A Comprehensive Three-Dimensional Rejuvenation Center

Monthly Archives: January 2016

Notable updates from the 2016 Atlanta Breast Surgery Symposium

I recently attended the preeminent breast surgery meeting of the year, sponsored by the Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS). This was the 32nd annual gathering of international thought leaders in plastic surgery. Many new topics have been introduced at this symposium over the years and discussed at length prior to other meetings or journal articles making this a cutting-edge event. I always make time to attend this meeting to ensure that I am offering the most current surgical services for my patients.

Here’s what I gleaned from this year’s symposium:

Fat Grafting – Around a decade ago at this symposium a panel was organized with plastic surgeons, ethicists, lawyers, bio-engineers, oncologists, radiologists and general surgeons to contemplate the concept of moving forward with fat grafting to the breast to override the ban that the American Society of Plastic Surgeons had placed on this technique many years ago. Fortunately, this sparked the movement of our society and our best researchers to invest time and money into the field of plastic surgery. Certainly the clinical experience of utilizing fat grafting to provide shape and improve contours of the breast has been well documented at this meeting before. This year, additional data added further proof that this technique is here to stay.

Dr. Steve Kronowitz, from MD Anderson Cancer Center, presented data that fat grafting does not disrupt the diagnostics of mammography nor does it promote cancer growth in the breast that has been fat grafted. Furthermore, fat grafting maturity in the new recipient tissues stabilizes by four months. Dr. Kronowitz and others have demonstrated that injecting fat cells under badly damaged radiated skin can greatly improve and heal these tissues, although the actual mechanisms have not been fully elicited.

Dr. Louis Bucky, a noted fat-grafting expert from Philadelphia, has demonstrated that large volume fat grafting into areas which have experienced significant neurologic pain from either breast cancer surgery or multiple operations resulting in scaring can provide predictable relief from this pain. The pain relief is the result of delaminating scar tissue and providing fat in its place to avoid further scaring around nerves.

The takeaway from the symposium is that fat grafting in plastic surgery continues to grow in scope and popularity among surgeons and their patients.

New concept for breast reconstruction – Patients who elect to undergo breast reconstruction with implants historically have the devices placed under the pectoralis muscle with or without the use of an Acellular Dermal Matrix (ADM) extending the coverage of the device down to the fold. The muscle provides additional soft tissue coverage of the implant, blending its presence with the surrounding tissues. This approach also has demonstrated benefit in preventing capsular contracture.

The downside of this procedure is animation deformity, meaning that when the muscle is activated during exercise, it will contract and may greatly distort the breast. Also some women will be numb on the skin surface but will have sensation around the muscle and feel the implant movement at times, which can be bothersome. Lastly, during the early postoperative period, placing an implant under the muscle causes a significant amount of muscle spasm pain for a few weeks.

A new interesting concept is removing the muscle from the reconstruction equation by wrapping an ADM graft around the implant then suturing the ADM to the chest wall to stabilize the orientation of either the expander or a final implant without elevating the muscle. This approach mandates having reliable thick mastectomy skin flaps to cover the device with ADM.

A secondary procedure utilizing large-volume fat grafting to provide additional thickness of skin flaps and correct contour deformities is also required three months later. The advantage is quicker surgery time, less pain, no muscle animation issues and no abnormal feelings with the muscle. I plan to offer this to selected patients shortly.

Look as good as you feel in 2016

So you work out, eat smartly and watch your calorie consumption but your face looks tired, and you look older than you feel. Trust me, you’re not alone. The good news is something can be done that is predictable and sustainable to make you look and feel better about your face.

The key to success is a thoughtful facial analysis, which evaluates your bone structure, muscle activity, soft tissue volume, skin quality and the position of your forehead, brows, eyelids, cheeks and neck. I approach a patient’s face much like an engineer with a sculptor’s artistic eye. I create a problem set followed by a detailed treatment plan, tailored to each of my patient’s wishes and financial parameters.

Treatment plans often include skin quality improvement with techniques such as serial chemical peels and micro-needling. Please see previous blogs on these therapies on my website. If excessive muscle activity leads to a harsh appearing forehead and brows, muscle modulation with Botox can be an excellent approach.

Looking at the upper third of the face, I evaluate brow position with respect to the bony orbital rim and its relationship with the upper and lower eyelids. On women you want the brow to be above the orbital rim with the outer third being elevated compared to the inner 2/3 of the brow. Heavy hanging brows make the eye aperture appear small and tired.

Another important factor in evaluating the upper eyelids is eyelid ptosis (the muscle mechanism which elevates and maintains resting tone of the upper lids). Eyelid ptosis must be addressed with the blepharoplasty to prevent a tired sleepy appearance despite correcting the fat pads and excess skin.

The lower eyelids must be evaluated carefully in comparison to the bony anatomy surrounding the eye and the supporting structure of the lateral canthus, which anchors the eyelids to the lateral bony orbit. Great care must be taken if you have a prominent eye compared to your cheeks and have deficient lower eyelid vertical skin coverage. Weak lateral canthi can result in disastrous results with excessive eye exposure leading to pain and visual disturbance.

Finally, the lower eyelid cheek junction must be inspected. A large tear trough and bulging fat pads can detract from a youthful appearance. Taking out too much fat can result in a hollow eyelid, which can actually create an even older appearance. Current techniques include judicious removal of some of the fat and then actually transposing the fat pad down onto the cheek mass obscuring the demarcation and giving volume to the cheek and avoiding a hollow look.

The midface is all about volume. As we age, the cheek fat pad shrinks in size leading to the face falling with accentuation of the nasolabial folds. In most cases midface restoration can be corrected with volume-added techniques of either fat or filler agents making tissue repositioning in this area less important. A non-invasive injection of Voluma can be a great treatment option.

The lower facial third and neck are evaluated with regard to the jaw line, chin neck angle, and the draping of the soft tissues including the skin and neck muscles. Younger people with good skin quality may well be treated with liposuction alone to achieve a pleasing neck line. If the lower jaw is small with respect to the rest of the face, a chin implant or chin repositioning may help your neck appearance, in addition to liposuction to improve results and create harmony with the lower facial third compared to the rest of the face.

Older skin, with bands of the platysma muscle showing through, is less compliant and is best treated with a neck lift procedure. This surgery includes fat equilibration, neck muscle tightening and soft tissue repositioning and stabilization around the ears.

Facial rejuvenation is not painful, although swelling and bruising will occur. After the dust settles, results can be natural and youthful in appearance with long-lasting results that will boost your confidence beyond any wardrobe or hair makeover.

Look as good as you feel in 2016. Happy New Year!