Cosmetic Surgery FAQ

February 06, 2012

A Word About PIP/French Breast Implants

You may have read recently about safety concerns with French-made PIP silicone breast implants.  If you are one of my patients, thankfully, you are not part of this European debacle.

I am posting to reassure my patients that I do NOT use PIP implants.  If you are one of my patients, and if you have recently undergone breast augmentations or reconstructions, please rest assured that your implants were made either by Mentor or by Allergan--not by PIP.  Both Mentor and Allergan are headquartered in the USA, and neither is being scrutinized for quality or safety concerns.

So, you are OK!

How did we in the United States manage to miss the PIP (Poly Implant Prothese) controversy?  Please thank the United States government; as early as 2000, the FDA had raised concerns about the implants manufactured by PIP.  In 1996, PIP had started selling its pre-filled saline implants in the United States under a 510(k) accelerated review application that did not require the company to submit clinical trials as long as the implant was said to be "substantially equivalent" to those already on the market.  However, by 2000, the FDA required all breast implant manufacturers to submit a formal application (known as a "pre-market approval").  Three companies submitted applications - Inamed (now Allergan), Mentor (now a division of Johnson & Johnson), and PIP.  Two companies received approval:  Inamed (Allergan) and Mentor.  PIP did not.  PIP then stopped selling its pre-filled saline implants in the United States.  That is why, although over 30,000 pre-filled saline implants manufactured by PIP have been reported sold in the United States, none of the offending PIP silicone implants have ever been implanted in the United States.

Unfortunately, PIP did not self-critique upon its expulsion from the American market.  It never addressed its quality issues.  PIP has been using a cheaper industrial-grade silicone in their silicone gel breast implants, rather than medical-grade silicone.  When this information came to light, PIP was finally shut down altogether.

But damage has been done.  These cheap PIP silicone implants are much more prone to rupture and leakage than normal.  Many European health commissions have recommended PIP implant removal (and replacement with new, safe implants from either Mentor or Allergan) as a precautionary measure.  While there appears to be no evidence of a cancer link due to these implants, we can never be sure.

I would like to reiterate that the implants that I use in my practice, made by Allergan or Mentor, are FDA-approved, and have an excellent track record.  However, I do frequently see patients whose breast surgery was done in Mexico and elsewhere.  IF YOUR IMPLANTS WERE PLACED AT A FACILITY NOT IN THE UNITED STATES, PLEASE CHECK TO SEE WHETHER YOU HAVE PIP-BRAND SILICONE IMPLANTS.  If you do have them, please come and talk to me about an implant exchange.  This is very important.  Your health may depend upon it.


July 26, 2011

The 3rd Botox: Xeomin Gains FDA Approval for Cosmetic Uses

About 11 months ago, I blogged about that...

  • Botox
  • Dysport

...were about to get more competition from the newest kid on the block, Xeomin.

On August 2, 2010, the FDA approved Xeomin for treatment for cervical dystonia (neck spasms) and blepharospasm (excessive eyelid contractions).  Late last week, on July 21, the FDA approved Xeomin for "the temporary improvement in appearance of moderate to severe glabellar lines in adult patients."

Xeomin is thus the third botulinum neurotoxin type A (BoNT-A) to enter the marketplace.  However, it is not expected to be available to physicians in the United States until the spring of 2012.

Why the delay?  I don't know.  I have called my Merz sales representative to get the scoop....


April 21, 2011

6 International Consensus Statements on Plastic Surgery Controversies

The International Confederation for Plastic, Reconstructive, & Aesthetic Surgery (IQUAM) recently published consensus statement regarding controversies in plastic surgery.  I thought that my readers might find this list interesting...

  • Multiple "medical studies have not demonstrated any association between silicone-gel filled breast implants and carcinoma or any metabolic, immune, or allergic disorder."

Translation:  Silicone breast implants are safe.  They do not cause breast cancer.  They do not cause lupus, rheumatoid arthritis, psoriasis, etc.

  • "Silicone-gel filled breast implants do not adversely affect pregnancy, fetal development, breast-feeding or the health of breast-fed children."

Translation:  If you have had silicone implants, feel free to breast feed your babies.

  • "Phosphatidylcholine has been used for prevention and treatment of fat embolism for many years, but it is currently being used 'off label' for dissolving fat in aesthetic applications.  Data concerning the efficacy, outcome, and the safety of its use for aesthetic indications in subcutaneous tissue have not yet been established. Further basic science and clinical trials are needed."

Translation:  "Lipodissolve" and "LipoZap" injections have not been shown to be either effective or safe.  While I know that everybody wouldn't mind getting rid of a "love handle" or two, don't submit to any unproven injection technique.  Liposuction remains the gold standard.

  • "Botulinum toxins (BTxA's) have been used extensively for aesthetic purposes. BTxA's in high dosages have been used in various therapeutic clinical applications with minimal reported significant adverse effects. Current clinical data confirm the safety of BTxA’s for aesthetic indications when used by experienced doctors under sterile office environment. Patients should be provided with detailed information, and a signed informed consent should be obtained prior to performing the procedure."

Translation:  Botox and Dysport kick ass!

  • Regarding injectable fillers...  "Today, more than 35% of the procedures performed by plastic surgeons are no longer purely surgical.  The use of resorbable substances is preferable to the use of nonresorbable fillers, as recommended by many national health authorities or academic societies....Permanent fillers (excluding autogenous tissue) can give a definitive correction, but have been reported to be associated with long-term, irreversible complications and should be used with extreme caution."

Translation:  Fillers are increasingly popular.  Choose one of the common resorbable fillers (such as Restylane, Juvederm, and Radiesse) rather than a permanent filler (such as Artefill or liquid silicone) because the temporary fillers are safer.

  • "IQUAM urges governments to pass legislation to prohibit the use of non-certified products and to protect patients from untrained physicians and nonmedical personnel injecting or implanting materials for various indications."

Translation:  Board Certified Plastic Surgeons wish that patients were protected from poorly trained injectors.  However, there are few laws that limit the practices of doctors and nurses, many of whom suck.  Make sure that your injector is certified by an appropriate specialty board.

(By the way, the only board recognized by the American Board of Medical Specialties to certify phyisicians in the practice of plastic surgery is the American Board of Plastic Surgery.)


April 13, 2011

Tax Deductions for Cosmetic Surgery: Legal?


According the IRS, if you itemize your deductions on Form 1040, Schedule A, you may be able to deduct expenses you paid that year for medical care for yourself, your spouse, and your dependents.  Specifically, you may deduct the amount by which your total medical care expenses for the year exceeds 7.5% of your adjusted gross income.

Technically, deductions are allowed only for expenses primarily paid for "the prevention or alleviation of a physical or mental defect or illness."  The IRS specifically states that you may not deduct "most cosmetic surgery."

However, many of the surgeries that I do are both cosmetic and functional.  Examples:

  • Breast reductions:  Not only are the breasts lifted and made cuter, but also the removal of the excess weight greatly relieves neck, upper back, and shoulder pain.
  • Breast lifts:  Elevating the breasts (so that a woman fails the "pencil test") diminishes sweating and rashes in the folds beneath the breasts.
  • Tummy tucks:  Certainly, flattening the tummy is the primary goal, but also removing the apron of excess skin diminishes sweating and rashes.
  • Blepharoplasties/Eyelid surgery:  Trimming the excess skin and fat from the upper eyelids creates a more rested, awake appearance, and also improves sight by ridding the patient of tissue that directly obstructs the visual fields.

So, for many cosmetic surgeries, I could honestly write a letter to the patient's accountant stating that the surgery alleviated a physical ailment, and, therefore, consideration should be given towards a tax deduction.


December 15, 2010

Urban Myth of Plastic Surgery: Rib Removal

True or False:

Janet Jackson underwent a rib removal to thin her waist.


Women are born with different lengths to their waists.  A long distance between the lower ribs and the pelvic bones is "long waisted"; a short distance between the lower ribs and the pelvic bones is "short waisted."

Long waists (along with a minimum of body fat and lots of working out) create hour-glass figures.  Short waists tend to produce "boxy" torsos.

If you are short-waisted, what can you do to lengthen your waist?  Not much.  Theoretically, removing one (or a few) of the lower ribs would increase the distance between the ribs and the pelvis.  But I don't know of any reputable plastic surgeon who performs costectomies for cosmetic purposes.

Why don't we plastic surgeons remove ribs more frequently?  Because ribs are important!  While God may have used one of Adam's ribs to create Eve, He left the rest in place to ventilate the lungs and to protect the heart, lungs, spleen, liver, kidneys, etc.  Without ribs, you can't breathe, and your critical innards won't be protected against routine falls and bumps.

In various magazines, I have read that Janet Jackson, Cher, Elizabeth Taylor, and others have undergone rib removals.  But this is almost certainly not the case.  This is just an urban myth concocted by jealous journalists.  While many in the Hollywood set have had tummy tucks and liposuction, their beautiful figures are mostly the result of strict diets, consistent exercise, and fortunate genetics.



October 30, 2010

The Newest Untested Fad: Stem-Cell Facelifts

When I first started to see advertisements for "stem cell" facelifts, I thought, "Am I missing out on a powerful new technology?  By not offering this therapy, am I not offering the latest and greatest to my patients?"

With a little research, I have unequivocally concluded, NO and NO!

Stem-cell facelifts are more about marketing and less about science.  The actual procedure is nothing revolutionary.  It involves facial injections of stem cell-enriched fat grafts, which is hardly any different from regular fat grafting--which, for the past decade, plastic surgeons have used to re-volumize the face, especially around the mouth and at the cheeks.

The addition of the stem cells has no proven efficacy and may even be dangerous.  While stem cell techonology has incredible potential, nobody in 2010 really knows how stem cells work or whether they will work consistently.

The American Society of Plastic Surgeons has advised patients considering facial rejuvenation to avoid stem-cell facelifts, as well as other “fad procedures” that lack clinical evidence demonstrating their effectiveness.  The U.S. FDA has not approved stem-cell-enriched fat grafting for any purpose.

While I hope that stem cells will improve medical care and aesthetics, as of today, it's more science fiction than science fact.


July 22, 2010

Take the Dysport Challenge until September 30

Dysport remains Botox's biggest competition.  Both are terrific for...

  • frown lines
  • forehead wrinkles
  • crow's feet
  • bunny lines
  • eyebrow lifting

Why choose one rather the other?

  1. Some patients like one rather than the other
    • My wife actually prefers Dysport.
    • A few patients prefer Botox.
    • On the other hand, my mother thinks, "They are the same."
    • Most of my office staff agrees with my mom.
  2. Price
    • Dysport is cheaper than Botox
    • Dysport comes with rebates

So, if Botox and Dysport are pretty similar, why not get $150 in rebates with Dysport?

  • Receive treatment with Dysport by September 30, 2010
  • Register at
  • Print the Dysport Coupon Rebate Form
  • Mail the rebate form and the treatment receipt to Medicis Aesthetics (the Dysport distributors)
  • Receive a $75 check
  • If you loved the Dysport, get another treatment in 3-6 months, and get another $75 check
  • Even if you prefer Botox, get your Botox in 3-6 months, and get another $75 check

That's confidence in the Dysport product!


April 22, 2010

Botox for Marionette Lines? Nope. Choose a Filler Instead

Hi, Dr. Pickart.  I was talking with someone about getting rid of marionette lines, and she was given Botox for that area.  Does that sound right to you?

Anyway, I was going to tell her about Sculptra.  Do you think that 1 vial may be enough for that area?

-Janet F.

Dear Janet,

Actually, the best treatment for marionette lines is NOT Botox.  I do sometimes use Botox to turn up the corners of the mouth, but Botox has NO EFFECT on the marionette lines themselves.
I would recommend a filler for marionette lines.  Sculptra is my favorite because it lasts the longest (at least 2-4 years).
Regarding how much Sculptra, it depends upon...

  • the depth of the marionette lines - Shallow will obviously require less than deep.
  • the patient's response to Sculptra - Younger patients respond more vigorously, with more collagen production, compared to older patients.

So, how many vials?  A young patient with mild folds and with a vigorous response to Sculptra might need just 1 vial.  However, an older patient with deeper lines and with less brisk collagen production might need 3-6 vials.  Make sense?
Mike Pickart


February 20, 2010

A Full Tummy Tuck (With or Without Circumferential Extension) Will Best Correct the Upper Belly and Bellybutton

I've lost 100 lbs. after having a Lap Band put in nearly 4 years ago.  My stomach issues are very unique looking, which is why I'm having the difficulty in determining what procedure I need.  My unwanted fat and loose skin are mainly only above the bellybutton, like they're sitting on a shelf.  I am unsure of which procedure would benefit me the most among simple liposuction, a modified Tummy Tuck, a full Tummy Tuck, or extended.  I'm open to any other suggestions as well.  I believe my skin has shrunk back as much as it can already.  Thoughts?


First and foremost, congratulations on your weight loss!  What a wonderful transformation. In addition to your improved health, your figure already looks terrific.

Second, even though you might think that your tummy has "unique" issues, nothing could be further from reality. I see at least one patient per week whose tummy looks like yours.

Third, go for a full tummy tuck.

  • After 4 years, your skin is not going to shrink on its own any farther--no matter how much exercise you do.
  • Liposuction will not be helpful to treat the upper tummy (called the epigastrium) and bellybutton. Since liposuction is a fat removal technique (without any significant skin tightening), liposuction is the wrong answer.  You are already skinny!  The problem is too much skin without good tone, not excess fat.
  • Mini tummy tucks are nonsense operations. I have never found the right patient for a mini tummy tuck--even after 8 years of practice!  A mini tummy tuck is for that very rare patient whose problem area is limited to her lower middle abdomen, just above her pubis.  Obviously, this is not where you are concerned.
  • A standard tummy tuck will work.  To minimize "dog ear" formation on the bilateral hips, weight-loss patients generally get their best results when the tummy tuck is extended all the way around circumferentially.  Whether you choose to keep the surgery just in the front or all the way around will be your decision.  Both are good choices, but the circumferential technique generally produces better contours.
  • Do not do a fleur-di-lis abdominoplasty.  The vertical portion of the scar is ugly, and the operation is now recognized as obsolete.  If any doctor offers you this surgery, run away!  He is out of date!!

Fourth, make sure that your lap band port is exchanged from a high-profile to a low-profile.  Now that you are thin, the low-profile port will be less visible.  You don't need that extra prominence to find the port anyway; you've got no subcutaneous fat.  (Congratulations again!)

Fifth, make sure that your surgeon is certified by the American Board of Plastic Surgery.  And, better yet, research whether he specializes in weight-loss patients.  I do a lot of post-bariatric contouring, and let me tell you that weight-loss patients are very different from "regular" plastic surgery patients.  Your surgeon needs the expertise only garnered from years of experience with your peer group.

Good luck!


December 26, 2009

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...





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