Posted on February 22, 2010 in Breast, Post Pregnancy Breast, breast augmentation, breast implant, interesting & new
This is the age old question.
How can we make breasts larger without a foreign object? They have tried all sorts of things in the past. The issue with many of them is:
1. Screening of the breast for cancer
2. Injury or hormonal stimulation to the breast- could it cause cancer or make a cancer which is there grow faster?
There are medications which claim to make the breast larger. Be careful of anything hormonally based. Many “herbals” are basic forms of hormones and are as potent as the prescription strength hormones you get.
There is a machine BRAVA that applies suction, causing the tissue to swell and get new blood supply to make the breast larger. It does seem to work, but it requires 11 hours a day for a median period of 18.5 weeks to go up about 100cc. It has been around for over a decade and never got traction in the cosmetic market. Why? To quote a plastic surgical colleague of mine, “The patients hated it. It required a lot of nursing time and assist because it was difficult to use, and the results were not impressive.” But now, BRAVA, the “machine looking for an indication” may have found it. It may help fat survive when transferred to the breast to do breast augmentation using fat.
Fat injections may be a promise in the future. Really thin women don’t have enough fat to harvest, so for them, this will not be an option. For others, it may. I went to a recent meeting (Feb 2010) in Miami with surgeons who are innovative in the field. The main issue still remains, how do you get the fat to survive reliably? How can you make sure it is safe? How much does it impair the ability to screen for breast cancer?
I will continue to blog about fat grafting to the breast, or as some believe, “stem cell breast augmentation.” I am just not sure yet I am ready to do it. My base question always with patients is would I recommend it to a family member? And as of now, I wouldn’t feel comfortable telling them I know it is safe. But with more research, time, and hard scientific data, I believe it may be.
(NOTE: This is a hot topic. Beware of untrained doctors who call themselves “plastic surgeons” who are doing fat grafting to the breast. We do know fat grafting when done poorly has poor survival, causing oil cyts, hard nodules, and calcifications. You can also easily get into the wrong plane and cause a pneumothorax, or the possible risk of fat emboli. This is only a technique which should be done by experienced board certified plastic surgeons. We do breast surgery, from breast reconstruction to lifts/ reductions/ augmentations, and we trained as general surgeons (doing mastectomies, etc) prior to plastic surgery.)
Posted on February 4, 2010 in Breast, Mommy Makeover / Body post baby, Post Pregnancy Breast, breast reduction, interesting & new
Ahhh. Marketing.
Do I sound like a broken record or what? I am just so dismayed by all of the hype and spin out there. It seems like everyone is trying to make a catchy new phrase for their surgery which will change the world, defy gravity, have no scars, and no downtime.
Bottom line still is when it sounds “too good to be true” it is.
I recently got an inquiry about the laser bra. Why don’t I do it, it only takes one hour to do, it keeps its lift better, etc etc. In general, good plastic surgery techniques get accepted by the general board certified plastic surgeon population over time. The hype and marketing things do not.
Lasers sound cool. They sound more modern, high tech, and less invasive. But there is a great deal of deception about lasers. When I was in residency and the CO2 laser came out, we all jumped on board. Now 15 years into plastic surgery, with a gazillion different lasers out there, I don’t use lasers at all. There are many types of lasers. Some address redness, some pigment, some promote collagen in the skin, some sandblast off the top layers. The one used in the laser bra is the CO2.
The CO2 laser does tighten the skin. I used to use it for resurfacing facial skin. I stopped using it due to issues with depigmentation, redness, and potential for scar. If you are using it on skin which subsequently is buried, those are not problems. The biggest thing with lasers is the amount of “tightening” is not much. Some people imagine lasers are like putting a wool sweater in the dryer. Oh. If that were only the case. We 40 somethings would jump in and laser every inch of us. But alas, lasers are more like an “iron”- they help remove fine light wrinkles only.
The laser bra involves lasering the top layer of skin, and then using that skin, tacked down to underlying tissue, as an internal “bra.” Sounds fantastic. Who wouldn’t want an internal bra to lift you?
But the laser bra will not “hold” the lift any better over time than traditional surgery. Traditional breast lifts already use the skin as an internal bra- we just deepithelialize it, not laser it. Regardless of what you do, skin stretches. Skin droops. This is deceptive marketing. I am saddened by the claims.
- “The Laser Bra surgeon can keep the breasts lifted in a natural, beautiful position.” Nothing can “keep” breasts lifted. They will droop again over time.
- The time claims of surgery are skewed. Normal breast reductions do NOT take 5 hours- in most hands it takes 2 1/2 to 3 hours.
- Finally, many of the photos involve augmentations. Implants will always help “lift” the breasts and give fullness in the cleavage area- and that has nothing to do with what reduction or lift technique you use.
I have done many different kinds of lifts over the years. The breast is made up of breast tissue and fat. In general
- the more breast tissue, less fat
- the smaller the breast
- the better you support the breast (ie good bras)
- the less you stress the breast (pregnancy, breastfeeding, jogging)
the better and longer your lift will last.
I find in my hands the best lift is the vertical lift. I do a lot of internal suturing. Why? It takes tension off the skin and shapes the breast better. Hmmm. Maybe I should make a catchy new term. “The hammock”? “The cone”? “The anti-gravity-little-scar-secret-special-exclusive-breast reduction-by-Dr. Greenberg” technique?
I think I will stick with being a good surgeon and leave marketing to others. There are many good breast surgeons to choose from. Meet a few. Look at photos. And beware of the gimmicks. When someone sounds like they are selling you a rainbow, they usually are.
Posted on February 1, 2010 in Skin / Nonsurgical, interesting & new, skin fillers
Both products are offering goodies right now.
Juvederm is offering a free Vivite lip plumper ($45 value) when you use a syringe.
Restalyne and Perlane are offering $50 back for every syringe you use.
Woo hoo! Call the office for an appointment. These are great fillers for the tear trough, cheek, nasolabial fold (the parenthesis around your mouth) and your lips (yes,don’t worry, you don’t have to look overplumped and ducky when it is done well.)
Posted on January 26, 2010 in Uncategorized, interesting & new
Herbal supplements are medications. As I have said in my other posts, just because it is “natural” and you don’t need a prescription, does not mean it isn’t a strong medication. I am still stunned when medications get labeled as “supplements” instead of medications, so they bypass the FDA. The FDA requires pesky things like proving they are safe and effective at what they claim. Instead, herbals fall under the Dietary Supplement Health and Education Act of 1994, so they are regulated with the food.
Anesthesia is an important part of having a surgery. For some of my patients, it is likely the only uninterrupted sleep they have had for a while. I respect the anesthesia risk. My patients have elective (ie they choose to do it), scheduled surgery. For many it is cosmetic. Most of my patients are moms. The safety bar for me is high. It should be high. I only operate in accredited centers, and for general anesthesia I always use a board certified anesthesia doctor.
The anesthesiologists use a combination of IV medication and gases to put you to sleep. They change the dosages based on your weight, length of surgery, etc. Herbal medications can affect the medications they use, by changing the heart and blood pressure dynamics, the liver metabolism of the drug, and other effects. BAD.
EPHEDRA (MA HUANG)
This is an ancient Chinese medication. It is a known stimulant, which constricts blood vessels, increases heart rate, increases blood pressure, and is “thermogenic” (increases metabolism). This was a common weight loss drug. It has also been used for asthma, hay fever, and to increase general “energy.” There are many known severe reactions to this drug. The New England Journal of Medicine in 2000 had a study showing sudden heart attack and severe disability in young people who were taking the drug within the recommended dose. (!!!!) Side effects are many: nausea, dizziness, seizures, heart attack, stroke, and heatstroke (see Steve Belcher and Korey Stringer, both pro athletes who died from heatstroke, likely after using ephedra for its “performance enhancement.”)
SO. This herbal medication is NOT benign. Surgery is a stress. I liken it to running a marathon. In healthy people who are not having surgery, ephedra causes issues. This herbal is well documented to cause heart attack, stroke, heartbeat irregularities, blood pressure issues, and body temperature issues. Supposedly the effects wear off quickly, but this is an herbal proven to be deadly when taken as prescribed. Not worth it.
KAVA
This is a drug from the root of a pepper plant, known to reduce anxiety and cause sedation. Issue? During surgery anesthesiologists use drugs to help patients relax, like Valium, Xanax, and others. Kava augments the action of these other drugs, and it sticks in your system for a while. You may think sedation during surgery is good, why not have more? The issue with oversedation is primarily breathing. If you are too sedated, you don’t breathe.
VALERIAN
Many herbal sleep aids contain valerian. It is also used as an anti-convulsant, migraine, and pain reliever treatment. It acts just like Valium. If you have used it for a while, you can withdrawal if you stop it. It also interferes with sedatives used during anesthesia.
I can’t repeat it enough- herbals, diet pills, and supplements are medication. You need to treat them as such. Please tell your doctor about them before your surgery. And for most, I strongly recommend stopping them 2 weeks ahead of surgery.
Posted on January 19, 2010 in Skin / Nonsurgical, Uncategorized, interesting & new
Yup.
Herbals are medications. In general, ones which are “heart healthy” and help you with atherosclerotic disease, peripheral vascular disease, impotence, or have anticoagulation properties = MAKE YOU BLEED. Seems obvious, but sometimes it is hard to think herbals are medications, and you may be taking an herbal for a different effect, like depression, and not know it is also an anticoagulant.
Common ones:
GARLIC
No, if you eat garlic bread at dinner you aren’t going to bleed to death if you get a cut (even if you go to the Stinking Rose in San Francisco). Garlic has been used as a medical remedy for thousands of years. It lowers cholesterol, reduces blood pressure, and inhibits thrombus formation (it inhibits platelets which help blood clot). The risk is dose dependent. Again, the amount in food is low. You are at risk if you take a specific supplement.
GINGKO BILOBA
Gingko comes from a unique species of tree located in China. It was thought to be extinct, but preserved by cultivation by Chinese monks for 1000 years. Gingko is used for a grab bag of indications, including improving memory and concentration, vertigo, dementia / Alzheimers, MS, and blood flow / microcirculation. Some of its effect is due to improving microcirculation and its antioxidant properties. Again, like garlic, it impedes platelet formation of clots.
GINSENG
Yes. The G herbals make you bleed. Ginseng is a staple of Chinese and Native American medicine. It is supposed to help the body fight stress and increase energy. It is also thought to help with libido and other hormonal and reproductive issues.
Issues for surgery? It has been said to increase coagulation time. Also, it may decrease blood glucose, which can be an issue for surgery patients who are not allowed to eat prior to surgery, particularly in diabetics. It can also interact with other drugs, including insulin, NSAIDs, anticoagulation drugs, blood pressure medications, and MAO inhibitors.
GINGER:
Thought to help with digestion and as a stimulant. It prolongs the action of some anticoagulation medications, and is supposed to have blood thinning capabilities.
ST. JOHN’S WORT
This drug is commonly used to treat depression. In some countries it is a prescription. ?It is thought to have anticoagulation properties. It is well known to cause increased metabolism of drugs and increased liver activity. This can lead to medications used in surgery not being at the appropriate level, as they are metabolized too quickly (and for you younger women out there, this includes birth control pills! women experience breakthrough bleeding because the blood levels of the birth control pill are too low). And in some medications like Plavix (a blood thinner) it amplifies the medication, causing an increase in bleeding time.
OTHERS
Alfalfa, capsicum, celery, chamomile, Chinese herbs, fenugreek, feverfew, fish oil, ginger, ginseng, horseradish, kava, licorice, passionflower, red clover and Vitamin E, meadowsweet, willow bark, tumeric, and bilberry.
There was a case report on echinacea- commonly used for colds- which caused bleeding in a woman who used it chronically. How? Her chronic use likely lead to liver issues, which caused the bleeding problem.
SO.
Remember herbals are medications. Tell your doctor what you are on, and likely stop them for two weeks ahead of surgery (at least if you are my patient). But that extra piece of garlic bread is okay.
Posted on January 15, 2010 in Skin / Nonsurgical, Uncategorized, interesting & new
Just because it is “herbal” and natural, does not mean it is safe.
Vincristine, a chemotherapy agent, comes from a common garden flower.
Herbal supplements are common, particularly here in the Bay Area. They are in everything: single pill diet herbal supplements, power drinks, teas, diet pills, and muscle building supplements. I joke it is probably in our water too. There are many issues with herbals.
- They are not regulated as closely as prescription medications, so you don’t know exactly what is in them. I saw an expose once on asian herbs, where they had taken them to a lab and analyzed the content. They found high levels of arsenic in one brand. Of course, the arsenic wasn’t listed on the “ingredient” list.
- People don’t think of them as being medications. On my sign in sheet, I ask what medications including herbals the patient takes. Even with that, many patients don’t mention herbals and vitamins until I specifically question them.
Why does it matter? Because some herbals make you bleed- a bad quality during many of my surgeries. Some interfere with anesthesia. And they can affect other systems: I had a patient who was in liver failure due to an “herbal supplement.” She had no idea. We discovered it when routine preop labs showed her liver function tests were through the roof and her platelet level (which helps you clot to stop bleeding- again a good quality during surgery) was low. Eeek! She was a healthy younger woman. Those labs made us think of liver failure, infections, cancers- we were thrilled to find it was just the herbal medication, and her functions returned to normal after stopping the herb.
It takes time to get the herbal medication effect out of your system. I have my patients stop all herbal medication two weeks prior to surgery, and I don’t let them restart until they are 2- 3 weeks out. There are some herbals which are okay, but you need to clear each individual one with your surgeon prior to surgery.
SO
Herbal medications are MEDICATIONS.
They can have a profound effect on your body.
Discuss them with your doctor prior to surgery.
Posted on January 12, 2010 in Skin / Nonsurgical, Uncategorized, breast cancer, interesting & new
Vitamins.
They are good for you. Is more better? What happens when you take more? Do you pee it out? Or does it help you heal better?
When looking into this, I went to the scientific articles, not the press. I do take things with a grain of salt: all scientific papers are not equal. Was it a good study with adequate numbers and controls? etc etc.
So. What did I find?
Wounds are harder to heal for some people:
- Age
- Steroids
- Radiation
- Chemotherapy
- Diabetes
- Smoking
- Poor nutrition
As a surgeon, I see the effect of poor blood flow causing wound healing issues. Diabetes, smoking, high cholesterol, exposure to cold. These are not important for small cuts. But when we do “flap” surgeries like breast lifts, facelifts, and tummy tucks, blood supply is critical.
One good study I saw stated the most important factor was not a vitamin level, but your protein level. They found if your serum protein was less than 6g/dl, you would not heal well. They did not see a correlation with Vitamin C, Vitamin E, or anemia. (I was suprised by the anemia part- you need blood to bring the oxygen and nutrients to the wound to heal.)
Vitamin A:
Vitamin A stimulates the early inflammatory resonse to healing (which is good- it’s like the paramedics have arrived). A deficiency causes impaired collagen synthesis. In normal people, taking extra Vitamin A likely does little. The place Vitamin A is well documented to help is in those on steroids. Steroids, like Vitamin E, inhibit healing. They measure this by looking at the tensile strength of the wound, ie how easy is it to break open?
A normal dose is 2000-3000 IU/day. When trying to do a supplement to help with healing, the dose is 25000 units. This should be done for a short period of time 1-2 weeks. High doses of Vitamin A are not good if trying to have a child, or if you have a history of liver disease.
Vitamin C:
We all know about those scurvy pirates AAARRRH.
One of the original papers I found supporting Vitamin C and wound healing was a 1937 paper, so this is not news. Vitamin C is needed to make collagen. It is also an antioxidant and thought to strengthen the connective tissue in skin, muscle, and blood vessels. When you don’t have Vitamin C, you get scurvy. Scurvy presents with skin lesions and bleeding from mucous membranes. People look pale, can lose their teeth, and are depressed. We humans lack long term storage for Vitamin C.
What dose? Normal daily recommendation is 60 mg/day. If you lack Vitamin C, they can recommend up to 1-2 grams a day. A typical wound healing dose though is likely around 500mg.
Vitamin E:
Aaaaah. This is such a tricky one. Vitamin E is a strong antioxidant and helps your macrophages work (fighters who eat up bacteria and invaders and call in more troops to fight infection).
BUT I make all my patients stop Vitamin E before surgery. Why? 1. Because it makes you bleed. The normal amount in your multivitamin is okay. The 400 IU is not. 2. At higher doses it can inhibit collagen synthesis and decrease tensile strength of wounds, just like being on steroids.
I get a lot of push back on vitamin E. “I hear it makes scars better.” It weakens scars. The only scars it “makes better” are those which are hypertrophic or keloid. For a normal scar, you don’t want to weaken it. It has just the right amount of scar and strength. If you weaken a normal scar, it will indent or widen. So for “good healing” I don’t recommend more than what is in a typical multivitamin.
SO to sum it all up, for normal patients you likely don’t need any supplements. You will heal just fine. If you have any issues on the list of healing issues, then consider supplements (after you clear it with your doctor of course).
Yes, Protein. Yes, Vitamin A. Yes, Vitamin C.
No Vitamin E.
Posted on January 5, 2010 in Face, Skin / Nonsurgical, interesting & new, skin fillers
Thanks to all of you for coming on Thursday for our informational session on Sculptra.
Here are some links to videos on the national news showing the injections: (No, I don’t look to these media outlets for my medical advice, but I do think these are good snippets to show you how the injections are done. There are needles, so don’t watch if you don’t want to see needles.)
The early show on CBS:
http://www.youtube.com/watch?v=dmBtJS-L6VU
Entertainment tonight:
http://www.youtube.com/watch?v=KReow3bFfW4&feature=PlayList&p=F2A53B8B3A22BCF5&playnext=1&playnext_from=PL&index=27
Posted on December 24, 2009 in interesting & new
Santa came early for us this year.
T’was the night before Christmas (well actually a couple of nights)
And all through the House (of Congress that is)
The doctors and patients lobbied
And the cosmetic surgery tax was doused.
I was hesitant to publish this until I confirmed it from multiple sources. Thank you to all who wrote in and called your representatives. Happy Holidays!
Posted on December 15, 2009 in Face, Skin / Nonsurgical, interesting & new, skin fillers
Volumizing isn’t just for hair anymore.
There was a big shift in plastic surgeon thinking about a decade ago.
Look at the eyelid. We used to remove fat when doing lower eyelid surgery. The thought was remove the bulge, and the eye will look youthful. But the face doesn’t work that way. As you age, you lose facial fat. (Yes yes, you gain it elsewhere where you don’t want it.) As you lose fat in your cheek, you look hollow under the eye, your lower eyelid looks longer, your cheek pad drops, you get lines around your mouth which deepen (stop! stop!) and your face skin slackens. (oy! can you stop already?)
But this is what happens. So fast forward to now- the new generation- no scar, nonsurgical, fill fill fill generation. There is validity to it. I am a surgeon. I love to do surgery. But I saw a patient yesterday who has lost weight. She also exercises more, causing a lower body fat percentage (yes, for those of you with the wee ones, there is hope for us yet to see a gym again.).
She has loose skin.
She would benefit from a facelift. Her skin is loose from age and weight changes. But as I showed her in the mirror, even when I tighten the skin, she is flat. Hollow. The “deflated beach ball.” She needs volume. So instead of rushing to surgery, I recommended she try filler first. To get the result she wants, she must correct the hollowness. She should add volume first (nonsurgical, cheaper, no scar, minimal downtime), and then reevaluate. Adding volume will buy her time, even years, before she wants to do a surgery.
What filler to use?
For first timers, immediate gratification people, and small areas, I like restalyne/perlane or juvederm. For those with higher volume needs who want a longer lasting fill, I like sculptra. Volume doesn’t have to be a overly plump fake look. As with all plastic surgery, when done elegantly and well, it looks seamless. The goal is the “How do you look so good for your age?”, not the “Oh my. did you have a fight with a helium tank?”
So. Pump up the volume. It works.
