Smart est Lipo

June 23rd, 2010

Smartest Lipo

What is going on in the field of Plastic Surgery and body contouring? First there was simple Suction Assisted Lipectomy (Liposuction for short), then along came “Tumescent Liposuction” with one Dermatologist claiming he invented everything and only doctors trained in his seminar were qualified. “Ultrasonic” liposuction became the rage in the 90’s with claims of less pain, more fat removal and improved skin contraction. I bought the first one of these machines in Sacramento in 1995 and was a true believer until it was obvious that the pain actually lasted much longer (one patient required physical therapy). Also people stayed swollen longer and the skin didn’t really contract like they said. I found that the only real advantage was treating really challenging problems (male breasts and re-do patients with scar tissue). In those patients the prolonged swelling and pain was a compromise they were willing to make.

Well not to be outdone, other manufacturers of medical devices came out with a “better” ultrasonic (Vaser), several lasers (Smart Lipo, as if everything else is dumb lipo), Water Jet and even radio frequency ablation. It’s enough to make a Plastic Surgeon’s head spin. These companies used high-pressure tactics to convince Plastic Surgeons to buy the latest and greatest “Fat Killing Toy” or risk being left behind. They had slick advertising campaigns making all kinds of subjective claims of more fat removal, less pain and bruising and skin contraction. Notice I said subjective because these claims are not really measurable and so the manufacturers can say whatever they want without getting in legal trouble. Besides, if a new technology or machine is that good, every Plastic Surgeon would own one.

Well the next thing you know, the Plastic Surgeons became wise to these facts and stopped buying these “Newest Advances” because they were very expensive (can run into the hundreds of thousands of dollars) and really did not offer any significant advantage. An entertaining story I tell my patients was a meeting I attended in Miami where they performed live surgery via video link with the audience (400 Plastic Surgeons from around the world). One famous Plastic Surgeon showed how to use the most advanced fat removal machine available and the other was Marco Gasparotti, a famous Plastic Surgeon from Rome who pulled out this bent and beaten-up cannula that was probably 15 years old. It looked like it had been run over by a car before it was sterilized! They each championed their personal techniques and operated on their patients. A year later, before and after photographs of each patient was shown to the Plastic Surgeons in attendance. The High-tech patient had been turned into a “Man-butt” with few feminine curves. But a lot of fat had been removed! Marco’s patient was transformed from a frumpy mommy-of-4 to an attractive, curvy figure that would be chased down the beach by all the healthy men. Helllooooo! The lesson that hit home was that the single most important factor in getting a great result is choosing the best surgeon. These fancy machines really don’t matter. However, they are easy to market to an unknowing public, especially if they have a cool name with “laser” or other gimmicky word.

The next thing to happen was that manufacturers began marketing directly to women in magazines and other sources. Now Plastic Surgeons had patients coming in asking, “Does Dr. Hause have the way-cool-fat-sucky-trick-machine? I hear it can remove more fat! Because I only want the newest best thing!” My response has been “Of course not. Why would I buy a machine that does not matter and will cost you more money?” After all, when a sculptor chips away at a piece of marble, does anybody really care what is on the floor when they finish? It’s not how much fat that is removed, it is what is left behind that gives the final result that is most important.

Then came the big investment franchises. Most people have heard of Bosley Medical for Hair Restoration. In many respects, it is a Hair Transplant franchise with a large marketing budget and big referral system to corral patients into a centrally located surgery factory. It turns out that Hair Transplantation is an operation that requires a team much larger than just the surgeon. In fact, the surgeon’s part of the procedure can be very minor. Thus, it is the system that is more important than the doctor. I have seen a lot of their work and it is very good. It is expensive. But this is because they have huge marketing budgets and operating expenses. However, they will offer “discounts” to undercut the competition from time to time. Well, this business model is now being applied to cosmetic surgery. You now see franchises for Liposuction and Face Lifts that tout a specific machine or make claims of faster recovery, etc. It is common for them to hire any doctor without concern for their credentials or experience. After all, it’s hard to get a Gourmet Chef to work in a fast food drive-up window. I recently had a patient come in (she was a nurse so should have known better) who had gone to Mexico for her liposuction because the costs she was quoted for her surgery here was over 20 thousand dollars. However, if she went to their clinic in Mexico, it was only $7000.00! You should have seen her face when I told her that most of the Plastic Surgeons who were trained in the United States and were Board Certified by the American Board of Plastic Surgery would have done her surgery here for less than $7000.00. Talk about a ‘bait and switch”.

I could go on with more facts about the Body Contouring marketplace that now exists. Unfortunately it is becoming a “buyer beware” situation. The truth is that the most important factor in choosing a Plastic Surgeon is finding one who is experienced in all techniques in body contouring (not just one liposuction gimmick), is ethical and has the artistic vision and ability to obtain the best results with the highest safety. After all, since franchises view customers as nails, patients are more likely to get hammered. Most private practice Plastic Surgeons who have made the investment to become Board Certified by the American Board of Plastic Surgery and become expert in Cosmetic Surgery value their reputation more than working in a franchise. Choosing a Plastic Surgeon with these standards is really the “Smartest Lipo.”

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Posted in Body Contouring, Cosmetic Surgery Ethics, Plastic Surgery, Plastic Surgery Innovation | No Comments »

The “Latest and Greatest” Plastic Surgery Advances and the Franchising of Plastic Surgery

October 14th, 2009

I am writing this editorial Blog in response to an increasing number of patient inquiries regarding specific “New” Techniques and Cosmetic Surgery Franchises that have entered the market place. The typical question is “Do you do (pick a way-cool-sounding procedure or machine) or “What do you think of the (for example, Turbo-Intelligent-Suck-a-lot-o-fat) clinic that just opened up? I must point out that the information discussed below is my personal opinion as a practicing Plastic Surgeon for the last 15 years who is board certified by the American Board of Plastic Surgery. I specifically request that the reader does not presume that my opinion is that of any of the official representative organizations within the field of Plastic Surgery.

Over the last 20 years the field of Cosmetic Surgery has expanded rapidly and has become a growing multi-billion dollar a year industry. There have been and continue to be ever advancing technological improvements in surgical procedures, equipment and instrumentation. Many of these have improved patient outcomes and made possible results that were only imagined a few years earlier. However, because of the eternal quest for fame and fortune, some practitioners and companies have become obsessed with being the first to offer the newest, greatest thing in Cosmetic Surgery. There seems to be a new “Catchy” named technique or device every month that is touted as the latest and greatest must-have in Cosmetic Surgery. In fact, if a doctor does not offer this new “Miracle”, well, they are just behind the times and obsolete. Because of this trend and the massive marketing blitzes that accompany these “new” advances, many patients are lured into seeking out the one doctor or clinic that possesses this new device. Manufacturers have found success in marketing directly to patients and attempt to convince them about the exclusivity and uniqueness of their device or technique. In return, they try to convince doctors that if they buy the new device or join their group offering the technique, that it will bring them more patients. It’s a match made in Marketing Heaven but it has one major shortfall. This scheme has a huge potential to violate the standards of medical ethics and misrepresent or even deceive patients into thinking they are getting something that they are not.

These slick used-car-sales methods fly in the face of some rather important clinical facts and traditional methods of advancing surgical state-of-the-art and competence. Some basic rules of thumb are the following:

  1. After all the years of medical school, surgical training and active practice, most Plastic Surgeons certified by the American Board of Plastic Surgery are smart enough to know what the state-of-the-art is. Medical Education is global and very rapid. If a specific surgical device, instrument or technique is really that good or an improvement, nearly all Plastic Surgeons will incorporate it into their practice. Most ethical and competent Plastic Surgeons are patient advocates and live by “if it really works and is better, I will do it.” If only “Special Doctors” or “Exclusive Clinics” do it, there is a reason and it usually is not because they are special or more qualified.
  2. If a device is only offered in a special clinic (franchise), it usually means that the manufacturer was unable to sell enough devices or convince enough qualified Plastic Surgeons to use it. This is usually because the claims made about the device were either untrue or offered no real benefit over other alternatives to accomplishing the desired Cosmetic Surgery result. Sometimes the risks can even be higher than normal. If the device has Laser or some other high-tech or catchy name it may really be suspect.
  3. If you hear of some new technique or device on a nationally televised show (I won’t name any, but you know which ones I mean) it is typically not because it is some great new advance or the doctor is so special. These shows exist primarily to entertain and sell advertising space. If they happen to give you some information that is helpful, okay. But if it is “new”, controversial or exclusive, it will sell no matter what. One of my mentors who was the first Plastic Surgeon to get a nationally televised interview told me that being seen on national TV was worth over two million dollars in new patient business. And that was in 1993! It is not hard to imagine that one way to make it rich in Cosmetic Surgery is to hire a prominent Public Relations Firm to get you on the air. It only takes money and an “amazing claim of result”, not superior ability. I don’t mean to be callous or harsh, but most people are aware of the Donda West tragedy. Her doctor was featured on one of those shows.
  4. Lastly, if you hear about a certain new surgical “technique” only available in your area through a special (franchised) clinic or a certain select doctor, it usually means that the technique is so easy to perform that any doctor (not highly skilled surgeon) can do it. The business model being used in this circumstance is similar to the Hair Transplant Industry (more on that below). In the case of cosmetic surgery, it also usually means that the results are so mediocre or non-existent that the fully qualified surgeons in the area would not even consider doing it that way. The only thing special about it is the corporate sponsor and the polish.

As a perspective, let me describe two of the business models commonly encountered by patients seeking Cosmetic Surgery and Aesthetic Services. Both models are legitimate but differ greatly.

Traditionally an individual wanting to be a Plastic Surgeon went to Medical School, trained for 5 to 7 years in General Surgery and Plastic Surgery and then found a place to live and practice. If they wanted to do Cosmetic Surgery they may have given seminars or market locally. As their career and reputation progressed, they would continue their education at professional meetings and incorporate improvements into their practice for the benefit of their patients. This process takes years and is based on improving knowledge and experience, again always primarily for the benefit of the patient. Although making a living is a fact of life, ethical surgeons kept the need for income well down on the priority ladder. They believed that their integrity and good reputation would be the basis for patients seeking them out for services. Because of their extensive education and experience, they can be thought of as a “Master Chef.” That analogy will make sense as you read below.

Contrast that model with the one that is commonly employed in Hair Restoration Clinics. Hair Restoration is dominated by “Franchised” clinics that spend heavily on marketing and centralize their surgery facilities. Patients initially visit outlying offices and undergo consultations with Patient Coordinators who then schedule patients to go to the regional clinics and have surgery by one of their “Surgeons.” This model optimizes the surgeon’s time by keeping them busy performing the service that generates money for the “Franchise.”. These Clinics, for the most part, get good results and most of their patients are happy. However there are some unique characteristics of a Hair Transplant Clinic that make it work well with this model. From a technical standpoint, the procedure of Hair Transplantation, while very labor intensive, is a relatively simple surgery that most doctors, regardless of their background, can learn to do by attending some short courses of instruction. That is why there are Family Practitioners, Emergency Room Doctors, Dermatologists and some formally trained surgeons working at these clinics. At the risk of sounding harsh, the doctor who “performs” the surgery is not really the most important team member of the clinic. The most important factor is actually the Clinic Brand Name, their marketing strategies and the staffing of the facility, namely the technicians who do most of the work of the procedure. Hair technicians, usually highly skilled medical assistants, are the ones who meticulously prepare and implant the Hair Grafts in the patient. The doctors mostly supervise to make sure it is done correctly. So in essence, these Franchises succeed based upon their Marketing Program and their investment in the “Team” to make this procedure profitable. Simply put, Hair Transplantation in not an “Operator Dependent Procedure” because the expertise needed by the Doctor to successfully perform the surgery is not that difficult to obtain. Although not a perfect analogy, Hair Transplant doctors function as the short-order cook in the diner. They are not really master chefs.

The problem occurs when Investors or Corporations try to Franchise an “Operator Dependent Procedure” (the talent and artistry of the surgeon is critical to patient outcome). There are many such examples in the marketplace. For obvious legal reasons, they will remain nameless. They are typically oriented around a specific procedure name or surgical device and claim exclusivity, great advantages or other difficult-to-measure-and-compare factors. Most of these have very aggressive marketing campaigns, aggressive consult follow-ups and pressure tactics. The catalyst for writing this editorial was a long discussion with one of my patients who had visited one of these clinics out of curiosity. She complained, that since her visit (two weeks), they would not stop calling her daily to schedule her surgery. Imagine that! Some of these clinics actually may have successful results, but it is rare that they are better than those achieved with conventional techniques. Many of these clinics just specialize in “Branding” and really offer the same or less result with a nice label.

In the final analysis the fact remains that most communities in the United States have dedicated and competent board certified Plastic Surgeons who spend their careers improving their skills and results for the benefit of their patients. They appreciate the fact that each patient is unique and deserves a thorough evaluation by someone who can offer many different approaches to solving a problem. “One size does not really fit all” in the world of Cosmetic Surgery. These dedicated professionals really are “Master Chefs” in the increasing environment of aggressive “Fast-Food Franchises.”

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Posted in Body Contouring, Cosmetic Surgery Ethics, Facial Rejuvenation, Plastic Surgery, Plastic Surgery Innovation | 2 Comments »

Ideal Implant ®: Donald W. Hause, M.D. FACS is selected to participate in the FDA Approved Clinical Trial

September 23rd, 2009

Ideal Implant ®: Donald W. Hause, M.D. FACS is selected to participate in the FDA Approved Clinical Trial

Donald W. Hause, M.D., FACS and Sacramento Aesthetic Surgery, inc. are proud to have been selected to participate in the FDA Approved National Clinical Trial of the Ideal Implant ®.

Although silicone gel implants are now available, have a strong safety record and give a very natural breast enhancement result, some patients are still concerned about the issues of incision requirements, possible silent gel rupture and the recommended costly surveillance of gel implants. The Ideal Implant ® was designed to combine the natural result of silicone gel and the safety of saline in one “hybrid” breast implant. This hybrid Saline-filled implant utilizes a series of additional implant shells that are nested internally with perforated baffles. This design controls the flow of the saline within the implant which, in turn, reduces the feeling of sloshing and bouncing. In addition it supports the implant edges to minimize wrinkling and upper pole collapse. They also give the implant a firmer feel which is similar to that of silicone gel. The Ideal Implant ® looks like a standard saline implant, except the edges have been lowered so it may contour better to the chest wall.

During the study surgical costs will be the responsibility of the patient and warrantees offered by Ideal Implant ®, incorporated will be similar to those of other implant manufacturers. However, the study will also require dedicated follow-up with Dr. Hause for an extended period of time for which Ideal Implant ® inc. will offer compensation. For specifics about the study and compensation for follow up participation please go to http://www.idealimplant.com

If you would like more information about participation in the FDA Approved Clinical Trial, please contact Sacramento Aesthetic Surgery’s office at info@hausecall.com or call (916) 646-6869 and schedule a free consultation and evaluation.

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Posted in Breast Enhancement, Plastic Surgery, Plastic Surgery Innovation | No Comments »

“Dr. Hause, what Plastic Surgery do I need?”

June 29th, 2009

I was at a Swimming Meet this weekend and one of my friends asked me if I perform Abdominoplasty at the same time as Breast Augmentation. My reply came in the form of explaining the concept of the “Hot Topic” of Mommy Make-overs and what they involve. She next told me that she knew a couple of friends (from the same grammar school) who had undergone these procedures. Strangely, both of them had gone in initially for Breast Enhancement and were strongly encouraged to add the Tummy Tuck. This was because that “would make the Breasts look even better.” I was visibly taken aback.

This brought up the discussion of “needing” versus “wanting” Aesthetic Surgery. Now let’s be honest. Although writing this may be blasphemy to the Priests of Nip Tuck, in reality no one “needs” Cosmetic Surgery. They “want” Cosmetic Surgery to improve their appearance. It is elective. I personally would find it appalling if I went to a Plastic Surgeon with one concern and they talked me into something additional.

This brings up the concept of vanity. We’re all familiar with the criticisms that Cosmetic Surgery is all about vanity. Well, frankly, it is. However, let’s put this into perspective. Since the dawn of time human beings have been altering their appearance to reflect the values of their culture. Consider the tattoos, piercings and scarification that are customary in some societies. Whether or not we want to accept it, the truth is that how we appear has an impact on how we feel about ourselves and how others perceive us. However, like most things, intelligent moderation is the key to success. A healthy amount of vanity may aid in maintaining our sense of self worth and positively impact our interpersonal relationships. In contrast, extreme vanity can emotionally cripple someone and turn them into a nightmarish Hollywood Cliché’.

It is true that when someone visits a Plastic Surgeon, they are looking for expert advice about their concerns. However, it is also true that this person is probably somewhat insecure and vulnerable. In my opinion, encouraging someone to have additional surgery when the advice was not specifically sought out is unethical. It is really easy to manipulate an insecure and vulnerable person into doing what you want them to do. As physicians, we have a much higher moral obligation to our patients. We are not selling cars and adding on an extended warrantee. Unfortunately, especially in our challenging times, patients need to beware of practitioners that insist on “the extreme makeover.”

As a Plastic Surgeon, it is a great privilege and humbling to have someone entrust their safety and well being to you while attempting to improve their life with surgery. However, the patient is the only one who has the right to decide what will work for them. I always tell my patients “There are a lot of things I know how to do that are great for my kid’s college funds. Not all of them are good for you.” When considering Aesthetic Surgery, be clear on what you are trying to accomplish and keep that in perspective. If you are curious, get options and get educated. Beware of grandiose artistic surgeons who “have a plan to make you better than you ever were before.” Getting more than one opinion is always prudent. As statistics of patient satisfaction will tell you, if done safely and well, Aesthetic Surgery can enhance your life. However, don’t let any interested party influence what you believe is right for you.

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Posted in Body Contouring, Breast Enhancement, Cosmetic Surgery Ethics, Plastic Surgery | 1 Comment »

Mastopexy (Breast Lift)

June 23rd, 2009

Some patients desiring Breast Enhancement have breast tissue that is loose and saggy. The medical term for this condition is Breast Ptosis. This may be a consequence of advancing age, pregnancy, nursing and/ or weight fluctuations. Breasts progressively hang lower on the chest with loss of upper breast projection (perkiness), elongation and flattening. In some cases, the nipples point straight down. These changes are also common in patients with naturally large breasts.

The basic problem with ptotic (saggy) breasts is that there is too much skin for the amount of breast tissue present. Additionally, the nipple may reside too low on the chest wall. With mild stages of breast ptosis, a breast implant may be all that is needed. However, in many women, the breast has fallen too far down the chest to allow an implant to give an aesthetically pleasing result. In these women, some form of breast lift (Mastopexy) is indicated. In this situation, a simple breast augmentation would result in the implant residing in the normal location with the nipple appearing to have slipped off the front of the breast. Some doctors may suggest placing the implant above the muscle to minimize this appearance. It may work. However, all too often what results is a “rock-in-a-sock” appearance. In my opinion, this is totally unacceptable. It is also very difficult to fix and may require multiple operations to improve.

When natural breasts are large, similar changes to the skin and nipple position usually occur. The techniques of Breast Reduction and Mastopexy are similar with the exception that in Reduction, breast tissue is removed to fashion a more pleasing size and shape. Reduction may also relieve symptoms of neck and back pain.

Because of the anatomical changes described above, Mastopexy and Breast Reduction procedures are designed to remove the extra skin (+/- the extra breast tissue) and reposition the nipple. One of the consequences of doing this is a visible and permanent scar on the breast. This is a real compromise (a scar versus a saggy and/ or large breasts). Although many scars will heal with little visibility, if a scar is completely out of the question, you are not a candidate for mastopexy, period. The only exception is in patients that have a small amount of enlargement that can be improved with liposuction alone. As common sense would predict, this usually worsens any ptosis and produces a more saggy and bottomed-out breast.

The classic technique of Mastopexy and Breast Reduction requires a scar that resembles an “anchor.” This scar is located around the areola (pigmented part around the actual nipple), down the front of the breast and along the fold under the breast. Most Plastic Surgeons continue to use this technique because it can give a reliable and safe result. It is still the gold standard for comparison within the Plastic Surgery community and many excellent results have been achieved. With the Anchor Technique, skin is removed so as to create a new “skin brazier” which holds the breast tissue in place. Relying on the skin for the result can be a negative because, after all, what caused the problem in the first place was the stretchy skin. Because of this fact and the resulting large scar, newer methods of “Minimal Scar” Mastopexy evolved that may offer a better option. Not all women are candidates for these techniques, but many are.

In selected cases of women desiring enlargement and mastopexy, the scar can be limited to around the areola. This technique is called a Doughnut or Binelli Mastopexy after Louis Binelli, the French Plastic Surgeon who described it. In essence the procedure is done is by removing a doughnut-like circle of skin from around the areola and leaving the nipple attached. This allows for placement of the implant and can lift the nipple up to 1 inch.

In women who desire to lift their natural breasts into a more youthful position and contour, a third technique, called Lejour Mastopexy (Verticle Mastopexy) after the Belgian Plastic Surgeon Madeline Lejour, may be the best option. This technique differs from the others in that the result is not dependent upon the breast skin. In this technique, the breast tissue itself is molded with sutures into a new natural shape. The scar can usually be limited to around the areola and down the front of the breast (”lollipop”). Also, the result can be more natural and last longer. Because of these factors, the Lejour technique is my preferred method for correcting breast ptosis in those not desiring enlargement and in those women needing moderate amounts of reduction.

Mastopexy is performed as an outpatient and patients can usually return to work in 5 to 10 days.

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Posted in Breast Enhancement, Breast Lift, Breast Reduction, Plastic Surgery | 1 Comment »

Breast Augmentation: A Perspective

June 15th, 2009

SAS Blog: Breast Augmentation; a Perspective

Breast implants were invented in the early 1960’s by Dr. Frank Gerow and Dr. Thomas Cronin, two Plastic Surgeons from Houston, Texas. The first implants were made from an outside shell of silicone rubber and contained silicone gel. They had a remarkably natural feel that compared to normal youthful breast tissue. The major complication of silicone breast implants was scar formation around the implant, which made them get very hard and even, in some cases, very painful. This is not surprising since all foreign objects that are placed into the body cause scar tissue to form. However in the case of stainless steel plates for fractures or a pacemaker, no one cares if they are hard because they started out that way. In the case of breast implants, it was a very big deal. After some research, Plastic Surgeons began placing the implants under the Pectoralis muscle in an attempt to prevent this “Capsular Contracture” from forming. This showed some improvement. Then research was done changing the surface of the implant to what is called textured or rough. The most successful of these was an implant that was covered with Polyurethane foam. However, because this foam degraded into possible carcinogens, it was discontinued. The use of modern textured surfaces has been somewhat controversial because they can be more easily felt through the skin and it is unclear of they truly make a difference in Capsular Contracture. Thankfully, with the latest generations of smooth implants, the likelihood of developing serious scar tissue has been remarkably reduced. In some patients utilizing Gel implants, successful augmentation can be done above the muscle.

In the early 1990’s a group of women who had undergone Breast Augmentation and Reconstruction began making claims that their Silicone Breast implants were causing diseases in their bodies. These were serious, progressive and non-curable auto-immune diseases such as Rheumatoid Arthritis, Lupus, and Chronic Fatigue Syndrome. Since the initial FDA’s ban on their use in the early 1990’s, silicone gel implants have been thoroughly investigated and there is no evidence that they cause any medical diseases. On November 17, 2006, the FDA reinstated their approval for the use of silicone gel for routine Breast Augmentation.

In recent years, implant manufacturers have been using a new type of silicone gel called cohesive gel or “Memory Gel.” You may have heard of this referred to as “Gummy Bear” implants. The issue that was addressed by this technological improvement was the fact that, with the old implants, if the implant ruptured and the scar tissue that was formed by the body did not seal it off, it could squirt out and cause serious inflammatory problems in the tissue. This new Gel actually sticks to itself and maintains its shape. So even if the implant wall breaks, the gel should not squirt out and cause problems.

Silicone Gel versus Saline-filled Implants. Issues and Answers:

Saline-filled Implants: Saline implants are made of a silicone rubber shell and are inflated at the time of surgery to their appropriate size with saline (0.9% salt water). If they leak (rupture), the body just absorbs the water with little side effect other than the volume is lost (Some patients just wake up with a “flat tire”). This is one big advantage of Saline-filled implants. A second advantage is that they come deflated and, therefore, require a much smaller incision for placement. However, saline-filled implants do not feel anything like silicone gel or normal breast tissue. This is why we recommend placement of these implants under the Pectoralis Muscle. This is a sculpting technique to hide this implant under normal soft tissue. In this way, the implant is less visible and feels more natural. They are still not as natural feeling as silicone gel but they are acceptable in appearance and feel for patients with adequate soft tissue (breast and muscle tissue).

Silicone Gel Breast Implants: Now that the FDA has concluded that Silicone Gel is safe, I expect that most Plastic Surgeons use them in a significant number of patients. This is because Silicone Gel is far and away the most natural feeling and looking breast implant available. However, like everything in life, they are not perfect. The most noticeable disadvantage of Gel implants is that they require a larger incision (2 inches) for placement. This fact may prevent the patient from using the preferred peri-areolar incision. This could require an infra-mammary approach and a more visible scar. Also the maintenance of Gel is more involved. The FDA and Manufacturer recommends routine follow-up with MRI scans (very costly) at various intervals to detect rupture. Another concern that has recently come to light is that some Health Insurance Carriers may have issues with these implants and this may even cause you to lose or prevent your getting individual coverage. I have not actually heard of this happening, but you should check this out with your carrier to be safe.

There are three standard options for placing breast implants; Around the nipple (Peri-areolar), Armpit (Trans-axillary) and under the breast in the fold (Infram-mammary).

Trans-Axillary Incision: Placing the incision in the armpit may be considered advantageous because there is no incision on the chest. However, the most critical part of Breast Augmentation is the placement of the implant in the fold below the breast. Since this incision is the farthest from the fold, it is technically more difficult to place the implant precisely. This may result in mal-position of the implant. Also if re-operation is necessary in the future, it may be impossible to re-use the incision and require a new second scar.

Infra-mammary Incision: Under the breast fold is the original method most Plastic Surgeons were trained to do because it is straight-forward and can be used with all implant types. The potential disadvantage with infra-mammary incisions is that they may widen and become visible. Unless I am revising a patient from another practice who has this scar or am required to use it because of the need of a larger incision, I do not prefer to use this approach. However, if I am placing a Silicone Gel implant and the patient’s areola is too small to accommodate a gel implant, I do not hesitate to use the infra-mammary incision and have found it to heal acceptably in most patients.

Peri-areolar Incision: There are three reasons that most surgeons prefer this incision when possible. For one, it is technically easier to create the implant pocket precisely. Two, it can easily be used for nearly all revisions, if necessary. However, the biggest reason why most surgeons use this incision is that for some reason, and no one knows why, this area heals with nearly an invisible scar in the majority of patients. There are some misconceptions about this incision. You might have heard that if you go through the nipple, you cannot breast feed in the future. This is not true. We never cut through the ducts that connect the nipple to the breast tissue and, therefore, patients should have no difficulty breast-feeding. Maybe you have heard that it is more painful to go through the nipple. This is, again, not true. Most of the pain associated with Breast Augmentation is related to muscle spasm that results from making the pocket for the implant. Since the same pocket is made regardless of the incision, the post-operative pain is the similar regardless of the incision. Lastly you might think that going through the nipple causes the nipple to become numb. This is not true either. However, can you get nipple numbness from this operation? The answer is yes. But it has little to do with the incision. The nerves that go to the nipple are located near the pocket for the implant and commonly get stretched and bruised. If they get stretched or bruised enough, they can stop working. In the 15 to 20 percent of cases that have numbness after surgery, most will resolve and be normal at 12 months.

Trans-umbilical (Belly Button): For a while it was trendy to put Saline implants in through the belly button. Because of the difficulty controlling where the implant would end up, the inability to safely place the implant under the muscle and the great difficulty of fixing anything, this option is not well thought of by the vast majority of Board Certified Plastic Surgeons.

Breast augmentation is performed as an outpatient. Although some practices perform Breast Augmentation with sedation and local anesthesia, I believe that general anesthesia (being completely asleep) is a much more pleasant experience which allows improved precision in implant placement. The risks of general anesthesia are greatly over-stated by some sources. After being in practice for 15 years, I would argue it is much safer than sedation. In fact, patients have a much larger risk of injury and death by getting into their car than from the sophisticated general anesthesia techniques now available.

Most patients take 4 to 7 days off of work. Most patients can only lift 10 to 15 pounds for the first two weeks. Mild exercise can usually be started in two weeks but upper body work outs should be put off for four to six weeks.

It takes about 6 weeks before you can draw any conclusions about the result so don’t stress out. As the implant settle, they will look and feel more natural. They may actually change for up to a year, but changes after 8 weeks are usually subtle.

Breast Augmentation has been a relatively safe and effective way to enhance your appearance and proportions for over 40 years. By choosing a Plastic Surgeon certified by the American Board of Plastic Surgery, you can increase your chances of a successful and satisfactory result.

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Posted in Breast Enhancement | 4 Comments »

Liposuction: A brief History and what you need to know

May 29th, 2009

By far the most common procedure in Body Contouring is Liposuction. Modern Liposuction was pioneered in Europe by the Parisian Plastic Surgeon, Yves G. Illouz, M.D. His technique took advantage of the fact that fatty tissue is fragile when compared to the nerves and blood vessels that travel through it. Therefore, if you take a blunt-tipped surgical tube (we affectionately call it a cannula because that sounds more impressive), place it under the skin and apply suction, a portion of the fatty tissue is removed. Although many patients request, “Take as much as you can get!,” surgeons should never do that. Many patients regret going to doctors who approach fat removal with this attitude. Lesson number one regarding Liposuction: It really does not matter how much fat you remove. What matters is how much and where you leave it. Think about it. When a sculptor is shaping a piece of marble, does anybody really care how much is on the floor when they are done?

The main drawback of the original technique of Liposuction was that 50 percent of the fluid removed was blood. Many patients were required to bank their own blood and received it after surgery. Obviously this was not acceptable. Tumescent Anesthesia was the solution for this problem. Although some practitioners still call this “tumescent liposuction,” the fact is that “tumescent” has nothing to do with liposuction. Rather it is a form of anesthesia. The word tumescent means to inflate. This technique involves the injection of very dilute local anesthetic that causes the blood vessels to contract. This prevents excessive bleeding. Therefore, instead of losing 50% blood, patients lose less than 5%. Obviously, because of safety concerns, no competent surgeon today performs liposuction without some form of “tumescent” or “Superwet” anesthetic technique.

It seems that every week or so a surgical equipment company comes out with a new type of Liposuction. Technologies include ultrasonic energy, lasers and even water under pressure. They make claims of more thorough fat removal (I think we covered that above), less down time, bruising, pain, etc. In time many of these marketing claims prove to be untrue or nearly impossible to substantiate or disprove. I personally bought one of the first Ultrasonic Liposuction units available in the middle 1990’s and found it to be effective and helpful with a few challenging patients. However, in my experience, the bruising and discomfort was the same and the recovery a little longer (because it probably caused a little more trauma). To illustrate the point I am trying to make, let me tell you a little story. A few years back I attended a Cosmetic Surgery meeting where live surgery was being performed. They were showcasing two techniques of Liposuction; Traditional vs. Ultrasonic. The Surgeon using the traditional surgical cannula was a master surgeon from Italy who had a real flare for artistry, curves and proportions. The Surgeon with the ultrasonic machine was an expert from the United States and was showcasing the latest technological advancement. In the end, the ultrasonic patient had a lot of fat removed and had an acceptable result that most would say was good. The patient that had the old-fashioned technique went from your typical proud mother of three to the woman that most healthy men would chase after on the beach!

Lesson number two regarding Liposuction: Choosing the right Surgeon to perform the Liposuction in Sacramento is an infinitely more important decision than what tool they are using to remove the fat. One should choose their surgeon based upon their credentials, experience and artistic sensitivity. Remember that just because a technology or instrument is new does not necessarily make it better. Although medical technology continues to evolve and improve, be careful about claims that are “too-good-to-be-true” and advertisements that push a tool or technique rather than a qualified surgeon. The reality is that if it was that much better, every Plastic Surgeon would have it. After all, Tumescent Anesthesia is used in all forms of liposuction for obvious reasons.

A final thought. Because of many factors, some Liposuction is being performed by doctors who are not Plastic Surgeons board certified by The American Board of Plastic Surgery. Many of these other doctors only offer Liposuction in their approach to Body Contouring. They are a hammer who only sees the world as a nail that they want to hit. Plastic Surgeons who have achieved  certification by the American Board of Plastic Surgery are qualified to offer an array of Body Contouring options for each patient. By offering a complete set of techniques, Board Certified Plastic Surgeons can arguably achieve  the highest quality results for each individual patient.

 

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Mommy Makeover

May 28th, 2009

Mommy Makeover is a recent term that has gained popularity on the Internet and in beauty reporting. It refers to a combination of procedures (Breast Enhancement and Body Contouring) that are designed to address the consequences of child bearing and age.

With pregnancy and the nursing of children a women’s body may experience the effects of breast atrophy (becoming smaller) and ptosis (sagginess) as well as abdominal muscle and skin laxity. This may also be accompanied by the undesired deposition of fat on the hips, outside thighs and abdomen. The typical “Mommy Makeover” consists of the combination of a breast enhancement (Breast Augmentation and/ or Breast Lift (Mastopexy) and body contouring (Liposuction and/or Tummy Tuck).

Depending on the number of pregnancies, the length of time she nurses and her genetics, a woman may experience a decrease in size of her breasts as well as sagginess (Ptosis). The degree of ptosis will determine whether or not a woman will need a breast lift.

The classic breast lift that performed by most Plastic Surgeons involves a scar that looks like an anchor. Because of dissatisfaction with this result, I began performing “limited scar” breast lifts over 10 years ago. Depending upon the individual patient, we may be able to achieve the desired results by limiting the scar to around the areola or by just adding a vertical scar to it (Lolli-pop scar).

The Body Contouring necessary to address the effects of child bearing and age may involve the reduction of fatty tissue (Liposuction) as well as skin (Tummy tucks, Body, Thigh and Arm Lifts).

With respect to removing fatty tissue, although there seems to be a new “High Tech” method advertised every week, I have educated my patients to the fact that the method of removal and the amount taken out doesn’t really matter very much. What is crucially important is the amount and location of the fat that remains. When someone has a sculpture commissioned, does anybody really care how much stone is on the floor when the artist is done? It’s the form of the object on the pedestal that matters, not what you throw away.

Many women also have extra skin of the abdomen, waist, thighs and arms that bother them. Techniques of Tummy Tucks and Body Lifts can improve these issues. Although claims have been made about non-surgical skin tightening technologies, none have been able to reliably produce the results of the skin removed using Body Lifting Plastic Surgical procedures.

Despite the physical costs to their bodies, having children and watching them grow is arguably the most fulfilling thing a woman can experience. Many women are concerned about the physical consequences of being a mother. Through the latest techniques of Breast Enhancement and Body Contouring, many women can reverse these effects and achieve a Mommy Makeover.

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Posterior Torso/ Hip Lift: “The rest of the story” in body lifting

May 27th, 2009

Most patients are familiar with Body Contouring techniques involving Abdominoplasty or Tummy Tucks and liposuction. These procedures are designed to address the lax, redundant tissues as well as fat deposits of the abdomen that occur with age and child bearing. Nearly 90 percent of patients that undergo these procedures are happy with the results. However, many patients express concern with the saggy and loose skin of the back, hips, buttocks, thighs and arms that remain after a successful Tummy Tuck.

What is less appreciated is that the processes of aging, weight gain and loss have consequences to the entire body, not just the abdomen. These processes result in an overall looseness of the posterior torso (Hips, back and saggy buttocks) as well as the arms and thighs. Working out generally does not help this laxity. By employing the same concepts that result in successful Abdominoplasty, Plastic Surgeons are able to improve skin rolls of the bra strap area and back and posterior waist, lift the buttocks to give smoother and rounder bottom and tighten the skin of the upper arms and thighs. As Paul Harvey used to say “and this, is the rest of the story!”

A Posterior Torso/ Hip Lift removes the extra skin and soft tissue of the waist, posterior hip and back. In doing so, it lifts the saggy tissue of the buttock region and can restore a more “hour glass” curve. This improves the contour and perkiness of the buttocks and lateral thigh and results in a more pleasing and youthful round contour. It may even improve cellulite. The Posterior Torso/ Hip Lift (aka Buttock Lift, Lateral Thigh lift) is simply the completion of a Body Lift after an Abdominoplasty or Tummy Tuck.

Circumferential Body lifts have become more popular since the field of Bariatric Surgery (Weight Loss) has become successful. After massive weight loss, patients have a lot of extra tissue circumferentially around the body. Some people describe themselves as looking like a Sharpe’ dog before it grows into its skin. A Body Lift is simply a Tummy Tuck that is carried completely around the body. In those people that have lost a lot of weight, this can be a very big surgery.

However, in those individuals who simply have developed laxity from child bearing and the normal variations of weight and aging, treating these areas is more straight forward and simple. Unlike Tummy Tucks where we are tightening the abdominal muscles, there is much less discomfort and recovery in Posterior Torso lifts. It is well tolerated and most people can get back to work in 10 days. A similar claim can be made about the lax tissues of the upper arm.

In summary, over time and with the metabolic changes of child bearing and fluctuating weight, the skin and soft tissues of the body can lose their resiliency and become lax. Techniques of Body Contouring such as Posterior Torso lifts, thigh lifts and arm lifts can treat this looseness and improve contours and proportions of the legs, waist and buttocks and arms.

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