Abdominoplasty or tummy tucks when performed with women of color may have a higher incidence of scar formation along the lower Pfannenstiel or C-section scar associated with abdominoplasty.  Patients of color, including African-American women, Filipino and Middle Eastern women should be apprised of the situation of the possibility of keloids, hypertrophic scarring, widespread scarring, hyper- and hypopigmentation of scars associated with a tummy tuck procedure.

In the example, this patient has undergone a full abdominoplasty procedure.  She is a 48-year-old African-American female, having delivered two children, with excessive skin laxity in the lower abdominal wall with rectus diastasis.  The patient underwent an extensive full abdominoplasty up to the subcostal margin dissection with plication of the midline rectus sheath.  She underwent liposculpture of the iliac crest rolls.  The before photo shows stria from the umbilicus down to the suprapubic region.  The postoperative photo shows a full tummy tuck with the scar hidden low, just above the hairline of the suprapubic region, extended to the anterior superior iliac spine bilaterally and a circumferential incision around the umbilicus has healed well without hyperpigmentation, keloid or hypertrophy.  Lowering the scar on patients of color will help to reduce the visibility of this incision through underwear as well as through swimwear.  It is vital that patients of African-American origin as well as patients with increased pigment discuss the scarring and the possibilities of these problems thereafter.

The next four pictures represent a ruptured silicone on the right.  Notice the Linguine sign as well as the medial rupture of the implant on the right implant.  The left implant is completely intact.  There is no evidence of loss of integrity of the shell or Linguine sign.  The implants that rupture in silicone patients are referred to as “silent ruptures.”  This is different from saline implants that are referred to as “clinical ruptures” which can be diagnosed by visualization of the breast, showing an obvious asymmetry.  Remember that mammograms and ultrasounds can provide false positive or actually more often false negative results, indicating that the silicone implants are intact, but they are actually ruptured.

May 4 – 7, 2012

I recently attended the Annual American Society of Aesthetic Plastic Surgery Meeting in beautiful Vancouver, Canada.  This was an extremely interesting meeting and very informative with all aspects of cosmetic facial and body sculpting surgery procedures.  I attended courses in new techniques of breast lifting using the subareolar mastopexy approach, modified abdominoplasty surgery, as well as severe breast asymmetry and correction.  The conference included seminars with respect to dermal fillers, Botox and non-invasive fascioplastic surgery procedures, including a combination of Botox with hyaluronic acids, including Juvéderm and Restylane and Methyl Methacrylate Artefill.  In general, body sculpting procedures include the use of smart liposuction, vaso-liposuction as well as liposculpture of the breast.

This was an informative meeting.  It’s always wonderful seeing friends and colleagues from throughout the United States.  Vancouver itself was a beautiful and having the chance to fly to Victoria Island was quite amazing.

It is a privilege and honor once again to be recognized for the fourth year in a row  in the “Guide to America’s Top Plastic Surgeons.” Being chosen for this listing is an honor and is an impressive achievement being placed among the nation’s most excellent physicians.

SEVERE BOTTOMING OUT

Patients present to my practice in Beverly Hills for severe deformities, including malposition, technical areas of breast implant placement and in this case severe bottoming out, complete collapse of upper pole of pocket causing inferior displacement of the implant and a bottoming out appearance.  This is a case example in which the patient will undergo both repair of the bottoming out with an inferior internal capsulorraphy sling as well as a left inframammary tightening procedure of a breast lift nature.  Intraoperative photograph shows complete collapse of the upper pole of the pocket with the muscle completely scarred down to just above the level of the 12 o’clock position of the nipple areolar complex.  The implant has been pressurized down inferiorly and is approximately 1.5 inches too low.  Inferior capsule has been released and a small portion has been excised and has been sutured in place acting as a sling.  Skin was then removed and this double tightening procedure has brought the implant level back up to the normal position of the left side.  This is a classic example in which a thick capsule can be used as a sling in a capsulorraphy form to treat a patient with severe bottoming out.

We see patients with a multitude of different congenital deformities of the chest.  Women present for breast augmentation reconstruction in order to create a normal appearance to their chest wall.  Patients with concave chests do appear in my office.  This is referred to as pectus excavatum in which the sternum is depressed, the costochondral ribs are also depressed medially and then come out laterally.  This leads to a depression along the central aspect of the chest wall.  In terms of final surgical results, it is difficult to establish cleavage in a significant number of these patients.  However, I have found that implants will help to disguise the concavity to some extent, reducing the appearance of the pectus excavatum or concavity of the chest wall.  These are congenital deformities.  Severe pectus excavatum may require a thoracic surgical release of the ribs in order to expand volume space for the lungs.  Some patients do present with decrease in total lung capacity, forced expiration and thereby require chest wall reconstruction.  Patients that we see, however, have more mild forms of pectus excavatum that will simply require an augmentation mammoplasty procedure.  I am able to do the dual plane technique with saline or silicone implants in these patients.

Once again, we are able to disguise a significant portion of the concavity that appears from these chest wall deformities.

Many of my breast revision patients are patients who have undergone breast lifts that were not satisfactory to correct the skin laxity vertically as well as along the inframammary fold.  When patients present with grade 3 ptosis aka the nipple areolar complex is below 3 cm under the inframammary fold, normally a lollipop lift or a periareolar lift will not be sufficient and skin must be removed along the inframammary fold.  It is worth the tradeoff of an extra scar along the inframammary fold in order to have a perfect shaped breast.

Mastopexy and breast reduction surgeries are similar with respect to the Wise-pattern or anchor scar when patients present with severe grade 3 ptosis.  Remember, if you do the improper surgical operation such as a round block or a lollipop with severe grade 3 ptosis, you are sure to have a disfigured deform-shaped breast and will probably be knocking at our door for breast revision surgery.

March / April 2012 issue

The  Aesthetic Guide Magazine, March / April 2012 issue discusses the Poly Implant Prothese (P.I.P.) breast implant. I was asked by Aesthetic Guide to contribute to this article and had the opportunity  to discuss topics that included symptoms of a ruptured implant, european regulators, and public safety.

For more information regarding this topic and the Aesthetic Guide magazine go to www.miinews.com .

WITH FREE NIPPLE GRAFTING

The patient below is a 48-year-old female presenting with massive gigantomastic breasts/breast hypertrophy, 40KK breasts, with symptoms of severe back pain, neck strain, grooving around the shoulder blades and coracoid aspects of the shoulders, including ulnar neuropathy, rashes and ulcerations of the breasts due to poor circulation associated with the massive skin laxity and grade 3 ptosis.  This patient is a perfect candidate for bilateral breast reduction using the breast amputation technique with a free nipple graft.  The pedicle will probably be approximately 30 cm long, if not longer, and therefore will require most likely a free nipple graft in the operating room in order to prevent avascular necrosis of the nipple areolar complex due to the length of the pedicle and inadequate blood supply through osmotic diffusion.

The frontal and oblique views of this patient will be shown.  This patient is an extraordinary case due to the massive size of her breasts as well as the severe degree of skin laxity and ptosis.  These surgeries require skillful Board Certified Plastic Surgeons who specialize in breast reduction to reduce the risk of fat necrosis, bleeding, infection and nipple areolar necrosis.