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.

Case example macrolane before and after 180cc macrolane breast augmentation:

Macrolane is currently the most popular solution in non-surgical breast augmentation.

The augmentation shown does exhibit the, usually, maximum possible augmentat¡on in one session.

In this case, 80 cc macrolane were applied 20 months after the initial procedure.

This reflects the usual percentage of reabsorption.

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

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