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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.

Turn back the clock with facial volume restoration

mother

As we age, the volume in our faces diminishes over time. However, in the right hands you can age gracefully and look as good as you feel for a long time, which is the goal I have for all my patients. Volume restoration of the face, as a part of an overall comprehensive facial rejuvenation algorithm, combined with skin resurfacing and tissue repositioning, can yield beautiful results.

The aging process causes fat volume reduction in the face. The fat in our faces is organized into discrete packages and, predictably, the fat found just below our cheekbone is one package which reduces in volume first. The combination of gravity and volume loss in cheek fat results in our faces changing shape. Our cheeks appear to decrease, and our skin drops. Cheek folds become more pronounced, creating the inevitable downward-turning at the corners of the mouth and contributing to the jowling effect in the lower jaw line.

Another area that can experience volume loss is the lateral forehead in the temple region, which results in the brows re-draping downward, causing a hooding effect and obscuring the upper eyelids. Still another indication important to women is the loss of volume of the lips and the relative loss of the three-dimensional appearance of the upper lip with increased vertical lines emanating from the red border.
The tear trough region around the lower eyelid can lose volume, regardless of your age, particularly if the eyelid fat pads are prominent with a relatively soft mid face projection.

All the above areas can be treated nicely with filler agents. The advantages of out-of-the-box filler agents is they can be used quite nicely with topical anesthetic agents in the office. There’s relatively little to no bruising and no downtime. Many filler agents contain hyaluronic acid, which is a naturally occurring agent in our skin that acts like glue to hold components of our dermis together. Denser material with lots of cross-linking can have a better effect of lifting tissue. Because of its dense properties, Voluma can last up to two years and is routinely placed in the area where the cheek fat packet decreases. This filler is used to lift the cheek back to a normal position, thus improving the cheek fold and the corners of the mouth.

Lips can be enhanced to normal volumes (not the duck lips that I see coming from various spas) to create a natural red lip border with the adjacent skin helping to eliminate the vertical lines. I also enhance the vertical pillars that span between the base of the nose and the cupids bow high points, which returns a three-dimensional appearance to the upper lip. I mostly utilize Juvederm for this area.

The tear trough deformity can be handled nicely with Restalyn or Juvederm to blend the eyelid cheek junction and smooth the appearance of the lower eyelid.

Volume restoration of the temples to return the brow to a more normal position can be best handled using a step-wise approach with Sculptra, which is an injectable form of a polymer of lactic acid. When introduced to the tissue, the lactic acid induces an inflammatory response leading to the formation of new collagen. The advantage of this material is that it can restore large areas of volume loss, which would be difficult with traditional filler agents. It also slowly builds up collagen and restores volume over a six-week period making your transformation less obvious to your friends and family.

Without question, the concept of volume restoration of the face as a part of an overall comprehensive facial rejuvenation algorithm has led to superior results compared to plans that did not include volume replacement. As with Botox, the overall value of the injection material is greatly dependent on who is administering the filler agent.

Poor technique can result in poor outcomes. I liken filler agents to sculpting materials for the face. You can put clay in front of a true artist who can transform this simple material into a work of art. An untrained eye with no sense of perspective or artistic skill will create very little value out of the raw materials. The same goes for these injectable products in the Wild Wild West of aesthetic services here in American and abroad.

Fat grafts and textured implants enhance breast augmentation

Dr. Lucas

I recently attended the 2015 Atlanta Breast Symposium sponsored by the Southeastern Society of Plastic and Reconstructive Surgeons. This annual conference is the premier event for new products and technology specific to breast surgery. The symposium features live procedures, scientific paper presentations and follow-up exhibits from the previous year’s live surgeries. Each year, I spend time with industry colleagues exploring what’s on the horizon, so I can implement what’s immediately applicable to my practice.

Takeaways from the 2015 Symposium:

Surgeons are seeing increased efficacy and safety of simultaneous breast augmentation using implants with fat grafting. This composite augmentation of the breast yields both improved aesthetic outcomes as well as enhanced long-term results. Fantastic breast augmentation is created when there’s appropriate soft tissue coverage and support of the implant. I was already an advocate of fat grafting to revise existing implants. Going forward, I’ll offer implants with simultaneous fat grafting to my patients for an even more natural silhouette and better support.

Textured, shaped highly cohesive silicone gel implants were a hot topic at this year’s symposium. I was an early adopter of these breast devices and continue to expand their use on a case-by-case basis. They’ve proven to be very beneficial in providing optimal results in certain circumstances for both primary and revision surgeries in aesthetic and reconstructive procedures.

The debate over the use of smooth versus textured implants continues. Many surgeons prefer a smooth round silicone implant, because the experience with textured saline implants was not favorable. However, European surgeons have utilized textured silicone for many years with good success. My experience with the textured, shaped highly cohesive gel devices has been very rewarding. It’s my opinion that the texturing may benefit women who might be at risk for the implants drifting from their ideal position. Several papers were presented that support my clinical opinion.

The future is bright for women who choose breast augmentation or reconstruction after breast cancer. There are more options available than ever before to achieve your desired aesthetic. I look forward to discussing these exciting new techniques and products with you.

Call 865.281.6210 or visit thelucascenter.com to schedule your personal consultation.

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