ATX-101: FDA Approval for Dissolving Fat (?!)

Maybe, I shouldn't have been so quick to disparage injection lipolysis.  Kythera Pharmaceutical's ATX-101 just might prove me wrong.

Back in November 2009, I called attention to the farce of injection lipolysis and mesotherapy, also known as...

• LipoZap
• Lipostabil
• Flabjab
• Lipomelt
• Lipodissolve
• Fat-Away

http://www.pickartplasticsurgeryblog.com/2009/11/whatever-happened-to-lipozap.html

Mesotherapy, injection lipolysis, LipoZap, etc., involved injecting bile acids beneath the skin to melt fat--or at least that was the hope.  Compelling advertising enabled LipoZap centers to spring up throughout the United States and Europe.  As is so often the case, clever marketing preceded any clever science.  Without appropriate testing for safety and efficacy, many patients were swindled, and some were seriously harmed.

Enter Kythera Pharmaceuticals.  Led by executives and researchers from the established biotechnology industry (such as Amgen and Allergan), Kythera seems grounded in science and safety.  ATX-101 is Kythera's fat buster.  Preliminary trials have been completed for dissolving lipomas--benign fatty tumors, affecting 2% of the population, which can be painful and cosmetically displeasing.

The traditional treatment for lipomas has always been surgical excision.  However, surgery always entails risks, such as scarring, infection, damage to critical structures like nerves, etc.  The hope is that ATX-101 will significantly reduce the size or eliminate lipomas without the need for surgery.

If ATX-101 were to work on lipomas, then I don't see why it shouldn't work on those stubborn fat deposits that we have inherited from our parents.  Analogous to current lipoma treatments, stubborn fat is now removed with surgery--liposuction.  Wouldn't it be nice to sign up for a few injections rather than a surgical procedure (albeit a minor one)?

No Insurance Company Will Pay for a Tummy Tuck

I have a PPO.  How can I get my insurance company to pay for a tummy tuck?  Or will I have to pay for it out of pocket?

-Andy in Ventura, California

Dear Andy,

I think that you are confusing 2 separate procedures:

• panniculectomy
• abdominoplasty

A panniculectomy is a functional procedure for removing excess skin and fat.  An insurance company MAY authorize a panniculectomy if...

• The apron of excess abdominal skin impedes walking.
• The apron of excess abdominal skin impedes normal groin hygiene.
• There are recalcitrant fungal infections beneath the skin folds.
• The fungal infections have progressed to bacterial infections, necessitating hospitalization and IV antibiotics.

A panniculectomy is NOT an attractive operation.  The goal is function, not cosmesis.

• There is no tailoring of the skin excess.
• There is no liposuction to contour the flanks.
• The bellybutton is not preserved.
• The muscles are not tightened.
• The abdomen is not optimally flattened.

If your goals are functional, then you should consider a panniculectomy.  Find a Board Certified Plastic Surgeon who accepts your insurance, and then speak with him/her frankly.

If, however, your goals are to have a more attractive torso, then you are looking for an abdominoplasty, better known as a tummy tuck.  An abdominoplasty will take care of everything that a panniculectomy will, but it will also do more....

• The extra skin and fat (that creates the "apron" and/or the "roll") will be removed.
• The skin will be pulled taut, and will be tailored to your frame.
• The bellybutton is reconstructed and rejuvenated.
• The "six-pack" muscles are tightened.
• The abdomen is flattened.
• Often, some liposuction is done on the flanks to optimize the waist.

Obviously, no insurance company is going to pay for you to look cuter.  Medical insurance is supposed to help defray medical expenses.  An unattractive belly is not a medical problem; it is an aesthetic issue.  So, an abdominoplasty would be your financial responsibility.

There is one more caveat:  Sometimes, a patient suffers medical problems from an abdominal "apron."  Moreover, he/she wants not only functional relief but also aesthetic improvement.  In this circumstance, the surgeon can help the patient obtain authorization for a panniculectomy.  The patient might then pay the difference for a full tummy tuck.  In effect, the patient is getting the best of both worlds:  functional improvement (covered by the insurance company) and cosmetic enhancement.  Check out this example below...

 

Breast Implants: Consideration #9: Complications

Are you willing to accept potential complications

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poor scarring, bleeding, infection, malposition, asymmetry, capsular contracture, finite life span of implants, wrong size

Breast Implants: Consideration #8: Adjunctive Procedures? Lift Up? Lipo?

Adjunctive procedures

lipo of the anterior axilla or armpits or water wings

lift up

change shape, such as for constricted breasts

Breast Implants: Consideration #7: Size

not to exceed your body's frame

not to exceed your skin's elasticity

enough to fill the envelope

err on the bigger side

Volumes to go up by a size

32 250

34 300

36 350

38 400

40 ?

Gel is smaller than saline by 8%; go for bigger for gel

 

short, medium, or high profile

Breast Implants: Consideration #6: Position of Implants - Above or Below Muscle

 

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• Subglandular implant:  The prosthesis is placed under the breast tissue but on top of the pectoralis major muscle.
• Subpectoral implant (or submuscular implant):  The prosthesis is placed behind the pectoralis major muscle (which is itself behind the breast gland).

Obviously, Holly, you deserve a customized evaluation, and only then can a Board Certified Plastic Surgeon help you make the best decision.  Nevertheless, there are some general advantages and disadvantages of the two options....

Subglandular Implants

Advantages:

• Technically easier operation for the surgeon
• Can be placed without general anesthesia (without going totally to sleep)
• Larger implants can be accomodated
• Potentially, more cleavage can be created
• No surgery on the muscle; therefore, less discomfort
• No surgery on the muscle; therefore, faster recovery time
• More "lift" effect, so that formal breast up-lift operations can be avoided

Disadvantages

• The "look" tends to be more artificial and less natural
• More rippling
• Greater likelihood of capsular contracture
• More difficult to interpret mammograms

Subpectoral Implants

Advantages

• Usually, a more natural breast appearance
• Less rippling
• Lower risk of capsular contracture
• More successful mammogram readings

Disadvantages

• More difficult operation
• Requires general anesthesia
• Can not always produce as much cleavage as the patient might desire
• More discomfort
• Longer recovery time
• Among women with large pectoralis majors, muscle contraction can distort the implant

Practically speaking, I try to convince most of my patients here in Ventura, California (>90%) to undergo subpectoral placements.  The unusual exceptions...

• Extreme fear of general anesthesia
• Very low pain tolerance
• Looking for a "fake" look
• High performance athletes, whose pectoralis major muscles should not be altered
• Body builders, in whom muscle flexion would distort their breasts during competitions
• Male-to-female transsexuals, whose large XY pectoralis major muscles would not accomodate a subpectoral implant

I like saline implants above the muscle when the patient...

• ...already has a fair amount of breast tissue.
  • Saline implants tend to ripple more than silicone.
  • Hence, those implants need some sort of coverage to camouflage that rippling.
  • That coverage can come from the muscle or from breast tissue.
  • If a woman's breasts are already big, but she would like them even bigger, placing implants on top of the muscle is usually OK.
• ...wants the most natural results when she exercises (nearly) naked(!)
  • The breasts are naturally on top of the muscles.
  • Therefore, if the muscles move, the overlying breasts shouldn't move that much.
  • However, if the implants are beneath the muscles, the breasts might move unnaturally when the muscles contract.
  • Since most women don't exercise naked, this is a minor issue for most patients.
  • Nevertheless, some women do compete in sports in small bikinis, and they are aware of breast distortions with shoulder/chest muscle contractions (such as beach volleyball players, surfers, body builders...see below)
• ...is a body builder.
  • Body builders have very well developed muscles.
  • Contraction of those big muscles would significantly distort the positions of sub-muscular implants.
  • These women do pose nearly naked (in small bikinis) while flexing their muscles.
  • Even though these women do not have a lot of body fat, implants on top of the muscle are generally better.
  • In competitions, the rippling of the implants looks less bad than implant distortion.
• ...has droopy breasts and prefers to avoid formal lift-up procedures
  • Implants themselves provide breast rejuvenation.
  • The muscles tend to mute the rejuvenative/lift-up effects of breast augmentations.
  • Even though many women need mastopexies (lift-up surgeries) at the same time as their augmentations, some patients prefer to avoid the additional scars of mastopexies and accept the limitations of implants on top of the muscles.
• ...is looking for a quicker recovery
  • Most breast implants surgeries do not require a long recovery.
  • However, positioning of the implants below the muscle is more uncomfortable.
  • Staying on top of the muscle is much less painful.

Generally, I use silicone implants when patients choose to have their augmentations on top of the muscle.  Or, better yet, I place implants beneath the muscle in 90% of circumstances...

• to minimize rippling
• to reduce excess scar tissue around the implants (known as capsular contracture)

• Subglandular implant:  The prosthesis is placed under the breast tissue but on top of the pectoralis major muscle.
• Subpectoral implant (or submuscular implant):  The prosthesis is placed behind the pectoralis major muscle (which is itself behind the breast gland).

Obviously, Holly, you deserve a customized evaluation, and only then can a Board Certified Plastic Surgeon help you make the best decision.  Nevertheless, there are some general advantages and disadvantages of the two options....

Subglandular Implants

Advantages:

• Technically easier operation for the surgeon
• Can be placed without general anesthesia (without going totally to sleep)
• Larger implants can be accomodated
• Potentially, more cleavage can be created
• No surgery on the muscle; therefore, less discomfort
• No surgery on the muscle; therefore, faster recovery time
• More "lift" effect, so that formal breast up-lift operations can be avoided

Disadvantages

• The "look" tends to be more artificial and less natural
• More rippling
• Greater likelihood of capsular contracture
• More difficult to interpret mammograms

Subpectoral Implants

Advantages

• Usually, a more natural breast appearance
• Less rippling
• Lower risk of capsular contracture
• More successful mammogram readings

Disadvantages

• More difficult operation
• Requires general anesthesia
• Can not always produce as much cleavage as the patient might desire
• More discomfort
• Longer recovery time
• Among women with large pectoralis majors, muscle contraction can distort the implant

Practically speaking, I try to convince most of my patients here in Ventura, California (>90%) to undergo subpectoral placements.  The unusual exceptions...

• Extreme fear of general anesthesia
• Very low pain tolerance
• Looking for a "fake" look
• High performance athletes, whose pectoralis major muscles should not be altered
• Body builders, in whom muscle flexion would distort their breasts during competitions
• Male-to-female transsexuals, whose large XY pectoralis major muscles would not accomodate a subpectoral implant