Before Breast Augmentation

After Breast Augmentation

There are many different sizes and shapes of silicone and saline breast implants which are very safe that can give you very natural looking breasts. You can be pretty much any size you want to be with breast augmentation.

Dr Koo will show you many many before and after pictures of women who have had the same procedure that have breasts that resemble yours. She will also show you pictures of women who have similar height and weight as you to give you a better idea of the shape and size you might want for yourself.  Dr Koo will spend as much time with you as you want to determine what is the perfect breast implant size and shape is for you and whether you should have the breast implant placed under the muscle or breast tissue. These choices are determined by the shape of your breasts, how much breast tissue you have, how low or high you want your breasts and the incision she chooses for your breast augmentation.

She will be able to create the sexiest yet most natural looking and feeling breasts for you with the perfect breast implant for your body.

The first thing you should know about breast augmentation is that this will not be your last surgery. You will need to plan for at least 2 or 3 more surgeries in your lifetime depending on your age at the time of your first breast augmentation. Your breast implants will last approximately 20 years whether it is silicone or saline. Dr Koo recommends that you change the silicone implant at about the 20 year mark or when there is a change in the way the breast implants feel or look.

If your saline breast implants rupture, you will notice a change in size within 3-5 days of the rupture. The saline will be absorbed by your body and the ruptured side will be smaller than the breast that has not ruptured. You should then have BOTH breast implants changed and start at time zero with both breasts.

If you have silicone breast implants, you may not have to change your implants until there is a change in the way your breasts look or feel. Dr Koo’s recommendation is to change the breast implants at approximately 20 years or before if there is a problem. If, however, you are not having any problems, you can wait until there is some change.

Mammograms are recommended yearly starting at age 40. If you have a family history of breast cancer you might need a mammogram as early as age 30 or 35 depending on your breast examination. Dr Koo always follows her patients on a yearly basis without further charge and encourages women to see her every year to teach them how to examine their breasts and to educate them as to how their breasts feel with implants in place.

Dr Koo places the implants over and under the muscle and decides which is the perfect position for you depending on how much breast tissue you have, where your breasts fall in relation to the inframammary crease, and your desire to have higher or lower breasts. There are many many subtleties of breast augmentation and the type and placement of the breast implants that Dr Koo will determine for you and guide you for creating the perfect, sexy natural breasts that can be created with breast implants.

Call Dr Michele Koo, MD, FACS, Board Certified Plastic Surgeon, St Louis, Missouri for the most natural looking and feeling breast implanted breasts possible. She will take care of you throughout the years.

For more information about breast feeding and breast implants and the need for breast lifts after children and as the breasts age with implants in place, see the next blog coming up.

Dr Michele Koo, MD, FACS is a Board Certified Plastic Surgeon in St Louis, Missouri who has extensive experience with Juvederm and other fillers to minimize and plump those deep creases on your face. In 30-40 minutes in the office, Dr Koo will be able to fill those deep nasolabial folds, corners of your downturned mouth, and soften your lips to keep you from looking so sad and gaunt.

As we age and try to eat right and maintain our weight, our faces become volume depleted and the lines seem to deepen as the skin begins to lose its elasticity. With BOTOX AND JUVEDERM (FILLER), Dr Koo is able to soften your face and fill those deep crevices of your nasolabial folds and marionette lines of your chin. She can just ever so slightly plump your lips so your face is not so drawn and shrunken. Dr Koo is very subtle and gentle with her application of BOTOX AND JUVEDERM and you will not appear “done” or obvious with your BOTOX AND JUVEDERM. You will look rested and rejuvenated in 30 minutes!!

Dr Koo wants you to understand the safety of JUVEDERM and the following is the continuation of the article by Dr Mary Lupo as it appeared in the Plastic & Reconstructive Journal, January 2008.

Safety
The occurrence of treatment site reactions was similar for Juvéderm Ultra Plus and Zyplast. The majority of individual treatment-site reactions (e.g., erythema, induration, pain, edema, nodule, bruising, pruritus, and discoloration) lasted for no more than 7 days and were mild or moderate in severity, with no intervention required. No hypersensitivity reactions were reported for Juvéderm Ultra Plus, and there were no serious treatment-related adverse events.

Effectiveness
Initial Treatment Period
Although the mean correction after treatment was similar for both products, nasolabial fold severity scores from the treating investigators for the Juvéderm Ultra Plus filler were significantly better (lower) than for Zyplast at each follow-up time point from 4 to 24 weeks (Fig. 1). Over the 24-week period, the scores for Zyplast nearly returned to baseline (mean, 2.5), whereas the Juvéderm Ultra Plus scores remained low (mean, 1.3-equivalent to a mild wrinkle). Not surprisingly, the level of improvement in nasolabial fold severity score for both fillers was greatest at 2 weeks after the last treatment. At 24 weeks, the mean improvement was still 1.7 with the Juvéderm Ultra Plus product but only 0.5 with bovine collagen (Fig. 2). Clinically significant improvement (defined as mean greater than or equal to a one-point improvement relative to baseline) was maintained with Juvéderm Ultra Plus but not with bovine collagen at 24 weeks after optimal correction was achieved. The proportion of nasolabial folds showing significant improvement was consistently high for Juvéderm Ultra Plus (≥96 percent) but not so with collagen (41 percent at 24 weeks). Furthermore, 67 percent of the Juvéderm nasolabial folds had at least a two-point improvement at this 6-month visit (Fig. 3). Subject assessments of effectiveness were similar to those of the investigators. An overwhelming majority of subjects preferred Juvéderm Ultra Plus (85 percent) versus collagen (10 percent) or no preference (5 percent).

Among the subjects who returned at 1 year or beyond, assessments just before repeated treatment showed that 81 percent of subjects with severe nasolabial folds at baseline who were treated with Juvéderm Ultra Plus had maintained at least a one-point improvement in nasolabial fold severity and that 38 percent had at least a two-point improvement (Fig. 3), with a mean improvement of 1.3.

Repeated Treatment Period
The volume of Juvéderm Ultra Plus required to achieve optimal correction was significantly less at repeated treatment than at initial treatment. The median volume of Juvéderm Ultra Plus injected at initial treatment was two syringes (1.6 ml), and at repeated treatment 6 to 9 months later it was less than one syringe (0.7 ml).

Trends in Wrinkle Assessment Scale scores for the subset of subjects who were followed up to 48 weeks after their repeated treatments mirrored those observed in the initial study period. Although the sample size was small at 48 weeks, clinically significant mean improvement was still observed for Juvéderm Ultra Plus (Fig. 4), and 88 percent of the severe nasolabial folds treated with Juvéderm Ultra Plus in the original study and at repeated treatment still had a clinically significant correction at 1 year after repeated treatment despite the significantly lower injection volume at repeated treatment.

Continued in Next Blog

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI wants you to know that JUVEDERM and BOTOX are an extremely safe, economical way with no down time to soften your face in a significant way by smoothing and filling in the facial wrinkles that make you look tired and older than you are. Why always be asked if you are mad or tired? Take charge of your life and in 30 minutes in Dr Koo’s office rejuvenate your face with JUVEDERM AND BOTOX to lift up the frowns around your mouth, ever so subtlely plump your lips, and fill in those deep nasolabial folds.

Dr Koo wants you to know that JUVEDERM AND BOTOX are extremely safe and has been FDA approved for facial use to fill creases and smooth the dynamic lines of your face around the eyes and forehead.

The following is a continuation of an article by Dr Mary Lupo, published in the Plastic & Reconstructive Journal, January 2008. Dr Koo hopes that this is helpful information to let you understand the fillers that are available and to realize that the fillers are very safe.

One small open-label study in France treated 49 subjects with Juvéderm 30 in either one or two of four possible injection sites, the nasolabial folds (59 percent), upper lip (37 percent), glabella (16 percent), and bitterness folds (10 percent).4 Most subjects had a touch-up at 1 to 2 months after treatment, with a mean of 0.6 ml administered at each session. Wrinkle severity improvement of approximately 50 percent on a five-point scale remained stable up to 11 months after initial treatment.
Interestingly, in our study, the nasolabial folds initially treated with Zyplast returned almost to baseline after the initial 24-week period, but subsequent treatment with Juvéderm Ultra Plus resulted in the same duration of clinically significant improvement as seen in the nasolabial folds originally treated with Juvéderm Ultra Plus.

The most significant finding from our studies is the extended duration of correction for Juvéderm Ultra Plus, in particular, for severe folds. Other resorbable fillers (collagens and hyaluronic acids) have not been proven to last beyond 6 months. The most comparable product, Perlane, was developed to treat deeper folds in that it is indicated for injection into the deep dermis and has larger hyaluronic acid gel particles than its sister product Restylane, both from Medicis Aesthetics (Scottsdale, Ariz.).5 Juvéderm has a different manufacturing process that creates a homogenous gel without a granular consistency.

In a split-face study comparing Perlane to Zyplast in 68 subjects with a range of different wrinkle severities from mild to extreme, 26 percent were classified as having severe nasolabial folds before treatment, although results were not stratified by baseline nasolabial fold severity.6 At 6 months after optimal correction, 59 percent of all Perlane-treated folds maintained correction, as opposed to the 96 percent noted in the Juvéderm Ultra Plus severe folds study. Moreover, at 9 months, only 49 percent of the Perlane folds were rated as superior to Zyplast, with 37 percent showing equivalency between Perlane and Zyplast and 14 percent showing Zyplast to be superior to Perlane.

Given that Juvéderm Ultra Plus outlasts the temporary dermal fillers, perhaps it should be compared with the semipermanent fillers Radiesse (BioForm Medical, San Mateo, Calif.) and Sculptra (Dermik Aesthetics, Berwyn, Pa.). Radiesse consists of synthetic calcium hydroxylapatite microspheres suspended in a gel of glycerin, water, and sodium carboxymethylcellulose.7 Following injection, the gel dissipates, collagen production is stimulated for volumizing, and phagocytosis gradually breaks down and eliminates the microspheres.

In December of 2006, the U.S. Food and Drug Administration approved Radiesse for correction of moderate to severe facial wrinkles and folds such as nasolabial folds and for facial lipoatrophy in people with human immunodeficiency virus,8 although the product had earlier been approved for other uses such as vocal cord augmentation and was used off-label, particularly for deep creases such as severe nasolabial folds.9 The pivotal trial involved 117 subjects treated with Radiesse in one nasolabial fold and human collagen in the other nasolabial fold with up to two touch-ups allowed at 2-week intervals to attain optimal correction (mean Radiesse injection volume, 1.2 ml).8 Rated on a six-point scale using blinded photographic assessments, the mean improvement in wrinkle severity at 6 months was 1.3 (compared with 1.7 on a five-point scale for Juvéderm Ultra Plus at the same time point), and no long-term data were provided.

In a small open-label study, patient self-reports showed duration of nasolabial fold correction of 10 to 12 months for four of 18 subjects and greater than 12 months for 14 of 18 subjects.10 Another open-label study was based on surveys sent to 609 subjects who had received Radiesse injections to the nasolabial folds or other facial areas.11 Responses to the 6-month survey were received from 155 subjects, and responses to an additional survey sent between 12 and 24 months after initial treatment were received from 112 subjects. Average subject satisfaction at 6 months was 3.9 on a five-point scale (with 5 being most satisfied). In the 12- to 24-month survey, 69 percent reported satisfaction, although the most common comment was thought it would last longer. Importantly, 84 percent of subjects (n = 512) required repeated treatments to achieve or maintain optimal correction. Of those, 63 percent had touch-ups at 4 to 6 weeks and 53 percent at 5 to 9 months.

Sculptra is an injectable poly-L-lactic acid indicated for correction of lipoatrophy though, like Radiesse, it is used off-label for cosmetic wrinkle correction and volumizing. The product must be reconstituted with water at least 2 hours before injection, and the correction fades within 1 week as the fluid is absorbed. The mechanism of action is the stimulation of collagen production, which requires several injections at intervals of at least 2 weeks to generate cosmetic improvement.12 Clinical studies on Sculptra have focused on human immunodeficiency virus-positive subjects with facial lipoatrophy13; thus, the longevity of correction in facial wrinkles is unknown.

One salient point about the semipermanent fillers is that they are generally injected through larger needles than used with collagen or hyaluronic acid-based fillers to prevent the particles in the product from clogging the needle. A 25-gauge needle is preferred for Sculptra,14 and a 25- to 27-gauge needle is recommended for Radiesse,15 with a larger needle having greater propensity to generate tissue trauma and pain on injection. In contrast, Juvéderm Ultra Plus is injected through a smaller 27-gauge needle.2 Moreover, Radiesse and Sculptra are intended for placement only in the deep dermis or dermal-subcutaneous junction and do not have the flexibility to treat finer wrinkles and folds, as can Juvéderm Ultra Plus.

CONCLUSIONS
Juvéderm Ultra Plus represents an excellent combination of attributes for a dermal filler. Permanent products bear some long-term risk if the initial correction is excessive or misapplied and can result in an unnatural appearance as aging tissues shrink and make the filler visible.16 Semipermanent fillers, in contrast, are prone to the problems endemic to the particulate nature of these products, may require larger needle sizes, and have limited utility in superficial defects or wrinkles. Juvéderm Ultra Plus may have found the sweet spot of an ideal duration for wrinkle correction with a good safety profile.

DR MICHELE KOO, MD, FACS, BOARD CERTIFIED PLASTIC SURGEON, ST LOUIS, MISSOURI wants you to have to latest information of the research on BOTOX AND JUVEDERM. This is the continuation of the article by Dr Mary Lupo published in Plastic and Reconstructive Surgery Journal, January 2008.

Dr Koo stays ahead of the learning curve and constantly re-evaluates the products available to you as well as her own results to give you the best and newest most optimal treatments. Furthermore, she performs all of the treatments herself and follows you very closely so as to tailor all future treatments for you so they will be as perfect as possible for your skin and face. Dr Koo believes in custom tailoring your treatment. She is respecful of your budget and time and will discuss all the options available to you for smoothing the wrinkles on your face and softening the years away with filler.

This continues the article on Juvederm by Dr Mary Lupo as published in Plastic & Reconstructive Surgery January 2008.

Subjects in the subset with severe nasolabial folds (Wrinkle Assessment Scale grade 3) were included if they had fully visible bilateral nasolabial folds that were severe at the deepest part (as assessed by the evaluating investigator) and were approximately symmetrical and of equal severity on each facial side. Exclusion criteria included hypersensitivity to bovine collagen or hyaluronic acid; history of atopy, anaphylaxis, multiple severe allergies, or allergy to meat or lidocaine; current immune therapy or history of autoimmune disease; tendency to develop hypertrophic scarring; use of oral retinoids or, in the nasolabial fold area, over-the-counter or prescription antiwrinkle treatments, microdermabrasion, or chemical peels in the 4 weeks before randomization; and any cosmetic procedure or tissue augmentation at the nasolabial folds in the 6 months before study entry.

Subjects were eligible to enroll in the repeated treatment study if they completed the initial 24-week period, indicated at the final visit that the Juvéderm-treated side was preferred, and the repeated treatment was performed between 24 and 36 weeks (±14 days) after initial optimal correction was achieved in the pivotal study. The main exclusion criteria included facial hair that would interfere with the visual assessments of nasolabial fold severity and having undergone or having plans to undergo any tissue augmentation with temporary, permanent, or semipermanent dermal fillers; botulinum toxin injection; laser resurfacing; dermabrasion; chemical peel; or face lift in the lower two-thirds of the face less than 30 days before the repeated treatment or at any time thereafter through the end of the extended follow-up period. Eligible subjects underwent their repeated treatment to both nasolabial folds on the same day with the same Juvéderm formulation that was used during the pivotal study treatment.

Statistical analysis was performed on the intent-to-treat population for effectiveness data and on the as-treated population for safety data. A value of p < 0.05 was used to determine statistical significance. The improvements in nasolabial fold severity score were compared with baseline using a signed rank test, and the proportion of nasolabial folds with a clinically significant improvement (one or more point decrease on the five-point scale compared with baseline) was evaluated using a McNemar test. Mean nasolabial fold severity scores were compared against the control by means of generalized estimating equations analyses.

RESULTS
Subjects
The initial study enrolled 439 subjects through 11 investigational sites across the United States. A total of 87 subjects with severe nasolabial folds (both nasolabial folds rated as a 3 on the five-point scale) were randomized to treatment with Juvéderm Ultra Plus in one nasolabial fold and Zyplast in the opposite nasolabial fold. Nearly all [n = 82 (94 percent)] of the subjects completed the 24-week follow-up period and most [n = 70 (81 percent)] of the subjects returned for the complimentary repeated treatment. Because of varying circumstances (e.g., scheduling issues, Hurricane Katrina), a small number of subjects (n = 16) had effectiveness evaluations 1 year or more after their last study treatment (before any repeated treatment). These subjects were statistically similar to the other study subjects in terms of injection volume and nasolabial fold severity at 6 months. Thus, these subjects’ long-term results (i.e., effectiveness at 1 year or more) can be extrapolated to the overall population.

Demographic data revealed that most subjects were female Caucasians with a mean age of 49 years (range, 26 to 74 years). The full range of Fitzpatrick skin types was represented, and 36 percent of subjects had darker skin types (Fitzpatrick types IV through VI).

Five of the original 11 sites participated in the repeated treatment study, enrolling 17 subjects from the Juvéderm Ultra Plus severe fold baseline cohort, all of whom completed the originally planned 24-week follow-up period after repeated treatment. Although the 48-week time point had already passed for a number of these subjects before the protocol amendment extending the study, eight subjects enrolled and received an effectiveness assessment at 48 weeks. Demographic details for those subjects participating in the repeated treatment study were similar to the original study.

Continued on Next Blog

The advantage of something like BOTOX and Juvederm is that it only takes 20-30 minutes in your plastic surgeon’s office. The disadvantage of course is the cost and you must maintain the BOTOX every 3-5 months and the filler every 12-18 months. However, if you start BOTOX before the lines and creases become deep and relatively permanent, your skin will stay quite a bit more smooth and youthful appearing as you age.

The animation muscles of your face have worked all of your life, your skin is much more resilient during the first 25 years and therefore you see no lines and creases. As you incur sun damage along with age, your skin begins to show the results of that muscle action and sun exposure as well as exposure to toxins such as nicotine from cigarettes if you are a smoker.

It is better to start with the BOTOX in the mid to late 20’s to prevent the deep creases from ever beginning. There really is no age limit on the other end except that the BOTOX and fillers are not as effective if there are so many creases and they are so deep. Same thing for the fillers in that you will need so much more filler if your wrinkles are extremely deep and you in fact may need to have the skin redraped with surgery in addition to the filler to regain softness and volume to your face.

The following exerpt continues the information from the study by Dr Mary Lupo published in Plastic and Reconstructive Surgery, January 2008. Dr Michele Koo hopes that this is helpful and that you understand that outcomes and effects are continually being studied and monitored by plastic surgeons throughout the country to ensure the safety of the products we use for WRINKLE REDUCTION.

Dr Koo is extremely respectful of your time and money and will only use what she feels is the best product for you and will not use any more than you need to address your concerns. She truly believes that often, “less is more” and that subtlety is the key to looking better without looking done.  Why should anyone know what your secret is. Dr Koo will be your best kept secret on the War Against Wrinkles.

With the baby boomer generation firmly ensconced in middle age, there is increasing interest in maintaining a youthful appearance to match this energetic generation. After the 2002 U.S. Food and Drug Administration approval of botulinum toxin type A (Botox Cosmetic; Allergan, Inc., Santa Barbara, Calif.) for treatment of glabellar lines, nonsurgical correction of wrinkles became a possibility. With Botox management of dynamic wrinkles, a plethora of new dermal fillers are vying to address static wrinkles, providing an overall rejuvenation of the aging face.

Among these promising new treatments is the family of Juvéderm hyaluronic acid dermal fillers (Allergan), approved in the United States in 2006 for treatment of facial wrinkles and folds. Juvéderm Ultra Plus Injectable Gel has a high degree of cross-linking, which makes it particularly well suited for volumizing and correcting deeper folds and wrinkles.2 Patients with deep facial wrinkles and folds are generally at a disadvantage when it comes to cosmetic correction, as they require a large volume of dermal filler and their correction may not be sustained; thus, a filler that is specifically designed to treat severe wrinkles is an important advancement.

Results from the randomized, controlled study of three Juvéderm formulations compared with bovine collagen have been published previously.3 We sought to further characterize the clinical characteristics of Juvéderm Ultra Plus treatment (and to compare this to bovine collagen treatment) among subjects who had severe nasolabial folds before treatment.

A multicenter, double-blind, randomized, within-subject, controlled study was conducted as part of a submission for approval by the U.S. Food and Drug Administration. This study compared three different formulations of Juvéderm against bovine collagen (Zyplast; Allergan). One-third of subjects were randomly assigned to receive treatment with Juvéderm Ultra Plus, containing 24 mg/ml of cross-linked hyaluronic acid, in one nasolabial fold and Zyplast in the other. Results presented here are limited to those subjects who received Juvéderm Ultra Plus and had severe folds at baseline.

Blog to be Continued in What age is good to start BOTOX…