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COSMETIC SURGERY TIMES
4
Fat transfer
for breast augmentation
Physicians discuss how far lipoaugmentation of the breasts has come
— and where it may be headed
Dr. Malan
“This is truly an exciting time for
fat transfer breast augmentation. What began as a controversial (and at one point banned)
procedure in the mid 1980s has
re-emerged today as a minimally
invasive cosmetic surgery procedure.
“Many people don’t realize that micro-deposition
fat transfer (where fat is harvested via liposuction) came to the United States in the mid 1980s,
at the same time traditional liposuction did.
Unfortunately, the equipment used in those early
days damaged fat tissue as it was harvested. We
didn’t understand that the fat cells needed to be
injected in microdroplets to survive the transfer.
Survival of the fat cells was very poor, and many
industry professionals feared the resulting scar
tissue and calcification would make it difficult for
mammograms to accurately detect breast cancer.
As a result, fat transfer to the breast was abandoned in the U.S. in 1987.
“Efforts were continued in Europe and Asia
to improve upon the technology, and in 2007
Japanese doctors released a study on a new
technique in fat transfer to the breast that met
with very good success. These doctors had
begun to utilize stem cell-enriched fat. The
stem cells, found in abundance within the
harvested fat, were isolated from a portion of
the fat tissue, activated and re-concentrated
with the remaining fat tissue and then injected.
The stem cells then went to work creating new
blood vessels that would supply oxygen to the
grafted fat, ensuring long-term survival.
“A handful of doctors in the U.S. looked at the
Japanese study, as well as techniques being used
in Germany and Brazil, and developed a technique that employed the best aspects of these
procedures. We discovered the key to successful
fat transfer lies in removing the fat with minimal
damage and injecting it into the breast in microdroplets. This new technique achieves both a
high fat-survival rate and zero interference with
mammograms.
“Are we there yet? As I see it, we are very close
to perfection. While we’re having phenomenal
success with our current protocol for fat-transfer
GETTY IMAGES: PETER TELLER
Todd K. Malan, M.D.
Innovative Cosmetic Surgery Center
Scottsdale, Ariz.
6
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COSMETIC SURGERY TIMES
6
Exchange continued
breast augmentation, we do have a few challenges to overcome.
“First, there is continued room for improvement with the procedure itself. We’re now at
a point where we see a consistent 80 to 90
percent fat-survival rate, as opposed to less
than 50 percent three decades ago. We are
continually striving to find better methods to
remove fat without damaging it, and we have
not yet determined the ideal location in the
breast to inject the cell-enriched fat. Should it
be injected in the superficial fat layer, beneath
the gland or in the muscle? We are working to
answer these questions.
removal of fat from a problematic area and costs
around $6,000 to $8,000.
“
Current studies are actually
working on the harvesting
of stem cells, combining
them with growth factors
in a petri dish and then
transplanting them back
into the breast region for
breast reconstruction.
Michael S. Kluska, D.O., F.A.A.C.S., F.A.C.O.S.
Greensburg, Pa.
“Second, a number of physicians are now
offering stem cell-enriched fat-transfer procedures without truly understanding the techniques and equipment that ensure the best
possible results. Only Cytori Therapeutics has
created a tested, proven automated device to
process and activate stem cells. Nothing else on
the market has been tested or documented in a
formal study.
“So, while great strides have been made in fattransfer breast augmentation, the field as a whole
risks a negative backlash unless physicians
educate themselves on best practices.”
Michael S. Kluska, D.O., F.A.A.C.S., F.A.C.O.S.
Cosmetic Contours
Greensburg, Pa.
“Cosmetic breast surgery comes
in all shapes and sizes ranging
from smooth, round, saline
implants to textured, anatomically shaped cohesive gel
implants. Recently, a new trend
has evolved for the female to
Dr. Kluska
enhance her breast with the use
of her own fat. Although no real scientific data
exists in the United States as of yet, some studies
in other countries, including Japan, are showing
promise.
“Fat transfer involves the harvesting of one’s
own fat cells from one site of the body and
transferring or transplanting them to another
site in the body. The concept is quite simple:
Find areas of fat on the body that have high
concentrations of stem cells and then transplant
these cells to the recipient site. It has been
suggested that the best area to find these cells
is any area on the body that stores fat posterior
to the midaxillary line. The procedure takes oneand-a-half to two hours, many times results in
”
Some theorize that this technique may become
quite reproducible and may be available as
early as 2015. If this were to become reality, this
technique may become available to the cosmetic
patient as well.
“Autologous fat transfer has been around for
years and has recently gained momentum for
the augmentation of female breasts for cosmetic
purposes. Although autologous breast augmentation using one’s own fat is a new, potentially
exciting option, more research is needed so
that both the consumer and the surgeon are
completely informed of the potential risks and
results.”
Daniel Del Vecchio, M.D.
Back Bay Plastic Surgery
Boston
“Fat transfer in the average surgeon’s hands
usually results in a 20 to 70 percent take, and
many times requires more than one treatment.
What this means is that the fat that doesn’t take
results in conversion to dead cells (fat essentially
turns to oil) and is absorbed by the body.
“To answer, ‘Are we there yet?’
with regards to fat transfer for
breast augmentation, you need
to define what you mean by
‘there.’
Dr. Vecchio
“With that said, the ideal candidate for this
procedure is a patient who has realistic expectations and is looking for only moderate enlargement, less than a cup size. The wide range of
take can often result in both an unhappy patient
and unhappy surgeon. In addition to less-thansatisfactory results, there is some concern that
the transferred stem cells could result in the
stimulation of an undetected malignant breast
cancer, or the process could result in scarring
and calcifications that mimic breast cancer on
mammography.
“Over the past five years, we
have demonstrated fat grafted
into the breast can result in persistent volume
maintenance at six months, a year, three years,
five years postgrafting, and that the volume
after six months is generally going to remain in
the long term; we have demonstrated that preexpansion, when applied externally to the breast,
can result in an augmentation of 250 cc on
average, or a doubling of original breast volume;
we have developed instrumentation and operative techniques that can allow the safe performance of this procedure in two hours or less; and
“
Although there does not appear to be any short-term
increase in breast cancer incidence among patients
receiving fat transfer to the breasts, this cohort of patients
will need to be followed over a lifetime before anyone
can definitively say that the risk of breast cancer in this
group of patients is any different than one in eight, as
currently quoted by the National Cancer Institute.
Daniel Del Vecchio, M.D.
Boston
“There is current research going on right now
for the use of a similar technique which could be
used for breast reconstruction following partial or
complete mastectomy for breast cancer. Current
studies are actually working on the harvesting of
stem cells, combining them with growth factors
in a petri dish and then transplanting them back
into the breast region for breast reconstruction.
”
we have demonstrated radiologic evidence that
is not difficult to distinguish calcifications seen in
fat grafting versus micro-calcifications suggestive
of breast malignancy.
“In fact, we have seen evidence that more
calcifications are seen in mammograms after
breast reduction than after fat grafting, although
GETTY IMAGES: KEVIN JORDAN
no one seems to condemn the breast-reduction
procedure. So to clearly frame this debate, I would
say we are definitely ‘there’ in establishing that fat
grafting for breast augmentation is a technique
that has demonstrated efficacy and has demonstrated safety in terms of cancer surveillance and
reasonable intraoperative times.
“We are not ‘there’ yet in unequivocally demonstrating the long-term cancer risk for patients
undergoing fat grafting to the breast. Although
there does not appear to be any short-term
increase in breast cancer incidence among
patients receiving fat transfer to the breasts, this
cohort of patients will need to be followed over a
lifetime before anyone can definitively say that the
risk of breast cancer in this group of patients is any
different than one in eight, as currently quoted by
the National Cancer Institute. I would remind you
that this is the same situation pioneers of breast
augmentation with implants faced in the 1960s
when patients asked if implants caused cancer.
Two generations later, what appeared to be an
unanswerable question is generally considered
a nonissue (For the sake of this discussion, my
comments exclude the recent association of
textured silicone implants and anaplastic nonHodgkin’s lymphoma).
“Lastly, we are not ‘there’ yet when it comes to
evolved thinking about the clinical applications of
fat grafting to the breast, nor are we ‘there’ yet when
it comes to the acceptance of fat grafting by breast
implant experts and breast implant manufacturers.
This is exemplified by our continued binary thinking,
looking at this issue as ‘fat versus implants.’
“Key opinion leaders in breast implant surgery
are not experienced fat grafters, and (with rare
exception) breast fat-grafting experts are not experienced implant surgeons. In a sector where the
advent of fat grafting may seem as a competitive
threat cannibalizing implant sales, the future of
breast augmentation using implants will actually
end up being increased by the versatility of fat
grafting. In summary, we are getting ‘there,’ but we
are not all the way ‘there.’ Stay tuned.”
Doctors’ Bios:
Todd K. Malan, M.D., is the founder of the Innovative Cosmetic
Surgery Center in Scottsdale, Ariz., and creator of the BeautiFill X™ fat-transfer breast-augmentation procedure. He has
performed more than 100 stem cell fat transfers to date. Dr. Malan
reports no relevant financial interests.
Michael Kluska, D.O., F.A.A.C.S., F.A.C.O.S., is board-certified
in plastic/reconstructive and general surgery. He is also a fellow
of the American Academy of Cosmetic Surgery and the American
College of Osteopathic Surgery. Dr. Kluska reports no relevant
financial interests.
Daniel Del Vecchio is in private practice at Boston’s Back Bay
Plastic Surgery. He is on the associate attending staff at Harvard’s
Massachusetts General Hospital. Dr. Del Vecchio is on the advisory board of Keller Medical and Precision Light. He is a paid
consultant to Lifecell Inc.
COSMETIC SURGERY TIMES
8
Au naturel
Stem cell-enriched fat tissue offers organic look and feel
Quick
read
Japanese stem cell-assisted
procedure attempts to reduce
variability in fat-grafted
breast augmentations.
Rochelle Nataloni
S ENIOR S TAFF CORRESPONDENT
B
reast augmentation techniques employing fat grafts
are growing in popularity, but in many cases they are
still hindered by variability in volume achieved and
longevity of results. Japanese plastic surgeon Kotaro
Yoshimura, M.D., department of plastic surgery, University
of Tokyo Graduate School of Medicine, is making strides in
improving the outcomes of fat grafting for breast augmentation
with his cell-assisted lipotransfer (CAL) technique.
CAL converts progenitor-poor harvested fat to progenitor-normal
or enriched fat tissue before transplantation.1 Dr. Yoshimura
discussed his technique at the 9th annual Anti-Aging Medicine
World Congress & Medispa in Monte Carlo in March. His
presentation illustrated how adipose tissue is remodeled after
grafting; how stem cells work in the remodeling process; how
an adipocyte dies when removed from the tissue; and how new
adipocytes are born and grow.
MAY 2011
9
“Relative deficiency of adipose
progenitor cells in aspirated fat tissue
may lead to long-term atrophy of the
grafts, whereas supplementation of
vascular stromal fraction containing
adipose progenitor cells may boost the
efficacy and safety of lipoinjection to
the breasts,” Dr. Yoshimura says.
Dr. Yoshimura has performed
more than 550 CAL breast
augmentation procedures since
2003. He describes the basis of
his technique this way: “Stem
cells work as adipose progenitor
cells and contribute to
regenerating adipose tissue
after lipografting. Grafted
adipose tissue mostly
dies and is then
regenerated. Adipose progenitor cells contribute
to the reconstruction of adipocytes and capillaries
in the regenerating fat. Aspirated fat tissue is
generally progenitor-poor and the deficiency in
progenitor cells is compensated for by adding
adipose progenitor cells.”
Dr. Yoshimura reports that he has tweaked his
technique in small but important ways throughout
its evolution. “We have not
changed the main strategy
but have modified some of
our devices and surgical
techniques in details,” he says.
“For instance, we developed a
new syringe for a large-volume
injection to the breast, which
is a ‘screw-type’ syringe to
achieve diffuse and precise
distribution of fat.”
Dr. Yoshimura’s belief in
lipoinjection as a promising
treatment led to his development
of CAL, which attempts to minimize
some of conventional lipotransfer’s
limitations, such as unpredictability
and a low rate of graft survival due to fat
necrosis.
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Dr. Yoshimura’s CAL breast
augmentation retention results
fall in the 40 to 80 percent
range. He admits these
results are variable, but says
the results are much better
than conventional fat-grafting
augmentation procedures that
do not convert progenitor-poor
fat to progenitor-normal or
enriched fat.
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“Increase in breast size
obtained by CAL
lipoinjection is moderate,
Dr. Yoshimura says,
“but patients can
achieve soft and
natural-looking
breasts without
any concerns
associated with
foreign bodies.”
GETTY IMAGES: PHOTOALTO/RAFAL STRZECHOWSKI
CAL BOOSTS EFFICACY In CAL,
autologous adipose-derived stem (stromal)
cells (ADSCs) are used in combination with
lipoinjection. A stromal vascular fraction (SVF)
containing ADSCs is freshly isolated from half of
the aspirated fat tissue and recombined with
the other half.
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COSMETIC SURGERY TIMES
10
CAL
continued
“The preliminary results suggest that CAL is
effective and safe for soft-tissue augmentation
and superior to conventional lipoinjection,” Dr.
Yoshimura says. The technique, he says, is a
particularly good option for women who want to
reduce excessive fat in other parts of the body.
Additional studies are under way to further
evaluate the efficacy of his technique.
OUTLINING PROCEDURES When
discussing lipoinjection breast enhancement,
Dr. Yoshimura describes three separate
procedures: conventional lipoinjection, full-CAL
and mini-CAL.3
A 30-year-old female patient before (top) and after breast
augmentation at 24 months. The patient underwent breast
augmentation with CAL (310 mL in each breast). Results
demonstrated an 8.0 cm increase in breast circumference
at 24 months. The breast mounds were soft with no
subcutaneous indurations. An original inframammary fold
on the left breast is slightly visible, but injection scars are
not visible. (Photos credit: Kotaro Yoshimura, M.D.)
In an early but pivotal study of 40 of his
patients who underwent CAL for breast
augmentation, Dr. Yoshimura found that final
breast volume showed augmentation by 100 mL
to 200 mL after a mean fat amount of 270 mL
was injected.2
In conventional lipoinjection breast
augmentation, he says, lipoaspirate is harvested
by liposuction, centrifuged and then placed
in a 1,000 mL metal jar that is kept cool in
water with crushed ice. Because the centrifuge
processing reduces the adipose volume by 25 to
30 percent, Dr. Yoshimura suggests the volume
reduction be taken into consideration during
tissue harvesting.
POSSIBLE COMPLICATIONS Cyst
Postoperative atrophy of injected fat tissue was
minimal and did not change substantially after two
months, and he says, “almost all the patients
were satisfied with the soft and natural-appearing
augmentation.”
Cyst formation or microcalcification was detected
in four patients.
“A larger volume of liposuction in lean
patients could induce postoperative donorsite problems such as irregularity or
seroma, so preoperative selection
of patients and careful procedures in
liposuction are important,” he says.
To prevent or minimize the likelihood of
complications, Dr. Yoshimura recommends
maintaining the integrity, or viability, of the
adipose tissue until grafting; discarding as much
unneeded water and oil — which represents
dead adipocytes — as possible; and injecting
the graft as diffusely as possible by placing it as
small particles or thin strings in many layers and
directions.
In the full-CAL procedure, about twice the
volume of lipoaspirate is harvested, and half of
the adipose portion and all of the fluid portion of
the liposuction aspirate are used for isolation of
SVF. The cell-processing procedure takes about
80 minutes, during which time the other half of
the lipoaspirate is harvested and processed in
a centrifuge. Next, the freshly isolated SVF is
added to the centrifuged fat tissue, followed by
gentle mixing and a 10- to 15-minute incubation
to achieve appropriate cell adhesion to the
centrifuged fat tissue.
In mini-CAL, the same volume of lipoaspirate is
harvested as in the conventional lipoinjection;
the adipose portion is centrifuged as the graft
material, while only the fluid portion of the
liposuction aspirate is used for isolation of SVF.
The cell processing takes about a half hour and
the remaining process is identical to full-CAL.
A 36-year-old female patient before (top) and after breast
augmentation view 12 months. The patient, whose body
mass index was 17.3, underwent breast augmentation with
CAL (245 mL in each breast). The breast mounds were soft
with no subcutaneous indurations or visible scars at 12
months.
Identifying these calcifications on
mammogram every year is important
and is useful in distinguishing them from
potential abnormal changes in the future,
according to Dr. Yoshimura.
formation (found under ultrasound) and
calcifications (seen in mammography)
are among potential complications of Dr.
Yoshimura’s technique. “If injection is
performed incorrectly, problems deriving
from fat necrosis will be seen, such as
no augmentation effects, cyst formation,
fibrogenesis and calcification,” Dr. Yoshimura
says. “Small cysts, smaller than 5 mm,
detected by echogram usually disappear
between six and 18 months, so no treatment
is needed. Small calcifications may occur
one to two years after surgery, but they are
relatively rare and easy to distinguish from
malignant signs.”
A 33-year-old female patient who underwent breast
augmentation immediately after implant removal. The
patient, who had 210 mL saline implants, underwent CAL
(260 mL in each breast). The preoperative view (top)
showed capsular contractures and upward displacement of
the left implant. At 12 months (bottom), the breasts were
symmetric and had a natural appearance.
“Major complications are not seen as long
as the injection technique is correct. Our
preliminary experiences with the CAL technique
suggest that ADSC supplementation is safe
and effective. Through further improvements
of the technique and longer follow-up studies,
autologous tissue transfer may become widely
used for augmentation and reconstruction of the
breasts in the future,” he says.
References:
1. Yoshimura K, Suga H, Eto H. Regen Med. 2009;4(2):265-273.
2. Yoshimura K, Sato K, Aoi N. Aesthetic Plast Surg. 2008;32(1):48-55.
3. Yoshimura K, Asano Y. Fat injection to the breasts. Aesthetic and
Reconstructive Surgery of the Breast. Hall-Findlay EJ, Evans GRD, London:
Elsevier Ltd.; 2010:405-420.
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COSMETIC SURGERY TIMES
12
Nipple
reconstruction
GETTY IMAGES: TOM DE BRUYNE
Optimal — and individualized — techniques drive patient, surgeon satisfaction
Quick
read
Many different products and
techniques can be effective in
nipple reconstruction. Surgeons
should be aware of all modalities
available in order to choose the
optimal procedure for each patient.
Ilya Petrou, M.D.
S ENIOR S TAFF CORRESPONDENT
MAY 2011
13
T
echniques used for nipple
reconstruction surgery have evolved
over the years, many of which
now include the use of fillers and
tissue-regenerative biologic matrixes. The
reconstruction technique chosen, however,
largely depends on the expertise of the surgeon
and the specific cosmetic needs of the patient.
like nipple that appears natural,” says James H.
Carraway, M.D., director, Plastic and Cosmetic
Surgery Center of EVMS, Virginia Beach, Va.
“These reconstructed nipples, however, need
to be over-projected and made slightly larger,
because they will shrink a bit over time and
ideally will settle to a size in concordance with
the aesthetic goal of the patient.”
“The two main issues in nipple
reconstruction that remain
the limiting factors in terms
of achieving good aesthetic
outcomes are atrophy of the
reconstructed tissue and lack of
projection of the nipple in the
Dr. Glasberg
long term,” says Scot Bradley
Glasberg, M.D., a cosmetic and reconstructive
plastic surgeon in New York. “Not all techniques
are equally effective, and choosing an
Should a given pedicle flap technique fall short
of the patient’s aesthetic goal, fillers such as
Restylane (hyaluronic acid, Medicis) or Perlane
(hyaluronic acid, Medicis) can supplement
nipple rigidity and bolster surgically improved
nipple projection. Ideally, filler treatment should
be done in stages and injected gradually and
progressively over time in order to better finetune the aesthetic result desired by the patient.
Though the longevity of aesthetic outcomes may
vary with fillers, Dr. Carraway says he believes
Today, there are about 20 different products available on the
market used for tissue regeneration and reconstruction that
call themselves either equivalent to or better than AlloDerm.
However, according to Dr. Glasberg, not all biologic matrixes
are the same, and not all achieve equal surgical outcomes.
appropriate, individualized approach for each
patient is key in achieving good and long-lasting
aesthetic outcomes.”
that because the reconstructed nipple area is a
relatively static region with a diminished blood
supply, aesthetic results could last for years.
RECONSTRUCTION OPTIONS
DERMAL MATRIXES In addition to the
Historically, nipple reconstruction has been
challenging to perform. Surgical approaches
range from skin grafting using tissue from
the contralateral nipple, labia minora, pulp
of the toe and earlobe with subsequent
micropigmentation to color-match tissues, to
more sophisticated techniques involving various
kinds of pedicle flaps as well as fat grafting.
All of these approaches can achieve good but
varying aesthetic outcomes, and many are often
combined in order to achieve the most optimal
aesthetic result.
constructed pedicle flaps, biologic acellular
dermal matrixes such as AlloDerm (LifeCell),
Strattice (LifeCell) or Surgisis (Cook Medical) are
commonly used to achieve further stability of the
reconstructed nipple. These tissue-regeneration
matrixes are designed to rapidly stimulate tissue
remodeling, including the generation of stem
cells and collagen, resulting in a firmer, stronger
and more vascularized nipple.
Hyaluronic acid fillers and biologic matrixes
are much newer modalities that can be used
in nipple reconstruction, either alone or in
combination with other techniques. Just
as patients’ aesthetic goals can differ from
one another, however, so do the preferred
reconstruction approaches chosen by surgeons.
“I often prefer to create my own cylinder in the
nipple using a modified skate flap, and in the
center portion of this cylinder I often will place
a piece of AlloDerm or Strattice
for added support. This combined
technique helps to regenerate
the tissue, resulting in a firmer
nipple structure that can typically
maintain its projection in the long
term,” Dr. Glasberg says.
Dr. Carraway
“The goal of nipple reconstruction is to create a
papilla that can permanently maintain its shape
and projection. Most nipple reconstruction
techniques involve folding small skin flaps, like
the petals of a flower, to create a prominent bud-
Biodesign (Cook Medical) Tissue Generation
Matrix and Biodesign Nipple Reconstruction
Cylinder are new to the market and claim very
similar properties and aesthetic outcomes as
the more time-tested AlloDerm and Surgisis
AlloDerm rolled into the center of a modified skate fl ap
during a nipple-areola reconstruction following a breast
reconstruction with a cohesive gel implant. (Photos credit: Scot
B. Glasberg, M.D.)
products. The Biodesign Nipple Reconstruction
Cylinder provides a scaffold for re-establishing
a nipple projection. Engineered to maintain
a precise balance of strength and flexibility,
the Biodesign matrix and cylinder is said to
completely remodel into fully vascularized
tissue that becomes stronger over time, giving a
natural thickness and feel to projections.
According to Dr. Carraway, any biologic matrix
that can help achieve adequate vascularization
of the tissue, does not resorb over time and
regenerates local tissues can be very helpful in
nipple reconstruction.
“My typical nipple reconstruction technique
would consist of a pedicle flap followed by
tattooing to finish the color,” Dr. Carraway says.
“If an improved shape were still necessary, I
may either inject filler or use a small piece of
porcine acellular dermal matrix. Using these
techniques, I can achieve the targeted volume,
and my patients have been very happy with
outcomes.”
Today, there are about 20 different products
available on the market used for tissue
regeneration and reconstruction that call
themselves either equivalent to or better than
AlloDerm. However, according to Dr. Glasberg,
not all biologic matrixes are the same, and not
all achieve equal surgical outcomes.
“I have done extensive research with most of
the biologics on the market, including histologic
examination, and have found that no two
products are the same or work the same in
terms of the histology and their regenerative
properties. A good product is one that will not
resorb over time and will ideally regenerate
tissues, hold its form and still be present five to
10 years down the line,” Dr. Glasberg says.
Disclosures:
Dr. Glasberg is a consultant for LifeCell. Dr. Carraway reports no
relevant financial interests.
CosmetiC surgery times
14
z
Quick
read
transumbilical breast augmentation
(tuBA) is a useful addition
to the surgical repertoire of
cosmetic breast surgeons,
because the technique delivers
safe results with high patient
satisfaction, one surgeon says.
Si
g
u
Transumbilical breast
augmentation delivers favorable
aesthetic results with little risk
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
mAy 2011
15
involves placing breast implants via a single
3 cm incision created within the superior lip
of the umbilicus. Dr. Shumway performs the
TUBA technique, but he also created the
modified TUBA (called the transabdominal
breast augmentation, or TABA) for patients
with pre-existing abdominal scars. Either
way, the implantation can be performed
within a prepectoral or a subpectoral position
via tumescent anesthesia and IV conscious
sedation, he says.
GETTY IMAGES: TETRA IMAGES
“After learning from an experienced TUBA
surgeon, the new surgeon should tackle the
‘easy’ cases first. Patient selection is the key for
any novice TUBA doctor, i.e., choose reasonable
patients who are not obese, possess fairly
symmetrical breasts, have realistic expectations
and are seeking an appropriate augmentation
size,” Dr. Shumway says.
C
osmetic surgeons who already
perform cosmetic breast
enhancement procedures should
learn the transumbilical approach
because it is faster and safer relative to
all other saline augmentation techniques,
says Robert A. Shumway, M.D., F.A.C.S., of
Shumway Cosmetic Surgery, La Jolla, Calif. Dr.
Shumway is a past-president of the American
Society of Cosmetic Breast Surgery (ASCBS),
the immediate past-president of the California
Academy of Cosmetic Surgery (CACS) and a
trustee of the American Board of Cosmetic
Surgery (ABCS) and the American Academy of
Cosmetic Surgery (AACS).
tuBa HistorY, tecHNiQue
Transumbilical breast augmentation (TUBA)
is a special endoscopic technique developed
by Gerald Johnson, M.D., in 1991. It
“
After learning from an experienced TUBA surgeon, the
new surgeon should tackle the ‘easy’ cases first. Patient
selection is the key for any novice TUBA doctor, i.e.,
choose reasonable patients who are not obese, possess
fairly symmetrical breasts, have realistic expectations
and are seeking an appropriate augmentation size.
”
Robert Shumway, M.D., F.A.C.S.
La Jolla, Calif.
“The first 10 TUBA surgeries must be
successful, or else the developing physician
will desert the procedure,” he says. “However,
most well-trained aesthetic breast surgeons
will find TUBA much like sliced bread … yes,
it’s a magnificent idea that makes each one of
us wonder why we didn’t think of this sooner!
Just remember to pick your slam-dunks first,
so that you will not become discouraged and
prematurely abandon the procedure.”
Dr. Shumway says TUBA is faster and safer
because the thorax is approached superficially
in a tangential fashion with blunt dissection
via one small, distant incision that is located
in a universal scar — the navel. The risk of
pneumothorax, internal organ injury, hematoma
and scarring are diminished compared to
other breast augmentation routes that utilize
a perpendicular approach to the chest wall or
cutting instruments and electrocauterization.
In addition, chemical vasoconstriction from the
epinephrine-containing tumescent solution,
along with the hemostatic nature of tissue
expander usage, further reduces the risk of
bleeding and subsequent scar formation, he
says.
TUBA also provides an opportunity for cosmetic
surgeons to perform several simultaneous
cosmetic procedures through the navel. For
example, the cosmetic appearance of the navel
can be improved with concurrent umbilicoplasty.
And TUBA and mastopexy surgery are often
coupled together to improve nipple areolar
complex (NAC) ptosis and asymmetry. The
Benelli, crescent or vertical mastopexy may be
performed directly after TUBA without violating
fat or breast parenchyma, Dr. Shumway
16
says.
CosmetiC surgery times
16
TUBA
continued
Procedural details According to
Dr. Shumway, with proper TUBA technique and
“
At the end of the first postop visit, patients are given
written post-op instructions
with a one-week return (or
sooner as required) along
with appropriate instructions
about icing the breasts and
taking oral antibiotics, and
analgesics as needed.
Most well-trained aesthetic
breast surgeons will find
TUBA much like sliced bread
— yes, it’s a magnificent
idea that makes each one
of us wonder why we didn’t
think of this sooner!
”
Robert Shumway, M.D., F.A.C.S.
La Jolla, Calif.
instrumentation, excellent results are routinely
achievable whether placing implants above or
below the pectoralis major muscle.
Dr. Shumway uses his modified tumescent
solution with 1 gm lidocaine, 2 mg
epinephrine, and 10 mL 8.4 percent sodium
bicarbonate in 500 mL of normal saline for
TUBA analgesia
along with conscious
IV sedation. The
solution is introduced
at the navel along
the subcutaneous
abdomen and then
either above or
below the pectoralis
major muscle. The
tumescent solution
also assists with the
subsequent blunt
tuBA implant introduction.
surgical dissection.
The 3 cm (or less) superior navel incision
is created with a #10 blade, and dissecting
facelift scissors are used over the anterior
rectus abdominis muscle fascia to generate the
initial approach.
Blunt solid trocars
are introduced and
advanced superficially
over the abdominal
musculature within
the same plane as
liposuction, either
medial or lateral to
the NAC (depending
on prepectoral or
retropectoral implant
tuBA fill tubes.
placement). It follows
that if the implants
are to be placed in the prepectoral packet, the
approach will be medial to the NAC, Dr. Shumway
the tuBA tissue expander. (Photos credit: Robert Shumway, M.D., F.A.C.S.)
says. If the placement is subpectoral, the surgical
pocket is approached lateral to the NAC.
Once the proper surgical space is entered and
bluntly developed, the inferomedial fibers of
the pectoralis major muscles are released from
their origin of attachment up to the fourth rib
using various types of curved “hockey stick”
a closed fill system developed by the implant
manufacturer, Dr. Shumway says, and the
patient is evaluated in the sitting, inclined and
supine positions for symmetry and bilateral
breast volume/appearance. Volume adjustments
can be made prior to removal of the fill tubes.
A superior umbilicoplasty or even abdominal
liposuction may be performed at this point
Before (left) and six months after the tuBA procedure.
instruments. The pockets are further defined
with additional blunt instrumentation and then
the tissue expanders are placed behind each
NAC and filled with either saline or air.
The use of these tissue expanders confirms
the next step of the operation, which is the
actual placement of the breast implants, Dr.
Shumway says. The inframammary crease can
be manipulated and adjusted with TUBA at
anytime during the procedure.
After the surgeon changes gloves, the breast
implants may be positioned under endoscopic
visualization. The implants are then filled with
during the operation, Dr. Shumway says.
The navel is closed with dissolvable 4-0
chromic suture in three layers at the superficial
fascia, dermis and skin edge in an interrupted
fashion. Dr. Shumway says he instructs his
patients to keep their navel clean with 70
percent isopropyl alcohol once a day until the
sutures dissolve and fall out.
Immediately postop, patients are placed in a
soft jog bra with an elastic wrap for 24 hours
along with several sterile 4 X 4 gauze pads
that are secured over the navel to absorb any
overnight tumescent fluid solution. All patients
mAy 2011
17
TUBA data
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
Findings from a retrospective chart review of 3,300 consecutive
transumbilical breast augmentation (TUBA) cases underscore
the assertion of Robert A. Shumway, M.D., F.A.C.S., that
TUBA is a faster, safer and better procedure than other breast
augmentation approaches.
During the 27th annual American Academy of Cosmetic
Surgery scientific meeting, Dr. Shumway reported on the
complications, complaints and patient satisfaction ratings from
TUBA procedures he performed between 1994 and 2010.
Capsular contracture (69 cases, 2.09 percent) was the most
common complication, although he notes the rate is lower than
the published national average for augmentations performed via
other routes.
There was one possible infection (0.03 percent), and only
several other types of complications, all with rates equal to
or less than 0.18 percent, he says, adding that there were no
acute hematomas.
“TUBA is about as safe as breast augmentation can get,” Dr.
Shumway says. Delayed hematomas presenting several weeks
to months after surgery secondary to external manipulation
were rare, and represented less than 0.05 percent of cases,
Dr. Shumway says. The events, he says, were associated with
aggressive postoperative manipulation and were surgically
treated to full resolution without adverse sequelae.
(0.06 percent). One case involved a patient who presented four
months after surgery with a self-induced breast skin injury that
she allowed to fester and eventually erode into the breast, Dr.
Shumway says.
“The patient never looked under her own homemade
bandages,” he says. Upon assessment of the situation, Dr.
Shumway says he removed the exposed implant, cleaned the
affected area and debrided the wound. After several months,
the resulting lateral breast scar was eliminated by a large
“O” to “T” local skin-flap closure. Months later, the patient
underwent a unilateral TUBA to replace the removed implant.
The second patient reportedly consumed large amounts of
abortion medication (morning-after pills) directly following her
implant surgery. She also wore unsanctioned postoperative
underwire bras directly against written medical orders, Dr.
Shumway says.
Breast asymmetry occurred in six cases (0.18 percent), and
size dissatisfaction presented in five cases (0.15 percent).
“The key to happy patients and excellent breast symmetry
is the notion of placing breast implants directly behind each
nipple areolar complex. It is very important to first document
any preoperative asymmetry by photography and then explain
to patients that breasts are sisters, not twins,” Dr. Shumway
says, adding that the distinct possibility of postop asymmetry
is included in every informed consent he obtains from patients.
He says that patients must also give signed approval of their
selected implant size after thorough consultation, and that
there is a monetary charge for any future surgical size changes.
The single report of possible breast infection was an event that
was diagnosed and managed with several doses of overnight IV
cefazolin by another surgeon, Dr. Shumway says.
“Remember, if you feel there are two appropriate sizes, pick
the larger size,” Dr. Shumway says.
Four patients (0.12 percent) developed minor hypertrophic
navel scars that were easily treated either with intralesional
corticosteroid injections or by simple surgical excision and
direct closure. Implant extrusion occurred in two patients
The results of the patient satisfaction ratings at two and six
months after surgery were revealing, he says. Using a scale of
one to 10, all two-month scores were eight or higher, with a 9.7
mean.
are seen postop on day one to evaluate the breasts, implant
mobility and the navel incision. Postoperatively, the bilateral
implants should be mobile and possess excellent symmetry, Dr.
Shumway says.
At the end of the first postop visit, patients are given written
postop instructions with a one-week return (or sooner, as required)
along with appropriate instructions about icing the breasts and
taking oral antibiotics, and analgesics as needed.
Weekly follow-up visits occur until the internal surgical breast
implant pocket has totally healed. Thereafter, the patient returns
to the office every six months for two years and then for annual
check-ups during the life of the implants, Dr. Shumway says.
Disclosures:
Dr. Shumway reports no relevant financial interests.
Dr. Shumway offers the following tips to cosmetic surgeons
performing the TUBA procedure:
• Ask and specifically know about every OTC and prescription
drug in the medical history of each patient, including products
taken weeks before and weeks after surgery;
• Use a psychiatric screening system that includes a
mechanism that reveals how a potential surgical patient feels
about lawsuits;
• Avoid general anesthesia; use tumescent anesthesia;
• Always use the minimal touch techniques for handling implants;
• Teach patients to keep their superior breast implant surgical
pockets open and mechanically instruct them how to “pinch
and slide” the implant upward once a day;
• Provide quality postop care and see patients on postop day
one and again at one week, or sooner if they are experiencing
any discomfort.
Double
TAKE
Study highlights
connection between highly
textured breast implants
and double capsules,
related complications
Rochelle Nataloni
S ENIOR S TAFF CORRESPONDENT
Quick
read
a retrospective analysis illustrates
an association between aggressively
textured implants and late seromas
and/or double capsules.
GETTY IMAGES: JAMES WOODSON
COSMETIC SURGERy TIMES
18
May 2011
19
A
ggressively textured breast
implants are associated with
double capsules and late seromas,
according to a retrospective
study of several hundred primary bilateral
breast augmentations and primary bilateral
mastopexy augmentations.
The study, which was performed and
published recently by Canadian plastic
surgeon Elizabeth J. Hall-Findlay, M.D., is a
look back at her own patients treated at Banff
Plastic Surgery, in Banff, Alberta, over almost
two decades.
“
with an expanding seroma 19 months after
her original surgery.
Dr. Hall-Findlay says she recalls that the left
breast of this patient kept enlarging, and it
was assumed that the problem might have
been some form of infection, but detailed
questioning and eventual cultures ruled that
out. When the patient was taken into surgery,
there was a large amount of serosanguineous
fluid and a double capsule, Dr. Hall-Findlay
reports, adding that this is just one example
of several that eventually prompted her study.
Study methodS Dr. Hall-Findlay
I have always followed my
results in all of my breast
surgery patients because
I think it is important to
review outcomes. I have
been performing careful
measurements to be able to
add some ‘science’ to the
‘art’ of plastic surgery.
”
Elizabeth J. Hall-Findlay, M.D.
Banff, Alberta, Canada
“I have always followed my results in all of
my breast surgery patients, because I think it
is important to review outcomes. I have been
performing careful measurements to be able
to add some ‘science’ to the ‘art’ of plastic
surgery,” Dr. Hall-Findlay says.
Dr. Hall-Findlay says she had not seen
significant numbers of late seromas or double
capsules in the early years of her practice,
which she started in 1983. She began to
notice them in 2006.
“Given that it is difficult to assess capsular
contracture when comparing different
surgeons’ outcomes, I decided to compare
my own outcomes to each other. I tried not
to change any of the other variables such as
prep solution, pocket irrigation and so on,
and I noticed that late seromas and double
capsules were a new finding that I had not
seen in the first 25 years of my practice. The
study was my way of figuring out what was
happening,” she says.
Dr. Hall-Findlay says she noticed doublecapsule formations on some Biocell (Allergan)
textured-surface implants when revisions were
being performed for various reasons, such as
size change and capsular contracture. She
did not really take notice, however, until a
patient with Style 410 implants presented
reviewed all of the primary bilateral breast
augmentations and primary bilateral
mastopexy augmentations performed in her
practice after 1992. There were 209 patients
with saline implants; 160 patients with CML
and CMH (CUI) MicroCell textured-surface
implants; 105 patients with Biocell texturedsurface silicone gel breast implants; and 152
patients with smooth round (Allergan and
Mentor) silicone gel breast implants. She
reviewed these cases for complications and
revisions to see whether any patterns emerged
and found that 14 patients developed double
capsules, and that these double capsules
were only seen with the Biocell texturedsurface implants.
Three patients developed late seromas —
more than a year after their original surgery
— with two patients requiring urgent drainage
of an expanding seroma/hematoma. Seven
patients were found to have double capsules
as an incidental finding for procedures, such
as asymmetry and bottoming out, and five
patients were found to have double capsules
when surgery was performed for capsular
contracture.
This image illustrates how a complete double capsule
formed around an aggressively textured (Biocell) implant,
and shows that the double capsule did not form where
the implant is smooth. (Photos credit: Elizabeth J. Hall-Findlay, M.D.,
F.R.C.S.C.)
The double capsule is cut open, and this view reveals how
the double capsule has contracted over the implant and has
caused it to fold as the capsule tightened.
the Baker classification; no patient had a
Baker IV capsule in this series.
“
Given that it is difficult to
assess capsular contracture
when comparing different
surgeons’ outcomes, I
decided to compare my own
outcomes to each other.
”
Elizabeth J. Hall-Findlay, M.D.
theorieS There are several possible
theories for the late seroma/double-capsule
outcomes. While some surgeons suggest
that infection or biofilm may be the culprit,
cultures tend to be negative, and infection did
not result after replacing the original implant.
Dr. Hall-Findlay says a more plausible
rationale may be of a mechanical nature.
Banff, Alberta, Canada
The review of complications and revisions
showed that the silicone gel implants
performed better than saline implants;
highly cohesive MicroCell textured CMH and
CML implants had by far the best capsular
contracture profile; and Biocell texturing
had an increased capsular-contracture rate.
Capsular contractures were evaluated using
“The mildly textured surfaces can cause some
irritation and a mild seroma, but the more
aggressive textured surfaces are designed to
adhere to the capsule. This capsule can be
forcefully separated from the implant, causing
shear forces to result with an expanding
seroma and/or a double capsule,” she says.
“The problem does not happen in the
20
polyurethane implants, because there
COSMETIC SURGERy TIMES
20
Double capsules
continued
a distinction between using a subpectoral
versus subglandular implant placement.
was true tissue ingrowth that could not be
separated from the implant.
AdditioNAL ComPLiCAtioNS
“The problem does not happen in the less
With respect to complications in Dr. HallFindlay’s study, other than late seromas
There are several possible theories for the late seroma/
double-capsule outcomes. While some surgeons suggest
that infection or biofilm may be the culprit, cultures
tend to be negative, and infection did not result after
replacing the original implant. Dr. Hall-Findlay says a
more plausible rationale may be of a mechanical nature.
aggressively textured implants, because
there is no true adherence to allow
subsequent separation.”
Dr. Hall-Findlay says other than the important
double-capsule/late seroma finding, her
most interesting observation was how well
the CUI implants performed compared to
both the saline implants, on which she had
longer follow-up, and the newer silicone gel
implants, of which she had fewer years followup. The impressive performance of the CUI
implants confirmed her clinical impressions,
she says, but “it is always important to
actually put the numbers together rather than
just going by impressions.”
Dr. Hall-Findlay points out that she can
no longer get the CUI implants in Canada,
and that they have not been available in
the United States for some time. “The CUI
implants had a textured surface that rarely
adhered, but they were more cohesive than
the implants currently available in Canada,”
she says. “It will be interesting to see if the
more cohesive implants perform better over
time.” Dr. Hall-Findlay adds that “it makes
me wonder whether the higher cohesivity is
a factor in the lower capsular-contracture
rate.”
Dr. Hall-Findlay says she has discontinued
use of aggressively textured implants. “I am
now applying to the Health Protection Branch
in Canada to attempt to gain approval for
each patient to use the smooth-walled breast
implants that are more cohesive than the
ones we can use without additional approval,”
she says. “I still prefer a subglandular pocket
for my patients who have enough padding,
and I use a subpectoral plane for patients
who are thin with minimal padding.”
Dr. Hall-Findlay’s study did not reveal any
complications that were associated with
and double capsules, one patient had an
infection (transaxillary CMH implant) in the
primary bilateral breast augmentation group;
one patient had a hematoma (smooth-walled
gel subpectoral); two saline (subglandular)
implants leaked; and four patients had
a revision because they wanted smaller
implants. Seven patients had a revision
because they wanted larger implants.
Since the publication of her
study, Dr. Hall-Findlay says
she is often approached
by surgeons who say they
have also seen a case or
two of double capsules,
but that they had not
noted the association with
the aggressive texturing
until she reported it.
Since the publication of her study, Dr.
Hall-Findlay says she is often approached
by surgeons who say they have also seen
a case or two of double capsules, but that
they had not noted the association with the
aggressive texturing until she reported it.
“Many of the younger surgeons did not
realize that this was a new problem that
had not occurred with smooth-walled
silicone implants,” Dr. Hall-Findlay says.
She expects that her findings will have an
impact on breast surgery trends for the
foreseeable future. “I suspect that fewer
surgeons will use the aggressively textured
implants,” she says.
Disclosures:
Dr. Hall-Findlay reports no relevant financial interests.
mAy 2011
21
fat
GETTY IMAGES: INGRAM PUBLISHING
Frank talk about
Pros, cons and controversies surrounding
breast lipoaugmentation
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
Quick
read
Available evidence seems to allay concerns that fat
transfer to the breast might interfere with cancer
detection, but surgeons recognize further study is
needed to optimize its efficacy and safety.
S
urgeons who perform fat grafting of the
breast acknowledge a need for further
research to answer a number of questions
about the procedure. But based on available
evidence and their personal experience, they consider
lipoaugmentation a valuable option for select women
seeking cosmetic breast enhancement and for those
with various reconstruction needs.
“Autologous fat injection with or without stem cell
enhancement appears to be a very worthwhile
alternative for addressing a variety of plastic and
22
CosmetiC surgery times
22
� Lipoaugment
continued
cosmetic breast issues, and one of its benefits
is that it avoids the potential risks associated
with large tissue grafts, flaps and implants,”
says Maurice Sherman, M.D., who discussed
lipoaugmentation of the breast at The Art of
Cosmetic Breast Surgery, a workshop preceding the
annual scientific meeting of the American Academy
of Cosmetic Surgery in January in Phoenix.
Sean Rice, M.D., spoke about harvesting
techniques and primary augmentation with
fat at the 11th annual Toronto Breast Surgery
Symposium in Toronto. He emphasizes the need
for patient education.
“As with any procedure, patients choosing
breast lipoaugmentation need to be welleducated, so that they have appropriate
expectations and are aware of potential
risks. In addition, as highlighted by the
2009 report of the American Society of
Plastic Surgeons (ASPS) Fat Graft Task
Force, patients and surgeons must realize that
outcomes of fat grafting in the breast are very
dependent on technique and surgeon
expertise,” Dr. Rice says. “This
means women interested in breast
lipoaugmentation should be
careful in selecting a surgeon,
while surgeons who want to
perform these procedures
should be prepared to face a
learning curve.”
CanCer deteCtion
In 1987, concerns that
postlipoaugmentation
scarring and calcifications
could interfere with detection
of early breast carcinoma led
the American Society of Plastic
and Reconstructive Surgeons Ad-Hoc
Committee on New Procedures to issue a
statement deploring the use of autologous
fat injection in the breast, Dr. Sherman
says.
“This condemnation not only limited
use of the procedure worldwide, but
also research and discussion of the
topic,” he says. “Fortunately,
reports began to surface during
the 1990s on the success of
autologous fat grafting in
A patient before (left) and five months after breast lipoaugmentation using approximately 300 cc of autologous fat
injected into each breast. (Photos credit: Sean Rice, M.D.)
breast reconstruction that led the society to
re-evaluate its position.”
In 1997, the ASPS recommended that
lipoaugmentation of the breast undergo further
review as a potentially worthwhile treatment
modality. In 2009, based on a comprehensive
review of the literature, the ASPS Fat Graft Task
Force concluded there was no evidence strongly
suggesting that fat grafting to the breast could
interfere with breast cancer detection. The
group called for more studies to confirm what
they considered still preliminary findings, but
they also concluded that fat grafting may be
considered for breast augmentation, as well as
correction of defects associated with medical
conditions and previous breast surgeries.
Regarding the cancer-detection issue,
Dr. Sherman says the macrocalcifications
that can occur with any type of trauma to
the breast are easily differentiated from the
microcalcification pattern of early cancerous
changes of the breast. Dr. Rice says radiologists
have experienced no difficulties identifying
breast cancer in women with a history of
mammaplasty, which results in much more
significant scarring and mammographic
changes than fat injection. He says, however,
he encourages his patients to make sure
the radiologist who reads their cancerscreening studies has solid competency in
interpreting the images. Women are instructed
to obtain a mammogram or MRI prior to a
lipoaugmentation procedure and to have regular
follow-up studies, beginning about one year
after the procedure.
teChnique topiCs
The question of how much fat survives after
breast lipoaugmentation has been another
controversial issue. Results of a recently
published study by German surgeons (Herold C,
et al. Handchir Mikrochir Plast Chir. 2011 Feb
1. (Epub ahead of print)) indicate that about 75
to 80 percent of fat survives, assuming proper
injection technique, Dr. Rice says.
“Fat survival depends on the injected cells
being in close proximity to a blood supply, and
that, in turn, requires that the fat be injected
in small quantities. In the past, some surgeons
were injecting fat in larger aliquots, as if it were
a synthetic filler, but fat is made up of living
cells that must receive nourishment from the
circulation in order to survive,” Dr. Rice says.
Dr. Rice uses a 3 mm cannula to deposit
2 cc to 3 cc aliquots in multiple planes. The
fat is delivered below and into the muscle and
subglandular space, as well as beneath the
skin, but none is placed into the breast tissue.
Dr. Sherman also emphasizes that the fat
should not be injected into the parenchymal
or glandular substance of the breast. Not only
does this tissue have less blood supply than
muscle or the subcutaneous space, it contains
contaminated ducts, so that there is a risk for
abscess or lipid cyst formation.
“Due to the potential risk of cellulitis, antibiotic
prophylaxis is recommended pre- and postlipoaugmentation,” Dr. Rice says.
Dr. Sherman says whether considering the
breast or another recipient site for fat grafting,
there is a need for further laboratory and
clinical research to understand the optimal
combination of harvesting, processing and
delivery techniques for maximizing fat viability
and survival. Additional study is also warranted
to determine the potential benefit of adjuncts
such as hyperbaric oxygen, stem cells and
mAy 2011
23
tissue expansion with a proprietary device
(Brava System, Brava) for increasing the volume
achieved and take rate, Dr. Sherman says.
Dr. Rice says individual surgeons have their own
preferences for harvesting and processing of fat
for grafting. His favored approach, however, is to
use water-assisted liposuction to obtain the fat,
because it is gentle and the aspirate contains a
relatively high proportion of fat and does not have
to be centrifuged.
“Concerns in the past about limited survival of fat
after transfer to the breast may have been related
to the harvesting and preparation technique. In
some cases, the injected material contained a lot
of water that should not have been there in the
first place,” Dr. Rice says.
to direct an outward-turning nipple-areolar
complex inward.”
Therefore, Dr. Rice suggests when performing
breast augmentation, surgeons should not be
asking the question, “Fat or implant?” but rather
they should take into account the pros and cons
of each modality and consider if the two might be
used in combination for optimal results.
“The idea should not be whether to use A versus
B, but whether A plus B equals a better C,”
he says. “The enhanced ability to manipulate
the aesthetics of the breast using fat grafting
also makes this technique an excellent tool for
reconstructing deformities.”
Disclosures:
Drs. Rice and Sherman report no relevant financial interests.
Join Our Family of Happy Customers…
pros and Cons of fat
Autologous fat injection as a method for cosmetic
enhancement can augment the breast by about
one-half to one full cup size. Additional volume
increase can be achieved using a staged approach,
although lipoaugmentation cannot match the
enhancement volume possible with an implant.
“SINGLE BEST LASER”
—Dr. Albert Nemeth
“the closest thing there is to magic”
Lipoaugmentation has some unique advantages,
however. In addition to allowing contouring at
the sites of fat harvest and transfer, fat grafting
affords the surgeon greater control in shaping
the breast.
“The beauty of fat is that you can mold it and
shape the breast in a way that will optimize the
cosmetic result,” Dr. Rice says. “For example,
fat can be placed preferentially in the upper
pole if the patient wants more cleavage, or
more fat can be put laterally than medially
—Dr. Ken Arndt
Photos courtesy of Drs. G Munavalli, R. Weiss, W. Baugh, and J. Niamtu.
“Even with a second session, fat transfer can
increase breast size by about 1.5 cup sizes, and
in my experience, additional injections of fat
into the breast are mostly performed in women
whose primary reason for cosmetic surgery is
liposculpting at another body site,” Dr. Rice
says. “Most women seeking breast augmentation
want a substantial size increase, and breast
lipoaugmentation is not for the individual who
is interested in the kind of results that require a
400 cc round implant. Rather, it is for someone
wanting a slightly larger, natural-looking breast
who does not want a saline or cohesive gel
implant.”
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AD0118
COSMETIC SURGERY TIMES
24
Personality impacts
quality of life following
breast reconstruction
after mastectomy
Ilya Petrou, M.D.
S ENIOR S TAFF CORRESPONDENT
The personality type of a patient
undergoing breast reconstruction
following mastectomy appears to
influence quality of life outcomes.
Patients undergoing this procedure
should be closely evaluated
to help them overcome the
psychological trauma associated
with breast cancer and subsequent
surgical reconstruction.
GETTY IMAGES: TRIPOD
Quick
read
MAY 2011
25
T
he goal of breast
reconstruction
following
mastectomy is to
help patients improve their
self-image and augment their
quality of life. Depending
Dr. Bellino
on the individual personality
traits of the patient,
however, quality of life outcomes following
breast reconstruction surgery can vary. This,
in turn, underscores the need for an indepth evaluation of mental characteristics
of all breast reconstruction patients to help
improve outcomes.
“New and very encouraging reconstructive
techniques can provide a very significant
According to Dr.
Bellino, patients with a
“vindictive and selfcentered” model of
interpersonal relationship
are “resentful and
aggressive,” and here,
breast reconstruction could
symbolize the conclusion
of a reparative process
and fulfill the desire of
revenge on cancer.
help to patients with breast cancer. However,
an accurate investigation of individual
personality characteristics is essential to
improving quality of life outcomes, and
a brief course of psychotherapy, where
appropriate, following reconstruction should
be part-and-parcel of a complete breast
cancer treatment,” says Silvio Bellino,
M.D., professor, department of psychiatry
and neuroscience, Faculty of Medicine,
University of Turin, Italy.
MEASURING QUALITY OF LIFE In
a recent study, Dr. Bellino and colleagues
evaluated the clinical and personality
characteristics related to quality of life in 57
women who underwent breast reconstructive
surgery following mastectomy.
Psychometric evaluation included a
semistructured interview for demographic
and clinical characteristics; the
Temperament and Character Inventory; the
Inventory of Interpersonal Problems; the
Short Form Health Survey Questionnaire;
the Severity Item of the Clinical Global
Impression; the Hamilton Depression Rating
Scale; and the Hamilton Anxiety Rating
Scale. An assessment with the Short Form
was repeated three months after breast
reconstruction.
Results showed that those patients who
were assessed with the temperamental
characteristic of “harm avoidance” and
characterized as “apprehensive and
doubtful” scored high in their quality of
life scores. According to Dr. Bellino, the
restoration of their body image helped them
reduce social anxiety and insecurity.
Similarly, those patients who were evaluated
as “vindictive and self-centered” on a scale
of interpersonal problems also had high
quality of life scores.
According to Dr. Bellino, patients with a
“vindictive and self-centered” model of
interpersonal relationship are “resentful and
aggressive,” and here, breast reconstruction
could symbolize the conclusion of a
reparative process and fulfill the desire of
revenge on cancer.
None of the other psychological or
other factors evaluated, including the
characteristics of the cancer and its
treatment, were significantly related to
quality of life scores.
“Overall, all of the patients in our study
showed significant improvements in quality
“
With very few exceptions,
breast reconstruction
following mastectomy has a
positive impact on quality
of life. However, the positive
psychological effects can
be differentiated in relation
to individual characteristics,
begging the need for a closer
care for these patients.
”
Silvio Bellino, M.D.
Turin, Italy
of life following breast reconstruction
surgery. With very few exceptions, breast
reconstruction following mastectomy has a
positive impact on quality of life. However,
the positive psychological effects can
be differentiated in relation to individual
characteristics, begging the need for a closer
care for these patients,” Dr. Bellino says.
PATIENT EDUCATION Immediate
reconstruction is currently considered
the standard of care in post-mastectomy
patients. According to Dr. Bellino, it is
better to perform a mastectomy and breast
reconstruction in the same procedure,
in order to shorten the period in which
patients have to suffer the psychological
consequences of a change in their body
image as a consequence of illness.
Patients who can receive breast
reconstruction should be carefully assessed
with psychometric evaluation tools, and
a detailed personality profile should be
investigated and established, Dr. Bellino
says.
“Available evidence on the effects of
personality and relational factors on the
outcome of reconstruction should be the
object of a complete information of patients,
in order to allow them to give their informed
consensus to treatment procedures with a
full and updated knowledge of the effects of
reconstruction on long-term functionality and
quality of life,” Dr. Bellino says.
According to Dr. Bellino, physicians should
take into account personality issues and
their effects on treatment outcome in these
patients. They should be able to listen
to patients and their problems to accept
functional consequences of interventions.
“Here, we believe that a better and more
structured interspecialty cooperation with
psychiatry is clearly needed to deal with
these problems,” Dr. Bellino says.
Disclosures:
Dr. Bellino reports no relevant financial interests.
Quick
read
Multiple features of highcohesive, form-stable silicone
gel implants make them a
valuable option for breast
augmentation and particularly
for addressing a variety of
challenging situations.
finesse
Form-stable
High-cohesive silicone gel
implants have a special place
in breast augmentation
surgery, one expert says
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
GETTY IMAGES: TETRA IMAGES
COSMETIC SURGERY TIMES
26
MAY 2011
27
E
xperience with
high-cohesive, formstable silicone gel
implants (Allergan and
Mentor) throughout the past
14 years has convinced one
European cosmetic surgeon of
their unique benefits for breast
augmentation surgery.
Dr. Randquist
Form-stable implants have been available in
Europe since 1996. Speaking at the 2010
annual meeting of the Canadian Society of
Aesthetic Plastic Surgery in Toronto, Charles
Randquist, M.D., told attendees that when
he first heard about these devices as a next
generation in breast implants, he was wary
that their touted advantages were marketing
hype. His viewpoint was altered, however,
after using the devices in more than 2,000
procedures.
“With all modern implants — and assuming
the surgeon has good technical skills and
maintains sterility — problems with infection,
bleeding and capsular contraction should
not be a major issue,” says Dr. Randquist,
Victoriakliniken, Stockholm. “Nevertheless,
the highly cohesive form-stable implants,
anatomical and round, have allowed me
to conquer some challenging situations in
breast augmentation that I could not address
adequately before. I believe the form-stable
implants are predictable and clearly superior
in certain regards, and I believe the data
“
With all modern implants
— and assuming the surgeon
has good technical skills and
maintains sterility — problems
with infection, bleeding and
capsular contraction should
not be a major issue.
Charles Randquist, M.D.
Stockholm
”
I have collected over the years proves this
point.”
CUSTOMIZATION, PREDICTABILITY
Since the anatomical implants are available
in a variety of heights, projections and sizes
and because of their highly cohesive material,
the form-stable implants provide the surgeon
with increased opportunity to customize the
procedure.
This is a benefit for augmenting breasts
with a lower constricted pole that has not
been possible before using any other type of
implant.”
Consequently, early results are more
predictable and better. Because the implants
are textured, long-term outcomes are
superior, as well, Dr. Randquist says.
VARIATIONS, ASYMMETRY Since the
“When a smooth implant is put into a
relatively large pocket, depending on the
anatomical form-stable implants can vary
in three dimensions — in contrast to twodimensioned, round implants — they have
benefits for use in flat-chested women with
limited glandular tissue.
Greater firmness to the touch on the table does not
mean the implant feels unnatural once it is in the
body, and besides, there is already natural variation
in breast firmness among women that depends on the
amounts of fatty and glandular tissue present.
quality of the woman’s tissue and size of
the implant there may be bottoming out,
asymmetries and less control over time.
In contrast, my data show that using the
textured cohesive implants, a preoperative
planned breast shape depending on volume
of breast tissue and shape of implant can be
achieved after surgery and stay maintained
after one year, five years or 10 years,” Dr.
Randquist says.
The form-stable implants also provide better
results in breasts with a lower constricted
pole because the implant is firm and better
able to shape the surrounding tissue than a
softer material. Some critics of form-stable
implants cite firmness as a negative feature,
arguing that it imparts a less natural feeling
to the breast. Greater firmness to the touch
on the table does not mean the implant feels
unnatural once it is in the body, however, and
besides, there is already natural variation in
breast firmness among women that depends
on the amounts of fatty and glandular tissue
present, Dr. Randquist says.
“Better shape is one of the primary reasons
why women seek augmentation, it is not all
about volume, and the form-stable implants
meet this goal better than other devices,” Dr.
Randquist says. “When placed into a precise
pocket, it can act like a controlled tissue
expander, adding volume where needed.
“In this situation, the form-stable implant
allows me to shape the breast into what
I consider an aesthetically superior
appearance, and it gives me an opportunity
to individualize the results in a way that has
not been possible before,” Dr. Randquist
says.
The form-stable implants also have a unique
role for addressing asymmetry, which Dr.
Randquist says is present in almost all women
to some degree and is usually related to rib
cage configuration and bone structure, rather
than a consequence of differences in the
amount of tissue present between breasts.
The increased versatility for varying projection
and width available using an anatomical
form-stable implant enables asymmetry to be
addressed in a way not possible with other
prosthetic devices, he says.
“One-third of all of my augmentation patients
receive two different implants because of the
unique potential the form-stable implants give
me to minimize asymmetry,” Dr. Randquist
says. “With these devices, I am even able to
solve minor differences between breasts as I
strive for perfection.”
Disclosures:
Dr, Randquist is co-chairman of the Allergan Asia Council on Breast
Aesthetics (AACE), but he reports he has declined any financial
compensation. Instead, the money offered goes to a fund for
charity. He reports no other relevant financial interests.
Quick
read
An implant-selection system
integrates easily obtained patient
measurements with information
on patient outcome preference to
suggest implants of varying volume,
projection and base diameter.
Free implant-selection system aims to match implant dimensions
with patients’ anatomy and desired outcome
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
GETTY IMAGES: MOMENT
COSMETIC SURGERY TIMES
28
MAY 2011
29
se of a system designed to
aid breast implant selection
can help to optimize
patient satisfaction after
augmentation mammaplasty and reduce
the rate of reoperation for size change,
according to Dennis C. Hammond, M.D.,
Dr. Hammond
who spoke at the 2010 meeting of the
Canadian Society of Aesthetic Plastic Surgery in Toronto.
The system integrates information on breast anatomy
with patient preference. It is available as a kit
(BodyLogic) and is distributed by Mentor, but
the information it generates is applicable to all
available implants.
Dr. Hammond originated the idea, and he
developed the system in collaboration
with Mentor consultants. After they
established the basics, a working
group of high-volume breast
augmentation surgeons was
organized to help finalize the system,
which was introduced in 2008 and
is being used by surgeons worldwide.
STUDYING SATISFACTION
According to Dr. Hammond, a survey
of patients who used the system to
guide implant selection before their
operations indicate it is fulfilling its
design objectives. In a cohort of 30
women whose implants were selected with
use of the kit, 96 percent indicated they
were satisfied with their size and agreed with
the surgeon that the desired result had been
obtained, says Dr. Hammond, a board-certified
plastic surgeon practicing in Grand Rapids, Mich.
“Available data on breast augmentation indicate a
surprisingly high rate of reoperation for size change. This
problem reflects in part the pitfalls of trying to use cup
size for determining the outcome. Many women presenting
for breast augmentation have a certain cup size in mind,
but cup size is variable and an inaccurate representation
of breast size,” Dr. Hammond says. “Therefore, even when
the surgeon has completed a technically perfect breast
operation, if implant selection was based on cup size, the
woman can be very dissatisfied because she may not be
the full C she hoped for.”
“The implant selection system is designed to help the
surgeon better understand how the patient hopes to look
after augmentation and to pick the implant in a more
accurate way to match that goal,” he says.
Using supplied skin-fold calipers and a slide ruletype instrument, the surgeon determines breast base
diameter, breast height, skin thickness of the medial and
lateral skin folds and the upper pole and the position
of the nipple and areola. The data are recorded on a
worksheet that also captures assessment of the skin
envelope, inframammary fold position and patient input
on the desired outcome.
For the latter, patients are asked to choose one of
four outcomes depicted pictorially as representing the
following: a modest, natural result; a breast that looks as
full as possible but still appears natural; a full breast that
looks somewhat artificial; or an out-of-proportion breast
that is as big as possible.
“Most patients select the second option. However, the
system also features an educational component that
reflects its purpose to increase the likelihood of picking
an implant to match the patient’s desired result ‘within
reason,’” Dr. Hammond says.
“
The implant selection system
is designed to help the surgeon
better understand how the patient
hopes to look after augmentation
and to pick the implant in a more
accurate way to match that goal.
”
Dennis C. Hammond, M.D.
Grand Rapids, Mich.
“The outcome some women have in mind is not safe to
create. To help prevent problems before they occur, the
system includes an element of preoperative evaluation to
help identify this situation, so the patient can be advised
that what she is seeking is not a good idea,” he says.
Using the data in hand, the surgeon refers to the implant
selection booklet that will identify a range of devices
varying in terms of implant volume, projection and base
diameter but that would be appropriate to provide the
desired result.
The breast implant selection kit is available without
charge to any surgeon who requests it from their Mentor
sales representatives, the company says. It includes an
instructional CD that Dr. Hammond developed to outline
its use. A chapter about the selection system is also found
in Dr. Hammond’s book, Atlas of Aesthetic Breast Surgery,
Elsevier, 2009.
COMPLEMENTARY TOOL The implant selection
system is intended to be an adjunctive tool that
still allows for surgical judgment and experience.
Disclosures:
Dr. Hammond is a consultant for Mentor.
COSMETIC SURGERY TIMES
30
B O D Y
B R E A S T
F A C E
ATLANTA — Understanding the anatomical basis of
the tear trough deformity provides a foundation for
choosing appropriate techniques that will successfully
correct this common cosmetic complaint, says Mark A.
Codner, M.D.
Dr. Codner
“Until fairly recently, the need for specific
techniques to address the tear trough deformity was commonly
overlooked when treating patients seeking lower eyelid
rejuvenation,” says Dr. Codner, a board-certified plastic surgeon in
private practice in Atlanta and clinical assistant professor, division
Tear fix
trough
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
A n a t o m i c a l a n a lys i s g u i d e s s u c c e s s f u l c o r re c t i o n o f d e fo r m i t y
of plastic surgery, Emory University. “However, this problem has
received attention in the past several years both in published
papers and scientific presentations that have increased surgeon
awareness of the issues and led to improved surgical outcomes and
patient satisfaction.”
Quick
read
Tear trough deformity confers a
tired, sad and aged appearance to
the face and may be present with
or without other significant signs of
periorbital aging. Both nonsurgical
and surgical techniques can be used
to fill the concavity and achieve
improved cosmetic results.
The tear trough deformity is defined as a groove below the medial
canthus and the nasolacrimal crest that runs from the medial portion
of the lower eyelid along the side of the nose and angles toward the
cheek. It lies over the inferomedial orbit, where the skin and muscle
layers are very thin and there is minimal fat.
The deformity can be corrected nonsurgically with soft tissue
augmentation or surgically with blepharoplasty. The choice between
these techniques depends on whether the patient presents with
lower eyelid bags and excessive skin laxity in addition to the tear
trough deformity. It also depends on the patient’s desire for a more
permanent correction.
MAY 2011
31
“Some patients who present with complaints
about a tear trough deformity are fairly young,
in their late 20s or early 30s and have concerns
about looking tired or sad, but have no other
signs of periorbital aging. While they may benefit
from soft tissue augmentation alone, surgery may
be a reasonable option considering the need for
repeat filler injections,” Dr. Codner says. “There
is also a role for filler and fat transfer at the time
of lower blepharoplasty to improve results of
surgery alone.”
hyaluronidase (Wydase), and he has a preference
for a particular hyaluronic acid product (Prevelle,
Mentor) because of its flow characteristics.
“This hyaluronic acid formulation is thinner than
other fillers, which makes it particularly useful for
achieving a natural result with a reduced risk for the
development of contour irregularities or a Tyndall
effect in this area where there is minimal soft tissue
coverage over the bone,” Dr. Codner says.
LOWER EYELID BLEPHAROPLASTY
Surgical correction of the tear trough deformity
via lower eyelid blepharoplasty requires surgeons
to use a fat transposition technique.
“Blepharoplasty with fat resection may improve
the appearance of lower eyelid bags associated
with prolapsed orbital fat, but will not address
the tear trough deformity, and in fact may
even accentuate it, worsening the hollowed
appearance,” Dr. Codner says.
“
GETTY IMAGES: MICHAEL HALL
Some patients who present with
complaints about a tear trough deformity
are fairly young, in their late 20s or early
30s and have concerns about looking
tired or sad, but have no other signs of
periorbital aging. While they may benefit
from soft tissue augmentation alone, surgery
may be a reasonable option considering
the need for repeat filler injections.
Mark A. Codner, M.D.
Atlanta
OPTING FOR FILLERS Augmentation can
be performed by injecting either an alloplastic
filler or autologous fat along the orbital rim to add
volume. Dr. Codner says he prefers hyaluronic
acid fillers, because any overcorrection or
irregularity can be reversed with injection of
“
Blepharoplasty with fat
resection may improve
the appearance of lower
eyelid bags associated
with prolapsed orbital fat
but will not address the
tear trough deformity,
and, in fact, may even
accentuate it, worsening the
hollowed appearance.
Mark A. Codner, M.D.
Atlanta
”
The correction provided using this hyaluronic
acid filler usually lasts for six to 12 months.
Other hyaluronic acid fillers offer slightly greater
longevity of improvement, and autologous fat
injection can provide permanent correction,
although Dr. Codner says particular care must be
taken with the technique used when injecting fat
in this area of the face.
“The fat must be injected in multiple, very small
aliquots using a fine 25-gauge cannula, and a
blunt needle is recommended with any injection
in this area to minimize bruising and the risk of
inadvertent intra-arterial injection,” he says.
Whether using fat or a hyaluronic acid filler,
the injections must be delivered deep, to the
preperiosteal level, because injection that is
too superficial may result in the material being
visible or palpable. It is also important to inject
only to the desired level of correction, rather
than overcorrecting in anticipation of resorption,
because resorption is minimal at this site compared
with other areas of the face, Dr. Codner says.
”
Dr. Codner says his preferred blepharoplasty
technique involves release of the medial and
nasal fat pads with elevation of the orbitomalar
ligament at the preperiosteal level to allow
the fat to redrape and add volume to the tear
trough. A medial dissection is performed to
release the origins of the orbicularis muscle to
create a space for fat transposition. The fat can
be fixed to the periosteum underlying the tear
trough deformity with 6-0 Vicryl.
“In my experience, the surgical technique is
safe, effective and provides long-lasting, natural
results,” Dr. Codner says.
DISCLOSURES:
Dr. Codner has received research grants from and is a consultant to Mentor.
FOR MORE INFORMATION:
Codner MA, Hirmand H. Lid Cheek Blending: The Tear Trough Deformity. In: Aston S,
et al, eds. Advances in Aesthetic Surgery. Elsevier; 2009.
Codner MA, Ford DT. Blepharoplasty. In: Grabb TC, ed. Grabb and Smith’s Plastic
Surgery. Lippincott, Williams and Wilkins; 2007.
Codner MA, Hanna MK. Upper and Lower Blepharoplasty. In: Nahai F, ed. The Art of
Aesthetic Surgery. Quality Medical Publishing; 2007.
B O D Y
B R E A S T
F A C E
Forehead flap,
modified
Three-stage forehead
flap with modified
folded lining can
address anatomical
and aesthetic deficits
of full-thickness
nasal defects
Cheryl Guttman Krader
S ENIOR S TAFF CORRESPONDENT
Quick
read
A plastic surgeon specializing in nasal reconstruction finds that
a forehead fl ap with his personal modification to the traditional
folded-fl ap technique reliably achieves success in the vast
majority of patients requiring full-thickness nasal repair.
GETTY IMAGES: ZLATKO KOSTIC
COSMETIC SURGERY TIMES
32
MAY 2011
33
TUCSON, A RIZ. — A full-thickness
forehead flap procedure
incorporating a modification of
the traditional folded forehead
flap technique for the nasal
lining with delayed primary
graft replacement offers a
Dr. Menick
safe and reliable method for
successfully restoring form and function in
patients with a major defect of the nose, says
Frederick J. Menick, M.D.
Currently, Dr. Menick relies on this approach as
his workhorse for the majority of patients who
present for the repair of full-thickness nasal
defects. Exceptions are those patients with a
very large defect where a free flap is needed, as
in an individual with irradiation injury or extreme
cocaine abuse.
While this approach employs a three-stage
operation that takes two months to complete,
Dr. Menick says he believes it provides better
cosmetic and functional results compared with
traditional methods, which are less reliable or
more destructive to the remaining nose.
“Based on color and texture, forehead skin is
the best donor tissue to resurface the nose, and
it is best transferred as a full-thickness flap,
especially when repairing defects that extend
through the full thickness of the nose,” says
Dr. Menick, a board-certified plastic surgeon
in private practice in Tucson, Ariz., and clinical
associate professor of surgery, University
of Arizona College of Medicine. “Taking a
little extra skin for folding provides a simple
and effective way to restore a thin, supple,
vascularized nasal lining.”
“Achieving the goals of restoring both form and
function in the reconstruction of complex nasal
defects requires a multistage procedure, and in
my experience, patients are more than willing to
delay pedicle division to achieve better functional
and cosmetic results,” he says. “In the end,
these patients are happier than those left with
a suboptimal outcome after a ‘simpler’ repair.
The latter patients may not only be unhappy, but
angry, as well, because of a poor result.”
THE APPROACH In Dr. Menick’s
approach, an extended full-thickness
forehead flap is elevated and
transposed into the defect,
folding the distal end for lining.
The flap is not thinned at this
stage, because it can result in scarring and
compromise vascularity, he says.
While this approach
employs a three-stage
operation that takes two
months to complete, Dr.
Menick says he believes it
provides better cosmetic
and functional results
compared with traditional
methods, which are less
reliable or more destructive
to the remaining nose.
The flap is left in place and allowed to heal to
the recipient bed for one month. At the second
stage, forehead flap skin with 2 mm to 3 mm of
subcutaneous fat is raised in the subcutaneous
plane over the entire nasal inset, creating
thin supple covering skin. The distal folded
forehead skin is incised free along the nostril
margin, separating the distal lining extension
from the proximal covering flap. Then, excess
subcutaneous tissue and frontalis muscle
are removed, and delayed primary cartilage
grafts are positioned to support the nose and
establish an ideal subunit support framework.
“During the initial healing phase, the folded
aspect of the flap becomes well-integrated into
the adjacent normal lining and receives sufficient
blood supply so that at the intermediate
operation, the folded lining layer can be
completely separated from the proximal overlying
covering flap,” Dr. Menick says. “Then, excess
soft tissue and frontalis muscle are removed
from the lining aspect of the flap, creating
thin vascular lining and allowing placement of
cartilage grafts at the second operation.” The
thinned forehead skin flap is replaced and
allowed to heal for another month before the
pedicle is divided at the third stage.
BENEFITS OF MODIFICATION In their
textbook, first published 16 years ago, Dr.
Menick and Gary Burget, M.D., introduced the
intranasal lining flap for use in repairing complex
nasal defects. While this technique revolutionized
nasal reconstruction, Dr. Menick says he finds
that his modification of the folded forehead
flap for lining provides equal or better results
in a procedure that is technically easier for the
surgeon, and less traumatic for the patient.
The technique is illustrated in Dr. Menick’s new
textbook (Menick FJ. Nasal Reconstruction: Art
and Practice. Elsevier; 2009).
“The folded forehead flap modification avoids
additional injury to the remaining lining of the
nose that can be created by intranasal lining
flaps, minimizing that additional surgical
morbidity. Since the skin extension used for
lining lies within the area of dog-ear excision
on forehead flap closure, taking additional skin
from the forehead does not significantly increase
forehead donor injury,” he says.
Dr. Menick’s modification of the traditional
folded forehead flap for lining also avoids the
limitations of the traditional folded technique.
“Because of inadequate soft tissue thinning and
insufficient cartilage support, the traditional
method frequently led to a thick, collapsed and
bulky reconstructed nose,” he says. “In contrast
to the original technique, my approach does not
add morbidity to the reconstruction, because
it does not cause injury inside the nose,
and it allows for improved molding of
cartilage grafts, because there is
no scarring and the cartilage is not
placed in the folded area.”
COSMETIC SURGERY TIMES
34
O F
‘e’
- R E P U T E
Experts weigh in
on how to manage
negative online reviews
Lisette Hilton
GETTY IMAGES: OZGUR DONMAZ
S TAFF CORRESPONDENT
E
Quick
read
Cosmetic surgeons who are turning
to social media to boost business
are finding there’s a dark side.
Experts weigh in on how to handle
negative comments and reviews.
nglewood, Colo., plastic surgeon
Gregory A. Buford, M.D., remembers
the disgruntled patient who gave him a
less-than-favorable online review years
ago. The patient complained that Dr. Buford
was too expensive and that she had to wait 15
minutes for her appointment. She gave him a low
star rating, he says.
opportunity to address or change the comments.
“So, it wasn’t about being unhappy with results
or anything having to do with her care,” Dr.
Buford says.
“I view the feedback and spend a lot of time
answering questions and looking at blogs,” he
says. “It’s important to know what people are
saying about you or about your specialty.”
He says he remembers being frustrated, because
he wasn’t able to respond. And that’s Dr.
Buford’s beef with user-generated comments
and reviews: They’re not always constructive,
and those being attacked don’t always have the
Nevertheless, Dr. Buford says he is a social
media advocate. He blogs on his website
(www.beautybybuford.com/news/bufords-blog)
and spends time addressing patients’ questions
and concerns on general cosmetic surgery
websites, such as RealSelf.com.
COMES WITH THE TERRITORY Bad
comments come with the social media territory,
says Alan J. Bauman, M.D., a hair42
restoration physician in Boca Raton, Fla.
| MAY 2011
35
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continued
Dr. Bauman, who lectures to colleagues on
social media, knows about the ins and outs of
Tweeting, Facebooking and blogging on
www.BaumanBlog.com.
“The Web is the ultimate communication tool;
so, if you’re not using the Web to communicate
to physician colleagues, potential patients,
etc., then you’re kind of on a desert island,” Dr.
Bauman says.
complaints. If you don’t have a Facebook page or
blog, you should launch these online platforms.
This way, the surgeon can dictate the online
narrative and terms of the debate, instead of an
irate patient doing it for them,” he says. “(Third),
do not ignore online complaints. As we know, in
cyberspace, these complaints do not disappear,
and, at worse, the surgeon’s indifference might
communicate ineptitude per the doctor-patient
relationship. That perception alone can threaten a
large share of medical income.”
TRADE TOOLS Cosmetic surgeons can
There’s no escaping the potential for negativity,
according to Dr. Bauman, and there’s no reason
to shun social media because of it. He says
would-be patients aren’t necessarily turned away
by occasional uninviting remarks.
“I think as more and more people get used to the
reviews — whether it be to a steak house or for
your local massage therapist, spa or surgeon —
the savvy consumer realizes that there is going to
be pros and cons,” he says.
monitor at least some of what’s being said about
them or the industry by doing Google and other
online key term searches. Crisis management
or public relations professionals experienced in
social media might be better suited to address
situations that are potentially damaging.
Still another option is to pay for reputationmanagement reports.
According to David Jackson, digital strategist
with SEOward.com, New York, these reports vary,
depending on the practice.
TAKE CHARGE Dr. Bauman says surgeons
should be proactive, rather than reactive, to the
criticism.
“I’m not saying that you should engage a
disgruntled patient in a forum. That’s not
appropriate. But I think that you do in some way
have to address the issues. You can’t let them
fester,” he says. “The most important thing
is that physicians have to build their positive
images. And they have to put out the good
information and encourage their patients to
post their good results and talk about their good
experiences.”
Public relations and social media consultant
Amanda Vega of Amanda Vega Consulting in
New York; Dallas; and Scottsdale, Ariz.; says
physicians should, in most cases, ignore posts,
reviews and comments that have no validity. But
they should pay attention in many cases.
For those comments that are constructive,
“Respond (usually with facts, but nothing that
breaks HIPAA regulation) and an offer to help,”
she says.
Responding should be anything but a knee-jerk
reaction, according to Babak Zafarnia, president
of Praecere Public Relations, Washington.
Cosmetic surgeons need to anticipate negative
comments and plan for them, he says.
Mr. Zafarnia recommends three steps: “Determine
the probable universe of likely online criticism,
and prioritize these possible complaints. (Second),
plan your outreach to address and counter the
“For a recent research project, we ran a report on
a cosmetic surgery practice with two surgeons for
$450 up front and $200” each month, broken
down to updates every two weeks, he says. “This
included reports for the practice name and for
each surgeon. We provide a detailed account
of where/when reviews were posted and their
disposition, as well as advising whether specific
reviews should receive a response. We will also
petition sites to have incorrect reviews removed
when possible.”
GONE TOO FAR While not an attorney,
Michael Roberts is a victim’s advocate, forensic
analyst and litigation support consultant with the
international firm Rexxfield (www.rexxfield.com).
Roberts founded Rexxfield, which specializes in
false allegations of medical malpractice online,
after he survived being a victim of an Internet
smear campaign.
“Cosmetic surgery is by far the most requested
specialty as far as these problems,” Mr.
Roberts says. “In our experience, in addition
to complaints by patients, we have also found
that there are some unscrupulous physicians,
particularly in specialties relating to cosmetic
procedures and hair transplants, who are not
below anonymously executing unfounded smear
campaigns against their competitors.”
Emotionally unstable patients have been known
to turn on their capable and skilled physicians
with online smear campaigns, according to Mr.
Roberts.
As a result, he says, “We have had successful
doctors who are experts in their respective fields
forced to file bankruptcy.”
The sad truth is that targeted Internet smear
campaigns leveled against physicians, personally
or professionally, endure indefinitely and have
very few remedies.
“This dilemma is exacerbated further by the
fact that the defamatory postings can be made
anonymously,” Mr. Roberts says. “Furthermore,
the statute of limitations for libel and defamation
in most states is only one year from the date of
posting. If a victim of Internet libel does not file
suit within that time, they are left with no legal
recourse for damages or for injunctive relief.”
Mr. Roberts says he does not recommend
responding to or refuting damaging allegations,
because that often inflames antagonists. Filing
lawsuits can also backfire and become public
relations nightmares, he says.
Mr. Roberts recommends physicians engage a
specialist in reverse search-engine optimization.
It’s important in a crisis to elevate positive
content and work with a digital forensic specialist
(“social forensics”) to identify potential offenders,
he says.
IT IS WHAT IT IS For the most part, user-
generated comments and reviews are marketing
and learning opportunities. Constructive criticism
should make cosmetic surgeons look at, and
possibly correct, negative patient experiences.
The experts says physicians should look at the
comments for what they are, and learn from
those that are constructive.
“I use the example of my favorite steak
restaurant — I love it. I go there all the time. I
know the quality of the food and service, and I’m
always surprised at some of the negative reviews
that pop up,” Dr. Bauman says. “I just know
that those people have some kind of ax to grind
or maybe that steak restaurant isn’t the right
restaurant for them.” GETTY IMAGES: OZGUR DONMAZ
‘e’-repute
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Important RADIESSE Wrinkle Filler Treatment Considerations
RADIESSE wrinkle filler is FDA-approved for subdermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds. After injection, patients may experience redness,
bruising, swelling or other local side effects. Most side effects of treatment resolve within a few days. More rare side effects may include swelling that lasts longer, unevenness or firmness in the area injected,
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¹ Data on file
Berlin, A, Hussain, M, Goldberg, D. (2008) Calcium Hydroxylapatite Filler for Facial Rejuvenation: A Histologic and Immunohistochemical Analysis. Dermatologic Surgery, Volume 34, S64-S67.
Marmur, E, Green, L, Busso, M. (2010) Controlled, Randomized Study of Pain Levels in Subjects Treated with Calcium Hydroxylapatite Premixed with Lidocaine for Correction of Nasolabial Folds.
Dermatologic Surgery, Volume 36 (3), 309-315
4
Moers-Carpi M, Vogt S. (2007) A Multicenter, Randomized Trial Comparing Calcium Hydroxylapatite to Two Hyaluronic Acids for Treatment of Nasolabial Folds. Dermatologic Surgery, Volume
33 (S52), S144-S151.
5
Moers-Carpi M, Tufet J. (2007) Calcium Hydroxylapatite versus Nonanimal Stabilized Hyaluronic Acid for the Correction of Nasolabial Folds: A 12-Month, Multicenter, Prospective, Randomized,
Controlled, Split-Face Trial. Dermatologic Surgery, Volume 34:1-6
2
3
Copyright © 2010 Merz Aesthetics, Inc. All rights reserved. MERZ AESTHETICS is a trademark of Merz Pharma GmbH & Co. KGaA. RADIESSE is a registered trademark of Merz Aesthetics, Inc. ML00663-00
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