and wrinkles with laser resurfacing, elevates the results to excellent. There is no question now that these multi-pronged (multi-modality) approaches give the best results. As always, remember that the best results are natural results. You should never notice good surgery, because you can’t tell.
I was recently watching some DVD’s of a TV series (I hate live TV because of the ongoing commercials), and I could see the pull lines on a middle aged actress’ face. I would give her surgical results a “B minus” grade, because the surgeon did not use volume to restore the three dimensional shape of the her face. Pulling on the skin is an old technique, and in my opinion should not be used on its own because it flattens the subtle curves that define the face. Pulling on the skin of the cheek, without restoring volume, results in a flatter cheek. It seems like some surgeons are more interested in re-upholstering than rejuvenating their patients! In my opinion, the best results come from multi-pronged approach that addresses problems at each tissue layer. Just redistributing wrinkled skin is not a good solution. It is like sending your old couch back to get repaired, and they return it to you with the same old cloth it had when you sent it in! The wrinkles and age spots should be treated, as well as any laxity. Finally, any loss of fat from the face should also be treated with replacement from the patient’s own body. Doing that will give a great overall result that lasts a long time and does not look “done”. Remember that you will never notice good plastic surgery!

Copyright Claudio DeLorenzi all rights reserved 2012

References:
Chauhan N et al. Perceived Age Change After Aesthetic Facial Surgical Procedures. Archives of Facial Plastic Surgery, Published online February 20, 2012. doi: 10.1001/archfacial.2011.1561

Photo of two capsules from a different patient, showing broken implant and chalky calcium buildup in the capsule that has been opened. The other capsule containing the implant is shown in the foreground.

Silicone may raise fears, but in practical terms, silicone is one of the safest, most inert substances for medical devices. That is why it is used in most joint replacements and pacemakers as well as hundreds of other medical devices. Furthermore, silicone is used as a lubricant in most syringes, such that you do get a little bit of silicone injected every time you get an injection (a flu shot, for example). Diabetics, who inject themselves with insulin several times per day may inject a significant amount of silicone every year. But, although silicone is safe, there are problems that can occur with breast implants. I will describe the important ones below.

Old implant, removed with capsule shown in other photo.

Capsule removed at surgery. Note some calcium build up inside this capsule. Newer implants do not seem to form this type of crunchy calcium buildup in the tissues.

The most common problem of breast implants is called ‘capsular contracture’. Whenever anything is inserted into the human body, the body wraps it in scar tissue. When the scar tissue is thin and loose, the implant will feel soft and will move a little bit when it is touched (that’s normal). If the scar becomes thick for whatever reason, the implant will start to change shape. All scars will shrink somewhat (you may have noticed that on your own body- a 5 cm cut will end up as a ~4 cm scar!).

The degree of shrinkage which occurs in this scar tissue will determine whether or not the implant feels soft. Capsular contraction can occur at any time, but most often it occurs within a few months of surgery. I have personally seen it happen many years after surgery, associated with a cold or flu, or sometimes after a mild to moderate injury to the breast, even after a routine mammagram.
The actual cause of capsular contraction is unknown, but recent work has strongly suggested a relationship to bacteria. Contamination of the breast implant, either during surgery or after surgery appears to be the most important factor (in fact, the patients most likely to have a capsular contracture are those patients who had one previously). How could a breast implant become ‘contaminated’ after surgery? It turns out that the breast tissue itself in many women is colonized by some bacteria that live inside the breast (for example, inside the little tubes that breast milk passes, the lactiferous ducts). These bacteria are usually harmless, like the ones that normally live in your skin, your mouth, and inside your intestines and everywhere else on our bodies (these are called commensal organisms, and they live with us our whole lives). However, in the presence of an implant, these bacteria can adhere to the implant and start to create a reaction (called a biofilm), and the body responds by building up more and more scar tissue. The final result is a breast that is too round (like a ball) and too firm. Some of these get so hard and firm that they cause discomfort. The treatment of capsular contracture is surgical, since none of the non-surgical methods ever tried has been effective in stopping the progress of contraction. Complete removal of the implant and the capsule is the treatment of choice. Whether or not to replace the implant is the important question. If you have bacteria that live inside your breast, then any implant will likely undergo the same process, and expecting a different result is not reasonable. There is a medication (called zafirlukast) which I have tried on occasion, but this has not been satisfactory in actual use (not to mention that Health Canada has issued a warning that this medication can cause permanent liver damage!). There is hope however, since some manufacturers are working on a special coating that will help put antibiotics on the surface of the implant, so that it slowly dissolves and releases a tiny amount of antibiotic into the surrounding tissue over a prolonged period. These are nowhere near actual clinical release however, and it will be several more years before we see this available for clinical use. For now, surgery is the best method of management, with one proviso. If you have had two capsular contractures following good surgery that was properly done, and you have had a contracture each time, ‘then three strikes and they are out’! The risk of getting a problem is about 3 in 100 patients in my practice. Most patients have a good outcome, and they don’t have any complications. But, what if you happen to be one of the three out of a hundred? Remember, that any operation can have complications, that is a fact of life. Calcium buildup inside the capsules of older implants was often seen (see photos). These can be of a chalky consistency, or sometimes of an egg shell (crunchy) consistency. I do not see this type of problem in implants inserted in the 1990′s and beyond, since a new type of barrier membrane was used in the shells of the implants.

Capsular contracture, resulting in rounding of the right breast. The right side feels too firm.