What is "bottoming out" after breast surgery?

This is a frequently misunderstood concept. Even some plastic surgery websites get it wrong!

Traditionally, bottoming-out was the term applied when the lower half of the breast skin stretched and lengthened out after a traditional "inverted-T" style breast reduction surgery. This lower-pole stretch could give a characteristic appearance to the breast, with the following features:

1) the illusion of an overly high placement of the nipple,
2) a vertically oblong-shaped breast,
3) loss of upper pole fullness with excess fullness in the lower half of the breast (more "teardrop" than "round"), and
4) an upward-oriented nipple.

The usual treatment was to surgically remove the stretched out skin, using a horizontal ellipse pattern, placed in the infra-mammary crease area. This fixes the problem nicely, especially in women that already have a scar in the crease.

Recently, the same term has been applied to certain complications after breast implant surgery, and this is where the terminology sometimes goes astray. Two situations can look similar to the untrained eye....

A) Expansion of the pocket. In this situation, the inframammary crease descends to a abnormally low position and the implant falls downward into a lower position with gravity. Look for the distance between the original incision (if it was in the crease) and the crease itself (which is moving downward) to be greater than it was originally.

B) True bottoming out. Here the crease level stays fixed. The scar position does not migrate. The skin of the lower part of the breast is ballooning out. As before, a skin tightening operation - a modified mastopexy - is the usual treatment.

Why is it important to make this distinction? Because the treatments are quite different.

Treatment of pocket expansion typically involves a few steps in the operating room. Make sure the pocket is not scarred down or encapsulated in the upper part of the breast. Suture plication of the abnormally opened lower part of the breast with permanent sutures is then used to close off the lower portion of the pocket. Additionally, textured implants, which have a bit of a velcro-effect with the chest wall, sometimes help to keep in implant in the desired position, and can be considered.

Despite good surgical technique, sometimes it's the patient's tissue that doesn't hold up. Sutures can pull through the weak tissue, resulting in a return of the abnormally low implant position problem in about 20% of patients. This seems to happen in women who are very thin, who have larger volume implants (greater than about 400 cc), or who are overly active after the repair surgery and don't allow things to heal properly.

Recently, a technique originally used in reconstructive breast surgery is gaining popularity for these difficult and challenging cases. A large sheet of dermal matrix, known commercially as "Strattice" or "Alloderm" is used to create a sling, running from the lower part of the pectoral muscle down to the desired infra-mammary fold level. Results of this have been fairly good, but the cost of the material is very high - about $2000 per side, just for the Strattice alone. Talk about "sticker shock"!

As usual, the best treatment of a problem is to avoid it in the first place. Appropriate implant selection, surgical technique which preserves the infra-mammary crease whenever possible, and appropriate post-operative care by both patient and surgeon will go a long way to minimize these issues. But sometimes, Mother Nature just doesn't co-operate...and it's back to the operating room.

How long do I have to quit smoking for?

It's well known that smokers have more surgical complications than non-smokers.

One of the most frustrating complications for plastic surgeons is called flap necrosis. This is where part of the skin can literally turn black and die, following surgery on the area. If that sounds bad, you're right. And it's much, much more likely in smokers, even those who only smoke a few cigarettes each day. It's especially a problem in plastic surgery operations where large skin flaps are elevated - facelifts, breast lifts and tummy tucks, to name a few.

This month, a new study published in Plastic & Reconstructive Surgery, looked at the risks of flap necrosis due to smoking, trying to scientifically determine the right amount of time needed for a patient to quit smoking prior to surgery. The investigators used an animal model, with a standardized design of skin flap, and had various smoke-free intervals prior to skin flap surgery, keeping track of the amount of skin necrosis in each group.

Their results:
1) Even at 8 weeks smoke-free prior to surgery, the ex-smokers had bigger zones of flap necrosis (=bad!) than the non-smoking control group.

2) Increasing duration of being smoke-free was significantly correlated with decreased amounts of flap necrosis. In other words, the group that was smoke-free for only 2 weeks did worse than the group that was smoke-free for 8 weeks.

Take home message: Please don't smoke for at least 8 weeks before your tummy tuck, facelift, or breast lift surgery. If you smoke and have a wound healing complication, you really have no one to blame but yourself. It's wiser to postpone your surgery if you can't quit.

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!"

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.

Herbal Supplements and Surgery - Safe or not?

Herbal supplements are everywhere. And cosmetic surgery patients love them - in a recent survey, 55% of cosmetic surgery patients surveyed took 2 or more supplements, compared to only 24% in the general population. The most commonly used supplements in the survey were: chondroitin, ephedra, echinacea and glucosamine.

Some supplements have some serious side effects that may be problematic, if you are having general anesthesia and surgery.

Here's a quick guide to which supplements should be stopped, and the reasons why. The general recommendation is to stop these supplements two weeks before surgery.

These supplements can cause bleeding problems:
Chondroitin / Glucosamine --- can also cause low blood sugar
Fish Oil
Garlic
Ginger
Gingko
Ginseng --- can also cause low blood pressure under anesthesia
Saw Palmetto
Vitamin E

These supplements affect drug metabolism and can cause excessive sedation:
Echinacea
Goldenseal --- can also cause photosensitivity reactions from laser light
Kava
St. John's Wort --- can also cause low blood pressure under anesthesia
Valerian

Ephedra ("Ma-Huang") - can cause cardiac arrhythmias, stroke, heart attack, low blood pressure under anesthesia


Since the whole idea of cosmetic surgery is to have a wonderful outcome and to minimize the risk of complications, the problems these seemingly-innocent supplements can cause are just not worth it. Please avoid them - and have a smooth recovery!