oh my.

They don’t know what this person was injecting, but being a foreign substance, it 1. got infected and 2. the body didn’t like it so it spit it out. 

There are more and more of these cases popping up: a NY woman injecting free silicone, the Florida injections of super glue, tire sealant, and cement.   I don’t have a lot of patients seeking to enhance their bottoms.  If you want a larger or curvier bottom, the best way in my opinion to get more curve is to 1. take down the surrounding areas like the love handles and outer thighs using liposuction, to help define the buttock area more, and 2. fat graft into the buttock to give more volume.  (This is a surgical procedure, and in my view should be done by a board certified plastic surgeon well versed in liposuction and fat grafting.) 

I cringe when I read these stories.  I get these hotel room, back room injections are cheaper.  But are they?  When you get infections and ER visits and operations to try to fix things… and the likely irreversible scarring and disfigurement which comes with it…. I don’t understand.  In this age of computers and information, please do your homework. 

• Safe surgeon.  Look at their credentials and training.  Research them.
• Safe technique and substance.  Research it.  Free silicone has issues which are well known.  And who would ever think cement and tire sealant are good things to inject?
• Safe place. When doing a large scale injection, you need sterile technique.  Otherwise you can get infections. 

http://abcnews.go.com/GMA/WaterCooler/wireStory/nc-woman-charged-buttocks-injections-bad-15114376

I remember a colleague of mine studied this when we were in residency at Stanford.  The study was small, but hinted maybe there was a health benefit.  It is an interesting question.  If you reduce the fat cell load, will it affect your body in other ways?  Will it lower cholesterol? Lower triglycerides?  We know when overweight people lose weight, they often show improvement in other ways:  blood pressure improves, cholesterol lowers, and diabetes may reverse.  So it begs the question: if you remove fat by liposuction will you get the same benefits?

My society, the ASPS (American Society of Plastic Surgery) had our annual meeting in Denver this fall.  At it, a new study by Dr. Eric Swanson was presented, showing a dramatic decrease in the triglyceride level of patients following liposuction.    He also found a lower white blood cell count, which is thought to be associated with inflammation, and inflammation has been linked to cardiac disease.

This prospective study looked at 322 patients who underwent liposuction and/or tummy tuck (71% were liposuction only).  Findings:

• Those with normal triglyceride levels had unchanged levels
• Those with elevated or at risk levels (defined as > 150 mg/dl) had an average of 43% reduction in triglyceride levels after surgery.  (this is 2x the amount found when taking medications to do so). 
• The effect was found to be similar for men and women
• White blood cells levels decreased by 11%
• Cholesterol level changes were not significant.

What does this mean?  It is hard to tell.  It is unclear how fat contributes to heart disease.  We talk about how intraabdominal fat and the apple shaped person has a higher risk of heart disease.  Dr. Swanson suggests these findings show fat which is outside of the belly, the subcutaneous fat, is “just as metabolically important.”

To read more of his study, you can look for it.  “Prospective Clinical Study Reveals Significant Reduction in Triglyceride Level and White Cell Count after Liposuction and Abdominoplasty.  No Change in Cholesterol Levels,” presented by Dr. Swanson et al at the Denver ASPS meeting, September 2011.

• do not involve surgery and
• can melt your fat away. 
• Some claim to be pain free. 
• many claim to have no downtime

What are they? Do they work?  At my recent favorite plastic surgery meeting ever, the TIPS meeting in San Fran, there was a talk about some of these.  First lets get to how do they work.  They all use different methods:

• mechanical (it breaks fat down)
• thermal (heat)
• ultrasound
• cooling
• external massage (also mechanical)
• injections (chemical)
• water (mechanical)
• RF (heat the tissue)

Wow.  Lots of ways to get rid of fat.  Seems surprising with all of these ways to get rid of fat that we manage to keep it on our bodies.  So, in the interest of not irritating a lot of companies directly by using the names of machines, let me just say some overriding things to think about.

• Many of these machines were brought out under the 510K method of approval.  This does not require as much analysis.  Many studies were done on few patients (less than 10), studied for short periods of time, etc.  Some argue the FDA and governing agencies care much more about safety than the efficacy and reality of their claims.  So if a machine says it “melts fat” and they show a EM (electron microscope) image of a fat cell bursting and leaking its contents, that may be enough proof it works.
• These machines and inventions are expensive.  They are hard to bring to market, the cost to develop and research them is a lot, and they usually have about a 24 month window on the market before the newest greatest thing is out.  The cost for many of the machines for doctors is 90K and above.  That is a lot of patients you have to see to recoup the cost.
• I still believe in the general rule: no downtime =  no results.  Those procedures which give results tend to have more pain, recovery, bruise, etc than those which give no results.
• I do think noninvasive body contouring may be good for SMALL things.  The fat under the chin.  A small irregularity or fat pocket.  For doctors out there, think less than 100cc of fat. 
• Beware of marketing.  I am a broken record on this, but I think the hype of products now is more than the reality of the product.  Many of these companies appeal directly to consumers and media.  Splashy catchy headlines precede the scientific proof.  One of the speakers was talking about how doctors may be implementing procedures which they might not believe in due to the demand of their patients.

Be thoughtful and critical of new machines, products, and claims.

“I went to Dr. Greenberg about 6 years ago. She was the last of the 6 doctors I interviewed in search for a doctor to do my breast augmentation. She was the ONLY one who said she would not do it. I had lost about 100 lbs at the time and had not yet had kids. She said, she would not do the tummy tuck I was considering either as I should wait to have my kids and see her when I was done. She did offer to do some other work on me at the time that would not be damaged by a pregnancy weight gain and would help my overall look in the meantime.

It was a very intense procedure called a Medial Thigh Lift but the results I believe were phenomenal. She did some lipo too to help contour my shape a bit more. It wasn’t to lose more weight, as I had done that already but it was to take out the extra skin I had on my legs and inner thighs and stretch marks that were always very embarrassing.

My scars healed very well and are almost unnoticeable. I have since had 2 kids and now am ready for my “mommy make over.” Again, I interviewed other doctors because I really wanted the “gummy bear” implants. Dr. Greenberg doesn’t do them but does the cohesive gel implants and she did explain the difference to me.

I chose to go with Dr. Greenberg again for this surgery because I knew what her bedside manner was, she was straight forward with me last time about the expected results and she is always more cautious and looks long term for you.

I would highly recommend going to Dr. Greenberg if you are considering any plastic surgery, she is professional and is constantly educating herself as you can read in her blogs. I met with her twice for a consult already before my pre-op and she said to call or email if I have any further questions. We’ve chatted through email and on the phone and for a busy surgeon that says a lot. ”

SB, Inner thigh lift and liposuction patient, San Jose, CA

Now found in the filtered section of Yelp

What sources of stem cells are there?

• Embryonic- pluripotential stem cells.  Can form any cell in the body
• Fetal -amniotic, cord blood.  These are multipotential cells
• Adult- Bone marrow, fat

We know our body, even we old decrepit adults, regenerate.  Our skin regenerates and turns over every 3 weeks.  Our intestinal lining every 6 days.  Our bones, every 6 years.  So how can we harness this energy of turnover?  This talk at our recent meeting left more questions than answers.

Can we increase the number of stem cells?

Can we induce pluripotential cells?  They have started to do “reprogramming” of stem cells, to make stem cells pluripotential that otherwise would not be. 

The plastic surgeons interest has stemmed a great deal from our experience with fat and fat grafting.  (Who knew fat was such a valuable resource in the body?)  The hope is someday we could harvest fat, take out the stem cells, and program them to become liver cells, insulin producing cells, etc.  They have found there is some “memory” in the cells, so if you wanted to try to make skeletal bone, thigh fat is a better source than fat from other parts of the body.  Can we identify subpopulations of fat?  Is one better for blood vessels, another for bone, another for cartilage?

This research has been going on for a decade.  Don’t expect to be able to suck out some fat and grow new knee cartilage next week.  But that may be the direction we are heading.

There are none.  As I said in my prior blog, the cosmetic surgery laser and technology industry is skipping doctors and going straight to you, the consumer.  Many have gotten FDA approval via the 510K route (see my blog on that to understand better.)  What works?  What claims are real?  Is the whole world a big blob of marketing?  Where is the science?

Tons of new cosmetic surgery lasers and products flood the market.  They have 24 months to recoup their earnings.  They have 24 months to be the hot new plastic surgery darling on the market.  The new laser and ultrasound companies do try to meet us doctors.  They do have educational meetings.  They do come to our offices.  But they flood the market well before.  Their online and print ad and commercial media campaign starts well before they do a mass marketing to us doctors.

Example: Laser liposuction.  I, and some of my colleagues, do a lot of liposuction.  When the smart new laser liposuction companies came out, they did not come to us first.  I saw articles in  People magazine well before anyone had tried to inform me of the new technology and get me to buy the laser.  I read an article by one doctor who had been a researcher for the machine.  “So and so fancy actress had the NEW laser liposuction.”  “No downtime! No anesthesia!” 

When I went to their informational course, I do think it offers some benefits, but no more than ultrasonic liposuction which we were already doing.  I do think they are misleading.  The instructors for the course admitted for larger areas (which is what most of us who are not supermodels need) they use ultrasonic liposuction first and then used the laser as a finishing tool at the end.  It is a smaller caliber, which may increase irregularity, and definitely increases OR time.  So my other colleagues and I, who have published and written chapters on liposuction, did not buy the machine.  It offered no benefit.  I have written blogs about this. 

The issue?  The marketers are winning.  They appealed to non plastic surgeons.  They had great ad and media campaigns.  I have patients who call specifically wanting “XX lipo.”  Even when I explain what the pros and cons are, they have a deaf ear.  LASER.  NEW.  They have bought into the media campaign.  They will go to a family practice doctor who has no surgical training and have the new great liposuction done instead of me, a board certified plastic surgeon with extensive liposuction experience and a published chapter in a textbook on liposuction.  Egads.  They will seek me out when they don’t get the desired result or have a complication.  At that point, it may be too late for me to help.

So BEWARE.  Find a doctor who will be your gatekeeper, who will evaluate the new plastic surgery products and instead of trying to just sell you something new, will only sell you things they think really work.

Beware of the new trend, which focuses on hype and not science:

• Comapanies and products appeal direct to consumers (magazines, online, TV )
• FDA doesn’t check efficacy claims as much as safety
• Patients drive demand (so doctors offering it may not be because they believe in it, but because patients are asking for it)
• Don’t look at science based medicine (ask to see the scientific studies which show it does what it says it does.)

Communication with your doctor is SO important.  When you don’t like your belly, it is important to figure out why.  I think this woman’s question could have been better written- Communication 101: Make sure you and your doctor are on the same page.

Is it

• stretch marks?
• hanging skin?
• loose skin when you sit?
• the muffin top?
• wrinkling around the belly button?
• you look pregnant?
• loose muscles?
• is the problem mostly above the belly button? Below?

You need to be very clear about what bothers you. This patient was bothered by loose skin above her belly button.  She then had her first tummy tuck, a mini tummy tuck.   Ug.  She was destined to be unhappy with her results, as a mini tummy tuck does not tighten the skin above the belly button.

This communication is a dual thing- your surgeon should be blunt in their communication and let you know what will be improved.  There is a lot of verbage out there.  What I call a mini tummy tuck may not be what Dr. X calls a mini.   I have had patients who think they had “full tummy tucks” who only had a mini.  Ask your doctors for specifics.  “By doing a mini tummy tuck,  the scar will be on the abdomen here.  There will be no scar around the belly button.  Your belly button will move down a bit.  This will not tighten the skin above the belly button at all.  This will not tighten your muscles.” 

There are all sorts of variations.   Is your issue Fat? Skin? Muscle?  In what order? Tummy tucks involve removing skin, tightening muscles, and sometimes liposuction.  There are things which are not safe (full tummy tuck and liposuctioning the anterior abdomen).  And again, the names are confusing: full tummy tuck, mini tummy tuck, mommytuck (what is that?), hybrid tummy tuck (a trademarked name for what is likely a mini tummy tuck with muscle tightening by Dr. Moelleken), lipotuck (those that overestimate the tightening effects of liposuction), etc etc.  You get my drift.

Expectation is everything.  If this patient is considering a third surgery, I would recommend sitting in front of the mirror and write down her ultimate wish list.  Some things are not achievable.  (Where is that fairy godmother and her wand?)  Also I would recommend getting a second opinion, just to have two board certified plastic surgeons looking at the same thing.  If there is controversy, consider a third opinion. 

There is a law of diminishing returns with multiple surgeries.  Many times the enemy of good is going for the “better.”  And some things can’t be done.

Liposuction is not a weight loss technique.  You hear this, but then someone after liposuction drops 2 pant sizes, so you think, “how could they not lose weight?”  Liposuction is a body contouring and shaping technique.  We do remove fat, which has some weight to it, but it is never as dramatic as you would think. 

You should lose some weight.  I estimate for every liter of fat removed (not liter of fluid, but of fat) you should lose 2.2 pounds. 

• You will not see this weight loss immediately.  In fact, some people weigh more after surgery than they did before surgery due to swelling. 
• When I see you at your six week visit, you should have lost some of the weight.  If you have not, it means you gained weight during your recovery period (not a hard thing to do since you cannot exercise during this time. So watch what you eat!)
• Weight gain is tricky- when I remove 5 liters of fat from your abdomen and love handles, your pattern of where you gain weight changes.  If your “fat” test used to be when your jeans are tight you need to cut back, after liposuction, you may gain weight and your jeans still fit you just fine.  Your fat pattern changes.  So your jeans may be fine, but your arms may have gotten a little larger. Or your chin. Or your breasts.  These are signs you are gaining weight. 
• At 3 months, you should see the full weight loss.  It isn’t much, but it is something.  So for 5 liters of fat removal, you should lose about 11 pounds.  If you weigh the same as you did before surgery, it means you gained 11 pounds during your recovery.  You won’t get the results you should have from the surgery.

Liposuction is not a weight loss technique.  It is a sculpting procedure.  For the best results, have a good eating and exercise regimen firmly in place before surgery. So go hike that Stanford dish!

I know it is tempting.  You likely look smaller already.  How much did I lose?   Let me just get on this scale and see…

EEK! And then I get the frantic email.  “Dr. Greenberg, I just weighed myself and I weigh more than I did before surgery!”  Sometimes it is the day of surgery, other times a day or two after.  It doesn’t matter.  You won’t show any weight loss in this timeframe, and it has nothing to do with the surgery.

• Liposuction is not a weight loss technique.
• Tumnescent, the fluid we inject into your body before we remove the fat, is largely still in your tissue.  You are like a giant sponge.  This fluid stays in your tissue until a couple days after surgery.
• Around 3 days out, you will find you are peeing.  A lot.  Your body mobilizes the fluid from your tissue.  You will still weigh more than you think you should.
• Swelling.  Your body is not normal after surgery.  It is injured.  A controlled, sculpted, purposeful injury.  When your body is injured it likes to swell.  This has weight and volume to it.
• Your body will swell more than normal for weeks.  Know those dents you get in your ankles from your socks? This is normal swelling.  After liposuction surgery, particularly if you had your thighs done, you will swell more, and it is harder to get rid of it.  It will go back to normal. 

The more you avoid swelling, the better.  SO….Keep your legs elevated when you can after surgery.  Gravity pulls the fluid into the legs, and it makes your swelling worse.  I have an herbal regimen I recommend which helps some with swelling and bruise.  Avoid things which make you bleed- Vitamin E, aspirin, advil NSAID products, fish oil.  The more bruising, the more swelling.   I don’t recommend diuretics (water pills).  When you have normal functioning kidneys, your body will get rid of the excess fluid as it needs to.  Let it work.

I will weigh you, so you can’t go hog wild on Ben and Jerrys during your recovery- you can gain weight in a bad way.  But give your body time to heal.

So put the scale away.

For now.

So what am i going to say?  Eat broiled fish and salad?  Lose the weight by “chasing your children” and breastfeeding??

NO!

I love to read Men’s Health magazine.  The articles are great.  Here are some good rules of thumb, and he focuses on the tiny changes- not the “I am going to exercise for 2 hours every day” kind of programs, but the “I am going to not put the extra food on the table” kind of things. So I am not going to write this article again- I think he did a great job.  But I will post it here because he cites some interesting studies.  And much of the body work I do as a plastic surgeon has everything to do with weight.

7 Habits That Make You Fat
By David Zinczenko of Men’s Health

FAT HABIT #1: Putting the Serving Dishes on the Table
Researchers at Cornell University found that when people served themselves from the kitchen counter or the stove, they ate up to 35 percent less food than they did when the grub was on the kitchen or dining room table. When there’s distance between us and our food, the scientists theorize, we think harder about whether we’re really hungry for more.

FAT HABIT #2: Getting Too Little (or Too Much) Sleep

A sleep schedule is vital to any weight-loss plan, say Wake Forest University researchers who tracked study participants for 5 years. In the under-40 age group, people who slept 5 hours or less each night gained nearly 2½ times as much abdominal fat as those who logged 6 to 7 hours; also, those who slept 8 hours or longer added nearly twice as much belly fat as the 6- to 7-hour group. People with sleep deficits tend to eat more (and use less energy) because they’re tired, says study coauthor Kristen Hairston, M.D., while those who sleep longer than 8 hours a night tend to be less active.

FAT HABIT #3: Not Multitasking While Watching TV
We don’t need to tell you that too much TV has been linked to weight gain. But here’s what you may not realize: You can have your TV and watch it, too. Just do something else at the same time. Washing dishes burns 70 calories every 30 minutes. So does ironing. Here’s another thing to keep in mind: Cutting TV time even a little helps you burn calories, say researchers at the University of Vermont. In their study, overweight participants who cut their viewing time in half (from an average of 5 hours to 2.5) burned an extra 119 calories a day. “Nearly anything you do—even reading—uses more energy than watching TV,” says study author Jennifer J. Otten, Ph.D.

FAT HABIT #4: Drinking Soda
Researchers say you can measure a person’s risk of obesity by measuring his or her soda intake. Versus people who don’t drink sweetened sodas, here’s what your daily intake means:

½ can = 26 percent increased risk of being overweight or obese

½ to 1 can = 30.4 percent increased risk

1 to 2 cans = 32.8 percent increased risk

More than 2 cans = 47.2 percent increased risk

That’s a pretty remarkable set of stats. You don’t have to guzzle Double Gulps from 7-Eleven to put yourself at risk—you just need to indulge in one or two cans a day. Wow. And because high-fructose corn syrup is so cheap, food marketers keep making serving sizes bigger (even the “small” at most movie theaters is enough to drown a raccoon). That means we’re drinking more than ever and don’t even realize it: In the 1950s, the average person drank 11 gallons of soda a year. By the mid-2000s, we were drinking 46 gallons a year. A Center for Science in the Public Interest report contained this shocking sentence: “Carbonated soft drinks are the single biggest source of calories in the American diet.”

FAT HABIT #5: Taking Big Bites
Dutch researchers recently found that big bites and fast chewing can lead to overeating. In the study, people who chewed large bites of food for 3 seconds consumed 52 percent more food before feeling full than those who chewed small bites for 9 seconds. The reason: Tasting food for a longer period of time (no matter how much of it you bite off) signals your brain to make you feel full sooner, say the scientists.

Fat Habit #6: Not Eating Enough Fat
You don’t have to go whole hog on a low-carb diet to see results. Simply swapping a few hundred calories of carbs for a little fat may help you lose weight and reduce your blood-insulin levels, according to researchers from the University of Alabama at Birmingham. People in their study who consumed just 43 percent of their calories from carbohydrates felt fuller after 4 hours and maintained their blood-sugar levels longer than those who ate 55 percent carbs. Carbs can cause blood-sugar levels to spike and then crash, leading to hunger and overeating, says study author Barbara Gower, Ph.D. Fat, on the other hand, keeps you satiated longer. Some easy swaps: butter instead of jam on toast; bacon instead of potatoes; low-fat milk instead of a sports drink.

FAT HABIT #7: Not Getting the Best Guidance!
Signing up for e-mails (or tweets) that contain weight-loss advice can help you drop pounds, a new study reveals. When researchers from Canada sent diet and exercise advice to more than 1,000 working adults weekly, they discovered that the recipients boosted their physical activity and ate smarter. People who didn’t receive the reminders didn’t change.

EAT RIGHT RULE: If your food can go bad, it’s good for you. If it can’t go bad, it’s bad for you.