Issue Highlights

East, West and The In-between
There is a right procedure for the right type of patient, Mariel Chow discovers.
There is the tendency to over-generalise when it comes to comparing the defining physical differences between Westerners and Asians. When prospective clients come into a consultation brandishing photos of very Caucasian and Aryan-looking beauties, it is important that doctors explain how racial specifications will impact on ideal surgical needs and treatment pathways.
Although this may not always be a foolproof method to cosmetic surgery and dermatological procedures, differences in physical and ethnic factors among races will aid in providing the right course of treatment for each patient. Plastic and Reconstructive Surgeons, Dr. Mohamad Nasir Zahari and Dr. Somasundaram Sathappan (Dr. Soma) and Consultant Dermatologist Dr. Apratim Goel explain the dermal, anatomical and cultural differences between Asians and Caucasians, then further disclose how these dissimilarities affect patients’ treatment choices.
Similarities and dissimilarities of the skin.
Plastic and Reconstructive Surgeon, Dr. Mohamad Nasir Zahari
According to Dr. Apratim, general similarities between Asian and Caucasian skin are their proneness or susceptibility to dryness and hair loss. She explains that both races maintain the same dermal structure of the epidermis and dermis and can both be subject to pigmentary disorders.
Dr. Nasir explains, “Patients with Caucasian skin have yellow melanin while Asians possess brown-black melanin.” He adds, “Take East Asians or South East Asians for example, although the skin may look naturally yellow, increased sun exposure will turn the skin brown.” This phenomenon is caused by melanin pigment, which acts as a protective barrier against UV rays. Because melanin is produced in higher amounts among Asians, Caucasians tend to suffer increased instances of sunburn, sunspots, freckles and even melanomas. In fact, because melanin works like an umbrella – which protects us from cancers – patients with lower levels of melanin will be predisposed to dangerous skin diseases. “Despite many factors being responsible for skin cancer – genetics, moles, carcinogen exposure etc – one of the main causes for melanoma is UV damage affecting in DNA changes from sun exposure,” Dr. Apratim states.
Although skin tones are one of the first things most notice, we must further examine the differences between dermal qualities that lie under the surface. Dr. Soma divulges that fair-skinned Caucasians tend to sag more and earlier because their dermis is much thinner when compared to that of Asian patients. He clarifies, “If you have Asian skin – whether Chinese, Malay or Indian – your skin will be quite thick, affecting in delayed aging.” Dr. Soma, Dr. Nasir and Dr. Apratim all agree that Caucasian patients tend to age up to a decade earlier than Asian patients and may even require facelifts at only 45-years young. So, this begs the question: Why do Caucasian patients age at such advanced rates? Well, the first cause is triggered by the skin’s light tones. Because yellow melanin has difficulty filtering UV rays, photo damage will exacerbate fine lines, wrinkles and early sagging. Asians however, are blessed with brown-black melanin and therefore, experience improved filtering of UV rays. While this may affect in culturally associated problems such as tanned tones and a higher susceptibility to pigmentary disorders such as melasma, Asians suffer less photo aging and hence, look younger for longer.
Moreover, Asians are genetically predisposed to better quality collagen and elastin where tighter and less creased visages can be enjoyed for longer periods. Conversely however, too much of a good thing can be bad as immoderate amounts of collagen may cause keloid scars. “Although Asians may still remain youthful at 40 due to good collagen and elastin accumulation, excessive depositions of collagen to traumatised areas may affect in hypertrophic scars – which is not so much a problem among Caucasians,” Dr. Nasir cautions.
The Face
Based on the many differences discussed, it comes as no surprise that treatment pathways will differ based on the patient’s unique problems and needs. According to both Dr. Nasir and Dr. Soma, Asian patients very rarely undergo open facelifts, as invasive surgery is most times unnecessary. Dr. Soma reveals, “If I had a 60-year old Caucasian facelift patient, I would have no choice but to conduct an open facelift where skin, muscle and fat will have to be repositioned.” He adds, “Asian patients of the same age can conversely get away with nothing more than an endoscopic lift or a thread lift which doesn’t necessitate skin excision.” Furthermore, Caucasian patients tend to undergo non-invasive treatments like Botox and fillers in their twenties or early thirties because crow’s feet, frown lines and nasolabial folds form much earlier. Asians however, can delay treatments and only undergo non-invasive procedures in their forties.
Plastic and Reconstructive Surgeon, Dr. Somasundaram Sathappan
As a dermatologist, Dr. Apratim agrees that dermal differences do affect in changes of treatment choices and thus, endorses specific procedures based on patients’ unique skin and desires. “For Caucasian patients, I suggest treatments such as neuromodulators, dermal fillers and thread lifts to reduce visible signs of sagging and volume loss. Should premature aging be a concern, IPL and fractional CO2 resurfacing can be quite effective,” she recommends. On the flip side, Asians don’t suffer ageing signs such as excessive wrinkling or sagging but are prone to melasma and acne scarring, which can affect in aged faces. To treat such issues, Dr. Apratim highly advises fractional Q-switched lasers, chemical peels, radiofrequency resurfacing – which is safe for Asian skin – and Botox to prevent occurrences of fine lines at later stages.
The Nose
Dr. Nasir expounds that when skeletal and facial features come to mind, Caucasians tend to sport longer and narrower bone structures with highly projected features. Asians contrastingly, normally possess rounder and broader faces with flatter features. “Take the nose for instance, Caucasians will generally have higher nose bridges with more defined tips and smaller nostrils. Asians have flatter bridges, less defined tips and wider alars or nasal wings,” Dr. Nasir points out. While these physical attributes are completely normal, studies have been done on preferred nasal shapes. Based on the results, patients across most cultures and continents prefer Caucasian noses.
Dr. Nasir reveals that because most patients prefer Caucasian noses, he’s encountered many Asian clients desiring noses like the ones they see on white celebrities. This request is unfortunately ill advised because typical Asian faces with archetypal Asian noses will not be suited to the classic Caucasian honker. Dr. Nasir cautions, “If patients with round and broad faces end up with high dorsums and overly defined tips plus tiny nostrils, they won’t look balanced or natural.” He further explains, “This is why we normally recommend that Asian patients opt for augmentations that are conservative but yet natural where bridges and tips are slightly higher and stronger with nasal bases that are marginally reduced.” Although rhinoplasty may be a popular procedure among Asians, this doesn’t discount the fact that nasal procedures are too common among Caucasians. Dr. Nasir clarifies, “Caucasians more commonly undergo nose reductions as opposed to augmentations because dorsal humps, bulbous noses or hooked tips are typical Western concerns.
The Eyes
The other distinguishingly different facial feature between Caucasians and Asians are of course the eyes. This may be more difficult to define as many Asians – like Caucasians – have wide eyes with heavily defined creases. To better put this in perspective, let’s take a look at the Malaysian populace. Indians tend to have larger, rounder eyes with deep folds. Malays are somewhere in between where the eyes are slightly smaller but with visible creases. The Chinese or East Asian dissimilarly, may either possess eyes that are commendably wide with notable folds or have longer eyes with no folds.
Blephroplasty is a heavily requested procedure among both Asians and Caucasians. Despite the similar name, Asian and Caucasian blepharoplasties are completely different procedures and vary based on patients’ needs and age. According to Dr. Soma, Asian blepharoplasty normally revolves around the creations of eyelid creases while Caucasian blepharoplasty is carried out to reduce sagging upper lids. He states, “Asian blepharoplasty necessitates tucking of the eyelid muscle under the tarsal plate in order to achieve the crease. Western blepharoplasty adversely, is simple excisions of the droopy skin due to aging.” Apart from eyelid surgery, eye bag removals are correspondingly common procedures among both Asians and Caucasians. Although there is no difference between either race, Caucasians tend to undergo eye bag removals much earlier as the skin and face age at quicker rates.
The Lower Face
As Dr. Nasir has previously explained, Caucasians normally possess highly defined lower facial features where the jaw and chin are sharper and more sculpted. Asians have comparably rounder faces that are more U-shaped. Like noses, studies have been done and numbers prove that patients across the board prefer Caucasian facial shapes where bone structures look sharper and more contoured. While this may be, Dr. Nasir confirms that needs and desires differ based on ethnicity. He affirms, “Asians normally covet a highly sculpted V-shaped jaw while the Caucasians generally request for added volume along the masseter.” These expectations are reflected on the many available procedures and treatments that allege to provide patients with slimmer jawlines. Such non-invasive and invasive procedures can include, Botox, thread lifts, Thermage, buccal fat removal and even orthognatic surgery.
In regards to the mouth, Caucasians normally sport narrow lips that continue to thin or dissipate as aging continues. Asians however, have shapelier and thicker lips. As such, lip injections are more popular among Caucasians and will only be a requested treatment among Asians should augmentations of shape or pout is required.
The Body and Tummy
Dr. Apratim clarifies that differences which appear on the face will also emerge on the body. She explains that because Caucasian skin is generally thinner, patients are more prone to stretch marks and sagging. Asian patients, on the other hand, have thicker skin that’s more resilient to damage but will have other complaints including hairiness and general dark tones. Due to differing ethnic concerns, Dr. Apratim generally recommends microdermabrasions, chemical peels and fractional Q-switched lasers for general skin lightening and triple wavelength primelase lasers for effective removals of thick and coarse hair. Caucasian patients are conversely suggested non-invasive rejuvenative therapies such as anti-aging facials, hydrating cleanups and body massages followed by exfoliations to promote soft, dewy skin.
Consultant Dermatologist Dr. Apratim Goel
In regards to invasive procedures, Dr. Soma concurs and confirms that Caucasian patients do – on average – undertake tummy tuck procedures at much earlier stages. In truth, Dr. Soma even confesses that because Asian women suffer fewer stretch marks, they’re quite happy undergoing simple liposuctions to attain the figure they’ve lost. He does however advise against tummy tucks before completion of all pregnancies and cautions, “I highly recommend that tummy tucks patients undergo surgery after giving birth because every pregnancy will affect in reappearance of stretch marks and tummy distensions.”
The Breasts and The Butt
Although both Caucasians and Asians desire breast augmentations, breast enlargements are by and large more popular among Caucasians because such cosmetic procedures are accepted in the West. As stated by Dr. Soma, Asians are generally more conservative and prefer smaller breasts. Having said that however, Dr. Soma is concerned about the rise of illegal silicone injections that are conducted in beauty salons. He says, “This is becoming a real problem because Asian patients assume that silicone injections to the breasts are cheap, scarless and a lifelong solution.” In reality, illegal injections can cause permanent pain, scarring, granulomas and even total loss of the breasts. Contrastingly, Western patients head straight to their plastic surgeon when seeking augmentations. Dr. Soma affirms that this occurrence is due to education and exposure to problems associated with illegal cosmetic treatments. “Western patients are well exposed and more aware because plastic surgery is common in the West. Asians are unfortunately quite dismissive of medical safety standards and hence, assume that augmentations with beauticians are discreet and harmless,” Dr. Soma points out.
Other differences in bodily procedures are breast reductions, breast lifts, body lifts and butt lifts. Such surgeries are commonly requested by Caucasian patients as Westerners generally have larger assets that are susceptible to higher chances of sagging. When it comes to male patients, Dr. Soma has found growing numbers of male Asian patients seeking breast reduction surgery. “The number of male patients desiring breast reduction surgery has increased tremendously over the last few years,” Dr. Soma shares. Along with gynaecomastia reduction, Dr. Soma additionally reveals that non-invasive facial rejuvenation treatments are also beginning to gain popularity. Western men, on the other hand, generally seek procedures like liposuction, facelifts and hair transplants.
Cultural Dissimilarities
Despite variations in skin and skeletal factors, cultural differences do affect how patients choose procedures. Dr. Soma does regrettably confess that Asians – mostly women – are sometimes very much influenced by their beauticians. What Asian patients fail to understand is how little beauticians – with only a high school certificate – are able to safely offer. Dr. Soma counsels, “If Asian patients go down the wrong path, they could end up with horrible complications that are difficult to correct or even reverse.” He continues, “Illegal injections are becoming such an epidemic in Malaysia that I see as many as two patients per month who require reconstructive surgery caused by illegal injections.” In Dr. Soma’s opinion, Asian patients don’t normally seek the advice of surgeons because invasive surgery can put Asians off. Nevertheless, the high chance of complications arising means patients would still need surgical intervention. This will undoubtedly result in more surgery, more pain and more money spent. So, ask yourself this “Why choose your neighborhood beautician when you can undergo safe, effective procedures with a qualified and credentialed plastic surgeon?”
Twin Peaks
Mariel Chow keeps abreast with chest trends.
All women have their own boob stories. Whether fantastic or awkward, most of us have either loved our breasts or hated how they felt when premenstrual syndrome kicked in. Breasts are so much more than round globs of fatty tissue. They connote fertility and our ability to feed and sustain life. For babies, nothing feels more natural than suckling on a mother’s breast and it is through breasts that infants develop the mother-infant bond. According to research, human evolution has applied ancient neural circuitry that evolved from mother-infant bonding into current brain activity to strengthen bonds between couples. In summation, not only do breasts play an important role in sustaining future life, they represent a woman’s sensuality and sexuality.
Although breasts come in all shapes and sizes, they irrevocably represent womanliness, and changes in the way they look can affect in a loss of perceived femininity. Due to such decreases in self-confidence, women are turning to cosmetic surgery to regain their womanhood. Five Plastic and Reconstructive Surgeons discuss the most requested mammary procedures and explain how they can improve patients’ confidence and quality of life.
The Bigger the Better
Trends for medical breast augmentation began in America in the 1950s where women would have their breasts injected with silicone. Despite causing grave complications, patients still subjected their bodies to dangerous treatments and hence, medical authorities intervened. Surprisingly, the solution consisted of simple encapsulations of filler material, or what we come to know today as breast implants. As the years passed, medical and technological developments brought about improved surgical pathways and implant types, which held up to international medical standards. Consultant Plastic and Reconstructive Surgeon Dr. Ruslan Johan explains how breast augmentations are carried out and what patients can expect before, during and after surgery.
Consultant Plastic and Reconstructive Surgeon Dr. Ruslan Johan
What are breast implants?
Implants are made of two elements including the capsule and filler material. This filler material comes in many forms including saline, soymilk and silicone. The problems related to saline are its unnatural feel due to low viscosity and immediate deflation should implants rupture. Soymilk, on the other hand, possesses improved viscosity but tends to granulate within its capsule over time. In my opinion, silicone implants remain the most consistent as it feels natural. I therefore only recommend silicone and also endorse Silimed implants– the largest manufacturer of silicone implants in South America – because they’re FDA and CE approved.
Silicone implants are either round or teardrop shaped. I personally don’t offer teardrop implants as their rotation tendencies affect in odd shapes. Round implants, on the other hand, have minimal margins for error because implant rotations won’t result in unaesthetic outcomes.
Who are the best implant augmentation candidates?
Photo Courtesy of Dr. Ruslan Johan BA + Nipple reduction (Before and After) Before and After Breast Augmentation Before and After Breast Augmentation
Good augmentation candidates are not only women with small breasts. Based on personal experiences, patients with asymmetrical breasts and those who have undergone pregnancy or significant weight loss may also be appropriate candidates. Breasts are like balloons and once deflated will not expand back to pre-pregnancy states. This phenomenon however, affects in empty breast syndrome because the upper pole will look and feel saggy and flat.
How is the procedure carried out?
There are many incision types with related pros and cons. First, we have the armpit cut. While this may be an available option in my clinic, it’s more costly and challenging since scopes are utilised to ensure zero bleeding. Furthermore, because the armpit is far away from chest muscles, added incisions could lead to increased downtime. Next, we have the inframmamary incision where cuts are made on the folds of the breasts. Although this method is appropriate for larger implants, aging will affect in sagging and displacement of the inframmamary crease, which causes visible scars. Lastly, we have the periareolar incision. This method is my favourite because clothing covers any visible scar. While some doctors have issues with areolar incisions, I have found very few associated problems and therefore recommend it to most of my patients. In addition, I prefer to place implants under pectoral muscles, as results look and feel more natural.
Implant augmentations will require general anaesthesia and take at least 1.5 hours to complete. After four hours of in-office recovery, patients are allowed to go home. They are expected to return for dressing changes and suture removals in the first two weeks and will be taught how to massage breasts by the third.
Patients won’t experience much pain as painkillers are provided. Furthermore, religious application of pressure bands is recommended to ensure breasts don’t move or cause discomfort and bleeding. They should avoid all forms of exercise during the first week but may conduct lower body exercises in the second. On average, patients will return to normal routines within a month and find ideal results after a year.
Graft that Fat
Fat grafting – also known as autologous fat transfer – is emerging as a new solution to breast augmentations via a method where carefully extracted tissues are processed and injected into the breasts for increments in size and volume. Fat grafting is gaining traction among augmentation patients because current mammary trends call for natural results that look neither inflated nor exaggerated. Moreover, fat grafting removes fatty tissue from problem areas and additionally reduces implant-related complications including leakages or contractures.
Although an effective and popular technique, it’s not free from specific problems, especially when resorption is concerned. Injected fat has the propensity of being reabsorbed by the body and this can affect in insufficient results that require added treatment sessions. Furthermore, injected fat cells may turn necrotic, leading to pain, infection, numbness and discharge. To reduce adverse effects, patients may choose to undertake an added procedure, namely Stromal Vascular Fraction (SVF). Known to be rich in stem cells, SVF treatments have proven to vastly improve fat survival rates and therefore, reduce complications and the need for added treatment sessions. Korean Cosmetic Fat Surgeon and fat grafting expert, Dr. Kasey Sung shares his expertise.
Before Fat Grafting
After one session of fat grafting.
Before treatment and After two sessions of fat grafting.
What is fat grafting and who best candidates for this procedure?
Fat grafting is extraction and reinjection of the patient’s own fatty tissues to the breasts in order to achieve firmer, tighter and bigger breasts. Autologous fat transfer’s best candidates are women who have undergone pregnancy and breastfeeding or those who’ve previously boasted good volume but suffered reductions in proportion and size. Other applicable patients can be women who possess good amounts of adipose (fat) tissue but have small breasts.
Korean Cosmetic Fat Surgeon and fat grafting expert, Dr. Kasey Sun
Despite an efficacious method, procedures aren’t comprehensive and may be unsuited to women who have insufficient fat tissue but desire bigger volumes. For patients such as this, I advocate implant augmentations instead because immediate and optimal projections can be better achieved. Nevertheless – and as long as patients have fat to spare – fat grafting boasts soft results that look and feel like natural, God-given breasts.
What can patients expect before and during fat grafting surgery?
Fat grafting will require consultations because patients have tendencies to unrealistic desires and expectations. Not everyone is suited for fat grafting, especially if they have inadequate fat cells or have family histories of breast cancer. Therefore, in addition to body fat analysis, patients may have to undergo scans to ensure they’re not only applicable, but also free from malignant lesions.
Fat grafting procedures are normally done under intravenous sedation or general anaesthesia. Extracted amounts should be a minimum of 200cc per breast with or without without centrifugation. Although fat grafting may seem similar to liposuction, its extractions aren’t applicable for transfer because tissues need to be clean, non-traumatised, bloodless and free from fibrotic material. As such, surgeons will be required to conduct soft manual harvesting or utilise the Harvest Jet to attain even fat lobules that boast minimal complications and better survival rates.
Why do you recommend SVF in addition to fat grafting?
SVF is endorsed because of its tendencies to improve fat survival rates and reduce complications. To obtain SVF, harvested fat will be centrifuged down and subjected to enzyme digestion and incubation. What are left at the bottom will be stem cells that will be mixed with processed fat tissues and injected back into the patient. Despite being a recommended procedure, SVF is elective and will incur added costs and will increase surgical time by two hours.
What can patients expect after surgery?
Fat cells are living organisms that need good blood supply. Some will survive because they’re in good contact with host tissues while others die from poor vascularisation. In short, dead fat cells will affect in diminishing breast sizes. While patients may find large breasts immediately after surgery, this may be principally due to swelling and oedema. As part of fat grafting’s normal recovery processes, patients will lose volume at the end of the first month but begin seeing stabilizing sizes in the following months. Should patients desire amplified effects; added treatments are always an option.
Masto-Sexy
A breast lift, or mastopexy, is a procedure designed to elevate the nipple and reshape the breast. Cosmetic surgery statistics show an increased interest and uptake of breast lift procedures since the early 2000’s, reflecting increasing awareness and appeal of the procedure. Mastopexy is designed to treat drooping of the breast and looseness of the breast skin, which can be caused by age, genetic predispositions, pregnancy, breastfeeding, weight loss and gravity. If the drooping and stretching of the skin is significant, no amount of diet and exercise can reverse its effects, with plastic surgery being the best possible option for correction. Consultant Plastic, Reconstructive and Cosmetic Surgeon, Dr. Yap Lok Huei tells us more.
Consultant Plastic and Reconstructive Surgeon Dr. Yap Loke Hui
What is breast lift surgery and who are its best candidates?
The suffix ‘pexy’ refers to surgical fixation; hence ‘mastopexy’ refers to securing the breast to the chest wall. Mastopexies are applicable to all patients but most suited to those who have experienced stretched skin caused by aging, breastfeeding or weight fluctuations. The aim of a breast lift or mastopexy procedure is to balance the skin envelope to breast volume ratios. Some patients have good breast volume (filling) but have excess skin. These patients can be treated primarily with skin tightening and reshaping. Other patients however, may have lost significant breast volume and in this situation, volume restoration such as with breast implants may be required as well.
Some patients may experience deflated-looking breasts due to aging, sagging skin and gravity. Patients who have lost a significant amount of weight and body fat may see loss of breast volume. In patients who breastfeed, the natural shrinkage of breast volume after stopping breastfeeding may also contribute to loss of volume thus, increasing the need for a mastopexy – however this is variable and not every patient who breastfeeds may need a breastlift.
What can patients expect from breastlift surgeries and is scarring obvious?
There are numerous types of operation and this varies based on both the surgeon’s personal preference and the patient’s needs. Ultimately, incision methods will depend on the patient’s acceptance of the site and size of the incisions, how much excess skin excision is required and whether or not a pleasing shape can be attained. For example, patients with too much excess skin may not be suitable for circumareolar incisions, as lateral tissues may need to be taken in. The scars resulting from the surgical incisions should fade over time in most cases, but this depends on a patient’s unique dermal characteristics. Asian patients for example, tend to have stronger dermis layers, which hold stitches well but may be susceptible to keloids and disorders of pigmentation.
What can patients expect after surgery?
Contrary to expectations, the discomfort after surgery is usually minimal and well tolerated by the majority of patients. Most patients can be discharged from the medical centre after an overnight stay. Support garments are used in my practice to help avoid downwards or sideways pulling and to reduce the risk of excess tension on the suture lines. Regular follow-ups and wound checks are provided in the immediate and short-term as part of active wound management to ensure complications are minimised. However, I do recommend patients take time off work for comfort and ease of recovery. Most patients can return to work within 10 - 14 days as the suture lines and wound sites are hidden unlike procedures on the face. Gym activities can be resumed after about 4 - 6 weeks.
When can patients expect good results?
There should be an immediate, visible change in the breast shape and contour after the procedure. However, there may be some minimal swelling, which resolves gradually over time. Patients may not achieve final settling of their contours until an average of six to eight months after the procedure.
Building Breasts
According to the American Society of Plastic Surgeons, breast reconstructions aim to restore one or both breasts to near normal shape, appearance, symmetry and size following a mastectomy, lumpectomy or even congenital deformities. The procedure often involves multiple techniques, which can either be performed immediately after breast cancer surgery or delayed till a later date. Consultant Plastic and Reconstructive Surgeon, Dr. Rica Abdullah Ichihashi stresses that breast reconstruction generally falls under two categories – implant or flap reconstruction – and states that the decision to undergo either technique remains multifactorial and necessitates practical and rational discussions between the patient and her doctors.
Consultant Plastic and Reconstructive Surgeon Dr. Rica Abdullah Ichihashi
When should breast surgery patients undergo reconstructions?
Each patient is different and will have their own unique needs based on factors that are either personal or social or based on future cancer treatment. Because of these unique needs, I hesitate to suggest that there’s a ‘right’ time to undergo breast reconstructions. Having said that, plastic surgeons do understand that immediate breast reconstruction offers better aesthetic results as original breast skin is maximally preserved. Bearing this in mind, aesthetic aims should always come second to the main aims of cancer surgery.
What is implant reconstruction?
Implants are traditionally useful in cases where bilateral reconstruction is needed. This is because of the perceived idea of immediate achievable symmetry and shorter operating time. While this may be, bilateral breast reconstruction with your own tissues can be safely done in a time saving manner. This can be particularly seen in centres where there are two surgeons – breast surgeon and plastic surgeon – concurrently operating on the same patient at the same time. Moreover, evidence from studies has suggested that autologous breast reconstruction patients reported higher long-term satisfaction rates than implant-based patients. On top of that, implants have shelf lives and aren’t lifelong solutions. Nonetheless, the decision to have either implant-based or autologous breast reconstruction is very personal and will necessitate comprehensive counseling between a patient and her surgeon.
What is autologous breast reconstruction surgery?
Autologous breast reconstruction is generally applicable to most patients unless they’ve previously experienced recurrent breast cancer. Explaining the ins and outs of autologous reconstruction can be very technical and I don’t want to bog your readers down with too much detail. For the benefit of laypersons however, I can say that autologous breast reconstruction uses a combination of your own tissues (muscle, fat and skin) to reconstruct the breasts. The technique can be further divide into a pedicled flap which utilises tissue with its supplying blood vessel still connected to its source and a free flap which employs tissues with disconnected blood vessels.
The difference with the first option – pedicled flap – is that tissues are ‘moved’ into the breast area with its blood supply is still intact. The second option – free flap – conversely, has its blood vessels cut from its original source but later reconnected to a new vessel in the breast region. Free flaps involve microsurgery whereby vessels are joined together with very fine stitches under a microscope. The advantage to this technique is its capabilities of employing tissues far away from the breast. The disadvantage, however, is its demanding technique, which entails longer operating time.
Fat frafting is another promising autologous technique. It’s especially useful in cases where patients originally have small breasts or when surgeons want to ‘fine tune’ reconstructions.
How can patients choose between the many techniques and what results can patients expect after surgery?
Mindful consultations and exchanges between the surgeons and patient are vital. This process can involve multiple consultations and can even turn emotional, as patients have to additionally deal with the diagnosis of cancer. Ultimately, patients have to be comfortable with their doctors and confirm that reliable surgical techniques with predictable recoveries are being employed.
Patients should expect to feel like they still have their original breast after reconstruction surgery. As plastic surgeons, our main aim is to reconstruct the original breast and not create an enhanced or ‘new and improved’ one. To be quite honest, some of my patients find it difficult to guess which is the reconstructed breast especially if scars have faded well.
What advice would you give breast cancer patients who plan to undergo reconstructions
The decision to undergo reconstruction is completely personal but ensure that a specialist – not Google or Facebook – guides you. Furthermore, upcoming treatment journeys may continue for months so make sure you choose a doctor or physician you’re comfortable with as you’ll need good continual support.
Headlining Headlights
Though any cosmetic issues regarding one’s nipples may be harmless, it’s completely understandable how unaesthetic nipples may affect ones self-confidence. Whether patients were born with certain conditions or have suffered changes due to puberty, weight loss or breastfeeding, there are various techniques, which can aid in the correction of inverted nipples, enlarged nipples or wide areolas. Unlike other breast surgeries, nipple procedures are not as invasive and are normally carried out as outpatient procedures without general anaesthesia. In addition, patients suffer zero downtime and can normally resume normal routines almost immediately. World-renowned Plastic and Reconstructive Surgeon Dr. Marco Faria Correa is no rookie when it comes to matters of the nipple, so let’s hear what he has to say.
Consultant Plastic and Reconstructive Surgeon Dr. Marco Faria Correa
What is nipple inversion surgery?
There are some patients who suffer from nipple inversions due to scar tissue caused by trauma or infection. Nipple inversion surgery is a procedure that selectively releases fibrotic ligaments to ensure nipples point forward for both cosmetic and functional purposes including breastfeeding. If surgery is not preferred, non-invasive techniques such as continual manual or vacuum-assisted stretching can be applied. Despite the availability of non-invasive lateral stretching methods, inversion severity based on a grading system comes into play. For instance, if there is an inversion scale out of five – with five being the most severe – patients who may only benefit from non-invasive physiotherapy should have severities no more than a three.
How is nipple inversion surgery carried out?
Nipple inversion surgery is an outpatient procedure with zero downtime. After local anaesthesia infiltration, a small cut will be made along the areolar. After tissues are hooked out with a stitch or thread, fibrotic tissues – which are normally milk ducts – will be released. Surgeons will selectively release only traumatised tissues to allow future breastfeeding. However, severity does apply and if doctors need to cut all the milk ducts, breastfeeding may be impeded. This is why consultation is key, as both the patient and surgeon will have to determine whether procedures are either for cosmetic or functional purposes. In my opinion, if reasons behind nipple release procedures remain functional, it’s best that patients undergo non-invasive techniques instead. Patients are expected to return for a follow-up after five to seven days to have their stitches removed and it’s best they avoid too much compression, as we want the nipple to project outward.
What is nipple reduction surgery?
Nipple reduction surgery is a popular procedure which entails differing techniques depending if patients have plans for breastfeeding. If patients have not breastfed, we will utilise techniques that avoid cutting of the milk ducts or refrain from reducing the nipple’s height. If nipples are in fact thick and hard, we will try to apply compression and remove a wide ring of skin and subcutaneous nipple tissue but avoid the tip where milk is expelled. If patients are no longer breastfeeding, I will employ another technique, which allows me to make cuts right from the top of the nipple down to the base. Although this method produces stunning results, it does mean cutting off the ducts and therefore isn’t suitable for mums who would like to breastfeed. Patients may experience some numbness and loss of sensitivity for a month or so, but side effects should resolve in time. Similar to nipple inversion surgery, patients are expected to return for stitch removals after five to seven days. Patients can however, apply light compression because the point of surgery is to have the nipples reduce in size.
What is areolar reduction?
Areolar reduction surgeries are normally done under local anaesthesia with sedation or general anaesthesia. It normally requires a periareolar plus vertical cut (lollipop incision) or a periareolar, vertical and submammary fold incision (Inverted-T) because such techniques affect in better results. Periareolar incisions – around the nipple – are only appropriate for small reductions, as large cuts made around larger areolas will affect in continual skin wrinkling and stretching which causes unaesthetic scars. Techniques will of course depend on a case by case basis but from my experience, the lollipop and Inverted-T incisions provide better results because dermal tension is better distributed. In contrast to nipple procedures, areolar reductions are suitable for breastfeeding mothers because nipples are left unharmed. In addition, loss of sensation should not be cause for concern unless patients have suffered bad scarring.
The Patient’s Perspective
Mariel Chow documents how two very different patients researched, prepared and dealt with their surgeries.
As a medical publication, Cosmetic Surgery and Beauty routinely features many different cosmetic procedures and the doctors who specialise in them. To do this, our writers are taught to interview surgeons and later, translate medical jargon into something comprehensible to the average reader. While we do this well, the doctor’s perspective in many cases is not necessarily reflective of the patient’s standpoint, and most times echo medical observations and explanations as opposed to true experiences. We believe firsthand perspectives are sometimes just as important because they provide insights into the patient’s thought process and experiences. In view of this, we sought out two very real patients – one with medical knowledge and one without – who were gracious enough to tell their stories and share first-hand accounts of their passages through plastic surgery.
The Nurse
I am a mother and surgical nurse by profession. I have been heavily exercising for the past year and a half, particularly focusing on strength training and bodybuilding. Despite being much healthier and developing more muscle tone, I have also burned a significant amount of fat all over my body, including my breasts. Although the shape and size were maintained, I had lost volume in the upper pole of my breasts. This is why I decided to undergo an augmentation.
My surgical consultation experience was out of the ordinary because firstly, I’m a nurse with cosmetic surgery knowledge. Secondly, my doctor is a man and sometimes, men don’t fully grasp what women want. Therefore, I never consulted with my surgeon, but instead, sat down with my colleagues to discuss everything from surgical pathways up to which implant types would be best. Based on what was deliberated, my colleagues and I decided that silicone implants of 255ccs would be appropriate as I would attain immediate results with good shape, volume and projection. Although my anesthetist recommended fat grafting, I didn’t think such a procedure would be applicable because I’ve seen other patients undergo the surgery. Although I am not saying that fat grafting won’t provide great results, constant exercising and strength training will burn fat and that would affect in contradicting outcomes. Furthermore, because grafted fat does dissipate, additional follow-up procedures are occasionally necessary, and I just don’t have the luxury of time.
Concerning surgical pathways, I chose to undergo the periareolar incision, as scars heal faster and aren’t too visible. In addition, we also decided to place the implant under the muscles as opposed to directly beneath the skin because results will look more natural. This surgical pathway does adversely affect in other problems including higher chances of bleeding, capsular contracture and longer downtime. However, patients must remember that implant borders will be more visible when placed directly under the skin and this could result in abnormal-looking consequences.
Before the operation, I undertook a blood test to ensure that I would be safe for surgery. On the day of the procedure, I was placed under general anaesthesia around noon and was knocked out until seven in the evening when my surgeon woke me up. At that point, however, I was still extremely drowsy and had difficulty coughing, but could still muster the strength to drink some water. I remember only being fully alert at 3am and although I didn’t suffer any pain, my chest did feel tight. I was discharged at eight in the morning the next day and despite experiencing some pain, constriction, swelling and bruising, the discomfort was completely bearable. Such problems subsided by the third day and although I refrained from lifting heavy objects, I did return to normal routines and even worked from home. In addition to taking it easy for a few days, compression bands were religiously applied in order to keep the breasts in place.
While most patients have to return to their doctors after three days for bandage or dressing changes, my experiences as a surgical nurse gave me the liberty to care for my wounds and conduct my own dressings at home. My medical experiences further helped in reducing downtime. In fact, I was back to work after a week and already working out after two. My wounds also healed at advanced rates, and although the surgery was merely carried out a month ago, the scars no longer look red or raw.
The secret to advanced recovery is nutrition. Should patients desire good outcomes with reduced pain and downtime, they should stock up on vitamin C, protein and Brand’s chicken essence as such vitamins, minerals and foods undoubtedly aid in extraordinary healing. Moreover, patients should also stay hydrated and eat healthily because implants placed in the sub-muscular plane will affect in more blood loss and increased downtime. Last but not least, I additionally recommend that patients wear their compression bands every day for three weeks for at least 22 to 24 hours a day – only removing it during showers or baths. Even though I must admit that compression bands can be uncomfortable during sleep, they reduce muscle instability and this results in greater relief throughout normal activity.
Most doctors will normally advise against exercising too early because implants may become dispositioned. In my experience however, patients can carry on with normal routines as long as they feel comfortable, or suffer no pain or soreness. Likewise, the breasts must also be massaged because lack of implant manipulation can lead to tightness, blood clots and capsular contractures. While most doctors will only recommend massages after three weeks, I conducted implant manipulations a week and a half after surgery. My methods, however, are not recommended for the layman; but my advice is to massage early and continue to manipulate implants everyday for three months in order to reduce tightness and improve suppleness.
Now that it’s been three weeks post-surgery, my breasts have reduced in size and now feel much softer because of constant massaging. As previously explained, bruising and swelling of the breasts and areolar were notable in the first few days but have now settled so well that the wounds are barely conspicuous. In summation and based on my own experiences, breast augmentations are not as painful or as scary as what many assume. As long as patients pay attention to healthy nutrition and their doctor’s advice, they’ll soon return to work and normal routines in no time.
The Expatriate
I am an American who has been living in Malaysia for over ten years. I’m a psychologist working as a professor and research supervisor at the University of Malaya and additionally run a private practice which specialises in psychotherapy. I chose to undergo breast reduction and mastopexy (breast lift) surgery four years ago because I’ve always been top heavy with Double-E breasts. Apart from that, I’ve had two children, and while I never breastfed either of them, pregnancy did affect in further engorgements, which fostered supplementary sagging. What’s even more frustrating is that I’m actually quite small in stature, and short as well as having a small frame. Needless to say, my breasts never fit my body type and were always a little too much for me. As the years passed, my breasts proceeded to sag due to aging and this triggered pain in my upper back and shoulders. At times, I would even find myself automatically hunching over if I were sitting for long periods of time. Ultimately, while the choice to undergo surgery was mainly due to cosmetic reasons, I knew that I would be happier if my breasts were smaller, lifted and not so floppy.
Before undertaking my consultation, I researched everything there was to know about breast lifts and breast reductions. The main things I wanted to investigate were patient success and horror stories, incision pathways and of course, scarring. In my opinion, breast reductions are much safer than augmentations because there aren’t any adverse foreign body effects like implant contractures and leaks. With reference to looking for the right doctor, I wanted a surgeon who was not only practicing locally but also legally certified and credentialed. Although I’m American, I chose not to undergo surgery in the United States because it would be much too expensive. To further explain, even if I didn’t take surgical costs into account, there would be expenditures including travel fees and pricey accommodation expenses. Moreover, I didn’t believe medical tourism would work because I’m such a busy working woman who doesn’t have the luxury of taking three weeks off.
Therefore, I researched online looking for an appropriate plastic surgeon and found Dr. Yap Loke Hui. From there, I had opportunities to speak and discuss with a few of Dr. Yap’s previous patients to further ensure that he was indeed a recommended choice.
On the day of consultation, I told Dr. Yap what I was interested in doing and explained that I wanted breasts that were firmer, higher and smaller. Upon examining my chest, Dr. Yap clarified that I would be a good candidate for surgery because I suffered from hypermastia or overly large breasts that would continually sag with age. In addition, Dr. Yap also asked what size breasts I desired, as some women want to be completely flat chested. Not me! Later, and based on my preferences in size and shape, Dr. Yap exhibited some before and after photos of previous, similar patients to give me a general idea of what could be expected. Last but not least, he explained the many surgical pathways available and what the prognosis would be. Based on the many surgical options Dr. Yap suggested, I chose the lollipop incision where surgeons cut around the areolar and also straight down the lower half of the breast. By and large, I was very comfortable with Dr. Yap as he was not only knowledgeable and professional but additionally took the time to mention both the pros and cons and options available.
On the day of surgery – which was a Monday, I was scheduled to be at the hospital at 10am. I was then prepped for surgery and placed under general anaesthesia. Upon waking up, my breasts were bandaged and placed in a pressure garment. I was still hooked up to an IV and a catheter, as Dr. Yap didn’t want me getting up or walking to the loo for at least 24-hours. Though this may seem frightening, I honestly didn’t suffer any pain whatsoever.
What was uncomfortable however, were the pressure garments and bandages, as they do feel a little hot especially under the Malaysian sun. Mastopexy patients are generally recommended to stay in the hospital for at least two days so I returned home on Thursday afternoon. I spent the weekend resting and returned to work on Monday but refrained from exercise for three weeks. Nevertheless, I was expected to return for check-ups with Dr. Yap every three days for two weeks so that dressings could be replaced. The stitches contrastingly, were dissolvable so they didn’t need to be plucked out or removed.
I was very lucky to have suffered zero swelling but this varies from patient to patient. Within a month, I found excellent results and felt so much lighter because Dr. Yap removed half a pound off each breast! I was also finally able to button my blouse across my chest without the fabric either bunching up or pulling apart. In short, my breasts looked and felt good and I was definitely much happier.
My experiences with Dr. Yap have been spectacular and I can’t recommend him enough. In fact, I returned to Dr. Yap two weeks ago and underwent blepharoplasty procedures to correct my dark circles and droopy lids. Along with great outcomes from my breast reduction and mastopexy, I was also very pleased with the eye surgery as well. Although the bruising hasn’t completely faded, I can see massive improvements in the dark circles and even reductions of the crow’s feet and saggy skin.
If people desiring cosmetic surgery were to ask for my advice, I would suggest they undergo surgery for themselves and not for the acceptance of others. Secondly, do your research and find the right doctor because there have been many cases of botched surgeries. Make sure you scope out the right doctor with the appropriate credentials especially if you’re undergoing surgery this side of the world. In America, if surgeons claim they’re board-certified, they must be board-certified. If not, they can be imprisoned for false credentialing. In Malaysia however, many claim they’re credentialed when they’re not, so make sure you do your homework and ensure you’re undergoing surgery with doctors that are legitimately certified by the Ministry of Health.
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October, 2017

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Freda Liu
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  • ASK THE DOCTORS
  • MEDICAL, AESTHETIC & DENTISTRY
  • BEAUTY+
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Sensational Skin
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Fitter, Fresher and Firmer
The White Wail
East, West and The In-between
Twin Peaks
The Patient’s Perspective
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