Top 20 advances in plastic surgery and aesthetic medicine in the past 20 years Part 2

6. New materials for internal bra to maintain breast shape after reduction/lift

 When a breast needs to be lifted, it is because the skin envelope and the internal ligaments have weakened, yet surgeons have always had to rely on them for support. That is why breast lifts and breast reductions tend to lose fullness in the upper part of the breast regardless of how well the operation was performed. The concept of the internal bra is to add the support that the patient’s own tissues cannot provide. One of the first materials used for this was Seri scaffold, made from purified silk. I gave the first presentation on this at a plastic surgery meeting, and we participated in the first clinical trials.


I have been working on the internal bra concept for many years. The product we use most often now is Galaflex mesh, which we also helped prove in clinical trials. It is made from a natural biological molecule and is very biocompatible.

7. Progressive tension sutures for better results with tummy tucks

This one actually pre-dates the 1998 live webcast, but we didn’t know it as progressive tension sutures (or PTS) at the time. When I published an article on the technique in 2001, we had already determined that it enabled the drain tubes used with tummy tucks to be removed much sooner. It also gives more control over the location of the scar.

8. Reduction of capsular contracture with insertion funnel

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Despite significant advances in understanding the causes of capsular contracture (a hardening of the scar capsule that forms around breast implants), it remains a problem. With the introduction of the Keller Funnel, a sterile plastic sleeve used for implants placement, the incidence is now less than 2% in our experience. In 2015 we co-authored a study documenting lowered rates of capsular contracture with the funnel. 

9. Immediate post-mastectomy breast reconstruction

This one’s a biggie, as it combines several of the other advances. In the early days of breast reconstruction after mastectomy for cancer, results were frankly not very good and patients were often required to have several months of healing time before even starting. Now it is increasingly common for the plastic surgeon to place an implant immediately after the mastectomy, potentially completing the cancer treatment and the reconstruction all at once.

For this to happen, three things had to be proven: First, the safety of skin-sparing mastectomy; second, the use of ADM (Alloderm); third, improved shapes and options for implants. Although I no longer do reconstructive surgery, I am really happy to have helped prove the case for ADM’s and been involved in setting things in motion.

But even as immediate reconstruction has become increasingly available, awareness of the option has lagged. Reconstruction can’t happen if women are not informed in time to make an unhurried decision! In 2012, the American Society of Plastic Surgeons launched a campaign called BRA day (for Breast Reconstruction Awareness) to be held every October 17. It consists of both local grassroots events and national efforts. In its first year I held the Seattle BRA Day Soiree, featuring a tango show organized around empowering themes of Beauty, Time, Wisdom, Choices, and Awareness, choreographed by Michelle Badion along with performances by some of Seattle’s best tango dancers, and bandoneon player Ben Thomas.


10. Rise of the injectables

It’s hard to believe now, but in 1998 the only injectable filler was collagen, and even that was a radically new thing. With so many options now, we can customize and fine-tune the aesthetic result. Voluma adds volume that is lost with aging, Vollure addresses wrinkles in the midface, and Volbella gives natural but fuller lips.

Oh and let’s not forget Botox, controversial at first but now commonplace. In fact I started using Botox in the mid-1990’s, but it was off-label for cosmetic use so we couldn’t really promote it much. Once it received the FDA’s blessing for wrinkle treatment in 2002, there was no looking back. There are several other brands of Botulinum toxin now on the market or in the pipeline, but as Xerox is to photocopying and Kleenex to tissue, Botox continues to define the category.

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