A Comprehensive Three-Dimensional Rejuvenation Center

Monthly Archives: September 2017

Breast enhancement with implants and fat grafting utilizing lipofilling technique

Style and personal preferences continue to evolve in breast enhancement trends. Women are requesting a more natural, proportionate breast enhancement compared to the 1990’s Bay Watch appearance. This reflects both style changes and is better aligned with outcome data by both The American Society of Plastic Surgery and the American Society of Aesthetic Plastic Surgery, which denotes smaller revision rates for patients who chose implants offered to them by surgeons who base the choices from a tissue based diagnostic analysis. Women today want long term results which will provide “perky” uplifted breasts proportionate with their frame and will not bottom out overtime from excessively large implants. This lends itself to other trends seen in popular magazines such as the “free the nipple campaign,” and evening gowns with side breast exposure which looks much better with a breast well confined to the anterior chest wall. This profile provides an attractive lateral breast silhouette compared to an overly protruding lateral bulging breast from excessive breast volume or excessive implant size.

I have incorporated an amalgamation of several analyses from leading authors for determining the best implant options for my patients. However, I strongly focus not only on the soft tissue but the underlying skeleton as well. Just as an architect or a civil engineer has to factor the underlying topography of a building site so should a plastic surgeon in the final treatment plan for their patients. The shape and width of the sternum (breast bone) and the shape and slope of the underlying rib cage as it merges with the axillary region has significant impact on how successful a breast enhancement will appear. Imagine if you would a wide breast bone separating the two breast will not allow a tight cleavage appearance no matter how large of an implant is placed. Rapidly sloping rib cages from the sternum to the axilla will result in the overlying breast laying divergent from one another and the larger the enhancement with an implant the more divergent the nipples will become. Also long torsos often times will result in a long distance from the breast fold to the collar bone giving an appearance of a low set breasts. And the situation of a narrow chest wall with a long torso often times, in my opinion, mandates a shaped implant (taller in height than in width) with a highly cohesive anatomic gel compared to a responsive gel to provide an appearance that the breast begins higher on the chest wall. In my clinical experience, roughly forty percent of all the women who seek breast augmentations either have a skeletal configuration issue or a breast soft tissue issue such as a constricted breast deformity that may result in less than satisfactory results with an implant alone. This is why a very thorough physical exam combined with the patient being able to see themselves in a three dimensional imaging system (VECTRA) will allow them to understand why they cannot achieve a result that their best friend may have with a given implant due to individual anatomic variations.

Why Fat Grafting?

The evolution of large volume fat grafting with the expanded volume lipofilling technique to the breasts has been a paradigm shift in how I deliver care to my patients. Fat grafting has proven to be an integral component of an augmentation procedure with implants by helping to overcome some of the anatomic limitations stated above that women may exhibit which can greatly diminish the outcome of these procedures. It has elevated my results additionally by softening the outline of the implants superiorly and helping to avoid the pleating appearance which may occur with even silicone gel placed in the sub-glandular plain. Certainly a controversial topic in any plastic surgery forum on breast augmentation is which anatomic plain is superior for placement of implants. However, my current view, as well as many other highly respected plastic surgeons is: if it is at all possible avoid the downsides of the muscle by placing the implant under the gland. This can reduce animation deformities and the continuous strain of the muscle contracting overtop of the implant increasing the likelihood of the devise from being displaced inferior-laterally overtime. Also, for the constricted breast deformity where the anatomic fold is too high and the lower pole of the breast is tight with less breast volume present, the plan of action is to score the breast tissue underneath and lower the fold to allow the limited breast volume to unfold around the lower pole of the implant to avoid a double bubble effect. Unquestionably, the use of added fat volume to fill this space to further cover the lower implant will, at the same time, result in superior outcomes. I also think that the soft tissue/ implant ratio, if unfavorable, may also lead to an increase risk of capsule contracture outside of the normal biofilm/inflammatory mediated model. I also utilize fat grafting in many of my mastopexies (breast lifts) when performed with or without an implant or in the event that some women wish to permanently remove their implants and wish a breast lift only. Fat grafting can be a wonderful means of adding upper pole volume without the implant. Some women choose to enhance their breasts with fat grafting alone. I first discuss with them that, in my opinion, a combination technique is best but the fat grafting technique alone can yield a modest increase in cup size. Generally, breast volume is stable at around four months post surgery with around 30-40% of the initial fat grafting volume lost due to lack of vascularization. Unfortunately, the best outcome with this approach is right after surgery with all of the fat grafting present combined with natural swollen tissue.

What is expanded volume lipofilling.

Dr. Sydney Coleman was the first plastic surgeon to strongly pursue fat grafting in many areas of the face, hands, and breast. He initially was viewed as a pariah in the industry but his persistence has led to a wide spread acceptance of the concept of fat grafting. He initially used very small cannulas with limited volume application and placed in many different plains to ensure the fat graft take with a blood supply. Fast forward to today, critical thinkers such as Drs. Simeon Wall and Dan DelVecchio have risen to the needs of large volume fat grafting to the buttock and breast and have created a technique of simultaneously expanding the volume of the recipient site (i.e. breast tissue and overlying skin) while back filling this enlarged space with fat in a very expeditious method utilizing PAL (Power Assisted liposculpting) headpiece with an expanded basket cannula. Essentially, the vibrating headpiece is connected to a hydrostatic pump that moves fat from the harvested reservoir retrograde through the cannula and dispenses the fat in a very laminar pattern similar to shaking tiny mustard seeds from a hand onto the ground. This very much avoids clumping which can lead to fat necrosis nodules. The vibrating motion of the basket cannulas expands the volume of the space thus reducing hydrostatic forces on the newly placed fat cells allowing for a greater volume to be placed without strangling the cells under undo force. Additionally, this process rapidly speeds the placement process compared to pushing single aliquots of fat being injected via a syringe thus reducing expensive operative time for the patient. I generally agree with the technique of fat harvesting into a large canister with fat separation from the aqueous component with decanting methods only for the buttock, but with the breast containing a more limited space particularly with an implant underneath, I prefer to clean the fat and more thoroughly remove the excess aqueous fluid with a single use devise called Revolve by Allergan. Therefore, I can be assured all volume injected is viable fat and not excess fluid as well.

In conclusion, successful and extraordinary results in augmentation mammoplasty can be achieved but requires three dimensional thinking, of not just the breast, but the surrounding skeletal and soft tissues of the chest wall. Implant decisions are not just based on volume alone but on the distribution of volume in various implants and may require a shaped implant to achieve a superior result of a round devise. The use of fat grafting to enhance areas of soft tissue deficiencies surrounding implants or to place volume outside of where an implant cannot be placed such as the decollate can lead to superior results not previously available with implants alone utilizing sculpting techniques with fat. Lastly, the newly acquired techniques of expanded volume lipofilling are creating more efficient and larger successful volumes of fat administered with this methodology.

If you are interested in a thorough three dimensional analysis for an ideal breast enhancement tailored to your specific needs please contact The Lucas Center, Plastic Surgery,Knoxville, Tennessee at thelucascenter.com or 865 218 6210.

September is Craniofacial Awareness and Acceptance Month

I am a craniofacial trained plastic surgeon from Stanford University having provided craniofacial, cleft lip, and palate care to my patients in academia in North Carolina I then transitioned into private practice in Knoxville Tennessee. I currently no longer take on new pediatric patients in plastic surgery but I extend my love and support for children and their families who have to endure many years of surgical procedures to reach a state of normalcy. It certainly is an uphill battle and I am always amazed at the resiliency of these small children to endure very complex and long surgeries to achieve rehabilitation from congenital birth defects. I was always honored to be in a position to provide this care for families in need.

Currently I am mostly an aesthetic plastic surgeon. I very much value my training in the field of craniofacial surgery because it has given me such a unique insight into the normal form and function of the skeleton surrounding the eyes, face and nose as it interacts with the multiple muscles and fat pads creating the complex composite of how we appear to our friends and family. In depth study of the face through transitions in time from infancy to adulthood to the unwelcoming aging facial appearance provides me an aesthetic eye from which I can provide treatment plans to optimize facial balance of the skeletal form, soft tissue volume, and overlying skin to achieve a youthful face.

With aging the bony orbital volume increases resulting in changes in globe position, the soft tissue support mechanism of the eyelids and fat pads diminish resulting in looser lower eyelids and prominence of the lower eyelid fat pads increases. In regard to the upper eyelids and brows we see the temporal fat pads both above and below the muscle begin to waste away giving a skeletonize look to the upper lateral orbit and descent of the lateral brow that hangs over the upper eyelid. The actual upper eyelid skin becomes loose and redundant and the support mechanism of the upper inner fat pad decreases allowing it to be more visible.

Rejuvenation of the periorbital region all depends on the degree of the aging disorder. Early stages can be treated with filler agents such as an induction technique with Sculptra. This product when injected into the tissue results in an inflammatory mediated process to induce collagen production as a replacement for the fat lost in a given fat pad zone such as the temporal fat pads which, by restoring volume, can re-suspend the lateral brow tissue to reduce hooding over the upper eyelid. The areas of the lower eyelid such as the tear trough and the lower eyelid fat pad -cheek junction can often be smoothed similar to photo-shopping with the injection of hyaluronic acid fillers deep to the eyelid muscle as an enhancement of the skeletal rim. This may even change refraction of the light off of the skin of the lower eyelid, modestly reducing a dark appearance. However, if there is significant excess skin of the brow and upper and lower eyelid then an endoscopic brow lift with upper and lower eyelid surgery is generally required to achieve satisfactory results.

The midface is the area along the cheek bone and extending inferiorly down to the cheek fold line (nasolabial fold). This is an important anatomic region that houses a large fat pad. The shape and the projection of this area is dependent on the upper jaw bony structure as well as the volume of the fat pad. Unfortunately, the fat volume is programed with aging to shrink in size leading to less cheek projection and the deflated net result can lead to enhancement of the nasolabial fold and produce unwanted downward turning of the corners of the lips and jowling (hanging skin over the inside border of the jaw line lateral to the chin.) The number one most important intervention is restitution of the volume loss of the fat pad. This can be corrected with a very dense crosslinked hyaluronic acid filler agent like Restylane Lyft or Voluma. Another option is the induction technique of Sculptra if multiple areas need restoration simultaneously. If a face-lift is indicated I always replace the fat volume with a deep fat grafting injection in the same anatomic relationship of the fat pad.

And finally, a review of the lower face which, in my facial analysis, occupies the lips, lower jaw including the chin point, and the neck region. Once again the lips lose volume and definition with aging. The upper lip’s vertical columns extending from the base of the nose down to the cupid bow points flatten with age and the skin above the lips lose volume and become flat and can demonstrate vertical lines emanating above the vermillion. This is a dead give- away for aging on a women. Simultaneously the lower lips thin as well and the corners of the mouth turn inferiorly giving a sad appearance. Accurate and judicious restoration of volume in this area, with an appropriate aesthetic eye, is required to restore the vertical columns cupid bow points, the central tubercle as well as the two lateral tubercles and volumize the commissures of the mouth. Nothing is worse than a blown up upper lip without delicate definitions of the above mentioned points. I see many grotesquely enhanced lips today that don’t represent normal youthful anatomy. The other important component of the lower face is the underlying skeletal relationship between the upper and lower jaws. If there is a small lower jaw often the chin is retruded and there is an increased fold below the lower lip and chin due to lack of lip support by the lower incisor teeth. This weak jaw relationship also leads to an obtuse cervical –mental angle with loose hanging skin of the anterior lower neck. Skeletal correction with a screws retained implant or a small chin bone advancement can greatly improve the neck line. Vertical bands in the anterior neck can only be corrected with surgical correction as part of a lower face-neck lift with excellent long term results. If a person has excess fat in the neck with some lose skin and no vertical bands then a judicious removal of fat with liposuction can result in a tighter looking neck with less full appearance. I personally feel that other techniques like CoolSculpting is an expensive less effective technique because it does nothing to lead to skin tightening and has less precision of selective fat removal.

In summary, I feel that having a craniofacial surgery background provides me with unique skills of facial analysis and three dimensional correctional treatment options. These treatment options, which can correct or restore normal anatomy for better balance, provide a means to harmonize aging facial deformities to look more rested and youthful without leading to an abnormal appearance that would cause people to ponder what you had done.

For more information visit http://www.thelucascenter.com/