Tag Archives: surgery

Latest Cosmetic surgery techniques 2014

The American Society of Aesthetic Plastic surgery meeting 2014

latest techniques

I was recently at the annual meeting of the American society for aesthetic plastic surgery (ASAPS) in San Francisco to see the latest cosmetic surgery techniques 2014.

There are about 6500 Board certified plastic surgeons in the US. Of those, only about 2000 are members of the American society for aesthetic surgery (ASAPS). This select group of plastic surgeons are those whose practice is primarily devoted to aesthetic plastic surgery- cosmetic surgery. Plastic surgeons from all over the world go to the meeting to learn the latest techniques in cosmetic surgery.

Fat injections to the face

The concept of fat injections, and by definition almost, stem cells, continues to be widely popular.

Plastic surgeons are increasingly injecting fat into the face for facial rejuvenation during a face lift. The fat seems to stay in the face for some patients and not for others. Cause unknown.

Fat injections into breasts

fat injections into the breast continues to be problematic. A recent study shows that fat injection by itself does not cause breast cancer. But… if you have a breast cancer, the fat injection will make the migration of  the cells faster and increase the chance of metastatic cancer- not good. Specially when 1 out of 9 women in the US is going to get cancer, getting metastatic cancer is a death sentence.

Fat injections into joints

The most exciting reports for fat/stem cell injections come from studies where fat is being injected into knee joints that have suffered injury. The torn cartilage actually seems to heal itself. Studies are being done now to reproduce the early study which cam from Pakistan…

Deep Vein Thrombosis

Deep vein thrombosis or DVT is a cause of pulmonary emboli which is the number one cause of death in cosmetic plastic surgery patients. Several protocols have been identified for dealing with patients at high risk for DVT. These are patients with previous history of DVT, women who are smokers, and women on birth control. Sitting in a particular position for a long time will also increase the risk.

Putting patients on blood thinners before the surgery was widely advocated as the thing to do. It now turns out the the risk of bleeding during the surgery outweighs the risk of actually getting a PE.

Bacteria around breast implants

Bacteria have long been thought of as being contributors to capsular contracture- a condition which occurs for unknown reasons around some breast implants. The bio-film, a film of bacteria that covers the implants was thought to be the main contributor to this “chronic infection”. Now it may be that the bio-film does nothing or may actually protect against the contracture! Essentially, no one knows.

Take home message

I have rarely come back from a medical conference more confused that when I went there. It seems that the science of cosmetic surgery is in a period of flux. What we thought was true, isn’t, and  what was not true is not true or is true.

What was it that former defense secretary Rumsfeld said recently,

“Reports that say there’s — that something hasn’t happened are always interesting to me, because as we know, there are known knowns; there are things that we know that we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know.”

 

 

Surgical checklists

Checklists do not work for surgery

checklist

A few years ago a a book came out that made a big splash called ” The checklist manifesto” by Dr. Atul Gawande.

The premise of the book was that having checklist will decrease errors in surgery. The prime example given was that of airline pilots who run a checklist before every flight.

Everyone started to make checklists for everything- and to a great extent they do work. The work for airline pilots, fr inventory and distribution of products etc. They do not work for surgery, as a recent study in the New England Journal of Medicine has shown.

“There may be value in the use of surgical safety checklists, such as enhanced communication and teamwork, and the promotion of a hospital culture in which safety is a high priority; however, these potential benefits did not translate into meaningful improvements in the outcomes we analyzed,” they reported.

… and all this despite the fact that this study, was conducted in over 90 hospitals in Canada with over 91% compliance, and covering 200,000 surgical procedures. No difference in mortality or complications occurred as a result of use of checklists.

Surgical checklists

One of the themes of “The checklist manifesto” was that checklists would prevent complications and standardize protocols. Other research has shown that in a hierarchical grouping of people, such as with airline pilots where the captain is all knowing, members of the group will rarely question decisions of the group “leader”.

In many hospitals, the  group”leader” (surgeon) in the operating room still cuts the wrong leg off or operates on the wrong side of the brain because other group members ( anesthesiologists, nurses and techs) do not question the decision and authority of the surgeon.

Still, why do checklists not work in the operating room or in medicine? I don’t know! They should!

 

Fat injections for breast enlargement

Fat Injections to Breasts

 

I have previously written about fat injections for breast enlargement but new information keeps on coming up and cosmetic plastic surgery patients continue to show interest in this plastic surgery procedure. here are photos from an article in the Aesthetic Surgery Journal of March 2014 by Drs. Spear and

 

Breast augmentation with fat injections  Breast augmentation with fat injections

Breast Enlargement with implants

The traditional methods of breast enlargement by either placement of saline or silicone breast implants under the chest muscles have been performed by board certified plastic surgeons since the late 1960 s.  Breast augmentation surgery has withstood the test of time. The surgery will produce consistent results and has a 98% satisfaction rate amongst patients.

Multiple variations of breast sizes and shapes are possible now that moderate profile implants, moderate -plus sized implants, and high profile implants are available from multiple breast implant manufacturers. These implants satisfy the needs of patients who typically are looking for at least a 2 cup size increase in their breasts.

Breast implants are foreign objects for the body and will form capsules of scar tissue around them which can become problematic at time. The implants can also break or rupture and in general need upkeep.

100% of patients will get a substantial improvement in breast size that is long lasting. Breast surgery with implants takes one hour.

Breast Enlargement wit Fat injections

In order not to have the problems that implants can sometimes cause, fat injection to the breasts has been advanced as an alternative surgery by some plastic surgeons.

Fat is removed by liposuction from one area of the body and injected into the breasts to enlarge them. Breasts are made up of a combination of breast glandular tissues and fat. Breast enlargement with fat injections adds to the fatty tissue already there.

Advantages of breast augmentation with fat injections

  1. Natural tissue and feel of breasts

Disadvantages of breast augmentation with fat injections

  1. Un-predictable loss of  breast volume- some of the fat always dies after a fat transfer. How much will die is unpredictable despite multiple techniques for handling and injection of the fat. Typically the latest study shows that only 30% – 40% of the fat injected remains within 6 months.
  2. Risk of development of breast cancer – The fat that is injected will have stem cells which when in the vicinity of breast tissue could cause breast cancer. This has been shown to occur in animal models. Even the latest plastic surgery article about breast enlargement with fat injections mentions that patients should be counselled about the risk of developing breast cancer!
  3. Small volume of breast enlargement possible.  In general breast augmentation achieved with fat injections only gives one cup enlargement of the breast. Typically about 250 cc fat is injected.  Within a few months after surgery only 30- 40 % of the fat remained. How much of that actually stays long term is unknown.
  4. Longer operative time. Typically surgery took 3 hours for fat injections.
  5. 10% of patients have substantial improvement in breast size, and 50% have a moderate improvement in breast size.

So,

Breast enlargement with fat gives minimal improvement in breast size ,has un-predictable results, of unknown duration, requiring three times longer surgery, and increases the risk of breast cancer.

No thanks- I’ll stick to implants for now.

 

 

 

Tummy tuck scars

Abdominoplasty tummy tuck scars in wrong location

Often a picture is worth a thousand words.

Look here;

High abdominoplasty scar

 

This young patient came to see me after having had an abdominoplasty – tummy tuck surgery by another plastic surgeon. It’s not the first time I see this type of scar after a tummy tuck on a patient. Unfortunately it is far too common and worst of all, in many situations little can be done to fix it by any cosmetic plastic surgeon. The scar is just too high and the plastic surgery patient cannot cover it up even with larger style of panties.

 

Abdominoplasty scar too high

 

 

Reasons why tummy tuck scars are too high

  1. Easier surgery for surgeon

The sad fact is that some board certified plastic surgeons are lazy and do not wish to have any headaches with their surgical procedures even at the cost of a shoddy surgical result.

Placement of the tummy tuck scar high on the abdomen means that the surgeon has

  • less work to do,
  • the work he does perform is easier,
  • the risk of any wound opening or scar disruption is less
  • the patient will have less pain as there is less tension in the abdomen.

It also means that the patient will have

  • a lesser result
  • an unsightly scar forever.

       2.  Easier for the plastic surgery patient

The high scar means there is less tension on the wound and  also a better blood supply. Unfortunately trying to get away with an easy surgery, less pain, and less risk, though something we all want, is not going to give you the result you want. In fact it will give you a result you will hate and regret. Not what we want plastic surgery to do for you!

Many plastic surgery patients who have been to doctors in other countries to have surgery will return with these types of tummy tuck scars. I cannot blame them. They have a medical tourist who is going to be around for a short period of time and who wants a quick fix.  The plastic surgeon will not be there to give post-operative care and does not want any headaches- so, a high scar solves his problem. By the time the plastic surgery patient realizes where the scar is and that it cannot be hidden by normal panties, it is too late and the patient has long left the country.

In summary, for the best surgical results after a tummy tuck the scar should be as low as possible just above the pubic area. Though this may mean that scars may have some small disruption in the early post operative period, they can always be fixed later. The high abdominal scar can rarely be fixed if ever.

 

Hypertrophic scars

Thick scars after plastic surgery- hypertrophic scars

 

One of the topics that I am constantly trying to explain to my cosmetic plastic surgery patients is the occurrence of hypertrophic scars.   A recent study showed that 50% of scars will become hypertrophic after surgery and that the majority will decrease with time. Making patients understand that hypertrophic scars are a condition due to their skin type and reactivity and not due to what their cosmetic plastic surgeon can control is challenging.

Hypertrophic scar Good normal scar

 

 

Causes for Hypertrophic scars

There are many theories as to why Hypertrophic scars occur. The short answer is that no body knows why some patients develop hypertrophic scars or even Keloid scars. Hypertrophic scars are scars that produce extra collagen and become thicker and inflamed.  Keloid scars are the same process but occurring on skin on the outside of the area of trauma and also having even greater collagen deposition.Patients also have itchiness and sometime pain in the scars. The scars occur commonly at injury sites to the skin dermis layer such as occurs with burns or trauma, but also occur along surgical incisions.

Hypertrophic scars are known to be more prevalent in patients with darker skin color. Why? Again no body knows but that fact has allowed people to study the differences between darker and lighter skin and to look for other differences which may also be involved.

It turns out that darker skin individuals have more sebaceous oil glands in their skin than light individuals. That may be one of the causes.

More importantly, it  appears that hypertrophic scars occur more commonly in areas of the body that have higher concentrations of sebaceous glands; the arm pits, around the areola and under the breast, around the umbilicus and the pubic areas. Unfortunately all of these are areas where we plastic surgeons have to put our scars for cosmetic surgery!

Sebaceous glands

If sebaceous gland are in fact a contributor for hypertrophic scars then what are they?

Sebaceous glands are a type of oil gland in our skin that produces sebum- an oily discharge that lubricates the skin and hair .  Each hair follicle has a sebaceous gland attached to it which lubricates the hair. Those of you who have greasy skin have a lot of sebum production. These glands are also the ones involved in causing acne and other skin conditions.

Typically they will get larger and grow with puberty. The sebum also has a bit of an odor which like any oil can become rancid and cause you to become smelly . The sebaceous glands are found in all areas of the body except the soles and palms; these areas do not have hairs.

Demodex mite

… and one other thing, sebum produced by the sebaceous glands is the food source for the Demodex skin mite that lives in the shafts of hair follicles. That’s right we all have millions of insects living off our skin oils and dead cells. These mites normally do not cause much bother but can at times grow in population to cause itching ,irritation,  and redness of skin. All of these are what is seen with hypertrophic scars. They have also been associated with various forms of acne.

Treatment of hypertrophic scars

The treatments available for hypertrophic and keloid scars have had poor results. When we don’t know why something occurs its obviously difficult to find a treatment.

  1. Steroid injections ; Steroids injected into the scars can decrease the swelling, redness and itchiness in some patients. injections are given three times with six week intervals. In many patients it does not work.
  2. 5-Flurouracil ; An old cancer drug that reduces the rate of collagen production. I usually mix this with steroids.
  3. Excision; Cutting out the scar and re-closing  with steroid injections at the same seems to work in some patients- and not in others!
  4. Silicone cream; has been shown to help flatten the scars. I tell patients to use it on all scars.
  5. Pressure; has been shown to help in some cases.
  6. Radiation therapy: an old treatment rarely used today

Treatments and causes for hypertrophic scars are plainly a shot in the dark. Plastic surgery patients need to be aware that scars may become hypertrophic and though in most the hypertrophy will disappear with time, some patients may need other treatments that may or may not help. Its not the surgeon’s fault but it might be the fault of the skin bugs.

 

Plastic surgery causes jealousy

Why plastic surgery causes jealousy in husbands

 

I have written in the past on the psychological effects of plastic surgery and specifically cosmetic plastic surgery.

Over the last few weeks though I have seen two husbands who reminded me  that cosmetic surgery effects the partner of the patient as much as the cosmetic patients themselves.

jealousy

Reasons for jealousy in partners of plastic surgery patients

There are a number of reasons that a plastic surgery patient’s partner may become jealous .

1. Fear of being dumped

The most common reason for being jealous of plastic surgery patients is the fear of the patient’s partner of being dumped. I have had several patient’s husbands ask me just that. ” Doc, how many women get a breast augmentation and then move out and leave their husbands?”

There are obviously some serious problems of self-confidence in these chaps if they feel that the only reason a woman is staying with them is because she has small breasts. Still you would be surprised at the number of men who think like that- and rightfully so!

After a breast augmentation or any cosmetic surgery for that matter, a patient’s self confidence is markedly improved. Patients will stand taller, smile more, be more outgoing etc. That new state of psyche obviously makes people react to the patient differently and, if there were any problems in a relationship to begin with, it just might be enough to push the patient to realize the dud they are with and move on to better things.

2. Fear of partner looking too good

Another set of fears for plastic surgery partners is related to the fear of being dumped but takes the form of possessiveness. Some people are jealous if their partners are attracting too much attention. They fear that if their wife has bigger breasts they will attract too much ogling and that makes them uncomfortable. These are people who are again not confident enough in themselves to allow their partners to wear anything but a sac and cover their heads with a bag.

The subject comes most commonly when discussing sizes for breast implants. All husbands of this type will tell the patients to choose smaller breast implants while the other types of husbands will go for “the bigger the better” size of implants. It is the patient who must make the decision about the size of implants and others point of view is guidance and nothing else!

In summary there are multiple reasons for cosmetic plastic surgery patients’ partners to become jealous of the newly found  self- confidence that their partners achieve after plastic surgery.

The normal, balanced, happy, confident partner is one who supports the decisions of their spouse in cosmetic surgery, is there to be of help during the recovery period and is there to benefit from the improved outlook on life that their spouse has.

By the same token, plastic surgery patients should realize that just changing their bodies through surgery will not solve all of life’s problems and may make relationship issues come to a boil.

Breast enlargement surgery revisions

Breast augmentation revisions

 

Breast enlargement surgery revisions are a tricky topic since its is a mixture of  a number of factors which are all prickly to consider for plastic surgeons and patients. This patient came to me complaining of differences in breast size after surgery elsewhere. The previous  plastic surgeon had placed two implants of markedly different sizes in her. I assume he had his reasons. She was unhappy with the difference in size and in the revision surgery I performed, I placed two implants of the same size for a great result.  However, breast revision surgery can be a tricky surgery due to previous scarring and changes in blood supply and the results can sometimes be worse! A careful analysis of the risk benefits of the cosmetic breast surgery must be performed. Even here the difference may not be noticeable to the untrained eye!

 

Before breast revision surgery

after breast surgery

 

 

 

 

 

Causes for breast augmentation revisions include

  • Technical error by plastic surgeon
  • Poor tissues  and tissue healing of patient
  • Lack of patient following directions post op
  • Complications of surgery
  • Perception of a bad result by patient
  • Perception of a bad result by plastic surgeon
  • perception of results by everybody else
  • Bad luck

Technical errors

Problems arising from technical errors by the surgeon at surgery include

  • rupture of breast implants
  • mal-position of breast implants
  • Inadequate hemostasis leading to bleeding

Poor Tissues

These problems arise from poor genetics on part of  patients.

  • Loose skin /poor elasticity
  • Thin skin / lack of strength
  • Reactive skin / skin which does not heal properly

Poor follow up

Specifically poor follow up of the plastic surgeon’s directions. After breast augmentation massage is essential. Lack of massage can lead to capsular contracture and breast hardening needing a revision surgery.

Complications of Breast surgery

  • Bleeding
  • Infection
  • Nerve damage
  • Implant deflation
  • Scarring
  • These are all known reasons for complications of surgery amongst many others

Perceptions of surgery result

Perceptions of defects ion the surgery results and the reason to change the surgical result with another procedure differ amongst

  • Plastic surgeons- for whom minor defects in the surgical result are acceptable based on the patient’s anatomy and the naturalness of the result
  • Patients – who may have expectations that are not real. Often patients forget that their two breasts are not exactly the same and never will be
  • Friends and family of patients may say something regarding the surgery result which even the patient and plastic surgeon were unaware of .

Bad luck

Sometimes the reason is just bad luck and no known cause can be found and there is no one or anything to blame!

In summary- beware of revisions and listen to your plastic surgeon. Sometimes the risk is just not worth it.