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Archive for the ‘breast lift’ Category

Galaflex Mesh in Breast Lift Surgery

Sunday, April 23rd, 2017

Correction of the sagging breast with various breast lift procedures is an important part of breast rejuvenation surgery. Many different types of breast lift procedures have been described over the past century and all involve the use of skin removal and breast envelope tightening to create their effects. Unfortunately the thin breast skin is well known to stretch out and does not usually do a good job of maintaining the lifted breast by itself.

Adding to the armamentarium of the plastic surgeon for breast lift techniques has been that of parenchymal sculpting. This is where the breast tissue itself (not the skin) is reshaped and lifted back up onto the chest wall and secured. This adds to a breast lifting effect and helps to take some of the necessary support off of the tightened breast skin. But often breast skin tightening and parenchymal sculpting still does not provide pleasing long-term results.

A more recent innovation and breast lifting technique has been the implantation of various synthetic meshes. By creating a sling across the lower pole of the breast an additional layer of support is added which theoretically aids the lifted breast long-term.

In the January 2017 issue of the journal Plastic and Reconstructive Surgery, a paper entitled ‘Use of Poly-4-Hydroxybutyrate Mesh to Optimize Soft-Tissue Support in Mastopexy: A Single-Site Study was published. Over a two-year period, 11 consecutive patients underwent a breast lift with the placement of Galaflex mesh across the lower pole. 3D scans were done for postoperative assessment out to one year after surgery.

There were no complications or infections in the study. Postoperative breast settling occurred between 1 and 3 months after surgery with lower pole stretch of 5% and an average of 8mms increase in the nipple to inframammary fold distance. No significant change occurred from 3 to 12 months after surgery as measured from the sternal notch to inframammary fold distance.

Similar to repairing a hernia, the use of mesh is breast surgery is to reinforce weak tissue.  Galaflex is a unique and newer synthetic mesh. It is composed of poly-4-hydroxybutyrate polymer which is a high-strength and resorbable monofilament fiber. It maintains its initial strength out to 3 months after which it remodels and is replaced by collagen (scar)  by one year after surgery. The fact that it is resorbable and replaced by one’s tissues is an appealing feature, particularly in the thin lower pole skin of the female breast.

More clinical work is needed to determine the longer term results of Galaflex in breast lift surgery. But the concept remains very appealing has the lifted breast is not very resistant to the effects of gravity.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Combination Breast Implant and Lift Surgery

Sunday, January 15th, 2017


Background:  The breast is subject to many changes from the influences of time, gravity, pregnancy and fluctuation in weight. But whatever the cause the changes are very typical, loss of breast volume and sagging. Efforts to reverse these negative shape changes are also very consistent through the addition of volume and lifting and tightening the breast skin.

Breast implants can have a lifting effect but it is not as significant as many patients hope. The lifting effect of an implant works best when the breast sag is no greater than the nipple being ideally above the lower breast fold or even just at the fold level. Because one of the effects of implant expansion on the breasts is to fill out the lower pole and even lower the level of the fold to accommodate the additional volume, the nipple and the breast mound will seem to be lifted. This change is partly illusionary but there is some real lift involved also.

Significant breast sagging, however, requires some type of breast lift even when implants are used. The two types of breast lifts that have real lifting power are the vertical (lollipop) and combined vertical-horizontal (anchor style) techniques. Combining implants and lift in a single breast reshaping operation is challenging as the two operations work against each other, one expanding the breast volume and the other lifting and tightening the breast mound. Getting the right balance between the two that can meet the patient’s expectations often requires more than one operation.

Case Study: This 32year-old female wanted to reshape her deflated and sagging breasts after having several children and losing weight. She had loose stretched out breast skin as well as asymmetry with the left breast sagging lower than the right.

Breast Implant and Lift surgery result front view Dr Barry Eppley IndianapolisUnder general anesthesia, she had vertical breast lifts which moved her nipple-areolar complex upward by 6cms on the right and 7cms on the left. Concurrently 500cc high profile silicone breast implants were placed in the submuscular position

Breast Implant and Lift surgery result oblique view Dr Barry Eppley IndianapolisBreast Implant and Lift Surgery result side view Dr Barry Eppley IndianapolisHer three month after surgery results show good implant positions, adequately lifted breast mounds up on the implants and good symmetry. Her breast scars remain red as expected at this point after surgery and will take another six months to lose the red color.

This combination breast implant and lift surgery had about as good a result as could be expected for this type of body contouring operation. Whether she will ever need a revision will now depend on how the scars mature and appear later. But many such breast reshaping operations will not do as well nor should patients expect them to do so. There are many variables in this operation that make for less than perfect results. The national average for the need for a revision in combination breast implant and lift surgery is over 30%. The most common reason is that the breast tissue remains inadequately lifted and tightened around the augmented breast mounds…or has dropped off of them a bit as the tissues have relaxed in the healing process.


1) Breasts that have lost volume and sag usually need a combination of implant volume and a lift.

2) The breast reshaping combination of breast implants and a lift is a challenging procedure to achieve good symmetric results in a single operation.

3) The revision rates in combination implant and lift breast operations is high and averages over 30%.

Dr. Barry Eppley

Indianapolis, Indiana

The Evolution of Breast Lift Scars

Saturday, October 22nd, 2016


Breast lifting is often needed in breast augmentation surgery when the nipples sits at or below the level of the inframammary fold. While there are four different types of breast lifts, the most effective of them involve the excision and tightening of skin beyond the areola on the lower pole of the breast.

Breast lifts create unavoidable scars that traverse vertically down the lower pole of the breasts and often along the inframammary fold as well. While not as visible as a scar that is on the upper pole of the breast, such healing scars are disconcerting to most women nonetheless.

late-breast-lift-scar-result-dr-barry-eppley-indianapolisLike all scars, breast lift scars undergo an evolution in their healing process. While many breast lift scars go own to look very acceptable, it is a long process of scar maturation to get there. Initially after surgery the scar lines from a breast lift look very fine with good skin color. This is because in the first few weeks after surgery there is a minimal inflammatory response along the incision lines. This fools patents because they mistakenly believe that this is the worst they will look and time will make them even better.

early-breast-lift-scar-result-dr-barry-eppley-indianapolisBut the very early appearance of breast lift incisions belies what is forthcoming. As the inflammatory response ensues and true healing of the incisions begins they will turn red due to the ingrowth of blood vessels. The scars will continue to turn red and will remain so for several months as the healing process continues. Once the incisions are fully healed only then will the color of them begin to fade. This scar maturation process can take six to nine months, and sometimes longer, to appreciate what the final appearance of the breast lift scars will be.

While breast lifts are always a ‘necessary’ aesthetic surgery in breast reshaping, they create their own adverse tradeoffs. While implants create an immediate and gratifying effect, the scars of breast lifts take longer to reach a satisfying conclusion

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Large Breast Implants with Vertical Lift

Friday, June 24th, 2016


Background: Breast sagging can be treated by either the use of a lift or an implant. A lift works by removing sagging skin and physically moving the nipple upward. Any lifting effect of an implant comes from tissue expansion with an outward and upward push. In many cases of breast sagging both a lift and implants are used because an implant can not really push the nipple up very much.

Many women understandably try to avoid the need for a breast lift by using a large breast implant. While this would seem to be an effective approach, the reality is that unless the nipple is at or above the level of the inframammary fold a large implant will push the nipple further down. Thus it becomes important to get the nipple moved upward by some form of a breast lift even if it is not a complete one.

Case Study: This 44 year-old female had lost some weight and had breast implants placed years ago. She was never completely happy with their small size and how they did not lift up her breasts. Since she has lost weight her breast sagging had become worse.

Large Breast Implants with Lift result front viewLarge Breast Implants with Lift result oblique viewUnder general anesthesia, vertical breast lifts were performed as well as breast implant exchange. Her existing 450cc saline implants were replaced with 900cc saline implants (700cc base size filled to 900ccs) Given her large and taller body size, this size of breast implant did not look too big.

Large Breast Implants with Lift result side viewEven with a larger breast implant size, a sagging breast may still not be sufficiently lifted. Only a formal lift through tissue excision and nipple-areolar relocation can  a breast be lifted. With larger breast implant sizes the type of breast lift can be affected. With larger breast implant sizes, the need for skin to accommodate that volume may eliminate the possibility of any horizontal skin excision. This leaves the vertical or the lollipop breast lift as the only breast lift of choice.


1) Many women want to lift their sagging breasts by implants alone but this rarely is successful.

2) Even with the use of larger breast implants some actual lifting of the breast is usually needed.

3) The size of the breast implant chosen affects the type of breast lift that can be used. (vertical vs anchor pattern)

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Vertical Breast Lifts with Implants

Saturday, April 30th, 2016


Background: Sagging of the breasts is a common result from pregnancies and weight loss. The loss of breast volume withdraws the support of the overlying breast skin leading to collapse of the breast mound. The breast mound then falls over the fixed inframammary fold creating a sagging breast appearance.

Breast Sagging classification Dr Barry Eppley IndianapolisThe classification of breast sagging is well known and is based on the location of the nipple relative to the inframammary fold. The relevance of this classification is in how it directs how the sagging breast is best treated and what type of breast lift is used to get the nipple back up above the inframammary fold.

In Grade II breast ptosis where the nipple sits just below the fold, the best correction is that of a vertical breast lift. Known as the lollipop lift because of its scar pattern, It moves the nipple vertically upward leaving a vertical scar between the nipple’s new position and its former location. In some cases, surgeons may try and make the periareolar or donut lift      work to avoid the vertical scar but the lifting effect will not be the same.

Case Study: This 35 year-old female had two children and lost much of her original breast volume. She wanted her breasts lifted and large breast implants placed at the same time.

Vertical Breast Lift and Implants result front view Dr Barry Eppley IndianapolisUnder general anesthesia, a vertical breast lift was performed raising the nipples 7 cms in the process. Silicone breast implants of 650cc high profile were after the lift was completed. The push of the large breast implants had its own lifting effect as well.

Vertical Breast Lift and Implants result oblique view Dr Barry Eppley IndianapolisVertical Breast Lift and Implants result side view Dr Barry Eppley IndianapolisHer one year result shows a major change in breast shape and size. Her vertical breast lit scars were remarkably imperceptible. The areolas were wider and the nipples ‘flatter’ as often happens after breast lift with a large implant push behind it.

The vertical breast lift is a very effective tool in the management of the sagging breast. While many women fear the resultant scars, in the right patient even large implants placed at the same time do not cause excessive widening or prolonged redness of the scars.


1) Vertical breast lifts and implants is a common combination breast enhancement procedure when ptosis occurs after pregnancy.

2) Vertical breast lifts are useful when the degree of breast sagging is modest with the nipple at or just below the inframammary fold.

3) The size of the breast implant placed partially controls how much breast lifting effect can be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Lifts with Implants

Wednesday, March 16th, 2016


Background: Severe sagging of the breasts occurs for a variety of reasons but the most common is weight loss. Weight loss creates the unaesthetic combination of excessive stretched out breast skin and loss of breast volume. Occurring together this allows many breast mounds to fall over the inframammary fold carrying the nipple with it. The empty sack of breast skin creates a very deflated breast appearance. While its look may be masked when compressed upward in a bra, its lack of support is very apparent without it.

Breast Sagging classification Dr Barry Eppley IndianapolisSevere sagging or Grade III breast ptosis always requires a full breast lift to get the breast mound and nipple back up on the chest wall. A full breast lift is an anchor pattern procedure with the result scars appearing like its description. It is identical to the breast lift component used in a breast reduction procedure. An implant is always needed for some degree of volume restoration and to create support to hold the breast lift up.

The combination of a breast lift with an implant, the so called implant mastopexy, is always a difficult procedure to perform and get consistently pleasing results. This is because the two aesthetic breast procedures fight against each other. The breast lift tightens and make the enveloping breast skin smaller. While the role of the breast implants is to push out and expand the overlying breast tissues. These two opposing forces can make it challenging to get the right combination of implant size and degree of breast lift. When one factors in the issue of secondary tissue relaxation after any lift, the naturally ‘stretchy’ nature of the breast tissues in the weight loss patient, the normal risks and complications that come from breast implants and that every woman has two breasts that ideally should match, it should be no surprise that the revision rate on this type of aesthetic breast procedure is significant.

Case Study: This 47 year-old female was bothered by the very saggy appearance of her breasts. While once having much larger breasts significant personally-induced weight loss caused her breasts to deflate and severely sag. She passed the ‘pencil test’ with flying colors. (placing a pencil under her breasts and it stays in place) She had a full Grade III ptosis with the right breast hanging lower than the left.

weight loss BAM LIft results front view Dr Barry Eppley IndianapolisUnder general anesthesia and using preoperative markings made in the standing position, a full breast lift was performed. The bottom part of the lift was left open through which anatomic shaped silicone breast imlpants of 450cc size were placed in the partial submuscular plane.

weight loss BAM Lift results oblique view Dr Barry Eppley Indianapolisweight loss BAM Lift result side view Dr Barry Eppley IndianapolisHer three months postoperative results show dramatic improvement in her breast shape and size. While her breast mounds appear to be in good position at this point after surgery, I would not judge the final result until six to nine months when full tissue relaxation has occurred. I would anticipate some residual drop of the breast mounds to occur over the implants with further tissue settling.

While early combination breast lifts and implant result may be very acceptable, the poor quality of the breast skin/tissues will inevitably make for some secondary tissue sag off of the implants. Whether that will be enough to bother the patient is a personal decision. But it is wise in combination breast lifts with implant surgeries to anticipate the potential need for a revisional surgery.


1) Severe sagging of the breast always has the nipple located below the inframammary fold and is associated with significant breast tissue loss.

2) Full anchor style breast lifts are needed with Grade III ptosis and an implant to restore volume to the elevated breast mound.

3) The revision rate for combined full breast lifts with implants in Grade III ptosis is as high as 50% or more due to secondary tissue relaxation of the overlying breast mound.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Breast Implant Surgery with IMF Lowering

Sunday, March 6th, 2016


Breast Sagging classification Dr Barry Eppley IndianapolisBackground: It is well known in breast implant surgery that the final shape of the breasts afterwards is highly influenced by what they looked like before. Besides asymmetry, the most common adverse breast shape problem seen in breast augmentation patients is sagging or ptosis. Such breast mound sagging can occur in many degrees of which most will require some type of breast lift technique to adequately address at the time of implant placement.

The most challenging breast sagging problem in breast implant surgery, in my experience and opinion, is the woman with a more mild or first degree breast ptosis. The amount of sagging they have is not quite enough to justify a breast lift. But there is enough sagging that the implants will likely drive down the nipple on the breast mound in a more downward direction or force most of the breast mound on the bottom side of the implant. This is a particular risk when the patients desires larger breast implant sizes.

In mild cases of breast sagging there are several strategies to help the breast mound and nipple get centered over the implants. The most common approach is to lower the inframammary folds (IMF) to center the implants over the low hanging nipple. An accompanying technique is a superior crescent mastopexy or an upper nipple lift. This simple technique helps move the nipple up on the breast mound up to 1 cm superiorly

Case Study: This 34 year-old female wanted breast implant surgery but had some moderate breast sagging after multiple pregnancies. She did not appear to have enough sagging to warrant a breast lift and did want such scars anyway. She also wanted larger breast implants.

Breast Implant Surgery with IMF lowering results front view Dr Barry Eppley IndianapolisUnder general anesthesia, 650cc silicone breast implants were placed in a partial submuscular plane through inframammary incisions. The original inframammary fold (IMF) creases were still evident above the new fold levels. The original inframammary fold creases were released right under the skin and rigotomies were also done using an 18 gauge needle. Superior nipple lifts were also done.

Breast Implant Surgery with IMF lowering result oblique view Dr Barry Eppley IndianapolisBreast Implant Surgery with IMF lowering results side view Dr Barry Eppley IndianapolisHer postoperative results show a centric nipple position on the enlarged breast mounds. Her nipple lift scars are barely noticeable at this early healing period. The original inframammary fold (IMF) creases are still present. Whether they will ever completely go away and round out remains to be determined.

Management of the persistent fold crease in breast implant surgery when the inframammary folds (IMF) are lowered can be done through several strategies. One technique is further rigotomies of the crease line with underlying fat grafting. Another technique is to reposition the implants up higher and re-establish the original inframammary fold levels.


1) Breasts that have mild to moderate degrees of sagging poses challenges in breast implant surgery.

2) Lowering of the inframammary fold (IMF) is one maneuver in breast implant surgery that can help avoid the need for a more formal breast lift.

3) Persistence of the original inframammary fold crease is one of the trade-offs, as well as the risk of bottoming out, when the inframammary fold is lowered in breast implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Correction of Tuberous Breasts

Monday, August 3rd, 2015


Tuberous breasts are a well known congenital breast problem that presents in varying degrees of deformity. It has its greatest impact with the patient who presents for breast augmentation and often adjunctive strategies must be done at the time of implant placement to get a good breast shape result. Women often recognize that their breast(s) are misshapen but don’t know the exact name of the deformity.

Tuberous breasts are characterized by a breast base constriction (narrow diameter), small breast development, a high inframammary fold and inferior pole skin shortage and the classic areolar herniation presentation. Since it presents as a spectrum of deformity several classification systems have been devised which can be used to help with matching the deformity with the type of corrective breast procedure needed.

In the January 2015 issue of the journal Plastic and Reconstructive Surgery the article entitled ‘Tuberous Breast Deformity: Classification and Treatment Strategy for Improving Consistency in Aesthetic Correction’ was published. Using 26 patients (51 breasts) a three-tiered classification system was used based on the degree of base constriction, level of the inframammary fold, breast volume, amount of skin envelope, degree of ptosis and amount of areolar herniation. What differentiates their classification system are the added descriptors of ptosis and areolar herniation. The surgical technique included periareolar incisions, glandular dissection down to the level of the new inframammary fold, radial scoring of the inferior dermoglandular flap, submuscular release and dual plane tissue expander or implant placements. Circumareolar lifts are performed lastly to correct ant ptosis and enlarged areolas.

Of the tuberous breasts treated, 12 type 1, 26 type 2 and 13 type 3s were treated. MOst patients (92%) had a one-stage correction while a two-stage approach using a tissue expander was needed in the remaining 8%. A periareolar mastopexy was used in almost every patient (96%) with the addition of a vertical mastopexy in a limited few. (8%) Few complications occurred (8%) which were capsular contractures or implant malposition.

Tuberous Breast Augmentation result Dr Barry Eppley IndianapolisSurgical treatment of the tuberous breast is a challenging problem that often defies consistent and reliable correction. In very minor cases, a breast implant alone with or without areolar reduction may be all that is needed. But this represents the exception and not the rule. One of the keys in the correction of the tuberous breast is using the periareolar incisional approach. This provides access to a variety of the anatomic problems that the tuberous breast presents, not the least of which is the glandular dissection and release. While it has been historically taught that a subglandular breast implant should be used to help expand the lower breast pole this need is obviated by the glandular dissection and release technique. Dual plane breast implant placement can then be used and the long-term higher risks of subglandular breast implants are avoided.

This article provides a logical and thoughtful approach to the treatment of  tuberous breasts that can be done as a single stage correction in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Breast Implants with Periareolar Lift

Wednesday, July 29th, 2015

Background: Loss of breast volume is very common amongst women usually caused by pregnancies or weight loss. As the breast deflates sagging of the breast mound often occurs. As long as the nipple remains positioned at or above the inframammary fold (lower breast crease) augmentation with breast implants will adequately fill up and out the deflated breast creating a more pleasing breast size and shape.
But with increased degrees of breast sagging (nipple at or below the inframammary fold), an inplant alone will not be satisfactory solution. While it will expand the breast volume the nipple will likely be driven downward not upward creating a breast look that few would desire or accept as an improved breast shape outcome.
The need for a breast lift at the time of breast augmentation is very common. While no woman wants a breast lift and the skin scars that result they may have little choice. The options for true breast lifting are three fold. The most common and effective are the vertical breast lift (lollipop lift) and the combined vertical and horizontal breast lift. (anchor lift) But the breast lift that creates the least scar and also has the least lifting benefit is that of the periareolar or donut pattern breast lift.
Case Study: This 42 year-old female presented for breast augmentation. She had lost some weight, and between that and having had children, had a bit of a breast sag. Her nipples were exactly at the level of the inframammary fold. The dilemma was whether just getting breast implants would create a nipple positioning problem on the enlarged mound or whether she should just have a breast lift at the time of her implants. She was adamantly opposed to any type of breast skin scar on the mound itself.
MM Bam results front viewUnder general anesthesia she had silicone gel breast implants (475cc) placed in a dual plane position through a small inframammary incision. At the same time she had an eccentric ring of skin removed from around her areolas. (donut breast lift)
MM Bam results oblique viewMM BAM result side viewAt three months after surgery, her breasts show an acceptable breast mound enlargement and nipples that were in good orientation on the breast mound. There was no appreciable sag of the breasts although her breast mounds remained in the same overall position as that before surgery. Her areolar diameters were increased.
Of all the types of breast lifts, the donut lift is the ‘weakest’ of the group. It really has a very limited breast lifting effect and this could be seen if it was ever just done on its own. It does provide a bit of a lift when combined with implants although the implants really do the heavy lifting in the final result. But the donut lift does have a role to play in the woman who is questionable if she really needs a lift or not. It may be just enough in some women to allow them to get by without having to get scars on the skin portion of the breast mound. It is hard to say whether the increase in areolar diameter seen is due to the natural stretch of it from the underlying implant expansion or from the combined tension of the periareolar skin reduction.
1) Minimal to modest amounts of breast sagging can be improved with a perirareolar or donut style breast lift procedure.
2) A periareolar breast lift works best when combined with breast implants.
3) A periareolar breast lift almost always enlarges the diameter of the areola, particularly when used in combination with breast implants.
Dr. Barry Eppley
Indianapolis, Indiana

Case Study – Breast Reduction with Breast Lift

Sunday, July 12th, 2015


Background: Breast reduction persists as one of the most common of all body plastic surgery procedures. Breasts that are too large  and heavy are common and ultimately the back shoulder and neck pain that they create is best relieved by making the breasts smaller and more uplifted. The improvement is musculoskeletal symptoms is as much the  result of the lift as it is from the volume of breast tissue removed…contrary to popular perception.

Many patients ask whether there is a lift that is done with the breast reduction or whether the breast reduction leaves the breasts smaller but still hanging. When looking at the design of how a breast reduction is done, the marked skin pattern that is drawn on the breasts represents the lift that will result. Thus a breast reduction can not be done without a breast lift but a breast lift can be done without a breast reduction.

Case Study: This 44 year-old male had always had large breasts since she was a teenager. But with getting older and having children her breasts actually became somewhat larger but had fallen and gotten very heavy. They were now so large that she was embarrassed to wear a swimsuit and would not do any water sports which her family loved to do.

Large Breast Reduction results front viewLarge Breast Reduction result oblique viewUnder general anesthesia, an inferior pedicle breast reduction was performed. The amount of breast tissue removed was 450 grams per side. The amount of skin removal and tightening exceeded visually the amount of breast tissue removed. The areoalas were reduced in diameter from 65 mms to 40 mms in diamater.

Large Breast Reduction result side view Dr Barry Eppley IndianapolisHer postoperative results showed much smaller and more uplifted breasts. She was thrilled with the result as she felt more comfortable with her breast size and could now resume all water sport activities with her family. Like all breast reductions and/or full breast lifts the scar burden is significant but well worth the tradeoff for the psychological and pain relief benefits.


1) Every breast reduction is a breast lift also. Thee relief of musculoskeletal symptoms is a result of a combination of both effects.

2) Breast reduction produces a fair amount of breast scarring but is usually viewed as a worthwhile tradeoff.

3) Nipple sensation preservation through retained attachment and mound relocation is usually successful.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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