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
2. • 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.
3. 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 www.dysportusa.com
• 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!

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?
 
Sincerely,
Mike Pickart

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!

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

Breast Implants: Consideration #5: Location of Incision

There are four commonly used incisions for breast augmentations.

1. Inframammary fold - a gently curved incision in the fold beneath the breast
2. Periareolar - a semicircular incision around the lower half of the areola
3. Transaxillary - a straight incision in an armpit crease
4. Transumbilical - a curved incision in the upper half of the umblicus

According to a recent study published in the Aesthetic Surgery Journal, Board Certified Plastic Surgeons in the USA prefer the inframammary fold and periareolar approaches.  The actual percentages of Board Certified Plastic Surgeons who prefer a particular approach...

1. Inframammary fold - 64%
2. Periareolar - 25%
3. Transaxillary - 8.7%
4. Transumbilical - 0.4%

Why is the inframammary approach most popular?

• Most versatile:  Any type of implant (saline or silicone, round or tear drop, smooth or textured, small or large) can be placed through this incision.  The inframammary approach allows access into either of the available pockets (under the breast or under the breast + muscle).
• Useful for secondary surgery:  Hopefully, you will not need a second (or third) surgery.  However, most implants will not last the lifetime of a women undergoing primary breast augmentations in her 30s.  She should plan on additional procedures.  The inframammary incision can be reused again and again for replacements of implants, corrections of problems, etc.
• Excellent precision:  Because the incision is directly beneath the breast, the surgeon can see what he is doing.  Any bleeding can be immediately stopped.  The pocket domain can be precisely controlled.  There is no need for guesswork.
• Distant from nerves and milk ducts:  Because the inframammary incision is away from nerves and milk ducts, there should (theoretically) be a decreased incidence of nipple numbness and fewer difficulties with subsequent breast feeding.  Moreover, since milk ducts may contain bacteria, remaining distant to bacteria may reduce a patient's risk of infection.
• Good aesthetics:  Inframammary scars tend to heal well; scars rarely hypertrophy (become thick and raised).  Moreover, since an attractive breast has a subtle "hang," the mound should itself obscure the resultant scar.  At the minimum, the inframammary scar should fall within the shadow of the breast.
• Limitations:  Very, very few.
• • Rare patients may have so little natural breast tissue that they don't really have folds; these patients may benefit from another approach.
  • Constricted breasts may be better treated with periareolar incisions.  (Constricted breasts are tight breasts with little tissue other than immediately behind the areolae.)
  • Others may object to the scar, but they must remember that the other scars (periareolar, transaxillary, and transumbilical) may be more advantageous only in the short term.  If those patients need secondary surgery, they are probably going to end up with inframammary incisions anyway.  Then, they have two sets of scars. 

Why is the periareolar incision also frequently used?

• Somewhat versatile:  Many types of implants can be placed through this incision; however, large silicone implants cannot always be placed through small areolae.  Tear-drop-shaped implants may be difficult to maneuver through small areolae too.  Both the subglandular and subpectoral pockets can be created through this incision.
• Particularly useful for constricted/tubular breasts:  The areola can be reduced in size at the same time.
• Can be useful for some secondary surgeries:  Some secondary surgeries can be performed through this approach.  However, on other occasions, the surgeon must convert to an inframammary technique.
• Excellent precision:  Like the inframammary incision, the periareolar approach allows for great control and precision.
• Good aesthetics:  Periareolar scars may be somewhat invisible.  For maximum camouflage, some plastic surgeons advocate tattooing any visible scars with ink similar in color to the patient's natural areolae.
• Limitations:  Some.  But this is still a useful technique.
• • If the patient has small areolae, then the periareolar incisions may not allow for placements of large silicone implants or tear-drop-shaped implants.
  • Some secondary surgeries may still require an inframammary approach.
  • Periareolar incisions may be more likely to damage the nerves that supply nipple sensation.  If erogenous nipple sensitivity is important to the patient, this may not be the best approach.
  • Periareolar incision may be more likely to damage milk ducts.  If the patient might breast feed in the future, then this may not be the best choice.

What are the problems with the transaxillary approach?

• Only somewhat versatile:  Saline implants can be easily placed through the armpit.  However, it is difficult to place even moderate-sized silicone implants through the transaxillary incision.  It would be very difficult (if not impossible) to place tear-drop-shaped implants through this approach.  Both the subglandular and subpectoral pockets can be created through this incision.
• Not useful for most secondary surgeries:  Most of these patients will end up requiring a second set of incisions (probably at the inframammary folds.  Then, they are stuck with four incisions, rather than just two.)
• Reduced precision:  Unless complex endoscopic equipment is used to improve visualization, precision is markedly reduced.
• Usually, good aesthetics:  If the scar heals nicely, then the breast itself has no scars (until the secondary procedures).  However, some of these incisions heal thick.  Then, the patient is stuck with scars that other people will see when she wears routine clothes, such as tank tops.
• Limitations:  Many.  I don't use this technique anymore.
• • While some surgeons claim that they can place small silicone implants through transaxillary incisions, they certainly cannot get medium or large silicone implants through this approach.
  • It would be very difficult to orient tear-drop-shaped implants via the armpits.
  • Secondary surgeries can only very infrequently be performed through the under arms.  Usually, these patients will require inframammary incisions.
  • Without complex endoscopic equipment, visualization is impaired.  Could there be a greater likelihood for bleeding complications and for malpositioned implants?

Why is the transumbilical breast augmentation (TUBA) condemned?

• This is a novelty technique.  Most Board Certified Plastic Surgeons think that it is foolish.
• No versatility regarding implant type:  Only round, saline implants are possible with the TUBA.  It would be impossible to place a silicone implant or a tear-drop-shaped implant with this technique.
• No subpectoral placement:  Only subglandular placement is possible.
• Not at all useful for secondary surgeries, under any circumstances.
• Poor precision:  Most of the patients complain that at least one of the two breasts is "off to the side" or "too close to the middle."
• The scar may be invisible.  However, a secondary procedure would necessitate inframammary or periareolar scars.
• This technique is officially condemned by implant manufacturers.  Use of the TUBA approach invalidates device warranties.

Bottom lines: 

• Like my colleagues around the country, I advocate incisions at the inframammary folds and around the areolae.
• For most patients, the fold will be best, especially since silicone is becoming so much more popular than saline.
• In the unusual patient who either has constricted breasts or poorly defined folds, periareolar incisions may be better.

Breast Implants: Consideration #4: Smooth v. Textured

The shell of a breast implant can be smooth (as shown on the left) or textured (as on the right).

Biophysicists first developed texturing in their attempt to decrease capsular contractures.

• All foreign materials (whether knee replacements, artificial heart valves, or metal rods for stabilizing bones) stimulate inflammation and surrounding scar.
• • The body thinks, "What the hell is this thing?!  I need to protect myself."
  • The resultant inflammation produces the scar.
• Capsular contracture is the specific term for the scar around breast implants.
• While all breast implant patients have some degree of capsule, in 7-9% of patients the scar can be excessive. 
• • The breasts can be too firm;
  • they can be distorted;
  • they can even be painful.
• Below is a patient from Hawaii who presented to my Ventura office with severe capsular contractures.  Ouch.

Textured shells were supposed to decrease the incidence of capsules and to minimize their extent when they did form.  The rationale was that any scar formed around textured implants would be irregularly oriented, and thus less likely to become hard, firm, or distorting.

Most studies, however, have not supported this theory.  Textured implants become hard ("contracted") as often as smooth implants.

Moreover,...

• Textured implants have thicker shells.  Thus, to begin with, textured implants are a bit firmer.
• Textured implants tend to produce more rippling.

Now you know why 92% of Board Certified Plastic Surgeons in the USA use smooth implants rather than textured implants.

So, why do we ever use texturing?

• Rarely, some patients benefit from tear-drop-shaped implants.  The texturing helps to stabilize the implants so that they maintain their orientation.  (Please read my post from 3 days ago.)
• Tissue expanders used in breast reconstruction also have an "anatomic" shape.  Whenever I am treating a mastectomy patient who is interested in a prosthetic breast reconstruction, I always use textured devices to create a pocket for a permanent implant.

(By the way, the Hawaiian patient had a happy ending--albeit after a corrective surgery....)