December 16th, 2011 Dr. Mele
The Liquid Facelift - Wrinkle Fillers: Restylane, Perlane, Juvederm, Radiesse; and Neuromodulators: BOTOX Cosmetic, Dysport and Xeomin.
The Liquid Facelift is a quick way to reduce the signs of facial aging. Technically not a facelift, the term liquid facelift refers to use of volume restoring injectables like Restylane, Perlane, Juvederm and Radiesse. These products can fill unwanted wrinkles and enhance facial features that are desired.
Filling Unwanted Wrinkles
Dermal Fillers are a class of pharmaceuticals designed to plump sagging skin. Unwanted facial wrinkles, like those found around the mouth, can be carefully filled to significantly reduce their appearance. The treatments are performed right in the office, and the downtime is minimal.
Dermal Fillers are administered with a fine needle, and come complete with local anesthetic inside. The most common unwanted side-effects are temporary and include swelling and bruising. Icing after treatments can help reduce both. A few days prior to your treatment, it is important to avoid medication that thins the blood like: aspirin, ibuprofen, naprosyn, vitamin E, fish oil and many natural supplements. This will reduce your risk of bruising. If you are planning to do some wrinkle reduction for a special occasion, do not delay. Ideally you should have the treatment done several weeks in advance. If you bruise, you will have plenty of time to recover, but your results will last for months.
Enhance Facial Features
Sometimes the goal is not to disguise, but to augment. Restylane, Perlane, Juvederm and Radiesse can be used to increase the size of some of the face’s most desirable features. Hyaluronic based fillers like Restylane, Perlane, Juvederm, can be used to enhance the lips. While Radiesse can be used to enhance the cheek bones and chin. If you are considering facial augmentation with cheek or chin implants, dermal fillers can provide a way to try it out on a temporary basis.
Maintaining the Result You Want
If you want to maintain the results, it is necessary to touch up the areas from time to time. For most patients, touch-ups require less volume than the initial treatment. This is because we are adding volume before the previous correction has completely resorbed, and because these product promote your face to produce collagen in the areas of injection. Even after treatment, the face continues to age. Dermal fillers cannot provide permanent results. The amount of wrinkle reduction, and the time it will last for you, may vary.
2011 Holiday Discounts on Selected Dermal Fillers and Neuromodulators
For the month of December several promotional specials are being offered in our San Francisco Bay Area, Walnut Creek plastic surgery office:
- Any HA filler, buy two get one free includes: Restylane, Juvederm, and Perlane. All product must be administered by December 31, 2011.
- Up to $65 rebate with each syringe purchased. (May be combined with above!)
- Perlane – $65 rebate on each 1.0 cc syringe (maximum of 6 cc’s)
- Restylane – $50 rebate on each 1.0 cc syringe (minimum of 2 cc’s & maximum of 6 cc’s)
- $50 rebate on BOTOX Cosmetic and Dysport treatments of $200 or more.
Liquid Facelift Appointments
If you are interested in learning more about the liquid facelift and facial wrinkle fillers, or you want to know more about neuromodulators like Botox, Dysport and Xeomin, please give our San Francisco Bay Area Plastic Surgery office a call at (925) 943-6353, and schedule a personal consultation appointment. More information is also available on our web site under face: facial wrinkles (minimally invasive) or on DrMele.com under skin.
December 7th, 2011 Dr. Mele
As 2011 draws to a close, so do the first 50 years of breast implants. In 1961, American plastic surgeons Thomas Cronin and Frank Gerow, and the Dow Corning Corporation, developed the first silicone breast prosthesis, filled with silicone gel. In 1962, Timmie Jean Lindsey became the first woman to receive silicone breast implants.
Breast Implants Have Come a Long Way in 50 Years
Saline Breast Implants
You might be surprised to find out that saline filled implants did not appear until the French company, Laboratoires Arion, began manufacturing them in 1964. Filled with 0.9% saline, water that is the same saltiness as your body, these implants are filled in the operating room after insertion, allowing for a smaller incision compared to the incision needed for pre-filled silicone gel breast implants. While early models were fragile, contemporary saline breast implants have a stronger silicone elastomer shell. These implants became the most frequently used in the US during the 1990′s, when silicone gel filled breast implants where restricted to reconstructive use only.
Silicone Breast Implants
While saline filled breast implants have changed relatively little over their lifetime, silicone filled breast implants have gone through five distinct generations.
First Generation Silicone Breast Implants
The first generation was tear-dropped shaped. Yes, that’s correct, the first breast implants were silicone filled and tear dropped shaped. These implants have a smooth surface, so to keep them from rotating, a Dacron patch was attached to the back. It had the texture of the soft side of Velco, and allowed the body a point of attachment to prevent rotation. The shell was thick, as was the gel inside. This helped prevent deflation and tearing at the point of fixation. The thicker gel also made it easier to take care of any leaks, as the thicker the gel, the less it migrates.
Second Generation Silicone Breast Implants
In the 1970′s, in an attempt to improve the look and feel after breast augmentation, the shell and the gel inside the implant was made thinner. Unfortunately, new technology doesn’t always mean improved. With these changes came more complications. The thinner shells broke more frequently and the thinner gel could migrate farther after a leak. Even without a leak, silicone gel could “bleed” through the intact shell like Helium through a balloon. This resulted in a class action lawsuit against Dow Corning and other breast implant manufacturers. Other “improvements” which arrived in the 70′s were polyurethane foam coating for the implant shell and double lumen implants.
Polyurethane foam coating reduced the incidence of capsular contracture, but a concern that a breakdown product of the coating (TDA) might cause cancer stopped sales. The FDA later stated the risk was infinitesimally small, but no breast implant manufacturer has sought FDA approval for sale in the US. These implants remain available in Europe and South America.
Double lumen implants have two sections, an inner chamber pre-filled with silicone gel and an outer chamber that can be filled with a varying amount of saline. Double lumen implants were used mostly for breast reconstruction. Unfortunately, the increased complexity of dual chamber breast implants led to increased device failure, and eventual withdrawal from the market.
Third Generation Silicone Breast Implants
Around 1985, breast implants where manufactured with elastomer coated shells. This significantly reduced the number of implant failures and also the problem with gel “bleed”. Since that time the rate of capsular contracture has dropped. Coincidence? Maybe. At the same time the changes in the shell were made, additional improvements in manufacturing and quality control also occurred.
Fourth Generation Silicone Breast Implants
Fourth generation implants are defined by a return to a thicker, cohesive silicone gel filler. Back to the future is the theme for the third and fourth generation breast implants. Like the original breast implants, with thicker tougher shells and thicker less runny filler, the safety and predictability of fourth generation, cohesive gel breast implants has improved. Fourth generation silicone gel filled implants are currently the only FDA approved silicone breast implants currently available in the US.
Fifth Generation Silicone Breast Implants
The next incarnation of silicone breast implants are the gummi-bears. They are filled with a soft, semi-solid silicone with the consistency of gummi-bear candy. They are soft enough to give when compressed, but firm enough to return to their original shape when the pressure is released. Since they are essentially a solid, these implants do not experience problems with leakage or gel migration. Most are made with an anatomical shape. To prevent rotation, the implants surface is textured to allow the capsule to attach to the shell. This works most the time, but implant malposition from rotation can be a problem (not seen with smooth round implants). Overall, the form-stable implants are more firm, but still soft. Somewhat surprisingly, they can still ripple (wrinkle).
Allergan Natrelle Style 410 (gummi-bear) breast implants come in 12 shapes and many sizes.
Since they are solid, gummi-bear breast implants require a larger incision for placement. This can be a deterrent when a simple breast augmentation is being considered. The mastectomy incision used for breast reconstruction and the breast lift incisions allow for the insertion of solid implants without additional incision length.
Soft-solid breast implants are figuratively sitting on the shelf at the FDA. Despite some advantages, the approval process has ground to halt over the last several years. The FDA has all the information it has requested, and no new requests for information are forthcoming. Despite this, no vote has been taken. It is increasingly unclear to industry, plastic surgeons and patients alike what the reason is. These fifth generation breast implants have a good record in Europe, where they have been used since 1995, and they have been available since 2000 to our northern neighbor, Canada. Dear FDA, how about approving silicone implants that can’t leak this year?
December 3rd, 2011 Dr. Mele
Earlier this year, the San Francisco Plastic Surgery Blog reported an extremely unusual, but possible association between breast implants and a rare form of Non-Hodgkin’s Lymphoma named Anaplastic Large Cell Lymphoma or ALCL. The tumor is extremely rare. Of the 5-10 million women with breast implants, fewer than 100 cases have been identified. Literature reviews have identified 34 unique cases, and as many as 75 cases may have been identified worldwide. Because of the rare nature of the tumor, it is not clear what the association between ALCL and breast implant is.
Anaplastic Large Cell Lymphoma
Demographics of all Known Reported Cases
Demographics of the cases are as follows:
- Age: Median 51 years old, Range 28-87 years old
- Implant Type: Silicone 24, Saline 7, Not specified 3
- Time from implant to ALCL diagnosis: Median 8 years, Range 1-23 years
- Reason for Breast Implant: Reconstruction 11, Cosmetic 19, Not Specified 4
The American Society of Plastic Surgery (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) have partnered with other international plastic surgery societies like the International Society for Aesthetic Plastic Surgery (ISAPS), to provide an organized way to report, and characterize the diagnosis and treatment of ALCL since its discovery.
ALCL is Not Breast Cancer
Breast cancer dwarfs ALCL in both numbers of cases and lethality. Breast cancer has an incidence of 1 in 9 women. This means for a group of nine randomly selected women, one woman would be expected to develop breast cancer in her lifetime. The actual breast cancer rate is a little higher, and this is why routine mammograms after age 40 are so important for early detection. The risk of getting breast cancer is about 700 times higher than the risk of getting struck by lightning.
No Increased Rate of Breast Cancer for Women with Breast Implants
While the association between ALCL and breast implants is still being worked out, there is no increased risk of breast cancer in women with breast implants. In fact, the results of more than seven long-term follow-up studies show that women with implants have a lower rate of breast cancer than is expected in the general population, and higher survival rates, perhaps due to enhanced breast awareness and early detection.
Looks Like ALCL, but Doesn’t Act Like ALCL
ALCL associated with breast implants is not as aggressive as other types of ALCL. It acts more like cutaneous lymphomas than the more systemic form of ALCL. ALCL associated with breast implants has been characterized as a rarely occurring, low-grade lymphoma, that seems to grow slowly and locally. While the risk of breast cancer is 1 in 9, the risk of ALCL is less than 1 in 300,000, and most resources quote ranges of 1 in 500,000 to 1 in a million. The risk of getting ALCL associated with breast implants is 50 to 150 times lower than the risk of getting stuck by lightning.
Last week, news of the first reported death from ALCL associated with breast implants hit the French news. The details are not known at this time, and unfortunately, the case is further complicated by the use of fraudulent breast implants that were filled with industrial grade silicone instead of the required medical grade silicone. The implants were manufactured by Poly Implant Prothèses (PIP) at La Seybe-sur-Mer in the Var. The company was forced to close in March of 2010, after it was determined that the implants were filled with non-medical grade silicone gel. These implants have more gel bleed, and are ten times more likely to break. Even though the company was forced to withdraw its products from the market when the discovery was made, thousands of French women are known to still have the defective implants. These implants have never been FDA approved in the US. Only Allergan’s Natrelle and Mentor’s Memory Gel breast implants are currently FDA approved.
The Latest ALCL News
The best information currently available on the topic is a review of opinions by a panel of experts from RAND Health, UCLA’s department of medicine’s division of hematology-oncology, the University of Michigan Health System’s department of surgery’s division of plastic surgery and others. The article has been accepted by ASPS’s Plastic and Reconstructive Surgery Journal, but has not yet been published. The results are based on the small number of cases known to exist, represent the opinions of the seven panel members and are not based on prospective randomized evidence. A copy of the article can be found here. The article’s disclaimer reads: Support for this study was provided by the Plastic Surgery Educational Foundation (PSEF) and the Aesthetic Surgery Education and Research Foundation (ASERF) through unrestricted grants from Allergan, L.L.C.; Mentor Worldwide, L.L.C.; and Sientra, Inc. Neither the study sponsors nor the listed companies had roles in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
As more information becomes available, I will post more updates. It is important to remember that this is an extremely rare problem. It is a sensational story though, so it is sure to hit the mainstream media soon. The ASPS, ASAPS and ISAPS are actively seeking all known cases of ALCL found around breast implants to determine what, if any association exists, if there is a causal relationship and how best to treat the disease when discovered. If you have, or know someone who has, ALCL associated with breast implants, please contact one of these plastic surgery societies and the FDA.
More Information About ALCL
A current summery of ALCL cases appeared in the June issue of Plastic and Reconstructive Surgery. The abstract can be read here.
The FDA has an ALCL and breast implants FAQ page here. Moreover, all confirmed cases of ALCL in women with breast implants should be reported to Medwatch, the FDA’s safety information and adverse event reporting program. Report online here or by calling 1-800-332-1088.
How to Detect ALCL Associated with Breast Implants
The chances of getting breast implant associated ALCL are extremely remote. I have thousands of patients with breast implants, and chances are that I will go my entire career without seeing one case. This, however, will not keep me from looking for it.
Most cases of ALCL in patients with breast implants have presented with a seroma (fluid collection) around the breast implant more than six months after the initial surgery. To try and detect ALCL as soon as possible, experts are recommending aspirating (draining) seromas around breast implants when they occur later than six months after breast augmentation or breast augmentation revision surgery, and also sending the fluid for cytologic analysis to check for abnormal cells. If you feel you have a problem with your breast implants, do not delay; seek the advice of a Board Certified Plastic Surgeon in your area.