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When it comes to breast reconstruction, there are several considerations patients need to take into account.

Breast reconstruction is the surgical restoration of breast shape and volume after mastectomy (complete removal of breast tissue), usually due to breast cancer. The breast surgeon performs the mastectomy and the reconstruction is typically done by the plastic surgeon.

The main considerations for breast reconstruction are timing and method. Immediate reconstruction is done on the same day as the mastectomy while delayed reconstruction is done months or years later. The reconstruction can be achieved using the patient’s own tissue from another part of the body (autologous reconstruction) or with a breast implant (alloplastic reconstruction).

When should it be done?

Before the 1990s there were fears that immediate breast reconstruction was unsafe
and that early reconstruction could risk cancer recurrence. However, studies have shown that immediate reconstruction is as safe as delayed reconstruction for early-stage breast cancer.

Pros and cons

In immediate breast reconstruction, skin-sparing mastectomy is performed. This removes the breast tissue and nipple-areolar complex while keeping the skin. The plastic reconstructive surgeon then restores the breast volume within this breast skin envelope. The ability to preserve the native breast skin envelope is important to produce a natural-looking result.

In delayed breast reconstruction, the breast tissue and overlying skin are removed. This leaves more scars and the breast looks less natural compared to immediate reconstruction.

Immediate reconstruction has a positive benefit for the patient, who awakes from surgery without feeling the loss of body form, and is more cost-effective. However in advanced breast cancer, delayed breast reconstruction is preferred since the risk of recurrence is higher.

Reconstruction methods

Reconstruction should ideally be performed using the principle of “replacing like with like”. Therefore, autologous breast reconstruction using the patient’s own tissue is preferred. The result is long-lasting and the reconstructed breast appears more natural in appearance and consistency.

The transverse rectus abdominis myocutaneous (TRAM) flap is the most common autologous breast reconstruction procedure. Like a tummy tuck, this removes excessive lower abdominal skin and fat with a portion of the abdominal muscle, transferring it to the breast for reconstruction. The result is a flatter tummy and reconstructed breast. Patients who have had caesareans may also undergo this procedure.

TRAM flap reconstruction is unsuitable for women who wish be pregnant after the treatment. The latissimus dorsi (LD) flap is more suitable for them. The LD is a fan-shaped muscle on the back. It does not provide much volume and a breast implant may be added.

Breast reconstruction using implants is a simpler and faster procedure. The recovery process is less complicated. Sometimes, a tissue expander is used to serially stretch the skin before placing the definitive breast implant. It may be also more difficult for the implant to match the shape of the contralateral unoperated breast. In the long run, implant replacement may be required in the event of rupture or capsular contracture (scarring around the implant). The initial cost of implant reconstruction may be lower than autologous breast reconstruction, but the long-term cost may even out.

Additional procedures

Nipple reconstruction is planned four to six months after the first stage of breast reconstruction. Local tissue is used to reconstruct a new nipple. This is followed by nipple areolar tattooing one to two months later.

Fat transfer can subsequently be introduced to correct contour imperfections, if any, of the reconstructed breast.

Advancements in medical science, technology and techniques have made cosmetic surgery safer, more effective and the results more natural-looking.

Surgery is the gold standard for facial rejuvenation and imparts the most lasting and dramatic results. Since the 1900s, facelifts have been used to reduce the appearance of sagging skin, iron out wrinkles, tighten and return shape to the brow, cheek and jaw and lift loose folds in the neck.

Since then, surgical facelift procedures have advanced by leaps and bounds. There are many surgical options to choose from – each addressing a specific area of the face and neck. Techniques have also become more refined and safe, with less scarring and quicker healing.

Types of lift

The areas that droop with age include the brow, mid-cheek, lower cheek and neck. There
are several types of facelifts available and the choice of procedure depends on the issues to be addressed and the extent of skin laxity. It is ideal to perform conventional facelift with a neck lift or browlift for a more harmonious result.

Conventional facelift

A conventional facelift is ideal for older people or those with severe laxity. There are several classifications and terminologies which are often confusing to the patient. In a long scar full facelift, the incision starts from the temporal area, passing in front of the ear and curving backwards behind it. A short scar face lift dispenses with the temporal incision and minimises the cut behind the ear. The longer the incision, the greater amount of laxity to be addressed.

The skin is then separated from the underlying tissue layer (called SMAS), redraped and shifted. The SMAS layer
is sutured to provide strength to the lift and any excess skin is trimmed. This type of facelift is the longest lasting and achieves the most dramatic results.

In recent times there has been great interest in the mini facelift. This involves a shorter scar, less tissue separation, reduced swelling and bruising, and shorter downtime. The result may not be as drastic as a full facelift, and most patients can return to work within one to two weeks after the procedure.

Browlift

A brow lift corrects sagging skin in the forehead, upper eyelids, and eyebrows. Also called a forehead lift, the procedure restores the appearance by correcting a heavy, sagging brow, and smoothing out deep furrows, to the upper third of the face. It is usually done with the use of an endoscope via several small incisions behind the hairline. The forehead skin is lifted and secured with sutures fixed to the skull. The result greatly complements a facelift.

Threadlift

Patients with mild skin laxity and redundancy may opt for a less invasive threadlift procedure. Threadlifts last for up to two years and are repeatable as new threads can be attached or existing ones adjusted.

The procedure is done under local anaesthetic and sedation and involves placing specially designed surgical threads under the skin in different positions using a thin needle. These implanted threads have barbs or cones which are pulled in different directions to lift the sagging skin. Side-effects include bruising and swelling which may resolve within a week.

Non-invasive lifting procedures

Minimally invasive or non-surgical facelifts are increasingly popular though they do not offer the same results. They are a good option for those who do not wish to undergo surgery. They generate heat damage to the collagen in the deep dermis resulting in regeneration and lifting. Some of these treatments are based on infrared, focused ultrasound and radio frequency.

Filler injection has been inappropriately termed as a face lifting procedure. Strictly speaking, a lifting procedure is anti-gravity and has a single direction of pull with stable fixation of tissue. Fillers provide generalised multi-directional distension of tissue with volumisation effect.

There is no ‘right’ or ideal procedure as it all depends on an individual’s desired results, the shape of his or her face and the extent of laxity. It is important to speak with your surgeon on the most suitable procedure appropriate for your unique case.

The quest for youth has spurned a multi-billion dollar industry. Today, the multitude of rejuvenation options is bewildering. A person’s choice of rejuvenation technique is generally determined by his or her physical state, tolerance for pain and downtime, and financial constraints.

The clinical problems that we commonly address include pigmentation, superficial textural imperfections, wrinkles (dynamic or static), deep folds or contour deformities, and skin laxity.

Rejuvenation options are divided broadly into non-invasive (non-surgical) and invasive (surgical) procedures with a few options in the “borderline” zone. Patients should be aware that all these rejuvenation techniques have a common goal of causing controlled damage to the various layers of the skin in order to stimulate repair and regeneration. Sun avoidance and strict usage of sunscreen are the keys to maintaining the results and preventing hyperpigmentation.

NON-INVASIVE (NON-SURGICAL) PROCEDURES

The most common form of phototherapy treatment is Intense Pulsed Light (IPL) or Broadband Light (BBL), which is able to improve the general complexion, lighten pigmentation, improve fine wrinkles and mildly tighten the skin. It is also effective for permanent hair removal. IPL/BBL is a suitable option for regular maintenance without downtime.

To achieve further textural improvement to the superficial layer of the skin, laser resurfacing is more effective. Erbium Yag lasers or carbon dioxide lasers are commonly used to ablate a thin epidermal layer. Erbium Yag is more suited for Asian skin types than carbon dioxide laser. The treated area will be raw and require regular application of antibiotics; the downtime for microlaser peel is around 3 to 5 days, after which a patient can resume putting on makeup.

Various treatment modalities are available to further tighten the dermal layer to for lifting and improvement of static wrinkles. Profractional Erbium Yag (or carbon dioxide) laser, radiofrequency, focused ultrasound and infrared waves can be used to cause thermal injury to the dermal collagen and elastin in a controlled manner. This induces regeneration of new collagen with a skin-firming effect. The clinical results are best assessed 3 to 4 months after the procedure, though most patients would notice improvements after about a month.

Botulinum toxin injection is the standard treatment for dynamic wrinkles – i.e., wrinkles that are worsened by facial animation. Effects usually last for 3 to 4 months. Mild bruising may be present at the needle entry sites. Clinical judgement needs to be exercised to deliver the optimal amount of toxin to alleviate wrinkles without causing an unnatural mask-like appearance.
Filler is used to replace volume; it can correct static deep facial folds (e.g., tear troughs and nasolabial folds) and contour deficits (e.g., sunken temporal areas), and can volumise the cheeks for a more youthful appearance. Filler provides an alternative for those patient who wants augmentation of the nasal dorsum without undergoing rhinoplasty. However, very rarely, the injection of filler into the nose can result in blindness or tissue necrosis. The chemical composition of fillers can be biological (e.g., hyaluronic acid or collagen) or synthetic (e.g., polytetrafluoroethylene). Synthetic fillers may last for more than a year but there is risk of infection and granuloma formation. In the interest of safety, shorter-acting filler material is preferable.
Botox and fillers complement each other, and some patients require both for optimal outcome.

INVASIVE (SURGICAL) PROCEDURES

Fat transfer (grafting) has gained much popularity over recent years as a method of volume replacement. Fat is a good filler option because it is autologous and contains a small amount of stem cells with rejuvenating properties. Fat grafting has been shown to improve the healing of post-irradiated chronic wounds. The final result is firmer skin with increased volume and improvement in wrinkles; the procedure may be repeated for a better cumulative result.

A thread lift procedure provides added levels of skin lifting to the cheeks and temporal area. Several threads made of absorbable material are inserted skin deep and stabilised by suturing to the temporal area. Swelling and bruising can last for a few weeks. The initial appearance may appear over-corrected; this normally improves over a few weeks to months. The clinical effects may last for one to two years.

Common surgeries for facial rejuvenation include blepharoplasty (eyelid surgery), brow lift, temporal lift, facelift and neck lift. These procedures can be done as a single procedure or as a combination, depending on the clinical state.

Upper eyelid surgery (blepharoplasty) can be done to create or improve the configuration of double eyelid or remove excessive droopy skin. It is therefore suitable for young patients who wish to create upper lid folds or older patients with droopy and puffy eyelids.

Ptosis (drooping) of the upper eyelid can co-exist with excessive skin. Not all patients with excess skin have ptosis. The various methods of ptosis correction depending on severity include levator plication or advancement, and in more severe cases something referred to as the FOOM flap.

Eyebags are caused by excessive fat accumulation and also laxity of skin and the orbital septum containing the bag of fat. Lower blepharoplasty can address both eyebags and excessive lower lid skin. There are two methods to remove eyebags: subciliary lower blepharoplasty (external method) and transconjunctival lower blepharoplasty (scarless method).

Subciliary lower blepharoplasty is suitable for patients with excess lower eyelid skin and fat pocket. Removal of fat would result in the gathering of excessive loose skin. Transconjunctival lower blepharoplasty is suitable for young patients with no skin laxity/ excess. The fat pocket is removed via a small cut in the back of the lower lid leaving no scar on the exterior.

A facelift and neck lift would address the problem of a sagging chin and jowl. The contour of the neck can be further improved by dividing the muscle band of the neck (platysmal band division for turkey neck deformity).

Endotine facelift is done via small incisions in the hairline, into which Endotine fixation devices are inserted. These are absorbable strips with small claws to lift up the cheek, jowl and neck. They are absorbed in about 3 to 6 months. Thus, Endotine lifting is suited for patients who do not have significant skin excess.

I often counsel patients that surgery to rejuvenate one area of the face may cause the neighbouring non-operated structure to appear out of sync. For example, in severe ageing eyelids, surgery to improve the eyebags without an upper eyelid procedures may cause the upper lid to appear slightly out of place. It is essential to understand that all features of the face age together. To achieve a harmonious appearance, a combination of procedures may need to be done simultaneously to address the various ageing features.

What happens during the ageing process?

The skin becomes thinner with loss of ground substance, collagen, elastin fibres and, occasionally, fat. This is accompanied by uneven accumulation of pigments. The result is deterioration of skin texture and colour, wrinkles, skin laxity and loss of volume.

How do you formulate a rejuvenation regime?

Every patient requires a personalised regime.
I identify the most significant problems and the ones that bother the patient most. I plan the regime based on the patient’s work schedule, tolerance for downtime, pain threshold, risk adversity and financial constraints.

What are the simpler rejuvenation techniques?

For improvement of skin texture, pore size, pigmentation and fine wrinkles, I recommend intense pulsed light (IPL) or broadband light (BBL). This treatment is well tolerated and has no down time. Clinical results are usually seen within two to three treatments up to one month apart. Some patients report results as early as one week after treatment.
Botulinum toxin injection is the standard treatment for wrinkles which are worsened by facial animation. It can improve crow’s feet, frown lines and forehead wrinkles and its effects usually last for three to four months. Clinical judgement is needed to alleviate wrinkles without causing an unnatural mask-like appearance.
Filler replaces volume to correct deep facial folds and volumise the cheeks for a more youthful appearance. For non-surgical augmentation of the nose, fillers can be a temporary alternative. Most fillers are composed of hyaluronic acid which lasts for about six months. Long-lasting filler materials are associated with side-effects such as infection and granuloma formation.
Botox and fillers complement each other and some patients require both.
Several non-invasive therapies are available to tighten the skin moderately. These include the use of infrared wave therapy (Sciton SkinTyte®), radiofrequency (Thermage®), and focused ultrasound (Ultherapy®). Post-procedure oedema and erythema commonly resolve within a few days, but clinical results may not be as dramatic as ablative laser procedure.
Microlaser peel (resurfacing) can further improve superficial skin texture, and the patient can put on make-up about three to five days after the procedure.

What of moderately complex techniques before surgery?

Profractional laser is used to achieve further skin tightening. This ablates narrow channels into the skin, and is used to treat atrophic acne scars. The healing process is faster and patients can return to work in a few days.
Thread lift provides added skin lifting to the cheeks and temporal area. Several barbed threads made of absorbable material are inserted skin-deep and stabilised by suturing to the temporal area. The initial appearance may appear over-corrected but normally improves over a few weeks to months. The effects can last for one to two years. Fat injection (grafting) has become popular for volume replacement. Fat tissue contains stem cells with rejuvenating properties which are harvested from the abdomen or thighs and processed before being injected. Post-procedure swelling and bruising last for a few weeks, and the final result is firmer skin with increased volume and improvement in wrinkles.

How do you devise a surgical plan for facial rejuvenation?

Ageing affects each part of the face at different speeds and times and this must be understood in the context of the desire for facial rejuvenation.

爱美是人的天性，也正如此，无论是古时或今日，男男女女不断采用各种手法或护理，努力让自己拥有美丽的肌肤和漂亮的容颜。

一些临床问题包括：色素、表层结构缺陷、皱纹（动态或静态）、深褶、畸形轮廓和松弛皮肤。

面部年轻化（facial rejuvenation）疗程可分为非手术疗程（非侵入性）和手术疗程（侵入性）。这些疗程都有个共同点，即对不同皮肤层进行控制性破坏，刺激修复和重生功能。

非手术疗程（非侵入性）

最普遍的光线疗法是IPL或BBL（broadband light）。它们能够同时改善多个肌肤问题，如斑点、皱纹、疤痕等等，让肌肤达到更加紧致、饱满、明亮及年轻化。

若想让皮肤表层取得更大的效果，激光换肤是理想选择。Erbium Yag 激光或二氧化碳激光是用来消除表皮层的一般做法。Erbium Yag 激光的其波长接近水的吸收能力，热能量更低，对周围邻近组织的热损伤也更小，尤其适合亚洲皮肤。处理后的皮肤需涂抹抗生素。微激光焕肤的康复期是3-5天，之后病人就可上妆。

为进一步紧缩外胚层，改善静态皱纹，顾客可选择不同的疗程模式。Profractionl Erbium Yag（或二氧化碳）激光、射频（radiofrequency ） 、聚焦超声（focused ultrasound）和红外（infrared wave）波可在控制的情况下，对真皮胶原和弹性蛋白造成热伤，从而刺激新胶原再生，达到紧肤效果。

传统激光换肤烧蚀整个处理范围。Profractional激光仅烧蚀皮肤窄道，这让上皮可以更快地再生。Profractional激光一般用来治疗萎缩性痘疤（atrophic acne scars）。

肉毒杆菌（botulinum toxin）具有瘦脸淡化皱纹的功效，主要用来出来抬头纹、眉间纹及鱼尾纹等，效果一般可维持3-4个月。

填充物（fillers）适合处理静态面部皱纹如泪沟（tear trough）和鼻唇沟（nasolabial fold），以及轮廓缺陷如太阳穴凹陷（sunken temporal areas）。它也能用来让两颊看起来更加丰润，肤质更紧实细致。肉毒杆菌和填充物有辅助作用，一些病人必须两者兼具，才能取得最佳效果。

手术疗程（浸入性）

移植脂肪整容术（fat transfer）近年来深受欢迎，它是指将人体自身脂肪较丰富的部位如腹部或者大腿等处的皮下脂肪细胞，用负压吸脂方法吸出，经过特殊处理后，通过注射的方式在移植到需要进行脂肪填充的部位。由于脂肪是自体移植，还含有一小部分具年轻化功能的干细胞（stem cells），因此是理想的填充物选择。这项疗程也对化疗后的慢性伤口有疗效。

微针拉皮（thread lift）利用可与人体相融并被自然分解的幼细材料穿入皮下组织内，将松弛下垂的皮肤上提拉紧，适用于眉毛和双颊皮肤的提升。

面部年轻化（facial rejuvenation）的常见手术包括眼皮整形（blepharoplasty）、提拉眉术（browlift）、太阳穴提拉术（temporal lift）、面部拉皮（facelift）和提拉颈术（neck lift）。这些手术可单一进行或配合多项手术进行，情况视顾客实际状况而定。老化的下垂眼皮（aged droopy eyelids）可能结合眼皮整形、提拉眉术或者太阳穴提拉术等。

眼皮整型手术（blepharoplasty）是修饰眼睛周围下垂和松弛的组织的外科手术。若要消除眼袋（eye bag removal），可能必须把多余的皮肤赘肉和脂肪除掉或者重新分配（fat redistribution）。这项手术可结合迷你拉皮（mini facelift），取得更和谐的整体美。

下垂下巴（sagging chin）和颌（jow）可能需要结合脸部拉皮和提拉颈术，通过去除颈阔肌让松弛颈项（turkey neck）达到紧实效果。

Who would potentially require breast enlargement?

Patients with a natural breast volume deficiency, that could affect their level of self-esteem and choice of clothes.

“Some patients need enhancement due to breast volume deflation after pregnancy and breast feeding. A smaller group seeks correction for severe volume discrepancy which may be in-born or post surgery,” said Dr Ng.

What are the various methods of breast enhancement?

There are surgical, non-surgical methods and combination of both. Patients who are not keen in foreign material may consider the Brava (negative suction device) or a combination of Brava with fat transfer to the breast.
Artificial filler injection has been controversial and associated with undesirable complications.

Is fat transfer to the breasts effective?

Each session of fat transfer to the breast can increase the volume by half to one cup size. This can result in soft and natural breast consistency.

Fat is harvested from the abdomen and thighs in a non-traumatic fashion. It is then processed after centrifugation.

Injection is given carefully in the subcutaneous layer of the skin to ensure optimal survival of the fat cells. Non-surviving fat cells do not turn cancerous but leave behind calcification that may cause confusion during mammography.

Several sessions may be necessary to achieve the desired outcome.

What are the various types of breast implants and are they safe?

Breast implants can be filled with saline or silicone. They are either circular or tear drop (natural profile) in shape.

To most common implant used nowadays contains cohesive silicone gel in tear drop shape. This type of implant simulates the natural appearance of the breast and its content resists extensive leakage even when the implant is ruptured.

Silicone breast implant has good safety record.

What are the considerations when choosing breast implants?

The main points of discussion with your surgeon would include size, type of implant, location of the cut and placement of the implant.

The most common incision is at the breast fold. This incision affords easy access and allows more accurate orientation of tear drop shaped implant.

Incision in the armpit used to be popular with round implant.

Incision around the areolar can affect nipple sensation and limit the size of implant if the areolar is small.

“For most Asian patient with smaller breast volume, the implant is usually placed behind the chest muscle (subpectoral). This placement provides more soft tissue coverage and reduces the incidence of capsular contracture (scarring) around the implant,” said Dr Ng.

What is the recovery process after breast implant surgery?

Breast enhancement is a day surgery procedure.

Most patients return to work within a few days and the swelling and bruising would resolve in about two weeks. Self-massage would be taught to hasten the recovery.

Q: What aspects of the nose do most patients want correction?

A: A Rhinoplasty or commonly referred to as a “nose job” can be done for cosmetic or corrective purpose. Common problems include a low nasal bridge, bony hump, crooked, broad and drooping nasal tip, widened alar base and retracted columella.

Q: How does a nose job change the face ?

A: A good nose job can make the face appear slimmer, sharper and more three-dimensional. From the side profile, the angle between the columella and the lip would be improved. For patient with a receded upper lip (which makes them appear older than their age), this can make them look younger.

Q: What are the various methods to augment the nose?

A: These are minimally invasive and surgical procedures. Minimally invasive procedures are unable to produce all the features of an ideal nose.

Examples include hyaluronic acid filler injection and thread insertion. The latter technique is still fairly new and the long term risk of scar formation and thread extrusion is unknown.

Surgical techniques include closed and open rhinoplasty which is more versatile.

Q: Can filler injection alone do the job ? Is it safe?

A: Filler injection can improve the height of the nose bridge. It is not able to narrow a broad nose tip or wide alar base. It provides immediate result which lasts for about six months. Infrequent complications include alar skin tissue loss and blindness.

Dr Ng Siew Weng, a consultant plastic and reconstructive surgeon of Sweng Plastic Aesthetic and Reconstructive Surgery, said “I have encountered several patients who had received repeated filler injections by their previous doctors, resulting in a broad and undefined nose bridge due to migration of filler. Filler in this region may take longer to resolve compared to injection elsewhere in the face.”

Q: Tell us more about rhinoplasty using a L-shaped implant.

A: This short procedure can improve the dorsal height and tip projection. It has limited ability to augment a contracted columella or narrow the nose tip and alar base.

“In Korea where I had my advanced training, the L-shaped implant is infrequently used by rhinoplasty surgeons due to frequent implant extrusion and deviation,” said Dr Ng.

Q: What are the different types of rhinoplasty ? What is involved ?

A: Rhinoplasty can be divided into open or closed procedure. Closed rhinoplasty involves only a small cut inside the nose. Its efficacy is limited compared to open rhinoplasty which visualises all the structures in the nose for definitive correction.

The typical Korean-style open rhinoplasty for an Asian nose involves a small cut across the columella, placement of silicone implant, cartilage from the nose septum and ear cartilage to achieve a natural-looking and refined nose profile. Some patients do not have sufficient cartilage of their own and rib cartilage may be used.

Q: Recovery process after rhinoplasty ?

A: After surgery the nostrils are sponge dressed to prevent bleeding for 24 to 48 hours. Patient wears a supportive splint over the nose for one to two weeks. Sutures are removed after one week.

Most patients are able to return to work in one to two weeks. The swelling subsides after a month and the final result will be assessed in about three to six months.