Arm rejuvenation

Younger, tighter, arms.

A common complaint of many women with regards to the aging process is the shape and appearance of their upper arms. Despite diet, exercise, and moderation of sun exposure, the upper arms—the area between the elbow and the arm pit—can lose its elasticity and shape. Many women report that the youthful contour of their arms is difficult to maintain through diet and exercise. Patient report a looseness and laxity of the arms that can be seen and felt spanning from the arm pit to the elbow. The severity of the problem varies from one individual to another and can be best understood as four different categories:

Category 1: In the first category, the unwanted shape of the upper arm is primarily a result of excess fat. The quality and tone of the skin is relatively good. These individuals respond well to volume loss either by additional diet and exercise or through liposuction or non-invasive fat reduction technologies. More information on this last part with the next blog entry on non-invasive fat and soft tissue treatment technology.

Category 2: Skin and soft tissue laxity is present, but it is primarily located in the upper part of the upper arm near the axilla (arm pit). These patients are best suited either by an axillary tuck, also known as a short incision arm lift, or by a series of non-invasive treatments designed to tighten the deeper tissue of the arm. An example of this type of non-invasive therapy is Ulthera. Which modality would be best is determined by the extent of the laxity as well as the goal of the patient.

Category 3: Skin and soft tissue laxity is present throughout the entire length of the upper arm. These individuals are often best treated by a full arm lift requiring an incision the length of the upper arm. If laxity is only moderate or if some degree of residual deformity can be tolerated a short incision arm lift with the future addition of a non-invasive soft tissue tightening technology may also be reasonable. In my experience, however, category 3 patients are often best treated by a full incision long enough to accomplish a more definitive result as opposed to utilizing a smaller incision and leaving residual upper arm laxity.

Category 4: Skin laxity is present primarily just above the elbows. These patients have traditionally been the most difficult to treat as the options have been limited. An incision at or just above the elbow is visible and is prone to healing poorly due to the mechanical action of the elbow joint. Recently treatment with non-invasive soft tissue tightening technologies has provided a very good option for those with mild to moderate elbow skin laxity with the only downside being that the procedure would have to be repeated yearly.

All the best,

Dr. Remus Repta

Phoenix/Scottsdale Plastic Surgery

Better looking thighs.

One of the most common body contouring requests involves the thighs. Women, and sometimes men, of all ages have variable complaints about the appearance of their thighs. Problem areas may be the inner thighs, the outer thighs, front part of the thighs, and of course the back part of the thighs. Although patients often complain more about one section of the thighs as listed above it is the entire upper leg or thigh area that needs improvement. The problem or issue that requires improvement usually falls into one or both of the following categories:

1) Excess fat

2) Excess laxity

Excess fat

Excess fat in the thighs can present as an overall size issue “my thighs are too big” or as a shape issue “I hate the bulge of fat on the outer thighs, or my inner thighs touch”. Excess fat is one of the easier problems to fix. There are various forms of fat removal available including that fall into various categories including non-invasive, invasive, immediate improvement, delayed improvement, etc. Most patients who have appreciable amounts of excess fat and want the best possible result will be good candidates for the more direct and definitive fat removal technologies involving liposuction such as power assisted liposuction, ultrasound assisted liposuction, traditional liposuction, etc. Patients who simply have excess fat without excess laxity and good skin will be served well by reduction of this excess fat through such liposuction technologies. These can be performed under local or general anesthesia and usually involve one or more small, 2-3 mm, access incisions. Patients who have only an excess fat issue tend to be between 20-40 years old and usually have not had significant fluctuations in their weight.

Excess laxity

Excess soft-tissue laxity of the thighs is a very frequent complaint from patients. Excess laxity is usually seen in the slightly older patient population, perhaps 30-onward, but can also be seen in patients who have had significant weight fluctuation or weight loss. To date, there does not exist any technology that can significantly reduce, on a long term time frame, excess soft-tissue laxity via a non-invasive modality. To put it another way, significant improvement in soft-tissue laxity requires an direct removal of the excess tissue laxity and therefore requires an incision and by definition some form of scar. Excess laxity of the thighs can be treated by various forms of lifts as described below:

1) Back of the thigh: the back of the thighs or “posterior” thighs can be lifted and tightened by performing a buttock lift. By repositioning and tightening the buttock the posterior thigh is also lifted and tightened. The final incision is in the bikini line at the junction between the buttock and lower back. This incision can be well hidden and heals very well if performed properly. This procedure usually creates substantial improvement in the shape, position, and contour of both the buttock and thighs. It can also be combined with liposuction and fat grafting of the buttock to achieve maximum improvement in the appearance of the buttocks area.

2) Inner thigh: The inner thighs can be treated for excess laxity in one of two ways. Significant laxity the whole length of the inner thigh also involving components of the anterior and lateral thighs is best treated with a length-wise or vertical thigh lift. This requires removal of excess soft tissue laxity the entire length of the inner thigh and results in a subsequent vertical inner thigh incision that is as long as needed to maximize the results. This can potentially span the entire length of the inner thigh from groin to the knee area. Although the scar is long, the reduction of laxity is significant and the results are usually the longest lasting. Massive weight loss patients are usually good candidates for this procedure. Patients with small amounts of laxity, particularly near the groin area, can be treated with a crescent inner thigh lift where the final incision is located at the crease between the thigh and groin area. This procedure has a more concealable scar but its ability to remove tissue laxity is much less than the vertical thigh lift procedure. Care needs to be taken to not place undue tension on the closure as lowering of the scar can bee seen and spreading of the outer labia can occur.

3) Body lift: The body lift procedure involves a tummy tuck, lateral (side) thigh lift, and buttock lift. It is designed to place the final incision in the bikini line and provide global improvement of the soft-tissue laxity of the outer thighs, posterior thighs via the buttock lift, and a portion of the front of the thighs. The inner thighs may require additional treatment for maximum correction as indicated in #2 above. This can be done at the same time or as a separate surgical proceure.

All the best,

Dr. Remus Repta

Phoenix/Scottsdale

Decisions in breast lift surgery. Incisions, scars, and breast shape.

A frequent discussion that takes place with regards to breast shaping and breast lift surgery is scars. It is no surprise that the desire to minimize and prevent scars on the breast is an important discussion point. The breasts, aside from breast feeding, are an extremely sensual part of the female body. For women who have lost their natural breast shape and have developed laxity and drooping a breast shaping procedure such as a breast lift is usually required to restore the position of the breast tissue, shape and size of the areola, and firmness or skin tension to its natural and most aesthetic level.

My discussion, whenever skin is in excess or there is excess skin and soft tissue laxity, inevitably revolves around the idea that fat and mucsle can be changed through diet and excercise but significant excess skin must be removed surgically. Removal of excess skin by definition involves making an incision. For breast lift surgery, an incision is needed to make the areola smaller, to elevate the areola to a higher position, and to remove the excess skin and contour the breast and breast tissue.

The inevitable questions then becomes, do we accept the needed incisions and subsequent scars in exchange for better breast shape? The simple answer is that the overall shape is always more important than an extra incision. The more detailed discussion goes as follows. An incision that heals well and is in the end a paper thin scar should be accepted in exchange for a significantly improved shape. I have never had one patient that has regretted getting a breast lift. They see the improved breast shape and position and the presence of paper thin scars becomes a very easy tradeoff to make. Remember, we make incisions on the face for facial rejuvenation including incisions on the eyelids and nose for eyelid and nose shaping. It seems that a well healed and positioned incision that delivers the best result possible in terms of breast shape and position should be judged in the same way.

When it comes to incisions and scars two things must be understood. If they are done properly the final scar should be paperthin and nearly invisible when full healing has occured. The second is that a perfectly shaped breast with a thin, nearly invisble incision is much more aesthetic and desireable then a droopy breast with a large areola and no scars. In the end, its the patient who has to decide what they value most. For my family, friends, and loved ones I would certainly steer them toward better shape.

All the best,

Dr. Remus Repta

Board Certified Plastic Surgeon

Phoenix/Scottsdale AZ

Capsule contracture

What is capsule contracture?

Capsule contracture or capsule formation is a condition where excessive internal scar tissue develops. Although it is most commonly discussed in reference to breast augmentation using an implant it can occur in a variety of situations. The body naturally develops a layer of scar surrounding any object that inside the body that is deemed foreign or otherwise not usually present. This can include a variety of implants such as breast implants, facial implants, calf implants, as well as pace makers and other medical devices including joint replacement implants, etc. The thin layer of scar tissue that naturally develops over these implants is deemed normal and in fact beneficial since the implant is separated from the surrounding tissue by this thin layer of scar tissue. Capsule contracture or capsule formation are some of the terms used to describe an abnormally thick capsule formation. Capsule contracture can be detected and diagnosed by excess fullness, excess firmness, or distortion of the surrounding area. When capsule contracture occurs in relation to breast augmentation the breast can become firm and painful and the shape of the breast becomes distorted by the abnormally thick capsule scar.

Why does capsule contacture occur?

This is a question that is sometime debated amongst specialists. My philosophy is as follows. If a thin layer of capsule formation is normal then a capsule contracture occurs when the body simply continues the process for an extended period of time. That is, the body forms a thin layer of capsule through the healing process which is a result of the natural inflammatory phase of healing. A capsule contrature is simply the body saying that there is an excess or prolonged inflammatory phase and it needs to build a thick capsule. An excess or prolonged inflammatory phase can occur in a variety of circumstances and includes: infection, bleeding, and seroma or excessive healing fluid.

How is capsule contracture prevented?

With regards to breast augmentation, the incidence of capsule contrature can be minimized by having minimal or no bleeding during the procedure and by placing the implant through a minimal touch technique where the implant touching the surrounding skin is minimized. Beyond this, additional ways to minimize the occurrence of capsule contracture may include massage of the breast, post operative antibiotics, the use of certain medications such as singulair, the use of post operative drains, etc. This second group of measures are debatable in terms of reducing the incidence of capsule contracture.

How is capsule contracture corrected once it forms?

Once capsule contracture occurs the incidence for recurrence of capsule contracture is increased for subsequent breast augmentation revisions. Because of this I favor the philosophy of treating the problem aggressively. To accomplish this my treatment plan for breast capsule contracture involves:

1) Removal of all breast capsule (full capsulectomy)

2) Replacement of the implant with a new implant (implant exchange)

3) Placement of the new implant in a newly formed pocket (neo pocket creation)

4) +/- use of a drain, massage, singulair, etc.

Another interesting discussion point to consider is the formation of a capsule contracture following a tummy tuck. This is often referred to as a pseudobursa and often occurs as a result of persistent presence of healing fluid or seroma. Just as in breast augmentation capsule contracture, pseudobursa following a tummy tuck is simply the creation of excessive scar tissue. This can occur following a tummy tuck when the body detects an elevated or persistent inflammatory phase. The body forms a thick scar tissue or pseudobursa in response to this inflammatory phase. It can be detected by excessive fullness usually just above the central part of the lower incision or just above the belly button. Prevention and treatment of a tummy tuck pseudobursa occurs in much the same way as prevention and treatment of a breast augmentation capsule contracture.

Sincerely,

Dr. Remus Repta

Phoenix Scottsdale plastic surgery

Dr Remus Repta

Phoenix/Scottsdale Plastic Surgeon

Welcome

This is the first entry in what I hope will become the primary site for information sharing concerning the tummy tuck procedure. I encourage anyone with questions, concerns, or information regarding tummy tuck to post here.

The tummy tuck procedure can be a wonderful way to rejuvenate the appearance of the abdomen. In the words of one of my mentors, the tummy tuck procedure can "thin, tighten, and flatten" the shape and contour of the abdomen. Since every patient and abdomen is different, a unique tummy tuck technique must be selected to deliver the best result possible.

Recently released, The Atlas of Abdominoplasty, is a comprehensive plastic surgery textbook on the tummy tuck and the related body contouring procedures. It is 15 chapters and covers all of the different tummy tuck techniques. In addition to sharing information and answering questions I will periodically post the details about each unique type of tummy tuck procedure, the ideal candidate, the recovery process, as well as some of the pros and cons associated with each procedure.

All the best,

Dr Remus Repta