Bioengineered Breast: Hybrid Breast Reconstruction

 
 
 
 
 
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𝘋𝘦𝘷𝘦𝘭𝘰𝘱𝘪𝘯𝘨 𝘢 𝘩𝘺𝘣𝘳𝘪𝘥 𝘤𝘰𝘯𝘤𝘦𝘱𝘵 𝘪𝘯 𝘪𝘮𝘮𝘦𝘥𝘪𝘢𝘵𝘦 𝘴𝘵𝘢𝘨𝘦 𝘣𝘳𝘦𝘢𝘴𝘵 𝘳𝘦𝘤𝘰𝘯𝘴𝘵𝘳𝘶𝘤𝘵𝘪𝘰𝘯. ⁣⁣⁣

I was first introduced to the concept of “bioengineered breast” in 2009 by Dr. Pat Maxwell and colleagues. He originally coined this term to describe an enhanced breast form consisting of a combination of cohesive gel breast implant, regenerative scaffold, and regenerative cells. ⁣⁣⁣

The implant and the soft tissue covering it can both be enhanced to achieve the optimal female breast form.

Enhancing the soft-tissue cover not only supplements volume and shape but also further alters how the recipient’s host tissue responds to the foreign body implant. ⁣⁣⁣

This powerful combination of constructs better allows us to achieve the ultimate goal of breast reconstruction: to recreate a breast that appears and feels like the natural breast. ⁣⁣⁣

This patient had large breasts and underwent bilateral skin-sparing mastectomies. She opted for one-stage reconstruction to minimize downtime. This was achieved using a hybrid concept after the mastectomy flap perfusion was evaluated. ⁣⁣⁣

I was able to pair an anterior acellular dermal matrix sheet with a posterior stable Galaflex base to provide the patient with both softness and stability. ⁣⁣⁣

She plans on having fat grafting during her nipple-areolar reconstruction to further augment her soft tissue envelope and soften her breast borders.⁣⁣⁣
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Can I Still Breastfeed with Implants?

You can still breastfeed after breast augmentation surgery. A typical breast implant surgery involves an incision made in the inframammary fold (crease under your breast) to place the implant behind the pectoral muscle which is below the breast tissue. With this procedure, the implant is away from the breast tissue and does not interfere with breast ducts or mammary glands that produce milk. Even in cases where some glandular tissue is removed, enough tissue is left to facilitate milk production after the procedure.

Incision site

If you intend to breastfeed after breast implant surgery, the location of the incision matters. An incision made under the breast, in the armpit, or in the belly button is less likely to damage your milk ducts, nerves or glands.

But an incision made across or around the areola is more likely to damage nerves, affect the sensation of your nipple, interfere with the signals necessary for the letdown reflex, and reduce milk supply. Speak with your plastic surgeon about whether you might still have children so that an incision site is chosen that reduces the need for future adjustments to facilitate breastfeeding.

Implant location

Since breast implants can alter breast tissue, change the sensation of the nipple area, pinch or damage milk ducts, nerves, and milk glands, or reduce milk availability and release from glands, the location of the implant is critical. If you still want to breastfeed after breast implant surgery, you should make this clear to your plastic surgeon. To ensure implants do not interfere with breastfeeding, they can be inserted between your breast tissue and chest muscle or placed under your chest muscle.

Breast implants and milk safety

Breast implants do not make breast milk unsafe for your baby. Saline breast implants are filled with saline water, but there is no significant harm involved if the saline water mixes with breast milk. Likewise, silicone gel-filled implants are not harmful because the gel does not leak outside the implant shell.

There is no need to worry about chemicals in the implants mixing with the milk and making breastfeeding unsafe for your baby. Whatever implants are used, be sure to ask your plastic surgeon if it is safe for you to breastfeed after your implant surgery.

Reason for the surgery

Whether you can breastfeed after breast implant surgery also depends on your reason for the procedure. If your breasts are fairly symmetrical and regularly shaped and you only want a small boost, you are less likely to run into difficulties breastfeeding. But if you have flat or tubular shaped breasts before the procedure, you may already be at risk of low milk supply even without breast implants.

At Politis Plastic Surgery, we generally advise our patients to wait until they have had children before undergoing breast implant surgery. However, we do evaluate and recommend the procedure on a case-by-case basis after a personal consultation with each patient. If we find the procedure ideal for you, even when you still plan to have children, we will ensure that the incision site and implant location have the least possible effect on breastfeeding.

Would you like to enlarge your breasts and enhance your self-confidence but worry that it will affect you in other ways? Consider a private consultation with Dr. Effie Politis to discuss your specific goals and concerns. She will listen and guide you in making an informed decision about the procedure. For more information about breast augmentation and other cosmetic surgery procedures, visit the Politis Plastic Surgery website.

Reconstructive Surgery on Cutaneous Malignancies

 
 
 
 
 
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As plastic surgeons, dermatologists typically refer us cases involving skin cancers dealing with the head/neck which require advanced closure techniques to minimize scar burden and resulting deformities. ⁣⁣

We are trained in “cutaneous oncology” in terms of evaluation and treatment of skin cancers, as well as coverage of resulting defects. ⁣⁣
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Micrographic surgery (Mohs surgery) is performed by our dermatology colleagues and is a technique based on complete tumor excision with maximal normal tissue preservation. ⁣⁣
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We often work with Mohs trained dermatologists who remove skin cancers that meet requirements. ⁣⁣
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We assist them in covering the resulting defect after tumor excision with margin clearance. Mohs surgery ensures margin and tumor clearance in areas requiring maximal tissue preservation (nose, lips, eyelids). ⁣⁣
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In some cases, Mohs is not indicated and we are able to perform the oncologic portion as well as the reconstructive portion. ⁣⁣
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In this patient, I was able to visualize tumor margins and perform a margin analysis (to ensure negative margins) prior to central tumor removal. ⁣⁣
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Once the margins were deemed negative via a pathologist on site who performs frozen sections, the remaining tumor is removed and the defect can be closed in the same setting. ⁣⁣
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Please note this patient did not receive Mohs surgery. ⁣⁣
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I performed the excision, achieved margin control, and then also performed
the reconstruction with local tissue rearrangement.

 
 
 
 
 
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Previously, we presented an example of reconstructive surgery I perform for cutaneous malignancies (skin cancers) involving face, scalp, and neck. ⁣
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Removal of cancer in an aesthetic unit (with margins) and closure of the defect with scars in an inconspicuous location. ⁣
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Principal in replacing like tissue with like tissue (color match and tissue thickness are taken into consideration) and tissue is moved or rotated or advanced with its corresponding blood supply. ⁣
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This is where the art of plastic surgery comes into play. We are trained to respect aesthetic subunits and cover like tissue with like tissue to ensure minimal distortion, and best color match and thickness. ⁣
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When considering coverage options, we need to be aware of how to best rotate or re-arrange adjacent tissue to cover the defect with a design that respects blood flow or tissue perfusion to ensure healing. ⁣
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Sometimes adjunct procedures are needed to get the best results (eg. revisions including debulking, dermabrasion, etc). ⁣
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This lady underwent partial chin defect coverage with bilateral V-Y advancement flaps and a single revision. ⁣
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Healing time is 4-6 weeks. ⁣
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Revisions are small office procedures with minimal downtime and healing in 1-3 weeks. ⁣
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Additionally, I advise my patients on sun avoidance and scar maturation postoperatively. ⁣
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It can take 6-8 weeks for scars to regain most (but never all) of their tensile strength. Scars often look worse before they look better. ⁣
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We recommend sun avoidance or covering the scar for 1 year (physical block or sunblock and physical block).⁣
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No scar revisions prior to one year. It usually takes one year for scars to really settle and look as close to normal as possible. ⁣
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I also remind patients there is no “scarless” surgery but we try to optimize the size and placement of scars according to local and aesthetic units.

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Breast Augmentation Risks and Complications

Breast augmentation is a surgical procedure to make breasts appear larger and fuller. Performed using either special implants or by fat transfer from a different area of the body, the procedure helps to restore breast fullness after pregnancy or weight loss, correct asymmetrical breasts, or enlarge smaller breasts. It is also valuable as reconstructive surgery after a mastectomy or other breast surgery.

A safe, effective procedure

When done by a skilled and experienced board-certified plastic surgeon, breast augmentation is a safe and effective procedure. The surgeon takes the necessary measures to minimize the risks of the operation, and the majority of women have no issues after the surgery. In fact, among millions of women with breast implants, complications have been observed in fewer than 1% of patients.

However, like every surgery, the procedure has general surgical risks, including temporary pain, swelling, bruising, tightness in the chest, bleeding, infection, poor scarring, allergic reaction to anesthesia, hematoma, changes in breast or nipple sensation, or need for revision surgery.

Besides, breast implants are designed to be temporary devices which wear out, degrade chemically, and release their content. So when getting breast implants, women should know that they are temporary devices that will need removing or replacing at a later date—the longer you have the implants, the higher the chances of complications.

What are the specific risks and complications of breast augmentation?

1. Pain

You will experience some pain or contraction for a while after the operation. Your surgeon can prescribe pain-relieving medication to help you manage pain which should be gone after 7-10 days. Do not take any other medication apart from the painkillers and additional medications prescribed by your doctor.

2. Seroma

Seroma — a buildup of fluid under the skin surface—may occur after the procedure, often at the site of the incision. The fluid is called serum and may begin to accumulate soon after surgery or several weeks later. Seromas pose a risk of infection and are resolved by draining the fluid buildup, especially when they are large.

3. Breast Implant-Associated Illness

Breast implant illness (BII or BIAI) is a self-reported complication and not an official medical diagnosis. Patients who believe they have the condition have reported a number of common symptoms, including fatigue, chest pain, hair loss, chills, headaches, chronic pain, rash, anxiety, photosensitivity, brain fog, and sleep disturbance.

There is still a need for research to find out why the symptoms occur and how they can be remedied. Many patients reporting these symptoms have also reported that the removal of breast implants alleviates the symptoms.

4. Implant rupture and deflation

Although breast implants have changed significantly since their inception and are now more durable than before, they can still rupture or burst under trauma or extra pressure. Most implant ruptures occur between 10-15 years after initial surgery, but this depends on the type of implant.

Silicone gel-filled implants have thicker liquid, so they do not deflate completely after rupture. But a hole or tear in saline-filled implants can cause a complete deflation, as the fluid escapes into the surrounding tissue.

Silicone implant rupture comes with risks such as pain, lumps, tenderness, and swelling. The breasts are also deflated in a manner visible to the eyes. Therefore, for patients with silicone gel-filled implants, it is advisable to have regular MRI scans after the procedure to detect possible rupture. If rupture is found, the implants are removed and replaced to prevent infections, discomfort, and cosmetic deformities.

5. Capsular contracture

The natural tissue of the body may react to the breast implants through an immune response. When this occurs, the collagen fiber around the implant forms a scar tissue (membrane) around the implant, resulting in hardening, stiffness, implant deformity, and pain in the breast over time.

Capsular contracture is classified into four grades: I to IV. Grade I contracture can go away with massaging and usually does not need treatment as it causes minimal problems. Grade II contracture creates more firmness in the breast and requires ultrasonic massage instruments. Grade III and IV contracture makes the breast hard and unnatural and requires surgery to remove and replace the implant.

6. Hypertrophic scarring

Breast augmentation is associated with a severe form of scarring, called hypertrophic scarring. It is a small but notable risk—only observed in 5% of patients. It is characterized by a thick, red-colored scar that is raised above the skin. Surgical scars tend to occur around the nipple and the lower part of the nipple. Your plastic surgeon may carry out renovation procedures to eliminate or reduce these scars.

7. Breast Implant-Associated Anaplastic Large-Cell Lymphoma

Though there is a low risk of Breast Implant-Associated Anaplastic Large-Cell Lymphoma (BIA-ALCL) occurring after breast augmentation, patients should still be aware of the risk. BIA-ALCL is a cancer of the immune system and is not related to breast cancer.

The condition is curable, with early detection offering patients the best chance for a quick recovery. Women considering breast augmentation should speak with their plastic surgeons about the risk of BIA-ALCL.

8. Surgical site infections

Infection may develop in or around the surgical site if bacteria enter the surgical wound either from the skin or in a contaminated saline solution or implant. The infection may be mild or severe, with the potential of infiltrating into deeper layers of the skin. Symptoms include pain in the surgical area and high fever. The implant may need to be removed to allow for the treatment of the infection before it is eventually replaced.

At Politis Plastic Surgery, we understand that the possible risks and complications of breast augmentation vary depending on your medical history, body type, allergies, medication, and other individual factors. We uphold the highest standards of medical care and take the necessary steps during the procedure to minimize the risks associated with the surgery. And after the procedure, we will keep in touch with you to ensure that any issues are promptly resolved.

Want to meet with a plastic surgeon to have your specific questions and concerns addressed? Dr. Effie Politis will listen to your cosmetic goals, explain available options, and guide you through your preparation for the surgery and your post-surgical journey. For more information on breast augmentation, visit the site Politis Plastic Surgery website.

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How to fix a displaced fold (inferior fold displacement after breast reconstruction)?

This lovely lady had the unfortunate diagnosis of breast cancer found on her annual screening mammogram. ⁣
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She underwent bilateral nipple-sparing mastectomies through an inframammary approach. She then underwent bilateral immediate breast reconstruction with silicone implants and acellular dermal matrix. ⁣

Because of the elastic properties of the acellular dermal matrix (its ability to stretch over time just like skin), she suffered from an inferior displacement of her fold (descent of her native inframammary fold) resulting in device malposition. This descent of her right inframammary fold created an increased lower pole breast skin out of proportion to her upper pole. ⁣
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I always tell my patients that during the mastectomy, the primary role of the breast surgeon performing the mastectomy is to act as an oncologic surgeon and safely remove all of the breast tissue to increase disease-free survival. ⁣
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During the mastectomy, all the natural landmarks and ligaments of the breast are removed with the actual breast tissue and this includes obliteration of the inframammary folds as well as the medial and lateral borders of the breast. ⁣
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It is our job as plastic surgeons to reconstruct these with suture techniques and also with adjunct materials that inherently have properties to support the missing ligamentous structures. ⁣
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The soft tissues are variable in every patient according to their age, weight, and subcutaneous tissues as well as fascial tissues. ⁣
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She was brought back to surgery for revision and stabilization of the fold with GalaShape. Again, this material provides a scaffolding and support to counteract increased downward pressure from the implant in a patient with low body weight and minimal subcutaneous fat.⁣

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How do you treat a cyst on your jaw?

 

 
 
 
 
 
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This young lady presented with a 5-year history of a mobile subcutaneous mass along her mid-right mandible.⁣⁣⁣⁣

She opted to have her cyst removed because it was enlarging and more noticeable. She also found good timing given most are wearing masks during the current pandemic.⁣⁣⁣⁣

When evaluating the subcutaneous masses, we do a careful head and neck examination of the patient to rule out a possible cutaneous malignancy. This includes a careful history as well as a lymph node evaluation and intra-oral evaluation. She denied any trauma to this area or any drainage.⁣⁣⁣⁣

 

 
 
 
 
 
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After careful evaluation, the area is numbed with local anesthesia, and then the cyst removed with sharp dissection followed by a layered closure to ensure a fine, hidden scar.

Sebaceous cysts may develop as a result of trauma or blocked glands in the skin and rarely cause pain or other symptoms. They’re most commonly found on the face, neck, and trunk. ⁣

Many patient prefer the removal of any lesions or cysts on the face to be performed by a plastic surgeon to ensure optimal scar healing and placement along with aesthetic units.⁣

 

 
 
 
 
 
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This is the defect after the entire cyst including sack and contents are removed.

Important structures in this area are the facial artery and vein and marginal mandibular nerve. ⁣

These structures were abutting the cyst but knowledge of anatomy helps us dissect them away without damaging them. ⁣

The defect was cleaned with betadine and peroxide and saline prior to layered closure for a nice fine scar.⁣⁣

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What are breast implants?

A breast implant is a medical device (prosthesis) inserted under breast tissue or chest muscle to change the size, contour or shape of the breast. In plastic surgery, breast implants are used to increase breast size, replace breast tissue removed due to trauma or cancer surgery, or to correct severe birth defects and deformities of the breast and the chest wall.

There are three main types of breast implants used in plastic surgery: saline implants, silicone implants and structured implants.

Saline breast implants

Saline breast implants are filled with saline solution. They are placed by means of a less invasive surgery through smaller incisions. During the surgery, empty saline implants are inserted into implant pockets and then filled with saline solution. The incisions made for this insertion are smaller and shorter compared to the relatively longer incisions required to place pre-filled implants.

Saline breast implants offer an increased breast size with a realistic texture and smooth contour. However, they are associated with cosmetic problems such as the wrinkling of breast skin and the implant being more noticeable to the eye and touch, particularly in women with less breast tissue. For women with enough breast tissue, saline implants produce aesthetically better results.

Silicone gel breast implants

The current models of silicone gel breast implants are filled with a high-strength, highly cohesive silicone gel which reduces the likelihood of filler leakage to the body. These form-stable implants can retain their shape even when their shells are broken. They are also less likely to wrinkle and tend to feel a bit more like natural breasts. However, they require slightly longer incisions for placement and they can spread into the breasts, causing lumps. Breasts augmented using silicone gel implants require regular ultrasound or MRI images for assessing the condition of the implants.

Structured breast implants

Structured implants incorporate both saline and silicone gel implant technologies. They use the saline solution as the filler while having the natural feel of silicone. Their internal structure consists of a series of nested shells that support the upper pole and two lumens (cavities) where the filler material is added.

During surgery, a structured implant is inserted while empty and then filled with saline once placed, requiring a smaller incision than a pre-filled implant. And if one of the lumens ruptures after the procedure, it just leaks and empties, leaving the other lumen intact and the implant only partially deflated. This feature allows for ease of removal and replacement.

How are breast implants placed?

When choosing a plastic surgeon for breast implant surgery, finding someone experienced reduces the risk of complications after the procedure. Before the surgery, you will have an appointment with the surgeon for a medical evaluation. Your consultation will allow you to share your goals and expectations with the surgeon, and learn how to prepare for the procedure.

Breast implant surgery is usually carried out under general anesthesia. The plastic surgeon makes a cut in the skin below or next to the breast. The implant is positioned either behind your chest muscle or between your breast tissue and chest muscle. The doctor then closes the incision and covers it with a dressing.

The procedure usually takes 60 to 90 minutes. You may be able to return home the same day, or you may need to remain in the hospital overnight if the operation is scheduled late in the day. You will be given pain medication to help manage the discomfort after the anesthesia wears off. Your breasts will be covered with compression garments, and drainage tubes will be applied in order to drain the surgical area. Expect to need rest for a few days after the surgery and avoid heavy lifting for at least 6 weeks.

Are breast implants safe?

Breast implants are quite safe and rarely cause issues. Though it is possible for the implants to rupture and leak, they rarely cause medical problems. When saline implants rupture, the salt solution is safely absorbed by the body. For silicone gel implants, the gel either remains in the shell or leaks out following a rupture that results in no obvious symptoms.

How are breast implants maintained?

Breast implants are, by design, not intended to last a lifetime. They may have to be replaced if there are complications or if the breasts change in size and shape over time. If you have silicone gel-filled implants, you will need an MRI scan three years after your implant surgery, and then MRI scans every two years to check for silent ruptures. Ruptured implants should be removed or replaced.

At Politis Plastic Surgery, we offer breast implant surgery to enhance the natural appearance of your breasts, create fuller curves, and give you a more aesthetically pleasing shape. We understand that your breasts are a defining feature of your body and enhance your femininity, sexuality and beauty. Through breast augmentation, you can change the size and shape of your breasts and, in turn, your self-confidence.

Are you considering breast augmentation?

Schedule a private consultation today with Dr. Effie Politis and have your questions answered and concerns addressed. For more information on breast implants and breast augmentation, visit the Politis Plastic Surgery website.

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“Breast in a Day” Surgical Technique

 
 
 
 
 
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Another ‘Breast in a Day’ case, but executed differently since she has much larger ptotic breasts (sagging breasts). ⁣

She basically had a mastectomy performed through a Wise pattern skin mastopexy and I kept the nipples on an inferiorly based adipodermal flap. ⁣

I reduced her mastectomy envelope, reduced and repositioned her nipple areolar complexed, and placed a cohesive Natrelle Inspira SCF 520cc implant in the prepectoral position with anterior Galaflex sheet. ⁣

“Wise pattern or inverted-T mastopexy has traditionally been used in patients with severe excess of skin relative to breast parenchyma (tissues of the breast essential for functioning) in a patient with severe ptosis. Incisions are made around the areola with extensions for the vertical limbs as in a vertical mastopexy.” (Qureshi, Myckatyn, & Tenenbaum, 2018)⁣

“The Wise-pattern incision addresses any redundant mastectomy skin envelope and avoids excessive and unsightly scarring on the “social” aspect of the breast mound.” (Newman, 2016)⁣

“The pattern allows removal of skin in both vertical and horizontal dimensions allowing for lifting and coning of the breast into a less ptotic shape.” (Todd, 2016)⁣

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20-Year Old Implant, Capsular Contracture

These implants were placed in the sub-glandular condition, which has a higher incidence of capsular contracture. ⁣⁣ ⁣⁣ I performed a change of plane and placed him in a partial submuscular position and supported the lower pole with GalaFLEX scaffold (P4HB). ⁣⁣
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Breast Revision Case: Before and After

 
 
 
 
 
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𝐁𝐫𝐞𝐚𝐬𝐭 𝐑𝐞𝐯𝐢𝐬𝐢𝐨𝐧 𝐂𝐚𝐬𝐞 ⁣⁣

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Before: ⁣⁣
– Saline implants, dual-plane⁣⁣
– Breast and nipple-areolar ptosis⁣⁣
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After: ⁣⁣
– Removal and replacement of saline implants for Sientra 385cc moderate profile hsc+⁣⁣
– GalaSHAPE 3D ace

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