Celebrity Plastic Surgery, News, Gossip

By, David Shafer, MD

Liposuction is a general term used to describe removal of fat using a suction machine. Tumescent liposuction is the most popular method. In this technique, tumescent solution is injected into the area of fat to be removed. The tumescent solution typically contains lidocaine (to reduce pain) and epinephrine (to minimize bruising). After the solution is injected, liposuction is performed using cannulas (long, thin tubes) to suck out the fat. Fat can be removed from almost anywhere on the body. The most popular areas are the abdomen, waist, back, bra rolls, thighs, buttocks, and chest. Liposuction is usually performed under anesthesia to help minimize any discomfort and to monitor your body during the procedure. Awake liposuction is also possible, but it takes a motivated patient and surgeon since the tumescent solutions must be injected very slowly and the suction performed very meticulously. The volume removed during awake liposuction is also much less than can be removed under general anesthesia in a hospital or surgical center. All types of liposuction are based on variants of the tumescent technique. Liposuction is only for healthy patients.

Recently, laser liposuction (particularly Smartlipo) has received considerable attention and popularity. Smartlipo involves an extra step after the injection of tumescent fluid and before sucking out the fat. During the Smartlipo procedure, a small fiberoptic cable is inserted under the skin and uses a laser to destroy or melt the fat cells. The laser can be set to different modes with different wavelengths to focus more on destroying fat and/or heating up the skin. It is thought that heating the skin leads collagen production and a slight tightening of the skin. After the laser treatment with Smartlipo, the surgeon then performs traditional liposuction with smaller cannulas to remove the melted fat. In most cases, Smartlipo can be performed while you are awake. The advantages are potentially a quicker recovery, slightly smaller incisions, focused treatment and potential for slight skin tightening. Disadvantages, however, are less aggressive treatment since you are awake and can feel the movement of the cannula, smaller volumes of fat removed, inadequate skin tightening and potential for skin burns if you are being treated by an inexperienced surgeon. Also, you should keep in mind that the Smartlipo machine is also sold to doctors who are not plastic surgeons and they perform the procedure with little or no training in liposuction.

In my Manhattan plastic surgery practice, I use both Smartlipo MPX and Power-Assisted Liposuction. I use the Smartlipo MPX, a dual-wavelength laser lipolysis machine, for patients who have small or focused areas requiring liposuction such as love handles, abdomen, arms and neck. I perform these procedures in an accredited, office-based operating room while my patients are awake. In most cases, we perform the procedure on a Friday and patients are ready to go back to work on Monday. For patients requiring larger volume liposuction on multiple areas of their body, I perform Power-Assisted Liposuction in a hospital or surgical center while the patient is under general anesthesia. The Power-Assisted Liposuction (PAL) machine uses a vibrating cannula to quickly breakup the fat and easily such it out. This is a great device for larger volumes of fat to be removed. This can still be performed as an outpatient procedure. However, in the hospital setting, the patient has specialized monitoring. Our priority is patient safety and every precaution is taken to ensure that the procedure is safe and effective.

Whether Traditional or Smartlipo is best for you should be determined in consultation with your plastic surgeon. In either case, liposuction should not be viewed as a weight-loss procedure. Rather, it should be considered a body contouring procedure. Liposuction is not going to prevent you from gaining weight. It will, however, remove fat from specific areas and make drastic changes to your body shape. I like to tell patients that liposuction is a “second chance” to have a nice body. For one reason or another, you let your body get out of control and need fat removed. After liposuction, the patient needs to maintain a healthy lifestyle, eat a balanced diet, and exercise regularly to maintain the results.

Dr. David Shafer completed his plastic surgery residency at the world famous Mayo Clinic. He was then selected to continue his education at the prestigious Manhattan Eye, Ear & Throat Hospital. While most plastic surgeons go directly into practice after residency, Dr. Shafer had the honor to operate with many of the world’s most distinguished plastic surgeons. This unique experience allowed Dr. Shafer to advance his skills to a level that most surgeons take a lifetime to develop. Dr. Shafer continues to operate at MEETH and now teaches the next generation of plastic surgeons from NYU, Columbia and Cornell.

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Visit us at www.ShaferPlasticSurgery.com.

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By John Di Saia, MD

When a reality show contestant ruptured her breast implants after jumping 20 feet off a rope swing, I felt compelled to address the concern that some breast augmentation patients have about this problem.

Bursting a breast implant is not usually so dramatic as what the reality show girl experienced.  Then again, it is uncommon for a patient to know when the break occurred. Breast implant rupture is usually a low key event. Maybe in this case the lady did do some soft tissue damage as well as the break seems to have occurred with a fall from some height. It is conceivable to cause a muscle tear although I have only seen small ones. Torn muscle can hurt.

Usually the implant ruptures quietly and slowly over a few days the breast gets smaller (with a saline implant). If the implant is a silicone gel type, the rupture may not be noticed for quite a while. This is one of the reasons the new FDA recommendations are for breast MRIs periodically after silicone gel breast implant surgery.

The “fix” involves removal of the broken implant and frequently the capsule of scar tissue around it. Silicone gel implants generally have a larger amount of this scar reaction and in removing this scar the healthy tissue available to cover the implants gets thinner. This can be a problem if done repeatedly or if the reaction is long standing or extensive as the breast can be left looking more foreign. The newer generation silicone gel implants will hopefully have less of this reaction than their predecessors, but the truth is we don’t have enough information yet to really say that. The answer to how surgeons minimize this potential problem is a matter of opinion.

John Di Saia MD (www.ocbody.com) is a board certified Plastic and Reconstructive Surgeon. He has been board certified by both the American Board of Surgery and the American Board of Plastic Surgery. He reviews cases for the California Medical Board in their expert reviewer program and contributes to a number of medical journals and internet forums. His practice is founded on the concept of a Higher Level of Care.

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By Dr. David Shafer

Dysport is often called the “New Botox.” However, Dypsort has actually been available in Europe for therapeutic indications since 1991 and for cosmetic applications since 2001. In April 2009, Dysport (officially known as BoNT-A/D) was approved in the United States for the “temporary improvement in the appearance of moderate to severe glabellar lines.” These are the lines between your eyebrows. However, just like Botox Cosmetic, Dysport can be used “off-lable” for treatment of crow’s feet (squinting lines around your eyes), forehead wrinkles, chemical brow lifts, platysmal bands (neck bands) and sweaty palms and armpits.

The molecule in Dysport is exactly like Botox Cosmetic but is covered by a different coating, which dissociates (dissolves) at a different rate. That is why the onset of action of Dysport is thought to be faster than Botox Cosmetic since the coating comes off faster. In Botox Cosmetic Treatment the usual onset of action is 3 to 7 days where the Dysport onset of action seems to be a few days faster. The dosing is different with Dysport, so there may be some confusion when translating Botox “units” with Dysport “units.” This is why you need to see an injector who has experience specifically in Dysport injections. Also, there is a learning curve with Dysport injections, so you may not initially achieve the same results as you are used to receiving with Botox Cosmetic.

There is also some confusion about the pricing of Dysport with many reports on the Internet and advertising claiming that it is cheaper than Botox Cosmetic. There is a discrepancy in the potency of units. A “unit” of Botox is not equivalent to a “unit” of Dysport, so unit pricing is not comparable. There is a slight savings with Dysport, but it is about 5% - nothing substantial. So, do not expect to go to your plastic surgeon to achieve the same results as Botox Cosmetic for half the price. However, with competition, hopefully prices will come down. Allergan (Botox Cosmetic) is currently offering a $50 mail-in rebate for Botox Cosmetic customers and Medicis Aesthetics (Dysport) is offering a $75 mail-in rebate. With these rebates and introductory pricing, you may be able to get a better deal than your last injection.

In the end, it is great to have another minimally invasive product approved on the market which can give consistent and noticeable results with virtually no downtime and minimal risks.

Dr. David Shafer completed his plastic surgery residency at the world famous Mayo Clinic. He was then selected to continue his education at the prestigious Manhattan Eye, Ear & Throat Hospital. While most plastic surgeons go directly into practice after residency, Dr. Shafer had the honor to operate with many of the world’s most distinguished plastic surgeons. This unique experience allowed Dr. Shafer to advance his skills to a level that most surgeons take a lifetime to develop. Dr. Shafer continues to operate at MEETH and now teaches the next generation of plastic surgeons from NYU, Columbia and Cornell.

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By Lois W. Stern, Editor-at-Large, Makemeheal.com

Two simple words hold the keys to understanding the concept of skin renewal: wound and heal. The skill of the practitioner – be s/he dermatologist, esthetician or plastic surgeon – makes all the difference in whether that wound ultimately stimulates the production of healthier, younger looking skin, has little impact or, worst scenario, scars the patient.

That youthful glow you see in a child’s face is the result of constant skin renewal, the shedding of old skin cells continually being replenished with new cells. A baby’s skin is in a constant state of renewal, shedding old cells while growing new ones. Alas, as we enter our teen years and beyond, skin renewal already begins to slow.

Research has shown that by the time we reach our forties and fifties, skin sheds approximately once every fifty-three days. As old, unshed cells build up on the skin’s surface, they become dual culprits to our skin’s dull, aging appearance. This is where the skill and experience of a knowledgeable practitioner who understands both theory and technique behind the wound-heal concept can come to the rescue, helping us kick the skin out of its old habits and coaxing it along into some new ones. Today one popular method for accomplishing this goal is found in a variety of laser treatments. A second, lesser known method for achieving similar goals is through dermal roller treatments.

Let’s begin with a basic understanding or the anatomy of our skin.

Stratum Corneum (the outermost surface of the Epidermis)

The outer layer of our skin is called the epidermis, with the stratum corneum its outermost surface. Beneath the epidermis lies the dermis. When we talk about resurfacing the skin, we are targeting treatment within the epidermis. When we speak of remodeling for wrinkle treatments, we are targeting treatment within the mid-dermis.

The basic concept behind both laser and dermal roller technologies is the same: wound and heal. One must wound the skin to remove old surface tissue, which in turn stimulates the growth of new collagen.

Let’s first take a look at the newer breed of lasers, known as nonablative fractional lasers, claiming to produce the results of older ablative “field” lasers, but with minimal downtime. Fraxel is one fine example of these newer lasers.

To best understand how fractional lasers work, you need to think of your skin as a digital photograph in need of restoration or touch up. Just as you can alter a photographic image pixel by pixel, fractional lasers treat your skin with thousands of tiny microscopic laser spots. During treatment, these thousands of columns penetrate deeply into the dermis. What distinguishes fractional lasers is their ability to leave untouched specific skin areas while treating others. By creating microscopic treatment zones, the laser affects only a fraction of your skin at a time.

During treatment, the fractional laser penetrates the non-living protective barrier of the skin, the stratum corneum, as if it were a window, leaving it completely intact. It then creates microscopic “wounds” within the targeted areas well beneath the outermost epidermal layer of skin. Both epidermal and dermal tissue are removed. In so doing, it triggers the body’s natural healing process to accelerate the production of collagen and new, healthier skin cells.

Below you can see some befre/after photos of one patient treated with a Fraxel laser.

Now let’s take a look at the dermal roller technology, of which the Microneedle Roller is one fine example

The Microneedle Roller uses its 200 extremely fine needles to penetrate the skin. During treatment the Roller leaves the epidermal barrier fully intact, while creating micro-channel wounds with its 200 fine needles. An effective optional compliment to this treatment is the simultaneously infusion of therapeutic serums, which penetrate more deeply while the skin is in its wounded state. These channel wounds fully close within just a few hours after initial application, providing enough time for new collagen structures to form within the skin’s lower layers, but short enough recovery time to ensure the patient nearly immediate resumption of normal schedules.

Photos First Printed in Chapter 3 of Tick Tock, Stop the Clock

During treatment

Immediately following treatment and saline rinse

Clinically-conducted studies in South Korea, Europe, and U.S. have shown that the Roller can increase serum absorption by as much as 1,000 percent. Moreover, the Microneedle Roller is “skin friendly,” in that it leaves the epidermal barrier fully intact, and the micro-channels created by the 200 fine needles fully close within just a few hours after initial application. This provides just enough time for new collagen structures to form within the skin’s lower layers, while ensuring the patient of rapid recovery with the ability to almost immediately resume one’s normal schedule.

For every microscopic zone the Fractional laser or Roller targets and treats intensively, it leaves the surrounding tissue unaffected and intact, allowing the skin to heal much faster than if the entire area were treated at once. Both treatments wound the skin and then use the body’s natural healing process to create new, healthier, tighter tissue to replace the imperfections of the older skin.

Both the Microneedle Skin Roller and the non-ablative Fraxel laser are two viable non-surgical treatments for stimulating elastin and collagen production, thereby thickening the skin, smoothing away fine lines and wrinkles and ridding the skin of hyperpigmentations. Because these treatments spare healthy tissue, they are effective even on delicate skin areas such as the neck, chest and hands. But for more dramatic results, with the downside of more visible wounds and longer downtime, the ablative laser might be a better option for you.

Lois W. Stern, Editor-At-Large at Makemeheal.com, is the published author of two books: Sex, Lies and Cosmetic Surgery www.sexliesandcosmeticsurgery.com and Tick Tock, Stop the Clock www.ticktockstoptheclock.com/ as well as a number of magazine articles. Her Professional Edition DVD is a popular aid to office staff while interacting with their patients. She and Patty Kovacs are the co-founders of http://coast2coastbeauty.com/CURRENT_NEWS.html. Check it out!

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By Lois W. Stern, Editor-at-Large, Makemeheal.com

A little over a year ago I wrote an article about the tragic death of Donda West, mother of the celebrity rapper, Kanye West, following plastic surgery. In the aftermath of Kanye’s rude mishap with Taylor Swift at the VMA Awards , I thought I would revisit his mom’s tragic story.

Why tragic? After doing some research on her case, I concluded that a significant factor in her death was due to poor medical judgment. Well, here we go again, some more bad news following plastic surgery. But this time, due diligence may avert the supreme tragedy of another life lost.

While investigating the Donda West tragedy, I had called both the ABPS (American Board of Plastic Surgery) and the ABMS (American Board of Medical Specialties) to inquire about the board certification of Donda West’s surgeon, Dr. Jan Adams. I learned two alarming facts. Dr. Jan Adams was not listed as a board certified plastic surgeon. Furthermore the only physician on record with the ABMS bearing the name Dr. Jan Thatcher Adams was board certified in Family Medicine – not plastic surgery.

I concluded that if Donda West had only made those phone calls prior to selecting her surgeon, she might have selected differently. She might even be with us today.

Donda’s autopsy results yielded no physical findings (such as a heart attack or blood clot) to explain why she went into cardiac arrest. According to Barry L. Friedberg M.D., a board certified, globally recognized leader in the field of office-based anesthesia, it was unlikely that either the length or extent of West’s surgeries caused her death. “More likely, it was the manner in which the surgery was performed; i.e. under general anesthesia which does not reliably produce pre-emptive analgesia and, therefore, often necessitates postop narcotics to manage pain. If West had sleep apnea as a pre-existing condition, even average doses of narcotics could easily prove fatal,” claims Dr. Barry Friedberg.

We will never know for sure what killed Donda West. But we do know that sound medical judgment comes only with quality training followed by lots of experience putting that training to practice.

On June 13^th, 2009, the Hartford Courant ran a story about Dr. Efraim Gomez-Zapata, a name currently in the news for allegedly practicing plastic surgery without proper credentials. (According to the Hartford Courant, Dr. Efraim Gomez-Zapata is credentialed as a family practice physician, but because his name is not listed with the Connecticut State Medical Board, I was unable to verify this information.). His medical license has been suspended by this same board based on charges that he violated medical standards by performing plastic surgery without appropriate qualifications or standards to protect patient safety. The allegations of the Connecticut Department of Public Health against Dr. Efraim Gomez-Zapata include administering anesthesia and performing plastic surgery on patients without the proper license or qualifications and failing to keep proper records or have the appropriate staff, equipment, office setup and hospital privileges required in case of complications. In two patient cases cited where complications did occur, one woman had a seizure after Gomez-Zapata administered a combination of painkillers, anti-anxiety medication and a local anesthesia; while a second went into respiratory arrest after Gomez-Zapata gave her a spinal anesthesia.

What simple steps can the rest of us take to avoid fates similar to those of Donda West or the unfortunate patients treated by Dr. Gomez-Zapata? I like to think of the word TEE (short for Training, Experience and Expertise) as a handy acronym to help me remember how to investigate the credentials of any prospective surgeon.

TRAINING: Know that ANY board certified physician in any field of medicine can legally perform plastic surgery and call himself a cosmetic surgeon.
DO YOUR HOMEWORK. Be sure you have selected a surgeon board certified in the area that relates to your surgical needs or desires.

EXPERIENCE: You can check out the history of any prospective surgeon by calling the medical records department of the state where he practices. Visit http://www.floridamalpractice.com/linksotherstatebds.htm for the telephone number of the medical records department of the state where your surgery will take place.

I do not know how many cosmetic surgeries either Dr. Jan Adams or Dr. Efraim Gomez-Zapata has performed. But I do know that their surgical histories send up some immediate red flags. According to medical records from the state of California, in 2001 two malpractice lawsuits were filed against Adams, ending in payouts of close to half a million dollars. Prior to the Donda West tragedy, three new, unsettled medical malpractice lawsuits were pending against this same doctor. As for Dr. Gomez-Zapata’s record, we do know that one of his patients experienced seizures during surgery and a second went into respiratory arrest. These are enough red flags to alert us to quickly do an about face and walk away from either of these offices.

Another way to assess the adequacy of a surgeon’s experience is to inquire about the number of procedures of a particular type he performs each year and how long he has been performing them. Ask to speak with some of his patients and try to meet with them in person to assess the surgeon’s work.

EXPERTISE: Ask your surgeon where he has hospital privileges and place a phone call to that hospital to inquire if he has privileges to perform the exact procedures you are considering. This step is essential, even if your surgery is to take place in an outside surgical facility. Why? The chief of plastic surgery assesses the experience and skill of the surgeon before granting him privileges for any surgical procedure. Surgeons are often granted privileges for some procedures while having privileges for others withheld, based on their experience and expertise. If a surgeon skirts this issue or tells you it isn’t necessary for him to have hospital privileges since surgery will take place in an outside facility, turn around and walk!

It is important to learn how to separate the sound from the noise. Donda West’s surgeon, Dr. Jan Adams had appeared on numerous national TV shows, including Oprah, CNN, Entertainment Tonight, and Discovery Health, to name a few, as a plastic surgery ‘expert’. I congratulate his PR agent for doing a phenomenal job. But great hype does not a great surgeon make. Surgical expertise does not come from making TV appearances.

Statistically, cosmetic surgery procedures have a strong safety record, but you need to heed some cautions. In a study evaluating the safety of accredited office based surgical facilities, only 1 death occurred in 58,810 surgical procedures, but there is one important caveat to that study that should not be overlooked: All of these procedures were performed in office surgery facilities accredited by the AAAASF.

While in the process of writing my first book, I had the privilege of interviewing Dr. Keyes, the lead surgeon of the above study. He explained that each surgical facility accredited by the AAAASF mandates that a) the doctor be board certified in the medical specialty recommended for that procedure and b) that the doctor has been granted privileges to perform those same procedures in the hospitals with which he is affiliated. Again, remember to do your homework.

Here are just a few of the life saving questions you should ask before engaging a surgeon

Do you have hospital privileges to perform the procedures I am considering? If so, where?

What you should do next: Call the hospital(s) to inquire.

What is your board certification?

What you should do next: Contact the American Board of Medical Specialties (Internet: www.abms.org/ Phone:1-847-9091) Consider surgeons with board certification in: plastic surgery, ophthalmology, otolaryngology, dermatology. Here is where Experience and Expertise come into play.

Is the facility where your surgery will take place an accredited facility?

What you should do next: Ask by whom? You are in good hands if accredited by the AAAASF or AAAHC for ambulatory facilities or the JCAHO for hospital facilities.

Who will administer my anesthesia?

What you should do next: Find out if this person is a board certified anesthesiologist? Understand that the training of a board certified anesthesiologist is far more comprehensive than that of a nurse anesthetist. In determining the extent of your anesthesia needs, consider the extent of your surgery, your physical condition and age.

You need to consider the risks and rewards to your surgery. Here are some additional questions to ask your surgeon:

What are the risks to my surgical procedures?

Do you consider me a good candidate for the surgeries I am requesting?

Do I have any medical condition, health habits, etc. that we need to consider?

I am ever mindful of the words of Dr. Rohrich, former president of the ASAPS and a member of their Innovative Procedures Committee: Most women spend more time selecting a pair of shoes than selecting a plastic surgeon. You can take back your shoes, but you can’t take your face or your life back.

Lois is the author of Sex, Lies and Cosmetic Surgery and Tick Tock, Stop the Clock. She also has developed a special Support Tool DVD for Professional office use – a practical communication tool to help surgeons personalize their services while communicating with their patients. Check out Lois’s website at: www.sexliesandcosmeticsurgery.com.

Lois and Patty Kovacs are the co-founders of Coast2Coast - Eye on Beauty Newsletter.

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By Shervin Naderi, MD

Although Collagen based fillers such as Zyplast and Cosmoderm had initially dominated the market, they fell out of favor due to their short lasting results and the potential for allergic reactions.

Over the last five to ten years, we have seen the Hyaluronic Acid dermal fillers become the predominant work horse for most Plastic Surgeons and Dermatologists. These are used for reduction of nasolabial folds (smile lines), Marionette lines as well as other wrinkles on the face. They are used for cheek enhancement as well as lip plumbing. Tear troughs under the eyes can often be reduced using these fillers. As with any filler, a properly trained and licensed injector with good judgment and technique is the key in success and avoiding complications.

Restylane gained FDA approval first in the United States followed by Juvederm. These two Hyaluronic Acid (HA) fillers have been the most versatile synthetic dermal fillers in the United States. Other HA fillers such as Hylaform, Captique and Prevelle never became as popular. Allergan plans on introducing a Juvederm with Lidocaine (numbing medicine) pre-mixed, in the near future.

However Hydrelle by Coapt is already here! This is an FDA approved HA filler with a higher concentration of HA molecule and Lidocaine added. The higher concentration of HA molecules mean that 1cc of Hydrelle will give you more HA and volume and wrinkle correction than 1cc of Restylane or Juvederm. The added numbing medicine means that patients who require several shots in the same area for fine contouring will have less pain and more comfort during the procedure.

There is no one great filler. Each patient needs a unique assessment and approach. For those who are happy with Restylane or Juvederm then I would recommend sticking to what you like and what works best for you. But for those who want to try something new, then Hydrelle may be worth a shot!

You can find out more here:

http://www.hydrelle.us/patients/patients_landing.html

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A Q & A with Jason N. Pozner, M.D., F.A.C.S.

What are the main reasons patients seek revision breast augmentation procedures?

Previously, capsular contracture, implant rupture, and size were the reasons most women sought revision breast augmentation. However, today many patients tend to complain about shape and skin texture abnormalities following subglandular saline augmentation.

What are the primary benefits of submuscular conversion?

Conversion to submuscular implant placement provides four main benefits:

A well vascularized cover

Separation from the breast parenchyma

“Padding” that prevents implant palpability

Framework that prevents excessive inferior descent of the implant

More specifically, what type of patients typically seek submuscular revision augmentation?

Patient seeking reaugmentation following subglandular augmentation falls into four broad categories that have considerable overlap.

Caegory 1- Size Change

Patient with adequate tissue coverage seeking size change often request submuscular conversion. Although there are no studies to verify it, in my experience there is considerable evidence that submuscular placement decreases capsule rate and implant palpability.

Category 2- Palpability and Ripping

Palpability and rippling are usually due to inadequate tissue coverage and can be compounded by type of implant used (i.e., textured saline). Submuscular conversion will improve upper pole and medical rippling but will not usually correct lateral rippling. Submuscular conversion with smooth silicone implants may be needed if lateral rippling is extreme.

Fig 1 Preoperative Preoperative Postoperative

Subglandular saline implant with superior After conversion with mentor

Pole and lateral rippling smooth silicone 800 cc high

Profile implants

Category 3- Ptosis, Shape, and Position Changes (Fig 2)

Breast Malposition-patient with subglandular implants, especially after multiple pregnancies, often present with grade three pstosis and the “rock in sock” phenomena. Submuscular conversion with mastopexy offers some advantage for long-term support.

Implant Malposition- patients may have misplaced subglandular implants. During consultation a “tilt test” is performed by having patients sit in a power chair. The chair is then lowered to assess the degree of lateral implant movement. Submuscular conversion in itself will improve superiorly and medially displaced implants, but capsulorrhaphy is needed in addition for lateral or inferiorly displaced implants.

Fig 2 Preoperative Postoperative

Subglandular 275 cc with dropped left and failed previous repair. Exchanged with conversion for 400cc smooth moderate profile silicone with capsule repair.

Category 4-Cacpsular Contracture (Fig 3)

In my experience, submuscular conversion with capsulectomy appears to improve recurrent contracture. It is important to consider nipple areolar viability in extremely thin-skinned women in which Capslectomy and mastopexy is performed simultaneously.

Fig 3 Preoperative Postoperative

Subglandular saline with Baker 3 contracture. Exchanged the conversion or 425 cc smooth saline with Benelli.

What’s involved in your patient evaluation process?

During patient evaluation, a determination is made regarding the breast pocket dimensions and position, implant size, skin dimensions and nipple position. Both the patient’s and surgeon’s input is important to determine the best surgical plan. For example, a patient with capsular contracture may need a larger implant or mastopexy with a smaller implant after capsulectomy.

What surgical technique do you prefer?

Ideally, an aereolar approach is used, although an existing inframammary incision may be used if mastopexy or full caspsulectomy is not needed. If capsular contracture is present, full capsulectomy is performed. With no siginifigant capsular contracture, the subglandular pocket is opened and the implant is removed. If the fold is to be lowered or remain constant, the capsule is removed from the pectoralis major muscle. The anterior capsule is scored and brushed with a electrocautery device. Partial capsulectomy (at least) is always performed to allow the tissue to heal without serroma or excessive scarring (Fig 4). The pectoralis major muscle is elevated and divided. The muscle is then plicated to the anterior tissues, usually at the level of the superior areola with several 2-0 Vicryl sutures. Sizers are placed to determine size and pocket shape. Drains are placed in all Submuscular conversions. After the implants are placed, the patient is brought to a seated position and symmetry is assessed and corrected. If no mastopexy is indicated, the wounds are closed.

Are the special considerations that must be considered during surgery?

Implant Descent

If the inframammary fold needs to be elevated, a capsule flap is elevated from the pectoralis major muscle prior to elevation. The inferior capsule is excised and the tissues closed. The capsule flap is then sutured to the anterior tissues to reinforce the inferior tissue placation.

Symmastia

Overdissection of the medical pocket may create symmastia or excessive cleavage. IN such cases, medial capsulectomy with closure of the overdissected pocket and creation of a submuscular pocket is performed. Postoperative taping and support are essential.

Lateralized Implants

For lateralized subglandular implants, the lateral pectoral attachments are preserved if possible, and the overdissected tissue is corrected with partial capsulectomy and suture of the cut capsule ends.

Ptosis

After submuscular conversion is complete, the skin is tailor tacked with silk sutures to gauge areolar position and the degree and/or necessity of skin excision. Saline implant fill tubes are then removed at the end of the mastopexy.

What breast implant do you prefer for this procedure?

I prefer smooth round implants. A revision augmentation qualifies the patient for silicone gel implants; however, saline implants can be used if the patient prefers. Postoperatively adjustable implants are useful when there is significant asymmetry or insufficient skin.

Fig 4

Previous conversion with failure to remove subglandular capsule. Note the muscle below and the thickened capsule above.

About Jason Pozner, MD

Jason Pozner, M.D., F.A.C.S., can truly claim aesthetic surgery and skin care as his life’s work. The son of a successful health spa and diet center physician in New York, Dr. Pozner is certified by both the American Board of Plastic Surgery and American Board of Surgery, and is a member of the American Society of Plastic Surgeons, the largest and most prestigious organization of board-certified plastic surgeons in the world.

Learn more about Jason Pozner, MD

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Many of us try to fight fat on our own. Spending countless hours at the gym, deprived of our favorite foods and treats. Yet stubborn areas still manage to elude us. To help with remaining fat deposits, companies are constantly coming out with new and improved ways to eliminate them, with the most popular weight loss plastic surgery tool being liposuction.

Liposuction continues to be one of the most popular plastic surgeries performed in the United States, helping to slim and reshape the body by removing deposits of fat to help improve the appearance of contours and proportion. Traditional liposuction is suitable for healthy, disease and medical condition-free adults who are within 30% of their ideal weight, but have been unable to lose fat through diet and exercise alone.

While traditional liposuction is an effective fat loss tool, it still comes with many health risks. Some of these include: fat clots, blood clots, bleeding (hematoma), damage to internal body structures such as nerves, blood vessels, muscles, lungs, and abdominal organs, as well as deep vein thrombosis, cardiac and pulmonary complications and complications from anesthesia, among other serious problems. In addition, traditional liposuction plastic surgery procedures may include cosmetic risks, including rippling or loose skin, skin discoloration and swelling as well as other abnormal occurrences that would need to be rectified by a secondary or revision procedure. Into the bargain, because liposuction is an invasive procedure, requiring anesthesia, it also requires significant recovery time.

While liposuction is a very good way to eliminate unwanted fat areas, it is not suitable for all areas of the body where fat deposits may occur. On the other hand, the special technology of LifeSculpt can be just the answer for fat deposits in difficult-to-reach areas such as the fat under the chin, backs, arms, and inner thighs.

The LifeSculpt procedure features the SlimLipo laser body sculpting technology in a minimally invasive way, allowing for much quicker recovery time than traditional liposuction. Not only that but, the minimally invasive laser treatment offers little to no bruising.

While liposuction can leave behind loose skin that requires another procedure to tighten, LifeSculpt not only allows qualified physicians to remove fat, but also to tighten the skin through laser-assisted lipolysis.

What The Experts Say

Doctors and patients both agree that LifeSculpt is an invaluable tool in the fight against fat.

A recent limited study published in US Dermatology, by Robert Weiss, M.D., Director of the Maryland Laser, Skin, and Vein Institute found that all patients who had the LifeSculpt procedure saw an improvement in the area treated. Furthermore, all patients also saw an improvement in skin’s smoothness and tightness within three months after treatment.

“This study proved what I’d been experiencing in my own practice; LifeSculpt offers superior results, better than any other type of fat reduction and fat removal method on the market,” said Dr. Weiss.

“During the recovery period after the LifeSculpt procedure, skin tightening may occur as new collagen is laid down in the layers of the skin. Improvement in skin firmness can continue for up to six months after the procedure; this is particularly gratifying to patients who have experienced significant skin laxity that is often associated with age and weight loss,” noted Brooke Seckel, M.D., plastic surgeon at Boston Plastic Surgery Associates, Concord MA.

“There is an emerging demand for this kind of option among consumers – people want stellar results, but do not want to have to take time out of their busy schedules to achieve those results,” noted Richard Bankowski, Field Clinical Director for Palomar Medical Technologies, Inc..

How It Works

Using a few small incisions in the area to be treated, LifeSculpt “melts” fat for quick and permanent removal from the body. LifeSculpt uses state-of-the-art SlimLipo™ laser lipolysis, which melts fat and sucks it out of the body through a medical suction device. Unlike other liposuction procedures, the fat is removed as a liquid, rather than a clumpy material.

Small areas of fat can be quickly and permanently eradicated, although results vary from patient to patient and are not guaranteed. One treatment is all takes for an area to become fat-free.

Recovery From Lifesculpt

Because LifeSculpt is minimally invasive, downtime for the procedure is also minimal. Some treatments on small areas may take less than an hour, while larger areas will require more time. LifeSculpt can be performed on an outpatient basis, depending on the doctor’s preference. Many patients report little to no pain, only a slight warmth in the treatment area. LifeSculpt allows patients to resume their normal activities almost immediately and patients can return to work the very next day.

Some patients may notice slight bruising which goes away within a few weeks. Depending on the treatment area, compression garments may be necessary and your physician may have special recommendations for your recovery period.

If you’ve already had traditional liposuction and have been left with a lumpy appearance, LifeSculpt may be a good option to help smooth and tighten the appearance of skin. While LifeSculpt is commonly used for patients with stubborn fat deposits, it can also be used on heavier patients, especially after they have lost weight on a program.

The cost of LifeSculpt varies, depending on the area to be treated. Discuss the cost during your consultation with your physician. It is generally less than traditional liposuction, as only a local anesthesia is used and the procedure may or may not take place in an operating room.

LifeSculpt is not a substitute for diet and exercise, but it can help fight against residual fat deposits.

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By Lois W. Stern, Editor-at-Large, Makemeheal.com

The world of plastic surgery seems poised for innovation once again! How about a facelift without surgery? Sounds too good to be true? Stay tuned.

By lifting the ban on federal funding for promising stem cell research, on March 9, 2009 President Obama brought this highly charged topic to the forefront once again. Not surprisingly, anti-abortion rights activists condemned Obama’s decision. Although I strongly applaud his stand, I certainly would never support the use of our finite supply of embryonic stem cells for beauty enhancement treatments – nor have I heard of any reputable surgeon who advocates such research and application for anything short of curing human disease and restoring body parts. But anti-aging specialists and plastic surgeons now have discovered other sources of stem cells - unburdened by moral and ethical decisions. Enter adult stem cells.

Understanding Stem Cells

A stem cell is a cell from which other types of cells develop. Stem cells have the ability to make more of themselves and to differentiate as they do so, in order to grow a wide variety of tissues. While embryonic stem cells are the most well-known type, not all multi-potent cells come from embryos. An abundant source of stem cells also can be harvested from our own fat. Within this past decade, researchers have begun to recognize that these pre-fat cells were actually stem cells that could be coaxed into becoming not just more fat, but cartilage, bone, and even neurons and heart muscle. Because of their diverse capablilities, these stem cells are known as multipotent.

Researchers are discovering that the lipoaspirate from liposuction, which we make in our bodies, can be converted into cells having the ability to differentiaten and replicate. By capitalizing on stem cell biology, plastic surgeons are beginning to implement methods for using those cells to reconstruct lost tissue and to build new tissue in less invasive ways than ever before.

Fat Grafting in Development

Plastic surgeons, recognizing that fat is an ideal material for soft tissue augmentation with the most natural-appearing results, have been reinjecting fat into faces for decades. The biggest problem with this procedure has been the resorption or breakdown of the reinjected fat, with resulting impermanence to the improvement.

“The grafted fat must gain its own blood supply in its new location in order to persist long-term, and this generally is not possible when large amounts are

injected at once and when specialized instrumentation and techniques are not employed,” explains board certified plastic surgeon, Dr. Michael Law.            

Structural fat grafting, also known as lipostructure or microfat grafting, has been a step forward in establishing permanence of the reinjected fat. With this process, small amounts of fat (less than 0.1 cc at a time) are carefully microinjected in a series of discrete layers to gradually build new soft tissue structure. As there is space between each microinjection, new blood vessels are able to grow into the grafted fat, allowing it to persist.

This procedure requires specialized training and specialized surgical instruments, as well as patience on the part of both surgeon and patient, but when performed properly, permanent improvement in facial plastic contours is possible.  

Researchers are experimenting with new ways to process fat so that these fragile stem cells can create a blood supply for the transplanted cells to help them survive. One experimental method has involved separating out multipotent adult stem cells and growing them in a petri dish, while coaxing them to differentiate into specific tissue types such as fat or cartilage.  Those differentiated cells are then injected into the patient, where they continue to grow and divide, creating a small amount of natural tissue.

Photos courtesy of Dr. Vincent Makhlouf - Des Plaines

A second method uses mechanized means to accomplish similar goals. Cytori is a San Diego-based company that makes equipment to process fat stem cells immediately after the doctor liposuctions off some of the patient’s fat. Half that fat gets set aside, while the other half is processed to extract a condensed mixture rich in stem cells. That mixture is then injected back into the reserved fat, producing a fat graft supercharged with stem cells, ready to be reinjected into the patient. The result is an immediate fat graft supercharged with stem cells. An additional benefit is that because the patient is the donor, there is no risk of tissue rejection.

Photos Courtesy of Skin Essentials@bod:evolve 

The Facelift of the Future

Today many diverse procedures are being utilized to rejuvenate the face. While some involve surgery such as eyelifts and facelifts, other non-surgical options have emerged in the past ten years as a means to temporarily rejuvenate the face. Enter muscle relaxers as Botox (and more recently Reloxin), and fillers such as Juvederm, Radiesse and Restylane. These options can provide patients with a younger, more rested appearance, but because they are only temporary measures, injections need to be periodically repeated.

Photos courtesy of Dr. Vincent Makhlouf - Des Plaines

If clinical trials continue to show promise, the “Stem Cell Facelift” may just be the next huge step forward in facial rejuvenation. This Stem Cell Facelift would involve removing fat from a patient’s body – typically from the thigh or abdomen - processing it in some way and then injecting it back into that same person’s face - all in a single procedure. Anti-aging specialist and plastic surgeon, Dr. Vincent Giampapa, Assistant Clinical Professor at UMDNJ Medical Center in Newark, New Jersey and Director of The Plastic Surgery Center Internationale and the Giampapa Institute for Age Management, has pioneered this procedure and has been performing it for the last four years. He claims that the patients he has treated have exhibited not only marked improvement in both the underlying soft tissue contours of the face but also in skin quality and tone and that the results it yields are extremely natural. Priced at $5,000, it is considerably less costly than a surgical facelift that typically costs triple that amount.

Photos courtesy of Dr. Vincent Makhlouf - Des Plaines

Dr. Renato Calabria, a plastic surgeon with offices in both Italy and Ca., is slowly integrated this technique, which he calls the “Stem Cell Enhanced Facelift”, into his own practice. By introducing these reengineered stem cells into specific layers of facial tissue during the surgical facelift, he claims to see dramatic improvement in not just facial contour, but in skin quality and tone as well. He believes that the growoth factors contained in the implanted  cells stimulate skin renewal properties.

Will this change the way facelifts are done in the future or better yet, provide us with that dream come true -  a cost effective, knife-free facial rejuvenation procedure performed in an office setting requiring only local anesthesia, with shorter downtime and natural, long lasting results.

The hope for the future is that one day we will be able to say yes to all of the above and that these reengineered stem cells will be used not only to fill out wrinkles on an aging face, but also to replace lost breast tissue or augment the breast without the insertion of an implant.

Lois W. Stern, Editor-At-Large at Makemeheal.com, is a beauty expert and author of Sex, Lies and Cosmetic Surgery and Tick Tock Stop the Clock.

Lois has also just come out with an incredible DVD for plastic surgeons, which is a practical communication tool for use between surgeon and patient.  Check out Lois’s website at: www.sexliesandcosmeticsurgery.com.  Lois and Patty Kovacs are the co-founders of Coast to Coast - Eye on Beauty Newsletter.

as well as a DVD for Professional office use - a practical communication tool for use between surgeon and patient. See her website at: www.sexliesandcosmeticsurgery.com/

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By Patty Kovacs, Editor-at-Large, Makemeheal.com

Want to increase your breast size and slim down your mid-section at the same time?

After years of medical research, specialty trained plastic surgeons are successfully increasing a woman’s breast size using the patient’s own fat along with fat stem cells. This revolutionary plastic surgery procedure is opening a new frontier in breast augmentation and causing interested patients to look more closely at their options.

For years, saline and silicone implants have served as the most viable method for breast augmentation patients, but inserting saline or plastic into one’s body is considered by some women as a procedure that poses health concerns. While saline or silicone implants are ‘foreign objects’ placed into the body, innumerable studies and FDA approval declare both saline and silicone implants to be safe. Breast augmentation and liposuction were front runner plastic surgery procedures for 2008, and are proving to continue to be so in 2009.

The relatively uncommon fat grafting breast augmentation procedure has women everywhere buzzing about the benefits of this seemingly more natural breast enhancement option. So what’s a woman to do? First, decisions mean options and options are a good thing. Present clinical evidence does not conclude that fat grafting is safer or better than saline or silicone implants, but the idea of taking one’s own fat and repositioning it to augment the breasts is rapidly capturing the attention of medicine, consumers, and the media. I decided to take a more careful look into this procedure as the beauty buffet of breast augmentation procedures is likely to bring a feast of pros and cons and confusion is best converted to clarity.

Autologous fat grafting, also known as fat transfer (AFT), is a procedure in which fat cells are harvested from one part of the body and injected into another. It’s gaining acclaim rapidly. Proponents of fat grafting breast augmentation say it can be very effective in enhancing the size and appearance of the breasts using one’s own tissue. The procedure can also soften the appearance of existing implants and hide visible rippling which is particularly apparent in very thin women with a bony chest wall and little skin or fat with which to work.

The process typically increases breast size by one cup size. Recovery time is argued by opponents to be less than with traditional implants, as both the breast and donor site must heal. Also, patients need to have an adequate supply of excess fat for the procedure. Opponents claim it can take up to six months or more for breast shape results to complete post surgery as opposed to implants where recovery and results appear in six to eight weeks. But the surgeons with whom I spoke expressed short recovery following the fat transfer procedure claiming their patients could return to work in only a few days.

Methods for tissue harvest and tissue injection have been refined. Fat cells are carefully removed by a specialized liposuction procedure using numerous syringes and transferred to the breast via dozens of minutely small injections. This technique results in increased survival of the fat cells. There remains debate over how much of the transferred fat remains long-term, but the doctors with whom I spoke said it could possibly last a lifetime, unlike implants which are recommended to be replaced at least every ten years.

The procedure can be very effective in enhancing in enhancing the appearance of the breast for breast reconstruction. Fat grafting breast augmentation can also soften the appearance of existing implants, particularly in very thin women who experience visible rippling with their implants.

Augmenting the breast with the body’s own fat first became popular in the 1980s; however, both ASPS and ASAPS initially cautioned its members against the technique because of side effects such as oil cysts, calcification, and tissue scarring. The calcification in particular made it difficult for mammogram readings to distinguish between calcifications associated with breast cancer and calcifications associated with fat transfer.

A renewed clinical interest in fat grafting for both reconstructive and aesthetic purposes has emerged and surgical proponents of the procedure are calling it the wave of the future in aesthetic breast enhancement procedures.

I decided to go straight to the top and speak with Dr. Mel Bircoll, retired Board Certified Plastic Surgeon and Chief of Plastic Surgery at the former Beverly Hills Medical Center, a prestigious facility which catered to the upper crust of Beverly Hills, on the site of what is now the Peninsula Hotel. Dr. Bircoll, an icon of medicine and the first doctor to perform liposuction in North America in the latter 1970’s, now resides in Bel Air and remains active on advisory boards for fat transfer procedures and stem cell research.

“My esteemed clientele were so pleased with the progressive face lift procedures I performed in the 60’s, 70’s and 80’s, they kept asking me, ‘Dr. Bircoll, can you take it from here (thighs) and place it here (breasts)?’ To accommodate their pleas I introduced the first fat transfer procedures in the United States in 1984,” Dr. Bircoll declared.

How did he come up with the first successful fat transfer procedures in North America? Dr. Bircoll explained that fat transfer procedures were going on as early as 1890, but that the procedures did not produce tissue that could be oxygenated; thus, the fat transfer tissue would die. He figured if he could inject a small enough quantity into the center of vascularized tissue, each minutely small quantity would get its oxygen supply and survive. Breathing room meant survival of the fat cells and that meant success. His procedure is the very foundation of today’s multiple micro injections procedure for successful fat transfer. Each of the micro injections receives oxygen and the procedure, when done properly, brings outstanding results, he reports. Fat is successfully removed from the patient’s own body and placed into the patient’s breast, all using the person’s own fat, creating a naturally enhanced breast with no foreign implant.

One of Dr. Mercoll’s select students is Board Certified Dr. Todd Malan of Scottsdale, AZ, now a teacher of Dr. Bircoll’s method and Founder of the signature breast augmentation procedure, the “Natural Breast Augmentation.”

Dr. Malan explained to me, “The method for harvest and injection of the patient’s tissue is a highly refined approach. But we’ve achieved success unlike any other fat transfer breast augmentation procedures. Procedures previously performed in the 1980s provided only 50 per cent of fat cells surviving. The procedure we perform today maximizes fat stem cells to provide an 85-90 percent survival of the cell. We implement a method of harvesting the fat cells that places little to no trauma on the harvested fat and allows the aesthetic enhancement to last (potentially) a lifetime. Fat cells are carefully removed by liposuction using syringes and transferred to the breast via dozens of micro injections. The ‘Natural Breast Augmentation’ technique results in greatly increased survival of the fat cells, and though there remains debate over how much of the transferred fat remains long term, we see no reason to believe it is not for life.”

Dr. Malan has trained only six surgeons in the United States due to the precision and surgical expertise required to perform the procedure correctly. One of his elite students, Dr. August Accetta, of Huntington Beach, CA (www.accettamd.com) told me he is amazed regarding patient satisfaction and success with the procedure.

“Finally my patients who have long desired breast enhancement but did not wish to have implants due to their not wanting a foreign substance in their body nor on their breast wall, comment that the procedure has offered them a wonderful, full, all natural, utterly beautiful breast enhancement and they’re elated. It’s a tedious procedure requiring meticulous attention to every detail and should only be performed by a highly trained specialist, but the end results can be astonishingly natural and beautiful,” acclaims Dr. Accetta.

He says there are four primary reasons for patients to request Natural Breast Augmentation: First, general augmentation. Second, restoration to pre- pregnancy breast size, shape, and appearance. Natural Breast Augmentation is also performed to correct embarrassing size discrepancies, and, lastly, restoration following surgical lumpectomy procedures.

“As long as the fat is injected in the correct way, the patient will be overjoyed that her breasts look and feel 100% natural,” said Dr. Accetta. “This is the very first procedure to allow doctors to use everything nature gave us to help a woman obtain that perfect hourglass figure… naturally!”

In 2007, the highly respected medical association, American Society for Plastic Surgery (ASPS) , formed a Fat Graft Task Force to conduct an assessment regarding the safety and efficacy of autologous fat grafting (AFT). I spoke to Dr. Karol A. Gutowski, Chair for the ASPS review, about the results of the study.

“We looked at studies from around the world and concluded that while there are a lot of concerns, there’s much evidence showing positive results from this procedure. We actually couldn’t find strong evidence showing why not to perform this procedure for breast augmentation, but we also didn’t conclude this is the best technology there is for achieving certain specific goals, say for breast reconstruction. The standard now for breast augmentation is implants which has its pros and cons; same is true for fat grafting. Unfortunately, we have no formal studies comparing the two. Maybe in the near future as we could use more information and studies on this.”

While there is one registered prospective clinical trial (BRAVA, clinicaltrials.gov ID:NCT00466765) and other non-registered prospective trials involving fat grafting to the breast, no randomized controlled trials were identified during the literature search.

As the procedure continues to grow in demand, numerous surgeons are creating their own ‘signature’ or trademark procedure of the fat transfer breast augmentation. In reply to safety, proponents argue that sophisticated radiology and modern digital mammography equipment of today can better distinguish cancer cells from benign ones when examining dense breast tissue. Advocates state that fat grafting breast augmentation does not compromise accurate mammography readings any more than implants, and, in fact, most of them feel the procedure means far less mammographical compromise than implants. Opponents suggest more research is needed before concluding that the procedure’s benefits outweigh risks.

The process typically increases breast size by one cup size. Recovery time may be less than with traditional implants, as both the breast and donor site must heal. Patients need to have an adequate supply of excess fat for the procedure.

Opponents claim it can take longer for results to take shape after the procedure as opposed to implant procedures. There remains debate over how much of the transferred fat remains long term. Formal clinical trial evidence does not exist to suggest that fat grafting is safer or better than saline or silicone implants.

The American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) urge consumers to proceed carefully with any breast enhancement procedure.

As with all aesthetic surgical procedures, research the facts, I want to emphasize how important it is to consult only with a Board Certified Plastic Surgeon, compare the stratum of fat transfer breast augmentation procedures, and examine carefully all before and after procedure results.

Patty Kovacs, Editor-At-Large at Makemeheal.com, is a published author and beauty expert. Patty is the Executive Producer/Host of The Health and Beauty Revolution Show on wsRadio. Her 800+ interviews include over 450 New York Times best-selling authors. Patty

See Patty’s Websites: www.pattykovacevich.com

Patty Kovacs and Lois W. Stern are the co-founders of Coast to Coast - Eye on Beauty Newsletter. Check it out!

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