This is part of a series from one of my eloquent patients who wanted to share her insights and experiences with the BRAVA.

Todays topic? The nipple.

This patient had more of an issue than some of my patients.  As always, everyone is different.  To quote her directly, “Brava is brutal on nipples.  The suction causes them to get large, pale, and hypersensitive.”

Why would this happen?  Anytime you are stretching breast skin, the nerves in the skin get mad.  When nerves are mad they can act in different ways: pins, needles, burning, itching, numbness, and hypersensitivity.  Not everyone has the same response.  It is the same thing which happens when you are pregnant or when you start to breastfeed.  That initial engorgement causes a quick stretch of the skin. For those with hypersensitivity, anything touching your nipple (including clothing or people) can make you want to holler.

What to do?

• Nipple sensitivity improves.  As your skin accommodates to the new stretch, the nerves calm down.  This patient said it lasted for a couple weeks “until my breasts were used to the suction.”  Again, everyone is different.
• Cover the nipple.  If your nipple can’t rub on things, it won’t get as irriated.  The issue here is bandaids and other adhesives can cause an issue with the Brava system and give you a “welt.”  This patient used Op Site over her colored areola portion, but said she saw the areas covered with the bandage did not respond to the suction.

The increased “hypersensitivity” sensation in the nipple is not something unusual to BRAVA and breast augmentation with fat transfer- I see it in almost all breast surgeries.  Again, it is due to the stretching of the breast skin.  It tends to be a temporary thing.

So hang in there.

Mother’s Day 2012

1. Congratulations!
2. Today is your day.
3. You’re off to Great Places!
4. You’re off and away!

1. Though you have lost the brains in your head
2. And can’t find your shoes
3. You are so sleep deprived.
4. A free 10 minutes- nap or shower- which to choose?

You are a mom now. And you know what you know.

You will find you are not the one who decides where to go.

You’ll research the best way to sleep, teach, and eat. You’ll make lists of the options for the BEST baby car seat. You will photograph and record every last smile.  You will walk with the stroller for mile upon mile.

You will giggle. You will fret.  You will obsess every detail.

You feel like time is as fast-as-a-jet and as   s  l  o  w   as a snail.

The world is so different, and full of surprise

When you see it anew through your own child’s eyes.

So to my Mothers out there, today is your day

congratulations! Good job!

Hip hip hooray!

You have embarked on this most impossible task, where your heart is exposed and tied to a toddler in the mask.  Somedays will be up, and others be down.  You may feel like moving to a whole other town.

But to quote Dr. Seuss, since he is so wise, and likely all you can muster to read as you close your eyes:

1. “you’ll get mixed up, of course,
2. as you already know.
3. You’ll get mixed up with many strange birds as you go.
4. So be sure when you step,
5. step with care and great tact,
6. and remember that Life’s
8. a Great Balancing Act.
10. Just never forget to be dexterous and deft.
11. And never mix up your right foot with your left.

Will you succeed?

Yes, you will, indeed

98 and 3/4 percent guranteed.”

Happy Mother’s Day to my friends and patients. 

One of my patients recently was very kind to share her tips on what worked for her. She compiled this from message boards, talking with Brava coaches, info from me(but I am always learning and every patient is different!) and good old fashioned trial and error.  This is not medical advice.  This is what one patient found worked for her.  I am lucky to be in the Bay Area- my patients are incredibly educated, diligent, and resourceful.  I wanted to share her insights.

DOMES

• Follow Brava standard protocol.
• Wash with Johnson and Johnson baby wash. She found the Brava cleanser too harsh.
• Really rinse domes well after washing as “the dome cleanser is especially brutal if every trace isn’t rinsed away.” (**This is something the Brava coaches emphasize as well.)

SKIN

• Wipe the breast area which will be under the Brava rim with No Sting Skin Prep (Use at least 1 wipe per breast. expect to purchase an extra box or two of wipes beyond what was provided with the system.  She thinks this step is essential to prevent skin breakdown.)
• LET SKIN THOROUGHLY DRY before applying domes.  (**This is something the Brava coaches emphasize as well.)  If you put the domes onto moist or wet skin, it will cause the skin to breakdown, just like running with wet feet and no socks would do.
• When you remove the Brava, liberally apply aquaphor to the entire breast concentrating on the area under the silicone rim. Reapply ointment throughout the day.
• If irritated: Rub aquaphor ointment onto irritated areas and cover with op site flexi fix(she liked op site better than Tegaderm because she found it easier to apply)
• If irritated: She would leave the Op Site on for two to three days until it started to come off on its own.  She would shower over it, etc.  You don’t want to be ripping off the Op site and causing more irritation.
• If itching is an issue she used a topical Benadryl itch relief spray.

Some things she tried but didn’t work for her: paper tape (adhesive is too strong), Band aids or blister patches (adhesive too strong, and the Brava can make a “welt” reaction), Hydrocortisone (I have seen this work for some patients- again every patient is different), trying to cover the actual dome adhesive with Tegaderm (instead of putting on your skin- the dome doesn’t suction well if you do that.)

Cellulite, that wrinkly dimply skin, plagues many women. It tends to get worse as we age due to poorer skin tone.  (lovely, eh?  This aging thing isn’t so fun sometimes).  A way to fix or improve cellulite has been a kind of holy grail in plastic surgery.  We have seen some things in the past help, like ultrasonic and laser liposuction. The thought is the energy in these systems essentially helps form scar under the skin. Scar contracts and tightens. Tighter= not as loose= prettier skin.

Cellulaze is an attachment for smart lipo brand laser liposuction. It has two directions of laser, with one pointed up at the skin. It is said to have a sensor to prevent too much energy to the skin to avoid burns.  They have been on a full out media blitz.  They have been in print, on TV, on the internet.

Does it work? What do I think?

• The premise makes sense, but is not a big reach from what we are already doing. I use ultrasonic liposuction and can target some of the energy up to the skin to help tighten the skin.  The same can be done with existing lasers as well.  We have know for years energy to the skin can help cause scar under the skin, which helps to tighten it. 
• Cellulite correction won’t work as well if you are doing volume reduction at the same time. (So if you do liposuction to get rid of your outer thigh fat at the same time as you try to reduce your cellulite, the two processes are at odds with each other.  Anytime you reduce volume, you loosen your skin.)
• The longevity has not been well documented yet.  The FDA approved it, with “the indication should be for short term improvement.”  It was approved by the 510(k) route, not the PMA- which means it doesn’t have the same rigors of testing as you may think.  I have prior blogs on the subject, and there was an article in the chicago tribune which summarized it well. 
• The machine hasn’t been out in broad use for a long time. I think the fine tuning of how to use it, when, and where isn’t well developed.  The New York Times published an article which I thought was good, discussing a happy patient and an unhappy one.
• $$$$ Cellulaze has been on an expensive media blitz, they are selling what they call the holy grail of plastic surgery, and the machine is costly.  Expect to pay a lot for a small area.  I’m not saying it isn’t worth it. I just don’t know yet.

This month’s May 2012 issue of Plastic and Reconstructive Surgery Journal has an article which I like.  “Brava and Autologous Fat Transfer Is a Safe and Effective Breast Augmentation Alternative; Results of a 6 year, 81 patient, Prospective Multicenter Study.”    This is a study by Dr. Khouri with other Plastic Surgeons from around the world.  The quick synopsis:

• 81 patients
• Patients were non smokers; must do BRAVA system pre (4 weeks) and post (1-4 weeks) surgery;  average BMI 19.8; age range 17-63
• MRI presurgery
• Post-surgery MRI at 6 months to document the volume change
• Follow up range 12 months to 6 years
• These patients were compared to NON BRAVA fat grafting patients 

FINDINGS:

• MRI showed no changes between 3 months and 6 months. (ie what they had at 3 months stayed)
• 71 patients were compliant with BRAVA- mean augmentation at 1 year was 233cc per breast, with graft survival of 82% +/- 18%
• Patients who did fat transfer without BRAVA has 134cc per breast, and 55% fat survival +/- 18%
• No suspicious breast masses or nodules were found.
• MRI saw a 16% incidence of fat necrosis easily identified at the 1 year mammogram

So the conclusion? The addition of BRAVA expansion before fat grafting allowed significantly larger breast augmentations, with more fat surviving and minimal necrosis or complications.  They found a strong linear correlation between how big you got before surgery with BRAVA (“pregrafting BRAVA expansion”) and what you see for your actual fat graft breast augmentation results.

I was glad to see this.  I started doing fat grafting breast augmentations and assist to my breast cancer reconstructions almost a year ago.  I am thrilled with what I have seen so far, and I have patients who are over 6 months out.  But BRAVA can be a pain to wear.  It does not always go easy.  So the question lingering in my mind—do you really need the BRAVA?  I knew I needed it for my young patients who have tight skin.  Young patients are easy- they need BRAVA because they haven’t had gravity, pregnancies, and breastfeeding stretch things out yet.  When you have tight skin, you must stretch out the skin envelope to allow room for the fat grafting- otherwise the tension on the fat is too much, and it kills the fat.

But for those with loose skin….. Do you need BRAVA?  This study shows in a prospective, multicenter trial with pre and post op MRI volumetric analysis at 6 months, there is a lasting increase in breast volume.  This increase is more than those done without the BRAVA system. 

For those who want to see the study, I have reprints in my office.  As you know, I trained with Dr. Khouri last summer to learn his technique.  I am glad to see this paper come out.  For the right patient, I am increasingly a fan of fat grafting.

(Mother’s Day is right around the corner, and I think ALL moms deserve this card! Let the celebrations of  Moms begin!)

The inside reads “But in a non cape non tights kinds of way.”

Thank you for the card.  It made me smile. I am proud and honored to be your surgeon. 

What is botox day?

Botox day started so I could cluster patients to insure they received fresh botox (which is mixed that day.  As I have blogged about before, I think fresh botox is better, more effective, lasts longer, etc.  In the past, they only had large, multi patient use vials, so we would cluster patients on the same day.).  Now they have a smaller vial, so I can mix up fresh botox anyday. 

The Special Promotional Discounted Botox day started during the recession when I had a special day every quarter where botox was discounted (thanks to my rep).  As Allergan Botox historically didn’t offer many deals in the past, the botox day was a big deal.

But with new competition on the market (or coming soon –see Dysport and Xeomin), Allergan is starting to discount to loyal botox users.  They have done this primarily through their brilliant distinction program.

For those of you who come to my office, you should be enrolled in the brilliant distinction program.  They are having a deal for the year which totals up to $200 off.

• You get $50 off your first treatment (which for my patients was entered for you during your March or April visit).
• Then you get $75 off if you do your next treatment 3-4 months after that initial treatment.  ANY DAY.  ANYTIME.  You just have to be in that window (ie- not at 2 months out, and not at 5 months out).

How to do it?

On brilliant distinctions when you log in, it will tell you when your next $50 rebate is available (it is 3 months from the date of your last treatment).  They will send you an email to remind you as well.  You can get an additional $25 off if you redeem your points to print out a coupon.  $50 + $25 = $75.

If you do your second treatment in the 3-4 month window (again did I tell you come in ANYTIME after your rebate is available to do so? it doesn’t have to be on the next “botox day”) , then you qualify for a third $50 rebate in 3-4 months, with another $25 coupon = $75.

The link is here.  http://www.brilliantdistinctionsprogram.com/bdpoints/BotoxCelebration.aspx

The botox day may offer a little more off for people who do 2 areas/ 48 units or higher… but know once it has been 3 months since your last visit (if you came in March or April- check your BD account) you can redeem the $50 + $25 anyday.

  NEXT BOTOX DAY IS JUNE 28

You can log onto your brilliant distinction account and check up on points and when you are due.  If there are ever any issues, please contact the office and we will get it fixed.

 I hope this was clear. Again, any questions call the office.

How much is enough? And when do you put it on?

• Put it on 20 minutes BEFORE you go outside.  If you are already at the beach, it is too late.
• Apply it to any exposed areas.  This includes hands, legs, feet, ears, scalp (you can use a spray- or better yet- wear a hat!) and lips (apply lip balm with sunscreen in it).
• For a body, the academy of dermatology recommends usually about one ounce to cover the body (they say it is the size of a shot glass).
• Reapply every 2 hours or after swimming, heavy exercise/ sweating.

They estimate most people only use about 25- 50% of the recommended amount of sunscreen.

So don’t skimp on sunscreen.

• Dark skies overhead? Cloudy days do not protect you.  They estimate up to 80% of UV rays still penetrate on cloudy days.
• Skiing and snow?  Snow actually reflects the UV rays, so it increases your need for sunblock.  Snow reflects 80% of the suns rays.  See my prior blog on windburn.
• Beach days on sand?  Uh oh.  Sand is another reflector, increasing exposure by 25%.

Clothing protection?  Clothing helps, but it is not always as protective as you think.  Any clothing which is porous (can you see through it?), particularly when wet may not protect you much.  If you want protective clothing there are companies like solumbra which specialize in SPF shirts, jackets, pants, and hats.  Also look for surf shirts for the beach- buy from a well known brand which will specify SPF equivalent on it.  Your kids surf shirt from last year you can read a newspaper through? Yes. You need to get a new one.

I am a big fan of clothing though for beach / swim time (who can reapply sunscreen every 2 hours and when you are wet?) and for those who work-out outside like bikers and runners who sweat a lot.  I have treated many many skin cancers on bay area men and women who are avid bicyclists, runners, hikers, surfers, and swimmers.  Clothing is easier than sunscreen sometimes.

Sunglasses? Beware! Find ones which specify UV protection on them.  Cheap sunglasses or cosmetic sunglasses may not protect as well.  Look specifically for 99-100% of blocking for UVA and UVB.  “Polarized lenses” do not necessarily protect from UV rays- polarization just cuts down on glare.  Larger lenses (go movie star chic!) and wrap around lenses are better. Polycarbonate, Blue blocking lenses, and photochromic lenses do not give you information on their UV blocking capability.

Warm days lie ahead…

30.

The guidelines used to be less, but it turns out we tend to be stingy in how much sunscreen we put on, we don’t reapply it enough, we sweat it off, and other things. So it is better to put on SPF 30 or higher.  Should you buy SPF 60? 90? infinity?   Higher SPF isn’t necessarily better–you need to follow directions.   Apply enough (generously coat all exposed skin), often enough (reapply every 2 hours), and before you go outside (20 minutes before you go out into the sun).

Pearls from the dermatology guidelines:

SUNSCREEN:

• Covers UVA and UVB
• SPF 30 or higher
• Water resistance good
• This does not negate the need to seek shade, wear protective hats and clothing (go surf shirts!), and avoid peak sun hours.

See my prior blogs on sunscreen here.  I still am a fan of the micronized clear zinc sunscreens.