On July 15th, Alameda County Superior Court Judge Wynne S. Carvill tentatively ruled that Kaiser Permanente cannot systematically classify removal of excess skin following bariatric weight loss surgery as a cosmetic procedure, and that Kaiser misinformed patients and doctors by claiming removal of disfiguring excess skin following gastric bypass surgery is not a covered procedure. This may be good news for Bariatric Patients, but the ruling is not final.
It’s a question as old as insurance companies, “Is it cosmetic or reconstructive?”
The class action lawsuit, Wendy Gallimore, et al. v. Kaiser Foundation Health Plan Inc, was heard in the Superior Court of the State of California for the County of Alameda. While the ruling would prohibit Kaiser from arbitrarily denying all bariatric patients access to post bariatric plastic surgery, it would allow Kaiser doctors to decide on a case-by-case basis whether patients qualify for a referral to a plastic surgeon.
According to the Insurance Journal Article, Judge Carvill rejected Kaiser’s argument that excess skin is not a disease, and instead ruled that its policy of only providing referrals to plastic surgeons for patients whose excess skin presented a functional problem stands in contrast with the California Health & Safety Code. The code requires insurance companies to pay for reconstructive surgery to repair disfigurement caused by trauma or disease.
Insurance Companies Are Saving You Money
Insurance companies will claim their behavior is aimed at controlling costs, and I understand that they do not want to cover Cosmetic Surgery. What I don’t understand is why Plastic Surgeons have to prove each procedure is not “cosmetic.” More than half the procedures that Plastic Surgeons perform are reconstructive.
How Breast Reconstruction Became “Reconstructive”
There was a time in the not distant past, when insurance companies considered reconstructive breast surgery after a mastectomy for breast cancer Cosmetic Surgery. The insurance companies claimed that since the cancer was removed, there was no immediate threat to a woman’s health, so reconstructing the breast was unnecessary, and that breast reconstruction provided only a cosmetic result. While it is true that a woman can live without her breast, and that a minority of women choose not to have breast reconstruction after a mastectomy, it is equally true that most women do not feel whole until after breast reconstruction is performed.
While some states acted on behalf of their female residents, not all did. Through massive lobbying efforts, including patients, doctors and professional societies like the American Society of Plastic Surgeons, the Federal Government was compelled to act. The choice to have insurance coverage for breast reconstruction was not ensured, or insured, until the Women’s Health and Cancer Rights Act was signed into law on October 21, 1998.
The Women’s Health and Cancer Rights Act of 1998
The law known as Janet’s Law was championed by Republican Senator Alphonse D’Amato from New York, and our own San Francisco, California, Democratic Senator Dianne Feinstein, and twenty-one other US Senators in a truly bipartisan effort.
Janet’s Law is named after a 32 year-old Long Island woman, Janet Franquet, who was diagnosed with an aggressive form of breast cancer in late 1997. She required chemotherapy to try to shrink her tumor, followed by a mastectomy. A young woman, she desired reconstructive surgery to restore her amputated breast. Her Plastic Surgeon, Dr. Todd Wider, contacted her insurance company for permission to reconstruct her breast. Janet’s insurance plan refused to cover the reconstructive surgery, and considered it cosmetic. The carrier recommended using a skin graft if the wound could not be closed primarily. Dr. Wider, disgusted by the insurance plan’s idea of medical care, performed the breast reconstruction for free. When insurance companies claim they do not make medical decisions, think about Janet’s plight. If not for the generosity of a Plastic Surgeon, her breast would remain flat, or more likely indented with a skin graft.
Dr. Wider did more than give away his skills, he contacted his federal representatives and went to bat for all patients. Senator D’Amato said the following to then US President Bill Clinton from the floor of congress when he had heard that the insurance carrier had denied Ms. Franquet coverage for her surgery:
“Mr. President, I decided that I would give Mrs. Franquet’s insurance company a call. When I spoke with the Medical Director, he told me that “replacement of a breast is not medically necessary. This is not a bodily function and therefore cannot and should not be replaced” … Luckily for her, Dr. Todd Wider agreed to forgo payment of this surgery. … I ask you, Mr. President, how many other Janet Franquets are out there? Will they be lucky enough to have a Dr. Wider to take care of them? … Too many women have been denied reconstructive surgery because insurers have deemed the procedure cosmetic and not medically necessary. It is absolutely wrong.”
Problem (Not) Solved
In case you think the problem is solved, I assure you it is not. This week, I corresponded with a local insurance plan that promises you will “Be Heard.” Despite multiple interactions with the insurance plan by my staff and myself, including writing two letters, sending pictures, twice, speaking with the nurse reviewer, speaking with a physician reviewer, I was told almost exactly the same line that Senator D’Amato was told almost 20 years ago. My patient’s breast reconstruction did not not pose an eminent health risk and reconstruction would be denied. Perhaps he has forgotten, The California Health & Safety Code requires insurance companies to pay for reconstructive surgery to repair disfigurement caused by trauma or disease. Do we need a specific law for every diagnosis?
We do have the right to appeal, but no new information will be necessary, and all of us, my patient, her family, my staff and myself have to spend more time away from our otherwise productive lives trying to get the insurance plan to do the right thing. The only difference is my patient does not have breast cancer, she was born with a severe form of tubular breast deformity. Fortunately, she is a very strong, very mature young woman, and even though she was not even born when Mrs. Franquet’s Insurance Company’s Medical Director proclaimed “replacement of a breast is not medically necessary,” she must again fight the same battle.
Keep The Faith
Without the legislative process, there would be no coverage for breast reconstruction. When Insurance plans can’t justify their actions medically, they simply stop providing coverage. A good example is Breast Reduction. Breast Reduction relieves chronic neck and back pain, among other symptoms. There is overwhelming clinical evidence of the benefits, so now that they can no longer decline the benefit of the procedure, insurance companies are excluding Breast Reduction from their coverage. Check your policy and see if you are covered or excluded. Will we need another law to keep coverage for Breast Reduction when medically indicated?
I look for the good in people, but I’ll admit, I was very disappointed with my patient’s insurance company, especially after spending so much time and effort informing multiple reviewers of the situation. Their decision is troubling, but I suppose made easier by not having to see my patient and realize she is a real person who has a real promising life ahead of her.
On the other hand, Alameda County Superior Court Judge Wynne S. Carvill’s ruling gives me hope. The goal of medicine is enhance our population. By relieving physical pain with Breast Reductions or emotional pain with Breast Reconstruction, Plastic Surgeons improve the quality of our patients’ lives. This is not just true for the patient, but for their family, friends and co-workers. Happier patients are nicer to those around them and more productive citizens. The reconstructive vs. cosmetic arguments will continue; however, if more productive citizens get involved, more reconstructive surgeries can remain reconstructive.
On April 29, 2015 the US FDA Approved Kybella. If you are considering Kybella read on for more information from the San Francisco Plastic Surgery blog. I’ll cover the good, the bad and the ugly.
Kybella is the first drug FDA approved to dissolve fat.
What is Kybella?
Kybella, also known as ATX-101, is deoyxcholic acid. It sounds like a mouthful, but you already know how to make it. Deoyxcholic Acid, or Deoxycholate, is a bile acid that is released by your gall bladder to help digest fat. The manufactured Kybella and the bile acids are chemically identical. Bile acids emulsify fat, much like dish soap, so that the fat can be broken down and absorbed by the gut. Deoyxcholic Acid has been used with phosphatidylcholine for mesotherapy; however, only Deoxycholate has received FDA approval.
Kybella is the bile acid deoxycholic acid.
When properly injected into submental fat, the fat under the chin, the drug destroys fat cells; however, it is not discriminatory. It can also destroy other types of cells, such as nerves and blood vessel. It can also destroy skin cells, if it is inadvertently injected into the skin. It is very important that Kybella, like Liposuction, be provided by a licensed professional who has been properly trained.
How is Kybella Administered?
Kybella is administered as an injection into the fat tissue in the submental area. Patients may receive up to 50 injections in a single treatment, with up to six single treatments administered no less than one month apart. Kybella is being provided in single patient use vials and should not be diluted or mixed with any other compounds. The vials have a hologram on them to prevent counterfeiting, and you should ask to see the unopened, hologram containing vial before your procedure to be certain you are getting the right stuff. If there is no hologram, do not use the product.
The official Kythera packaging for Kybella and the holographically labelled single patient use vial.
Where Can I Get Kybella Injections?
Kybella is only approved for reduction of submental fat under the chin. This is the annoying collection of fat that can occur under the chin. It is not approved for other parts of the body. The established treatment for this area is Liposuction, a surgical procedure which vacuums away the disproportionate fat from under the chin.
What Are The Side Effects Of Kybella?
The usual worries from injections apply:
areas of hardness in the treatment area (lumps)
Adverse events specific to Kybella:
nerve injury (paralysis)
skin ulcerations (open wounds)
dysphagia (problems swallowing)
Nerve Injuries occur because Kybella kills cells. Temporary weakness or paralysis of the muscles controlling the mouth occurred in 4.3% of the Kybella pivotal study population. In the placebo group, only 0.4% of the population had temporary paralysis. The average duration of injury was 42 and 85 days respectively. To reduce the risk Kybella should not be injected above the lower aspect of the mandible. This percentage of nerve injuries with Kybella is much higher than I have seen with liposuction of the same area.
Skin Ulcerations that occurred tended to be small areas that healed in a few weeks. Skin ulcerations can potentially be reduced with proper injection techniques. Since Kybella kills cells, injecting Kybella into the skin, or too superficially, results in death of the skin and an ulcer. This may not be avoidable in people without enough subcutaneous fat, but then again, people without subcutaneous fat should not be treated with Kybella in the first place.
Dysphagia, or problems swallowing, occurred in 2% of Kybella treated patients, and 0.2% of the placebo treated controls. Most episodes occurred 1 to 5 days after treatment, were described as mild and resolved in a few days.
Why Patients Dropped Out Of The Kybella Study
About one-third of patients had to stop treatments due to insufficient remaining submental fat. About 10% stopped because they were happy with the results. The most common reasons for study discontinuation were patient convenience and loss to follow-up. The percentage dropping out was greater for the Kybella treatment group than the placebo group, most likely because Kybella shots hurt more. The common most adverse reactions leading to discontinuing Kybella treatments were injection site pain (1%), injection site anesthesia (0.8%) and injection site swelling (0.8%).
MRI Results Of Fat Loss
The amount of fat under the neck was measured with an MRI scan. Response was defined as a 10% reduction in submental fat. Even with this relatively low bar, less than half the study population was considered MRI responders (40.2% to 46.3%). Only 5.2% to 5.3% of placebo treated controls were MRI responders. On the other hand, the same populations showed improvement in satisfaction in 47% to 50% of patients in the Kybella group compared to 15%-20% in the placebo group. Compared to the 91% “worth-it” rating that liposuction receives on Real-Self.
Who Is A Candidate For Submental Fat Reduction?
There are three factors that must be true for you to be a good candidate for Liposuction:
You must be healthy. – seems obvious
You must have a collection of disproportionate fat. – also seems obvious
You must have good skin tone. – the most common reason for unhappy results
Despite what other articles you may find on the Internet, Liposuction and Kybella do not shrink skin. The skin shrinkage comes primarily from the elastin fibers in the skin, and represents the natural recoil of the skin. Thus liposuction and Kybella is not right for everyone. For liposuction, Patient Selection is an important component in obtaining good results. It will not work for everyone, and adding lasers, ultrasound, radio-frequency or other voodoo does not help significantly. Healing may take weeks or months and may be significantly prolonged in certain individuals such as smokers and diabetics.
Can Kybella Tighten Loose Skin?
When compared to placebo (PBO), ATX-101 (Kybella) did not provide significant improvement in laxity.
As expected, the short answer is no. The results graphed above show no improvement in skin laxity for Kybella (ATX-101) compared with placebo (PBO) at 4, 12 and 24 weeks. The majority of both groups show no change in skin tightness. Both groups also show about 10% of patients with worsened (more) skin laxity. The placebo group had 15% with improvement. Why is the placebo affect always 15%? The Kybella group had about 20% with improvement, not a statistical difference. The range of improvement 15% to 25% is about the same as seen with tumescent liposuction with or with lasers, ultrasound, radio-frequency or other destructive energies added.
Consumers and health care professionals are encouraged to report adverse reactions from the use of Kybella to the FDA’s MedWatch Adverse Event Reporting program at www.fda.gov/MedWatch or by calling 800-FDA-1088.
We are always looking for faster, cheaper and more convenient ways to get what we want. I am not sure Kybella is there yet. Six treatments over six months versus one treatment for liposuction does not say faster, cheaper and more convenient to me. With an increased risk of nerve injury, a limitation in areas treated, minimal fat reductions, no improvement in skin tightening and lower patients satisfaction scores, I will not be injecting bile acid into my patients’ necks for now. I will be watching from the sidelines, and still searching for the skin-shrinking-ray.
Tummy Tuck (Abdominoplasty) Video Presentation (As Seen on KRON 4)
So when I had the opportunity to discuss San Francisco Bay Area Plastic Surgery on the Bay Area’s News Station, KRON 4’s Body Beautiful, Tummy Tuck (Abdominoplasty) was a popular choice. While the decision to have plastic surgery should be made only after an in-person consultation with an Experienced Board Certified Plastic Surgeon, the Tummy Tuck Video below provides good general information about Abdominoplasty.
So Liposuction or Tummy Tuck?
As much as I would like to perform minimally invasive surgery on everyone of my San Francisco Bay Area Plastic Surgery patients having abdominal rejuvenation, good results can only be obtained with good judgement. The first step toward a good result is defining what needs to be fixed. Once the problems are defined, the best procedure usually selects itself. This does not mean that compromises can’t be made, as long as it is understood that smaller procedures can only correct smaller problems.
Tummy Tuck vs. Liposuction Guide
Many specifics need to be reviewed to determine the best course of treatment for abdominal rejuvenation, and all of them are important. If I had to choose one, the most important factor is skin tone. If your skin tone is good (tight) and there are localized areas of fat in the abdominal wall or sides, then the indicator needle on the plastic surgery procedure meter points more toward Liposuction. On the other hand, if your skin is loose or redundant (folding over), especially if the underlying muscles are lax (commonly seen after weight loss or pregnancy), then the needle moves to Tummy Tuck.
Tummy Tuck Consultations
The decision of whether to have plastic Surgery, and deciding which procedure will provide the best results takes teamwork. While you provide the drive, a Board Certified Plastic Surgeon can help with the navigation. If you are dissatisfied with your belly, and want to learn more about Liposuction, Tummy Tucks or another Cosmetic Plastic Surgery procedure, give me a call at (925) 943-6353, and schedule a private and informative consultation appointment.
Breasts are like sisters, not twins. I don’t know who said it first, but googling the quote finds over 15 million web pages in 0.42 seconds. Over the last twenty years I have measured a lot of breasts, and like most generalizations, exceptions exist, but they are rare. I bring it up because today the San Francisco Plastic Surgery Blog is all about Breast Augmentation.
“Natural” Breast Augmentation
Usually, the goal of Breast Augmentation is to make the breasts larger, but still “natural-looking.” What is meant by natural varies patient-to-patient, but the word proportionate often comes up.
Whether it’s restoring volume lost to childbirth, weight loss or poor luck in the gene pool, creating breasts that are proportionate can help with how bathing suits fit, dresses hang and a woman’s confidence in general. A big part of my job it trying to determine the comfort range for Breast Enlargement. Some of those points are reviewed below in this Breast Implant Television Presentation, which first aired on KRON 4’s Body Beautiful last month.
Breast Augmentation (Breast Implants) Video Presentation (As Seen on KRON 4)
A Few Words and Pictures About Breast Implants
The above video answers some of the most frequently asked questions about Breast Implants, and the Breast Augmentation procedure is reviewed and illustrated with several Breast Augmentation Before and After Pictures. While it cannot substitute for an in person consultation with a Board Certified Plastic Surgeon, the goal is to provide some general information that can be viewed at your leisure.
Breast Implants Come in Many Shapes and Sizes
The fact that breast implants are available in many shapes and sizes has never been more true, or more confusing, for my patients. Last year, Sientra expanded their breast implant options with new sizes and shapes. Earlier this year, Allergan received FDA approval for their Natrelle Inspira line of breast implants. With five profiles and sizes ranging from 110 to 800 cc’s, the Inspira Breast Implants alone provides me with over 200 new options, and options are good.
Schedule Your Breast Augmentation Consultation
Now, before you try to figure out exactly which Breast Implant is right for you, get some guidance. The most critical piece of information you can bring to your breast implant consultation is the size you expect to be after surgery. You can bring pictures, a stuffed bra, a friend, whatever it takes to communicate the goal. That one piece of information is the most important piece of information I need to determine which breast implant will do the job best for your frame.
If you are ready to take the next step toward Breast Augmentation, give me a call at (925) 943-6353. I can give you the information you need to make an educated decision, and sort through the thousands of options currently available, and if I can make your sisters, look a little more like twins, so much the better.
Kim Kardashian makes hers smaller, while Eva Longoria has hers made bigger. I talking about arms, of course. It is no secret that many celebrity photos are air brushed, and the three areas almost always made smaller are the waist, thighs and arms. While maintaining a balanced diet and getting exercise remain the best ways to maintain a healthy weight, the ideal body for advertising seems unobtainable. When we have to air brush even the most beautiful women in the world to sell swim suits, the bar is quite elevated.
How to Thin the Arms
When it comes to a well proportioned body, it’s hard to beat good genes, but maintaining a healthy weight can help. In some cases, however, the genes are working against us. Sometimes, the fat is not stored evenly, and the result is sequestered fat causing disproportionate bulges. As we talked about in the Liposuction Video from last week, when diet and exercise are not vanquishing that stubborn fat pocket, a little spot removal can help. But what happens when the weight is lost, the arms deflate, and large “bat-wings” of skin remain?
Arm Lift Video (Brachioplasty)
This month on the San Francisco Bay Area’s News Station, KRON 4, I discussed Arm Lifts. The Arm Lift or Brachioplasty was created to remove excess skin from the upper arms. Host Janelle Marie and I discuss the indications and the typical results after Brachioplasty, illustrated with sets of Arm Lift Before and After Pictures and answers to many Arm Lift frequently asked questions.
Brachioplasty (Arm Lift) Video Presentation (As Seen on TV)
Arm Lift Consultations
Arm Lift Surgery is not as common as many other Cosmetic Plastic Surgery procedures. So, if you are considering Brachioplasty, contact a Board Certified Plastic Surgeon near you, who is experienced with the Arm Lift procedure, its variations and alternatives. This gives you the best options to choose from, and a qualified Plastic Surgeon to help you through the process.
Greater San Francisco Bay Area patients, can reach me at (925) 943-6353. We will schedule your confidential and informative Arm Lift Consultation appointment, so you can learn the latest and best treatments available specific to your arms.
The concept of Liposuction is very simple. It is the suctioning of excess fat from an area of the body that is overstuffed with fat. While it cannot be used for weight loss; however, liposuction can remove fat directly from a specific area of excess.
What Does Liposuction Mean?
Sometimes Liposuction is just what the doctor ordered for flattening that stubborn belly fat. These liposuction before and after photos show off the flatter belly that she has worked hard for.
Lipo means fat. Body bulges are caused when there is too much fat in one place. Fat is soft so, the excess can be vacuumed away. Fat sucking is literally what Liposuction means, and is exactly what Liposuction does.
What Does Liposuction Do?
Liposuction is sometimes all that is needed to smooth out stubborn man boobs (moobs). If the fullness is due to fat, and the area under the nipples is soft, liposuction may be the cure.
Liposuction removes disproportionate fat. Ideally, other than temporary bruising and swelling, Liposuction does not effect the skin above, or the muscle deep to the fat. The fat can be reduced from many different areas safely and effectively. Here are a few common examples:
The neck (under the chin)
The upper arms
The chest (most often for men)
The back and flanks (love handles)
Liposuction Before and After Photos
Liposuction of the abdomen can be extended around the sides and back to remove the love handles and the muffin top.
Liposuction Before and After Pictures are included on my main web site (www.DrMele.com) and some are included below in the Liposuction Video. The following television segment aired on the Bay Area’s News Station, KRON 4’s, Body Beautiful. It includes information about Liposuction including: Who is a good candidate; the liposuction surgery, recovery and aftercare.
Liposuction Video Presentation
If you are considering liposuction, contact a Board Certified Plastic Surgeon near you. A qualified and experienced Plastic Surgeon can evaluate your needs and determine if Liposuction is right for you, or if another Cosmetic Plastic Surgery would be a better choice.
If you are in the Greater San Francisco Bay Area, give me a call at (925) 943-6353 and schedule your private Liposuction Consultation appointment. If you have Liposuction questions check out Liposuction under Categories in the column, or fill out our contact form.
Dennis Aabo Sørenson from Denmark wired with the LifeHand 2 bionic prosthetic in 2013 was able to identify the shape and hardness of items through electrodes implanted in his nerves, while wearing a blindfold and ear buds too. photo credit: LifeHand 2 / Patrizia Tocci
In February, I wrote about innovations in bionic hands; specifically, how the newest prosthetics provide not only increased movement and dexterity, but can also move with input directly from the brain. The peripheral nerves that would normally drive the injured limb, are sensed and relay the commands directly to the motor units in the prothetic hand. It is very exciting to have the ability to move your artificial limb by just thinking about it, but what’s next?
Hands are very important for getting through the day. They help us take care of ourselves and others. I could not perform Plastic Surgery without a good pair of hands. Hands are extremely efficient for manipulating our environment and communicating. They protect and caress. It is difficult to compensate for the loss of a limb, especially an arm. While great strides have been made in fine motor control, it is really only half of the equation.
What If You Could Feel With Your Prothetic Hand Too?
The ability to grasp and assist with an artificial hand is great, but what if it could provide sensory feedback too? Accessing pressure, temperature, weight, texture and protective sensation are jobs our hands perform every day. Increasing sensory input in the artificial limb is the next frontier for artificial limbs.
Very exciting work is being done by Plastic Surgeons at the University of Michigan. Chair of the Division of Plastic Surgery, Paul S. Cederna, M.D., has received a $5,500,000 from the Department of Defense, Army Research Office, for the development of a totally biointegrated upper extremity control system. In other words, a system that allows one to move their artificial limb by thinking about it. In the June issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS), Dr. Cederna and coauthors write, “The ultimate goal is to develop a prosthesis that closely mimics the natural limb, both in its ability to perform complex motor commands and to elicit conscious sensation.” The artificial limb should look, act and provide the feedback of a normal arm.
How To Feel With Your Artificial Limb
The hand pictured at the top of this article has evolved to the IH2 Azzurra Series from Prensilia. It is lightweight (640 grams), has its own embedded CPU and can produce a full strength grip with an 8 volt, 5 amp current.
Without sensation, you have to compensate with your eyes. You need to see what the limb is doing in order to get the feedback necessary to successfully complete a task. While this is still better than not having a limb, sensory feedback allows the wearer to feel their arm, and to not have to stare at their arm to make it work. Having to watch every move is a “cognitive burden” on the brain, relieving this burden is the goal of direct sensory feedback from the limb to the pathways our body already has developed to interpret this kind of information. Several techniques are available or are currently in development.
One method currently in use is Sensory Substitution, where one type of sensation is substituted for another. For example, and intact area of skin is fitted with a device that vibrates when the prothesis touches an object. This can be on the limb, or somewhere else on the body, and provides feedback for touch without visual cues. Advantages to this are that the devices can be simple and cheap, and since they are applied to the skin, surgery is not necessary.
Direct Neural Stimulation
Another technique involves directly stimulating the nerves. Similar to sensory stimulation, sensors on the prosthesis are sensitive to pressure. Instead of providing a vibratory stimulus, the prosthetic sensors stimulate electrodes placed in or near the nerves. By varying the sensors output, properties like stiffness, shape, and size can be conveyed. This allows the wearer to control fine-motor movements without having to look.
Targeted Muscle Reinnervation
Targeted muscle reinnervation (TMR), involves the transfer of nerves to provide sensation to intact skin and muscles. TMR was developed to improve control of the prosthesis; however, by providing sensory feedback from the prostheses, the feedback loop of action, response and compensation is closed.
Alternatives to Direct Electrical Stimulation of Nerves
Sensory Regenerative Peripheral Nerve Interface (SRPNI) is more than just a mouthful. It is still experimental, and seeks to avoid the need for nerve electrodes, by providing an interface that transfers sensory signals directly from a prosthetic sensor to the remaining nerve. Another developing approach is using lasers to control nerve signaling. Potentially, this could be provided topically also, and may be a viable alternative to direct electrical stimulation of nerves.
The great variety of what Plastic Surgeons do is one of the qualities that attracted me to Plastic Surgery. Most people do not think of Plastic Surgeons as researchers, but we all are. Some pursue a better prosthesis, others are trying to find a skin shrinking ray. Whether it’s an arm prosthesis to help patients get dressed, or a breast prosthesis to help the dress fit, Plastic Surgeons are constantly looking for ways to improve our patients lives.
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My surgical oncology professor, Dr. James E. Goodnight, of the University of California, Davis Medical Center, used to say,”Melanoma is the tumor that gives cancer a bad name.” Melanoma is the most deadly form of skin cancer. While it accounts for only 2% of all skin cancers, it is responsible for the majority of skin cancer deaths. 70,000 new cases of melanoma are diagnosed each year, with a projected 9,000 deaths.
The Typical Melanoma has: A) Asymmetry; B) Borders that are irregular and not smooth; C) Colors that vary from red, white to blue; D) Diameter that is increasing in size. These are the ABCD’s of melanoma.
Prevention is the Best Medicine
While melanoma treatment has come a long way, the incidence of melanoma is going up, according to data presented this week at the annual meeting of the American Society of Clinical Oncology. Over the past 40 years, the incidence of melanoma among U.S. children and young adults has increased over 250%. Young women are particularly vulnerable, despite nation-wide educational efforts to increase awareness of the dangers of UV exposure.
Tanning beds and Skin Cancer Go Hand-In-Hand
According to the FDA, anyone who uses a tanning bed before age 35 increases their lifetime risk of melanoma by 75%. Young patients who use tanning booths more than ten times a year increase their risk of melanoma seven fold. Moreover, UV exposure also increases the risk of squamous cell carcinoma, the second most deadly skin cancer by two and a half times, and the risk of basal cell carcinoma of the skin by one and a half times. In addition to the increased risk of cancer, tanning is associated with premature aging, immune suppression, eye damage and allergic reactions. This has sparked many states to restrict the use of tanning beds for minors, a movement that has more recently become international.
There is No Such Thing as a “Safe Tan”
Whether you get your UV exposure from the Sun or a tanning bed, there is no such thing as a safe tan. Sun protection is a must. The umbrella would do more good shading her body than shading her possessions.
All tans, whether from the sun or a sun bed, are bad; however, sunburns are even worse. As few as five blistering sunburns as a child is associated with and increased incidence of melanoma, squamous cell carcinoma and basal cell carcinoma. The risk of melanoma continues to rise with an increasing number of sunburns. This is true for children, adolescents and adults.
Other Melanoma Risks
There are several risk factors for melanoma including:
Excessive ultraviolet (UV) light exposure – Natural sun or otherwise
A history of sunburn – Even just one
Fair skin – Less pigment = less protection, especially if you can’t tan
Lighter hair color – The lighter the worse
Living closer to the equator – Less atmospheric refraction
Living at a higher elevation – Less atmospheric diffusion
Having many moles or unusual moles
more than 100 “normal” moles increases the risk
more than 10 “normal” moles on your arms increases the risk
moles greater than 10 mm in diameter
multicolored or irregularly shaped moles
A family history of melanoma – more family members and more closely related family members
Weakened immune system – immunosuppressive drugs or diseases
Increasing Age – Older then 55
Male Gender – sorry guys
Previous melanoma – 8-12% melanoma patients have more than one
History of Breast Cancer – may be due to a weakened immune system
What to Look For
Each melanoma above depicts a typical finding. From left to right they are: A) Asymmetry; B) Borders that are irregular and not smooth; C) Colors that vary from red, white to blue; D) Diameter that is large or increasing in size.
90% of melanomas can be cured, and the key is early detection and treatment. A yearly full body check with a Board Certified Dermatologist is recommended for anyone with an increased risk for skin cancer. Self examination can help, if you know what to look for. Seek care from a dermatologist or your family doctor for moles with any of the following:
Bleeding or itching
Change in shape or color
Increase in size
New mole or freckle
Not All Melanomas Are Black!
As if melanoma was not evil enough, 5% of melanomas are “amelanotic”, or without pigmentation. These are the toughest to diagnose, and can give even experienced doctors trouble. Unlike their darker cousins, amelanotic melanoma can look very bland.
Though we Californian’s will have less water for our pools this summer, the sun will still be shining. Be certain to wear sunscreen, and avoid excess sun whenever possible. And if any of your moles are growing or changing, be certain to get them checked out.
Breast Implant Revision Surgery Before and After Pictures Bottoming-Out Correction
Severe Bottoming-Out: Breast implant revision surgery before and after pictures of the correction of severe bottoming-out with an internal lift. No additional exterior incisions were needed to provide correction.
Breast Implant Malposition
Malposition literally means “Bad Position,” and it is a generic term applied to any situation where the breast implant is not in its ideal position. Breast Implant Malposition can be too high (superior) or too low (inferior) like Bottoming-Out. In can also be too far to the side (lateral) or too close to the middle (medial) also known as Symmastia, Uni-Boob or Bread-Loafing.
Breast Implant Revision Surgery Before and After Photos Bottoming-Out Correction Side View
Severe Bottoming-Out: Side view of breast implant revision surgery for severe breast implant inferior malposition and lower pole rippling. Correction was obtained with an internal capsulorrhapy (pocket tightening) and no additional exterior scars.
Correction of Bottoming-Out
Breast Augmentation Revision Surgery is used to correct problems with Breast Implant Malposition, and there are several methods for correcting bottoming out. The most common methods tighten and reinforce the lower pole of the internal capsule, which supports the implant. When the lower capsule is stretched out, the breast implant falls. Tightening the pocket raises the implant on the chest. If the capsule is too weak to repair primarily, reinforcement with a surgical scaffold like an acellular dermal matrix (Allo-Derm, Statice and others) or Seri, may be helpful. If the problem is that the skin can’t support the weight of the implant, a smaller implant may be a good compromise.
Breast Implant Revision Surgery Before and After Photos Mild Bottoming-Out Correction with Nipple Reduction
Mild Bottoming Out: Most the volume of the breast implant is below the nipple before the breast implant revision surgery. Note the enhanced fullness above the nipple and the improved angle at the bottom of the breast. Nipple reduction was also performed.
Mild Bottoming-Out and Large Nipples
Even mild Bottoming-Out can cause problems. In the case below, the obtuse angle underneath the breast made finding a comfortable bra difficult. The open angle allowed the bra to ride up on the breasts. After Breast Augmentation Revision Surgery, the infra-mammary fold under the beasts is crisp and well defined, allowing the bra to engage properly. It also provides enhanced fullness to the upper pole of the breast. Additionally, she complained about large nipples that were easily visible through clothing. Nipple Reduction Surgery was performed at the same time as the correction of her bottoming-out.
Breast Implant Revision Surgery Before and After Pictures Mild Bottoming-Out Correction and Nipple Reduction
Mild Bottoming Out: The breast implant was too low before this breast revision. The breast implant volume was moved from below the nipple to a more centralized position, providing enhanced upper breast fullness, and a sharper infra-mammary fold under the breasts. Nipple reduction surgery was performed at the same time.
Breast Augmentation Revision Surgery
When considering Breast Augmentation Revision Surgery be certain to find an experienced and Board Certified Plastic Surgeon near you. Dr. Joseph Mele, is Board Certified by both the American Board of Plastic Surgery and the American Board of Surgery.
To schedule a private consultation with Dr. Mele call (925) 943-6353 today, or use the contact form in the margin.
As the number of auto safety devices increases, the number and severity of injuries decreases.
The recent headlines about the Massive Takata Airbag Recall, got me thinking about how many fewer Facial Fractures I see in the ER. It is true that an increasing number of drivers, and passengers, are seen with facial abrasions from hitting these powerful air cushions. However, the number of patients seen in Emergency Departments with facial fractures continues to decrease.
Maybe We Are Driving Safer? (Why Are You Laughing?)
The incidence of facial fractures decreases (P < .01).
The probability of facial injury with newer car models decreases (P < .01).
The risk of facial fractures decreases (OR, 0.14; 95% CI, 0.09-0.22).
Interestingly, air bags alone were not associated with a reduced probability of injury (OR, 0.78; 95% CI, 0.58-1.06). Moreover, side impacts (OR, 1.81; 95% CI, 1.14-2.86) and mismatch in the sizes of the crash vehicles (OR, 1.99; 95% CI, 1.27-3.12) were associated with an increased risk of facial fractures.
Rene Le Fort documented how the face breaks with severe trauma. In Le Fort I fractures, the upper jaw is separated from the face. With Le Fort II fractures, the nose and upper jaw are separated from the face. A Le Fort III fracture is the separation of all the facial bones from the skull. All Le Fort fractures are worth avoiding, and are less likely, if you wear your seat belt.
Plastic Surgeons classify Facial Fractures by the location and pattern of the breaks. The most commonly used terminology is based on the often gruesome work of French surgeon Rene Le Fort. While the number of facial fractures is reduced by the combination of air bags and seat belts, the pattern of fractures is almost the same. The only exception was for ZMC fractures of the cheek, which points to an area that can still be improved.
Memphis Grizzlies point guard Mike Conley is familiar with the ZMC fracture. You may have noticed him wearing a protective mask during his team’s attempt at eliminating The Golden State Warriors from the 2015 NBA playoffs. Go Dubs.
Use It, or Lose It
Studies show the importance of personal protection while driving. The human body was not designed to accelerate, or more accurately decelerate, as fast as our cars can. With more states mandating the use of passive restraints, and more requirement for smart restraints, fewer facial fractures can be expected. On the other hand, your seat belts only protect you if your are wearing them properly.
Vehicles on the Takata Airbag Recall List
Takata has been the subject of several recalls recently. Be certain to check the site below for an up-to-date list.
I have tried to include all vehicles on the Takata Airbag Recall List here:
2005 Acura RL
BMW (approximately 765,000):
2000–2005 3-series sedan and wagon
2000–2006 3-series coupe and convertible
2001–2006 M3 coupe and convertible
Chrysler (approximately 2.88 million, including Dodge):
2004–2008 Chrysler 300
Dodge/Ram (approximately 2.88 million, including Chrysler):
2003–2008 Dodge Ram 1500
2004–2008 Ram 2500, Dakota, and Durango
2004–2008 Ram 3500 and 4500
2008 Ram 5500
Honda (approximately 5.5 million, including Acura):
2001–2007 Accord (four-cylinder)
2001–2002 Accord (V-6)
2001–2004 Infiniti I30/I35
2002–2003 Infiniti QX4
2003–2005 Infiniti FX35/FX45
2006 Infiniti M35/M45
Mazda (330,000, est):
2004–2008 Mazda 6
2006–2007 Mazdaspeed 6
2004–2008 Mazda RX-8
Nissan (approximately 1,091,000, including Infiniti):
2002–2006 Nissan Sentra
2003–2005 Baja, Legacy, Outback
2004–2005 Impreza, Impreza WRX, Impreza WRX STI
Toyota (approximately 1,514,000*):
2002–2007 Toyota Corolla and Sequoia
*Estimate including Lexus and Pontiac Vibe
Other Auto Recall Resources
You can also lookup your vehicle by Vehicle Identification Number (VIN) on the SaferCar.gov website. The site includes all recalls, not just airbags. Since it can take a few weeks for new defects to be listed, be certain to recheck the site periodically.