Blepharoplasties in Men?

Yes, men benefit from blepharoplasties--plastic surgery of the upper and lower eyelids.  In this fellow's case, he was concerned that excess upper eyelid skin impeded his vision, especially in the upper, outer portions of his field of vision.

Formal visual fields testing at his ophthalmologist's office confirmed that his sight was significantly hampered.  His insurance company agreed to pay for his upper blepharoplasties.

But what about those "bags" beneath his lower eyelids?  Since his upper eyelids were being rejuvenated, the patient and I agreed that simultaneous lower blepharoplasties would produce facial harmony.  (But there's no convincing an insurance company to pay for even rational aesthetic surgery.  This gentleman had to pay for his lower eyelid surgery out of his own pocket.)

The end result is excellent.

He sees better, and he looks better.  He still has a masculine appearance, and is certainly not "over done."  A happy, confident patient is always my goal!

Why Am I Gaining Weight After Liposuction?

I had liposuction of my tummy about a year ago.  My doctor removed 2000 cc.  I didn't lose weight, but I looked good.  But, now, my love handles are growing.  I have a muffin top, and I am up 5 pounds.  What gives?  I thought that I wasn't supposed to gain weight after lipo.  Isn't there some kind of guarantee?

- Heather C., from Oxnard, California

Heather, let's reeducate you about liposuction...

Myth #1:  Liposuction is great for weight loss.

Liposuction is not a good weight loss technique.  Most patients usually lose just 1-2 pounds after liposuction.

Liposuction removes stubborn fat deposits and thereby improves a patient's contours.  Ideal liposuction patients are already at their ideal weights; they just can't lose those darn saddle bags, or tummy pooch, or chin fat, or whatever.

Heather, I am therefore not surprised that you didn't lose much (if any) weight after liposuction.  This is typical.  However, you did get what a good liposuction procedure should provide:  a better appearance and more confidence.

Myth #2:  After liposuction, I won't ever gain weight again.

Liposuction cannot change the future!  If a liposuction patient ingests more calories than she burns, then she will gain weight.  If she wants to lose weight, she should either eat less or exercise more (or better yet, both).

Liposuction removes fat cells.  They are gone and will never come back.  However, if a patient ingests more calories than she burns, then her body will deposit fat somewhere.  It's just less likely to be stored in the liposuctioned area than somewhere else.

Heather, your 5 pounds are being stored preferentially in areas that were not liposuctioned.  Since your tummy was treated, the weight is going elsewhere--to your flanks and hips.  Hence, you have developed love handles and a "muffin top."

If you lose those 5 pounds, I bet that you'll get back your old post-op "look."

Myth #3:  Plastic surgeons can and should guarantee their work.

Plastic surgeons can't, in good faith, ever guarantee their work.  There are too many variables.  Biological systems (i.e., human bodies) are far too complex for any person to perfectly control in all instances.  Abnormal healing, infections, and other acts of God can mar the results of the best surgeons.  Patients themselves overindulge in sweets, forget to exercise, forget to follow post-operative instructions, etc.  And, yes, even superstar surgeons have bad days; Michael Jordan didn't dominate every basketball game.

Rather than a guarantee, Heather, your surgeon should have offered you a frank discussion about liposuction, including all the risks.  In my pre-operative conversations, I always inform patients that weight gain after liposuction can detract from the final result.

I hope that this helps, Heather.  Try to lose those 5 pounds; skip desserts and increase your exercise regimen.  Then, recheck your figure.  You'll probably look great again...without the muffin top!

Did I Just Get Fake Botox?

The Plastic Surgery Group of Albany has pled guilty to misleading the public regarding fake Botox.  Apparently, five of the physicians in the practice admitted that they used "Tritox" on patients who were told that they were receiving injections of real Botox.

Tritox is a version of botulinum neurotoxin type A--just like Botox.  However, Tritox is not FDA approved.  On the contrary, it is not even approved for use on human beings!

Tritox, manufactured by Toxin Research International, Inc., in Tucson, Arizona, may be a good product.  I don't know; nobody does.  We are all still awaiting research documenting its efficacy and safety.

I suppose that the New York doctors purchased the Tritox in lieu of Botox because the price point was better.  However, those doctors should not have been so short sighted.  In addition to paying their legal fees, the surgical group now faces a fine of up to $500,000, and an order to pay restitution to 150 patients, who had forked over approximately $100,000 for treatments that they thought were for genuine Botox.

Also, the individual surgeons face up to one year in prison and fines of up to $100,000.  (Frankly, these guys got off light.  I am surprised that they are not going to lose their licenses.)

How can you avoid being duped?  Ask your plastic surgeon to show you the vial.  The label on authentic Botox Cosmetic is imprinted with an Allergan hologram.  (Allergan is the manufacturer of Botox.)

The only FDA-approved alternative to Botox is Dysport.  (Check out http://www.pickartplasticsurgeryblog.com/2009/05/ventura-patients-ask-botox-or-dysport.html.)  I really like Dysport--just like I love Botox.  Nevertheless, if you ask for Botox, and if you pay for Botox, that's what you should get.

Patient Dies in Florida After Liposuction...Performed by an Occupational Medicine Specialist

Awful stories of bad plastic surgery outcomes abound on the internet.  Unfortunately, there is a common theme:  The plastic surgery is often NOT performed by plastic surgeons.

Rohie Kah-Orukotan, who was herself a nurse, died after liposuction surgery on September 25, 2009, in Broward County, Florida.  The operation had been performed in a medical spa by Dr. Omar J. Brito Marin, an occupational medicine specialist, who had taken a three-day course on cosmetic surgery procedures.

This case nearly brings me to tears.  Not only is she an attractive young lady with a bright future, but the circumstances surrounding her death are unsafe and bizarre.

• Her physician is an occupational medicine specialist.
• • What the heck is that?!  I have been a physician for 13 years, and I don't even know what an occupational medicine specialist is.
  • Everyone should know what a real plastic surgeon is--a physician who has been certified by the American Board of Plastic Surgery. 
  • How could a nurse not know the difference? 
• He took a three-day course on cosmetic surgery.
• • I spent close to seven years in surgical training after four years of medical school. 
  • How could a nurse not know that a three-day course over a long weekend is not adequate?
  • Couldn't she have found a Board Certified Plastic Surgeon with years of training?
• The surgery was performed in a medical spa.
• • Liposuction is real surgery.  It should be performed in a real operating room!
  • Safety equipment and appropriate monitoring is essential to ensure good outcomes.
  • Board Certified Plastic Surgeon are required to use accredited facilities.  No occupational medicine specialist would even be let in the door to a certified facility.
  • How could a nurse not know that it is unsafe to have surgery in a spa where people usually just get massages?
• Apparently, the liposuction was performed with carboxytherapy, which supposedly reduces stretch marks and cellulite.
• • I have never even heard of carboxytherapy.
  • There is certainly NO scientific evidence that carboxytherapy reduces stretch marks and cellulite.
  • Carboxytherapy is NOT a standardized liposuction technique.
  • (For discussions of other liposuction gimmicks, check out http://www.pickartplasticsurgeryblog.com/2009/10/waterjet-assisted-liposuction-breakthrough-or-gimmick.html or http://www.pickartplasticsurgeryblog.com/2009/01/smartlipo-and-brazilian-butt-lifting-can-a-patient-use-the-smartlipo-fat-for-buttock-augmentation.html) 
  • How could a nurse fail to know that she was being duped with a gimmicky procedure?

This case teaches me that even professionals can be tricked.  If a nurse can be convinced to undergo gimmicky liposuction in the back room of a spa by a non-surgeon after he trained over a long-weekend, then the lay public is in deep trouble.

The Boob Jab: Enlarging Breasts Via Injections Rather Than Implants

In Ventura, and elsewhere in Southern California, breast augmentations are the most popular cosmetic surgery.  Placing a prosthesis (filled either with saline/salt water or with silicone) beneath the breast increases its size and improves its shape.

Despite the relative safety of breast surgery, many patients fear "going under the knife."  Others are not looking for a pneumatic change in their silhouette; just enough to fill up B cups, please!  What to do if you fear operating rooms, or if you're after a more discreet enhancement?

Enter the boob jab.

Yes, you read right.  Jab, not job.  Some of the injectable products, which have revolutionized the way plastic surgeons treat aging faces, may be good not only for filling in sunken cheeks but also for subtle breast enhancement...

• in the office
• not in the operating room
• with local anesthesia
• no IV
• no general anesthesia

Macrolane injections--the boob jab--are currently available in Europe.  A few thousand women have now undergone treatments, and they can expect their results to last for 18 months.

It is unlikely that boob jabs will be available in the US in 2009 or 2010.  We can only hope that Macrolane (manufactured by the same people who have brought us the wildly popular Restylane and Perlane) makes it to our shores soon.  It could be another option for women seeking breast enhancement.

Pamela Anderson Has the Best (and Worst) Breasts

Paradoxical results from the International Society of Plastic Surgeons:

• When plastic surgery patients are asked, "Which celebrity has the best breasts?" Pamela Anderson tops the list.
• When plastic surgery patients are asked, "Who has the worst breasts?" Pamela Anderson also tops the list.

 

Obviously, some people like "the fake look," and others hate it.  Nobody seems to lack a strong opinion!

The tops of the 2 lists:

    The Best:

1. Pamela Anderson
2. Britney Spears
3. Xuxa (Brazilian singer)
4. Gisele Bundchen

    The Worst:

1. Pamela Anderson
2. Dolly Parton
3. Victoria Beckham

Family Doctors Performing Plastic Surgery?!

Sickening story from Las Vegas:

A woman won free breast augmentations from the doctor at the "Skin Body Institute," a local medi-spa.  She underwent surgery under local anesthesia but then suffered horrible complications. Some details from ABC 13...

• She was awake for the whole procedure, and was crying the entire time. The doctor reprimanded her for complaining during the painful procedure.
• (I never do breast augmentations under local anesthesia.  Patients should be put to sleep--by a Board Certified Anesthesiologist--so that they are comfortable.)
• Just weeks later, the implant became infected and was exposed through the skin.
• She subsequently underwent 10 hours of surgery under local anesthetic to try to fix the problem.
• Two weeks later she presented to the ER with ruptured and exposed implants.
• The doctor had made 10-centimeter incisions.
• (By the way, for routine breast augmentations, my incisions are typically 3-4 cm long for saline implants and 4-5 cm long for silicone).
• The doctor's website had stated he was board-certified.
• He was NOT certified by the American Board of Plastic Surgery, but by the Family Practice board.
• Still, his website listed him as an associate member of the American Academy of Cosmetic Surgery, the American Society of Laser Medicine and Surgery, American Society of Liposuction Surgery, and the American Society of Cosmetic Dermatology and Aesthetic Surgery.
• His medical license has been suspended.

This is another terrible incident where the patient did not do her homework and was the victim of a phony plastic surgeon.  Most patients do not understand that not all "Board Certifications" are legitimate. The American Board of Medical Specialties (ABMS) recognizes 24 "real" Boards. The only member Board that qualifies physicians to practice plastic surgery is the American Board of Plastic Surgery (ABPS).

This might seem obvious, but notice how confusing the situation can get. The offending family doctor also claimed certification by the American Board of Cosmetic Surgery (ABCS), etc., etc. The average person cannot know that the American Board of Cosmetic Surgery is not recognized by the American Board of Medical Specialties, and that in most states, the American Board of Cosmetic Surgery has no standing.  Simply stated, the American Board of Cosmetic Surgery is NOT a real board.

We doctors need to lead the charge on these issues.  However, these infractions are not on President Obama's radar screen.  Mr. President, in your forthcoming legislation, why not add commonsensical language preventing doctors from practicing outside of their formal training?  Otherwise, they really are just practicing.

Water-Jet Assisted Liposuction: Breakthrough or Gimmick?

More than in any other surgical technique, liposuction technology is marketed directly to consumers with little (to no) scientific evidence.  Some background...

• Standard suction assisted lipectomy employs a strong vacuum to remove stubborn fat deposits.
• Most surgeons add tumescent fluid to numb the surgical area and to constrict blood vessels (and thereby minimize bleeding).
• Power assisted liposuction involves a vibrating handle to minimize surgeon effort when removing the fat.
• Ultrasonic assisted liposuction uses ultrasonic energy to melt the fat before it is sucked out.
• Laser assisted liposuction uses a laser for melting fat before it is vacuumed out.
• Water-jet assisted liposuction supposedly limits intra-operative tissue distortion caused by the tumescent anesthetic fluid.

If all you knew about plastic surgery was learned from daytime television, then you would think that plastic surgeons perform liposuction...

• in their offices
• under local anesthesia--with tumescent fluid alone
• employing lasers to melt the fat
• water jets to minimize distortion

The truth is much less sexy.  The vast majority of Board Certified Plastic Surgeons prefer...

• an accredited surgical facility rather than the back room of their office
• heavy sedation--either "twilight sleep" or general anesthesia provided by an appropriately trained anesthetist
• some quantity of tumescent fluid for additional comfort and to decrease bleeding
• performing the actual liposuction with... standard techniques, power assisted devices, or ultrasonic machines

While I do like ultrasonic assisted liposuction (and I use the VASER system), as a Board Certified Plastic Surgeon, I have to admit that there are no good scientific studies documenting the superiority of ultrasound or laser-assisted liposuction relative to standard or power-assisted tumescent liposuction.

The water-jet is so new on the scene that there are exactly ZERO articles about it in the most prestigious plastic surgery publication Plastic & Reconstructive Surgery.  So, is water jet liposuction a breakthrough or gimmick?  I have absolutely no idea.

The best study on laser-assisted liposuction (from Chile, and published in Plastic & Reconstructive Surgery in 2006) demonstrated no major clinical differences between standard liposuction and laser assisted liposuction.  However, there were higher concentrations of free fat molecules floating in the blood of the laser patients, which alerts me to the possibility of potential damage to the liver, kidneys, or lungs.

So, truthfully, when patients ask me about laser and water-jet liposuction, I don't even know what to tell them.  In the past, I have mentioned the potential dangers of minimally tested technologies, and patients have actually become angry at me for my skepticism!  It's amazing to me that my caution turns people off.  Typically, patients express disbelief that lasers or water could be anything but positive.

The effects of marketing can obviously be pernicious.  It's incredible that the makers of these product have been able to convince the public of their products' efficacies before they have even convinced the surgical community!  Crazy!!

Botox in Your 20s and 30s: You Can Prevent Wrinkles

I have a friend who is just 29 years old, and she is already getting Botox.  She tells me that its for preventing wrinkles.  Is that legit?

-Sara F.

Surprisingly, yes.

Botox and the other botulinum neurotoxin type-A products (such as Dysport) can prevent certain wrinkles before they even start.

Many facial wrinkles are primarily the result of muscle over-activity.  The most common sites include...

• horizontal forehead wrinkles
• frown lines between the eyebrows (the 11s)
• crow's feet
• bunny lines on the sides of the nose

If those muscles are relaxed, and they are never excessively used, then the wrinkles at those locations will be minimized (if not prevented altogether).

So, when young adults in their 20s and 30s ask whether there is something to do to remain looking youthful, I do mention Botox.  Your friend's Botox habit is legit, Sara F!   However, please remind her about the other basics of skin care....

• Avoid the sun and ultraviolet light.
• Do exercise, and enjoy the great outdoors, but don't forget sunscreen (SPF >30), a hat, and sunglasses.
• No smoking.  Nothing is worse for your skin than tobacco.
• Moisturize.
• Brush and floss your teeth!  Gum disease is one of the causes of "smoker's lines," even in non-smokers.