Raleigh Plastic Surgeon Dr. Michael Law discusses:
Upper Blepharoplasty (Upper Eyelid Enhancement)
The eyes are the primary facial feature that communicates tiredness or exhaustion (and, likewise, energy and vitality). Your cheeks and your neck don't really reflect whether or not you've had a good night's rest. But miss a night of sleep and your eyes will make it obvious to everyone.
Aesthetic plastic surgery of the eyelids can produce a dramatic rejuvenating effect, literally taking years off of a person's appearance. Interestingly, many patients find that following eyelid surgery friends will say 'You look great!', but they usually cannot pinpoint exactly why.
Excessive or 'redundant' upper eyelid skin is a very typical aging change that leads people to seek eyelid surgery. In many patients, this surgery can be performed under light sedation with local anesthesia as an outpatient office procedure. In a few cases, protruding fat behind the eyelids is also removed. As with most facial aging changes, no two people present with exactly the same eyelid concerns. Surgical treatment is therefore individualized to the needs of each individual patient.
My approach to upper eyelid surgery is to be conservative with skin excision, and to reserve excision of fat for patients with significant fat excess. In my opinion, aggressive removal of upper eyelid skin and fat is a 'skeletonizing' procedure which risks making eyes appear more deep-set and aged, rather than younger. In fact, in many patients I perform structural fat grafting (using the patient's own fat, from the abdomen or hips) to help restore soft tissue volume around the eyes.
The next time you flip through Vogue or Allure (guys, just grab one at the checkout stand) take a close look at the eyes of the models. In most of them, women in their teens and twenties, you will see only a sliver of the upper eyelid, if it is visible at all. In many, the upper lid is completely obscured by soft tissue fullness between the brow and eyelashes, which I sometimes refer to as the 'brow roll'. Perusing the fashion magazines provides quick confirmation that the youthful upper lid is not a skeletonized upper lid.
Structural fat grafting provides a mean for restoring or enhancing this 'brow roll' area. In patients that have always had, or who with age have developed a deep recess between the upper lid and brow, the addition of soft tissue volume can dramatically rejuvenate the appearance of the eyes. This novel aesthetic enhancement of the upper lids does not look like surgery - it just looks youthful.
In some individuals the upper lids appear heavy and 'droopy' because of descent of the lateral brow. A lateral browlift can reduce or even eliminate the need for excision of upper eyelid skin in patients with lateral brow descent.
Friday, July 18, 2008
Structural Fat Grafting
Plastic Surgery Trends including natural-looking results from plastic surgery and non-surgical aesthetic medical procedures with little or no downtime.
Great plastic surgery doesn't look like surgery. It just makes people look great.
Raleigh Plastic Surgeon Dr. Law discusses structural fat grafting:
Structural Fat Grafting: permanently restoring youthful facial contours
A number of 'soft tissue fillers' are available for temporarily improving facial areas that have lost volume or have developed deep lines and creases. Probably the most popular fillers currently are hyaluronic acid products like Restylane, which can be used to plump up thin lips and to fill out nasolabial folds (lines that run from beside the nostrils to the area beside the corners of the mouth) and marionette lines (lines that run from the corners of the mouth towards the jawline). The improvement generally lasts four to six months.
Some synthetic materials are available which can be used in an attempt to produce a permanent soft tissue augmentation. Unfortunately, the body treats such materials as foreign objects, and as a result the placement of synthetic materials may lead to inflammation, infection, migration and granuloma formation. In general, synthetic materials are less likely to produce a result that looks and feels natural.
For patients seeking permanent enhancement of soft tissue volume, the ideal material to use would obviously be something that is naturally-occurring and not rejected by the body or treated by the immune system as a foreign material. Whether the goal is to restore volume to an area such as the lips or the cheeks, or to fill in a crease or depression such as the nasolabial folds or marionette lines, the ideal material is quite clearly the material that one wishes was there in greater abundance in the first place: YOUR OWN FAT.
The grafting of autologous (your own) fat to reliably restore or improve facial volume is now possible. The fat is harvested from the abdomen, thighs, hips or buttocks using specially-designed instruments and a specialized technique, processed (by centrifugation, which eliminates all components of the harvested material which is not viable fat), and meticulously injected into the facial areas to be enhanced.
Fat grafting has been performed by plastic surgeons for decades. There is no question that fat is the ideal material for soft tissue augmentation, and that the results obtained with fat grafting are the most natural-appearing. However, one problem with this procedure in years past has been resorption (breakdown) of the grafted fat, so that the resulting improvement is not permanent. The grafted fat must gain its own blood supply in its new location in order to persist long-term, and this generally is not possible when large amounts are injected at once and when specialized instrumentation and techniques are not employed.
A relatively new technique has been developed called structural fat grafting, in which small amounts (less than 0.1 cc at a time) of fat are carefully microinjected in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each microinjection, new blood vessels are able to grow into the grafted fat, allowing it to persist. If this process of blood vessel ingrowth (neovascularization) does not occur, then the injected tissue cannot truly be considered a 'graft' and is instead just another 'soft tissue filler' of limited duration.
This is a procedure that requires specialized training and specialized surgical instruments, as well as patience and attention to detail on the part of the surgeon. When performed properly, permanent improvements in facial contours are possible. If enough fat resorption occurs following a fat grafting procedure such that the desired result is not achieved, a second 'touch-up' procedure can easily be performed to augment the result obtained from the first injection.
Great plastic surgery doesn't look like surgery. It just makes people look great.
Raleigh Plastic Surgeon Dr. Law discusses structural fat grafting:
Structural Fat Grafting: permanently restoring youthful facial contours
A number of 'soft tissue fillers' are available for temporarily improving facial areas that have lost volume or have developed deep lines and creases. Probably the most popular fillers currently are hyaluronic acid products like Restylane, which can be used to plump up thin lips and to fill out nasolabial folds (lines that run from beside the nostrils to the area beside the corners of the mouth) and marionette lines (lines that run from the corners of the mouth towards the jawline). The improvement generally lasts four to six months.
Some synthetic materials are available which can be used in an attempt to produce a permanent soft tissue augmentation. Unfortunately, the body treats such materials as foreign objects, and as a result the placement of synthetic materials may lead to inflammation, infection, migration and granuloma formation. In general, synthetic materials are less likely to produce a result that looks and feels natural.
For patients seeking permanent enhancement of soft tissue volume, the ideal material to use would obviously be something that is naturally-occurring and not rejected by the body or treated by the immune system as a foreign material. Whether the goal is to restore volume to an area such as the lips or the cheeks, or to fill in a crease or depression such as the nasolabial folds or marionette lines, the ideal material is quite clearly the material that one wishes was there in greater abundance in the first place: YOUR OWN FAT.
The grafting of autologous (your own) fat to reliably restore or improve facial volume is now possible. The fat is harvested from the abdomen, thighs, hips or buttocks using specially-designed instruments and a specialized technique, processed (by centrifugation, which eliminates all components of the harvested material which is not viable fat), and meticulously injected into the facial areas to be enhanced.
Fat grafting has been performed by plastic surgeons for decades. There is no question that fat is the ideal material for soft tissue augmentation, and that the results obtained with fat grafting are the most natural-appearing. However, one problem with this procedure in years past has been resorption (breakdown) of the grafted fat, so that the resulting improvement is not permanent. The grafted fat must gain its own blood supply in its new location in order to persist long-term, and this generally is not possible when large amounts are injected at once and when specialized instrumentation and techniques are not employed.
A relatively new technique has been developed called structural fat grafting, in which small amounts (less than 0.1 cc at a time) of fat are carefully microinjected in a series of discrete layers to gradually 'build' new soft tissue structure. As there is space between each microinjection, new blood vessels are able to grow into the grafted fat, allowing it to persist. If this process of blood vessel ingrowth (neovascularization) does not occur, then the injected tissue cannot truly be considered a 'graft' and is instead just another 'soft tissue filler' of limited duration.
This is a procedure that requires specialized training and specialized surgical instruments, as well as patience and attention to detail on the part of the surgeon. When performed properly, permanent improvements in facial contours are possible. If enough fat resorption occurs following a fat grafting procedure such that the desired result is not achieved, a second 'touch-up' procedure can easily be performed to augment the result obtained from the first injection.
Laser Hair Removal (National Training Center)
Raleigh Plastic Surgeon Dr. Michael Law discusses:
LASER HAIR REMOVAL
For many women and men, unwanted hair is a nuisance....or even a source of embarrassment. Until recently, laser hair removal has been uncomfortable, time-consuming, expensive and provided results that were inconsistent at best.
Advances in laser technology have resulted in far better results, and treatments that are safer, faster and more comfortable than ever before. Laser hair removal works on just about any area of the body where smooth skin is desired... underarms, face, neck, back, legs, shoulders, bikini line, you name it.
Not all lasers, or all laser centers, provide the same level of treatments.
Here are a number of advantages of laser hair removal
with Blue Water Spa & Michael Law MD Aesthetic Plastic Surgery:
EXPERIENCE:
We have provided training for physicians on laser hair removal since 1995 and we are a national training center for laser hair removal and medical spa technology.
EFFECTIVENESS:
The lasers we use have been evaluated as the most effective in peer-reviewed medical journals. These sophisticated lasers target the root of the hair so specifically that they not only eliminate very dark and coarse hair, but are also the most effective lasers for the removal of fine hair and even hair with a light brown root.
SPEED:
Full legs or a back can be treated in just 20 minutes. Our GentleLASE uses an 18mm spot size (about the size of a quarter). This larger spot size coupled with more hertz (power), means a faster and more effective treatment. A full back, for example, can be treated in less than 15 minutes and full legs in less than 20 minutes.
SAFETY:
We use a patented cooling device for that means a more comfortable treatment and eliminates the need for topical anesthetic.
AFFORDABILITY:
Our laser performs treatments quickly, therefore, we are able to charge less per treatment. We never insist on paying for packages up front, our clients pay per treatment. We feel confident about our laser and know that our clients will return for follow up treatments.
FREQUENTLY ASKED QUESTIONS
How does laser hair removal work?
The laser targets the darkness of the melanin pigment in the hair follicle. Since melanin is only produced in the growth phase of the hair, the laser must target the hair follicle during this cycle. At any given time, 20-40% of the hair in a particular area may be in a growth phase. Therefore, more than one treatment needs to be scheduled, preferably at 6-8 week intervals. With multiple treatments we can ensure that all hair follicles are being disabled.
Can all hair and skin colors be treated effectively with laser?
While laser hair removal can be performed on virtually any skin color, the color of the hair is the most important factor. The laser is attracted to the melanin (the dark pigment) in the hair follicle. Thus, darker hair is treated most effectively. If your hair has a blonde, red, or dark gray root, you may not be a good candidate for laser hair removal.
Do you offer free consultations?
Absolutely. We believe that a consultation is important for any client considering laser hair removal. We will perform a test spot so the client can see how the laser feels and we can answer any questions so the client can better understand what the laser can do. We can also determine if you are a good candidate for laser before you commit to any treatment.
Does my hair need to be "grown out" before my treatment?
No. We actually recommend that you shave the area to be treated. Waxing, bleaching, tweezing, or any other method that removes the root of the hair must be discontinued at least two weeks prior to treatment. Since the laser targets the root of the hair, it must be present for the treatment to be effective.
What areas of the face or body cannot be treated with laser?
None. All areas of the face or body can be treated with the GentleLASE or GentleYAG Laser.
Is laser hair removal painful?
While everyone's pain tolerance is different, the majority of clients do not think it is painful. Clients find laser hair removal with our laser much more tolerable than waxing. Our laser is equipped with a DCD (Dynamic Cooling Device) that makes the treatment both comfortable and safer to the skin than other lasers.
Will I have to use any topical numbing preparations before my treatment?
Absolutely not. We do not, nor have we ever prescribed, dispensed, or recommended any topical numbing preparations (prescription or non-prescription) prior to laser hair removal. The DCD (Dynamic Cooling Device) our laser is equipped with eliminates the need for any topical numbing preparations. Before every laser pulse, a cryogen (cooling agent) is automatically sprayed onto the skin within the laser field that protects and partially numbs that area. This makes the treatment safer and more comfortable.
What are the risks involved with laser hair removal?
Laser hair removal is a 'lunch time' procedure. There is no recovery or down time. Patients can return to their normal activities immediately. These lasers do not injure the dermis so the risks are extremely low. As with any procedure, you will be given an informed consent to read over that explains all the possible risks.
Do you sell packages, and is laser hair removal affordable?
We don't sell packages - we never insist on payment of multiple treatments up front. Every patient differs in the way that their hair responds to the treatment. Any given area typically requires an average of five treatments but this can vary from person to person. This is why we price per treatment. We are confident in the way our laser performs and there is no reason to require clients to pay up front before seeing the results of a treatment.
Is there a board-certified physician on-site?
Yes. We are a fully-integrated medical spa and plastic surgery office. Blue Water Spa is owned and operated by Dr. Michael Law who is a board-certified plastic surgeon and his wife, Kile Law, who has over 10 years experience in training doctors and other aesthetic professionals on laser hair removal. Our office is a national training center for laser hair removal and other medical spa services. Physicians, laser technicians and other aesthetic professionals come to us for training.
LASER HAIR REMOVAL
For many women and men, unwanted hair is a nuisance....or even a source of embarrassment. Until recently, laser hair removal has been uncomfortable, time-consuming, expensive and provided results that were inconsistent at best.
Advances in laser technology have resulted in far better results, and treatments that are safer, faster and more comfortable than ever before. Laser hair removal works on just about any area of the body where smooth skin is desired... underarms, face, neck, back, legs, shoulders, bikini line, you name it.
Not all lasers, or all laser centers, provide the same level of treatments.
Here are a number of advantages of laser hair removal
with Blue Water Spa & Michael Law MD Aesthetic Plastic Surgery:
EXPERIENCE:
We have provided training for physicians on laser hair removal since 1995 and we are a national training center for laser hair removal and medical spa technology.
EFFECTIVENESS:
The lasers we use have been evaluated as the most effective in peer-reviewed medical journals. These sophisticated lasers target the root of the hair so specifically that they not only eliminate very dark and coarse hair, but are also the most effective lasers for the removal of fine hair and even hair with a light brown root.
SPEED:
Full legs or a back can be treated in just 20 minutes. Our GentleLASE uses an 18mm spot size (about the size of a quarter). This larger spot size coupled with more hertz (power), means a faster and more effective treatment. A full back, for example, can be treated in less than 15 minutes and full legs in less than 20 minutes.
SAFETY:
We use a patented cooling device for that means a more comfortable treatment and eliminates the need for topical anesthetic.
AFFORDABILITY:
Our laser performs treatments quickly, therefore, we are able to charge less per treatment. We never insist on paying for packages up front, our clients pay per treatment. We feel confident about our laser and know that our clients will return for follow up treatments.
FREQUENTLY ASKED QUESTIONS
How does laser hair removal work?
The laser targets the darkness of the melanin pigment in the hair follicle. Since melanin is only produced in the growth phase of the hair, the laser must target the hair follicle during this cycle. At any given time, 20-40% of the hair in a particular area may be in a growth phase. Therefore, more than one treatment needs to be scheduled, preferably at 6-8 week intervals. With multiple treatments we can ensure that all hair follicles are being disabled.
Can all hair and skin colors be treated effectively with laser?
While laser hair removal can be performed on virtually any skin color, the color of the hair is the most important factor. The laser is attracted to the melanin (the dark pigment) in the hair follicle. Thus, darker hair is treated most effectively. If your hair has a blonde, red, or dark gray root, you may not be a good candidate for laser hair removal.
Do you offer free consultations?
Absolutely. We believe that a consultation is important for any client considering laser hair removal. We will perform a test spot so the client can see how the laser feels and we can answer any questions so the client can better understand what the laser can do. We can also determine if you are a good candidate for laser before you commit to any treatment.
Does my hair need to be "grown out" before my treatment?
No. We actually recommend that you shave the area to be treated. Waxing, bleaching, tweezing, or any other method that removes the root of the hair must be discontinued at least two weeks prior to treatment. Since the laser targets the root of the hair, it must be present for the treatment to be effective.
What areas of the face or body cannot be treated with laser?
None. All areas of the face or body can be treated with the GentleLASE or GentleYAG Laser.
Is laser hair removal painful?
While everyone's pain tolerance is different, the majority of clients do not think it is painful. Clients find laser hair removal with our laser much more tolerable than waxing. Our laser is equipped with a DCD (Dynamic Cooling Device) that makes the treatment both comfortable and safer to the skin than other lasers.
Will I have to use any topical numbing preparations before my treatment?
Absolutely not. We do not, nor have we ever prescribed, dispensed, or recommended any topical numbing preparations (prescription or non-prescription) prior to laser hair removal. The DCD (Dynamic Cooling Device) our laser is equipped with eliminates the need for any topical numbing preparations. Before every laser pulse, a cryogen (cooling agent) is automatically sprayed onto the skin within the laser field that protects and partially numbs that area. This makes the treatment safer and more comfortable.
What are the risks involved with laser hair removal?
Laser hair removal is a 'lunch time' procedure. There is no recovery or down time. Patients can return to their normal activities immediately. These lasers do not injure the dermis so the risks are extremely low. As with any procedure, you will be given an informed consent to read over that explains all the possible risks.
Do you sell packages, and is laser hair removal affordable?
We don't sell packages - we never insist on payment of multiple treatments up front. Every patient differs in the way that their hair responds to the treatment. Any given area typically requires an average of five treatments but this can vary from person to person. This is why we price per treatment. We are confident in the way our laser performs and there is no reason to require clients to pay up front before seeing the results of a treatment.
Is there a board-certified physician on-site?
Yes. We are a fully-integrated medical spa and plastic surgery office. Blue Water Spa is owned and operated by Dr. Michael Law who is a board-certified plastic surgeon and his wife, Kile Law, who has over 10 years experience in training doctors and other aesthetic professionals on laser hair removal. Our office is a national training center for laser hair removal and other medical spa services. Physicians, laser technicians and other aesthetic professionals come to us for training.
Breast Lift (Mastopexy)
Breast Lift (Mastopexy): restoring a youthful breast profile
An unavoidable consequence of aging is the loss of elasticity, or tone, in skin and soft tissues. This process, which may be compounded by changes which occur during and after pregnancy, will ultimately lead to 'drooping' of the breasts. A variety of surgical techniques can be used for restoring the breasts to a more youthful position and shape. The goal is to both relocate the nipples to a higher position, and to restore breast projection (and to maintain projection for the long term).
Having a breast lift operation involves making a decision to trade an improved breast shape and contour for some (well-placed and concealed) surgical scars on the breast. For the patient who is displeased that her nipples are downpointing, it may be a relatively easy decision. The surgical incisions are strategically placed to be as minimally noticeable as is possible. One component is around the areola, which is usually well concealed by the color difference between breast skin and areolar skin. The second component extends vertically from the '6 o'clock' position of the areola to the fold below the breast, and as the majority of this scar faces downward, it is usually quite acceptable.
Traditionally, breast lift or mastopexy surgery has involved a long, horizontal incision below the breast (in addition to the circumareolar and vertical scars), but a relatively new technique allows elimination of this incision completely.
The 'vertical scar' breast lift
For several years I have been using a 'vertical scar' technique for most breast reductions which eliminates the long, horizontal incision in the inframammary fold below the breasts. I have also adapted this technique for breast lift surgery, and have been extremely pleased with the results. As with breast reduction patients, this new technique not only eliminates the horizontal incision, but also creates more impressive breast projection and maintains it better over time. The procedure I perform not only removes breast skin but also moves some lower pole breast tissue to a higher position, increasing the projection of the nipple/areola area.
Breast lift surgery works well for patients with enough existing breast tissue to build a projecting 'breast mound'. However, in most patients it is difficult to create sustainable fullness in the upper poles of the breasts by means of a mastopexy alone. This is particularly true in patients who have experienced significant deflation following pregnancy and lactation. For patients who indicate that they wish to achieve a fair amount of fullness in the cleavage area as a result of their breast lift surgery, I recommend that they undergo augmentation mastopexy. This surgery combines a breast lift with the placement of an implant usually of modest size, which produces the most youthful breast profile possible.
An unavoidable consequence of aging is the loss of elasticity, or tone, in skin and soft tissues. This process, which may be compounded by changes which occur during and after pregnancy, will ultimately lead to 'drooping' of the breasts. A variety of surgical techniques can be used for restoring the breasts to a more youthful position and shape. The goal is to both relocate the nipples to a higher position, and to restore breast projection (and to maintain projection for the long term).
Having a breast lift operation involves making a decision to trade an improved breast shape and contour for some (well-placed and concealed) surgical scars on the breast. For the patient who is displeased that her nipples are downpointing, it may be a relatively easy decision. The surgical incisions are strategically placed to be as minimally noticeable as is possible. One component is around the areola, which is usually well concealed by the color difference between breast skin and areolar skin. The second component extends vertically from the '6 o'clock' position of the areola to the fold below the breast, and as the majority of this scar faces downward, it is usually quite acceptable.
Traditionally, breast lift or mastopexy surgery has involved a long, horizontal incision below the breast (in addition to the circumareolar and vertical scars), but a relatively new technique allows elimination of this incision completely.
The 'vertical scar' breast lift
For several years I have been using a 'vertical scar' technique for most breast reductions which eliminates the long, horizontal incision in the inframammary fold below the breasts. I have also adapted this technique for breast lift surgery, and have been extremely pleased with the results. As with breast reduction patients, this new technique not only eliminates the horizontal incision, but also creates more impressive breast projection and maintains it better over time. The procedure I perform not only removes breast skin but also moves some lower pole breast tissue to a higher position, increasing the projection of the nipple/areola area.
Breast lift surgery works well for patients with enough existing breast tissue to build a projecting 'breast mound'. However, in most patients it is difficult to create sustainable fullness in the upper poles of the breasts by means of a mastopexy alone. This is particularly true in patients who have experienced significant deflation following pregnancy and lactation. For patients who indicate that they wish to achieve a fair amount of fullness in the cleavage area as a result of their breast lift surgery, I recommend that they undergo augmentation mastopexy. This surgery combines a breast lift with the placement of an implant usually of modest size, which produces the most youthful breast profile possible.
Breast Reduction
Raleigh Plastic Surgeon Dr. Michael Law discusses:
Breast Reduction: enhancing breast aesthetics and patient comfort
For several years I have been using a 'vertical scar' technique for breast reduction surgery which eliminates the long, horizontal incision in the fold below the breast. The modern vertical mastopexy was initially developed by Belgian plastic surgeon Dr. Madeline Lejour (who adapted her procedure from the work of two pioneering French plastic surgeons), and that technique has since been modified by a number of plastic surgeons. I use a modification of Dr. Lejour's technique that was developed by a Canadian plastic surgeon, Dr. Elizabeth Hall-Findlay of Banff, Alberta. I have been using Dr. Hall-Findley's technique for some time now, and have been extremely pleased with the results.
Not only does this approach to breast reduction surgery eliminate the horizontal incision, but it also produces much more dramatic breast projection, and better maintains breast projection over time. One important limitation of older breast reduction techniques has been that many of them tend to flatten the breast, and over time they may become excessively full in the lower pole of the breast (the ''bottomed out" look). The vertical breast reduction, because it preserves breast tissue in the upper and medial quadrants of the breast, and because it employs internal suturing to form the breast mound back into an aesthetically ideal shape, tends to produce quite impressive breast projection which is durable over time.
There are some patients with very large breasts for whom the vertical reduction technique may leave a patient with excessive skin, and ultimately excessive fullness, in the lower poles of the breasts. In these patients, once the vertical reduction is complete, I may add a horizontal skin excision hidden in the inframammary folds. This additional skin excision usually does not need to be as long as the inframammary incision used in older 'inverted T' breast reductions, and it prevents the development of excessive lower pole fullness over time.
For most patients, this operation significantly enhances patient comfort as well as overall breast appearance. The weight of excessively large breasts puts significant strain on the neck, shoulders and upper back, and may produce deep grooves in the shoulders from the impingement of bra straps. Many patients experience relief from back and neck pain, headaches, and other unpleasant symptoms following breast reduction surgery. Most also report that they are able to increase their overall physical activity and to enhance their exercise regimens once the excessive size and weight of their breasts have been corrected.
For many women, excessive breast volume exists independent of their overall size and weight. Others experience significant variation in breast volume with weight gain and loss. It is important that a patient undergoing breast reduction surgery be at a healthy and stable weight in order to experience the greatest possible benefit from the procedure. If a patient's Body Mass Index or BMI (a ratio of weight and height) is excessively high (greater than 30), an attempt must be made to bring the BMI within a healthy range before undergoing breast reduction surgery. It is worth noting that a high BMI can be due to either excessive fatty tissue OR to excess lean body mass (muscle mass), so the BMI is always considered in light of whether it excess fat or muscle development that is causing the number to be high.
Breast Reduction: enhancing breast aesthetics and patient comfort
For several years I have been using a 'vertical scar' technique for breast reduction surgery which eliminates the long, horizontal incision in the fold below the breast. The modern vertical mastopexy was initially developed by Belgian plastic surgeon Dr. Madeline Lejour (who adapted her procedure from the work of two pioneering French plastic surgeons), and that technique has since been modified by a number of plastic surgeons. I use a modification of Dr. Lejour's technique that was developed by a Canadian plastic surgeon, Dr. Elizabeth Hall-Findlay of Banff, Alberta. I have been using Dr. Hall-Findley's technique for some time now, and have been extremely pleased with the results.
Not only does this approach to breast reduction surgery eliminate the horizontal incision, but it also produces much more dramatic breast projection, and better maintains breast projection over time. One important limitation of older breast reduction techniques has been that many of them tend to flatten the breast, and over time they may become excessively full in the lower pole of the breast (the ''bottomed out" look). The vertical breast reduction, because it preserves breast tissue in the upper and medial quadrants of the breast, and because it employs internal suturing to form the breast mound back into an aesthetically ideal shape, tends to produce quite impressive breast projection which is durable over time.
There are some patients with very large breasts for whom the vertical reduction technique may leave a patient with excessive skin, and ultimately excessive fullness, in the lower poles of the breasts. In these patients, once the vertical reduction is complete, I may add a horizontal skin excision hidden in the inframammary folds. This additional skin excision usually does not need to be as long as the inframammary incision used in older 'inverted T' breast reductions, and it prevents the development of excessive lower pole fullness over time.
For most patients, this operation significantly enhances patient comfort as well as overall breast appearance. The weight of excessively large breasts puts significant strain on the neck, shoulders and upper back, and may produce deep grooves in the shoulders from the impingement of bra straps. Many patients experience relief from back and neck pain, headaches, and other unpleasant symptoms following breast reduction surgery. Most also report that they are able to increase their overall physical activity and to enhance their exercise regimens once the excessive size and weight of their breasts have been corrected.
For many women, excessive breast volume exists independent of their overall size and weight. Others experience significant variation in breast volume with weight gain and loss. It is important that a patient undergoing breast reduction surgery be at a healthy and stable weight in order to experience the greatest possible benefit from the procedure. If a patient's Body Mass Index or BMI (a ratio of weight and height) is excessively high (greater than 30), an attempt must be made to bring the BMI within a healthy range before undergoing breast reduction surgery. It is worth noting that a high BMI can be due to either excessive fatty tissue OR to excess lean body mass (muscle mass), so the BMI is always considered in light of whether it excess fat or muscle development that is causing the number to be high.
Liposuction
Raleigh Plastic Surgeon Dr. Michael Law discusses:
Liposuction: bringing out the best in every body
Liposuction is a body contouring surgery that requires not only an artist's eye, but also the insight to determine which patients are likely to benefit from the procedure, and which specific areas of a patient's body are appropriate for liposuction. When artfully and appropriately applied, liposuction can produce dramatic contour improvements. As with all plastic surgery, the goal should be to produce a natural contour.
Some liposuction patients that I treat seek a 'total body makeover', and undergo circumferential liposuction of the trunk, thighs and lower legs. The soft tissue contraction and resulting contour enhancement that is achieved by circumferential liposuction of a given area can be truly amazing. At the same time, I am increasingly seeing patients who come in for what I refer to as 'finesse' or 'refinement' liposuction, where very fit individuals seek refinement of specific areas that they feel are resistant to further improvement with diet and exercise.
To achieve ideal results, the skin tone overlying the area to be suctioned must have adequate tone in order to 'snap back' and redrape in a manner that is aesthetically pleasing. Areas with significant skin excess or redundancy generally require some manner of skin excision in addition to the reduction in the volume of subcutaneous fat by means of liposuction.
It is important to understand that liposuction is not designed to be a weight loss surgery, but rather a body contouring procedure. Patients undergoing liposuction ideally need to be at or near their goal for their long-term weight, and their weight needs to have been stable for several months.
Aren't there different kinds of liposuction?
Liposuction is traditionally performed using vacuum suction. Recently, new technologies have become available in an attempt to improve the efficiency of fat removal. The liposuction technology that I have been using for the past several years is called 'power-assisted' liposuction (MicroAire Corporation). This device consists of an electric handpeice that pistons the tip of the attached liposuction cannula (the hollow tube that extracts fat) a few millimeters, several thousand times per minute, which greatly enhances the efficiency of fat removal.
One great advantage of power-assisted liposuction is that much less physical effort is required on the part of the surgeon to complete the surgery. While a conventional liposuction apparatus requires a firm grip and forceful arm motion to accomplish fat removal, the power-assisted liposuction device allows one to pass the cannula with great ease. Liposuction surgery using this technology becomes a finesse operation instead of a 'workout', and more energy may be spent on artistic sculpting instead of on just getting the surgery done.
'Ultrasonic' liposuction first appeared in the 1990s, and after gaining some popularity, gradually faded in prominence. It is a technology in which ultrasonic energy is emitted at the tip of the liposuction apparatus to emulsify (liquefy) fat and thereby enhance its removal. A consequence of ultrasonic energy emission is the local heating of tissues, which can lead to burns and other complications if a number of precautions are not carefully followed. This has led some plastic surgeons to not adopt or to abandon ultrasonic liposuction.
In my experience, ultrasonic liposuction does not allow me to produce results that are superior to that which I obtain with power-assisted liposuction. Given the complications that can be associated with the use of ultrasonic energy, I no longer use ultrasonic technology. While I formerly found an ultrasonic device to be of use in fibrous areas that have greater resistance to the passage of a liposuction cannula, such as the back and the buttocks, I now rely on the power-assist device to obtain beautiful results in these more 'stubborn' areas.
Is 'tumescent' liposuction better?
Well, yes, but tumescent technique is used for almost all liposuction, and has been for a quite some time. 'Tumescent technique' essentially means that a saline solution containing epinephrine (and usually a local anesthetic such as lidocaine) is injected into the areas to be suctioned, so that the blood vessels in the fat constrict prior to the passage of the liposuction cannula. The vasoconstriction produced by the epinephrine solution minimizes bleeding during fat removal, and liposuction of a large volume of fat can be performed without significant blood loss.
Occasionally I see advertisements for 'tumescent liposuction', which always seems rather odd. Advertising that one performs 'tumescent liposuction' (as opposed to some other, unnamed kind of liposuction, I guess) is a little like bragging that you drive a car with wheels.
Choose your surgeon carefully
Liposuction, as you may have heard in the popular media, is the most commonly performed surgical procedure each year in the United States. Here's a statistic that you may not have heard: the majority of physicians performing liposuction in the United States are not plastic surgeons; in fact, many do not have any formal surgical training whatsoever. It seems hard to believe, but many physicians performing liposuction have had no more training in liposuction than a 'weekend course'. One way to determine whether or not a physician has had appropriate training in a particular surgery is to confirm that they have hospital privileges for that procedure.
I fear that some practitioners view liposuction as a 'simple' surgery, since it does not involve making large incisions, and it requires little, if any, suturing. Nothing could be further form the truth. Liposuction, in my mind, is a very challenging operation that requires careful planning and preparation, and a great deal of care and finesse when it is actually performed. It requires a three-dimensional understanding of the layers of human anatomy, an understanding that is second nature to a surgeon alone. I think that it is often an inadequate understanding of anatomy (and, perhaps, of the body's response to surgery) which leads to the poor results in liposuction that unfortunately are so often seen.
Great Links
Blue Water Spa
Blue Water Spa is a plastic surgery medical spa and laser center. Three different aesthetic lasers and two light sources are available for the most effective treatments and skin rejuvenation.
Michael Law, M.D., Aesthetic Plastic Surgery
Dr. Michael Law is a Board-certified plastic surgeon in Raleigh, NC. Information about thefull range aesthetic plastic surgery procedures of the face and body.
New Beauty Magazine
See what a leading aesthetics magazine has to say about Dr. Law.
Liposuction: bringing out the best in every body
Liposuction is a body contouring surgery that requires not only an artist's eye, but also the insight to determine which patients are likely to benefit from the procedure, and which specific areas of a patient's body are appropriate for liposuction. When artfully and appropriately applied, liposuction can produce dramatic contour improvements. As with all plastic surgery, the goal should be to produce a natural contour.
Some liposuction patients that I treat seek a 'total body makeover', and undergo circumferential liposuction of the trunk, thighs and lower legs. The soft tissue contraction and resulting contour enhancement that is achieved by circumferential liposuction of a given area can be truly amazing. At the same time, I am increasingly seeing patients who come in for what I refer to as 'finesse' or 'refinement' liposuction, where very fit individuals seek refinement of specific areas that they feel are resistant to further improvement with diet and exercise.
To achieve ideal results, the skin tone overlying the area to be suctioned must have adequate tone in order to 'snap back' and redrape in a manner that is aesthetically pleasing. Areas with significant skin excess or redundancy generally require some manner of skin excision in addition to the reduction in the volume of subcutaneous fat by means of liposuction.
It is important to understand that liposuction is not designed to be a weight loss surgery, but rather a body contouring procedure. Patients undergoing liposuction ideally need to be at or near their goal for their long-term weight, and their weight needs to have been stable for several months.
Aren't there different kinds of liposuction?
Liposuction is traditionally performed using vacuum suction. Recently, new technologies have become available in an attempt to improve the efficiency of fat removal. The liposuction technology that I have been using for the past several years is called 'power-assisted' liposuction (MicroAire Corporation). This device consists of an electric handpeice that pistons the tip of the attached liposuction cannula (the hollow tube that extracts fat) a few millimeters, several thousand times per minute, which greatly enhances the efficiency of fat removal.
One great advantage of power-assisted liposuction is that much less physical effort is required on the part of the surgeon to complete the surgery. While a conventional liposuction apparatus requires a firm grip and forceful arm motion to accomplish fat removal, the power-assisted liposuction device allows one to pass the cannula with great ease. Liposuction surgery using this technology becomes a finesse operation instead of a 'workout', and more energy may be spent on artistic sculpting instead of on just getting the surgery done.
'Ultrasonic' liposuction first appeared in the 1990s, and after gaining some popularity, gradually faded in prominence. It is a technology in which ultrasonic energy is emitted at the tip of the liposuction apparatus to emulsify (liquefy) fat and thereby enhance its removal. A consequence of ultrasonic energy emission is the local heating of tissues, which can lead to burns and other complications if a number of precautions are not carefully followed. This has led some plastic surgeons to not adopt or to abandon ultrasonic liposuction.
In my experience, ultrasonic liposuction does not allow me to produce results that are superior to that which I obtain with power-assisted liposuction. Given the complications that can be associated with the use of ultrasonic energy, I no longer use ultrasonic technology. While I formerly found an ultrasonic device to be of use in fibrous areas that have greater resistance to the passage of a liposuction cannula, such as the back and the buttocks, I now rely on the power-assist device to obtain beautiful results in these more 'stubborn' areas.
Is 'tumescent' liposuction better?
Well, yes, but tumescent technique is used for almost all liposuction, and has been for a quite some time. 'Tumescent technique' essentially means that a saline solution containing epinephrine (and usually a local anesthetic such as lidocaine) is injected into the areas to be suctioned, so that the blood vessels in the fat constrict prior to the passage of the liposuction cannula. The vasoconstriction produced by the epinephrine solution minimizes bleeding during fat removal, and liposuction of a large volume of fat can be performed without significant blood loss.
Occasionally I see advertisements for 'tumescent liposuction', which always seems rather odd. Advertising that one performs 'tumescent liposuction' (as opposed to some other, unnamed kind of liposuction, I guess) is a little like bragging that you drive a car with wheels.
Choose your surgeon carefully
Liposuction, as you may have heard in the popular media, is the most commonly performed surgical procedure each year in the United States. Here's a statistic that you may not have heard: the majority of physicians performing liposuction in the United States are not plastic surgeons; in fact, many do not have any formal surgical training whatsoever. It seems hard to believe, but many physicians performing liposuction have had no more training in liposuction than a 'weekend course'. One way to determine whether or not a physician has had appropriate training in a particular surgery is to confirm that they have hospital privileges for that procedure.
I fear that some practitioners view liposuction as a 'simple' surgery, since it does not involve making large incisions, and it requires little, if any, suturing. Nothing could be further form the truth. Liposuction, in my mind, is a very challenging operation that requires careful planning and preparation, and a great deal of care and finesse when it is actually performed. It requires a three-dimensional understanding of the layers of human anatomy, an understanding that is second nature to a surgeon alone. I think that it is often an inadequate understanding of anatomy (and, perhaps, of the body's response to surgery) which leads to the poor results in liposuction that unfortunately are so often seen.
Great Links
Blue Water Spa
Blue Water Spa is a plastic surgery medical spa and laser center. Three different aesthetic lasers and two light sources are available for the most effective treatments and skin rejuvenation.
Michael Law, M.D., Aesthetic Plastic Surgery
Dr. Michael Law is a Board-certified plastic surgeon in Raleigh, NC. Information about thefull range aesthetic plastic surgery procedures of the face and body.
New Beauty Magazine
See what a leading aesthetics magazine has to say about Dr. Law.
Breast Augmentation
Breast Augmentation: seeking natural-appearing results
Having practiced plastic surgery in the 'breast augmentation capital of the world' (Los Angeles), I have developed some fairly strong opinions about this operation. In thinking about breast augmentation surgery, I believe that the most important question for a prospective patient to ask themselves is this: Am I seeking a natural-appearing result? When the goal of this operation is a natural breast enhancement, the results can be absolutely beautiful.
However, if the goal is to create a breast profile which is out of proportion to a woman's body, the results (by definition) never appear natural, and these patients not infrequently end up having a series of operations to address problems with their abnormal appearance. For that reason, I encourage women who are investigating breast augmentation to consider an implant size that will help them 'fill out clothes better' and improve the overall proportions of their body, not one that makes them look like "the gal with the boob job".
Quite a number of my breast augmentation patients are moms. After one or more pregnancies, most women experience a loss of breast volume combined with some 'stretching out' of the breast skin. In many of these patients, an implant of moderate size will restore a very pleasing breast contour. These patients are NOT looking to raise eyebrows at work or around the neighborhood - they just want to throw their padded bras away, and to feel better about their appearance in private.
When there is laxity of the breast skin that makes the breasts appear somewhat droopy, the addition of an implant of moderate size can 'fill up' the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or 'mastopexy'). This is often a situation that exists after pregnancy and lactation, but I also see quite a number of patients with significant breast skin laxity who have never been pregnant. In patients with more advanced drooping of the breasts, particularly when the nipples are pointing downwards instead of slightly upwards, a mastopexy (breast lift) needs to be combined with the augmentation surgery to tighten the skin envelope of the breasts, in order to produce a result that is truly youthful and aesthetically ideal. This procedure is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming. It is discussed in greater detail as the next topic under the heading 'Body Contouring Surgery'.
Attention to detail
While the issue of 'over' or 'under' the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall. In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.
In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear 'bottomed out', with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast - another situation with a distinctly unnatural appearance.
The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Excessive lateral dissection of the implant pockets will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal 'side by side' appearance. As it is lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an 'hourglass figure', careful attention must be paid to ensure that lateral breast projection is not inadequate.
Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient that is 5'3" will be inadequate for a large-framed patient that is 5'10". Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.
Choosing the implant size
In consultations I listen carefully to each patient to ensure that I clearly understand their goals for breast augmentation surgery. Based on that discussion, and on the physical examination, I go into surgery knowing what the ideal volume should be within two or three implant sizes. However, the patient and I do not decide on one particular size prior to surgery. There is absolutely no way, in my opinion, to know exactly what size implant is the ideal size for a particular patient in advance of creating the implant pockets in the operating room. For that reason I keep a wide range of implant sizes on hand in the surgery center.
If natural is the goal, then the way to get the size right is to 'try out' different implant volumes in the operating room. Once the implant pockets have been created, I place a 'sizer' in one implant pocket and have the upper half of the O.R. table raised so that the patient is in an upright 'sitting' position (chest fully upright). The sizer is then inflated gradually to the point that the breasts appear full, but not unnaturally so. In this manner the exact volume that produces a full but natural breast profile is determined.
For any patient there is obviously a range of implant volumes that would be considered natural. While one patient may seek an augmentation that is 'the small side of natural', another may be interested in something that is more on 'the large side of natural'. By using implant sizers to determine exactly what breast profile a given implant volume produces in the O.R., I am able to provide patients with the closest possible approximation of their preoperative goals.
Incisions and implant position relative to the pectoralis major
Breast implants can be placed through different incisions and in different positions relative to the pectoralis major muscle. No two patients are alike, so it is important to individualize the surgical plan for each patient's own needs. The most commonly used incisions are peri-areolar (from about the 4 to 8 o'clock position along the areolar border), infra-mammary (in the fold below the breast) and axillary (underarm area).
An advantage of the peri-areolar incision is that the color difference between areolar skin and the adjacent breast skin conceals the resulting scar very nicely. In many patients the scar is almost undetectable after only a few weeks. The infra-mammary scar works very nicely for patients who do not have a marked color difference between areolar skin and breast skin, and who have adequate fullness in the lower pole of the breasts. As full breasts conceal the infra-mammary fold very well, the scar is never visible when standing or sitting upright. The axillary or underarm area incision is primarily used for sub-pectoral ('under the muscle') implant placement, particularly in patients with small areolae (where the peri-areolar incision is not ideal) and smaller breasts (where the inframammary fold is not concealed).
The decision to place breast implants 'on top of' or 'under' the muscle is individualized to the specific needs of each patient. I think that the term "under the muscle" is a bit misleading for the following reason: when implants are placed below the pectoralis major muscle only about half of the implant surface is actually beneath the muscle - the medial/upper half - while the lateral/inferior half is immediately below the breast. Sub-pectoral placement is advantageous in patients who are slender and very small-breasted preoperatively, as the pectoralis muscle helps to conceal the implant in the most important place aesthetically: the cleavage area. In other patients, sub-muscular placement affords no significant advantage, and sub-mammary (on top of the pectoralis major muscle) placement is preferable.
Again, the decisions regarding the surgical incision and the placement of implants relative to the pectoralis major muscle are completely individualized, as no single approach is the best approach for every patient. The decisions are based upon physical examination at the time of the physician consultation, and on discussion with each patient of the 'pros and cons' of each alternative.
Saline or Silicone Gel?
Since 1992 there has been an FDA moratorium on the use of silicone gel implants for primary aesthetic breast augmentation. While there is no unequivocal, scientific evidence that silicone gel implants produce the systemic illnesses that have been the subject of a great deal of litigation, the moratorium remains in place. Patients undergoing breast reconstruction (after mastectomy, following injury or for congenital problems) may receive silicone gel implants, and silicone gel implants are currently available for aesthetic breast augmentation in a few practices as part of scientific studies.
Does any of this affect my practice? Not in the least, and here's why: saline implants of a moderate (and in my opinion, appropriate) volume look and feel natural. The implant sizes I most commonly use blend in nicely with existing breast tissue, and patient satisfaction is high. In the ten years I have been using saline implants I have yet to have a patient with saline breast implants return to say "I'm not happy with these…take them out and put silicone gel implants in their place."
Great Links
Blue Water Spa
Blue Water Spa is a plastic surgery medical spa and laser center. Three different aesthetic lasers and two light sources are available for the most effective treatments and skin rejuvenation.
Michael Law MD Aesthetic Plastic Surgery
Dr. Michael Law is a Board-certified plastic surgeon in Raleigh, NC. Information about thefull range aesthetic plastic surgery procedures of the face and body.
New Beauty Magazine
See what a leading aesthetics magazine has to say about Dr. Law.
ADDRESS:
10941 Raven Ridge Rd, Raleigh, NC 27614, USA
Having practiced plastic surgery in the 'breast augmentation capital of the world' (Los Angeles), I have developed some fairly strong opinions about this operation. In thinking about breast augmentation surgery, I believe that the most important question for a prospective patient to ask themselves is this: Am I seeking a natural-appearing result? When the goal of this operation is a natural breast enhancement, the results can be absolutely beautiful.
However, if the goal is to create a breast profile which is out of proportion to a woman's body, the results (by definition) never appear natural, and these patients not infrequently end up having a series of operations to address problems with their abnormal appearance. For that reason, I encourage women who are investigating breast augmentation to consider an implant size that will help them 'fill out clothes better' and improve the overall proportions of their body, not one that makes them look like "the gal with the boob job".
Quite a number of my breast augmentation patients are moms. After one or more pregnancies, most women experience a loss of breast volume combined with some 'stretching out' of the breast skin. In many of these patients, an implant of moderate size will restore a very pleasing breast contour. These patients are NOT looking to raise eyebrows at work or around the neighborhood - they just want to throw their padded bras away, and to feel better about their appearance in private.
When there is laxity of the breast skin that makes the breasts appear somewhat droopy, the addition of an implant of moderate size can 'fill up' the excess skin and create the appearance of a breast lift (although this is not truly a breast lift or 'mastopexy'). This is often a situation that exists after pregnancy and lactation, but I also see quite a number of patients with significant breast skin laxity who have never been pregnant. In patients with more advanced drooping of the breasts, particularly when the nipples are pointing downwards instead of slightly upwards, a mastopexy (breast lift) needs to be combined with the augmentation surgery to tighten the skin envelope of the breasts, in order to produce a result that is truly youthful and aesthetically ideal. This procedure is called an augmentation mastopexy, and the results of this operation can be dramatic and absolutely transforming. It is discussed in greater detail as the next topic under the heading 'Body Contouring Surgery'.
Attention to detail
While the issue of 'over' or 'under' the pectoralis major muscle receives a great deal of attention, even more important than implant position relative to this muscle is implant position vertically and horizontally on the chest wall. In many patients, the inframammary fold needs to be lowered in order to allow the implant to rest at a level that appears natural relative to the position of the nipple and areola, and in order to prevent the appearance of excessive upper pole fullness.
In profile, the natural-appearing breast is not convex in the upper pole, and an excessively convex and overly full upper pole is a dead giveaway that an implant sits below the skin. Likewise, if the inframammary fold is lowered too far, the augmented breast will appear 'bottomed out', with an excessively full lower pole, an empty upper pole, and a nipple/areola that appears to sit too high on the breast - another situation with a distinctly unnatural appearance.
The horizontal position of breast implants also requires a great deal of attention, both in pre-operative planning and in the operating room. Excessive lateral dissection of the implant pockets will result in augmented breasts with an excessively wide space between them in the cleavage area, and the appearance that the breasts are abnormally far apart. Inadequate lateral dissection, on the other hand, will result in an augmentation with an abnormal 'side by side' appearance. As it is lateral projection of the breasts beyond the lateral limit of the chest wall (in frontal view) that, along with the concavity of the waist profile and the convexity of the hip profile, produces the appearance of an 'hourglass figure', careful attention must be paid to ensure that lateral breast projection is not inadequate.
Another consideration is that the implant base diameter must match the existing anatomic limits of the breast preoperatively and the breadth of the anterior chest in general. Obviously, a given implant volume and diameter that works well for a small-framed patient that is 5'3" will be inadequate for a large-framed patient that is 5'10". Careful evaluation of all of these issues is necessary if the ultimate goal of the surgery is a natural-appearing breast enhancement.
Choosing the implant size
In consultations I listen carefully to each patient to ensure that I clearly understand their goals for breast augmentation surgery. Based on that discussion, and on the physical examination, I go into surgery knowing what the ideal volume should be within two or three implant sizes. However, the patient and I do not decide on one particular size prior to surgery. There is absolutely no way, in my opinion, to know exactly what size implant is the ideal size for a particular patient in advance of creating the implant pockets in the operating room. For that reason I keep a wide range of implant sizes on hand in the surgery center.
If natural is the goal, then the way to get the size right is to 'try out' different implant volumes in the operating room. Once the implant pockets have been created, I place a 'sizer' in one implant pocket and have the upper half of the O.R. table raised so that the patient is in an upright 'sitting' position (chest fully upright). The sizer is then inflated gradually to the point that the breasts appear full, but not unnaturally so. In this manner the exact volume that produces a full but natural breast profile is determined.
For any patient there is obviously a range of implant volumes that would be considered natural. While one patient may seek an augmentation that is 'the small side of natural', another may be interested in something that is more on 'the large side of natural'. By using implant sizers to determine exactly what breast profile a given implant volume produces in the O.R., I am able to provide patients with the closest possible approximation of their preoperative goals.
Incisions and implant position relative to the pectoralis major
Breast implants can be placed through different incisions and in different positions relative to the pectoralis major muscle. No two patients are alike, so it is important to individualize the surgical plan for each patient's own needs. The most commonly used incisions are peri-areolar (from about the 4 to 8 o'clock position along the areolar border), infra-mammary (in the fold below the breast) and axillary (underarm area).
An advantage of the peri-areolar incision is that the color difference between areolar skin and the adjacent breast skin conceals the resulting scar very nicely. In many patients the scar is almost undetectable after only a few weeks. The infra-mammary scar works very nicely for patients who do not have a marked color difference between areolar skin and breast skin, and who have adequate fullness in the lower pole of the breasts. As full breasts conceal the infra-mammary fold very well, the scar is never visible when standing or sitting upright. The axillary or underarm area incision is primarily used for sub-pectoral ('under the muscle') implant placement, particularly in patients with small areolae (where the peri-areolar incision is not ideal) and smaller breasts (where the inframammary fold is not concealed).
The decision to place breast implants 'on top of' or 'under' the muscle is individualized to the specific needs of each patient. I think that the term "under the muscle" is a bit misleading for the following reason: when implants are placed below the pectoralis major muscle only about half of the implant surface is actually beneath the muscle - the medial/upper half - while the lateral/inferior half is immediately below the breast. Sub-pectoral placement is advantageous in patients who are slender and very small-breasted preoperatively, as the pectoralis muscle helps to conceal the implant in the most important place aesthetically: the cleavage area. In other patients, sub-muscular placement affords no significant advantage, and sub-mammary (on top of the pectoralis major muscle) placement is preferable.
Again, the decisions regarding the surgical incision and the placement of implants relative to the pectoralis major muscle are completely individualized, as no single approach is the best approach for every patient. The decisions are based upon physical examination at the time of the physician consultation, and on discussion with each patient of the 'pros and cons' of each alternative.
Saline or Silicone Gel?
Since 1992 there has been an FDA moratorium on the use of silicone gel implants for primary aesthetic breast augmentation. While there is no unequivocal, scientific evidence that silicone gel implants produce the systemic illnesses that have been the subject of a great deal of litigation, the moratorium remains in place. Patients undergoing breast reconstruction (after mastectomy, following injury or for congenital problems) may receive silicone gel implants, and silicone gel implants are currently available for aesthetic breast augmentation in a few practices as part of scientific studies.
Does any of this affect my practice? Not in the least, and here's why: saline implants of a moderate (and in my opinion, appropriate) volume look and feel natural. The implant sizes I most commonly use blend in nicely with existing breast tissue, and patient satisfaction is high. In the ten years I have been using saline implants I have yet to have a patient with saline breast implants return to say "I'm not happy with these…take them out and put silicone gel implants in their place."
Great Links
Blue Water Spa
Blue Water Spa is a plastic surgery medical spa and laser center. Three different aesthetic lasers and two light sources are available for the most effective treatments and skin rejuvenation.
Michael Law MD Aesthetic Plastic Surgery
Dr. Michael Law is a Board-certified plastic surgeon in Raleigh, NC. Information about thefull range aesthetic plastic surgery procedures of the face and body.
New Beauty Magazine
See what a leading aesthetics magazine has to say about Dr. Law.
ADDRESS:
10941 Raven Ridge Rd, Raleigh, NC 27614, USA
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