Scarless breast reduction generally refers to a liposuction-alone procedure in which the overlarge breasts are made smaller by removing the excess fat. Mammogram prior to surgery is critical to evaluate the proportion of fat [and the glandular tissue as well] in the breasts to see if the patient can benefit from it.
However, liposuction can produce no or very little improvement should the overlarge breasts are mainly compromised of glandular tissue, which is extremely dense that the only way to remove it is through direct excisions (with the use of scalpel, as opposed to a cannula or suction tube).
Liposuction uses a cannula that can fit into a 1.5 mm round incision that typically fades into imperceptible scar after 6-12 months. To further hide any “reminder” of surgery, renowned Los Angeles plastic surgeon Dr. Tarick Smiley says that incision placement will also play a critical role.
In scarless breast reduction via liposuction, he says the “puncture holes” are typically positioned in the armpit, on the underside of the breast (about 2 cm above the natural crease), and within the areola’s perimeter (specifically at the junction where the darker skin meets the lighter skin) to further hide the reminders of surgery.
The standard liposuction technique, aka tumescent approach, is ideal for treating the highly fibrous breast fat. It involves injecting a solution into the fatty area containing epinephrine to decrease bleeding, lidocaine which is a type of local anesthesia, and saline (sterile saltwater), and then waiting for at least 10 minutes to take its full effects.
Properly marking the patient in an upright position is critical to avoid the danger zone—i.e., the area between the clavicle and the beginning of the breast tissue.
When the patient lies on the operating table, some of the breast tissue will “spill” to the so-called danger zone. But with proper markings, the surgeon can avoid this highly perforated area.
Contrary to popular belief, liposuction is not all about removing the optimal amount of fat; this is particularly true for scarless breast reduction in which a good surgeon should also make an effort to produce a more symmetric appearance, and to avoid skin asymmetries and sagging appearance.
Sagging after breast liposuction occurs when the patient has poor skin shrinkage to begin with and/or the surgeon removes too much fat without taking into account the skin’s inherent elasticity.
However, patients with a decent amount of skin elasticity might even expect some improvement in the “perkiness” of their breasts. Because they are smaller and lighter, it may be safe to surmise that they are less susceptible to the effects of gravity.
The transaxillary breast augmentation technique uses an incision within the natural skin crease of the armpit, so the resulting scar is completely hidden. For this reason, leading Beverly Hills plastic surgeon Dr. Tarick Smiley says it is one of his most preferred incision sites due to optimal scar concealment.
Dr. Smiley has recently posted a Snapchat video showing one patient who had a transaxillary breast augmentation. She had a relatively small areola, which could make it more difficult to hide the U-shaped scar at the junction where the dark skin meets the light skin.
In the video, Dr. Smiley said he prefers the transaxillary technique to the under the breast crease incision because the latter is susceptible to “thicker” and more obvious scar. This was a particular concern since the patient’s preoperative breasts had no “deep” fold to begin with.
Aside from optical scar concealment, Dr. Smiley said the transaxillary breast augmentation technique allows easy and direct access to the muscle during the creation of implant pocket; hence, no breast tissue is “violated” in the process, ultimately resulting in less bleeding, less surgical trauma, and possibly quicker recovery.
Simply put, the technique is “perfect” for patients opting for under-the-muscle (submuscular) implant placement in which the prosthesis is covered by the thick and strong layer of muscle, as opposed to the tissue and skin alone.
However, the transaxillary technique does not allow over-the-muscle placement in which the implant is only supported by the glandular tissue and skin. Fortunately, this is rarely used nowadays particularly in patients with very little soft tissue because of the increased risk of palpability and rippling.
Through an incision made in the armpit, Dr. Smiley was able to create a pocket for the implant with long instruments such as “finger extension.” Pocket dissection is particularly critical since the prosthesis must lie centrally behind the areola to produce natural-looking shape and “sufficient” volume especially in the cleavage area.
Dr. Smiley said saline and silicone implants are both used in transaxillary breast augmentation, despite common misconception that it only allows for saline implants, which are propelled into their pocket while “empty,” only to be inflated by a saltwater-like solution once settled in their place.
In the video, the leading Beverly Hills plastic surgeon was seen using a Keller Funnel (a disposable cone-shaped bag) to propel a 375 cc silicone implant into its pocket. This technique has allowed for quicker and gentler implantation.
Despite the appeal of short scar arm lift surgery, this is not sufficient enough for massive weight loss patients due to the amount of their redundant skin, according to California Surgical Institute.
Simply put, only a small subset of patients with sagging upper arms are suitable for short scar arm lift surgery in which the incision is limited to the armpit area.
Oftentimes, this modified form of arm lift removes a crescent-shaped excess skin to create a tighter appearance. The resulting scar goes parallel to the natural skin crease of the armpit, an area that is highly resistant to aggressive scarring such as keloids and hypertrophic scars.
Occasionally, a simultaneous liposuction is performed to further improve the shape of the arms. This ancillary procedure uses a cannula or flexible hollowed tube to remove the excess fat; it is critically to leave behind some fat particularly beneath the skin (at least 5 mm) to avoid dents and bumps and other reminders of the surgery.
Contrary to popular belief, arm lift surgery is not just about removing the redundant skin and some excess fat. A more critical goal is to turn the flabby arm into a smooth cylindrical shape.
To further create a more natural-looking result, many surgeons these days employ a proactive scar treatment approach. For instance, doctors at the California Surgical Institute recommend the use of silicone sheets or creams to help the scar fade better.
It is also important to avoid exposing the incision site in the sun to prevent hyperpigmentation in which the scar permanently darkens, they add.
Despite the contouring effects of a short arm lift surgery, particularly when performed simultaneously with liposuction, massive weight loss patients (i.e., 80 lbs. or more of weight loss) will have no or very little improvement from this technique.
For massive weight loss patients, a full arm lift is the only technique that can produce a near normal arm shape; however, they should accept a long scar between the armpit and the elbow. While it may always seem ideal to place the scar on the inner side of the arm, some individuals can achieve a better shape if the incision is placed more posteriorly.
The truth is, every time an incision is made the body naturally forms a scar. Nevertheless, the term scarless breast augmentation surgery has become a common lingo in Los Angeles plastic surgery.
Scarless breast augmentation surgery results in scar, albeit the placement and size of the incision makes it almost impossible to detect any reminder of the procedure. Oftentimes, this “technique” refers to the trans-axillary technique, TUBA, and fat grafting.
In trans-axillary breast augmentation technique, an incision as short as 2-3 cm (if saline implants are going to be used; however, silicone implants require a slightly longer slit to fit in) is made within the natural skin crease of the armpit. This area is highly resistant to keloids, thus it favors ethnic or dark-skinned patients who are susceptible to aggressive scarring.
Contrary to popular belief, silicone implants, which are always propelled into their pockets “prefilled,” can be used in the trans-axillary technique. However, they should not be too big lest the incision needs to be lengthened, thereby defeating the purpose of a scarless breast augmentation.
TUBA technique, meanwhile, uses incisions within the inner edge of the navel where an empty saline implant is pushed toward the pocket; the use of small instruments, including an endoscope which is a lighted articulating camera, has made this method possible.
While the trans-axillary and TUBA techniques do not result in any scar on the breast skin, they are not for everyone. In general, patients with existing deformity like tuberous breasts, ptosis or sagging, and large existing cup size are poor candidates for these procedures.
If there are pre-existing deformity or sagging appearance, there is always a need for direct incisions on the breasts in order to reshape them, tighten their underlying tissue, and reposition their areolas. With proper scar placement (exactly at the areola’s border or within the submammary fold) and wound suturing techniques, most patients are nonetheless happy with their results.
Meanwhile, some patients want to augment their breasts without resorting to the use of synthetic implants. Fat grafting, which is also touted as scarless breast augmentation, might be a possible alternative provided that they have sufficient donor fats and only want a conservative result (i.e., not more than a cup size increase).
Fat grafting starts with liposuction to collect the donor fats from two or more areas (e.g., tummy, hips, back rolls, flanks, etc.). Liposuction uses a few round incisions where a flexible steel tube is moved back and forth to harvest the fatty tissue.
Due to the small size of liposuction incisions, most patients can expect that these will fade to the point that even they would find them difficult to detect.
The collected fats are then purified to get the healthiest cells, which are later re-injected into the breasts. Most surgeons aim to achieve a 60-80 percent survival rate; the grafts that remain after about three months are expected to last a lifetime.
Buttock augmentation procedure is either accomplished through fat grafting (or more commonly referred to as Brazilian butt lift) or gluteal implants. Occasionally, these two methods are combined to deliver the patient’s desired look, as suggested by leading Los Angeles plastic surgeon Dr. Tarick Smiley.
Dr. Smiley says it is not uncommon to hear patients request for a “natural-looking” result, although each person has her own unique interpretation. Hence, a good surgeon focuses on building good communications to deliver results that would satisfy both parties, he adds.
Meanwhile, he explains the markers of a successful buttock augmentation procedure and the “tools” to make this a possibility.
* The overall result should meet most if not all of the patient’s aesthetic goals and personal preference. For this reason, anyone with unrealistic expectations is discouraged to have surgery.
A good plastic surgeon knows how to listen to his patient’s input, particularly the amount of projection she wants to achieve, the shape (e.g., heart, large C, or “bubble butt”), and the hip width.
It is important to note that each buttock augmentation procedure has its limits. For instance, the gluteal implants can only reshape the upper half of the butt cheek due to the way they are positioned; hence, it is difficult to achieve the large “bubble butt” look. Another ramification of using this technique is that the hips will receive no or very little improvement.
Brazilian butt lift, meanwhile, allows to the surgeon to reshape the hips and the lower and upper buttock cheeks because the fat grafts can be injected anywhere. Nonetheless, the overall results are primarily determined by the amount of the donor fats.
* The results are gender appropriate. While the vast majority of patients are women, men are slowly catching up. But due to the nuances in male anatomy and their different beauty ideals and cosmetic goals, they need a different set of approach.
For instance, male patients who are bodybuilders ask for gluteal implants to make their backside look proportionate to the rest of their muscular body. Due to their low body fat percentage, they are generally poor candidates for Brazilian butt lift.
In general, men ask for a conservative amount of projection. Women, on the other hand, are more particular about the shape and hip width improvement.
* There is no visible reminder of plastic surgery. When gluteal implants are used, there should be no inadvertent displacement, palpability, and visible scars. Oftentimes, these complications are avoided by selecting the right implant size based on the patient’s soft tissue coverage and other relevant anatomies.
In Brazilian butt lift surgery, the stigmata that must be avoided include asymmetry (which happens when one of the butt cheeks has lower fat survival rate), and skin asymmetries in the donor/liposuction sites.
Open rhinoplasty surgery is one of the two basic techniques employed in nose-reshaping surgery. This uses an incision along the columella, which is the wall of tissue separating the right and left nostrils, giving the surgeon direct visibility of the patient’s underlying anatomies.
Closed rhinoplasty, meanwhile, only uses incisions inside the nostrils; they run parallel to the nostril lining in order to expose the cartilaginous framework of the nose.
One of the main factors that dictates the ideal approach is the amount of correction the patient needs. In general, the open rhinoplasty surgery suits individuals who have complex or severe deformities such as twisted nose or botched results from a previous operation.
Also, open rhinoplasty surgery is best reserved for patients who need significant augmentation or reduction because of its precise visualization and improved manipulation.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says the risk of visible scar from the columella is very low with proper suturing techniques and other surgical maneuvers. Hence, avoiding this technique (and resorting to closed rhinoplasty instead) despite the presence of complex deformity is impractical.
Instead of the risk of scar, Dr. Smiley says a more pressing issue is the longer recovery time after an open rhinoplasty due to the more postop swelling and bruising. However, most patients find this an acceptable tradeoff as long as their long-term results meet their aesthetic goals and personal preference.
When using the open rhinoplasty technique, Dr. Smiley highlights the importance of perfect realignment of the sutures holding the trans-columellar incision. Hence, the surgeon’s experience will play a critical role in the overall success rate of nose surgery, which is described as a surgery by millimeters.
Furthermore, the patient’s healing will also determine how much the trans-columellar scar would fade. Contrary to popular belief, ethnic patients who are perceived to be prone to aggressive scars (keloids) can still achieve good results from an open rhinoplasty in a sense that there are no surgical stigmata.
Provided that the patients are healthy and have cosmetic-related problems that can be realistically improved by surgery, the risk of scarring is very minimal.
However, cocaine users and patients with compromised healing (e.g., diabetic and smokers) are not good candidates for any type of rhinoplasty because of the increased risk of poor healing, ultimately predisposing them to visible scar in the columella and less than optimal cosmetic results.