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Gluteal enhancement and lift with expanded volume lipofilling

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

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

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

Brows that WOW – Microblading

On the cutting edge of aesthetic services, The Lucas Center is now offering Microblading.  Microblading is a semi-permanent eyebrow tattoo for those who wish to create or enhance their natural eyebrows. This procedure allows you to fill and redefine the eyebrows creating results with a natural appearance. Unlike permanent cosmetics, Microblading is performed by manually depositing pigment into the upper layer of the dermis. These micro-strokes mimic the appearance of real hair, lasting up to 2 years.

Microblading is performed in two sessions 4-6 weeks apart to achieve a full eyebrow appearance. A touchup every year is recommended to keep eyebrows looking fresh and crisp.  Eyebrow shape and size are customized to individual client preference.  Color options are available for desired aesthetic results. 

This procedure is ideal for those who want a natural look without daily maintenance.  For the comfort of our clients at The Lucas Center, we offer a local anesthetic administered by our RN/Aesthetician at no additional charge.

Call The Lucas Center to schedule your procedure today!

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.

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