Posted on October 31, 2009 in Face, Skin / Nonsurgical, botox, skin fillers
The Medi Spa. Who doesn’t want to have medical procedures done in a spa? The soothing lights, smell of lavender, and cucumber ice water. Sounds much better than a doctor’s office. Oooh, and it is in the mall? Maybe I can go get a pair of shoes afterwards.
The issue is no one should inject who is not trained. That means the injection should be done by a doctor (plastic surgeon, dermatologist, or facial plastic surgeon), or a “nurse under the direct supervision of a doctor.” I do all the injections myself: botox, fillers like restalyne and juvederm, sculptra. I don’t use nurses. Be careful! Many offices do have nurses, but many of those nurses surely are not under “direct supervision” by the doctor.
We seem to forget injecting medications and substances into the body isn’t something to be done lightly. It is not as one article said “changing your hair color.” There are things which can happen: if botox is injected poorly, you can get eyelid droop. I have seen photos at our national meetings of people who lost skin on their face from a bad injection of soft tissue filler. Devestating to see or fix.
I am a surgeon. I know anatomy. I do eyelifts and facelifts and browlifts, so yes, I am better at injecting. I can visualize in my mind where I am, what is important nearby, and what is safe. I recently went to a CME (continuing medical education) workshop where we dissected cadaver heads (yes yes, I know it isn’t how you would like to spend an afternoon). It was fantastic. But I was amazed at the number of physicians with busy injectable practices who were not surgeons, and didn’t know their anatomy like we plastic surgeons do. They do not know exactly where they are when they stick the needle through the skin. I was surprised.
The bill AB252 is to stop the medispas from running amok. These are medical procedures with real risks. When done well, those risks are low. But we shouldn’t forget we are doctors. I like the California Medical Board’s Synopsis:
‘Medical Spas . The increasing popularity of cosmetic
procedures or treatments, and the lucrative business they
offer have given rise to a new model of providing cosmetic
services outside the traditional physician settings and
into malls and local spas. Medical spas or popularly known
as “medspas” are increasingly becoming the destination for
various cosmetic procedures or treatments.
has posted on its web site a fact sheet. The fact sheet
indicates that “medical spas are marketing vehicles for
medical procedures. If they are offering medical
procedures, they must be owned by physicians. The use of
‘medical spa’ is for advertising purposes to make the
procedures seem more appealing. In reality, however, it is
the practice of medicine. There is no harm in seeking
pampering or in wanting to look better. A visit to a spa
may provide a needed respite for our stressful lives, and
treatments that make us look better often make us feel
better. The Medical Board, however, is concerned when
medicine is being marketed like a pedicure, and consumers
are lead to believe that being injected, lasered, and
resurfaced requires no more thought than changing hair
color. According to the MBC’s fact sheet, cosmetologists,
while licensed professionals and highly qualified in
superficial treatments such as facials and
microdermabrasion, may never inject the skin, use lasers,
or perform medical-level dermabrasion or skin peels. Those
types of treatments must be performed by qualified medical
personnel. In California, that means a physician, or a
registered nurse or physician’s assistant under the
supervision of a physician. Patients must know the
qualifications of persons to whom they are entrusting their
health. Those seeking cosmetic procedures or treatments
should know that the person performing them is medically
qualified and experienced.
SO. Who is doing your injections? Clearly my bias is a plastic surgeon doctor. Board certified by the American Board of Plastic Surgery. Next would be other doctors trained specifically to do injections, dermatologists and facial plastic surgeons. Then it falls apart a little for me. I know of nurses who are excellent at what they do…but how are they trained? do they know the anatomy? and more importantly do they get complications? how do they treat them? The true test of someone is not what they do when all goes well. It is what they do when it doesn’t.
Posted on October 23, 2009 in Skin / Nonsurgical, scars & scar care
We plastic surgeons do not do scarless surgery.
We make pretty scars. We hide scars. We try to make small scars. But anytime you cut through skin you will have a scar. In our training, plastic surgeons learn how to make a good skin closure. To do this, we have multiple layers of closure under the skin which you don’t see. We undermine and advance the tissue (a fancy way of saying we loosen the tissue up and move it), so when we close the skin it isn’t under tension. We try to orient the scar with a wrinkle fold (which helps it hide) or put it into a crease or other hidden area.
What can you do to make a scar prettier?
1. Start when the scar is new. When people come in with a scar 6 months or older, there isn’t a lot of change occurring in the scar. It is harder to reverse bad changes, ie it is better to nip it in the bud before it happens. This doesn’t mean you have to put creams on the scar on day one. I usually recommend letting the initial scar heal first, and starting the treatments 2-3 weeks out.
2. Sunscreen. Sun is bad for scars. Particularly here in sunny Palo Alto, we are constantly exposed to the sun. Sun can essentially tattoo the scar, so the color never fully fades.
3. Don’t irritate the scar. (Who would want to irritate a scar? That sounds as bad as waking a sleeping baby.) But we irritate scars without thinking about it: clothing, bras, waistbands, picking at it. When a scar is trying to heal, I think it needs to be left alone. For this reason I found covering the scar with simple paper tape helps.
4. Too dry or too moist is bad. Studies show scars heal better in a moist environment. So the alcohol, hydrogen peroxide cleaning of a scar in general is bad because it dries it out too much. (There are cases where it helps, but usually not.) Too moist and goopy is bad. I see people glop on the neosporin, or cover the scar with a bandaid they don’t change for days on end. One reason I love paper tape is it breathes better than bandaids.
5. Pigmentation. Anyone who has any color in their skin runs the risk of depigmentation (fancy way of saying the scar turns white) or hyperpigmentation (fancy way of saying it turns dark). Other than what we plastic surgeons do at the time of surgery to get a pretty closure, you may need a cream like hydroquinone to help even out color. There may be some lasers which help, but you must always be careful when lasering anyone with colored skin- there are many pitfalls associated with it.
5. Massage. Wait til you are healed, and then you can massage the scar to help it flatten and soften.
6. Mederma, Kelocote (a liquid silicone gel) are my favorite over the counter to help reduce scars. No one knows why silicone gel helps scars, but using silicone gel sheeting on major scars has been done for years.
Other notes:
- I am not a fan of vitamin E for normal scars (not elevated, ropey hypertrophic scars). Vitamin E has been shown to break down scar. It is great for when you have a scar which is too much scar, but on a normal scar it can cause the scar to indent or widen.
- Keloids are out of the scope of this talk. If you have a personal or family history of keloids let your doctor know. A true keloid is difficult to treat. Many patients tell me “I keloid” when they don’t.
- Scars in certain places never heal well. High movement areas like the shoulder and knee, places where you don’t have loose skin like the calf and back, and areas which get constantly irritated like the foot tend to be worse.
Posted on October 21, 2009 in Uncategorized
testing twitterfeed
Posted on October 20, 2009 in Body, Post Pregnancy Body, interesting & new, liposuction
There is a lot of trickery and marketing in liposuction. I have had people ask me, “Do you do liposculpting?” Liposelection, liposculpture, laser liposuction, UAL, Vaser, ultrasonic liposuction- what do these all mean? Please see my liposuction page on my website. Much of this terminology doesn’t mean anything. We all sculpt (or should) when we do liposuction. Ultrasonic, UAL, Vaser are all ultrasonic energy used to break up fibrous fat. Smart lipo, laser liposuction are lasers which are a smaller caliber than ultrasonic, but the purpose is the same: to break up fibrous fat. My favorite marketing gimmick is “We use the new tumnescent procedure.” Perhaps tumnescent is new to that doctor, but it is not a new technique. Everyone uses tumnescent, and it has been around for 20 years. (Tumnescent is infusing the fat with a mixture of anesthetic, epinephrine, and saline prior to fat removal which significantly cuts down on blood loss.)
The laser liposuction while effective, has a small caliber. It is great for a small area like the chin, but not good for more broad fat removal. It is like painting a room with a small paintbrush instead of a big roller. Key to fat removal is smooth. Many of the laser machines say: no anesthesia, no downtime, no need for traditional liposuction. What they don’t tell you is this is only true for small areas. When doing a normal person I will typically get 2-5 liters of fat (4-10 pounds, and no, these are not fat people. We all have more fat than you’d think). When I oriented for the laser liposuction machine, they admitted their photos of 2+ liters of fat involved liposuction with ultrasonic energy. The laser was used as a finishing tool. For those of us adept with ultrasonic, we see no advantage to using another machine. The instructor told me his laser liposuction patients who only used laser had an average BMI of 19. For a 5′6″ woman, this means you weigh 120 pounds. Most of my Palo Alto patients who weigh 120 pounds aren’t in my office looking for liposuction.
I see patients for redo liposuction all the time. The two major factors are 1. not enough fat was removed. 2. uneven fat removal. Revisions are tougher: you now have scar under the skin. I find you need ultrasonic energy to break up this scar to help achieve a smooth result. If you are irregular but still have a lot of fat, the fix is easier. If you are too thin in an area, the only fix is fat grafting, which is difficult.
So. My biases:
- Board Certified Plastic Surgeon. We operate and train as general surgeons before plastic surgery. We do tummy tucks and other abdominal procedures. We know the anatomy better.
- Board Certified Anesthesia Doctor. Many horror stories are from anesthesia and fluid issues. This is elective surgery. You need to be safe.
- Don’t spot treat. No one has fat just in their outer thighs or lower belly. Treat it all or have a funny body shape down the road. (Unfortunately we all fall off our good eating and exercise wagon at some point.)
- This should be done in an accredited OR. Outpatient ORs should be “Quad A” certified. True board certified plastic surgeons can operate in a hospital. Hospitals do not grant operating privileges for liposuction to nonsurgeons: dermatologists, family practice, internal medicine. Hence many of these doctors will do surgery under local anesthesia in their office.
- Ultrasonic or laser energy is good to help break up fat. For anything above a small area like the chin, ultrasonic is better. With both you need to use traditional liposuction (SAL) to remove the liquefied fat, or you will get a seroma (a collection of fluid under the skin).
- If your skin is loose, you are older, or you have a lot of fat, you will get some skin irregularity.
- Stable weight. If you yo-yo or gain weight, you will create new fat cells and ruin your result.
Posted on October 14, 2009 in Body, Post Pregnancy Body, tummy tuck
Tummy tucks hurt.
I know I know. Clearly G-d is not a woman. How can something as miraculous as a baby wreak such havoc on our bodies? And then, when we decide “Okay. I am going to suck it up, get the scar, and go through the surgery,” why oh why does it hurt so much?
Tummy tucks are a two layer repair. The first layer is inside, and looks like an internal corset. This layer permanently sutures the fascia tighter. We don’t sew the muscle when we do a tummy tuck. If you ever try to sew muscle, you know sutures don’t hold. You need something stronger, more leathery… something with ooomph in it. So we use fascia.
You would think the long scar on the skin is what hurts. It looks like it should hurt, eh? But it doesn’t. Right after surgery, just like in a Csection, your abdominal skin is numb. The part hurting you is the muscle repair. If you are a typical Bay Area athelete (read triathalon, marathon, “I’ll just bike to the coast today,” or my favorite “I went for a 5 mile hike, but I stayed on the flat parts”), your muscles are well developed and may hurt more.
I use a pain pump which I feel is helpful for my patients after surgery. It is not a PCA, the morphine pain pump with a little button you push and runs via IV. This is a pump filled with a numbing medication, marcaine, and has two small catheters which drip the numbing medication internally along your muscles. You don’t do anything. It lasts for 3 days. I like it. It cuts down on the number of pain pills you take, which makes you feel less woozy and helps with constipation. And it helps keep you from feeling severe pain from right after surgery. There is a lot of research supporting prevention of pain- if you can keep the first pain wave from happening, staying “ahead of the pain,” you do better.
So, pain pumps have been a nice addition to our tummy tuck patients. They don’t stop the ouch all together, but they help.
Posted on October 10, 2009 in Breast, breast reduction, interesting & new, liposuction
Large pendulous breasts suck. They give you neck pain, shoulder pain, rashes under your breasts. You hunch over due to the weight and droopiness. Forget about jogging. Oh, and the lovely feeling of the breast sticking to your skin on a warm summer night. But the scars of a breast reduction aren’t so nice either, particularly the large anchor style scar of the inferior pedicle technique. (Please do see my lollipop, shorter scar on my vertical breast reduction.)
So you hear about a breast reduction by liposuction with no scar, easier recovery, and can reduce my breast size by 30-50%? Sounds fantastic! Great! Sign me up!
I saw a woman recently for a breast reduction. She presented to me with chronic pain and large, pendulous breasts which were rock hard. She is a smart woman But even she, who is a doctor, was pulled in by the media, hype, flashy office, promise of no scar and quick recovery.
I have to be honest. I went to our national meeting and saw beautiful results of breast reduction by liposuction. I left the meeting and thought, I should look into that. The next day I met my patient. I have never in my decade of private practice seen a breast like hers. It was droopy, hard, painful. She relates to me her story. “I researched the procedure and talked to a few plastic surgeons. I work a lot, and couldn’t take weeks of downtime. I wanted to do something where I would heal quickly. They had a hard time getting the fat out of me. Afterwards, I am bigger than I was before. I have chronic pain throughout the breast every day. I wish I could go back in time.”
Liposuction of the breast has issues.
1. It does not lift. A major benefit of a traditional breast reduction is the lift you get. Most women want the reshaping, firming, and lifting as much as they want the reduction in size. Some surgeons advocate when you remove tissue, the weight of the breast is lighter, so the skin will lift. In younger patients with good skin tone, this may be true. But this leads to the second issue…
2. Breasts, particularly young breasts, have a lot of breast tissue. Breast tissue is dense, firm, and won’t reduce with liposuction. Liposuction can only remove fat. So for many 18 year olds with large breasts, liposuction is not an option as a significant portion of their breast is not fat. Older women (read 60s, 70s, 80s) breasts are mostly fat. But then the liposuction will not correct the drooping, just reduce the size.
3. The lift is important. What bothers large breasted women is neck pain, back pain, poor posture. A study came out of Sweden (where they have nationalized healthcare and it is easier to study such things) showing the act of LIFT improved symptoms. In other words, even if the breasts were not reduced, the pure act of lifting them improved symptoms.
4. What happens to breast tissue when you liposuction? Particularly ultrasonic or laser liposuction? We always worry when we do anything to the breast about
- cancer. could this increase the rate of cancer?
- imaging to look for cancer. could this obscure cancers? give us calcifications?
5. Pathology. Whenever I remove any breast tissue, I always send it to pathology. Rate of breast cancer in women is 1 in 6. When liposuction is done, the tissue is sheared, you have no idea where it came from in the breast, and it usually is not even sent to pathology.
So. I do a lot of liposuction. I have written a chapter in a major plastic surgery 7 volume set on liposuction. I am a fan. But when it comes to the breast, I am timid. The issues I listed are real. And after having met my patient, who is a 50 year old woman with rock hard, scarred, abnormal, painful breasts, I have to wonder if the scar is so bad.
Posted on October 7, 2009 in Body, Breast, Mommy Makeover / Body post baby, Skin / Nonsurgical, breast reduction, scars & scar care, tummy tuck
No plastic surgeon can do surgery without a scar.
I know. Shocking the “doctors” on shows like Nip Tuck and every soap opera out there can fix a major accident with not a single scar, but real doctors cannot. In the real world, anytime you cut through the skin there will be a scar.
Our goal is to make that scar as fine, hair lined, tiny, well placed, and invisible as possible. But even a scar which will be a good scar (and fade to nothingness) starts as a scar you can see. I show scars when they are new. Most of the photos on my website are of scars at 6-8 weeks. On some surgeries, like eyelifts or breast augmentations, these scars are almost invisible quickly. Why? Breast augs and eyelifts have small scars, which are hidden and under no tension.
The common surgeries I do with larger scars are breast lifts and breast reductions (both of which I use a shorter, lollipop scar) and tummy tucks. You may be thinking, good heavens woman, why would you show those scars?!? Why are you not like the other plastic surgeons who only show scars at a year when they have faded or have every tummy tuck scar hidden under underwear? I could be cheeky and say, I am not like other plastic surgeons. But the true answer is you pay a price for surgery. I feel strongly you need to know that price, or I guess I should say potential price. I expect most of my patients will have scars which fade well. I don’t have many issues with ugly raised scars, keloids, etc. But I do have some patients who don’t scar well….usually it is a part of the scar…and for their surgery that patient paid a bigger price.
When you lift your breasts so they don’t hang to your knees after breast feeding three kids, the price you pay for cute perkier breasts is a scar. Many years ago I converted from the inferior pedicle technique, where we had a large anchor scar (where it is like the lollipop WITH an additional scar running the entire length and position of an underwire) to the vertical technique. Why? It shapes and holds better, and it is a smaller scar on the skin. If you are trying to limit a scar, why not go all the way and do the cute little donut lift where the scar only goes around the areola? (Excellent question from my educated Bay Area crowd…) That procedure is fraught with issues, and the scar though smaller frequently wrinkles, elevates, and bunches. A larger flat hairline scar is less noticable than a smaller wrinkly one.
Tummy tucks are a great operation to tighten the muscles and get rid of the loose, stretch-marked, muffin top skin, but the price you pay is a scar. Again, particularly in my fair skinned patients, I expect the final scar will be a hairline almost invisible scar. But what if it isn’t? My Bay Area patient base is very well educated. We had our children at older ages, so many of us got used to having a fit, healthy, tighter body. The changes after pregnancy can be tough. When you were hit hard by pregnancy, to get your muscles and skin tight again with a tummy tuck, you need to be okay with the scar. I find the patients who focus on the other changes- the flatter tummy, waist definition, tight skin, no stretch marks, smaller size- will be happy. The patients who are really bothered by the scar have a lower “price” they are willing to pay. I advise these patients to take a black sharpie marker and draw the scar on their belly. Wear underwear, your swimsuit, low rider jeans. If you had a tummy tuck and you were one of the few who did not heal well, would you be okay?
Here may be a place where being a female plastic surgeon who has had kids, pregnancies, and (eek) looser belly muscles and (sigh) looser skin, here may be a place where I am different in how I advise my patients. I watched my body change. I knew it was coming. I wanted these children more than anything. But my body will never be the same. Every person has what price they are willing to pay for perkier-lifted-firmer breasts or a flatter-tighter-waist-defined belly. What amount of risk? sensory change? scar? I can sense when I have a patient who has a low price they are willing to pay. They need a surgery to go perfectly and scarlessly or they will regret it. For these patients I advise them what you have now sucks, but it is G-d given. You earned it with your kids. Do you want to do this?
So I show scars. I show them when they are new and red and visible. The patients who can see these and go forward will be happy. The ones who can’t are usually the ones who had too low of a price and should stick with what they have.
Posted on October 5, 2009 in Body, Mommy Makeover / Body post baby, Post Pregnancy Body, liposuction
Liposuction is tricky. I do a lot of liposuction; I have published on liposuction; I fix other people’s liposuction.
There are pitfalls and risks to liposuction. If you can lose the weight on your own, do it. I think liposuction is great for diet and exercise resistant fat, but there can be issues. I do not candy coat these risks, among them irregularities, discoloration, sensory change, and loss of result if you gain weight. If you have loose skin, are older with poor skin tone, or have a large amount of fat removed, you will get some irregularities.
I believe using machines like ultrasonic energy or laser energy are good to help break up fat, allowing more, smooth fat removal. I believe you need an assortment of cannulas in different shapes and sizes. I believe you need to come at things from different angles to achieve smooth fat removal. I believe you should not treat one area like your outer thighs- your fat comes in units ( ”the thighs” “the torso” ) and should be treated as a unit to prevent funny body shape in the future. I believe you need a board certified anesthesia doctor who understands how liposuction and tumnescent is different from other surgeries to give your anesthesia.
Currently, what I see scares me. Smart lipo, slim lipo, and other laser liposuction companies need to sell machines. There aren’t many board certified plastic surgeons, so they target other specialties like family practice, ob / gyn, even internal medicine.
Recently I have seen a slew of patients coming in for a tummy tuck. One patient called my office frantically, “I need to come in immediately, I had liposuction of my belly. They removed a lot of fat, but now I need you to do a tummy tuck.” When I met her, I knew her doctor was not a plastic surgeon. She had loose skin, very irregular fat removal, and thick fat which had not been touched on her love handles and back. The correct surgery for her would have been a tummy tuck, with liposuction of her back and love handles. Instead, because of her liposuction on her belly, her skin is scarred in a wrinkled, uneven pattern. It is loose on the surface, but now will not stretch because of the scar under her skin from her liposuction. I can’t pull out the wrinkles. I can’t fix it.
Anyone can call themselves a plastic surgeon. Anyone can decide “I will do liposuction” and start doing it. You need to do your research ahead of time. A nonplastic surgeon can’t do a tummy tuck. They don’t have the same decision making, because they can’t do the other surgical procedures. They don’t understand sometimes the fat you leave behind is more important. Doing liposuction right the first time is important.
Posted on October 2, 2009 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast augmentation, breast implant
Breast implants come in all shapes and sizes.
Basic differences in implants:
- volume
- shell: smooth or textured
- profile: low, medium, or high
- shape: round or anatomic / shaped
- fill: saline or gel
The gummy bear implant is the style 410 implant. It is essentially the fourth generation of gel implant. It is a shaped anatomic implant, firmer than current implants. Due to its shape, it has a textured surface so it will not move or rotate.
The gel implants we use now are cohesive gel implants. In English that means the implant fill is not a liquid, but thicker like jello. The reason to thicken the internal fill is to help prevent “gel bleed.” It is thought this microscopic leakage leads to capsular contracture, the hardening of the breast. The implants still feel soft. The gummy bear implant fill is thicker than current cohesive gel breast implants. It essentially is supercohesive, and the thought is it will have lower capsular contracture rates.
Great! I love the whole name gummy bear. This all sounds swell. Where can I get one?
Ah. Here’s the rub. The FDA approved cohesive gel implants in Nov 2006, but did not include the style 410. For some reason, they still have not been approved. Don’t be disheartened. Most women currently get round smooth gel implants. Why? They look natural and move like natural breasts. The most common type of implant most plastic surgeons use around the country is a smooth round implant. Why would we use round implants and not put in something supposedly shaped to look like a breast? Excellent question (I love my educated Bay Area crowd)! Textured shaped implants were the rage in the early 90s. They were supposed to look better, have lower capsular contracture rates, yadda yadda. But about 5-8 years out, we saw issues with them. They can rotate, have wrinkles which get stuck and are palpable, many have higher rippling rates, and many had higher leakage rates. A study came out which showed by MRI when behind the muscle the “shaped” implant gave no difference in shape than a “round” implant. In other words, when behind the muscle, they look the same. So the pendulum swung back to the round implant. (All of the implants you see on my website are smooth round implants.)
The style 410 may be an answer for some patients in the future. For patients with whisper thin skin, patients after mastectomy who have no natural tissue, or patients with recurrent capsular contractures no matter what they try, the gummy bear breast implant may be helpful. But it likely has many of the issues we have seen before in textured anatomic shaped implants. And due to its firmer fill, it can’t be compressed as much, so requires a larger incision. Most patients don’t want a larger scar.
So the gummy bear style 410 breast implant.
It will likely someday be another implant in our legion of implants we use. But currently there is no word on when they will be approved, and again, they aren’t for everyone.
