Dr. Richard Moss, Boston breast enlargement expert has 27 years experience with breast augmentation and has some definite ideas as to what offers great value and what does not. “First and foremost I feel that a patient interested in breast augmentation surgery needs to select a physician who is board certified in Plastic Surgery for her breast augmentation surgery. Plastic Surgery residency programs are the only residency programs that train surgeons in breast augmentation surgery.”

Patient before incision	Sizer for stretching breast

“Experience is another important factor,” Dr. Moss explains. “Not only do I have 27 years experience with breast augmentation, I also have almost 15 years experience implanting silicone gel breast implants. Many surgeons have experience that began only in 2006 when the newer style silicone gel breast implants received their FDA approval for sale in the United States. I have experience with the earlier models of silicone gel implants from the 1980’s and 1990’s as well as the newer models from 2006.”

“I have found that pricing is a factor that is very important to patients, more so than I would have thought. However, it is very important to know what exactly you are getting for the price you are paying,” Dr. Moss stresses. While the price we charge for breast augmentation is very competitive we offer much more than many patients realize when they first call.”

Besides the surgical fee, silicone gel implants, hospital fee, and anesthesia fee, Dr. Moss’ pricing includes quite a few additional items that provide for a more pleasant experience and can contribute to a better outcome. Dr. Moss, Boston, breast augmentation specialist explains, “The price quoted to the patient includes 2 bras as well as a state of the art pain suppression pump, and the Marcaine medication that is used in conjunction with this pump. Patients don’t have to worry about purchasing bras for surgery and my staff will assist them with proper fitting. In addition, the pain suppression pump that I utilize with my breast augmentation patients allows them greater post operative comfort and it most likely results in patients needing less pain medication the first night. We have definitely seen a difference in the amount of pain and discomfort that patients experience post operatively, when the pain suppression pump is used,” continues an enthusiastic Dr. Moss.

Breast sizer being inserted – left breast	Breast sizer with syringe attached for filling right breast

The other two items that Dr. Moss includes in his surgical fee is the use of 2 disposable breast implant “sizers” for the use of stretching the breast cavity to accept the pre-filled silicone gel implant and the Keller Funnel for the purpose of placing the gel implant into the breast cavity. The Keller Funnel prevents the silicone gel implant from touching the patient’s skin during placement as well as reducing stress on the implant during implant placement. The Keller Funnel also allows surgeons to use the same small incision for placement of silicone gel filled implants as for saline filled breast implants. Boston plastic surgeon Dr. Moss relays, “Most patients are unaware of the surgical challenges presented when trying to place a relatively large implant into a breast cavity. Unlike the saline filled breast implants which are implanted in a deflated form and then filled, the silicone gel filled implants are manufactured in a filled state and are therefore more challenging to implant.”

Patients easily understand the added benefits such as bras and a pain suppression pump. It can be more difficult for them to understand the benefits of surgical equipment that is utilized during a surgical procedure to make the procedure run more smoothly. For this reason, Dr. Moss has absorbed the cost of the breast implant “sizers” and the Keller Funnel in his surgical fee. He did not raise his price when he added these two items to his surgical regimen. “I feel that having the implant “sizers” and Keller Funnel available during surgery allows me to do a better job for the patient and also allows me to give her a greater selection of implant size choices,” states Dr. Moss.

Breast sizer being filled – right breast	Breast sizer being filled with more – right breast

Another benefit that Dr. Moss feels he offers patients is the extensive consultation that is initially provided. “I sit down with my patients and spend a full hour to review all of the pertinent information. I also examine every patient at her consultation. Plenty of time is allowed during this consultation to answer any questions a patient might have. I want a patient to leave her breast augmentation consultation, feeling confident that she has all the information to make a decision, and has had all her questions answered,” he further explains.

Another added benefit in choosing Dr. Moss for breast augmentation surgery is the breast implant sizing experience that is provided at both the initial consultation and the pre-operative visit. “A major factor in the success of a patient’s breast augmentation surgery is the size selection of the breast implant,” states Boston breast augmentation expert, Dr. Moss. “This relies on a patient’s input and I have found that the best way to assist a patient in selecting the size is to allow her to try breast implant samples on with a sizing bra. In my experience this provides for a much happier patient than me trying to guess what she thinks she wants,” he further elaborates. “There is no standard in the bra industry and many patients already own different size bras, so trying to guess what size a patient wants based on a bra size can be problematic. I avoid these problems by allowing time for breast implant sizings, supervised by my competent staff.”

Breast sizer – right breast filled	Both breasts with implant sizers filled

Breast Augmentation surgery continues to be the most popular cosmetic surgery procedure. There are many factors that a patient should consider when selecting a plastic surgeon. While pricing is important, it is also essential to choose a plastic surgeon that has experience, an excellent reputation, and provides the necessary time to explain the procedure properly. If you are interested in breast augmentation surgery call Dr. Moss’ office at 508-747-1322 or 781-337-2421 and inquire about a consultation with Dr. Moss.

Keller Funnel out of packaging	Trimming the Keller Funnel to accept the implant size

“Regardless of how much experience one has with silicone gel implants it always is a bit of a struggle to get the implant in.” Dr. Moss further elaborates. “And the larger the implant, the more of a struggle it can be to push it through a small incision.” Dr. Moss knew the minute he saw the Keller Funnel for the first time that he wanted to try it.

Pouring breast implant into Keller Funnel	Keller Funnel with implant loaded

“I loved it the first time I tried it.” It turns out that there are more benefits than just an easier surgery. With time, the Keller Funnel is being thought of as not only better for the surgeon, but also better for the patient. The Keller Funnel allows the surgeon to insert a silicone gel implant through a smaller incision which all patients like. Because it allows for easier insertion, it limits stress to the shell of the breast implants. Boston plastic surgeon Dr. Moss believes that the Keller Funnel also may reduce trauma to the patient tissue because there is less of a struggle to insert the implant. And lastly it allows the implant to be implanted without it touching either the surgeon’s surgical gloves or patient’s skin. This is considered excellent surgical technique, and it is thought by many, that this feature may reduce the chance of either infection or capsular contraction.

Implant positioned in funnel	Keller Funnel being placed into incision – right breast

So what does the Keller Funnel look like? “Sometimes the simplest tool can provide the greatest solution for a difficult task,” says Dr. Moss, Boston Breast Augmentation specialist. The Keller Funnel looks like a pastry funnel. It is made of nylon and is coated with a patented material called LubriLAST™. The effectiveness of the Keller Funnel is due to the combination of design elements including the LubriLAST™ coating. LubriLAST™ is a water activated lubricious coating that makes the breast implant slide very easily through the opening in the smaller end of the Keller Funnel into the breast implant pocket.

Keller Funnel introducing breast implant into the left breast	Keller Funnel squeezing to introduce implant

Dr. Moss determined that after a few surgeries with the Keller Funnel, that it provided such an advantage that he currently uses it for all silicone gel implants of at least 300cc. Even though the Keller Funnel costs $130 each he has decided to use it without charging the patient any additional fees. “Sometimes you know something is just better for the patient and you can’t always expect the patient to thoroughly understand surgical technique. If I made it optional some patients might not want to pay the extra $130. At the same time, I understand that in this economy some patients might find the extra $130 difficult for them to afford. For these reasons I just decided to use the Keller Funnel whenever I wanted and not to pass the cost on to the patient,” Dr. Moss explains. “I think that this has been a wise choice.”

Both implants in position – last layer of closure	Surgery finished – bra in place

Dr. Moss always takes the time to explain the Keller Funnel to all of his breast augmentation patients who are considering breast augmentation with silicone gel implants.

So what are the national statistics when comparing 2009 to 2008 and how does Dr. Moss compare?  When looking at the statistics for major cosmetic surgical procedures for 2009 compared to 2008, nationally there was a 17% decrease in the number of procedures.  “I saw less than a 10% decrease in major surgical procedures when comparing 2009 to 2008.  The more minimally invasive non-surgical treatments such as Botox® and Juvederm® were not affected as greatly as the more expensive surgical procedures.  “It is easier for a patient to spend $400-$700 for a treatment with Botox® that requires no time off from work, states Boston Botox specialist, Dr. Moss, as compared to $5500 to $6500 for breast augmentation surgery that requires 1 to 2 weeks time off from work.  The national statistics show that non surgical procedures such as injections were up slightly (.6%).  “I was fortunate in that I experienced a 10% increase in my facial injectable treatment business,” states an enthusiastic Dr. Moss.  Whenever, we had a chance, we would have “specials” that allowed patients to save monies on their Botox®, Juvederm®, and Radiesse® treatments.  I also made sure that my patients were able to take advantage of all of the rebates and special offers that Allegan (makers of Botox® and Juvederm®) provides.  This year, because of my high volume, I am able to offer the “Brilliant Distinctions” discount program to my patients.  We discuss this discount program with any interested patient.

Breast augmentation continues to be the most popular cosmetic surgical procedure in the United States and this is true for Dr. Moss’ practice.  “Hands down breast augmentation surgery is by far, my most popular cosmetic surgical procedure,” states Dr. Moss.  About 40% of my practice is breast enlargement surgery.  It is very popular and I find that my patients come from all over the state as well as many of the other New England states.  I offer very competitive pricing with many added benefits.  My initial consultation for breast augmentation is one full hour with me followed by 1-2 hours with my staff performing an implant sizing, photos to take home, as well as reviewing costs and scheduling availability.

Our pricing also includes a state of the art pain suppression pump, 2 bras, and for the silicone gel breast implant patients, the new Keller Funnel.  The Keller Funnel allows a surgeon to insert the silicone gel implants with far less stress to the implant and the funnel prevents the implant from touching the patients’ skin, which can help prevent infection at the wound site.  Despite the fact that the Keller Funnel costs $130 per device, Dr. Moss has decided to absorb the cost of this product and not increase his surgical fee.  “One of the reasons for my success in these difficult economic times is that I have chosen to spend money where I feel the cost will significantly increase the quality of the surgical procedure.  In addition, I have not passed these costs on to the patient, but rather absorbed them myself.  Yes, it means that I make a little less profit per procedure, but in the long run, I continue to have a very successful practice, at a time when many surgeons are finding it difficult to have a practice that is supported exclusively with cosmetic surgical procedures.  I consider myself lucky and am appreciative that patients are choosing my practice so frequently for their cosmetic surgical and procedural needs.

Abdominoplasty and rhinoplasty surgeries also made the top 5 procedures nationally in 2009.  These are also included in Dr. Moss’ top 5 procedures.  Dr. Moss is well known locally for the abdominoplasty procedures that he performs using the “progressive tension suturing” technique.  The major benefit of progressive tension suturing is that it eliminates the need for post-operative surgical drains.  It also reduces the stress on the incision and provides for an easier recovery.  In addition, he has worked with the anesthesiologists to provide an epidural for pain relief post operatively.  And as with all procedures he has kept his price reasonable.  “Again, I feel that the reason for my success in these tough economic times is that I provide patients with a high quality surgical procedure that has been very well thought out as to how we can make the patient as comfortable as possible after the surgery.  And I am able to deliver this high quality of service at extremely reasonable costs.  This,” states Dr. Moss “is the very essence of my success.”

“Rhinoplasty is another surgery that I feel that my practice excels in,” Dr. Moss further elaborates.  I have always been very interested in rhinoplasty surgery and am careful to stay current in the training and trends.  Being board certified in Otolaryngology (ear, nose and throat) provided me with a strong base of knowledge to learn rhinoplasty surgery when I was a Plastic Surgical resident.  In addition, I added computer morphing to my consultation years ago, so that my patients could visualize what the goal of the surgery would look like.  Patients are now able to participate in establishing the goals of the surgery much more so than without computer morphing.

Liposuction is another cosmetic surgical procedure that made the top 5 list nationally and also is one of Dr. Moss’ top 5 procedures.  “Even though liposuction is very popular in my practice, I probably downplay this procedure more so than my patients would wish me to.  I chose my patients very carefully and turn down some that I do not think are good candidates.  I look for patients that are not overweight.  The best advice I can give to a patient considering liposuction is that this is not a weight reduction procedure and they should only consider a “board certified” plastic surgeon for liposuction.  For some reason this is one procedure that physicians who are not “board certified” in plastic surgery gravitate to when they want to perform cosmetic surgery.  Liposuction requires experience and the correct training to be performed properly.  Board certified plastic surgeons are by far the most experienced and educated surgeons for this procedure.

The 5^th most popular surgery for Dr. Moss is blepharoplasty (eyelid) surgery.  This was also on the national list as one of the top 5 procedures.  I find that many of my Botox® and Juvederm® patients appreciate the discussions we have about the upper eyelids and brow.  This is the area of the face that tends to sag first and many facial injectable patients will obtain a significant improvement in their facial appearance with an upper lid blepharoplasty.  Often times I am able to perform this procedure in my office with local anesthesia.  This allows for a more economical procedure, which my patients appreciate.

And so as we enter a time (spring) that tends to be one of the “busy seasons” for cosmetic surgery, Dr. Moss is very optimistic.  “I have been extremely busy, as busy as I want to be,” he exclaims.  “I treat my patients as I would want my family members to be treated.  I take time with patients and ensure that all of their questions are answered.  I try to explain the procedures so that my patients can make educated decisions.  We also schedule appointments so that patients don’t feel rushed.  We provide ample time for pre operative visits so that patients understand their medication and instructions.  And my patients have been very kind in referring their friends and family members to me for procedures.  About 50% of my patients are either patients returning for additional procedures or have been referred by a patient who has had surgery with me.”

________________________________________

The Internet is an invaluable tool for plastic surgeons and, as New Jersey plastic surgeon, Dr. Paul M. Parker, noted in a recent press release, “We have a responsibility to empower [our patients] with knowledge.” Like Dr. Parker, we strive to keep our Websites up-to-date as our techniques and procedures improve.

Because research is right at their fingertips, we have to ensure that our Websites contain the right tools for effective patient education. The press release used Dr. Parker’s New Jersey breast augmentation pages as an example of solid educational tools. Dr. Parker acknowledges that one of the first things potential patients look for are the before and after pictures of real patients. As with his site, we recognize that these images are invaluable tools.

In the release, he says, “Patients who can see real results and identify with other patients approach their consultation with a higher level of understanding and comfort.”

In the release, Dr. Parker also addresses the importance of procedural information, emotional considerations, video testimonials, staff bios and facility photos. Along with this pertinent information, our patients also look for a site that looks professional and easy to navigate. But, they also get a feel for our personality. Like New Jersey plastic surgeon, Dr. Parker, we recognize the importance of what is often a first impression. Dr. Parker acknowledges that “ while perusing a Website doesn’t take the place of a face to face meeting, it’s mood and arrangement offers insight in to the people behind the site and gives a good basis for choosing the right surgeon.”

Pregnancy and Breast Implants

Breast augmentation is currently the most popular cosmetic surgical procedure in the United States. There are two primary groups of patients who request this surgery. There are women who have always had small breasts and wish to be made larger. And there are women who seek breast augmentation because pregnancy has caused their breasts to lose their fullness. Women in this latter category may also have some sag to their breasts. If the patient has also breast fed, her breasts may have more sag than patients who have bottle fed their babies. In fact, it is not unusual to find that women who have breast fed favoring one breast, end up with asymmetrical breasts and that the favored breast sags more. Readers should not interpret this to mean that they should not breast feed, but rather understand that these are typical situations that Dr. Moss deals with on a daily basis.

Breast feeding can cause sag to a woman’s breasts. However, in most cases breast feeding is considered a very viable option for today’s mother.

Young women who have never been pregnant and have small breasts, rarely have breast sag of any significance to their breasts. A woman who has experienced large weight gains and losses (50 pounds or more) may find she has breast sag even if she has never been pregnant. A woman who has both experienced pregnancy(s) and large weight gains and losses is very likely to have sag to her breasts. Breast augmentation does not lift breasts, however many patients with pre-existing breast sag find that after breast augmentation surgery, that they wish no further surgery to their breasts. If a patient feels that she does want her breasts lifted after breast augmentation surgery, Dr. Moss will discuss the available options concerning breast lift surgery, also referred to as mastopexy.

This patient is a young 24 year old woman who has never had any children. She has no breast sag. This patient had Moderate Profile 457 cc Natrelle® Silicone Gel Breast Implants. She has an excellent result that is typical of young women who have had no children.

Patients need to be aware that most mastopexy surgeries do produce significant scarring to the breasts as opposed to breast augmentation surgery, which usually results in much more limited and usually much less visible scarring. While scarring usually fades with time it does not disappear. Breast lift surgery will not produce a permanent result and patients should consider this in their decision to have mastopexy surgery. It is not uncommon for patients to have another breast lift later in life, if the sag returns. If a patient’s breasts have any significant level of sag (also referred to as ptosis), Dr. Moss will always discuss with a patient what her options are concerning breast augmentation and/or breast lift before undertaking any cosmetic breast procedure.

This woman is 30 years old and has had 3 pregnancies and childbirths. Her pre-operative pictures demonstrate some breast sag and asymmetry. She had breast augmentation surgery with 375 cc Natrelle® High Profile Silicone Gel Implants. While some asymmetry and breast sag remain after breast augmentation, her breasts now have a nice fullness to them. This patient could have a breast lift if she chose, however she would need to be accepting of scars. This patient has lovely cleavage and fullness to her breasts when she wears a bra.

Breast ptosis is a condition that describes the level of sag of the nipple in relationship to the inframmary crease (junction of the breast to chest wall, underneath the breast). There is also another term called pseudo ptosis which describes the amount of sag to the lower part of the breast structure, below the nipple. Having breast augmentation surgery does not prevent either type of sag from occurring later in life. Breast sag is one of those conditions that happens and can be related to pregnancies, breast feeding, weight gain and loss, aging, or simply one’s genetics.

When researching breast augmentation on the internet it is important to understand that what a patient’s breasts look like before surgery will affect the final result.

One of the most frequently asked questions concerning breast augmentation and pregnancy is “Can I have breast augmentation surgery if I still want to have children?” The answer is yes. If you become pregnant after having breast implant surgery, your breasts will grow and go through all of the normal changes associated with pregnancy.

These pictures show a 40 year old woman who had already had 2 pregnancies and childbirths before having breast augmentation. She chose 300 cc Natrelle® High Profile Breast Implants. She did have one more child after having her breast implant surgery. These pictures show her breasts before breast implant surgery, then at 7 months post operatively. At one year post operatively the patient was pregnant and these pictures demonstrate the normal breast enlargement that takes place with pregnancy. The last pictures demonstrate the patient at 2 years post operatively, and no longer pregnant.

However, it is important that a breast augmentation patient not get pregnant for 6 months following her breast augmentation surgery. The reason for this is that during breast augmentation surgery the milk ducts are transected. At six months post operatively these transected milk ducts should be sealed off. Milk production is one of the natural hormonal responses to pregnancy. Should these transected milk ducts not be given adequate time to seal off, milk could flow into the breast implant cavity and cause a problem called a “galactoma”. Because there are more milk ducts above the pectoralis major muscle than below the pectoralis major muscle, the problem of galactomas (in a situation of a pregnancy within six months of breast implant surgery) could be more of an issue with a breast implant that had been placed above the muscle than below the muscle. Galactomas are not usually a problem with either placement of breast implants, if pregnancy has not happened within six months of breast augmentation surgery.

The next question that is frequently asked is “Can I breast feed any children I might have in the future, if I have breast implants?” Dr. Moss’ first response to this question is “Many women, who have never had any breast surgery whatsoever, are unable to breast feed when they attempt to, after childbirth.” However, once the patient is informed of this fact Dr. Moss then elaborates that “Many women with breast implants are able to successfully breast feed.” In fact Dr. Moss has many women on whom he has performed breast reduction surgery, who have been able to breast feed later on. Breast reduction surgery is a much more extensive surgery to the breasts and is known to carry a much higher incidence of disruption of the milk ducts, than breast augmentation.

Some surgeons feel that if a woman finds breast feeding in the future important to her, that she consider the inframmary approach (incision at the inframmary crease, under the breast), as opposed to the peri-areola approach, (incision around the areaola and nipple complex). This is because there have been some breastfeeding difficulties reported, following breast surgery, particularly when the surgeon uses the peri-areolar incision. Patients should always voice any post breast augmentation surgery concerns and goals, when discussing this surgery with Dr. Moss or any other plastic surgeon.

Another question less frequently asked, but just as important is “How long do I have to wait to have breast enlargement surgery, after childbirth?” A woman needs to wait six months after childbirth and six months after cessation of breast feeding (whatever comes last) in order to have breast augmentation surgery. This is to prevent a galactoma which was discussed above. Therefore, any woman who is breastfeeding and considering breast augmentation surgery should keep accurate records on her last breast feeding event. It should be noted that any pumping of the breasts also counts as a breast feeding event. In addition, it does not matter if the breast feeding frequency was less near the end; it is simply the last time a woman breast fed her child that is the beginning of the six month waiting period.

If a woman is eager to have breast augmentation as soon as possible after childbirth and breast feeding, she should carefully record the last time she breast fed her baby.

It is not unusual for Dr. Moss’ staff to receive a phone call from a distressed mom (with baby crying in the background). These women can exhibit signs of sadness and distress over what they perceive as a total destruction of their body. And they want an immediate overhaul. If they have stopped breast feeding (or never started) they find themselves with deflated breasts after enjoying months of full breasts, often for the first time in their lives. Add newly acquired breast sag, a still bulging and wrinkled abdomen, not to mention the un-lost pregnancy weight, and we have a very unhappy woman. Then add lack of sleep to the equation, possibly post partum depression, and it’s easy to understand why Dr. Moss’ staff might suggest taking a slower approach to a cosmetic “mommy makeovers”.

As much as Dr. Moss and his staff want to help all prospective patients achieve their goal of a more beautiful body, patient safety and well being are always a first priority. Any patient considering cosmetic surgery needs to be able to handle the increased stress and discomfort of surgery. And with a new baby, there also needs to be appropriate child care, in place for at least one to two weeks after surgery. Dr. Moss’ staff will always explore the resources a prospective patient has for post operative care and childcare with any new mom, before scheduling a consultation for any cosmetic procedure.

Dr. Moss finds that many women come in for breast augmentation surgery when their youngest child is around five years old. At this time they find that some of the child care demands are not quite as burdensome as when they are caring for an infant.

For moms who are considering breast augmentation surgery after childbirth and are “doing well,” Dr. Moss will consider breast augmentation surgery at the six month, post delivery date or six month, post breast feeding, cessation date, whichever comes last. It is best to schedule the consultation at least three months out from childbirth and/or cessation of breast feeding so that the breasts will more likely resemble their size and shape at surgery. A final sizing and review of the goals of surgery will take place approximately two weeks before surgery, to ensure accurate implant size, and an understanding between patient and Dr. Moss of realistic goals of the surgery.

While it may seem obvious, Dr. Moss would like to point out that breast augmentation surgery, like any other cosmetic surgery procedure, should not be performed while a patient is pregnant. Besides the above mentioned problems of galactomas, there is always the safety of the fetus to consider. Anesthesiologists will usually not consider anesthesia for surgery on a pregnant woman unless it is necessary for the safety of either the mother or fetus. Any woman considering cosmetic surgery of any type should be confident that she is not pregnant, and should either use birth control if sexually active, or refrain from sexual intercourse, until safe to do so. Dr. Moss encourages patients to bring up any questions they might have in this area.

Dr. Moss encourages all women considering breast augmentation surgery to involve their spouse or significant other as soon as they are serious about the surgery. Dr. Moss also encourages patients to bring their spouse or significant other to the initial consultation.

Read More About Breast Implants and Pregnancy in Boston:

• Breast Implants and Pregnancy

This picture shows a patient who has Mondor’s disease. The patient had her breast augmentation approximately 2 weeks earlier.

After examining the patient, Dr. Moss usually comments, “What you have is Mondor’s disease.” While this sounds serious and ominous, Mondor’s disease, when associated with breast augmentation is usually self limiting and resolves on it own. “So what exactly is Mondor’s disease?” many patients ask. Dr. Moss will respond that “Mondor’s disease is a benign condition. Most patients,” he continues, “present with inflammation or thrombphlebitis of the veins in the breast area, usually just below the inframammary crease when it is associated with breast augmentation surgery. At first the vein or veins are tender and then they become asymptomatic and ultimately disappear.” It should be noted that these cord like structures are more evident when a patient lifts her breast upward or applies traction to the area. In fact, it is not uncommon for Dr. Moss to notice the visual symptoms of Mondor’s disease when he examines a breast augmentation patient and realize that the patient has felt nothing and is unaware that she has Mondor’s Disease. Dr. Moss always reassures patients that they need not worry and the situation will resolve on its own. “My wife, Carla had it when she had breast augmentation surgery and it resolved on its own with no problem,” he further elaborates.

This is a picture of Carla Moss having her broken capillaries (telangiectasias) around her nose treated. The treatment is painless and you look normal after treatment.

Dr. Samaha has a cosmetic surgical practice similar to that of Dr. Moss and like Dr. Moss performs many procedures such as breast augmentation, abdominoplasty surgery, and liposuction as well as many facial procedures. In addition to his surgical practice Dr. Samaha has opened a Skin Wellness Center within his practice and also offers many of the current treatments for skin care such as Photodynamic Therapy (PDT), the Titan Laser, Photo Laser, and the Genesis Laser Treatments. These treatments provide improvements to the skin with very little down time. Dr. Samaha also provides treatments with an Erbium laser. For more information on specific treatments please go to www.bostonplastic.com This link will take you directly to Boston Plastic Surgery website pages that are specific to the laser skin care treatments.

Because Dr. Moss has chosen not to include laser skin treatments within his practice, his wife, Carla, needed to seek treatment in another physician’s office. Well aware of the quality work provided by Kathy Antonowicz R.E., R.I., she chose to have her treatment provided by Kathy. “There is an absolute proliferation of medical skin spas but unfortunately many of them are not overseen by physicians that have a background in cosmetic surgery,” states Carla Moss. “Many of these spas are in the local malls and the main streets of many of our towns and cities. The actual facilities may be very impressive from an aesthetic standpoint, but it is often near impossible to figure out who is the physician in charge is and what specialty he/she is board certified in,” she further explains.

It is so important that potential patients understand that while many of these treatments are performed by licensed medical aestheticians, they are done so under the medical license of a physician. It is important that the medical aesthetician has easy access to this physician for questions and advice and that the physician has extensive training and education in the area of cosmetic laser procedures and safety. Plastic surgery is one of the few board certified specialties that include training in the use of lasers for cosmetic treatments in both their residency programs and in their courses for continuing education.

Medical lasers are usually classified as Class IV lasers. These are considered the lasers having the strongest effect and capability and need to be operated under the safest of conditions. “I always feel very comfortable with my safety when I am being treated at the Skin Wellness Center in the office of Boston Plastic Surgery,” Carla Moss says. “Kathy is very knowledgeable and follows all the safety precautions.”

The new spring colors in the Jane Iredale Mineral Makeup

On a lighter topic it should be noted that a new order of Jane Iredale Mineral Makeup has arrived. “I was so excited to look at the new spring colors,” said Carla Moss. “I started using this makeup at my very first laser session and found it to be my favorite brand. I love the way it evens out my skin tone in a very natural way. In addition, I have very sensitive skin and have had no allergy or irritation problems with the Jane Iredale line.”

This picture shows Kathy and me selecting my Jane Iredale Mineral Makeup purchases. Please note that my skin shows no discoloration or irritation from the laser treatment I had just received from Kathy.

It should also be noted that Dr. Samaha moved his practice and the Skin Wellness Center a few months ago to a lovely new location at 2300 Crown Colony Drive, in Quincy. This new office also houses an in office accredited Surgery Center as well as Dr. Samaha’s medical practice and the Skin Wellness Center. Anyone interested in an appointment can call 888-806-4844 or 617-786-7600 and ask for an appointment.

“Nobody likes to see the signs of aging on their face and with the high quality of injectable products available today, I can help to eliminate or soften some of those unwanted lines with a 10 to 30 minute appointment,” says an enthusiastic Dr. Moss, of his Juvederm and Botox® Boston treatments.

The facial injectable market has been steadily growing, and the statistics from the American Society of Plastic Surgeons provide proof that the American public wants to stay young looking, especially when there is little or no down time involved in the treatment.

Botox® still reins “King” in the facial injectable category. There was an estimated 4,625,192 Botox® injections performed by board certified plastic surgeons in 2007. This was a 13% increase over 2006. There are a number of reasons why Botox® is so popular.

Botox® produces results that are unique and often cannot be duplicated in any other way, including surgery. By injecting Botox® directly into a facial muscle, a physician can weaken the muscle and the contractions associated with this muscle. These facial contractions which can cause the unwanted wrinkles are therefore eliminated or softened for periods up to four months. The areas that have traditionally been treated are the frown lines between the eyes, the horizontal forehead creases, and crow’s feet around the eyes.

“Patients will often tell me that friends and co-workers will comment that they look like they are scowling or are angry when they are not,” comments Dr. Moss, Boston cosmetic surgeon. Frequently the offending muscle is the “corrugator” muscle causing the unconscious scowl.

“Patients love how a 5 minute injection with little discomfort eliminates or softens this unwanted facial expression,” Dr. Moss continues. “In addition, there usually is no bruising or swelling associated with this treatment and patients can return to work or go home with no one knowing they just had a Botox® injection.”

Patients should expect to see the effects of Botox® in about 4 days, although in some instances it can take up to 14 days for the full effect of Botox® to be seen. In addition, patients need to be aware that there can be bruising at the site of any Botox® injection.

Although bruising does not usually result from a Botox® injection, patients should be aware of its possibility, especially if they are having their treatment in preparation of a special occasion.

“My wife Carla has a tendency to bruise more than most patients, so she has purchased a concealer product from the Medical Aesthetician, Kathy Antonowicz R.E., R.I. (888-806-4844), who performs her laser skin treatments. “Carla is always happy to share any helpful hints with any of our patients, as she is aware that this can often make a patient’s treatment much easier and more pleasant,” relates Dr. Moss.

If Botox® reins “King” of the facial injectable market then Juvederm™ is the “Queen” of the facial injectables. It is important to understand that Botox® and Juvederm™ work by completely different methods. While Botox® paralyses muscles; Juvederm™ fills in valleys in the skin.

Juvederm™ is the newest of the hyaluronic acid formulations to reach the cosmetic marketplace. Restylane® and Perlane® are two other popular hyaluronic acid products that have been available for some time.

Boston cosmetic surgeon Dr. Moss has been injecting Restylane® and Perlane® since their availability and has extensive experience with the injection techniques for all of these facial fillers.

“Until the introduction of Juvederm™, I would choose a filler product that best addressed a patient’s individual needs,” states Dr. Moss. “However, with the availability of Juvederm™, I am now finding that this product has the benefits of all of the other products combined and I expect it to soon be the market leader in the facial filler category” he adds.

“What makes Juvederm™ so unique is the combination of longevity and versatility. Juvederm™ is the first hyaluronic acid that the FDA has allowed to be labeled “the effects may last up to one year.” The other available hyaluronic acids, Restylane® and Perlane® have labeling that states “the effects may last up until six months.” Radiesse® which is calcium-based microspheres suspended in a water based gel does have labeling that states “the effects may last up until one year,” however, Radiesse® cannot be injected into the lips or vermillion border.

“Having a product that lasts longer and can be injected into the lips is a big advantage for a number of reasons,” Dr. Moss continues. “Patients need to be aware that when a product is labeled “lasts on average one year” means that a patient should expect that 50% of the correction is gone at six months. This meant that any product we had for injections in the lips before the introduction of Juvederm™ would lose 50% of the correction at three months. Patients really appreciate a correction that lasts for a longer period of time.”

“Another factor concerning facial fillers that patients need to be aware of is that the more animated the area of injection, the quicker the filler is absorbed and the correction diminished. The area around the mouth has the most activity and therefore fillers are absorbed at a faster rate in this area. For example, it would not be unusual for the correction to be lost sooner in the lips than in the nasolabial folds (the lines that run from the nose to the mouth, also called the parentheses) because the lips are much more animated than the nasolabial folds. Therefore the availability of a product such as Juvederm™, which lasts longer and can be injected in the lips is big advantage,” Dr. Moss further elaborates.

Juvederm™ is available in two formulations. While both the formulations are interchangeable, the Juvederm™ Ultra Plus is more robust and used more frequently in areas such as the nasolabial folds, while the Juvederm™ Ultra, which is less viscous, is used primarily in areas such as the lips where a softer result might be more desirable.

Like Botox® injections, facial filler injections also continue to increase in popularity. The total combination of facial filler injections performed by plastic surgeons in 2007 was around 1,250,000, making facial fillers by far the second most popular procedure in the field of cosmetic surgery and procedures. Dr. Moss attributes this to both the efficacy of injections and the ease of having the treatments.

Another new trend that is appearing in the facial injectable arena is the concept of “full correction” or sometimes simply called the “Wow effect.” This is where the physician injects sufficient filler into the areas of the face needing correction in amounts that greatly diminish the wrinkles rather than softening the wrinkles.

In conjunction with fillers, Botox® is also injected in areas of concern to the patient to reduce or eliminate the dynamic wrinkles. While this is more costly to the patient the effect that can be produced will often justify the added expense. In addition, the subsequent maintenance injections are often far less than the initial injections. Achieving a “full correction” can be more difficult than simply injecting one syringe of filler or one site of Botox®. Therefore, patients considering having injections to achieve “full correction” should choose a competent physician for their treatment.

“Plastic surgeons are some of the best trained physicians for administering facial injections,” states Dr. Moss. “We fully understand the muscular and neurological anatomy of the face. It is part of the core training in a plastic surgical residency program. You cannot perform facelifts, brow lifts and eye lid surgery without fully understanding the anatomy and the perils that lie beneath the facial skin. There is no other specialty that is better trained for facial injections than the specialties of plastic surgery and facial plastic surgery. I sometimes wonder why any patient would want to choose a provider from a website that does not clearly state who the physician in charge is at the facility, his/her training, and what specific board this physician is certified by.”

In order to stay current on all of the popular facial injectable techniques, Dr. Moss frequently attends courses.

In February of 2008 Dr. Moss attended the “Baker Gordon” Cosmetic Symposium in Miami, Florida. In May Dr. Moss attended an advanced course on Botox®, Juvederm™, Restylane®, and Perlane®. He is also scheduled to attend another full day course in June devoted to the more advanced techniques on the injection of Botox® and many of the facial fillers including Juvederm Ultra™ and Juvederm™ Ultra Plus.

“Patients who come to me do so because they are looking for the expertise of a Board Certified Plastic Surgeon. Whether it’s breast augmentation, tummy tucks, or Botox®, I pride myself on staying abreast of all of the latest techniques as well as continually evaluating the results my patients receive. I always offer my patients the opportunity to return and have 2 week to 1 month post injection pictures taken and to compare them to their pre-injection pictures. We can discuss if any further treatments are necessary or if the patient is happy with his/her result. I find that most are happy but occasionally someone wants more of a correction or even another area treated. My goal is always to have a satisfied patient.”

April is here and as the days become warmer the telephone rings more frequently in the office of Dr. Richard Moss, Boston tummy tuck specialist. Many of these calls are from women who are dissatisfied with sagging skin of their abdomen and breasts. Frequently these women are looking to reverse the results of pregnancy and the devastating effect it can have on a woman’s body.

The after effects of pregnancy is one of the most common reasons that women seek cosmetic surgery of the abdomen (abdominoplasty surgery) and breasts (breast lifts, breast augmentation, and breast reductions).

Our Boston plastic surgeon, Dr. Moss, is also receiving an ever increasing amount of phone calls from women who have lost large amounts of weight and have considerable amount of skin sag over their entire body. Often times these women have had a gastric bypass procedure but there are also some who have lost 100 pounds or more by adjusting their caloric intake. “Massive weight loss” patients usually find that their sagging abdominal and breast skin can be quite bothersome not to mention unpleasant to look at.

Patients who have lost large amounts of weight either through gastric bypass or appropriate diet management often seek cosmetic surgery afterwards to reduce the excess skin of their abdomen and breasts.

Many of these callers accurately ask for consultations that are appropriate for their situation while others have goals that are entirely unachievable. This article will focus on helping women determine what surgery will help them achieve their goal as well as what scars she can expect to have after her procedure. One fact that all patients with sagging breast or abdominal skin need to accept is that it is impossible to remove excess skin without leaving a scar. While some of these scars are hidden others are quite visible, especially when a patient is without clothing. Plastic surgeons always try to place scars in areas of the body that are hidden by clothing. Some women, however find that a scar even though it is hidden beneath clothing can be bothersome to the point that they will choose to forgo the surgery and live with their skin sag. “While there is no perfect answer to reducing skin sag,” states Dr. Moss, Boston tummy tuck specialist, “one of the most important factors in a successful cosmetic surgery outcome, is that the patient fully understands the length of the scar and where it will be placed on her breasts or abdomen.”

This article will address the skin sag of the breast and abdomen separately since the surgical options are different and a patient’s feeling about the scars on the breast can be different than her feelings about a scar on her abdomen. Dr. Moss finds that many women are far less accepting of scars on their breasts than on their abdomen. What is also factored into the decision of whether a scar is acceptable or not is the extent of sag. The more their abdomen or breast sags the more a woman is accepting of the scar from an abdominoplasty or breast lift. In addition, a woman with excessively large breasts that also sag will get two benefits from a breast reduction (smaller, more appropriate sized breasts that sag less); and therefore, is usually more accepting of the resulting scars. In addition, if she has had back and neck pain or rashes under her breasts, she often sees improvement here as well. These patients rarely complain about breast scars.

Abdominal Skin Sag: There are really no other options for abdominal skin sag other than an abdominoplasty or mini-abdominopasty, (only if a patient meets the requirements). While these scars can be extensive, Dr. Moss tries to place them as low as possible so that they can be hidden even underneath a two piece bathing suit. Patients do need to keep in mind that this two piece bathing suit needs to have some amount of fabric around the front portion to hide the scar and therefore a string bikini would not suffice. Most patients who need an abdominoplasty find that without this surgery they can’t wear a two piece bathing suit anyway.

Dr. Moss likes to point out that he performs abdominoplasty surgery using the “progressive tension suturing” technique that can often result in a better quality of scar. Because the additional suturing throughout the abdominal flap, removes some of the tension from the incision area, the quality of the scar may be better. While “progressive tension suturing” will not reduce the length of the scar it may reduce the thickness of the scar.

These pictures demonstrate what the scar might look like within the first year after abdominoplasty surgery.

Breast Skin Sag: Skin sag of the breast is more complex and there are more choices depending on the situation. The following paragraphs outlines the options available to women with breast sag, medically referred to as breast ptosis. It is important to understand that a patient needs to be a clinically acceptable candidate for each individual option and cannot simply chose the option she finds most desirable. In some situations she may be a candidate for more than one option and she will need to weigh the advantages and disadvantages of each.

Women who have breast fed may find that their breasts have more sag after they stop breast feeding than women who did not breast feed. Sometimes if the baby favored one breast more than the other, the favored breast will sag more than the non favored breast.

Breast Augmentation: A woman who has always had small breasts (A-cup) may find that after pregnancy and breast feeding that while her breasts sag, the skin envelope of the breast remains relatively small and they are best served by having breast augmentation surgery. These women really don’t have skin sag as much as they have deflation of the breast or loss of breast tissue after pregnancy and especially breast feeding. Breast implants will very nicely replace this lost breast tissue. The good news is that the scars are minimal with breast augmentation surgery. Dr. Moss, Boston breast augmentation expert, offers patients two choices for scar surgery. He can make his incisions through either an inframammary incision or a periareola incision. Either one of these incisions is well hidden after surgery and healing takes place.

It is important that patients understand that breast implants do not lift the breasts but rather fill them out. While this often sufficient enough to aesthetically make the breasts more attractive, some women may decide to have a breast lift at a subsequent surgery.

The following pictures demonstrate a patient who had breast sag prior to breast augmentation. The breast implants filled out the breasts sufficiently that a breast lift would not be necessary.

Breast Lifts: A breast lift, medically referred to as mastopexy, reduces the amount of skin sag but does not increase the size of the breast. For women who are bothered by the amount of sag to their breasts, but are satisfied with the size of their breasts, Dr. Moss will offer a breast lift. Because the scarring is much more extensive (anchor scar), than that of a breast augmentation, breast lift surgery is not as popular as breast augmentation surgery. Patient’s also need to factor in that breast lift surgery does not provide the patient with a permanent result as her breasts may sag again with time.

Besides the rather extensive scarring that breast lifts result in, breast lifts do not provide a patient with the “perky” breasts of a teenager. So often patients are pushing their entire breasts up to their upper chest region and stating “this is what I want!” Unfortunately, this is not achievable, and in many instances an under wire push-up bra might give her more of this result. Women with sagging breasts have usually lost the support of internal ligaments called “Cooper’s ligaments.” It is Cooper’s ligaments that normally support some of the breast tissue and fat in what is medically referred to as the “superpole” (upper) region of the breasts. While breasts that have been surgically lifted almost always have a much nicer overall shape than before the lift, they will not have the “perky” shape of a young breast. It is also important to note that when performing a breast lift, the surgeon will also reposition the nipple in a higher more aesthetically pleasing position.

These pictures demonstrate a patient who was an excellent candidate for a breast lift and abdominoplasty. Her breasts were not too large (a B cup), she had breast ptosis (sag) and her abdominal skin sagged as well. In addition she was at her ideal body weight.

Dr. Moss always addresses the issue of how long a breast lift will last during his consultation with a patient. He states “While it is impossible to accurately predict the length of time a patient’s breast lift will last, it could be months, it could be years, there are some factors that can influence the duration of the result. One is the size of the breast that is lifted. A smaller breast such as a B-cup will most likely retain its result longer than that of a full C-cup or a D-cup. I always recommend that a woman with a large C-cup or D-cup who is contemplating a breast lift also consider a small reduction as well,” he further elaborates. “Unfortunately, some of these women, especially the C-cup women do not want this and so in the end do nothing. Many of them find that the trade off of scars and smaller breasts outweigh the benefit of reducing the sag and in the end decide that doing nothing, at least for the present, is the better option.”

Another factor that influences the longevity of a breast lift is the elasticity of the skin. A woman’s breasts that have not been stretched to a much larger size at one time are more likely to retain the result than breasts that have been stretched due to pregnancy, breast feeding or large amounts of weight gain and loss. Also age can be a factor. A younger woman’s skin that has more elasticity than an older woman’s skin is more likely to retain the result of a breast lift.

Breast Reduction: Breast reduction surgery is very similar to that of breast lift surgery, except that breast tissue is removed as well as breast skin. These patients obtain the same type of correction in skin sag as that of a breast lift. In addition, the nipples are repositioned, as in the breast lift. The scars are often identical to that of a breast lift (anchor scar).

Although the scars from a breast reduction are as extensive as those from a breast lift many of the breast reduction patients are more tolerant of them. This is because they are so bothered by the large size of their breasts that they are more than accepting of the scars in order to have their breasts made smaller.

This patient was an excellent candidate for a breast reduction. Her breasts were large (32DD) and she was at her ideal body weight.

There are also situational factors that can influence a woman’s acceptance of scars on her breast or abdomen. Generally, younger women are more sensitive to their appearance and therefore less accepting of scars. At the same time these young women, often young mothers who have had a child at a very young age, are very troubled by their bodies after a pregnancy. Dr. Moss finds that most of these young women who seek him out for abdominoplasty surgery do proceed with a tummy tuck because they are so unhappy with their bulging bellies and abdominal skin sag they are willing to accept the scar.

Another situation that is often a factor in a woman’s acceptance of a scar is whether or not she is already married or in a committed relationship. These women generally feel more secure about their bodies and are less concerned about a scar. Frequently, they have already discussed it with their significant other and he has relayed to her that a scar does not bother him. Women who are not married or in a committed relationship are sometimes more anxious about a scar because they feel a man might be less attracted to them in the future. Dr. Moss states that “There is no right or wrong decision about a woman’s acceptance or unwillingness to accept a scar. The most important thing is that she is aware what the resulting scar will be and then she makes her own decision.”

Another factor that sometimes influences whether a patient elects to go forward with surgery is the predictability of the quality of the scar once the skin has healed. “Women with darker complexions are more likely to have more noticeable scars. Also women who have some natural redness to their hair color and skin tend to scar more poorly,” Dr. Moss says. “Women with blue eyes and fair skin (not redheads), generally have better quality scars. However, I always point out to patients that scarring is not in the hands of the surgeon, and it is what it is, and patients need to accept this before proceeding with surgery. The good news is,” he further elaborates, “is that scars tend to fade with time. Although they do not disappear, I am often impressed with how much they have faded when a patient returns years later for some other surgery. I usually don’t have the opportunity to evaluate my scars beyond one year and most of my post operative pictures are at one year or at six months. I am often impressed with the improvement in the scar when I see these patients years later.”

The following pictures demonstrate that a scar from an abdominoplasty does fade with time.

Tummy Tuck before	Tummy Tuck 1 month after	Tummy Tuck 6 months after	Tummy Tuck 2 years after

“Another issue that is most important,” Dr. Moss further elaborates, “is that a patient doesn’t choose a surgery that doesn’t correct her problem, solely for the reason of avoiding a scar. We have many women calling in who inquire about liposuction of the abdomen because they think it will eliminate their abdominal sag without a scar. Not only will the skin sag not be reduced or eliminated, it will be made worse.” Dr. Moss emphasizes. “My staff always tries to redirect potential patients to surgeries that are appropriate for their problem and instill realistic expectations before they are given an appointment. It is a waste of time to spend thirty minutes with a patient reviewing all the details of abdominoplasty surgery with her, if the only thing she can think about during the consultation is the scar. I would rather wait and see a patient like this only after she is willing to accept that to reduce her abdominal skin sag, she will have a scar on her abdomen. Although the scar is permanent it will fade with time.”

“My staff members also relay to me that often women ask to see me in consultation for breast augmentation surgery,” Dr. Moss relays. “In asking the patient about her situation they discover her breasts are often at least a C-cup with considerable sag. When they bring up the subject of a breast lift they are told by the caller that they find a breast lift unacceptable because of the scars. However, they really are happy with the size of their breasts but not the amount of sag. Somewhere in this caller’s mind she has come to think that a breast augmentation will lift her breasts. This is basically a misinformed caller that my staff members try to better educate. Sometimes I think what happens is that these patients spend hours on the internet scrolling through hundreds of before and after pictures and they prefer the after pictures of the breast augmentation patients compared to the breast lift patients, so they just assume they can have a breast augmentation and obtain the same result of a patient who had no sag before surgery. This is not the case. Appropriate patient selection for any surgery is as important as a surgeon’s technical skills. And a patient needs to have realistic expectations. This is why a consultation with a board certified plastic surgeon like myself is so important. Realistic expectations for the correction of a given body deformity, need to be in place for a patient to have a satisfactory result.”

Patients sometimes inquire as to whether there is anything that they can do to help improve the quality of a scar. “First and foremost I would recommend that patients not expose the area of incisions and surgery to the sun or a tanning booth at least two weeks before or six months afterwards. I am not a fan of tanning in the first place as it is well known to increase a patient’s chances of having skin cancer, but it can also worsen the quality of scar tissue,” states Dr. Moss.

There is also a product that patients can purchase in Dr. Moss’ office called Scarguard ScarCare. This product combines hydrocortisone, Vitamin E, and silicone in a clear liquid that brushes on, dries quickly and forms a nearly invisible protective film over the wound. This product is one of the most popular products with plastic surgeons for the treatment of scars. No treatment will “erase” a scar, but Scarguard ScarCare will minimize the risk of a poor scar. Dr. Moss will usually allow patients to start using this product at about one month post-operatively.