Saturday morning cartoons confirm, when an artists wants to impart strength to the hero, a Strong Chin is part of the package. By their nature, cartoons exaggerate normal features, but here, art imitates nature. Strong chins are often found on the faces of our favorite movie star heroes and heroines. Whether it’s the smooth strength of Brad Pitt or the clefted chiseled look of Henry Cavill, leading men lead with their chins. Wether you like him or not, there is no denying that Mission Impossible Rogue Nation leading man, Tom Cruise, has a strong chin. The same is true of many leading female stars including: Angelina Jolie, Olivia Wilde and Jennifer Aniston.
The Chin Augmentation Before and After Pictures above demonstrate the difference a strong jaw makes on the profile view. Chin Implants can provide balance to a disproportionately small jaw.
Size Matters But…
Chin Augmentation can dramatically change one’s profile and the way people see your facial features. Small Chins are frequently referred to as weak. Smaller chins are normal in children. The upper jaw, the maxilla, usually is formed by age nine. The lower jaw, the mandible, takes twice as long to reach its adult size. So, for most of our childhood, the chin is small. For women, the lower jaw stops growing around age sixteen, while for men, it’s closer to nineteen. Since the lower jaw takes until adulthood to develop fully, we associate the smaller chin with children.
A strong female chin still looks feminine and helps to define the border between the face and neck.
The Aging Chin
Small Chins are also associated with old faces. As we age, the skin thins, the soft tissue of the chin drops and the bone of the jaw begins to resorb. Chin Augmentation can be an important part of facial rejuvenation. A Chin Implant can replace lost volume, support the drooping soft tissue of the chin and enhance the jaw line. With a Facelift or Necklift, a Chin Augmentation can be a winning combination. Below is an example.
Chin Augmentation and Facelift Before and After Photos
Chin Augmentation can be combined with neck and face lifts to correct a small chin and enhance the jawline.
How to Pick the Best Chin Implant
The single most important aspect of selecting the best Chin Implant size is selecting one that balances your face. No one wants a cartoonish face, and that is the risk of going too large. It’s not the size of the chin, it’s the proportion that is most important. This is why Chin Augmentation is often considered during Rhinoplasty consultations. On profile, the apparent size of the nose is influenced by the projection of the chin. The smaller the chin, the larger the nose appears. Computer imaging has been very helpful in my San Francisco Bay Area Plastic Surgery practice in helping to demonstrate how a Chin Implant can help balance a larger nose.
Chin Implants and Rhinoplasty Before and After Pictures
Chin Augmentation can provide proportion to the profile and balance a nose that is too large for the chin.
Chin Implants and Chin Augmentation Consultations
If you are considering a Chin Implant, select an experienced, Board Certified Plastic Surgeon near you for your Facial Plastic Surgery needs. Computer Imaging has removed some of the guess work and anxiety from Chin Augmentation, by providing a simulation of what is possible. The images help you communicate to me what you are looking for, and help me explain what is possible. Computer images are not a guarantee. Your exact results will depend on the properties of your chin; however, computer imaging can assure us both that we understand the goals and the limitations of the procedure, before proceeding with surgery.
To schedule a private consultation appointment, call (925) 943-6353. There is no substitute for an in-person consultation; however, if you submit a question via the contact form in the margin, I will do my best to answer you.
Sientra continues to push breast implant boundaries with their latest offering – the style 107.
Sientra of Santa Barbara, CA, announced this morning the release of a new breast implant. The Style 107 HSC+ smooth round breast implant will be available in September. The HSC+ stands for High-Strength Cohesive plus, the stronger, more cohesive silicone gel that they are filled with.
What’s New About Sientra’s Style 107?
Sientra’s style 107 breast implants will offer additional options for my Breast Augmentation patients. The main features include:
Most Cohesive Silicone Gel available in a Round Implant
UPDATE:Currently, there are no details on Sientra’s website regarding the dimensions of the new Style 107 breast implants, but I got my hands on the new catalogue and here’s the scoop. The Sientra Style 107 HSC+ Breast Implants will be the same dimensions as the the Style 106 implants currently available; however, they will have the new HSC+ gel inside, and provide the benefits listed above. According to the Sientra home office in Santa Barbara, samples are on their way, so I will keep you posted. (pun intended)
Are the New Style 107 Breast Implants for Everyone?
The short answer is no. The dimensions of the implants, the details of your chest anatomy and the ultimate desired goal size will determine if you are a good candidate for this style of breast implant. They will be especially helpful for some of the more challenging Breast Augmentation cases as well as Breast Implant Revision Surgery.
Where Can I Get These New Breast Implants?
Sientra is unique among all US breast implant manufacturers. Sentra is the only US breast implant company that sells exclusively to Board Certified Plastic Surgeons. The company’s President and CEO, Hani Zeini, has emphasized his commitment to all plastic surgery patients by selling only to Board Certified Plastic Surgeons, the specialty best trained and most committed to breast augmentation excellence. If you are looking for any of the excellent Sientra Breast Implant styles, start by finding a Board Certified Plastic Surgeon near you with lots of training and experience in Breast Augmentation, and ask if they use Sientra Breast Implants.
SF Bay Area Sientra Breast Implants
I have been using Sientra’s Breast Implants since their approval three-and-a-half years ago. As a primary investigator for Sientra’s long term follow-up study, I continue to be impressed with the quality of the implants and the strength of the gel used to fill them. With zero reports of gel migration on their long term studies, it gives me confidence that their Silicone Breast Implants are made in the safest and most reliable way currently possible. If you are interested in Breast Augmentation with Sientra, Allergan or Mentor Breast Implants, give me a call at (925) 943-6353. There is no substitute for an in-person consultation appointment for learning the best options for your body and your goals.
Ariel Winter at PaleyFest 2015, three months before her breast reduction procedure.
Ariel Winter made an appearance at PaleyFest LA in March of this year. She is seen above, three months before her Reduction Mammoplasty. Per her interview in Glamour, prior to her surgery she was wearing a 32F bra. If Ariel is anything like the many Breast Reduction patients I have taken care of, her preoperative bra size was probably too small. Women with large breast wear bras that are too small in an effort to control the weight and momentum of their large breasts. A smaller band size is tighter against the chest and helps to control bounce, while a smaller cup size can help hold and minimize the breast itself.
The Problems With Larger Breasts
Ariel Winter at the January 2014 SAG Awards. Not too many cute little teeny-bopper dresses will fit an F-cup.
For most men and women with small breasts, it may be hard to understand why a woman would want Breast Reduction Surgery. Unless you or someone close to you has the problem, ample breasts may seem more like a blessing. The truth is large breasts hurt. Their weight pulls down on the shoulders, causing ruts where the bra straps dig in. The muscles of the neck and upper back often spasm trying to support the torque caused by the large, cantilevered breasts, leading to chronic neck and back pain. Rashes under the breasts are common, especially in hot Walnut Creek summers, from the skin-on-skin contact.
The Pain is Not Just Physical
The emotional pains associated with large breasts may weigh more on the mind than the physical pains. Ridicule and teasing are commonly experienced by women with large breasts. Ariel was often criticized for her weight, due to her out-of-proportion breasts on her 5′-1″ frame. She does great work as an actor on Modern Family, but felt undermined by headlines like “Ariel Winter Shows Huge Boobs At… (fill in the event)!”
Breast Reduction Before and After Pictures
Breast Reduction Before and After Pictures illustrating the typical goals of reduced size and lifted breasts.
Typically, the Reduction Mammoplasty has two goals. The primary goal is to reduce the size of the breast, and the secondary goal is to lift the breasts. Both reducing the breast volume and tightening the skin envelope provide less torque on the neck and back. A smaller breast is lighter, and a tighter breast stops moving when you do, and the improvement is immediate. Most patients notice improvement of their symptoms as soon as they wake-up from surgery.
Ariel Winter After Breast Reduction
Ariel Winter after her breast reduction. The size, while still large, is significantly better proportioned to her body, and her physical and emotional improvement was immediate.
Ariel Winter describes her motivation for Breast Reduction in an article in Glamour Magazine. Quite a bold move from a courageous young woman. I thank her for sharing her story, because she is not alone. There are many young women with similar stories who may now feel more comfortable discussing the subject with someone close to them after hearing Ariel’s Story. Unfortunately, as the benefits of Breast Reduction become more well known, many insurance companies are removing Breast Reduction as a covered procedure. This a real injustice to women who are disabled by their disproportionately larger breasts.
Breast Reduction Consultations
If you or your daughter is considering Breast Reduction Surgery, there are several options. A focussed medical history is important to determine whether the breasts’ development has plateaued and to determine a goal size that is most appropriate. To schedule a private Breast Reduction Consultation call (925) 943-6353 today, or send your questions via the contact form on the San Francisco Plastic Surgery Blog.
This is part two of a series on Eyelid Surgery or Blepharoplasty. Last week, we reviewed Upper Blepharoplasty. This week, it’s all about the lower eyelids. Lower eyelids have different anatomy, different function and are operated differently than the upper lids.
Lower Blepharoplasty Before and After Pictures
There are four major components that distract from a pretty lower eyelid: bags, wrinkles, lower position and increased height of the lower eyelid. Lower Eyelid Lifts are designed to improve all these.
Lower Eyelid Surgery (Lower Blepharoplasty)
Last post we discussed the changes usually desired for the upper eyelids: removal of excess skin, removal of fat from the inner and central aspect of the upper lids if disproportionate, changing the upper eyelid fold and repositioning the lid margin to open the eye. These goals apply to the lower eyelids too, but the methods and priorities change. For Lower Eyelid Lifts the goals are: removing lower eyelid bags, tightening the lower eyelid skin, creating or maintaining normal lower eyelid position and shortening the length of the lower eyelid.
Removing Lower Eyelid Bags
The primary concern with the Lower Eyelids is the baggage. As we age, the facial fat over the lower eyelid thins and descends, revealing the fat pads located under the eyes. For some, these bags enlarge with age. For others, the large bags are present at birth and become more noticeable as the facial fat descends. Either way, Lower Blepharoplasty is designed to reduce excess fullness under the eyes.
Transconjunctival Lower Blepharoplasty
The heading above is a mouthful, but easily understood. Trans means across, or in this case through, and the conjunctiva is the pink lining of the eyelid. Lower blepharoplasty, from last post, means lower eyelid changing surgery. Transconjunctival Lower Blepharoplasty is a method of reducing the lower eyelid’s fat pads through the lining of the eyelid. The advantage is that the scar is completely hidden inside the eyelid. This method works best for younger patients who do not have excess skin and wrinkles on the lower eyelids as shown below, and is common enough to be shown on the Wikipedia blepharoplasty page.
Transconjunctival Lower Blepharoplasty Before and After Pictures
The Transconjunctival Lower Blepharoplasty before and after pictures above show how the lower eyelid is smoothed by removing the excess fat contained in the lower eyelid via an incision inside the eyelid.
In the Lower Blepharoplasty Before and After Pictures shown above, you can see the bulge in the lower eyelid caused by the excess fat this woman was born with. You can also see her attempt to minimize the appearance with a lighter shade of makeup over the bag. After her Lower Blepharoplasty, the eyelid is smooth and flat. Just enough fat is removed to flatten the bump the excess causes. Removing too much, will cause a hollow. If this patient had wrinkles of loose skin on the lower eyelid, the transconjunctival approach would not be used. Unlike the external approach described below, excess skin cannot be removed with the completely internal transconjunctival method alone.
Tightening the Lower Eyelid Skin
Bigger problems require bigger tools. When the excess lower eyelid fat is combined with loose baggy skin, a Subciliary Lower Blepharoplasty is preformed. Cilium is Latin for eyelash, so the subciliary incision is placed just below the eyelashes on the lower eyelid. This area heals very well, making the incision difficult to see, hidden in the shadow of the eyelashes.
The most frequently used approach for rejuvenating the lower eyelid is the external, subciliary approach. Not only can it remove excess fat like the transconjunctival approach, but it can also tighten the loose skin while lifting and supporting the lower eyelids.
The advantage of the subciliary approach to Lower Eyelid Lifts is the ability to remove excess skin at the same time as reducing the lower eyelid fat. The lower blepharoplasty before and after pictures above show a marked reduction in the lower eyelid bags with tightening of the lower eye skin using the subciliary approach. In this case, only removing the fat is treating only half the problem, and would leave a deflated bag of excess skin under her eyes.
While deep lines caused by skin folds are improved by Lower Eyelid Lifts, the fine lines within the skin need different treatment. The analogy made is between the eyelids and a quilt. Wrinkles in the quilt can be smoothed by gently tugging the quilt flat. This is what lower eyelid surgery does. However, no matter how hard you pull, you cannot smooth the quilting stitched into the fabric. This requires modifying the quilt, not how it lays. For the skin, topical treatments like chemical peels, lasers and dermabrasion are used.
Creating or Maintaining Normal Lower Eyelid Position
The normally positioned lower eyelid covers the lower edge of the colored iris and white sclera under the iris. When the lower eyelid weakens, more of the iris and sclera are revealed. This is termed scleral show, and is associated with a tired, stressed appearance. As the lid descends further, the lower lid may progress to frank ectropion – gapping away from the eye, and interfering with the lower eyelids function of protecting the eye. The pink conjunctival lining may be seen and the tears may not flow properly. This makes the eye feel dry and look red and inflamed. Lower blepharoplasty can be combined with eyelid tightening procedures to prevent or correct this problem.
Before and after photos of lower blepharoplasty with tightening of the lower eyelid support show how the lower eyelid moves up to its ideal position. On the other hand, simply removing the excess fat and skin without the lid tightening would most likely expose more of the white of the eye beneath the iris.
Lower Blepharoplasty for the above patient was more risky. He already had scleral show, and the normal lower blepharoplasty removes the excess fat and tightens the lower eyelid skin potentially removing support and pulling the eyelid down further. However, when the problem is recognized before surgery, the lower blepharoplasty is modified to include a lid tightening procedure. This improves the eyelid position and prevents the scleral show from progressing to hound-dog appearance of frank ectropion. Nothing against hound-dogs.
Shortening the Length of the Lower Eyelid
All the pictures above show a reduction in the overall height of the eyelid. More accurately, this is caused by a decrease in the how far onto the cheek the eyelid descends. As discussed above, supporting the eyelid during Blepharoplasty is important to preserving the function of the lower eyelid and for maintaining a rested, alert appearance. A shorter eyelid is also associated with youth. An infant’s lower eyelids are so short that often it looks like the cheeks are encroaching on the eye opening. As we age, the cheek drops, and the lower eyelid becomes more apparent. Around puberty, the eyelid appears as its own aesthetic unit, and as we age, it occupies more vertical space above the cheek, While blepharoplasty can help decrease this appearance, the underlying cause is the cheek descending. Cheek decent is more directly treated with a Facelift, or in cases where the cheeks are small or retruded, with Cheek Augmentation.
Blepharoplasty Consultation Appointment Available Now
If you are considering tightening up you eyelids, give me a call at (925) 943-6353. Eyelid surgery and other facial cosmetic plastic surgery procedures are provided by my San Francisco Bay Area private practice in the East Bay city of Walnut Creek, CA. Your personalized consultation will include reviewing the areas you want addressed and creating a plan specific to your goals.
Blepharoplasty is an Eyelid Lift, and literally means eyelid changing. The nature of the changes can be both cosmetic and reconstructive. Differences in anatomy determine the best methods by which to accomplish our desired goals, and since the anatomy of the upper and lower lids are different, so are the methods used.
The changes usually desired for the upper lids are: removal of excess skin, removal of fat from the inner and central aspect of the upper lids if disproportionate, changing the upper eyelid fold and repositioning the lid margin to open the eye. Other adjustments are sometimes incorporated, and often multiple corrections are performed simultaneously. While these are accurate generalities, every upper eyelid surgery needs to be evaluated individually for safe and predictable results.
Upper Blepharoplasty Before and After Photos
The goal of upper eyelid surgery is the removal of excess skin, enhancement of upper eyelid alignment and removal of disproportionate fat.
Removal of Upper Eyelid Skin
The Upper Blepharoplasty Before and After Photos above demonstrate the changes possible when the excess skin is removed from the upper eyelids. This patient’s stern and tired appearance is replaced with a more relaxed and rested sparkle in the eyes. Patients with excess upper eyelid skin often complain about being asked, “Are you tired?” even when well rested. Excess skin may also block the upper and outer gaze, obstructing vision. Blepharoplasty can help alleviate these unwanted signs and symptoms.
Removal of Disproportionate Upper Eyelid Fat
The close-up view of the upper eyelid before and after photos below shows both the excess skin and fat present before Upper Blepharoplasty, and the improvements possible with an Eyelid Lift.
Upper Blepharoplasty removes excess skin and fat from the upper eyelids, providing a more rested and alert appearance.
Above, the heaviness and flattening of the upper eyelids is caused in part by excess upper eyelid skin sagging over the lid margin and resting on the eyelashes laterally. Disproportionate fat of the upper eyelid compounds the problem, giving a tired, puffy and disinterested appearance. Once the excess fat and skin are removed, the appearance is more attentive and approachable.
Changing the Upper Eyelid Fold
While seen to some extent in all races, the Asian eyelid is the most likely to have an indistinct eyelid crease. Sometimes there is only the hint of a crease, and sometimes there are folds on multiple levels. It is caused by a softer attachment between the eyelid skin and the deeper structures of the lid. This allows the eyelid fat to push lower on the lid. This is normal anatomy, but can lead to increased upper eyelid fullness and an increased risk of recurrence after eyelid surgery.
Asian eyelid surgery often includes the formation of a more distinct eyelid crease called the palpebral fold.
The above Asian Eyelid Before and After Photos reveals the creation of a distinct palpebral fold (eyelid crease), with elevation of the eyelid skin, reduction of eyelid fat and an elevated upper eyelid position. Several fine sutures are used under the skin to create an attachment that allows the skin to fold smoothly. The eyelid margin was also elevated to open the eyes.
Repositioning the Upper Eyelid Margin
Changing the upper eyelid fold and position is aesthetic in the case above, but is reconstructive in cases where vision is obstructed. In the next case, the eyelids are so saggy that they block the pupils.
Before upper blepharoplasty and levator advancement (muscle tightening), ptosis (sagging) of the upper eyelids is blocking the patient’s vision. He underwent reconstructive plastic surgery to tighten the muscles that elevate the eyelid and raise the upper eyelid’s edge above the pupils.
In the above case, excess skin and fat were removed, and the muscles that raise the eyelids were tightened. The result is obvious when looking at the pupils. Before surgery, the upper eyelid is partially covering the pupils. After Upper Blepharoplasty, a few millimeters of iris are now visible above the pupils. This means light can get into the eye without obstruction, and vision is improved. Lower eyelid surgery was also performed to improve the eyelid position and remove the bags. For about Lower Eyelid Surgery read my next post: Lower Eyelids – Blepharoplasty SF Bay Area.
Upper Eyelid Lifts and Blepharoplasty Consultations
Hopefully, the narrative and photos above help illustrate some of benefits of Upper Eyelid Surgery. To learn what blepharoplasty can do for you call (925) 943-6353 to schedule a private consultation. While the Internet is a great source of general information, there is no substitute for the skill and experience of a Board Certified Plastic Surgeon.
The Tummy Tuck provides excellent cosmetic results, but there may be medical benefits, also.
The Tummy Tuck, also known as Abdominoplasty, is a great procedure for firming up a loose belly. The procedure tightens loose skin and muscle and removes disproportionate fat from the lower abdomen, which results in a belly with more tone and less laxity. The cosmetic results are obvious for my patients and can be seen in the many Tummy Tuck Before and After Pictures available on the web.
Tummy Tuck Medical Benefits
First, the disclaimer: Abdominoplasty is a Cosmetic Plastic Surgery procedure designed to improve body contour. So it is not the primary treatment for the issues discussed below. On the other hand, researchers have shown that there is more to a Tummy Tuck than good looks. There are proven medical benefits to Abdominoplasty, too. Here are a few:
Improvement in Stress Urinary Incontinence after Abdominoplasty
Abdominoplasty tightens the lower abdomen and may also improve stress urinary incontinence.
A recent article in the Journal of Aesthetic Surgery caught my attention. Entitled, “Improvement in Stress Urinary Incontinence after Abdominoplasty,” the authors studied 250 women having Abdominoplasty. Of the 100 women completing their pre and post operative surveys, half had stress urinary incontinence preoperatively. Sixty percent of the fifty women with preoperative stress urinary incontinence reported improvement after their Tummy Tucks. Not having had a C-section before the Abdominoplasty was a predictor of improvement.
Improved Abdominal Tone = Better Posture and Reduced Low Back Pain
After weight loss or pregnancy, the abdominal muscles are over distended and often cannot recover with diet and exercise alone. With extreme weight loss, and multiple pregnancies, the stretching is more extreme and less likely to respond to non-surgical intervention.
Not only do the overstretched muscles lead to less support in front and a bigger belly, but they also lead to an increase in the curvature of the lower back, lordosis. Also known as sway back, this puts additional strain on the lower back and can aggravate lower back pain.
The Tummy Tuck can increase the support for the belly and the back.
After Abdominoplasty, the abdominal muscles are tightened and realigned resulting in improved support for the abdomen and the spine. Which can result in decreased lower back pain.
A ventral hernia is a hernia located in the midline of the belly. They can be caused by a weak muscular abdominal wall (primarily the muscle’s tough covering or fascia), injury (heavy lifting or previous surgery), massive weight and pregnancy. Many of these are the same indications for a Tummy Tuck.
Abdominoplasty makes ventral hernia repairs can be made safer and more secure.
Current methods of repairing a ventral hernia include primary closure (sewing it up), staged repair (more than one operation) or the use of a patch (bio derived or artificial). According to this article from the Annals of Surgery, “Abdominoplasty Repair for Abdominal Wall Hernias,” by combining these traditional methods with an abdominoplasty, the procedures are made safer and the results are improved. The authors conclude: “The abdominoplasty approach isolates the incision from the hernial defect and repair. This technique is safe with a low risk of complications and a low rate of recurrence. It is particularly helpful in obese patients, in patients with multiple hernias, and in those patients with recurrent hernias.”
Will My Insurance Company Cover My Tummy Tuck?
If you have urinary incontinence, chronic low back pain or a ventral hernia, a Board Certified Plastic Surgeon should not be your first consultation. Even though the Abdominoplasty has proven medical benefits, your insurance company is unlikely to provide a Tummy Tuck as a covered benefit anytime soon.
Even with multiple proven medical benefits, Tummy Tucks are not covered by insurance.
If you read my last post, Reconstructive Vs. Cosmetic Surgery, you know insurance companies put not spending money on you high on their list of things to do. They will sometimes cover a panniculectomy, but only if you provide evidence or repeated infections in the skin folds. A panniculectomy is not a tummy tuck. It is the removal of the panniculus, the skin and fat that overhangs the groin, and does not include tightening the abdominal muscles or upper belly skin.
If you have a stretched out belly that is not responding to diet and exercise, and are otherwise healthy, a Board Certified Plastic Surgeonshould be your first consultation. By tightening the abdominal wall and removing excess fat from the lower abdomen, your belly will look better. And when we look better, we feel better.
Abdominoplasty is a cosmetic plastic surgery procedure and should only be performed by an experienced, qualified expert. Find a Board Certified Plastic Surgeon. You are worth it.
Call my San Francisco Bay Area Plastic Surgery Office at (925) 943-6353 today, and schedule a convenient, completely confidential consultation appointment, or use the contact form in the margin to drop us a note. Videos are also available here: Tummy Tuck Videos. If you have lost the weight, why not loose the belly, too? Abdominoplasty could be the answer for you.
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.
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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.