When you do a lot of a particular surgery, it’s not uncommon to see patients that have had a procedure elsewhere, that come in to see if a previous result can be improved.  Recently, I performed two full “re-do” tummy tucks….which is the topic of this blog.
While there isn’t a formal classification system, I would suggest that patients seeking out a re-do tummy tuck, or “secondary abdominoplasty”, fit into one of four main groups.
These are:
1.   the “under-done” first operation
2.   scar-related issues
3.   recurrent abdominal wall stretch
4.   an unsatisfactory umbilicus
The first group, in my experience, is the most common.  It includes people that had a mini-abdominoplasty when they probably should have had a standard or extended tummy tuck, or patients that didn’t have plication (repair) of the upper abdominal wall muscle fascia when they probably should have.
The second group includes both widened or irregular incisional scars, as well as poorly placed incisions.  It also includes patients that had wound healing complications after their first procedure.
The third group, less common, are patients who despite a good first operation, seem to have poor quality fascia that stretches out sooner than ideal, or bulges in other locations after the midline separation is repaired.
The fourth group have belly-button issues: too big in diameter, too small, heavy scarring, and so on.
The first step in treatment is to find out the patient’s story and do a good physical assessment.  Is the problem primarily one of skin laxity?  Where is this laxity located?  Is it a muscle wall problem?  Or subcutaneous fat?
For patients that had a mini-tummy tuck the first time, we typically see a pattern of upper abdominal looseness or bulging and lateral “dog ears” (excess skin towards the sides of the trunk).  This can often be improved by converting the patient to a standard or extended abdominoplasty, excising the extra skin, and re-doing the muscle repair in both the upper and lower abdomen.  It does mean a longer incision.  Additionally, sometimes there is a small vertical incision in the midline, due to the closure of the umbilical cut-out.  Overall, good results are seen.
For patients with scar issues, standard techniques of scar treatment and revision can be used.  For those where surgery is required, the old scar is excised, and a careful re-closure of the tissues, including scarpa’s fascia, dermis and a tidy subcuticular closure, is performed.  If there is some laxity in the skin above the scar, we can borrow that looseness, to move the scar to a somewhat lower location.
Poor quality “stretchy” fascia is a challenge to deal with.  I’ve seen this problem most often in women that have had 3 or more children, but there are other causes as well.  Repair methods can include re-suturing the fascia, or adding some internal supporting structure, like hernia mesh or dermal matrix – but both of these have associated trade-offs as well.
Finally, and one of the most challenging of all 4 types, is to fix the badly distorted umbilicus.  Our surgical techniques here are limited, and sometimes the results are a compromise.  Large belly buttons can be reduced in size, but may stretch out again, despite internal sutures.  Stenotic, tiny belly buttons can be enlarged with V-Y Plasty techniques – but sometimes will scar down again.  We win some, and lose some.  This is a category where realistic expectations and clear communication between surgeon and patient is especially important.
in summary, this is a diverse group of patients.  Many times, we can offer the patients a nice improvement, and a happy conclusion to their tummy tuck story.
With more emphasis in pop culture on the shape of the derriere, more patients are coming to see us about the idea of buttock augmentation.  One of the most common questions I hear is:  Which is better – the brazilian butt lift or buttock implants?
While both methods can work, for patients that have a reasonable amount of fatty tissue that we can borrow, the brazilian butt lift – also known as fat transfer to the buttock –  clearly wins.  Here’s why:
  • you get the twin benefits of buttock enhancement and the slimming effect of liposuction of the waist, abdomen, thighs or wherever the fat is taken from
  • fat grafting, when performed by experienced plastic surgeons, is a safe procedure and has a lower complication rate than buttock enhancement with solid silicone implants
  • contouring of the buttock is much more flexible with fat grafting.  When a buttock implant is used, there are a limited number of sizes and shapes.  You are also limited about what size of implant can fit in an intra-muscular pocket.
  • Post-op recovery is more painful with buttock implants.
  • Some complications, like migration of the implant, capsular contracture, or wound separation – can only happen when solid buttock implants are used.  They can not happen with the fat injection technique, as the surgical method doesn’t involve making an incision and a large pocket.  Since fat transfer uses your own tissue, there is no risk for capsular contracture.
That being said, there is one group of patients who do better with buttock implants:
  • patients that don’t have enough fat to graft, and can’t or won’t gain weight
Additionally, fat grafting to the buttock does have a downside.  Sometimes that fat that is transferred may not survive the move, and may melt away.  A second fat transfer procedure may be required to optimize the size and shape of the buttock.. But that is usually much easier than the revision of a buttock implant.

The drug anastrozole cuts breast cancer incidence in half among high-risk post-menopausal women, according to an study just published in the Lancet.

Anastrozole, also known as “Arimidex”, is a type of drug known as an aromatase inhibitor.  It works by reducing the production of estrogen, like its better-known cousin, Tamoxifen.

In the study, nearly 4000 post-menopausal women at increased risk for breast cancer were randomized to receive daily anastrozole or placebo for 5 years. During the 5 years of average follow-up time, breast cancer developed 53% less often among anastrozole recipients (2% vs. 4%). The researchers estimate that 36 women would need to receive Arimidex to prevent one cancer during a 7-year period.

The researchers say their results “strongly support” anastrozole for preventing breast cancer in high-risk women. The once- daily pill is relatively inexpensive, since the patent has expired. And it works better than tamoxifen in this group.

 Now, if they could only come up with something for pre-menopausal high risk women….
In this month’s issue of Plastic & Reconstructive Surgery, is a study that will be of interest to all who follow breast augmentation.  It’s a 5 year analysis of capsular contracture rates using Sientra implants for first-time breast augmentation, and a look at some of the factors that influenced capsule formation in 2560 first-time breast augmentation patients.  A variety of surgical methods – subglandular, submuscular, different incisions, and other factors were reviewed.
The investigators found that, in looking at the group as a whole:
–  subglandular placement of implants increased the risk of a capsule by 4.6 times
–  use of  periareolar incisions had more contractures than inframammary incisions by 1.5 times
–  Sientra smooth implants had 4.7 times more contractures than Sientra textured implants overall.
These findings have been noted in previous implant studies, so they were not any big surprise to me.  They confirm my decisions to switch away from the periareolar incision, and stay with the submuscular dual-plane placement method.
To me, the most interesting part of this article was the grouping of capsule formation rates by technique:
smooth implant in a subglandular pocket 21% capsule rate
smooth implant in a submuscular pocket 5% capsule rate
textured implant in a subglandular pocket 5% capsule rate
textured implant in a submuscular pocket 2% capsule rate
Since I currently do my breast augmentation operations with a submuscular pocket, this data suggests that if I were to use Sientra textured implants, I could reduce my capsule rate to 2%, from its current rate of 4% with smooth gel implants.  That’s a pretty convincing argument to recommend these implants.  Based on 200 augmentations a year, for example, I could potentially prevent 4 women from having issues with capsules each year, just by choosing a different implant.  And that, to me, is well  worth considering.

How often do you hear about “no recovery” or “lunchtime” treatments when reading about lasers, peels and other treatments in the media?  Until recently, there was no accepted definition for these terms. What does “minimal recovery” really mean – minimal to whom, the doctor, or to you?

The American Society for Aesthetic Plastic Surgery (ASAPS) has developed a set of standardized definitions that consumers and industry can use, when talking about issues like downtime, bruising, redness, swelling and pain.  We’re trying to encourage the cosmetic laser industry to adopt and use these terms in a consistent and honest way, so that consumers can really fully understand what they’re choosing, and can compare treatments while shopping around.


Downtime –the expected time to return to normal lifestyle

Essentially None: less than 24 hours

Minimal: 24-72 hours

Moderate: 3-7 days

Significant: more than 7 days


Bruising – visible on the skin without concealer

Essentially None: no bruising but there may be an immediate change in skin tone

Minimal: less than one week

Moderate: 1-2 weeks

Significant: more than 2 weeks


Redness –visible without concealer

Essentially None: returns to normal (pretreatment or improved) in less than 24 hours

Minimal: 1-3 days

Moderate: 4-7 days

Significant: more than 7 days


Swelling –obvious swelling

Essentially None: less than 3 days

Minimal: 3-7 days

Moderate: 8-14 days

Significant: > 14 days


Pain –significant discomfort associated with the treatment

Essentially None: no anesthesia or medication is needed except over the                                      counter  medication

Minimal: requires pretreatment with oral prescription medication, topical anesthetic agents                or skin cooling and/or post-treatment prescriptions for pain management.

Moderate: same as minimal but with local anesthesia (injections)

Significant: same as minimal but with IV sedation or general anesthesia

On Friday, Sientra announced a new warranty program, which they are calling “C3”.  The program, which begins Novemeber 1, 2013, will apply to first-time breast augmentation patients who choose Sientra-brand textured implants.
In addition to the current implant deflation warranty, the C3 program provides a free replacement implant if the patient requires revisional breast surgery for a Baker Grade III or IV capsular contracture, within the first two years after the original implantation surgery.
No additional registration forms or fees will be required.
Capsular contracture is one of the most frustrating and unpredictable complications after breast implant surgery.  Previous studies have found that it happens more often in the subglandular implant, if a periareolar or trans-axillary approach is used, or if there is bleeding or infection in the breast.  In some studies, smokers have an increased risk.
In the upcoming November issue of Plastic & Reconstructive Surgery, a new study looking at Sientra implants also found a protective effect for their textured breast implants, when compared to the smooth Sientra implants.
Bottom line:  I’m sure that patients who choose Sientra’s gummy bear implants will be pleased to hear about this program, going forward.  It will be interesting to see how the other established manufacturers – Allergan & Mentor – react to this new program.

At least 24 people in Hawaii have developed acute non-viral hepatitis after using the dietary supplement OxyElite Pro, marketed for use in weight loss and muscle building. Additionally, two patients have received liver transplants, and one patient died, but it is not clear whether they took OxyElite Pro or a different dietary supplement.

The cases (median age, 33) all lived in Hawaii, but the CDC is investigating whether there are cases of liver injury elsewhere, since the supplement is sold nationwide. The FDA advises consumers to stop using OxyElite Pro during the investigation.
Bottom line:  Dr. Fiala does not recommend OxyElite Pro or similar non-FDA approved dietary supplements to his patients. 
portions reprinted from New England Journal of Medicine online Journal Watch; Kelly Young – author.
Benelli Breast Lifts Orlando, Advances in Breast Lift SurgeryMany patients who would like a more uplifted and perky breast shape tell me that they are very worried about a breast lift, due to the surgical scars.  Most women worry that they will need the traditional anchor lift – and that’s not always the case.  Today, I’d like to talk about one type of breast lift, which has a very minimal amount of scars:  the donut lift.  It goes by several names.  You might also hear the terms “Benelli lift” or “circumareolar lift” mentioned by surgeons.
The concept is simple:  limit the scars to just the outside of the areola.  There’s no scar down the front or underneath the breast.  This technique can work nicely for women that have reasonably elastic skin, and only need a small lift, where the nipple position just needs to lift up 1-1.5 inches to look centered properly.  The nipple stays attached, and sensation is preserved.  Only an off-center donut-shaped zone of extra skin is removed. A careful skin closure, with multiple layers of sutures, is then performed.
The Benelli lift works particularly well for women with tuberous breasts or prominent, dome-shaped areolas. (“puffy nipples”)  It is also very effective when combined with a breast implant or with fat grafting to the breast to restore missing breast volume.  There are many examples of this technique in our photo gallery.
Most times, the incision blends in nicely at the edge of the areola, and a nice improvement is obtained.  An internal “purse-string” suture, made of a long-lasting Gortex thread, helps to prevent the new areolar shape from stretching back out, maintaining the lift effect over many years.
If you are thinking about a breast lift, but are worried about the scars, ask Dr. Fiala if this method might work for you.

In a pilot study of 10 patients just published in The Lancet, Danish researchers showed that the addition of stem cells to a fat graft improved the survival of the fat graft at 4 months, compared to a plain unenhanced fat cell graft.   This study is significant, as it represents the first randomized study of its kind for fat grafting.

Here’s what the researchers did: participants had liposuction twice – once to harvest stem cells, and once to harvest fat cells. The stem cells were then grown in the lab, using specialized cell culture methods, and mixed back into one of the two fat cell preparations in large numbers, equal to 12% of the volume grafted.  The two fat cell grafts of about 1 ounce each – one with stem cells, one without – were then placed on the back of the patient’s arm. MRI was used to measure the fat cell volume at the time of injection, and 4 months later.

They found that the stem cell enhanced grafts did much better, with 80% retention, versus the plain fat grafts, which only had 16% retention.

Pretty cool – but what does this mean? Despite the encouraging result, this preliminary study needs to be repeated with many more patients, using much larger volumes of fat, before we can decide whether it’s clinically useful. And we need an FDA-approved method to get the huge numbers of stem cells that we would need to make this work in the volumes that we use in daily practice.

For example, if we were going to perform a Brazilian buttock lift, we might typically use 400 cc of fat on each side, or more. The Danish study would suggest we would need 50 cc of concentrated stem cells per side – and without cell culture techniques, this would take the isolation of every single stem cell in 3.5 liters of fat to get this amount. – for each buttock!! That’s neither practical nor safe.  So clearly, without some new FDA-approved method, we can’t duplicate the recipe of the Danish study in our daily practice.

I found it interesting that the retention rate was only 16% for the non stem cell group. That’s really low. By contrast, other studies that studied fat grafting to the breast found a 65% retention rate in the breast, as long as the breast was prepared with pre-operative BRAVA expansion – without needing stem cells.

Just this month, the FDA decided to officially grant Allergan another approved indication for the use of Botox: the treatment of Crows’ Feet. The approval was granted after the FDA reviewed data for effectiveness and safety of Botox in the crows’ feet area in a placebo-controlled study of over 800 patients.
Of course, physicians have been using Botox for this purpose “off-label” for years – pretty much ever since Botox was approved for cosmetic use for glabellar wrinkles, back in 2002!  It’s a very effective treatment – depending on the dose used, it can soften and reduce the crow’s feet wrinkling at the corner of the eyes for up to 6 months. So, this approval is not going to change our day-to-day practice patterns, but I do think it is useful for patients, as it will give them a greater feeling of safety and confidence in the treatment.
Allergan’s competitors, namely Xeomin and Dysport, do not yet have this approval, as it’s something the manufacturers have to apply for with lots of study data. With an official FDA indication behind them, Allergan can now advertise this particular use. So expect to see lots of direct-to-consumer advertising from Allergan starting immediately.
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