Posted on November 25, 2009 in Welcome, interesting & new
I have a lot to be thankful for.
I am particularly thankful to be able to do a job I love and live in a part of the country where every woman I meet is great– interesting, insightful, intelligent. Just great women.
Recently I was told I received the “Patient Choice Award.” Always curious, and wondering if this is some kind of weird marketing ploy, I researched it.
Every month, 40,000 patients provide online feedback about their experiences with their doctors. They rate bedside manner, how much time you spend directly with your doctor (versus their nurses or magazines waiting), follow up, courtesy of the office staff, and the doctor’s soundness of medical opinion.
What I found was this information was compiled from a collection of websites including google, right health, vitals.com among others. “Over the course of the year, these patient reviews totaled hundreds of thousand patient opinions. While physicians generally receive positive reviews from their patients, only a select few receive uniformly rave reviews across the board. Of those that receive rave reviews, only physicians like yourself– with near perfect scores- have been voted by their patients for this honor. In fact, of the nations 720,000 active physicians, less than 5% were accorded this honor by their patients.”
Yay.
To my wonderful patients, thank you so much for this award. Happy Thanksgiving.
Posted on November 23, 2009 in Uncategorized, interesting & new
Dear________,
HEALTHCARE PLAN IN THE SENATE TODAY WILL UNFAIRLY DISCRIMATE AGAINST YOU!
I’m writing you today about an issue that affects not only plastic surgeons but everyone who utilizes our services for anything from Botox to Tummy Tucks.
Perhaps you’ve heard of the current healthcare bill before the US Senate, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the “Patient Protection and Affordable Care Act. This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement.
So what’s the problem? YOU would be paying this tax, the FIRST time this country has levied a tax on patients for medical procedures. What’s at stake?
- This is a discriminatory tax. According to the Aesthetic Society Annual Statistics, 91% of all cosmetic procedures are requested by women
- This will not have considerable consequences on the wealthiest patients but, as usual, affects the middle class. Working women, soccer moms, and scores of others who carefully save and budget to improve their appearance and self esteem will be penalized for doing so.
- Procedures such as breast reduction that have been cited in the literature for improving self esteem and quality of life would be taxed as well
- Your doctor as tax collector: This provision places physicians in the role of tax collector and holds physicians liable should an individual fail or refuse to pay the tax. Is that the relationship you want with your medical provider?
Please help us stop this silly and penetrative tax. To find your State Senator please click here: http://www.senate.gov/general/contact_information/senators_cfm.cfm
We urge you to personally inform the government that you are against this tax – together we can fight for your right to no government interference in medical care and stop this discriminatory measure against women!
Posted on in Body, Breast, Mommy Makeover / Body post baby, Skin / Nonsurgical, interesting & new
The government has gone mad.
I get why they would want to tax elective medical procedures. They need money. They have gone wild on spending, and they need new revenue. This new tax is proposed to go into effect January 1, 2010 (!!!).
5%.
They are going to tax every “cosmetic” procedure by 5%. What is truly scary is their definition of cosmetic procedure is broad, and includes whether paid by insurance or otherwise (!!!) Their definition:
COSMETIC SURGERY AND MEDICAL PROCEDURE- ”1. is performed by a licensed medical professional and 2. is not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.”
I understand many of the surgeries I do are not going to save the world. So government thinks “Hmmmmm…. we need money. Cosmetic procedures are a growing business. Let’s tax it.” But taxing cosmetic procedures is a slippery slope. When I do a breast reduction and insurance actually covers it as “medically necessary” (which is tough to get covered these days), will this be taxed? When I do a tummy tuck and repair the muscles, so my patient no longer has back pain, is it cosmetic? One of my general surgery colleagues calls the diastasis a “ventral hernia” and insurance covers it. Am I being discriminated against because I call it what it is- a diastasis, not a hernia? Will my patients pay the tax, but his won’t? Oh but wait. They said they will tax it even if insurance does cover it. So maybe they will tax me AND the general surgeon.
WHAT IS COSMETIC? Is having twins which blow out your belly so you look 5 months pregnant every day of your life a cosmetic repair? or is it reconstruction to get you back to where you were, so you won’t have chronic back pain? Do we just need more women in Congress who have had kids, so they can understand us better?
What is cosmetic? Botox patients who do botox injections to treat migraine headaches- cosmetic or not? Instead of living for months headache free, will they, must they go back to medications which they take after they already have the headache?
1. women are the majority of plastic surgery procedures and patients.
2. this tax won’t affect the wealthy. they’ll do things anyway. this tax will affect much of my patient base- my moms, who are in the middle class.
3.Will this create artificial distinctions between specialties? Looking at botox injections- if it is done to treat wrinkles will you be taxed, but to treat headaches it won’t? Will it only be taxed if I do it, a plastic surgeon for their headaches, and not if done by a neurologist?
4. The bill specifically states if done by a medical professional. Will this spur nonmedical people doing injections (an already scary trend)?
This is a horrifying step. Why should my 40 year old woman’s desire for botox be taxed, and a 50 year old man’s desire for medications for his “erectile dysfunction” not be?
Ahhh. the slippery slope. Once they tax cosmetic procedures, do you think others are not steps behind?
Is a hernia repair cosmetic? If a man has a bulge in his groin from a hernia which reduces easily (means it isn’t stuck, and therefore not a medical emergency) is that a cosmetic repair? It is not a congenital deformity, it isn’t an injury from an accident or trauma, and it isn’t disfiguring. I would argue a hernia is no more disfiguring than breasts which touch your waist and cause you incredible back pain, neck pain, tingling in the fingers, and a hunched posture. Oh. But women asked for that when we had kids and breastfed them to make them healthier.
Forget the removal of that mole. Or sebaceous cyst on your cheek. Those are not disfiguring, congenital, or a result of injury.
Do not tax procedures. It will create a slippery slope, it disproportionately and unfairly affects women, and it will cause weird practices and loopholes which have no business in medicine.
Posted on November 18, 2009 in Breast, breast augmentation, breast implant, breast reduction
I got a question from a 5’3” woman who got 690cc implants. “I did not want to go that big but unfortunately my doctor put in these huge implants.” She now wants to downsize but does not want a lift.
Eek.
I was so sad to read this. A 690 implant is a huge implant in any woman, but particularly in a petite one. A large implant like this will thin your skin and cause your breast to droop. Will she need to do a formal breast lift?
1. The longer your implant is in
2. the older you are
3. the less bounce-back your skin has (have you had pregnancies? Breastfed?)
4. the droopier you are currently (do you pass the pencil test?)
the more you will need a lift.
Volume lifts the breast. Some women come in after pregnancy or aging and have droopy breasts. The amount of droop varies, and the droopier you are, the more likely you need to do a formal breast lift. Breast lifts have scars. I do the short scar vertical technique; many doctors still do the longer “anchor” scar (eek. even here in the Bay Area the anchor is still the most popular lift.). No plastic surgeon likes to put scars on the breast. If we can achieve what you want with a simple augmentation, we like to.
So a young woman comes in, is droopy, and wants to be bigger. How much volume do you add? How big of an implant do you use? Eventually every woman can “lift” her breast by adding volume, but in many cases the amount of volume you need is obscene. Some doctors want to avoid the scar of a lift at any cost, so they will put in a huge implant. Size is important. Every day when you get dressed, try to jog, meet new people, drop your kids off at school you will be that size. Are you comfortable?
I see many of these women. I have patients, particularly those who were droopy at a younger age, where the doctor told them, “Honey, I’ll take care of you.” These women did not participate in choosing the volume of their implant (which is crazy to me). They come to me a few years out, wearing jackets or vests to hide their large breasts. They are DD, DDD on top of a tiny frame. And they are unhappy. Most women in Northern California do not want to be as large. Those from the Bay Area and Palo Alto tend to be athletic women. My common surgery to fix their issues is to downsize the implant and do a breast lift. I always wish I would have met them first. I would have had an honest talk with them: size, scar, and perkiness. I could have saved them years of discomfort, achieved what they wanted in their first surgery, and they would have a better result. The years of being too large thins the skin and causes the breasts to droop more- irreversible changes.
So I have not met this woman. I have not seen her tissue, what it looks like, how droopy she is. But this is a big big implant. She should definitely take it out ASAP. The longer it is in, the more irreversible thinning and damage to her tissue. As far as the lift goes, I don’t know what she looked like before the implant. I don’t know if this doctor put in the obscene implant size to try to avoid a lift. From the sound of things though, to get this woman into the land of women who can jog, have people talk to their face, or buy a shirt which can still button, she will need a lift. Which is probably what she needed in the first place.
Posted on November 16, 2009 in Body, Mommy Makeover / Body post baby, Post Pregnancy Body, liposuction, tummy tuck
The belly.
How much does it suck to still look pregnant after your baby is out? I wore my baby like a necklace, always in the baby bjorn, so no one would make the horrid mistake of asking me, “When are you due again?” It is totally unjust, unfair, unreasonable our bellies look like they do after children.
So to fix it you can do liposuction or a tummy tuck. Liposuction only fixes the fat- not the loose skin, stretch marks, loose muscles, or hanging skin. Tummy tucks tighten the skin and muscles, but can’t thin the fat so much (see my blog on why you can’t do both at the same time). Frequently you need one more than the other, so you should do that surgery and avoid the other one.
But what if you need both?
Ah. If you need to tighten the skin, muscles, AND remove thicker fat… which surgery do you do first? Plastic surgeons disagree on this one. Some surgeons advocate liposuction first, stating you will “debulk” (fancy way for saying to thin the area) to allow for better tummy tucking.
I disagree. When you liposuction you create scar under the skin surface. This is not visible or palpable, but it is there. During a tummy tuck your abdominal skin needs to stretch to allow for the removal of the extra skin, ideally putting the scar as low and inconspicuously as possible. If your skin does not stretch well, the scar will end up too high. Imagine trying to stretch a bathing suit (belly with no prior lipo) versus leather (a belly with scar under the skin from prior lipo.) Give me the bathing suit every time. Also the scar under the skin from liposuction affects the blood supply to the skin, causing increased risk of wound healing and infection along the tummy tuck incision.
I know this from personal experience. I had two patients with prior liposuction who did not tell me they had it done. I could see the scar plane during the tummy tuck procedure, and both of them had little healing issues along their scar and did not stretch to where they should. Their liposuction clearly affected their results. Some doctors advocate doing the liposuction and waiting a long time to let the blood supply reestablish. These patients had liposuction years before, and their blood supply was still not that of normal tissue.
Some people are in the grey zone. If you are borderline needing a tummy tuck and your biggest issue is fat, I like to liposuction first. But I recommend this in patients I expect will never need the tummy tuck. For those patients I know need liposuction and a tummy tuck, I like to do a two stage procedure:
1. the tummy tuck (with liposuction to the back/flank/and thighs) at the first stage, and then
2. liposuction of the abdomen at a second surgery.
I focus on your final result. I want your scar as low and hairline as possible. To best achieve that, I need to tuck first, lipo second.
Posted on November 11, 2009 in Body, Post Pregnancy Body, liposuction, tummy tuck
Many women need liposuction and a tummy tuck. The issue for the belly is you can’t beat it up with both at the same time.
Medical definition of flap: (American heritage medical dictionary)
noun
“Tissue used in surgical grafting that is only partially detached from its donor site so that it continues to be nourished during transfer to the recipient site.”
Advancement flap (Merriam Webster dictionary)
“A flap of tissue stretched and sutured into place to cover up a defect in a nearby position.”
Blah blah blah. What does this all mean in English?
A tummy tuck is based on something called a flap, a fancy medical term (we do like these fancy terms) to indicate the blood supply to the skin isn’t coming from all directions anymore. When we make our incision, we interrupt the blood flow.
Imagine blood cells are like cars; your arteries are streets; and the incision / scar is where your house is. You need to get your car to your house- in your car you have all the food and supplies to keep your house alive. (Bear with me; this is liberal arts education at work.) Instead of being able to drive straight there, when I cut through the skin those streets are now all dead ends. Hmmm. It’s harder to get home now. And you need to get there to bring in the food and supplies. You need it more than ever. Your house is injured.
When you do a tummy tuck, you cut where a c section scar is and you lift up the fat and skin like a giant apron. (Sorry for the graphic vision, but it is what we do.) This is the flap. We then pull this apron down and cut away the extra. Walah. Tighter belly skin.
This flap needs blood to get to its edge to heal the scar. We don’t want anything which will hurt the blood flow to the edge. Using our nifty example of cars and streets, we need to get as many cars to our house as we can. We need supplies!
But by making the incision, we already blocked many streets. By pulling on the skin to stretch it, we narrow those streets. We need those streets which remain to stay open. And we don’t want anything more to hurt the streets: no making the streets one lane instead of two, no putting road blocks or traffic jams. This is why we don’t do tummy tucks in smokers, and there are increased risks in people with poor blood flow like diabetics, ex smokers, and those with high cholesterol. Their streets are narrow and slow. Not enough cars get through.
If you liposuction this flap at the time of tummy tuck, all those blood vessels carrying oxygen and nutrients to the edge of the flap to heal the large incision would be hurt. Because we made a flap, we really need all the blood flow we can get, so we don’t have problems healing: infection, wound breakdown and opening, or potentially skin loss. (where the skin turns black and dies. eek!)
Some surgeons are cavalier and will liposuction the abdomen at the time of tummy tuck. I am not. There are good studies in our Plastic Surgery literature which studied where it was safe to liposuction at the time of tummy tuck. These zones are consistent. You can safely liposuction your back and love handles, your thighs, your chin…. I am happy to combine these areas with a tummy tuck. But if you need liposuction on the front part of your belly, you need to wait and stage it at a second surgery.
The key to a pretty abdominoplasty is the best scar you can get. Pretty scars come from good solid closures, and no issues with wound healing. We have all seen photos of dead abdominal skin from someone who pushed the limit too far. Remember this is elective, cosmetic surgery. Safe surgery and pretty results are what we need.
So get as many cars to your house as you can.
Posted on November 4, 2009 in Face, Skin / Nonsurgical, interesting & new, products
The eyes have it.
I have to admit. It is my biggest vanity. I forget the make up. Sometimes I forget the shower. But forget mascara? Nope. I was one of those girls who was given lovely blonde hair and lashes, only to find when I got older, I got to keep the blonde invisible eyelashes and my hair turned brown. (ugh.) So mascara it is.
Then a few years ago products came out claiming to make your eyelashes thicker and fuller. As with all things medical cosmetic, I am a skeptic. People try to sell me products all the time which smell nice and have lovely packaging, but don’t do a thing. They called these new products “eyelash enhancers” for a problem called eyelash hypotrichosis (OHMY! Sounds horrible! Can I catch that? But all eyelash hypotrichosis means is “hypo” little, “trichosis” hair. So you have thin eyelash hairs.)
The original ingredient was used by glaucoma patients. They found glaucoma patients getting lovely eyelashes .(this blog is containing a lot of the word lovely. But you should see the lashes.) Then Jan Marini came out with a product. Followed by Revitalash. Both of these brands original products were very effective, but now are not- the issue is they don’t have the patent. So fast forwarding to now, Latisse (owned by Allergan) has the patent. Latisse really works.
Side effects? They say it can tint your eyelashes and the skin at the base of the lashes a little darker. This reverses. In rare instances, they say it can darken the color of the eye. Not okay for pregnant or nursing women. (Your baby isn’t focused up there anyway.)
You apply it daily to the base of the upper eyelashes. It takes 1-2 months to see the effects. You must maintain use otherwise after about 4 months you’ll lose the improvement you got. But it works. Just look at the photos on their site. For me I have many close friends and relatives on it and have seen the results firsthand.
Until December they are running a promotion. $20 off each box, limit 2 per household.
So know two things:
1. I don’t believe women should do everything. Plastic surgery and cosmetic products are not for everyone, and let’s face it. This stuff can get pricey: Botox, fillers, Skinceuticals, Obagi. Pick and choose what works best for you. I also believe in timing. If you are getting married, going to a reunion, the Christmas holiday parties, time your products for maximal benefit.
2. I am a natural girl, and don’t like those things which distort the way people look. (There are some scary looking people out there, especially some of the front office staff at cosmetic offices.)
But we all have our vanities. For me it is eyes. Smiling eyes. Fluttering eyes. Do-you-know-your-shirt-matches-your-eyes? (really??)
If you are like me and all the about the eyes, give this eyelash product a try. Latisse subtly enhances what you have.
Posted on in Body, Breast, breast reduction, liposuction
I heard the term “moobs” the other day. It conjured up images of men with breasts, the man boob, the “manssiere” (love Seinfeld with the bra for men). So I did what all people do these days to find out information. I googled the term. If you look in the urban dictionary, you will see it defined:
Moobs: A combination of the words “man” and “boobs.” This is what happens when fat gathers in a male’s chest area, and gives him the appearance of having breasts.
Usually seen in overweight males, but can strangely also occur in men who are not really overweight
or my favorite
Moobs: Floppy, Jell-O like protrusions in the male chest area. Usually sported by fat, overweight men or men who attempted sex change. Can be used as a form of communication when jiggled properly
I’m curious about how the moob can be used as a form of communication when jiggled, but that sounds like a whole other blog.
As with all things medicine, we have a technical term for man boobs. We call it gynecomastia. “gyne” female. “mastia” breast.
True gynecomastia is breast tissue in men. It is composed of fat, breast glandular tissue, usually an enlarged areola, and extra skin. When you feel the chest, you will often feel a firm disc of breast tissue behind the areola. These chests do not look like an overweight guy with extra on the chest: usually the areola is enlarged and there is ptosis (droopiess) of the skin. To treat true gynecomastia, we combine liposuction (usually ultrasonic to help break up the fibrous fat and tighten the skin) and direct excision of breast tissue. If needed, this is accompanied by a reduction in the areola and tightening of the skin, though I usually try to steer toward the smallest scars possible. The goal of surgery is to get you to feel comfortable taking your shirt off in public. Scars on the chest aren’t so good for that.
Most cases I see though are not really gynecomastia. Most are due to fat with little or no breast gland component, which you may hear referred to as “pseudogynecomastia” or “lipomastia”. These are most of the “man boobs” or “moobs” you see in photos. The good news is breasts made of fat are easier to treat. In these patients there is less droopiness of the skin, and the areola is normal sized. These chests tend to respond well to simple ultrasonic liposuction.
Adolescent gynecomastia is common and usually temporary. Regardless of age, if you have a case of gyecomastia which is persistent, you need to also look at other causes such as steroids, liver failure, tumors, genetic disorders, marijuana use, and some medications.
Most of my male liposuction patients have liposuction done to their chest. Liposuction is for areas of fat resistant to diet and exercise, a pocket of fat, just like the “love handles” or “abdomen”. Sometimes men in great shape with low body fat percentage preferentially gain fat in the chest. I find many of my patients will not bring it up, but I consider it part of my standard operation for liposuction in men.
Do you need a moob job? As with all things, I encourage patients to fix things they can without surgery. Look for underlying causes. If you are overweight, lose weight. There is much advice from others on what to do: I I have seen sites on cardio, special exercises and diets, herbal supplements, and even a site with the newest male bra. One site has the secret key to burning fat on just the chest. (It is only $50 for the step by step guide, and shhh, you can’t share the secret!) But as I find with a lot of cosmetic surgery, many people try to sell you a rainbow. Most patients I see have moobs of mostly fat, so lose weight. Tone up. And if the fat persists, get liposuction to improve it.
