Using adjustable implants, Myron M. Persoff, MD, FACS, can modify the outcome— even 2 months postsurgery
Many women who undergo breast-augmentation surgery end up dissatisfied with the results. Their plastic surgeon did the job correctly, so that’s not why they’re unhappy. The problem is buyer’s remorse: They regret not having chosen larger implants when they had the chance.
South Florida aesthetic plastic surgeon Myron M. Persoff, MD, FACS, ran into that situation a lot. Even though he offered ample opportunity during consultation for patients to opt for more ampleness, the fear of emerging from surgery ridiculously overenlarged nagged at them to settle for less.
“The worst part was that some of these patients who wished they had gone with a bigger size would, in the back of their minds, blame me for their not making the right choice,” he says. “They sent signals that conveyed their feeling that I had misunderstood exactly how big they wanted me to make them.”
Now, however, disappointment of this sort is extremely short-lived. Sure, many of Persoff’s patients still experience those regrets, but the difference today is that he can easily modify the outcome—even 2 months after the fact. The secret is that Persoff stopped using conventional saline implants and switched to the postoperatively adjustable type.
“If, after a couple of weeks, the patient wants her augmented breasts made even larger, all I have to do is add more fluid to the implant, and the shell will extend accordingly,” he says. “Conversely, if the patient feels the breasts are too big, it’s equally simple to reduce the fluid volume. Of course, patients almost never ask for that. It’s rare that they want to go smaller.”
Reliance on Referrals
Persoff credits his use of adjustable implants for causing patient-satisfaction scores to practically jump off the charts.
“Not only do these implants allow you to go larger later, they also result in an extremely natural breast shape and softness,” he says. “You achieve this naturalness by overfilling the shells, which, of course, causes the tissues of the chest to stretch concomitantly. But then, 4 to 8 weeks later, when you drain some of the fluid, the overstretched tissues leave you with breasts that look like they were grown instead of having been surgically produced.”
Postoperatively adjustable implants (also known as expansion implants) have been offered by Persoff in his Miami practice since 1988. His practice goes by the name of Coconut Grove Plastic Surgery, and almost all of Persoff’s patients come for aesthetic services.
Thirty years ago, when Persoff opened his first practice, aesthetic cases were few. In those days, the vast majority of his work was reconstructive.
“Very few of us at the time built a practice with advertising, because it was seen as unbecoming for a physician to engage in that type of outreach,” he recalls. “The way you attracted patients was by taking on reconstructive cases referred from the emergency room and from your colleagues in other disciplines. The idea was that those reconstructive patients would remember you years later when it was time for a facelift. Or, if they had relatives, friends, and coworkers who needed cosmetic work, you would be the one they recommended.”
It took about 10 years for that strategy to deliver enough aesthetic patients to shift Persoff’s practice patterns over to a predominantly aesthetic focus. But today, as in the past, Persoff continues to eschew advertising—if you don’t count his good-looking Web site—and most new patients still come by way of referral from previously satisfied patients.
“The first problem with advertising is that you have to pay for it,” he declares. “The second problem with it is that it tends to attract people who don’t really know you and don’t come with a built-in sense of bond or commitment to you. The opposite is true of the ones who’ve been told all about you ahead of time by the patients that referred them.”
Another big change in Persoff’s practice is its demographic mix. Originally, Persoff was located in Boca Raton, Fla. There, he saw almost exclusively retirement-age Caucasians. In the mid-1990s, he relocated to the Coconut Grove section of Miami. Now, more than half of his cases are younger Hispanics. This change in demographics has also led to a change in demand: In Boca Raton, facelifts were one of Persoff’s most-requested procedures; today, breast augmentations and body contouring top the list.
Persoff, who grew up in West Palm Beach, Fla, clearly loves what he does. But in his youth, a career in medicine was not what he envisioned for himself. He wanted to become an aeronautical engineer. But by his sophomore year at the University of Florida, Gainesville, he came to the grim realization that he lacked the requisite aptitude for mathematics to be a builder of planes.
Casting about for an alternative, he decided on a career in medicine. “My older brother influenced me greatly in that regard—he was himself a doctor, and it looked like a fun, exciting job,” Persoff relates.
After gaining admission to the University of Miami School of Medicine, Persoff toyed with the notion of specializing in orthopedic hand surgery. However, it was plastic surgery that ultimately held the greatest attraction for him.
“Plastic surgery impressed me as being the most hands-on of any field in medicine,” he says. “Not even general surgery could compare, because, in general surgery, everything is for the most part done by the book, whereas in plastic surgery you have lots of latitude to tailor the operation to the circumstance.”
The entire time Persoff was in medical school (which he completed in 1967) he was also a junior officer in the US Navy. That set him up for internship at the Naval Hospital in Philadelphia and, later, a tour of duty as a flight surgeon at military bases in Southeast Asia.
Toward the end of his days in the Navy, he volunteered to lead a Philippines-based paramedic team. “I thought I was going to be riding around in an ambulance,” he says. “I had no idea that ‘paramedic’ in the Navy meant ‘medic with a parachute.’ So imagine my surprise when they told me to report to jump school.”
As an airborne, drop-in doctor, Persoff engaged mainly in rescue work. “It was pretty thrilling stuff; sometimes it got scary, though. Good thing I was still young enough to not really appreciate the danger I was in.”
Persoff left the Navy in 1971, having attained the rank of commander. From there, he went on to general surgery residency at the University of South Florida in Tampa. In 1974, he entered the plastic surgery program, which included a preceptorship in Houston under the tutelage of Thomas Cronin, MD—who, in 1963 with Frank Gerow, MD, developed the first silicone gel–filled breast implant.
In 1976, Persoff began his private practice. Over the years, Persoff has welcomed numerous associates to his office, but he has never taken on a partner. That’s not entirely true: Technically, he does have a practice partner—his wife, Tere, who serves as his office manager. They have three adult children and one teenager between them.
Not many plastic surgeons in the Boca Raton area had their own outpatient surgical facilities when Persoff put together his first modest procedure room back in 1979. About a decade later, that room morphed into a 6,000-square-foot, freestanding ambulatory surgery center.
The facility featured fully certified twin operating rooms. Persoff sold it when he moved to Miami a few years later.
In Miami, he established another outpatient facility, smaller than the first. “The two-room facility I built in Boca Raton proved to be too much in terms of overhead, so the one in Miami had only one room—same high level of quality but half the overhead,” he says.
But even with the reduced operating costs, Persoff found that his Miami center was too financially burdensome, not to mention too unnerving a liability risk. This prompted him to sell it and begin performing all of his major procedures at a newly opened, state-of-the-art outpatient facility: Bayside Surgical Pavilion, owned by nearby Mercy Hospital. “It was a move that I’ve never been happier about,” he enthuses. “Now, my overhead stops the minute I complete my work in the operating room and walk out the door.”
It is, of course, somewhat more expensive to perform surgery in a hospital-operated outpatient setting. But Persoff’s patients rarely, if ever, object. “I thought that my going over to Bayside Surgical Pavilion would cause a drop in my caseload because of the slightly higher prices I would be obliged to charge,” he says. “The exact opposite turned out to be true. My practice actually grew. The reason was that there are many consumers who feel better about using a plastic surgeon who operates in a facility that is part of a hospital—it gives them assurance that they will be operated on in the safest of all possible environments.”
Although Persoff soured on the idea of owning an outpatient facility, he hasn’t given up on in-office procedure rooms. In his 2,500-square-foot office, which is located on the Mercy Hospital campus, he performs blepharoplasties, minor liposuction, and other minimally invasive work.
Advantages of Adjustability
Persoff tends to shy away from adopting new technologies and techniques too soon. “I like to see some evidence that it works before I incorporate it into my practice,” he says.
But once he learns about an innovation that boasts a track record of success, he hones in on it like a heat-seeking missile. That’s how it was when he became a proponent of adjustable breast implants.
“Adjustable implants resemble standard implants in that both types have a shell and a fill tube,” Persoff explains. “The main difference is that there is a three-way valving mechanism in the adjustable type that allows for connection to a reservoir so that you can implant it nearly empty and then fill it afterward.”
Persoff says he prefer to place this reservoir as close as possible to the incision so that it won’t later be necessary to make a subsequent incision to remove it after the postoperative stretching period has ended.
Another characteristic of adjustable implants Persoff finds to his liking is the way they are engineered to accept significantly greater volumes of fluid than standard implants. “A patient who wears a small A-cup bra but wants to go to a B-cup will need about 300 mL of fluid per implant,” he says. “If she wants instead to go to a C-cup, she will need 500 mL of fluid per cup. The problem is that the maximum amount of fluid you can realistically load into an A-cup patient’s muscle cover is between 350 and 400 mL. If you fill conventional saline implants beyond that volume of fluid, you end up with breasts that don’t look or feel natural if the implants are kept totally submuscular.”
So, how does one achieve a fill of 500 mL and still have natural-shaped, soft-to-the-touch breasts? Adjustable implants. “They can be filled to 600 or even 700 mL for tissue stretching and will nicely contract when I bring the fluid level back down to 500 mL,” Persoff explains.
For the first week of overfill, Persoff says a typical patient reaction is alarm at the sight of the breasts’ unnatural roundness. But then, dismay turns to marvel as the stretching process progresses and the appearance becomes increasingly natural. “When I drain the excess fluid, patients often become suddenly ecstatic,” he says. “Healing has taken place, and they just can’t believe how amazing their breasts look. The gratification is immediate.”
Adjustable implants also afford the ability to postoperatively resize one of the breasts so that both are perfectly symmetrical. “As sometimes happens with conventional implants after a breast lift with augmentation, there could be some fat necrosis, and one breast will turn out slightly bigger,” Persoff says, adding that the scalability of the implants makes them ideal for use in patients who present with breast asymmetries from Poland’s syndrome or conditions akin to it. The same applies to women who come by a size differential naturally.
Persoff says that one of his most challenging breast procedures involves a combination of augmentation and mastopexy. Here again, the adjustable implant plays an invaluable role. “Success requires careful synchronization of these twin procedures,” he asserts. “It’s not enough to just place the implant and raise the breast—it has to be placed in the correct location. Otherwise, you end up with two breasts on the same side of the body.
“Compounding matters, a mastopexy causes skin tightening. Adding an implant causes even more skin tightening and the possibility of overtightening to the point that circulation to the skin, nipple, or both is jeopardized. With the adjustable implant, you don’t have to fill it all the way. Just put in a few milliliters to start with, wait for the circulation to restore itself, and then fill it the rest of the way a few weeks later.”
Pursuit of Excellence
It takes just as long to place adjustable implants as it does to place conventional ones. However, adjustable implants require more time in the surgical planning stage, owing in part to the need to collect very precise volumetric measurements from the patient. Persoff contends that makes the product difficult to incorporate in practices striving for the highest possible volume.
“Also, there is a need to see the patient a few more times than you would if you were using standard implants,” he says. “If time is at a premium for you, you’re probably better off staying away from adjustable implants.”
Time is something Persoff, now nearing retirement age, would have in abundance were he to give himself the proverbial gold watch and hang up his lab coat for good. But leaving the profession is not a step he plans to take—at least not in the foreseeable future. “I might slow down a bit by doing fewer surgeries and being a bit more choosy about the cases I take,” he says. “Apart from that, I want to keep at this for a good long while to come.”
For however long that turns out to be, Persoff promises the one facet of his practice that will remain fixed in place is the commitment to provide unmatched service. With technologies like adjustable implants in his corner, he seems well positioned to deliver on that pledge. PSP
Rich Smith is a contributing writer for Plastic Surgery Products.