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

Cosmetic surgery in Spain…….

….is doubtlessly changing its face.
Patients are being more critical, which is good.

In my practice, I notice that patients seeking cosmetic surgery, which is not the only kind of surgery we do of course, ask more well-informed and detailed questions. Spain does traditionally represent a very high standard of cosmetic surgery, with very large numbers of cosmetic surgery cases done each year, amongst the highest rate in Europe. Numbers are not all in cosmetic surgery, but the are of relevance
However,there is still a lack of regulation.
We still see tourism for cosmetic surgery in Spain especially from the United Kingdom, although I think that in the future this has to reviewed critically. In our clinic we do for instance not accept patients any more who are not willing to involve their GP, just in case.

Cosmetic surgery is elective and is generally undertaken under optimal conditions, nevertheless, there are implications, and even if they rather have the nature of nuisances, they have to be adressed.
Cosmetic surgery in Spain has been a major field of interest for companies engaging in this field and I notice that this sometimes attracts patients which may lack basic understanding for what cosmetic surgery is about: working with living tissue with all its inherent pleasures, but also its complications.

With  companies organising cosmetic surgery travel to Spain,I have increasing concerns that understanding for this seems to get lost.

Cosmetic surgery is not like buying a car.
I still think there is a great role for cosmetic surgery in Spain in the future, especially when, hopefully in 2010, private healthcare providers in Spain will be under mandatory regulation, especially companies providing cosmetic surgery in Spain, and there will be no more space for unregulated commercial companies running without regulation or medical directory, purely guided by commercial targets that have to be met.
The structure that we, Plastic surgeons in private practice in Spain, are hoping for, is to establish regulation which might be very similar to the UK healthcare commission.
Whilst this will add a lot of bureaucracy, it will also create a more controlled working environment for us and put an end to commercial entrepreneurs without medical knowledge embarking on a delicate field that requires strict regulation.

The advertising of such companies can be highly misleading in a way that patients tend to believe that the company management might dispose of decades of experiences in cosmetic surgery, while it fails to clarify that this experience is restricted to selling cosmetic surgery and not to any medical knowedge.
This will bring cosmetic surgery in Spain a new face.

Read more about cosmetiy surgery in Spain here

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

Choosing implant size in breast augmentation

Choice of size is a difficult, but important factor in breast/breast enlargement surgery. 
To my experience, it can go two ways, but from a practitioners point of view it is much more frequent to see patients asking for bigger implants than having it the other way round.
I think a contributing factor is especially that many patients orientate on “celebrity”-examples of patients who have had more than one breast augmentation and in that case tend to look “over”operated indeed.
It is impossible to try a breast implant on like a shirt. You dont get this opportunity in breast augmentation. Several factors need to be considered.
1. Dissatisfaction with breast size is the number one cause for re-operation in breast augmentation surgery. Nevertheless, it is not a revision for a surgical complication because everything may have gone very well.
2. You cannot plan a cup size,a cup size is just a letter. It is more important to gather together photographs of your likes and dislikes when it comes to breast size, shape and form. Different brands of manufacturers will have different cup sizes for the same breast.
3. Sizing implants slipped into your bra can give you a relative estimate of breast implant volume.The tend to look a bit “stuck-on”. Most surgeons, who frequently perform this operation will have a set of sizing implants available for you to examine and place in a bra.
Go for the feeling in size and not for the look.
4.Remember that in breast augmentation there are factors that cannot be changed, like for instance the width of your sternum. Breast enlargement gives you a bigger breast and a certain
Change in shape. However, you cannot buy a breast “of the shelf”
5.The choice of projection and implant shape, be it teardrop or round, will depend on the shape of your breast before the operation and position on the implant. I frequently observe that patients translate a solution from a friend they might know and who has had a breast augmentation to themselves.This does not work this way. Every body is different and everybody is individual.

Read more about  breast augmentation here.

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