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Category Archives: breast reconstruction

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.

Notable updates from the 2016 Atlanta Breast Surgery Symposium

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

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

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

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

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

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

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

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

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

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

Natrelle 410 Breast Implants

There are many different kinds of breast implants in the market right now, and it can be confusing for anyone to know what is best. That is why Dr. Lucas is here to help you sift through all the clutter and introduce the latest breast implant.

The FDA recently approved the Natrelle® 410 highly cohesive, anatomically shaped silicone-filled breast implant for use in augmentation, breast reconstruction and revision surgeries. These gel implants provide an important new alternative to traditional round implants for women. It is designed to mimic the slope of the breast and hold its shape over time while remaining soft to the touch.

The FDA approval of the Natrelle® 410 gel implants was based on an extensive review of various data and studies, including pre-clinical device testing and clinical data from Allergan’s 10-year prospective, multi-center pivotal study. It involved nearly 1,000 women who have undergone breast reconstruction, augmentation or revision surgery.

During your consultation for breast surgery with silicone gel implants, Dr. Lucas can discuss which implant options are right for you. Natrelle® 410 implants with the highly cohesive gel offer a shaped profile alternative to a round devise which might be right for you.

If you have any questions about this breast implant or any others, please contact The Lucas Center of Plastic Surgery at 865-218-6210.

Dr. Jay Lucas is a board-certified plastic surgeon located in Knoxville, TN. He has a decade of experience performing a variety of cosmetic surgeries, and his unique educational background at some of the nation’s most prestigious medical centers allows him to perform cutting-edge plastic surgery procedures for his patients. This includes face lifts, breast augmentations, tummy tucks and rhinoplasties.

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