How to choose a Plastic Surgeon

If you've been doing your research prior to coming in for a consultation, you've probably come across one of those checklists that many of the plastic surgery advice websites seem to have. While I don't mind those lists, there's probably an easier way:

choose a member of ASAPS (the American Society for Aesthetic Plastic Surgery) as a first step.

Right away, you've automatically selected a Board-certified Plastic Surgeon with significant experience and interest in cosmetic / aesthetic plastic surgery. All members of ASAPS have been in practice for at least 5 years, must operate in accredited surgical facilities, must adhere to the ASAPS' Code of Ethics, and have been approved by their peers. Only about one-quarter of all plastic surgeons are ASAPS members - the specialists in aesthetic (cosmetic) plastic surgery.

Then, look for a ASAPS surgeon who has an aesthetic sense that matches yours. I often use the analogy of choosing an interior decorator - if you are redecorating your home, you might get three designers to give you suggestions on how to do it. While all 3 might offer competent designs, one will match your personal tastes better than the others. That's the one to go with. The same applies when choosing your aesthetic plastic surgeon.

Make sure your surgeon explains things well, and that his/her approach makes sense to you. Do they have lots of before and after photos for your procedure? Do the photos look the way you want to look?

Do you "bond" with the surgeon and the office staff? Do you feel comfortable there? Will they look after you, without a big hassle, should there be a complication?

If you can answer "yes" to these questions, then you've found your surgeon. :)

Fractional CO2 laser resurfacing

Every so often, a significant breakthrough comes along in Plastic Surgery - and this, I believe, is one of them. It's a new twist on a familiar theme. In this case, the new twist is a gadget called a "fractional laser scanner". This is an optical-mechanical device that manipulates an incoming laser beam, creating a polka-dot pattern of laser dots. Normal, untreated skin is left in-between the treated / lasered areas, rather than zapping the entire surface of the skin.

Since only a small fraction of the skin is treated, the technique is known as fractional resurfacing. It can be thought of as a kindler, gentler way to do skin resurfacing. It's not as dramatic a result as the traditional CO2 laser - but the recovery is also far, far easier. The down-time is about 3-7 days, with very little pain. I've been using a european machine, called the Ellipse Juvia, for my treatments since march 2007. (I believe we had the first Juvia unit in the entire South-East.) While laser resurfacing is not a replacement for a facelift, it does a nice job improving texture problems, fine wrinkles and clearing up sun damage.


There are about a dozen machines out there that use this fractional co2 laser technology - and to be honest, they are all fairly similar, whether they are called "Active FX", "DOT therapy", "mixto" or "Juvia". What's confusing for the consumer, however, is that the original "Fraxel" machine - isn't a CO2 laser. It uses a different, less powerful wavelength - so the results with the original Fraxel have not been as impressive.

There are also 2 machines - the Fraxel Repair and the Deep FX - that are designed for deeper treatments. The jury is still out on these...as the complication rate may be higher, and as yet, the treatment parameters have not been optimized.

If you decide to have this treatment done, make sure you go to a physician with plenty of CO2 laser experience. While fractional treatments can be done very lightly, all of these machines can be turned up to give a very intense treatment. They are by no means "goof-proof". Experience of the laser operator is the key to a good result.

Mini-facelifts

Ahh...the allure of the "mini" procedure. It sounds so pleasant, with its implications of short recovery and a less invasive nature, so...cute.

Take for example, the "mini-facelift". It's been marketed under all sorts of clever names: the quick-lift, the mini-lift, the S lift, the life style lift, Dr. X's own lift - but they are basically all pretty similar. Use pretty standard incisions - sometimes a little shortened in length, and do only a little "work under the hood" - and call it a day.

Less involved surgery, of course, means less swelling and a quicker recovery. But it also leads to lesser results - and that's my point here. The results of a mini-facelift are simply not the same as a properly done full facelift. Think "minimal facelift". When you do less surgery, you usually get less of a result.

While mini-facelifts can work, and I certainly perform them in carefully selected patients, I think they are best suited to:
1) people that have had a previous standard facelift a few years ago, and now just need a little touch-up,
2) people with early aging changes in the cheek and jawline areas, but who still have an excellent neckline.

Wel'll talk more about facelifts in future posts. Have a nice weekend!

The non-surgical rhinoplasty

With the advances in the world of injectable fillers, a concept known as the non-surgical rhinoplasty is beginning to become popular. Initially performed to disguise minor contour problems after a standard rhinoplasty, this technique uses Restylane or Juvederm to fill in divots or build up contours selected areas of the nose. When this is carefully done, it can sometimes save the patient from having to undergo a difficult secondary rhinoplasty procedure.

In addition, adding a small dose of Botox to reduce the activity of the small depressor septi nasi muscle can reduce the "plunging tip" effect that we sometimes see when people smile.

I've recently seen some pretty interesting results published by a group of cosmetic dermatologists, where they disguised a prominent nasal hump by building up the parts of the nasal profile immediately adjacent to the bump with fillers. While I applaud their skill with fillers, in my opinion, it makes more sense to actually perform a rhinoplasty in these cases, as reducing a prominent nasal hump surgically usually works out pretty well.

Implants & lifts - part one

One area of confusion I see frequently in our practice is the difference between when we should use a breast augmentation, and when we should use a breast lift, otherwise known as a "mastopexy". Many people think that a breast implant will lift a significantly droopy (ptotic) breast - sadly, this is not the case.

Adding an implant to a droopy breast most commonly converts it to a bigger, but still droopy breast. Some surgeons will try to "fill up" a droopy breast with a big implant. While sometimes this works, for most people, the effect is temporary - and the additional implant weight on the stretchy breast skin tends to make the droop worse as time goes by. And now, it's a much more complicated thing to fix...

For some women, who just have just a relatively minor degree of breast ptosis (droop) - an implant may work, especially if it is combined with one of our smaller breast lifts, like the "donut lift" - which involves an incision around just the areolar area. But only use an implant if you've decided you want to have a larger breast size. You can't count on them to act as an "internal bra".

Contour threads - the non-invasive facelift

In this business, there always seems to be the "next big thing", with promises of results that are almost too good to be true. That should arouse your suspicions - I'm sure you can bet how this one is going to turn out...

A few years back, there was a lot of excitement about a new technique for lifting the face, neck or brow. Special sutures - variously known as "Aptos" threads or Contour threads, depending on the manufacturer, were to be introduced under the skin, suspending the soft tissues of the face with their unique barbed design. The effect, it was hoped, would be a non-invasive method of facelifting.

Physicians, particularly non-plastic surgeons, jumped on this - as a way to give the patient a facelift-like effect without actually having to perform the complicated facelift surgery.

Well, the fatty tissues of the face are famous for not retaining sutures like this very well. The phenomenon, known as "cheese-wiring", results in a loosening of the suspension effect, in fairly short order. It's been known about for decades, so it wasn't any surprise when reports of problems started popping up. Patients who had paid several thousand dollars for the procedure were particularly displeased when their results disappeared in weeks to months! Even surgeons who honestly presented their data at medical meetings admitted, at best, the thread-lift probably didn't last more than 18 to 24 months.

Problems of being able to feel the sutures beneath the skin were also reported. Some were painful. Others eroded through the skin, and had to be removed.

Moral of the story: if you need a facelift or neck lift - get a real facelift (or neck lift). And don't let your friends waste their money on a thread lift. When you do less - you get less.

Medical Tourism - American Style

It occurred to me, after attending a recent meeting, that the prices of Plastic Surgery procedures here in Central Florida have remained pretty stable over the last 15 years - while most other areas have gone up significantly by comparison.

That means, out-of-town patients can fly in from the Northeast, the Midwest, or the West Coast, have their surgery with us here in sunny Orlando, staying all the while in a resort hotel - and still save a significant amount of money compared to doing the same procedure at home, while under the care of an expert Board Certified Plastic surgeon and MD anesthesiologist, in a AAAASF-certified facility.

While it is difficult to determine exact prices in different cities, a little detective work on the web found these prices for breast augmentation, as reported by patients themselves.

New York City.....................$8000-10,000
San Francisco, Dallas (tie).......$8000
Newport Beach....................$7500
National Average................$7500
Chicago............................$6500

Little ol' me..............$4999 for silicone, $3999 for saline with our fall special

You don't need to go outside the U.S. to have reasonably priced surgery. Just fly to Orlando - America's #1 family travel destination! Now that's what I call Medical Tourism - American style!!

Risks of Body Contouring Surgery Rise with Increased BMI

We've long suspected this, but now a recent study confirms the link between increased body mass index (BMI) and complications of body contouring surgery, such as tummy tucks, thigh lifts, breast reduction, and other similar procedures. The study, published in the July/August 2008 issue of the Aesthetic Surgery Journal, showed an increase in the complication rate with increasing obesity.

A statistically significant association was found between increasing BMI and an increased number of complications and poorer outcomes. Specifically, the percentage of complication increased as weight category increased. Major complications increased progressively from 6.6% in the ideal weight group to a shockingly high 43.7% in the severely morbidly obese group (BMI>40). Major risks were defined as wound breakdown, need for hospital readmission, re-operation, or death.

In particular, risks seemed to increase substantially with any BMI above 30-34.

Patients and surgeons alike need to be aware of these findings. In addition to making wound healing and anesthesia more complicated, many secondary medical conditions, including high blood pressure, diabetes, sleep apnea, and cardiovascular disease, are more common in patients with an increased BMI.

"Cosmetic Surgery for Dummies" - a book review

I wanted to give a big "two thumbs up" to this book by Marie Olesen, which is part of the "For Dummies" series which now seems to include almost any topic one could ask for. It's written for prospective patients - no, it's not some sort of introductory level text for interns! :)

Marie, who is well-known in the plastic surgery world for her consulting expertise, has written a wonderful primer for patients. I think it is an excellent introduction to our field, and it explains answers to common questions - like how to choose a surgeon, how to prepare for surgery, and recovering after surgery. Popular cosmetic surgeries are reviewed, in a way that is honest, straightforward and informative.

Nicely done!!

Myth: Liposuction can tighten my skin

For a successful result with liposuction, the key to great results is great skin elasticity. Liposuction - whether it be called tumescent liposuction, power-assisted liposuction, ultrasonic liposuction, VASER, or laser-assisted liposuction - does NOT tighten skin in any scientifically-proven reliable way. Many surgeons have hoped that the latest gizmo will somehow change this statement, but so far, skin tightening after any form of liposuction has been a complete disappointment. (Are you listening, SmartLipo fans?)

If there is obviously loose skin, some form of skin tightening procedure will be required, either at the same time as the liposuction, or as a secondary procedure a few months later. For the neck, this usually involves some form of facelift. For the tummy, loose skin requires some form of tummy-tuck (abdominoplasty).

Suctioning areas that have poor elasticity leads to a deflation effect as the fat is removed- with more laxity, ripples, wrinkles and cellulite showing up once the post-op swelling has resolved. Think of converting a fat neck into a "turkey gobbler" - nobody wants that!

If there are areas on the body that have a moderate, but less-than-optimal degree of elasticity, liposuction usually involves some form of trade-off. You'll look better in your clothes with a slimmer figure, but you won't necessarily look better naked or in a skimpy swimsuit. There may be more loose or sagging skin than you might like, and pre-existing cellulite might look worse. Most patients have to think about that choice pretty carefully!

Liposuction is not a magic wand.

Breast implants - choosing the right size

Breast augmentation is the most popular procedure in our practice - we help several hundred women with this each year. In order to have a happy patient, one of the most important choices we make together is figuring out exactly the right size for the implant. The three of us - the patient, my nurse and I work together on this, until we've found "just the right one".

Most of my patients request something that looks "proportional" for their frame. Most of them want something in the mid-C to small-D cup size.

In the old days, implants were chosen by volume - if you wanted to be 2 cup sizes bigger, you needed a 300-400 cc implant. Unfortunately, that calculation didn't take into account the patient's height, size of their ribcage, or other parameters that vary widely from one person to another.

I think the key factor is to get the implant width right. After all, most women who are signing up for breast surgery want a nice cleavage - and want to avoid a big gap in the center. Most augmentation patients also want to fill up the width of the breast nicely, but avoid looking excessively broad in the chest, with the implant being so wide that it ends up sticking way out the sides, under their armpits.

While other doctors may have different opinions, here's a quick summary of what I do:

1) Start by measuring the width of each breast with a tape measure - going straight across from the area of the cleavage, to the outside of the breast. This will give you a number which varies from 11-12 cm in a petite patient, to 15-16 cm in someone with broad shoulders.

2) Next, subtract a little depending on the amount of breast tissue the patient already has. I estimate this by measuring the "pinch thickness" of the breast laterally.

3) Now that we've determined the approximate "base width" - the footprint - of the implant, we can have the patient try on implants of this particular width in a sports bra and T-shirt, and see what she likes in the mirror. We know that these implants are going to be the right width for the patient's frame.

Of course, the look of the implant in the sports bra isn't identical to what we're going to see post-operatively, but it is a good approximation of the size and weight, and it's probably more accurate than computer imaging is at the present time. If anything, the implant in the sports bra looks a little bigger than it will once the surgery is done.

This try-on process takes a good bit of time with the patient, so that's the reason that many other surgeons don't do it - but it really makes a huge difference in the quality of the results and in overall patient satisfaction.


Tom Fiala

Beauty for Life Quiz

The American Society of Plastic Surgeons (ASPS) put together this presentation, which discusses popular cosmetic treatments & procedures.  

It focuses on the idea that patients have different cosmetic priorities at different ages.  We see this on a daily basis:  women in their twenties and thirties ask most frequently about liposuction and breast surgery, whereas women in their mid-forties (and up) are asking about eyelid tucks (blepharoplasty), neck-lifts and other facial rejuvenating procedures.

Tom Fiala

Welcome!

Hello, everyone!

Welcome to "PSB" - my plastic surgery blog. Here I'll discuss important issues in cosmetic plastic surgery, what's new in plastic surgery, and common questions that patients ask me in my practice.

I hope you enjoy it, and find it helpful!

Best regards,
Tom Fiala, MD, FACS, FRCSC

P.S. Mandatory disclaimer - the advice given in this blog is not a substitute for a consultation with an experienced Board-Certified Plastic Surgeon. While my explanations and descriptions of common plastic surgery concerns will apply to many people, they may not apply to your specific situation.