Cirumed Clinic Marbella

Reconstructive microsurgery

What is microsurgical free tissue transfer ?

In modern Plastic and Reconstructive surgery, free tissue transfer is used to

a)close or fill soft tissue defects following trauma, burns or tumor resection
b)Reconstruct organs (breast reconstruction following cancer or congenital anomalies, tongue reconstruction) also f.i. phalloplasty in transgender surgery
c)Reconstruct muscle function (functional muscle transfer following facial palsy)
d)Reimplantation of severed extremities

When is microsurgical soft tissue transfer carried out ?

Guidelines are the so called “ladder of repair”, which recommends that surgeons should always endeveaour to first embark on any procedure that is easier and more straightforward than microsurgical free tissue transfer.
The  “ladder of repair” has to be followed under consideration of comparable results, which have to be adequate or not inferior with view to form , function and aesthetic outcome.
In other words, sometimes a solution using local, pedicled tissue transfer may be possible , but in the long-term the patient may benefit more from the more extensive solution of microsurgical free tissue transfer.

In summary, the expected result bot with view to form and function have to be superior when microsurgical free tissue transfer is used, as compared to local, pedicled transfer.

Who is suitable ?

Generally everybody with a reasonable indication. Medically, microsurgical free tissue transfer is an extensive operation. Therefore patients must be fit to undergo such extensive surgery. This is normally a mutual decision between anestesist and surgeon.

What are the risks ?

Whenever free tissue is harvested for transfer as a so called “free flap”, there is a certain donor-site morbidity.
Ideally this is only a scar.

Some donor site scars are better and easier to hide than others, this depends on the case.
If muscle is harvested, there maybe functional deficits, which are held as small as possible by selecting muscle tissue which anatomically results in small donor site defects.
There is always the risk of flap loss, this may be technical (failure of anastomisis of vessel), or patient related ( smoker, small vessel disease, extended trauma zone, irradiation f.e. in breast reconstruction). There is no absolute percentage since preconditions depend on very individual factors.
A surgeon who performs many “free flaps” f.e. to cover lower extremity defects in acute trauma patients will lose more flaps than a surgeon performing rather selective breast reconstruction in well-conditioned patients.

Smoking is a key risk factor, especially in microsurgical breast reconstruction. Excessive smokers face a high risk of complete or partial flap failure. Long term smoking may leave vessels irreversably damaged, which may make any microsurgical procedure very hazardous.

What are the benefits ?

Microsurgical free tissue transfer enables surgeons to select optimum tissue for optimum form and function. In the ideal case, the donor site morbidity adds up to an aesthetic benefit for the patient.
An example is free tissue transfer harvesting tissue from the abdomen (TRAM, DIEP flaps) which is used for breast reconstruction.
The donor site closure results in a situation very comparable to an abdominoplasty, therefore the patient seeking breast reconstruction via this operation has actually got an aesthetic benefit from harvesting the flap.

This results in very high satisfaction rates with this kind of flap in breast reconstruction.

Other common options for harvest of tissue for microsurgical transfer in breast reconstruction are the thighs and the buttocks.

These breast reconstruction are mainly used when there is not enough tissue excess available to harvest as a flap.

Is it true that microsurgical breast reconstruction needs to be carried out in multiple stages ?

Normally yes. Again there is a certain range of opinion as to whether to perform an additional, adjusting procedure on the contralateral “healthy” breast, frequently a breats uplift. I mostly prefer to leave that for a second step because the results are more predictable once the reconstructed breats has fully settled.

Reconstruction in one session is fully acceptable, but from my view and experience at the price of a higher revision rate for the adjusting breast uplift.

Also, there may be requirement for additional nipple reconstruction in an additional session.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:

Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Breast enlargement without implants ?

Dr.Alexander Aslani, Specialist Plastic Surgeon and Head of the Department of Plastic, Aesthetic and Reconstructive Surgery of Hospital Quiron in Malaga, Spain, on of the  most controversial  topic in cosmetic surgery: breast enlargement without implants.

Macrolane

Is currently a very popular option with a few myths around it.

With view to the popularity of breast enlargement in Spain,I see significant numbers of patients looking for this possibility, with few of them actually being aware of the limitations in indications.

Basically Macrolane is hyaluronic acid, which is well known and a has a long history as a wrinkle filler , just used in a higher density. It is the most frequently used brand for the indication with new ones coming onto the market now.

The concept is to use this as a “filler” for the breast. The idea is very appealing and there are indeed some interesting indications for Macrolane in breast enlargement for selected patients.

Macrolane is also suitable to treat small contour deformities, especially after liposuction. I think this will be one of its prime and most widely used  indications in the future. Macrolane for breast enlaregment will play a role, of course, but patients seeking breast enlargement via this route will have to understand the limitations.

Macrolane injections have to be repeated, although required injection volumes for subsequent “touch-ups” are significantly less than for the first treatment. Macrolane can be administered using local anestetic, but macrolane injections have to take place in an operating theatre though, for the sake of patient safety.

Amongst surgeons, there is a certain range of opinion as to how much macrolane may be used in one session for breast augmentation. I prefer to restrict to about 100 cc per session. Some surgeons inject a lot more, but there are concerns whether distribuition of fluid is entirely predictable or not. To my opinion, with an injection of 100 cc one stays within a safe margin, preventing the danger of unforeseen and undesired fluid distribution.

Lumipness and adverse reactions have been observed in some cases. Patients need to be aware of this.

They problem is usually temporaray, but can last for some time.

Whilst  macrolane has already been available on the market for a couple of years, this is still a comparably short time from the surgical point of view.

Downside is furthermore  that the possible volume injection is restricted.

Free microvascular tissue transfer

It is possible to apply tissue transfer techniques parallel to those used for breast cancer , also  for breast enlargement.

Therefore tissue can be taken from the buttocks or from the abdomen and transferred to the breast.

Microsurgical techniques are then used to anastomose vessels taken with the block of tissue, to donor vessels,usually in the axilla. This is an extensive operation.

This makes any  implant removals in the future superflous. However it is a very expensive and long operation and will therefore remain a rather exotic indication. It may be used in cases of congenital breast deformities though, like Poland-Syndrome (failure of breast bud to develop on one side). In these cases, microsurgical free tissue transfer may be considered.

The extent and cost of this operation will leave this possibility random in the future. Some surgeons say that the extent of such surgery is disproportionate to the effort of mere breast enlargement.

I do not necessarily agree to this, but suggest that patients are entitled to decide individually after careful explanation of the implications involved.

It is a consideration in discussing breast enlargement options.

Autologous fat transplantation

The one of the dreams of Plastic surgery.

Take the patient´s own (autologous) fat from somewhere else and inject it for breast enlargement.

Unfortunately it is not that easy.

There are certain established methods to prepare fat for transfer, especially the so-called Coleman technique (centrifugation technique) and numerous preparation kits are on the market.

Success of these techniques is quite variable though.

They may, or they may not, work. The smaller the volume of fat injected, the larger the chance of “take”. Take means the percantage of fat that survuves the transplantation. This take of fat transplants is vetry variable and differs from patient to patient.

Current research is aiming at mixing free autologous fat with growth factors and even to “breed”patients own fat cells.

This may increase survival of fat tissue but there are, as I have to say, fundamented concerns that these growth factors may possibly promote growth of breast cancer.

We are still in the pioneering stages of such “tissue-engeneering” techniques.

Vacuum-assisted devices

Have received excessive marketing attention. Principle of these treatments is that continued vaccum pressure applied to te breast may assist in breast enlargement of tissues.

I personally cannot comment on possible success, since I have no experience with these.

From the strictly scientific point of view the success rates seem rather fictional. I do not see any physiological mechanism suggesting that this really works.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Gynecomastia

Dr.Alexander Aslani, Specialist Plastic surgeon and Head of Department of Plastic Surgery in Hospital Quiron Malaga, on the most important facts around male breast reduction:

Whilst it is difficult to verify exact statistics, it seems that gynecomastia (male breast reduction) is the most frequent request for cosmetic surgery among males, competing with liposuction and rhinoplasty.

There is a multitude of reasons for the condition, we have clearly identified a few drugs causing it, I personally see increasing numbers of steroid abusers.

Other common culprits causing gynecomastia are a couple of antihypertensive drugs, hormonal problems, and often, simply genetic predisposition to gynecomastia (in other words bad luck).

What is the ideal age for operating a gynecomastia?

There is none because the problem can occur at very different ages. Depending on the cause, the ideal age is when the condition becomes unbearable for patients. The most difficult question is normally what to do with young patient. Whilst cosmetic operations on miors are obsolete, gynecomastia is not strictly cosmetic and psychological distress can be unbearable.

Under these circumstances psychological distress for patients may well be unbearable and needs relief.

Does social insurance pay for gynecomastia ?

That depends. Some insurers, at least in Spain, accept grade II+ grades as medical indications. This reflects my opinion a swell, certain degress of gynecomastia are rather resonstructive by nature than cosmetic. Not all insurers share my opinion though.

In Spain the majority of cases are treated outside the social insucrance system,

Can gynecomastia be solved by liposuction alone?

In selected cases yes.In most cases resection of breast gland will be necessary.However, this depends always of the individual case. As a rule of thumb, being deliberately vague, one can say that the older you are the more fatty tisuue you will find and the more likely liposuction alone will be successful. Breast reduction can normally not be satisfactorily achieved by liposuction alone in younger pateints. In older patients with drug-induced gynecomastia it may well be possible to do lipsuction only.

What scars are involved ?

Depends. Normally a semilunar (half nipple) scar at the lower border of the nipple. I usually discuss two possible proceedings with patients: first the resection of glandular tissue (mastectomy) and , possibly later, as a second step tightening of the skin.

In the majority of cases I see sufficient skin retraction without going back to convential procedure.

If secondary skin tightening is necessary secondarily, then the scar will normally go circular around the nipple. This will only be necessary in very advanced gynecomastia cases, since in most cases skin retraction is very good.This can never be guaranteed though, but my experience is that it is preferable management of male breast reduction.

What is the biggest problem around gynecomastia ?

Recurrence. The gland behind the nipple needs to be resected in true gynecomastia cases, some part of it will usually remain and possibly lead to recurrence. Overly aggressive resection of the gland will usually lead to a dimpling nipple.

What is recovery time after a gynecomastia operation ?

Usually very short, defintely depending on the extent of resection. I like to use a compression garment of a minimum of two weeks post surgery, possibly longer.

What are the risks in gynecomastia surgery?

The main problem is insuffucient skin retraction and irregularities, mostly behind the areola. This can normally corrected by scar release and further skin resection.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

The most frequent questions around cosmetic surgery

Question: What is the most popular procedure in cosmetic surgery ?

Dr.Aslani:In women breast augmentation and liposuction, in men gynecomastia(male breast reduction),rhinoplasty and liposuction. This only reflects my personal experience though. Different surgeons may have different views regarding that

Dr.Aslani:You can prepare your skin with antiseptic solutions like for instance Hibiclens. You can furthermore treat your skin with moisturising lotions. I am unsure what effect that really has, but this is recommended. I do regard beneficial effects from so-called “scar-ointments” as purely fictional.

Question:Is it true that cosmetic surgery in Spain is more popular than anywhere else in Europe?

Dr.Aslani:Yes, I should think so.

Question:Do you think that the current situation has got an adverse effect on quality in cosmetic surgery , especially in Spain ?

Dr.Aslani:I hope not, but I am very much afraid this may well be the case.

Especially in the cosmetic surgery sector in Spain, we see very aggressive marketing moves from UK companies into the sector. We are seeing more and more petients hooked on unrealistic promises paired with ridicolously low pricing. I am afraid that this will not have any good long term effect neither on the cosmetic surgery sector in Spain, nor in the UK:

Question:Is it true that I can only have my eyelids done twice in a lifetime ?

Dr.Aslani:No, not entirely. You are likely to refer to the lower eyelids. There may be some truth in that regarding them though.Lower eyelid blepharoplasty is considerbly more complicated than upper.

Question:Is a deep peeling a good subtitute for a facelift ?

Dr.Aslani:Absolutely not. The mechanism as well as the indication are completely different. A peeling tackles different problems than a facelift.

The two can be combined, but I suggest to do one after the other and not two at the same time.

Round block breast uplift techniques

The Benelli breast uplift (concentric, or peri-areolar or doughnut lift)
This technique is considered less invasive and was designed with the scars being around the areolae. With the Benelli, a donut shaped piece of tissue around the areola border is removed and the surrounding tissue sutured to the areola. The incisions are normally closed with purse string sutures. Sometimes a little more tissue is removed above the areola (like the crescent) to compensate for a lifting effect when it is sutured. The Benelli lift results in a flatter, rounder breast shape post-operatively as opposed to a sloped breast. The flatter aspect after the uplift is, however, temporary, and given time to settle a pleasant effect does ususally occur quickly.

The Benelli breast uplift can be combined with breast augmentation in cases of moderate ptosis(saginess) of the breast and a very empty skin envelope.

Areola Reduction Surgery
Some women may be displeased with the size of their areolae which may be enlarged due to genetic predisposition, previously having had large breasts then undergoing tissue loss, stretching of the areola due to implants or other reasons. The areola reduction surgery is designed to remove the redundant areola tissue to improve the overall cosmetic appearance of enlarged areolae. The reduction may result in a slight lift and may also produce slight irregularities at the incision line if the reduction was significant.

Again the approach can be combined with  breast augmentation via implants

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es
www.cirumed.es

Breast augmentation-above or below the muscle ?

There are ongoing debates as to whether it is more advisable to place the implants in breast augmentation on top or below the breast muscle.

As in most cases involving aesthetic surgery, there is no single right answer.
The main reason for subpectoral (under the muscle) placement is as follows:
1. The muscle covers the implant, thus capsular contracture (“breasts that feel hard”) is less common.It has become rare anyway, but the cases that I usually see are breast augmentation on top of the muscle. Another theory is that should capsular contracture occur it may be less obvious to be detected.
2. For the same reason, rippling (wrinkling) of the implant is less apparent.It is never completely evitable though.If patients will normally notice such rippling on the lower pole and side.
3. Mammograms are more accurate.
4. In very small-breasted women, the outline of the implant is less visible.As a rule of thumb, if the thickness of breast tissue is less than 2 inches, submuscular placeement is mandatory.
5. Muscle tissue is well perfused. Perfusion is the best combat tool against infection, the most dreaded risk in breast augmentation .

The argument for subglandular breast augmentation (under the breast tissue) placement is as follows:

1. If any degree of ptosis is present, a subglandular implant lifts the breasts much better.
2. Lower risk of postoperative bleeding is involved.
3. Significantly less postoperative pain occurs.
4.  Breast augmentationcan be performed with intravenous sedation and local anesthesia, which is a safer alternative to general (complete) anesthesia.

There are no precut recipes for te best procedure in breats augmentation, but a lot ofsuitable solutions for different patients.

For more info please visit www.cirumed.es

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:

Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es
www.cirumed.es

Is breast augmentation combined with uplift a safe procedure ?

Breast augmentation mastopexy,which means a breast uplift combined with  breast augmentation with implants is probably, apart perhaps from rhinoplasty, the most demanding procedure in aesthetic surgery.

“There is a lot of misunderstanding around this operation,and whilst it may be extremely rewarding, patients need to understand the complexity of the operation to adequately appreciate the results “, says Dr. Alexander Aslani, who is head of department of Plastic surgery, Hospital Quiron, Malaga.
He has extensive experience with breast augmentation with mastopexy, because it is one the most frequently demanded operations within cosmetic surgery in Spain.

Indication for a breast uplift is breast ptosis (sagginess) of the breast, most commonly following weight loss and pregnancy.

This results in an empty skin envelope with no appropriate filling. The concept of the operation is to tackle the problem from two sides: firstly to tighten the skin envelope and secondly to fill it appropriately with a breast implant.
“The change can be very impressive and patient satisfaction is very high, however, depending on the degree of sagginess, a certain amount of scarring will be necessary,” says Dr.Aslani.”I normally advise patients that shape of the breast is much more important to patients than scarring in the long run, but scarring will be involved.
To what degree does very much depend on your skin type, the fairer the skin the better the result.”
There are still surgeons promoting a two-stage approach, which means doing the mastopexy in one go and then the implant placement in the next.
“The advantage of this is that the tissue reaction is more predictable” so Dr. Aslani.”On the other hand patients always need two operations. In my experience, although I completely agree that the overall revision and complication rate of combined breast implants and uplift is significantly higher than in a plain breast augmentation , it is safe and preferable to do the operation in one go.
There is a higher incidence of infection, wound healing problems, scar revision, that is true, but this is clearly outweighed by the benefit arising to the patient from a one-stage procedure.

My experience is that given that patients are aware of the complexity of such a breast augmentation and breast uplift procudure, they are usually very happy with the fairly impressive change achievable.

There is however a certain chance that both surgeon and patient agree on performing a touch-up procedure like a scar revision, often around the nipple, after about a year has passed.Whilst these are mainly minor procedures that can be done under local anesthetic, scientific literature reports incidence of such requests being as high as 15%.
Especially for UK residents coming to Spain for cosmetic surgery this has to be discussed and born in mind.
The most common misunderstanding within this procedure is the expected change of breast size.
“Uplift and implants combined do not necessarily increase cup size, but rather a preexisting cup-size is filled by proper breast volume than just by an empty skin envelope. It is about changing the shape of breast, not primarily about increasing the size. There must be a good understanding between patient and surgeon beforehand, I always say the patients with breast augmentation with uplift need to be selected very carefully.Especially patients rather wishing bigger breasts need to be advised that there is unfortunately no way to get around gravity in the long term.”
The change in breast shape is quite dramatic and patient satisfaction with the operation generally very high.
However, patient understanding regarding the procedure must be kept very clear.
Whilst scarring, implant positioning and staging were and will remain a controversial topic among Plastic surgeons for a while, the combination of breast implants with breast uplift can,on the other hand, be one of the most rewarding surgeries of all.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Are polyurethane coated implants better in breast augmentation ?

Lately polyurethane coated breast implants have received increased attention in breast augmentation surgery. The theory behind this is that the fine coating should prevent capsular contracture.

Whilst I think that this is a very interesting approach, I have encountered a few problems with the use of these implants, namely the use for slightly larger incisions and I have experienced that they are somewhat difficult to remove if one wants or has to exchange the implant for instance, for a bigger one, not an unusual event in breast augmentation surgery.

No implant prevents capsular contracture, and I currently reserve the use of polyurethane coated implants for cases where revisional surgery for capsular contracture after breast augmentation is mandatory.

If breast implants in breast augmentation are positioned below teh muscle primarily the chances of capsular contracture are generally very low. Most cases of capsular contracture are encountered once breast augmentation is combined with breast uplift surgery.

Dr.Alexander Amir Aslani, MD, EBOPRAS

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Which breast augmentation incision is best?

There is no one best incision, since it depends on factors like what kind of breast implants you are getting, your anatomy, your lifestyle, what size implants you are getting, and your surgeon’s preferences.

To some extent, it is up to the patient. In Spain, for instance, we observe many patients favouring  breast augmentation via a periareolar (nipple) incision, for a variety of reasons.

There is no single best incision, but lots of pros and cons.
There are surgeons who will insist that one is better than the other, and each type of incision has undoubtedly got advantages.
It all depends upon your needs. Remember, you will end up with bigger breasts no matter what incision is used, but some will give you less scarring than others. Always think long-term because implants may, one day, have to be replaced.

Read more about breast augmentation in Spain here.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es

Trigger finger release

….is a common condition mostly affecting 3rd and 4th finger. The principle is that, for a variety of reasons, the flexor tendon of a finger may get trapped in a “pulley” that normally forms they basis for the flexor tendon to glide in.

Should now the tendon thicken or other pathologic processes restrict movement of the tendon within the pulley, this can lead to entrapment of the tendon within the pulley and blockage of movement. it is one of the most common requests in hand surgery.

Whilst steriod injections have been suggested and are possibly still widely practised, state of the art treatment is surgical release of the pulley, which can easily be done under local anestetic.

Read more about trigger finger here.

Dr.Alexander Amir Aslani, MD, EBOPRAS

Hospital:
Chief Surgeon and Head of Department
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es

Private practice:
Cirumed Clinic
Avda.Ramon y Cajal 7-4°
E-29601 Marbella/Malaga
Spain
Phone:+34 607 307 515
info@cirumed.es
www.cirumed.es