Breast Implants Augmentation Reconstruction and a Natural Look

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Most of us know when we see a good result from breast surgery whether it be implants for breast augmentation or reconstruction after breast cancer surgery (mastectomy) or the results of a breast reduction surgery. As I described in my blog on facial proportions analysis a similar proportions assessment is used in planning any breast surgery and in assessing the end result.

That is to say for the average woman between 5 and 6 feet tall the desired proportions are that the nipples form an equilateral triangle with the upper notch of the breast bone and each side of the triangle is about 20cm in length. Additionally the distance between each nipple and the fold under the breast should be about 7cm with a gentle curve outline along the bottom of each breast. Together with equal sized nipple areola complexes this creates the left right symmetry and aesthetic look we strive for. The question then arises as to how one achieves this goal or result after breast surgery. This blog will only deal with breast implants rather than breast reductions and mostly with options available to correct for deviations from this pattern after breast implant placement i.e. redo breast implant surgery when the nipple is in the correct position.

New US Federal Tax on Cosmetic Surgery

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Perhaps you've heard of the current healthcare bill before the US Senate, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the Patient Protection and Affordable Care Act. This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement. The provision would add a five percent tax to "cosmetic surgery and medical procedures" to help cover the $849 billion price tag for health care reform. The tax would cover any cosmetic medical procedure deemed "not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease. The US government is trying to apply a sin tax akin to that on cigarettes and tobacco on cosmetic surgery.

The Internal Bra Breast Lift

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Breast sagging is a common problem women face with aging, breast deflation after breast feeding and/or after the placement of large breast implants. The cause is a disproportion between the size of the breast tissue and the amount of skin enveloping it combined with stretched out and weakened ligaments that connect the breast tissue to the chest wall. This flattens out the top half of the breasts so that most of the remaining breast tissue is in the bottom half of the breasts. Because the problem is related to the skin and breast tissue (fat, breast gland and suspensory ligaments) rather than muscle this problem is unaffected by exercise. Historically the treatment was surgical removal of excess skin sometimes with some manipulation of the breast tissue and/or a breast implant resulting in a firmer breast with more fullness in the upper half of the breast. Removal of skin alone does not always restore the more youthful appearing upper half fullness.

The pattern of skin removal (circle around the nipple, lollipop, inverted-T incision) used depends on the degree of drooping or amount of skin that needs to be removed. For larger skin removals the anchor pattern or inverted-T has been the mainstay. The problem with this is some patients develop large symptomatic scars.

New Discovery Could Make Breast Implants Obsolete

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Earth shattering news out of Australia this week could have monumental effects on breast surgery, both reconstruction after breast cancer and enlargement for cosmetic reasons. The technique discovered in Australia is called Neopec. So far the process has only been performed in pigs and was so successful that human trials are scheduled too begin in early 2010. The pigs grew new breasts in 6 weeks. The surgeon places a scaffold or shell of biodegradable material in the breast, redirects a small blood vessel from the arm into the shell, places a small amount of the patient's own fat inside the shell, and a dissolvable gel called Myogel is also placed in the shell. The Myogel and blood flow from the transferred artery stimulate the fat to grow until it fills the shell and therefore takes the shape of the shell. This is a direct finding from stem cell research. After that the biodegradable shell is dissolved by the body. In the future the shell may come with its own artificial blood vessel.

Stretchmarks

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The medical term for stretchmarks is striae (stria for a single stretchmark). They also referred to as tiger stripes. Skin with stretchmarks has been studied under the microscopic as far back as 1889. Every adult knows what they look like. They can be caused by rapid mechanical stretching of the skin or by hormones made by the body or taken externally. They can most frequently be found on the abdomens of women of have been pregnant (striae gravidarum) and on the shoulders of teenage body builders (striae distensae). They are also seen in overweight individuals, after rapid growth during puberty and adolescence, in people with Cushing's syndrome, after topical or prolonged treatment with steroids and on the breasts after breast augmentation or pregnancy and subsequent breast feeding. The combination of rapid growth in the early teen years and excessive weight gain is sure to result in stretchmarks.

Cellulite - Cottage Cheese Thighs

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Cellulite (Gynoid lipodystrophy in medical jargon) is the only word we have to describe the uneven pitted surface or dimpling of the skin commonly seen on the thighs of women. The appearance often is described to resemble the surface of an orange peel or that of cottage cheese. The term cellulite was first used by Alquin and Pavot in France to describe this condition. It is common in women, rarely seen in men and begins at various ages depending on body habitus, genetic makeup, etc. Most middle aged women have it. The remainder thinks they have it. As sure as a woman will grow breasts after puberty, she will get dimples and lumps on her skin. Cellulite affects only the buttocks, thighs and legs to about four inches above the knees. I see many patients requesting correction of their cellulite and an equal number of proposed treatments. These include aminophylline wraps, liposuction, liposuction with forked metal tubes to cut fascial strands to the skin and combinations of liposuction with lasers. None are truly effective.

Scars, Keloids and Hypertrophic Scars

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This blog covers skin scars only but does not include burn scars or scars related to breast implants.

Virtually everyone who lives long enough will have a skin scar from elective surgery or an injury. There has been a barrage of cosmetic surgery procedure modifications to decrease total incision length in the hope of creating less scarring. The healing of these disruptions in the skin surface follows a specific process. After the injury or cut there is bleeding. Once this stops an inflammatory process starts to get the cells needed for healing into the wound. New blood vessels grow into the area bringing in the energy needed to complete the healing process. You see this as a red color of the scar and the skin immediately next to the scar that blanches white with finger pressure. Within a week or two the healing is sufficiently strong that the wound should not reopen and any sutures that were placed can be removed. Even though the wound is healed it then must mature over the next 6 to 9 months depending on the type of injury, affected body part, age of individual etc. before the redness goes away and the increased blood flow is no longer needed. Once the scar has fully matured it usually does not blanch with finger pressure. Any problems in this process such as an infection, failure to suture a wound closed, certain vitamin deficiencies etc. prolong the healing time and in doing so result in worse more visible scarring. The skin of younger individuals makes strong repairs and tends to over heal, resulting in larger, thicker scars than on older skin. Skin over the jawbone is tighter than skin on the cheek and will tend to increase a scar's prominence. All scars are more amenable to treatment early in their life span before they mature. It is easier to prevent a bad scar from forming by control/manipulation in the early phases of wound healing than to treat one that has already formed.

Injectable Fillers - Collagen, Restylane et al

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The first injectable filler available in the United States was Zyderm I. It was approved by the FDA in 1981 for injection into skin folds and wrinkles related to the aging process or depressed skin scars. Zyderm II followed in 1983 and Zyplast in 1985. They were all basically collagen derived from cow hide. Each form was designed for injection at a different depth within the skin. The chemical composition of each differed slightly so they lasted for a variable number of months, usually 2 to 3 months. Aside from their temporary effect the other major drawback to their use was the need for skin testing. A small amount was injected under the skin and if the patient did not react to the material they could go ahead with a full treatment some weeks after the skin test. If the full treatment was given to someone who was sensitive/allergic severe allergic reactions could result including the loss of the skin over the injection site.

Facelift, Midfacelift and Neck Lift 2

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To make things easier I first give the prospective facelift patient a mirror for them to point out areas of concern. That way I can be assured to address these in my overall assessment. I then use a top down approach to evaluate the frontal hairline (high, low or average), brow drooping, presence or absence of forehead wrinkles and crows' feet at the outer corners of the eyes, temple wasting or concavity, aging changes of the eyelids (bags, drooping-ligament laxity, excess skin, nasojugal groove depth), nasolabial fold (laugh line) depth, amount of excess cheek skin, cheek surface contour and bone visibility, presence of vertical skin folds just in front of the ear, marionette line depth, severity of jowls, upper lip height and upper incisor show, neck fat, excess skin and muscle banding and finally the patient's overall health condition. Since a large portion of these patient's are elderly with multiple medical problems on multiple medications an Internist is frequently involved to ensure a safe operation with a smooth recovery.

Facelift, Midfacelift and Neck Lift 1

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Facelift surgery to treat the aging face started in the early 1900s. At first this only involved removing some skin in front of the ear and under the chin. Striving for greater improvement the surgeons started to cut just under the skin via these incisions to release it from underlying attachments and allow the removal of greater amounts of skin. This flattened the laugh lines (skin fold between the outer edges of the nose & outer corners of the mouth) and marionette lines and that was good enough. That was how it was done for the first half of the 20th century. Progress in the surgical technique was hampered by societal taboos. No doctor would admit he or she did the surgery and no patient would state they had had the surgery.

Lip Augmentation - How to make the lips fuller or bigger

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Lips express emotion, sensuality, and vitality.  As far back as 69 to 30BC Cleopatra used crushed beetles and ants along with red clay, henna, iodine and seaweed to create a red ink-like substance to apply to her lips. Nowadays we have lipstick to make the lips look more prominent.

In the commonly accepted youthful attractive female lips there is a distinct bow shape to the outline of the upper lip, prominent columns of skin are present between the nose and edge of the upper lip with a curving slope lip skin surface, in repose the lower few millimeters of the upper incisors are visible, the upper lip has a greater fullness centrally near the midline of the body and near the outer corners which turn up slightly while the lower lip has more fullness just to either side of the midline.

Negative Pressure Wound Therapy

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Since the beginning of Plastic Surgery as a modern specialty, around World War I, Plastic Surgeons have been consulted to close wounds. In these cases the wound edges could not just be pulled together and sutured because of tissue deficiencies. At that time Plastic Surgeons would raise tubes of tissue (fat and skin) and slowly after multiple operations advance those tubes into the wounds in order to achieve closure.

Abdominoplasty, thigh buttock lift and belt lipectomy

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Abdominoplasty - Tummy Tuck


Thigh Buttock Lift - Belt Lipectomy (mostly for patients after massive weight loss or bariatric surgery, gastric bypass etc.)


Abdominoplasty for excess skin and fat and loose muscle
Abdominoplasty for excess skin
Abdominoplasty after weight loss
Belt lipectomy 1
Belt lipectomy 2
Aaron Stone MD - Plastic Surgeon Los Angeles
Dr. Stone's Twitter

Facial Proportions - Facial Analysis in Cosmetic Surgery

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Faces that are considered youthful and attractive in general have certain proportions and relationships in common. These fall into 3 categories.

• The first is equivalent size where 2 different anatomical structures have the same size.
• The second is proportional size where one structure is a specific fraction size of another.
• The third is positional angle relationships between 2 structures.

The optimal values for the first 2 categories are the same for both sexes. The third category can be altered to achieve a more masculine or feminine look. In assessing a patient for facial surgery Plastic Surgeons must keep these proportions in mind in the process of deciding what specific operative procedures would benefit the patient. This also allows the surgeon to custom tailor the procedure for each patient. No 2 patients should have the exact same procedure unless maybe they are identical twins. This is especially important when the margin of error is small such as a rhinoplasty where the margin of error is a millimeter or less.

The Implications of Herbal Medications on Plastic Surgery

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A majority of otherwise healthy individuals currently are regularly taking herbal medications. This may be with multivitamins and or the usual heart or blood pressure etc medications. I myself regularly take glucoseamine and multivitamins. Although many associate these herbs with being more natural with less side effects than pharmaceutically manufactured prescription medications that is not actually true. Especially in the high doses frequently taken these herbs can thin the blood preventing clotting, prevent healing after surgery, have dangerous interactions with medications given at surgery etc. I have personally had to cancel surgery in the middle of an operation because of bleeding that could not be stopped because the patient took goldenseal or high doses of vitamin E within a few days of surgery without telling me. Vitamin E especially in high doses dramatically thins the blood.

Here is a list of commonly used herbal medications and their associated problems: