I recently found a little straight-forward article by a husband and wife plastic surgery team out in Columbus Ohio who summed it all up very nicely. Drs. Christine and Michael Sullivan of The Sullivan Centre are certified plastic surgeons and this is what they wrote:

The worst problem however is inadequate pain control. In the end, some patients simply feel more than others for reasons that are not clear. So some patients undergoing these awake surgeries will not know that they are going to feel significant pain until the pain starts. Once the patient has been giving the limit of local anesthesia and they are still experiencing extreme pain, two things can happen. Number one, the doctor continues and tries to ignore the patient’s screams, or, when the screaming is too much to bear the doctor stops and does an inadequate removal which will likely need to be repaired by a real Board Certified plastic surgeon.

In breast implant cases, this technique allows the practitioner to put the implant under the breast but not under the muscle. In order to release the muscle, which allows the implant to be inserted under, it takes general anesthesia. With an inadequate muscle release, the implants never settle and can often take on a funny shape. The article cites one case in Las Vegas where an implant actually began to work its way back out of the incision days later! That patient ended up needing emergency surgery where it was discovered that the doctor who placed the implants had done a butcher job on her and even left some random sutures in the pocket.

The other disturbing issue for these procedures is the amount of time they appear to take. Although technically it is safer to do a longer procedure under local then the six-hour limit which we accept for general anesthesia, there is no reason to keep the patient on the table for eight hours or spread a simple liposuction into two or three days which is apparently what these doctors do. In my hands a three area liposuction takes about three hours under anesthesia. A breast augmentation takes about 45 minutes. There is no reason at all why these should be expanded to eight hour torture sessions but for some reason, the skill levels or the difficulties presented by trying to do these surgeries under local appear to expand the surgical time by a factor of four.

Why is there this new interest in awake surgery? Well there are several reasons. Number one to do the awake surgeries you don’t need an operating room. You can do it in any old exam room. Number two it opens up the procedure is to family doctors, gynecologists, internists, and emergency room doctors who are struggling financially with insurance reimbursements. It doesn’t matter if they have often minimal or no surgical training or background. Number three monitoring of operating facilities is based on the level of anesthesia. So in other words, the less anesthesia you use for your procedures, the less oversight there is.

That is to say, if you have an M.D., you can do any surgical procedure in your office including a heart transplant if you do it under local. As soon as you do some sort of sedation you are subject to accreditation and oversight. Most of these offices that do awake procedures would never survive scrutiny in the light of day. Tiny cramped operating rooms, (and I use that term loosely), which are subject to contamination, lack of sterility, lack of gowning by the so-called surgeon and his staff are all issues. There is no accreditation or peer review. There is no one looking at these dirty deeds done dirt cheap.

Then what happens after the patient heals from the procedure. I just did a four hour liposuction revision on the patient who was the second experiment of her gynecologist who had just “learned” how to do liposuction. On-the-job training so to speak. This patient had a symmetric mounds of fat on the front of her abdomen as well as depressions and unevenness. Under proper sedation with an IV and a nurse anesthetist, the patient was extremely comfortable. She didn’t have to have a tube in her mouth. And I had to redo everything which was more difficult than if I had seen her initially without any previous surgery. On top of that she had major asymmetries which had to be adjusted and needed fat removed certain places and placed into others. Lastly because she had so much rippling and wrinkling in her upper abdomen I had to do a reverse tummy tuck with incisions under the breasts. Fortunately, everything went very well and she had an excellent result. It’s too bad that she had to have two procedures to get to that place. It would have been easier for me and cheaper for her if she had just come to me in the beginning.

I think everyone considering plastic surgery should read the article from Self Magazine. They should also realize that for all the posturing done by people that promot it, it is not about safety and it isn’t about the well-being of the patient. It is about a group of unqualified untrained unscrupulous physicians trying to cash in on the demand for plastic surgery. Is there a place for awake procedures? Of course there is. I do some minor procedures and small revisions under local. These procedures are brief, the can-do anesthesia is excellent and everything goes well. There is no place in modern plastic surgery for eight hour torture sessions. Research your physician and the facility well. It’s a jungle out there and it’s full of predators just waiting for the unsuspecting patient.

What is Wired referring to when they refer to “natural breasts?” The story talks about the renewed interest in fat grafting as an option for breast augmentation. Fat grafting for breast augmentation means plumping up a woman’s breasts with her own fat that is transferred from another part of her body rather than using silicone or saline breast implants. Just the other day I posted a press release that highlighted a recent study I took part in that showed the VASER liposuction system is ideal for this very purpose. Essentially, the story is the tale of a bio-tech start-up company called Cytori. This company is getting into the tissue engineering business via stem cells harvested from fat and are doing so by starting with breast augmentation.

Why breasts? Theoretically they are simple to build since they consist of only one type of tissue which is fat. Nobody’s talking about actually building mammary glands that secrete milk. It’s all about form and not function. Attempts were made beginning in 1980s to do augmentation with fat. They had mixed results, mostly due to the fat not surviving and just being absorbed by the body. There were many different techniques and many different technologies applied.

This new story begins with a UCLA plastic surgeon Mark Hedrick who wondered if fat had stem cells. In fact it does. Approximate one stem cell per 100 fat cells versus one per 250,000 to 400,000 in bone marrow. Stem cells are the darlings of cell biology. Theoretically they can be used to make any tissue. They also release substances which improve healing and regeneration. Cytori reasoned that if you separated stem cells from the fat, purify them and added them as a concentrated extract to more fat than the combined stem cell plus fat graft would take better. They ran two successful trials in Japan. One on reconstructing partial mastectomy another on breast augmentation. I actually have the opportunity to hear the investigator Dr. Karushima present his work. He successfully implanted approximately 100 mL per breast for an increase of 1.6 cupsizes his Japanese patients.

The rest of the article talks about the potential for these stem cells including heart and other organs. So is this the next big thing? Well it certainly could be for the hard if their studies continue to pan out.

Why isn’t this a done deal? There are many questions with respect to breast augmentation with fat grafting. The following are just a few:

1. The results are not significantly different than non-stem cell fat grafting to the breast. I’ve done in the past on selected patients with good results. Dr. Coleman in New York and Dr. Khouri in Florida have achieved excellent results without stem cells. To date I don’t know of any study comparing stem cell fat grafting with non-stem cell fat grafting.
2. Caution needs to be used for the mastectomy reconstructions. In animal studies stem cells can potentiate cancer growth. Now there has already been a lot of work with fat grafting to breast cancer reconstruction. No problems have been reported. However is there a critical mass of stem cells that might cause a cancer recurrence?
3. What are the comparative costs going to be? Taking time to remove enough that can be a long procedure, adding to anesthesia expenses and increasing patient risk. As long as we’re taking out these cells and manipulating them why not have an ideal scenario where you take out 10 CC a fat in the office under local and grow to 1000 CC in the lab and then inject?
4. Who will be doing this? Anybody they can buy cytoris stem cell machine? Building a breast is an art as well as a science we’ve already seen the problems when non-core physicians, that is, family practitioners and gynecologists get into the plastic surgery profession.
5. There is currently a limit on how much fat can be put in. This is related to the skin tightness and pressure which kills fat grafts themselves when too much is put in. Dr. Khouri has solved this problem for now with skin expansion using the Brava bra but this is time-consuming and burdensome. If the cells are augmented with the Cytori stem cell technique can this be avoided?

So are stem cells really the answer to natural breast augmentation? Cytori is certainly betting a lot of money that it is. Hopefully their studies will show that stem cells and fat grafts will create an easy breast augmentation with minimal downtime and no future complications that is superior to current techniques. If not someone else will eventually come up with the answer. Tissue engineering is already here. It’s just not perfected. So stay tuned it’s going to be a wild ride!

Lisa Rinna Recently Had Her Lip Augmentation Reduced.

Plastic surgery is a part of celebrity culture today. From reality stars like Heidi Montag, Kim Kardashian, Pamela Anderson, and “The Real Housewives of…” to comedians like Joan Rivers and Kathy Griffin, to actors like Lisa Rinna, Nicole Kidman, Meg Ryan, Micky Rourke and of course stage performers like Cher and Kenny Rogers. All of these celebrities and hundreds more like them appear to have had cosmetic work done, and most, save Kim Kardashian and Cher, seem to have gone too far and pushed the limits of what plastic surgery is capable of.

The force behind this Hollywood celebrity trend to use plastic surgery beyond what is rational is a collective obsession with youthful perfection. That is, in American culture, youth is romanticized and physical perfection is idealized. The problem is that we are only young for a brief time in reality. Indeed, this evanescent quality is probably an ingredient of the fuel feeding this obsession. Combine this with the fact that very few, if any of us, are genetically perfect and you end up with a majority of the country somewhat unsatisfied with their appearance. Add to the fire, the pressure celebrities are under to be examples of perfection to those who consume their movies, TV shows, and music videos and you can imagine the desperate feelings these people have to hold on to this image of perfection or lose their celebrity status.

Further complicating the mix is that the personalities who go into that line of work tend to already enjoy some degree of narcissism with their coffee and you have a perfect storm. Nowhere do we see example after example of drastic measures taken by desperate souls to enhance or hold onto any shred of perfect youth that medical science might be able to offer. Likewise, nowhere else do we see so many sad cases of the fuel of this collective obsession with youthful perfection igniting the fire that ends in plastic surgery disasters.

As a plastic surgeon who believes very much that plastic surgery, and other cosmetic procedures such as Botox and facial fillers, can improve a person’s appearance and make them feel more confident, I cringe when I see the next star to step onto the red carpet with lips the size of sausages or faces pulled so tight they look like, as a friend of mine recently described, “a screaming skull.” Likewise, it sickens me to see a breast augmentation disaster such as putting 700cc breast implants in a petite woman of 5 foot 2 inches as was done to Heidi Montag, so she ends up making Barbie look comparatively proportional! These cases are not medical science being used to improve lives, they are a shameful mockery of the fine art of plastic surgery.

The most difficult thing for me to get my head around is the process by which a trained doctor goes through with these surgeries. If he or she is even remotely educated in plastic surgery, or even the pretend plastic surgeons who call themselves, “cosmetic surgeons,” these doctors have to know how awful these results are going to be before they even put the patient to sleep. As a plastic surgeon, my job is to improve on nature while balancing these improvements with aesthetic principles of balance, physical limits, and genetic realities. And a reality of being a plastic surgeon is knowing that some patients will come in with unrealistic expectations. I regularly have to sit down and explain in no uncertain terms, that there is such a thing as “too big” when it comes to breast implant size. It is very common for small framed women who have A-cup breasts to request breast implants that are simply going to make her look very top-heavy, cause stress damage to the skin, and create discomfort to the point that she will need to have them removed. When I explain the physical limits and the reality, most women normally understand and opt for smaller implants. In cases where they are still unconvinced and determined to have the larger implants, I apologize and tell them that as an ethical plastic surgeon, I cannot perform the surgery with the implants requested and we go our separate ways. And yes, occasionally they come back to me to have their “too large” implants removed.

I can feel for these plastic surgeons who have celebrities for patients. I can imagine they hear a lot of desperate stories about needing “that edge” in order to stay relevant in the fast paced world that is Hollywood, where one day you may be the toast of the town and the next you are wondering why you can’t even get an infomercial job. I realize there is tremendous pressure to push the limits because if you don’t someone else will. At the same time, we are doctors first and we have to do what is right by the patient, even if the patient is demanding what is wrong. We know that lips that look like two sausages painted red will look like hell, we know that 700cc implants can not be sustained in a petite woman of 5 foot 2 inches, we know that if you stretch the face back too far you will create a lizard mouth. We know this because it is what we do. Just as an engineer knows what you can and can’t do if you want a bridge to stay standing, a plane to stay in the sky or a computer to crunch ones and zeros and end up with me being able to type this article.

One thing I always stress with my patients is that when all is said and done, a stranger should never be able to look at you and “know” you’ve had plastic surgery. Whether it is breast augmentation, lip augmentation, a tummy tuck or a facelift, all should be subtle enough to look perfectly natural. Sure, if you go from an A-cup to a C-cup overnight, your friends might notice, but to the world, you should just look shapely, balanced and aesthetically pleasing to the eye, not like a freak of nature. Similarly, a facelift should simply take 10 to 15 years off your face, not make you look like a new person. You should look like pictures of yourself from the past. If you look at Joan Rivers now and Joan Rivers from 15 years ago, it is like they are two different people. On the other hand, if you look at Cher now and Cher 15 years ago, she looks the same! That’s plastic surgery done right!

The collective obsession with youthful perfection will probably be a part of the American cultural reality for the foreseeable future. Perhaps, just being a little more aware of it and reminding ourselves and our children to actively work toward being less influenced by it and more happy with our own realities is the answer. Sure, a good plastic surgeon can improve on nature a bit, fix some of the effects of time and make your day-to-day life a little happier because you smile more when you look in the mirror. But youthful perfection is not something we are capable of producing and someone needs to see that Hollywood gets the memo.

1. The breast implants look disproportionate and make the patient look unbalanced.

2. Large implants in small women make them look fat in their clothes and top-heavy.

3. Large saline breast implants create more fitting of the skin and more wrinkling and rippling.

4. Large saline breast implants cause more dissent of the implant overtime and therefore more sagging.

5. Large saline breast implants because of the thinning of the skin feel like a waterbed.

It is true that some of these changes could happen with large silicone breast implants of equivalent size, however, they are more pronounced with saline breast implants.

To solve this issue and create a more balanced look for each of these women, I removed the larger implants replaced them with an appropriate sized silicone breast implant and then designed the breast lift over this new implant. As I’ve written before, you can make preliminary markings before the surgery but the actual proof is in the operating room. With the new breast implants in place, temporary sutures are placed on the outside of the skin without any incisions and the breast is tailor tacked to the appropriate shape. This process may take several tries until we are able to achieve the ideal shape. At that point, the extra skin is removed and the breast is tightened and lifted.

Breast revisions are never an easy operation but they are very satisfying one for both the patient and the doctor. The difference in comfort, aesthetics, and self-image are amazing. Every single patient that I have converted from saline to silicone implants has commented on how much better they feel. The average breast implant should last 20 to 30 years but if you have a result that you are not happy with, there is no reason to wait that long to change it.

Of course, the best option would have been to choose the right size breast implant from the very beginning. This is why I discuss the downside of choosing breast implants that are too large in the first place and then I don’t have to worry about the patient coming back in because they are unhappy with their results!

Part of the Bridalplasty’s concept includes the bride first showing her results to the groom at the “unveiling” during the actual wedding ceremony.

“Viewers will witness his emotional and possibly shocked reaction as they stand at the altar and he lifts her veil to see her for the first time following her extreme plastic surgery,” says E!, according to the Hollywood Reporter.

This, of course just takes the whole idea of the groom not seeing the bride in her wedding dress until the ceremony to a whole new level. A nose job, breast augmentation, lip augmentation and some liposuction and he may not even recognize her! That shouldn’t make an intimidating moment any more difficult, should it? Unfortunately, this is what the network and potentially, the audience,  is after. They are selling the shock of emotional vulnerability.

This concept trivializes plastic surgery, important life decisions, and it makes a mockery of the institution of marriage. It is beyond sad how far entertainment corporations, audiences and participants are willing to go in search of money and the cheap emotional thrills.

Surgery, whether it is cosmetic or otherwise is a serious life and death issue, (although I have personally never lost a patient during cosmetic surgery in 28+ years). Surgery is not entertainment and marriage is not trivial. The very concept of the TV show Bridalplasty trivializes both and knocks our culture down a few more notches in the ranks of civilized societies.

Kim Kardashian says she has only used Botox

Kim Kardashian, of Keeping Up with the Kardashians, admitted to using Botox, in an interview with ABC News show Nightline. However, she says she has not had a nose job or breast augmentation.

“Trust me honey, if I take this bra off you will tell me I need to get them done. I’m totally not against plastic surgery. … I’ve tried Botox before. That’s the only thing that I’ve done.”

Just the way she says that, I tend to believe her and while a great breast augmentation will look very natural, natural, can look natural as well!

However, Kim Kardashian’s sister, Courtney Kardashian says that she has had breast augmentation and seems to be very proud of it!

“I have had breast implants, but it’s so funny ’cause it’s not a secret, I could care less. It’s so funny because the ‘before’ picture that they [In Touch magazine] showed was after I had my boob job, so I’m like, they should have written ‘before Mason’ and ‘after Mason.’ Like my boobs have like tripled since breastfeeding.”

They go on to say that none of the Kardashians have had nose jobs and from looking at pictures on the Internet, even the “before and after” pictures that argue that she has, I tend to believe they haven’t. So much of what you see in those pictures can be explained by lighting and make-up. Kim Kardashian says that she actually did want to get her nose done but decided against it.

“But what’s funny is about my nose, it’s my biggest insecurity. I always want to get my nose done. … I went to a doctor, I had them take the pictures, he showed me what it would look like and it just didn’t– It– I wouldn’t look the same.”

I agree with Kim Kardashian here, if that is her natural nose, she does not need anything done to perfect it. If anything, there is more risk in changing it and it not looking as nice or as individual as it does naturally. Perfection doesn’t have to be generic, people all look different for a reason, plastic surgery is not about trying to make every face look perfectly the same, it is about enhancing what you do have or fixing issues that bother you. In Kim’s case, I would keep that nose, it looks great on her.

CHER at the 2010 Video Music Awards "VMA's"

Cher presented Lady Gaga with the Video Music Award for Video of the Year Award last night at the 2010 MTV Video Music Awards. When Cher first walked out wearing a similar or the same outfit she wore for her 1980′s video, “If I Could Turn Back Time,” you could almost hear a collective, “wow,” as the entire country watching realized she is now in her 60′s! Indeed, Cher is 64 years old and looks, even on my high definition T.V., like she’s in her early 40′s. Is plastic surgery the secret? Actually, no… as in, “no, it isn’t a secret.” Cher takes care of herself, but she also has been very open about her use of plastic surgery to maintain her looks.  Make Me Heal reports, “Cher has had a breast augmentation, rhinoplasty (nose job), blepharoplasty (eyelid surgery), and possibly many others including enhancing the appearance of her teeth, liposuction, and a facelift. Although speculation revolved around Cher getting cheek implants, a tummy tuck, and a rib removed, she has completely denied the truth in those rumors. However, Cher openly admits she has become “the plastic surgery poster girl”.

The great thing about Cher is that she doesn’t expect anyone to not realize how old she is, she’s been a celebrity since the mid 1960s! Instead, she’s realistic about her age and the fact that time and gravity tend to be harsh on us all. But this is where great plastic surgery can work. Of course, when we look at Cher we think, “wow, she must have had a lot of work done.” But we don’t think, “YIKES!” like we do with some of the really bad celebrity plastic surgery we are all familiar with. To me, She looks great. She looks like she’s had very talented plastic surgeons and beyond that, she also obviously listened to their recommendations. I’m sure a lot of those scary celebrity plastic surgery cases are more a result of the celebrity insisting on procedures than doctors may have recommended against. At 64, Cher is an example of plastic surgery as an art.

What did/do you think of Cher’s plastic surgery and her overall look? Please weigh in below!

Sheyla Hershey's largest Breast implants in the world

According to her official Website, Sheyla Hershey’s breast implants made her a size M (whatever that is), and she was awarded the Brazilian equivalent of the Guinness Book of World’s Records for largest breast implants after her most recent breast augmentation.

In the United States, plastic surgeons are only allowed to place implants up to 800 cc and for her to achieve this size, I’m guessing she was fitted with 4 implants of perhaps 800 cc each? Sheyla Hershey was originally from Brazil and flew back home where the laws are less strict so she could have this breast augmentation done. Since she is only 5’2 she would appear quite lopsided, as the attached picture illustrates.

I’ve blogged before where I discussed Heidi Montag’s breast implants,  about all the reasons why you don’t want to select breast implants that are too big for your body. In the case of Sheyla Hershey, it is even more an indication of likely mental illness than a misdirected attempt at having an attractive figure. Breasts this size are dangerous, painful and will have to eventually be removed 100% of the time, leaving the patient permanently disfigured.

NineMSN reported on the story:

“We’ve already taken her to surgery twice,” said the surgeon in charge of the breast removal, Dr Ron Bucek.

“We needed to open the area up to allow it to drain because we can’t leave an infection in a contained zone.”

According to reporting by the Herald Sun in Australia, many attempts were made to save her from having to remove four implants, TWO in each breast!

“But after the operation, Hershey became seriously ill and has since been closely monitored by a cosmetic surgeon, Dr. Ron Bucek, and an infectious disease expert, Dr. Shazia Gill.

Before yesterday’s surgery to remove the implants, Bucek performed two other operations to help drain the infected areas, and a special vacuum had been suctioning the infection from Hershey’s body 24 hours a day for months.

“It’s the only thing that has saved my life, to be honest,” Hershey said of the device, though she added that it was “annoying” and “heavy.”

My Fox Houston gave the most detailed report:

“None of the bacteria have cultured out. We had to start her on a third antibiotic, because it wasn’t resolving as rapidly as we wanted to see, so she’s on three antibiotics, and she was on an anti-fungal medication during this time as well,” says Dr. Gill.

Because of the severity of the infections, doctors have been closely monitoring Hershey twice a week.

“I look at white blood cell count, I look at electrolytes and inflammation and right now her drug level. She’s on one antibiotic if her levels get too high she can damage her hearing as well as kidneys, she is on very strong antibiotics,” explains Dr. Gill.

Even with all of this medical intervention, Hershey’s body hasn’t been able to ward off the infection. It has been progressively getting worse.

“What’s happening, the skin is opening because the implants, the two on each side, are beginning to open that area up”, says Dr. Bucek. Hershey’s doctors are confident that she will restore her health by removing all four implants.

Dr. Gill showed Sheyla’s CT scan to FOX 26 to demonstrate how the two implants are stacked up on each side. She says there is a lot of inflammation and thickening of the skin.”

It amazes me that there are doctors ANYWHERE in the world who would butcher an obviously disturbed young woman. Now she’s had to undergo what is essentially a double mastectomy at age 28 because along with the removal of all 4 implants, she also lost most of her breast tissue and her skin is going to be in terrible shape. I can’t imagine any number of surgeries that will allow her to have normal, attractive looking breasts now.

On the TresSugar blog, “Gigglesugar” asked in her poll:

This corresponds with what I’ve been doing for the last several years. However now there is a published study that shows that Singulair works. This doesn’t make it work any better but it does further legitimize the off-label use.

As mentioned before, many different things can cause contracture after breast implants. Factors like bacterial contamination and hematoma. These can prolong the inflammatory response. A colleague and friend of mine, Dr.Schlesinger, discovered that a drug called Accolate, which is an anti-inflammatory asthma drug, worked in improving capsular contracture and published this. However it was discovered later on that Accolate had a very small incidents of extremely severe complications including hepatitis liver failure and death. This led to the abandonment of the use of Accolate despite the fact that it worked very well. Cingular is a similar type of drug. It is what is called a leukotriene inhibitor. These are factors that are thought to be responsible for capsular contracture.

This particular study on women with breast implants confirms what I have personally noted over the last several years. Cingular can help reverse capsular contracture when it is caught early and just starting. It can also help prevent recurrence. However, if someone comes in with established capsular contracture or extremely firm contracture it has little effect. The repair of very firm contracture is still a surgical procedure

Capsular contracture still continues to be an annoying and expensive problem in plastic surgery. By using techniques like the no touch Keller Funnel while placing breast implants during breast augmentation, see my previous blog about the Keller Funnel, IV antibiotics and antibiotic irrigation weekendreduce the incidence of contracture. However it is good to know that Singulair has been shown to be effective. In my own practice I combine it with cold laser to make it even more effective and see about 4 out of 5 people respond to the combination.