Prophylactic mastectomy and breast reconstruction options

The most prominent recent news related to breast cancer and breast reconstruction has been the mainstream story that Angelina Jolie has been diagnosed with the BRCA positive gene and that she underwent bilateral prophylactic mastectomy (removal of both breast tissue mounds) as well as breast reconstruction.  Her generous sharing of information related to this event in her life and that of her family has generated a lot of discussion of breast cancer detection, breast cancer treatment, and breast reconstruction.

Along with my plastic surgery colleagues at Advanced Aesthetic Associates, I founded Breast Resource Arizona (breastresourcearizona.org) as a source of information for breast health and breast cancer particularly aimed at local women and their families.  Within the breastresourcearizona.org site there is information that addresses many of the common questions that have arisen from the recent Angelina Jolie story including the BRCA gene, prophylactic mastectomy, and breast reconstruction options.

Breast cancer detection, treatment, and reconstruction have made tremendous clinical progress over the last decade and it continues to make advancements each year with the help of courageous patients and hard working surgeons and researchers.

All the best,

Dr Remus Repta

Tummy tuck repair

What can be done to repair a tummy tuck?

I have covered some of the issues that can occur with a tummy tuck in prior posts and wanted to focus a little more on the idea of starting over again with a tummy tuck repair.

There are a handful of issues that can detract from an ideal tummy tuck result including:
-poor tummy tuck scar quality (thick scar, irregular scar)
-poor scar location (high tummy tuck scar)
-poor belly button appearance (belly button too big, scar visible, poor belly button appearance)
-too much residual fat
-too much residual skin
-insufficient abdominal wall tightening
-pseudobursa

Each of these issues can be addressed independently, however, in my experience I have found that frequently more than one of these issues exists and the best chance at an excellent result is often a full tummy tuck repair--essentially redoing the entire tummy tuck.  Although it is desirable to perform a smaller procedure a full tummy tuck repair often has the best chance of delivery the best result and really giving the patient the tummy tuck contour and appearance that they envisioned.

A full tummy tuck repair involves a careful assessment of the issues that have contributed in a less than ideal tummy tuck result and then an equally careful plan of correcting the issues and improving all of the components than will provide an excellent tummy tuck result.  In the end, I usually perform additional liposuction, lowering of the scar, removal of pseudobursa and foreign bodies, additional tightening of the abdominal wall, repair of the belly button, and proper closure of the incision line.

Below is a link from my website that represent some of what can be accomplished with a full tummy tuck repair.

http://www.aaaplasticsurgery.com/photo-gallery/details.cfm?ID=119&StartRow=6

All the best,

Dr Remus Repta

Breast Augmentation Revision

Breast Augmentation Revision

Breast augmentation is one of the most common plastic surgery procedures performed both in the United States as well as worldwide. We have discussed the specifics of breast augmentation in previous blog entries including types of implants available, incision location options, and whether the implants are placed on top of the muscle or below the muscle. With so many breast augmentation procedures being performed and the number of variables involved as mentioned above, it is not unreasonable to expect some breast augmentation procedures to require or benefit from revision surgery.

What is breast augmentation revision?

In general, a revision procedure is a procedure designed to improve or correct an undesirable characteristic of the initial procedure. Therefore, breast augmentation revision is repair or correction of any of the unfavorable characteristics that may be seen following breast augmentation. These may include:

1) Implant related problems of breast augmentation:

a) implant too big

b) implant too small

c) implants not the ideal size difference for symmetry

d) implant diameter too small

e) implant diameter too big

f) implant projection too small

g) implant projection too big

h) desire for silicone instead of saline (and vice versa)

2) Breast pocket related problems of breast augmentation

i) breast pocket too wide on the side (aka laterally, this is most common).

j) breast pocket too wide near the cleavage causing either too much cleavage or symmastia (inner breast borders touch)

k) breast fold too low

l) breast fold too high

m) breast fold shape not ideal

n) upper breast pocket dissected to much (breast implant migrates toward the clavicle when laying down)

o) breast pockets not symmetric

3) Breast tissue problems with breast augmentation

p) breast tissue too thin and implant visibility or palpability is an issue

q) animation. Breasts move too much when pectoralis muscle is flexed

r) capsule contracture. The capsule around the breast is excessively thick resulting in firm and/or painful breasts.

Over the next few weeks I will cover the breast augmentation revision procedures involved in every one of the breast augmentation revision problems listed above. I will designate the topic by name as well as its corresponding number-letter combination, i.e. 3p-Breast tissue too thin.

All the best,

Dr Remus Repta

Phoenix/Scottsdale, AZ

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