The technique of laser liposuction (SMARTLIPO):

The laserlight used has a specific wavelength which selectively destroys fat cells.
For the best effect, the laser probe, which is like a thin needle is brought into contact with the fat directly under local anesthetic.
The laser light is selectively absorbed by the fat cells which are destroyed and liquefied. The body does then absorb the liquefied fat (laser lipolysis) or it can be removed via gentle liposuction with a thin cannula in the same session (laser liposuction).

Key advantages of laser liposuction (SMARTLIPO)

The better skin retraction with laser is the by far most significant advantage of laser liposuction (SMARTLIPO,lipolaser). Areas which were very difficult to treat before, especially inner arms, inner thighs and lower abdomen give far better results when using the laser.
Since we use the laser, we can spare many patients arm and thigh lifts because of this better skin retraction.
In the immediate postoperative period there is significantly less pain, less bruising and a very fast recovery, if any.

Alternatives and comparison to other latest developments in fat treatment:

Invasive Ultrasound:Has a similar working principle but does not work as refined as Laser. From the surgical point of view, ultrasound (VASER) is also a good innovative liposuction technique, but the risk of skin burns and seroma formation seems to be significantly higher:

Lipolytic injections:Based on selective dissolution of fat via injected enzymes, this sounds very appealing to patients.
The great disadvantage is that the dissolution of fat is not easily controlled and undisghtly dimples are a real risk, which may be very difficult to correct.
Non-invasive ultrasound, radiofrequency:is a paramedical treatment without any scientifically proven effect.

For Cirumed Clinic Marbella, laser liposuction is currently the goldstandard in the treatment of fat deposits and with view to results, recovery as well as possible complications significantly superior to conventional tumescent liposuction.

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Dr. Alexander Aslani is director and head of the Department of Plastic, Aesthetic and Reconstructive Surgery in Hospital Quiron Malaga since 2009.

He has undergone extensive training in Plastic, Aesthetic and Reconstructive surgery and has held various academic consultant positions in university hospitals in South Africa, Germany and Austria, including a fellowship in craniofacial surgery.
Dr.Aslani has been senior lecturer in the Austrian academy for microsurgery and lecturing professor at PMU Medical school, Salzburg Austria.

Apart from Aesthetic surgery as head of department of Plastic surgery of Hospital Quiron Malaga he has special interest in Reconstructive surgery, especially microsurgery of the breast and head and neck, as well as Hand surgery.

Apart from his academic appointments, Dr.Aslani has been in private practice since 2003.
He is a registered expert witness of the Colegio de medicos Malaga.

Dr.Alexander Aslani works in the field of Plastic Surgery since 1995.
He has been a delegate of EBOPRAS, the European Board of Plastic,
Reconstructive and Aesthetic Surgeons since 2003.

Curriculum:

Director y Jefe de servicio del departmento de Cirugia Plástica y Reconstructiva de Hospital Quirón Málaga since 2009.

Director de Cirumed Clinic Marbella since 2007.

Previous appointements:
Consultant Plastic and Aesthetic Surgeon, Highgate Hospital, London, UK
Consultant Plastic Surgeon, Dolan Park Hospital, Birmingham, UK
Senior lecturer Microsurgical traing centre Austria
Lecturing Professor PMU University Salzburg  Austria
Fellow European Board of Plastic, Aesthetic and Reconstructive Surgery (EBOPRAS)
Consultant Plastic Surgeon, Abteilung für Plastische Chirurgie, Salzburg,  Austria
Consultant Plastic Surgeon, Departamento Cirugia Plastica, Reconstructiva Cirugia de mano, RWTH Aachen
Craniofacial fellowship, Wentworth Hospital, Durban, South Africa
Resident Plastic Surgeon, King Edward Hospital, Durban, South Africa
Resident and fellow general sugrery, UKH Salzburg

Reg.Nr Colegio de medicos Malaga 29/29/09754

28 year old patient requesting breast enlargement,moderate amount of gland

After submuscular breast enlargement, round implants.

The patient requested cleavage, therefore round implants where the better option. The submuscular position gave the patient cleavage but still a antural look.

This patient requested breast augmentation but a natural look was of utmost importance to her, therefore the decision was made to use anatomical implants.

Another example of a moderate profile implant in submuscular position:

Again the round implants do not cause an overly wound shape in the submuscular position, but provide cleavage.

The moderate profile prevents too much of gap between implants

The inframmary incision is not noticable in the new inframammary fold.

The next patient requested the most natural look possible, cleavage was of less importance to her, the decision was made to use anatomical implants.

Before and after augmentation with 335 cc anatomical implants

Different patients request different options, and a solution which is desired by one patient may not be so good for another patient.

There is no precut recipe which applies to all patients, therefore we suggest to take sufficient time to discuss in depth all options between surgeon and patient.

We do mainly use implants of the Natrelle, Allergan and Polytech brands.

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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.

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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.

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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

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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.

Examples from our gallery:

Breast augmentation 335cc anatomical implants submuscular before:

Breast augmentation 335cc submuscular anatomical implants after surgery:

Breast augmentation 340 cc moderate profile round implants subglandular before:

Breast augmentation 340 cc moderate profile round implants subglandular after:

There are no precut recipes for the best procedure in breast augmentation, but a lot of suitable solutions for different patients.

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“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.

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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.

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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.

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