Breast surgery has become one of the most popular forms of cosmetic surgery. Ranging from breast augmentation surgery to enhance a woman’s breast to surgical reconstruction following breast cancer, the team at Holcomb-Kreithen Plastic Surgery & MedSpa, a state-of-the-art plastic surgery center located in Sarasota, FL, offers all forms of breast surgery procedures. Aesthetic Insider™ spoke with leading plastic surgeon Dr. Joshua Kreithen, an aesthetic breast and body specialist board-certified by the American Board of Plastic and Reconstructive Surgery who is recognized for his use of advanced surgical techniques as well as laser and light technology to help male and female patients transform their appearance at any age. Dr. Kreithen, who is co-founder of HKPS along with Dr. J. David Holcomb, has more than eighteen years of experience as a surgeon, is a member of the prestigious American Society of Plastic Surgery, and is Chief of Surgery at Lakewood Ranch Medical Center. To learn more visit www.sarasota-med.com.
How long have you been performing cosmetic and reconstructive breast surgery procedures?
I did my plastic surgery fellowship at the University of Florida and have been doing breast procedures for over twenty years. Prior to my plastic surgery training I did general surgery where I did many breast procedures mostly pertaining to breast cancer and reconstruction. I am also an artist. I wanted to use my artistic skill, so I decided to become a board certified plastic surgeon. That was about fifteen years ago. Now I perform many cosmetic breast surgery procedures such as breast augmentation and reduction, but I also continue to offer breast cancer reconstruction surgery. I am still as passionate about helping my patients reach their goals, particularly with breast surgery, as I was when I started out 20 years ago.
What is the most popular type of surgery you perform on the breast?
Statistically, both in my practice and on a national level, the most popular procedure is breast augmentation surgery. Every year many women of all ages choose to increase and enhance the size and shape of their breasts. Close behind that would be breast lifts and breast reduction. In essence, some days I am making breasts bigger, and on other days making them smaller.
How can a patient choose an implant that is the right size and type for their body?
The key is to individualize each patient’s plan based on their needs and goals. When I see a patient in consultation I’ll do an exam and have a long discussion about what they want in terms of size and shape. Most patients want a natural look and choose an implant size that will bring more balance to their body. Some patients want much larger breasts and request a bigger implant. There are basically two types of implants that are currently available, saline and silicone. I would say, at this point in time, about eighty percent of my patients are choosing silicone implants. Saline and silicone implants each have their pros and cons. In the early nineties, there were issues with the old silicone implants and they were taken off the market. There was a lot of hysteria about silicone. Since then they have been redesigned and were FDA approved in 2006. Over the past decade, the new silicone implants have proven to be extremely safe and give excellent results. They also look and feel more natural which is what patients want.
Do you have any preference when it comes to type of implant you offer your patients?
I usually use smooth round implants that I place under the pectoralis or chest muscle because they really give fantastic results. I actually like to use either saline or silicone as they actually look pretty identical. The choice is really up to the patient. The major difference between the two is how the implants feel. The silicone implant is filled with a silicone gel that actually feels similar to natural breast tissue. The saline implant is essentially filled with salt water, so it has a little bit more of a water balloon feel to it. In certain situations, if someone already has a decent amount of breast tissue to begin with and they want to go bigger, they would do fine with either type of implant, saline or silicone. For women with a smaller amount of natural breast tissue, a silicone implant will definitely feel more natural. Given the current medical standards required of breast implant manufacturers, both are considered equally as safe so I leave the ultimate decision up to the patient.
What’s the typical age of a breast augmentation patient?
Here in Florida we see patients in all age brackets requesting breast augmentation surgery and I believe that to be pretty much the same across the nation. In Florida in general, we have a slightly older population, so many of our breast augmentation patients are women in the 40s to 70s. What is amazing to me is that many people are now taking such good physical care of themselves that the patients I see in their sixties and seventies are super fit. They look like they’re in their forty’s or fifty’s and come to us for breast enhancement or breast lifting and reduction procedures that help their bodies look even more youthful. Additionally there’s a younger population of women as well. I would say probably the average age of my augmentation patient is somewhere between thirty five to forty, but I am performing breast augmentation on women ages twenty to seventy five.
Why do you think breast augmentation has become the most popular cosmetic surgery procedure?
There has been a worldwide shift in many people’s opinion about plastic surgery in general. Not too long ago there was often a stigma toward somebody undergoing a plastic surgery procedure that made people want to keep it a secret. In recent years there has been much more public acceptance and understanding of plastic surgery and in the last ten to fifteen years it has been showcased in reality TV shows making it more commonplace. Many female patients say that breast augmentation helps them feel more confident about their body, or enables them to dress more stylishly in clothes that fit properly. Basically, it makes them feel better about themselves and they don’t have to keep it a secret anymore.
What’s the general reason for a breast augmentation procedure?
Most of my patients are seeking to either obtain or regain balance and symmetry to their body which in turn may boost self-esteem and improve self-confidence. Our younger patients are generally looking to increase size, where other patients have lost breast tissue due to breast feeding and may require a breast lift and augmentation to give them back the volume they had before having children. We see a whole variety of different types of patients wanting breast augmentation but often it’s really a sense of empowerment that they get when they begin to love their body more. My patients tell me they want to look and feel their best and this surgery helps them with that.
Do you feel your artistic background can improve your plastic surgery technique?
Absolutely. I see myself, and there are different metaphors that I could use, as sculpting the body as a painter would paint a canvas. I feel particularly grateful that I’ve always had natural artistic skills that I can bring together with my surgical judgment and technical abilities. The artist in me helps me see a better aesthetic in terms of harmony and balance of the human body, and I use it to help my patients obtain the look they want for themselves, regardless of the type of plastic surgery procedure they are undergoing. It’s been very fulfilling.
Some patients have revision or secondary surgeries after breast augmentation. Why?
The most common reason that a woman will want to have a revision surgery is because they want to go larger. Sometimes a woman, or her doctor, selects a smaller implant and after some time the patient wants larger breasts and will therefore undergo a revision surgery. I spend a lot of time in the initial consultation and use sizers that the patient will wear in their bra for a few days to make sure that we get the size right the first time. The second most common is called capsular contracture and that’s just a big fancy term for scar tissue that forms around the implants. Normally when an implant is placed inside the body, any kind of implant even a pacemaker or some other kind of health device, the body forms some scar tissue around it which is normal. Sometimes that scar tissue becomes firm which happens about fifteen to twenty percent of the time. We don’t know the exact reason why this happens but sometimes it does, and it can happen even 20 years after surgery. In this case, the scar tissue needs to be released so it results in a revision or secondary procedure. Occasionally, we do see breast surgery results that are less than ideal and the patient is unhappy because their augmentation has been performed by a doctor who is not properly trained in plastic surgery. So my advice is always to seek the expert care of a board certified plastic surgeon. That way they can be certain that the doctor has been properly trained and credentialed.
What about male breast surgery?
Gynecomastia, which is excessive fatty tissue in the male breast, is actually very common. I see two different types of gynecomastia, fibrous tissue and fatty tissue. There are many different reasons as to why some men have this condition, whether it is hormonal or genetic. Both types have excess tissue but the differences are obvious. In the case of fibrous tissue, the male patient often presents with a little nodule in the breast, whereas fatty tissue is more all over excessive tissue much like fatty tissue on other areas of the body. In the past the only way to remove the tissue was to surgically excise it. For the past five years or so I’ve been using a laser technique to remove the tissue and it provides excellent results. The nodule will still have to be surgically excised but we can keep that to a minimum and remove the remaining excess tissue by melting it with the laser. Then I will perform a light liposuction procedure to take out the remaining fatty tissue. The lasers also helps tighten the skin so the patient is left with a soft but firm and tight chest. What is most interesting is that many of the men with gynecomastia are generally slim with no excess fat anywhere else, or are even athletically built but cannot get rid of that excessive tissue.
Can you explain more about your breast reduction technique?
Breast reduction is performed when a woman feels that her breasts are too large. The patients that I see are often suffering from the weight of their breasts which can be causing neck pain and back pain, as well as a decreased ability to exercise. There is certainly a functional problem with having large breasts and these patients generally get to a point where they just cannot take it anymore. So fortunately when I did my plastic surgery training, I was trained in many innovative techniques to do a breast reduction. I was also taught how to minimize the scarring because notably with any breast reduction procedure, there will be a fair amount of scarring. So often my breast reduction patients are some of my happiest patients because not only have I helped them to look better and feel better about themselves, but I’ve also helped them remove symptoms of neck and back pain too. Breast reduction is a procedure that is frequently covered by health insurance because it does provide a direct health benefit to the patient. The procedure itself is more invasive than a breast lift or augmentation procedure, or even a gynecomastia procedure because it does require the removal of a lot of tissue as well as the repositioning of the nipple in many cases. At first the patient is quite sore from surgery and cannot lift or do any aerobic type of exercise for two to four weeks following surgery. While the scarring is as light as possible, there is some scarring that will take up to a few months for the redness to subside and for the scar to become less obvious. Over time the scars heal, the patient feels much lighter and able to do so much more physically. I am thankful to say that my breast reduction patients are generally my happiest patients.
How do you help women recovering from a mastectomy following breast cancer removal?
I trained as a general surgeon for five years and performed many breast cancer procedures. When I transitioned to become a board certified plastic surgeon I received more expert training in breast reconstruction. I love to be able to help patients restore their breasts after a mastectomy as it is particularly rewarding to see the difference it makes in their overall return to health and to life following cancer treatment. Unfortunately, about one in eight women develop breast cancer over their lifetime. The statistics are pretty shocking. No one really knows exactly why so many women get breast cancer. There are other ways to treat breast cancer besides a total mastectomy, and the cure rates have improved over time. However, I feel as a plastic surgeon it feels wonderful to be able to help these patients through their process and restore or reconstruct them back to having a beautiful breast. When a patient has been diagnosed with breast cancer I will often work in tandem with the general surgeon who will perform the mastectomy part of the procedure where they remove the breasts. Then I will begin the reconstruction aspect. The reconstruction is actually performed over several months and generally begins by placing a tissue expander – which is like an inflatable balloon – under the chest muscle. Once the expander is in place and the chest has been stitched, the patient will spend a few weeks to a month recovering from both procedures. Once we know she is healed from the mastectomy, she will return to my office so we can begin to inflate the expander. I use sterilized saline water to inflate the expander. Usually we start with a small amount of saline to begin to lift the tissue and then each week we inject more saline to slowly and gently stretch the breast. The skin will stretch over the course of a few months and ultimately a breast implant will replace the expander. The results so far have been fantastic.
Do you feel your particular approach to breast surgery is unique?
Personally, I’m honored that as a plastic surgeon I get to use my artistic creativity and combine it with my surgical and technical skill. I believe that is somewhat unique. I also spend a good deal of time communicating with my patients, and I really individualize each plan based on the patient’s needs and wants. Whether it’s providing a minimal scar approach to a breast lift, or perfect balance and harmony after reconstruction or augmentation, I do have some specific techniques that I’ve developed over the years which make my practice unique in its approach, as well as a highly recommended center for patients seeking any form of breast surgery.
Holcomb Kreithen Plastic Surgery is renowned for its expertise in facial plastic surgery, plastic surgery of the breasts and body and cosmetic laser surgery. Additional core areas of focus within H|K MedSpa include non- and minimally-invasive body contouring, facial aesthetics, medical hair restoration, laser skin rejuvenation and medical skin care. With its comprehensive range of services and dedicated staff the practice has developed a reputation as one of the most advanced centers in Florida. Receipt of the Allergan “Black Diamond Award” is an objective benchmark for the practice’ success, ranking it among the top 1% of practices in the entire country providing Botox Cosmetic, Juvederm (including Voluma) injectable gel, Latisse, Natrelle breast implants and SkinMedica skin care. To learn more visit www.sarasota-med.com.
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