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Tag Archives: Dallas Plastic Surgeon

In the current health care climate of diminishing reimbursements, more and more physicians are performing cosmetic surgery treatments and procedures.  Unfortunately, many of these physicians are not plastic surgeons and have not undergone the same rigorous training as board-certified plastic surgeons.  All patients should take certain steps prior to scheduling a consultation to ensure that their physician has the highest qualifications to perform cosmetic surgery.
  • Ask if the doctor is a member of the American Society of Plastic Surgeons (ASPS).  Membership in the ASPS ensures that the doctor is certified by the American Board of Plastic Surgery and meets requirements for ongoing continuing medical education.
  • Confirm that the doctor is certified by the American Board of Plastic Surgery.  Merely hearing that a doctor is board certified does not indicate which board has certified that doctor.  There is only one board, the American Board of Plastic Surgery, that is recognized by the American Board of Medical Specialties to certify surgeons in the field of plastic surgery.
  • Find out more about the surgeon’s specific hospital privileges.  Although some procedures are commonly performed in an office or ambulatory surgical center, it is important to learn whether the surgeon has the same privileges in an accredited hospital.  Hospital credentialing committees carefully evaluate a surgeon’s training and competency for specific procedures.  If a surgeon performs a procedure in an office or surgical center, but does not have privileges to perform the same procedure in a hospital, it may be because he was deemed unqualified to perform that procedure.

Taking these steps before scheduling a consultation with a cosmetic surgeon will ensure that you find a plastic surgeon with the highest qualifications.

Many patients have asked me if they can smoke cigarettes up to the time of their cosmetic surgery.  The procedures most often in question are breast lifts with or without implants, breast reductions, tummy tucks and facelifts.  Simply put, smoking and these procedures can be recipes for disaster.  I strongly encourage smokers to quit smoking before these surgeries, as tobacco, nicotine, and carbon monoxide, all of which are within cigarettes, can impede wound healing.  In operations which involve lifting and tightening large amounts of skin, this can result in skin separation, or worse yet, skin loss.

Most board-certified plastic surgeons are selective in the procedures that they will offer to tobacco users.  Some procedures that do not require a significant amount of skin lifting, such as rhinoplasty, liposuction and breast augmentation, are thought to be somewhat safer to perform in smokers than procedures that require more skin manipulation.  For that reason, most plastic surgeons will perform these surgeries in smokers, but will still extend significant disclaimers and warnings.

Virtually everyone knows that smoking can cause pulmonary problems, heart disease and lung cancer.  For those reasons alone, I encourage all patients to quit using tobacco products.  In regards to cosmetic surgery, tobacco usage can cause significant problems with healing.  Because cosmetic surgery is elective, it only makes sense to quit tobacco usage prior to surgery to minimize this potential risk.

Many of my patients ask how I choose the optimal size for a breast implant. Some women are very concerned about choosing too large of an implant, as they know this can make their breasts look unnatural. Other women are afraid that they won’t choose a large enough implant to see a discernible difference. There are a variety of tools that I use to help my patients select the best breast implant size:

  • Photos. Having patients bring photos of breasts they like and breasts they detest help me determine their goals. Some women desire subtle enhancement and others desire much more dramatic enlargement.
  • Measurements. The chest wall diameter, breast width and height are all important factors in selecting an appropriate implant. The breast skin envelope is only so large; selecting an implant that is too large invariably means that implant will sit too high, too low, or too lateral.
  • Trial sizing. Although it is inexact, having patients try different implants in a bra in the office is a useful exercise. It gives them a crude idea of breast size and shape in clothing and often helps them verbalize their goals.
  • Conversation. Different implants have vastly different shapes and profiles. It’s important that patients understand how this differs in appearance from other types of implants, and that can only conveyed adequately in the preoperative consultation.
  • Intraoperative sizing. I will often utilize intraoperative trial implants and always sit the patient up during surgery to ensure that the breasts have a pleasing appearance.  This is particularly the case for patients with breast asymmetry, to ensure that the final implants utilized provide the greatest possible symmetry.
All of these tools play a valuable role in choosing the best possible implant size.

In the past couple of weeks, I’ve had some patients engage me in conversations about breast implant profiles.  They had seen pictures on the Internet of patients with breast augmentation results they liked and wanted the same style implants as in the pictures.  These patients had a limited understanding as to what breast implant profile refers, prompting this blog entry.

The naming for implant profiles predominantly refers to smooth, round implants, which are the most common type of implants used for cosmetic breast augmentation.  The two major breast implant manufactures have different names for their implants.  Allergan refers to its saline implants as low, moderate, and high profile and its silicone implants as moderate, midrange and high profile.  Mentor has similar names, but also has a moderate profile plus implant, which is between its moderate and high profile implants.

The profile of an implant equates to the projection of that implant.  For a given volume, the higher the profile, the fatter and narrower an implant is.  As a result, higher profile implants tend to provide more fullness and a rounder appearance to the upper portions of the breast.  Higher profile implants tend to be really useful in women with relatively narrow breasts who want significant enlargement of the breasts; in these women, if a low or moderate profile implant were selected, to achieve the desired volume may entail the implant riding into the underarm region.  In contrast, a patient with a wider build or wider breasts may find that high profile implants may fail to adequately fill their entire breast; they often times benefit from implants with lesser projection.  Higher profile implants also tend to be useful in women who desire a small breast lift without the incisions associated with a formal lift.

Almost no patients choose low profile implants for aesthetic breast augmentation; the limited amount of projection provided with these implants does not coincide with their aesthetic goals.  Generally speaking, women looking to maximize their cleavage and perkiness often times opt for high profile implants.  Ultimately, though, the best implant profile for a patient can only be determined after a careful examination by a board certified plastic surgeon, taking into account the specifics of a patient’s breast anatomy, as well as their desired appearance.

Treatments with injectable fillers, such as Juvederm, Restylane, Radiesse, and Evolence, not to mention others, can restore a youthful appearance to the lips, nasolabial folds, marionette lines, midface, jowls and lower eyelids, with minimal to no downtime.  Many patients avoid these treatments, though, because they have heard horror stories from friends or colleagues about the pain associated with these treatments.  Suffice it to say, this needn’t be the case – there are steps your plastic surgeon can take to make these treatments more comfortable.

Recently, BioForm Medical, Inc., makers of Radiesse, received approval from the Food and Drug Administration to mix the filler with lidocaine, an injectable local anesthetic, prior to injection into the skin.  This approval was based on a large study of patients, in which 100% of patients reported feeling less pain when Radiesse was pre-mixed with lidocaine.  Many plastic surgeons, including me, have begun to pre-mix lidocaine with all fillers, including Juvederm, Restylane, and Evolence, not to mention Radiesse, prior to injecting into patients.  The results of treatment are still great, but patients are significantly more comfortable during treatment.

Others things your plastic surgeon can do to make your treatment with injectable fillers more comfortable include:
•    Using topical anesthetic gel for at least 30 minutes prior to commencing any injections.
•    Augmenting treatment with topical anesthetic gel with injections of local anesthetic into nerves above and below the lips.
•    Using small gauge needles and slow injection techniques

Combining all of these treatments can ensure that you’ll not only look fantastic after your treatment with injectable fillers, but you’ll feel pretty good during the treatment too!

Breast augmentation can give women with small or uneven breasts a fuller, better-proportioned look through the placement of saline breast implants or silicone breast implants, dramatically improving self-esteem and confidence. Any operation, though, including breast augmentation, poses some risks that can lead to complications or unfavorable results.

The most common complication is capsular contracture, or hard, firm scar that forms around the implant. Because the breast normally is soft, the development of scar tissue can make the breast feel and look hard, and in severe cases, can cause pain. With older silicone breast implants, capsular contracture was much more common. The frequency of capsular contracture has diminished with currently utilized silicone breast implants, so that the occurrence rate is now similar between silicone and saline breast implants. Mild capsular contracture is hardly perceptible, but severe contractures can be painful and unattractive. Treatment consists of surgery to remove the entire capsule and placement of a new breast implant. Placement of the implant in a pocket below the chest wall muscle results in a lower risk of capsular contracture than placement over the muscle.

Infection, if it occurs, usually does so within a few weeks of surgery. Infection occurs very rarely, but if an infection occurs it often requires antibiotics and the removal of the involved implant for several months.

Some women report that their nipples become oversensitive, undersensitive, or even completely numb. Some women also report small patches of numbness near their incisions. These symptoms usually disappear within time, but may be permanent in up to 15% of patients. If the possibility of having numb nipples is unacceptable to a patient, she should not have breast augmentation, as no plastic surgeon can predict which patients will develop this complication.

There is no evidence to indicate that breast implants will affect fertility, pregnancy, or the ability to breastfeed. If, however, a patient has nursed a baby within a year before breast augmentation, she may produce milk for a few days after surgery. This may cause some discomfort, which usually resolves within a few days. For women who get pregnant after having breast implants placed, in most cases, breast implants will not affect the fate of the breasts. After the breast tissue shrinks after pregnancy and breastfeeding, the breast skin may or may not shrink. If the skin does not shrink, the breasts will likely droop. Whether or not the skin shrinks is controlled by factors other than the presence or absence of breast implants.

Breast implants may break or leak. Most often, breast implant rupture is the result of normal wear and tear on the breast implant shell. If a saline-filled implant breaks, the implant will deflate within a few days and the salt water will be harmlessly absorbed by the body. To restore volume, another implant needs to be placed. If a break occurs in a silicone breast implant, silicone gel may move into surrounding tissue, provoking an inflammatory reaction which can lead to a severe capsular contracture. There may be a change in the shape of the breast, and the breast may become hard and painful. This will require a second operation to remove the breast implant shell and to replace the leaking implant.

No data exists suggesting that breast implants cause breast cancer. Silicone and saline breast implants, however, can alter surveillance for breast cancer. Breast implants can alter the amount of breast tissue visualized on a mammogram. When placed below the chest wall muscle, greater than 90% of breast tissue can be seen well on mammogram. When placed above the muscle, only about 75% can be visualized. Breast implants do not interfere with the ability to detect masses with self breast examination, regardless of position relative to the chest wall muscle. Self exam is the most successful way to discover new breast masses. Implants also do not interfere with ultrasound or MRI scans, which are helpful in the evaluation of breast masses.

Breast implants can move out of position anytime after breast augmentation surgery. If they move a lot, surgery may be needed them back into position. The larger the implant, the more likely it will displace downward.

Rippling or wrinkling of the implant is much more common with saline breast implants compared to silicone breast implants and in thin patients. The visualized wrinkles are the folds of the breast implant shell. Ripples can be particularly disconcerting if they occur on the upper pole of the breasts.

Because breast implants are manmade, mechanical devices, they are prone to problems over time. All women who undergo breast augmentation surgery should assume that, at some point in their lives, they will require a secondary procedure, whether it’s for capsular contracture, rupture, displacement, etc. Some women may never have problems, but it’s impossible to predict which patients will fall into this category.

Many patients want to know, “What’s better – silicone or saline?”  The answer is that it depends.  Both silicone and saline implants have pros and cons.  It’s important that the educated patient understands these differences before making an informed decision.  Before delving into these differences, though, it’s important to state unequivocally that currently utilized silicone breast implants are safe.  Over the past 15 years, many large and rigorous studies have been performed investigating whether silicone breast implants are associated with autoimmune diseases or any types of cancer.  All studies performed reached the same conclusion; there is no conclusive data supporting any link between silicone implants and these diseases.  Only after carefully considering these scientific studies did the U.S. Food and Drug Administration approve the use of silicone breast implants in all women for breast reconstruction and in women over the age of 22 years for cosmetic breast augmentation.

Some good things about silicone breast implants; breast implants filled with silicone gel look and feel more like natural breast tissue.  Also, particularly in thin patients, silicone breast implants tend to have fewer problems with visible rippling than saline breast implants.

Some bad things about silicone breast implants; breast implants filled with silicone are more expensive.  Silicone breast implants are approximately twice the cost of saline breast implants, which is factored into the price of surgery.  Also, a breast implant rupture is easy to detect when the implant is filled with saline; the breast tends to deflate rapidly, in the span of a few days.  A silicone breast implant ruptures is much more subtle to detect.  For that reason, the Food and Drug Administration recommends an MRI to monitor for rupture, the first one 3 years after surgery, and then every 2 years thereafter.  This test is expensive and most likely will not be covered by third-party insurers.  Lastly, capsular contracture rates, or pathologic scarring around the implant, traditionally were much higher with the older generation of silicone breast implants.  This does not seem to be the case with the newer generation of silicone breast implants used, which is largely attributable to a thicker implant shell and thicker, more viscous silicone gel within the implant.

So, what’s better?  To repeat, silicone breast implants look and feel much more natural, but it comes at a higher financial cost, the recommendation for MRI monitoring to detect for rupture, and a larger incision.  Despite this, with each passing year, more and more patients are opting for silicone breast implants.


<!–[endif]–>Evolence®, a collagen-based injectable filler used for the correction of facial wrinkles and folds, has recently been given permission by the FDA to advertise results lasting 12 months. While relatively new to the United States, Evolence® has been available in Canada and Europe for many years.

The filler uses porcine (pig) collagen to restore a more youthful appearance. This new generation collagen filler is injected into the mid-to-deep layers of the skin for the correction of moderate to deep facial wrinkles and folds, such as nasolabial folds. Results are visible immediately after treatment.

The most common side effects include mild swelling, redness, and pain. A skin test is not required because porcine collagen is the most genetically similar to human collagen.

Evolence® is now clinically proven to last for 12 months! Call 214-827-2814 to learn about our special rates!

This is a news release directly from the American Society for Aesthetic Plastic Surgery

New York, NY (July 16, 2009) – Have you seen the commercial for in-office procedures that will make your face wrinkle-free or sculpt your stomach, with no downtime and no scars?  Lifestyle Lift, Lunchtime Lift, Thread-Tox, and Smart-Lipo, are just a few of the brand-name surgical procedures being marketed to the public as a cosmetic quick fix with a clever name.Brand name surgical procedures generally fit under two categories; first, those that are legitimately assigned the name of the person that has popularized the technique, for example Saldanha’s lipoabdominoplasty or Furnas’conchal setback technique, (either through the efforts of that same person or others assigning his or her name to it) and second, those that are simply created by someone to market a the procedure to the public.  The first situation is usually a very legitimate situation and is often in the scientific literature, but not in the public domain.  However, the second situation has become very popular for cosmetic surgery procedures.  But are highly marketed procedures really the right choice when deciding on aesthetic surgery?

“In the wrong clinical setting, the results may not come close to the promises made in the advertising,” says J. Peter Rubin, MD, a plastic surgeon in Pittsburgh, PA.  “What is really indispensible for the best results, however, is not a specific procedure but the judgment of a board certified plastic surgeon who can match the right patient with the best procedure for them.”

“These named procedures are used by the marketing entity to popularize the technique so that patients ask for it whether it fits their situation or not.  This is a problem that can be very dangerous,” said Dr. Al Aly, a plastic surgeon from Iowa, and a member of the Aesthetic Society’s Body Contouring Committee.  “A procedure is only as good as the hands that perform it.”

“Patient safety and efficacy need to be the top priorities, not commerce or marketing,” says Robert Singer, MD a plastic surgeon from La Jolla, CA and a past-president of ASAPS.  If you decide a procedure is right for you, make sure you have done your homework, that the procedure has been fully explained, you know exactly who will be performing your procedure and that they are qualified to perform the exact procedure you are undergoing, and that you have thoroughly read and signed informed consent documents.

Facial surgery and body sculpting procedures are often marketed to the public with brand names.   “One does not have to be a plastic surgeon to know intuitively that one facelift technique will not be appropriate for all individuals undergoing a facelift,” says Sherrell Aston, MD, past-president of the ASAPS and member of the Society’s Facial Surgery Committee.  “The human anatomy and the aging process vary significantly from person to person. The so-called minimally invasive surgical procedures have gained popularity in all surgical specialties. For many procedures the work that is performed through the small incisions is rather extensive, and requires significant expertise on the part of the surgeon. A short incision facelift can give an excellent result, when properly performed for the appropriate patient.”

“The issue of untrained or inadequately trained practitioners, some of whom are not medical doctors, performing cosmetic plastic surgery is an extremely serious patient safety concern,” says Salt Lake City, UT plastic surgeon and president of the American Society for Aesthetic Plastic Surgery (ASAPS), Renato Saltz, MD. “For ultimate patient safety it is essential that the media and the general public be better educated about what constitutes appropriate training to perform operations such as facelifts, rhinoplasty, liposuction, abdominoplasty, breast surgery and cosmetic eyelid surgery.”   The demanding residency program that all plastic surgeons must complete before they can be considered for certification by the American Board of Plastic Surgery (ABPS) ensures that they not only acquire general surgical knowledge and experience but, additionally, that they master the principles, ethics and practice of plastic surgery.

Source: The American Society for Aesthetic Plastic Surgery

http://www.surgery.org/press/news-release.php?iid=531

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