A Comprehensive Three-Dimensional Rejuvenation Center

Monthly Archives: July 2016

State of the Art of Breast Reconstruction Techniques

When I think back to my first plastic surgery rotation as a medical student in the early 1990’s breast reconstruction was performed much differently then. During this time period the silicone implant crisis was at its peak, women were skeptical of breast implants, and the majority of reconstruction surgeries were with TRAM (Transverse Rectus Abdominus) flaps requiring large skin paddles because the breast surgeons were much more invasive in the way breasts were removed. Today silicone breast implants are safe and available in many sizes and shapes, providing patients and surgeons many more options than ever before. The technique of breast removal (mastectomies) have become much more selective, even being able to spare the nipple-areolar complex in many cases; therefore the need to transport new skin into the area is less often required in primary reconstruction. The advent of soft tissue regeneration with the addition of bio-matrices such as Acellular dermal matrices and guided tissue regeneration materials such as textile silk meshes have revolutionized the outcomes in prosthetic reconstruction. Without question one of the greatest advances in breast reconstruction is the art and science of fat grafting which can augment selected areas of volume deficiencies, improve the overall shape, and restore the health of the overlying tissues which has been previously damaged by radiation therapy.

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Dr. Pat Maxwell coined the term “the bio-engineered breast” which utilizes acellular dermal matrix grafts and fat grafting to rejuvenate the soft tissues surrounding breast implants after mastectomies. I have been modifying these two techniques in my practice since 2004, which has vastly improved outcomes in both primary and revision breast reconstruction. Fat grafting has provided plastic surgeons the ability to selectively sculpt and shape breasts like never before. Implants can only occupy and provide shape and volume in specific locations on the chest and breast. Fat can influence any area desired to be modified similar to photo shopping in pictures. Fat already occupies the majority of a natural breast volume therefore restoring a reconstructed breast to normal form and function with less donor site morbidity is seen with harvesting large flaps from the abdomen and buttock region. This truly is an exciting time in plastic surgery to provide excellent results with less invasive techniques, especially compared to the past.

In addition to the soft tissue restoration procedures the new silicone gel implants have also contributed to better outcomes. The fifth generation silicone gel implants (Gummy Bear Implant) are a very cohesive polymer which maintains three dimensional shape. This for me has two advantages; the first is that we can offer implants which can more easily match a patient’s unique chest wall architecture such as creating an implant narrower in width and taller in height (for a tall thin lady) or shorter and wider for a small wide chested woman combined with a fuller projection in the lower half of the breast mirroring a normal breast shape that will have adequate volume but will not encroach on the arm pit region or have an over expanded upper pole appearance. The second advantage of these implants are the result of a stiffer polymer which resists forces of capsular contracture that have been demonstrated to be a major cause of revision breast implant surgery. With the use of bi-dimensional conceptual planning through meticulous measurements we can offer a more customized approach to reconstruction and we can educate patients on their options with a three dimensional imaging system (Vectra) to demonstrate the effect of different shapes and volumes on their potential outcomes.

Even women who have been diagnosed with breast cancer and elected to undergo “breast conservation techniques” with a lumpectomy and radiation therapy can frequently experience distortions of the breast. The affected breast can shrink in volume and change in shape compared to its baseline and with the opposite breast as a result of surgical removal of tissue coupled with imposed radiation fibrosis changes to the tissues which are permanent and progressive. In my practice I see a number of these women and have been successful in reducing deformities and restoring shape and volume with the use of internal scar release combined with fat grafting. The amount of hard woody scarring of the overlying skin can often be suppler after treatment. Contour deformities which often occur directly in the surgical field where tissue was removed can be restored in shape and volume leaving a softer breast that is more symmetric with the opposing side.

I am very proud of my field of plastic surgery which by its very nature attracts thoughtful and innovating disciples of this surgical specialty leading to a continuous evolution of scientific insights that opens the door for continuous improvements in the care we can provide patients. Breast cancer reconstruction is just one small piece that is being tackled by our field of study.

The mommy makeover-Is it right for you?

Being a mom is one of the most challenging, frustrating, yet rewarding experiences a woman can have. You put forth blood sweat and tears, not to mention an untold strain on your whole body during pregnancy. It really boils down to the genetics of your skin and fascia as to how well you can bounce back after the weight gain and abdominal stretching from your baby. Many women lament that despite dieting, exercising and lots and lots of willpower your body is never the same as it was prior to child bearing. Fortunately for the masses of dissatisfied women there are options in Plastic Surgery to boost your self- confidence and your body image. Here is a list of body corrections (Mommy Make-over) that can be performed in tandem or separately to improve the shape and how you feel about your physique.

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Breast:
During pregnancy the glandular component of the breast must enlarge to ready for the enhanced production of milk. Additionally weight gain with fat storage all governed by the hormonal changes can increase the breast size immensely. Unfortunately fetal regulation also makes skin “stretchy” to accommodate the increased girth of the breast and abdomen. After the resumption of normal non-pregnant hormones and the lack of need for lactation the breast volume will revert back to baseline and can even reduce in overall size compared to the original baseline. Unfortunately many times the skin does not have the ability to shrink to the original size and will stay expanded resulting in a larger skin brazier with same or even less fill than before resulting in “saggy” breast shape. With increased skin length from the breast fold to the nipple it moves the breast mound lower on the chest with less upper pole fullness. I hear many women call their breasts “sad” in appearance when they come in for consultation. Ok enough depressing thoughts… what can be done? If the skin is not excessively enlarged, the nipple-areolar complex is correct and the fold to nipple distance is not greatly elongated the solution can be to place a silicone gel implant to act as a shaper and a filler of the breast envelope restoring a pleasing breast shape. If the breast has a low positioned nipple-areolar complex, with or without increase skin length from the fold to the nipple-areolar complex, then a mastopexy (breast lift) is required. Often times tissue volume might need to be enhanced to provide better shape and upper pole fullness, thus an implant or fat grafting can be incorporated at the same time. Sometimes upper pole fullness can be accomplished by transposing extra breast tissue in the lower pole and positioning it on the chest wall deep to the rest of the breast to enhance fullness.

Abdomen:
Hormones during pregnancy direct adaptive body changes that allow healthy growth of the baby but unfortunately create lasting changes to a women’s body. The abdominal skin stretches and often can result in stretch marks (tears in the dermis with intact epidermis). Excess skin rarely retracts in these cases leading to hanging skin that drapes over the pelvis. Next the abdominal wall is distorted to accommodate the growing fetus resulting in separation of the paired rectus muscles leading to increased abdominal circumference with permanent bulges in the abdominal wall both above and below the umbilicus. This unfortunately cannot be reduced with abdominal exercise because the stretched fascia between the muscles is not contractile and will not respond to muscle strengthening. Additional weight changes with aging often can be manifested with increased abdominal girth from excess fatty tissue. So what can a Mommy Make-over achieve in the abdomen?
If skin quality is excellent and the abdominal wall is only minimally distorted often liposuction with the addition of additional energy sources such as ultrasonic energy (VASER), oscillating power hand-piece (PAL), or hydraulic power can result in removal of excess fat and create skin retraction/redistribution to improve contour. However, many women will need a full abdominoplasty with correction of excess fat with liposuction, removal of excess lower abdominal skin with tissue resection, and abdominal wall restoration by returning the rectus muscles together with a permanent suturing technique. This can result in excellent contour of the abdomen but you will trade the contour for a scar. I find most people are surprised how long the scar has to be to create the contouring necessary. Once acquainted with the results, most women will gladly trade a scar for the results of a flat smooth abdomen.

Back and Flanks:
Some women can realize their goals by correcting the anterior abdomen by itself. However many women if given the opportunity would love to three dimensionally correct their torso by sculpting their midback (bra line folds) and flanks (muffin tops) at the same time as their abdomens to circumferentially adjust their shape. This can make a tremendous change on how clothing can be worn and how the individual feels about themselves. Liposuction with either PAL or VASER makes a great deal of improvement by releasing all the ligamentous attachments between the back and flanks and the superficial skin (which results in rolls on the back) and allows even removal of fat and the skin to re-drape much smoother.

Legs:
Some women naturally store adipose tissue in their lateral or medial thighs. Depending on the skin quality and the potential for the tissue to re-drape or tighten, fatty tissue can be sculpted just as on the back. Some have significant adipose tissue below the knee down to the ankle. I generally do not add the additional power source with liposuction in this area and have achieved good results.

Buttock:
Popular trends in body shape can change just like in fashion over time. The introduction of the Latin culture into the United States in conjunction with pop culture personalities have made the appearance of a full contour buttock something to aspire to. My preference for buttock augmentation is with fat grafting and not with a prosthesis. Utilizing concepts of tissue equilibration and liposculpturing we can remove unwanted fatty tissue, harvest it as a graft, and utilize the fat as a volumizer of the buttock- while improving the contour of the rest of the body. Women who have gained and lost weight may have loose sagging skin of the buttock and restoring volume can shape and lift the buttock with little or no scarring.

Women who are unhappy with their physical appearance after giving birth to one or multiple children can restore the body to a better place with a Mommy Make-over. To me this represents more than one area of the body to be rejuvenated simultaneously to make the woman feel refreshed and erase some of the “battle scars” of pregnancy so she can feel more confident in her appearance.

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