Current treatment for enlarged male breasts

Current treatment for enlarged male breasts (gynecomastia)


Gynecomastia (“man boobs”) is a condition in which the fibro-glandular structures centered under the nipple areolar complex on men may result in a wide range of enlargement deformities. Many males find that it occurs around puberty and will persist despite maintaining ideal body weight and good exercise habits. Certainly the enlargement can be made worse with excessive weight gain. Men may also experience new onset of this condition any time during their life time. Medications may potentiate gynecomastia such as exogenous testosterone replacement due to the fact that testosterone can be converted in fat to estrogen particularly if the testosterone levels are in excess of normal values. Some have argued using an estrogen blocking agent at the same time as giving testosterone if men developed increased in breast size. With legalization of recreational marijuana in many parts of this country there will undoubtedly be an increase the incidence of gynecomastia due to marijuana’s potentiating effect on male breast size. Older gentlemen may also experience increase in breast size as natural hormonal changes occur resulting in an increased estrogen/testosterone ratio leading to this deformity. In my practice I commonly see a full spectrum of ages ranging from young teenage boys who are embarrassed to go shirtless or wear tight fitting shirts to twenty somethings who participate in cross-fit and body building but still see an enlargement of their breasts that detracts from their well- earned physique, and finally men who had been overweight and have lost weight either from bariatric surgery or lifestyle changes and desire to eliminate a large amount of excess skin on the breast and chest region to regain a healthy masculine appearance.

Treatment options for gynecomastia

As with any deformity that has a wide spectrum of presentations the treatment varies as well. For the male who has excellent skin quality with minimal or no stretch marks and a normal nipple position with respect to the chest wall and has enlargement of the breasts, these are excellent cases for suction assisted lipectomy with an additional energy source such as an oscillating motor (PAL – Power Assisted Liposuction) or ultrasonic energy. The reason regular liposuction has limitations is that the male breast has lots of fibrous tissue encasing fat and glandular elements which help to tether the overlying skin to the chest wall to keep the tissue from excessive movement. Regular cannulas utilized in liposuction cannot break up and penetrate this tissue to extract the fat and glandular elements effectively nor can it release the fibrous tissue to allow for re-draping of the skin for a smooth contour postoperatively. Either ultrasonic energy or the oscillating motor in conjunction with liposuction provides the ability to breakup this tissue to both extract tissue and provide smooth contours. However, I have found that even after aggressive liposuctioning of the area, at least twenty five percent of patients require me to make a peri-areolar incision to perform direct resection of the residual fibro-glandular tissue under the areola to provide an ideal appearance. My experience with men who have enlarged areola (nipple) diameters is that with skin retraction after liposuction, the size generally contracts eliminating the need to surgically reduce the areola diameter such as a mastopexy (breast left) technique thus avoiding risk of scaring.

I have seen a number of teenage boys who are overweight and have loose skin, breast tissue herniating into the areola with the nipple-areola complex hanging down creating a matronly appearing female breast. This deformity requires not only liposuction but at least a peri-areolar mastopexy technique to reposition the nipple complex and reduce the areolar diameter to achieve a more masculine appearance.

Gynecomastia is a fairly common condition and many men find that it detracts from their appearance and leads to self-confidence issues. Fortunately surgical treatment can be very easy and effective to achieve wonderful, very natural results. Please consult a board certified plastic surgeon to discuss gynecomastia repair – there is no need to cope with this disfigurement.

What are the options for Post bariatric massive weight loss on body deformities

Individual Options:  Post bariatric massive weight loss and body deformities


The epidemic of obesity in this country is contributing to millions of Americans developing diabetes, hypertension, heart disease, and worsening the outcomes of degenerative joint disease. Ultimately a true commitment to life style changes will lead to healthier outcomes. Some morbidly obese individuals need invasive bariatric surgery to aide in this endeavor and the results can be spectacular.  Results including long lasting weight loss of sometimes two hundred pounds or more.  Many times the unfortunate end result is individuals being held prisoner by their deflated, left-over skin that hangs from the breasts, arms, abdomen, flanks, and/or medial and lateral thighs. There is well documented literature which supports body contouring after weight loss in motivating patients to maintain their new life styles.

What are the options for body contouring after massive weight loss?

For the lower torso

Many patients initially fixate on the fact they have a large pannus of the abdomen (layman’s terms:  apron or flap of tissue over the abdomen) and think all they need is to remove this isolated deformity. This is emphasized by bariatric surgeons who only feel comfortable offering panniculectomies (tissue/skin removal) for lower torso deformities because they do not possess the skills or have the aesthetic eye of a fully trained plastic surgeon.  In fact many women and men complain that the lower pelvic tissue also hangs and has thinned and fallen away from the pubic bone leading to aesthetic deformities of the external genital region such as the mons pubis (layman’s terms:  the area over the pubic bone) and vulvar region (layman’s terms:  the area around the entrance to the vagina). Panniculectomies do not address this condition. Secondly the abdominal rectus muscles (the “Abs”) which act as an internal corset for the abdominal contents, holding them in check, often times become separated resulting in not a hernia but a large abdominal bulge. Women who have had children often will have a greater deformity than men. This also is never addressed during a panniculectomy. Another thing to consider:  massive weight gain is not two dimensional therefore weight loss skin changes are also a three dimensional deformity.  In addition to the abdomen and pelvic region, lower torso problems include excessive skin and fat hanging on the flanks, very proximal lateral excess thigh tissue, as well as the buttock becomes flat and shapeless making clothing difficult to wear. My recommendation for this constellation of deformities is the circumferential lower body lift. This is a single stage operation which includes a full lipo-abdominoplasty (removal of excess skin of the abdomen, correction of the underlying muscle deformity), pelvic rejuvenation (suspending and reshaping the mons pubis or the tissue surrounding the penile shaft), Flank tissue recontouring, lateral thigh resuspension, and lastly buttock reshaping and elevation with transposing excess tissue from the flanks to the buttock region. Yes this is a significant operation around six and a half hours but it is outpatient and our results are excellent and have never had to readmit anyone after surgery. This truly is a transformational operation freeing patients of their unwanted excess skin and all associated deformities and a very distinct difference from just a panniculectomy.

For patients who have already undergone a lower body lift and still have excess tissue in the upper abdomen that is loose a reverse abdominoplasty can be an ideal method to remove this excess and can be used to provide added vascularized tissue to add volume to the breast if an implant is not selected as part of a mastopexy.

Upper torso options

Just as there are many body shapes there are many variations to massive weight loss body changes. Both women and men experience deflation and hanging tissue from the upper arms and   upper back region. The only way to correct this is through an aggressive skin reduction technique that commonly starts at the elbow and extends in a posterior medial line angle of the upper arm to the armpit and then continues on the posterior axillary line angle and follows the back as far down as required to remove the excess. In some women we can stop near the bra line. But our goal is to avoid hanging skin over the bra. Both men and women also have unsightly shapes to the chest and breast region. Women lose significant breast volume and have skin excess which leads to very flat deflated hanging breasts. In post-bariatric patients we try to avoid implants if we can because the residual soft tissue is generally not mechanically strong and holding implants in the correct position on a chest wall is quite difficult. I would prefer to perform breast lift with significant skin reduction and adding volume with either fat grafting or reverse abdominoplasties to obtain acceptable shapes. Sometimes I am forced to use implants but it increases the need for revision surgeries to get ideal results. Men often need gynecomastia (breast tissue removal) repair utilizing a significant skin reduction technique similar to a mastectomy and blending the scar into a chest fold. The standard gynecomastia techniques with PAL (power assisted lipectomy) with or without a periareolar (around the areola) mastopexy are not an option.

Medial Thighs

Once again there are many variations among patients and this region. I have seen men who have lost almost two hundred pounds and have near normal inner thighs. I have also seen women who are near ideal weight and have never lost any significant weight and have excess skin in this region. I will say I often see women who have cascading hanging skin of the inner thigh and upper knee area that prevent these people from feeling comfortable in shorts or skirts. Just as in the upper arms we aggressively liposuction the inner tissue and determine the skin excess and then remove this tissue blending it into the posterior and medial upper thigh and curving the incision into the groin crease. We purposely avoid anchoring the tissue superiorly to the ischium (curved bone forming the base of each half of the pelvis) to avoid deformities of the labia on women. Just as on the arm there is a scar but the vast improvement in contour out-weights the negative results of a scar.

Post-bariatric weight loss can be an amazing journey for patients allowing them to reclaim their health and happiness. Body recontouring is a  necessary step to realize the freedom from the prison of excess skin left behind by the weight loss. Understanding that everyone unique, please come to the Lucas Center, Plastic Surgery to hear about our customized approach to restoring your confidence in yourself after weight loss.

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Rejuvenate your breast shape and volume with simultaneous breast lift and fat grafting

Unfortunately gravity is unceasing and combined with age and sun related skin loss of elasticity a woman’s tissues surrounding her breast can lead to the breast mound falling lower on the chest. Additionally, the volume inside the breast can diminish with hormonal changes after pregnancy and menopause and with significant weight loss.  All these factors triumphantly combine to give an aged appearance that can be significantly disproportionate to the otherwise youthful feeling of a women. Sound depressing? Sure it does but the artistry and science behind plastic surgery can offset these changes to a woman’s breasts and make them feel good about the skin they are in.

If someone is unhappy with the appearance of their breasts it is helpful for analysis sake to deconstruct the breast into two separate components: the overlying skin brazier, and the volume and its distribution of the breast mound on the chest wall.

The mound itself may have adequate volume but most of the distribution of the volume is in the lower pole of the breast well below the breast fold requiring a bra to perform a heroic task of keeping the breast on the proper location on the chest wall. This situation can be improved by a mastopexy (lift) with creating a lower pole breast flap of tissue transposed under the rest of the breast mound and fixated to a non-mobile portion of the chest wall to provide upper pole fullness. In this situation the skin brazier is loose and has allowed the breast mound to sink inferiorly and requires and generous amount of skin to be removed and repositioned to be coincident with the newly shaped breast mound. For some women this may produce a nice result but particularly individuals who have a very long trunk with a great distance from the breast fold to the collar bone, creating the appearance of low set breasts, the above technique requires another means of providing upper pole fullness. Some women are comfortable with adding an augmentation with a breast implant to enhance shape and form and creating a nice upper pole roundness. Some surgeons are comfortable offering an augmentation at the same time as the mastopexy. Other surgeons would argue, based on data which has shown a 25% revision rate with the combined procedures, would prefer to stage these techniques. I personally like to perform the augmentation mastopexy in a single stage because I would rather have the implant in place to provide shape and volume to the overlying breast mound prior to tailoring the skin envelope of the lift procedure. I find this saves the patient a second general anesthesia, reduces expenses, and can be performed in the office setting with much less cost. Generally, it is only a minor skin re-tailoring to minimally reposition the nipple-areolar complex vertically on the breast mound.

Implants can provide structural shaping and volume enhancement of the breast mound but there are definitely limitations to their effect. Women who have structural limitations to their chest wall anatomy can have difficulty in achieving satisfactory results with implants alone. Individuals with very wide sternums and rapidly sloping chest walls cannot achieve meaningful cleavage with implants alone because the devise cannot be placed on the sternum. Another anatomic limitation eluded to in the above paragraph is the long chest wall with the accentuated length of the breast fold to collar bone giving the illusion of the low set breast. Even an anatomic shaped breast implant which is taller than it is wide still cannot mask this affect. In both of the above situations in which implants are chosen as the enhancer of choice the addition of fat grafting is necessary to create a much enhanced result. The beauty of fat grafting is that it can be placed in any position on the chest or breast. It can be similar to the concept of photo-shopping an image and allows the surgeon to truly sculpt the breast and chest wall to closer reflect an ideal form and helps to hide these difficult anatomic variants with your very own fat.

Other women may prefer to avoid implants all together and in consultation with their surgeon may choose to enhance the shape and volume of the breast mound and chest wall in conjunction with a mastopexy with just fat grafting lone without implants. Just as implants have limitations so does fat grafting. The current art and science of the techniques of autologous fat grafting has a yield of around seventy percent sustainable take of the viable fat implanted into the tissues. This has been reproducible shown over many series of papers presented in the literature. Since fat is a very soft material that cannot resist significant opposing forces of the skin it is difficult to globally enhance a breast mound much larger than a cup to a cup and a half sizes larger in one session. Therefore a women who has a large skin envelope and very limited breast mound volume and desires to have a very full shape should not consider enhancement solely with fat alone. A combined implant with fat grafting provides a much better and stable result. In my experience fat grafting alone is best to sculpt and shape the cleavage and upper poles of the breast and chest wall interface. It can enhance the overall volume by a cup size as well. The other nice advantage of fat grafting for breasts is it allows the removal of unwanted fat volume from places like the flanks, abdomen, and thighs to achieve improved breast shape and sculpting of the body contour.

If you feel self-conscious about the appearance of your breast and feel it is disproportionate to the rest of the body and how you feel about yourself, consult a board certified plastic surgeon to define your goals and options for rejuvenating your breasts.

Eye-opening concepts.

It has been said that the eyes are the windows to our souls. Certainly we often remember our friends and love-ones faces with the eyes playing a prominent role in facial identification. Unfortunately the aging process can strike this region relatively early leading to appearances that project fatigue, disinterest, and lack of vitality. Aging will result in skeletal changes around the eye, shrinkage of muscle and fat volume in the temples causing lateral brow descent, thinning and loss of elasticity of the skin of the eyelids, prominence of the fat pads of the upper and lower lids as a result of a weakening of the eye socket surrounding these structures, and in some cases the muscles that control upper eyelid position stretch or change leading to the upper eyelid drooping with respect to the pupil giving a sleepy appearance. All these symptoms of aging can hide the bright and vibrant person inside giving the false impression of a tired worn out individual. Take back the youthful appearance that is hidden under the veil of aging by consulting a board certified plastic surgeon who has expertise in eyelid and brow rejuvenation.

Brow

As with all anatomic areas deformities of the upper third of the face can span a wide range of severities. Many times women in their late thirties and early forties can show signs of early brow descent which can narrow the opening of the eye and brow skin resting on the upper eyelids. Many times in these milder forms of age and gravity related deformities we can correct with muscle balancing procedures utilizing neurotoxins such as Botox to weaken the depressors of the brow and allow unopposed brow elevators to prevail and elevate the resting tone of the brow.

Another targeted area to correct non-surgically, the brow position, is to restore volume to the temple region of the skull. This area in front of and superior to the ear and lateral to the brow represents the temporal fossa. This houses a large flat muscle that helps to elevate the jaw and is surrounded by soft tissue including fat and covered by hair bearing scalp tissue. Bony and muscle remodeling coupled with overlying fat shrinkage can lead to a hollowed out appearance which causes the brow to fall downward making the brow skin begin to cover the upper eyelid skin. Volume restoration can be accomplished with any number of filler agents but I prefer to correct the volume with a guided tissue regeneration product call Sculptra which is a polymer of lactic acid which promotes collagen deposition over time restoring volume and allowing the brow to be supported at a higher level compared to a depleted state.

As the brow tissue descends lower, further concealing the upper eyelid, the options narrow to surgical intervention. I prefer an endoscopic assisted brow lift over an open approach to avoid scars and hairline shifts. Just a few small openings spread out over the hairline allows for the complete release of the forehead and fixation internally to correct brow drooping leading to a pleasing brow position which looks natural without changing the hairline and allowing for improved visualization of the upper eyelid. In most cases the upper eyelid skin will require modification to give a harmonious smooth result. Errors such as trying to remove excess upper eyelid skin which includes excess brow tissue instead of performing a simultaneous brow lift will result in a poor result with very high eyelid crease scaring and the inability to close the eyelids resulting in dry eyes. Expertise in the aesthetic and functional evaluation of the upper third of the face is important.

Upper eyelid

The most common cause of excess upper eyelid skin is the underlying result of periodic eyelid swell causing excess thinning tissue. This can be addressed with conservative blepharoplasty techniques which can include some judicious fat removal. Of course a thorough exam to determine if the resting eyelid position with respect to the pupil is too low because not correcting the drooping of the upper lid will give a less than adequate rejuvenation because the patients eyes will still seem tired due to the lid lag.

Lower eyelid

Common aesthetic problems of the lower eyelid include excess skin, lack of lateral support of the lower eyelid giving a rounded eye appearance and excessive show of the whites of the eye ball, large fat pads with or without loose skin, increased separation of the eyelid cheek junction, and lastly crow’s feet. If skin quality is reasonable without excessive crepey skin and there is increase separation of the eyelid cheek junction then a conservative injection of a hyaluronic acid placed on the cheek bone under the muscle that closes the eyelids can smooth out the tear trough as well as build up the lateral eyesocket boney rim hiding some mild bulging of the lateral lower fat pad of the eyelid. This can create a Photoshop effect smoothing out the eyelid. Another conservative approach to helping the aging lower eyelid is to diminish activity of the lateral muscle that closes the eyelids with neurotoxins which can lead to a reduction in crow’s feet and can slightly help to elevate the lateral third of the brow.

Surgical interventions of the lower eyelid include judicious removal of the two lower eyelid fat pads through the inside of the lid with transposition of the fat on to the cheek to hide the tear trough, surgically removing excess skin from under the lash line vs skin tightening with a C02 Laser, lateral lid support to the bone enhancements with or without shortening the horizontal length of the lid. These procedures need to be selected based on clinical exam with the goal to provide a youthful eyelid with good support while avoiding excessive hollowing of the lower eyelids and poor lid support leading to rounded eyes and increased exposure of the eyeball.

The upper third of the face contains the aesthetic units of the brow, upper and lower eyelids and are a very unique region of our body for both special senses of vision, and provide our unique individuality of facial appearance. Aging can have a detrimental effect on both the aesthetics and function of this region which can bias people’s opinion of our vitality and mental sharpness. Non-surgical and surgical corrections can be important tools to correct these deformities restoring our appearance and giving back self confidence.

Customized Breast Enhancement

Remodel – Customized Breast Enhancement – Let the Lucas Center, Plastic Surgery offer you a customized approach.

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Are you a breast augmentation patient who either had surgery in the late 1990’s during the silicone false claim crisis or a patient who was misled into thinking that saline is an equivalent to the modern silicone gel implants? Or you were a fan of the 1990’s Bay Watch series and at the time felt that Pamela Anderson’s breast shape and size was the ideal standard. Just like houses with bathrooms and kitchens that seem dated after ten to fifteen years, requiring attention to remodeling to keep the house fresh and modern, so are breast enhancements. Stylistic changes and technology advancement of breast implant materials and fat grafting have come a long way, making your old decisions for your breast enhancement seem out of date and behind the times. Just like clothing styles and cars from the 1990’s seem dated now, so is the oversized sagging breast with saline implants, complete with rippling and pleating requiring an industrial strength bra to keep them in place. Ladies you don’t have to compromise any longer. Does your kitchen and bathroom still have brass fixtures? Then you should not have to put up with these heavy oversized misshapen breasts that are neither comfortable nor stylish. Consult a board certified plastic surgeon to review your options today.

Options not available 10-15 years ago.

First and foremost a modern plastic surgeon who has kept up with the current techniques and evidence based medicine related to breast enhancement will perform a complete tissue based diagnosis of the breast. Gone are the days hopefully of a surgeon standing in front of you without any measurements and eyeballing a one size fits all approach and telling you he or she will make you a “D” cup and you will love it. The facts are the 1990’s approach of shoving in multiple sizers or placing the largest possible smooth round saline implant under the breast without individualizing fit based on the patients breast tissue parameters lead to a revision rate of breast enhancement of 25% which manufacturers submitted to the FDA in the early two thousands. If gallbladders and knee replacements had that high of a revision rate insurance companies and Medicare would have a moratorium on the procedures. Fortunately our though leaders in plastic surgery have evaluated and re-engineered the procedures to minimize complications of capsular contracture, incorrect size placement, and avoidance of soft tissues being permanently thinned and distorted requiring complex revision procedures to correct poor outcomes. Most importantly the surgeon needs to determine the correct diameter of the devise both in width and height. The soft tissue thickness of the upper and lower pole (area above and below the nipple) is important as well as the tissue length from the fold to the nipple-areolar complex. The overall geometry of the chest and breast bone need to be noted requiring modification of procedures. It does not take an engineer to understand a women who is five feet tall and one hundred and ten pounds with a relatively short breast fold to collarbone and narrow chest with minimal breast tissue cannot have the same implant placed as a five feet, nine inch tall female with one hundred and sixty pounds with a wide frame and a large “B” cup breast. Unfortunately some surgeons did feel this way and some still do detracting from a customized approach that minimizes revision rates and unhappy patients.

Three dimensional imaging such as the Vectra has revolutionized my patient education and consultation for breast enhancements.  We can produce a very representative imaging of a women’s breast and torso and with computer simulation can demonstrate how any implant available in the United States can appear with your tissue parameters and allow the patient to see the proposed outcomes before a decision is made. This avoids wrong size surgery and allows patient expectation to be matched thus avoiding revision surgery. However the technology does not exist to provide this information if a breast already has an implant. This simulation also allows patients to see the limitations of an implant alone based on enhancement depending upon the individual’s soft tissue or bony deficiencies. This is where the discussion of fat grafting can be very beneficial to hiding the anatomic variances such as wide sternums that produce wide cleavages to provide an improved outcome and patient satisfaction. We can also demonstrate using a slightly smaller implant which has less weight and drag on poor quality soft tissue and supplementing the overall volume with large volume fat grafting to minimize implant malposition due to failure of soft tissues holding the implant in place.

Breast implants themselves have evolved over the last few decades. Today plastic surgeons can offer patients more options in size, shapes, and types of silicone than ever before also allowing for a more customized approach. I particularly have found the fifth generation silicone gel implants (Gummy Bears) to be particularly useful in petite women and very tall, thin women to exploit the positioning of the implant with differential heights and widths to maximize outcomes. I never use saline implants because they put too much strain on tissues, have excessive rippling, only can function as a round devise and can spontaneously deflate creating emergency surgical situations for patients. Based on clinical evidence, texturing of the implant can reduce capsular contracture, minimizing migration of the devise laterally over time and can maintain pocket size better than a smooth devise. Downsides include late seromas (fluid collections) and possible linkage with a very rare but easily treated form of implant related lymphomas. In my mind the benefits outweigh the small risks with texturing.

Lastly, the techniques of the actual surgery have evolved in the last ten years. These techniques include more precise, less traumatic dissections of the breast pocket, avoiding biofilm (a leading cause of capsular contracture) by minimizing the manipulation of the pockets with implants, and no touch techniques with the surgeon’s hands or patients’ skin on the devises that can minimize revision rates and improve outcomes.

In conclusion if you are a breast enhancement patient and are less than satisfied with your outcome don’t learn to live with compromise explore the modern day breast augmentation procedures available at board certified plastic surgeon’s offices around the country. Remember cell phones, cars, computers and styles have all rapidly evolved for the better compared to the 1990’s refresh yourself you will be glad you did.

For further information into customized breast enhancement procedures please visit www.thelucascenter.com or contact The Lucas Center, Plastic Surgery, PLLC in Knoxville, Tennessee 865 218 6210.

 

Plan Your Fall Chemical Peel

Summer is a fun, favorite time of year for all of us. From beach vacations, pool parties, backyard barbecues, and simply having more hours of daylight to enjoy the outdoors are some of the wonderful ways we enjoy summer and make wonderful memories. Try as we might to load up on sunscreen, wear large brimmed hat and sunglasses, our skin can still experience cellular damage. UVA rays can cause damage to the skin membrane, UVB rays damage the DNA of the cells and IR-A damages the mitochondria. Unfortunately, the SPF (sun protection factor) number of a sunscreen indicates only the level of protection from the UVB rays and UVA rays are 50 times more prevalent than UVB rays. They penetrate deeply into the skin cell layers damaging collagen and cells. It is very likely that some of these dangerous rays took a negative toll on our skin over the course of the summer months. Thankfully, there are ways we can correct some of the damage and prevent the unwanted photo-aging. The use of topical cosmeceuticals can rejuvenate the skin, growth factors help support the skin’s natural ability to support itself and anti-oxidants are free radical scavengers and help fight the signs of aging. In-office chemical peels are a must for reversing the damage and photo aging process. I recommend that all of my clients have a single chemical peel or series of peels at this time of year to correct sun damage. Chemical peels come in several different strengths. A treatment plan can be customized for each person based on their skin type, concerns, level of damage and desired outcome. Sometimes results can be achieved with a single peel, other times a series of two to three peels are necessary to work on more stubborn or deeper issues. I would encourage everyone to start planning now for their chemical peels. Minimal downtime can be expected post procedure. The skin will start off pink the day of the peel and will be very tight until peeling starts, generally 48 to 72 hours after the procedure, and can last 2 to 5 days. I would recommend looking ahead at your schedule and setting up a time to accommodate this process since it’s not too early to plan your fall skin rejuvenation. If you are unsure what your skin needs, please call 865-218-6210 to set up a complementary consultation.

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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