Plastic Surgery Articles New Jersey - Dr. Larry Weinstein

Plastic Surgery Articles

Advancements in breast reconstruction

To coincide with Breast Cancer Awareness Month, Wendy Lewis investigates the options available to women seeking breast reconstruction and how new techniques are greatly improving outcomesTo determine the best plan for every patient, there are many variables to be considered, including the patient’s age, body type, surgical history, tumour size, stage of cancer, previous treatment with radiation, and insurance coverage, along with the patient’s preferences. It is important to remember that there is a lot at stake for the patient. She will have to live with the consequences of this potentially life-altering decision, and therefore, she should ideally play an active role in the decision-making process.

There are concerns regarding breast cancer patients’ access to breast reconstruction, which has been shown to provide important psychosocial benefits. Breast reconstruction has increased over time, but it has wide geographic variability. Many women who face a cancer diagnosis are not informed of the reconstruction options available to them. Further research and interventions are needed to ensure equitable access to the multidisciplinary treatment of breast cancer1.

New trends in breast reconstruction

According to the American Society of Plastic Surgeons (ASPS), 95589 women underwent breast reconstruction in 2013 in the US, a 21% increase since 2000. A total of 76078 women opted for implant reconstruction. Of these, 19511 women underwent flap reconstruction, the majority of which were deep inferior epigastric perforators (DIEP), latissimus dorsi, and transverse rectus abdominis myocutaneous (TRAM) in descending order2.

One of the most notable trends is that nipple-sparing procedures are becoming an increasingly common choice for women undergoing mastectomy. Although considered a relatively new and technically challenging procedure, more surgeons are now offering nipple sparing mastectomy (NSM) to patients who are candidates.

According to plastic surgeon Aldona J. Spiegel, at the Institute for Reconstructive Surgery at Houston Methodist Hospital, in Houston, TX, ‘Among the new trends in reconstructive breast surgery is composite reconstruction that combines several procedural modalities to improve outcomes. These procedures include fat grafting to fill in thin areas or irregularities in the mastectomy, combined with the use of collagen over the implant for optimal aesthetic results. Also, over the last 5 years, nipple sparing mastectomy has become a more popular choice in select patients because it results in a more natural appearance where the scar is hidden under the breast.’

However, as Spiegel cautions, not every patient is a candidate for this option. ‘A lot of the modalities we can choose from will depend on the patient,’ she said. ‘Another trend in this field is where patients choose to use their own tissue, for example a DIEP flap combined with an implant. The implant is used like an augmentation to add conical projection, since abdominal tissue is maybe too flat to give adequate projection. This may greatly improve the final result in select cases. By combining a nipple sparing mastectomy with a DIEP flap and an implant, you can achieve a ‘mommy makeover’ result in patients who are candidates for that procedure.’

She adds, ‘For women who are not candidates for flaps, we can offer them composite breast reconstruction by using ADM (collagen) as a hammock for the bottom part of the implant, where the top is covered by pectoral muscle. We can also do fat grafting (liposculpting) over the muscle and ADM to camouflage the implant. In cases with radiated skin, this improves the quality of the skin. In nipple sparing mastectomies, the tissue under the nipple is removed, which flattens the nipple. We can then improve the projection of the nipple by performing fat grafting.’

According to Birmingham, AL plastic surgeon James C. Grotting, President-Elect of the American Society for Aesthetic Plastic Surgery (ASAPS), ‘Among the trends in breast reconstruction over the past several years, we have seen that autologous reconstruction fell quite a bit, from over half of women getting flaps, to now about a quarter of women. This can be attributed to the fact that women in general prefer to have less surgery. They are reading about quick recovery and that is what they want,’ he said. Another reason he cites is that implants have greatly improved. ‘Saline implants have been replaced with silicone gel that are far superior. High cohesive anatomical gel implants are most appropriate in reconstruction, at least in the US market. In many cases, women cannot afford to do autologous flap procedures, which involve a much longer recovery and hospitalisation that is not always covered by their insurance. You can get reasonable results with implant reconstruction alone.’

‘Another trend we are seeing is that bilateral procedures are becoming more common as preventative measures. Conservation treatment is not as popular now, as long term results have been evaluated and oncologists are seeing that there is a strong case for bilateral mastectomy, especially among women who are BRCA positive,’ he said.

Grotting adds that flaps in reconstruction are more frequently used as perforator flaps, where the surgeon tries to take little or no muscle with the flap. ‘This has resulted in an explosion of new donor sites. The abdomen is far and away the best donor flap for breast reconstruction because it happens to be an area of most women’s bodies where fat exists in excess, and skin is loose enough so in the right candidate you can end up with enough tissue to create a natural appearing breast. You can do it as a pedicle tram, muscle sparing free tram or DIEP flap. The important thing is that you leave the abdomen functionally reconstructed and leave only healthy tissue with good blood supply. Good results can be achieved with any of these techniques.’

Novel products for optimal results

Until recently, surgeons had the choice of porcine, bovine or human acellular dermal matrices for use in immediate breast reconstruction. New methods of harvesting and processing autologous fat, variations on surgical mesh, fat used in combination with ADM, and other techniques are revolutionising the way plastic surgeons are perfecting their results even in challenging cases like secondary reconstruction.

The SERI® Surgical Scaffold technology from Allergan (Irvine, CA) shows promise as an off-the-shelf, long-term bioresorbable scaffold for support and repair of weakened or damaged connective tissue. As patients are sometimes concerned about human-derived tissue implants, one of the main advantages of the new SERI® Scaffold is that it is composed of a bioresorbable surgical scaffold made out of a proprietary silk-based material. In Europe, at the current time, the product is not commercially available.

Fat grafting as an aesthetic refinement procedure in breast reconstruction has become a mainstay all over the world. ‘Autologous fat grafting is the future of breast reconstruction. Short of being able to grow a breast in vitro, and that is where we might be some day as fat grafting techniques keep improving. You can combine fat grafting with implants to produce a very natural and beautiful breast,’ said Grotting. ‘I prefer to use the patient’s own natural tissue to support an expander or an implant in place.’

Spiegel is an enthusiastic proponent of the PureGraft (Puregraft LLC, San diego, CA) system. ‘I really love PureGraft. I am now adding fat grafting to most of my breast reconstruction procedures. I usually liposculpt around the flap or implant and I use fat as an adjunct in reconstruction. You have to be very careful that you are not doing anything to the donor site that would cause contour irregularities, which is more difficult in thinner patients.’

The combination of several key components that compliment each other in various ways can produce beautiful results for patients. The concept of the ‘bioengineered breast’ was originally developed by plastic surgeons G. Patrick Maxwell and Allen Gabriel in 2007 when they were using acellular dermal matrix, fat grafting, and highly cohesive gel fifth generation implants. ‘Cells, scaffolds and fifth generation implants are utilised to create the bioengineered breast which creates a more natural shape,’ said Maxwell.

‘This concept has set a new standard in breast cancer reconstruction, allowing women less invasive mastectomies with reconstruction, which often leaves a better cosmetic outcome than the patient’s natural breasts. Not only is the appearance of the reconstructive breasts superior, but the feel of the breasts remain soft and natural over time.’ said Gabriel.

‘A quality of life study in these patients has documented that superior cosmetic results in breast cancer reconstruction lead to an improved quality of life,’ said Maxwell. ‘This same concept of ‘bioengineered breasts’ can be applied to risk reduction mastectomies for ‘prevention’ of breast cancer as well as primary and secondary cosmetic surgical procedures of the breast,’ he added. The authors have the world’s largest experience and clinical series.

According to Dr Marissa Tenenbaum, Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, MO, ‘I use the HydraSolve system from Andrew Technologies (Tustin, CA) for fat grafting in breast reconstruction. The quality of the fat and the ease of use are exceptional. I am seeing a lot less fat necrosis after moving to this technology.’

Patient-centred techniques are changing the landscape

In this day and age, insurers, institutions, and providers are more focused than ever on reducing recovery time for patients, and minimising complications and the need to bring the patient back for additional surgery. Plastic surgeons are also intent on improving outcomes for their patients.

Laser-assisted indocyanine green angiography is a relatively new tool for determining whether mastectomy skin flaps have adequate blood supply. The SPY Elite® System (LifeCell Corporation, Bridgewater, NJ) enables surgeons to assess tissue viability with real-time information that may be used to modify operative plans and optimise outcomes before the patient leaves the operating table.

According to Grotting, ‘The SPY scanner is helpful in surgery to tell you whether the mastectomy skin flaps are good. When the procedure is complete, surgeons can use the scanner to see if the flaps are good, and if adjustments are needed, they can reoperate right then. It can potentially reduce the complication and revision rate for immediate breast reconstruction. You can be surprised that tissue that looks healthy, when you scan it, is not.’

According to Speigel, ‘Restoration of nipple sensation is now also possible using a new method of DIEP flap nerve regeneration using the third anterior intercostal nerve. By connecting the nerve from a flap to the mastectomy nerve we can restore sensation, which is an area that is frequently not discussed and is usually not a procedure covered by insurance. This technique provides a significant increase in sensory recovery for breast reconstruction patients, while adding minimal surgical time.  It is difficult because you have to find a sensory nerve and anatomically, this is not so easy to locate.’?3

Botulinum toxin (BOTOX® Allergan, Irvine, CA) was shown to effectively address the source of severe pain associated with expanded/implant based breast reconstruction following mastectomy. According to Vancouver, WA plastic surgeon Allen Gabriel, ‘We no longer do a single breast reconstruction case without using BOTOX. Implant based breast reconstruction involves implantation of a temporary expander under the pectoralis major chest muscle, which is filled with saline serially to create a pocket where a lasting implant will reside. The muscle often contracts and spasms in response to the expansion, causing pain,’ he said.

In collaboration with Nashville, TN plastic surgeon and inventor, G. Patrick Maxwell, MD, they theorised that injections of botulinum could offer relief by temporarily paralysing the muscle, causing it to remain flaccid so that fewer spasms would occur and less pain would arise.

In their study, the women who received the botulinum injections were far more comfortable after surgery than those who received placebo. Drs Gabriel and Maxwell found a statistically significant increase in the volume of expansion per office visit, leading to full expansion more quickly in the botulinum group than in the placebo group. ‘Our average expansion time is less due to improved pain management with BOTOX®. We take a 100 unit bottle, add 5?ccs saline, and we inject 2.5?ccs on each side during the time of the primary reconstruction,’ said Gabriel. ‘Patients are happier, and the they are more comfortable during this phase.’

The AeroForm™ Tissue Expander (AirXpanders Inc, Palo Alto, CA) is an investigational device in the US that is poised to have a significant impact on reconstructive surgery. This novel patient controlled breast tissue expander that includes a small handheld wireless controller that administers small amounts of CO2 into the device to stretch the skin to accommodate a lasting breast implant. AeroForm allows women to complete their expansion at home, without needles and at their own pace based on their level of comfort. According to Dr Kamashki Zeidler, a plastic surgeon in San Jose, CA, and principal investigator of the clinical trial, ‘Breast reconstruction post mastectomy is a long process, and tissue expansion is one of the most tedious and painful aspects. For women to achieve expansion in 19 days on average and for the vast majority of patients to report high satisfaction throughout the expansion process, supports AeroForm as an exciting, much-needed innovation in breast reconstruction,’ she said. ‘Allowing women to expand at their own pace and level of comfort, offers mastectomy patients a convenient and needle-free option for expansion?—?and a chance to regain control over their body at a time when it is out of their control.

More choices offer optimised results

There are three manufacturers in the US currently offering shaped silicone gel implants cleared for marketing by the FDA; Sientra (March 2012), Allergan (February 2013), and Mentor (June 2013)4.

‘The more choices we have, the better we can tailor the operation to each patient,’ said Spiegel, noting the recent FDA approval of additional MENTOR MemoryShape® (Mentor Worldwide LLC, Santa Barbara, CA) implant styles. MENTOR® MemoryShape® Breast Implants have a teardrop shape, much like the silhouette of a natural breast and are filled with a cohesive gel that enables shape retention. ‘We needed these higher projecting implants, which are important to get the best results,’ she said.

The future of breast cancer therapy

A Hungarian born material scientist at the University of Akron, OH, Judit E. Puskas, PhD, P.Eng, is pioneering a unique polymer that is not permeable, unlike silicone, and can also be used as a way to deliver drugs for cancer, such as tamoxifen or chemotherapy drugs. ‘New delivery devices are badly needed for cancer therapy. Specific targeting is the optimal approach for any diagnostic and chemotherapeutic agent. The goal of our research is to integrate breast reconstruction with cancer diagnosis and treatment. The implant becomes a medical device itself. If the drug is delivered intravenously, a higher concentration must be used. By using a lower concentration, you can have less side effects for the patient,’ said Puskas. ‘First I would like to use my polymer as a cover or coating for existing implants, then we would like to replace the silicone shell, and then we can work on developing an all polymer gel as a filler for breast implants.’

Detecting breast cancer at an early stage is crucial to save lives. University of Nebraska-Lincoln scientists have developed a nanoparticle-based device that emulates human touch and that could significantly enhance clinical breast exams for early detection of cancer5.  Researchers Ravi Saraf and Chieu Van Nguyen developed a thin-film sensor, like an ‘electronic skin’, that can detect tumours too small and deep to be felt by human touch. The thin film is only one-sixtieth of the thickness of a human hair and is made of nanoparticles and polymers, which when pressed against the skin, creates changes in electrical current and light that can be captured by a high-quality digital camera. Using a silicone breast model, the researchers used the film to successfully detect tumours as small as 5?mm, hidden up to 20?mm deep. The technology would also allow improved detection for skin cancer.

Lastly, adds Grotting, ‘It is rather short sighted for plastic surgeons to think that these implants are going to last forever for patients. One of my least favourite operations is to take broken silicone gel implants out. In most cases, clinical findings are minimal to none with ruptured implants. You have to rely on whether the patient has seen a change, which would then prompt an MRI. I am recommending that we have a conversation with every gel patient at 10 years to consider preventatively changing the implants for a fresh device. It is still very difficult to make the diagnosis of a broken implant, and implant failures may be missed. I think of it as analogous to changing the tyres on the car before you have a blowout on the interstate,’ he said.

A note on the latest and the greatest non-surgical fat removal wonder treatments;

Just got a call for Vanquish Fat Removal. Not the Aston Martin beautiful car, a new RF (radio frequency) machine touted as the next best thing to a Vibrating belt machine which became popular in the 40’s. Promise of fat removal by vibration to a tiny waist, obviously was ridiculous and turned into comedy gold-they were spoofed everywhere from cartoons to “I Love Lucy”. Still, they remained popular well into the 1970s.Getting back to Vanquish RF device, apparently in some people it may be effective, in many it is not. The Zerona, an external LASER device treatment is no better than diet and exercise. The CoolScupt and the Vanquish are both painful, expensive and are of questionable efficacy. Syringe liposculpture, under local anesthesia is far more predictable, effective and result oriented. When diet and exercise don’t get results, it is worthwhile to see a reputable plastic surgeon in consultation.


DALLAS — Shopping — especially for swimsuits — is a lot more fun for Lori Rupp these days.
“I can feel comfortable being at the pool in a swimsuit and not worry about thinking I’m a 12-year-old boy,” she said.
Rupp feels more comfortable because of breast augmentation.According to the American Society for Aesthetic Plastic Surgery, more young women are having the procedure. More than 3,300 women under the age of 19 had breast augmentation surgery in 2013; that’s a 64 percent increase in the past decade.“We’re seeing more people interested in breast augmentation; it’s growing,” said Dallas plastic surgeon Dr. William Adams. “The demographic of 18-to-28 years old.”
Adams is considered an international expert in breast augmentation. He developed new surgical techniques that make implant surgery safer for patients.
He says education about the risks is especially important for young women, because it won’t be a one-time surgery.”They’re young,” Adams said. “They’re going to live a long time. There’s potential for having to replace the implant or having to do other surgeries. There could be unexpected risks and complications. All that has to be discussed.”Adams also says younger women should be carefully screened to make sure they are doing the procedure for the right reasons.
“I work out, eat healthy and try to take care of myself, but there’s only so much you can do for other aspects of your body,” Lori Rupp said.
She is 25, and got her surgery after college graduation. Her augmentation was subtle, but she says it has boosted her career confidence as much as her shape.

WEDNESDAY, Feb. 26, 2014 (HealthDay News)

WEDNESDAY, Feb. 26, 2014 (HealthDay News) — Eyelid surgery and facelifts are up. So are butt augmentations and neck lifts, according to new figures from the American Society of Plastic Surgeons that show a steady increase in cosmetic and reconstructive surgery procedures in the United States.

This was the fourth consecutive year of growth, the society reported, noting more than 15 million cosmetic surgeries and minimally invasive procedures were performed in 2013, an increase of 3 percent from the year before. Nose jobs, liposuction and laser hair removal missed the boom, however. These procedures declined from the previous year, the report said. Meanwhile, reconstructive surgeries increased by 2 percent, the society reported.

Better technology and new products, including a facial filler that uses hyaluronic acid to treat mid-face volume loss as well as two types of silicone gel breast implants recently approved by the U.S. Food and Drug Administration, are likely the reason behind the upward trend, the society noted.

“The demand for plastic surgery remains strong, with our statistics showing increases in both cosmetic surgical and minimally invasive procedures,” said society president Dr. Robert Murphy.

“Facial rejuvenation procedures were especially robust last year, with more Americans opting for facelifts, forehead lifts, eyelid surgery, fillers and peels,” Murphy said in a society news release. “With new devices and products hitting the market each year, there are more options and choices available to consumers wanting to refresh their look or [undergo] a little nip and tuck.”

Of the 13.4 million minimally invasive procedures performed in 2013, the most common included:

  • Botox injections: 6.3 million injections, up 3 percent
  • Soft tissue fillers: 2.2 million procedures, up 13 percent
  • Chemical peels: 1.2 million procedures, up 3 percent

With more people taking steps to smooth out their wrinkles and folds, the report noted that Botox injections jumped 700 percent since 2000. And hyaluronic acid facial fillers have increased 18 percent since 2012.

There were also 1.7 million cosmetic surgeries in 2013, up 1 percent from a year ago. Among the most common procedures:

  • Breast augmentation: 290,000 procedures, up 1 percent
  • Nose jobs: 221,000 procedures, down 9 percent
  • Eyelid surgery: 216,000 procedures, up 6 percent
  • Liposuction: 200,000 procedures, down 1 percent
  • Facelifts: 133,000 procedures, up 6 percent

Silicone implants were used in 72 percent of all breast augmentations, while saline implants were chosen for 28 percent of these surgeries. The experts noted new technology offers women more natural looking and feeling results.

Butt augmentation with fat grafting and neck lifts are two new procedures also on the rise in the United States, according to the report.

There were 10,000 butt augmentation procedures performed in 2013, up 16 percent from 2012. More than 55,000 neck lifts were also performed last year, up 6 percent from the year before.

Reconstructive plastic surgery to improve both the appearance and function of abnormalities also increased 2 percent in 2013. The top reconstructive procedures performed last year include: tumor removal, up 5 percent from 2012; laceration repair, with 254,000 procedures; and scar revision.

Breast reconstruction, with 96,000 procedures, was up 4 percent last year.
“It’s promising to see breast reconstruction rates rising,” noted Murphy. “Less than 20 percent of breast cancer patients undergo breast reconstruction because they are not always informed of their options, although studies show that reconstruction greatly improves quality of life.”

Are Brazilian butt lifts the new boob job? Kim Kardashian fever helps fuel 58% spike in the number of buttock enhancements

The number of Brazilian butt lifts being performed in the U.S. has grown by an astounding 58per cent over the last year, according to new research. The American Society for Aesthetic Plastic Surgery, which released a portion of its annual findings today, has discovered that the augmenting procedure has become so popular that 11per cent more surgeons have now begun offering it as a service.

‘The trend can definitely be attributed to more women wanting to emulate the look of Kim Kardashian’s and Jennifer Lopez’s shapely buttocks based on what I hear in my own offices on a near-daily basis,’ Dr Constantino Mendieta of Miami said of the surgery’s increase in a statement. The number of Brazilian butt lifts being performed in the U.S. has grown by an astounding 58per cent over the last year, according to new research.

He described the procedure, saying: ‘we take fat from unwanted areas and transfer it to the buttock region, allowing us to shape and mold the posterior.’ Brazilian butt lifts typically cost between $8,000 and $12,000. The ASAPS’s findings follow additional reports about the Brazilian butt lift’s growing popularity.

Earlier this month, it was discovered that New York City residents display the largest interest in the procedure when compared with other cities. Plastic surgery referral site RealSelf found that more than 378,000 New Yorkers inquired about the procedure between November 2013 and January 2014 — more than three times as many as Los Angeles, Miami and Atlanta. ‘It’s like fitness is a fashion statement. Curvy in the right places is the new sexy.’ Los Angeles had the second-highest interest in the operation, with 138,227 inquiries, followed by Miami (108,341) and Atlanta (98,993).

As Dr Mendieta noted, this growing interest is often attributed to curvaceous celebrities including Kim Kardashian and Nicki Minaj. Furthermore, experts say that the public’s desire to emulate these stars could allude to a shift in the ideal body mentality.

Dr. David Shafer, a Manhattan-based plastic surgeon, told the New York Post that the operation has become more popular in recent months because: ‘It’s no longer this anorexic-model look that the magazines tell people they’re supposed to look like.’

A 35-year-old plastic surgery patient concurred, telling the paper: ‘It’s like fitness is a fashion statement. Curvy in the right places is the new sexy.’

Read more:

Butt Lifts On the Rise

Allure Exclusive: Butt Lifts On the Rise

Keeping up with the Kardashians takes on new meaning today. The American Society for Aesthetic Plastic Surgery has just named the future Mrs. Kanye West as one of the reasons behind a stunning 58 percent leap in the popularity of buttocks augmentation—a.k.a the Brazilian Butt Lift—between 2012 and 2013, the latest year for which figures are available. This is the largest percentage rise for any cosmetic surgery procedure, the society reports (and by the way, we’re not for a second suggesting that Kim K. has had one!), followed by labiaplasty procedures, which rose by 44 percent in the same period.

Buttocks augmentation is usually done with fat injections—taking fat from the waist or stomach, say, and transferring it to the buttocks to achieve a higher and rounder posterior profile. Silicone implants are also available, but these have a higher risk of complications. What needs to be stressed when looking at these numbers is that butt lifts have been linked to a number of deaths and complications when performed by non-medical personnel who pose as physicians and, in some cases, use industrial silicone. Checking credentials is always important but especially with trendy procedures.

Castle Connolly, in Conjunction with U.S. News and World Has Selected New Jersey Plastic Surgeon, Larry Weinstein, MD as a Top Doctor in 2013

U.S. News & World-Health, in conjunction with Castle Connolly, has selected Morristown, New Jersey plastic surgeon, Dr. Larry Weinstein, for its highly selective inclusion as a Top Doctor® for 2013. Less than 5% of the nation’s 870,000 licensed physicians were selected by U.S. News and World as Top Doctors® in their region for 2013.

Castle Connolly Top Doctors® are selected by Castle Connolly after being nominated by peer physicians in an online nomination process. Physicians cannot pay to be included on the list. All board-certified physicians may be nominated and each year, tens of thousands of doctors cast tens of thousands of votes. The Castle Connolly research team, led by physicians, then select from the many applicants who the honorees will be for the year based on criteria including the physician’s training, education, and other contributions to the medical field. These results are published online and in a partnership with U.S. News & World Report.

Dr. Weinstein said, “It is humbling to be recognized as a top doctor in plastic surgery by my colleagues in New Jersey.”

According to Castle Connolly, “Anyone can draw up a ‘best of’ list – and many organizations do. Pharmaceutical companies favor those physicians who are high prescribers of their drugs. To many health insurers, a physician’s fees are often a more important factor than quality. Many magazines and websites recommend health care providers who pay to get their names mentioned. But Castle Connolly has no such conflicts of interest. Our sole purpose is to help patients, their families and their employers find health care providers who deliver superior results.”

Dr. Weinstein has been selected as a top plastic surgeon several years in a row by his peers and recognized by Castle Connolly and U.S News & World -Health. Dr. Weinstein continues to be selected as a top plastic surgeon in New Jersey because of his attention to detail, patient care and expertise in cosmetic breast surgery, rhinoplasty (nose-reshaping), tummy tucks, cosmetic facial surgery, liposuction and body contouring.

More About Dr. Larry Weinstein
New Jersey Plastic Surgeon, Larry Weinstein, M.D., F.A.C.S., teaches, lectures and performs technically advanced cosmetic and reconstructive procedures. He recently gave a teaching course on Natural Proportional Breast Augmentation. His expertise in Natural Face and Neck lifting techniques have been performed by him on patients from the far flung reaches of the world. During his Plastic Surgery training at the State University of New York (Brooklyn) he received Awards for his research on Melanoma and Breast Cancer Reconstruction. He was involved in the first team to use tissue expanders for Breast Reconstruction at Memorial Hospital (Cornell University) in New York, NY.

Dr. Weinstein is recognized for his charitable work, bringing Smiles to children’s faces and receiving the prestigious Song Award for Philanthropic Service from the American Society for Aesthetic Plastic Surgery (ASAPS) in May of 2012.

To learn more about Dr. Larry Weinstein, please visit his Morristown Plastic Surgery website at

New Jersey Plastic Surgeon Dr. Larry Weinstein Implements New VECTRA 3D Imaging System to Simulate Surgical Results

Dr. Larry Weinstein, a Morristown, NJ plastic surgeon, is now utilizing the VECTRA 3D Imaging System to better simulate surgical outcomes for patients seeking Face, nose, body and breast enhancement through cosmetic plastic surgery.

Dr. Weinstein is one of just a few plastic surgeons in Northern New Jersey to implement this simulation technology. The 3D Imaging allows patients to make more informed decisions about their cosmetic surgery procedure. It also allows Dr. Weinstein the ability to create a more specific surgical plan for each patient and couple science with his surgical skills and artistic approach to plastic surgery.

The VECTRA 3D simulation was primarily designed for patients looking for a breast augmentation procedure because a breast augmentation can be difficult to envision simply by placing implants inside a bra. The Vectra 3-D Breast Imaging system helps give breast augmentation patients in New Jersey a more precise illustration of what to expect after surgery.

As part of the consultation and planning for breast augmentation, patients can now see 3-Dimensional images of their breasts with the implants they choose.

With this enhanced simulated technology, Dr. Weinstein is better able to help his New Jersey patients understand what they will look like after their surgery by allowing the patients to visualize their desired results prior to surgery, in a full 3D Model. As part of the consultation, patient images can be modified for implant size and implant type, and then the result visualized again, until the patient is satisfied and comfortable with their choice.

The simulation is helpful for Dr. Weinstein as he establishes realistic surgical outcomes with each patient and prepares for each surgical case. “With VECTRA’s high-resolution, three dimensional photo-simulations, my New Jersey patients can now visualize results of their breast augmentation surgery during their consultation, with the ability to virtually try different sized implants with just a click on the computer,” notes Dr. Larry Weinstein. He continued, “Before we had simulation devices like the VECTRA 3D, we would simulate the new breast size by filling a tight sports bra with different size implants to get an approximation of the desired result. With the VECTRA 3D, I’m able to more accurately show how the implant, whether silicone or saline, will impact the body by adjusting the size and placement of implants.”

Vectra 3D allows for views from any angle. A patient’s anatomy structure, including the breastbone, collarbone, ribs, and nipple are marked to provide reference points. The volume of one’s natural breast tissue and the shape of their rib cage can be accurately displayed to see results of their breast augmentation surgery. Dr. Weinstein then develops a specific surgical plan based on this unique consultation.

Canfield, the maker of VECTRA 3D and Canfield’s Sculptor™ software has been developing cameras and software to enhance the patient and doctor experience for over 20 years. “I have been very satisfied with the VECTRA 3D Breast Simulator. The support from Canfield has been excellent and they have been very responsive to my questions both during our initial learning curve and with our ongoing needs,” remarked Dr. Weinstein.

More About Dr. Larry Weinstein
New Jersey Plastic Surgeon, Larry Weinstein, M.D., F.A.C.S., teaches, lectures and performs technically advanced cosmetic and reconstructive procedures. He recently gave a teaching course on Natural Proportional Breast Augmentation. His expertise in Natural Face and Neck lifting techniques have been performed by him on patients from the far flung reaches of the world. During his Plastic Surgery training at the State University of New York (Brooklyn), he received Awards for his research on Melanoma and Breast Cancer Reconstruction. He was involved in the first team to use tissue expanders for Breast Reconstruction at Memorial Hospital (Cornell University) in New York, NY.

Dr. Weinstein is recognized for his charitable work, bringing Smiles to children’s faces and receiving the prestigious Song Award for Philanthropic Service from the American Society for Aesthetic Plastic Surgery (ASAPS) in May of 2012.

About Canfield
Canfield Scientific, Inc., is the global leader in imaging systems services and products for scientific research and healthcare applications, including the pharmaceutical, biotechnology, cosmetics, medical and skin care industries.

Driven by a quality-focused mission to provide best-in-class imaging solutions and services, Canfield has achieved an industry-wide reputation for excellence and innovation throughout its product lines, industry services and customer support.

To learn more about Canfield Scientific, Inc, please visit their website at
To learn more about Dr. Larry Weinstein, please visit his Morristown Plastic Surgery website at

Journal of Plastic, Reconstructive & Aesthetic Surgery Articles

Surgical treatment of extensive subcutaneous calcification of the forearm in CREST syndrome
Published online: 15 July 2013
Harald F. Selig, Thomas Pillukat, Marion Mühldorfer-Fodor, Stefanie Schmitt,
Jörg van Schoonhoven
DOI: 10.1016/j.bjps.2013.06.035
Journal of Plastic, Reconstructive & Aesthetic Surgery, importance of the pose in three-dimensional imaging of the ptotic breast
Published online: 15 July 2013
Helga Henseler, Xiangyang Ju, Ashraf Ayoub, Arup K. Ray
DOI: 10.1016/j.bjps.2013.06.040
Journal of Plastic, Reconstructive & Aesthetic Surgery, to long term results following single stage Snodgrass hypospadias repair
Published online: 15 July 2013
R. Aslam, K. Campbell, S. Wharton, A. Bracka
DOI: 10.1016/j.bjps.2013.06.041
Journal of Plastic, Reconstructive & Aesthetic Surgery, on the open and closed rhinoplasty
Published online: 12 July 2013
Douglas H. Harrison
DOI: 10.1016/j.bjps.2013.05.041
Journal of Plastic, Reconstructive & Aesthetic Surgery, novel method for the harvest of a large full thickness skin graft using a quiver
Published online: 12 July 2013
Karl Walsh, Bart Bednarz, Reza Arya, Tania Cubison
DOI: 10.1016/j.bjps.2013.06.023
Journal of Plastic, Reconstructive & Aesthetic Surgery, extended fleur-de-lis latissimus dorsi flap: A novel flap and approach for coverage of lower back defects
Published online: 12 July 2013
Pedro Ciudad, Dhruv Singhal, Stamatis Sapountzis, Ram M. Chilgar, Fabio Nicoli,
Hung-Chi Chen
DOI: 10.1016/j.bjps.2013.06.034
Journal of Plastic, Reconstructive & Aesthetic Surgery, gangrenosum after breast reduction: A rare complication
Published online: 11 July 2013
Joana Costa, Diana Monteiro, Rita Valença-Filipe, Jorge Reis, Álvaro Silva
DOI: 10.1016/j.bjps.2013.06.038
Journal of Plastic, Reconstructive & Aesthetic Surgery, long-term morphometric analysis of auricular position post-otoplasty
Published online: 11 July 2013
M. Elise Graham, Michael Bezuhly, Paul Hong
DOI: 10.1016/j.bjps.2013.06.043
Journal of Plastic, Reconstructive & Aesthetic Surgery, cell enrichment does not warrant a higher graft survival in lipofilling of the breast: A prospective comparative study
Published online: 10 July 2013
Hilkka H. Peltoniemi, Asko Salmi, Susanna Miettinen, Bettina Mannerström, Kai
Saariniemi, Raija Mikkonen, Hannu Kuokkanen, Christian Herold
DOI: 10.1016/j.bjps.2013.06.002
Journal of Plastic, Reconstructive & Aesthetic Surgery, incidence of symptomatic neuroma in amputation and neurorrhaphy patients
Published online: 10 July 2013
D.J.J.C. van der Avoort, S.E.R. Hovius, R.W. Selles, J.W. van Neck, J.H. Coert
DOI: 10.1016/j.bjps.2013.06.019
Journal of Plastic, Reconstructive & Aesthetic Surgery, risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): A review of 9305 patients from the 2005–2010 ACS-NSQIP datasets
Published online: 10 July 2013
John P. Fischer, Jonas A. Nelson, Joseph M. Serletti, Liza C. Wu
DOI: 10.1016/j.bjps.2013.06.030
Journal of Plastic, Reconstructive & Aesthetic Surgery,

The impact of preoperative breast implant size selection on the 3-year reoperation rate

European Journal of Plastic Surgery
August 2013, Volume 36, Issue 8, pp 503-510
The impact of preoperative breast implant size selection on the 3-year reoperation rate
Umar Daraz KhanBackground
Revision surgery following primary augmentation mammoplasty is commonly performed. There are several long-term and short-term published studies on the incidence of revisionary surgery in primary mammoplasties. The current study is a single surgeon’s experience with reoperations following consecutively performed primary augmentation mammoplasties and an assessment of the role of the process of breast augmentation. A retrospective data analysis was performed to evaluate a single surgeon’s 3-year reoperation rate in primary augmentation mammoplasties.Methods
A retrospective analysis of data using the Excel Spread was performed. Data of patients having had consecutive primary augmentation mammoplasties, performed between January 2008 and December 2010, were collected to evaluate the efficacy of a structured process of primary augmentation mammoplasties and its impact on a 3-year reoperation rate. Patients with asymmetrical breast or chest requiring different size implants were excluded. Patients presenting with ptosis requiring mastopexy in primary augmentation mammoplasty were also excluded from the study.Results
A total of 507 primary bilateral augmentation mammoplasties were performed by the author between January 2008 and December 2010. All patients had muscle splitting biplane technique and all had round silicone cohesive gel silicone implants during the study period. All implants were inserted using inframammary crease incision. Mean size of implant in primary augmentation mammoplasty was 346.9 cc (range 200–700). Data showed 10 (1.97 %) patients had a reoperation following primary augmentation mammoplasty.Conclusions
This retrospective study showed a low 3-year reoperation rate. A clear understanding of the process of breast augmentation, good informed consent and careful selection of implant size in primary and revision augmentation mammoplasty can potentially reduce reoperations.
Level of Evidence: Level IV, Prognostic/risk study.

Breast Facts: 8 Awesome And Interesting Things To Know About Boobs

The Huffington Post | By Catherine Pearson
Posted: 08/12/2013 7:55 am EDT | Updated: 08/12/2013 4:41 pm EDTBreast augmentation combined with mastopexy is associated with a significantly higher complication rate than primary augmentation alone. Moreover, the combination of mastopexy and breast implant performed simultaneously has revealed a moderate reappearance of breast ptosis with a “bottomed out” aspect and loss of desired roundness in many patients particularly in the case of medium to large implants.We present a new technique, performed in one stage, that offers several advantages. An inverted-T mastopexy was performed using sopramuscular cohesive gel breast implants. Furthermore, to avoid the bottoming out of the implant and the surrounding tissue, the implant was enclosed in an inferior-based flap of de-epithelialized dermoglandular tissue, preserving the de-epithelialised dermal tissue and by anchoring the flap upper with long-lasting sutures to the pectoral muscle, thus improving the lower breast profile and increasing the consistency of breast tissue over the implant.Breast augmentation and mastopexy are two types of interventions that pursue differing objectives. In patients presenting both hypoplasia and ptosis, it is necessary to correct both problems simultaneously. Surgical correction1, 2, 3, 4, 5 consists of increasing mammary volume via augmentation mammoplasty, removing excess skin via mastopexy, or combining both methods as in the case of augmentation/mastopexy. This is a complex procedure which may not always guarantee good and satisfactory results. The objective of simultaneous augmentation/mastopexy with a “double implant” for moderate to severe breast ptosis is to remove as much lax skin as possible after the implant placement without compromising circulation to the skin and the nipple–areola complex (NAC).12 patients aged (from) 35–46 years (average age 39 years), who had undergone surgery, with grade III mammary ptosis (jugular-nipple distance from 24 to 28 cm, subareolar–submammary fold distance from 7 to 9 cm) were selected for the study. The inverted-T mastopexy technique, with sopramuscular gel cohesive II breast implant, was performed on all patients. Surgery was performed under general anaesthesia. A new areola of 4–4.5 cm in diameter was marked using an areolotome. A precise incision was made around the new areola according to the preoperative plan. The skin surrounding the new areola and the pedicle were de-epithelialised. The classical technique involves periareolar de-epithelialisation to lift the NAC. We present a technique, which adds a rectangular area to the classical de-epithelialisation, not less than 5 cm in length and positioned below the lower pole of the areola (Figure 1A).Starting from this point we wrap an inferior-based flap of deepithelialized dermoglandular tissue that will form a truncated pyramid. The flap extends from the rectangular area of the de-epithelialisation to the end of the pectoral muscle. To ensure the vitality of the pedicle, the base of the pyramid should be no less than 10 cm and no higher than 15 cm. In all patients a sopramuscular pocket large enough to contain textured silicone implants was created, the volume ranged from 250 to 300 cc, to ensure the increase in breast volume (Figure 1B). After the implant was positioned in the pocket, the deepithelialized dermoglandular flap was placed to cover and protect the implants and was anchored by the superior dermal tissue to the pectoral muscle at the second intercostal space using 3-0 prolene sutures. The repositioning of the NAC, located between 20 and 22 cm, was performed using a superomedial pedicle flap.The distance between the areola and the inframammary fold was reduced in all patients to 5 cm. Finally, areolar skin closure was performed with cardinal blocker 4-0 nylon sutures and intradermic 3-0 nylon sutures (Figure 1C). Skin suture was performed using intracuticular running suture with 4-0 nylon sutures.

Will your health insurer pay for plastic surgery?

The bottom line when it comes to an insurer’s decision to pay for plastic surgery is typically whether a procedure is considered medically necessary, experts say.Americans love to look good, but insurers are often reluctant to pay the bills to help us look better.Last year we spent nearly $11 billion on cosmetic procedures, according to the American Society for Aesthetic Plastic Surgery. Of the more than 10 million procedures performed, the most requested was breast augmentation.

But Cameo Wichinsky, a 42-year-old investment fund manager living in Santa Monica, wants to take her figure in the opposite direction.

Having long lived with the discomfort of breasts large enough to cause shoulder and neck pain and to limit her level of physical activity, she’s ready to go under the knife to reduce her breast size and, she hopes, improve her quality of life.

“I’m at the stage of my life when I’m ready to be active and be at my highest level. These things get in the way,” Wichinsky said.

Despite the fact that she has health insurance, she says she’ll have to shell out the nearly $9,000 for breast reduction surgery, which she has scheduled for November. Her insurer won’t cover the procedure.

“Insurance is a huge hassle,” Wichinsky said.

There was a time when health insurers more readily paid for breast reductions, said Dr. Michelle Spring, a plastic surgeon with Marina Plastic Surgery in Marina del Rey.

“We tend to think of breast reduction as reconstructive surgery and not cosmetic, even though it has that cosmetic aspect to it,” she said.

Plastic surgery is expensive. It’s important to know ahead of time what insurers will pay for.

The line between the desire for improved physical appearance and medical need can be fuzzy in the world of health insurance. Although few people expect to have their health plan pay for their tummy tucks or face lifts, there are procedures that legitimately warrant coverage.

The bottom line when it comes to an insurer’s decision to pay for a procedure is typically whether it’s considered medically necessary, experts say.

“Generally, if a procedure is necessary to repair or preserve the healthy functioning of the body, it’s likely to be medically necessary,” said Carrie McLean, senior manager of customer care with online insurance

“If the procedure is typically considered standard practice for any given diagnosis, that may also meet the criterion for medically necessary,” she said.

Exactly where that line is drawn depends on the individual and his or her circumstances, not the procedure itself, said Patrick Johnston, president of the California Assn. of Health Plans, which represents 40 health plans insuring more than 21 million Californians.

For example, a middle-aged man interested in a tummy tuck to restore the six-pack of his youth isn’t likely to get much sympathy from his insurer, he said, but it’s a different story for someone who lost 150 pounds after bariatric surgery and is left with excess skin.

“This is a recognized standard of treatment for morbidly obese individuals,” Johnston said.

In the same way, he said, a nose job to correct a deviated septum or surgery to lift drooping eyelids that impair vision are other common surgeries likely to be covered by a health plan.

Consumers have a variety of legal protections that guarantee access to certain cosmetic procedures.

Women who have undergone a mastectomy after a diagnosis of cancer, for example, are guaranteed coverage for reconstructive surgery.

“Both federal and state laws guarantee a woman who has had a mastectomy as a result of breast cancer coverage for breast reconstruction,” Johnston said.

California law also requires insurers to cover the repair of a child’s cleft palate, which includes any medically necessary dental or orthodontic services that are an integral part of reconstructive surgery.

If you’re in the market for a cosmetic procedure, here are some important reminders.

• Check with your insurer in advance. In most cases you’re likely to need your insurer’s pre-authorization to obtain coverage.

It’s a good idea to work with your doctor. Submitting medical records, letters from specialists who have treated you for long-term symptoms and in some cases photos can all lend support for the medical necessity of the procedure and increase your chances of gaining approval.

• Pre-approval may not be enough. Breast reduction surgery such as what Wichinsky plans is a good example of the devil being in the details.

Most insurers dictate how many grams of tissue must be removed from each breast for the procedure to be covered, said Dr. Fardad Forouzanpour, a cosmetic surgeon with the Beverly Hills Cosmetic Surgical Group. Asking in advance what those requirements are can help avoid surprise bills.

• You can appeal insurer decisions. Don’t be deterred if your insurer initially denies coverage. “I frequently have to appeal the claim … to obtain insurance coverage,” said Dr. Michael Will, spokesperson for the American Academy of Cosmetic Surgery.

If your request for coverage is denied, you have the right to appeal with your insurer as a first step, and initiate an external review by an independent third party if your first appeal is denied.

In California, people with HMO coverage can also file a complaint with the California Department of Managed Health Care. Those with PPO coverage typically should call the Department of Insurance.

Wichinsky said it would be nice if her insurer covered the cost of her surgery, but she feels fortunate that she can afford it. “At this point I don’t care. I’m just ready.”

Resources and links
Information about cosmetic surgery:
American Academy of Cosmetic Surgery:
Society for Aesthetic Plastic Surgery:

HMO appeals: California Department of Managed Care: (888) 466-2219 or visit

Insurance appeals: California Department of Insurance: (800) 927-HELP (4357) or go to

Zamosky writes about healthcare and health insurance.

Allure: A Guide to understanding, appreciating and flaunting two provocative body parts

Breasts: An Owner’s ManualWe invite you, for a minute, to think of breasts.They have been with us since we were born. They have seen us through puberty, prom, and pregnancy. They’ve been a source of curiosity, pride, and joy. That is, when they weren’t a source of anxiety, pain or embarrassment. We’ve labeled them and we’ve numbered them, but – please, God, no – we have never named them. We push them up, flatten them out, squeeze them together. We make them conform to our moods, our bodies, and our clothes. Maybe we’ve even considered surgery. Or had surgery. Or had to have surgery. We bless them, curse them, love them, and hate them. And through it all, they’ve stood by us. Sure, at some moments they’ve stood higher than at others, but every time we look down, they are there. So in celebration, in fascination, and in gratitude, we present the first-ever Allure guide to breasts. – DANIELLE PERGAMENT

Knocker Shockers

You probably think you know them pretty well by now. And fine, maybe you do. But we bet there are a few things you would be surprised to learn. Such as:

  • The sun makes them fall. Gravity isn’t the only thing working against you and your breasts. The sun also breaks down the collagen and elastin fibers in the skin of your breasts, making them sag faster, says Santa Monica dermatologist Karyn Grossman.
  • Human breasts are unique. We’re the only mammals whose breasts remain enlarged throughout our lifetime – rather than just while nursing.
  • The chest gets wrinkles too. Those fine lines between your breasts are often caused by sleeping on your side. To treat vertical lines, dermatologists suggest a combination of injectables, like Belotero and Botox. The results last longer on the chest than on the face because the chest isn’t exposed to the same stresses as the face, says New York City dermatologist Patricia Wexler. – CATHERINE Q. O’NEILL

In 2012, Americas spent more than $1 billion on breast-augmentation surgeries. That’s the approximate GDP of the Seychelles.


Compared with the previous generation, twice as many girls are developing breasts as early as age seven.

5 Things to Know Before You – or Your “Friend” – Get Implants

  • Bigger is not always better. “I’ve changed more women to go smaller,” says Los Angeles plastic surgeon Steven Teitelbaum. “Those who go too big can permanently damage their breast tissue and even their ribs.”
  • Cup size isn’t everything. Not only cup sizes vary among lingerie brands, they don’t denote shape, so there’s no point in asking your doctor for a D cup.
  • You can’t copy another woman’s breasts. “The size of the rib cage, breast width, and a dozen other factors determine the ideal size for each woman,” Teitelbaum says.
  • Armpits aren’t the best entry. The scar can be visible when you’re wearing clothes, says Teitelbaum. And neither are nipples – an incision there can increase the risk of bacterial exposure and result in a hardening of the implant. “For the average woman, the best incision is in the fold under the breast,” says New Jersey plastic surgeon Caroline Glicksman, who notes that the scar should look like a little red crease under the breast. “That entry has the lowest complication rates.”
  • Implants don’t lift breasts. Breast lifts do. A breast lift is a different procedure, without an implant. – C.Q.O.


Because sometimes you can’t help but wonder. Teitelbaum explains what to look for.

  • Fake breasts have a defined, 360-degree border around the edges.
  • Oversize implants create a wide, often bony gap between the breasts.
  • If they’re too big, fake breasts don’t fall to the side when a woman lies on her back.
  • From the side, fake breasts can look as full on top as on the bottom.
  • The nipples point down. Naturally, nipples point straight ahead or slightly up, even with a moderate amount of sagging. If the implants are too high, the nipples tip downward. – C.Q.O.

36DD : Today’s average bra size. That’s up two full cup sizes from 2002.

Confessions of a Body Double

Shelley Michelle may have the world’s most famous breasts – she has stood in for Julia Roberts, Sandra Bullock, and Kim Basinger. We asked Michelle, who has spent 20 years as a body-parts model, what tricks she’s picked up from her years on closed sets. – ELIZABETH SIEGEL

  • I always massage a moisturizer with glycerin over my breasts to given them a pretty sheen. A shimmery body lotion is the best for emphasizing cleavage – I apply it in a heart shape along the top of my breasts.”
  • “Posture makes a big difference. Pull your shoulders up, back, and then down, suck in your stomach, and stand up straight. And anytime I’m on a bed – sitting, lying, or rolling on top of someone – I glue my elbows to my waist to push up my breasts and keep my cleavage in a straight line. I swear I’ve added ten years to some actresses’ careers using that trick.”
  • “I live in a sports bra and always keep my breasts covered in the sun. And I’m always exercising. I do chest presses against the wall in the shower and yoga against the kitchen counter. But you’ll never catch a breast double doing chest presses with weights. Big pecs mess with your cleavage.”

To Your Health

You may have the world’s most lovely breasts, but if you aren’t doing whatever you can to keep them healthy, it’s not going to matter how great they look in an Agent Provocateur lacy demi-cup. Sure, we all know we’re supposed to check for lumps. And most of us do. Sometimes. And we know drinking to excess is a risk factor for breast cancer. But maybe having a couple of drinks isn’t so bad…right? Breast-health experts clear it all up for us. – E.S.

  • Diet is less important than you’d think. “When it comes to breast health, ‘superfoods’ is a total misnomer,” says Elisa Port, chief of breast surgery and codirector of the Dubin Breast Center at Mount Sinai Medical Center in New York City. “There’s no hard evidence that almonds or kale or organic, hormone-free milk are associated with a lower risk of breast cancer.” What scientists know is that obesity is a risk factor, as is habitual alcohol consumption, but the correlation only begins to appear when you drink in excess. “We’re talking more than two drinks every day, seven days a week,” Port says.
  • Check yourself. Do a monthly self-exam right after your period so you can monitor any changes. Lie on your bed, raise one arm above your head, and check the breast and underarm on that side for lumps by making concentric circles or vertical lines. Do the other side. Then do it all again in front of a mirror. Get checked out if you see dimpling under your breasts, a rash around the nipple, or retracted nipples.


We asked celebrities who has the best breasts in Hollywood. And the Allure Anti-Sag Award goes to… (Spoiler alert: It’s a tie!) – JEFFREY SLONIM

  • “I’m a fan of natural breasts, even though I have augmented breasts myself. I love Scarlett Johansson’s breasts; they’re beautiful.” – Lily Ghalichi, Shahs of Sunset
  • “Scarlett Johansson.” – Carmen Electra
  • “I think Scarlet Johansson has really nice boobs.” – Christa Miller, Cougar Town
  • “Halle Berry. I’m obsessed with symmetry – and hers are in perfect symmetry.” – Patti Stanger, Millionaire Matchmaker
  • “Halle Berry has the best boobs on the planet.” – Katheryn Winnick, Vikings

Annie Hawkins-Turner has the world’s largest natural breasts. Her bra size is reportedly 102ZZZ, and each breast weights 44.8 pounds.

Arm lifts grow in popularity

by Liz Szabo, USA TODAY”Arm lifts” have become one of the fastest-growing varieties of plastic surgery, a new study shows.More than 15,000 women underwent an arm lift in 2012, an increase of more than 4,000% since 2000, according to a report out Monday from the American Society of Plastic Surgeons.

The popularity of the procedures isn’t driven by a desire to look as good as Michelle Obama does in a sleeveless sheath.

Instead, the surgeries are growing because more people are losing massive amounts of weight, usually through obesity surgery, says David Reath, a plastic surgeon in Knoxville, Tenn., and chairman of the public education committee for the plastic surgeon society.

About 200,000 Americans a year undergo some kind of weight-loss procedure, such as gastric bypass, says Jack Fisher, president of the American Society for Aesthetic Plastic Surgery, from Nashville.

While surgery can help people lose weight and fat, it doesn’t decrease the amount of skin, Reath says. People who lose 100 pounds or more can be left with a lot of extra skin.

“Once skin is stretched out, it becomes like a broken rubber band,” Fisher says. “Even when you lose weight, the skin doesn’t go back to its normal shape.”

Patients sometimes refer to this extra skin as “bat wings,” Reath says. Depending on a patient’s weight loss and body type, some also opt for surgery to remove extra skin from the abdomen or all around their mid-section, a procedure called a “body lift.”

The extra skin can make it harder for patients to wear clothes — or enjoy their new look, Reath says.
“When they see themselves in the mirror, they don’t see themselves at an appropriate weight,” Reath says.
The number of cosmetic surgeries increased by 3% last year, to nearly 1.7 million, according to the American Society for Aesthetic Plastic Surgery. When non-surgical options such as botox injections are included, Americans had more than 10 million cosmetic procedures last year.

Arm lifts aren’t for everyone.

The surgeries can cost $5,000 or more out-of-pocket, Fisher says. And they leave patients with a scar that stretches from their elbow to their armpit.

Doctors say women who want to look like the first lady will have to earn their triceps the same way she did: at the gym.

Adeena Babbitt

A Tribute to Joseph Murray


On the whole, the specialty of plastic and reconstructive surgery is a forward-looking specialty. As a group, we innovate, create, refine, and advance surgical techniques and the practice of medicine for ourselves as well as for other surgical specialties. Plastic and Reconstructive Surgery’s philosophy of publishing largely reflects that forward-looking approach as well. With that said, however, an occasional backward glance helps us remain centered, because in doing so we remember where we have been and how far we have come. And we can celebrate those who brought us to this point.

A Tribute to Joseph Murray
This month in the journal, we bring you a tribute on the life of Joseph Murray, the only plastic and reconstructive surgeon to have won the Nobel Prize in Medicine or Physiology. Elof Eriksson, with contributions from many of Dr. Murray’s personal and professional friends, authored “The Nobler Angels of Our Nature: A Tribute to Joseph E. Murray, M.D., 1919 to 2012“. The tribute recalls Dr. Murray’s life and contributions, including the numerous seminal advances in surgery, medicine, and plastic surgery that he brought into being.

In a companion article, we stir the echoes of another giant of plastic surgery and reprint an editorial by Dr. Robert M. Goldwyn, former editor of PRS, and friend and student of Dr. Murray. The cover image of the April issue is Joel Babb’s “The First Successful Kidney Transplantation” (1996), reproduced with the kind permission from The Harvard Medical Library in the Francis A. Countway Library of Medicine. I hope you find Dr. Murray’s story inspiring; may it motivate us all to aspire to more with our own clinical practices.

The Launch of PRS Global Open
We have talked about this for months, and at last we are proud to announce the official launch of our companion Open Access journal, PRS Global Open ( The editorial “PRS Global Open: What You Need to Know” will provide you with the final editorial installment in our series of articles leading up to the launch of this journal, which is the first companion journal to PRS since its own launch in 1946. We invite you to visit us at the American Society of Aesthetic Plastic Surgeons meeting in New York on April 13-15 (Booth # 767) in order to take a test run on the new journal website. If you haven’t done so already, experience PRS on the iPAD at the same time and enter into a drawing for a new iPAD. We’re giving away 15 at the show, so visit us to win.

Using Double Opposing Z-Plasty in Patients Undergoing Primary Two-Flap Palatoplasty

97 Management of Velopharyngeal Insufficiency Using Double Opposing Z-Plasty in Patients Undergoing Primary Two-Flap Palatoplasty
Koh KS, Kim SC, Oh TS.
104 Optical Magnification Should Be Mandatory for Microsurgery: Scientific Basis and Clinical Data Contributing to Quality Assurance
Schoeffl H, Lazzeri D, Schnelzer R, Froschauer SM, Huemer GM.
109 A Scientometric Analysis of 20 Years of Research on Breast Reconstruction Surgery: A Guide for Research Design and Journal Selection
Moghimi M, Fathi M, Marashi A, Kamani F, Habibi G, Hirbod-Mobarakeh A, Ghaemi M, Hosseinian-Sarajehlou M.
Discussion by
Roh TS.
117 Feasibility of Use of a Barbed Suture (V-Loc 180) for Quilting the Donor Site in Latissimus Dorsi Myocutaneous Flap Breast Reconstruction
Thekkinkattil DK, Hussain T, Mahapatra TK, McManus PL, Kneeshaw PJ.
123 Risk Factors of Treatment Failure in Diabetic Foot Ulcer Patients
Lee KM, Kim WH, Lee JH, Choi MS.
129 Tourniquet-Free Hand Surgery Using the One-per-Mil Tumescent Technique
Prasetyono TO.
134 Survey of Attitudes on Professionalism in Plastic and Reconstructive Surgery
Kim JY, Kang SJ, Kim JW, Kim YH, Sun H.

Radiation for breast cancer linked to increased risk of heart problems.

Research linking radiation therapy to an increased risk of certain heart problems received a substantial amount of coverage in print and online. Despite the risk, experts said it does not mean that the treatment should not be used in breast cancer patients. Meanwhile, some experts pointed out that radiation treatments now pose less of a danger to the heart than during the time the patients in the study were treated. The Wall Street Journal (3/14, Beck, Subscription Publication, 2.29M) reports that, according to research published in the New England Journal of Medicine, women who undergo radiation therapy to treat breast cancer may face a higher risk of certain cardiovascular problems.
USA Today (3/13, Szabo, 1.71M) reports, “In a study of 2,168 breast cancer patients who had radiation therapy between 1958 and 2001 in Sweden and Denmark, doctors found that any amount of radiation” was linked to a higher risk of “heart attacks, surgeries such as a bypass or angioplasty, or a heart-related death.” This research “is the latest to document the serious long-term health problems faced by cancer survivors.”The New York Times (3/14, Grady, Subscription Publication, 1.68M) reports that the researchers “found that the risk began to increase within a few years after exposure, and that it continued for at least 20 years.” The study found that, “the higher the dose, the higher the risk, and there was some increase in risk at even the lowest level of exposure.”The AP (3/14, Marchione) reports, “Some chemotherapy drugs are known to harm the heart muscle, but the new study shows radiation can hurt arteries, making them prone to harden and clog and cause a heart attack.” Patients “who receive both treatments have both types of risk.” The AP points out that this research “comes amid greater awareness of overtreatment – that many women are being treated for cancers that would never prove fatal, leading to trouble down the road such as heart disease.”In Forbes (3/13, 928K), Larry Husten writes, “Findings from the study, according to the authors, ‘make it possible to estimate’ a patient’s risk for heart disease related to radiation.”The Los Angeles Times (3/13, Brown, 692K) “Booster Shots” blog reports, “Writing in an editorial that accompanied the study, Dr. Javid Moslehi, co-director of the Cardio-Oncology Program at Brigham and Women’s Hospital in Boston, argued that the findings should bolster efforts to offer cancer patients specialized cardiac treatment as they battle their disease.” Dr. Moslehi “also suggested that the breast cancer-radiotherapy study might represent merely ‘the tip of the iceberg’ – that exposure to radiation might also increase risks of conditions like pericardial disease and arrhythmias.” Additionally, “cancer treatments beyond radiation therapy might also increase heart disease risk, he said.”The Boston Globe (3/14, Kotz, 250K) “Daily Dose” blog reports, however, that some “oncologists…caution that the study findings may not apply to modern radiation treatments for breast cancer, which deliver lower doses using more targeted methods to minimize exposure to the heart.” Meanwhile, study co-author Dr. Candace Correa said, “Breast cancer patients who are candidates for radiation should still receive radiation.” Also covering the story are Reuters (3/14, Emery), MedPage Today (3/14), HealthDay (3/14, Doheny), and Medscape (3/14, Lowry).

Wear pink with pride and join in our celebration of Breast Reconstruction Awareness (BRA) Day USA, October 17, 2012

Only 2 of 10 women have breast reconstruction after mastectomy. National studies reveal women who have breast reconstruction after mastectomy live longer. Dr. Weinstein has been at the forefront of developments in breast reconstruction. He helped perform the first tissue expander breast reconstruction at Memorial Hospital in New York. He also performed one of the first TRAM flap breast reconstruction at Morristown Memorial and Memorial Sloan-Kettering in New York.As part of Breast Reconstruction Awareness Day (BRA), Weinstein Plastic Surgery would like to share this movement with patients, their family and friends who are seeking answers to breast reconstruction. Someone may suffer with severe scars, lack of a breast mound, lack of a nipple, asymmetry, or hardness of a mound all of which can be improved. If you, a friend or family have a question about breast reconstruction, please call us. As you know breast reconstruction by law is covered by your insurance.He would like to share The BRA Day movement with breast cancer patients, survivors, family and friends on Wednesday, October 17th, 2012, in his Chester office.

October 17, 2012, from 9:00 to 5:00 in celebration of BRA DAY USA.

Please call 908-879-2222 to schedule your complimentary consultation today, (space is limited). Lite Refreshments will be served.

All insurances will be accepted.

Analysis shows benefits of low-carb, meat-lovers’ diet

Posted: Wednesday, September 5th, 2012
USA Today (8/31, Hellmich) reports, “As people fire up their grills for barbecues over Labor Day weekend, a new analysis” published in Obesity Reviews “touts the benefits of a low-carb, meat-lovers’ diet.” The “review of 17 different studies that followed a total of 1,141 obese patients on low-carb eating plans – some were similar to the Atkins diet – found that dieters lost an average of almost 18 pounds in six months to a year.” Researchers reported that “overall, participants had improvements in their waist circumference, blood pressure, triglycerides (blood fats), fasting blood sugar, C-reactive protein (another heart disease risk factor) as well as an increase in HDL (good) cholesterol.”Note: low carb or no carb appears to be effective in helping weight loss.

Reconstruction Patterns in a Single Institution Cohort of Women Undergoing Mastectomy for Breast Cancer

Annals of Surgical Oncology, 08/23/2012 Clinical ArticleElmore L et al. – A significant percentage of women undergoing unilateral or bilateral mastectomy for breast cancer at the institution elect to undergo reconstruction. Prosthetic reconstruction was the most common method utilized. The impetus for referral to the reconstructive surgeon was nearly always initiated by the surgical oncologist.Methods

  • A questionnaire was administered to patients who underwent unilateral or bilateral mastectomy for breast cancer from 2006 to 2010.
  • The survey queried on demographics, surgical choices, and rationale for those choices.
  • Data were summarized by contingency tables and compared by chi–square test or Fisher’s exact test, as appropriate.


  • Of 321 patients queried, 185 (58 %) underwent unilateral mastectomy and 136 (42 %) underwent bilateral mastectomy (mean age 56 ± 12 years).
  • Overall, 189 (59 %) women underwent breast reconstruction, and 132 (41 %) did not.
  • Immediate breast reconstruction was performed in 125 of 189 (69 %) women, whereas 67 of 189 (31 %) underwent delayed reconstruction.
  • The method of definitive reconstruction included 143 of 189 (75 %) prostheses, 32 of 189 (17 %) abdominal tissue flap, 12 of 189 (6 %) latissimus flap (±implant), and 5 of 189 (2 %) with a combination of prostheses and tissue flaps.
  • Of the 114 patients who did not undergo reconstruction, 68 (60 %) reported lack of desire for reconstruction as their motive, and the remaining 46 (40 %) reported medical contraindications for reconstruction or did not report a specific reason.

Surgeons Are More Critical Than Patients; Preoperative Information Affects Satisfaction Rates

For Immediate Release: 07/30/2012ARLINGTON HEIGHTS, Ill. – Following breast reduction surgery, women generally rate the appearance of their breasts as “good” to “very good”-but plastic surgeons are more critical of the cosmetic results, reports a study in the August issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).Patients and surgeons focus on different factors; patients are most concerned about symmetry, while surgeons are focused more on technical factors. The study also suggests that the information provided before breast reduction surgery and the patient’s level of confidence have an important impact on satisfaction with the results. The new report by Dr. Line Bro Breiting of Herlev Hospital, Denmark, is one of the first to evaluate the cosmetic outcomes after breast reduction surgery.

Eighty Percent of Women Rate Cosmetic Results Good

In the study, 125 women who had undergone breast reduction surgery (reduction mammaplasty) rated their cosmetic results using a questionnaire. Data was gathered at six months and again one year after surgery.

In addition, plastic surgeons rated the outcomes using standard before-and-after photographs. Surgeon ratings were made by plastic surgeons in the Danish public health care system, as well as by a private practitioner in plastic surgery.

In general, the women rated their cosmetic results higher than the surgeons did. At six months, nearly 90 percent of women rated their cosmetic outcomes as “good” or “very good.” At one year, this figure had decreased somewhat, to 80 percent. The surgeon ratings were “good” to “very good” in about 75 percent of cases. The private surgeon was more critical than the public surgeons, rating the results “good” to “very good” in only about 60 percent of women.

The evaluation of specific breast features also differed between patients and surgeons. Patients were most concerned about asymmetry between the breasts. The surgeons were more critical about visible scars. However, over time, the patients became more concerned about scars as well.

The plastic surgeons also focused more on technical details, such as the position of the nipple and shape of the breast. Over the years, the public hospital surgeons increased their focus on achieving a more natural breast shape.

Older women were more critical of their cosmetic results than younger women, while women who had complications were more likely to rate their results “unacceptable.” Satisfaction was also related to information about and confidence in the procedure: “The better the information and the higher the confidence level, the better was the outcome,” Dr. Breiting and coauthors write.

Reduction mammaplasty is among the most commonly performed breast plastic surgery procedures. Previous studies have found it highly effective in relieving symptoms related to overlarge breasts, such as back, shoulder and neck pain, posture problems, and bra strap compression.

The findings show that most women are satisfied with the appearance of their breasts after reduction mammaplasty, although ratings may decrease over time.

The results also highlight some key factors affecting women’s perceptions of their cosmetic results, including the information received and level of confidence before surgery. Dr. Breiting and coauthors conclude, “One must not underestimate the importance of factors like preoperative information about the surgery and complications, together with proper and qualified care.”

Plastic and Reconstructive Surgery® is published by Lippincott Williams & Wilkins, part of Wolters Kluwer Health.

Long-term outcomes following fat grafting in prosthetic breast reconstruction: a comparative analysis

Plastic and Reconstructive Surgery, 07/11/2012 Clinical ArticleSeth AK et al. – The comparative analysis, the largest to date, suggests that FG after breast reconstruction does not adversely affect local tumor recurrence or survival on long-term follow-up. Surgeons may continue to utilize autologous FG as an aesthetic adjunct to prosthetic reconstruction with minimal complications. However, these preliminary results also indicate the need for multi-institutional, prospective studies to definitively establish its oncologic safety.Methods

  • A retrospective review of consecutive patients undergoing mastectomy with immediate tissue expander reconstruction from 4/1998-8/2008 at one institution was performed.
  • Demographic, operative, oncologic, and postoperative factors were recorded, including the use of FG. Mean follow-up was 42.1 +/- 28.8 and 43.6 +/- 27.2 months for non-FG and FG patients, respectively (p=0.63), including 24.8 +/- 5.9 months following the first FG procedure.
  • Fisher’s exact test, Student’s t-test, and regression analysis were used for statistics.


  • Review of 886 patients (n=1202 breasts) revealed no significant differences in demographics, operative characteristics, tumor staging, or radiation therapy exposure between FG (n=90 breasts) and non-FG (n=1112 breasts) patients.
  • Ninety-nine FG procedures were performed an average of 18.3 months following reconstruction, with one complication of fat necrosis.
  • FG did not affect local tumor recurrence or survival when compared to non-FG breasts.
  • Having a complication following reconstruction, including a poor cosmetic result, was an independent predictor of undergoing subsequent FG (p<0.0001).

Note: Fat grafting is an acceptable technique to help balance breast assymmetry in any situation. I have used this technique successfully for over 25 years in select patients.

Study: Teens, young adults may not perceive tanning beds as a particular danger.

Posted: Wednesday, June 20, 2012MSNBC /MyHealthNewsDaily (6/20, Rowan) reports that, according to a research letter published June 18 in the Archives of Dermatology, adolescents and young adults perceive “health risks everywhere around them, so tanning beds don’t stand out as a particular danger.” After surveying 600 college students, researchers “found that, of those who said they’d ever used a tanning bed, 59 percent said they agreed with the statement, ‘Tanning bed use can make me ill, but everything causes cancer these days.'” What’s more, “52 percent agreed with the statement, ‘Tanning bed use is no more risky than lots of other things that people do.'”Note: There are a number of studies that have revealed the dangers of skin cancers in tanning bed victims. Also the ultraviolet rays will cause premature aged skin. Younger people always want to look older…until their older then they want to look younger. The deformities from skin cancer and the real risk of a severe life threatening skin cancer should not be underestimated in the calculation of risk vs benefit of using tanning beds.

Dr. Larry Weinstein and Dr. Foad Nahai during Plastic Surgery Barnabas Conference in Livingston, New Jersey

Posted: Wednesday, May 30, 2012 11:14 am

Weinstein Plastic SurgeryDrs. Larry Weinstein and Dr. Foad Nahai

Dr. Larry Weinstein and Dr. Foad Nahai during Plastic surgery Barnabas conference in Livingston, New Jersey concerning techniques of Face Lift, eyelid rejeuvenation, blepharoplasty and brow lifting.

Lecture at James Madison High School in Brooklyn NY

Posted: Thursday, May 24, 2012 10:57 am

Weinstein Plastic SurgeryDr. Weinstein with James Madison High School Students

The James Madison High school kids have been fund raising for Cleft Lip charities. As an alumnus Dr. Weinstein was asked to talk to the kids about what he has done in India at the 8 plastic surgery camps he attended.

Mendham surgeon visits India on bittersweet mission of mercy

Posted: Monday, January 23, 2012 10:32 am | Updated: 12:25 pm, Wed Jan 25, 2012. By PHIL GARBER, Managing Editor, Observer-TribuneThe Observer-Tribune reported:
“MENDHAM – When Dr. Larry Weinstein arrived at the Sancheti Hospital in Pune, India, he found a surging crowd of more than 500 poor people with varying degrees of deformities, from severely cleft palates to grossly enlarged mouths.

Weinstein Plastic Surgery
Dr. Larry Weinstein, right, is with a very happy patient who had his double upper lip repaired during Weinstein’s recent trip to India.

Weinstein who lives in Mendham is a surgeon at Weinstein Plastic Surgery Center with offices in Chester and Summit. He was on his seventh mission of mercy to India to perform free plastic surgeries for everyone from babies to adults. But while the trip was a success, it was bittersweet because it was the first time that Weinstein had not been with his mentor and founder of the project, Dr. Sharadkumar Dicksheet.

Dicksheet, who lived in Brooklyn, N.Y., died on Nov. 14, 2011. Dicksheet started going to India and offering the free surgeries in 1968. Through the years, he conducted nearly 70,000 surgeries. The Indian surgeon had won international recognition for his work and had been nominated for the Nobel Peace Prize five times.

Weinstein met Dicksheet at Kings County Medical Center, where Weinstein completed his residency and Dicksheet was then an instructor.

According to Weinstein, despite his serious health issues, Dicksheet, 81, was prepared to travel again to India before he died.

Weinstein was in India from Jan. 4-15 with a team that included Dr. Barry Citron of Livingston and two nurses, Amanda Hayes of Bedminister and, Courtney Enman of Long Valley.

It was Citron’s second mission and a first for Hayes and Enman.

Enman is a nurse in the operating room at Hackettstown Community Medical Center and has known Weinstein for 10 years. Hayes works with a home care agency and helps with surgeries at Weinstein’s offices.”

Adding MRI to mammography, ultrasound may increase breast cancer detection

Posted: Thursday, April 5, 2012Bloomberg News (4/4, Ostrow) reports, “Magnetic resonance imaging tests added to annual mammograms and ultrasound caught 56 percent more breast cancers in a study that suggests the extra scan may improve detection for women at increased risk for the disease.” Investigators found that “adding just an ultrasound to a mammogram caught 29 percent more cancers than mammogram alone among women with a higher cancer risk or dense breast tissue.” However, “the added tests…also boosted false positive results, which can lead to unnecessary biopsies.”On its website, ABC News (4/4, Conley) points out that for the study, published “in the Journal of the American Medical Association and funded by the Avon Foundation and the National Cancer Institute,” researchers “examined data from the American College of Radiology Imaging Network trial.”

Medscape (4/4) reports, “The study is important because it addresses how the performance of breast imaging can be improved for women who have dense breasts or are inherently susceptible to breast cancer, Robert A. Smith, PhD, senior director of cancer screening at the American Cancer Society, said in an interview with Medscape Medical News. Dr. Smith was not involved in the study.” Also covering the story are Reuters (4/4, Pittman), HealthDay (4/4, Gordon), Diagnostic Imaging (4/4), and MedPage Today (4/4, Phend).

Note: 23 years ago I did studies on MRI with breast cancer. We were able to visualize tumors only 1mm in diameter. MRI is clearly a superior exam for breast surveillance especially for dense breast tissue.

– Larry Weinstein, MD FACS

Study: People who eat chocolate more often tend to be thinner.

The Wall Street Journal (3/27, Dooren, Subscription Publication) reports that a recent study published in the Archives of Internal Medicine suggests that people who eat chocolate more frequently tend to be thinner than those who eat chocolate less frequently. The Journal notes that participants who ate more chocolate did not consume more calories than those who ate chocolate less often. The Journal adds, however, that the researchers warn that their study does not prove that a link exists between consuming chocolate and losing weight.The New York Times (3/27, O’Connor, Reporter) reports in its “Well” blog that “the researchers could not explain precisely why something usually loaded with sugar, fat and calories would have a beneficial effect on weight. But they suspect that antioxidants and other compounds in chocolate may deliver a metabolic boost that can offset its caloric downside.”USA Today (3/27, Lloyd) notes that “the new research involved 1,018 healthy men and women, who exercised on average 3.6 times a week and had a balanced, nutritious diet. The body mass index of those who ate chocolate five times a week was 1 point lower than people who did not eat it regularly. Body mass index (BMI) is a measure of body fat based on height and weight.” Also covering the story are Reuters (3/26, Subscription Publication), the Boston Globe (3/27, Kotz), Bloomberg News (3/27, Ostrow), NPR (3/26, Aubrey), Huffington Post (3/26, Pearson), HealthDay (3/26, Dotinga), MedPage Today (3/26, Smith), Medscape (3/26, Brown), and WebMD (3/26, Goodman).

PS: This is one of those things where a little bit may go a long way. One hershey kiss, 3 M Ms or one piece a day may keep the doctor away.

-Larry Weinstein, MD FACS

Celebrating 15 Years of Trustworthy Plastic Surgery Statistics

American Society for Aesthetic Plastic Surgery reports almost 9.2 Million Cosmetic ProceduresNEW YORK, NY (March 20, 2012)
The American Society for Aesthetic Plastic Surgery (ASAPS) today released their 15th annual multi-specialty procedural statistics. The Aesthetic Society, which has collected plastic surgery procedural statistics since 1997, says the overall number of cosmetic procedures has increased 197 percent since the tracking of the statistics first began. Almost 9.2 million cosmetic surgical and nonsurgical procedures were performed in the United States in 2011. The most frequently performed surgical procedure was lipoplasty (liposuction) and the most popular nonsurgical procedure was injections of Botulinum Toxin Type A (including Botox and Dysport).
“For fifteen years these statistics have been a large part of the Aesthetic Society’s public education mission,” said Jeffrey M. Kenkel, MD, President of the American Society for Aesthetic Plastic Surgery. “Since 1997, the interest in and demand for cosmetic plastic surgery has risen exponentially and our comprehensive statistics continue to show that.”
Cosmetic surgical procedures increased almost 1 percent in the past year, with over 1.6 million procedures in 2011. Surgical procedures accounted for 18% of the total numbers of procedure performed representing 63% of total expenditures. The top five surgical procedures were:

  • Liposuction (325,332)
  • Breast augmentation (316,848)
  • Abdominoplasty (149,410)
  • Eyelid surgery (147,540)
  • Breast Lift (127,054)

Cosmetic minimally-invasive procedures performed one of the surveyed physicians decreased almost 2 percent, with over 7.5 million procedures in 2011. Nonsurgical procedures accounted for 82% of the total number of procedures performed representing 37% of total expenditures. The top five minimally-invasive procedures were:

  • Botulinum Toxin Type A (2,619,739 procedures)
  • Hyaluronic acid (1,206,186 procedures)
  • Laser Hair Removal (919,802 procedures)
  • Microdermabrasion (499,427 procedures)
  • IPL Laser Treatment (439,161 procedures)

For the first time ever this survey asked the doctors for the total number of non-surgical procedures being performed in their practices by BOTH physicians and their physician assistants and nurse injectors. Below is the TOTAL number of procedures performed in the practices surveyed:

  • Botulinum Toxin Type A: 4,030,318
  • Hyaluronic Acid: 1,662,480
  • Laser Hair Removal: 1,452,880
  • Microdermabrasion: 794,357
  • IPL Laser Treatment: 726,125

“Growth in demand will likely coninue to grow as baby boomers and their offspring begin to explore surgical options,” said Dr. Kenkel. “Minimally-invasive procedures such as Botox and soft tissue fillers work to a point. However, as you age and gravity takes over, surgical procedures that lift the skin and reshape the underlying tissues are necessary in order to show significant improvement.”
Women had almost 8.4 million cosmetic procedures, 91% of the total. The number of cosmetic procedures for women increased over 208% from 1997. The top five surgical procedures for women were: breast augmentation, liposuction, tummy tuck, eyelid surgery, and breast lift.
Men had almost 800,000 cosmetic procedures, 9% of the total. The number of cosmetic procedures for men increased over 121% from 1997. The top five surgical procedures for men were: liposuction, rhinoplasty, eyelid surgery, breast reduction to treat enlarged male breast, and facelift.
Americans spent nearly $10 billion on cosmetic procedures in 2011. Of that total $6.2 billion was spent on surgical procedures; $1.7 billion was spent on injectable procedures; $1.6 billion was spent on skin rejuvenation procedures; and over $360 million was spent on other nonsurgical procedures, including laser hair removal and laser treatment of leg veins.

Tanning-salon use said to contribute to Idaho’s high rate of melanoma deaths.

The New York Times (3/7, A11, Yardley, Subscription Publication) reports that in Idaho, “lawmakers and public health experts…are confronting a problem that they say has developed in one of its newer panoramas: suburban strip malls dotted with salons like Beach Club, Jamaca Me Tan, Planet Beach and Tan du Soleil. Along with an increase in white-collar workers seeking outdoor recreation on weekends, the use of tanning beds is viewed as a reason that Idaho consistently has one of the highest rates of melanoma deaths in the country.” Now, however, some state legislators are trying to pass a measure that would ban “children 15 and younger” from using tanning salons. Currently, the bill has been sent back to committee for further reworking.Note: Stricter regulation is indicated in the use of ultraviolet rays for tanning. Melanoma is the most dangerous of skin cancers. The cause has been strongly linked to unrestricted sun exposure and tanning salons.– Larry Weinstein,MD FACS

Prospective Outcome Study of 360 Patients Treated with Liposuction, Lipoabdominoplasty, and Abdominoplasty

Plastic and Reconstructive Surgery, 01/06/2012Swanson E et al. – Liposuction and abdominoplasty, either alone or in combination, provide high levels of patient satisfaction (88.8 percent overall). The combined procedure was similar in discomfort level to abdominoplasty alone (both 7.5/10), and produced the highest level of patient satisfaction (99.2 percent), with 97.6 percent of patients saying they would repeat the surgery and 99.2 percent recommending it to others.Methods

  • From 2002 to 2007, in–person interviews were conducted with 360 patients who attended a follow–up appointment at least 1 month after surgery, from a total of 551 consecutive patients treated with ultrasonic liposuction and/or abdominoplasty (response rate, 65.3 percent).
  • Questions were asked in six categories: patient data, indications, recovery, results, complications, and psychological effects.
  • Responses were analyzed in three groups: liposuction alone (n = 219), combined liposuction and abdominoplasty (n = 128), and abdominoplasty alone (n = 13).


  • For most recovery indices, liposuction patients recovered significantly more quickly than lipoabdominoplasty patients (p <= 0.01) and had less discomfort (pain ratings 6.1/10 and 7.5/10 respectively, p < 0.001).
  • The result ratings for lipoabdominoplasty (9.0/10) and abdominoplasty (8.7/10) were higher than for liposuction alone (7.8/10, p < 0.001).
  • Overall, 85.8 percent of patients reported an improved self

Note: Of 345 patients in my practice of whom 217 have had abdominoplasty with liposuction of some of the adjacent areas. The percentage of patients with results that are acceptable or greater then expectation exceed 96%. My experience concurs with this study.

Larry Weinstein, MD FACS

Study: 20% of body piercings may become infected.

The Los Angeles Times (2/24, Roan) “Booster Shots” blog reported, “In one of the most comprehensive health examinations of body piercing, researchers have found that the wildly popular fashion statement is relatively safe, although about 20% of piercings become infected,” according to a study published in the American Journal of Clinical Dermatology. After analyzing “the overall safety, complications and medical consequences of piercings, focusing on the ear, nose, mouth, nipple, navel and male and female genitalia,” researchers found that “infections, although treatable, were the most common complication, followed by allergies, loss of blood, scarring and interference of medical procedures, such as X-ray or ultrasound.” The piece went on to offer safety tips to people considering getting a piercing of any type.Note: I charge $50.00 for ear piercing with a 0% incidence of infection. If you need to have this done, do it by a professional.

The Impact of Reduction Mammaplasty on Breast Sensation: An Analysis of Multiple Surgical Techniques

Annals of Plastic Surgery, 02/14/2012Spear ME et al. – Moving and static sensation showed differential return after breast reduction irrespective of the specific surgical approach but sensation was uniquely conserved for the nipple. In the total cohort, the type of breast reduction procedure did not produce significant differences in breast sensation.Methods

  • The prospective clinical trial collected sensory data using a computerized pressure-specified sensory device comparing 4 procedures for reduction mammaplasty.
  • A total of 48 patients were assessed at baseline, 6 weeks (n = 42), 6 months (n = 15), and 1 year (n = 24) postoperatively.


  • The findings of the study showed pressure sensitivity for women < 43 years of age improved by pressure-specified sensory device assessment; whereas, outcome data merely indicated return to baseline in pressure sensitivity for women ? 43 years of age.
  • Improved sensitivities for moving and static pressures were found in patients receiving vertical or inferior pedicle reduction mammaplasties.
  • Reductions based on superior pedicles exhibited sensory loss as compared with baseline measurements while those receiving free nipple grafts showed negligible change.

Note: The inferior pedicle technique of breast reduction in my hands has a less then 1% significant loss of sensation. This study reaffirms my preferred technique of breast reduction as it most often preserves nipple and breast sensation.

Larry Weinstein, MD FAC |

After Massive Weight Loss: Patients’ Expectations of Body Contouring Surgery

Obesity Surgery, 12/08/2011Kitzinger HB et al. – Surplus skin resulting from gastric bypass surgery is a common issue that causes functional and aesthetic impairments in patients. Consequently, this increases the desire for body contouring surgery with high expectations for the aesthetic outcome as well as improved life satisfaction.Methods

  • A questionnaire addressing information on the satisfaction of body image, quality of life, and expectation of body contouring surgery following massive weight loss was mailed to 425 patients who had undergone gastric bypass surgery between 2003 and 2009.
  • Of these 425 individuals, 252 (59%) patients completed the survey.


  • Ninety percent of women and 88% of men surveyed rated their appearance following massive weight loss as satisfactory, good, or very good.
  • However, 96% of all patients developed surplus skin, which caused intertriginous dermatitis and itching.
  • In addition, patients reported problems with physical activity (playing sports) and finding clothing that fit appropriately.
  • Moreover, 75% of female and 68% of male patients reported desiring body contouring surgery.
  • The most important expectation of body contouring surgery was improved appearance, followed by improved self–confidence and quality of life.

Note: I have had multiple major weight loss patients who have had tremendous improvements after face lift, neck lift, cosmetic body lift, abdominoplasty, breast lift and breast augmentation.

Larry Weinstein MD FACS

Additional Benefits to Reduction Mammaplasty: A Systemic Review of the Literature

Plastic and Reconstructive Surgery, 11/17/2011INTRODUCTIONReduction mammaplasty (RM) is commonly described with regard to its qualitative benefits. We sought to perform a systemic review of the literature focusing on functional outcomes after RM with regard to physical and psychological symptom improvement, including weight related effects, exercise, and eating behaviors, as well as aesthetic outcomes.


A systematic review of the English literature was performed using PUBMED to evaluate outcomes following RM from 1977-2010. Studies were chosen that addressed the physical and psychological benefits of RM using a validated questionnaire.


Women who undergo RM have a functional improvement in musculoskeletal pain, headaches, sleep, and breathing. Psychological benefits are vast and include improved self esteem, sexual function, and quality of life, as well as less anxiety and depression. Following RM, women appear to exercise more and have a reduction in eating disorders.


We present a comprehensive review of the literature with regard to the physical and emotional concerns women with macromastia experience, and the broad benefits reduction mammaplasty could have on their daily functions, and quality of life postoperatively (C)2011 American Society of Plastic Surgeons

Note: Breast reduction patients in my practice report complete relief from back, shoulder and neck pain. They also report relief from ulnar nerve dysesthesias, breast pain and inframammary fold fungal inflammations. No patient in my practice has needed blood transfusion and are usually done as an outpatient same day surgery.

Nipple-areola complex sparing mastectomy with periareolar pexy for breast cancer patients with moderately ptotic breasts

Journal of Plastic, Reconstructive & Aesthetic Surgery, 11/02/2011Rivolin A et al. – Periareolar pexy-nipple-areola complex sparing mastectomy (PP-NSM) allows good cosmetic results and low complication rates in patients with moderately ptotic breasts requiring a mastectomy. In particular, PP-NSM seems to be a good option for women at high risk for developing breast cancer and for selected patients affected by non-locally advanced breast cancer.Methods

As the cosmetic results in moderately ptotic breasts may not be optimal, a modified NSM with a periareolar pexy (PP-NSM) was introduced at authors’ institution.

Patients selection criteria and complication rates of PP-NSM were prospectively recorded and compared with those of the classical NSM.


Over a period of 11 months, 22 PP-NSMs and 35 NSMs were performed.

The mean jugular-nipple distance was significantly longer in the PP-NSM as compared with the NSM (22.6 vs. 19.6cm; p=0.000), whereas the mean inframammary fold-areola distance was superimposable (5.4cm).

The periareolar mastopexy led to a mean cranial transposition of the nipple-areola complex (NAC) of 2.2cm (range 1.5-4cm).

Mean breast weight was significantly higher in the PP-NSM as compared with the NSM cohort (336 vs. 236g; p=0.003).

The only case of total NAC necrosis occurred in the PP-NSM group.

Partial NAC necrosis was slightly more frequent in the PP-NSM than in the NSM group (13.6% vs. 2.9%%; p=n.s.), possibly due to the higher percentage of smokers (41.0% vs. 14.0%; p=0.05). Early cosmetic results were good to excellent from the surgeon’s and the patient’s point of view in over 80% of the cases.

The No-Scar Lip-Lift: Upper Lip Suspension Technique Anthony Echo and Eser Yuksel

AbstractAddressing the long upper lip has been a complex problem for some time. Methods such as the subnasal skin excision and the vermillion advancement technique have been described, but both leave a visible scar. A no-scar lip-lift technique is necessary for a subset of patients who have a long upper lip and will not accept a visible scar.Methods

The upper lip is shortened via an intranasal incision and suspension suture that elevates the upper lip and anchors it to the anterior nasal spine. A retrospective review of 92 patients who had undergone upper lip-lift with the no-scar suspension technique was performed. Three plastic surgeons assessed the pre- and postoperative results and determined the presence of improvement in four categories: lip shortening, lip projection, incisor show, and vermillion show.


The lip parameters improved, with 85% of the patients showing noticeable lip shortening, 79% showing increased sagittal projection, 74% exhibiting increased incisor show, and 25% exhibiting increased vermillion show. All the patients had improvement in at least one of the four categories. Complications were experienced by two patients with a suture abscess and one patient with an unraveled suture.


The overall lip contours improved after the lip suspension technique, most noticeably in terms of lip height and sagittal projection, and the scar was hidden intranasally.
Keywords Lip lift – Lip suspension – Lip aesthetics – Long upper lip – Ptotic upper lip
Note upper lip elevation techniques have been described with or without skin excision. The lips need to look youthful with fullness and good angles. Suspension techniques maybe applicable in some cases.

Larry Weinstein,MD FACS

AMA, other groups urge tanning ban for minors.

The CBS Evening News (2/28, story 7, 0:15, Couric) reported that the American Academy of Pediatrics is urging a ban on allowing minors to use tanning beds.The Los Angeles Times “Booster Shots” blog reported that a policy statement released by the group “cites several studies, including research that shows a link between people overexposed to the sun in childhood and melanoma, one of the deadliest forms of skin cancer.” The AAP “joins the World Health Organization, the American Medical Association, and the American Academy of Dermatology in advocating for such a ban.”The Boston Globe “Daily Dose” blog reported that “last March, an FDA advisory committee recommended that people under 18 be barred from using tanning beds or at least required to have a signed consent form from their parents. The new AAP declaration could help convince the FDA to follow its committee’s recommendation, which it’s not required to do.”

According to CNN, “the Indoor Tanning Association disagrees that tanning should be legislated.” The AP and the USA Today “On Deadline” blog also covered the story.

Eating vegetables gives skin a more healthy glow than the sun

ScienceDaily, 01/12/2011New research showed that eating a healthy diet rich in fruit and vegetables gives you a more healthy golden glow than the sun. Carotenoids are antioxidants that help soak up damaging compounds produced by the stresses and strains of everyday living, especially when the body is combating disease. Responsible for the red colouring in fruit and vegetables such as carrots and tomatoes, carotenoids are important for our immune and reproductive systems. While this study describes work in Caucasian faces, the paper also describes a study that suggests the effect may exist cross culturally, since similar preferences for skin yellowness were found in an African population.Note: it is important to eat fresh vegetables and fruits to maximize your health and skin.

Larry Weinstein MD FACS

Nipple-Sparing Mastectomy in 99 Patients With a Mean Follow-up of 5 Years

Annals of Surgical Oncology, 01/12/2011Jensen JA et al. – Five–year recurrence rate is low when NSM (nipple–sparing mastectomy) margins (frozen section and permanent) are negative. Nipple necrosis can be minimized by incisions that maximize perfusion of surrounding skin and by avoiding long flaps. A premastectomy surgical delay procedure improves nipple survival in high–risk patients. NSM can be performed safely with all types of breast reconstruction.Note: Relative to individual Cancer surgeons opinion. Larry Weinstein MD FACS

Customized Planning of Augmentation Mammaplasty with Silicone Implants Using Three-Dimensional Optical Body Scans and Biomechanical Modeling of Soft Tissue Outcome Aesthetic Plastic Surgery, 01/11/2011 Gladilin E et al. – Based on individual three–dimensional data and physical modeling, the described approach enables more accurate and reliable predictions of surgery outcomes than conventionally used photos of prior patients, drawings, or ad hoc data manipulation. Moreover, it provides precise quantitative data for bridging the gap between virtual simulation and real surgery.

Note: This is a dubious at best.

Larry Weinstein MD FACS

Breast Augmentation and Mastopexy Using a Pectoral Muscle Loop

Aesthetic Plastic Surgery, 11/08/2010 Clinical ArticleAuersvald A et al. – Augmentation mastopexy has historically challenged the creativity of plastic surgeons. Recurrent breast ptosis is the main cause for revision after such a primary operation. Avoiding the need for reoperation and achieving long–term projection and upper pole fullness have been the main focus for the work of many authors. In this study, a new approach for a stable and lasting breast shape based on the use of the pectoral muscle was conceived. Augmentation mastopexy using a loop of the pectoral muscle to hold the implant is a new and effective way to obtaiin long–lasting projection and upper pole fullness.Note: Breast augmentation and breast lift are procedures I am doing for over 20 years which have not required a Pectoralis Muscle loop.

Larry Weinstein, MD FACS

Looking older than your age may not be a sign of poor health

EurekAlert, 11/08/2010Even though most adults want to avoid looking older than their actual age. The study found that a person needed to look at least 10 years older than their actual age before assumptions about their health could be made. Few people are aware that when physicians describe their patients to other physicians, they often include an assessment of whether the patient looks older than his or her actual age. For patients, it means looking a few years older than their age does not always indicate poor health status. The study found that when a physician rated an individual as looking up to five years older than their actual age, it had little value in predicting whether or not the person was in poor health. However, when a physician thought that a person looked 10 or more years older than their actual age, 99 per cent of these individuals had very poor physical or mental health.Note: It is true looking older than your stated age is equated with poor health. I have seen many people over the years with severe weight loss who looked much older then there stated age.

Larry Weinstein,MD FACS

Breast Reduction by Liposuction in Females

Aesthetic Plastic Surgery, 11/02/2010 Clinical Article Jakubietz RG et al. – Liposuction breast reduction is appealing due to selective removal of fat, ease of the procedure, and minimal scarring. The main disadvantage is that a correction of shape and ptosis is not possible with liposuction, and only young patients can expect an aesthetically pleasing result. Elderly patients may benefit from faster recovery times, a less invasive procedure, and low costs. The application of a new technique to a cancer–prone organ represents a potentially serious medicolegal issue because follow–up imaging may be impaired and a possible spread of cancer cells cannot be ruled out. Despite its technical appeal, breast reduction by liposuction alone mandates a cautious approach.Note: I have done a case with liposuction alone, and have done many cases with the aid of liposuction to remove the upper secondary fatty tissue, the lateral armpit fatty tissue and sometimes just to contour the breast for a better result.Larry Weinstein,MD FACS

Outcome Analysis in 93 Facial Rejuvenation Patients Treated with a Deep Plane Facelift

Plastic and Reconstructive Surgery, 10/29/2010Despite a significant recovery period, patient satisfaction is high, with 96.7 percent of patients reporting a more youthful appearance after surgery. Scar dissatisfaction is rare (2.2 percent). With proper patient preparation and education, facial rejuvenation effectively meets patient expectations. These findings support the recommendation of surgical facial rejuvenation to patients who wish to look younger.Note: If a SMAS alone is added to a facelift, it has been found in previous studies to last longer. A new PDS stitch I use under the neck appears to add results with little increase in down time.

Larry Weinstein, MD FACS

A prospective, randomised, double-blinded trial to study the efficacy of topical tocotrienol in the prevention of hypertrophic scars

Journal of Plastic, Reconstructive & Aesthetic Surgery, 10/14/2010 Clinical ArticleKhoo TL et al. – Despite widespread beliefs regarding the use of topical tocotrienol in the prevention of hypertrophic scars, there is very little evidence from well controlled and randomised clinical trials to justify its benefits for surgical scars. Twice–daily application of 5% topical tocotrienol had no significant effect on the appearance and vascularity of scars over 4 months post–surgery. Laser doppler imaging has a promising role as a scar assessment tool.Note: I have never recommended the use of Vitamin E on wounds. This study bears out my observations over 25 years.

Larry Weinstein,MD FACS

Enhanced Eyelashes: Prescription and Over-the-Counter Options

Aesthetic Plastic Surgery, 09/02/2010 Jones D – Originally indicated for the reduction of intraocular pressure, the synthetic prostaglandin analog bimatoprost was recently approved for the treatment of hypotrichosis of the eyelashes. In a double–blinded, randomized, vehicle–controlled trial, bimatoprost safely and effectively grew natural eyelashes, making them longer, thicker, and darker. Bimatoprost was generally safe and well tolerated and appears to provide an additional option for individuals looking to improve the appearance of their eyelashes.We have noted improvement in my office staff and in my patients of their eyelashes with the use of Latisse.Larry Weinstein,MD FACS

Consecutive Procedures and a Patient Satisfaction Assessment

Aesthetic Plastic Surgery, 10/07/2010 Clinical ArticleCastello MF et al. – A conventional superficial musculoaponeurotic system face–lift is well established because it allows the skin envelope to be rotated in a bit more lateral direction than the cephalad redirection of the superficial musculoaponeurotic system flap. The authors believe that the rhytidectomy technique described in this report has several beneficial attributes. High vertical elevation of the superficial musculoaponeurotic system flap delivers a long–lasting benefit and addresses the problem of neck laxity and platysma redundancy, leading to a correction of the neck contouring and jowls. Nasolabial folds appear to be smoothed, and malar flattening is restored by imbrications of the superficial musculoaponeurotic system flap over the cut edge in the malar prominence. This investigation demonstrates that the rhytidectomy technique is safe and produces highly predictable results.

Double-Mesh Technique for Correction of Abdominal Hernia Following Mammary Reconstruction Carried Out with Bipedicled TRAM Flap and the Primary Closing of the Donor Area by Using a Single Polypropylene Mesh

Aesthetic Plastic Surgery, 10/07/2010 Clinical ArticleSouto LRM et al. – Mammary reconstruction by using the transverse myocutaneous flap of the abdominal straight muscle is still an option well accepted in many parts of the world. However, bipedicled transverse myocutaneous flap of the abdominal straight muscle flaps are associated with greater morbidity of the abdominal donor area. The aim of this study was to describe an efficient technique for correcting the delayed defects of the abdominal wall following mammary reconstruction carried out with bipedicled transverse myocutaneous flap of the abdominal straight muscle flaps by using two polypropylene prostheses overlapped in different anatomical planes. The correction of delayed deformities of the abdominal wall after mammary reconstruction with bipedicled transverse myocutaneous flap of the abdominal straight muscle flaps using double mesh was carried out in an effective and secure way, providing an interesting surgical option for mastologists and plastic and general surgeons.

Autologous Gluteal Lipograft

Aesthetic Plastic Surgery, 10/07/2010 Nicareta B et al. – The key to successful gluteal fat grafting is familiarity with the technique, knowledge of the gluteal topography, and understanding of the patient’s goals. With experience, the surgeon can predict the amount of volume needing to be grafted to produce the desired result. Although the aim of every surgeon is to produce the desired augmentation of the gluteal region by autologous fat grafting in one stage, the patient should be advised that a secondary procedure may be needed to accomplish the desired result.

“Immediate Breast Reconstruction with Implants After Skin-Sparing Mastectomy: A Report of 96 Cases”

Aesthetic Plastic Surgery, 05/19/10 Fa-Cheng Li1 , Hong-Chuan Jiang2 and Jie Li2AbstractBackground: Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has become increasingly popular as an effective treatment for patients with early-stage breast cancer requiring mastectomy. This study aimed to evaluate the clinical outcomes of IBR using permanent gel breast implants and Becker expandable breast implants after SSM.

Methods: A review of 96 patients undergoing IBR with Beck expandable or permanent gel breast implants after SSM from July 2002 to December 2006 was performed. Of the 96 patients, 30 had IBR after SSM with conservation of the nipple–areola complex (NAC). The mean patient age was 42 years (range, 29–57 years). Aesthetic outcomes were assessed according to the breast volume, shape, and symmetry with the opposite breasts after a mean follow-up period of 44 months.

Results: The aesthetic outcomes were graded as excellent for 29 patients, good for 47 patients, fair for 12 patients, and poor for 8 patients. The overall complication rate was 11.5% (11/96). The complications included prosthesis loss after skin flap necrosis subsequent to hematoma formation (n = 1), skin necrosis (n = 2), partial necrosis of preserved NAC (n = 1), capsular contracture (Baker 4, n = 2), wound infection not involving the prosthesis (n = 2), inversion of the injection port (n = 2), and seroma (n = 2).

Conclusion: This study demonstrates that prosthetic breast reconstruction is a safe, reliable method with minimal complications and good to excellent aesthetic results for the majority of patients with early-stage breast cancer. For selected patients, NAC-sparing mastectomy can be performed without increasing the risk of local recurrences. Success depends on patient selection, proper incision for SSM, total coverage of the prostheses with muscles, and careful intra- and postoperative management.

Keywords – Breast implants – Breast neoplasms – Mammaplasty – Mastectomy

“Key Points in Mastopexy”

Aesthetic Plastic Surgery, 06/04/10 Javier De Benito1 and Kyrenia Sánchez1Abstract – Breasts represent femininity and any change of shape may affect their appearance. Breast ptosis may be caused by several factors, including significant weight loss, pregnancy, long breastfeeding periods, and involution of the postmenopausal breast tissue. Breast ptosis may be associated with breast hypoplasia; thus, in case of a mastopexy with or without the use of implants being indicated, several considerations have to be taken into account: the wishes of the patient, age of the patient, degree of ptosis, parenchymal volume, covering tissue, quality of the tissue, pocket implant, shape and content of the implant, and resulting scars.Keywords – Breast augmentation – Mastopexy Note: Breast ptosis or saggy baggies can be corrected with a breast lift – Mastopexy or sometimes with replacement of volume with an implant. An implant can be used with degrees of lifting that include a crescant lift, periareola lift, lollypop or inverted T. There is a high degree of patient satisfaction with this procedure.

Larry Weinstein,MD FACS

“A Comparative Study of the Transversus Abdominis Plane (TAP) Block Efficacy on Post-bariatric vs Aesthetic Abdominoplasty with Flank Liposuction”

Obesity Surgery, 06/10/10Abstract – The transversus abdominis plane (TAP) block acts on the nerves localised in the anterior abdominal wall muscles. We evaluated the efficacy on post-bariatric (PB) patients undergoing body-contouring abdominoplasty. We retrospectively evaluated PB patients undergoing abdominoplasty with flank liposuction and compared results to a matched group of TAP aesthetic patients. Outcomes evaluated were the analgesic requirements during the early postoperative days. Fifty-one patients (PB n?=?27, aesthetic n?=?24) were assessed. No complications were observed. All PB patients required analgesia until the second postoperative day contrarily to most aesthetic ones. Patients with greater flap resected and higher pre-abdominoplasty BMI had greater morphine consumptions. In PB patients, the larger amount of tissues resected corresponded to a greater stimulation of pain fibres that cannot be paralleled by a concomitant increase of the local anesthetic administered. This partially invalidates TAP’s efficacy on PB patients.Keywords – Transversus abdominis plane – Pain – Locoregional analgesia – Abdominoplasty – Body contouring – Obesity surgery – Bariatric surgery

Note: My patients with abdominoplasty usually go home the same day of surgery. They do well with oral pain medications.

Larry Weinstein,MD FACS

“No significant difference in benefit for longer surgical procedure… Comparison of Morbidity, Functional Outcome, and Satisfaction Following Bilateral TRAM Versus Bilateral DIEP Flap Breast Reconstruction Plastic and Reconstructive Surgery, 06/17/10”

Background: The potential for donor site morbidity associated with bilateral pedicled TRAM flap breast reconstruction has led to the popularization of DIEP flap reconstruction. This study compares post-operative morbidity and satisfaction following bilateral pedicled TRAM and DIEP flap reconstruction.Methods: One-hundred and five women with bilateral pedicled TRAM flaps were compared to 58 women with bilateral DIEP flap reconstruction. Medical records were reviewed for complications and demographic data. Post-operative follow-up data was obtained through Short Form-36, FACT-B, Michigan Breast Satisfaction, and Qualitative Assessment of Back Pain surveys.Results: The mean follow-up interval was 6.2 years in the bilateral TRAM group and 2.3 years in the bilateral DIEP group (p < 0.001). Demographic data was otherwise similar. Abdominal hernias occurred in 3 TRAM patients (2.9 %) and in no DIEP patients, whereas abdominal bulges occurred in 3 TRAM patients (2.9 %) and 4 DIEP patients (6.9 %); these differences were not statistically significant. Fat necrosis occurred less frequently in the TRAM group (p = 0.04). Post-operative survey results revealed no significant difference in patient satisfaction, incidence of back pain, or physical function. The TRAM group scored higher in the SF-36 subjective energy category (p = 0.01) and mean FACT-B score (p = 0.01).

Conclusion: This study suggests no significant differences in donor site morbidity, survey-based functional outcome, or patient satisfaction between bilateral TRAM and DIEP flap breast reconstruction. Although perforator flaps represent an important technological advancement, bilateral pedicled TRAM flap reconstruction still represents a good option for autologous breast reconstruction. (C)2010American Society of Plastic Surgeons Note; The extended surgical time, inherent risk factors in a longer procedure and lack of significant benefit may preclude the use of this flap in most patients.

Larry Weinstein, MD FACS

Aesthetic Breast Augmentation and Thoracic Deformities

Aesthetic Plastic Surgery, 05/03/10P. Wolter3 , S. Lorenz2 and C. Neuhann-Lorenz1(1) Praxis für Plastische und Aesthetische Chirurgie, Theatinerstrasse 1, 80333 München, Germany

(2) Department of Plastic, Reconstructive, Hand and Burn Surgery, Klinikum Bogenhausen, Englschalkinger Straße 77, 81925 München, Germany

(3) Department of Plastic Surgery, Hand Surgery, Burn Center, University Hospital of the RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany

Abstract – To ensure the best results from aesthetic breast augmentation, preoperative evaluation and adequate patient information are essential. However, assessment of the underlying thoracic shape often is neglected. Patients with obvious deformities are aware of the problematic reconstruction, whereas patients with mild or moderate deformities often are not aware of their condition and fail to see that standard breast augmentation will lead to unsatisfying results. The authors reviewed their charts for patients with breast augmentation and mild to moderate thoracic deformities, then compiled the therapeutic possibilities and the outcome. Of the 548 patients who underwent breast augmentation, 7.1% (n = 39) exhibited low- or midgrade thoracic wall deformities. Almost none of the patients were aware of their deformity. The patients were augmented with silicone-filled, textured round implants. Placement and volume were adapted to the anatomic situation. A reoperation was not performed in any case, and both patient and physician satisfaction was high. The percentage of patients with thoracic deformity in this group was high compared with an overall incidence of less than 2%. This emphasizes the need for cautious physical examination and preoperative documentation. By individualized surgical planning and diligent implant selection, optimal results and patient satisfaction can be achieved.

Keywords – Aesthetic breast augmentation – Thoracic deformities – Silicone breast implants – Breast asymmetry – Poland’s syndrome – Retrospective study Note: Many patients have thoracic problems with their chest wall which are enhanced with breast implants. Many more patients with real problems with their chest walls or breast maldevelopment have breast augmentation then movie stars or dancers.

Larry Weinstein, MD FACS

Correlation Between Scoliosis and Breast Asymmetries in Women Undergoing Augmentation Mammaplasty

Aesthetic Plastic Surgery, 04/28/10Background: Breast asymmetries and scoliosis influence the results of augmentation mammaplasty. Although a variety of methods have been proposed to resolve breast asymmetries, to date, no simple preoperative algorithm has been proposed for predicting the breast volume and decreasing breast asymmetries in the place of subjective or expensive evaluation. The relationship between the scoliosis and breast volume asymmetry was further analyzed statistically in this study.Methods: The study enrolled 60 scoliotic patients from 780 patients undergoing augmentation mammaplasty between January 2000 and March 2008. The average follow-up period was 2 years. The inclusion criteria required hypoplastic breasts, a difference in bilateral breast volumes greater than 20 ml, and scoliosis with a Cobb angle greater than 10°. The authors’ surgical algorithm demonstrated an anthropomorphic equation for predicting breast volume and selecting the correct implant size.

Results: Pearson regression analysis showed that the breast volume asymmetry difference was significantly correlated with the severity of scoliosis (Cobb angle) (correlation coefficient, 0.901). No correlation between the difference in pre- and postoperative nipple and inframammary levels and the severity of scoliosis was noted. Augmentation mammaplasty significantly decreased the breast asymmetry differences (volume and nipple level) (p < 0.001). The average preoperative estimated breast volume was 45.3 ml for the smaller breast and 88.4 ml for the larger breast.

Conclusion: This study found that the severity of scoliosis showed significant correlation with the breast volume asymmetry differences. Augmentation mammaplasty for breast asymmetries decreased not only the volume difference but also the difference in nipple levels. Keywords: Augmentation mammaplasty – Breast asymmetries – Implant – Scoliosis Note: Breast asymmetry can be secondary to spinal and chest bone deformities. Scoliosis is a special case which can give more significant abnormalities of the breast on a developmental and aging process. I have had good success with improvement in patients with scoliotic related breast asymmetry.

Larry Weinstein, MD FACS

Botox reduces wrinkles even in less frequent doses:

OHSU research shows patients can reduce frequency of Botox Cosmetic treatments over time, saving money while still reducing dynamic wrinklesPORTLAND, Ore. – Patients can decrease the frequency of Botox© Cosmetic injections after approximately two years and still receive most of the same wrinkle-smoothing cosmetic benefits, according to new research at Oregon Health & Science University.”After two years of treatment at recommended intervals, patients can potentially cut the frequency, and thus the cost, of their Botox© treatments by half,” said Roger A. Dailey, M.D., F.A.C.S., professor and Lester Jones Endowed Chair of oculofacial plastic surgery in the OHSU School of Medicine. The results of Dailey’s work were presented at a meeting of American Society of Aesthetic Plastic Surgeon on April 24 in Washington, D.C. The research was sponsored by an unrestricted educational grant from Allergen, Inc., the maker of Botox© Cosmetic.

The Botox© research effort also demonstrated that the injections have a wrinkle preventing – or prophylactic – effect. Patients who begin receiving injections between their 30s and 50s are able to prevent wrinkles from forming and reduce existing wrinkles, said Dailey, head of the Casey Aesthetic Facial Surgery Center, which opened in 1991 as part of Casey Eye Institute.

Based on previous studies, doctors advised patients who wished to reduce wrinkles in the glabellar region – the area between the eyebrows – that they needed to have Botox© Cosmetic injections every three months to maintain the cosmetic wrinkle-smoothing benefits. Such frequent treatment, however, deterred some patients, Dailey said.

Dailey studied 50 women ages 30 to 50, who received regular Botox© injections for two years. “We found that after the patient receives Botox© Cosmetic injections every four months for two years, the frequency of the injections can be changed to every six months and still achieve good results,” Dailey said. “This demonstrates patients have the ability to achieve good results with broader treatment schedules and ultimately at a lower overall treatment cost.

Botox© has been approved for cosmetic use for eight years. In 2008, more than 5 million patients in the United States received cosmetic Botox© treatments, according to Allergen, the manufacturer. About 313,000 of those patients were men.

Note: I have been using Botox for over 15 years for my staff and patients. Different strokes for different folks. Some patients require every 3 month treatment, some may have residual effects for as long as 6 months, I suspect some patients may eventually experience muscle atrophy from disuse and may need less as time goes on. However some patients develop taxyphylaxis which is a resistence to the medication that might require an increased dose or a slightly different compound; such as Dysport.

Larry Weinstein,MD FACS

Upper Body Reshaping for the Woman with Massive Weight Loss: An Algorithmic Approach

Aesthetic Plastic Surgery, 04/22/10AbstractBackground: Body contouring after massive weight loss represents a rather new surgical field. Many areas of the body are affected such as the back, the upper arms, and the breasts in the upper body. Combining more than one such area in a single operative step can yield many advantages. The author proposes a single-step approach to the upper body of the woman with massive weight loss and offers an algorithm to simplify the operative plan.

Methods: Based on the characteristics of the individual, each adjacent region is analyzed for the potential of surgical improvement. Several lifting techniques can be used to restore the shape of each region. The breast represents a rather unique entity in which three basic types can be recognized. Accordingly, a surgical plan is formulated and discussed with the patient.

Results: The presented algorithm was used successfully for 17 consecutive women after massive weight loss. Although the time for these combined operations was increased, patient safety was not reduced nor were the number of complications increased compared with multiple smaller operations. The overall treatment plan for this patient group was greatly enhanced and simplified with this approach and resulted in great patient satisfaction.

Conclusion: Body contouring after massive weight loss presents a steadily increasing surgical field. Typically, multiple operative steps are required to achieve the patient’s ultimate goal. The author offers a surgical algorithm that aids in the operative planning for the upper body of such patients that simplifies this operation and yields great patient satisfaction.

Note: I have been using an extended abdominoplasty with thigh lift for some years with very nice results in most patients.

LASER removal of fat cells.

Mary K. Caruso-Davis1, Thomas S. Guillot2, Vinod K. Podichetty3, Nazar Mashtalir4, Nikhil V. Dhurandhar4, Olga Dubuisson4, Ying Yu4 and Frank L. Greenway4
Published online: 15 April 2010AbstractBackground: Low-level laser therapy (LLLT) is commonly used in medical applications, but scientific studies of its efficacy and the mechanism by which it causes loss of fat from fat cells for body contouring are lacking. This study examined the effectiveness and mechanism by which 635–680 nm LLLT acts as a non-invasive body contouring intervention method.Methods: Forty healthy men and women ages 18–65 years with a BMI <30 kg/m2 were randomized 1:1 to laser or control treatment. Subject’s waistlines were treated 30 min twice a week for 4 weeks. Standardized waist circumference measurements and photographs were taken before and after treatments 1, 3, and 8. Subjects were asked not to change their diet or exercise habits. In vitro assays were conducted to determine cell lysis, glycerol, and triglyceride release.Results: Data were analyzed for those with body weight fluctuations within 1.5 kg during 4 weeks of the study. Each treatment gave a 0.4–0.5 cm loss in waist girth. Cumulative girth loss after 4 weeks was ?2.15 cm (?0.78 ± 2.82 vs. 1.35 ± 2.64 cm for the control group, p < 0.05). A blinded evaluation of standardized pictures showed statistically significant cosmetic improvement after 4 weeks of laser treatment. In vitro studies suggested that laser treatment increases fat loss from adipocytes by release of triglycerides, without inducing lipolysis or cell lysis.Conclusions: LLLT achieved safe and significant girth loss sustained over repeated treatments and cumulative over 4 weeks of eight treatments. The girth loss from the waist gave clinically and statistically significant cosmetic improvement.Keywords – Cold laser – Fat reduction – Low-level laser therapy – Non-invasive laserThis study was supported by Meridian Medical, Inc., Vancouver, BC, Canada V6K 4L9.

Saturday, April 24, 2010
Alex Colque, M.D. , The Methodist Hospital, Houston, TX
Michael Eisemann, MD , Eisemann Cosmetic Daysurgery Center, The Methodist Hospital, Houston, TX

Goals/Purpose: Breast augmentation has been performed under local anesthesia and intravenous sedation for 30 years. The senior author (M.L.E.) has observed, during over 20 years of practice, less intra-operative bleeding and post-operative nausea using intravenous sedation and intercostal nerve blocks than with general anesthesia. General anesthesia is only used when breast augmentation with or without mastopexy is combined with large liposuctions, body contouring procedures, obese patients or surgery expected to last over 4.5 hours. The described protocol can be administered by the surgeon and the circulating nurse. It deliberately avoids the use of propofol which should be used only by a nurse anesthetist or anesthesiologist. Patients, when given the option of monitored sedation with intercostal nerve block generally have preferred this technique over general anesthesia due to its safety, efficiency, and cost savings. We present our experience with using intercostal nerve blocks and intravenous sedation to perform breast augmentation with and without simultaneous mastopexy. We also compare these two groups of patients.

Methods/Technique: We used the following anesthesia technique: Patients were administered the first dose of intravenous sedation by the surgeon starting with 1mg midazolam (FDA schedule IV), 50mcg fentanyl (FDA schedule II), and 10 mg ketamine (FDA schedule III) and then additional doses as necessary by the circulating nurse. Local anesthesia solution consisting of equal parts of 0.25% bupivicaine and 1% xylocaine with 1:100,000 epinephrine was then injected into intercostal spaces 3-7 at the mid-axillary line. 2ml were used in each costal interspace. The solution was then injected at the lateral sternal boarder in varying amounts.

A retrospective review was done on 171 patients who underwent bilateral breast augmentation and augmentation- mastopexy from January 1st, 2007 to October 30th, 2009 at an AAAA accredited outpatient surgery center by the senior author (M.L.E.) using the protocol described above. All procedures were performed for cosmetic purposes. We excluded patients that had any other additional procedures including liposuction. All breast implants were placed in a subpectoral pocket. The two groups were then analyzed for age, BMI, operative time, total sedation used, total local anesthesia used, recovery room length of stay, and complications.

Results/Complications: A total of 171 patients were included in the study, 132 underwent breast augmentation and 39 breast augmentation-mastopexy. In the augmentation group the means were: age 31.7 (range: 17-66), BMI 21.5 (16.4-28.7), operative time 63.8 min (42-120), ketamine used 19.3mg (0-60), midazolam used 5.7mg (0.5-11), fentanyl used 160.5mcg (25-300), total local solution used 79.6ml (25-120), recovery room length of stay 49.9min (16-116), and 14 had post-operative nausea (10.6%). In the augmentation-mastopexy group the means were: age 34.5 (range: 20-54), BMI 22.8 (17.2-32.0), operative time 134.7min (56-210), ketamine used 18.2mg (0-40), midazolam used 7.3mg (4-10), fentanyl used 180.8mcg (100-300), total local solution used 90.9ml (45-144), recovery room length of stay 52.9min (17-107), and 5 had post-operative nausea (12.8%). There were no deaths, deep venous thromboses, pulmonary emboli, hematomas, reoperations, pneumothoracies, intubations, and none of the patients required admission to the hospital.

Conclusion: After reviewing our experience, we conclude that breast augmentation with and without mastopexy can be performed safely and with minimal discomfort under local anesthesia with intravenous sedation with minimal complications when performed by ACLS certified personnel in an AAAA certified facility. Although augmentation with mastopexy procedures requires a longer operative time than augmentation alone, this does not lead to a longer recovery room length of stay. This is likely due to the effectiveness of the intercostal nerve block for post-operative pain control.

Saturday, April 24, 2010
Alberto di Giuseppe, pastic, maxillo, surgeon , ASAPS, Ancona, Italy

Goals/Purpose: Give a 360 degree perspective of safe and aestheticre modeling of the thigh

Methods/Technique: Superficial and deep ultrasound liposculture of anterior thigh through patellar and inguinal incisions.

Results/Complications: Significant improvement of aesthetic results of the thigh remodeling, due to a real 360 degree sculpturing . no complications in our series with 2 years follow up.

Conclusion: The analysis of the proportions rules proposed by leonardo da vinci, kept in evidence that only 2 dimensions of the thigh have been evaluated even with photographic approach in te last decades. profile and 3/4 view give reason of the need of treatment also of the anterior thigh, when necessary, to complete and enhance the aesthetic outcome of the entire thigh. These concepts are realized through vaser superficial and deep ultrasound liposculture.

In the last decades, when planning a liposuction or liposculpture of the thigh, the analysis of the areas and zones to be corrected has always been taken from anterior and posterior views, and the surgical techniques have been addressed to correct flanks, trocanter deformities, banana fold, inner side of the thigh, inner side of the knees, etc.

I reviewed the story of the studies on body proportions by LEONARDO DA VINCI, starting from his paintings of nude man,1503,1509, exposed at the WINSOR CASTEL ROYAL LIBRARY, where he started studying the body figure and proportions from 2 standards views, frontal and dorsal ,or anterior and posterior, as we have been instructed through all these years by our masters.

LEONARDO DA VINCI introduced hid antropometric studies of body proportions and parts, simplifying the absolute criteria of VITRUVIO (1siecle a.c.) based on a Greek measurement scheme.

And finally introduced the third dimension, as indicated in his drawings analysis of leg proportion. Leg is measured with Greek letters at different distances, and comparison between upper, middle lower third of the leg are done in absolute and relative terms. The lateral view of the thigh appears finally, after frontal and dorsal view have been the only considered in the previous period .

In his drawing on study of proportions of the body standing, sitting, and on his knees ( Windsor Castle 1490) clearly indicated the correct way to approach and evaluate the body symmetry and evaluate body contouring.

The lost third dimension tells me of a different criteria to evaluate and thus correct body deformity mainly in the thigh area, which has been considered for long time assort of “forbidden area “. This relative hostility was due to the difficulty of sculpturing and mastering the anterior and antero medial part of the thigh, and for the fear to damage with secondary irregularities and depressions.



Scope of the anteromedial approach to the thigh is to thin the subcutaneous fat of the thigh in areas considered to be risky for the approach with classic liposuction. At the same time, the undermined tissues rises and represents a substantial benefit for the final contouring of the leg. Of course the approach to the anterolateral part is the final step of a circumferential sculpturing of the thigh. A tridimensional vision of the full area is mandatory to model the different sides in harmony in between them.

Infiltration of tumescence is vital in ultrasound assisted lipoplasty.

1. The tumescent infiltration initially distends the tissue, allowing vasoconstriction which diminishes bleeding, compacting the tissues which become uniform .The fluids are distributed superficially first and deeper, to follow.

2. The superficial superwet technique of infiltration really distends the tissue and allows a precise undermining by the 2,9 mm or 3,7 mm one or two rings probe. With the power tunneled at 70 per cent of power, the probe is directed parallel to the skin axis, as indicated in the diagram, in order to allows careful undermining of the tissue from underlying fat. This maneuver is essential for the final contouring of the area of the thigh, as will allow the reduced tissues to adhere to the new, reduced and shaped body. This selectivity distinguishes vaser ultrasound from whatever other technique in terms of protection of the subcutaneous vascular plexus.

3. Once completed the undermining, which may require 5, 6 minutes of delicate vaser action, always respecting the skin superficial layers, the probe is directed in the deeper layers of the thigh.

4. The emulsification ends when there is no more resistance in the deep layers of fat.

5. Once this phase is completed, the surgeon starts the most delicate part of the contouring, the removal of emulsified fat from the deeper layer, the superficial spreading of the skin, the careful aspiration in respect of the shape of the body. Aspiration in the superficial layer has to be very conservative This part of the sculpting of the body allows the plastic surgeon to express his own talent and artistry, and is the unique part of the technique which cannot be taught, but just shown.

6- Sculpturing the body, recreating lines of natural convexity or concavity is the fascinating and creative part of surgery. I utilize a 2,8 mm fine cannula to shape the superficial planes, with virtually no aspiration. And a 3,7 mm cannula to aspirate in the deeper planes.


Saturday, April 24, 2010
Alessandra Haddad , Disciplina de Cirurgia Plástica UNIFESP Universidade Federal de São Paulo, São Paulo, Brazil
Daniel Regazzini , Campinas Obesity Surgery Center, São Paulo, Brazil
Vanessa Contato Lopes Resende, Resident , Disciplina de Cirurgia Plástica UNIFESP Universidade Federal de São Paulo, São Paulo, Brazil
Lydia Masako Ferreira, MD, PhD , Disciplina Cirurgia Plástica UNIFESP – Universidade Federal de São Paulo. Departamento de Cirurgia, São Paulo, Brazil

Goals/Purpose: The purpose of this paper is the analyze the safety in the use of Hyaluronic Acid based filling substances of in the treatment of aesthetic imperfections of the face.

Methods/Technique: The aging process leads to facial outline alteration and global volume reduction due to dermal alterations and skin tissue reduction. Several substances have been used to minimize theses alterations and to compensate the wrinkle tissular volumetric form through dermal filling.

Because it’s an absorbable substance of non – animal origin, the Hyaluronic Acid have been greatly used as a facial filling. Hyaluronic Acid is a glycosaminoglycan polysaccharide present in dermis and other organic tissues that assists cellular growth and acts in membrane receptors and cellular adhesion.

The use of hyaluronic acid as a dermal filling presents many advantages, due to its non-animal origin and absorbability (less capacity of imunogenicity). Because of its characteristics, it was chosen as the filling material of this study, for facial wrinkles, lips contour, scar depressions and facial lipoatrophy.

This is a retrospective study on the application of hyaluronic acid with on 1366 patients, based on photographs right before application, 30 days afer and the 180 days application.

The selected patients were the ones with indication for dermal filling to treat deep wrinkles, scars in the fce, facial lipoatrophy, deep nasolabial fold and thin lips.

The criteria for exclusion are: patients with history of allergy to hyaluronic acid, presence of skin patologies at the local of application or decompensated systemic pathology, pregnancy, presence of scarring disturbances, previous treatments with non-biodegradable substances at the local to be treated or the use of anticoagulant for any pathology.

The patients were treated with 0,7ml and 1,4ml applications of hyaluronic acid, sterilized and with concentration of 20mg/ml, injected in mid-reticular dermis, deep reticular dermis and papillary dermis, on pre-determined spots, using 13×0,7 (27G) needle.

The markings were made with the patients seated, to highlight the spots that needed filling. Topic local anesthesia and /or anesthetic block may be used according with the indication of anesthetics local infiltration. The volume injected should be enough for the local to be treated. The aesthetic result is immediate and there should not be hypercorrection. The application technique used was retroinjection. After application, cold compress for 10 minutes and local massage are done.

The patients returned on the 7th and 15th day after the application, when they are evaluated, after the improvement of initial edema. At this point, if necessary, touch up can be made as complements on spots with hipocorrection or assimetry. Then they should return on the 30th and 180th day after application for new evaluation.

Results/Complications: It was documented 1366 patients submitted to hyaluronic acid dual filling, between 1997 and 2007. The application sites were: nasolabial fold (48,2%), lips (25%), nasolabial fold and lips (19%), earlobe (1,2%), malar region (0,7%) and other region (6,1%). 32% of the patients needed touch up application after 15 days. There were complications in 8 patients (0,6%): palpable fibrous string (2), ectopia (2), front cellulite (1), strange body granuloma (1) and extrusion (2).

The adverse effects are described in literature and generally are self-limited.

Conclusion: The conclusion of this paper is that Hyaluronic Acid is an excellent filling, with low complication rate and high degree of patient satisfaction.

Tuesday, April 27, 2010: 11:24 AM

Oscar M. Ramirez, MD , Plastic Surgery, Sanctuary Plastic Surgery, Boca Raton, FL

Goals/Purpose: Previously designed chin implants failed to do the changes that the sliding osteotomy can do. We describe a newly designed chin implant and its corresponding technique that can be considered a substitute for the sliding geniality.

Methods/Technique: The implant is a two-piece adjustable wraparound device that provides augmentation of the genio-mandibular area in all dimensions. A wide subperiosteal dissection and detachment of the digastric/mylohyoid muscles with latter reattachment in a new and more anterior position is performed. These accomplish some of the effects of the sliding genioplasty: increase of vertical height of the anterior mandible, soft tissue remodeling of the lower mandible and chin and tightening of the suprahyoid muscles. Lower perioral musculature dynamics also improves.

Results/Complications: This method was used for 13 years in 142 patients some as a solo procedure and others as a part of a more comprehensive plan. Soft tissue anthropometric measurements in 20 patients showed an improved soft tissue/skeletal advancement ratio of 1.5 (0.8 for the sliding genioplasty). Complication rate has been minimal: 4.2% temporary neuropraxia of the marginal mandibular nerve. One patient required trimming of implant at the gingivo-buccal sulcus. In other patient paresthesias of the mental nerve required trimming of the implant. Three patients (2%) required size adjustments: one exchange for a smaller implant, one in situ trimming and the third a further augmentation with an overlay implant. Two patients (1.4%) requested removal of their implants

Conclusion: High patient satisfaction and good to excellent aesthetic results were obtained in 90% of patients. The subset with anthropometric data showed positive soft tissue/skeletal advancement ratio compared to those described for the sliding genioplasty patients. Many patients’ candidates for sliding genioplasty were successfully treated with this implant and the described technique.

Tuesday, April 27, 2010: 1:31 PM
Douglas M. Senderoff, MD, FACS , Plastic Surgery, Park Avenue Aesthetic Surgery, PC, New York, NY

Goals/Purpose: The purpose of this study was to examine the results of a single surgeon in a consecutive series of buttock augmentations using solid silicone implants.

Methods/Technique: A retrospective chart review was conducted to identify all patients who underwent bilateral buttock augmentation using solid silicone implants over an eight year period. Demographic information, implant size, concomitant procedures and surgical information including the use of drains and implant position were recorded for each patient. Pre and postoperative photographs were taken. The data was analyzed to determine the rate of complications, need for surgical revision and aesthetic outcome. All patients in the series underwent buttock augmentation as an outpatient by the author in his AAAASF accredited office based surgical facility. Patients were positioned prone on the operating table after undergoing general or epidural anesthesia. A single dose of Cefazolin was given intravenously prior to skin incision. Solid silicone gluteal implants were inserted through a single midline intergluteal incision measuring 7 cm. in length. Implants were placed in either the subfascial (SF) or intramuscular (IM) position. Precise pocket dissection was accomplished through the use of a fiber optic retractor and long tip electrocautery in the subfascial plane. Intramuscular dissection was performed using a combination of electrocautery dissection and blunt dissection. Closed suction drains were used in select patients and removed when less than 25 ml. of fluid was obtained over a 24 hour period. Patients were discharged with oral analgesics and instructed to refrain from physical exertion for 4-6 weeks.

Results/Complications: A total of 400 solid silicone gluteal implants were placed in 200 patients during the 8-year study period. Of the 200 patients who underwent gluteal augmentation 26 (13%) were male and 174 (87%) were female. The average age was 34 years for the men and 30 years for the women. The implants were placed in the IM position in 46 patients and in the SF position in 154 patients. Concurrent aesthetic procedures were performed in 30% (n=59) of the patients and included liposuction of the back (n=51), breast augmentation (n=2), calf augmentation, (n=2), liposuction of the abdomen (n=1), liposuction of the thighs (n=1), scar revision (n=1), and sacral reduction (n=1). The overall reoperation rate was 13 % (n=26). Indications for reoperation were grouped by category which included: infection (n=11), seroma (n=6), aesthetic concerns (n=6), capsular contracture (n=1), hematoma (n=1), and wound healing (n=1). Seroma formation was the most common complication occurring in 28% (n=56) of patients. Seromas were treated successfully with serial aspiration in 80% (n=45) of the cases. Five patients were treated with drain reinsertion and six patients required surgery. The overall infection rate was 6.5% occurring in 13 of the 200 patients. The implant infection rate was 3.8% occurring in 15 of the 400 implants placed. Eleven patients required implant removal due to infection while 2 patients were successfully treated for buttock cellulitis with antibiotics alone. Three infections occurred in the IM group and 10 occurred in the SF group producing identical infection rates of 6.5%. Staphylococcus aureus was the most commonly isolated pathogen and was cultured from the buttock implant periprosthetic fluid in 11 of the 13 patients with infected buttocks. Escherichia coli bacteria were cultured from the buttock implant periprosthetic space in one patient requiring explantation. No fluid was available for culture in one of the patients with buttock cellulitis. Hematomas occurred in 2% (n=4) of patients and were treated with wound exploration in three patients and unilateral buttock aspiration in one. Wound dehiscence occurred in 1.5% (n=3) of patients. Two superficial wound separations were treated with local care only and one wound dehiscence which was limited to the deep subcutaneous layer was treated with debridement and closure in the operating room. Capsular contracture was noted in 1% (n=2) of the patients, both of which had postoperative seromas. Additional aesthetic procedures at the time of buttock augmentation did not affect the complication rate. There were no cases of sciatic nerve injury or gluteal muscle weakness. Keloid or hypertrophic scarring of the intergluteal incision did not occur although drain site scar hypertrophy did occur in several patients. IM patients required more time to recuperate and complained of more pain than SF patients. Final aesthetic results were evident more quickly in the SF patients than the IM patients. Satisfaction rates were very high in both SF and IM patients although IM patients more often complained of lack of inferior gluteal fullness.

Conclusion: Buttock augmentation with solid silicone implants is a safe and satisfying procedure. The most common complication in this series was seroma formation which was treated with serial aspiration in the majority of cases. Gluteal implants can be successfully placed in either the subfascial or intramuscular position with no significant difference in complications. SF implant placement can produce better aesthetic results in patients requiring inferior gluteal fullness.

Tuesday, April 27, 2010: 1:47 PM
Joseph Hunstad, MD, FACS , Plastic surgery, The Hunstad Center, Charlotte, NC
Roderick Urbaniak, MD , The Hunstad Center, Charlotte, NC
Bill Kortesis, MD , The Hunstad Center, Charlotte, NC

Goals/Purpose: This report describes a new method of providing buttocks augmentation with exceptional projection achieved using an innovative purse-string technique. This method of providing autologous augmentation and lifting of the ptotic buttock can be used as a stand-alone procedure for primary augmentation and lifting, as salvage after suboptimal prosthetic or fat augmentation, or most commonly, in concert with a circumferential body lifting.

Methods/Technique: There are three main techniques for buttocks augmentation: large-volume autologous fat transfer, prosthetic implant-based augmentation, and augmentation with dermo-adipose flaps. Each technique has unique characteristics. The highly popular method of autologous fat transfer requires the availability of suitable donor sites, is technique dependent and, has variable survival rates. While it remains an attractive option for patients with ample donor sites and desire for hip, thigh, or abdominal volume reduction, it may not be available for thin patients or many after significant weight loss. Prosthetic buttocks augmentation can add volume by placing silicone implants in the subfascial, intramuscular, or submuscular position. Although most results are acceptable, complications such as infection, rotation, visibility, palpability, surgical site dehiscence, extrusion, and appearance of stretch marks have been noted. Autologous flap augmentation is the method of choice for buttocks augmentation when excess tissue exists. Buttocks lifting is also achieved with this technique. This method of gluteal rejuvenation is ideal for patients with significant weight loss who exhibit significant skin laxity with variable residual adiposity.

Described initially in 2009, our purse-string gluteoplasty procedure provides lifting as well as exceptional projection and we have used it as a primary method for autologous augmentation gluteoplasty since 2006. It creates a buttock that is lifted and augmented with centrally based autologous dermo-adipose flap with completely preserved vascularity. The amount of added volume can be controlled with the design of the flap. Similarly, projection is adjustable and can be varied intraoperatively. We will present technical details, refinements, and our experience in sixteen consecutive patients.

Results/Complications: Sixteen female patients underwent autologous gluteal augmentation with purse-string gluteoplasty from December 2006 until August 2009. A retrospective chart review was performed. Complications were recorded and divided into major and minor categories.

All procedures were performed by the senior surgeon (JPH) in a fully-accredited (AAAASF) surgical center. 4 of 16 were African American, 1 of 16 was Hispanic, and the rest were Caucasian. The average age was 41.8 years and the average BMI 24.5 (18-34). 50% (8/16) were massive weight loss patients and all of which were at stable weight and at least 18 months after their bariatric operation. 12 patients had their gluteoplasty as part of a circumferential body lift, and 2 patients who had a prior abdominoplasty elected to have a gluteoplasty to complete their circumferential body contouring procedure. Interestingly, two other patients had a gluteoplasty as a stand-alone procedure. One had a salvage operation after removal of a rotated palpable silicone implant initially used for augmentation, and second one had a Purse-String Gluteoplasty after fat grafting to buttocks failed to provide adequate volume.

Average follow up in this series is 12 months ranging from 3 to 32 months. Eight patients developed complications for an overall complication rate of 50%. Two of these were major (12.5 %) and six were minor (37.5 %). One patient developed a non-fatal pulmonary embolus 14 days post-op despite a regimen including intraoperative sequential compression devices, early and frequent ambulation, and peri-operative lovenox (2 doses of 30 mg, first dose in recovery). She was treated with systemic anticoagulation and recovered without further sequelae. The other major complication occurred in a patient who had simultaneous liposuction of the upper back and subsequently developed a 10 by 5 cm area of fat and skin necrosis. Closure was achieved in a secondary fashion with interval revision of resulting scar.

Conclusion: Purse string gluteoplasty is a highly effective method to augment and lift a ptotic, volume deficient buttock. It produces the most reproducible, most harmonious, full and natural-appearing buttock. It can be used in combination with circumferential body lift, as a completion procedure after anterior abdominoplasty, as salvage of failed augmentation, or as a stand-alone procedure. It affords unparalleled vascularity far above any undermined rotational flaps with virtually no risk for necrosis. Flap position and projection are precisely controlled. Patient and surgeon satisfaction has been universally high and complication rate has remained low with average follow-up of 12 months. It remains our method of choice for gluteal augmentation and correction of buttock ptosis.

Tuesday, April 27, 2010: 4:02 PM
Juan Pablo Maricevich, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Natale Gontijo, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Rodrigo Duprat, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Franciele Freitas, MD , Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil
Marco Maricevich, MD , Visiting Resident from the Department of Surgery, Rochester, MN
Ivo Pitanguy, MD , Plastic Surgery, Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Inst, Rio de Janeiro, Brazil

Goals/Purpose: Prominent ears are a relatively common anomaly that presents as an instantaneously recognizable deformity. Numerous studies report psychological distress, emotional trauma, and behavioral problems prominent ears can inflict on children. The multitude of different approaches indicates that there is not a clearly definitive technique to correct all the prominent ears. Surgeons must be able to correctly and precisely analyze the deformity, then establish and implement a surgical plan based on the current available techniques. The goal of this study is to endorse the Pitanguy’s Island technique previously described by the senior author of this paper as an effective, simple, and reliable approach to correct prominent ears. This technique consists in creating a cartilaginous island to reconstruct the antihelix and the triangular fossa in addition to correct the conchascaphal angle.

Methods/Technique: We retrospectively reviewed the charts of all patients who underwent otoplasty using the Island technique at the Ivo Pitanguy Clinic from July of 1990 to July of 2008. Patients operated with any variation of the Island technique or using any other technique were excluded from our study.

Results/Complications: Using the Island technique, 111 patients underwent otoplasty from July of 1990 to July of 2008. There were 80 female (72%) and 31 male (28%) patients, aged from 5 to 65 years old (mean age of 28.2 years).

Simultaneous Augmentation Mastopexy: A Technique for Maximum En Bloc Skin Resection Using the Inverted-T Pattern Regardless of Implant Size, Asymmetry, or Ptosis
Aesthetic Plastic Surgery, 08/31/2011


Eisenberg T – The described technique maximizes the amount of tissue to be resected in simultaneous augmentation mastopexy for moderately to severely ptotic breasts. Symmetry is more easily achieved with this approach regardless of the implant size used or the amount of skin to be resected. This technique minimizes the chance of tissue necrosis from devascularized skin edges. It also may shorten the inverted T scar and reduce the operative time.


    • Simultaneous augmentation mastopexy involves invagination and tailor tacking of the excess skin after implant placement and then making a pattern around the tailor-tacked tissues for previsualization of the total area to be resected.
    • This contrasts with first making a pattern for the mastopexy, resecting the skin, and then tailor tacking the tissues together.

Over a 7-year period, 55 women had simultaneous augmentation mastopexy with this approach.

  • Saline implants were placed in the subpectoral dual-plane position before the mastopexy was started.
  • All surgeries were performed with the patient under general anesthesia, and the patients were discharged the same day.
  • In a retrospective chart review, breast implant size, degree of preoperative asymmetry, length of procedure, and complications were recorded.
  • The patient follow-up period ranged from 3 months to 7 years (median, 9 months).


  • Symmetric, aesthetic results were achieved for all the patients.
  • The range of saline implants used was 375–775 ml (average, 500 ml).
  • Of the 55 women, 15 had two different size implants measuring at least 50 ml or larger, with the greatest size disparity in a patient being 225 ml (left breast, 700 ml; right breast, 475 ml).
  • Six of the patients (10.9%) had small areas that healed by secondary intention, occurring mostly at the inferior junction of the inverted T.
  • Only two patients (3.6%) had recurrence of breast ptosis, and only one patient (1.8%) had a mildly hypertrophic scar.
  • There were no incidences of hematoma, infection, rippling, malposition of the nipple–areolar complex (NAC), NAC loss, capsular contraction, implant malposition, or dissatisfaction with implant size.
  • The bilateral augmentation/mastopexy surgery time ranged from 2 h and 29 min to 4 h and 30 min (average, 3 h and 8 min).

Influence of Age on Rhinoplasty Outcomes Evaluation: A Preliminary Study
Aesthetic Plastic Surgery, 08/31/2011

Arima LM et al. – The rhinoplasty outcomes evaluation (ROE) questionnaire is a tool for evaluating the outcomes of different surgical indications for correcting nasal deformities. The kind of surgical procedure had no influence on the mean difference between pre– and postoperative satisfaction scores. By using this tool authors found that the younger age group reported lower postoperative satisfaction scores than older patients.


  • A longitudinal study to assess patients’ pre- and postoperative degrees of satisfaction with their results was conducted.
  • The study was done at a tertiary-care medical center.
  • The ROE questionnaire was applied twice in the same visit and aimed at measuring the patient’s satisfaction in both pre- and postoperative moments.


  • The initial sample of this study was composed of 112 patients, 61 of whom have answered the ROE questionnaire.
  • A mean difference of 50.5 (P < 0.0001) was observed between the pre- and postoperative satisfaction scores.
  • No statistically significant difference was observed on the mean difference between pre- and postoperative satisfaction scores (CHANGE) according to sex (P = 0.673), the follow-up time period (P = 0.629), or the kind of surgical procedure (P = 0.904).
  • The mean postoperative score of the <30-year-old group was lower than the mean of 30 to <50-year-old (P < 0.003) and >=50-year-old groups (P < 0.009).

Contralateral Prophylactic Mastectomy: Long-Term Consistency of Satisfaction and Adverse Effects and the Significance of Informed Decision-Making, Quality of Life, and Personality Traits
Annals of Surgical Oncology, 10/17/2011

Frost MH et al. – Long-term satisfaction and adverse effects remained remarkably stable. It is important that women fully understand the benefits and adverse effects associated with contralateral prophylactic mastectomy (CPM).


A previously established cohort of women with unilateral breast cancer who had undergone CPM between 1960 and 1993 were surveyed using study-specific and standardized questionnaires at two follow-up time points.

The first survey was a mean of 10.7 years and the second survey a mean of 20.2 years after CPM.


  • 487 of the 583 women who responded to the first study were alive and resurveyed.
  • Data from both surveys were available for 269 women.
  • With longer follow-up, there was a small increase in the percentage of women satisfied (90%) and those who would choose CPM again (92%) (4% and 2% increase from first survey, respectively).
  • Most adversely affected were body appearance (31%), feelings of femininity (24%), and sexual relationships (23%).
  • Ninety-three percent of women felt they had made an informed decision.
  • Perception of making an informed choice and current QOL were moderately associated with satisfaction with CPM (r = 0.37 and 0.37, respectively) while associations with trait anxiety and optimism were weak (r = 0.27 and 0.21, respectively).

Ultrasound-Guided Bilateral Erector Spinae Block Versus Tumescent Anesthesia for Postoperative Analgesia in Patients Undergoing Reduction Mammoplasty: A Randomized Controlled Study

Authors: Gozen Oksuz, Fatma Bilgen, Mahmut Arslan, Yakup Duman, Aykut Urfal?oglu, Bora Bilal

First Online: 10 December 2018


The aim of this prospective, randomized, double-blind study was to compare the tumescent anesthesia method and erector spinae block with respect to postoperative analgesia consumption, pain scores and patient satisfaction, in patients receiving breast reduction surgery under general anesthesia.


The study included 44 females, aged 20–65 years, who were to undergo breast reduction surgery, without adjunctive liposuction on the breast. Using the closed envelope method, the patients were randomly separated into two groups to receive tumescent anesthesia or erector spinae block (ESB). Patients in the ESB group received the block before general anesthesia by a single anesthetist (G.Ö.).


The 24-h tramadol consumption with PCA, which was the primary outcome of the study, was determined to be statistically significantly less in the ESB group (p < 0.001). The NRS scores were compared at 30 min postoperatively and then at 1, 2, 4, 6, 12 and 24 h. At all the measured time points, the pain scores of the ESB group were statistically significantly lower (p < 0.001). Additional analgesia was required by one patient in the ESB group and by seven patients in the tumescent group and was applied as 1 g paracetamol. The requirement for additional analgesia was statistically significantly lower in the ESB group (p < 0.024). Patient satisfaction was statistically significantly better in the ESB group (p < 0.001).


According to the results of this study, bilateral ESB performed under ultrasound guidance in breast reduction surgery was more effective than tumescent anesthesia concerning postoperative analgesia consumption and pain scores. ESB could be an appropriate, effective and safe postoperative analgesia method for patients undergoing reduction mammoplasty surgery.

The Efficacy of Different Volumes on Ultrasound-Guided Type-I Pectoral Nerve Block for Postoperative Analgesia After Sub-pectoral Breast Augmentation: A Prospective, Randomized, Controlled Study

Authors: Mursel Ekinci, Bahadir Ciftci, Erkan Cem Celik, Muhammet Ahmet Karakaya, Yavuz Demiraran

First Online: 12 February 2019


PECS type-1 block, a US-guided superficial interfacial block, provides effective analgesia after breast surgery. Aesthetic breast augmentation is one of the most common surgical procedures in plastic surgery. Subpectoral prostheses cause severe pain. The aim of this study was to investigate the effect of different volumes of the solution on the efficacy of PECS type-I block for postoperative analgesia after breast augmentation surgery.


Ninety ASA status I–II female patients aged between 18 and 65 years who scheduled breast augmentation surgery under general anesthesia were included in this study. The patients were randomly divided into three groups of 30 patients each (Group 20?=?20 ml of anaesthetic solution, Group 30?=?30 ml anaesthetic solution, and Group K?=?Control group). Postoperative assessment was performed using the VAS score. The VAS scores were recorded postoperatively at 1, 2, 4, 8, 16 and 24 h.


Fentanyl consumption was statistically significantly lower in Group 20 and Group 30 compared to the Control group (p?<?0.05). There was no statistically significant difference in fentanyl consumption between Group 20 and Group 30. The right and left VAS scores were statistically significantly lower in Groups 20 and 30 than in the Control group (p?<?0.05). There was no statistical difference in terms of VAS scores between Group 20 and Group 30. The use of rescue analgesia was statistically lower in Groups 20 and 30.


PECS type-1 block using 20 ml of 0.25% bupivacaine can provide effective analgesia after breast augmentation surgery.

High- and Extra-High-Profile Round Implants in Breast Augmentation: Guidelines to Prevent Rippling and Implant Edge Visibility

Authors: Antonio Carlos Abramo, Marcio Scartozzoni, Thiago Walmsley Lucena, Romulo Grechi Sgarbi


Rippling and implant edge visibility after breast augmentation depends on several factors. Among the most relevant are breast soft tissue thickness, particularly the retroareolar mammary parenchyma, and implant profile. They were correlates to prevent these occurrences.


Thirty patients underwent breast augmentation through subfascial dissection involving the pectoralis, serratus, external oblique, and rectus abdominis fascias. The thickness of the retroareolar mammary parenchyma distributed patients into two groups. Group I: patients with thickness equal to or greater than 4.0 cm received high-profile 85% fill round implants. Group II: patients with thickness up to 3.9 cm received extra-high-profile 100% fill round implants. MRI was performed preoperatively and 5 years after augmentation to evaluate breast tissue changes and implant contouring.


Seventeen patients with high-profile implants and thirteen patients with extra-high-profile implants had noticeable improvement of the breasts without the occurrence of rippling or implant edge visibility. A natural appearance of the breast, increased mammary cone, balanced upper and lower pole contouring was maintained at 5 years postoperatively. MRI performed 5 years after breast augmentation validated patient clinical outcomes not evidencing implant deformities, or soft tissue thinning, parenchymal atrophy or chest wall deformities.


The adequate correlation between retroareolar mammary parenchyma thickness with high-profile 85% fill and extra-high-profile 100% fill textured round implants was of utmost importance in preventing rippling and implant edge visibility. The wide fascial support, width of the implant smaller than the breast diameter, and soft cohesive gel-filled implants were co-adjuvant factors in preventing rippling and implant edge visibility.

Comparative Study of Nipple–Areola Complex Position and Patient Satisfaction After Unilateral Mastectomy and Immediate Expander–Implant Reconstruction Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy

Authors: Hyungsuk Kim, Sun-June Park, Kyong-Je Woo, Sa Ik Bang

First Online: 11 February 2019


Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple–areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander–implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM.


Patients who underwent immediate expander–implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire.


Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p?=?0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p?=?0.043). The mean photography analysis score of total aesthetic outcome was 13.12?±?2.39 in the NSM group and 14.06?±?2.75 in the SSM group (p?=?0.052). The mean questionnaire score of NAC position was 2.88?±?0.85 in the NSM group and 3.80?±?0.84 in the SSM group (p?=?0.001). The mean questionnaire score of NAC sensitivity was 2.12?±?0.58 in the NSM group and 1.84?±?0.46 in the SSM group (p?=?0.003). Satisfaction with the reconstructed breast was similar (p?=?0.913) after NSM and SSM.


We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer.

The Comparison of Scars in Breast Implantation Surgery with Inframammary Fold Incision Versus Axillary Incision: A Prospective Cohort Study in Chinese Patients

Authors: Jingjing Sun, Dali Mu, Chunjun Liu, Minqiang Xin, Su Fu, Lin Chen, Wenyue Liu, Jie Luan

First Online: 03 January 2019


A prospective cohort study was developed to compare the surgical scars in the axilla and the inframammary fold at short-, medium- and long-term time periods after surgery.


Patients who underwent primary breast augmentation with implants in our department were divided into two groups based on the incision location they chose and were followed up for scar assessment at 1 month, 6 months and 12 months post-surgery from June 2012 to March 2016. Each scar was evaluated by the Vancouver Scar Scale (VSS) and patient satisfaction score. The data were analyzed with Wilcoxon rank-sum tests, Cochran–Armitage trend tests and Fisher’s exact probability tests based on the data type.


One hundred and sixty-three patients were completely investigated three times. Ninety-four patients underwent breast augmentation surgeries with implants through axillary approaches and 69 patients through IMF approaches. At 1 month after surgery, the median total VSS score was 6 in the axillary incision group and 4 in the IMF group, with statistically significant differences (P?<?0.05). Larger proportions of high scores in terms of vascularity and height were found in the axillary incision group (P?<?0.05). At 6 months after surgery, the median total VSS score was 4 in the axillary incision group and 3 in the IMF group, with statistical significance (P?<?0.05). The axillary group still had a larger proportion of high scores in terms of vascularity and height than that of the IMF group (P?<?0.05). At 12 months after surgery, the median total VSS score was 2 in both groups. The median patient satisfaction score was 9 in both groups. No significant differences were noted in the total VSS and patient satisfaction scores between the two groups. However, the axillary group had a larger proportion of high scores in terms of vascularity and low scores in terms of pliability.


The total VSS score for the axillary incision group was significantly higher than that for the IMF incision group one and 6 months after surgery, mainly on the subscales of vascularity and height. At 12 months after surgery, the total VSS scores were not different between the two groups, and patients with both kinds of incisions were highly satisfied with scar appearance. The research confirmed that the scars at two locations can achieve comparable appearance in the long term after surgery.

Standardized Practice Reduces Complications in Breast Augmentation: Results with the First 290 Consecutive Cases Versus Non-standardized Comparators

Authors: Adriano Santorelli, Ferdinando Rossano, Barbara Cagli, Stefano Avvedimento, Ali Ghanem, Sergio Marlino

First Online: 12 December 2018


Several systematic methods for breast augmentation have been published, providing key principles and technical steps for minimizing complications and optimizing patient satisfaction. The aim of this study was to compare complication rates in patients receiving a breast augmentation performed using a structured, standardized approach versus comparator patients operated on without a standardized approach.


This was a single-center, retrospective review of 290 consecutive breast augmentations performed between October 2016 and September 2017 based on a standardized technique (Randquist’s “five P’s” combined with Adams’ 14-point plan), and 235 comparators who underwent breast augmentations prior to standardization between April 2014 and September 2016. All study subjects were females aged ? 18 years, undergoing bilateral breast augmentation, either alone or in the context of augmentation mastopexy or implant replacement. Various implant ranges were used before standardization; most (94.8%) of the standardized procedures used Natrelle® devices. Follow-up lasted for ? 12 months.


Significantly fewer patients in the standardized surgery group experienced complications (14.5%, n = 42) compared with the non-standardized group [29.4%, n = 69; Chi square = 6.57; degrees of freedom (df) = 1; p = 0.01041]. Complication rates were also significantly lower in the standardized surgery group for each of the three types of breast augmentation surgery assessed separately. Reoperation rates with standardized and non-standardized surgery were 4.1% (n = 12) and 11.9% (n = 28), respectively (Chi square = 6.4; df = 1; p = 0.01145). Patient satisfaction was increased post-surgery in both groups.


The use of a structured, standardized approach to breast augmentation reduced the risk of postoperative complications.

Sensation-Sparing Correction of Inverted Nipples Using the ‘Drawbridge’ Flap Approach

Authors: Bhagwat Mathur & Charles Yuen Yung Loh


An inverted nipple can cause significant functional and psychologic disturbance to women. The holy grail of any surgical technique to correct this is to restore adequate nipple projection and at the same time, try to preserve lactation and nipple sensation. We describe our experience using an inferior dermal nipple-areolar interposition flap to correct the inverted nipple alongside with selective release of the lactiferous ducts of the nipple.

Materials and Methods

We have employed this technique successfully in 97 cases of inverted nipples in 60 patients with follow-up periods of up to 2 years. Twenty-three of them had unilateral inversion, and 37 of them had bilateral nipple inversion.


The appearance of the nipple was good to excellent. Seventy to 80% of the initial postoperative nipple projection at the end of 1 year was maintained. Postoperative complications included stitch abscess in one patient (n = 1) and an epidermal cyst in another (n = 1). Nipple sensation was preserved in 100% of cases. There was no recurrence of inversion in any of the nipples.


By identifying the root cause of inverted nipples in each individual case, and selectively targeting them, we minimize surgical morbidity with a simple technique that avoids any form of traction or compression of the nipple and minimizes the risk of altered nipple sensation.



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