Dont Sweat It

The technical term for excessive sweating is hyperhydrosis. This can be seen anywhere on the body but usually is most problematic when it occurs on the hands, face, and in the underarm area (axillary region). The most common area for complaints is in the underarm area.

There are many women and men who either have excessive underarm sweating or would prefer to not have to wear antiperspirant or cannot tolerate antiperspirant. Traditional methods of reducing under-arm sweating revolved around the injection of botox. While this is still a reasonable treatment option the recurring cost and need for multiple injections have spurred patients to ask for better solutions. My answer to these patient requests has resulted in a permanent solution.

The procedure is called SASS underarm TM (small access subdermal shaving). It can be performed under local or general anesthesia in about an hour. The majority or all of the underarm sweat glands and often hair follicles are removed through a small incision about the width of a dime. Recovery and down-time is relatively simple, involving a simple compression dressing for a few days.

All the best,

Dr. Remus Repta

Tummy Tuck Scars

A frequent concern of patients considering a tummy tuck is the final scars. Rightfully so, all cosmetic procedures involving removing large amounts of skin and soft-tissue will need to have some type of scar. The two-part question that prospective tummy tuck patients should consider is:

How will the final scar look and feel when I am nude? And, will it the scar be visible when a I am wearing a two piece bikin, low rider jeans, underwear, etc?

Since we can all agree that a scar will be present after a tummy tuck the the answer to the above questions should help to alleviate most concerns about scars.

How will my Tummy Tuck Scars look and feel when I am nude?

It is my experience and that of my colleagues that tummy tuck scars uniformly heal thin, without keloid or hypertrophic qualities. A keloid scar is one that becomes so thick that the borders of the scar are beyond the area of the initial incision. A hypertrophic scar is a scar that heals with above normal amount of thickness but remains overlying the area of the incision. Hypertrophic scars are bad, keloid scars are really bad. Quite frankly I have never seen keloid scars resulting from a tummy tuck procedure either from my own patients or from patients who have had their surgery elsewhere. Hypertrophic scars usually occur from one of several factors including: beyond the limit excessive tension on the closure, inadequate suturing, infection, or otherwise poor healing resulting from medical issues or insufficient blood supply. With current knowledge, skills, and technology, hypertrophic scars from the tummy tuck procedure should be a very rare event. Correcting a hypertrophic scar starts with identifying the cause and revising the scar. It is usually a very straight forward procedure that frequently can be performed under local anesthesia with or without sedation. In most cases a drain is not needed and in a good number of cases an abdominal binder is not needed as well.

Other types of non-ideal tummy tuck scars include very thin and wide scars, asymmetric scars, and discolored scars. Very thin and wide scars usually indicate that the stronger connective tissue underlying the skin did aid the skin in healing properly. This can be he result of poor tissue quality or improper repair of this stronger, deeper tissue. Revision of these scar usually involves removal of the thin scar and proper repair of the thicker deeper underlying tissue. Asymmetric tummy tuck scars are usually the result of the tummy tuck design although if one side of the abdomen has previous scars then asymmertic healing can also occur. Tummy tuck scars that are either too light or too dark can be corrected through revision or through non-surgical means. Dark scars can be lightened with certain creams, light scars can be corrected with something called medical trepenation. Some of my research during my training focused on the treatment of low pigment scars and this process seemed promising.

How will my tummy tuck scars look when I am wearing certain types of clothes including a bikini, low-rider jeans, and mid-drift bearing shirts?

This is a particular passion for me in terms of the tummy tuck procedure. What is the point of getting a tummy tuck if you cannot show your tummy afterwards without people noting you have had surgery. In order to accomplish this the final incision lines of a tummy tuck must be hidden. The lower incision of the tummy tuck must be kept very low in the panty line (except for reverse tummy tuck where it should be hidden in the breast fold) and the belly button incision must be hidden within the belly button.

To accomplish this it is very important to design the tummy tuck procedure properly. The location of these incisions in the end is almost solely dependent on the design and execution of the tummy tuck procedure by the plastic surgeon. Correction of high or visible tummy tuck scars often requires more than just a tummy tuck scar revision. It frequently involves a complete tummy tuck repair sometimes also known as a complete tummy tuck re-do. This is essentially the full tummy tuck redone from beginning to end. For more information on this, please see my previous post on tummy tuck repair.

In terms of tummy tuck scar care, scar care creams such as Miderma or Scarguard can help but only if everything discussed above has been properly addressed.

In summary, anyone that is a good candidate for a tummy tuck must decide if it is worth it to them to trade a better looking tummy for a scar. This should be easily answered "Yes" if there is confidence about the appearance and location of the final scars as discussed above.

All the best,

Dr. Remus Repta

Tummy Tuck Repair

What is Tummy Tuck Revision?

Many of the emails and questions I receive are from individuals who have had a tummy tuck and now are wondering how to fix or improve their tummy tuck result. The terms used for the group of procedures used to improve tummy tuck results includes "Tummy Tuck Revision", "Tummy Tuck Repair", and "Tummy Tuck Re-do". Regardless of which term we use we are communicating the same thing: surgical and non-surgical methods of improving the appearance of the abdomen and surrounding areas of the body following a tummy tuck. There are a handful of issues that can arise following a tummy tuck which can result in dissatisfaction with the appearance of the abdomen. A list of the more commonly encountered issues following a tummy tuck procedure is listed below:

List of potential tummy tuck issues:

Poor scars: Tummy tuck scars can be improved. Wide scars can be made thin by simple scar revision. Scars that are too high can be lowered by scar revision as well; however significant lowering of scars often requires full tummy tuck revision.

Belly button/umbilicus: There are many potential problems with the appearance of the belly button following a tummy tuck. Visible scars, a belly button that is asymmetric, too much fullness surrounding the belly button, a belly button that is either too small or too large or whose shape is unappealing can be corrected. Sometimes the solution can be fairly straightforward and even accomplished in the office under local anesthesia. Other belly button problems may require more extensive repair such as re-tightening of the abdominal wall and revising the tummy tuck to allow complete rejuvenation of the umbilicus.

Excess fat: Visible amounts of fat especially near the belly button and above the pubic bone can detract from the aesthetic result of a tummy tuck. Liposuction is often a great solution if there is not excess skin laxity. Localized pockets of fat can be performed under tumescent (local) anesthetic, more extensive liposuction is usually performed under general anesthesia.

Excess skin laxity: There are various reasons to have residual skin laxity following a tummy tuck. If the amount of excess skin laxity is relatively minor this can be corrected as part of a scar revision. Larger amounts of residual skin laxity may benefit from a formal tummy tuck revision or from the addition of a complimentary tummy tuck procedure such as a reverse tummy tuck following a traditional full tummy tuck.

“Dog-ears”: This term applies to excess skin and fat at the sides of the tummy tuck incision. They look like triangles of soft-tissue and are uniformally hated by any patient that have them. This is a result of several issues often it is a combination of too much laxity for the given tummy tuck procedure and/or the design of the incision and resection of the tummy tuck tissue. Correction of this problem can be accomplished in one of two ways. Either the excess soft-tissue is removed and the scar is lengthened thereby improving the overall appearance of this area, or the previous tummy tuck procedure is extended into a circumferential tummy tuck. This has the added benefit of improving the laxity that may exist at the side of the hips as well as in the buttock area for some patients.

Uneven surface: The surface of the abdomen should be smooth and natural. Lumps and bumps detract from the overall result and should be addressed. Small irregularities can be addressed with liposuction, larger irregularities should be addressed through a methodical assessment and correction usually requiring a formal revision tummy tuck.

Pseudobursa: A pseudobursa is a pocket of extra thick scar tissue that can form under the abdominal soft tissue following a tummy tuck. The most common area for pseudobursa formation is just above the waistline incision in the middle. This is the most gravity dependant area so it is naturally the most likely area for pseudobursa formation to occur. A pseudobursa can also develop just above the belly button. The presence of the belly button stalk and the surrounding tissue can form an area for a seroma to accumulate and for a pseudobursa to form. Small or relatively thin pseudobursa, if palpable or visible can be reduced by thorough liposuction and drain placement, most pseudobursas, however, need to be removed surgically during a revision tummy tuck for definitive correction.

All the best,

Dr. Remus Repta

Circumferential tummy tuck (Body Lift)

What is a Body Lift or Circumferential tummy tuck?

This procedure can be thought of as a full tummu tuck and a buttock lift. The incision goes all the way around the waist, hence the term circumferential, and helps remove skin laxity from the tummy, the hips, and the buttocks. The result is usually flattening and tightening of the tummy and lifting of the hips/thighs and buttocks. The tummy tuck component of the procedure is performed in similar fashion as a full tummy tuck with liposuction where needed, and muscle tightening to help flatten the tummy.

Who is a candidate for a Body Lift?

Patients with a lot of excess skin and soft-tissue laxity are good candidates for the Body Lift procedure. Often, candidates for a body lift have had some degree of weight loss either from bariatric surgery or from regular dieting.

Where are the incisions?

The incision is hidden in the underwear line around the waist and is very well tolerated. In certain circumstances, an additional vertical incision is made in the middle to reduce the laxity from side-to-side. This is done when there is a previous vertical incision and/or there is tremendous amount of laxity and the patient wants maximum correction and tightening.

All the best,

Dr. Remus Repta

Lip Augmentation

How can lips be made fuller, younger looking?

Recently I was interviewed by a local new station regarding the new PermaLip implant. See video in the side bar) The PermaLip implant is a soft silicone implant that is placed under local anesthesia in about 30 minutes. The benefits of the PermaLip implant is that it is easy to place, exchange, or remove. It feels soft and once it is placed no further scheduled fillers need to be used.

Other options for achieving fuller lips include using hyaluronic acid fillers (juvederm, restylane, etc), injecting fat, or placing various types of material including fascia, skin, and goretex.

All the procedures have advantages. The PermaLip implant is quick, easy, they look great, and they feel natural. Hyaluronic acid fillers also look and feel great but require priodic injections since the fillers go away. Fat grafting can be a good method to get fuller lips but requires a donor site and some of the fat tends to go away.

The best product or procedure varies for each patient. If temporary fillers give you the look you like than a permanent implant such as the PermaLip or fat grafting is often a good long term choice.

All the best,

Dr. Remus Repta

Breast Augmentation

Breast Augmentation

Breast augmentation goes by many names. Commonly used terms include breast enhancement, breast enlargement, and of course boob job. All of these terms refer to the same basic idea of using an implant (or fat grafting in certain circumstances) to increase the size and improve the shape of breasts.

To understand breast augmentation it helps to brake it down into the type of implant, incision location, and level of tissue placement. The list of each is shown below and a more comprehensive discussion follows.

Implant types

Saline

Smooth shell

Textured

Silicone (gummy bear)

Smooth shell

Textured shell

Silicone (form stable)

Textured shell only

Fat

Incision location

Peri-areolar (at the border of the areola and breast skin)

Trans-axillary (through the arm pit)

Inframmamary (at the breast fold/under the breast)

Trans-umbilical (aka TUBA, through the belly button)

Placement

Sub-glandular (under the breast gland)

Sub-fascial (under the covering on top of the muscle)

Sub-pectoral (under the muscle)

The goal of any breast augmentation is to match the patients goal of what they want their breasts and body to look like. This is important because there is a wide range of patient desire regarding the aesthetic appearance of a breast. Some patients want very modest results, wishing to avoid any suspicion of that a cosmetic breast procedure was performed. On the other end of the scale there are patients who want the very largest breast possible, maximizing volume and cleavage. Of course, most patients fall somewhere in between. This issue of personal choice is important because it will guide the selection process of implant type, incision location, and placement.

Breast implant type

The most natural feeling breast implant type in my opinion as well as the opinion of my staff and patients are silicone (gumy bear type). Therefore, my preference for breast implant type is usually either textured silicone or smooth wall silicone. I always present the pros and cons of each implant type and allow the patient to decide. Most patients agree that silicone is the most natural to feel. With the reassurance that silicone implants are just as safe as saline implant, the majority of patients choose silicone. I will use saline implants in a handful of situations including patient preferrence, placement via the belly button (TUBA, see above), placement through a very small areola of a large final volume implant, and occassionaly placement of a large final volume implant via the arm pit (transaxillary). The reason for use of saline implants in these situations is simply that a silicone gel implant requires a slightly larger opening. The difference between smooth wall and textured wall breast implants is negligible. I often use textured for the potential added benefit of less scarring internally as well as a more even feel as the breast tissue and the implant tend to more together more as a result of the textured shell. The last type of breast implant is the form stable breast implant. This implant is also made of silicone gel but the gel is more cohesive and therefor slightly firmer in terms of feel. These implants are still restricted for "reconstructive" use, but periodically they are used for cosmetic breast augmentation by some plastic surgeons. They have a nice shape but are firmer. They also require a slightly larger incision than the gummy bear implants.

Incision location

The location of the incision for placement of the breast implant is determined by patient preference but also by implant type and implant size.

The inframmamary incision (breast fold incision) allows the surgeon a great deal of control and access to shape the breast. Both saline and silicone breast implants can be placed via the inframmamry incision.

The trans-axillary incision (through the arm pit) can be used with either the saline or silicone implant but larger silicone implants become exceedingly difficult to place via this incision and therefore implants larger than about 400cc placed via the arm pit will likely be saline. The arm pit incision can also offer good visualization for the surgeon when an endoscope is used.

The peri-areolar incision can be used with either saline or silicone breast implants. Again, if the areola is particularly small and/or the implant is particularly large it may be difficult to use a silicone implant. How small the areola is or how big the silicone implant is before saline implant must be used needs to be judged on a patient by patient basis. The peri-areolar incision is especially useful if the areola is to be made smaller during the same procedure or the breast will also be "lifted" (mastopexy) during the same procedure. The peri-areolar incision is almost always the incision of choice for female bodybuilders since that incision is the oncly incision always hidden during body building exibitions.

The trans-umbilical incision is always used with saline breast implants. It is very difficult, or nearly impossible to get a silicone implant through the belly button incision and up to the breast area, especially without the risk of damaging the implant.

Implant placement

As listed above, implants can be placed underneath the breast tissue, under the covering of the fascia on top of the muscle, or under the muscle. If saline implants are chosen and especially if the patient is very thin, the implant should be placed under the muscle. In all other circumstances, I recommend the placement of silicone implants underneath the fascia on top of the muscle. This accomplishes three things. First the recovery is significantly faster and easier. Most of the pain associated with breast augmentation is secondary to the muscle being cut. Placing the implant on top of the muscle avoids this issue and makes recovery much easier. The other benefit of placing the breast implant in the subfascial plane is that the breast will be softer earlier and when all of the healing has been completed. Finally, placing the breast implant in the subfascial plane avoides "breast animation". Breast animation is the term used to describe movement of the breast when the arms are used. Breast animation occurrs when the muscle is placed under the pectoralis muscle. When the arms are used during regular daily activities or excercise the pectoralis muscle is naturally activated. When the muscle moves the breast implants move, usually in an out and up direction. This can be quite dramatic at times and can be very bothersome and unattractive for the patient as well as the patients partner.

I hope this helps. More to come in the near future about breast augmentation.

All the best,

Dr. Remus Repta

Buttock Fat Grafting

What is buttock fat grafting?

Buttocks fat grafting is the process of removing fat from other areas of the body such as the abdomen, lower back, hips, and thighs and placing it in the buttock area. The fat is harvested or removed by a method similar to liposuction and it is transferred or grafted to the buttock area after processing. The entire event occurs in the operating room (or procedure room for small areas).

When is buttocks fat grafting performed?

It is performed most commonly for augmentation, or increasing the size of the buttocks, as well as shaping and correcting contour irregularities.

What are the benefits of fat grafting?

It is your own tissue. The fat that is grafted into the buttocks area forms new blood supply. In doing so it changes as your body changes. It feels soft and unform without the notion that it is something distinct from the surrounding tissue. There is of course the added benefit of improved contour in the areas where the fat has been harvested from.

What are the drawbacks of buttocks fat grafting?

Buttocks fat grafting requires excess fat in other parts of the body. Some women, especially those that feel their butt is too small, are usually fairly thin and the amount of fat needed may not be readily available. These patients are better candidates for buttock augmentation using an implant (see next entry for buttock implants). Buttocks fat grafting should not be used to correct buttock ptosis (saggy buttock). In these cases, a buttock lift with or without augmentation should be perfomed.

What is the recovery time like?

Patients who have undergone buttock fat grafting have uniformily been suprised at the low level of discomfort. Usually, the areas where fat has been harvested is felt more than the buttock area. Restrictions involve avoiding vigorous activity or prolonged sitting especially on non-padded surfaces.

Stay tuned for buttocks augmentation using implants as the next blog entry.

All the best,

Dr. Repta

Phoenix/Scottsdale Plastic Surgeon