Massive weight loss will shrink our volume, but does not reliably shrink our skin. In the before and after pictures above, breast volume is restored with breast implants. Sagging breast skin is tightened with a breast lift. Excess abdominal skin is removed, and the belly bulge caused by stretched out abdominal muscles, is flattened by tightening the muscle sheath.
Post-Bariatric Plastic Surgery is Plastic Surgery after Massive Weight Loss. Whether this is after a lifestyle change or after Bariatric Surgery, the amount of skin that persists after weight loss is often large and frustrating. This Post-Weight Loss Plastic Surgery Video reviews several of the most common treatments including: Lower Body Lifts, Tummy Tucks, Breast Augmentation, Breast Lifts and Arm Lifts. The results of Post-Bariatric Plastic Surgery are illustrated and narrated in this video with before and after pictures, which describe and demonstrate what Board Certified Plastic Surgeons can do for the skin excess that often occurs after weight loss.
Post-Bariatric Plastic Surgery Video
Extremity Tightening Procedures
The majority of skin tightening procedures performed after weight loss are for the trunk; however, the face, arms and legs can also develop excess skin. Face Lifts (Rhytidectomy), Arm Lifts (Brachioplasty) and Thigh Lifts can help with excess skin on the face/neck, upper arm and thighs. Below is an example of an arm lift.
Brachioplasty literally means arm changing. An arm lift can change the way an arm looks, feels and fits into sleeves.
Brachioplasty changes the arm by removing the excess skin that often hangs off the upper arm after weight loss. The skin is removed from the lower border of the upper arm, leaving a scar along the bottom of the arm. This is the only procedure that can remove large amounts of excess skin.
Post Bariatric Plastic Surgery Consultations
As an active member of the American Society of Bariatric Plastic Surgeons, post bariatric plastic surgery is an area in which I specialize.
The American Society of Bariatric Plastic Surgeons was formed by Board Certified Plastic Surgeons specializing in skin tightening after massive weight loss.
When searching for an experienced post-weight loss plastic surgeon, be certain to look for a Board Certified Plastic Surgeon who is a Member of the American Society of Plastic Surgeons. Additionally, members of the American Society for Aesthetic Plastic Surgery specialize in the cosmetic side of plastic surgery, and members of the American Society of Bariatric Plastic Surgeons demonstrate additional dedication to the cosmetic side of post-bariatric plastic surgery.
If you are in the San Francisco Bay Area and want to learn more about your skin reduction options after weight loss, call (925) 943-6353, to schedule your private consultation appointment.
Male Breast Reduction is one of the most requested cosmetic plastic surgery procedures, year after year.
Male Breast Reduction Video (Gynecomastia Reduction)
Gynecomastia is the medical term for Male Breast Enlargement. The enlargement can be isolated to the nipple areolar complex (puffy nipples), or may involve the entire chest. This Gynecomastia Reduction Video reviews the most common treatments and illustrates the results of Male Breast Reduction with multiple, narrated male breast reduction before and after pictures.
How Is Gynecomastia Reduction Performed?
Gynecomastia Reduction is often a combination of procedures. The most common combination is Liposuction plus direct excision of any firm glandular tissue which remains attached to the back of the nipple.
In situations where the skin is loose or the gland is saggy, skin reduction may also be necessary. The key it to pick the procedure, or combination, that gets the job done.
With good skin tone, even large breast reductions can be performed through small, minimally invasive incisions.
Which Male Reduction Procedure is the Right One for You?
For more information about Male Breast Reduction, visit the links in this post. For specific information, there is no substitute for an in-person consultation. Call (925) 943-6353 today, and schedule a private and informative consultation appointment. A proper evaluation and plan are the keys to excellent results.
Breast Augmentation Lift combines the Breast Enlargement of Breast Augmentation with the firming and shaping abilities of a Breast Lift.
The desire for the Best Breast can be divided into two areas: The best size and the best shape. This Breast Augmentation and Breast Lift Video discusses combining a breast lift with a breast implant. The procedure allows your plastic surgeon to maximize your results when both shape and size need modification.
Breast Augmentation Lift Video (Mastopexy Augmentation)
This Body Beautiful video segment from the San Francisco Bay Area’s News Station, KRON 4, reviews Breast Lifts combined with Breast Implants and illustrates the benefits of Augmentation Mastopexy with numerous Breast Aug Lift Before and After Photos.
The ideal breast size varies from patient to patient, and it is important to recognize that the more you do your homework in determining what size makes you happy, the easier it will be for your plastic surgeon to give you the result you desire. Most patients request a cup size in the C plus to D minus range, but you should try it out at home, first.
Buy a bra the size you feel you want to be and stuff it. Ziplock bags filled with rice are a simple way to adjust your breast volume. Try it with different clothing to see how you like it. Do your normal activities, and see how it works. Also, think about your overall body size and your activity level. Marathon runners often go smaller, to avoid the added weight and momentum.
Breast size is determined by the volume of breast tissue you have now, plus the volume of the breast implant. When you have a good shape, Breast Augmentation alone is used to enlarge the breasts to the desired size. For most women this is the procedure of choice. When the breasts are saggy, asymmetrical or tubular, a breast lift may be recommended to improve the overall esthetic of the breasts.
Breast Augmentation Lift Before and After Pictures
Deflated, post child birth or post weight loss breasts can be lifted, tightened and enlarged with the breast enhancing Mastopexy Augmentation. Larger lifts require longer scars. In this case, the healing vertical scar is seen on the lower pole of the breast. After this breast augmentation mastopexy, the breasts are fuller, firmer and lifted.
The ideal breast shape also varies from patient to patient. Most patients desire perky, teardrop shaped breasts. A Breast Lift reshapes the breasts by removing excess skin, lifting and firming the breast mound. When the upper pole of the breast is empty, a breast implant is used to add volume. A Breast Implant can balance the upper and lower halves of the breast, or it can enlarge the entire breast.
Breast Lifts come in many sizes. The most common are periareolar (around the areola/nipple), vertical (lollipop) and inverted T (anchor or keyhole). The amount of lifting needed determines the type of lift recommended. It is always desirable to choose the smallest lift expected to work. Smaller lifts come with shorter scars, but they lift less. Be sure to consult a Board Certified Plastic Surgeon near you to learn what is recommended for your particular needs.
Breast Augmentation Lift Consultations
When considering Breast Augmentation, with or without a Breast Lift, be certain to consult an experienced Board Certified Plastic Surgeon. They can explain your options and select the procedure most likely to get you the results you want in the safest and most predictable manner. Call (925) 943-6353 and schedule a personalized consultation appointment, today.
The cost of plastic surgery procedures will vary. There are many variables including:
Type of procedure
Plastic surgeon’s fee
Location of surgery
Outpatient vs. inpatient surgery
There are also indirect costs like time off from work, child care and transportation.
Bargain Basement Procedures
When you buy a television, where you buy it matters little. All brand name TVs are made the same way at the same factory. If you are buying the same model number, you are getting the same product. Some outlets sell the same product for less, and who doesn’t like a bargain, right?
However, if you are having plastic surgery, the same rules do not apply. You are paying for a service, not a product. Your outcome is dependent on the labor put into the procedure more than the name of the procedure.
While it is good to know your options, try not to get too specific about the best procedure. Your time will be better spent looking for the best doctor. A good doctor will guide you through the process, from selecting the best procedure through the recovery process.
Variations In Procedures
The best way to keep costs down is to select the correct procedure. The most expensive procedure is the one that doesn’t work, even at half the price. Let’s use facelifts as an example. In over 20 years of practice, I am not sure I have done two facelifts exactly the same. Faces all have different structures. They are asymmetrical. They move differently, and as a result, they get loose in different places. The goals and expectations associated with the facelift can vary from person to person. Additionally, each face responds differently to the components of a facelift.
Often the facelift procedure is modified during the operation in order to get the best possible results. As a patient, you want an experienced, board certified plastic surgeon, who understands your goals and who has a variety of techniques at their disposal. Beware of providers bearing “name brand” facelifts, and those claiming to be “the only one” who performs their procedure. Plastic surgeons are always looking to improve their results, and good procedures and tricks spread quickly.
Lifestyle Lift, now bankrupt, marketed low cost facial rejuvenation in every major television market. Their glossy, if not outright deceptive ads, promised a quick fix at a low price. With such unattainable expectations, it is no surprise that they failed. However, the appeal of cheaper, faster and better is a powerful motivator. Some doctors will advertise quick and cheap procedures, and spend your consultation up-selling you to something that may actually work, also know as bait and switch.
You will see over and over on the Internet doctors explaining to patients that the best procedure for them cannot be determined until after an in-person consultation. It is not a ploy to get you into their office. It is because the feel of the skin is as important as the appearance. Pictures can help, but often, do not tell the whole story.
Now You Have Selected The Best Procedure
After you have selected the best doctor and the best procedure you want to know what is included. Estimates should include the surgeon’s fee, the operating room costs, anesthesia costs where applicable, and office visits. Surgeon’s fees will vary depending on years of experience and the demand on their time. Some surgeons spend more time with each patient, and will charge more accordingly. Surgery “mills” will often have technicians doing everything except the surgery (hopefully), and you may not see your doctor at your appointments.
Operating room costs vary by location and include the facility and staff. Hospital operating rooms tend to be more expensive than outpatient surgery center operating rooms, because hospitals have higher overhead. Anesthesia will vary by type of anesthesia. For local only cases, an anesthesiologist is not required. For procedures performed under general, there will be a charge for the anesthesiologist. Depending on the institution, this may be lumped in with the operating room charges.
Medication costs are usually minimal. Pain medication and antibiotics may be required. These are not usually supplied by your doctor, and you will need to pick them up at your local pharmacy, hopefully, before your surgery. If special garments are required, you may need to buy these separately, or they may be supplied during surgery.
Operations require follow-up. I follow most my patients for a year after surgery. Other doctors may only see their patients once or twice. Some doctors have an assistant do the aftercare. You should find out what is included in the cost of your procedure. How often will you be seen after surgery? Who does the follow up? What happens if you need to be seen after hours? What to do if there is an emergency? How are revisions handled? These are all good questions to ask before committing to a procedure.
Questions For Your Cosmetic Surgeon
Thanks for reading the five questions to ask your Cosmetic Surgeon. I hope it helps prepare you for a successful operation. Links to the posts covering the other four questions are listed at the top of this post. Next week we get back into specific procedures with the latest Plastic Surgery Videos from my TV show, Body Beautiful.
Today, we are discussing question number four, “What Is The Recovery Like?” After learning about your plastic surgeon’s training and experience, and how the procedure is performed, you need to know what to expect during the recovery period. Plastic surgery is elective; recovery time is not. You will need to budget some recovery time to get the most out of your surgery. Doing too much, too soon after surgery leads to more problems and increases your chance of needing additional revision surgery.
When Can I Get Back to Normal?
The bottom line is,”How long will it take to get back to normal?” The answer depends on two things: the procedure you are having and what you consider normal. Not every plastic surgeon does the same procedure, and not every surgeon uses the same recovery plan, but you can’t mix and match. If you choose Dr. X because you like their results, you need to follow Dr. X’s recovery instructions. The recovery plan goes with the procedure. Even my own recovery plans can vary depending on factors determined during surgery. My goal is always to get you back to your normal activities as quickly and as safely as possible, without compromising your results. The recovery times and activities listed below are general examples, but you should consult with your plastic surgeon for your specific recovery plan.
Recovery By Procedure
Some procedures require more physical limitations than others. For almost every procedure, you want to limit bending over, straining and activities which increase your heart rate and blood pressure for the first week after surgery. This is to prevent bleeding and other complications that bleeding may cause.
Movement, weight bearing and lifting may be restricted in the weeks immediately after your procedure. Be certain to ask your surgeon what restrictions should be expected and for how long. Overhead reaching may be restricted after breast surgery. Sitting may be retracted after Brazilian buttocks lifts. Lifting may be restricted after Tummy Tucks. Understanding why these restrictions exist may help you recover faster and achieve better results. If light duty is available, or you have a good helper, you may be able to resume work activities sooner.
Sometimes, returning to normal is limited primarily by your postoperative appearance. For many facial plastic surgery procedures, physical restrictions are lifted after a week, but bruising and swelling may still persist and limit your activities. If you work from home, you may be able to return to work in a few days after eyelid or nasal surgery. On the other hand, bruising and swelling can last 7-10 days after surgery, making face-to-face meetings much more difficult.
Recovery By Activity
If you have a desk job, returning to work is faster than if you perform manual labor. Working on a computer is usually not a problem a week after gynecomastia reduction, but lifting heavy objects is not recommended. Normal activities vary from person-to-person. Be certain to let your plastic surgeon know what type of work or activities you perform on a daily basis, so they can let you know when you can expect to return to normal. Be certain to ask specific questions of your plastic surgeon so you can properly prepare for you recovery.
Sometimes it takes longer than average to recover. By definition, about half or all patients will take longer than average to heal. Resist the self-defeating tendency to think you will heal faster than average. It will stop you from planning properly, and will make you feel like something is wrong, when it takes the expected amount of time to heal. If you give yourself a little extra time to heal, chances are you won’t need it. On the other hand, if you think you can return to all your normal activities sooner than your plastic surgeon tells you, you are likely to be disappointed, and you may end up hurting yourself or compromising your results. Surgery is a form of injury, and even carefully planned elective surgery requires the proper amount of recovery time.
Additional Treatments During Your Recovery Period
Follow-up visits are an important part of your treatment plan. Most surgeries are enhanced by proper follow-up care. When problems are recognized promptly, they tend not to progress and are easier to treat. Your plastic surgeon has years of training and experience which they use to recognize problems and prevent them from growing. Sometimes, additional treatment is required to keep your recovery on track. Ask your plastic surgeon about follow-up appointments early in the decision making process, so that you will know what to expect and can prepare accordingly.
How will your cosmetic plastic surgery procedure be performed?.
If you have been reading the Questions For Your Cosmetic Surgeon post sequentially, now you know the questions to ask about your Plastic Surgeon about their training and experience. The next topic is about the Cosmetic Plastic Surgery procedure itself. This post explores question three of the five questions you should always ask before having Elective Cosmetic Surgery – How will my procedure be performed?
The Internet is a good place to get a general idea of what plastic surgery involves; however, there are variations on every theme. Variations are necessary for obtaining the best results. Some variations are driven by your anatomical needs, and others are driven by your surgeon’s experience. During your consultation, ask about the who, what, where, when, why and how of your procedure.
Who Does the Procedure?
After asking the first two Questions For Your Cosmetic Surgeon, you should have a good idea about your surgeons training and experience, but are they actually doing your surgery? Patients often ask me who is in the operating room. I am the one doing the surgery, but usually, there are four people in the operating room: me, an anesthesiologist, a scrub nurse/tech and a circulating nurse. My job is to perform your procedure and guide the rest of the team. The anesthesiologist is there for your comfort and safety. The scrub is garbed sterilely, and assists me with the procedure, while the circulating nurse helps everyone and can open additional items that may be needed for the operation.
Some plastic surgeons will use a physician’s assistant (PA) or registered nurse (RN) as the first assistant during surgery. These are medical professionals who have received additional training, and they may do some of the suturing. In teaching institutions, interns and residents may be involved with your procedure. You should be informed before scheduling your procedure if someone other then your plastic surgeon is doing part of your procedure. Your surgeon is required to be present and provide supervision at all times.
What Procedure is Planned?
This may sound simple, and really it is. but there is nothing wrong with confirming what is planned. In fact, before every surgery, I take a “time-out” and review the particulars of your procedure with my team. Your name, procedure, allergies, medical conditions and status of prophylactic therapies (antibiotics, sequential compression devices and warming blanket) are reviewed, and everyone must be in agreement that everything is correct before surgery starts.
Before surgery you should know what is being done; what is being fixed, how much it can be fixed and what cannot be fixed. The risks, benefits, procedure, alternative, recovery and limitations of your surgery should be reviewed as apart of your informed consent.
Where is the Procedure performed?
If your surgeon is a member of the American Society for Aesthetic Plastic Surgery (ASAPS) or the American Society of Plastic Surgeons (ASPS), you can be certain that your procedure will be performed in an accredited surgical facility. This is a requirement of membership for these societies. If you cosmetic surgeon is not a member, be certain to ask about the facility in which you will be having surgery.
When Can We Do Surgery?
After a procedure is selected, scheduling your procedure at the appropriate time is important. Your surgeon will ask about your medical history, medications you take and other procedures you may have had. Be honest. Your answers to these question need to be accurate in order for you surgeon to provide you with the safest and most predictable experience. You will want to schedule your surgery at a time which allows for you to have the best experience and results. Fewer preoperative distractions allow you to concentrate on yourself and your results. The most common reasons for cancelling surgery are taking blood thinners, eating or getting a cold before surgery. Two of these three are completely preventable. For the best results, follow all your preoperative instructions.
Post-operative care is equally important. Good support from friends and family help. It starts with them getting any last minute post-operative care instructions. You may not remember me visiting you in the post-anesthesia care unit, or the instructions the nurse may give you there, but your designated driver will. Having someone to help you, especially the first few days after surgery, is recommended. How much help you will need depends on the type of surgery you are having. Follow-up visits are important and should be considered when planning your surgery.
Why Are You Choosing These Variations For Me?
Options are good, but can also be a source of confusion. For example, there are several choices of breast implants; additionally, there may be multiple ways to the procedure, like with breast lifts and tummy tucks. I like talking about options. Usually, after a brief physical examination, the number of acceptable variations is significantly reduced, allowing us to focus on the approaches which are most likely to work best for you. Your plastic surgeon is there to guide you to the procedure which will provide the most improvement and the least risk.
How is the Procedure Performed?
The Consultation Appointment: Consultation appointments are the time for planning your surgery. Selecting your procedure and planning how your procedure is going to be performed takes the most thought. It takes into account the answers to all the questions above. This is what consultation appointments are for. Your questions should be answered, and you should feel confident that the correct operation has been selected before going to the next step. If you are still confused, repeat the consultation appointment.
The Pre-operative Appointment: Pre-op visits are for making your surgery predictable. Once the best procedure is selected, the remaining steps are much more linear. A pre-op visit is scheduled a week or two before your surgery date. The details of your procedure are reviewed again, consent forms are signed, pre-operative photos are taken and your preoperative instructions are given. To maximize the benefits of your pre-operative visit, you should be past the planning stage. If you have questions, write them down, so that they can be answered during your visit.
The Day of Surgery: The day of surgery goes by quickly. You need to arrive one or two hours before you scheduled surgery time, depending on the surgical facility. There will be more paperwork. Your procedure and health will be confirmed. If anything has changed since your pre-op visit, be certain to let the staff and your surgeon know. An IV will be started for anesthesia and other needed medications. Once in the operating room (OR), you will be asked to breath oxygen through a mask, preoperative antibiotics and anesthesia are given through the IV, and the next thing you know, you surgery is completed.
You will wake in the post-anesthesia care unit (PACU). If you are going home the same day, you will likely remain in the PACU for an hour, until you are fully awake. If your procedure is performed under local anesthesia with sedation, you will feel normal. If you have general anesthesia, you may nor remember everything that happens in the PACU, including my visit, but this is a normal effect of the anesthesia. For larger procedures, staying the night is common.
Follow-up Visits: After care is equally important to good results. They are included in the cost of your surgery, because they are part of the procedure. Be certain to keep your appointments. Patients who disappear after surgery, are taking unnecessary risks. Medical tourism, while not uncommon, sells you short on follow-up care. Being near your surgeon, makes it easy to get care if problems arise after surgery.
The fourth question to ask you Plastic Surgeon is about recovery. We will cover this in the next posting. In the mean time, if you would like to learn more about your options for Plastic Surgery, in person, give me a call at (925) 943-6353, and schedule a private consultation appointment at our SF Bay Area plastic surgery clinic.
Experience shapes training into even better results. Ask your Board Certified Plastic Surgeon about their experience.
It is important to have all the information before deciding on a Cosmetic Plastic Surgery procedure. This post reviews question two of the five questions you should always ask before having Elective Cosmetic Surgery. The five questions are:
How often do you perform the procedure? This question gets to your surgeon’s experience. Excellent Training is a must and was reviewed in the previous post. What happens after training is equally important. You want a Cosmetic Surgeon who actively practices the procedure they are doing for you. Someone who has the skills and good judgement, specific to your needs.
Last year, almost two-million cosmetic plastic surgery procedure were performed by eight-thousand US based Board Certified Plastic Surgeons. This is an average of 225 operations per surgeon. This is a good number to have in mind when we are evaluating how many times a surgeon performs a certain procedure each year. Some surgeons do 100 operations a year, some do 500. Some surgeons operate fast than others. Some work three days a week, some work six. Specialists will do a higher percentage of a certain procedure, and necessarily fewer other procedures.
How To Measure Experience
Quantity and quality do not always correlate. There is a quantity with above which quality suffers. There are also some very busy, below average ability surgeons. They may have slick advertising campaigns. They may always be offering the absolute latest technology. They may provide cut-rate surgery costs. Unfortunately, often by corners are being cut behind the curtain. Buyer beware.
Two simple ways to measure experience are years in practice and a clean record with the medical board. Both are easily checked online, and these should always be checked. For your convenience, I have links for checking Board Certification and standing with the California Medical Board at the bottom of the San Francisco Plastic Surgery Blog’s American Board of Plastic Surgery Page.
How Many Procedures Are Enough?
How often your plastic surgeon does a particular procedure is a gauge of experience. But, how many procedures are enough? The answer varies.
Surgical statistics for each year are available on the ASPS and ASAPS web sites. Knowing how common a procedure is will help you determine how many procedures a year are reasonable.
Numbers go up depending on the popularity safety and reliability of the procedure, and there is regional variation. On the other hand, Plastic Surgeons with more skills, better judgement and more experience will require lower numbers to maintain their skills. If a surgeons only does a certain procedure, you should expect them to do a larger volume of that procedure. Unfortunately, there is no guarantee that a surgeon is better, just because they do, or claims to do, more procedures. Numbers are just one way to measure experience, but in general, more is better.
Some procedures are more popular than others, so higher numbers are expected for procedures like Breast Augmentation and Liposuction, and lower numbers are expected for less common procedures like Buccal Fat Pad Reduction and Lower Body Lifts. Dividing the number of procedures performed in the US by the number of plastic surgeons in the US gives us a rough average for each procedure. By the nature of an average, half the plastic surgeons in the US will do less than the average number of procedures. This does not necessarily mean they are worse at it.
Here is an example. If 300,000 Breast Augmentations are performed in one year, and there are 8000 Plastic Surgeons in the US, the average is 300,000 divided by 8,000 or 37 Breast Augmentations per Plastic Surgeon. In other words, the average US Plastic Surgeon would be expected to do about 37 Breast Augmentations a year or about three a month.
Breast Augmentation is often the most frequently performed Cosmetic Plastic Surgery procedure performed in the US. Other very popular procedures include: Eyelid Surgery, Liposuction and Nose Reshaping. Each of these are performed approximately 200,000 times a year or twice a month for the average Plastic Surgeon.
Facelifts, Tummy Tucks and Breast Lifts are at a frequency of 100,000 a year or a once a month average. Gynecomastia Reduction (Male Breast Reduction) is performed about 25,000 times a year in the US, or 3 operations a year for the average Plastic Surgeon. Arm Lifts have a lower frequency. Fewer than 18,000 Arm Lifts are performed each year, which works out to two a year on average. Thigh Lifts are performed even less frequently, so the average is about one a year. Buccal Fat Pad Reduction is even less common. It’s all relative.
Some Procedures Work Better Than Others
Some procedures work better than others. These tend not to be the latest and greatest procedures. The most reliable procedures are tried and true and tend to be mainstream general plastic surgery procedures. Surgeons with good judgement will do more of these general plastic surgery procedures and fewer very specialized niche procedures. You should expect your surgeon to do more “full” procedures than “mini” procedures. I prefer using the smallest hammer that will get the job done; however, mini procedures do less. To get a good result from a mini procedure, you need to have a mini problem. If your surgeon is only doing mini procedures, this is a red flag.
When Is The Last Time You Did This Procedure?
The question, “How often do you perform a procedure?”, is really two questions in one. “How many procedures do you do?” and “How recently have performed the procedure?” Two questions which combine to give insight into how familiar your plastic surgeon is with your procedure. Someone who has done 50 procedures ten years ago, may not be as qualified as someone who performed 50 procedures in the last year. So you might want to ask a follow-up question about the last time your surgeon performed the procedure you are interested in.
The Shape Of The Practice
The popularity of Cosmetic Surgery varies by country. While South Korea, Greece and Italy beat the US by surgeries per capita, the column to the far right shows that no country does more Cosmetic Surgery than the US.
As practices are busier, the number of procedures performed goes up. Hopefully, they are busier because they are doing a better job. Additionally, as surgeons specialize, they limit the number of other procedures they perform. Moreover, they should be expected to be doing more procedure in their area of specialization.
Specialization is good. It allows a surgeon to focus on a particular area of interest. I am Board Certified in General Surgery and Plastic Surgery. I am trained in many procedures, but I choose to specialize in Cosmetic Plastic Surgery. The majority of my practice is Cosmetic Plastic Surgery. I had excellent training, but I have learned more in my 20 plus years of practice than I learned during my many years of training. Moreover, being a Cosmetic Plastic Surgeon was a goal I set before beginning my training. This goal shaped the entire course of my training as well as the types of procedures I perform on a daily basis.
There is an expression which goes: When all you have is a hammer, the entire world looks like a nail. Be a little cautious of super-specialists. Most good super-specialists are well rounded surgeons who still do other procedures. On the other hand, there are some super-specialists who have only learned one way to do a procedure. They may lack the training, experience or ability to offer you alternatives that may actually work better.
The Life-style Lift company is a good example. The company specialized in facial rejuvenation. They promised a bargain basement, one hour fix, under local anesthesia, with minimal downtime. Essentially, they did a mini-facelift on everyone they met. Unfortunately, the downside to this one-size-fits-all solution was not explained. Risks were minimized and outcomes not maximized. They even employed Debbie Boone as their cheerful spokeswoman. She promised a low cost, low downtime solution wrapped in slick advertising and misleading before and after pictures. The company had many complaints, many lawsuits and was fined by multiple states for false advertising and unethical behavior. Lifestyle Lift is now bankrupt, but not before giving many patients, and plastic surgery, a black-eye.
The Only One
Be even more cautious of experts claiming to be the only one performing a certain procedure. Good procedures are like wildfires; they spread quickly. Fat grafting to the Buttocks, better known as the Brazilian Butt Lift, was unheard of in the US in 2000. It has been the fastest growing procedure for several years running. The number of Brazilian Butt Lifts performed increased from 3000 to 30000 procedures per year over the last five years. It has expanded quickly because it solves a problem better than the previous operations. It is by no means a perfect operation, but it is a good operation, that works better than the alternatives (Buttocks Implants). When something works better, word spreads quickly.
Good procedures are very unlikely to remain in the hands of a single surgeon. Most plastic surgeons share their good ideas at our annual meetings. This is done not for personal financial gain, but for the good of the profession. The American Society of Plastic Surgeons (ASPS) and the American Society for Aesthetic Plastic Surgery (ASAPS) have both stated that trying to patent or restrict the distribution of a medical procedure is unethical and grounds for expulsion. Sharing is caring, even for medical professionals.
Many plastic surgery procedures are similar. In some ways, Tummy Tucks, Arm Lifts and Thigh Lifts are the same procedure. The require similar skill set. This means there is some cross-over experience between these three procedures. What I learn through experience with common procedures, like Tummy Tucks, can help me achieve better results with less common procedures, like Arm Lifts and visa versa.
There Is No Magic Number
While a greater number of cases implies more experience, there is no number that can absolutely guarantee your results. Some people learn faster than others. This is true for doctors, too, so the number of repetitions needed to be safe and effective with a procedure will vary from doctor to doctor. Good training should make a surgeon safe, while experience makes them more effective. You want to choose a Cosmetic Surgeon who is both qualified and experienced.
We are fortunate. The San Francisco Bay Area is home to some of the best plastic surgery training centers in the world. We have many qualified and experienced Board Certified Plastic Surgeons to choose from. If you are interested in any of the procedures mentioned above, or elsewhere on the San Francisco Plastic Surgery Blog, call (925) 943-6353 today, and schedule a private consultation appointment to learn more.
What to ask you Cosmetic Surgeon, before having Plastic Surgery
There are many questions you should ask your Cosmetic Surgeon. By its very nature, Cosmetic Surgery is elective. You should know what to expect from your procedure, before making the commitment. Many lists of questions exist on-line; however, there are five questions you should always ask:
Each of these questions are straight forward, but they are also multifaceted. Over the next few weeks I will expand on the nuances of each question. Today, I am discussing the issue of training.
What Is Your Training?
Training is the foundation for good results, so you should ask your Board Certified Cosmetic Plastic Surgeon about theirs.
It is important to ask about your surgeon’s training. Many types of doctors practice Cosmetic Surgery, and those of us who have dedicated our lives to obtaining the best education and training are happy to get this question. Over the last 20 years of my Cosmetic Plastic Surgery practice, there has been a heightened awareness of Board Certification. Board Certification is important, but it should be a “real” board, and it should pertain to the surgery you are having performed.
The American Board of Medical Specialties is the gold standard for medical boards. The ABMS includes 24 member boards that cover all medical and surgical specialties. Boards outside the ABMS need to be held to the same standards. The following is from the ABMS web site.
The 24 certifying boards or Member Boards of ABMS were founded by their respective specialties to assess and certify doctors who demonstrate the clinical judgment, skills, and attitudes essential for the delivery of excellent patient care.
Board Certification is a voluntary process, and one that is very different from medical licensure. Obtaining a medical license sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board Certification demonstrates a physician’s exceptional expertise in a particular specialty and/or subspecialty of medical practice.
Maintenance of Certification is a system of ongoing professional development and practice assessment and improvement. It challenges physicians to focus on the continuous development of their skill set, especially those skills that enable them to function effectively in interprofessional teams, integrated systems of care and community settings.
The American Board Of Plastic Surgery
The American Board of Plastic Surgery is the only ABMS board for Plastic Surgery, and the only board exclusively dedicated to the performance of safe and predictable plastic surgery. It is important to note that the minimum requirements are the completion of Medical School, 3 years of general surgery training, 2 years of plastic surgery training and the completion of board certification examinations. Since 1995, ongoing yearly maintenance of certification (MOC) is also required (more tests, paperwork and expense). Doctors certified before 1995, are not required to participate in MOC, so you may want to ask if your Board Certified doctor voluntarily participates in MOC.
What Is My Training?
I have spent years more than the minimum required to get the best possible Cosmetic Plastic Surgery training. I also obtain 2 to 3 times the required continuing medical education (CME) units every year, so I am happy to answer questions about my training and qualifications.
The above certificate represents years of training and many weeks of ongoing continuing medical education.
I my case, I chose to become a Board Certified Plastic Surgeon, with specialization in Cosmetic Plastic Surgery. It is the longest training for Plastic Surgeons, and the only training dedicated exclusively to Plastic Surgery.
After college, my training includes medical school, general surgery and plastic surgery training leading to Board Certification in both General Surgery and Plastic Surgery. Here are some more details:
Four years as a medical student at the University of California Davis School of Medicine in Davis and Sacramento, CA
One year as a surgical intern at the University of California Davis Medical Center in Sacramento, CA
Three Years as a general surgery resident at San Joaquin General Hospital in French Camp (Stockton), CA
One Year as the general surgery chief resident at San Joaquin General Hospital in French Camp (Stockton), CA
Two Years as a plastic surgery fellow at Saint Francisco Memorial Hospital in San Francisco, CA
One Year as a plastic surgery chief fellow at Saint Francisco Memorial Hospital in San Francisco, CA
What Is My Board Certification?
That is 12 year of training after college. Three years of general surgery training at the same program are required for admission to a plastic surgery training program. Board Certification in General Surgery is not required. I completed five years of general surgery training, an entire General Surgery residency and Board Certification in General Surgery.
Two years of Plastic Surgery training are required for Plastic Surgery board certification. I completed three years and Board Certification in Plastic Surgery.
Is Training Enough?
Good training is the foundation for a good Plastic Surgeon. Having the appropriate knowledge base is what helps me choose the best procedures for my patients. Knowing multiple ways to accomplish similar goals, gives you options, too. If you would like to explore your Plastic Surgery options, give my San Francisco Bay Area plastic surgery clinic a call today at (925) 943-6353.
Without good training, surgeons become pigeon-holed and have limited options from which to choose. Experience, however, is equally important. Next week’s question, How Often Do You Perform The Procedure?, can help you select a Plastic Surgeon who is both well trained and experienced with the procedure you desire.
Through the years, I have posted several updates on the rare, but very treatable, Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) on the San Francisco Plastic Surgery Blog. As of January 4, 2018, a pivotal new study was released in JAMA Oncology.
An advanced case of BIA-ALCL. Arrows on this MRI point to white patches of increased fluid around the tumor cells.
What Is The Risk of BIA-ALCL in Women With Breast Implants?
To properly frame the answer obtained, it is important to note that BIA-ALCL is not breast cancer. However, the relative risk of BIA-ALCL compared to the risk of breast cancer is often used to give proper reference to how rare BIA-ALCL is.
What Was Found – The Absolute Numbers
The study utilized the Netherlands’ Nationwide Network and Registry of Histo- and Cytopathology (PALGA). Over the 27 years, the study identified 32 patients with primary breast ALCL with a breast implants. Overall, 782 female patients were diagnosed with a non-Hodgkin lymphoma (NHL) of the breast in the Netherlands during 1990 to 2016. 43 primary breast-ALCL cases were confirmed. The median age of the 43 patients with breast-ALCL was 59 years. 32 of these patients had ipsilateral (same sided) breast implants, compared with 1 among 146 women with other primary breast lymphomas (OR, 421.8; 95% CI, 52.6-3385.2).
Other Associations With BIA-ALCL
BIA-ALCL seems to form on the surface of textured breast implants. The cells can also be found in the fluid that accumulates around the breast implant. The bacteria that form a biofilm around the textured implants have been associated with this tumor.
BIA-ALCL is associated with textured breast implants. Out of 109,448 breast implants sold in the Netherlands, 49,109 were textured (P < 0.01). This means of the breast implants sold in the Netherlands, and presumably used, 45% are textured. In this study, however, 23 of 28 patients diagnosis with BIA-ALCL had textured breast implants at the time of their diagnosis or 82%. So the actual number of BIA-ALCL cases associated with textured implants was almost twice what would be expected if BIA-ALCL occurred at the same rate in textured and smooth breast implants. Even more importantly, in this study, it was unknown if the patients with smooth implants had previously had textured breast implants, but more on that below.
Textured Breast Implants & BIA-ALCL
The Plastic Surgery Foundation has the most complete and largest database of BIA-ALCL cases. As of December 1, 2017, of the 183 unique reported cases in the PROFILE database, every patient has had a textured breast implant prior to their diagnosis. Even women who had smooth breast implants at the time of their BIA-ALCL diagnosis, had previously had either a textured breast implant or a textured tissue expander prior to receiving their smooth breast implants.
Comparisons With Breast Cancer
If you live to 80 years of age, your risk of developing breast cancer is 1:8. If you have breast implants, your risk of developing BIA-ALCL ranges from 1:1000 to 1:30,000 for women with textured breast implants, depending on which epidemiological study you read. In 2018, about 40,920 women in the U.S. are expected to die from breast cancer. World wide there have been 17 deaths from BIA-ALCL over the 56 years that breast implants have been available. Like breast cancer, early diagnosis is the key to a cure. Unlike breast cancer, BIA-ALCL is very treatable.
The Signs of BIA-ALCL
Current treatment of BIA-ALCL is usually curative, but depends on early diagnosis and appropriate treatment.
Although it is unlikely that a woman with breast implants will ever have to deal with BIA-ALCL, it is important to know the symptoms and seek care if they develop. When BIA-ALCL is confined to the capsule, removing the breast implants and capsules has been curative for every patient to date. The majority of early stage patients require no additional treatment. Chemotherapy is required for unresectable disease to metastasis.
Delaying or declining treatment is not advisable. Analysis of the known deaths from BIA-ALCL revealed that patients either received radiation (x-ray therapy) or chemotherapy alone, died of the treatment itself, had incomplete surgical resection or had distant metastasis. All cases of BIA-ALCL should be reported to the PROFILE registry.
BIA-ALCL usually presents as unilateral (one-sided) swelling of the breasts, an average of 8-9 years after the insertion of textured breast implants (range 2-28 years reported). This can occur even if the breast implants have been replaced with smooth breast implants. Fluid around a textured breast implant is not usually due to BIA-ALCL, but it can be sent for analysis when the conditions are suspicious. BIA-ALCL can also present as a lump in the breast or in the armpit like breast cancer does.
The FDA does not recommend any additional screening or treatment for BIA-ALCL. BIA-ALCL is extremely rare, and it is impossible to predict who will develop it, but there are 4 identified risk factors: TIMD
T – Textured Breast Implants – There have been no reported smooth-walled device cases at this time.
I – Inflammation – Chronic inflammation has been implicated. Certain bacteria in the biofilm that forms around breast implants have been associated with an increased risk of BIA-ALCL.
M – Mutations – There may be a link with genetic mutations in JAK1 and STAT3. Further research is necessary.
D – Duration of Augmentation – Presentation is usually 8-9 years after textured breast implant insertion.
What To Do If You Suspect You Have BIA-ALCL
Get checked out. See your primary medical doctor or your plastic surgeon. Get an updated medical history and physical examination. If enough fluid is present around the breast implant, a sample can be sent for analysis. 2-3 tablespoons are required for cytology and CD30 immunohistochemisty to rule out BIA-ALCL. Mammograms are not useful. PET/CT scans are used for staging.
Saggy upper eyelids and lower eyelid bags make us look tired and add years to our face. This is why the Eyelid Lift remains one of the most popular cosmetic plastic surgery procedures which I, and other Board Certified Plastic Surgeons, perform.
Eyelid lifts can literally open our eyes, making us look more awake and alert. As the upper eyelid skin becomes more redundant, it begins to rub off upper eyelid makeup and can come to rest on the eyelashes. The result is a heavy sensation and a worn down appearance, even when we are well rested.
Blepharoplasty means eyelid changing, and it can rejuvenate our appearance and recharge our persona. San Francisco Bay Are Board Certified Plastic Surgeon, Dr. Joseph A. Mele, discusses eyelid rejuvenation and narrates numerous blepharoplasty before and after pictures on this video segment taken from KRON 4’s Body Beautiful.
Blepharoplasty Video (Eyelid Lift)
The following video segment reviews Eyelid Lifts and illustrates what Blepharoplasty can do with numerous Eyelid Lift Before and After Pictures.
The preview screen on the above Blepharoplasty Video shows how excess upper eyelid skin can weigh down the upper eyelid. In the picture on the left, the upper and lateral visual fields are obstructed and the skin is resting on the eyelashes, making the normal use of eye makeup impossible. In the after picture on the right, the eye and the upper eyelid are now visible.
The Correction of Lateral Hooding
In these Blepharoplasty Before and After Pictures, the before picture on the left shows the lateral brow skin completely covering the outer eyelid. In the after picture on the right the brow skin is elevated, giving a much cleaner, refreshed and younger look.
Lateral Hooding occurs when the eyelid or brow skin descends past the outside of the eye opening also known as the lateral orbital rim. Skin in this position blocks the lateral gaze, like blinders do on a horse. It also impacts a sleepy and older look to our eyes. In the above example, simply removing the excess skin corrected the problem. When the brow itself sags, a Brow Lift may be recommended.
Correcting Upper Eyelid Hooding
The upper (before) photo shows severe hooding of the entire upper eyelid. After her blepharoplasty, her upper eyelids are now visible, and a smooth upper eyelid crease has been created.
Sometimes the upper eyelid skin is so excessive that the entire upper lid is hooded. Wearing upper eyelid makeup properly is short lived at best. By removing the excess skin, the upper eyelid and lashes are revealed, and a natural eyelid crease is created.
If you would like to schedule a personalized consultation appointment, give me a call at (925) 943-6353. There is no substitute for an in-person eyelid consultation with an experienced and qualified, Board Certified Plastic Surgeon. A brief exam and medical history are needed to be sure the procedure is right for you. Safety and predictability are the most important aspects of any surgery, but this is especially true of elective plastic surgery.