Short Scar Mini Tummy Tuck Pre-Operative View

Short Scar Mini Tummy Tuck Post-Operative View

1) Exposure of the abdominal wall muscles.

2) Tightening of the abdominal wall muscles (rectus muscle plication).

3) Removal of the excess, redundant skin.

By definition, this procedure requires relocation of the umbilicus to a new position. The traditional tummy tuck is an excellent technique for the right candidate.

Certainly, for patients with a large amount of excess skin located below the belly button associated with laxity of the abdominal muscles (diastasis rectus), a traditional full tummy tuck makes sense. However, there is an ever growing subset of patients with a thin body habitus who develop weakness of the abdominal wall muscles following weight loss and/or pregnancy without having a significant amount of redundant skin and subcutaneous tissue.  These patients often complain to me that people note that they look pregnant; sometimes even years after their delivery. They may have a very small amount of loose skin just above the pubic area. However, these patients certainly do not have adequate redundant tissue to allow removal of all of the tissue that exists below the belly button. In order to reconcile this problem, the Mini-Tummy Tuck was invented. During this “mini-operation,”  the following sequence of events occur:

1) a shorter incision is made in the bikini line.

2) the tissue is elevated up to the level of the belly button.

3) the abdominal wall muscles are tightened below the belly button only.

4) a small amount of skin is removed just above the pubic area.

The problem with this operation is that by definition, the upper half of the abdominal wall muscles do not get tightened…at all. Commonly, these patients will have an awkward bulge of the upper abdomen months and years after the operation which is very difficult to repair. For this reason, I have found that a true “mini-tummy tuck” is rarely indicated. In order to provide excellent results in this subset of tummy tuck patients (very loose muscles, without much excess skin) I  modify the tummy tuck operation to design a procedure that combines the best aspects of both of these operations; namely, a shorter scar and a full muscle tightening. This operation is called the Short Scar Mini-Tummy Tuck^®. The key aspects of the Short Scar Mini-Tummy Tuck are:

1) A short bikini line incision that is slightly longer (2 cm on each side) than the traditional Los Angeles C-section scar.

2) Complete elevation of the skin and soft tissues off of the muscle.

3) Full muscle tightening (from the rib cage to the pubic area).

4) No scar around the belly button (or sometimes minimal scar).

During this operation, I use an endoscope to help facilitate this minimally invasive approach. Patients have loved the results for several reasons:

1) They get a flat abdomen as a result of complete muscle plication.

2) They are rid of the small amount of residual skin that was troublesome to them.

3) They almost never have a visible scar around the belly button.

4) The incision is much shorter than in a traditional tummy tuck, and located very low in the same location as a C-section incision.

ACM breast reconstruction

In recent years, the use of acellular dermal matrices (i.e. Alloderm) has significantly changed the manner in which breast reconstruction and breast revision surgery are performed.

Using acellular dermal matrices (ADMs) allows:

1) improved control over placement or creation of the inframammary fold

2) better control over breast contour

3) reduced absolute number of expander fills required

4) reduced time to complete expansion and eventual implant exchange.

5) enhanced soft tissue coverage, protecting implants under mastectomy flaps.

Use of ADMs has also been shown to improve the management of threatened breast implants, reduce the need for explantation, and possibly even reduce the incidence of capsular contracture. However, there are also known potential complications in this technique including seroma, hematoma, and both major and minor infection. A recent article reviewed the use of  acellular dermal matrices for this purpose*. The authors looked at previous studies reporting results of two-stage expander/implant reconstruction using an acellular dermal matrix sling  or those comparing ADM use to traditional full submuscular coverage.

alloderm breast reconstruction

What the authors found in this review is:

1) the efficacy and safety of procedures using acellular dermal matrix are equivalent to those using full submuscular coverage.

2) of all the known complications, the only complication significantly more frequent in the ADM use groups was an increased incidence of seroma.

3) infection rates were noted to be relatively equivalent between the two breast reconstruction techniques.

4) in cases of skin flap or incisional breakdown, incorporated ACM has the ability to protect the underlying breast implant.

5) use of ADM allows larger expander fill volumes during the initial operation, and fewer total fills needed to achieve full expansion.

*(Sbitany and Serletti, Acellular Dermis-Assisted Prosthetic Breast Reconstruction: A Systematic and Critical Review of Efficacy and Associated Morbidity, Plas Reconstr Surg, Vol 128, No 6, Dec 2011, p1162)

ROX Hernia Center re-launches hernialosangeles.com

Co-directors Dr. Kevin Brenner and Dr. Daniel Marcus are pleased to announce the launch of ROX Hernia Center and the re-launch of their Los Angeles Hernia Surgery website. The surgeons of the ROX Hernia Center are committed to providing unparalleled care in the surgical treatment of abdominal wall hernias. ROX Hernia Center provides a comprehensive, multi-disciplinary approach to hernia care. Our team combines advanced, minimally-invasive laparascopic techniques  with the latest plastic surgery procedures. Together, we are able to successfully manage surgical issues that either discipline, when working alone, wound not be able to accomplish. This includes:

1) Repairing umbilical hernias, para-esophageal hernias, & unilateral and bilateral inguinal (groin) hernias.

2) Repairing multiple hernia defects simultaneously.

3) Repairing huge ventral incisional hernias with abdominal reconstructive techniques (Components Separation).

4) Managing complications from previous hernia surgery that may require revision or reconstruction.

5) Performing hernia repair and cosmetic surgery (i.e. abdominoplasty, liposuction, & breast surgery) during the same operation.

ROX Hernia Center provides care in a state-of-the-art, safe, and fully accredited (AAAASF) outpatient surgical center. However, we recognize that some patients have certain medical conditions that must be managed in a inpatient hospital environment. Therefore, we all hold admitting and operating privileges at one or more local hospitals, including: Cedars-Sinai Medical Center, Marina Del Rey Hospital and Providence Tarzana Medical Center.

Abdominal Binder for Abdominoplasty Recovery

1) Abdominal Swelling: After your abdominal operation, you can expect to have post-operative swelling within the abdominal tissues. Swelling can be unpredictable and certainly varies from patient to patient. Post-operative swelling is more prominent during the first 24 to 48 hours after your operation. Swelling tends to subside gradually, and can take several weeks to go away completely.

2) Abdominal Binder: After your abdominal operation, you will be fitted with an abdominal binder (for all patients undergoing a tummy tuck).  Most liposuction patients will be fitted for a compression garment in addition to, or in place of, a binder. Undergoing liposuction as a stand alone procedure, or in addition to a tummy tuck may increase the amount of early post-operative swelling in the surgical area. However, doing so should not prolong your tummy tuck recovery period. Dr. Brenner generally recommends that binders and compression garments be worn for at least four weeks after your operation. Some patients may require using them for longer periods of time. Many patients like wearing the binder, as it offers a fair amount of core support during the healing period.

3) Abdominal Drains: Dr. Brenner will place surgical drains during your abdominoplasty (tummy tuck) procedure.  Surgical drains for tummy tucks will remain in place for about one to two weeks. Dr. Brenner most commonly will remove one drain on the fifth post-operative day. The second drain will usually be removed a few days later, but may remain in longer depending on the amount of fluid that is collecting within them. Drains are placed during tummy tucks in order to help close down the surgical space, remove the fluid the accumulates and prevent the development of a seroma.  You will be instructed on proper drain care by Dr. Brenner and his staff.

4) Scar Management: All abdominal surgery requires some type of incision; all incisions turn into scars. It is important to realize that scars take about one full year to completely heal, flatten and fade. Scars will appear to be their thickest and reddest at about two or three weeks after surgery. This is normal. From that point on, scars will continue to remodel, and refine for one full year. As the scar tissue heals, so too will their appearance. However, there are a few options for helping out the process. Topical silicone gel (Biocorneum) is available in Dr. Brenner’s office and can usually be applied starting two weeks after surgery. Silicone gel sheeting may also be ordered, especially for patients with longer incisions. Further, laser treatments are available through ROX Spa to help reduce thickening and color change that may occur in some scars.

*photos on this post are not actual patients of Dr. Brenner.

Post-Surgical Bras That Clip or Zip in Front Reduce Arm Raising

1) Wearing Bras After Breast Surgery: At the conclusion of your breast operation, Dr. Brenner will place a comfortable dressing of gauze and surgical bias wrap. This will stay on overnight and be removed on your first post-operative office visit. You will then be placed into either a surgical bra (fit to size) or a sports bra. We recommend that you shop for sports bras prior to your operation. You should plan to purchase bras that clip or zip in the front to facilitate putting on the bras without raising your arms. Further, you should get two bras in two different sizes; the first bra size should be big enough to account for the postoperative swelling that occurs over the first two weeks. The second bra should be one size smaller, so that it will fit comfortably once the immediate swelling goes down. Dr. Brenner recommends wearing either a surgical bra or sports bra for the first four to six weeks after surgery.

2) Breast Swelling: After your breast operation, you can expect to have post-operative swelling within the breast tissues. Swelling can be unpredictable and certainly varies from patient to patient. Post-operative swelling is more prominent during the first 24 to 48 hours after your operation. Swelling tends to subside gradually, and can take several weeks to go away completely.

3) Implant Settling: After breast augmentation (and in particular after sub-muscular placement), breast implants will tend to “ride high.” This is normal. Your breast implants will “drop into position” over about a four to five week period. Occasionally Dr. Brenner will place you into a breast band to help facilitate implant settling. Further, breast massage will further help encourage implant settling.

Post-Surgical Breast Band

4) Breast Massage: After your breast augmentation, you will be instructed on breast massage by Dr. Brenner and his staff.  Breast massage is usually started two weeks after breast augmentation surgery. This time frame may be different for patients who undergo breast lifting  or breast reconstruction with implants, so make sure you ask Dr. Brenner prior to starting.

5) Breast Drains: Occasionally Dr. Brenner will place surgical drains during breast reduction, breast revision, capsulectomy surgery or breast reconstruction. Drains are rarely placed during primary breast augmentation.  Surgical drains in breast surgery can stay in for one day or for several weeks. For instance, most breast reduction drains will be removed one to two days after surgery. However, revision or reconstruction cases (especially those that require acellular dermal matrixplacement) may require that drains stay in for a few weeks. You will be instructed on proper drain care by Dr. Brenner and his staff.

Breast Surgical Drain

6) Scar Management: All breast surgery requires some type of incision; all incisions turn into scars. It is important to realize that scars take about one full year to completely heal, flatten and fade. Scars will appear to be their thickest and reddest at about two or three weeks after surgery. This is normal. From that point on, scars will continue to remodel, and refine for one full year. As the scar tissue heals, so too will their appearance. However, there are a few options for helping out the process. Topical silicone gel (Biocorneum) is available in Dr. Brenner’s office and can usually be applied starting two weeks after surgery. Silicone gel sheeting may also be ordered, especially for patients with longer incisions. Further, laser treatments are available through ROX Spa to help reduce thickening and color change that may occur in some scars.

Vertical Breast Lift Incisions

7) Lifting and Reaching: It is important to remember that during your breast surgery recovery, lifting and reaching with your arms needs to be limited.  In general, Dr. Brenner restricts his patients from any heaving lifting for four to six weeks after breast implant surgery. This allows time for the breast tissues to heal around the implant, and reduces any potential complications.

*photos on this post are not actual patients of Dr. Brenner.

Rhinoplasty Recovery: Doyle Splints Help in Reducing Swelling

Rhinoplasty Recovery: Focus on Post-operative Swelling & Bruising:

Whether undergoing “closed rhinoplasty” or “open rhinoplasty”, swelling after rhinoplasty is normal. The reason that the nose swells after rhinoplasty has everything to do with the surgical dissection that occurs, resulting in local inflammation. If the nasal bones need to be surgically fractured during the surgery, you may expect slightly more swelling particularly on the cheeks and around the eyes. This is normal. Here are the steps that we take to help minimize post-operative swelling:

1) Dorsal Splint: At the conclusion of the rhinoplasty, a surgical splint will be placed across the nasal bridge. This typically stays on for one week and will help to minimize swelling.

2) Intranasal Splints: Swelling after rhinoplasty not only occurs under the skin, but also occurs inside the nasal airway. Dr. Brenner will place Doyle Intranasal Splints into the nasal airway at the completion of your rhinoplasty. This will serve to both stent open the airway, and also reduce intranasal swelling.

3) Nasal Taping: At the conclusion of the rhinoplasty, just prior to application of the the dorsal splint, Dr. Brenner will place surgical tapes across the nasal bridge and nasal tip. This tape will be taken off and replaced one week after your operation when your sutures are removed. After about two weeks of continuous nasal taping, you will be given instructions about how to “self-tape” and started on a regimen of nighttime taping.

Taping your nose after rhinoplasty will help reduce post-operative swelling.

4) Cold Compresses: Cold compresses do help reduce swelling during the initial 24 hours after your operation. However, cold compresses should only be placed on the cheeks and NEVER be applied directly onto your nose. If you place a compress onto your nose, you could potentially move the small cartilage grafts or bone segments.

5) Bromelain: Bromelain is an over the counter medication that is a derivative of a pineapple fruit extract. Bromelain has been shown to reduce surgical swelling and should be started the day prior to surgery.

6) Arnica Montana: Some patients will be bruised following rhinoplasty surgery. This is particularly true when the nasal bones are infractured in order to narrow the nasal width.

If you have done all of these things and think that your nose is still swollen, do not worry. This is normal.  As a rule of thumb, you can expect the swelling in your nose to persist for 3-6 months in the upper third of the nose, 6-9 months for the middle third of the nose, and 9-12 months for the lower third of the nose. After a rhinoplasty, it may take as long as one full year for the swelling to do down completely at the tip.

*photos on this post are not actual patients of Dr. Brenner.

The New Age of Surgical Education

Watch Dr. Brenner perform dual plane breast augmentation with silicone gel breast implants on a patient with a mild tuberous breast deformity from start to finish.

Dr. Brenner has joined Surgery Theater as a breast surgery expert, and has performed multiple breast operations as a part of The Masters Series. Surgery Theater was created by Dr. Brenner’s partner, oculoplastic surgeon Dr. Kami Parsa, with the specific goal of creating educational surgical media that can be shared with patients, physicians and medical students worldwide. Surgery Theater is revolutionizing the way in which we teach our patients, surgical colleagues and future physicians. Visit the Surgery Theater website to watch Dr. Brenner’s videos.

*photos on this post are not actual patients of Dr. Brenner.

breast reconstruction with alloderm

When it comes to breast reconstruction, there are many options for patients and their surgeons to consider. For instance, breast reconstruction technique will often depend on the type of mastectomy (or other breast procedure) that was performed in order to adequately remove the initial breast cancer. Some women choose to have no breast reconstruction at all. However, for those that do they must decide (in conjunction with their plastic surgeon) which options suits them best: tissue-expander/implant-based reoconstruction, pedicled latissimus dorsi muscle flap reconstruction, pedicled TRAM flap reconstruction, free flap reconstruction, etc. Further, in recent years there have been two growing trends that have changed the manner in which breast reconstruction occurs. The first increasing trend has been seen in performance of skin and nipple-sparing mastectomy procedures. This is particularly true for the growing number of prophylactic mastectomy for BRCA gene positive family members of cancer patients. The second increasing trend has been seen with respect to the use of acellular dermal matrices and other regenerative matrix products. These graft materials have become very helpful during breast reconstruction procedures (and breast revision surgery) since they allow coverage of the lower pole of the breast implant or tissue expander, where there is an anatomic deficiency of native muscle coverage. Further, when sewn in and placed properly, they help to reduce tension on the mastectomy flaps that can be created by the sheer weight and mass of the breast implant device.

A new study has reviewed one institutions experience with use of Acellular Dermal Matrix (i.e. Alloderm) in patients undergoing immediate single stage, direct to implant breast reconstruction(Colwell, et al. Plas Recon Surg, Vol 128, No 6, p1170, Dec 2011). The authors reviewed the charts of 211 patients who collectively underwent 331 direct to implant reconstruction procedures using Alloderm (one-stage reconstruction) following nipple-sparing  or skin-sparing mastectomies for cancer (216) or breast cancer prophylaxis (115). They reviewed the total number of complications which included 10 infections (3%),  five seromas (1.5%), four hematomas (1.2%) and 30 cases (9.1%) of skin necrosis (loss) which resulted in five implant losses (1.5%). They compared these statistics to 158 similar reconstruction for patients who underwent tissue expander reconstruction (two-stage reconstruction) without the use of Alloderm. They had similar complication rates which included: nine infections (5.7%), three seromas (1.9%), three hematomas (1.9%)  and 16 reconstructions (10.1%) with skin necrosis leading to 11 implant losses (7.0%). In their experience over the three year study period, the total number of complications did decrease in each subsequent year as total experience increased. Further, there was also noted to be a higher complication rate in both groups for patients that required external beam irradiation.

*photos on this post are not actual patients of Dr. Brenner.

No more taxes on Plastic Surgery

Governor Chris Christie signed into law a bill that will phase out (and eliminate) an eight year old state tax on cosmetic surgery in New Jersey.  The original law from 2004, imposed a gross receipts tax on many plastic surgery procedures including cosmetic surgery, cosmetic injections and fillers, dermabrasion, laser hair removal and hair transplantation. This repeal is a big win not only for plastic surgery patients in New Jersey, but also for plastic surgery patients nationwide.  The bill’s sponsors, Senator Joseph Kyrillos  and Senator Paul Sarlo, say the eight-year-old tax was not only a “burden” to patients, but to the medical offices that had to collect the tax and state agencies that enforced it.  Repealing this law has sent a message to lawmakers across the country that these types of taxes not only increase the financial burden on patients seeking elective plastic surgery care, but also that they are ultimately biased against women. The tax is scheduled to drop from 6 percent to 4 percent in the first quarter after the bill’s enactment, then to 2 percent from July 1, 2012 to July 1, 2013, then disappear after July 1, 2013. (Source: ASPS)

*photos on this post are not actual patients of Dr. Brenner.

Breast Implant Rupture

In a follow-up to new guidelines issued by the British government earlier this year, the French government recently advised about 30,000 women to remove PIP implants that may possibly be defective. PIP implants, manufactured by French company Poly Implants Protheses, are thought to contain a type of non-medical industrial silicone. Although the dangers of non-medical grade silicone are well known, the risk to patients in these cases is very low. For women who received these implants during reconstructive breast procedures for breast cancer, the government will pay for the cost to remove and replace the PIP style implants. However, for women who received PIP breast implants for cosmetic purposes (aesthetic breast augmentation), the cost of removing and replacing the implants will be incurred by the patients. A panel of French researchers, in combination with the National Cancer Institute, noted that there currently is no increased risk of cancer for women with PIP implants in place.  However, they note that PIP implants have an outer shell that has an increased risk of rupture and therefore are encouraging all women to have them removed. If you currently have PIP implants and are considering having them removed, contact the office of Dr. Brenner soon for a consultation.

*photos on this post are not actual patients of Dr. Brenner.

Breast Reduction for Juvenile Breast Hypertrophy

Juvenile Breast Hypertrophy is a relatively rare, benign (non-cancerous) disorder of the breast in which one or both of the breasts undergo a rapid, massive increase in size during adolescence. This condition is also commonly known by the names  Juvenile Gigantomastia, Juvenile Macromastia,  Virginal Macromastia, and Virginal Mammary Hypertrophy. Prepubertal Hypertrophy is usually bilateral; Virginal Hypertrophy (which develops after the onset of puberty), may be either unilateral or bilateral. Due to the rarity of this condition, there historically have been  no evidence-based guideline for the treatment of this condition. A recent study by Hoppe et al (Plast Reconstr Surg, Vol 127, No 6, p2224, June 2011) reviewed the various case reports in the past plastic surgery literature to help create a more cohesive set of guidelines for treatment of these patients. Here is a summary of what was found:

1) CAUSE: An exact cause has not been determined.  Hypersensitivity of the breast tissue to normal levels of circulating estrogen is one hypothesis for this “dysregulated breast enlargement.” Estrogen levels have been measured in patients with Juvenile Breast Hypertrophy and have not been significantly elevated compared with unaffected patients.

2) DIAGNOSIS: Juvenile Breast Hypertrophy is a diagnosis of exclusion. Other conditions such as Virginal Fibroadenoma, Fibrocystic Disease, Phyllodes Tumor and Endocrine Conditions may need to be excluded. Ultrasound or mammography may be indicated as part of the work up. Symptoms that occur are often similar to adults who present with macromastia; namely bra strap grooving, back pain and intertriginous rashes.

3) SURGICAL TREATMENT: In some cases, surgical breast reduction alone is sufficient treatment for Juvenile Breast Hypertrophy. However, this is not always adequate, as is evidenced by the high rate of recurrence. Subcutaneous mastectomy (with subsequent tissue expansion and implant placement) has also been used with success, with a decreased chance for recurrence. Unfortunately, subcutaneous mastectomy with complete removal of breast tissue often has an inferior aesthetic result compared with breast reduction. Some surgeons feel that surgery should be delayed until the end of puberty (when breast growth is complete) if possible. All breast tissue that is removed should be submitted to a pathologist and then tested for the PTEN gene mutation and distribution of estrogen and progesterone receptors.

4) MEDICAL MANAGEMENT: Dydrogesterone (a medication similar to progesterone) and Tamoxifen (a medication that modulates estrogen receptors) have been the most popular medications used to control Juvenile Breast Hypertrophy. Tamoxifen has been used successfully pre-operatively to arrest breast growth as well as post-operatively to inhibit further breast growth. Typical doses range from 10 to 40 mg per day and may continue for 4 months. Potential side effects of Tamoxifen are real and may include: endometrial hyperplasia (with increased risk for endometrial cancer), hot flashes, increased risk for venous blood clots, and changes to bone density.

Juvenile Breast Hypertrophy is a complex condition, and usually requires a coordinated and long term management effort between the patient, the plastic surgeon and the endocrinologist.

*photos on this post are not actual patients of Dr. Brenner.

Unsafe Plastic Surgery

As a board certified plastic surgeon, I see patients every week who are seeking either functional or cosmetic improvements for their body parts. This includes procedures such as breast augmentation, tummy tuck, liposuction, rhinoplasty, and fat injections (fat transfer). These are all excellent procedures that are very safe when performed by a well trained, board-certified plastic surgeon.  Unfortunately, there are many non-plastic surgeons out there who continue to try and perform plastic surgical procedures. The results can be disastrous and sometimes even fatal. There really is no substitute for safe plastic surgery.

Pictured to the left is Oneal Ron Morris, a male to female transgender patient who has been posing as a Florida plastic surgeon and administering toxic chemical injections (glue and Fix-a-Flat) to unsuspecting patients.

Florida authorities note that one victim who was looking to get a nightclub job sought treatment with Morris in order to achieve a curvier figure. This victim paid Morris $700 for the injections in 2010.  Practicing illegally, and within an un-sterile environment in her home, Morris allegedly used some type of tubing and inserted the toxic chemicals into her buttocks and abdominal soft tissues..

The victim, who has not been  identified due to HIPPA laws suffered very serious infections which resulted in permanent scarring around the injection sites. The victim required multiple operations in order to treat the infections and also required a prolonged period of home health nursing visits.

Don’t miss Dr. Brenner discussing this story and plastic surgery safety on Entertainment Tonight.

*photos on this post are not actual patients of Dr. Brenner.

Surgical Friends Foundation at UCLA

After a long day of operating yesterday, I woke up this morning to find the most amazing thank you letter in my email. As a member of The Surgical Friends Foundation, I not only have the opportunity to help patients who lack access to plastic surgical care, but I also have the chance to mentor and teach UCLA undergraduate students. Yesterday I had a wonderfully enthusiastic pre-medicine student observe one my skin cancer reconstruction cases. This student is a member of the Surgical Friends Foundation at UCLA club, and is clearly destined to become a plastic surgeon. Here is her letter:

November 16, 2011

Dear Dr. Brenner and Roxbury surgical team,

Once again, I take this opportunity to thank you guys for having me at the skin cancer reconstructive surgery on Wednesday, November 16, 2011 at 7:30AM. I am thankful to Surgical Friends Foundation at UCLA for providing undergraduate pre-med students with such opportunities, but more importantly, I’m thankful for Dr. Brenner and his surgical team for working in tandem with Surgical Friends Foundation and permitting students to monitor their hard work and surgical cases.

During the two hours I spent observing Dr. Brenner’s surgery, I learned many important topics that will come in handy in the future, either in medical school, the field, and/or in my future studies. Dr. Brenner talked me through his surgery and explained each and every step, as well as the reasons for each step. He began by marking the area he was reconstructing, the nose, and explained each parts of the nose: the dorsum, root, lateral sides tip, alae, nostril, and columella. His goal for this surgery was to reshape the alae that had previously been affected with basal carcinoma. Dr. Brenner’s method of teaching was clear, precise, and simple, which made it so much easier to remember later on.

Furthermore, Dr. Brenner’s chemistry with his staff was wonderful. The whole team connected like a family and helped each other throughout the surgery. A memorable moment was when Dr. Brenner literally called “time out” prior to starting the surgery to re-check with his anesthesiologist the patient’s prior history of diseases/conditions and any allergies the patient might have to certain products/medications used throughout the surgery. The entire surgery was videotaped and is available for streaming online on Dr. Brenner’s website. This tool is very helpful for students who were not able to observe the surgery and gives them the opportunity to watch the entire surgery on their own time.

In addition, Dr. Brenner showed me before and after pictures of the patient who was affected with basal carcinoma. Dr. Brenner explained that the dermatologist had already removed the tumor on the patient’s alae. It was now up to Dr. Brenner to fill the hole that was left from removing the tumor by excising tissue from the adjacent cheek, flipping it over, rotating it, and attaching it to the lateral side of the nose. This step had already been performed in the prior surgery; however, during this second surgery (which I observed), Dr. Brenner just had to reshape and contour the alae on the patient’s right side to match the healthy alae on the patient’s left side.

When I asked about the complications of this surgery, Dr. Brenner ensured me that there would be none and that the patient would be able to breathe normally, have a normal looking and functioning nose, and even be scar-free.

It was amazing to see the outcome of this surgery: a perfectly contoured nose with both alaes matching and the lack of a scar! The patient’s nose looked so good, real, and healthy that no one would have been able to tell she had every received reconstructive plastic surgery. If I had seen the patient for the first time after her surgery, I wouldn’t have had the slightest clue that she had skin cancer reconstructive surgery done. The patient is now tumor-free and has her great-looking, natural nose back. I’m so happy for the patient and this awe-inspiring, eye-opening experience.

All my thanks and appreciation goes to Dr.Brenner, nurse Ryan, surgical assistant Jose, and anesthesiologist Lisa for all of their hard work and kindness.
Wish you all the best and good luck with your future surgeries!

Sincerely yours,

Gilda Djabarzade
Surgical Friends Foundation at UCLA

*photos on this post are not actual patients of Dr. Brenner.

WEIGHT LOSS PATIENT BEFORE BREAST REDUCTION

WEIGHT LOSS PATIENT AFTER BREAST REDUCTION

Frequently, breast enlargement (macromastia) and morbid obesity are related entities, occurring simultaneously in some patients. There certainly are many patients who only have enlarged breasts without also being obese. In fact, in 2009 over 78,000 breast reduction procedures were performed in the United States.

The reasons to consider breast reduction include:

1) back pain

2) skin rashes under the breasts

3) pain from bra strap grooving

4) inability to exercise.

5) feelings of unattractiveness

Previous reports have shown that for many patients, breast reduction surgery can become a stimulus for further weight loss. However, many obese patients who do have severe breast enlargement are now considering both massive weight loss surgery (gastric bypass, lap band, etc.) and breast reduction. In these patients the question arises: Which operation should I have done first…breast reduction of gastric bypass?

Commonly the answer lies in the severity of symptoms related to breast enlargement. There is no question that breast reduction surgery provides almost instantaneous relief of most of the symptoms related to having severely enlarged breasts, namely back pain, shoulder pain and rashes. However, when plastic surgeons perform breast reduction surgery, we are aiming to provide the best shape possible for the new, smaller, reduced breast tissues. Rarely considered, is what will happen to the volume and shape of the breast tissues when breast reduction patients then go on to lose massive amounts of weight. Since breast tissue is comprised of significant amounts of fat, subsequent weight loss will certainly result in a further decrease in breast volume.

A recent study looked at just this issue (Plastic and Reconstructive Surgery, Breast Reduction and Massive Weight Loss, Vol 128, Number 3, p643, September 2011). The investigators noted that the majority of patients were glad that they underwent breast reduction surgery prior to undergoing surgical weight loss. However, most of the breast reduction patients reported a decrease in the satisfaction with the appearance of their breasts following massive weight loss. Some patients may have medical problems resulting from their enlarged breast that dictate breast reduction surgery be done early. However, if some morbidly obese patients with enlarged breasts can wait to have their breast reduction surgery until after their post-weight loss surgery weight loss, they may ultimately be more satisfied with their breast aesthetic.

*photos on this post are of an actual patient of Dr. Brenner.

Skin Anatomy

A recent study from a comprehensive Dutch national cancer registry showed that almost 30% of patients diagnosed with a first pathologically confirmed basal cell carcinoma will develop one or more additional primary basal cell carcinomas within 5 years. During 5 years of prospective follow-up in PALGA, the Dutch nationwide network and registry of histology and cytopathology, 29.2% of the patients (2483 patients were studied) were diagnosed with one or more additional primary basal cell carcinomas. More than one-third of patients who developed a second primary basal cell carcinoma within 5 years did so during the first 6 months after diagnosis of the first.

These results would seem to indicate that aggressive annual follow-up with full body examinations should continue for a minimum of 3 years after a patients first basal cell carcinoma diagnosis.
The cumulative risk during the first 6 months of follow-up was extraordinarily high at 11.2%, as compared with 13.9% through 1 year, 18.5% after 2 years, 22.1% at 3 years, 25.5% after 4 years, and 29.2% after 5 years. This translates into an incidence rate of 25,318 cases per 100,000 person-years during the first half-year after diagnosis of a first primary tumor. In an analysis of this study, men had an adjusted 30% increased risk of developing one or more subsequent basal cell skin cancers, and patients aged 65-79 years had an 81% greater risk than those under age 50.

How the results of this study translates to Los Angeles skin cancer patients remains to be seen. In the meantime, continue to wear your sunscreen and maintain close follow-up with your doctor. If you think you have a suspicious skin lesion, contact your dermatologist or Dr. Brenner.

*photos on this post are not actual patients of Dr. Brenner.

This patient previously underwent closed rhinoplasty several years prior to presenting to my office for corrective nasal surgery. Specifically, this patient’s complaints involved the following:

1) Unattractive appearance of the nasal tip: She did not like the visibility of her nasal tip cartilages through her skin.

2) Retraction of the nostril rims: She did not like the appearance and position of her nostrils and felt that others could see up her nose in photographs.

3) Inability to breath through her nose: She related a history of progressive nasal airway obstruction since her last operation. The patient is quite athletic, and noted an inability to move air through her nose all the time. This was particularly troublesome during exercise.

Operation in detail:

1) Open approach, revision rhinoplasty. The correction of the internal airway and complex nasal tip reconstruction required an open approach via a transcolumellar incision.

2) Correction of alar malposition & nasal tip reconstruction. The orientation of the nasal tip cartilages was incorrect and resulted in a very unnatural tip appearance.  Further, the cartilages had been asymmetrically trimmed  and over-reduced during the primary operation. Reconstruction required alar extension grafts made from septal cartilage. The native weakness of the left ala required placement of a small PDS rhinoplasty plate.

3) Correction of alar retraction. The nostril rims were lowered by placement of composite ear cartilage grafts on both sides.

4) Correction of tip position. The nasal tip lacked support and had an unnatural orientation. This was corrected with placement of an angled columellar strut between the medial crura (tip cartilages).

5) Correction of nasal airway obstruction. The patient had internal valve collapse as a result of her primary operation. The was corrected by reconstructing the middle vault with placement of spreader grafts.

6) Correction of dorsal inclination and irregularities. The patient’s bridge was lowered, and the both visible and palpable bony irregularity was removed.

7) Correction of nasal skin scarring. The patient had an incredibly thin skin envelope that was scarred down to the underlying bones. This was corrected by placing a lining graft along the nasal bridge of deep temporal fascia.

*photos on this post are of an  actual patient of Dr. Brenner.

Revision Rhinoplasty Before

Revision Rhinoplasty After

Revision Rhinoplasty Before

Revision Rhinoplasty After

Revision Rhinoplasty Before

Revision Rhinoplasty After

Revision Rhinoplasty Before

Revision Rhinoplasty After

Before Breast Implant Removal

After Breast Implant Removal

Before Breast Implant Removal

After Breast Implant Removal

Occasionally, I will have patients come to me and request breast implant removal without replacement.  Many women are hesitant to do so for several reasons. For one, they have all already gone through the cost and effort that was involved with their breast implant placement operation. However, foremost among these reasons is that they are afraid that their breasts will look bad after their breast implants are removed.

The patient pictured above underwent breast augmentation with saline implants along with a circumareolar breast lift (aka Benelli Mastopexy) by another surgeon several years prior to presenting to my office. Although she was happy with result from her primary operation, she simply just did not want her implants any longer. This patient underwent removal of her breast implants along with a partial anterior capsulectomy. She ended up with a good result. The only appreciable difference is a clear loss of  breast volume.

I usually recommend that when women decide to have their implants removed, that they also have the surrounding capsules removed as well (capsulectomy). Although this decision may differ amongst patients, if the capsules are left in place there is a distinct risk of developing a seroma in the old implant space.

*photos on this post are of an actual patient of Dr. Brenner.

Rox Center to Sponsor STOP CANCER RUN

Thank you to all of my patients, colleagues, family and friends who have already lent their support for the 2011 STOP CANCER walk. This Sunday, my colleagues will be joining me for the STOP CANCER walk at Woodley Park. ROX Center is an official sponsor of the event this year.  If you would like to support me, or even better join me in this most worthy charitable endeavor, please visit the respective links to learn more.

Information about STOP CANCER and the race:

In partnership with STOP CANCER, I.C.O.N./Cure for a Cause and Krav Maga Worldwide/The Marni Fund will be holding a a charity run. In 2011, we have increased the stakes and added a 10K run to the 5K Run/Walk from last year with proceeds benefiting cancer research at UCLA, USC and City of Hope Comprehensive Cancer Centers.

Join TEAM ROX for the STOP CANCER 5K/10K Run.

The collaboration of a rapidly growing international hair care products company, a unique and world-renowned self-defense organization, all in partnership with STOP CANCER, serves as an extraordinary demonstration of the success of fundraising partnerships to accomplish an enormously important mission: developing new therapeutics, diagnostic procedures and the ultimate goal … a cure for a disease that touches so many lives.

As part of STOP CANCER’s unique arrangement with the three NCI-designated Comprehensive Cancer Centers, each Research Award granted to scientists is matched by each of these institutions in the form of in-kind support, effectively doubling its value.

Your charitable donation can help amplify my hard work.

Thank you,
Kevin Brenner, MD, FACS

*photos on this post are not actual patients of Dr. Brenner.

Techniques in Revision Rhinoplasty

When it comes to rhinoplasty surgery, choosing the right surgeon is crucial.  After completing his residency in plastic surgery, Dr. Brenner devoted another year to specialized training in rhinoplasty surgery. This specialized training, along with an extensive interest in advancing the field of rhinoplasty surgery have opened the opportunity for Dr. Brenner to publish his knowledge on advanced techniques in rhinoplasty in a wide range of surgical journals and books. Most recently, Dr. Brenner wrote two new chapters, along with co-author Dr. Jay Calvert, in the surgical textbook Master Techniques in Rhinoplasty (Azizzadeh, Murphy, Johnson and Numa, editors, copyright 2011). The first chapter, Rib Grafting Simplified, reviews the techniques that Dr. Brenner uses to harvest rib cartilage for use during revision rhinoplasty. The second chapter, Saddle Nose Deformity, reviews Dr. Brenner’s approach to correcting a formidable problem in revision rhinoplasty patients; namely the saddle nose deformity.

*photos on this post are not actual patients of Dr. Brenner.