Reconstructive Plastic Surgery

Pocket revision breast augmentation corrects implant malposition that causes deformity such as bottoming out, “double bubble” (the breast appears to have two folds), and excessive lateral bulge. The idea is to allow the implants to settle into the most natural position, which is approximately at the center of the “breast mound.”


Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently demonstrated pocket revision breast augmentation in his Snapchat account. It involved a patient who has had surgery done by a different doctor last year.


breast reconstruction pocket repair


The patient’s right breast had its submammary fold positioned 2 cm lower than the other side. Dr. Smiley said the asymmetry was caused by incorrect pocket dissection—i.e., the previous surgeon made it too big—leading to implant drooping and thus causing “slight double bubble” due to the appearance of two breast creases.


The bottoming out of the implant not only caused unnatural placement of the right submammary fold, but also poor projection of the entire breast mound, excessive lateral bulge, and unnatural nipple position. Meanwhile, the left breast had no such problem because its pocket was done correctly.


pocket revision breast augmentation

Dr. Smiley measures the breast dimension from different angles, allowing him to determine the ideal implant size range and design and ultimately deliver natural-looking, proportionate results.

“When you lift the base of the right breast, you would see that everything shifts. This means that correcting the bottom of the pocket can improve the symmetry of the cleavage, projection, nipple position, and lateral bulge. After all, the breast has a three-dimensional geometry,” Dr. Smiley said in the video.


Prior to surgery, the celebrity plastic surgeon performed extensive breast exam with the use of multiple measuring devices such as laser and vernier caliper. The goal was to improve the symmetry of both breasts in terms of base width, submammary fold position, and volume distribution.


The surgery was performed under local anesthesia. The patient requested for it so she could immediately see the results and decide if these would meet her aesthetic goals, explained Dr. Smiley.


Aside from pocket repair, the patient also requested for slightly bigger implants (from 350 cc to 450 cc) filled with silicone gel, which is known to provide more natural feel and contour than saline-filled implants.


To avoid additional scar, Dr. Smiley used the previous incision site created at the border of the areola. To prevent puckering of the skin and promote the best scar possible, he released the previous scar tissue and closed the incision in several rows of absorbable sutures.


The skin, meanwhile, was not “picked up” by any suture to eliminate tension on its surface (it was held together by a surgical tape instead), which is the key to the best scar possible.

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Breast implants with fat transfer can be a powerful tool in breast reconstruction, as recently demonstrated by leading Beverly Hills plastic surgeon Dr. Tarick Smiley on his Snapchat account.


The patient shown in the video had breast implant removal two years ago due to capsular contracture, a complication in which the thin scar capsule surrounding the prosthesis becomes copious and hard, leading to pain and deformity. Some studies have linked implant contamination at the time of surgery and low-grade infection during the initial recovery to this problem.


breast implants with fat transfer

Dr. Smiley is able to deliver natural-looking results with meticulous and customized breast reconstruction surgery.


(Note: A thin scar capsule always forms around any implanted device. In fact, this is an auspicious natural process that prevents the breast implants from migrating or causing deformity. It only becomes problematic when the scar tissue becomes too thick and thus causes pain and unnatural contour.)


However, the patient’s previous corrective surgery (i.e., the capsular contracture was removed simultaneously with the implants) left her with marked asymmetry between her breasts, with the left side having its submammary fold riding higher and its tissue looking droopier than the other side.


To improve breast symmetry, shape, and projection, Dr. Smiley performed breast implants with fat transfer. The implants would provide additional volume and improve the overall contour, while fat transfer would give extra padding to make the left submammary fold match the other side.


During breast reconstruction surgery, Dr. Smiley created a small incision right at the border of the areola (pigmented part of skin) to propel the implants into their respective pocket. This incision technique generally leads to invisible scar provided that it heals well and lies precisely at the dark-light skin junction.


In the video, Dr. Smiley said the peri-areolar incision would suit the patient because it was also the incision site during her two previous surgeries (primary breast augmentation and breast implant removal due to capsular contracture). Hence, she has avoided additional scar.


After ensuring that both implants were positioned in their most natural, symmetric placement, Dr. Smiley released the lower pole of the left breast so it could take fat grafts. He then performed fat transfer with the use of blunt cannula that released “minute droplet of fat graft one at a time,” a technique known to result in high survival rate (70 percent is expected to last a lifetime).


With the concurrent fat transfer, Dr. Smiley said the once higher submammary fold of the left breast would match the other side.


He then closed the tissue in several rows with absorbable sutures, without “picking up the skin.” By eliminating most of the tension on skin, the incision is expected to heal well and its resulting scar can fade better into the background.

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Over the past several years, plastic surgeons have been using a biological mesh that serves as an internal bra to hold the breast shape and maintain its “perky” appearance long term. However, some experts say that due to its flat or two-dimensional shape, its contouring effects on a curved surface such as the breast could be limited.


To rectify the inherent problem of flat-surfaced biological mesh, one company has released a three-dimensional scaffold called GalaShape. Unlike its earlier design, this new breast lift technique has a curved surface with a rim that closely resembles a bra cup, which can be easily wrapped around the breast and fixed to the tissue.


new breast lift technique

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According to the company website, GalaShape is a biological mesh made of poly-4-hydroxybutyrate that triggers minimal inflammatory response. Thus, once positioned beneath the breast it triggers the body to create more collagen or scar tissue, which will hold the new contour of the breast.


It takes between 12-18 months before the biological mesh is completely absorbed by the body, leaving just the internal scar tissue to support the perky appearance of the breast long term.


The use of biological mesh, or any type of scaffolding or internal bra, is sometimes referred to as scarless breast lift technique because it only entails one incision that fades into the background—i.e., precisely at the border of the areola.


Despite the invisible scar, leading Los Angeles plastic surgeon Dr. Tarick Smiley says that scarless breast lift only works in patients with mild to moderate sag, which means that the areolar complex has not drooped way below the breast fold.


Should the areolar complex sag below the breast crease, Dr. Smiley says the traditional breast lift remains the best approach. This involves incisions around the areola, which then go down the midline and across the base of the breast, resulting in an inverted-T scar.


The traditional breast lift relies on soft tissue rearrangement to improve breast projection and shape. When done properly, most surgeons would agree that the use of additional materials like biological mesh is unnecessary.

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Fat transfer to breast is a good alternative to implants and may even serve as a viable option in breast reconstruction. This is now a well-established technique that allows the patients to improve their breast shape and size with the most natural material possible—their very own fat.


One of the early criticisms of fat transfer to breast or any part of the body was the low survival rate or temporary results. However, plastic surgeons have fine-tuned their techniques that nowadays most are able to achieve at least a 70 percent survival rate.


fat transfer to breast

The photo shows the difference between the breast injected with fat and the other side that is yet to receive the procedure.

Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says any fat volume that remains after six months is expected to be near permanent, with the breast expanding and shrinking depending on the patient’s weight.


Recently, he performed fat transfer to a patient who asked her implants to be removed, which could leave her breasts deflated—particularly its upper pole and mid cleavage—if no volume restoration procedure was performed simultaneously.


After removing the implants from their pocket, Dr. Smiley injected discrete layers of fat above the area where the prostheses were previously positioned. His goal was to inoculate the fats into highly vascularized tissue (i.e., they have more blood vessels), allowing the grafts to persist long term.


Aside from women having implant extraction, Dr. Smiley says that fat transfer is also a viable option for first-time breast augmentation patients who want to avoid implants, which carry risk of leak and displacement.


Fat transfer can also complement the results of implants; this is particularly true for women with notably poor cleavage or very little soft tissue to begin with that makes them prone to implant rippling and palpability.


While fat transfer to breast can deliver near permanent results, the celebrity plastic surgeon says it also comes with certain limitations, particularly in terms size. In general, the technique cannot double the breast size as over-filling the tissue can lead to low survival rate and other complications.


In most cases, fat transfer to breast involves around 200 cc of fat injection per side, although a 2011 study has shown that up to 300 cc can be injected provided that the breast has been pre-expanded weeks leading up to the surgery.


To expand the breasts and create more room for the fat grafts, the researchers required 25 patients to use Brava, which is a bra-like device that releases negative pressure. The technique allowed them to inject up to 300 cc of fat on average.

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Breast reconstruction with internal lift aims to correct the sagging appearance without the extensive use of incisions. Some doctors refer to it as scarless breast lift, although the term might be confusing because it still uses a short incision right at the border of the areola.


breast reconstruction with internal lift

Anytime the skin is injured the body creates a scar—its natural way of repairing tissue. Nonetheless, the scar from breast reconstruction with internal lift is made precisely at the areola’s border (light-dark skin junction) so it blends well into background.


Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a series of videos and images on Snapchat to demonstrate the results of breast reconstruction with internal lift.


But to enjoy the full benefits of breast reconstruction with internal lift, Dr. Smiley says meticulous patient selection is critical.


“A lot of people are asking who are good candidates for it. Usually, patients with no severe sagging will be able to do this,” he said in one of the videos.


The patient shown in the video had minimal sag. While her areola was positioned lower than ideal, it was still above the inframammary fold or breast crease.


Dr. Smiley positioned a small curved incision precisely at the lower border of the areola for optimal scar concealment. Then, he used a surgical mesh that would serve as an “internal bra” to support the new contour without the appearance of long scars, which is an issue with the traditional breast lift.


In traditional breast lift, the appearance of scar down at the midline (between the areola and the breast crease) is one of the main concerns of patients due to its more conspicuous placement. The peri-areolar and horizontal breast crease scars, meanwhile, are more concealed and so many patients would find them “acceptable.”


Aside from the use of surgical mesh, the success of breast reconstruction with internal lift also boils down to meticulous suturing technique. Dr. Smiley says all efforts are made to eliminate tension on the skin to promote healing and fading of scar.


He says that he uses buried tension suturing technique in which several rows of stitches are used to close the incision. The skin, meanwhile, is not “picked up” by any suture, with its edges simply allowed to “kiss” each other. This method promotes the best scar possible because it eliminates most if not all of the tension.

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Extreme tummy tuck and panniculectomy is a reconstructive plastic surgery and so it is typically covered by health insurance. In this procedure, the primary goal is to improve the patient’s quality of life by removing the gigantic apron-like skin, or medically referred to as pannus.


Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a series of videos on his Snapchat showing a patient whose pannus has almost reached her ankles, which of course results in a gamut of medical problems such as:


extreme tummy tuck

  • Skin breakdown and dimpling
  • Non-healing irritation
  • Difficulty moving since the gigantic hanging skin/flesh droops over her legs, almost reaching her ankles.
  • Stress on her heart and entire body
  • Swelling of her legs and feet due to the massive extra weight of the pannus


Dr. Smiley said the female patient will not just require panniculectomy or excision of the pannus. Aside from the large hanging flesh, she also has complete herniation of the abdomen, which happens when the fascia (a sheet of fibrous tissue) becomes weak that the internal organs protrude.


After conducting a comprehensive physical exam, Dr. Smiley said the patient will require an extensive abdominal reconstruction in which one of the goals is to create a new synthetic wall (with the use of mesh) to keep the abdominal contents inside.


Mesh acts as a scaffolding to prevent the abdominal organs from herniating (protruding). This material, which is either positioned under or over the weak or “defective” part, allows for tissue re-growth, meaning it incorporates into the surrounding tissue over time.


While it cannot be denied that the patient’s extreme tummy tuck and panniculectomy is medically and vitally warranted, Dr. Smiley said there is an increased risk because of the extent of the pannus.


Significant blood loss (due to the long blood supply of the pannus) and fluid imbalance/shift are to be expected, thus Dr. Smiley said he is “debating” and recommending “ICU admission” to further ensure patient safety.

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