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Adaptation and Awareness Lead to Better Results

Posted July 17, 2018 in Adapting Procedures

On June 18, 2018, Birmingham, Alabama’s Dr. James Grotting addressed the Southeastern Society of Plastic and Reconstructive Surgeons. In the presentation, Dr. Grotting explained the importance of surgeons reexamining traditional plastic surgery techniques to better provide patients with the highest quality of results in the safest and least invasive ways. Dr. Grotting has tried to evolve his surgical techniques in response to the current demand for less open surgery, less time away from work, faster recovery, less pain, and long-lasting results. As new techniques become available, it is crucial that plastic surgeons rethink what they have traditionally been taught and decide if a new way is a better way. Dr. Grotting talked about “Primacy Effect,” which refers to the difficulty of relearning something—it is considerably more difficult to “unlearn” something than learning it the first time around. Among early fighter pilots, relearning to use a new safety feature called an “ejection seat” was very difficult for the first adopters because they had always been taught to fly the airplane all the way to the ground in the case of a catastrophe. Similarly, plastic surgeons may have a hard time moving to new and better ways to accomplish their craft unless they stay continually educated and informed.

Adapting Procedures

The Free TRAM Flap for Breast Reconstruction

Over his 33-year career, Dr. Grotting has continued to learn through trial and error as well as create new techniques in plastic surgery to become a leader in the field. He was the first surgeon in the world to use the microvascular muscle-sparing free TRAM flap for immediate breast reconstruction. This technique continues to be utilized widely for autogenous breast reconstruction.

The free TRAM flap is a procedure that uses a wedge of excess skin and fat from the lower abdomen (the “flap”) and transfers it to the chest after a mastectomy has been performed. The tissue can live in it’s new location by restoring its blood supply by hooking up an artery and a vein going into the flap to a donor artery and vein either under the arm or under one of the ribs. The blood vessels are connected with suture material no bigger than the width of an eyelash by working under the microscope. Once the tissue is connected by its blood supply, it can be shaped into the form of a breast to match the other side. Or it can be divided in half and two breasts can be reconstructed. The revolutionary advancement of the microvascular free TRAM procedure over the traditional tunneling TRAM procedure, was that the tissue was healthier with less possibility of partial loss and much less muscle was removed from the abdomen.

The Vertical Sculpted Pillar

The Vertical Sculpted Pillar has become Dr. Grotting’s technique for breast reduction, a method that has evolved from combining several different techniques to beautifully shape breast tissue. This technique is based on the concept that very large breasts are not only too wide, but that they are over projecting. This is what produces the drooping of larger breasts. By focusing on what is left behind rather than what is removed, Dr. Grotting has developed a way of restoring high, firm, and round breasts that are natural but shaped almost like a breast implant. This technique leaves much of the tissue from the superior pole so that the desired fullness is left in the upper and inner aspect of the breasts. All of this is done through much shorter scars that previously required. Patients who have had this procedure sometimes stop other women on the street to tell them what can be done!

Facial Rejuvenation

Dr. Grotting’s original facelift and facial rejuvenation approach involved many steps, including an extended SMAS flap, an endoscopic brow lift, a neck lift, and traditional blepharoplasty, all of which used extended incisions. However, he now knows that patients generally want less surgery, and through an evolution of his thinking and modification of techniques, Dr. Grotting now relies heavily on fat grafting to produce highlights and improve surface contours on the face as opposed to more invasive surgical procedures. His plication technique is also proven to provide similar results as the extended SMAS flap that he was using previously with fewer complications and a shortened recovery time. The results are natural—never pulled or “over-operated.” The key is to focus on surface contours and aesthetic lines to give natural results.


Dr. Grotting’s dedication to continuous learning and adaptation provides his patients with the most current techniques and the highest quality of results. To learn more about these procedures, contact Dr. Grotting today by calling 205-930-1600.