Breast Augmentation Through the Belly Button? Don't Be Fooled

Many women would like breast implants, but they are turned off by the thought of visible scars...

• around the areola, or
• in the fold beneath the breast, or
• in the arm pit

So, some surgeons offer breast implants through the bellybutton.  Termed the TUBA (Trans-Umbilical Breast Augmentation), I have seen more disasters with this technique than any other....

• How can the surgeon expect to do finesse work from a foot away?  The belly button is too far away from the breasts.
• Hence, the implants are never placed 100% correctly.
• And the breasts are frequently asymmetric.
• How do you control operative bleeding from a distance?
• Hence, there are more bleeding complications with the TUBA.
• The long-term complication of bleeding around an implant is capsular contracture (hardening and disfigurement of the prosthesis).
• Surgeons cannot use silicone implants for TUBAs.  They are limited to saline, which are suboptimal for most patients.

I try to dissuade patients from undergoing TUBAs.  Los Angeles and Beverly Hills are filled with TUBA practitioners who have no intention of correcting their own mistakes.  So, in my practice in Ventura, California, I have to revise the breast implants on at least 5-10 TUBA patients each year.

On the other hand, non-surgical, "scarless" breast augmentations may be available soon....

• Commercially available fillers, similar to Restylane and Juvederm, have been trialled in Europe.  These products are injected into the breasts to produce small augmentations (maybe 1/2 of a cup).  While the fillers might last only 6-12 months, their placement involves no general anesthesia, no cutting, and no down-time--just a few needle pokes.
• Fat grafting may have efficacy.  Imagine liposuctioning fat from your tummy or hips, and then injecting it into your breasts.  It's a two-fer!  The big problem is the issue of cancer.  Will the fat cause breast cancer?  Will scarring from the fat transplant obscure tumors on mammograms?
• Vacuum?  Could you apply a vacuum to your existing breasts to stimulate their growth?  Sustained tension on your teeth allows your orthodontist to correct your smile.  Little people have been stretched to increase their height.  Why not suck the breasts bigger?!  This is an awfully compelling area of research which I hope pans out.

Breast Augmentation: Over the Muscle Versus Under the Muscle

I want breast implants, but I am confused whether they should be placed on top of the muscle or under the muscle.  What are the advantages and disadvantages of the two techniques?

-Holly S.

Holly, this is a very common question among breast augmentation patients.  The surgical terms are...

• Subglandular implant:  The prosthesis is placed under the breast tissue but on top of the pectoralis major muscle.
• Subpectoral implant (or submuscular implant):  The prosthesis is placed behind the pectoralis major muscle (which is itself behind the breast gland).

Obviously, Holly, you deserve a customized evaluation, and only then can a Board Certified Plastic Surgeon help you make the best decision.  Nevertheless, there are some general advantages and disadvantages of the two options....

Subglandular Implants

Advantages:

• Technically easier operation for the surgeon
• Can be placed without general anesthesia (without going totally to sleep)
• Larger implants can be accomodated
• Potentially, more cleavage can be created
• No surgery on the muscle; therefore, less discomfort
• No surgery on the muscle; therefore, faster recovery time
• More "lift" effect, so that formal breast up-lift operations can be avoided

Disadvantages

• The "look" tends to be more artificial and less natural
• More rippling
• Greater likelihood of capsular contracture
• More difficult to interpret mammograms

Subpectoral Implants

Advantages

• Usually, a more natural breast appearance
• Less rippling
• Lower risk of capsular contracture
• More successful mammogram readings

Disadvantages

• More difficult operation
• Requires general anesthesia
• Can not always produce as much cleavage as the patient might desire
• More discomfort
• Longer recovery time
• Among women with large pectoralis majors, muscle contraction can distort the implant

Practically speaking, I try to convince most of my patients here in Ventura, California (>90%) to undergo subpectoral placements.  The unusual exceptions...

• Extreme fear of general anesthesia
• Very low pain tolerance
• Looking for a "fake" look
• High performance athletes, whose pectoralis major muscles should not be altered
• Body builders, in whom muscle flexion would distort their breasts during competitions
• Male-to-female transsexuals, whose large XY pectoralis major muscles would not accomodate a subpectoral implant

 

 

"My Blood is Thin. Can I Still Have a Tummy Tuck?"

I have von Willebrand disease.  So, my platelets don't function properly, and my blood is thin.  Can I still have a cosmetic tummy tuck?

-Nicole

Yes!

There are variety of situations that cause the blood to be thin....

• von Willebrand disease
• hemophilia
• the prescription use of warfarin (also known as Coumadin)
• the over-the-counter use of aspirin, ibuprofen, naproxen, etc., for headaches or other pains

In most circumstances, the blood can be safely thickened so that it will clot normally even during major operations.  Tummy tucks typically produce very little bleeding, so Nicole's surgery went perfectly....

 

The Lifestyle Lift Company Fined for Fake Online Reviews

I have blogged before how I am not necessarily a fan of the lifestyle lift (http://www.pickartplasticsurgeryblog.com/2008/01/lifestyle-lifts.html).  It's just a mini-facelift, and it's no different than what every plastic surgeon has been doing for the past 10-15 year.

Yet, I have always been amazed that this mediocre operation could create so much positive buzz.

Now I know how.  New York Attorney General Andrew Cuomo announced last month that the cosmetic surgery company that promotes the Lifestyle Lift has agreed to a settlement over fake online reviews.  As part of the settlement, the company has agreed to stop publishing anonymous reviews of its offerings and to pay $300,000 in penalties to the state.

Apparently, Lifestyle Lift paid its employees to write positive reviews about the company on various websites.  These employees also apparently "attacked" legitimate internet posters who criticized its services, and even tried to get those reviews removed.  Cuomo's office says that its investigators came across internal e-mails that specifically instructed employees on what actions to take.

While $300,000 might be just a slap on the wrist, I hope that this story generates at least a little bad buzz about the Lifestyle Lift.  Could karmic justice be for real?

Botox for Acne?

For the past decade, Botox (and now Dysport too) has been the primary wrinkle cure for smoothing the forehead and erasing crow's feet.  Less well known are its established uses in...

• reshaping the eyebrows, especially increasing the arching of the brows
• getting rid of "bunny lines" on the sides of the nose
• lifting the corners of the mouth (to soften sad frowns)
• diminishing the banding of the neck muscles
• minimizing sweating in the arm pits, hands, and feet

And now one report published in the Journal of Drugs in Dermatology suggests that Botox can effectively treat acne.  17 of 20 patients treated with Botox into the skin noticed that...

• their skin was less oily
• their pores were smaller
• their acne improved

I am excited to offer this option to my patients in Ventura, especially for those who have not had success with benzoyl peroxide, antibiotics, salicylic acid, light therapy, Accutane, and other types of acne treatments.

Package Deals in Plastic Surgery: Why They Make Sense

I have increasingly seen advertisements for plastic surgery "packages":

• New mommy makeovers:
  • Breast enhancement
  • Tummy tuck
  • Liposuction

• Surgical facial rejuvenation:
  • Browlift
  • Eyelids
  • Facelift
  • Necklift

• Non-surgical anti-aging:
  • Fotofacial/intense pulsed light lasers
  • Botox or Dysport
  • Fillers (like Juvederm, Restylane, Radiesse, or Sculptra)

My wife has been skeptical.  "Aren't those packages just gimmicks to sell additional services?"

Yes, but that's a good thing.  These bundled procedures do work well together.  Combining services can lead to results that are greater than the sum of their individual parts.

Consider the "new mommy makeover."  All women know that pregnancies and breast feeding cause both the breasts and the abdomen to swell.  In many women, the skin never snaps back to its pre-pregnancy elasticity.  Lifting or augmenting the breasts makes the chest look great.  However, the whole torso is not balanced until the tummy is also flattened and tightened.  So, combining breast enhancement with a tummy tuck does produce the best proportions.

Non-surgical solutions can also be performed concurrently to optimize results.  For example, the "11's" between the eyebrows will usually respond to Botox or Dysport; a 60-80% improvement is typical.  However, for some patients, 60-80% is not good enough; they want 90% erasure of the wrinkle.  So, adding a little bit of filler beneath the relaxed wrinkles (such as with Restylane or Juvederm) can nearly eradicate the 11's.

Fillers can even be used to enhance a surgery.  Everybody knows that a face/neck lift can improve the cheeks, jowls, jaw line, and neckline.  However, the area around the mouth is usually not rejuvenated.  So, I will often recommend Restylane or Juvederm to minimize the "smoker's lines" radiating from the lips.  Combining these fillers with the face/neck lift can produce the most harmonious result.

Topical Toxin? The Effect of Botox Without the Needles

Very soon, there will be four different types of injectable botulinum neurotoxin type-A (BoNT-A).

• Botox is the industry leader.
• Dysport was FDA approved just a couple of months ago.  In my practice in Ventura, California, it has performed admirably.
• PurTox will probably be on the market within a year or two.
• Xeomin is also in the pipeline.

All of these products contain the muscle relaxant that soften facial wrinkles.  And all work after they are injected with needles.

While almost all of my patients have loved Botox and Dysport, a significant minority hates the needles.  For these needle-phobic folks, it would be ideal to have a topical cream which can produce the effects of an injectable muscle relaxant.

Enter Topical Toxin.

Preliminary studies have demonstrated that this topical, noninjectable form of botulinum toxin can effectively treat crow's feet.  The outer eyebrows can be raised, as well.

Irritation has been minimal.  There have been no inadvertant paralyses of adjacent muscles.

Also, the injectable BoNT-As have been useful in treating excessive sweating, especially in the armpits, palms, and feet.  Topical Toxin has shown promise for the reduction of sweating at these locations too.

It remains to be seen whether Topical Toxin will supplant Botox as the king of cosmetic muscle relaxants.  Certainly, Topical Toxin will be a great option as part of a comprehensive rejuvenation package.