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Monthly Archives: June 2011

Trends In Gynecomastia Beverly Hills

We see patients weekly in my Beverly Hills practice who present with gynecomastia.  Many of these patients in fact are in excellent shape; however, they have significant gynecomastic tissue in the retroareolar region which is very thick glandular tissue which cannot be removed through diet or exercise.  Etiologies of gynecomastia can include the use of steroids at a young age as well as possible use of marijuana.  It can also be genetic and associated with increased estrogen or estradiol levels in the body.  This increased incidence of men presenting for gynecomastia surgery has been significant over the last decade.  Below I indicate a preoperative photograph of a typical male chest with significant gynecomastia, although the pectoralis muscle is well-defined.  

Notice, there is herniation of glandular tissue into the nipple areolar complex, and a significant amount of retroareolar glandular tissue and fatty tissue along the chest well. 

 

The next photograph shows the actual glandular tissue that is being removed through a partial subcutaneous mastectomy through the periareolar approach. 

 

 

 

 

The next photo will show the actual tissue that has now been removed and will be sent for pathological diagnosis. 

Finally, the before and after show the transition, having removed the gynecomastic tissue and the incision has well-healed.  Also note that the nipple in the areolar has retracted and has become smaller in size due to less pressure from the herniated tissue beneath the areolar.

FDA's Discussion And Update On Breast Implants

On June 22, 2011, the updates included silicone breast implants are mostly safe.  The most important considerations that they determine are that the silicone and saline implants are safe; however, these implants are not lifetime devices and that they must be replaced and on the average, 8 to 10 years.  The studies have shown 40 to 70 percent of women who undergo breast reconstruction will under revision surgery in 8 to 10 years, while 20 to 40 percent of patients who have cosmetic elective augmentation mammoplasty will undergo secondary surgery in the next decade.�
The most common side-effects found by the FDA include scar tissue around the implant (also referred to as capsular contracture), visibility and palpability of the sides of the implant which also may be associated with scar tissue.  Also problems they have found include rupture, wrinkling and a lopsided appearance, according to the report.
 All of this study information was found through two U.S. Manufacturers, Allergan Pharmaceuticals and Johnson and Johnson (Mentor Corporation).  They also found that 15% of the women enrolled in a thousand-patient study of Mentor were accounted for over eight years, but 42% were not accounted for.  In other words, there was a significant drop-off of women who remained in the study and therefore final conclusive information was difficult to achieve.  There has also been a small incidence of a cancer, referred to as anoplastic large cell lymphoma (ALCL) which there have been 60 cases out of 10 million women with breast implants.  This is a very, very rare cancer, but women should be aware of the very low risk of this tumor.�
Finally, they indicated that most women have reported very high levels of satisfaction with body image, shape, feel and size of their implants.  Women must monitor their breasts for the rest of their lives to make sure there are no problems.

DR. OZ DOUBLE EMMY AWARDS!

It has been an honor and a privilege to work and continue to work on segments in Plastic Surgery with the Dr. Oz Show.  The Dr. Oz Show/Zoco Production/Harpo Production has just won two Emmys for its Aware Winning hour program on the multitude and variation of health issues.  It has always been an exciting and humbling experience to have the opportunity to work with Mehmet Oz on segments on Body Sculpting and Plastic and Reconstructive topics.  Last Sunday night the Dr. Oz Show won two Emmy Awards which signifies the continued dedication, hard work and excellence in a multitude of topics on health issues.  In the last season I was thrilled to work on segments, including The Bra Bulge Procedure, The Muffin Top Procedure and Saddlebags.  I look forward to this new season and upcoming creative topics on body sculpting as well as reconstructive surgery.  Once again, I am so pleased and proud of the Dr. Oz Show and their Emmy wins this year.  He is most certainly deserving of such a high and distinguished honor.

Typical Liposuction Regions

Patients present for liposuction daily in my Beverly Hills practice.  There are generally localized areas that are considerable favorable, including periumbilical, lower abdomen, iliac crest roll, hips, flanks, lateral breast, medial and lateral thighs.  There are also typical areas which include the knees, arms, as well as anteromedial thigh fat pads.  The difficulty in these regions can be associated with skin laxity in which liposuctioning aggressively can increase contour deformities and skin contour irregularity. 

For example, liposuctioning of the brachial region or arms, can lead to lumpy contour deformities due to the fat being more globular and less compact or dense.  This is a typical area to maintain a predictable result and therefore should be only performed by skilled Board Certified Plastic Surgeons who are well experienced.  Liposuctioning of the medial lateral knees can be difficult as the fat can be more dense and thick and there are structures that must be avoided.  Liposuction of the calves or ankles can be extraordinarily difficult as the fat is quite thin and compact and it is vital not to risk injury to nerves or blood vessels in these regions.  The anteromedial thigh fat is a favorable are in some patient; however, skin laxity preoperatively can increase contour deformity associated with increased skin drag.  The fat of the anteromedial thigh is quite different than the lateral thigh in which there is more favorable suctioning of the outer thigh saddlebag areas due to the compact fat which smooths out nicely.  The anteromedial thigh fat, however, can have increased contour lumpiness and deformity if liposuctioning is close to the skin or over-zealous surgery is performed.  Only experienced Board Certified Plastic and Reconstructive Surgeons should perform liposuction in these remote, difficult and often fibrotic regions.

Inadequate Pectoralis Muscle Release Deformity

The below example is an excellent case of inadequate release of the parasternal attachments of the pectoralis major muscle.  Inadequate release of the muscle attachments along the inner chest wall can lead to severe deformity which can plague the patient for years to come.  The patient below has had multiple surgeries, actually three operations, and still has the severe banding along the parasternal ridge extending up towards the nipple areolar complex.  She has had multiple surgeries and at each setting the muscle was not appropriately released which continued to cause this deformity. 

The preoperative photo shows the severe doubled-like folds which shows the banding and on flexion at the hips there is even displacement of the implants.  I refer to this as a “catcher’s mitt” deformity in which the muscle attachments push the implants up and outward, causing severe deformity which cannot be corrected unless the muscle is completely released.  This patient by the purple markings shows the areas where the muscle will be released and capsulectomy will be opened through an open capsulotomy.  Care was taken not to remove a large amount of tissue or capsule in order to prevent visibility and palpability of the implant edge.  This patient underwent removal and replacement with style 45 extra high profile 800 cc silicone gel implants in order to regain fullness, as can be noted.  Also, note that the nipple areolar complex is now more centralized into the middle of the breast rather than as had been bottomed out previously.  The open capsulotomy extended under the clavicle and superior pocket which allowed the implant to lie in the correct position.  The muscle was completely released with electrocautery and a small portion of the capsule was opened obviously as well. 

The postoperative results show a smoothing out of the medial pole of her breast bilaterally with symmetry and recentralization of the nipples.  This patient is now three months out.  This is a classic example of a type of revision that I perform almost weekly, in which the muscle again was not adequately released on three previous attempts.

International Travelers For Breast Revision Surgery

It is a humbling experience and a privilege to be able to operate on patients worldwide.  This week alone we have had breast revision patients arrive from Bombay, India, Alberta, Canada, London, England, as well as patients from the east coast United States.  The common theme has been breast revision surgery where these patients have had multiple operations on their breasts, and dissatisfactory outcomes.  Being able to create a perfect breast is not always possible.  Once the clay has been molded, it is difficult to remold it back to a normal shape.  My goals on each and every one of these revisions is to try create a normalcy, proportionality, recentralize the nipple areolar complex to its normal position, and minimize scarring when possible.  However, on some cases scarring is a requirement.  Performing mastopexies either through an inframammary scar or an anchor is required, especially with double-bubble deformities as we saw with the patient from Las Vegas, Nevada and Alberta, Canada this week.  The patient with severe bottoming out presented from Bombay, India, which required both internal capsulorraphy as well as removal of skin along the inframammary fold.  I was able to recentralize the nipple areolar complex beautifully as well as reduce the size of her implants by 40% as she desired.  She now has a significant improvement in the proportionality of her breasts to her body. 

Whether breast revision patients come from close by neighborhoods in Beverly Hills or West Los Angeles or whether they come from interstate lines throughout the United States or as far as Shanghai, Singapore, Dubai, or Bombay, India, all women have a common desire and that is to create a normalcy to their breasts from their past results that are dissatisfactory.

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