Recently I went to Sweden to observe the practice of Dr Charles Randquist.  Dr Randquist has extensive experience with form stable breast  implants -  Mentor’s CPG implants and Allergans 410 implants -  which are not currently available in the USA except under study conditions.  These implants are shaped -  with a sloping upper pole .  We used to have shaped implants in the United States but the FDA did not include them in the approval process along with round implants so they were taken off the market in the States five years ago.    I am hopeful that soon we will have shaped implants as I think especially for the reconstruction patient they are a valuable tool.

When a woman is diagnosed with breast cancer she is faced with a multitude of decisions -  lumpectomy or mastectomy, decisions about chemotherapy and radiation therapy - it can sometimes seem like too much to have to decide about breast reconstruction (implant reconstruction, flap reconstruction, silicone vs saline implants) at the same time.  Our goal as plastic surgeons is to try and make sure each patient has all the information she needs to make the best choice for her.  For some patients this might be to undergo the breast cancer treatment and not even worry about the reconstruction until later.  For others it might be to undergo breast  reconstruction at the same time as the mastectomy.  Recent data suggests that 70% of breast cancer patients are not informed of the various reconstructive options available to them.  This is not acceptable.  We need to work harder to make sure that women are given all the information they need at the time of their cancer diagnosis so they can make the best , informed decsions for themselves.

Plastic surgery as a specialty encompasses both cosmetic as well as reconstructive surgery.  The definition of cosmetic surgery is surgery  ”to improve on the normal”  whereas reconstructive surgery is surgery  ” to restore to normal form and function”.  In some cases it is clear -   repair of a cleft lip is clearly reconstructive surgery and liposuction of small amounts of fat that one just does not like is cosmetic surgery.  In other situations it is more difficult.  An upper eyelid lift to improve one’s appearance is cosmetic while an upper eye lift to remove excessive skin which is blocking one’s vision is reconstructive.   Breast reconstruction after cancer treatment is unusual in that there is a Federal Law signed into effect by Bill Clinton mandating that breast reconstruction and surgical treatment of the opposite breast (if needed) is covered by insurance.  Thank you Mr. Clinton!

Surgery on patients who have lost a lot of weight can take a lot of time.  This is a problem for many reasons .  The risk of complications can go up with a patient on the operating room table for an extended period of time  -  risks of wound infection, healing issues, risk of DVT or even pulmonary embolism can increase.   New sutures are now available which can lessen the time on the operating room table.  These sutures are an exciting  advance  especially  for plastic surgeons working with  Massive weight loss patients .  The sutures are barbed which work to close the wound without  knots.  This decreases the time to close the wound and reduces the incidence of knot related issues such as stitch abscesses.     I have been really pleased with the barbed suture -  and especially the combination of the barbed suture and surgical glue to seal the wound.  This combination is great for my patients -  less time on the OR table, less tape and bandages and patients can shower right away !  A win for all!

A few years ago I surveyed a group of female plastic surgeons as to what they would choose for reconstruction if they were faced with the diagnosis of breast cancer.,  My thinking was that this group of doctors had an unique perspective on breast reconstruction options -  they were very well informed as to  not only the options available but also to the risks and outcomes of each reconstructive option .  The results were interesting.,  A total of 54 female plastic surgeons were surveyed.  Ninety one percent stated that they would opt for mastectomy over breast conservation .  Most   (87%) choosing a mastectomy would opt for reconstruction.  For their reconstructive procedure 54% would choose tissue expansion with implant reconstruction and, 28% would choose a Tram flap and only 5% would choose a latissimus flap.  For the women choosing implant reconstruction 79% would choose a silicone implant , 24% would choose a saline implant and one respondent felt that either choice would be acceptable.  The most frequently chosen reconstruction then was tissue expansion followed by a silicone implant (43%).  Interesting  and food for thought!

Liposuction has been the most common plastic surgical procedure done in the United States.  In 2007 over 450,000  patients underwent liposuction.  Liposuction is best used to reduce pockets of fat which have been unresponsive to weight loss.  Liposuction removes fat only and does not remove skin.  For this reason it is usually only used as an adjunct to skin removal for patients who have lost a lot of weight.  There are several methods of liposuction available  including traditional liposuction, Vaser or ultrasonic liposuction (UAL) and power assisted liposuction (PAL).  A plastic surgeon may use one or more of these techniques in treating a patient depending on the areas being treated.  For example fibrous areas such as the back or male chest are usually treated with either Vaser or PAL rather than traditional liposuction.

Patients who have lost significant amounts of weight often are concerned about the appearance of their breasts.  For many patients they are unclear if the best procedure for them would be a breast reduction or a breast lift.  A breast lift (also called a  Mastopexy) repositions the breast on the chest wall but does not change the size of the breast. A breast reduction not only repositions the breast higher on the chest wall ( a lift) but also removes some of the breast tissue to make a smaller breast.  In some cases if a large enough amount of breast tissue is being removed a breast reduction may be covered by insurance.  A breast lift is not usually covered by insurance as it is considered a cosmetic procedure.  In some cases during a breast lift a breast implant will be placed in order to restore breast volume lost by pregnancy or weight loss.  If you are unclear about which procedure is best for you try and pinpoint what bothers you most about your breasts ( for example -   I don’t like the droopiness but I am happy with the size) and then the best procedure to address those issues can be chosen.

Loose skin of the upper arms is of great concern for many women after weight loss.  An arm lift (Brachioplasty) can remove the excess skin but it does leave a scar.  The scar extends from the armpit to the elbow and may even extend onto the forearm if the excess skin extends there as well.  The scar is placed on the inner surface of the arm in order to hide it but it will be visible when one’s arm is raised.  For many women however the scar is a very acceptable alternative to the excess loose skin.  The scar and the amount of excess skin should be discussed before deciding on an arm lift to see whether the procedure is right for you.  Some women who still have very heavy arms despite weight loss may require a two stage procedure with removal of the fat first with liposuction and then removal of the excess skin at a later time.

For most patients after a large weight loss their abdominal area is of the most concern.  For these patients an abdominoplasty or Tummy Tuck is the first procedure they consider.  If the patient also has a lot of loose skin on their thighs and buttocks they may consider a belt Lipectomy or Lower Body Lift (LBL).  In these procedures the removal of skin and fat continues all the way around the body lifting the buttocks and lateral  thigh areas as well as removing the excess  skin and fat of the abdominal area.  The LBL can be done in two stages as well -  first doing the abdominal area and at a later time doing the back area.  The decision on whether a LBL or a tummy tuck is the right procedure for you depends on many factors including the looseness of the skin and what other procedures you are considering.

Plastic surgery after weight loss can involve several stages and the question patients often ask - is how many procedures can be done at the same time?  Several procedures can be done at the same time.  For safety sake most plastic surgeons try to plan for what can be accomplished in a time period of six to eight hours.  This seems to be a good time frame within which patients can recover well from both the anesthesia and the surgery.  For patients who want to push and try to do more - I will explain - lets face it - after six to eight hours I will also be tired and not doing my best work! 

The second question is : how long do I have to wait in between procedures?  The goal is that a patient gets back to their good health before they proceed on to the next surgery.  For most patients this is a minimum of three months.  For some patients it might even be longer.  of course life has a way of getting in the way of our plans so that even if initially one might want to do everything as quickly as possible something might come up that would delay the process.  There is no advantage as far as the final result  to doing everything quickly and no disadvantage to spreading things out over time .  What is important is what works for you and your life.