Problem or panacea: "awake" cosmetic surgery

More and more, I see ads by non-plastic surgeons touting the alleged advantages of having major elective procedures, such as a tummy tuck or a breast augmentation, done "awake" - under local anesthesia. Invariably, these ads tout "avoid risky general anesthesia", or "quick recovery".

While liposuction under tumescent (local) anesthesia is an accepted and validated technique, performing breast augmentation or tummy tucks while awake is very controversial, to say the least. The New York Times recently did an investigation on this issue - their article is here (link)

Typically, these procedures are heavily advertised by cosmetic surgeons who are not board-certified in plastic surgery, and who do not have hospital privileges to work in the operating room. Their offices are usually not accredited, inspected surgical facilities. And they don't typically have an anesthesiologist monitoring the patient.

Really, I feel that the "local anesthesia" angle is a bit of a dodge. It's a clever bit of marketing spin. The reason most of these "wanna-be's" promote this is because it's their only option for anesthesia....they usually can't get the hospital privileges or work in accredited surgery centers, due to lack of credentials.

There are also real disadvantages to the "local only" technique:
- It can be hard to numb large areas completely, even with the tumescent technique. Remember, just like when you visit the dentist, it can take a few painful shots before the injected area is numb.
- If the local isn't working 100%, the patients may be fully aware and in pain, as the procedure goes on. I wouldn't wish that on my worst enemy, thank you.
- You can't get satisfactory muscle relaxation with just local anesthesia, either - which is important for procedures like tummy tucks, or sub-pectoral breast augmentation.
- it isn't good for patients who are nervous, or who are resistant to lidocaine.
- lidocaine, the most commonly used numbing agent, isn't risk free. Toxic doses can occur, resulting in seizures and cardiac arrhythmias.

If you want a rapid recovery from anesthesia, use an expert anesthesiologist, who can monitor the patient, and give them exactly the right doses of medication, keeping them comfortable, but not over-sedated.

Modern anesthesia, administered by an anesthesiologist in an accredited facility, is actually very safe. The risk of something bad happening under anesthesia is less than 1 in 57,000, according to recent studies. Essentially, you are far safer under anesthesia than you are driving your car to work every day.

As for the claims of "quicker recovery", the recovery from the surgery depends more on the nature of the surgery, on delicate handling of the tissues by the surgeon, good hemostasis, and avoidance of tension on the tissues, all of which are skills that are stressed in Plastic Surgery school.

If I were to have a surgery done, I don't want to feel it, see it, or smell it, thank you very much. Wake me up when it's all over. Most of my patients feel the very same way.

Choosing the right breast implant - 2010 edition

This is an update of a classic blog from 2008 - but the information I wrote then is still relevant to selecting the right breast implant size & shape, which is one of the most important factors in getting a nice result, and a happy patient!

*****

Breast augmentation is the most popular procedure in our practice (ed: still is now in 2010, too!)- 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".

Many 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. Some want more, some want less. We try to give the patients "what they want", as much as possible.

In the old days, implants were chosen strictly by their 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. With this old fashioned method, some implants would be too wide - making the patient look heavy; some implants would be too narrow, leaving a big gap in the cleavage area. Not optimal.

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. Most patients want to stay "slim and trim" when it comes to the side of their ribcage.

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 inside of the breast (near 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, measure the thickness of the patient's own tissue. This can be done by measuring the "pinch thickness" of the breast laterally. Subtract this number from the width number.

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 diameter in a sports bra and T-shirt, and see what she likes in the mirror. We know that these implants are going to be a nice proportional size for the patient's frame, which makes a good place to start our discussion. We make adjustments from there, depending on the patient's wishes...

Of course, the look of the implant in the sports bra isn't 100% identical to what we're going to see post-operatively, but it is a pretty good approximation of the size and weight, and it's probably more accurate than most computer imaging software is at the present time.

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.

The "Mommy make-over"

Here at our Orlando plastic surgery practice, it's very common for me to see women in their 30's and 40's who would like to restore their body to the "way it used to be", back before pregnancy. Typically, the body parts most affected by the wear and tear of pregnancy are the tummy and breasts.

A tummy tuck and breast augmentation or breast lift can work wonders for these patients. We call this combination the "Mommy Makeover". Often, a proportionately-sized breast implant will restore the volume and fullness that was lost as a result of pregnancy. We might additionally suggest a breast lift, if the nipple position is low.

A tummy tuck can get rid of stretched out skin, and lower abdominal stretch marks - and can also repair separated abdominal muscles. If needed, we also do a little liposuction around the waist, which helps to give a youthful figure.

And we do our special belly button technique, that we've discussed in an earlier chapter of PSB, as part of our tummy tuck.

The Mommy Makeover can sometimes be done during one surgery, depending on the length of anesthesia needed. Other times it is best to divide the procedures up over more than one day. (It's really all about doing what is safest.)

The results have been very gratifying. When your patients say, "Doctor, I never looked this good, even before I was pregnant!" - you know you're really on to something.

New Dysport promotion: save up to $150

Dysport, as most readers of the Plastic Surgery Blog know, is the new competitor to Botox. Like David taking on Goliath, they have announced an exciting new marketing promotion, called the "Dysport Challenge". It just started March 1, and runs until April 30, 2010.

It's actually quite a deal, especially if you are someone who likes the wrinkle-fighting effects of either Botox or Dysport.

Within 14 days after your first Dysport treatment, you must sign up for the Dysport Challenge, download your Dysport Coupon Rebate Form from dysportusa.com (link) and mail the rebate form and itemized receipt.

If you love it, you can get another $75 rebate on your second treatment of Dysport. Even if you didn't like Dysport for some reason, and prefer the effect of Botox, you can still get a $75 Rebate Check from Medicis, the makers of Dysport, on your Botox treatment!

Technicalities:
You must wait a minimum of 3 months between your first and second treatments.
First treatment must occur between March 1 and April 30, 2010.
Your second treatment must occur between June 1 and September 30, 2010.
Itemized receipts must be submitted with forms.

Dr. Fiala now has an iPhone app

Yes, it's true - we're entering the age of the iPhone.

My friend, Dave Tessitore, has programmed an iPhone app for us, and it's now available through the Apple app store. Look for "Plastic Surgery with Dr. Fiala", or just click here (link). Currently, it's a free download. We're one of the first plastic surgery practices in the country with this new feature!

In addition to making it easy to make and keep track of your appointments with us, the app also helps you to remember any medications / supplements that you take, your physician contact list, allows direct email access to us, has links to our website and blog, and a number of other cool features.

An FAQ section will be added in an upcoming version. If people have suggestions for improving the app, let me know, and we'll see if we can add them in!

A Big "Thank you" to Dave Tess and Dashy Apps for their work on this project.

Breast implant exchange surgery

It's not uncommon for women who have already had a breast augmentation some years ago to come and consult with us about an implant exchange. Most commonly, this is for reasons of wanting a different size; most often a little bit larger, sometimes a little smaller. People do change their minds about the look they want, compared to their original implant choice, and we understand that.

In situations like these, where the breast is soft (doesn't have capsular contracture) and the pocket where the implant sits is in good shape, we can do what's termed a "simple" implant exchange surgery.

This involves helping the patient select the desired new size and shape, and going to surgery to replace the older implants. There's definitely a skill to selecting the new implant - and we've got a few little tricks for this!

With the resurgence in popularity of silicone gel implants, many women who first had breast implant surgery back in the "saline-only" era often consider switching to silicone gel implants. Here at our Orlando practice, four out of five patients who have experienced both types of breast implants tell me that they far prefer the gel implants. Gel implants also help to reduce wrinkle and ripple problems in the slender patient with saline implants. Using a different implant shape can also be a helpful suggestion. This keeps the implant width proportional to the patient's frame, but allows more (or less) fill up front, where most patients want it.

At surgery, we can typically use the same surgical incision - so there are no new scars. And if the old scar has widened out, we get a chance to revise it during surgery, and hopefully get a nicer looking scar.

Most women are pleasantly surprised: the recovery from a "simple" implant exchange is usually very easy, with little pain, bruising or swelling. Since the pocket for the implant is already present, and only few small adjustments need to be made to the tissue pocket, the recovery is much quicker.

More complex implant exchange surgeries involve the correction of tissue stretch or pocket expansion, or the correction of scar tissue / capsular contracture issues. As the name suggests, these surgeries are much more involved. But that's a topic for another day. Cheers!!

Do-It-Yourself Botox Site Busted in Texas

This story from WFAA-TV in Dallas / Fort-Worth....

Undercover officers raided the home of a Mansfield (Texas) woman who they say was selling "do-it-yourself" wrinkle treatments.

Police confiscated boxes, computers and more at the home of Laurie D'Alleva. Texas Attorney General Greg Abbott charged the woman with illegally offering prescription drugs -- including botulinum toxin (Botox) injections -- without a license.

The legal action also alleges that D'Alleva operated illegal Web sites to market her products. The state obtained a restraining order to keep her from selling the drugs and shut down her Internet sites, Discount Medspa and Ontario MedSpa.

The sites included video demonstrations of how to use the prescription drugs, along with customer testimonials about the results they were getting. Doctors caution that self-injecting or taking any drug without the authorization of a doctor can be harmful -- even deadly.

The state said D’Alleva falsely claimed that her membership in the "Texas Medical Council" authorized her to sell prescription-only products. There is no such organization. According to court documents, undercover investigators bought a “Newbie Starter Kit” from D'Alleva which contained the prescription Restylane in a filled syringe. They also purchased Dysport and Freeze, both of which contain purified neurotoxins, which are used for wrinkle-reduction.

Comment: I don't know what "Freeze" is - it's certainly not an FDA-approved Botox product. People must have short memories: remember the "Tritox" business in South Florida, where some self-injectors of a home-brew botulinum product ended up in the ICU on ventilators?

Don't self-inject. Don't use unapproved, untested compounds, just to save a few bucks.

Propofol found in Weston Medi Spa patient

New details have now emerged regarding the tragedy which occurred in south Florida, following liposuction surgery at an unlicensed medispa, which we discussed in an earlier chapter of the blog (here).

According to an October 30, 2009 article in the Sun-Sentinel (here), the patient was not having the liposuction surgery performed with just local anesthesia (numbing with lidocaine), but she also was given the anesthesia drug Propofol for intravenous sedation. Propofol is a safe drug in the trained hands of an anesthesiologist, but, as Michael Jackson found out, it can be lethal in the hands of an amateur.

This discovery makes a huge legal and regulatory difference. It's giving anesthesia without a trained anesthesiologist or nurse-anesthetist being present.

Receiving any sort of intravenous sedation automatically defines the procedure, according to existing Florida regulations, as a "level II office surgery" at a minimum. The level II category mandates significantly more stringent requirements than a procedure performed with local anesthesia only, such as:
- a well-defined list of safety equipment present in the office
- certain monitoring standards for the patient's vital signs and oxygenation
- completion of inspection of the surgery center by either the State of Florida or one of the national accreditation agencies
- hospital privileges for the surgeon
- a standing hospital transfer agreement in case of emergency.

None of these regulations were being followed by the Weston Medi-spa. The physician who performed this surgery was not board-certified in a surgical specialty, and reportedly did not have hospital privileges to perform liposuction in any hospital.

The Board of Medicine is now looking at a new rule, which would require all Medi Spas where surgical procedures are performed to follow the same regulations as surgery centers. I think this is an excellent idea, that would enhance patient safety.

However, these rules have to have some "teeth". It's one thing to write a good law, but another thing altogether to insure that the law is followed. Currently, it is the enforcement of existing regulations that is lacking. There are some good people working for the Board of Medicine - but they are stretched thin, in terms of manpower and funding.

Super Latisse & Botox combo deal

Hot off the press....

I just spoke with our Allergan reps: we will be one of the select few practices in Florida to offer this unbeatable combo bargain.

Buy Latisse (Allergan's eyelash growing treatment) for only $99 per box (regularly $120) and receive a rebate of $50 on a Botox treatment performed before the end of November, with the manufacturer's coupon. Call the office for details, at (407) 339-3222.

Fine print: Limit of 2 boxes of Latisse. While supplies last. Not combinable with other offers.

Fillers, the Liquid facelift and "Puffy Face" Syndrome

Everything evolves. When cosmetic fillers were first used, we applied them to the problems of wrinkles - and they worked pretty well. Then we used them to enhance lips, and then to enhance cheekbones, and to smooth out jawlines...and the list of uses kept on growing.

This ever-increasing use of fillers has directly led to the concept of the "liquid facelift", which is simply the use of a significant volume of injectable filler agents to add volume to the face. When done appropriately, and done well - the technique can look good, restoring the lost contours of youth, at least for a time, until the costly products are absorbed by the body. But like anything, it can be overdone. And quite expensive.

Hype alert: the liquid facelift technique is not really "just like a regular facelift", despite the marketing hype of some websites. The two methods work totally differently. Let's review some of the basic differences:

- In a surgical facelift, you remove excess neck and cheek skin. Not possible with the liquid facelift technique, which works by inflation.

- In a surgical facelift, you can tighten the neck muscles and re-suspend the SMAS layer (the fibro-fatty anatomic layer between the skin and the muscles). Not possible with the liquid technique.

- Traditional facelifts (with the exception of those that use fat grafting techniques) work by tightening tissue planes. This can sometimes cause a flattening effect on soft-tissue facial curvature.

- The liquid techniques work by inflation or "re-volumizing", and can add fullness to areas that would otherwise be difficult to correct. Traditional facelifts can sometimes shift soft tissue fullness by re-distributing or lifting tissues, but they don't add new volume.

- Surgical facelifts typically have an effect of 8 to 10 years, on average. Injectable products, even the newer, longer-lasting ones, last 1-2 years at most.

So, the two procedures are not directly comparable. Don't be fooled - choose the right procedure for your particular needs. If you have a lot of lax skin, get a surgical facelift. If you have loss of facial volume issues with minimal skin laxity, then you might be a candidate for re-volumizing with fillers. Your plastic surgeon can advise you.

I'm also starting to see patients who have been over-treated with the facial fillers. It used to be just the lip area - but now it's the entire face that is involved. Since there isn't an official name for this, I'll call it "puffy-face syndrome". Features of "Puffy face syndrome" that I've seen include:
- generalized swollen or bloated look to the face, due to the over-injection of filler agents, which is out of keeping with the pre-procedure appearance;
- excessive fullness in some or all of the injected areas: brow, cheekbones, paranasal and perioral areas;
- obliteration of normal naso-labial creases.

Interestingly, many of the patients that I feel are over-injected seem to be somewhat addicted to their filler treatments. When I tell them "no, you really don't need any more volume" - they react with shock and disbelief!

So, while I think that facial fillers are useful, they are but one option among many for the treatment of facial aging. Too much filler can lead to Puffy Face Syndrome! This is another example of how aesthetic judgement is important.

Scars: Part one - Keloids and Hypertrophic scars

Many people have heard the word "keloid", and think it means "any bad looking scar". This is a common misconception. Scars fall into a couple of categories. Since different types of scars and scar problems are treated differently, it's important to diagnose the scar situation accurately.

A keloidal scar is a scar that continues to enlarge and spreads beyond the borders of the initial wound. They are more common in African-American patients as well as Hispanics, Philipinos and Orientals, but can occur in patients of any race. Keloids often recur after excision, and do not tend to improve with time on their own. They are common on the face, earlobes and the chest. They are more common in women than men.

A hypertrophic scar may be thick, raised or reddish in color - but the key diagnostic difference is that they do not spread beyond the boundaries of the original wound. Most of the "bad scars" that patients show me are in this category. Hypertrophic scars may partially regress over time, becoming more flat and pale. They usually show up during the first few months after a surgical incision. They occur in equal frequency in both men and women.

A third type of scar, called a "wide-spread scar", is also common. These are typically surgical incisions that remain flat, but widen out, like a stretch-mark. They do not have the ropey consistency of a hypertrophic scar. These scars have a normal amount of collagen in them (unlike keloids and hypertrophic scars). They typically have widened out from mechanical tension (pull) across the incision. These usually respond quite well to surgical re-excision.

Commonly used treatments for these abnormal scars can involve scar massage, pressure application, use of topical silicone sheeting or gel, use of steroid injections into the scar, in addition to various surgical excision methods. Since the recurrence rate with surgical excision alone in keloid scars is about 50%, surgical excision is usually combined with one or more of the other listed techniques.

We'll discuss more about surgical scar revision in future chapters of the blog.

"Sisters, not identical twins": breast asymmetry

As one of the busiest breast surgery practices in Central Florida, I see many patients who would like a breast augmentation performed. As part of our routine, we carefully examine the patient, and during our examination, it's very common to find several differences or asymmetries between the two sides.

Most patients have no idea about these minor asymmetries of the breast until we show them...and then they see them. The reason we do this, of course, is to explain that these asymmetries will still be there post-operatively after a standard breast augmentation operation, since they were present pre-operatively.

There are several interesting studies about pre-operative asymmetry in patients undergoing breast augmentation.

Rohrich, Hartley & Brown, in their 2003 review of 100 patients, published in Plastic and Reconstructive Surgery found:
- 88% of women had natural breast asymmetries when critically examined,
- 72% of these women had more than more asymmetric feature.

In other words, nearly nine out of ten women have some degree of breast asymmetry. We commonly say "Think of the two breasts as sisters, not identical twins!"

Common asymmetries in this study included:
- nipple / areola position differences in 53%
- breast volume differences in 44%
- infra-mammary fold position differences in 30%
- chest wall (bony) differences in 9%

Similar findings were seen in 2009 study by de Chardon and associates, who examined 200 breast augmentation patients. They found a higher incidence of chest wall asymmetries, at 17%, which was most commonly caused by scoliosis of the spine with secondary changes in the rib shape.

Perhaps the most interesting finding from this French study was, of the patients that complained about breast asymmetry after surgery, 83.3% (five out of six) of them had the same asymmetry pre-operatively.

This finding certainly indicates the need to explain to patients what is present prior to the implant surgery, and help the patients to understand which features can or can not be corrected by implants alone.

Cosmetic surgery and the competitive edge: looking good and the job market

Here's some interesting data from a press release from the American Society of Plastic Surgeons:

"Faced with news of difficult economic times, and a belief that hiring is based on looks, millions of American women are looking at cosmetic medical procedures to give them a competitive edge in the workplace. In a new telephone survey compiled by the American Society of Plastic Surgeons (ASPS) of 756 women between the ages of 18 and 64, many reveal cosmetic plastic surgery procedures now appear to be an important rung on the success ladder.

- 13 percent (more than 1 out of 10 of the 115-million working-age women) say they would consider having a cosmetic medical procedure specifically to make them more confident and more competitive in the job market.

- An astounding 3 percent (nearly 3.5-million working women) say they've already had a cosmetic procedure to increase their perceived value in the workplace.

- 73 percent (almost three out of four or, 84-million working women) believe, particularly in these challenging economic times, appearance and youthful looks play a part in getting hired, getting a promotion, or getting new clients.

- 80 percent (four out of five or 92-million working women) think having cosmetic medical procedures can boost a person's confidence."


Actually, this trend is not really that new. Men have been coming to me for years, getting their upper eyelids fixed, so they don't look like the "sleepy, old-guy-past-his-prime". Executives often have specifically told me that they want to look more like their youthful and energetic business competition, and want to have surgery to give the appearance of still being in their prime, rather than being perceived as being "tired" or "over-the-hill".

Investing in yourself is always a wise investment!

Marketing hype in cosmetic surgery

Hype. Spin. Puffery. Exaggerated claims. Call it what you will - there is a lot of it out there in the world of cosmetic surgery. Unlike most other fields of medicine, the commercial influences on cosmetic surgery and aesthetic medicine have changed the traditional doctor-patient-medical supplier relationship - and not for the better.

Where does the hype come from?

1. Marketers of new technologies: Claims of wonderful new technology that works "better than anything that has come before" should always be viewed with caution. Most progress is evolutionary, not revolutionary. Laser-assisted liposuction is a great example of marketing hype getting way ahead of what has been scientifically proven. For example, is there any solid data that has been published in a reputable journal showing that laser-assisted liposuction tightens the skin? Nope. Yet, claims of skin tightening are all over the internet.

2. Marketers of "new procedures": It's become fashionable for physicians to put their name on a variation of a standard surgical technique. This is especially true for the various forms of mini-facelifts. Call it a "fill-in-the-blank" lift using some cutesy name, and market the heck out of it - and patients will seem to flock to the door. But, as we've discussed in earlier chapters of this blog, mini operations usually have mini results - and subsequent disappointment for the patient.

3. Commercial Media: Take for example, the various websites that claim to be give lists of the "best surgeon in town" or "top cosmetic surgeons in the state". Usually these are paid listings. The only qualification required is that the physician pays the bills for this marketing exposure!

The same is true with many of the local lifestyle magazines. Did you ever notice that the surgeons that are awarded "best surgeon" or who are featured on the cover by these magazines are typically the ones with the biggest advertising budgets? Hmmm....

And don't even get me started on some of the over-the-top hyperbole seen on some surgeons' websites. The descriptions make it sound like they could part the Red Sea, or walk on water! Take it with a grain of salt, people!

So, what's a consumer to do?

It boils down to old-fashioned research.

1. Ask around - get referrals from people you trust - your own doctor, OR nurses, close personal friends that have had a good experience with a local plastic surgeon. See who has good "word of mouth" endorsements.

2. Check out the ASAPS website (www.surgery.org), the ASPS (www.plasticsurgery.org) or the Florida Society of Plastic Surgeons (www.fsps.org) website to see some of the possible people you should interview in your neighborhood.

3. Interview several highly experienced, Board-certified Plastic Surgeons who do your procedure of interest routinely. Make notes and compare.

4. Look at plenty of "before and after" photos with a critical eye - we've discussed how to do this in an earlier chapter of this blog.

5. Has the staff had surgery by that surgeon? Do you like how their results look?

6. Does the surgeon have a list of actual patients that you can speak with?

7. Do you like the "feel" or "vibe" of the office? Do you feel sure that these people will look after you if you should happen to have a complication from your procedure?

8. While price is important to many people, don't always be tempted by the lowest price. If it seems too good to be true, it probably is.

Do longer surgeries have a higher complication rate?

A common question around here from patients is whether they can combine surgeries - say, a tummy tuck with a breast operation.

To answer this, we have to look at things from 2 different angles:
1) legal - what do the Florida regulations permit, and
2) medical - what do the studies looking at surgical complications find.

First of all, the applicable Florida regulations for office-based surgery state that the "maximum combined duration of anesthesia shall not exceed 8 hours."
Longer procedures can be performed - in a hospital.

From the medical literature, the answer to the question relating complication rates and duration of surgery is, surprisingly, somewhat of a mixed picture, when it comes to plastic surgery operations for healthy people.

Data against long surgeries:

- increased overall complication rates with longer anesthesia / surgery times in multiple studies in the anesthesia, cardiac surgery, orthopedic surgery, and urology literature. In particular, the study from the British Journal of Urology found a fourfold increase in non-urologic complications with anesthesia durations > 6 hours.

- increased rate of DVT (deep vein thrombosis) and pulmonary embolism. For example, in one orthopedic study, these potentially life-threatening complications were 3.5 times more likely when the anesthesia duration exceeded 3.5 hours for hip or knee replacement surgery, which are infamous for high rates of DVT's.

- increased pulmonary complications with anesthesia times greater than 2.5 hours, in both normal patients, and especially in those with pre-existing chronic lung conditions.

- increased rate of surgical site (wound) infections with longer surgeries.


Data supporting combination surgeries

- no increased risk seen when facial surgery operations were combined, in a study performed at Yale University. Anesthesia / surgery duration was not associated with increased risk in this study when surgeries under 4 hours and over 4 hours were compared.

- no increase in the complication rate when aesthetic tummy and breast operations were combined in a study from a private clinic in California. However, in this study, all surgeries were less than 6 hours in length.

The bottom line: Combination surgeries can be performed safely, but that doesn't mean we should throw caution to the winds and have a marathon surgical make-over. Despite our best efforts at prevention & prophylaxis, DVT, pulmonary embolism and pulmonary complications of anesthesia are lingering issues related to longer surgeries with general anesthesia. And when these problems occur, they can be devastating.

I do not typically recommend combinations of surgery exceeding 6-7 hours of planned surgery time, even for healthy patients. I feel it is safer to divide up the surgery into two stages, if the length of surgery exceeds this number.

So, going back to the original question: I will combine a breast augmentation (approx. 1 hour procedure) with a major abdominoplasty (3-4 hours). But I will not generally combine a major breast reduction or complex mastopexy (3-4 hours) with a big tummy tuck, as I feel the lengthy anesthesia / surgery time is worrisome.

As always - safety first.

Problems with laser-liposuction: who's the Smart one now?

Over the last few months, I have seen an alarming increase in the number of patients that come in for a second opinion about poorly-performed liposuction (done elsewhere, I might add.) All of these casse have been performed with new high-tech liposuction machines, either laser-assisted (like the SmartLipo) or ultrasonic (like the VASER).

I've seen major skin laxity, uneven liposuction, and obvious over-resection of fat leaving major divots and dents. Many of these problems are very difficult to fix, even with fat grafting techniques.

Here's a few observations:

1. All of these cases were performed by physicians and surgeons operating way outside of their specialty. They were not done by plastic surgeons or dermatologists, who are trained during residency in this technique.

2. In the majority of these patients, physical examination of the patient revealed crummy skin tone and poorly elasticized skin. In other words, since this skin won't contract like we want it to after liposuction, it's completely predictable that the post-op results will be poor, with floppy, deflated areas, and a worsened appearance. A surgeon with any significant training or experience in liposuction would have recognized this - and would have avoided performing liposuction in these patients. It's the wrong tool for the job!

3. All of these patients were preoperatively told by their physicians, "This new wonder lipo machine will tighten your skin".

4. All of these patients now say, "Skin tightening clearly did not happen...now I look worse."

5. None of these patients have an easy fix for their issues. All will require complex and expensive revisional surgery.

Lessons:

A fancy hammer does not a good carpenter make. Any doctor can buy (or rent) a fancy lipo machine.

There is, as yet, no reliable scientific evidence that laser-assisted liposuction:
a) tightens the skin, or
b) works better than standard liposuction.
Any claims to the contrary are "spin" or marketing hype; consider the source and what they're selling.

That being said, the problems seen here were not caused by the type of liposuction machine - but by the doofus using it! While the concept of liposuction is easy, getting excellent results with liposuction takes significant skill.

Please be careful about whom you choose to perform your liposuction. Even if it's performed in an office setting, with local anesthesia, liposuction surgery is still SURGERY. Training, experience and credentials matter.

"We Fix Cheap Haircuts"

True story: I was walking around downtown Orlando recently, and I came across an old-time barber shop. "Haircuts for men and boys", the sign said, "eight dollars". Seemed like quite a deal.

About a block further down the same street, I came across another barber shop. This one had a sign in the window, "We fix cheap haircuts".

I laughed at the sly reference to their low-cost competition down the street. If you think about it though, the world of plastic surgery is not that different.

Sometimes the "cheap haircut" is surgery that has been performed outside of the U.S., usually in South or Central America, with the patient returning to Florida with an infection, an open incision, thick scars, or a crummy-looking result. (I've seen all of these issues!)

Sometimes the "cheap haircut" is cosmetic surgery that was performed locally, by people that advertise ridiculously low-cost liposuction or breast augmentation surgery.

These patients with complications from inexpert surgery all tell the same sad story: "It seemed like a good idea at the time. I was hoping to get a deal on cosmetic surgery....and look what happened".

Either way, the total price for the initial surgery PLUS the required fix-up procedures is far more expensive than having it done right the first time, by a real board-certified plastic surgeon in an accredited surgery facility with U.S. level standards of quality. Worse yet, sometimes the problems can't be undone.

It's unwise to gamble with cheap cosmetic surgery....or cheap haircuts, for that matter. While some patients are satisfied with their discount surgery, why spin the roulette wheel with your health? Like that old slogan, "It may cost a little more, but I'm worth it!"

Capital One exits cosmetic surgery financing

Capital One is pulling out of the health care financing market -- removing one financing option for medical services. As of April 10, 2009, Capital One is not accepting any new installment loan applications for cosmetic surgery, or any other medical expenses.

If you already have an approved Capital One loan, you're OK - that won't be affected.

While understandable from a business point of view, it's too bad. Capital One provided a helpful service, and their loan plan was one of the more popular ones with many of our patients.

NYC Woman Dies after Silicone Injection

Injection of liquid silicone - used for soft tissue augmentation - has a long and very controversial history. Liquid Silicone is not FDA approved for cosmetic indications, like plumping up wrinkles, lips or other body parts, but is approved for the treatment of retinal detachments by ophthalmologists. The legality of cosmetic silicone injections is, to say the least, complicated.

Underground "pump parties" by unlicensed non-medical personnel go on, especially in South Florida - as people seem to want a permanent soft-tissue filler, despite the long-term potential side effects. Often the products injected are of dubious purity, and are designed for industrial applications, rather than being medical-grade purity.

Well-known side effects of silicone injections include:
- migration of the injected material
- chronic inflammation with swelling, redness and tenderness
- granuloma formation
- extrusion of the material
- scar tissue formation with possible distortion of adjacent soft tissue
- pulmonary embolism and pneumonitis (potentially life threatening lung issues)

Every year, there are several reports of deaths following liquid silicone injections, typically by unlicensed personnel. Another one happened this week in NYC. Here's the link to the story. The article says that a silicone-related pulmonary embolism was determined to be the cause of death.

Frequent readers of PSB - the Plastic Surgery Blog will be able to name a number of obvious problems with this lady's injection: Non-FDA approved material injected in large quantities, by an unlicensed practitioner, in a non-medical setting. This death was needless, tragic, and entirely preventable.

Bottom line: Get your injectables from a reputable, experienced physician in a medical environment. Use only FDA-approved injectable products. I do not recommend liquid silicone for soft tissue augmentation. More information on safe, FDA-approved products for soft tissue augmentation can be found at www.injectablesafety.org.

Special offers on injectables

Good news for those patients who are fans of Juvederm, Restylane, Evolence and Botox: the manufacturers seem to be trying to out-do each other with special offers, rebates and coupons. That means savings for you.

Here's some of the current special offers:

Botox cosmetic
- Schedule your initial botox treatment before February 28, 2009 and receive a $50 rebate coupon from Allergan. Make your follow-up treatment between May 1 and July 1, 2009 and receive a second $50 rebate.


Juvederm Ultra and Juvederm Ultra Plus injectable gel
- Schedule your Juvederm treatment before February 28, 2009, and receive a $100 rebate coupon from Allergan with your second syringe of Juvederm.


Evolence collagen dermal filler
- Schedule your Evolence treatment before December 31, 2009 and receive a $50 rebate coupon for each syringe used, up to $150.


Restylane and Perlane injectable gel
- Schedule your Restylane or Perlane treatments before February 28, 2009, and get the "buy-one, get the second half-off" special.

It seems like the time to get those wrinkles treated, doesn't it!