Posted on September 29, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast augmentation, breast implant, interesting & new
If only we could take fat from where we DON’T want it and put it where we do.
This is the premise behind fat grafting to the breast. Lipoaugmentation, fat transfer to the breast, fat grafting are all terms you will hear. Your own fat is a wonderful substance. It is soft, part of you, not a foreign object with issues of body rejection. So what is the story? Why do we do breast augmentations with silicone and saline implants at all?
Fat grafting is not a new technique. We plastic surgeons have been doing fat grafting for years. The techniques have been refined over the years to try to increase fat survival. When you move fat from one area (your inner thigh) and put it in another area (your buttock, breast, etc), the fat must recruit a new blood supply to live. Fat cells are living cells. They need blood to bring oxygen and nutrients so they can live. The newer fat grafting techniques involve harvesting the fat with less trauma, to preserve the health of the fat cell, and placing the fat cells in the new area by smaller injection sizes to improve the blood flow to the newly moved fat cell.
Imagine you are laying new grass in your backyard. You created a fertile, rich soil bed. It is moist. But there is no lawn sprinkler system yet. You have to wait a week until that will hook up to feed your new grass. If you lay down grass by rolls of sod in a low water environment, it will have a hard time surviving. If instead you tried to grow the grass in a low water state with individual seeds, you will have more of your product survive.
What does fat do if it dies? Ahhh. Here’s the rub. If fat dies, it does two things which are not good for breasts. First, the fat can harden. Second, the fat can calcify. The second point is the one which prevents most plastic surgeons from doing large scale fat grafting to the breast: what do we do about calcifications? Mammograms are based on finding clusters of calcifications to detect breast cancer early. What do we do for a 40 year old patient who had breast augmentation with fat years ago who now has calcifications throughout the breast?
There is also the issue of how much fat survives. If the fat does not get a blood supply, in addition to turning hard (fat necrosis) and calcifying, it can just melt away. This is the “take” of the fat graft. To compensate for this, many will fat graft more fat than they think they need, assuming some will melt away. Others will do a series of grafting to add more as needed. And even if the fat has good take, it is not unusual to see the fat gradually lessen in volume over time.
I am a natural girl. I have had three kids and know firsthand how fat goes from where you do want it (breast) to where you don’t want it (everywhere else). I think fat is a wonderful graft substance in other areas of the body: cheek, lip, back of the hands, indents and divets on the body. But the breasts are a unique place. Breast cancer rates used to be quoted as 1 in 11 when I was in med school. Now they quote 1 in 6.
This is a hot topic for us plastic surgeons. We want to use natural substances to do breast augmentation. There are currently studies being done to specifically look at our issues: how much fat can be grafted at a time? Will we be able to increase breast size by one cup ? more? What are the changes seen after fat grafting to the breast on serial mammograms? Does the breast hold the change in volume?
Until these are better studied, hold onto that fat and don’t put it in your breast quite yet.
Posted on in Face, Skin / Nonsurgical, botox
Ahhh.
So you are wondering why the spa down the street is offering “one area” of botox for $150 and another place costs $400. How can this be?
Botox comes in a vial with 100 units. We doctors must reconstitute the botox, which is a fancy way of saying we add saline to it to suspend the botox in fluid so we can inject it. Whoever is mixing the botox can add a different amount of fluid. This means 1cc of fluid could have totally different amounts of active botox depending where you are. So how do you know what you are getting?
girlfriends guide to plastic surgery questions to ask (ie what I tell my girlfriends to ask):
1. How many units am I getting? They can dilute away, but asking how many units will tell you what you are really getting. A standard dose for “one area” is 24 units.
2. What is one area? This is a somewhat old terminolgy, though we still use it as well. One area is the forehead, or the glabella (the area between your eyebrows), or the eyes / crows feet. The usual dose per area is 24 units, so one area is 24 units, and two areas is 48 units. These areas aren’t concrete, and my most common dosing is “two areas,” but I spread those 48 units between the forehead, glabella, and eyes, which is technically 3 areas.
3. Do you use fresh botox? When we started injecting botox a decade ago, everyone had botox days to use fresh botox. Then people became lax, and the word on the street was an opened vial of botox lasts up to a week. I am a plastic surgeon, and I am a 40 something year old female. I use botox. I can tell you a botox vial that is even a day old doesn’t kick in as quickly or last as long for me as fresh botox does. So I stick with the fresh stuff. I think it works better. Most places don’t care if your botox doesn’t work as well. It just means you will be back sooner.
4. Why do I care if a doctor injects it? Granted I clearly have a bias in this area, but I think doctors do it better. There is an art to botox. I don’t like the frozen face. I like patients to be able to animate, smile, frown… just not as deeply as before. Subtle, natural results are hard to achieve. I think we plastic surgeons have an advantage as we are injecting the same muscles we operate on. I know where the orbicularis and corrugator muscles are. I operate on them. I know how they move, how deep they are, etc etc.
SO, my biases:
Ask for units. Is it fresh? Who is injecting it? Whoever is injecting should write down what they did. Where did they inject? how much? Again, botox is an art. Every patient is different, and only if you document what you do can you fine tune it in the future.
Posted on in Breast, Post Pregnancy Breast
Stretch marks are essentially a tear in the skin.
Breast implants can cause stretch marks. This is not common, but it is a risk. I see it most often in a young patient with thicker skin (think Asian, Latina, Phillipino). When this skin needs to stretch quickly to accept the new implant, it can cause a “tear” in the skin. Again, I must repeat, this is not common.
Will it stretch marks happen to me?
If you got stretch marks on your thighs when growing or have bad stretch marks from a pregnancy, these may indicate a higher risk. There was a recent study showing a genetic component to stretch marks. The finding was the dermal fibroblasts in these patients were the issue, producing less elastin and collagen than expected. There was also a study finding stretch marks could be made without stretching the skin, just using a steroid cream. This may support a multifactorial cause which also includes hormonal changes.
Regardless, we see a correlation with rapid change in size and strech marks. Therefore breast implant size is also a factor. The bigger you go with your breast implants, the more you stretch your skin. In general women who have babies and breastfed have essentially “pre-stretched” their skin. I find the occurence of new stretch marks for these patients is less.
How to prevent stretch marks? You can’t totally prevent them. Genetics you can’t change. You can watch what size you are doing with your breast augmentation, but that doesn’t guarantee you won’t get stretch marks. I see women who go to large sizes with no stretch marks, and women with small implants form strech marks.
I do believe in hydration and massaging of the breasts. Studies are unclear if there is a specific lotion which is better. Start massaging the skin before your surgery date, and continue after for about a month.
There is a lot of buzz about nutrition: Vitamin C, Vitamin A, Zinc, avoiding caffeine. I don’t know of any particular studies which support this, but it likely won’t hurt.
Posted on September 25, 2009 in Face, Skin / Nonsurgical, interesting & new, skin fillers
Sculptra is not a new soft tissue filler. It has been out for years and is good to add volume to the face. What started out as a basic treatment for those with “lipoatrophy” (when your cheeks are hollow and sunken from losing your facial fat), has now been approved for cosmetic applications by the FDA.
Sculptra is a collagen stimulator. In english that means it seeds the face and stimulates your body’s own collagen production. Essentially you are thickening your own skin, with a little kick start by the sculptra. The benefit of this is a slow change, a natural look, and a natural substance- your own collagen. It requires a series of two to three injections spaced by 4- 6 weeks. The results last an average of 25 months.
Sculptra is applied all over the face: the tear trough (lower eye), the cheek, the jawline, the eyebrown bone, and temporal region. When we age, we lose a little fat from all over. The goal of Sculptra is to replace soft tissue fullness. Youthful faces are not thin and gaunt. Look at your children to see what youth looks like. The other fillers in major use are hyaluronic acid fillers (Juvederm, Restalyne). They have a wonderful results, are immediate gratification, and can be used in the lip (Sculptra cannot). But if you need volume- two, three, four syringes of a HA filler, every 6 months, it adds up in time and cost. Scultpra has been approved for 25 months of longevity. I like it because there is good science behind it, showing histologic biopsies with the newly produced collagen. It is not a magic answer. But for many women who are in their 40s and 50s, particularly those who don’t want to do a facelift, it gives a longer lasting alternative to help rejuvenate the face.
Over the past decade plastic surgeons have shifted from taking fat out of the face to adding fat to the face, or “volumizing.” The analogy is your face is a beach ball, gradually deflating over time. When you want to fix the beach ball, you need to add air. The “air” is soft tissue volume. You will now see most of us plastic surgeons during our lower eyelid surgery won’t remove fat, doing what we call a “fat preservation” technique. We graft fat to the face: eyelid tear trough, cheek, and lips. Back when I was in residency, they advocated removing the cheek fat (buccal fat pad) to give that hollow cheek look. Now we would never imagine that.
Sculptra will be starting their new advertising campaign soon, this Fall of 2009. It was just approved by the FDA for cosmetic use. I think it is a good product. I have been using it for a while, and I am pleased by the results.
Posted on September 16, 2009 in Body, Post Pregnancy Body
Body
When thinking about body alterations, it is important to identify whether your dissatisfaction is driven by excess fat, excess skin, or a combination of both. To help identify if your skin tone is good, look for stretch marks, fine wrinkling, or sagging of the skin. As we age, our skin tone naturally declines, but treatments such as liposuction, abdominoplasty, and body lift can improve the appearance of these areas. The following questions will help guide you to possible appropriate procedures for you.
Abdomen
Do you have stretch marks? Overhanging skin? Muscles stretched from pregnancy or weight loss? Have you been pregnant before?
If you have excess fat, can you ‘pinch an inch’? Is the fat resistant to diet and exercise? Are you within 20 percent of your ideal weight? Is your weight stable? Is your skin tone good?
Treatment options include liposuction, an abdominoplasty (also known as “tummy tuck”), a mini-abdominoplasty, or a combination.
Love Handles/Flank
This is an area where liposuction is great, EVEN if you have stretch marks. It is also a very common area for men to need help with. Can you “pinch an inch?” Is this where you hold your weight? Do you have a bulge that comes over pant waistlines or is visible in shirts or dresses? Do you have an “apple” shape?
Inner Thigh
We all hate it when our thighs rub together. To analyze your skin tone, look for fine wrinkling or sagging of the skin. You can pinch the skin together to get an idea of how much excess fat you have. If you have a bulge, but the skin is not wrinkled or sagging, liposuction is a good alternative. If you have fine wrinkling or sagging of the skin, you may need to undergo a medial thigh lift to remove excess skin.
Outer Thigh
Do you have a “pear” shape? Do your pants pull tightly at the level just below the bottom? Do you have to buy pants that are too large in the waist in order to get the thighs to fit? Liposuction works well in this area.
Arms
Do you have skin that hangs down when you put your arms out horizontally? Are you embarrassed to wear tank tops? Have you undergone significant weight loss? If you have a lot of loose skin, you may need skin removal, known as a brachioplasty. If your skin tone is good, liposuction works well to give good muscle contour and definition.
Posted on in Breast, Post Pregnancy Breast
When considering an alteration to your breasts, it is important to figure out what you do and don’t like. Are your breasts symmetric? Do you like their volume? Do you like the shape? Do they sag? Do you want a mature looking breast or a more youthful one? How do you feel about implants?
Treatment options a cosmetic surgeon may recommend for the breast are breast augmentation (also known as “augmentation mammaplasty,” “breast enhancement,” “breast aug,” “breast implants”), breast reduction (also known as “reduction mammaplasty”), breast lifts (also known as “mastopexy” – there are many types of breast lifts), and breast reconstruction.
Symmetry
First, are they symmetric? Most breasts are not. Usually one is larger, one sits higher on the chest wall, the nipples are at slightly different heights. Which shape or size suits you better?
Volume
Do you like the volume? Do you want them to be the same size, larger, or smaller.
Shape
Do you like the shape? Do you want more cleavage and upper breast fullness? Do you have narrow or tubular breasts (tubular breasts are a natural variant where the lower half of the breast is not as full, giving a tubular shape)? Do you have wide flat breasts? Do they sag
Cancer
Are you missing a partial or total breast due to cancer?
Remember that your insurance will cover changes to both breasts, even if the cancer impacted only one. So consider your other breast. Is your risk for breast cancer in this side very high? (Do you have the BRCA gene?) Do you like your unaffected breast? You don’t need to change it, a cosmetic surgeon can match the reconstructed breast to it. But if you don’t like your natural breast, do you want it larger? Smaller? Lifted? Look at this as an opportunity to modify it if you would like.
Posted on in Face
When considering alterations to the face, the first step is to decide precisely what feature you’d like to improve: Brow? Eyes? Mouth? Neck? How is your skin tone? Is the skin loose? Common procedures to address these problems include facelift, brow lift, blepharoplasty, and non-surgical skin treatments.
Forehead
Do you have deep wrinkles? This may mean you need to raise your forehead to lift your eyebrows or upper lids to help your peripheral vision. Treatment can include non-surgical methods like BOTOX® injections, soft tissue fillers, or skin resurfacing, or surgical methods like a browlift, endobrow lift, eyelid surgery, or a combination.
Upper Eyelid
Do you have excess skin, or overhanging skin on the side of your eyelid? Does your eye area seem smaller? Do you have a difficult time applying eyeshadow? Treatment can include skin resurfacing with a peel, an eyelift, a browlift, or a combination
Lower Eyelid
Do you have pooching of the skin? A shadow under your eye that makes you look tired or sad? Are there fine or deep wrinkles under the eye? Depending on the severity, a skin resurfacing with a peel, a surgical eyelift, or a combination is appropriate.
Cheeks and Nasolabial Fold (crease from nose to mouth)
Does your cheek seem less full or lower? Is your jaw line not as defined as it once was? Is the crease from your nose to your mouth deeper than it once was? For finer lines you can non-surgically treat the area with soft tissue fillers or a peel. For deeper lines, a facelift is the treatment of choice
Mouth
Do you have lines around the mouth? Do you like the size and fullness of your lips? As we age, the lips tend to thin. Treatment options include skin resurfacing with products and peels, soft tissue fillers to fill out the lip a little, or a combination.
Neck
Does the neck/chin have excess fat? Poor definition? Banding? A double chin? A “waddle?” If you are younger or have good skin tone, liposuction may be a good alternative. Otherwise, a facelift is the treatment of choice.
Posted on in Pre Pregnancy
So you are going to take the plunge. I think it is fantastic. There is nothing I have done as moving and rewarding as having children. Pregnancy is hard on the body. Common changes occur. Here is a brief overview of some things to do before you get knocked up.
1. Exercise. A healthy body does better with pregnancy. A lot of the women I see with great figures after pregnancy had them before pregnancy. So improve your muscle tone, particularly your core muscles (especially the rectus muscles and oblique muscles which you use to do pilates/the plank/sit ups).
2. Healthy skin. The “rosy skin” of pregnancy sounds great. And many women do get it. They also get a lot of pigmentation. The sun spots, age spots, freckling- call it what you will- worsens with pregnancy. So prior to pregnancy, try to reverse any skin pigmentation you have. Hydroquinone and Retin A are great for pigmentation, but they are NOT baby safe. There are products with Vitamin C and E which are okay while pregnant and breast feeding. And the key to pigment? SUNSCREEN and the big floppy sun hat. You should apply sunscreen daily. Try to find a moisturizer or makeup base with sunscreen in it. When doing activities in the sun, apply sunscreen 20 minutes before going outside, reapply every 45 minutes in water, reapply every 2 hours regardless, and use sunscreen less than a year old. I am a fan of the clear zinc based sunscreens. They are mechanical blockers, not chemical, so they are likely less absorbed in the skin. Very effective and thought to be a little more baby safe.
3. Ideal weight. You will gain weight with pregnancy. (Oh my!? shocking.) The amount of weight you gain varies, but the usual recommendation is 25 pounds. There is a correlation with weight gain and body changes- stretch marks, loose skin, diastasis, and higher post pregnancy weight. There are studies which link obese children to mothers who were obese before pregnancy. (The amount of weight gain has been revised to 11-20 pounds for women with a BMI of 30 or more.)
4. Stop smoking. I could go on for ages on this one. It affects every body system; increases your chance of heart attacks, stroke, and cancer; along with sun exposure it is the biggest ager of the skin, and does things I can’t fix with products and peels; no surgeon will do a tummy tuck or a breast lift on a smoker, so you might as well stop now; it is expensive; you can’t do it in restaurants; it yellows your teeth.
The health effects on the baby: it lowers the amount of oxygen they get in utero, increases heart rate, and increases rate of miscarriage and low birth weight. There are other studies indicating after birth these babies have issues with asthma, behaviorial issues, and higher SIDS. For more information go to: http://cerhr.niehs.nih.gov/common/smoking.html.
5. Surgeries. The one surgery I like before pregnancy is liposuction. If you have a discrete problem area, like “my outer thighs,” or are an exaggerated pear or apple shape, your shape will not improve with pregnancy. Particularly for those women who are teeny tiny up top and carry all their weight in their thighs/hips, when you put on baby weight it will all go there. Fast forward: you are now 10 years older and have stretched that skin more, for a longer time, and your skin is older- it won’t bounce back after liposuction like it would at age 25. Skin tone is key to liposuction, and young skin is better.
I do not like to do abdominoplasty (tummy tuck) or breast surgery right before babies. If your breasts really bother you and you will not have babies for 5-10 years, then it may be worth it to do now. But pregnancy and breast feeding affect the belly and the breast the most. If you can, wait to fix up those areas until after you have kids.
So,
Exercise. Wear sunscreen. Eat well/be your ideal weight. Don’t smoke. Sounds simple, eh?
Now go get practicing to have that baby.
Posted on September 15, 2009 in Skin / Nonsurgical
Look at your skin. Be crazy and get out the magnifying mirror. Be critical.
How do you assess your skin? What do you look for?
General
Do you look tired with a dull complexion? Acne scarring? Pre skin cancers or skin cancers? Do you want to do things to prevent aging? Do you prefer nonsurgical methods?
Sun Exposure
Do you have sun damage? Sun spots? Age spots? Freckles? Are you fair skinned with light eyes and hair? Do you wear sunscreen daily? Have you had a lot of sun exposure (work outside, golf, tennis, swimming)? Do you have precancers? Scaling patchy red areas? An area that won’t heal?
Rx: Sunscreen, Hydroquinone, Vitamin C, Vitamin E, Retin A, Chemical Peel
Pigmentation
Do you have pigment problems? Age spots? Dark patches? Irregularities?
Rx: Hydroquinone, Retin A, Vitamin C and E, Chemical Peel
Fine Lines and Wrinkles
Do you have fine lines? Deep lines? Where are they located?
Rx: Botox, soft tissue fillers, chemical peels, and surgery.
Possibilities:
There are many non-surgical methods to improve your skin. Not only will your skin look better, it will be healthier – reversing some of the sun and aging damage. Skin products with Retin-A®, hydroquinone, Vitamin C, Vitamin E, sunscreen, and exfoliants all improve the quality of your skin. I like products from the Obagi NuDerm line, the Skinceutical Vitamin C lines ( Vitamin C E Feurlic and Phloretin CF), and the zinc sunscreens which give a total mechanical block.
Skin resurfacing with a chemical peel will improve skin quality. I am a fan of the TCA Blue Peel. It works for light and dark skin types (which includes Phillipino, Latino, Indian, and darker skin types). I used to use more lasers, but many are not good for darker skin, they are expensive, and you usually can’t safely go onto the neck and chest. Peels have been around for a long time and are effective “ironing” the skin, reducing pore size, and improving fine wrinkles. For more information go to the page. I do not believe in many of the current lasers out there.
You can also treat fine lines with BOTOX® and soft tissue fillers .
I do not believe in selling you a rainbow. There are things we can make better, and others we can’t fix. There has been much growth of the laser and product industry. I am critical when evaluating these new products. Can they prove to me they work? I think a lot of products are hype, short term improvements, and unproven claims. If you are spending money at a department store on expensive products, I would recommend changing to products from a doctor’s office. Over the counter products cannot have the same strength as those sold from a doctor. Not all products from a doctor are effective. I screen all new products, and make the rep show me the scientific studies to back their claims. For this reason I don’t carry a lot of products, and I don’t carry all products within a line. I cherry pick the ones I think work. As for skin resurfacing, I am skeptical of treatments with “no down time.” I find many of them look better for a short time, with little long term effect.
Posted on in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction
Insurance coverage has gotten more difficult over the years. When I started my practice, most of my reductions were covered by insurance. Now most are not. I believe the act of lifting and reducing the breast helps with neck and back pain, posture, ease of dressing, and ability to exercise. You can check with your insurance to see if “reduction mammaplasty” is a covered surgery with your plan. All plans are different, even within the same insurance company. If you have seen other doctors such as a back doctor, physical therapist, or chiropractor for neck and back pain, a letter from them supporting a medical benefit in your breast reduction is helpful. A minimum reduction of at least two breast cup sizes is necessary. With current recommendations, a 5′6″ woman who weighs 140 pounds needs a reduction of 370-400 grams per breast to be covered. If she weighs 160, she would need about 450 grams per breast. Liposuctioned fat cannot be applied to this total. In the office I can show you with sizers the approximate amount. For some of my patients, the “minimum” needed to be removed is almost a mastectomy.
Please read below for a sample of an insurance letter to understand what we face now. We are happy to help the process with photos, letters, and the coding. I am your advocate.
“Reduction Mammaplasty for symptomatic breast hypertrophy or hypermastia may be considered medically necessary when the documentation provided shows that the member meets all criteria of our medical policy.”
- Clinical documentation of pain in the upper back, neck, and shoulders which is long standing in duration and increasing in intensity, and is not related to other musculoskeletal causes (eg poor posture, acute strain, post traumatic conditions, poor lifting techniques. or over use)
- Clinical documentation of ulnar nerve paresthesia or compression, which results in pain and/or numbness in the arms and hands.
- Physical exam documenting hypertrophy.
- Clinical documentation showing failure of a minimum of 6 weeks of physical therapy for back, neck or shoulder pain including a maintenance home exercise program.
- Clinical documentation showing failure in the use of an appropriate support bra with weight distributing straps.
- Clinical documentation showing failure in the use of anti-inflammatory agents, unless medically contraindicated.
- Clinical documentation showing failure in the use of symptomatic measures, including the application of heat and cold.
- Documentation of the patients body surface area based on the Schnur Sliding Scale, where the patient’s breast weight per breast is estimated at greater than the 22nd percent line, consisting of breast tissue, not fatty tissue to be removed.
(Dr. Greenberg note: You can see the Schnur Sliding scale at http://www.bcbst.com/mpmanual/The_Schnur_Sliding_Scale_chart.htm and the body surface area calculator at http://www.bcbst.com/providers/calculator.asp )
