Why avoiding muscle coverage in augmentation mammoplasties results in fewer long term complications

As a plastic surgeon who trained in the late 1990’s and who has been in practice eighteen+ years I have witnessed many changes and evolutions in breast augmentation surgery.  As I started my practice we were only afforded the use of saline implants for our cosmetic patients. These devises yielded less than satisfying results due to rippling, a very stereotypical augmented round shaped breast. The saline filled plastic bags demanded that the surgeon place the implants partially under the muscle to soften the outline and attempt to hide the rippled appearance of the implant.  However, the outer edges of the breast could not be covered by the chest muscle and still showed the underlying implant.   Additionally, the visual results were pleasing at first but, over time, the constant chest muscle contraction overtop of the smooth round saline implant resulted in compressing the water inferior and laterally similar to a water hammer affect. The net result over many years is an over-expanded pocket that becomes larger than the implant and, in a reclined position, the devise falls off the chest wall and into the armpit resulting in widely displaced implants and breasts without cleavage.  Additionally, a less than desirable appearance occurred when a woman bent forward and the weight of the implant, combined with the over-stretched skin of the upper pole resulted in significant pleating of the saline implant.

Today I do not offer saline implants to my patients because I feel the results are so inferior compared to silicone gel devises. I was trained originally in the nineties to perform mostly a blunt dissection of the muscle off the chest wall and create larger pocket sizes than the implant. The modern surgical approach utilizes finesse with meticulous dissection to create bloodless fields and to make a pocket size similar to the width and height of the devise. I currently offer all types of silicone gel implants ranging from shaped to round devises with varying degrees of cohesiveness and surface textures customized to the individual needs of each patient.  Looking at data collected from industry experts and reviewing my own personal results over the years I have concluded that the pectoralis major muscle, even if elevated with great precision, may introduce a number of variables overtime that reduce the long-term control of outcomes by surgeons.  It is my goal to provide patients with an excellently executed surgical procedure combined with a customized implant choice leading to a desired outcome for many years, without the need for multiple revisions. Therefore, if an individual’s breast anatomy has adequate thickness in the upper pole for optimal coverage over the implant without the need for additional thickness of the muscle then I will proceed with a sub-glandular/ sub-fascial placement of the implant.  If there is slightly less than adequate thickness I will recommend simultaneous autologous fat grafting to enhance the upper pole breast tissue as opposed to elevating the muscle.

Historically speaking, other indications for utilizing muscle in augmentation mammoplasty procedures was to reduce capsular contracture rates.  Most experts feel that biofilm is the major mechanism leading to capsular contracture. Bacteria flora in the breast ducts can be introduced onto the surface of the implant during surgery setting up colonization leading to many antigens triggering our immune system resulting in an array of events such as capsular contracture and even implant associated lymphomas. This idea, even with a dual plain placement of an implant under partial muscle coverage, reduces the surface area of the breast directly in contact with the devise. Data shows a reduction in at least one percentage point in capsular contracture in the subpectoral plain compared to sub-glandular placement. However, thanks to the contributions of surgeon- researchers such as Dr. Bill Adams, our society has good benchmark data regarding the most appropriate irrigation solutions to combat the most likely bacteria present to control biofilm as well as intraoperative techniques to minimize bacterial loads on the implant during the procedure. Utilizing all this data has led to a very low capsular contracture rate even in the sub-glandular plain of my patients, thus, I feel the risk benefit ratio still favors avoiding the muscle.  

Additionally, another way to reduce capsular contracture in the sub-glandular plain is to place textured rather than smooth devices. The data is quite clear:  there is a 50% reduction in capsular contracture rates with textured vs smooth devises sub-glandularly.  But wait, it gets more controversial – textured implants have an increased risk of developing implant associated atypical lymphomas (ALCL).  Fortunately, the number of confirmed cases is very low compared to the very large denominator of all patients who have received breast implants since the late 1960’s.  In fact, the likelihood of being hit by a car while walking on the street is far greater than developing ALCL.  As far as I can glean from the data, there is no stratification of ALCL of textured devised in the sub-glandular vs sub-pectoral plain.  It is my belief without proof that the inflammation of textured devises under a dynamic muscle is greater than a textured devise in the sub-glandular non-dynamic plain. The overwhelming majority of plastic surgeons in the United States utilize smooth implants mostly because, in the late 1990’s, textured saline implants resulted in poor outcomes with greater rippling under the muscle and higher deflation rates compared to smooth implants.  However, surgeons in Europe were never forced to use saline implants and always had the availability of silicone gel devices.  They have mostly embraced textured gels with excellent results and very low ALCL rates.  Based on all of the risk-benefit analysis combined, I prefer a sub-glandular textured breast implant for the vast majority of my aesthetic breast patients.  This devise has the least capsular contracture rate with the least amount of risk for implant malposition inferiorly-laterally, and avoids a waterfall effect of the inferior pole breast tissue falling away from the implant which is held to the chest wall muscle, and avoiding any unnecessary muscle animation deformity of the breast during pectoralis muscle activation. I have also found the soft touch gels which are more cohesive than the workhorse responsive gels but less stiff than the highly cohesive gels to minimize rippling of gels in rather thin breast tissue patients. Even in the breast reconstructive realm where there is even less overlying tissue, the push for pre-pectoral placement of silicone gels completely wrapped in acellular dermal matrix material is gaining favor to avoid muscle animation deformities. For the prospective patient reading this blog don’t be hampered by simply listening to your girlfriend who had implants some fifteen years ago and tells you to have a augmentation with saline under the muscle because that is what she had and she is happy.  I applaud you for exploring implant options and encourage you to seek modern options with less long term negative outcomes with sub-glandular placement of textured implants.


Gluteal enhancement and lift with expanded volume lipofilling

Based on the most recent data from the 2018 American Society of Plastic Surgery statistics: buttock augmentation and lift continues to increase in popularity. Some of the enticement that draws prospective patients to seek this operation is the fact that areas of unwanted fat distribution such as excess flanks, bra line fat, abdomen, and thigh tissue excess can be lipo-contoured to give improved body shape while being the donor site to provide needed fat to be placed into the buttock to correct volume and aesthetic form to the gluteal region. This is one example of robbing Peter to pay Paul that benefits both.

Many varied techniques exist to perform this operation but clearly the best approach that provides excellent outcomes and safety is the expanded volume lipofilling technique described by Drs. Wall and DelVecchio and I have incorporated their methods into my practice. The approach allows for efficient application of fat with an oscillating cannula and an expanded tip which actually creates an enlarged space while simultaneously layering the area with fat. The gravest risk associated with this procedure is being unfamiliar with the anatomy and losing reference of the tip of the cannula and injecting the gluteus muscle with a small diameter tip which can cannulate rather large veins which are confluent with a venous network which ultimately returns to the heart and lungs. A large bolus of fat can act just like an emboli of blood clot and can result in death. Several cases in South America and in the state of Florida have resulted with this outcome. Understanding the human anatomy is very important to prevent this outcome as well as using large cannulas that are two big to enter the venous system and always pointing the tips toward the skin. The process starts by filling areas of deficiencies laterally and superiorly followed by inferiorly to achieve an attractive buttock.

The results are very satisfying for both the patients as well as myself because we create pleasing hour-glass figures by eliminating unwanted contours of the upper and mid- back and sculpting the flanks to get rid of the muffin tops and enhance the aesthetic curves of the back as it sweeps to the buttock. If this sounds like it could apply to you and you wish to have a consult to perform body sculpting with buttock enhancement please contact my office either by thelucascenter.com , or 865-218-6210 to schedule an appointment.

Are you considering liposuction for body contouring? Here is why you should choose SAFE liposculpting as the procedure of choice.

The trend continues: a high demand for body contouring by women and men. In recent years cryolipolysis (CoolSculpting) has received lots of hype just like LASER-liposuction did before it. Even though it is a non-surgical procedure it still requires a large time commitment and significant cost to the patient with limited results due to its lack of skin tightening. Liposuction, in its basic form, has been employed for many decades and, with proper patient selection and appropriate execution of good techniques, can produce results which sculpt the human form to a more pleasing shape without surgical excision of skin. I have been in practice for seventeen years and I have seen many modifications of liposuction with various added energy sources such as ultrasonic, water pulses, LASER, and mechanical oscillation cannulas. Regardless of the technology the most important variable is the surgeon who is performing the liposuction. They should be a Board Certified Plastic Surgeon who understands the concept of even skin flap elevation, the normal desired anatomy of the body part, the concept of wound contracture related to inflammation and collagen deposition, and the understanding of the potential life- threatening complications which need to be minimized or avoided. Liposuction is surgery whether performed in an office, surgery center or hospital and appropriate judgement and skill is required. So, do your homework and choose wisely to ensure predictable safe outcomes.

Liposuction to improve or enhance the shape of the body can result in unwanted contour irregularities of the skin. This can be the result of incomplete fibrous tissue release and or skin retraction or uneven removal of the underlying fat. Even in experienced hands some contour deformities can occur requiring minimal revisions. In my hands, the most predictable lipocontouring technique is the one championed by Dr. Simeon Wall called PAL/SAFE which is not a completely new concept but has led to much more precision and artful outcomes. Essentially it employs the use of a power added handpiece attached to an oscillating cannula. I also utilize a technique by Dr. Dan DelVecchio called SST (simultaneous separation and tumescence) to enhance the pace of the surgery. The essential features of the amalgamation of these two concepts include infusing a wetting solution containing dilute epinephrine and lidocaine retrograde through an oscillating expanded basket cannula which allows the surgeon to immediately wet the fat and prevent bleeding while also breaking up the fibrous encasement surrounding the fat cells under the outer skin. This is also when any cellulite (ligaments that bridge deeper tissue to the dermis of skin) can be released as well. The key principle is to completely release the fat to be freely mobile while still attached to a blood supply and the overlying skin is completely released. The second stage is the aspiration of the unwanted fat volume of a given area to create the new shape. The last step is the equilibration of the remaining fat left behind and re-distributing relative areas of excess fat to areas of deficiencies with a cannula similar to racking pea gravel to an even level throughout the area of concern leaving behind an even surface. The concept of the skin re-distribution or retraction can occur evenly if the overlying skin is released and the skin quality is acceptable for the technique. Loose hanging skin with lots of stretch marks are not candidates for any contouring without associated skin resection such as tummy tucks.

Liposuction to create new body contours can be a very effective technique with the right trained surgeon and the appropriate candidate. The precision advanced techniques described above are the best way, in my opinion,to ensure good results with minimizing contour irregularities. Therefore, I prefer to use the MicroAire PAL system with SAFE and SST concepts for my body contouring procedures. To inquire about a consult and to see if this procedure is right for you please contact my office, The Lucas Center, at 865-218-6210 or email thelucascenter.com

Things to do in Knoxville TN

The beautiful Knoxville TN area has long been one of the most popular tourist destinations in the southeastern United States. Located in the eastern have of the state, near the Great Smokey Mountains, Knoxville offers a wide variety of exciting and interesting things to do for everyone. It doesn’t matter if you are a sports fan, a brew fan, or a history buff, this town has something for you. A picturesque town filled with old south charm combined with a bustling and energetic modern city, Knoxville is a must visit destination. Let’s take a look at some of the cool things that you can do while in the Knoxville and the greater Knox County area.

The worlds Fair of Knoxville, held in 1982, was without a doubt one of the most important events to occur in the state in modern times. The exposition received over 11 million visitors during its run which closed on October 11, 1982. When the Worlds Fair closed, however, unlike locations of previous worlds fairs, the city didn’t let the grounds of the exposition fall into ruin or be redeveloped into something else. Instead, the city embraced the park and has turned it into a jewel that is beloved by all citizens of the area and visited every year by thousands. The park includes the Tennessee Amphitheater, the historic Volunteer Landing, the Festival Lawn, and the massive performance lawn. There is always something happening at or near the Worlds Fair Park. Check out the website for more information. Hours and any admission vary by event, but the park is open to the public daily.

Constructed for the Worlds Fair, the Sunsphere was the fairs official symbol. There was an observation deck as well as a full-service restaurant. It is one of only two structures that remain from the fair, the Tennessee Amphitheater being the other. IN 2005 the mayor of Knoxville announced that the sphere and the amphitheater would be renovated for public use. In 2007 the observation deck reopened to the public and private businesses took up residence in spaces on the 5th thru 8th level. There is no charge to visit the observation deck which is usually open 9 am to 10 pm daily. More information can be found on the Sunsphere page of the Worlds Fair Park website.


Knox Brew Tours offers tours to all of the major breweries in the greater Knoxville TN area. There are also exclusive brewpub tours. All tours are conducted by professional guides and are transported on comfortable mini charter busses. Each tour includes four breweries. The brewpub tours include three brewpubs. Tours take place on Thursday, Friday, and Saturday at set times. Tours for groups and on days Sun-Wed can be booked privately. Tours include three 4oz pours per brewery for a total of 12 beer tastings per tour. Tours average $49 per person per tour. Check out the website for Knox Brew Tours for more information.

These are just a few of the many great things to do while in the greater Knoxville TN area. Knoxville is a wonderful place to visit, once you see the charm, history, and excitement of this great old American city, you will for sure want to visit again and again.

The Lucas Center Plastic Surgery
280 Fort Sanders W Blvd 4 #112, Knoxville, TN 37922
(865) 218-6210

Protect yourself and your love-ones only chose a board certified plastic surgeon for cosmetic procedures

If you have coronary heart disease and need open heart surgery to bypass clogged vessels would you chose a family practice doctor or an ER physician to perform the surgery? No! Likewise why do some people who desire cosmetic surgery go to a non-plastic surgeon like the ones mentioned above for their cosmetic needs? Seems strange don’t you think? Actually it is flawed reasoning and it could cost you your life. In fact, recently in Miami Florida a surgery center which allowed a family medicine trained doctor without any surgery training or in depth knowledge of critical surgical anatomy to perform a Brazilian Buttock lift. Tragically, the patient died of cardiac arrest most likely as a result from injecting large volumes of fat directly into large veins within the gluteal muscle resulting in fat emboli to heart and lungs. Plastic surgeons with years of surgical training supported with constant continuing medical education supported by the American Society of Aesthetic Plastic Surgeons and The American Society of Plastic Surgeons would be far less likely to make that same mistake. Why take that chance when life is too precious and ultimately irreplaceable. Saving a few dollars by using a fringe doctor could ultimately kill you and, needless to say, not worth it. Aesthetic plastic surgical procedures can provide enhanced self-esteem and permanently alter the form and function of undesired areas of the face and body. These procedures are real surgeries which are technically demanding and can result in unwanted complications even in the best of hands. As is the case in any other surgical field, expertise coupled with a large volume of clinical experience results in best outcomes.

Unfortunately, economic driving forces such as reduced physician reimbursement, health insurance monopolies, and greed for maximizing profits have enticed practitioners to leave their comfort zones to pursue procedural based fee-for-service businesses outside of insurance contracts. Other contributing factors include the driving force of equipment manufacturers encouraging sales of their surgical devises along with weekend educational courses to stimulate sales. Many of these individuals have limited training, almost no clinical experience, and zero credentials in the way of professional society’s support of education and analysis of clinical outcomes for a given procedure. In fact, The American Society of Aesthetic Plastic Surgeons leaped into action to delve into cases of operative deaths related to the ever increasing popular procedure of the Brazilian Buttock Lift. Such cases within the United States and abroad were analyzed using data from operative records, interviews with surgeons and staff as well as autopsies to define the problem and make recommendations to avoid unwanted deaths. Unfortunately most of the deaths occur under the care of non-plastic surgeons who probably don’t even know what they don’t know. This past spring the annual national meeting of ASAPS in San Diego dedicated time to brief the membership on important steps to avoid unwanted outcomes. In the right hands, with experience and excellent surgical training, these procedures can provide amazing results that fulfill the aesthetic goals of women seeking a more pleasing shape to the buttock area while enhancing unwanted contours elsewhere on the body. The bottom line: liposuction and fat grafting are true surgeries not to be performed in back rooms of clinician’s offices or unregulated outpatient surgical centers where peer review and outcome analysis is absent and best practice guidelines are intentionally ignored.

I spent almost a decade and a half in training specifically to provide exclusively high quality surgical care for my aesthetic plastic surgery patients. Together with my plastic surgery colleagues, I am passionate about providing excellent outcomes for our patients with minimal complications and I find it offensive when untrained people try to enter the same arena to provide services simply to make extra money. This is not just business to me its personal because we in the field of plastic surgery have dedicated our lives to this cause.