Awake Breast Augmentation - fad or fantastic?

The New York Times not long ago published an article touting the benefits of breast augmentation while "awake" (link here). The supposed benefit of this technique is that the patient, who has been given valium and other sedatives for the procedure, can participate in the sizing process during surgery, and help to select her implant size.

The NYT article implies that anything other than a full general anesthetic could be considered "awake" - which is really quite misleading, as anyone who has experienced the drunken state that a good dose of IV sedation creates will tell you!

I've got some issues with this whole concept. First: the best time for you to pick the implant size is BEFORE surgery, rather than DURING surgery when there are sedative agents floating in your bloodstream, impairing your judgement. Before surgery, you have plenty of time to think about the many options, and ask your surgeon about the implant choices that would best give you the desired results and would best fit your frame. It's really hard to imagine how a sedated patient can give any kind of valid "informed consent" after getting medicated.

Second: if the breast is pumped full of tumescent local anesthesia fluid, as is recommended by the practitioners of this technique, then the shape and size of the breast is obviously going to be distorted, and the intra-operative appearance wouldn't be very accurate anyhow.

In the New York Times article, the surgeons doing this were not Board-certified Plastic Surgeons, but general surgeons and OB-GYN's dabbling as cosmetic surgeons. Active blog readers will recognize this as a red flag. Searching the internet doing research for this post, I was unable to find any board-certified plastic surgeons who perform breast augmentation under straight local anesthesia. Only wanna-be's.

Many of these non-plastic surgeons do this procedure in their office because they do not have hospital privileges to perform it in an accredited operating room, such as a hospital or surgery center. That's another red flag. Only ever have surgery in an accredited surgical facility.

Impression: Consider me underwhelmed by the evidence for this technique. Our careful pre-operative sizing method, with exact measurements, tissue-based planning and actual try-ons of implant sizers in an alert, well-informed patient well in advance of surgery works far better than asking a woozy and drugged patient to OK the result in a breast distorted by large volumes of injected fluid. And I've yet to see any published clinical data documenting happier patients, better outcomes or fewer complications with this technique in any peer-reviewed publication. Show me the science!

Does that mean I'm totally against operating with just local anesthesia? No, but I only use it when it's safe, comfortable and appropriate for the patient.

Capsular contracture and incision choice

As we've discussed before, capsular contracture around a breast implant is the #1 most frustrating problem of breast augmentation surgery. Despite a "textbook" surgical procedure and a perfect patient, hardness around the breast implants still can sometimes occur. Until recently though, we've always thought that the choice of the incision doesn't affect the results of the breast augmentation. Turns out that may not be the case.

In this month's issue of Plastic and Reconstructive Surgery Journal, a review article on breast augmentation discusses a recent clinical study which showed capsular contracture happens much more frequently with a peri-areolar (nipple) incision, and less often with an infra-mammary (crease) incision.

In the study, the incidence of capsular contracture was just 0.59% in the inframammary incision group,but a whopping 9.5% in the peri-areolar incision group. Periareolar mastopexies performed at the same time as breast augmentation also showed this elevated contracture number, but were not significantly different than peri-areolar breast augmentations alone. These findings do correspond with my own observations, but I am amazed at the huge percentage difference between the two groups, which is much more than I expected.

Why does this happen with the nipple approach? Probably due to biofilm. Cutting through the breast will inevitably open the micro-ducts within the breast tissue, which are colonized with skin bacteria.

Does this mean we should completely abandon the periareolar incision? No, but it's certainly a major drawback to this approach, even though, cosmetically speaking, the nipple incision may look and hide better than a infra-mammary (crease) incision, when the color of the scar blends in with the color of the nipple skin. The question now becomes: is the improved scar worth the gamble of developing a encapsulated breast? I suspect that, given the choice, most patients will choose the approach that avoids capsular contracture.

When I speak with patients in future, I'll certainly tell them about this study, and that a periareolar incision breast augmentation is 15 times more likely to develop capsular contracture.

Happy Thanksgiving!

Happy Thanksgiving to all our friends and their families.

My wish for you - if you can get possibly together with your families, that you do so, and share some time together and give thanks for what we have, and for what we have been blessed with. And maybe have a little turkey and mashed potatoes at the same time!

Best wishes to all!
Dr. F.

CNN covers breast reconstruction surgery story

CNN has done a nice human interest story on a lady who had bilateral breast reconstruction after mastectomy and radiation therapy using a fairly new microsurgical technique called the S-GAP flap. The link is here. It's good to get the word out about these newer options for breast cancer patients.

There are several important "teaching points" about this story:

1) Even today, many breast cancer patients don't realize that breast reconstruction is possible and available to them. A 2009 survey from the American Society of Plastic Surgeons found that 7 of 10 women don't fully understand their options for breast reconstruction after mastectomy. Breast reconstruction after mastectomy is covered by all health insurance plans - by law.

2) There are multiple methods of performing breast reconstruction. For the lady in the CNN article, since she had radiation therapy, most experts recommend some form of autologous tissue reconstruction (using your own tissue) rather than using an expander or implant. While radiation can be quite effective at sterilizing any remaining cancer cells, it also has permanent side effects on the tissue. All surgeons know this, but few radiation oncologists seem to discuss it with their patients!

3) Although the article made it sound a little like she had some form of fat injection to the breast, it is probably more likely that she actually had a microsurgical tissue transfer called an S-GAP flap (explained here). This is a relatively new technique, developed around 1993, in which a small blood vessel and its attached fat and skin is microsurgically transferred from the buttock area to the breast, to bring new tissue and a new blood supply to the reconstructive site. It's a pretty cool method!

4) Even once the cancer has been treated, and reconstruction has been finished, that doesn't mean that cancer survivors can let down their guard. Studies show that we really have to be on the look out for a sneaky recurrence of the disease for up to 20 years!

Thanks CNN, for spreading the word about this reconstructive option for breast cancer patients.

Darvon & Darvocet to be withdrawn from U.S. market

Source: WebMD

The US Food and Drug Administration (FDA) has asked that propoxyphene, (brand names Darvon and Darvocet) be removed from the US market. The decision will also affect generic manufacturers and the makers of propoxyphene-containing products.

At a press conference last week, Dr Gerald Dal Pan, director of the FDA's Office of Surveillance and Epidemiology, said "For the first time, we now have data showing that the standard therapeutic dose of propoxyphene can be harmful to the heart." Side effects of cardiac arrhythmias and other electrical disturbances were noted.

The FDA is advising healthcare professionals to stop prescribing propoxyphene. Patients who are currently taking the drug should not abruptly halt their medication but should contact their physician as soon as possible to discuss switching to another pain-management therapy.

"Long-time users of the drug need to know that these changes to the heart's electrical activity are not cumulative," Dal Pan added. "Once patients stop taking propoxyphene, the risk will go away."

Propoxyphene is an opioid typically used to treat mild to moderate pain. It was first approved by the FDA in 1957. It is sold by prescription under various names alone or in combination with acetaminophen.

A phased withdrawal of propoxyphene is already under way in Europe. The European Medicines Agency made that decision in June 2009.

Fat (cells) good for the heart?

You've heard about stem-cell enhanced fat grafts for rejuvenating the face and the hands...but here's a new & very cool idea: stem cells to fix an ailing heart.

Here's the concept: Do some liposuction, and isolate out the small percentage of fat-derived stem cells from the rest of the fat enzymatically. Take these stem cells, and inject them (carefully!) into the heart muscle. The stem-cells then go on to repair the damaged heart muscle, hopefully helping the heart function better, and improving the patient's symptoms and quality of life.

In the United States, more than one million patients have a severe form of heart disease, known as "no-option chronic myocardial ischemia" with a 10 year mortality rate exceeding 20% and an annual healthcare cost of more than $10 billion. If the idea works, it would be a huge step forward for these patients.

A recent multi-center, 27 patient, double-blind, placebo-controlled European study known as "PRECISE", looked at this very idea, and the results were recently presented at the American Heart Association meeting. And they are very promising. The patients selected really had no other option, other than cardiac transplantation. As part of the procedure, a small amount of fat tissue was removed with liposuction from each patient's abdomen. The stem cells were then extracted, and injected into the muscle of the left ventricle.

The researchers found that the stem-cell treated patients not only had a lower cardiac mortality rate over the course of the study, but that they could perform more physical activity after the treatment, and that the heart had a higher functional capacity and better maximum oxygen consumption (reflecting a higher work capacity) when compared to untreated control patients.

Impression: very exciting stuff! Sure it's a small study, but if it pans out in larger trials, this could be a major breakthrough. Soon, maybe we'll be seeing the plastic surgeon helping out some CCU (coronary care unit) patients with liposuction for stem-cell harvesting.

Better pre-op meds for less post-op pain & nausea

Ask anybody what they worry about when they are thinking of having surgery, and I'm willing to bet that answers like "I'm worried that I'll be in pain or be nauseated" are near the top of the list.

What if I told you that, with improved medications prior to surgery, we could make this a lot better than traditional methods? Interested? You betcha!

Anesthesiologists and surgeons have been doing a lot of research on this area, to determine the best types of drugs to reduce post-op pain. And the answer isn't always "just give more", because the side effects of nausea, vomiting, sedation and respiratory depression from opioids like morphine, fentanyl or demerol can start to become problematic. It turns out that the combination of several different strategies works best. Technically, this is called "multi-modality treatment for postoperative analgesia". (Impress your friends with that phrase!)

Interestingly, a medication used for years as an anti-epilepsy agent, called gabapentin, is a real winner for ambulatory surgery patients. One dose given pre-operatively has been proven in multiple studies to reduce post-op pain, reduce the need for opiate medications post-operatively, and reduce the incidence of nausea and vomiting after surgery.

Also, a non-steroidal anti-inflammatory medicine (NSAID) called diclofenac has be proven to be helpful in reducing post-op pain and swelling. Unlike many other NSAID's, this one doesn't have a significant effect on platelet function, so it's OK to take at the time of surgery.

We're in the process of switching over to this improved pre-op combo. By reducing post-op pain, patients will be obviously have an easier time with their recovery. By reducing the need for strong narcotics, they'll have fewer side effects.

Should be a winner for everyone!

Collagen fillers discontinued - no more Zyplast & Zyderm

While it seems hard to imagine today, back before the early 1980's, plastic surgeons didn't really have any reliable injectable products to use for wrinkle correction or lip enhancement. When Zyplast and Zyderm arrived in the early 80's, a new generation of of non-surgical corrections via injectable fillers became possible. These bovine-collagen fillers weren't by any means perfect - they required skin testing, had a potential for allergic reactions, and didn't last all that long. Still, they caught on like wildfire, and were used by millions worldwide with reasonable results most of the time.

Today, we hardly use Zyplast, Zyderm, Cosmoplast and Cosmoderm anymore. They have long been replaced by better products, like Juvederm and Restylane. The newer HA gel products are easier to use, are available in a variety of consistencies and formulations, don't need skin testing, have a far smaller risk of allergic reactions, and can be "erased", if need be, by an injection of hyaluronidase. It's a big improvement.

Earlier this year, Allergan announced that the old generation of collagen fillers would no longer be distributed at the end of 2010, due to lack of demand. (Allergan actually stopped production of the products in 2009, but had enough inventory in stock to meet the projected demand for another year.)

Should you be worried? No. In addition to Restylane, Perlane, Juvederm, Juvederm Plus, Prevelle Silk, Radiesse, Selphyl, Sculptra and others, new filler agents like Belotero are just around the corner. You'll still have plenty of excellent choices. Technology has advanced, and we have considerably better choices now.

Updates & announcements

1. The new e-book "Plastic surgery 101: What to know before your consultation" is now completed and available. Yay! It will be a free download for patients that schedule a consultation, and I hope everyone will find this guidebook to be educational in nature. If our established patients would also like to get a copy, just send us an email, and we'll be delighted to send it to you. Feel free to share it with your friends, too.

2. We're also working on an updated version of our iPhone app "Plastic Surgery with Dr. Fiala". Not only will this include the new e-book, but various YouTube video segments of ours. It will also have some enhanced functionality and appearance.

3. I'm in the process of finishing up a second e-book. This one is about breast augmentation surgery, and covers dozens of frequently asked questions that prospective patients like answered before surgery.

I find that the better educated patients are about surgery before they have it, the happier they are afterwards. That's one reason why we are so pro-education. Plus...I like to teach.

Remember our Veterans tomorrow!

The non-surgical nose job

Do you have a fairly minor shape problem with your nose, but don't care for the idea of a complex rhinoplasty procedure? Well, here's an option for you to correct it, without the fuss of surgery.

Called a "non-surgical rhinoplasty", the technique essentially uses filler agents like Restylane, Juvederm or Radiesse to disguise the less desirable contours of the nose, and enhance the good parts. We've been doing this at our office for several years, and it works quite nicely for selected patients. The idea is just like using a filler to enhance the shape of the lips, or to fill in a wrinkle on the face - except this time, we use the same shaping principles for the nose...

It's especially exciting to treat people that have had previous rhinoplasty work that might have a minor contour issue. The use of a little bit of injectable filler to take care of a little irregularity on the nose can make a dramatic improvement...in just a few minutes. Or one can enhance the shape and projection of the nasal tip, if it's not quite ideal.

The technique also works for people that have a small bump in their nose. One can put a little filler both above and below the area of the bump, disguising it, and making the profile appear straighter, without making the nose look obviously bigger.

Of course, most of these fillers are not permanent, but even Juvederm and Restylane last a long time in the nose.

Bottom line: If you are candidate for this minimally invasive method, non-surgical rhinoplasty can give a significant improvement with minimal downtime and cost. Patients that have a large bump on their nose, breathing issues, or complex nasal tip problems should still consider traditional surgery.

OT: Really, Officer - it's the botox!

This report, from my hometown of Vancouver, Canada, has me wondering if the place has suddenly turned into a northern version of L.A.

Here's the story: a woman was pulled over by the police for a possible D.U.I., as she had been driving only 30 mph on the freeway and had nearly collided with two cars. While she admitted she had been drinking, she couldn't or wouldn't perform a breathalyzer test for the police officer. Her excuse - recent Botox treatments around the mouth made it impossible for her to purse her lips. These had been performed a few weeks earlier in Mexico, where the lady resides part-time.

Naturally, the officer said, "Tell it to the judge" and charged her with refusing to give a breath sample.

On her day in court, the lady was able to produce a letter from her Mexican plastic surgeon attesting to recent Botox treatments around the mouth. The surgeon stated that these may have indeed made it difficult for her to pucker up.

Her charge - refusing to give a breath sample - was dropped. Legal experts everywhere are shaking their heads in amazement - the Botox defense is certainly a "new wrinkle" for trial attorneys! (pardon the pun)

Read the full report here.

Could an asthma medication be the next fat-melter?

Answer: Maybe. Lithera, Inc. - a privately held pharmaceutical research group, recently presented some exciting results of a randomized, double-blinded study of their new injectable lipolysis drug, called "LIPO102" at the ASDS meeting.

In the study, volunteers were injected weekly in 22 locations in the abdomen and flanks with the drug, over 8 weeks. On average, the study group lost about 1/2" more of abdominal circumference than the control group did, without diet or exercise. Computerized 3-D imaging was used to take the measurements.

The fat reduction worked best in patients who were younger than 40 years and relatively thin.

Here's the interesting part: the ingredients in LIPO-102 are salmeterol xinafoate and fluticasone propionate. Asthma patients might recognize these medicines better as the very same ingredients that are used in Advair, the FDA-approved inhaler. The same beta receptors that are used to help relax the airways for asthma and COPD patients are also found on fat cells, where a beta agonist can trigger lipolysis. Dosing and administration, of course, are quite different between the two products.

Lithera isn't the only group with an injectable agent for melting fat, though. Kythera Biopharmaceuticals is also working on the same concept, with a totally different injectable formula called "ATX-101", which is also in the testing phase.

Impression: All very exciting, but very preliminary stuff. It may be the next generation of non-surgical body contouring, or it may turn out to be more trouble than it's worth. Much more research is needed.

"Botox Bandit" gets 5 years of jail time

This week in Orange County, California, the "Botox Bandit" was sentenced to five years in prison for committing multiple burglaries, fraud and identity theft against several Orange County businesses. The California woman got her nickname after using fraudulent checks to pay for more than $3,000 worth of Botox treatments, in addition to a string of other crimes.

Melissa Chesney, 46, pleaded guilty to 21 felony counts, including nine counts of burglary, five counts of identity theft, four counts of forgery, two counts of grand theft, and one count of possession of a controlled substance.

According to the D.A.'s office, Chesney admitted using fake identities and fraudulent checks at six different businesses between February and May 2009. She also admitted to committing burglary and grand theft against a department store in January 2009, and burglary, forgery, possession of a fraudulent driver's license and possession of methamphetamine in February 2009.

Sounds like her facial wrinkles were the least of her problems!!

Source: O.C. Register