Augmentation in Ptotic and Densely Glandular Breasts: Prevention, Treatment, and Classification of Double-bubble Deformity Hamid Massiha, MD, FACS

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After breast augmentation, separation of breast tissue from the implant is common, especially in patients with well-formed preoperative breasts. This problem is enhanced to a marked deformity in cases of scar contracture with firm, fixed implants. This paper addresses this problem preoperatively and therapeutically in secondary correction of double-bubble and waterfall deformity. The author classifies and explains double-bubble deformity in patients in whom the implant is below the normal crease, with glandular breast tissue superior and anterior to the implant. In "waterfall" deformity (a term suggested by the author), the glandular breast tissue droops over the implant and is inferior and anterior to the implant. Treatment used consists of opening the breast tissue from its posterior surface using radial incisions to accommodate the implant. This allows the two structures-the breast tissue and the implant-to blend as one unit with satisfactory results. The technique is easy to perform and teach. Complications are similar to those of regular breast augmentation. Strangely, radial incisions have not increased complications, and there have been no cases of seroma or hematoma to date.

Massiha H. Augmentation in ptotic and densely glandular breasts: prevention, treatment, and classification of double-bubble deformity. Ann Plast Surg 2000;44:143-146

From Louisiana State University School of Medicine, New Orleans, LA.

Received Sep 3, 1999. Accepted for publication Sep 6, 1999.

Address correspondence to Dr Massiha, 3939 Houma Boulevard, Suite 216, Metairie, LA 70006.

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Breast augmentations are performed predominately in breasts that are originally flat or have very soft textured tissue. During the dissection and creation of the pocket, this tissue opens adequately to accommodate the round shape of the implant and, ultimately, the two become one unit. However, in cases of extremely dense breasts that are quite formed (usually with a small base), in cases of tubular breasts, and especially in ptotic breasts, this natural unity does not happen, resulting in a double-bubble deformity. This deformity occurs because the implant stays firmly in the original area in the chest wall while the breast tissue sags over it like a "waterfall" over a rock. Conversely, in the case of very firm breasts, the implant stays in place while the firm, highly glandular breasts stay up and do not conform to the implant. In the last several years, I have tried to remedy this problem by opening the breast tissue using radial cuts from the inside at the level of the pectoral fascia to accommodate the spherical shape of the implant. This procedure not only accommodates the implant but also widens the base of the breast, which helps it form better to the implant, enhancing the future shape of the breast.

Materials and Methods

Patient Selection Several categories of breast shapes may benefit from this technique:

1. Ptotic breasts with well-formed hanging breasts or even atrophic breasts
2. Highly formed, firm, and glandular breasts
3. Cone-shaped breasts with small bases
4. Mild to moderate cases of tubular breasts
5. Double-bubble (waterfall deformity) in class III to IV firm breasts

Technique

After the decision to use the radial cut incisions in the treatment of the aforementioned deformities, a submammary pocket is created under general endotracheal anesthesia. Radial cuts are made behind the breast tissue. The breast tissue is then spread in different directions (Fig 1). The openings created by this technique are made with relative uniformity, so that the expansion of the breast tissue will be symmetrical. Usually, three radial cuts are made, producing a six-prong star (Fig 2). Then, with blunt dissection or, if necessary, with the aid of a sound or other blunt instrument, these cuts are deepened as needed to accommodate the implant. Care should be taken to carry these cuts far enough peripherally to

open and expand the small base of the breast and expand the base of the postoperative breast (Fig 3). After the implant is placed and the opening is considered satisfactory, the operation is terminated by regular repair of the skin. If any residual deformity is present, this resistance is resolved by dissection at the proper site. The old crease of the breast is usually the most resistant part of this procedure. Cuts made vertically along the crease usually provide a satisfactory result. That is, if the crease is from medial to lateral, the cuts will be superior / inferior in direction. In some cases in which this technique is used but the correction is not adequate, the most resistant areas (usually the dense glandular tissue) are excised. This is especially necessary for advanced cases of tubular breasts and extremely glandular breasts.

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Fig 1. Posterior views showing radial incisions. (A) Before incisions are spread and widened. (B) After widening of incisions and expansion of the base.	Fig 2. Lateral view of the breasts with implants showing the location of the radial incisions and their relationship to the implant.
Classification of Double-bubble Deformities Type Implant Location Result I High or correct Breast tissue hangs over implant ("waterfall" over a rock) II Low or correct Breast tissue sits separately and superior
Fig 3. Lateral view showing how the radial incisions help to redistribute and change the center of gravity, resulting in a nice unity of breast tissue and the implant. (A) Implant without radial incision. (B) Implant with radial incision.	Fig 4. An example of a type I deformity with breast tissue sliding down over the implant.

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Results

I have tried this technique with a diverse group of patients of different age groups for a variety of deformities. With proper patient selection and technical management, generally satisfactory results have been achieved.

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Fig 5. (A) Preoperative view of a type II deformity. (B) Postoperative view. Correction with radial incision and reconstruction of a new submammary crease in a higher position.

Fig 6. (A) Preoperative view of a ptotic breast with a narrow base. (B) Postoperative view. Implantation with radial incisions and a lowering of the submammary crease.

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Discussion

Visual separation of the breast tissue from the implant is a notable deformity of the postaugmented breast. This deformity may even be seen in the case of regularly augmented breasts with initially good results. After the breasts become firm, the breast tissue hangs loosely over the firmly attached implant, creating a double-bubble, or as I have named it, a "waterfall deformity." This technique is especially useful in the treatment of this secondary breast deformity. After the implant is removed and the new implant is ready for insertion, radial cuts are made in the breast tissue so that the breasts can drape nicely over the implant. This can be likened to a cap being fitted properly to a person's head. In a secondary deformity of the breast, in which capsular contracture is encountered, special attention must be paid to the surrounding tissue, which will be firm and scarred, even after removal of the capsule. In general we have seen two kinds of double-bubble deformities (Table): The type I implant is at an anatomically proper level or is too high, but loose breast tissue hangs over the implant (Fig 4). The type II implant is either in its proper location or is too low, with breast tissue sitting above it and high (Fig 5A). The type II deformity is usually the result of trying to lower the submammary crease to lift the postimplanted breast without using the recommended radial cuts. In treatment of type II deformities, in addition to opening the breast tissue with radial cuts, reconstruction of a new submammary crease, usually to its original location, may be necessary (Fig 5B).

Conclusion

In summary, radial cuts at the undersurface of the breast with opening of the breast tissue have proved very useful in breast implantations in patients with ptotic breasts, breasts with a small base, mild to moderate cases of tubular breasts, or in primary cases of augmentation mammaplasty (Fig 6). This technique is also extremely useful in surgical treatment of secondary deformities of the postaugmented breasts.

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Presented at the Southern Society of Plastic and Reconstructive Surgeons, Boca Raton, Florida, June 5-9, 1999.

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Open Discussion

Samuel W. Parry, MD (New Orleans, LA): Hamid, in your abstract I believe there is one sentence (I don't see it right now) where I believe you said you sometimes remove some breast tissue? This seems counterintuitive to what you are trying to accomplish. Dr Massiha: Yes. In the severe tubular and cylindrical breast, removing the posterior part of the breast helps to open up the tissue and decreases the anteroposterior dimension of the breast in which it is coming straight out of the body. So by decreasing that length, the cylinder is shortened and is opened. By adding the radial cuts to it, you get the desired cone shape to the breast.

Sherry S. Collawn, MD (Birmingham, AL): In your patient with the double-bubble, how did you recreate your inframammary fold? Dr Massiha: For the lower pole, I just use the original incision and remove the implant. I had marked where I wanted the new fold in the sitting position beforehand. I put 2-0 nylon sutures in the same spot to get the line. Then I put the old implant in, inflate it, and sit the patient up to see if I like it. Then I go ahead and insert the new implant and finish it. If I don't like it, I may change my sutures. I'd like to make one comment about breasts that have a very strong submammary crease that needs to be lowered. You have to make small cuts in the fibrous band that is normally there. With finger pressure it cannot be done, but with small cuts it helps a lot to erase the old crease and create a new fold.

Short-Scar Face Lift With Extended SMAS Platysma Dissection and Lifting and Limited Skin Undermining Massiha H (Louisiana State Univ, Metairie) Plast Reconstr Surg 112:663-669, 2003

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Background

Short-scar rhytidectomy is a procedure with the capacity to meet the high standards of minimal scars and deformities without any noticeable signs of manipulation. In the short-scar cervicofacial rhytidoplasty (also known as the S-lift), extended dissections with maximal correction are combined with short scar and decreased signs of manipulation. Over the past 8 years this technique has been used with great success and a high level of patient satisfaction. Described are the S-lift and the devolution of this technique from its more complex form, which is reserved for patients with severe aging damage and redundant neck skin to a simpler technique that is adequate for most younger patients with moderate aging-related changes. Overview

The initial incisions in this procedure are limited incisions in the sideburn and periauricular areas, extending just around the fold of the ear lobule (Fig 1). Extensive undermining of the superficial musculoaponeurotic system (SMAS)/platysma is performed, and lifting of the face and neck is performed primarily at this level. Minimal skin undermining is performed, which eliminates the need for extended incisions for reduction of dog ears. The preservation of fibrous bands between the skin and the SMAS/platysma unit is an important factor in making an operation such as this one practical, and the preservation of these fibrous bands facilitates the use of short skin incisions (Fig 6). Dissection of large areas of skin and the separation of the skin from the underlying SMAS will require larger incisions.

Conclusions

The S-lift has been shown to be safe, speedy, less traumatic, and well tolerated among patients at high risk for complications, such as smokers. This procedure also reduced the risk of complications.

Back

FIGURE 1.-Preoperative (top) and postoperative (bottom) views of 48-year-old female patient. Postauricular scar is limited to crease. No submental procedure was performed. Patient underwent simultaneous blepharoplasty and endoscopic forehead treatment. (Courtesy of Massiha H: Short-scar face lift with extended SMAS platysma dissection and lifting and limited skin undermining. Plast Reconstr Surg 112:663669,2003.)

FIGURE 2.-Area of initial skin excision (line A), extent of skin dissection (line B), and extent of SMAS/ platysma dissection (line C). (Courtesy of Massiha H: Short-scar face lift with extended SMAS platysma dissection and lifting and limited skin undermining. Plast Reconstr Surg 112:663-669, 2003.)

Reconstruction of the Submammary Crease for Correction of Postoperative Deformities in Aesthetic and Reconstructive Breast Surgery Hamid Massiha, MD, FACS

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This article discusses a method of reconstruction of breast crease for correction of postoperative deformities. These deformities are usually the result of implant insertion for the purpose of breast enlargement or reconstruction. The operation is performed by creating a new crease in the appropriate site by suturing capsular and soft tissue structures from the anterior to the posterior wall of the pocket to eliminate excess space at the lower, medial, or lateral breast. This article will detail crease reconstruction through an internal approach. Patient selection, technique, and results are discussed.

Massiha H. Reconstruction of the submammary crease for correction of postoperative deformities in aesthetic and reconstructive breast surgery. Ann Plast Surg 2001;46:275-278

From the Louisiana State University Medical Center, New Orleans, LA. Received Sep 19, 2000, and in revised form Oct 11, 2000.

Accepted for publication Oct 11, 2000.

Address correspondence to Dr Massiha, 3939 Houma Boulevard, Suite 216, Metairie, LA 70006.

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The submammary crease is a very important landmark with regard to aesthetics of the female breast. In asymmetry of the breast after augmentation mammaplasty, it may be necessary to reconstruct a new crease to correct asymmetry and any resulting deformity. Also, in reconstructive breast surgery, having a reliable means of reconstructing a crease anywhere that is appropriate would be a great asset in the surgeon's armamentarium. For example, an expander can be used to expand tissues of the lower chest somewhat below the ideal submammary crease. At the time of placement of a permanent implant, the submammary crease can be reconstructed in the desired location.

Technically, the desired site of the crease is marked preoperatively with the patient in a sitting position (Figs 1A, B). During surgery, after removal of the implant or the expander, the crease is created by suturing the anterior capsular tissue to the posterior part of the capsule at the anterior chest wall. Nonabsorbable sutures are used after implant insertion. The patient then is placed in a semisitting position. If correction is not adequate, sutures are placed in a more proper location. I have used this technique in the last 20 years with good, long-lasting results. The submammary crease, and its continuation laterally and medially, is the most important determining factor in beauty and contour of the female breast. Irregularities in this area of anatomy are detected easily by simple observation. Asymmetry after breast augmentation is frequent (Fig 1C), not only in the submammary crease, but frequently at the lateral boundaries of the mammary pocket and less frequently at the medial aspect. At times we have seen cases that have transgressed the midline, creating a severe deformity. In any and all of these kinds of deformities, this method of correction works well (Fig 1D).

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Fig 1. (A) Preoperative marking in a patient with a palpable implant that is located too medially. (B) Markings of the area of capsular contracture and adhesion to be opened. Notice the double-bubble deformity medially and inferiorly as well. (C) Preoperative view of the left breast deformity with media] displacement and lateral contracture. (D) Postoperative view with correction of the deformity. (The patient did not desire to undergo right crease elevation.)

Fig 2. (A) Lateral view showing the lower breast with a low submammary crease. (B) Desired correction. (C) The correction is made by lifting the submammary crease and decreasing the distance from the nipple to the crease.	Fig 3. (A-C) The sutures at the top of the new crease are all internal.

Fig 4. (A, B) Shown is how the capsule and surrounding soft tissue at the lower parts of the pocket are sutured to the chest wall. The capsule is incised superficially to create a better healing surface before suturing.

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Patients and Methods

The patient is marked carefully in a sitting position (see Figs 1A, B). The patient is then anesthetized (I use general anesthesia in my practice), and proper prepping and draping are completed. Entry is made into the breast capsule area using previous incisions. The implant is removed and the capsule is evaluated. The capsule is then incised and the pocket is expanded. The capsule is then deeply sutured to the chest wall at the appropriate site, preferably with 2-0 Prolene sutures. As much subscapular soft tissue is incorporated as possible. Incising the capsule along the line of repair may be helpful. Suture placement is guided by preoperative markings. Although interrupted sutures can be used, I find running sutures easier to place and fully functional After completion of the repair, the old implant is introduced to the newly formed pocket, If the shape is satisfactory and the new crease is in a desirable location, the old implant is replaced with a new one, and the wound is closed (Figs 2-4). Whether the implant is too high [Fig 5A] or otherwise improperly situated, the capsule may be revised into a more satisfactory shape with this technique.

In the case of an implant being too high, simply dissecting the inframammary crease area is not enough. Because the skin is usually tight in the inferior chest wall area, it does not have enough laxity to accept and maintain a filled implant. An excessively large pocket at the inframammary crease (or lateral or medial crease, as needed) must be created, and the expander placed there (see Fig 5B). After a few weeks and after the expander is expanded adequately, the patient is taken to the operating room, the expander is removed, a new submammary or lateral crease is created, and a permanent implant is placed (see Fig 5C).

Results

I have used this technique in a diverse group of deformities in 200 cases ranging from postaugmentation deformities to severe deformities (Fig 6A) resulting from breast reconstruction with implants. This is an effective and reliable method. In the past 20 years that I have used it, no failures have been observed. With careful attention to detail, this simple method is suitable for all sorts of breast deformities that result from capsular malformations (see Figs 5 and 6).

Discussion

This paper expands on a previous article on postimplantation breast deformity.' In the correction of certain kinds of postaugmentation double bubble deformities, reconstruction of a new submammary crease is essential.' In addition, this technique has proved to be very simple and useful in correcting a variety of deformities that result from the breast reconstruction and augmentation. Whether these deformities are the result of the patient's own soft-tissue defect is uncertain, though it is readily observed that some people have more elastic skin than others, even in youth. Regardless, this technique is effective in ameliorating the problem. During the correction of these deformities, careful marking is essential. After the crease is reconstructed it will not "give" in terms of stretch nor will it self-correct. Thus, no overcorrection is needed and should be avoided.

This method is also needed in some cases of mastopexy in breasts with previously inserted implants. In these patients, if the capsule is not modified from the inside, mastopexy alone will not render excellent results. For example, if the implant is already too medial, mastopexy alone is not capable of bringing the implant to a more normal central location.

I prefer submammary and periareolar incisions. Although the operation may be performed through a 5 to 6-cm submammary incision, exposure through a periareolar incision is superior, especially for medial and lateral suturing. In patients in whom the implant is too high, conventional opening of inferolateral space is prone to failure or overcorrection. The current technique opens up a larger space and creates a new crease in the desired location. Also, if needed, inframammary skin from the area can be mobilized to increase the nipple-to-crease distance.

In severe high-implant deformities after breast reconstruction, use of an expander is necessary, especially in the inframammary area. The new crease is reconstructed at the second stage at the time of implant replacement. Adding inframammary skin to the lower portion of the breast improves roundness at the same time. Sometimes sutures placed into the capsular tissue may cause dimpling. However, in the inframammary area, they are rarely visible and usually improve with time. It is possible that incising the capsule at the proposed suture site may enhance breast configuration, although this has been difficult to confirm.

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Fig 5. (A) Preoperative view of the deformity after multiple attempts at breast reconstruction on the right side. (B) The same patient after removal of her implant and expansion to an extremely low level. (C) Postoperative view with the new crease and lower breast, with enough skin pulled up for the breast to stay relaxed and full.

Fig 6. (A) A patient after multiple unsuccessful attempts at breast reconstruction. (B) Crease reconstruction.

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Conclusion

This technique of reconstructing submammary and perimammary creases for correction of deformities after breast augmentation and reconstruction is a very simple and useful. No additional external incisions are needed. Results are permanent, although further stretching of the breast tissue will continue as years go by. This technique has worked well in my hands. It is easy to do and it is easy to teach.

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Presented at the Southeastern Society of Plastic and Reconstructive Surgeons, Bermuda, June 4-8, 2000.

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Reference

1 Massiha H. Augmentation in ptotic and densely glandular breast: prevention, treatment, and classification of doublebubble deformity. Ann Plast Surg 2000;44(2):143-146.

Open Discussion

Felmont F. Eaves, MD (Charlotte, NC): Concerning inframammary fold control, some of the newer suture materials will give tensile strength for up to a year and a half. Do you think there is any advantage in a patient like this in fixing the fold? And how long do you think you actually have to be able to control that level postoperatively? Is permanent suture material really part of that? Dr Massiha: I have not seen one of these from the inside after surgery. But from my experience on redo facelifts, when I identify the 3-0 Prolene sutures I have previously placed into the SMAS and remove them, nothing falls back. Applying that knowledge to this situation, I would imagine that something that lasts 6 months or more would be enough. Also, please be certain that the knots don't face toward the implant or they may erode the implant. Be certain they are buried.

What will the final results be?Most people who undergo eyelid surgery are thoroughly satisfied at the refreshed, alert appearance. Many have said they've experienced a new confidence in business and social situations they had never known before. The results of cosmetic eyelid surgery are long lasting. Remember, however, that your face will continue to age. During the post-operative follow-up visit, Dr. Massiha can evaluate your progress and advise you on the best way to maintain your results.

Allison Muniz

Deep cleansing facial and skin consultation There is no "one fits all" guide for skin care. Skin care can vary greatly from one individual to another depending on climate, lifestyle, skin type, diet and personal preference. However, you can begin on the road to healthy, vibrant skin today with a relaxing and therapeutic Deep Cleansing Treatment (DCT). The entire simple procedure, which is customized for your individual skin needs, is performed in the Massiha Surgical Center by Dr. Massiha. Here are the eight basic steps: 1. Consultation -The basic DCT begins with a consultation where you will be asked questions about your medical history, current medications, allergies to medications, skin care produces you are using and any problems you may have had with your skin and treatment problems you may have. It is helpful to bring any skin care products you may be using. All this information will be used for future reference. 2. Preparation - Depending on your individual needs and skin type, a proper treatment course will be determined. You will be asked to wear a gown and will be treated to soothing, relaxing music. 3. Cleansing - Your face will be cleansed with a cleanser appropriate for your skin. This will also help relax the facial muscles, increase blood circulation while softening the skin and opening the pore to aid in the removal of dead surface cells, and extraction of any whiteheads, blackheads and pimples. 4. Massage -Throughout the entire DCT, you will experience a custom designed facial massage which aids in relaxation and increased blood circulation. 5. Exfoliation - The gently scrubbing custom designed exfoliation process, removes dead cells from the surface of your skin. 6. Extractions - At this point the aesthetician will place a magnifying lamp above your face. If you need extractions of acne, blackheads, whiteheads, etc. it will be done at this time. 7. Mask - The aesthetician will use a mask designed for your skin type while massaging your hands and arms with lotion. Warm steam towels will be used to remove the mask. 8. Alphahydroxy and Protection products - After the mask has been removed, if needed, an alphahyroxy product may be applied. Lastly, Cffectives, our topical vitamin C will be applied. At the close of the facial, products will be recommended for your skin. It is important to remember that skin care begins at home. You should use products that stimulate and correct your skin in order to slow down the aging process and correct problems that occur from early years of sun damage. Although there is a charge for the facial, there is no charge for skin consultation. Simply call the office and make an appointment.

DR. MASSIHA: "Breast augmentation surgery (also called augmentation mammaplasty) can usually bring the desired results that leave a woman not only more physically attractive, but also more confident and self assured about herself"

If you are considering breast augmentation, please feel free to call. Dr. Massiha will be happy to answer any questions you may have.

The Obagi Blue Peel Tones, Firms Skin

We are all `blue' now and then. It's part of the human condition. But did you know there's a `blue' that can change your life for the better? That blue is the revolutionary new Blue Peel skin treatment from Obagi that can give you healthier skin for a lifetime. The Obagi Blue Peel goes far beyond conventional alpha-hydroxy peels and other superficial procedures because it is a treatment 'tailor-made' for your own particular skin needs. The Blue Peel is simple, quick (about 20 minutes , in most cases, does not require sedation and can give a healthier, more attractive look to neck, chest, hands, back, arms and legs. What exactly is Obagi Blue Peel? The Obagi Blue Peel is an in-office procedure designed to significantly improve the appearance and health of your skin. It uses a low concentration of the chemical trichloroacetic acid (TCA) mixed with a special blue base for slow penetration. The Blue Peel allows Allison Muniz, the aesthetician of Massiha Plastic Surgery and Skin Care to monitor the appropriate depth to effectively remove the thin surface layers of aged and damaged skin from the face or other parts of the body. These dead skin cells are replaced by healthier ones, allowing the skin's own clarity and tightness to resurface into a new and vital appearance. Will I feel pain?The patient will usually experience a mild burning, tingling sensation trhat lasts only a minute or two (Allison can use a small fan to minimize the sensation. Following the procedure, a bluish tint will remain on the skin which will wash off within 12- to 24 hours. The skin will then swell slightly and will begin to peel within two to three days. This peeling will continue and should be completely healed in an average of seven to 10 days. What results can I expect?When the skin has completely finished peeling, the result will show through dramatically as you look into the mirror and see a beautifully improved complexion and the look of vitality you never knew possible. The skin will continue to improve over the next month to six weeks and your confidence and joy will grow, as your skin becomes firmer, clearer, smoother, healthier and more youthful looking. More than one Blue Peel? Allison will thoroughly discuss with you the number of Blue Peels that are necessary to achieve the desired results. In most cases, one to three Blue Peels can achieve dramatic improvements in most skin problems. Blue Peels can be performed in six to eight week intervals until those desired results are realized. Will the results last? That new healthy glow and youthful appearance of your skin is an ongoing process. The Obagi Nu-Derm restoration system is an at home program designed to promote long-term overall skin health and works in perfect conjunction with the Blue Peel.

I am deeply humbled...

Someone once asked me, if I were proud of the work I did. Naturally, I said that indeed I was. But the more I thought about it, the more I realized there was one word more appropriate to describe how I feel about the work I do: humbled. I am deeply humbled in knowing that I have been blessed with the honor of assisting God in his work of helping to create not just outer beauty, but the inner peace, joy and confidence that one of my procedures may bring to a patient. I remember the words of our late President, John F. Kennedy at his 1961 inaugural address urging us to go forth with our life's work but: "...knowing that here on earth, God's work must truly be our own..." and I have thought of how apt those words are for all of our undertakings. Recently I was blessed with the birth of a daughter - Maia Massiha, In addition, I was promoted to the position of clinical professor of plastic surgery at the LSU School of Medicine. Proud? Certainly. Any new father and professional would be.But again, I am humbled in the thought of being given the responsibility of nurturing new life in this world and of being thought of so highly by my colleagues. I have come to truly believe that humbleness expands our humanity. It opens an entire universe to us, one that brings us into total contact with those people we serve. I have found this to be true in the relationships I have with my patients. I find myself looking at an abdominoplasty or facelift or breast augmentation and seeing not just a patient with a cosmetic problem but a person of seeking a new level of confidence and joy in their inner beings. When I realize this patient has placed his or her complete trust in me, I am deeply humbled. And as such, I find myself no longer on only a physical or artistic level. I truly find myself at one with my patient, knowing their innermost desires as intimately as they do and giving them my best effort to help them fulfill those desires. To all of you who have humbled me by the trust you place in me, I say, 'Thank you.' - Dr. Hamid Massiha

Massiha Plastic Surgery & Skin Care Center What better gift to give than a gift certificate for care for the skin? A gift certificate to pamper the skin is a tribute of love to that special person. Listed below are a few of the skin care techniques designed for long lasting beauty.

For an appointment or information on Skin Care Gift Certificates, call 455-9441 Office (504) 455-9441 • Fax (504) 885-5063 • www.art-plasticsurgery.com

So often when a patient goes to a plastic surgeon, he or she envisions a "new beauty" that is merely skin deep: a few less wrinkles, a more aesthetically pleasing nose, a tighter tummy. With the advances made in the art and science of plastic and reconstructive surgery over just the past few years, achieving these changes are certainly more possible than ever before to the skilled, experienced plastic and reconstructive surgeon. What I have always strived to give to my patients, however, is what we in Louisiana call "Lagniappe", that something extra. That something extra to me always means using my god-given talents and experiences to reconstruct not merely the flesh, but a rejuvenated inner spirit that comes with a more pleasing outer beauty. That goal is always appropriate, but perhaps never more so than at this time of year as we approach and make ready for the holiday season. It matters not whether one is Christian, Muslim, Hindu, Jewish ... we are all bound by the same spirit that leads us to seek peace, inner joy, accomplishment, generosity and concern for our brothers and sisters of many colors and many backgrounds, whether they live next door or on some faraway continent; in a mansion or a mud hut. Our kindnesses move outward like ripples on a pond to reach others as we attempt to build that theoretical matrix of one strong hand holding on to a weak hand, thus lifting up rather than tearing down. A more beautiful outer person is the first step toward a more beautiful inner person. When a person feels more confident about him or herself because of that outer beauty, it is then that they ripple out over the pond of the world to reach out to share that new found beauty and confidence with others. Bringing that to fruition has been the driving force in my life throughout my career. And so, as each of us runs about during these hectic days, preparing for the holiday season, the visits from family and friends, the joyous celebration, I would like to thank each of you, my patients and friends, for influencing my life by your faith in me. I wish each of you a joyous holiday season. - Dr. Hamid Massiha

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Your toughest wrinkles before after It took forty years to get them. And ten minutes to do something about them.

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DR. MASSIHA: "Some have called Botox miraculous."

Botox called "Miraculous"Botulinum toxin Botox'") has been hailed as nothing less than a "revolutionary" new treatment for the long-lasting elimination of facial wrinkles.

Recently approved for cosmetic application by the Food and Drug Administration, Botox has been used by ophthalmologists to treat nervous twitching of the eyelid since the early 1990's.

In its application as a facial cosmetic therapy, Botox has proven enormously successful in removing vertical "frown lines" between the eyes and horizontal "crow's feet" at the side of the eyes.

"Miraculous" "Some of my patients have called Botox miraculous'," Dr. Massiha says. "I can easily see how many of them feel that way. It's simple, quick and enormously effective. Results are immediate and usually last three to six months. Because Botox is used in extremely small amounts and because its effects are localized and do not spread to other parts of the body, the patient can come back for follow up therapy after that three to six month period."

And, Dr. Massiha says, unlike surgically invasive procedures that require a recuperative period patients who are administered Botox can return to full activity immediately.

"And," Dr. Massiha says, "Botox can be used by just about everybody except women who are pregnant or breastfeeding or anybody who has a neurologic disease."

Other applications of Botox In addition, research in Botox therapy is proving highly effective in treating other ailments in other parts of the body.

Scientific research has shown that approximately 80% of migraine and tension headaches sufferers have found relief from Botox injections. Similar relief has been found by patients suffering from back and neck pain.

Dr. Massiha explains: "Muscles in a natural state of relaxation produce no pain or deformity. This is true throughout the body. The brain controls the state of muscles causing them to tighten or relax. Often, where there is brain disease or injury, it cannot perform this function and there is involuntary muscle tightness which often causes pain. Botox injections have been shown highly effective as a therapy to involuntary muscle tightness.

"The same, of course, is true of the areas of the face where years of frowning and stress and the natural effects of aging form the common creases we see on cheeks, forehead and around he eyes. Over the years, these creases and valleys that we call wrinkles are formed by the frequent almost constant tightening of the muscles. Because Botox is a relaxant it does just that: relaxes the tightenened muscles that cause the wrinkles."

Dr. Massiha would be happy to discuss Botox therapy as a means of eliminating facial wrinkles. Simply give him a call to discuss your particular needs and desires.

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Breast surgery can offer more than you think

Often, breast surgery is thought of in only one dimension: enlargement. In fact, breast surgery in the 21st Century can mean so much more from correcting many abnormalities of the breast in women including breast reduction, breast reshaping and reconstruction following mastectomy or lumpectomy or dissatisfaction with earlier breast surgery. Dr. Massiha is a world renowned pioneer in the field of "small scar" breast surgery and has performed literally thousands of surgical breast procedures that have had enormous positive impacts on the lives of his patients. As always, the first step is a cost-free consultation with Dr. Massiha who will go over your individual needs and expectations and explain all facets of the surgery from risks (all surgery involves some risk, pre- and post-operative procedures, what you can expect, recuperative time, insurance coverage, available financing, and answers to all questions you may have.

DR. MASSIHA: "We've made great strides..."

Enormous strides "Over the years, the art and science of breast surgery has made great strides," Dr. Massiha says. "One of the things we've learned is that when a woman is dissatisfied with her breasts, whether that be size or shape, it can have an enormous negative physical and psychological impact on her life. I have had many women come to me saying she felt `less like a woman' because of a mastectomy or because a previous augmentation or reconstructive procedure by another surgeon fell far short of her expectations. Thankfully, because of my experience in this area I was able to help every one of them to regain what they once had."

A brief look at various procedures: Breast size enhancement: Many women choose to have their breasts enlarged in order to satisfy their desire for a fuller bustline. Their breasts may not have developed to a size that meets their expectations, or one breast may be noticeably smaller than the other. Often, after weight loss, childbirth or as a result of aging, the breasts lose volume and their shape changes. Breast augmentation can enhance breast size and shape, and give a woman the more proportional figure that she always wanted. Breast reconstruction can be the key to a new, fuller lifestyle. Dr. Massiha's reconstructive procedures have often produced results far beyond the normal expectations of his patients. In reconstruction, breast tissue lost during mastectomy or lumpectomy is replaced, thereby restoring the breast shape. The goal is to match as closely as possible the remaining natural breast by creating a breast size and shape with an implant which is placed beneath the skin and muscle that covers the chest or by using muscle from another part of the patient's body such as lower abdomen tissue to build new breasts. A combination of these techniques is used in some women. Not surprisingly, about half of all women who have undergone mastectomy or lumpectomy choose to have breast reconstruction surgery. Nipple reconstruction is also possible, generally as a separate operation once the reconstructed breast has settled into its final shape.

Breast reduction is designed for women with very large breasts they may have caused them medical or psychological problems.Women with very large breasts may experience a variety of medical problems. Common complaints are back and neck pain, breathing problems and irritation of the skin under the breasts. Breast reduction will provide a cure for some of these symptoms by reducing the size of large breasts. Women with very large breasts may also be extremely self conscious and reducing the size of the breasts will help them in this aspect. The procedure removes breast tissue, and skin from the breasts, making them smaller and firmer. Breast reduction is usually done as an inpatient procedure in a hospital. The surgery usually takes two to four hours. A hospital stay of two to three days is not unusual. Breast reduction surgery is usually performed under general anesthesia. Some women can return to a normal lifestyle in one to two weeks and others may take as long as two to three weeks depending on the nature of their job or responsibilities. Most of the patients are satisfied with the results of their surgery and most of them get rid of the symptoms associated with very large breasts. "With all the advances made in the field of breast surgery over just the past few years, there is hardly any need for any woman to suffer physically or psychologically any longer," Dr. Massiha says.

To set an appointment for a consultation about a breast surgical procedure, call Dr. Massiha's office at 455-9441.

Vitamins play important role in surgery

Facing surgery and wondering what you should do to prepare for it? One of the best preparations anybody who is facing surgery can make is the "Surgery Vitamin Supplement Program" offered by the Massiha Plastic Surgery & Skin Care Center.

But then, there is Vitamin A, Vitamin B-complex, Vitamin C, Niacin, Iron, synthetic vitamins, all natural vitamins ... Matching the right vitamin with the need along with dosage, brand names, cost ... What is a chelated mineral, anyway?

It can all be terribly confusing. And, let's face it, you're a busy person. You may know the important role vitamins play in a healthy life, but you just don't have time to inch you way through the maddening maze of options that are out there.

Well, you can stop pulling out your hair as you try to assess your own unique vitamin needs as you face surgery.

Massiha Plastic Surgery & Skin Care Center offers a complete line of VitaMedica vitamins and minerals to meet your needs.

Vitamins are vital "Often we don't connect vitamins and surgery" Dr. Massiha says. "We may think we have the surgery and then just let our bodies recuperate. But vitamin supplements prior to surgery play a vital role in just how our bodies recuperate. But a supplement such as Arnica Montana is designed to reduce discomfort, bruising and swelling following surgery. Bromelain with Quercetin is a supplement that has excellent anti-inflammatory properties. Vitamins A and C are very strong antioxidants that must be present for healing and proper immune system function and infection control.

"There are other considerations prior to any surgery such as alcohol consumption and smoking," Dr. Massiha says. "Overall health and intake of certain over the counter medications such as aspirin that is an anti-coagulant (blood thinner and can promote bleeding during surgery, must be considered. So must things such as drinking the proper amount of water and even proper relaxation techniques and support of family and friends. All of these things may seem unconnected to surgery or minor, but in fact, they all play a part in the success of the procedure and the length of recuperative time. We don't just schedule surgery then perform that surgery. We look at everything that can or will insure success and fast, proper healing."

Dr. Massiha works in conjunction with the highly successful VitaMedica Surgery Program and will be happy to discuss every phase - before, during and after - of your surgical procedure.

Someone once asked me, if I were proud of the work I did.

Naturally, I said that indeed I was. But the more I thought about it, the more I realized there was one word more appropriate to describe how I feel about the work I do: humbled. I am deeply humbled in knowing that I have been blessed with the honor of assisting God in his work of helping to create not just outer beauty, but the inner peace, joy and confidence that one of my procedures may bring to a patient. I remember the words of our late President, John F. Kennedy at his 1961 inaugural address urging us to go forth with our life’s work but: “…knowing that here on earth, God’s work must truly be our own…” and I have thought of how apt those words are for all of our undertakings. Recently I was blessed with the birth of a daughter – Maia Massiha. In addition, I was promoted to the position of clinical professor of plastic surgery at the LSU School of Medicine. Proud? Certainly. Any new father and professional would be. But again, I am humbled in the thought of being given the responsibility of nurturing new life in this world and of being thought of so highly by my colleagues. I have come to truly believe that humbleness expands our humanity. It opens an entire universe to us, one that brings us into total contact with those people we serve. I have found this to be true in the relationships I have with my patients. I find myself looking at an abdominoplasty or facelift or breast augmentation and seeing not just a patient with a cosmetic problem but a person of seeking a new level of confidence and joy in their inner beings. When I realize this patient has placed his or her complete trust in me, I am deeply humbled. And as such, I find myself no longer on only a physical or artistic level. I truly find myself at one with my patient, knowing their innermost desires as intimately as they do and giving them my best effort to help them fulfill those desires. To all of you who have humbled me by the trust you place in me, I say, ‘Thank you.’

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Blue Peel We are all ‘blue’ now and then. It’s part of the human condition. But did you know there’s a ‘blue’ that can change your life for the better? That blue is the revolutionary new Blue Peel skin treatment from Obagi that can give you healthier skin for a lifetime. The Obagi Blue Peel goes far beyond conventional alpha-hydroxy peels and other superficial procedures because it is a treatment ‘tailor-made’ for your own particular skin needs. The Blue Peel is simple, quick (about 20 minutes), in most cases, does not require sedation and can give a healthier, more attractive look to neck, chest, hands, back, arms and legs. What exactly is Obagi Blue Peel? The Obagi Blue Peel is an in-office procedure designed to significantly improve the appearance and health of your skin. It uses a low concentration of the chemical trichloroacetic acid (TCA) mixed with a special blue base or slow penetration. The Blue Peel allows Allison Muniz, the aesthetician of Massiha Plastic Surgery and Skin Care to monitor the appropriate depth to effectively remove the thin surface layers of aged and damaged skin from the face or other parts of the body. These dead skin cells are replaced by healthier ones, allowing the skin’s own clarity and tightness to resurface into a new and vitally appearance. Will I feel pain? The patient will usually experience a mild burning, tingling sensation that lasts only a minute or two (Allison can use a small fan to minimize the sensation). Following the procedure, a bluish tint will remain you’re the skin which will wash off within 12- to 24 hours. The skin will then swell slightly and will begin to peel within two to three days. This peeling will continue and should be completely healed in an average of seven to 10 days. What results can I expect? When the skin has completely finished peeling, the result will show through dramatically as you look into the mirror and see a beautifully improved complexion and the look of vitality you never knew possible. The skin will continue to improve over the next month to six weeks and your confidence and joy will grow, as your skin becomes firmer, clearer, smoother, healthier and more youthful looking. More than one? Allison will thoroughly discuss with you the number of Blue Peels that are necessary to achieve the desired results. In most cases, one to three Blue Peels can achieve dramatic improvements in most skin problems. Blue Peels can be performed in six to eight week intervals until those desired results are realized. Will the results last? That new healthy glow and youthful appearance of your skin is an ongoing process. The Obagi Nu-Derm restoration system is an at-home program designed to promote long-term overall skin health and works in perfect conjunction with the Blue Peel.

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Laser resurfacing Laser resurfacing can best be defined as a “renewal” of your face to the days before those fine wrinkles at the corner of your eyes, vertical lines around your mouth, acne scars, sun damage streaks on your cheeks, unattractive pigmentation that sometimes comes with age and even facial scars caused by injury or accident. The results of laser resurfacing are a smoother, more evenly toned complexion and are being enjoyed by men and women of all ages. Each year, thousands of men and women undergo laser resurfacing with greatly satisfying results and no major complications. However, prior to the procedure, you will meet in consultation with Dr. Massiha to discuss your medical history, specific cosmetic goals and pertinent information such as previous surgical procedures such as dermabrasion or facial peels, medications you are presently taking or have taken in the past, allergies, facial injuries and any other factors which may have a bearing on your laser resurfacing. How is laser resurfacing performed? Quite simply, a precision-directed beam of laser energy is used to vaporize the upper layers of damaged skin. As new cells form during the healing process, a smoother, tighter looking skin surface appears. The laser is carefully passed back and forth over the skin until Dr. Massiha reaches the safest level that will make the imperfection disappear or become less visible. If imperfections are deeply seated, Dr. Massiha may recommend that the procedure be formed in two or more stages. How long will the recovery period last? Dr. Massiha may cover the resurfaced area with a bandage which will be changed one or more times during the first seven days or he may have you cover your face with a protective ointment and give you additional ointment for home use to use for about a week during the healing process. During the first three weeks, your skin will be bright pink or red, as healing proceeds and new, healthy layers of collagen replace the heretofore-damaged area. During this healing period, you may wish to return to work and after about two weeks, you may safely apply makeup. After a month, the redness will begin to fade and you will begin to notice the visible improvement you seek. With each passing week, the pink tint of your skin will gradually diminish, but some pink tint may be slightly visible for three to four months. The results? The vast majority of patients are completely satisfied…even thrilled with the significant improvement in the tone and texture of their skin. And to show that beauty is not only “skin deep”, many say that their new look makes them feel more confident in work and social settings.

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Breast Augmentation As with many procedures in plastic surgery, the desire for and goal of breast augmentation is more than cosmetic beauty. Often, the feeling that their breasts are too small bothers women. Perhaps, weight loss, the birth of a child, genetic underenlargement and even age have left breasts smaller or less firm than they once were. Occasionally, a woman may have one breast smaller or of a different shape than the other. Whatever the case may be, the usual…and best motivation for breast augmentation surgery is simply wanting to feel better about oneself. Breast augmentation surgery (also called augmentation mammaplasty) can usually bring the desired results that leave a woman not only more physically attractive, but also more confident and self assured about herself. What is the first step? Consultation with Dr. Massiha is always the first step for any woman considering breast augmentation surgery. During the consultation, you will be asked about past and present medical conditions, medications (including nutritional supplements) and the results of past breast examinations and the history of breast cancer in your family. Also, your breasts will be examined and possibly photographed for your medical records. At this time, Dr. Massiha will consider the size and shape of your breasts and which procedure or procedures will bring the best results. In addition, Dr. Massiha will discuss with you preparations for your surgery. How is that procedure performed? The technique used for your surgery depends not only on Dr. Massiha’s preferences, but also on your desired results. The incision is small and usually made in one of three locations: under the breast, just at the crease; around the nipples (areolas) or within the armpit. Once the incision is made, Dr. Massiha creates a pocket into which the implant is inserted. This pocket is made either directly behind the breast tissue or beneath the pectoral muscle located below the breast tissue and above the chest wall. Is breast augmentation safe? Each year, thousands of women undergo breast augmentation surgery and have no major complications. However, as with all surgery, you must understand there are risks as well as the benefits. The risks are usually minimal and will be discussed with your during your initial visit. After surgery? Within a day or two after surgery, you should be up and around. Most of the discomfort you will feel can be controlled with medication prescribed by Dr. Massiha. A gradual healing process will have begun. The day following surgery, you will be permitted to shower. Since dissolving sutures are used under your skin, there will be no need to remove them. You may feel able to return to nonstrenuous work and resume gentle sexual relations within days. Also within a short time period of time, most of the swelling will have subsided, you may discontinue wearing your support bra and you will begin to see the final results. What will those final results be? Like most women, you will be very pleased with the final results. You will no longer need padded bras or other bust-enhancing undergarments and your new figure will open a world of new fashion to you. Most importantly, your self-confidence will soar. Also, Dr. Massiha may request that you return for period checkups in order that he may assess your long-term results and address any questions you may have. So there you have it. Breast augmentation is a procedure being sought by more and more women each day to build not only shapelier figures, but also heightened self confidence and deep inner joy. If you are considering breast augmentation, please feel free to call. Dr. Massiha will be happy to answer any questions you may have.

DR. MASSIHA: “Breast augmentation surgery (also called augmentation mammaplasty) can usually bring the desired results that leave a woman not only more physically attractive, but also more confident and self assured about herself.”

Massiha Plastic Surgery & Skin Care Center What better gift to give than a gift certificate for care for the skin? A gift certificate to pamper the skin is a tribute of love to that special person. Listed below are a few of the skin care techniques designed for long lasting beauty.

• Lunchtime MegaPeel with Vitamin C Treatment
• Deep Cleansing Facials
• Deep Cleansing Back Treatment
• Vitamin C/Glycolic/Lactic Acid Peel (Package of six)
• Obagi Blue Peel
• Skin Care Products
• Obagi Nu-Derm Skin Fitness System
• Theraderm Skin Care Products

For an appointment or information on Skin Care Gift Certificates, call 455-9441