Combined breast augmentation and breast lift

I have recently returned (not without protest) from a plastic surgery conference on the island of Tortola in the Bahamas where I presented my experience with performing combined subfascial breast augmentation and breast lift and I thought I would do a quick summary on the blog for everyone else.

Everyone knows quite a bit about breast augmentation. There is the understanding that there exists saline breast implants as well as silicone or “gummy bear” breast implants. It is also commonly understood that implants can be placed on top of the muscle or under the muscle and that one option for placing an implant on top of the muscle is called subfascial breast augmentation. This technique of breast augmentation has been proven to be safe, effective, and to give great results if performed in the right group of patients.

Breast lift procedures are any surgical procedure that is used to reshape the breast. The placement of the incision or incisions may vary depending on the need of the patient and the overall effect of the breast lift may also vary, but the common idea is that a breast lift does not remove breast tissue—that is called a breast reduction—and does not add any volume to the breast—that is called a breast augmentation. There are two basic categories of breast lifts.

1) Breast lifts that are designed to lift the areola higher up on the breast mound

2) Breast lifts that are designed to reshape and reposition the lower breast tissue higher by reducing laxity through removal of excess skin.

Of course, there are a large number of women who need both a breast augmentation to replenish volume as well as a breast lift to address the shape and position of the areola and/or breast tissue. About 10 years ago, there was still a sizeable amount of discussion about the safety and efficacy of performing a breast augmentation and breast lift at the same time. Over this period the amount of literature that has been presented to support the safety of performing an augmentation and lift at the same time has been considerable and today most surgeons (this one included) perform the vast majority of their breast augmentation and breast lift procedures together at the same time. Performing combined subfascial breast augmentation and breast lift is now the focus of a little skeptical attention in the plastic surgery community and my research has been an attempt at providing information on the safety and efficacy of doing so.

In essence, the take home point of my research is that combining subfascial breast augmentation and breast lift is definitely safe—as I have not had any complications, and it is effective in that my patients have been overwhelmingly happy with their results. Early long term result—about 1-2 years after surgery—have shown that the combination of the two procedures is long lasting as well. There are some patients however that would likely be better served by placing the implant under the muscle along with their breast lift procedure and these patients are those that are both very thin as well as contain significant breast soft-tissue laxity.

Anyways, I will keep following all of my patients out for longer long term result and report back again. As of now, I think we can begin to conclude, based on the information coming in that subfascial breast augmentation performed at the same time as breast lift surgery is a safe and effective option when patients are selected properly.

All the best,

Dr Remus Repta

Phoenix/Scottsdale, AZ

Facial Rejuvenation

Although I initially started this blog as a source of information for patients considering body contouring surgery I have received a fair number of inquiries regarding facial rejuvenation. Below is (almost) everything you ever wanted to know about facial rejuvenation. I hope you find it helpful.

Facial Rejuvenation

Aging is a process that involves more than just an increase in loose skin. Here are the three main components of aging.

1) Atrophy/volume loss: The young face is full. As we age we lose volume. Most of this volume is lost as fat but also in bone and muscle. This is perhaps the biggest component of aging and it is ironically the part of aging that has only begun to be appreciated and properly corrected as part of facial rejuvenation in the last few years. Atrophy is the reason why overweight individuals tend to look younger longer--they have more facial volume.

2) Soft-tissue laxity: The tissue between our bone and our skin is our soft-tissue. This consists of muscle and connective tissue. With time, as gravity continues, this soft-tissue moves downward. Tissue that once was located in the lower cheek descends below the jawline and becomes jowls, eyebrows become closer to our upper eyelids, the neck develops laxity, and so on. Individuals who have gained and lost significant weight will have stretched this tissue more and often have increased soft-tissue laxity.

3) Skin aging: Our skin is our first line of protection from the environment. Sun exposure, pollution, and the remainder of the environment constantly bombards our skin. In response to this our skin fights back by repairing itself but over the years it accumulates the signs of aging. Fine lines, pigment changes, laxity, large pores all develop in response to environmental damage. The top layer of our skin (epidermis) get thicker, and the bottom layer of our skin (dermis) gets thinner. With time, the near constant movement of our facial muscles also results in wrinkles. These wrinkles such as those found between the eyebrows, in the forehead, and on the sides of our eyes are called dynamic wrinkles since they are largely the result of the movement of our facial muscles.

So how do we reverse facial aging?

There are a vast number of different ways that we can achieve a more youthful appearence. The best way to understand all of these treatments is to group them according to each of three aging factors listed above. In addition, each treatment can be identified as short term or long term, indicating the length that the results are expected to last. Over the last 10-15 years there has been an increasing emphasis on minimally invasive, low downtime, repeatable treatments. Although these type of treatments may be desirable for some patients, the longer lasting, more definitive treatments remain the gold standard and are in fact enjoying a resurgence in popularity.

1) Atrophy/volume loss:

Short term treatment: Fillers are the short term treatment for facial volume loss. Fillers are products that are created by companies that are injected into the face to increase volume. There are many types of fillers including and all of them have positives and negatives. The basic idea of any filler is that it is designed to be repeated anywhere from 6-24 months. They are not permanent. Visit the spa section of our website for a list of available fillers .

Long term treatment: There are really only two long term (10+ years) or permanent treatment options for facial volume rejuvenation and those are facial implants and fat grafting. Facial implants are really designed to improve the prominence of our facial skeleton. The most common type of implants are chin and cheek, but a whole variety of facial implant are available. These implants are solid and are designed to last a lifetime, although some patients choose to revise the size and shape of these implants as they age and their facial shape changes. Fat grafting involves placing small droplets of fat in areas where fat has diminished. It is obtained from areas of our bodies that we have excess fat and placed carefully and patiently in the areas of our face that would benefit from additional soft tissue volume including the cheeks, jaw line, lips, lower and upper eyelids, temples, earlobes, and occasionally even the nose. The fat that manages to establish blood supply will last forever, although additional volume loss is likely with continued aging.

2) Soft-tissue laxity:

Short term treatment: Most of the treatment options available for the short-term treatment of soft-tissue laxity involve trans-cutaneous delivery of energy. Currently the best technology for this is the Ulthera system where ultrasound is used to deliver heat to the deep tissue below the skin. The results are not as powerful as surgery and are really only designed to last about a year.

Long term treatment: Long term treatment of soft-tissue laxity is largely confined to surgical procedures such as face lift, neck lift, eye lid lift, and brow lift among others. These treatments involve surgery to gain access to the deep facial tissues where they are properly positioned. The recovery time and cost of the long term procedures are higher than the short term procedures as expected, but the results are longer lasting, more encompassing, and usually considered as the gold standard.

3) Skin Aging:

Short term treatment: There are many short term treatments for skin rejuvenation. In fact many of these constitute the "medical spa" type treatments that have become so well known. Among these include Botox to relax skin wrinkles caused by facial muscle movement, light chemical peels, laser, and microdermabrasion for light skin resurfacing, IPL for skin color pigmentation, and a variety of skin care products to improve the texture and appearance of the skin. All of these treatments, especially when done in a medical spa environment, are designed to lightly improved skin aging. They are low to medium down time treatments that often have to be repeated once or twice to get maximum results. The longevity of the result often depends on how the skin is cared for.

Long term treatment: Most of the long term treatments for skin aging are just more aggressive versions of the short term treatments for this category. The deeper the skin is resurfaced via laser or chemical peel the better the result and the longer the results are likely to last given the same skin care. The downside is that these treatments usually require some form of sedation, additional cost, and longer recovery times.

Although facial aging and facial rejuvenation can be a complex and sometime daunting category of information it can be simplified by organizing the information as we have done above. Treatment of aging should also be considered in similar categories including short term and long term treatments as the cost, down time, quality of the results, and longevity of the results will be different.

Below is a quick two question survey regarding preference for short term vs long term facial rejuvenation treatments. Thanks.

Quizzes by Quibblo.com | SnapApp Quiz Apps

All the best,

Dr Remus Repta

Phoenix/Scottsdale, AZ

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

Laxity: what is it, what causes it, and how do we fix it.

Aging is a complex process that is a result of environmental experiences as well as genetics. Its effects are seen in our both, face, mind, and spirit. Although some aging effects are positive--wisdom, patience, experience-- most of the physical signs are undesirable. Among the undesirable effects of aging, laxity is the most easily recognized and often unwanted.

Laxity related to aging can be seen in any area of the body. The face, neck, arms, breasts, abdomen, hips, and thighs are frequent areas of undesirable excess soft tissue laxity related to aging. Soft tissue laxity related to aging occurs secondary to underlying volume loss, loss of elasticity of the skin, and stitching of the underlying ligaments that attach the skin to the underlying muscles and structure. This process is largely genetic but can be significantly impacted by a handful of environmental experiences including but not limited to sun exposure, smoking, poor nutrktion, certain chronic medical conditions, and weight gain/ weight fluctuation. The rate of development of soft tissue laxity as well as the extent of the excess laxity that develops is a complex interaction of genetic and environmental factors listed above. Minimizing development of soft tissue laxity is an important part of aging gracefully. Notice that we have not said "prevention" of laxity, since currently preventing aging is still a futuristic idea.

So how do we go about minimizing development of soft tissue laxity. Well, since we currently cannot control our genetics we must focus all of our attention on the environment. Treating our body well by giving it the proper rest, dehydration, and nutrition is a good start. Avoiding smoking, excessive sun exposure, and the development of certain chronic illnesses is next on the list. Lastly, there are a number of technologies on the market that may help to slow down some of the laxity that would normally develop. These technologies revolve around the idea of imparting energy, usually transcutaneously (through the skin), to help slow down the stretching of the ligaments that attach the skin to the underlying structures and to help build collage which would help in the rate of elasticity loss of the skin. There are many brands of machines that work on this principle. Some work better than others and none offer a magic bullit. Skin care products that are applied to the skin as lotions and claim to have the same affect are many but how well they work if at all is even more in question.

So, we can't completely prevent laxity from developing, then how do we treat it when laxity becomes too much. Treatment of soft tissue laxity should be generally thought of in two categories: non-surgical and surgical. The list of effective non-surgical treatments for soft tissue laxity is short. In my personal opinion, Ulthera is probably the only non surgical soft tissue laxity treatment that has reasonable effectiveness. There are a handful of treatments for the face that result in less facial laxity but these work primarily on the skin to "shrink wrap" it and not on the underlying soft tissue. These include the larger category of deep chemical and laser skin resurfacing procedures.

Finally, there are the surgical solutions to excessive laxity. A brief list of surgical solutions to excess laxity is shown below and can be found more in depth in earlier blog entries.

Full body lift: The body lift is the cornerstone procedure in the rejuvenation process following significant weight loss. It allows complete correction of the abdomen, the hips, the buttocks, as well as the back and sides of the thighs. The body lift procedure also results in lifting and tightening of the mons pubis. The final incision line is near the mons in front and follows the bikini line around the waist running at the natural border of the upper buttocks and lower back. It can be combined with liposuction or with a procedure known as purse-string gluteoplasty that is designed to use your own tissue that would have been removed to add volume to the buttocks.

Brachioplasty: There are a handful of different options designed to improve the appearance of the arms following weight loss. The procedure of choice depends on the amount of skin and soft-tissue laxity present and the amount of improvement desired. The final incision can be in the arm pit or in the middle part of the inner arm surface.

Breast augmentation and lift: Most patients who have experiences significant weight loss require a breast lift to improve the shape and position of their breasts. A breast lift or mastopexy can be combined with an augmentation to restore the breast volume. Breast augmentation can be accomplished by using an implant or by using the excess skin and soft-tissue that would have been removed by the breast lift procedure. During your consultation Dr. Repta can discuss which combination of procedures will best give you the result that you are looking for.

Bra Line Back Lift: Dr. Repta’s Bra Line Back Lift procedure is designed to eliminate the folds and rolls that accumulate in the upper and middle back near the bra line as a result of excess skin and soft-tissue laxity. Liposuction alone will not correct these areas since in addition to some excess fat there is often a significant amount of excess laxity. The final incision line of the Bra Line Back Lift is placed in the horizontal part of the brassiere strap. Recovery is relatively easy and straightforward and patients who have been good candidates for the Bra Line Back Lift procedure have been uniformly ecstatic about their results.

Thigh Lift: In addition to the full body lift which helps improve the laxity of the sides and back of the thighs, there are two specific thigh lift procedures designed to improve the appearance of the thighs. These include the crescent thigh lift and the vertical thigh lift. The crescent thigh lift is designed for patients who have laxity primarily in the upper inner thighs while the vertical thigh lift is designed for patients who have substantially more laxity the entire length of the inner and outer thighs.

Face and Neck Rejuvenation: Many patients who have experienced significant weight loss desire facial rejuvenation to correct the substantial amount of skin and soft-tissue laxity of the face and neck. A variety of facial rejuvenation procedures are available to help you achieve your goal. Although weight loss has been the primary goal, the face often needs a healthy amount of volume to maintain its youthful shape and contour. Fat grafting for volume replenishment of the face is an integral component of facial rejuvenation following significant weigh loss.

All the best,

Dr. Remus Repta

Phoenix/Scottdale, AZ

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