Breast implant removal with smaller replacement can pose some challenges such as risk of sagging appearance and poor breast contour, although with close attention to details great results can be achieved.
Recently, leading Los Angeles plastic surgeon Dr. Tarick Smiley has performed a surgery on a woman with 500 cc silicone implants who wanted them replaced with 270 cc, which could slash her breast size by almost half.
The patient asked for breast implant removal immediately followed by replacement. But since the new implants were significantly smaller than the old ones, a simultaneous breast lift was performed to maintain natural breast contour.
Due to the significant downsize, she was deemed as a good candidate for a simultaneous breast lift. Without this procedure, her implants would settle too low, resulting in a drooping appearance and deflated-looking upper breast pole.
To remove the old implants along with their scar capsule, Dr. Smiley created a small incision within the breast crease (submammary fold), which would result in a well-concealed scar. He then replaced them with a new pair of smaller implants.
Next, he performed a standard breast lift in which the incision pattern ran around the areola, which was extended downward towards the crease and then across the base of the breast. This would result in an inverted T or anchor-shaped scar that is expected to blend into the background 1-2 years postop.
For long-lasting effects, breast lift should not just be about skin tightening and resection. After all, its elasticity makes it susceptible to the effects of gravity and aging. Hence, the celebrity plastic surgeon creates a more resilient support by remodeling the deeper tissue.
The use of “deep tissue work,” according to Dr. Smiley, also allows the surgeons to elevate some of the tissue of the lower breast pole, resulting in additional upper pole fullness. According to studies, the most preferred breast shape has a 45:55 upper to lower pole ratio (resembling a teardrop shape).
To further promote youthful and natural-looking results, the new position of the nipples should be horizontally and vertically aligned with each other.
Furthermore, tightening the deeper tissue allows the skin to receive no or very minimal tension, which is the key to good healing and “nice looking scars,” says Dr. Smiley.
Breast augmentation transaxillary refers to the creation of a hidden incision at the deepest skin fold of the armpit, thus allowing the surgeons to propel implants into the breast pocket.
Celebrity Beverly Hills plastic surgeon Dr. Tarick Smiley says breast augmentation transaxillary is one of his favorite incision techniques, along with the peri-areolar method (or “through the nipple”), due to the well-concealed scar.
The breast augmentation transaxillary incision technique results in a well-hidden scar.
Aside from the well-concealed scars, Dr. Smiley says the incision technique offers other advantages such as perceived lower risk of infection, implant contamination, nipple numbness, and breastfeeding difficulty.
The benefits of this technique stem from the fact that the implants will not pass through the milk ducts, which are known to harbor staph bacteria.
But as with any breast augmentation technique, Dr. Smiley says the ideal candidate candidate should have aesthetic goals and breast anatomy that are in line with what the transaxillary incision can accomplish.
- Women whose breasts are relatively symmetric and perky.
Since there is no direct incision on the breast, there is no way that the surgeon can elevate or transpose the sagging breast tissue. Hence, the technique is only reserved for women whose pre-existing bosom has a relatively good shape and projection.
Meanwhile, patients with sagging or pendulous breasts and those with deformity (e.g., tubular or torpedo breasts) are not good candidates for the “through the armpit” technique.
- Patients who asking for moderate-sized silicone implants or saline implants of any size (provided they are within the breast/chest dimension).
It is important to note that silicone implants are always prefilled, while saline implants are propelled into the breast pocket empty (they are rolled up like a cigar) before they are inflated with sterile saltwater.
Hence, extra large silicone implants (or 600 cc and higher) require longer incision than that of saline implants, which of course makes it difficult or even impossible to hide the scar within the armpit.
Nonetheless, most patients today prefer silicone implants due to their softer, more natural results than saline implants. For this reason, Dr. Smiley typically uses Keller Funnel during surgery to ensure that the scar remains relatively short and well concealed within the armpit.
Keller Funnel is a disposable device that closely resembles a piping bag. This is used to propel the silicone implant into its pocket with one squeeze and so the implantation process is quicker and less traumatic to the tissue. Furthermore, doctors are able to use a shorter incision with this technique.
- Patients with a strong history of keloids.
Several studies have suggested that darker skin is susceptible to keloids; hence, ethnic patients tend to choose breast augmentation transaxillary since the incision is placed in this hidden area, which is also known for being highly resistant to aggressive scarring.
Aside from ethnic patients, younger women (i.e., Millenials) often find it unacceptable to have scars on their breast and so they typically inquire about the possibility of placing the incisions within their armpit.
Lip lift procedure elevates the upper lip, which in turn creates a shorter distance between the nose and the [vermilion] border of the upper lip. Recently, leading Beverly Hills plastic surgeon Dr. Tarick Smiley has performed the surgery, which was posted on Snapchat.
The patient shown in the video did not like the expansive distance between her nose and upper lip, which prior to surgery was around 2 cm. For females, the ideal length is usually 1.1-1.3 cm, while for men it is slightly longer, about 1.3-1.5 cm.
Dr. Smiley says there are two ways to perform the upper lip lift: the first one involves placing incisions inside the mouth in order to “roll up” the upper lip, while the second technique entails the use of external incisions at the base of the nose to shorten the space between it and the lips.
Since the patient required extensive reduction the intra-oral (inside the mouth) technique would not suffice.
During surgery, Dr. Smiley created incisions at the base of the nose to remove a small strip of skin and tissue (measuring 0.4 cm). In the process, the upper lip has been elevated and so now the teeth are slightly visible in frontal view.
Elevating the upper lip has also increased the pink part or volume of the lips.
This incision pattern results in a hidden scar as it lies precisely at the natural skin fold of the nose.
After removing the excess skin and tissue, Dr. Smiley closed the wound in a way that the scar would settle precisely at the skin folds of the base of the nose to hide it from view.
Meanwhile, the surgery was performed under local anesthesia, which could pave way for shorter downtime.
After recovery from upper lip lift, patients may opt for lip filler (fat injection or dermal fillers) to further improve their volume and shape. It should be noted that lip augmentation, especially with over-zealous injection, tend to provide unnatural results (duck lip appearance) if there is too much space between the nose and the upper lip.
Dr. Smiley has explained the general rule of thumb to ensure natural results from lip fillers:
- There should be a 1.0-1.6 ratio in terms of volume distribution and height between the upper lip and lower lip (phi or golden proportions).
- The outermost corners of the mouth should have very little volume. Over-injection to this area results in unnatural lip contour.
- The volume of the lips gradually increases as it goes towards the center.
- To avoid the appearance duck lips, the philtrum (two columns right above the upper lip) is occasionally filled in.
Facial fat transfer procedure is an already established technique to rejuvenate the aging face. In the past, doctors were only focused on addressing the loose skin and soft tissue laxity without taking into account that facial volume loss (or fat loss) was also contributing to the aged appearance.
But nowadays, skilled plastic surgeons typically combine facial fat transfer procedure and facelift, a combo procedure that accomplishes two goals: tighten the loose skin and restore the lost volume. With this approach, which is also referred to as three-dimensional facelift, patients enjoy more natural and more “stable” results, meaning no surgical stigmata appear years after their surgery.
Leading Inland Empire plastic surgeon Dr. Tarick Smiley, who commonly combines facelift and facial fat transfer procedure in one surgical setting, explains some of the most surprising facts about the latter.
- Only a few teaspoons of unwanted fat is needed.
The tummy area is the usual donor site, where a few teaspoons is collected and is later processed and re-injected into the soft tissue of the face. Meanwhile, it is not uncommon practice to slightly over-fill the recipient site since it is expected that about 25-30 percent of the volume will be resorbed by the surrounding tissue; anything that remains 2-3 months postop is expected to be near permanent.
- Facial fat transfer procedure is “cheaper” than dermal fillers in the long run.
The average cost of facial fat transfer is $2,000-$5,000, while dermal fillers are typically priced at $250-$600 per treatment. Despite its higher “upfront” cost, in the long run it is more affordable than the standard fillers because of its near permanent results—i.e., 12-15 years.
Dermal fillers, meanwhile, typically require touch-ups performed at 3-4 months interval should the patient desire to preserve her rejuvenated appearance.
- It can be performed simultaneously with “hand rejuvenation” procedure.
In Dr. Smiley’s previous post on Snapchat, a female patient had fat injection not just to her face but also to her hands (and fingers) to correct their thin and wrinkled appearance.
- All the biomaterials are removed prior to fat injection.
It is important to remove the oil, red blood cells, and other “non-fat” biomaterials to achieve near permanent results and high survival rate of fat grafts. Centrifuge is particularly helpful during the purification method because it separates materials based on their weight.
- Blood vessels need to grow into the grafted fat.
In order for the grafted fat to persist long term, blood vessel ingrowth must occur. Hence, Dr. Smiley highlights the importance of micro-droplet injection in which layers of fat are gradually created (less than 0.1 cc at a time) during surgery.
Without blood vessel ingrowth, which is medically referred to as vascularization, the surrounding tissue will resorb the grafts within months.
Dermal fillers are primarily used to fill in depressions caused by facial aging or hereditary predisposition (e.g., flat cheeks). However, doctors are now starting to use them in non-surgical rhinoplasty although their use can be quite limiting.
Renowned Los Angeles plastic surgeon Dr. Tarick Smiley says fillers only suit patients with minor nasal deformity: a small hump or irregularity along their nasal profile. Those who require minimal bridge augmentation may also consider this non-surgical approach.
Patients with severe or more complex nasal deformity—e.g., drooping tip, significant nostril flare, large bridge, etc.—will need the standard rhinoplasty, a surgery in which the bony and cartilaginous framework of the nose is reshaped. It is important to consider the patient’s skin shrinkage to ensure that it can redrape well to the new contour, instead of appearing amorphous especially at the tip.
When performing non-surgical rhinoplasty, Dr. Smiley only uses FDA-approved fillers to conceal minor imperfections of the nose. Hyaluronic acid-based materials like Juvederm and Restylane are the ideal choice since they can be easily reversed should the patient is not happy with the results; an enzyme called hyaluronidase can be injected into the tissue to dissolve the particles.
Hyaluronic acid-based fillers generally last four to six months and so they require upkeep should the patients want to preserve their results.
For patients who want longer-lasting fillers, one possible alternative is to use Radiesse whose results can last between nine and 15 months. Its main ingredient is calcium compound, which is not easily broken down by the body.
Meanwhile, permanent fillers such as silicone injection should be avoided due to increased risk of lasting deformity, infection, and skin injury, Dr. Smiley says in a previous Snapchat post.
One of the selling points of fillers is the zero downtime, while rhinoplasty typically requires 7-10 days of social recovery due to the postop bruising and swelling.
Despite the impressive safety track record of FDA-approved fillers, they nonetheless demand meticulous injection to avoid skin changes (redness), lumpy appearance, and skin necrosis (death of tissue). Hence, a prudent patient ensures that only a licensed/qualified injector does her procedure.