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!

Another American Dies During Plastic Surgery in Mexico

Another awful tale of a Southern Californian who died as a result of a botch job from a disreputable Mexican plastic surgeon.  From 10news.com...

Lourdes Trinidad Died After Liposuction Procedure Performed By Dr. Louis May Villanueva

CHULA VISTA, Calif. -- A local doctor who may have overstated his credentials is being held responsible for the death of a Chula Vista woman he operated on recently.

 

According to family members, 48-year-old Lourdes Trinidad underwent a liposuction procedure performed by Dr. Louis May Villanueva of Bonita.

 

Family members said Trinidad was a healthy and active pharmacy technician who opted for liposuction and went to May's Millennium Cosmetic and Laser Institute in Tijuana for the procedure.

 

"The doctor assured her it was real simple, it was a real simple procedure," said Trinidad's brother, Sergio Salazar.

 

It ended up becoming a deadly procedure, although Trinidad's family has yet to receive a good explanation as to why it turned out that way.

 

"We're just shocked and we're amazed that a doctor like that could just leave, could leave her there by herself," said Trinidad's brother, Bernard.

 

Trinidad's mother is warning others, not just because of her daughter's death, but what happened after. The family said May disappeared.

 

"He was nowhere to be found ... The doctor was gone," said Salazar.

 

The family said after Trinidad's accounts were frozen when she died Saturday, May still wanted his $2,000.

 

"On Monday, we get a call from the bank that said he tried to cash it. He had the nerve to try to cash the check that killed her," said Bernard Trinidad.

 

10News visited May's Bonita home for his version of events, but he was not there.

 

May said he is a member of the American Academy of Cosmetic Surgery, but 10News learned from academy officials that he is not a member.

 

Additionally, May also claims membership in the American College of Phlebology, but any member of the public who wants to learn about leg veins is allowed to join.

 

"We don't want any money from him. We want to stop him from doing this again to someone else," said Bernard Trinidad.

 

Trinidad's family will bury her Thursday, and they continue to question whether it was a complication or incompetence that led to her death.

 

10News contacted May's clinic and they said they did not have any information right now.

 

10news also contacted the Ministry of Health in Tijuana to determine if May is fully licensed, but there has been no response.

Please beware of plastic surgery in Mexico.  While there are many excellent physicians south of the border, it can be very difficult for an American to vet the qualifications of her Mexican doctor.  Even when tragedy doesn't strike, standard "botch jobs" end up costing the patient much more than she would have saved had she seen a Board Certified Plastic Surgeon in the USA.  Make wise choices.

Few Breast Cancer Victims Opt for Reconstruction

Over the past few decades, plastic surgeons have documented that breast reconstruction improves the emotional well-being of breast cancer victims.  Creating an attractive breast mound after a mastectomy is not only possible, but is beneficial.  Some studies have even demonstrated that the decrease in depression that results from being "made whole" can minimize anti-depressant usage and maximize compliance with adjuvant cancer treatments, such as chemotherapy.  The net effect is increased longevity; breast reconstruction can help breast cancer victims live longer.

Recognizing the value of breast reconstruction, the State of California passed legislation in 1996 mandating insurance coverage for reconstructive surgery.  The federal government followed in 1998.

However, a number of recent analyses suggest that only about 20% of mastectomy patients opt for breast reconstruction.

Researchers from the City of Hope Medical Center, in Duarte, California, recently reported the problem is especially acute in...

• women older than 40
• certain ethnic groups (especially African Americans)
• public insurance (especially MediCal or Medicaid)
• smaller hospitals

Obviously, the results indicate that it is very important to get information out to patients about reconstruction options.  Breast reconstruction is a right!

I would suggest that most breast cancer victims at least consult with a plastic surgeon before cancer surgery.  They need to know that breast reconstruction does not delay cancer treatment, does not minimize the effectiveness of chemotherapy, and does not indicate that they are "vain."  I always want women to really think about their choices.

Tissue Glue Rather Than Drains (?!)

There is an old surgical adage:

If a surgeon thinks that the patient might benefit from a drain, he should put it in.  A surgeon never regrets placing a drain.

Patients, however, hate drains.  They are a post-operative nuisance.  Most patients grudgingly accept drains because they minimize fluid collections (called seromata) and infections.

Since drains are so uncomfortable, there have been a number of products and techniques developed to obviate the need for drains....

• Quilting sutures beneath tissue flaps to minimize "dead space"
• Tissue glues

Biological tissues glues are particularly exciting because they are quick, effective, and precise.  Unfortunately, there have been no specific research studies which have rigorously documented the safety and efficacy of biological glues for plastic surgery.  A study published in Plastic and Reconstructive Surgery in 2008 proved the success of tissue glues in a canine abdominoplasty ("tummy tuck") model; however, dog and human tissues do respond differently, and the results of an animal model can not necessarily be generalized to human beings.

To investigate human plastic surgery patients' response to biological glues, Cohera Medical, Inc., has just enrolled its first few patients in a study of its TissuGlu.  The clinical investigation is a prospective, open-label, randomized study to investigate the safety of TissuGlu, its effect on wound drainage, and its relationship to complications.  The study will compare 40 abdominoplasty patients in Bonn, Frankfurt, and Freiburg, Germany, who will undergo...

standard wound closure techniques versus

standard wound closure techniques plus the application of TissuGlu

Currently, patients who undergo abdominoplasties require the insertion of one or more drains to remove fluids that accumulate under the skin at the surgical site.  (The old surgical adage remains true in tummy tucks!)  However, TissuGlu will hopefully adhere the flaps created during the procedure to reduce fluid accumulation, and, ultimately, the duration of use of surgical drains.  With the use of TissuGlu, patients may experience a reduction in fluid accumulation, a more comfortable recovery, and a quicker return to normal activity.

If the European trial goes favorably, Cohera will apply for a larger U.S.-based trial later this year.  Let's say our prayers that TissuGlu works!...

Breast Implants: Consideration #9: Complications

Are you willing to accept potential complications

asdf

asdf

asdf

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

 

asd

f

 

• 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....)