Aaron Stone MD - Plastic Surgery

Slap Your Way to Larger Breasts

2011-12-31T20:56:00.000-08:00

35 year old Bangkok, Thailand beautician Khemmika Na Songkhla also known as Khunying Tobnom claims to be able to enlarge your breasts without surgery—by slapping them. Her grandmother mocked her for wasting time rubbing her nipples with a miracle cream when she was in her early teens in hopes of sprouting big breasts. Her grandmother then advised her to rub them till they hurt and repeatedly push fat from her sides and abdomen towards her chest, and then douse the breasts with ice water. She claims that by following her grandmother's advice she boosted her breast size by 4inches and her confidence soared. Ms Khemmikka says that by using this non-surgical technique (squeezing, pinching and slapping fat and muscle on the upper chest, the sides of the torso, and the belly of clients with cream or gel for an hour over six 10-minute sessions for a total cost of $380) she has enlarged the breasts up to 4 inches in thousands of Thai women over the past 14 years without injections, chemicals or implants. After the treatment Khemmika instructs her customers in special exercise techniques and massage to keep their breasts in shape.

Her customers come from a wide range of backgrounds, ages and professions including college girls in their early 20s, a 70-year-old retiree, models, actresses and politicians. “These women once had chicken-egg size breasts. After the course, they have become ostrich egg size,” she says. She turns down customers who are too skinny or do not have much fat on their upper chest or sides of their torso and advises them to gain weight before returning.

She claims that she does not need to advertise as she is living proof of the procedure but a billboard in front of her house-cum-clinic in a suburb of Bangkok reads “beat small busts to be big.” She has been pursuing a patent for her grandmother’s secret fat-kneading technique.

A distraught client claimed that her breast cancer was caused by the slapping technique so Ms Khemmikka asked the Health Ministry to investigate the allegation. The ministry then launched a six -month study on volunteers aged 20 to 60, and found vigorous massage left their breasts cancer-free and measurably bigger or should I say swollen.

Dr. Pennapa Subcharoen, head of the Public Health Ministry’s Thai traditional medicine institute, said Khemmika’s methods were equivalent to the exercises used by body builders. “It is like men going to a gym to build specific parts of their bodies by lifting weights with that part”. I personally do not see the connection and have never seen anyone in the gym slapping themselves to get bigger muscles. Despite that the technique was approved by Thailand's government health board in 2003 as a natural alternative to surgery.

Khemmika also records her clients’ original breast sizes before their treatments, then records their new sizes after the treatments, and lo and behold, a woman with a 30-inch bust should end up with a 32-inch bust by the end of it all. Two whole inches? Wow.

Breast slapping can be relaxing, stimulating and painful. Khemmika’s clients say it hurts.

Interestingly, slapping isn’t just for breasts, either. Khemmika offers slapping treatments for the whole body, including faces. Khemmika considers slapping to be valuable knowledge—she learned it from her grandmother, and apparently no one else in the world knows how to do it but she can teach you how to do it. The application process for enrollment in the classes is lengthy, and the prices of the classes themselves are high: $330,000 for body-sculpting; $260,000 for breast-slapping; and $165,000 for face-slapping. She’s had 40 applicants for these classes, but so far she’s only accepted 4 of them.

Go book your ticket to Thailand now!

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

PIP Silicone Breast Implant Recall

2011-12-28T00:11:00.000-08:00

The French company Poly Implant Prothese, or PIP manufactured breast implants and supplied a large portion of the European breast implant market. The company was based in the south of France and for awhile was the number 3 breast implant producer in the world. 80% of production was exported out of France. While having undisclosed financial problems it began to cut costs by using a cheaper industrial grade silicone in the implants rather than medical grade silicone. This cut manufacturing costs by up to euro 1 million ($1.3 million) a year. A lawyer for the company told authorities that the switch to cheaper silicone began in 1991, shortly after the company began production. These implants were also marketed under the name M-implant by the company Rofil Medical in the Netherlands and distributed in Germany by the company Rofil Medro. Affected Rofil implants are designated as IMGHC-TX, MX-IMGHC, and IMGHC-LS.

The company was closed in 2010 after its improprieties were discovered following reports by surgeons of excessively high rupture rates and an anonymous letter denouncing company manufacturing processes but by then it had produced and sold over 300,000 implants worldwide including France (30,000), Portugal (2,000), Denmark (less than 100), Spain, Italy, Britain (40,000), Brazil (25,000), Venezuela, Australia (8,900), Chile, etc. Recent studies by the French authorities determined a rupture rate of 11.1% for PIP implants vs. 2% for other implants over the same time period. The durability of the PIP/Rofil implants is therefore substandard and the rupture rate is 5 to 6 times higher than other implants. This is particularly problematic given the use of industrial grade silicone which incites a greater inflammatory response from tissue than medial grade silicone. Between 2007 and 2009 50 to 58 percent of its exports went to South American countries including Venezuela, Brazil, Colombia and Argentina. In the same period, 27 to 28 percent of exports went to western European nations including Britain, Spain, Italy and Germany. These implants were never approved for use in the United States. PIP saline-filled implants were available in the United States but the authorization was revoked after a re-evaluation by the Food and Drug Administration in 2000 found 11 deviations from ‘good manufacturing practices’ including PIP's failure to investigate the deflation of its saline implants and a failure to report more than 120 complaints in France and elsewhere to the FDA. 35,000 PIP saline implants had already been implanted in the US by that time.

I suspect there were also some issues with the shell surrounding these implants as in the past when I held them in my hands the shells seemed flimsy. More than 1,000 of the 30,000 such implants in France have burst, according to the French health safety agency AFSSAPS. It is now estimated that these implants have double the rupture rate of implants manufactured by other companies. In April 2010 Argentina, Colombia and Brazil banned importation of the implants.

More than 2,000 legal complaints have been filed since the implants were recalled in 2010. The liquidation of the company and subsequent loss of company assets means the only remaining lawsuit defendants though are the surgeons who placed them or the government agencies that allowed their use.

French authorities have advised all women with the implants to have them replaced but stated the removal was not urgent. They set up a hotline in France that received 9,500 calls between the end of November and December 2011. It is unclear yet if company founder Jean-Claude Mas will be charged but I suspect there is some jail time in his future. Interpol is currently has a warrant for his arrest. To my shock they even set up a cheaper industrial grade and more expensive medical grade silicone implant to differentiate between lower socioeconomic and higher socioeconomic customers. I suspect the French national health care system will cover removal of all of the implants but not for replacement of those placed for cosmetic reasons. I do not think they currently have the money or enough surgeons though to perform all of the resulting operations.

Venezuela has already said it will remove the PIP implants at not cost to patients. They just have to show up at their nearest hospital with a Plastic Surgery ward. It is currently unclear what other Governments around Europe (Britain, Italy, Spain, Denmark..) will do. Given the group speak of Europe at present the other countries will have to fall in behind France's decision and since they also all have nationalized health care those governments will have to spend the money to remove the implants. Money which they do not have!

Several executives of the company are being sent to trial next year on charges of fraud that carry potential sentences of five years in jail. Names have not thus far been made public.

The World Health Organization has posted a webpage that links to the specific recommendations by national regulatory authorities of countries around the world listed by country with each posted in the native language of that country.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Dynamic vs. Static Wrinkles

2011-12-14T14:58:00.000-08:00

This is a guest post by Stacie Morris, a writer for Botox Ottawa. Stacie’s primary concern? Wrinkles, of course! Her favourite treatment is a customized skincare regimen at home (which includes peptide-rich products) and Botox.

Did you know that there are two types of wrinkles on your face? You’ve got dynamic and static wrinkles.

Dynamic Wrinkles
Remember when you were younger, and your facial skin was pretty much smooth all over when you weren’t expressing any emotion at all? When your face was neutral, your skin had no trace of crease or line. But as soon as your facial muscles contracted to allow the conveying of an expression, like smiling and frowning, a wrinkle appeared. When your facial muscles contract, the skin overlying them stretches and creases to accommodate their movement.

Now that you’re older, you’ll probably notice that the wrinkles that only appeared when you formed an expression are now permanent. This is a natural part of the aging process, as your skin can no longer bounce back from the repeated creasing caused by muscle contractions. These creases in your skin, resulting from the contractions of your muscles, are known as dynamic wrinkles.

Areas on your face most prone to dynamic wrinkles are those that are located where your muscles are most active. These tend to be across the forehead (frowning and surprised expressions), between your eyebrows (frowning), and at the outer corners of your eyes (squinting, smiling, laughing, frowning). The area around your eyes is particularly vulnerable to dynamic wrinkles because not only do we use our eyes pretty much at every waking moment, the skin here is far thinner and sensitive and the rest of your face.

Static Wrinkles
Any wrinkles or creases that are visible even when your face is absolutely neutral and at rest are considered static. Static wrinkles are the result of the natural disintegration of essential components in the skin that are responsible for maintaining structural integrity. These include collagen, elastin, and hyaluronic acid, and all deplete with aging. Environmental factors, such as UV exposure, can accelerate disintegration. Neglected dynamic wrinkles left on their own eventually become static wrinkles.

So what can you do about it?

For the best course of treatment, you should first, determine the type of wrinkle you’d like to eliminate or minimize. If it’s dynamic, you may want to consider something that effectively and safely impacts the mobility of the muscles responsible without being dangerous or unnatural. A treatment such as BOTOX can help especially if the wrinkle completely disappears when the skin on either side of it is pulled away from the wrinkle.

Static wrinkles may be effectively treated with something that replaces lost volume and suppleness, such as injectable fillers. Even a customized skincare regimen can help, but make sure it features products containing beneficial ingredients, such as Retin A, peptides, and stabilized Vitamin C (ascorbic acid).

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Asthma - Reversible Lung Disease and Cosmetic Surgery

2011-11-21T16:15:00.000-08:00

Obstruction to airflow in the lungs can be due to

fixed or irreversible lung disease (COPD)
reversible (responsive to medications) obstruction due to heart failure
reversible (responsive to medications) obstruction due to asthma

The obstruction can be due to just one of the factors or any combination of 2 or more factors.

In asthma the walls of the breathing tubes into the lungs swell (become inflamed), muscles surrounding the tubes contract squeezing the tubes and then increased mucus secretions inside those tubes plugs them. This results in obstruction to airflow with audible wheezing and a tight feeling in the chest as the individual tries to get the air through narrowed plugged tubes. Attacks can be mild resolving quickly with medication or severe and life threatening.

Attacks of asthma can be stimulated or triggered by environmental factors like pollen, cigarette smoke, dust mites, pet hair, insect excretions, air pollution, stress, exercise, infections etc. The trigger can be something you are allergic to. The primary medications used to treat asthma are bronchodilators which counteract the muscle spasm and steroids which treat the inflammation.

For the asthmatic undergoing cosmetic surgery an attack can be triggered by irritation from the breathing tube in general anesthesia, dehydration associated with any surgery, inability to clear secretions while lying down under the influence of anesthesia or even pain medications used during surgery. The anesthesia staff needs to adjust the medications given in such situations and the patient needs to bring their inhaler with them to surgery, if they have one. If they patient smokes it is imperative that they not do so for at least one week prior to surgery. Cosmetic surgery in an asthmatic who was smoking within days of surgery is a dangerous combination as they are very sensitive to asthmatic triggers.

Abdominoplasty and belt lipectomy patients who are asthmatics are at higher risk of attacks because the immobility after surgery combined with greater pain medication needs.

The steroids used to treat inflammation in asthmatics also prolong the healing process so sutures may have to stay in longer than they otherwise would. The adverse affect on healing can be reversed by taking Vitamin A before and after surgery. The vitamin does not affect the anti-inflammatory effect so it will not exacerbate the asthma.

This is a tricky situation because even if normal lung function tests and a normal physical examination an asthmatic attack can occur due to any of the factors mentioned above. Furthermore, significant impairment of lung function can occur in asthmatics without symptoms. The history and general physical examination may not accurately indicate the severity of the asthma. The answer is not to just do the surgery under local because you think it would be safer. If you have an asthmatic attack induced by a cosmetic procedure and cannot have a breathing tube placed because of the spasm you will not survive. The answer is to do the surgery in an environment where should any of these problems arise the right personnel and equipment are present to handle the situation. Certified operating rooms will have the necessary oxygen, IV fluids, inhaled and injectable bronchodilators, oral and intravenous anti-inflammatory agents to treat an attack. It is highly unlikely that a non-certified operating room will have those medications.

Only asthmatics with stage I disease and an forced expiratory volume greater than 75% of predicted values can undergo surgery without a higher than normal risk of airway complications. Any asthmatic who has taken steroids, whether orally as a pill or as an inhaled medication, within 6 months of surgery needs perioperative steroids to cover for diminished adrenal function. Inhaled steroid medications may have to be temporarily replaced by oral prednisone until the patient has recovered from surgery. Any asthmatic with audible wheezing should not be having elective non-emergent surgery.

I am personally aware of a fit individual in his 30s who went to a martial arts practice session without his inhaler. He suddenly developed an exercise induced asthmatic attack. By the time the ambulance and paramedics had arrived he could not be revived and passed away. Prompt use of an inhaler would most likely have circumvented this. A similar situation could just have easily occurred with cosmetic surgery.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Tips for Bikini Line Laser Hair Removal

2011-10-19T15:58:00.000-07:00

This is a guest post by Sachin from the Cosmos Clinic in Sydney Australia

Laser hair removal is a great way to get rid of hair on the bikini line, so follow these tips for the best results!

Are you tired of shaving your bikini line and seeing those red bumps and black spots? Does the idea of waxing down there seem way too painful to be worth it? Then you might want to look into Candela laser hair removal for your bikini line. Here are some general tips to choose a clinic, prepare for the removal and maintain the results.

1. Choose a physician with experience

When choosing a clinic, go for those who have a doctor on staff and have a long experience in laser hair removal. Practitioners with longer experience are better at evaluating your skin tone and hair thickness and density to give you the best possible treatment. It’s especially important with the bikini line because the skin is more sensitive there than on other parts of the body.

2. Discuss the treatment before making your appointment

Don’t give in to pressure to get an appointment right away and ask to meet a practitioner before you commit. Laser hair removal, especially for the bikini line, is costly and may require several visits, so make sure you trust the doctor and feel comfortable at the clinic.

Ask questions about the light type, the length of the treatment, the hair cycle, etc. The better informed you are beforehand the more likely you are to be satisfied with your results.

3. Have realistic expectations

Contrary to popular belief, laser hair removal is not permanent. Hair does regrow, however thinner and slower. Going to the clinic and expecting all your hair to be gone after one treatment is sure to lead you to disappointment.

During your preliminary appointment, discuss your expectations with the doctor. He or she will explain the procedure in more detail.

4. Avoid shaving or waxing too close to your appointment

In order to work properly, the laser machine requires a certain length of hair. If you shave or wax right before your treatment, the machine might not have enough to find the hair follicle.

To prepare for your appointment, follow your clinic’s instructions. They will have all the information you need to make your treatment as painless and easy as possible.

5. Be ready for return visits

Because the hair growth cycle isn’t uniform with all hair, you will probably need a few visits to get the most out of laser hair removal. This is because hair is better removed at a specific time in the hair growth cycle.

To get all the hair at this specific period, then, you may need to visit your clinic more than once. The usual number of treatments varies between five and ten, but it may be different for you.

6. If in doubt, abstain

If you think that laser hair removal might not be for you (if you have dark hair on dark skin or pale hair on pale skin or have a skin condition), don’t be afraid to say no. Don’t spend money on something that won’t be effective for you.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Laser Safety

2011-10-07T08:17:00.000-07:00

Different wavelengths of light penetrate to different depths below the skin surface and are absorbed by different skin or tissue components. For example CO2 and Erbium laser light is absorbed by the water in cells exposed to it. Flahslamp laser light is absorbed by red blood cells. Nd:Yag laser light is absorbed by skin pigment cell melanin and tattoo pigment. Since the eyes contain water, pigment cells, red blood cells etc they can be damaged if exposed to most laser lights either directly or indirectly (from reflected laser light). Even the laser pointers used by lecturers can damage the eye if pointed directly into the eye. Some lasers such as the CO2 have a beam whose wavelength is not visible by the human eye but they can still cause damage to the eye. The CO2 and Erbium will damage the cornea and surface of the eyeball first. Flashlamp and vascular lasers are absorbed by red blood cells and are the most damaging to the eye as they are absorbed by and damage the retina.

For safe laser use one should never look directly into the laser light source or scattered laser light from reflected surfaces. All laser treatments should be performed in treatment rooms or operating rooms that are not open to the public. All persons in the treatment area must wear protective goggles or glasses with side shields. A laser safety sign should be placed outside the door of these treatment rooms so that nobody inadvertently opens the door and gets eye exposure to the lasers being used. Because of the wide variety of wavelengths used in laser treatments today the goggles have to block the specific wavelengths employed. Goggles that block 1064nm wavelength light used to remove black tatoos will usually not block out 532nm wavelength light used to remove red tattoos. All laser safety goggles have the wavelengths they block written on the edge of the lenses. Whenever I use a laser facility for the first time I check the numbers on the goggles before I give them to the patient or put them on myself. If the laser treatment is applied directly to the eyelids metallic dulled eye shields that look like large contact lenses should be placed directly on the eyeball surface.

If you suspect that your eyes have been damaged by a laser treatment you need to be examined by an Ophthalmologist as soon as possible.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

What is Botox?

2011-10-04T10:53:00.000-07:00

This is a guest post by Sachin from the Cosmos Clinic in Sydney Australia

Botox here, botox there… it seems that all we hear about these days in the cosmetic surgery industry is botox. Hollywood stars use it, New York socialites swear by it… but what is it? If you’re like me, you don’t want to put something in your body if you don’t know what it’s made of. So I did a little research on botox and I want to share my findings with you.

Composition

Botox is kind of scary: it’s a protein that comes from the clostridium botulinum bacterium. (Botulism is a paralytic disorder caused by poisoning through the aforementioned bacterium. It can be caught in the digestive tract, from food or through contamination of a wound.) Botox is basically the most powerful neurotoxin known to man.

In its current form, Botox is a denatured version of the toxin that can be safely introduced in muscle tissue.

How it got in cosmetic medicine

The medical effects of Botox were first studied for ophthalmic treatments. It was first used to treat strabismus, or “crossed eyes” and uncontrollable blinking.

After the FDA approved botox in 1989, plastic surgeons started using it to treat frown lines between the eyebrows. Trials were conducted and botox was again approved for wrinkle and frown line treatments in 2002.

Since then, there has been an explosion of research about the potential therapeutic uses of this otherwise deadly toxin.

Other uses

Other than for treating wrinkles and frown lines, botox can also be used to treat:
• Muscle spams
• Upper motor neuron syndrome
• Excessive sweating
• Cervical dystonia
• Chronic migraine

How it works

Botox works by applying the paralyzing effect of the toxin locally and in small doses. Wrinkles appear because of muscle tension; botox works by paralyzing or relaxing the offending muscles, thus reducing or smoothing out the wrinkle.

In more scientific terms, botox blocks the brain’s signals to the nerves that control the muscles. It means that your muscle will stop receiving the “order” to contract, since the message can’t make it to your nerve endings.

How it’s used

Botox is injected without any anesthesia. The procedure is quick and mostly painless—only the prick of the needle in your skin.

Botox lasts between 3 and 4 months and up to 6 months, depending your body’s ability to absorb and eliminate the toxin. This means that if you want the effects to last, you need to repeat the injections two to four times a year.

Risks and side effects

Botox is generally safe but there are several side effects, minor and temporary, that may appear. These include allergic reaction to the toxin, bleeding, bruising or loss of sensation.

The idea of using a deadly toxin to reduce the look of wrinkles might be scary, but millions of patients every year use Botox and dermal fillers and very few get any serious side effects. For a quick rejuvenating effect before an important event, it might actually be your best bet! Just remember it takes a few days for the Botox to become effective.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Topical Botox Gel

2011-09-30T12:59:00.000-07:00

A new topical gel botulinum toxin (Botox) is currently being studied. This will allow patients to apply the medication topically to erase crow's feet, frown lines and forehead wrinkles without the need for needle injections of Botox. 90% of patients in a phase 2 clinical trial treated with the experimental gel had visible reduction of moderate to sever crow's feet wrinkles compared to 28% of similar patients randomly assigned to a placebo group.

Effects of the gel last for about four months which is comparable to the effective duration of Botox injections.

Phase 3 studies are in the works to compare the gel to injected Botox.

It is not yet known when this will be available for public consumption but I think you will see this as an active ingredient available in cosmetic counter cosmeceuticals in the very near future.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Massive weight loss and breast reduction surgery

2011-09-13T13:25:00.000-07:00

Obesity is another term for being overweight. It is medically defined as a weight to body surface ratio (BMI) of 30kg/m2 or more. Morbid obesity is defined as being 100 pounds or more above one's ideal body weight which in turn is defined relative to one's height. This correlates to a BMI of 35 to 45. Higher BMIs are referred to as super obesity. The incidence of obesity in general has been steadily increasing in North America, Australia, Europe, the Middle East and South America (i.e. worldwide) over the last few decades leading to a rise in weight loss surgery procedures performed and profitability of weight loss groups like Weight Watchers, Jenny Craig etc.

The frequency of large breasts and medical problems related to them like back, neck and shoulder pain as well as skin breakdown is of course higher in the obese population. The question that is increasingly coming up for review of health insurance coverage is whether or not patients with higher BMIs should have breast reduction surgery before weight loss surgery or diet/exercise induced weight loss. Having the breast reduction first does relieve the large breast associated pain and does increase the ability of these women to exercise. However, after losing the excess weight almost 90% of these women who had breast surgery first were unhappy with the look of their breasts after the weight loss. Around half of these women said they would have additional surgery to improve the look of their breasts. Had they waited until after the weight loss to perform the breast reduction surgery they most likely would not need a second breast operation. In contrast only 70% of women who only had bariatric weight loss surgery were unhappy with the appearance of their breasts after the weight loss.

Insurance claims data from seven Blue Cross and Blue Shield plans were examined for patients who underwent elective breast procedures (breast reduction, breast reconstruction, breast augmentation, breast lift) covered by insurance between 2002 and 2006. 2,403 patients of these patients were obese and 5,597 were of normal weight. Within 30 days of surgery, 18.3 percent of the obese patients experienced at least once complication, while only 2.2 percent of patients in the control group did so. The differences between the two groups of patients were most pronounced in complications, such as inflammation (with obese patients 22 times more likely to suffer a complication), infection (13 times more likely) and pain (11 times more likely).

My personal feeling is the only elective procedure (that includes cosmetic surgery other than minor procedures) a morbidly or super obese individual should have are weight loss surgery. The risks of surgery in these patients in my clearly outweighs any benefit from the cosmetic procedure. They are prone to complications after surgery and many are malnourished despite being obese so they cannot heal properly.

A morbidly obese patient came to me after her cosmetic abdominoplasty performed by another surgeon reopened and failed to heal. After an examination and diet history it was clear to me that although she was morbidly obese she was also malnourished and therefore could not heal. That surgeon kept placing sutures and prescribing antibiotics for almost 2 months with little change in her condition. After forcing her to change her diet she healed up completely in less than 2 weeks.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Some surgical and non-surgical techniques to treat cellulite.

2011-09-09T00:08:00.000-07:00

This is a guest post by Sachin from the Cosmos Clinic in Sydney Australia.

Don’t believe the hype—there is no final cellulite treatment. Nothing but a genetic makeover could get rid of cellulite. Actually, 80 to 90% of women have cellulite at one point in their life, so you’re definitely not alone. But that also gives pharmaceutical companies and cosmetic surgery clinics an enormous clientele pool to help or abuse… depending on what treatment you choose.

While cellulite can’t be completely removed, there are ways to help reduce is appearance and even temporarily drain it away. Here are some of them.

Laser lipolysis

Among the newest treatments in the liposuction line, laser lipolysis proponents claim that using lasers help tighten the skin as well as break up fat cells stuck under the skin, thus improving the appearance of orange peel skin. Traditional liposuction may make cellulite worse, so avoid it as a cellulite treatment. There have not yet been any studies on the effectiveness of laser lipolysis for cellulite treatment.

Acoustic Wave Therapy

Using ultrasound to break up fat in the body is also a relatively new treatment for cellulite, even though it’s been used for a while in liposuction. It’s less invasive as the acoustic wave is applied externally through the skin. Again, no long-term studies have been made but there have been some promising results.

Cellulite subcision surgery

This intervention is rarely used, with limited availability and success. It involves using a v-shaped knife and running it under the skin, cutting the bands of connective tissue that cause cellulite. Thus, the fat is released and can be removed. This is extremely invasive (and thus more dangerous) and cannot be used everywhere on the body.

Lower body lift

This is another invasive intervention that carries the most risks and may produce excessive scarring. It involves cutting excess skin and lifting the remaining skin to lift and tighten the appearance of the abdomen, butt and thighs. It doesn’t get rid of cellulite but can significantly reduce its appearance.

Fat grafting

Fighting fire with fire—or fat with fat: that’s what fat grafting is about. By harvesting fat through liposuction and re-injecting under the skin to smooth it out, fat grafting can help reduce the appearance of cellulite. However it is a temporary measure, as the body usually reabsorbs fat cells.

Endermologie

This patented treatment involves a massage device that supposedly massages water retention, breaks up fat cells and stretch out the connective tissue under the skin. The company also claims that the massage stimulates the production of collagen, thus thickening and strengthening the skin. This treatment is temporary and must be repeated regularly to maintain the effect.

Velasmooth

This is like Endermologie, with added technology of infrared light and radiofrequency waves. It’s also temporary and the results are rather modest.

There is no easy body sculpting solution. Cellulite cannot be gotten rid of only through cosmetic intervention—you must also have a good diet and exercise program. But some of these interventions and products can help smooth away the skin and reduce the dimpled appearance of cellulite.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Bleeding Disorders, Hemophilia, Antithrombin III Deficiency, Aspirin, Anticoagulation and Cosmetic Surgery

2011-08-07T04:49:00.000-07:00

Blood clot formation is a complex process involving first the accumulation of cells in the blood called platelets to form a plug and then a number of proteins/enzymes also called clotting factors that act upon one another in a specific sequence one after the other like dominoes dropping called a cascade to form a mesh that reinforces the platelet plug. The end result of which we see and call a clot. The platelets are the white circles in the video below. The cascade allows immense production of clot in a shorter period of time from a small amount of initiating stimulus so it has been programmed into our systems through evolution i.e.the organism that can stop bleeding the quickest after injury has the best chance of surviving. Along the way there are built in inhibitory enzymes at different parts of the cascade so that the cascade does not get out of control and turn your bloodstream into a solid clot.

Normally this clot formation process helps healing after cosmetic surgery and works in the background unnoticed for the benefit of patient and surgeon. It becomes a problem when the blood can form clots too easily or will not form clots or the clots form but are destroyed too quickly by the body. All of these situations can be dangerous for any type of surgery. These conditions can occur because of something the patient was born with, a disease the patient developed, a side effect of certain medications or a vitamin K deficiency. If it is medication induced the patient just stops or substitutes the medication sometime before surgery. In urgent or emergent cases another medication can be given to reverse the action of the first such as vitamin K for coumadin and protamine for helparin. Most of the blood clotting factors are manufactured in the liver so liver disease can result in the loss of this manufacturing ability resulting in a bleeding disorder.

Hemophilia is a classic case of an inability to form clots. It is caused by a deficiency or absence of some of the factors required for the clotting cascade to proceed and is something one is born with. They form the initial platelet plug but then cannot reinforce it. The defective gene is on the X chromosome so XX females tend to be carriers with only one affected X chromosome and their XY male sons can actually have the disease. In these cases the patient only needs to be injected with the missing clotting factors after which they can proceed with cosmetic surgery like any other patient. The injection is given 2 hours before surgery to raise the level of factor to 80% or more of normal and then maintained by additional injections for 10 to 14 days after surgery.

There is another form of hemophilia called Von Willebrand's Disease which involves defects on chromosomes other than the sex chromosomes X and Y. The bleeding tendencies are usually less in these cases than regular hemophilia but the severity of the bleeding disorder is highly variable. These patients have difficulty forming the initial platelet plug. The treatment of choice for mild von Willebrand disease is Stimate® or desmopressin acetate (DDAVP), a nasal spray that stimulates the body to increase factor VIII and von Willebrand levels. It is given to patients to increase the amount of the von Willebrand factor long enough for surgery or dental procedures to be performed. DDAVP is a synthetic product that carries no risk of infectious disease because it is not isolated from the blood of other individuals.

For excessive bleeding in Von Willebrand's Disease, infusions of a factor VIII concentrate rich in von Willebrand factor, such as Humate-P®, Alphanate®, Wilate® or Koate DVI®, may be required. Humate-P, manufactured by CSL-Behring, Alphanate, manufactured by Grifols and Wilate, manufactured by Octapharma are the only FDA-approved Factor VIII concentrate for use in von Willebrand Disease. The level should be raised to 80% or more of normal and maintained at that level for 10 to 14 days after surgery

Aspirin and many of the drugs used for pain can aggravate bleeding because they interfere with platelet function. People who have von Willebrand disease can take tylenol for pain relief because it does not inhibit platelet function. They should avoid any aspirin containing medications.

At the bottom of the cascade prothrombin is converted into thrombin which in turn converts fibrinogen to fibrin. Fibrin is the white hair like strands visible in the video above that form a mesh around the platelet plug so the clot does not come apart. The visible clot that we see with the naked eye consists of multiple fibrin molecules stuck together with cells called platelets that group together to form a plug at the site of injury.

Antithrombin III is a protein in the blood that binds to thrombin or other protein/enzymes at the bottom of the cascade to put the brakes on, stop or slow the clotting cascade. Patients who have antithrombin III deficiency are prone to making too much clot. They form clots in the deep veins of the legs and large veins in the abdomen. This can be precipitated by surgery, trauma, pregnancy, oral contraceptive use, or infection. These patients are given a medication called heparin to increase the activity of whatever amount of antithrombin III is present. Since the 1980s a purified (low molecular weight) heparin has been available that is easier to take and does not have to monitored as closely for overdose. This form can be taken at home instead of being restricted to in hospital use. They can also be given Antithombrin III concentrate to bring the blood levels to normal or close to normal.

Protein C and S inhibit the pathways involved in clot formation specifically at Factor VIII and Factor V. Individuals with genetic deficiencies of these proteins are also more prone to making clot than normal (6 times more so than individuals with normal protein S levels) especially in the veins. Protein S deficiency can be hereditary or due to vitamin K deficiency, sex hormone therapy, liver disease or chronic infections. Inherited Protein S deficiency occurs in 1 in 500 people in the US. Those who also are inactive, have a previous history of blood clots, smoke, are obese or are taking birth control pills are at a very high risk for forming blood clots. Protein S deficient patients therefore need to exercise regularly, stop or never start smoking, control their weight and stay away from birth control pills.

The primary goal in protein S deficient patients is to prevent the first big clot. Once that forms future ones are much more likely to form. Surgery can damage blood vessels stimulating the clotting cascade which in these cases can over react to the surgical stimulus. If the over reaction is severe enough it can be life threatening.
These patients need prophylactic anticoagulation with heparin before, during and after surgery with a hematologist directly involved in their care. In contrast to protein C and antithrombin, there is no purified form of protein S available for clinical use. Therefore surgery in these cases must be done in a hospital in case fresh frozen plasma (FFP) is required in the event that the clotting cascade starts to over react. That is the only way to replenish the Protein S stores. Surgery in an office operating room is not safe for these patients.

Aspirin changes the platelet surface so the platelets cannot stick together to form the initial platelet plug. If a blood vessel is then cut it will continue to leak blood for a prolonged period of time. This is why even removing a skin surface mole can be a problem in patients taking aspirin. Cutting into the skin and performing surgery on deeper structures in patients taking aspirin can be very dangerous. Even liposuction, which involves skin incisions only followed by introduction of a blunt metal tube to remove the fat should not be performed on patients who have recently taken aspirin. It takes 7 to 10 days for your body to make new platelets to replace those that have been altered by aspirin. It is you crucial that you stop any aspirin intake a week or more before any surgery. Even one aspirin in that time frame can cause a problem. The only other way to reverse the effect of aspirin is to transfuse platelets (a blood transfusion).

As I mentioned in a previous blog vitamin E and multiple herbal medications prevent blood from clotting normally and can be very dangerous when combined with surgery.

One of my patients had a history of blood clots in the deep veins of his legs. With the aid of his internist he received low molecular weight heparin around the time of his abdominoplasty and sailed through surgery without complications.

Another patient had a stent placed in a neck artery feeding directly into the brain. She was taking blood thinners to prevent clotting within the stent. Again with the aid of her medical doctors we stopped the blood thinners a week before surgery and started low molecular weight heparin. I removed a skin tumor from her scalp and she went back on the blood thinners a day after surgery.

I reviewed a case where a hemophiliac underwent facelift surgery. That patient was transferred directly from the surgeon's office operating room to a hospital operating room where blood components had to be transfused emergently until the bleeding stopped. After a couple of days in the intensive care unit that patient was sent home.

The bottom line is if there is an intrinsic problem with the ability to form clots cosmetic surgery that could result in significant bleeding should be done in a hospital with a hematologist familiar with the patient readily available. That way should the need arise for transfusing blood components or specialty care they are readily available. Safety during surgery should take precedence over cost of surgery.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Sickle Cell Disease and Cosmetic Surgery

2011-07-19T16:48:00.000-07:00

Hemoglobin is the protein in red blood cells that carries oxygen. It is encoded by 2 genes in one's DNA, 1 gene from each parent. Either or both of these genes can have a sickle cell trait so that the hemoglobin produced by either or both as the case may be is abnormal. If only one gene is abnormal the individual is said to have sickle trait. If both are involved the individual has sickle cell disease. The sickle gene is most commonly found in those of sub-Saharan African descent. It is thought that that is because the sickle trait confers resistance to the malaria that is present there. 0.5% of the Afro-American population has both genes and 8% have the trait. Under low oxygen levels the sickle hemoglobin changes shape and makes the red blood cell it is in turn into a sickle shape. Conditions that make the abnormal cells sickle include lowered body temperature, infections, acidic metabolic conditions, dehydration and as mentioned lowered blood oxygen levels. The sickle shaped blood cells have a shorter life span and tend to get caught in the smaller blood vessels of the body. The manifestation of this depends on the percentage of total body red blood cells/hemoglobin that is abnormal. Those with only the trait (one gene) have an easier time. When the percentage is high it is associated with anemia, stunted growth, sores on the legs, heart problems, shortened life span, organ failure etc.

The affect on cosmetic surgery and the measures needed to ensure safe surgery depend on the percentage. At low percentages you do not need to do anything different from other patients. At higher percentages the patient may need pre-surgery treatment with one or more of the following supplemental oxygen, blood transfusion, over-hydration etc. If the percentage is very high the patient should probably not be having elective cosmetic surgery. Your surgeon needs to work together with a hematologist in order to ensure a smooth recovery after surgery.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Mommy Makeover Abdmoninoplasty with Pelvic Sling for Urinary Incontinence

2011-07-18T16:28:00.000-07:00

Urinary incontinence (leaking of urine) can be problematic and embarrassing for women past their childbearing years. Pregnancy and/or the aging process weakens or damages nerves, muscles and/or their supporting structures in the pelvic area. This results in incontinence (inability to hold back urination). There are different types such as stress incontinence, urgency incontinence etc. After trials of non-surgical treatments such as injection of bulking agents around the urethra (tube extending down from the bladder that urine flows through) have failed sling or bladder neck suspension surgical procedures may be needed to treat stress incontinence.

Sling Procedures for Urinary Incontinence

In the sling procedures a piece of human or animal tissue or a synthetic tape is passed around the urethra and then over the pubic bone. The sling lifts the urethra and changes the angle between it and the bladder so that urine dose not come done the urethra or leak until the bladder contracts in a controlled manner in the bathroom.

Bladder Suspension Procedures for Urinary Incontinence

Suspension procedures involve placing stitches (sutures) in vaginal tissue near the bladder neck (where the urethra and bladder meet) and then passing the stitches to a ligament near the pubic bone (Burch procedure) or in the cartilage of the pubic bone itself (Marshall-Marchetti-Krantz procedure). These sutures reinforce the urethra and bladder neck so that they don't sag.

Urethra Before (Left) and After (Right) a Sling Procedure
Because of social stigma, an estimated 50 to 70% of women with urinary incontinence do not seek medical evaluation and treatment. Only 5% Of women with urinary incontinence in the general population and 2% in nursing homes receive appropriate medical evaluation and treatment. Women with urinary incontinence often endure this condition for 6 to 9 years before seeking medical treatment.

Both types of procedures can be performed via an abdominal incision that can be incorporated into an abdominoplasty procedure.

Some surgeons prefer to do these separately for fear of infection because the bladder procedure involves operating inside the abdomen of abdominal organs. Although that is theoretically correct I have not found that to be a problem. Extra care needs to be taken in order to avoid cross contamination. I have also performed abdominoplasty in conjunction with a tubal ligation and vaginal tightening performed by an OB/GYN and have not had a problem with that procedure either.

Mommy Makeover Surgery - Abdominoplasty
Abdominoplasty - Tummy Tuck
Mommy Makeover Abdominoplasty - Tummy Tuck on Youtube
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Plastic Surgery and Mesothelioma Align

2011-07-01T12:12:00.000-07:00

This is a guest post by Jackie Clark assistant to Heather Von St James, a cancer survivor.

When someone mentions plastic surgery, we tend to think of face-lifts and breast implants, but plastic surgeons are able too much more. What would burn and accident victims do if there were no plastic surgeons to repair their faces and bodies? What kind of life would a deformed infant have if there were no plastic surgeons to correct nature's mistakes? There are millions of people in the United States alone, not to mention the rest of the world, who feel they were not given the body or face they deserve. Being unhappy with one's looks can cause many problems like depression, low self-esteem and even suicidal tendencies. There are forms of cancer like mesothelioma, breast cancer and skin cancer that can kill if not treated by surgery.

This surgery falls into 3 categories:
1--Reconstructive surgery involving pediatric birth defect surgery, injury repair, burn surgery, hand surgery, breast cancer surgery, adult birth defect correction surgery and other corrective procedures.
These are surgeries that are done for medical reasons and can make life expectancies longer. Repairing accident damage can give people their lives back.

2--Cosmetic surgery includes procedures like tummy tucks, eyelid surgery, breast implants or reduction, buttock augmentation, face lifts, liposuction fat removal, chin implants, chemical peels, lip enhancement, laser treatment, neck lifts, eyebrow lifts and other procedures to enhance a person's looks.

3. Surgery that treats forms of cancer like mesothelioma, skin cancer, breast cancer and other diseases that are life threatening. This is not cosmetic surgery, but surgeons that are able to perform plastic surgery are often also qualified to perform other life saving medical procedures that increase patient life expectancy.

Plastic surgery like any medical procedure carries risks that one should be aware of before making a decision. The risks can range from swelling and bruising to infection, organ punctures, bleeding, scars, fluid accumulation and allergies to anesthesia and other drugs used in the procedures. A good surgeon will go over all the benefits and risks with every patient, taking medical history of each patient to be safe. It is standard procedure for the plastic surgeon to talk about allergies and expectations of results with every potential patient. Anyone considering surgery of any kind should look for a surgeon who is board certified and professionally affiliated as well as being licensed and degreed from a good medical school.

Plastic surgery is not cheap and is not always covered by your insurance provider. If one's life expectancy, health or self-esteem is involved, no price is too high. Specifically concerning a mesothelioma prognosis an operation maybe the only available resource to save ones life or for that matter lengthen it. These medical procedures are more likely to be covered by insurance and costs vary depending on the seriousness of the condition. Before agreeing to surgery it is a good idea to check with your insurance company to see if they will cover all or part of the cost of the procedure. You can get more information on plastic surgery and mesothelioma on these web sites: http://www.Mesothelioma.com, or http://serg-group.org/the-general-basic-fact-you-should-know-about -plastic-surgery.php.

Aaron Stone MD - twitter
Aaron Stone MD - Plastic Surgeon Los Angeles

Online Physician Rating and Ranking Services are Biased and Unreliable

2011-06-14T20:45:00.000-07:00

A study of online physician review, rating and ranking services such as Angie’s List, healthgrades.com, RateMds.com, Vitals.com, and Yelp.com by professors of the University of Maryland’s Robert H. Smith School of Business and the School of Public Health at the University of Minnesota found that they are biased and unreliable. This is particularly worrisome as physician ratings are gaining popularity among patients and an increasing number of patients consult these rankings before making an appointment to see a prospective surgeon. According to a 2010 Pew Internet and Life Project survey, 59% of U.S. adults have looked online for health information.

The study looked at the way patients determine which physicians to rate and the intensity of opinions they express using 4 data sets:

online data from RateMDs.com, one of the largest American physician rating services;
an offline patient survey conducted by the consumer advocacy group Consumers’ Checkbook for the cities of Denver, Memphis, and Kansas City;
the U.S. Census 2007 Economic Census, which was a source of information about population and median income in the three cities examined;
and state medical board websites.

They asked if patients using these online sites reviewed the full range of doctors (including those viewed positively, neutrally, and negatively); if they were biased toward giving negative reviews to doctors (which the authors characterized as “bad mouthing”); or if they were biased toward giving mostly positive reviews (providing what the authors call “sounds of silence” about poor caregivers). It turns out patients posting their opinions about doctors on online are much less likely to discuss physicians with low perceived quality and are more prone than offline populations to exaggerate their opinions,.

The authors came to two major conclusions:

First, they found that physicians with low ratings in offline surveys are less likely to be rated online, therefore supporting the “Sound of Silence” effect in selecting what physicians to rate.

Second, although authors found a strong correlation between the online ratings and offline population opinion, the association is strongest in the lowest quartile of opinions. These results suggest that online ratings are more informative when identifying low-quality physicians, but not as effective in discerning high quality physicians from median ones. The authors also confirm that patients are most likely to provide ratings for their most flagrant or negative experiences with physicians.

Doctors and professional medical societies were initially caught like deer in headlights when these online ranking and rating (but mostly raking) sites appeared. It is a premise of marketing that the few dissatisfied customers are the most vocal. That does not always mean that the product or service is inherently bad. Some irate and sometimes irrational patients without valid complaints posted highly negative reviews. These hurt the reputations of some surgeons and they lost patients, not always through any fault of their own. Complaints to these review and ranking sites went unanswered and they refused to remove negative reviews. Lawsuits against the defamers were hard to initiate because the reviewers were largely anonymous. One surgeon was somehow able to track the negative reviewer at which time it was found out that that person had never even had the surgery that was complained about. On the other side of the coin a doctor in northern California and a cosmetic group of doctors in New York were found to be posting false positive reviews. The New York group was using employees to post multiple fake positive reviews. They were cited and fined hundreds of thousands of dollars related to false advertising. The California doctor hired a public relations firm to boost the practice and the firm posted the fake positive reviews.

Next came companies that promised to remove negative reviews and track them as they appear for removal, for a price of course. Interestingly after some investigation it was noted that some of these companies were actually the source of the negative reviews and some were even the company that owned the ranking/review website. I was contacted by someone who was writing a book about these companies to expose them.

A negative review was posted about me that contained general information that could be obtained from my website but did not mention having any specific surgical procedure. This coincided in time with the first of the companies calling me to offer their paid services to remove negative reviews. A colleague of mine had a certifiably unstable patient who underwent a minor procedure, so minor that it would be hard to have a complication much less a bad result. This patient went literally into orbit posting negative reviews and even creating websites that would appear on searches for that doctor's name.

Doctors have collectively come to the conclusion that the only way to deal with this situation is to drown it out with online content like blogs and multiple websites and have happy patients post reviews. Unfortunately, happy patients in general are less motivated to post reviews no matter how happy they are. They got the result they wanted and now they want to go on with their lives. They have nothing more to gain by posting a positive review.

Aaron Stone MD - twitter
Aaron Stone MD - Plastic Surgeon Los Angeles

Diabetes and Cosmetic Surgery

2011-05-30T14:03:00.000-07:00

Diabetes in all its forms (diet controlled, medication controlled and insulin controlled) impacts all surgery patients. Since diabetics are more prone to coronary artery disease and blood chemistry alterations they require more extensive lab work including electrocardiograms before surgery and should be medically cleared for surgery by their internist. After surgery their healing time is prolonged, fluid balance is altered and they are more prone to infection. Therefore care after surgery including insulin doses should be performed under the guidance of the physician who medically cleared the patient for surgery accounting for the type of surgery performed and the patient's condition.

For surgery of any kind in diabetics the goal is to complete the surgery without the patient experiencing keto-acidosis, high blood sugar or low blood sugar levels. This can be reached by one of 3 approaches

no insulin-no sugar where the patient is fasted before and during surgery, takes no insulin the day of surgery and is given no intraveonus sugar

a 1/3 to 2/3 split dose of insulin and intravenous sugar given during surgery

the patient is given continuos insulin intravenously and blood sugar is monitored during surgery

For most cosmetic surgery patients who are not seriously and undergo more minor or shorter time operative procedures like rhinoplasty, blepharoplasty, breast augmentation, liposuction etc. the no insulin-no sugar approach is adequate. For longer procedures that are more involved such as belt lipectomy the split dose insulin and intravenous sugar approach are more appropriate. For seriously ill patients who may be undergoing reconstructive surgery and are not likely candidates for cosmetic surgery continuous intravenous infusion of insulin and sugar adjusted for blood sugar readings during surgery is most appropriate.

No special treatment is required for diabetics controlled by diet especially if the surgery is minor.

The care of patients whose diabetes is controlled by oral medications is more complicated. Most can be treated by the no insulin-no sugar approach taking their last dose of medication on the day before cosmetic surgery and then resuming it once they start eating after surgery. If the medication is a long acting sulfonylurea (like Glipizide) it should be stopped 3 days before surgery. If it is active in the body and the patient does not eat because of surgery the blood sugar level can become dangerously low. These patients are more likely to need blood sugar levels read right before, during and/or after surgery especially if the surgery time is longer than a few hours. They may also require a temporary switch to insulin from oral medications around the time of surgery.

I had a borderline diabetic patient whose diabetes was controlled by diet alone. The day following surgery their pancreas produced so little insulin that the blood sugar and potassium levels became alarmingly high. This was the body's response to the stress of surgery. Luckily the surgery was performed in the hospital and the patient stayed in the hospital afterward. Administering bicarbonate intravenously and insulin normalized the blood chemistry cured a potentially disastrous problem. Unabated the abnormal blood chemistry can lead to coma, seizures and even death. Lengthy cosmetic procedures should be performed in a hospital in these patients and the blood sugar levels checked periodically after surgery.

Because of all of the above if you are a diabetic and your plastic surgeon is operating on more than one patient on the day of your surgery - you must be the first case of the day. Also lengthy cosmetic procedures should be performed in a hospital setting.

Aaron Stone MD - twitter
Aaron Stone MD - Plastic Surgeon Los Angeles

The difference between panniculectomy and abdominoplasty - tummy tuck

2011-05-14T00:28:00.000-07:00

Abdominoplasty or tummy tuck is a cosmetic procedure that involves placement of horizontal lower abdominal and around the belly button incisions. The abdominal skin is then tightened by separating the skin and fat layer from the muscle layer, pulling down the upper edge of the incision and creating a new hole for the belly button higher up on the skin that has now been stretched downward. In most cases suture tightening of the abdominal muscles is also performed. In some cases additional tightening for very loose muscle is achieved by placing additional vertical and/or horizontal rows of sutures. The result is frequently improved by liposuction peformed at the same operation. It is not a medically necessary procedure and therefore not covered by health insurance unless the excess skin and/or fat is required to close an open wound or reconstruct a breast after breast cancer surgery rather than being removed for cosmetic reasons.

Markings for Abdominoplasty - Tummy Tuck

Abdominoplasty - Tummy Tuck Surgery

Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the upper abdominal skin tightening via around the belly button and lower abdominal incisions. The hanging fold of skin and fat is called a pannus so its removal is called a panniculectomy. The skin and fat are removed as a wedge without any lifting of the surround skin - fat from the underlying muscle layer. It would be medically necessary rather than cosmetic in nature if the removed skin has had recurrent infections or rashes (known as intertrigo) or is dead etc. In such cases the panniculectomy surgery is covered by health insurance. It is called a mini-tummy tuck when the excess skin and fat is slight and does not hang over the undergarment or genitalia when standing. Like a full abdominoplasty a mini-tummy tuck is a cosmetic procedure.

Skin Removal Patterns for Panniculectomy
The pattern of removal as you can see in many cases results in removal of the belly button. Since the upper excision line is shorter than the lower excision line, especially when the skin-fat hang very low, a dart of skin has to be removed along the lower excision line in order for the 2 lines to match for closure.

Insurance coverage criteria for panniculectomy typically include:

stable weight for 6 or more months
photo documentation of skin and fat hanging over the pubic area
medical record documentation of recurrent skin rashes and/or infections in the fold of hanging skin that does not respond to 3 or more months of topical and/or oral medications

It is important to make sure you see your doctor right away if you develop these rashes or infections and have him/her document all office visits for and treatment of these skin conditions in your medical records in order to get health insurance coverage.

Although panniculectomy can be performed in morbidly obese individuals abdominoplasty should not. The act of lifting skin-fat off the underlying muscle in abdominoplasty places these patients at a very high risk of complications. For these patients it is better to lose the weight surgically or non-surgically before undergoing an abdominoplasty.

Abdominoplasty
Aaron Stone MD - twitter
Aaron Stone MD - Plastic Surgeon Los Angeles

Breast Implants and Bodybuilding

2011-05-02T13:02:00.000-07:00

Female body builders in general have little body fat and the process can also melt away breast tissue. Refilling the breast skin envelope is then challenging in this situation because there is so too little fat or breast tissue to cover the edges of a breast implant placed on top of the muscle. So saline implants above the muscle are out of the question. Implants placed under the muscle are even more problematic because the pressures or forces applied to them during weight lifting can rupture the implant or more commonly shift them out of position. I saw one patient who while bench pressing squeezed her implant out of position so it formed an unsightly U-shape around the lower border of the pectoralis major chest muscle.

The only answer although not optimal is a cohesive gel breast implant placed on top of the chest muscle and in selective cases the addition of acellular dermal matrix to ensure the edges of the implant and rippling are not visible, although that is costly and is not be the right choice for all such patients.

Breast Implants Augmentation and a Natural Look
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Bite a breast implant and die

2011-04-10T07:57:00.000-07:00

An Israeli model Orit Fox, 28, was doing a photo shoot for Spanish television network Telecino in Tel Aviv that required her to embrace a snake. Shortly after starting the shoot she licked the snake's head with her tongue. It then recoiled and bit her left breast containing a silicone breast implant. An assistant then rushed in to remove the snake from her breast. The model was taken to a nearby hospital where she received a tetanus shot. The snake died from silicone poisoning. No autopsy is planned for the snake and apparently no charges will be filed. Snake bites are a more common occupational hazard of modeling than I had previously thought.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Awake Cosmetic Surgery - Surgery Without Anesthesia

2011-03-29T17:10:00.001-07:00

The new and aggressively marketed Awake cosmetic surgery is performed under local anesthesia only without even an IV. Some doctors will add a mix or cocktail of oral medications such as valium. These procedures are heavily advertised as a cheaper, safer and more medically advanced alternatives to liposuction, abdominoplasty and breast enhancement surgery, especially liposuction. Awake surgery ads promise that patients remain lucid throughout the operation able to interact with their doctor and even voice opinions about such things as breast implant size at prices less than half of conventional surgery with general anesthesia. They may even propose surgery a doctor’s cozy office, not in an intimidating outpatient surgical center or hospital, which is dangerous distortion of the facts.

The facts are that with respect to liposuction this type of anesthesia is frequently inadequate so that the doctor has to use smaller shorter tubes for liposuction making many more skin holes, that leave scars, than otherwise would be required. The patient squirms around in pain making it harder to achieve a good result. General anesthesia is expensive, and the anesthetists/anesthesiologists who provide it prefer to work in hospitals or clinics that have met high safety standards i.e. are certified. Awake surgery has become a way for doctors who lack hospital privileges and requisite surgical training—but who want to cash in on the plastic surgery market—to exploit a loophole in the law by performing the operations in the privacy of their offices in rooms that are not accredited operating rooms and do not contain required safety equipment. The California state law requires all surgery under general anesthesia or medications that dull airway reflexes to be performed in a certified accredited operating room. Furthermore the cocktail of medications impairs judgement so that the patient although technically awake cannot hold a meaningful conversation or make any judgement decisions with respect to their care during surgery.

The amount of local anesthetic (lidocaine) injected can reach toxic limits and a number of deaths have occurred due to this overdose. In 2010 a patient died from lidocaine overdose during awake liposuction in Southern California. That doctor's license was immediately pulled. The lidocaine may depot in the fat layer and then slowly release after the patient leaves the doctor's office. The toxic level is then reached at home some hours later and there are multiple reports of patients dying alone at home in these circumstances.

The growing number of cases where this mode of surgery was employed under dubious circumstances is mind boggling. A radiologist with no surgical training opened an office in Beverly Hills to perform only awake liposuction in a non-accredited exam room. Patients complained of pain during surgery, bad results and non-medical office staff performing surgery on them. When the authorities came to shut down the office and take his medical license he had already disappeared. A general practitioner was performing awake breast augmentation in Northern California and advertising it on roadside billboards. Complaints were filed on the basis of the false advertising on the billboards. When some of his patient records were examined the evidence was so damning that he lost his medical license. The ex-wife of one of my patients underwent an awake surgery facelift in Beverly Hills and told him the pain was excruciating.

Awake surgery is not safer than surgery under general anesthesia when overdoses of lidocaine local anesthesia are given and/or the procedure is performed in a non-accredited operating room that does not contain the requisite safety equipment in case of an emergency.

July 22, 2011 Addition:
An Arizona emergency-room physician, certified as an internist, but who had never done a residency in plastic surgery or anesthesiology was convicted last week of murder and manslaughter for the deaths of his liposuction patients. Two died from an overdose of local anesthetic and another from an injection of fat into a vein. The fat traveled up to the heart and lungs killing the patient. The first 2 basically died from an overdose of the local anesthetic used in awake surgery. In one of the overdose patients the doctor inserted a breathing tube into the esophagus instead of the trachea and refused to let paramedics change the tube thereby contributing further to the patient's demise.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Mixed Martial Arts MMA and Plastic Surgery

2011-03-25T12:40:00.000-07:00

When most people think about plastic surgery and mixed martial arts (MMA), boxing etc they think of broken noses, facial bone fractures, cauliflower ears, skin abrasions and cuts. In unarmed fighting the skin is torn open when an outside blunt force pushes that skin against the edge of a bone. You see this frequently in boxing matches with skin around the eye socket being torn open. In boxing they put pressure on the tear while the boxer is in the corner to stop the bleeding. Some fighters have a facial bone structure with less edges or flatter surface contour. These fighters are less susceptible to having tears in the skin when struck. For both boxers and MMA fighters these tears are usually sutured by non-plastic surgeons who just suture the outer layer of the skin. After these heal there is a thinner layer of tissue between the skin surface and the edge of the bone. This condition leaves the fighter more susceptible to another tear in the skin when it is struck. The blow could even be an otherwise inconsequential one.

Some of these fighters are now undergoing surgery to rasp or burr down these bone edges. At the same time the deeper layers that separated at the time of the initial injury are repaired and/or the surgeon inserts an acellular dermal matrix (commercially available human skin collagen without skin cells) to increase the tissue between the skin surface and the bone. This so to speak softens the blow.

The question remains whether athletic commissions will allow this or will they consider this performance enhancement comparable to anabolic steroids and ban it.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Cosmetic Surgery for Men Increased in 2010

2011-03-22T10:09:00.000-07:00

Statistics released this week by the American Society of Plastic Surgeons revealed increases in male patients undergoing plastic surgery in 2010.

The noted percentage increases for surgical (denoted by *) and non-surgical procedures were:
1) Facelift* – 14% Increase
2) Ear Surgery* (Otoplasty) – 11% Increase
3) Soft Tissue Fillers – 10% Increase
4) Botulinum Toxin Type A – 9% Increase
5) Liposuction* – 7% Increase
6) Breast Reduction in Men* – 6% Increase

2010 Top Five Male Cosmetic Surgical Procedures were:

1) Nose Reshaping (64,000)
2) Eyelid Surgery (31,000)
3) Liposuction (24,000)
4) Breast Reduction in Men (18,000)
5) Hair Transplantation (13,000)

2010 Top Five Male Cosmetic Minimally-Invasive Procedures were:

1) Botulinum Toxin Type A (337,000)
2) Laser Hair Removal (165,000)
3) Microdermabrasion (158,000)
4) Chemical Peel (90,000)
5) Soft Tissue Fillers (78,000)

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Medical Tourism - Going Abroad for Discount Plastic Surgery

2011-03-02T12:07:00.000-08:00

Medical tourism refers to patients traveling far from home for plastic surgery, usually to another country, for discounted services or perceived care that cannot be obtained at home. There is nothing inherently wrong with doing this. I as well as many of my colleagues here in Los Angeles receive patients from many parts of the world such as China, the middle east, Europe, Latin America etc. Although you can find good doctors and appropriate care all over the world as a prospective patient you have to do your due diligence before committing yourself to plastic surgery anywhere be it India, Thailand or even the United States. The criteria you use to search for a surgeon should not change just because he/she is in a different country. (see my web page how to choose a plastic surgeon) Above all else do not let the price tag blind you to the quality of care. Breasts implants at a quarter of the price in your home country may sound to good to pass up but if you do not do your due diligence in researching the care it could end up costing you a lot more than surgery at home. It can even cost you your life.

You should not travel long distances by plane and then have surgery on the day of or day after your arrival. The prolonged time on the plane sitting in one position combined with air pressure changes and the usual travel dehydration puts you at risk for blood clots. Adding surgery to this where you do not eat before surgery, have anesthesia that lowers your blood pressure during surgery and lie still on the operating table for some hours dehydrates you further, stagnates more blood and increases the risk of blood clots even more. After arriving at your destination you need to rehydrate and be active to recirculate your blood for a few days before having any surgery. The same reasoning applies after surgery. Failing to do so can be life threatening if a formed clot passes through your blood stream to the lungs.

There is also an issue of medical clearance for surgery. If you are older and/or taking multiple medications that clearance is best made by the internist who knows you best i.e. subscribes those medications. Anytime a surgeon in any country tries to bypass the issue of medical clearance that is a major red flag indicating you need to find another surgeon.

You have to be especially careful of travel packages that include surgery, air travel, hotel accommodations etc. as an all inclusive package. The agenda of maximizing the number of medical procedures sold to travelers, the possible choosing by the travel agency of substandard surgeons that are cheaper and the selling of procedure(s) prior to an evaluation, examination and planning of surgery or postoperative care by a qualified surgeon is a toxic mix that is sure to lead to complications. Medical tourism is marketed on the basis that health care including plastic surgery can be off-shored like the production of automobiles and electronics or computer technical support call centers. Good medical care involves more than just the mechanical act of surgery. It requires preoperative consultation between the doctor and patient and often times between doctors of different specialties, access to medical records, careful treatment plans, and proper postoperative care. This process can also be hampered by language barriers if the patient does not speak or understand the language of the country in which surgery is performed. The assumption that patients can fly in, undergo surgery right away and then return home after a brief period convalescing in a hospital or hotel for less than a week without any plan for follow-up care is an erroneous one.

In mid-2010 reports appeared that medical tourism patients were returning to Europe and North America with infections of a NDM-1 strain of bacteria. This resistance was reported to be able to jump between species of bacteria and was resistant to most antibiotics necessitating treatment with a cocktail of antibiotics. The appearance of this resistance may be due to the indiscriminate use of antibiotics in some countries.

A 31-year old Swedish woman responded to a website advertisement by a travel firm specializing in organizing medical treatments abroad. She went to Poland in mid-2010 to have her breast augmentation operation which was performed in an old hospital that was quite different from the modern hospital depicted in the ad. Due to the grave mistakes in anesthetic care and poor postoperative recovery routines, she sustained severe brain injury because of prolonged lack of oxygen. It took more than seven hours to have her transferred to an intensive care unit across the street. 6 months following the operation, she was in a nursing home, in a vegetative state. There is no hope of improvement. Her life and that of her family is ruined.

Research performed by investigative journalists from Swedish national television revealed that there are about ten such firms in Sweden advertising on the web. None of the managers has any medical education. Patients were enticed to believe that the doctors and the facilities abroad had the same technical and safety standards as at home. The travel agent selects the surgeon and the operating facility. It was also discovered that medical records were falsified and the doses of anesthetics and analgesic drugs were altered. Several officials in the hospital management and the Regional Health Commissioner had to resign or were dismissed after this came to light.

In May 2010 a Chula Vista, California woman died on the operating table in Tijuana Mexico while undergoing liposuction of the abdomen. Her doctor was charged with manslaughter by the Mexican authorities who stated that "it was found that the surgeon did not have the documents accrediting him as a plastic surgeon.”

In late 2010 a 20 year old woman flew from London England to Philadelphia for silicone injections to the buttock. These were performed by a non-physician in a hotel room. She returned in early 2011 for more injections but this time the injector nicked a vein in the buttock and the injected silicone traveled up to the lungs and killed the woman. The same procedure by anyone in any country could have ended the same way. There is no FDA approved injectable silicone for that procedure.

In my own experience I am aware of one female body builder who went south of the border to have calf implants placed. She developed an infection that was mistreated or not treated and then had to have her lower leg amputated. Another Persian patient decided to have lip augmentation by a dentist in Iran while visiting relatives there. The material injected was not FDA approved for use in the US. After returning home to California her body reacted to the material and her lips swelled and continued to increase in size till she saw me. Luckily we were able to control the situation with removal of the material and injection of anti-inflammatory medications. Although this intelligent woman would not have done this at home in the US she dropped her guard while in Iran because the price was too good to pass up. That is not to say this could not happen in the US if you are not careful in choosing a surgeon and procedure but at least here you have recourse in the courts and with the state medical boards that license doctors to practice medicine.

May 20, 2011 addendum:
A 60 year old Arizona woman found a Mexican surgeon online to perform a facelift. She awoke from surgery in pain and felt that things were not healing properly. "My head start to grow 3 times size a human head. I was black and blue, I was scared. I didn't know what to do," she said. The surgeon damaged a salivary gland at some point during her procedure. Because of that, bacteria and saliva began to accumulate in her neck. The company that set her up with her doctor said her issues were a result of her not fully complying with the doctor's orders.

December 28, 2011 addendum:
Australian Plastic Surgeons noted a 38 per cent rise in the number of Australians seeking help after botched cosmetic procedures performed out of the country in 2011 vs. 2010. 81 members of the Australian Society of Plastic Surgeons also found that 62 per cent of bungled surgeries they saw in 2011 were so severely botched that victims would remain "permanently disfigured" and almost 50 per cent could have led to life-threatening complications. Almost 70 per cent of botched jobs were breast related and 15 per cent were facial procedures.

How to Find and Choose a Plastic Surgeon
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Breast Implants and Lymphoma Cancer

2011-02-06T21:14:00.000-08:00

Patients with either saline- or silicone gel–filled breast implants may have a very small but significant risk for a rare cancer called anaplastic large-cell lymphoma (ALCL), a cancer of the immune system, adjacent to the implant. This is currently under investigation and its existence should be considered if there is a build up or collection around the implant (seroma) years after the original surgery. Because the risk is very small the current policy is one of data collection only and no changes have been recommended for the use of breast implants or the frequency of follow up after breast implant surgery. The FDA continues to state that breast implants are "safe and effective when used as labeled."

ALCL can occur anywhere in the body in the absence of breast implants. It is diagnosed in 1 of every 500,000 women per year in the United States. ALCL in the breast is rarer still, diagnosed annually in roughly 3 of every 100 million women without implants. In women with breast implants, it is usually inside the fibrous scar tissue — called a capsule — surrounding the implant. It is not a cancer of the breast per se.
ALCL associated with breast implants is limited to the fluid inside the capsule and the inner wall of the capsule. It can occur whether the breast implants were placed for cosmetic (breast augmentation) or reconstructive purposes (reconstruction after breast cancer surgery).

Treatment options for ALCL are chemotherapy, radiation, and surgery. The ALCL found related to breast implants is less aggressive and is sometimes treatable by simply removing the implant, the capsule, and the collected fluid resulting in a cure. Those patients who have had new implants placed at the time of lymphoma and prior implant removal have not had a recurrence of the lymphoma to date. The problem is in most capsulectomies with implant exchange the back wall of the capsule is frequently left at least partially intact. In cases with ALCL it is imperative that no capsule be left behind. An FDA review of scientific literature published from January 1997 through May 2010 uncovered 31 unique cases of ALCL in women with breast implants throughout the world. As of this writing the FDA is aware of 60 cases in all, some of them identified through other channels. The FDA does not know how many of the 60 may be duplicates of cases found in the literature. An estimated 5 million to 10 million women worldwide have received breast implants, according to the FDA.

Of the 31 published cases of ALCL, 24 involved silicone implants, and 7 saline implants. It is not known if the implant surface texture has any bearing on ALCL. The median time from implant to ALCL diagnosis was 8 years. For most of the women, the cancer was diagnosed when they sought treatment for implant-related pain, lumps, swelling, or asymmetry, after their surgical sites had healed. The main presenting symptom is an enlarged swollen breast 8 to 10 years after surgery in the absence of infection. Prophylactic breast implant removal in patients without symptoms or other abnormality is not recommended.

Because of the small number of cases worldwide the vast majority of plastic surgeons will not see a single case in a lifetime of practice and the current recommendations for women with breast implants are:

Do not change your routine medical care and follow-up because ALCL is very rare; it has occurred in only a very small number of the millions of women who have breast implants Monitor your breast implants. If you notice any changes, contact your health care provider promptly to schedule an appointment.
Get routine mammography screening.
If you have silicone gel-filled breast implants, get periodic magnetic resonance imaging (MRI) to detect ruptures as recommended by your health care provider. The FDA-approved product labeling for silicone gel-filled breast implants states that the first MRI should occur three years after implant surgery and every two years thereafter.

The risk for breast cancer is 1 in 9 and the risk for ALCL is 1 in 500,000.

The American Society of Plastic Surgeons is collaborating with the FDA to develop a centralized registry to collect more information on existing case reports and any new cases that may be identified going forward. Only patients with confirmed ALCL will be entered into the registry. It is estimated that only 2 or 3 patients will be entered into the registry per year.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Skin Necrosis with Dermal Fillers

2011-01-28T12:30:00.000-08:00

The skin necrosis after dermal filler injection is due to direct injection into an artery or compression of an artery by the filler preventing blood flow. This is the only reference I could find "The most serious side effect is localized tissue necrosis, which is induced by mechanical interruption of local vascularity, though it occurs very rarely (nine in 10,000 patients who underwent collagen implantation)". This was a review of collagen fillers done some years ago. When injected with proper technique the incidence should be zero. Certain areas like the area between the eyebrows are at higher risk because of the architectural layout of the blood vessels under the skin. The incidence of heart attack from injection of a skin filler should be close to zero.

The most import thing besides proper injection technique is that if you experience inappropriate pain after filler injection and/or see significant skin discoloration beyond a little bruising your doctor needs to go into emergency mode. That could involve application of nitropaste to the skin surface, application of warmth, injection of a filler dissovling agent, hyperbaric oxygen etc. All of these modalities will minimize the amount of skin necrosis.

With appropriate care and some luck the skin necrosis will be very superficial and heal without visible scarring as in these photos.

Radiesse injectable dermal filler for nasolabial folds
Injectable Fillers - Collagen, Restylane et al
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Skin Bleaching

2011-01-19T23:20:00.001-08:00

In many countries worldwide including the Philippines, India and South America, lightening your entire face or large areas of your body is a common goal to make one's self more competitive in the marriage or job market. A lighter complexion is often seen as a way to climb up the social ladder, make new contacts, find a spouse, get a job etc.

In late 2009 Dominican-born Chicago Cubs baseball player Sammy Sosa showed up at the Latin Grammies with skin lightened by several shades. Sosa admitted to using creams to lighten his skin as well as getting bleaching treatments.

Pigment cells in the skin called melanocytes produce skin pigmentation called melanin from the amino acid tyrosine. The reaction is stimulated by genetics, sun exposure, skin inflammation or irritation and the aging process. The melanocytes put the pigment in packets called melanosomes and transfer them into skin surface cells.

Darker skinned individuals have larger sized and a greater number of melanosomes in their skin surface cells.

Hydroquinone, a molecule discovered in the late 1800s and initially used to develop photographs, can block this reaction. The ability of hydroquinone to depigment skin was first noted in 1940 in wearers of rubber gloves made with compounds related to hydroquinone. Skin discoloration (the opposite of depigmentation) from chronic over application of hydroquinone was first noted in 1960. We call this onchronosis.

Later it was discovered that the addition of vitamin A derivatives and topical steroids allowed patients to tolerate higher concentrations of hydroquinone and lighten skin more quickly. The combination was so effective that it could create complete white patches of skin on an Afro-American no matter how dark their baseline skin color was. The problem was application of 3 different creams a day was cumbersome. At that time if you combined them they would interact with room air and the resulting product (triple bleaching cream) had a very short shelf life. By the late 1990s that problem was solved so stable triple skin bleaching creams became available. I would use them to prepare patients for laser skin resurfacing and then restart the creams a week or 2 after the laser treatment. This regimen prevented the temporary increased pigmentation we used to see after laser skin resurfacing treatments.

In 1982, the FDA published a rule to propose that over the counter skin bleaching drug products containing 1.5 to 2 percent hydroquinone be generally recognized as safe and effective (GRASE). The higher concentrations of 4% or more required a prescription. In 2006 research revealed that hydroquinone taken orally by mice or rats could cause cancer. Note that humans only apply it to the skin surface at much lower doses. They do not eat it. It also has been linked with a medical condition in humans known as ochronosis (skin darkening and disfiguration) when applied topically. At that time the FDA requested more scientific testing on hydroquinone because doctors and patients protested against an outright ban. Those tests began in 2009 despite a hydroquinone ban in Britain beginning in 2001. In 2011 sales of 4% hydroquinone products was banned in the state of Texas.

Less than 10 years ago a commercially available triple bleaching cream called Triluma became available by prescription. On 11/17/10 the FDA recalled specific batches of Triluma, "Firm was notified by supplier of a subpotent active ingredient". That is not the same as a complete ban and the product can still be used. It contains 4% hydroquinone and therefore requires a prescription.

Directions for usage of both over the counter and prescription strengths clearly state that hydroquinone is to be used for only short term (4-6 months) and should be stopped if no result is seen by that time.

With prolonged exposure to hydroquinone, even the weaker over the counter formulations, there is progressive sooty darkening, inflammation, irritation, thickening and hyperpigmentation of the skin (darkened bluish/gray patches of skin). This condition is called onchronosis and individuals with darker complexions are at higher risk of getting it after prolonged use. It can occur with frequent applications in less than a year. For this reason it is recommended that hydroquinone be used for spot treatment and not all over the skin and for short durations. Allergic reactions to hydroquinone can cause dermatitis, which may lead to dark or reddened, inflamed and scaly patches on the skin.

Episode of Dr. Oz highlighting the problems with the over use of hydroquinone containing products.

For this reason it is recommended that hydroquinone be used for spot treatment and not all over the skin and for short durations. Typically, skin lightening can be seen in about four weeks. Once the desired effect is achieved, the treatment may be used less frequently to maintain results.

Those with sensitive skin, should test the hydroquinone product on a small patch of skin before applying to large areas. If no adverse reactions are seen within 24 hours, the treatment can be continued. Mild side effects such as itching, stinging or slight redness are usually temporary. More serious side effects include: burning, itching, crusting or swelling, and unusual skin discoloration one should stop using the product immediately and see a doctor if any of these reactions occur.

Lumixyl™ is a non-toxic, non-irritating, synthetic that can also lighten skin color or even out skin surface pigmentation by blocking the melanin producing enzymes. Lumixyl is an over the counter product sold through professional channels, whereas Triluma requires a prescription from a doctor.

Studies show that Lumixyl™ can reduce melanin synthesis by as much as 40 percent compared to treatments with hydroquinone, which reduced production by only 7 percent in the same study.

Other skin-lightening options include:

* Arbutin: Derived from the leaves of blueberry, bearberry, cranberry or mulberry shrubs, or from certain genus of pear, arbutin contains the natural form of hydroquinone.

* Azelaic acid: Most commonly, this ingredient treats acne, but recent studies have shown it benefits skin discoloration, too. Azelaic acid is made from wheat, rye or barley, and is usually found in creams at a concentration of 20 percent.

* Kojic acid: Derived from fungus and fermented rice, kojic acid also inhibits melanin production. Kojic acid oxidizes quickly and will turn brown if left exposed to air. Check the expiration date and be sure to store kojic acid products in a cool, dark place, away from heat or light.

* Licorice extract: A tyrosinase inhibitor, licorice extract is a potent skin lightener that disrupts skin’s melanin synthesis and also has anti-inflammatory qualities.

* Mild alpha hydroxy acids like Malic acid act as exfoliants. By sloughing off dead skin cells, they take away extra pigment and pigment cells as well.

* Dermamelan is a mixture of mild chemical peels, sunscreen, vitamin C and a natural hydroquinone like substance (Kojic Acid, Phytic Acid, Ascorbic Acid, Titanium Dioxide, Arbutine and Retinyl Palmitate) that is first applied as a mask in the doctor's office. The patient goes home with the mask in place and then applies a cream of the material on a daily basis for several months. Skin lightening is visible within 2 to 8 weeks.

Before and After Dermamelan Treatment

* Cosmelan1 is a similar cream containing Azelaic Acid, Kojic Acid, Phytic Acid, Ascorbic Acid, Arbutin, and Titanium Dioxide. It is applied in the doctor's office as a mask that is left on for a total of 4-8 hours depending on your skin type. The mask is then washed off with water and a neutral cleanser. Cosmelan2 which lacks the Arbutin is then applied at home twice a day for 2 weeks then once a day for up to a year as a maintenance cream. Redness with skin flaking and itching may be seen in the first few days of this treatment regimen. The effects begin within the first week and peak 4 to 6 weeks into the regimen.

All of the treatments described above either prevent melanin formation (which takes a week or 2 to become effective and a month or more to see results) or removes the outer surface of the skin. Lignin peroxidase is an enzyme that breaks down existing melanin so its results can be seen right away. A product containing this is scheduled for release in the United States sometime in 2011.

Some have used glutathione administered intravenously (Glutathione IV) as a skin-whitening agent. It has to be administered intravenously because it is destroyed by acid in the stomach and liver enzymes in the intestines. It may induce a skin-whitening effect by inactivating the enzyme tyrosinase, which is needed in melanin skin pigment production and converts the pigment to the lighter pheomelanin. At very high doses it is unsafe and may result in serious consequences such as the deadly Stevens-Johnson syndrome and toxic epidermal necrolysis; thyroid function derangement; suspected kidney dysfunction, potentially resulting in kidney failure; and severe abdominal pain.

Anything that lightens the skin automatically makes it more sensitive to sun damage including sun induced skin cancers. Also sunlight exposure directly counteracts the effects of skin bleaching creams. So these products should always be used in conjunction with sunscreens. You can get more information about sunscreens at my blog Suntanning and sunscreens

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

The drooping nasal tip - drooping tip of the nose

2011-01-04T23:41:00.000-08:00

Drooping nasal tip is a term used to describe downward movement of the nasal tip with smiling. More severe forms of this include shortening of the upper lip with the appearance of a horizontal crease and elevation of the outer lower edge of the nostril in the same motion.
Drooping Nasal Tip With Upper Lip Shortening and Horizontal Crease on Smiling
This appearance is created by the actions of the levator labii superioris alaeque nasi and depressor septi nasi muscles.

>Muscles That Cause Drooping Nasal Tip

The treatment is to prevent the actions of the muscles. This is achieved by cutting the depressor septi nasi via an incision in the floor of the nose or the inside of the lip and transecting the outer portion of the tip cartilage with a portion of levator labii superioris alaeque nasi so that it can no longer raise the outer lower edge of the nostril.

The commonly performed trimming of the tip cartilage also helps to rotate the tip upward.

Rhinoplasty
Correction of the Pinched Nasal Tip
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Treatment of Vitiligo, Hypopigmentation and Hypopigmented Scars.

2010-12-20T14:58:00.000-08:00

Lighter colored (hypopigmented) areas of skin can be due to skin damage with scarring or for unknown reasons. When the cause is unknown the process is called vitiligo and is presumed to be due to an autoimmune phenomenon or a viral infection. Regardless of the cause the common factor between all of them is white patches of skin where the skin pigment cells called melanocytes have been killed. If the line width of the area is in the order of a few millimeters application of a tattoo needle without tattoo pigment or application of an excimer laser has corrected the problem. Tattoos have also been employed but this is impractical when the hypopigmented patches are large. Tattooing a skin color into the white patch has not been reliable as the approximation of any given individuals native skin color is very difficult. Of course cover make up has been around for centuries and can provide adequate camouflage but has to be repeatedly applied.

With modern scientific knowledge and technical know how these larger hypopigmented areas can be effectively treated. The process involves harvesting skin from one area as with a very thin skin graft. Pulverizing that skin into a thin paste and then spraying it onto the hypopigmented area after the area has been dermabraded to create a raw surface. The process is much easier to perform using the Recell device depicted in this video.

Before and 16 weeks after dermabrasion and cell spray application to inner left ankle vitiligo

Before and 7 months after laser abrasion and cell spray application to the forehead for depigmentation from chemical peel and previous laser dermabrasion

In these cases the depigmented areas were repopulated with pigment cells.

Before and 6 months after dermabrasion and cell spray to decrease the pigmentation of a skin graft placed for a scald burn

Vitiligo of the Lower Lip

This cell spray methodology can clearly increase or decrease skin pigmentation in the appropriate patient but the evenness and intensity of the resulting re-pigmentation is not predictable. For larger areas more than one treatment session may be required. The treatment may also be limited in Afro-Americans or others who are prone to keloid or bad scar formation. In such cases it would be prudent to first test patch a small patch of skin with dermabrasion or laser abrasion to make sure the patient does not form bad scars after the procedure.

July 5, 2011 addendum:
A just released report describes the use of topical bimatoprost 0.03% ophthalmic solution (a prostaglandin F2-alpha analogue) in the treatment of vitiligo. 1 drop is applied per 2 cm2 of affected skin twice daily for 4 months. Repigmentation begins after 2 months of application and more than half of patients get the majority of the area repigmented. Vitiligo less than 6 mohnths old responds better than older patches of vitiligo. Facial areas respond more quickly (generally within 4 to 6 weeks) with less risk of recurrence after the 4 month treatment period than other areas of the body. This may end up being a cheaper alternative to surgery.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Botox Resistance or Fatigue

2010-11-26T11:50:00.000-08:00

Botox resistance or fatigue occurs when the injection does not last as long or is ineffective. If the botox is fresh and effective this can be due to circulating antibodies against Botox formed by the body in response to previous injections or changes in the muscle itself over time.

Zytaze (a zinc and phytase prescription medication) given in oral capsule form 2 capsules a day for 4 days (total 10 capsules) prior to Botox injections to patients who responded poorly to Botox injections improved the effect of the Botox injections or how long they last. It is dispensed as 10 per box. This was studied in patients with uncontrolled eyelid twitching (blepharospasm) treated with Botox but should also hold true for Botox administered solely for cosmetic reasons. The mechanism as to why this supplement would be effective or how it works are not known.

Contraindications to botox injections include pregnancy, breast feeding, allergies to components in the botox (human albumin), neuromuscular disorders (myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis) and use of medications that strengthen the effect of botox (quinine, calcium channel blockers and aminoglycoside antibiotics).

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Stem Cell Face Lifts

2010-10-27T14:13:00.000-07:00

Stem cells are cells that can turn into any one of a number of cell types hence the term pluripotential. Some stem cells can only turn into one of a specific cell type (multipotent, oligopotent etc). The majority of cells in an embryo have not fully differentiated or turned into their final cell type be that a skin, liver, heart or muscle cell. The majority of cells in an adult person have turned into their final cell type. Furthermore that final cell type if it is a dividing cell will only produce more of the same cell type. Stem cells can divided into more stem cells or turn into different types of cells such as skin, muscle etc. Much media exposure has been given to the embryonic stem cells, mostly those that would otherwise be discarded at fertility clinics rather than implanted. This blog is about those stem cells found in an adult human. Apparently many of these stem cells are located in the fat layer that covers the body just under the skin layer and they can be harvested by a simple liposuction procedure. Stem cell treatments have been proposed for everything from spinal cord injuries to stroke, alzheimer's, diabetes, parkinson's, arthritis, organ or limb regeneration etc. The can fix anything including the kitchen sink.

I discussed free fat grafting in my previous blogs
free fat grafting
injectable dermal fillers.
As I had stated the benefits of fat grafting are well established in terms of facial, hand etc rejuvenation with improving quality of the overlying skin as well.

Now some surgeons are claiming that they harvest the fat and then treat or manipulate it in some way to increase the content of stem cells . One surgeon employs a laser to do this. Others use a centrifuge with washing etc. They then inject the fat as a free fat graft and claim it is much better than a fat graft alone. Some do this in the face and call it a non-surgical stem cell facelift. Others do it in conjunction with a regular facelift and advertise it as a new and improved facelift. One surgeon is doing a regular facelift and injecting harvested liposuction fat without any processing into the face. This is being advertised as a stem cell facelift which is considered unethical marketing. It is just a facelift with free fat grafting.

There currently is no scientific data that supports any of these claims for the benefit of fat stem cell injections . No one can say for sure that these treatments and manipulations actually increase the number of viable stem cells in the finally injected fat or that doing so is better than just injecting small fine lines of fat that have not been exposed to room air. It is interesting that when fat grafting first started to be employed different surgeons prepared the fat in different ways in order to get "better results". These included washing the fat, straining the fat, putting the fat in insulin etc. Most of these methodologies have since fallen out of favor. Now it seems we have come full circle and are back to treating the fat before re-injection.

On the face of it these look like marketing ploys by these doctors to try and differentiate the services they offer from other doctors. That does not mean their work is necessarily bad, it may be good but that does not justify increased costs related to these marketing gimmicks.

Furthermore the stem cells become less potent at being able to differentiate or to change into other cell types as we age. Diseases associated with the aging process such as diabetes also directly affect the capability and the potency of these stem cells. So, the younger you are the better able your stem cells are to function. Facelift patients are typically older and it may turn out in the distant scientific future that patients will donate fat derived stem cells when they are younger and keep them in storage until they are needed for facelifts etc.

May 9, 2011 Addendum:
A joint task force at the annual meeting of the American Society of Plastic Surgeons and American Society of Aesthetic Plastic Surgeons released a position statement at the meeting recommending against the marketing and promotion of stem cell procedures in aesthetic surgery until there is adequate clinical evidence to support doing so. They also stated that the efficacy and safety of doing these procedures had not been proven. They recommended that terms such as "stem cell therapy" or "stem cell procedure" should only be used to describe treatments or techniques where the collection, concentration, manipulation, and therapeutic action of the stem cells is the primary goal, rather than a passive result, of the treatment and these should only be currently performed within clinical studies under Institutional Review Board approval. That means if the surgeon does the procedure it should be considered investigational or experimental and follow standard consent and review rules for such studies. These consent forms are different from those used in standard cosmetic surgery.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

New Botox Available in US in September 2010

2010-09-14T15:09:00.000-07:00

A new type of Botox called Xeomin (Merz Pharmaceuticals] will become available in the US in September 2010. The drug was approved by the FDA in August 2010 for treating certain neuromuscular conditions, such as blepharospasm (chronic blinking), cervical dystonia (tight neck muscles that distort the head's position). It is not yet approved for cosmetic purposes to treat dynamic wrinkles between the brows and on the forehead. Such use would be considered off label but Botox was used in such an off label fashion for years before it received FDA approval for cosmetic use.

That means we will now have 3 products available, Botox, Xeomin and Dysport to treat aging wrinkles of the face. More Dysport has to be injected to get the same results as Botox but since the per unit price is cheaper the end cost to achieve a given result is the same for Botox and Dysport. Xeomin is formulated differently in that it does not contain the complex proteins found in the other 2 formulations. It is too early to say if this is a positive or negative attribute. It could lead to migration of the Xeomin away from the injection site with more side effects or it could mean you will not form antibodies or develop resistance to the medication after many injections.

Since the price of Botox did not change after the introduction of Dysport is likely those prices will not change after the introduction of Xeomin. That may be due to Dysport's failure to steal market share from Botox but only time will tell.

Countries where plastic surgery is most popular

2010-09-08T14:52:00.000-07:00

The International Society of Aesthetic Plastic Surgery recently conducted a survey and came to the conclusion that the countries where plastic surgery is most popular or the largest number of per capita procedures performed are :
1. United States
2. China
3. Brazil
4. India
5. Mexico
6. Japan
7. South Korea
8. Germany
9. Turkey
10. Spain
11. Argentina
12. Russia
13. Italy
14. France
15. Canada
16. Taiwan
17. United Kingdom
18. Colombia
19. Greece
20. Thailand
21. Australia
22. Venezuela
23. Saudi Arabia
24. Netherlands
25. Portugal

Brazil and China have taken the place of Japan and South Korea in previous surveys. The emerging markets of the world have emerged.

Abdominoplasty - MuscleTightening + Diastasis Repair

2010-08-27T14:19:00.000-07:00

This is how much muscle tightening I was able to achieve from this week's abdominoplasty for a mommy makeover.

The placement of the vertical row of sutures is the repair of a diastasis and in doing this repair the abdominal muscles are tightened. In this case I placed an extra horizontal row of sutures at the belly button level to get even more muscle tightening.
Mommy Makeover Surgery - Abdominoplasty
Abdominoplasty - Tummy Tuck
Mommy Makeover Abdominoplasty - Tummy Tuck on Youtube
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Botox Manufacturing Kills Mice

2010-08-09T17:08:00.000-07:00

I just found out today that for every batch of botulinum toxin created, tests are performed on laboratory mice. The test employed is the LD 50, that is the dose of botox that kills 50% of the mice it is given to. After the toxin is administered by a needle stick to the belly impaired vision, paralysis and respiratory arrest follow. Those that die suffocate. The process takes three or four days. The surviving mice are then euthanized. It is estimated that worldwide at least 600,000 mice die in the production of botox each year. In the European Union alone, tens of thousands of animals are estimated to be used in this testing per year. As the use of botox increases so does this number. Europe has a ban on animal testing for cosmetics but botox is considered a medical treatment so the ban does not apply. There currently is no other assay available or in use to determine botox strength and doseage in each batch of botox that is manufactured.

July 26, 2011 addendum:
Allergan (the manufacturer of Botox) spent $65 million on more than a decade of research that led to a new animal-free test, testing the effect of Botox on cells in a lab dish. The Food and Drug Administration approved the test in June 2011. Allergan estimates it will be able to reduce its animal testing by 95 percent over the next three years as countries outside the United States approve the new procedure as a replacement for the old LD50 test.

Baby Ear Deformity - Deformed Baby Ear

2010-07-05T11:43:00.001-07:00

25% to 35% of babies born in the United States each year are born with an ear deformity. That is 1.5 million babies each year. There are 4 types of ear defects:
1-small or absent ears
2-folded ears also called lop ear where the top of the ear is folded downward or Stahl's ear when the top of the ear is pinched like a Star Trek Vulcan look
3-cup or constricted ear which looks like there is an invisible ring around the ear squeezing it
4-protruding ears that stick out from the sides of the head

Either or both ears can be involved in any of these processes. Historically 2 and 3 have been treated preferably shortly after birth with the application of splints that were made for each patient. Since the baby has its mother's estrogen flowing through its blood stream for a month or so after birth it is thought that this estrogen makes the baby's young cartilage malleable. Therefore if you hold the infant ear in a specific position for a month or more it will then keep that shape after the splint is removed. If you to wait until later in childhood or teenage/adult years the splints will not work and surgery will be required which never gives as good a result as splints applied during infancy.

Now we have commercially available ear splints called Earwell that can be easily be modified for each baby, are easy to apply and give consistent good results.

These Earwell splints stay in place about 14 days and 3 serial applications are usually sufficient to correct infant ear deformities. That is a 6 week long treatment protocol.

Results Achieved After Application of Earwell Ear Splint for Baby Ear Deformities

The results after application of this splint have been very good in infants under 2 months of age, less so in 2 to 4 month old infants and only partial correction in those over 4 months of age. 6 to 8 weeks of treatment with the splint are required and the earwell splint adhesive loosens so the earwell has to be replaced about every 2 weeks. Most medical health insurance plans cover treatment with the earwell splint.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Hidradenitis of the Armpits

2010-06-22T12:52:00.000-07:00

The skin contains two types of sweat glands, the eccrine and the apocrine. The eccrine glands are distributed over the entire body's skin surface. The apocrine are found only in the armpits, groin, anal and pubic areas and the crease under the breast. Apocrine glands are 1arger than eccrine, are located more deeply in the skin and are derived from hair follicles. They do not function until the age of puberty. In lower animal forms the apocrines are a scent g1and of sexual function. Apocrine glands are more numerous in females and in Afro-Americans. Apocrine sweat secretion contains part of the gland itself while eccrine sweat glands produce a water like secretion without any disruption of the gland.

Inflammation of the armpit glands or Hidradenitis, was first described by Velpeau in 1839. In 1854, Verneuitt suggested that this condition might arise from the sweat glands of the skin and described the clinical condition which is now recognized as hidradenitis suppuritiva. Since then, physicians have recommended many forms of treatment for this entity: lotions, vaccines, fever therapy, toxoids, steroids, ultraviolet light, X-rays, antibiotics, and surgery. The disease does not occur before puberty because the apocrine sweat glands do not function at that age.

Hidradenitis is not caused by deodorants, antiperspirants are hair removal creams/procedures. Usually, a plug of dead skin in the apocrine gland's duct initiates the infectious process as bacteria multiply within the plugged gland. The obstructed gland ruptures into the deep layers of the skin; adjacent glands become involved; and abscesses form. Subsequently, multiple draining sinuses or holes appear on the skin surface and the whole hairbearing area may become inflamed. Such inflammation may result in star shaped skin scars and tunneling, causing ridging of the skin.
In this case of Hidradenitis of the armpit of many years duration multiple draining sinuses or holes on the skin surface, star shaped skin scars and tunneling causing ridging of the skin are easily seen.

This chronic infection usually continues for years with periodic remissions. The problem is these specific glands, the material they secrete and the way in which they secrete it. The disease is most common in the second and third decades of life and is three times more common in women. Only rarely is it controlled or cured with medications alone. The treatment for active infection is incision with drainage of the pus. The cure is to cut out all sources of infection and closure of the resulting wounds directly or with skin grafts or preferably skin flaps while the process is in a quiescent phase. The best appearing results are after direct or skin flap closure. Hence the need for a plastic surgeon.

When those sources of infection are removed they cannot cause any future problems. However, glands that have not been problematic to that point in time may become so at a future date. Although that is a theoretical possibility I have not seen that happen in my patient population. The most common problem I see after surgery is some separation of the suture line days to weeks after surgery. This is due to the tension of closure and the condition of the skin, which prolongs the healing process. In all cases these small separations have healed without any further problems. To decrease the risk of this happening and make any such separations smaller I place a few mattress sutures which approximate the skin edges without applying any tension to the edges.

TREATMENT
Treatment should take account of the phase in which the process is observed. In the initial stages, corticosteroid preparations are useful. During acute flare ups with draining pus incisions are made to ensure all of the pus is removed and the patient is given antibiotics. You cannot removed the infected skin during these flare ups because you will not be able to suture the cut edges together in this infected environment.

When the chronic phase with sinuses is present only surgery will be effective. The operative treatment should consist of complete surgical removal of the involved area. Closure should preferably be with local flaps of skin. Free skin grafts are useful in certain cases.
If you just cut out the hidradenitis and try to suture the wound closed the edges may not meet with larger excisions and if they do meet the resulting scar and skin loss usually restricts arm movement.

Historically the remaining wounds were aloud to hear on their own which took months. A period of wound closure with skin grafts followed but only one armpit could have surgery at a time, the grafted armpit had to be immobilized with an airplane splint holding the arm out to the side for 2 weeks and the act of obtaining the skin graft created a remote area of skin scar elsewhere on the body. Also the skin grafted area is a different color than surrounding skin and lies in an indented area so the result is less aesthetic than skin flap procedures.

Airplane Splint

With improvements in plastic surgery techniques in the 1950s and 1960s a switch from skin grafts to skin flaps for closure after excision took place. The initial flaps used for this came with their own set of drawbacks. They were quite large and required skin grafts to close the area where the flap came from.
Combination Skin Flap Skin Graft Closure

Then came skin flaps that were designed in such a way that skin grafts were no longer needed.

Skin Flap Only Closures

Then it became common knowledge that it was better to have 2 smaller flaps than one large one as that kept the scar confined within the armpit, still allowed closure without skin grafts, had a quick recovery without the need for splints, allowed a quick return to work, maintained arm range of motion and could be performed as outpatient surgery all without compromising the amount of armpit tissue that could be removed.
Z-plasty Closure

CASES
Closure with Flap from the Back
For more extensive disease the hole after removal is so great that I can only close it by moving a flap of skin from the back into the armpit area. In this case the after photo was taken 10 years after surgery without any recurrence of hidradenitis in that 10 year period.

For less severe cases or those who have surgery earlier I prefer 2 opposing V to Y advancement flaps of skin.

Excision with V to Y Flap Closures Maintains Range of Motion Without the Need for Splints
In this case the surgery was performed while the hidradenitis was in a quiescent phase so the armpit in the before surgery photo does not look so bad but it looks much worse when the disease is active and there is pus draining out of the skin sinuses. The surgery is considered successful because she no longer has active periods with draining pus and she has retained full range of motion. The cosmetic look of the armpit after surgery vs. during the quiescent phase before surgery is not a factor here.

The flap techniques used by plastic surgeons to close these wounds are based on the same principles we use to perform facelifts and tummy tucks. In those cosmetic procedures we take out the excess skin and close the wound with flaps of skin. In this case we take out the hidradenitis and then close the wound with skin flaps of skin.

Hidradenitis can occur around the anus in which case one needs to make sure there is no anal fistula or perirectal abscess before proceeding with surgery.

Surgical Treatment of Hidradenitis
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Nasojugal crease, tear trough deformity, nasojugal groove, bags under eyes, under eye hollowness

2010-04-26T10:52:00.001-07:00

In the young individual the transition between lower eyelid and cheek is imperceptible. The dividing line between these areas in older individuals is the nasojugal crease also called the nasojugal groove (term first used in 1961) or tear trough (term first used in 1969). It is an early sign of aging around the eyes, lending a fatigued and aged appearance to the face. As part of the aging process ligaments that fix facial skin to the underlying facial bones thin and lengthen or stretch, facial bones recede back and facial fat shrinks. This results in the drooping of facial skin and appearance of laugh lines, jowls, nasojugal creases, eyelid bags etc.. The skin within the nasojugal groove or crease becomes thinner and/or darker in color than the slightly lower nose or cheek skin. It can also seem deeper or be more visible if there is protrusion of fat into the lower eyelid. The aging process starts near the nose as the tear trough and progresses outwardly towards the same side ear becoming what is called the palpebromalar groove.

Tear Trough and Palpebromalar Groove Boundaries

Examples of Tear Troughs in Younger Patients Without Protruding Eyelid Fat

In the aging eye a loose orbital septum membrane and/or receding bone under the eye allow eyelid fat to bulge outward making the tear trough more noticeable.
Aging Patient with Protruding Lower Eyelid Fat Making the Tear Trough and Palpebromalar Creases More Visible
Plastic surgeons treat the nasojugal crease or tear trough in a number of ways. Drooping tissue can be lifted up with the aid of sutures, material (fat or synthetic fillers) can be injected or placed right into the crease line to efface it or implants can be placed to replace the absorbed receded bone. It is difficult to treat the area because the soft tissue between the edge of bone and outer skin surface is so thin and the skin is very thin as well. Because most of this soft tissue is in fact muscle with little fat or skin there is a tendency for anything injected into this area (restylane, fat, sculptra etc.) to form visible lumps and/or be visible through the thin skin. Muscle movement also tends to make the injected material coalesce into lumps. The width of area you can safely inject into is very thin and if you inject right on the bone or just under the skin you will have a problem with most fillers. Some surgeons therefore advocate placing an implant made of silicone, medpor or goretex right on the edge of bone under the eye with the thought of augmenting to replace lost receded bone.
For over 50 years plastic surgeons removed the eyelid fat through a skin incision (as in this Afro-American patient) or an incision on the inner surface of the eyelid when performing lower eyelid blepharoplasty. This approach hollowed out the eyes and accentuated the appearance of the tear trough. Although it got rid of the protruding eyelid fat it did not restore the youthful invisible transition between lower eyelid and cheek.

The facial skin is different than other areas of the body in that there are ligaments directly connecting the deep surface of the skin to the bone. In the palpebromalar groove the ligament is called the orbicularis retaining ligament. Lower down on the cheek is another ligament called the zygomatico-cutaneous ligament. The reason for all this is that different parts of the face move separately and with variable ranges of motion. Without these separating ligaments facial expression could not be so diverse.

The zygomatico-cutaneous ligament can be tighter or shorter relative to the other ligaments causing a line along its length or malar bags to appear.

TREATMENT BY INJECTION
37 Year Old Right After Injection of Hyaluronate Filler
Injection works best for patients with thick, smooth skin, and a well-defined tear trough, without excessively protruding lower eyelid fat. Patients with extremely wrinkled skin and less of an actual indentation to fill do less well with injections. The larger the overhanging eyelid fat, the less improvement you will get from filler injection alone. The older and more crepe-like the skin, the less well the injection works.

In the tear trough, hyaluronic acid like restylane or juvederm lasts far longer than it does in the lips and nasolabial folds. One to 1½ years is not uncommon. Only small amounts 0.2 to 0.4cc are injected at a time and into or beneath the muscle. Then massage is used to even it out and prevent lumps but over massage can displace the filler. Some doctors prefer using a blunt tipped needle to avoid piercing any blood vessels under the skin. If you need skin removed as well its better to have it removed and then recover before doing the injection. Filler injection is not a substitute for surgery in those who would benefit from surgery i.e. have protruding eyelid fat or excess lower eyelid skin.

TREATMENT WITH IMPLANTS
Implant and outline of implants used with notch for sensory nerve to cheek

Before and After Placement of Infraorbital ImplantsThis seems excessive given the results that are currently achievable by injection as depicted above.
I prefer to use implants only if the vector of a perpendicular from the cornea drops down in front of the cheek tissue, a negative vector. In such cases the use of an implant can convert the patient to a positive vector and significantly add to the end result. The presence of a negative vector in and of itself also makes the tear trough more visible over time.

This patient had a negative vector that was improved with the use of an implant.

TREATMENT WITH FAT GRAFTS OR MANIPULATION OF EYELID FAT
This is my preferred approach because it gives virtually permanent results with less risk and a natural look but it cannot be performed on every patient.Cutting the orbital septum membrane allows eyelid fat to be used to fill the groove with or without removal of excess skin (first described in 1981)

In this patient I removed excess eyelid skin via an incision just under the eyelashes, cut the orbital septum membrane and sutured the eyelid fat to the deep cheek fat. Only a small amount of eyelid fat was trimmed away or removed.

This younger patient had no excess eyelid skin so I only cut the orbital septum membrane and then sutured the eyelid fat to the deep cheek fat. I did not remove any fat from the eyelid.

In older patients with hollowed out eyes that are undergoing a facelift I prefer to take some superficial cheek fat (SMAS) and place that is a graft over the edge of the bone. That gives much the same result as the filler injection shown above with almost no risk of lumps or unevenness and the added advantage of being permanent.

The most difficult patients to treat are those with protruding eyelid fat that moves in and out of the eyeball socket as the eye is moved around. If you just suture the eyelid fat to the deep cheek fat the continual backward forward movement of the fat will separate it from the cheek fat and over time lead to a recurrence of the problem.

Blepharoplasty
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Gynecomastia

2010-04-25T09:58:00.001-07:00

Gynecomastia means enlargement of the male breast. The definition has nothing to do with what causes the enlargement or what tissue it is composed of. It is most common around puberty & can involve one or both sides of the chest. Most commonly the enlargement is centralized in the breast but occasionally it is not. It is present to some degree in about a third of male population. It appears either early in adolescence or later in the adult years of life and can be very disruptive in the life of a teenager or adult. Working out in the gym, going to the beach and changing in the locker room can become unpleasant ordeals.

The causes can be classified as:

Pathological

Deficient production or action of testosterone
Congenital defects
Testicular infection
After testicular trauma
Increased estrogen production as occurs with obesity or certain tumors
Tumors within the breast or other organs
Liver, adrenal or thyroid disease including alcohol induced liver disease
Decreased serum testosterone from kidney failure & hemodialysis

Drug Induced

Steroids including anabolic steroids used by body builders
A wide variety of prescribed medicines such blood pressure medication
Heroin
Marijuana

Familial-inborn error of metabolism

The majority of cases are physiological or drug induced. Evaluation
by a qualified physician is required to see which category you fall into.
The treatment of the physiological category is straightforward while the
pathological is more complicated. Drug induced gynecomastia just requires
stopping use of the drug. If the gynecomastia is resistant to treatment
or is the adolescent type but persistent surgery is required. Gynecomastia arising before the onset of puberty requires a vigorous diagnostic workup because of the possibility of life threatening or shortening pathology.

Grades of Gynecomastia
The specific surgery required for treatment depends on the type of tissue contributing to the breast enlargement and the severity of gynecomastia i.e. the amount of extra skin present. Gynecomastia is graded as follows:

Grade I =Small breast enlargement with localized button of tissue that is concentrated around the areola. This is usually glandular with minimal fat contribution and only requires surgical removal of the glandular tissue. I prefer to do this through an incision around the lower half border of the areola so it is less visible after surgery.Grade I Gynecomastia

Grade II =Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. These are fatty-glandular and require surgical removal of glandular tissue with or without removal of adjacent fat to give the best overall shape. I prefer to remove this fat using liposuction because that gives the best skin surface contour afterward. Usually these patients do not require any skin removal.Grade II Gynecomastia

Grade III =Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. This patients require skin removal and the pattern of removal/incision is based on the amount of skin that needs to be removed. Smaller skin removals can just be ellipses or half moon shaped sections right next to the areola.Grade III Gynecomastia-moderate severity
Grade III Gynecomastia-more severe

Grade IV =Marked breast enlargement with skin redundancy and feminization of the breast. These require removal of breast tissue under the skin and the breast skin as well.Grade IV Gynecomastia

The American Society of Plastic Surgeons has recommended health insurance coverage for grade III and IV adult gynecomastia. Surgery for grade I and II is not considered medically necessary, it is cosmetic and therefore insurance coverage is not recommended. Individual health plans however differ in their written policies for coverage of gynecomastia. At least in California coverage of Grade IV is mandated by state laws regarding insurance coverage of reconstructive surgery.

Dealing with Extra Skin
The way to assess the amount of excess skin is to take the measurements depicted above. The sternal notch to nipple distance should be 18 to 20cm, the midline to nipple distance should be 11cm, areola diameter should be 3cm and the nipple to chest abdomen junction should be 5 to 6 cm apart. Deviations from these measurements should be taken into account when planning the pattern of skin removal that needs to be removed at surgery. In most patients with extra skin the breast tissue has stretched the overlying skin, gravity pulls it downward and the treatment is simple removal of a crescent of skin above the areola. Some surgeons believe that the skin will shrink after removal of the underlying breast tissue and therefore never remove any skin. Although this may be true for patients in their early teens I do not believe that is the case for adult patients past that age. In my experience these patients are very unhappy if excess skin when present is not addressed at the same surgery.

After liposuction and rhinoplasty, gynecomastia surgery is the third most common cosmetic surgery procedure performed on men in the United States.

CASES

This is a 29 year old, 5' 11" tall, 186 pound indvidual with sternal notch to nipple distances of 23cm and nipples 11cm from the midline. These measurements indicate that there was excess skin before surgery. I performed liposuction to remove the fat portions, directly cut out the glandular portions behind the nipples and then cut out 2cm high crescents of skin from just above the areola. I chose that method to get the most results with the smallest amount of skin incisions.

This is a 29 year old, 5'10" 220 pound individual who had lost 130 pounds by dieting. This left him with a lot of excess skin over large areas of the body. In this case I cut out the excess fat and removed a 1cm crescent of skin from the upper edge of the areola. He had an abdominoplasty - tummy tuck at the same time and I was able to pull some chest skin down towards the abdomen in the process which gave him more chest skin tightening with less chest skin scarring.

This is a 33 year old individual with feminizing features. The sternal notch to nipple distance was 21.5cm on the right and 22cm on the left, midline to nipple distance was 8cm and areola diameter was 4cm. This case is clearly more severe than the others and in order to achieve a male appearance the nipples have to be shortened, the areola diameter decreased and extra skin and breast tissue removed. I did so by removing an ellipse of skin with underlying breast tissue. The upper edge of the ellipse lied above the areola while the lower edge was at the chest-abdomen junction. I then sutured the edges together and created a new smaller hole for nipple and areola in a better position on the chest wall.

Gynecomastia
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Asian Rhinoplasty - AfroAmerican Rhinoplasty

2010-03-29T22:39:00.000-07:00

There are 3 main types of noses - Caucasian, Asian or Oriental and African. The Asian nose has characteristics between those of the Caucasian and African. Today one increasingly finds mixed features between these groups as well so some individuals can have a Caucasian tip with an African bridge or vice versa. The most visible difference is the more vertical nostril alignment with a longer strip of skin between the nostrils in the Caucasian nose vs. the Asian or African nose. The Asian and African nasal bridges are flatter and broader than the Caucasian. In some cases the bridge may be so flat that it appears scooped out or ski sloped. The nasal tip skin is usually thicker with a more rounded tip in the Asian and African noses. The thinner nasal tip skin in the Caucasian nose makes the tip cartilages and their shapes more visible on external viewing.

As you can see in the above diagram these differences are due to differences in the skin but mostly due to differences in the underlying bone and cartilage. In Asian and African noses:

the tip cartilages tend to be buckled at the dome of the tip and unfurled giving the individual less tip projection

there is less nasal bone at the top of the bridge

the nasal bones extend more outward to the left and right sides creating a wider bridge

the septal - bridge cartilage does not extend as far outward and forward into the tip

This photo shows the narrower higher bridge and less rounded tip in the Caucasian on the left. In the Asian on the right the bridge is flatter and wider and the nostrils are oriented more horizontally. Consequently the tip of the nose does not project outward as much from the face as in the Caucasian. If you examine the Asian nose closely you will see that the deficit in forward projection of the nasal bridge bones is greater than that of the bridge cartilages.

Implant Augmentation of the Nasal Bridge
The most common part of Asian rhinoplasty or AfroAmerican rhinoplasty is insertion of an implant or cartilage graft to augment the bridge. This is depicted in the above diagrams. Since the bridge nasal bone deficit is usually greater than the bridge cartilage defect (the cartilage usually projects 2 or 3mm more outward/forward than the bone) I place an implant that is double thickness over the bone portion and single thickness over the cartilage portion. The only other option would be to cut back the cartilage to the level of the bone before placing the implant. I do not like that approach because it creates an irreversible situation should the patient have a future change of heart/mind. Augmenting the bridge will indirectly change the nostril orientation making it more vertical as in the Caucasian nose in the first diagram in this blog.

The tip procedures performed at the same operation are highly variable from patient to patient because of the variances in how they want the tip to look.
Suture Shaping of the Tip of the Nose
Most commonly the tip cartilages are advanced forward and sutured together (re-furled) in order to make the nostrils more vertical and increase forward projection of the tip.Infracture, Tip Surgery & Tip GraftingAdditional procedures performed are depicted here. On the left the broken black lines above the tip represent the infracture performed under the skin to narrow the bridge. The broken black line in the nostrils signifies where tissue is removed to narrow the distance between the outer edges of the nostrils when they appear flared before surgery. And the broken line on the tip cartilages represents where cartilage is removed in order to refine and raise the tip. This gives the final result in the middle. If the patient then wants a less round or more Romanesque look tip cartilage or synthetic grafts are placed on the dome of the tip (depicted here in grey).

CASES

For this patient I sutured the tip cartilages together advancing the tip forward 4mm. I removed 4mm from bottom of each nostril to narrow the outer nostril edge to outer nostril edge distance and reduce the nostril flaring. The bones were infractured to narrow the bridge width and a medpor implant was placed on top of the bridge. As described above the implant was double thickness over the bone part of the bridge. Additionally I placed a batton between the septum and the tip cartilages to correct the retruded strip of skin between the nostrils. A tip graft was not placed because this patient wanted to keep her ethnic round tip appearance.

For this patient I removed the upper part of the tip cartilages so the tip would rotate upward slightly, advanced (re-furled) the tip cartilages 3.5mm, removed 3mm from the bottom of each nostril, infractured the nasal bones, placed a synthetic bridge graft (double thickness over the bone portion) and placed a tip graft of medpor. The tip graft was placed to make the tip less round and forward project the tip a few millimeters.

As you can see from the before and after photos this surgical regimen allowed us to meet the desired goals. The after photos were taken shortly after surgery so there is still some significant swelling.

Asian Rhinoplasty
Asian Rhinoplasty 2
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Even a dog can benefit from a facelift

2010-03-09T12:44:00.001-08:00

As you can see even a dog can benefit from a facelift. This Shar pei required a facelift because the extra folds of skin were damaging the dog's eyes.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Axillary Hyperhydrosis Hyperhidrosis - Excessive Armpit Sweating

2010-02-22T14:01:00.001-08:00

Excessive seating from the armpits can be very debilitating causing a bad odor, staining of clothing and restriction of social as well as exercise related activities. This problem can also affect the palms of the hands or soles of the feet.

Sweat glands maintain skin surface health and regulate body temperature by supplying water to the skin surfaces for evaporation. Two types of sweat glands are present over human skin, eccrine and apocrine glands. Millions of eccrine glands are distributed throughout the entire body surface and produce a high salt content sweat that is excreted directly onto the skin through an excretory duct. The greatest density of these glands is found in the armpit, palm, and sole of the foot. The apocrine sweat glands are less in number and are distributed over the armpits, around the anus, around the breast nipple complex, and eyebrow regions. In addition to salt, the sweat from these glands contains fat and cholesterol and is excreted indirectly by passing through the shaft of hair follicles. The apocrine gland is 10 times larger than the eccrine gland, and both are present in equal numbers in the armpits. The apocrine glands start secreting at puberty and stop after menopause in women. Overproduction of either gland in the presence of certain skin surface bacteria can produce a bad odor. Clogging of the apocrine glands leads to a condition called hydradenitis suppuritiva with abscesses and draining pus. The treatment for this is surgical removal of the glands together with the damaged skin and then surgical closure of the resulting wound.

The treatment of excessive sweating alone is more straight forward though a number of treatment modalities have been used to reduce the volume of sweat produced. However no single treatment is without its weakness or complications.

non-surgical treatments produce acceptable results with minimal risks but are not permanent

topical antiperspirants and deodorants

Agents applied to the skin achieve their effect either by blocking the excretory ducts of the eccrine glands or are astringent, acting on the sweat glands and the skin surface. A commonly used effective antiperspirant is aluminum chloride hexahydrate. Drawbacks to this treatment include its short-lived effect, with continued success depending on daily application. Skin irritation is a potential complication of treatment and may be intolerable.

oral medications

Anticholinergic medications, such as glycopyrronium bromide and propantheline bromide, can be used but have a number of unpleasant side effects that limit their usefulness. Common side effects of these drugs include a dry mouth, blurred vision, urinary retention, and constipation, and generally exclude long term use.

botox injections into the armpits or palms

Botox is particularly useful in the treatment of focal areas of excessive sweating. Multiple injections spaced 1 to 2.5 cm apart into the affected area are required. The duration of the therapeutic effect of botulinum toxin varies depending on each individual and the dose given, with a return of sweating reported after a gap of between 3 and 8 months. Reports of continued adequate control of sweating at 1-year have been reported using a higher dose, with 500 units of botulinum toxin being injected into each armpit. Weakness of the small muscles of the hand can be a problem in the treatment of palm sweating, leading to a weaker grip. The major drawback to this treatment is the discomfort associated with the use of multiple injections particularly in the treatment of the palms of the hand and soles of the feet.

surgical treatments are a valuable option for treatment but because of a number of potential complications, surgery should be reserved for only the more aggressive forms of the disease that remain unresponsive to non-surgical treatment.

endoscopic transthoracic sympathectomy or Thoracoscopic sympathectomy.

Sympathetic nerve fibers in the upper back chest cavity supply the eccrine glands of the palm and armpit. Cutting these nerves stops sweating mostly in the palms and to a lesser extent in the armpit. Historically this was done by cutting into the chest which necessitated a long recovery time with greater risk of complications. Currently this can be done using a scope inserted through a small hole between the ribs. Patients can usually return to normal activity within a few days after the operation. The condition may return if the nerve is incompletely divided, anatomic landmarks are incorrectly identified, or nerve regeneration occurs. It is an invasive procedure even though less so using the scope and therefore the risk of injury to deeper structures is a possibility. Side effects of the sympathectomy itself include compensatory sweating (excessive sweating on the trunk, limbs, or face or sweating while eating) that can affect as many as 50 percent of patients, and is more common in patients having both right and left sympathectomies. Therefore it may be wise to do only one side. Permanent nonfunction of the eccrine glands after sympathectomy can lead to skin overgrowth, scaling, and fissuring.

direct removal of the sweat glands by liposuction

Liposuction close to the undersurface of the skin almost scraping it has been described. The success of the technique may partly be because of disruption of the nerve supply to the sweat glands and removal or destruction of the apocrine glands that are present in the axilla in high density. The true efficacy of this treatment has not been established.

direct removal of the sweat glands by surgical excision

These involve removal of skin and/or underlying tissue. This is currently my preferred technique as it has the best mix of effectiveness, reliability and low complication rate when only the glands are removed leaving intact skin. Three parallel transverse incisions 1.5 cm in length and .75cm apart are made across the armpit. The skin between the incisions is flipped and the glands underneath removed directly. Small drains are left in place for 3 to 5 days to prevent any blood from collecting underneath. There is no hand raising for 10days and the sutures are removed about 12 days after surgery. Making of the armpit incisions to remove sweat glands Using this modality there is a risk of permanent armpit hair loss, separation of the incision lines, slow healing, skin loss if the gland removal is too aggressive or infection.

In the absence of infection or skin damage the only problem are the glands themselves so removal of armpit skin seems excessive and has a propensity to leave bad scars.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Asian Upper Eyelid Surgery - Asian Upper Blepharoplasty

2010-01-29T11:40:00.001-08:00

In the caucasian upper eyelid the deeper layers of the eyelid converge 6 to 8mm above the eyelid margin/eyelashes to create a crease (labeled upper lid crease in the diagram above). In the typical asian upper eyelid these layers do not converge so there is no crease. The absence of this convergence allows fat to descend into the eyelid (as noted in the diagram above) giving the puffy look that is seen in some asian eyelids and the no upper eyelid crease appearance.

The surgical procedure to correct this involves removing some of this fat and suturing these layers as well as the skin of the eyelid to the upper edge of
the eyelid cartilage in order to create a crease. The puffy look is thereby also diminished. The suture used is absorbed by the body but the healing process keeps the new point of convergence intact. This is referred to as double lid or double eyelid surgery because just one surface of the skin is visible without a crease while the addition of a crease allows the viewing of two skin surfaces. When there is just a single no crease eyelid makeup applied to the eyelashes tends to rub off onto the skin above when the eye is open.
These sutures can be placed with or without the removal of upper eyelid skin as needed.

The inner corners of the eye remain unchanged with this approach so that an Asian look still exists. To treat the fold at the inner corner of the eyes if it is present and if the patient wishes it addressed it is best to augment the nasal bridge. This takes up or lifts the excess skin and gets rid of the inner corner skin fold without leaving any visible scar. Some minor surgical procedures have been devised to treat the inner corner folds but these leave scars in the area and do not address the root problem which is insufficient nasal bridge in the Asian nose.

As mentioned above this is the typical asian eyelid. However in reality there is a spectrum of asian eyelid appearance with an almost caucasian appearance at one end and the very asian appearance as depicted in the first diagram above at the other end. The surgical approach must then take into consideration what the patient wants to change and where they lie in this spectrum. Also each eye may be on a different part of this spectrum.

CASES
The upper photo in this set is before surgery. The middle photo shows the result after a blepharoplasty with removal of skin and placement of sutures to adjust the upper lid crease position (as in the second diagram above)-a double lid procedure. The lower photo was taken after a radix implant was placed at the root of the nose to diminish the inner eyelid skin folds.

This patient had a rhinoplasty with a bridge implant but no direct surgery on the eyelids. This demonstrates how the inner upper eyelid skin fold can be addressed with an implant. By diminishing this fold the distance between the inner corners of the eyes appears to be less when in fact it is unchanged.
Although this is not a case of double lid surgery this Asian patient had hanging excess upper eyelid skin. The excess was so severe that the overhanging skin partially blocked her visual field. Because of this sensory deficit such procedures are covered by health insurance. In this patient I only removed the excess upper eyelid skin.

Asian Upper Eyelid Surgery Blepharoplasty
Asian Upper Eyelid Surgery Blepharoplasty 2
Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

Breast Implants Augmentation Reconstruction and a Natural Look

2009-12-24T15:44:00.000-08:00

Most of us know when we see a good result from breast surgery whether it be implants for breast augmentation or reconstruction after breast cancer surgery (mastectomy) or the results of a breast reduction surgery. As I described in my blog on facial proportions analysis a similar proportions assessment is used in planning any breast surgery and in assessing the end result.

That is to say for the average woman between 5 and 6 feet tall the desired proportions are that the nipples form an equilateral triangle with the upper notch of the breast bone and each side of the triangle is about 20cm in length. Additionally the distance between each nipple and the fold under the breast should be about 7cm with a gentle curve outline along the bottom of each breast. Together with equal sized nipple areola complexes this creates the left right symmetry and aesthetic look we strive for. The question then arises as to how one achieves this goal or result after breast surgery. This blog will only deal with breast implants rather than breast reductions and mostly with options available to correct for deviations from this pattern after breast implant placement i.e. redo breast implant surgery when the nipple is in the correct position.

In planning/performing breast implant surgery the surgeon must diagnosis deviations from these proportions before surgery. In the non-reconstructive patients i.e. implants placed for breast augmentation the surgeon firsts addresses nipple position on each breast with respect to the breast bone notch and the fold under the breast. After that the breast tissue has to be centered under the original or corrected nipple position. Surgical adjustments of nipple position are in reality various degrees of breast lifting or mastopexy. The more lifting that is required the more skin has to be removed and the bigger/longer the skin scar. Then the breast implant has to be centered under all of that preferably with breast tissue overlapping the edges of the implant. If the implant goes past the edge of the breast tissue it may be visible as a second edge and we call that a double bubble. The double bubble can also appear when breast implants are placed under the chest muscle separate from the native breast tissue. As the patient ages the breast tissue can sag downward separating from the submuscular implant that is held in place by the chest muscle and thereby creating a double bubble deformity.

The average 12 to 13 cm breast base diameter patient gets an 11 to 12 cm diameter implant. If the implant is too large for the space under the breast the normally curved breast contour may be squared off or the 2 implants may touch across the midline. I had a short asian patient with an 11cm base diameter breast in whom another surgeon put a 13cm diameter implant and she ended up with squared breasts. After a simple change to a smaller base diameter the problem was resolved. That change did not alter the front to back projection of the breast because today we have a vast selection of implant sizes available.

Deviations from the above desired proportions can be due to surgeon, patient or implant related factors or any combination of these factors. The surgeon can pick the wrong implant or surgical technique. The patient may not follow instructions after surgery such as too early a return to exercise. Too large an implant overtime can shift in position. The patient's body can react adversely to the implant by forming scar tissue around it that contracts thereby squaring off the contour. You can see there are lots of things that can become a problem during, shortly after or sometime after surgery.
These problems can be classified as bottoming out, bad positioning of the fold under one breast, symmastia or synmastia and wrinkling or rippling as depicted on the left above. A combination can also occur such as bottoming out and rippling. Possible surgical solutions involving the placement of allogenic acellular dermal graft or tissue matrix are depicted on the right. This graft material is processed from human organ donors' skin and all skin cells are removed to prevent rejection. The deep layers of skin that do not contain skin cells are left intact so what is left is basically a sheet of collagen. It has been used for a variety of purposes since the early 1990s, including skin grafting of burn wounds, nasal reconstruction, eyelid reconstruction, gum surgery etc. In the mid- 1990s plastic surgeons began using it for cosmetic surgery such as making the lips fuller. Use of the material in breast surgery followed.

This is a cut away view of the breast showing how the graft can be sutured along the upper and/or lower edge of the implant as needed.

Bottoming out occurs when the implants shift position downward and are no longer (if ever) centered under the nipples. This can be due to disruption of the folds under the breasts, excessive disruption of chest muscle fibers near the midline breast bone at the time of surgery or development of a capsule that is so thin that it cannot withstand the pull of gravity on the implants. Surgical correction involves placing sutures between the under surface of the skin and the rib cage, suturing the capsule to itself under the implant or placing an acellular dermal graft at the bottom of the breast. The graft is sutured in place to reshape the fold.

The phenomena of bottoming out can be used in a controlled fashion to improve a result over time. For example in breast reduction surgery the nipple to fold distance is made slightly shorter because settling of the tissue over time with some bottoming out is expected and the surgeon is looking for a better long term result at the expense of a poorer short term result.

Synmastia or symmastia after breast augmentation - breast implant placement is a condition where the breasts meet across the chest midline with migration of one or both implants so they touch across the midline. Patients who have had multiple breast operations especially if done only to place sequentially larger implants, excessively large breast implants with large base diameters, or overaggressive surgical dissection across the midline are susceptible to developing synmastia. This is much less common than outward or downward shifting of the implants. It can also happen if too large an implant is placed so that the inner sides of the implants touch. In subtle cases you can only see the synmastia when you push on the implants but not when the patient just stands upright. This can occur with the implants above or below the muscle but appears to be more common when they are below the muscle. The treatment is suturing the capsule near the midline to itself and or placement of acellular dermal grafts at the inner edges of the breasts. If the patient has very large implants above the muscle this can also be treated by replacing them with smaller implants under the muscle.

Wrinkling or rippling is an inherent property of implants. Implants may look very good when lying flat on a table. However, when upright the upper portion of the implant collapses (wrinkles or ripples) as the implant contents fall to the bottom of the implant and can't support the upper part of the implant.

If the implant is placed on top of the muscle in a thin individual with small breasts the collapsed upper part of the implant can be very unsightly when the patient stands upright. The collapsed edges appear as rippling when viewed from outside the body. The rippling becomes more apparent after the swelling from surgery resolves and the pocket around the implant shrinks to meet the dimensions of the implant. When placed under the muscle the rippling is more apparent to the side of the chest wall, where there is no muscle, and when leaning forward because this positions the implant closer to the surface. This rippling affect is more apparent and the implant edges are more visible with saline filled implants because of the chemical properties of salt water especially when the soft tissue (breast gland and fat) between the outside world and the implant is thinner. Rippling is least apparent with the cohesive gel implants because when upright or even with the implant shell removed the gel inside retains its shape.

This patient had saline implants that were too large for her chest placed under the muscle. On standing upright these oversized implants give the breasts a vertical rectangular look instead of a smooth curved contour and when leaning forward the rippling of the implant is visible outside the area of muscle coverage.

The treatment for rippling historically was to replace a saline implant with a gel implant and/or move an implant under the gland to a position under the muscle. Now there are more options available to treat this problem. The implants can be changed to cohesive gel, their position can be changed to under the muscle and/or acellular dermal matrix can be sutured above the portion of the implant that ripples in order to hide the rippling.

Comparison of Saline, Silicone Gel and Cohesive Silicone Gel
Top view lying flat Saline, Silicone Gel and Cohesive Silicone Gel

Front view standing upright Saline, Silicone Gel and Cohesive Silicone Gel

Top view standing upright Saline, Silicone Gel and Cohesive Silicone Gel

Oblique upper view standing upright Saline, Silicone Gel and Cohesive Silicone Gel
Regular silicone gel and cohesive gel side by side
These photos show the inherent properties of the implants. All three look the same when lying flat and viewed from above. They are quite different when upright as when a patient with breast implants stands up. The saline has the most rippling and the cohesive gel has the least.

Example Cases
Symmastia following saline implant augmentation under the muscle and mastopexy breast lift and correction by placing acellular dermal grafts at the inner edge of each breast

This case shows bottoming out of implants placed above the muscle. Moving the implants under the muscle corrected the problem by allowing the now overlying muscle to hold the implants in position so they do not drop with gravity. The after photo is 1 year after the corrective surgery.

The bottom line is there are currently more options available to treat these problems than there were in the past. Which option is best for a given patient is dependent on the patient and the experience of their surgeon. The main drawback to the use of acellular dermal grafts is that 1 sheet is required per breast and each sheet costs between $1000 and $2000. Currently most revisions using this material are for breast reconstructions after breast cancer surgery and so are covered by insurance. That is because revisions after cosmetic breast augmentation are not covered by insurance and the average patient cannot afford to pay up to $4000 just for the material used in surgery.

Aaron Stone MD - Plastic Surgeon Los Angeles
Aaron Stone MD - twitter

New US Federal Tax on Cosmetic Surgery

2009-12-09T16:13:00.000-08:00

Perhaps you've heard of the current healthcare bill before the US Senate, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the Patient Protection and Affordable Care Act. This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement. The provision would add a five percent tax to "cosmetic surgery and medical procedures" to help cover the $849 billion price tag for health care reform. The tax would cover any cosmetic medical procedure deemed "not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease. The US government is trying to apply a sin tax akin to that on cigarettes and tobacco on cosmetic surgery.

So what's the problem? YOU would be paying this tax, the FIRST time this country has levied a tax on patients for medical procedures. What's at stake?

• This is a discriminatory tax. According to the Aesthetic Society Annual Statistics, 91% of all cosmetic procedures are requested by women

• This will not have considerable consequences on the wealthiest patients but, as usual, affects the middle class. Working women, soccer moms, and scores of others who carefully save and budget to improve their appearance and self esteem will be penalized for doing so.

• Procedures such as breast reduction that have been cited in the literature for improving self esteem and quality of life would be taxed as well

• Your doctor as tax collector: This provision places physicians in the role of tax collector and holds physicians liable should an individual fail or refuse to pay the tax. Is that the relationship you want with your medical provider? Furthermore the IRS will be able to obtain access to your medical records in search of procedures that should be taxed but the tax was not paid. They will end up deciding what is cosmetic and what is not cosmetic.

• It is misleading to say this is just 5%. If you have a complication or result you are not exactly happy with all touch ups and revisions will also be taxed. If they tax the procedure it isn't long before they tax the materials used in these procedures. If the feds tax it the states will follow. New Jersey already implemented a tax on cosmetic surgery. All that did was force patients to leave New Jersey for surgery in New York and Pennsylvania. The predict tax windfall failed to materialize.

• Those proposing the tax say it is to pay for health care reform. My question is what health care reform? The supposed public option is not in fact public like Canadian and European systems. It will be subcontracted out to the same current insurance company thieves just with more government oversight. We all know how that works looking at the banking fiascos of 2007 to 2009 that occurred under government oversight. Furthermore we all know that just like the money from tobacco companies that was supposed to go to healthcare this money will end up in the general fund. It will end up buying bombs, payoffs to governments we hope will do our bidding, infrastructure buildout, etc.

Please help us stop this silly and penetrative tax. To find your State Senator please click here: http://www.senate.gov/general/contact_information/senators_cfm.cfm
Also please visit http://stopcosmetictax.org/ to sign the online petition, found out what you can do and tell all your friends and family.

We urge you to personally inform the government that you are against this tax – together we can fight for your right to no government interference in medical care and stop this discriminatory measure against women!

The Internal Bra Breast Lift

2009-12-02T10:34:00.001-08:00

Breast sagging is a common problem women face with aging, breast deflation after breast feeding and/or after the placement of large breast implants. The cause is a disproportion between the size of the breast tissue and the amount of skin enveloping it combined with stretched out and weakened ligaments that connect the breast tissue to the chest wall. This flattens out the top half of the breasts so that most of the remaining breast tissue is in the bottom half of the breasts. Because the problem is related to the skin and breast tissue (fat, breast gland and suspensory ligaments) rather than muscle this problem is unaffected by exercise. Historically the treatment was surgical removal of excess skin sometimes with some manipulation of the breast tissue and/or a breast implant resulting in a firmer breast with more fullness in the upper half of the breast. Removal of skin alone does not always restore the more youthful appearing upper half fullness.

The pattern of skin removal (circle around the nipple, lollipop, inverted-T incision) used depends on the degree of drooping or amount of skin that needs to be removed. For larger skin removals the anchor pattern or inverted-T has been the mainstay. The problem with this is some patients develop large symptomatic scars.

This patient had a traditional skin removal breast lift mastopexy using the inverted-T or anchor pattern skin removal.

The latest option on the horizon, as of today it has mostly been performed on pigs, is the "Internal Bra Breast Lift" also called the "Cup & Up". It was developed in Israel and trial on human patients has just begun in Europe.

The blue dots represent where the small less than half inch incisions are made under the breasts to insert the silicone sheet and higher on the chest to allow the straps to be attached to the ribs.

As I see it the pros are that this will give the breast the desired upper half fullness with minimal surgery or skin incisions. The cons are that
1-this will not work if there is still significant breast tissue breast skin disproportion in which case it would look odd if you did just this internal bra procedure.
2-the upper chest scars can be visible with a low cut dress and in patients prone to bad scarring this is the last place you want a problematic scar
3-the procedure is advertised as a minimal procedure performed under local anesthetic but the upper ends of the straps are screwed into the rib bones and surgery on bones under local anesthetic is painful as anyone who has broken a bone can tell you
4-if the skin is very loose and thin from being stretched out there may not be thick enough tissue to adequately cover or camouflage the silicone sling at the bottom of the breast

In short it is too early to tell if this procedure will amount to anything or if it will be good for specific types of patients. What we can say for sure at this point is that it will not be good for all patients with drooping breasts.

This sling idea is not exactly new. Some surgeons routinely remove the surface of the excess skin and then move the deeper layers of this excess skin into position as a deep sling that is sutured over the ribs at the bottom of the breasts. Some surgeons in Brazil place a nonabsorbable mesh under the breast at the time of surgery. The material used in Brazil incites a reaction and scar tissue formation which the surgeons say keeps the breast in position. The problem there is controlling the degree of tissue reaction and scar formation.

Breast Lift Mastopexy Los Angeles
Aaron Stone MD - Plastic Surgeon Los Angeles
Dr. Stone's Twitter

New Discovery Could Make Breast Implants Obsolete

2009-11-13T23:39:00.000-08:00

Earth shattering news out of Australia this week could have monumental effects on breast surgery, both reconstruction after breast cancer and enlargement for cosmetic reasons. The technique discovered in Australia is called Neopec. So far the process has only been performed in pigs and was so successful that human trials are scheduled too begin in early 2010. The pigs grew new breasts in 6 weeks. The surgeon places a scaffold or shell of biodegradable material in the breast, redirects a small blood vessel from the arm into the shell, places a small amount of the patient's own fat inside the shell, and a dissolvable gel called Myogel is also placed in the shell. The Myogel and blood flow from the transferred artery stimulate the fat to grow until it fills the shell and therefore takes the shape of the shell. This is a direct finding from stem cell research. After that the biodegradable shell is dissolved by the body. In the future the shell may come with its own artificial blood vessel.

If this all works out breast implants for cosmetic breast augmentation or breast reconstruction would become obsolete. Also this procedure is much less taxing on the patient than a transfer of fat with intact blood supply to the breast from the lower abdomen or other areas of the body. It could readily available for breast reconstruction within 3 years and for cosmetic breast augmentation within 10 years.

The first few frames show the shells lying on the belly of a pig and the blue lines outline the blood vessels that will be redirected into the shells.

UPDATE MARCH 2011
The procedure will be called Neopec. The breast is scanned in order to obtain the measurements for the shell. The shell or chamber will be available within 3 days. The chamber is made of biodegradeable biocompatible synthetic material. The chamber is placed under the skin and a piece of armpit fat with its feeding artery intact is placed into the chamber. The fat grows to fill the dimensions of the chamber and the chamber dissolves over 3 or 4 months.
It is a 2 hour surgery with a 2 day hospital stay. The donor site scar is much smaller than that for surgery using abdominal fat or back fat-muscle. The result is permanent as long as your weight is stable.

Aaron Stone MD - Plastic Surgeon Los Angeles
Dr. Stone's Twitter

Stretchmarks

2009-10-12T14:27:00.001-07:00

The medical term for stretchmarks is striae (stria for a single stretchmark). Skin with stretchmarks has been studied under the microscopic as far back as 1889. Every adult knows what they look like. They can be caused by rapid mechanical stretching of the skin or by hormones made by the body or taken externally. They can most frequently be found on the abdomens of women of have been pregnant (striae gravidarum) and on the shoulders of teenage body builders (striae distensae). They are also seen in overweight individuals, after rapid growth during puberty and adolescence, in people with Cushing's syndrome, after topical or prolonged treatment with steroids and on the breasts after breast augmentation or pregnancy and subsequent breast feeding. The combination of rapid growth in the early teen years and excessive weight gain is sure to result in stretchmarks.

As pregnancy progresses the breasts engorge/enlarge in preparation for breast feeding after delivery. Once breast feeding is completed they can shrink back down in size or deflate and in some cases even become smaller than they were before the pregnancy. The degree of drooping that results depends on the difference in size between when they are the largest and when they have shrunk down in size. The appearance of stretchmarks is proportional to the size they reach during engorgement. Sometimes a breastlift or breast implant is required to improve the look but these should not be done until at least one year after stopping breast feeding. In other cases the stretchmarks may be less visible on the deflated breast and more visible after placing breast implants to re-inflate the breasts.

Stretchmarks after Breast Implant
--------------------------------------------------------------------------------------
Fresh pink abdominal stretchmarks of pregnancy.
--------------------------------------------------------------------------------------
The faded abdominal stretchmarks years after pregnancy.
---------------------------------------------------------------------------------------
Stretchmarks of the right inner thigh.
--------------------------------------------------------------------------------------
Stretchmarks on the back of a 15 year old after a growth spurt.
-------------------------------------------------------------------------------------
Stretchmarks on the shoulder/across the armpit of an athlete.
-------------------------------------------------------------------------------------
The factors that contribute to stretchmarks of pregnancy are family history of stretchmarks, younger age of mother (women in their 20s), greater weight gain during pregnancy, and larger infant birth weight and older gestational age at delivery. They tend to appear in the last 3 months of pregnancy when skin stretching is maximal and the skin has had prolonged exposure to the hormones of pregnancy. Many people claim the application of cocoa butter will prevent these stretchmarks but this has never proven to be the case. There is some evidence though that topical vitamin E can be preventative. This is most likely because it acts as antagonist to the hormones that contribute to stretchmark formation. One has to be careful though because I have seen patients develop allergic skin reactions after prolonged application of available topical vitamin E preparations. Retin-A has a similar effect on stretchmark prevention but cannot be used during pregnancy because it can cause deformities in the baby. It therefore is only of preventive use in the bodybuilder etc. Ironically a women may not develop stretchmarks after the first baby but then do so after the second.

At a microscopic level we see alignment of collagen fibers into parallel sheets rather than the normal random orientation of the fibers present in normal skin. Also, there is a flattening of the normally wavy or sinusoidal junction between deep and superficial skin. This makes the stretchmark skin more susceptible to shearing forces so if you pulled at the skin it would disrupt along the striae first. In fact in morbidly obese patients with hanging abdominal skin when I look under the fold of skin I see striae and if large enough the weight of the excess tissue partially tears the skin open along the striae.

An evolution of these striae has been noted. They start out flat with a faint pink color and sometimes itch. Overtime they widen, lengthen and darken in color. After several years they fade whiten and become depressed. When the stretchmarks are pink a flashlamp laser can be used to lessen the redness and this makes them less noticeable but this laser can depigment darker skin. More recently fractional CO2 laser has been shown to stimulate collagen production within the stretchmarks and yield some visible improvement. Radiofrequency application has shown similar results but the degree of improvement is less. Collagen induction therapy (CIT) involves the application of a roller with multiple small needles to the skin surface. The resulting holes in the skin without damage to the skin surface are believed to stimulate collage production. As of this writing the only thing that has been proven is that CIT does not alter skin pigmentation and may be of use in skin rejuvenation. There is no proof at present that it improves stretchmarks. Further study of CIT is required before it can be recommended. Others have tried chemical peels. None of these treatments has been able to erase stretchmarks and multiple applications are usually required before any result is seen.

The only treatment that consistently removes stretchmarks is an abdominoplasty or tummy tuck but this only works for stretchmarks below the belly button.
This patient had stretchmarks after pregnancy that extended up past the belly button to the rib cage and many around the belly button. I removed those below the belly button by abdominoplasty but was only able to move the upper abdominal stretchmarks downward. Sometimes the pulling on the skin by the surgery makes the few remaining stretchmarks more visible.
-----------------------------

This patient had stretchmarks confined to the lower abdomen below the belly button. In this case I was able to remove all of the stretchmarks at tummy tuck surgery.

Abdominoplasty for excess skin and fat and loose muscle
Abdominoplasty for excess skin
Abdominoplasty after weight loss
Belt lipectomy 1
Belt lipectomy 2
Aaron Stone MD - Plastic Surgeon Los Angeles
Dr. Stone's Twitter