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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.

Skeletal augmentation of the chin

Our brains are hard wired to perform pattern recognition. We subconsciously analyze faces for proportionality of the vertical facial thirds and right and left axial symmetry and then attach an aesthetic value based on the harmony. Without even contemplating this, a person’s bias to say one face is more pleasing than another occurs almost instantaneously. Men are routinely viewed as more masculine and stronger in appearance if they possess a symmetric lower jaw in harmony with the middle facial third or conversely they may appear weaker or less vital if they portray a retruded jaw with an obtuse chin-neck angle. Additionally, having a stronger skeletal support of the soft tissues of the face and neck will lead to less of an aged appearance compared to a less prominent skeletal relationship. People with under-bites and small lower jaws having fuller, less defined neck lines look older or even appear more overweight compared to an individual with a normal jaw line. Therefore, correction of this anomaly of the jaw and neck makes sense for projecting a powerful image and to offset an premature aged appearance.

The treatment for this condition is heavily dependent upon a three dimensional facial analysis. If the lower jaw is retruded with a steep mandibular plain angle and a vertically elongated chin with lip strain, without question, the best approach is to perform a sliding, vertically reducing and forwardly advancing osteotomy of the chin with skeletal fixation. This allows the projecting chin point to move forward while shortening the chin and reducing the lip strain. In conjunction with this approach additional soft tissue support just under the lip and above the chin is required with fat grafting to soften the labiomental crease which increases as the chin is moved further forward than the teeth. Fat is an easy approach with less cost than a bone graft which can provide the same results. Lastly to tone the skin under the jaw and to crisp the chin-neck angle, liposuction is performed to remove unwanted fat but more importantly to induce scar contracture of the overlying skin to allow for neck retraction and an improved jaw line.

If the chin is retruded and has a normal proportion to that of the middle third of the face, I prefer a Medpor chin implant which can provide skeletal enhancement without the need for an osteotomy. Unlike a silicone gel implant it can be carved and customized to meet the exact needs of the patient. I then perform bone screw fixation so the implant is not free floating like other implants and becomes the normal extension of the bone. Just as in the previous scenario soft tissue support of the lower lip is required to avoid accentuating the labiomental fold as the chin point is increased over the dental support elements of the lower lip. I also generally utilize liposuction as described above.

The last case type is a patient with a short, vertically deficient chin with respect to the middle facial third. This requires an osteotomy (moving the chin forward) and necessitates an inter-positional bone graft from a bone bank to make the vertical facial thirds the same.

Skeletal enhancement with fat grafting and neck liposuction can produce a very powerful outcome without changing the overall identity of the patient and generally makes the person appear to lose weight and demonstrates a more youthful neck line.

If you are interested in being evaluated for these procedures please contact The Lucas Center, Plastic Surgery, www.thelucascenter.com. 865 218 6210.

State of the art of liposculpturing in 2017. What should the prospective patient understand?

The concept of fat removal through hollow cannulas attached to high pressure suction introduced through small stab incisions has been around since 1978 and was crafted in France, Switzerland, and the United States. At that time, tumescence infusion techniques (high volume fluid infusion with lidocaine and epinephrine to minimize blood loss) had not evolved which limited the amount of fat removal due to excessive blood loss. Today the concept of liposculpturing in 2017 has evolved greatly.  There are many technological advancements ranging from liposuction with additional energy sources such as mechanical oscillation (PAL), ultrasonic liposuction (UAL), and laser lipolysis. The first two technologies work to reduce the fibrous tissue network encircling fat which can also reduce tractional forces attached to the dermis which cause cellulite. By releasing this fibrous conglomeration it frees the fat cells to be either removed or redistributed from areas of excess fat to relative areas of fat deficiency. Laser Lipolysis targets fat cells, which alone leads to cell death in conjunction with fat cell removal with suction. However, no matter the technique or the technology, the most critical factor for excellent outcomes is a surgeon’s keen aesthetic judgement.  This judgement is derived from a well versed three dimensional surgical anatomy of a particular body part to appropriately discern what is required to transform a less pleasing shape into an aestheticly desired form. New technologies will come and go but the educated aesthetic surgical eye is what ultimately creates the art.

I personally utilized ultrasonic liposuction as my mainstay from 2001 to 2016 but after delving into the concepts of SAFE liposuction (Separation of fibrous tissue away from the fat, Aspiration of the fat, followed by tissue equilibration of fat) based on concepts from Dr. Simeon Wall, I rethought my techniques and felt the (PAL) Power Assisted Liposuction could provide a more versatile approach particularly with fat equilibration. In my training and early clinical years I approached liposuction as merely a subtraction technique to sculpting the body. Clearly, in areas such as the posterior lateral thighs and the gluteal region, and in gynecomastia, exceptional results can only be achieved with fat removal followed by fat grafting to areas of deficiency and regional equilibration of adipose thickness by dispersing free floating yet vascularized fat cells from areas of relative excess to thinner areas. This is where artistry can be employed to create a whole new shape as compared to just a subtraction technique. Non-surgical procedures such as cryolipolysis (Coolsculpting), and endermology (Kybella) pale in comparison as they only produce subtraction of fat cells in a relatively uncontrolled manner without any mechanism to create skin retraction or tightening.  

The power of SAFE liposculpting with expansion and large volume lipofilling can produce attractive buttock shapes with enhancement.  Additionally, SAFE liposuction can redefine male breast enlargement correction to not just remove the fibroglandular elements, which could leave a flat amorphous chest, to providing an even more masculine appearance by utilizing fat subtraction from the armpits, upper abdomen and placing the fat into the pectoralis muscle borders to yield an enhanced appearance. Some surgeons are performing liposculpting of the abdomen to create the appearance of a “Six Pack” by removing excess fat then lipofilling the rectus, serratus, and external oblique muscles to provide the appearance of a ripped abdomen. My concern is that this may look very appealing at first with the younger generation but long term aging, weight changes and overlying skin inelasticity might appear odd looking over time.

The good news:  thanks to many contributions of forward thinking plastic surgeons, which I am proud that our specialty as a whole are a group of innovators by nature, patients can reap the rewards of these efforts by realizing artisticly predictable results of body sculpting like never before. I encourage patients to seek out board certified plastic surgeons who have significant experience in this area to ensure results with safety because in the wrong untrained hands serious complications can occur. Unfortunately the economics of medicine today has motivated physicians of other specialties to attempt to provide these services which have led to poor results and even deaths. Please choose wisely and remember you often get what you pay for.

What I learned from the 50th American Society of Aesthetic Plastic Surgery Meeting in San Diego April 27- May 2 2017

First off I have to congratulate all the contributions of past and present board members and officers who forged a society which was originally viewed as a rogue society within the frame work of organized plastic surgery, shunned by all chairman of academic programs and has progressed to be the preeminent society for education of aesthetic surgery and safety concerns to provide the highest quality of care for all patients.

There were more classes and presentations than I could attend so I was strategic in my mission to glean information pertinent to my aesthetic solo private practice in Knoxville, Tn.

Facial Rejuvenation

Many advances in non-invasive techniques to slow the aging process have occurred but in the poignant words of Dr. Dan Baker, “surgery still remains the gold standard and stop apologizing for being a surgeon”. No question that the absolute best and in many ways a far more economical approach to face and neck aging problems is surgery. Many techniques can be employed to achieve natural and balanced results but the absolute most important factor is a surgeon with a good aesthetic eye and prudent judgement in the execution of a procedure. In my opinion adjuvant use of fat grafting to the main areas of facial fat wasting demonstrated by Dr. Rohrich is imperative to achieve outstanding results when atrophy is noted. Additionally Dr. Little showed some nice results of secondary procedures around the upper eyes and brows from over-resection of too much tissue with high riding eyelid crease and hollowed eyes with fat grafting. A provocative panel on sub-platysma tissue resection in neck lifts demonstrating that the subcutaneous layers of the neck actually thin with age and the deep plain below the platysma increases in size with fat deposition and salivary gland enlargement contributing to a fuller neck appearance. Some interesting results were seen with submandibular gland resection and even parotid gland resection to achieve a more sculpted look of the neck. However some of the results did appear overdone and not as natural compared to corset platysmaplasties. They report few complications but my concern for hematoma and salivary gland fistulas certainly would be higher than pre-platysma procedures.

Refinements in hyaluronic acid filler agents continue to occur both in terms of product as well as techniques and the science behind them. New findings are being seen with the interaction of the mimetic muscles and hyaluronic acid. Muscles adjacent to filler agents tend to reduce muscle activity. For example direct injection into the nasolabial fold can reduce muscle activity of the levator, and orbicularis muscle thus reducing the retraction activity thus softening the fold. Higher G’ fillers injected into the vermillion cutaneous border can weaken the pursing action of the orbicularis muscle softening the vertical lines. More studies to follow but this was a new concept for me.

A class in secondary rhinoplasties discussed the early experience of Dr. Rohrich’s use of tissue bank fresh frozen rib cartilage for visible grafts for noses. The cost is very reasonable avoids donor site morbidity and handles like native tissue. I see a number of revision surgeries from elsewhere and I plan to use this material in the future.

Breast

Many interesting topics but in general I find the Southeastern Society Atlanta Breast Meeting to be a more intense study of this field of aesthetic surgery. Certainly a poignant topic was ALCL related to breast implants sparked by the FDA recent public notification of this topic. The Aesthetic society has been at the forefront of this issue since it became a known entity over ten years ago. More in-depth studies are needed. Of particular interest is the etiology of this inflammatory derived lymphoma. It appears that individuals who have a certain genetic predisposition that become exposed to certain biofilms adjacent to implants containing certain bacteria that have antigens which trigger antigen presenting lymphoid cells to produce certain interleukins which overtime create clonal expansion of T cells resulting in lymphoma. Textured implants have been identified as a risk factor for developing this disease but based on the above mentioned model it is suspected that the texturing only increases the surface area of the implant surface compared to a smooth devise creating a larger area of biofilm contact with the opposing tissue around the implant. Fortunately successful treatment occurs with early detection and diagnosis and complete capsule removal and implant exchange. Late stages can result in distant disease and death. Fortunately compared to the denominator of all implants placed this is a very rare disease with low risk of death. It is interesting there are geographic clusters of this disease with Australia and New Zealand with higher rates than Europe which utilizes more textured implants than the United States which has a very low incidence.

Body Contouring

One interesting aspect of this meeting demonstrated the increase in male aesthetic surgery demands by having the first ever male only body contouring panel. I found Dr. Wall’s presentation for gynecomastia intriguing in his technique of not just contouring the male chest with liposculpturing and direct sub-areolar tissue removal as a subtraction technique. He actually employs axillary and serratus anterior and epigastric overlying fat removal and utilizing it for lipo-filling the anterior free border of the pectoralis major muscle as well as the lower insertion points on the chest wall to enhance a muscular appearance avoiding a flat amorphous look to the chest. Other presenters are trying to give a more masculine appearance by enhancing the appearance of the underlying muscle anatomy with fat enhancement. My question is:  what is the long term appearance after aging (i.e. sagging skin and weight gain)?

Of course the biggest discussions involved the ever increasing demand of buttock reshaping and enhancement with fat grafting. Based on pulling data from all countries including the United States this procedure has the greatest risk of dying compared to any other aesthetic procedure. The number one cause is the misplacement of a fat grafting cannula and injecting the piriformis muscle with fat which just below houses very large bore veins that can transmit the fat to the heart as an embolic event. It is imperative to use large bore cannulas over 4mm and stay always in the subcutaneous plain and keep the instrument moving. I agree with embracing the techniques of Drs. Wall and Del Vecchio with SST (simultaneous separation and tumescence) as a single step to enhance vasoconstriction and reduce time while separating the fat from stroma. Then the paradigm shift away from Coleman concepts of fat graft with EVL (expanded volume lipofilling) for buttock enhancement as well as breast. My couple of month experience with this technique mostly in the breast has been favorable.

Labia Majora and Labia Minora rejuvenation

This is another segment of aesthetic surgery which has flourished in the last several years based on changes in grooming habits and the athleisure trends of yoga pants that make women seek out these procedures. I also have seen more demand with my post-bariatric patients as well. The two most common techniques for labioplasty is the direct trim and the wedge technique respecting the posterior blood supply to the region. Excessive clitoral hooding must be addressed at the same time. I suspect the demand will continue for some time.

Skin Strategies

Strategies to maintain a youthful face throughout your life


Age is certainly just a number. What is more important is your physiologic age which is a culmination of genetics, diet, exercise, sun exposure protection, smoking status, and how well a person manages any chronic diseases. But in general terms I find it useful to stratify algorithms for best practices for maintaining a youthful face into decades of life.

The Twenties

In the late teens and twenties the single best strategy for long term health and appearance of the skin of the face is appropriate sun block protection. Excessive unprotected sun exposure and tanning beds may yield what appears at a brief moment in time as a healthy glow to the skin will ultimately result in loose inelastic skin with greater degrees of wrinkling along with unfavorable splotchy pigmented appearances. The sun makes everyone happy and feel good but our skin must be protected with hourly reapplication of sun screen while in direct sunlight and every morning a layer of sunscreen applied as part of a normal routine for face care. Peels, Laser’s, micro-needling, and home skin care can improve and repair some of the damages but prevention is the best course to look your best over time. Another aspect of care during the twenties is preventative treatment of severe acne formation of the skin. Anyone who has been left with multiple ice pick scars from cystic acne would do anything to improve the surface of the skin. Once again Lasers and micro-needling can improve the appearance but cannot eliminate all the scaring. Routine facials, extractions of pores, topical application of metronidazole or doxycycline, toners, retinols and, fruit acid applications are all useful tools to combat skin pores from clogging, become infected, and resulting in severe inflammation with resultant scaring of the dermis.

The Thirties

While still being youthful the physiology of the skin can change somewhat particularly dependent on genetics, the degree of skin pigmentation protection, sun exposure, and hormonal changes related to pregnancies. If someone is an avid tanner the repercussions of a couple of decades of excess UVA and UVB radiation from sun can already be seen in the skin’s appearance. Also unfortunately women who have been pregnant may experience hyperpigmentation of the skin about the face. As skin elasticity is reduced the animation of muscles directly under the skin around the eyes, forehead, and mouth may begin to create wrinkles during this decade and rapidly progress throughout the rest of the life of the individual. An important tool to alter the progression is the use of neuromodulators such as Dysport and Botox. These chemicals, derived from the botulinum toxin, block nerve transmission to the muscle thus reducing their tone leading to ellimination of wrinkles of the skin overlying the muscle. This treatment can help not only the immediate appearance of the facial lines but can also act as a preventative measure to avoid deep folds in the face if administered routinely from the thirties on. Also depending on an individual’s anatomy or issues of chronic sinus disease of the ethmoid sinuses some people may begin to have the appearance of bulging lower eyelid fat pads with an increased eyelid cheek junction demarcation which may lead to a fatigued demeanor of the eyes. Many times this can be reduced in appearance with the injection of a hyaluronic acid filler agents ( Restylane and Juvaderm) blending the eyelid and cheek junction similar to photo-shopping the bags out of a portrait. Even in the thirties this can make a nice refreshing improvement in the eyes and face with no down time except some minor bruising that can be easily covered up with makeup.

The Forties

This is the decade where programed fat atrophy begins to occur leading to aging facial appearances. The fat in our face is in discrete packets under our skin and when certain fat pads begin to shrink in volume particularly the cheek fat pad (sub-malar fat pad), and the temporal fossa fat pad (in the temples) the cheek projection begins to diminish leading to a landslide affect that pivots along the nasolabial fold enhancing this structure and flattening the upper cheek, and causing the corners of the mouth to descend. In the temple region with reduction of volume the lateral brow begins to fall into the upper eyelid space. Fortunately plastic surgeons can reverse these changes with adding volume back into these spaces with either hyaluronic acid filler agents or induction therapy with Sculptra which stimulates the body to produce collagen to replace the missing fat. These non-surgical techniques have made big strides in warding off the early signs of aging. Also during the forties neuromodulators such as Botox and Dysport can play even more important roles in balancing muscle activity to provide subtle lift to the brows, minimize crow’s feet around the eyes, and reduction of muscle tone of the upper lip to avoid animation vertical lines during smiling. Lips are certainly a focal point of the middle third of the face and can experience signs of aging with the loss of a three dimensional appearance of the upper lip, down-turning of the corners of the mouth, and reduced skin tone leading to vertical lines. Hyaluronic acid filler agents can be utilized to subtly define the vermillion-cutaneous border of the lips, recreate the vertical columns that extend from under the nose to the each high point of the cupids bow of the upper lip as well efface deeper vertical lines that extend vertically from the vermillion. Improvement in the tone of the upper lip skin can be developed with micro-needling (Please see previous blog for this technique).  Unwanted pigmentation blotches can be reduced by home treatments with retinols, topical vitamin C, and niacinamide combined with serial skin peels to provide more even tones.

The Fifties and beyond

All treatments listed in the forties can certainly be continued into the later decades to promote longevity of youth. However gravity and tissue thinning and loss of elasticity is ongoing and never ceasing, leading many to pursue surgical options to correct hanging brows, loose upper and lower eyelid skin, and restore normal jaw line appearances. See blogs on surgical rejuvenation of the face.  

Three dimensional breast rejuvenation, my personalized approach for the breast enhancement patient.

Just as no two faces are identical no two women’s breast and torso’s are the same either. At The Lucas Center, Plastic Surgery I do not use a cookie cutter approach to breast enhancement. I employ many algorithms to determine the best treatment plans for my patients. I am not just focused on just the breast mounds nor am I content to just place the same round implant in everyone. I analyze your breast bone (sternum), the shape and slope of the rib cage, any spine asymmetry such as scoliosis, the amount of soft tissue in the arm pits just lateral to the breast tissue, and the breast fold to collar bone length before even evaluating the breast themselves. I then measure the actual width and height of the breasts, how much thickness exists in the upper poles, the overall shape and position of the nipple areolar complexes with respect to the breast mound, how much stretch the tissues exhibit, and the volume and distribution of the volume and any skin excess. Many patients are surprised how analytical and detailed my exam is for the consultation compared to many surgeons who just eyeball the breast and decide on an implant after placing many different sizers in the OR. Normally I go to the operating room with a plan and have pre-determined the shape and size and texture of the implant prior to surgery. I avoid sizers when at all possible because the more implants are pushed through the incision the greater the likelihood of creating biofilm in the pocket (a leading cause of capsular contracture.) I also utilize a three dimensional imaging system which helps patients see themselves from a new prospective and have the ability to evaluate truly what a given implant looks like on their specific body. Much more exact than asking a patient to fill a desired cup size bra with different size implants.

My operative plan not only includes which implant to employ but the position within the breast (partially under the muscle, under just the gland or under the layer of tissue which wraps around the pectoralis muscle.) Each of these pockets have advantages and disadvantages and is not a one size fits all approach for me I use them all depending on circumstances. The shape and type of implant very much is determined by all the above mentioned measurements which involve the breast and the surrounding chest wall each type of implant has their benefits and downsides. I also determine well before hand any need for a breast lift in conjunction with implant placement.

Other adjunct procedures I often employ which can maximize the aesthetic outcomes of breast surgery beyond determining the implant size and shape or additional skin and breast lifting procedures may include the process of fat grafting. The addition of lipo-filling the breast and chest wall is analogous to photo-shopping this area of the body to uniquely sculpt your tissues such as the decollate area to enhance cleavage of in the upper pole of the breast to give the appearance of a higher positioned breast on the chest wall or even to correct contour asymmetries. This tissue refinement is invaluable to enhance the overall result for a women which cannot be achieved with an implant alone. Another fine detail which can separate an excellent result from a normal good outcome is to evaluate the arm pit / bra skin roll of tissue as it intersects with the lateral breast silhouette. Excess tissue can generally be removed or reshaped with power assisted liposuction techniques which includes removal of excess fatty tissue and equilibrate the fat volume from areas of excess to deficient regions giving an artistic aesthetic lateral profile to the breast which many surgeons ignore all together but when viewed with a discerning eye certainly creates a whole different level of excellence weather viewed with or without clothing.

My goal for my patients who seek either primary breast enhancement or “Mommy make-over” breast rejuvenation is to provide customized excellence for their outcomes. No two people are alike therefore with a thorough three dimensional examination of all associated tissues of the chest and breast we can devise a unique surgical plan incorporating all means necessary to maximize the aesthetic outcomes. I view myself as an artisan not a mass production factory for my breast services.

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.

Consider custom solutions for a sagging neckline

neck-blog

Consider custom solutions for a sagging neckline

Necklines for both men and women can be a focal point of self-consciousness. However, the etiology of an unattractive neckline can be diverse, so treatment options must be tailored to the underlying cause. There is no one solution for everybody. Careful three-dimensional analysis of the soft tissue and underlying bony structure of the midface, lower jaw and neck are imperative to choosing the correct modality to improve your neckline.

Some common underlying causes of poor aesthetic necklines:

Small lower jaw – If you have a deep underbite despite orthodontics and a short chin, this leads to less bone support of the soft tissues of the jawline and submental region. People with this type of lower jaw may have a very obtuse chin-neck angle leading to redundant skin. An ideal treatment for this situation is bony chin advancement (genioplasty).
If your chin is horizontally too short, then an augmentation with a chin implant is an excellent choice. I prefer the Medpore implant, which is carvable, and screw fixated and becomes an extension of the bone.

Both genioplasty and chin implants can easily incorporate the technique of liposuction as a means of sculpting the soft tissues of the neckline by removing unwanted fat. Liposuction induces collagen production and facilities skin shrinkage and redistribution yielding a pleasing result. This combination therapy can produce a wonderful outcome that makes you look more facially balanced. However, if your skin is too loose and hanging, a more formal neck lift may be preferable to liposuction.

Mid face descent of soft tissues – Aging can affect facial fat compartments leading to decreased volume, which results in the midface falling over time. This sagging increases nasolabial folds and causes lower facial soft tissue to drape over the jawline. A crisper jawline can be restored by replacing missing soft tissue volume in the fat compartments of the midface with filler agents like Voluma and Sculptra or via fat grafting. Subtle volume enhancements can create a nice effect on the jawline without looking like you’ve undergone a surgical procedure.

Gravitational changes to the soft tissue of the neck – Gravity affects all of us. The skin and muscles of the anterior neck begin to pull away over time. The appearance of the platysma muscle medial bellies becomes apparent leading to unsightly banding. In the early stages of gravity-induced changes, treatments such as chemical peels, micro-needling and radio frequency can yield improvements and delay the inevitable soft-tissue sagging.
Ultimately the best treatment option is a face/neck lift. A well performed facelift by an experienced board-certified plastic surgeon will yield excellent results with longevity of up to ten years depending on how well you age forward and take care of your skin, avoiding further sun damage.

Obesity: People with elevated body mass indices will accumulate increased fat throughout the body. The neck is no exception. Very mild amounts of fat excess with firm, good quality skin may realize improved contours with Kithera (an injectable product that dissolves fat in the neck). However, in my experience, few patients I evaluate are ideal candidates for this treatment. The injection results in inflammation, which can cause collagen production and skin remodeling, but most people need bigger guns to fight the battle. The price of several rounds of injections is as much as a true liposuction with less effective results.

If you have significant fat in the submental region and reasonable skin quality, liposuction can be a great treatment option to uncover a more normal neckline without a lot of expense or downtime. However, a face/neck lift with a corset platysmaplasty is the tried and true corrective option that works very predictably.

If you’re obese and undergo bariatric surgery or make lifestyle changes to produce massive weight loss, you’ll likely develop excess deflated skin that hangs off your face and neck creating an aesthetic deformity. Modifications of standard face and neck lifts must be incorporated to achieve a pleasing result.

The takeaway is that if you’re unhappy with your jaw and neckline, you can improve your appearance and boost your self-confidence by seeking out proper consultation with an experienced plastic surgeon. During the consult, a detailed facial analysis should be performed. Treatment options can be formulated to yield the best results by addressing your unique issues as presented during the interview. No need to hide your neck behind scarves and turtlenecks any longer.

The bottom line on fat grafting

The buttock area has reached new levels of interest thanks to the influx of the Latin culture from South America and pop culture’s fixation on the shapely, self-absorbed Kardashians. Surgeons on the cutting edge of buttock enhancement choose to use fat grafting instead of buttock implants to avoid some very difficult complications.

Thanks in part due to Dr. Simeon Wall’s concept of tissue equilibration in body sculpting, tissue can be removed from areas of excess and transposed to areas of deficiency. For example, we can take excess areas like the muffin top and the lateral thigh and place that fat into the under-projected gluteal areas creating the idealized shape of the buttock both in terms of the outer framing and the projection.

The breast is another area where fat is very important. Most of the breast volume under the skin is composed of fat with small islands of glandular material dispersed throughout. With aging, volume in the breast is lost by glandular atrophy and some fat loss. Previously breast rejuvenation or enhancement was only thought of with augmentation via implants, with or without tissue repositioning such as a mastopexy. Today fat grafting is critical to achieving superior results. Research suggests that over 60% of breast augmentation procedures could be improved with the addition of fat grafting performed simultaneously.

Furthermore, fat that is harvested contains peripheral stem cells. The presence of stem cells in harvested fat has implications for rejuvenation medicine and the potential growth of tissue such as bone, skin, solid organs and bone marrow cells. Unfortunately, the art of marketing has outpaced science, and many clinicians are calling fat grafting to the face a “stem cell face lift.” This is a misleading statement. Much energy has been directed toward the understanding of the stem cell, but it’s not ready for prime time yet.

Plastic surgeons employ biologic tissue as our medium to create beautiful forms of living art. Fat is a wonderful way to sculpt the human body. It is truly like airbrushing imperfections in three dimensions.

Regardless of the Kardashians over-developed assets, fat grafting is worth the hype. Call 865.218.6210 today or go online to thelucascenter.com to schedule your consultation. I look forward to discussing with you the myriad of options for face, breast and buttock enhancement via fat grafting.

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