Posted January 13, 2018 in Home, Patient Safety
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?
The article, available on-line, is titled, “Breast Implants and the Risk of Anaplastic Large-Cell Lymphoma in the Breast.” The key question which the authors tried to answer is, “What are the relative and absolute risks of breast anaplastic large-cell lymphoma (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.
Posted October 22, 2017 in Home, Patient Safety
Fires have devastated wildlife and neighborhoods alike in the San Francisco North Bay Area.
The recent Napa Sonoma fires make me think about my experience taking care of burn patients. Burn care was one of the most challenging aspects of my Plastic Surgery Training. I’ve treated burns at every stage, from new injuries to old scars. For most of us, burns are unsightly, but for the patient they are so much more.
I had the privilege of training in two of the best burn centers in Northern California: The University of California Davis Medical Center, Burn Center in Sacramento, California, and the Bothin Burn Center inside Saint Francis Memorial Hospital in San Francisco, California. Both these centers are accredited specifically to provide the specialized care that burn patients require.
University of California Davis Medical Center – Sacramento, CA
The University of California Davis Medical Center in Sacramento, CA. I spent many years here between Medical School, General Surgery training and research in Plastic Surgery.
My experience at UCD was during my Medical School and General Surgery training years. This was the first time I saw the consequences of a large burn. He was a 9-year-old black boy. The story was that he had taken a bath and the water was too hot. I expected him to have a burn on his foot or hand from testing the water, but over half his body was scalded. His entire lower half was blistered an peeling, and there were multiple smaller areas of first and second degree burns on his chest and arms where the water has splashed against him. It was unclear if he had jumped into the bathtub and had trouble jumping back out, or if he had help staying in the tub. That was for CPS to sort out.
We had to worry about his injury. The ER doctor quickly taught me the Wallace rule of nines. It added up quickly: 18% for each leg, another 18% for the lower half of his torso and 1% for his genitals. This boy had sustained a 55% total body surface area (TBSA) burn. Then we calculated the amount of IV fluids he needed using a modified Parkland Formula. It seemed like a lot, but the sparse volume collected in his urinary catheter told us he needed it, and more.
Meanwhile, the Plastic Surgeons started addressing his wounds. His beautiful, smooth, and youthful tan skin slid off his legs in sheets, revealing the angry pink dermis. I knew his skin would never be the same, but first he had to survive. Dressings slathered with silver sulfadiazine, a thick white paste of antibiotic, were applied to the exposed dermis. This seemed to ease his pain a little, but he still required a lot of morphine.
Burns are serious injuries. While most burn patients survive, even those with large percentage body area burns, it is not a pleasant trip. Multiple operations, weeks in the hospital and years of therapy are usually required. The pain, the smell and the change in appearance, all take a toll on both the patient and those who care for them.
Saint Francis Memorial Hospital Bothin Burn Center – San Francisco, CA
Saint Francis Memorial Hospital, located at 900 Hyde Street on Nob Hill, contains the Bothin Burn Center, a 16 bed ABA certified burn unit, which contains an operating room dedicated to burn care.
As a medical student and General Surgery Resident, my role was more resuscitative and supportive. We dealt with the arrival and stabilization of the patient, but not the healing or recovery. It was at Saint Francis Memorial Hospital, during my Plastic Surgery training, when I found out how long the healing process takes, and other hazards that patients are exposed to when burns are caused by fire rather than hot water.
The first burn patient I took care of at Saint Francis Memorial Hospital had a relatively small TBSA burn, but she had a much more dangerous injury. She was a 70-year-old woman rescued by SFFD from a burning building, I’ll call her Mary. The first problem I encountered was getting to the hospital. The single lane of my one-way street was full of cars which were not moving. I left my car on the sidewalk in front of my apartment, to see what the problem was. It turned out that the burning building, the one my patient was rescued from, was on my block.
I introduced myself to one of the firemen, the one with the biggest shield on his helmet, as he seemed to be in charge. I told him I was the Plastic Surgery Fellow at the Bothin Burn unit and that I needed to get to the hospital, preferably, before the patient. I asked if traffic was likely to be diverted, or if I should start walking and find a cab down on Columbus. He looked a little surprised, spoke a few words into his 2-way radio and said, “We’ll get you there doc.” The road was cleared by diverting traffic down Romolo, a road too steep to walk, never mind drive.
I arrived in the ED just before Mary. She had minor burns on her hands and arms, and was having trouble breathing. The biggest hazard of being in a structure fire is not being burned, it is not being able to breath. Fires consume oxygen and produce carbon monoxide (CO), hot gases and noxious fumes. None of which are good for breathing. Her CO levels were high. An oxygen mask was applied to Mary’s face to try and displace the CO from her red blood cells. Bronchoscopy revealed char in her airway all the way down into her lungs, a clear sign of airway injury from breathing in hot gasses. She was intubated and placed on a ventilator to prevent her airway from swelling shut. She was able to breath on her own, off the ventilator in a week. Her burns were superficial and healed with just dressing changes. She was lucky. Her biggest problem was trying to find another apartment in San Francisco.
Most burn patients were not as lucky. All of them were memorable, but there are too many to list. A few of the more tragic stories include:
- A trucker driving a gasoline tanker was in an accident. The officer who pulled him out of the cab, melted the soles off his police boots in the process.
- An electrician who contacted an energized panel. The current travelled down his right arm and out his left foot.
- A woman who passed out drunk into her fireplace.
- Too many children who pulled the hot tea pot off the table as their family was enjoying a meal in Chinatown.
- A young girl who was standing on the other side of the barbecue when her father decided to help the coals along with a cup of gasoline.
Plastic Surgery is not always glamorous.
Napa Sonoma Fires
As I watch the Napa Sonoma Fires, I think about the people I have taken care of with massive burns. I have several friends and families of friends who have lost their homes and everything in them over the last few days. Most left with only their wallets and the clothes on their backs. It is tragic, but they are safe. While I am sad for all those who have lost so much, I am very happy that most were able to escape unharmed.
As of this afternoon, 18 have lost their lives in this firestorm, and 65 people are still unaccounted for. My thoughts and prayers are with them, their families and the thousands of first responders doing their best to protect lives and property at great personal risk.
Posted August 12, 2017 in About Dr. Mele, Home
For the sixth year in a row, Dr. Joseph Mele has won the Talk Award for Excellence in Patient Satisfaction.
The 2017 Talk Award Winner
The 2017 Talk Award Winners were announced last week, and I am humbled and honored to announce that for the sixth year in a row, my staff and I have been awarded the 2017 Talk Award for Excellence in Patient Satisfaction.
Thank you, to all my patients who have taken the time to post a positive review. After 20+ years in practice, I know how rare that is. This is especially true for Cosmetic Plastic Surgeons, like myself, who practice in Northern California, where results are more often very personal and private, than they are something to be live streamed for the world to see.
Dr. Joseph Mele, your San Francisco Bay Area patient rated, five-star, Cosmetic Plastic Surgeon.
Talk Awards Selection Process
The Talk Award Committee gathers information from a combination of highly respected, no-cost, online user-review websites, blogs, social networks and business-rating services to measure customer satisfaction. Star ratings from the websites, the number of user reviews, scores from other business-rating services and accolades found through their research establish the basis for ratings. This annual audit provides data for a review process to evaluate and rate its findings.
Based on the results of this review and internal guidelines, the Talk Awards assign their own rating to act as a representation of the data accrued. By combining all online information into one score, consumers and businesses receive a fairer overview of customer feedback without having to spend hours locating all the information. Talk Awards takes the worry and work out of finding the top consumer-rated businesses across the country.
…And Thanks For All The Stars
Thank you for all the positive reviews. I run a very personal practice, and do not actively solicit on-line reviews. Perhaps I should, but I find that word of mouth is still alive and well. A referral from a happy patient is the best five-star review I can receive.
If you are considering Cosmetic Plastic Surgery, information on specific procedures is available on the San Francisco Plastic Surgery Blog via the search box in the “Find a Post” section either in the side column, if you are on a big screen, or lower on the page if using a smaller device. You may also search by category by using the drop down menu under “Search By Category.”
Despite the massive amount of information available on the Internet, there is no substitution for an in-person consultation with a Board Certified Plastic Surgeon. To schedule your personal and private consultation appointment, call (925) 943-6353, today.
Posted February 05, 2017 in Breast Augmentation, Breast Augmentation Lift, Breast Lift (Mastopexy), Home, Mommy Makeover, Tubular Breasts
Mastopexy Augmentation is the combination of Breast Augmentation and Breast Lift. When is Breast Augmentation alone enough? When is a Breast Lift the best choice? When should a combination of Breast Augmentation Lift be performed? It’s a big subject, and requires an in-person consultation for your specific needs, but some general rules for the procedures are explained below. There are many options, so be certain to consult with a Board Certified Plastic Surgeon before making the decision.
Breast Augmentation Lifts Come in May Sizes
Breast Augmentation with Breast Lift was used to enlarge the breasts, elevate the nipple and tighten the breast skin, especially the skin that hangs at the bottom of the breasts. The technique used, a horizontal breast lift, does not require the vertical scar seen in the anchor or inverted-T type breast lifts.
Breast Augmentation lifts, like the breasts themselves, come in many shapes and sizes. When the shape of the breast is good, but a larger version is desired, Breast Augmentation with a Breast Implant is often enough. When the size of the breast is good, but the breast tissue sags, a Breast Lift alone may be enough. The exception in this case is when there is no upper pole fullness, often seen as gapping of the upper bra. A small implant may be beneficial to add a bit of volume to the upper breast in these cases. When the breasts are small and saggy, the Breast Augmentation Lift is the procedure of choice.
The case above is an unusual lift in that a periareolar (defined below) and an inframammary incision (hidden in the crease beneath the breasts) were used, but there is no vertical scar. The “Horizontal Breast Lift” is great for breasts that have bottomed out or for breasts with more extreme sagging.
Breast Augmentation Lift for Tubular Breast
Smaller Breast Lifts require smaller scars. In the case above, a periareolar scar was used to reposition the nipple and reshape the breasts. Periareolar literally means “around the areola”. The areola is the pigmented skin that surrounds the nipple. While this does provide the smallest scar, it does the least. It tends to flatten the end of the breast and it is not great for reducing the size of the areolae.
The Breast Augmentation and Breast Lift combination with the smallest scar is the Periareolar Mastopexy Augmentation. An incision around the areola is used to raise the nipple and insert the Breast Implant. In the above case, the flattening effects of the periareolar lift are exploited to help reshape these tubular (tuberous) breasts.
For cases of Tuberous Breasts, flattening of the shape of the breast is a plus. It can be used to prevent the puffy nipple from sticking out like a cherry on top of a sundae. This patient’s breasts are narrow at the base, and the constriction gives a narrow, elongated, tubular breast. The Breast Implant helps to round the breast out, but it may not correct the areola when it is puffy.
Bigger Sagging, Bigger Problems, Bigger Breast Aug Lifts
For patients with severe postpartum breast involution (shrinkage), and for patients after massive weight loss, the breast volume has left the building, leaving only a loose, empty flap of skin. Breast Augmentation Lifts are the only solution to this problem. Breast Implants are used to restore the breasts’ volume, and it is combined with a Breast Lift to restore the breasts’ shape.
Severely deflated breasts, like those seen above after massive weight loss, need more volume and bigger lifts. An Anchor shaped scar was needed to raise the nipple, remove the overhanging lower breast skin and to tighten the breast skin in the horizontal direction, too.
Often, I will see on the Internet the misconception that if a big enough implant is placed, you will not need a lift. This is not true. Imagine an implant, the size of the one used above, placed under the skin of the pre-op picture. The breast would be the same size; however, the loose skin holding the nipple would hang off the end. In the above case, only a Breast Lift can correct the problems with the breasts’ shape, nipple position and excess skin at the bottom of the breast.
More Scar = Happier Patient?
The ultimate goal of Cosmetic Plastic Surgery is a happy patient. So how can more scar lead to a happier patient? It all depends on the circumstances. If a scar is not needed, then more scar is bad. I have had patients on the borderline of needing a lift elect to not have lift because of the extra scar. Some are happy with their decision of not completely correcting the sagging, and not having extra scars. Others have come back for a Breast Lift after their Breast Augmentation, and are much happier now, after the Breast Lift. Staging does make it easier to see what each procedure has to offer the final result.
The main goal of Cosmetic Plastic Surgery is a pretty result. The Breast Augmentation Lift allows for control of both the size and the shape of the breasts. The cost is additional scar. In this case, an Inverted-T scar was needed.
Above, an inverted-T Breast Lift was performed along with placement of a Breast Implant. A periareolar lift would have left the nipples low, the areolae much larger and the end of the breasts flat. A vertical lift would not have tightened the lower pole sufficiently, or coned the shape of the breast as beautifully. In my experience, the incision underneath the breasts is well hidden. By keeping its length short, the scar will hide in the shadow under the breasts.
Breast Augmentation Lift Consultations
If you are considering a Breast Augmentation, Breast Lift or the Combination Augmentation Mastopexy, be certain to consult an experienced Board Certified Plastic Surgeon. While there are advantages to combining the procedures, it is also more complicated than both procedures done separately.
If you are in the San Francisco Bay Area, give me a call at (925) 943-6353, and schedule a private comprehensive consultation. Your options will be reviewed and the best course selected to optimize you breast aesthetics.
Posted November 28, 2016 in Board Certification, Breast Augmentation, Eyelid Lift (Blepharoplasty), Home, Liposuction, Patient Safety, Rhinoplasty (Nasal Surgery)
Miami, Florida, seems to be hot bed for Deceptive Plastic Surgery Practices, and is giving good Miami Plastic Surgeons a bad name. The most recent incident to make the national news is a Botched Brazilian Butt Lift at Encore Plastic Surgery. The clinic is linked to a chain that focuses on cheap plastic surgery for medical tourists visiting Florida for a procedure and a vacation.
Fake San Francisco Plastic Surgery
Miami is not unique, however. This year, Carlos Guzmangarza was sentenced to 20 years in prison for performing illegal plastic surgery out of his fake San Francisco, California “plastic surgery” clinic. His Mission District clinic preyed on many Central American immigrants. Allegations include: smoking a cigar during surgery, flushing Liposuction fat down the toilet, sexual assault, the injection of unknown skin fillers and leaving a four inch needle in a patient’s buttocks. Eventually, he was convicted of thirty-three felonies and eight misdemeanors.
Caveat Emptor – Let the Buyer Beware
In most cases, there are clues that everything is not up to the usual standard of care. In the case of Mr. Guzmangarza, not only was he not a Board Certified Plastic Surgeon, he was not a doctor. He did not have a medical license, and that’s something that anyone could check.
Check the Medical License
Notice the medical license is for a “Physician and Surgeon.” California, like all states, does not differentiate.
Medical Licenses are issued by the state in which the doctor practices. Simply google your state’s medical board to use their free online look-up service. If you are in California, click here to check your doctors medical license and any disciplinary actions.
Check For Plastic Surgery Board Certification
I am Certified by the American Board of Plastic Surgery. The only ABMS recognized board for Plastic Surgery.
The American Board of Plastic Surgery offers a free, online certification lookup. Click here to see if your doctor is certified by the American Board of Plastic Surgery. Most doctors claiming the title “Plastic Surgeon” are not certified by the American Board of Plastic Surgery. In fact, it is estimated that only one in twelve practitioners practicing plastic surgery are Certified by the American Board of Plastic Surgery. Does your doctor have the best training?
Check For Other Board for Certifications
I am also certified by the American Board of Surgery, because I completed a residency in General Surgery, too.
If your doctor is not certified by the American Board of Plastic Surgery, who are they certified by? Click here to see if your doctor has any board certifications.
If your doctor is certified by the American Board of Ophthalmology, they are trained in surgery of the eyes. So if you are having Eyelid Surgery, they should have had the appropriate training. On the other hand, if you are having Liposuction, buyer beware.
If your doctor is certified by the American Board of Otolaryngology, the are trained in ear, nose and throat surgery, so Facial Plastic Surgery is within the scope of their training. If you are having Rhinoplasty, this is an appropriate board for certification. If you are having Breast Augmentation, buyer beware.
Non-Surgical Board Certification
The non-plastic surgery boards listed above are at least surgical boards. Some “cosmetic surgeons” have non-surgical board certifications. Certification by Family Practice and Internal Medicine Boards is not reassuring if you are having a surgical procedure. Proof of additional surgical training should be made available, and it should be years or training, not a weekend course.
Do Your Homework
A well trained, experienced practitioner will be up-front and honest about their training and abilities, but those who are not honest may be even more convincing. You need to do your homework. Use the links above to confirm what you are being told. If it does not fit, do not commit.
Posted October 22, 2016 in Breast Cancer Awareness, Breast Reconstruction, Home
October is Breast Cancer Awareness Month.
You may have noticed that the silver and black are wearing pink this month. For the last few Octobers, the National Football League has teamed up with the American Cancer Society to highlight breast cancer awareness and raise funds for breast cancer research.
Who Gets Breast Cancer?
One in nine women will develop breast cancer. That’s 12% of the female population, and women make up 99% of the cases of breast cancer. Less than 1% of people with breast cancer are men, and a man’s chance of a breast cancer diagnosis is about one in a thousand.
How Does Breast Cancer Spread?
By definition, breast cancer starts in the breast. Theses abnormal breast cancer cells begin to grow uncontrollably and invade the normal breast tissue. It takes months, sometimes years, for enough cells to amass to be felt. A one centimeter lump contains about a billion cancer cells. As the cells grow they continue to directly invade their neighbors, but cancer cells can also float through the circulatory system.
The most common place that breast cancer cells are found outside the breast are in the axillary lymph nodes. Let me translate that from medicine to English. Lymph is the liquid part of the blood, also called plasma. It slowly leaks out of the blood vessels from the capillaries and needs to be collected and returned to circulation. If lymph is not returned to circulation, we swell. If you ever looked at pictures of Elephantiasis as a kid (maybe it was just me) this disease is what happens when lymph does not return to circulation. In Elephantiasis, the lymph vessels become clogged and the lymph fluid become trapped in the legs. The legs begin to resemble elephant’s legs as the lymph fluid continues to build up and inflate the skin.
What Are Lymphatics (Lymphatic Blood Vessels)?
The lymphatic vessels are a third type of blood vessel, the first two being arteries and veins. Lymphatics are found throughout the body, including the breasts. Breast cancer cells can float through the lymphatic system and migrate to other organs. For cancer cells, this migration is called metastasizing. After a breast cancer lump reaches a critical size, the chances of a metastasis increases rapidly. This is why breast cancer awareness and early detection are so important.
What Are Lymph Nodes?
The breast’s main drainage system is through the axillary lymph nodes.
Lymph is only fluid, so unlike other blood vessels, it is not normal to have a lot cells traveling through the lymphatic blood vessels. In fact, the body has filters along the lymph vessels, called lymph nodes, which trap unwanted cells, preventing them from moving freely throughout the body. The two types of undesirable cells that lymph nodes filter most frequently are bacteria and cancer cells. In both cases, the lymph nodes present the invaders to the body’s immune system, it’s police force if you will. When the immune system recognizes the invaders as bad, it kills them, and prevents any further invasion. This probably happens all the time without us being aware of it. Unfortunately, sometimes the immune system cannot handle the invasion, and the problem spreads.
The majority of the lymph from the breast drains to the armpit (the axilla), so the most common place we find breast cancer outside the breast is in the lymph nodes of the armpit or the axillary lymph nodes. This is why checking the axillary lymph nodes is so important in staging breast cancer. No nodes involved (negative lymph nodes) is good, and means there is a higher chance that the cancer has not escaped the breast and thus a higher chance of curing the breast cancer. Breast cancer found in the lymph nodes (positive lymph nodes) are a worse sign, and often means additional treatment will be recommended to try and kill any cells that have escaped the breast.
Why The Push For early Detection?
If you understand how breast cancer usually spreads, then the emphasis on early detection becomes clear. The sooner breast cancer is detected, the smaller it is and the less likely it is to have spread. Small tumors found in the breast early can often be cured by simply excising them. Larger tumors will be more likely to require a mastectomy, but once the tumor has left the breast, surgery alone is not enough. Additional treatment is needed to kill the cells that have escaped. Unfortunately, the more cells that have escaped, the harder it is to cure breast cancer. The goal of breast cancer awareness and early detection is to find tumors when they are small are treatable and to prevent the larger tumor that cannot be cured.
Different Breast Cancers Require Different Treatment
Since there is more than one cell type in the breasts, there is more than one type of breast cancer. The most common types of breast cancer behave as described above, the majority of the time. However, there are exceptions to every rule. For example, some less common tumors that arise in the breast spread directly through the blood stream, bypassing the lymphatics. Moreover, tumors that develop at the edge of the breast can directly invade the skin, muscle or bone of the chest wall. In every case though, the earlier it is detected, the better your chances of survival. If you don’t do monthly breast exams, I hope this makes you reconsider how such a small chore can prevent an enormous amount of suffering.
What Can I Do About Breast Cancer?
Awareness is the first step. Next comes action. Do your monthly breast self-exams, get your mammograms as recommended, and if you find something, don’t be scared, be proactive. Most breast lumps are not dangerous, cysts and benign fibroadenomas are the most common, but if you find one that is not benign, the sooner it’s identified the better your chances. Do it for yourself. For men, the most common breast lump is Gynecomastia.
Early detection means you increase your chances of living a longer, cancer-free, life.
If you want to help others there are many avenues available. The American Cancer Society accepts donations, which are used to accelerate breast cancer research, and many volunteer opportunities are available if you can spare a little time. If you want more information on how to get involved check out the Get Involved page on the American Cancer Society’s website.
Posted October 10, 2016 in About Dr. Mele, Board Certification, Home, Patient Safety
Dr. Joseph Mele maintains his Board Certifications with two ABMS recognized boards: The American Board of Plastic Surgery and the American Board of Surgery to demonstrate his commitment to excellence in up-to-date Plastic Surgery
Plastic Surgery Board Certification and MOC
Another year, another round of American Board of Plastic Surgery MOC (Maintenance of Board Certification) chores. I have two American Board of Medical Specialties (ABMS) recognized board certifications. One is from the American Board of Plastic Surgery and the second is from the American Board of Surgery. Both represent years of training and hard work and now with the additional MOC requirements, the completion of yearly chores.
Achieving Board Certification
Achieving Board Certification is an important milestone in a doctor’s training. It certifies that they graduated from a recognized residency training program and that they have passed a series of written and oral examinations, and if I had graduated two years sooner, that would have been the end of the story. I graduated and certified in the era of time-limited certification, so every year there are some requirements to fulfill.
Maintenance of Board Certification
The MOC examinations are given at computer based testing centers throughout the nation. All sorts of examinations are given at these centers and most have nothing to do with medicine. The staff at these institutions have strict regulations to enforce. The rules are designed to stop cheating and protect the proprietary information that is contained on the examination. I recently visited one such institution to take my ten-year recertification examination for the American Board of Surgery, and am required to take the American Board of Plastic Surgery MOC examination by 2019.
Why Maintain Board Certification?
This question is becoming more and more controversial as the fees, exams and other hurdles are raised higher and higher each year. It took several days to complete the application and collect the required information, and it’s not cheap. Those in favor of MOC claim that board certification is a way to make sure that your doctor is still good. Those opposed cite the ever escalating cost and time away from the practice required as prohibitive. They are also correct in pointing out the lack of evidence that MOC actually makes us better doctors. Personally, I don’t mind. It is a hassle, and it does not change the way I practice. On the other hand, it shows my patients a clear commitment to being the best Plastic Surgeon I can be. I don’t mind being tested. Plus, when I pass, I will have another lovely certificate to show everyone.
My Board Certifications
I completed a General Surgery residency in 1994. I passed my General Surgery Boards in 1995 and have recertified twice. I am good until 12/31/2025, as long as I complete my yearly chores and pay my yearly fees.
I completed a Plastic Surgery residency in 1997. When I finished my training, it took two years to take the certification exams. I passed my Plastic Surgery Boards in 1999, and have recertified once, so I am good until 12/31/2019. Looking forward to the next exam.
American Board of Medical Specialties
There are many boards out there, but the “real” boards are those under the umbrella of the American Board of Medical Specialties (ABMS). This is the longest standing body for Medical Certification in the US. The American Board of Plastic Surgery was born from members of the American Board of Surgery and the American Board of Otolaryngology who did what is now recognized as Plastic Surgery, and remains the only ABMS Board certifying Plastic Surgeons.
Board Certified Plastic Surgeon
If you are considering Plastic Surgery, be certain to check your doctor’s training. Good training, and the maintenance of that training, are essential for providing the safest and most predictable results.
If you are in the San Francisco Bay Area and would like to schedule an appointment, call (925) 943-6353. And if you want to check out my, or any doctor’s, qualifications, here are some links to help you:
Check if your doctor is Board Certified by the American Board of Plastic Surgery.
Check if your doctor is Board Certified by another American Board of Medical Specialties board. You will need to register to use this site, but it is safe, free and fast.
Check if your doctor has an unrestricted California Medical License. Read the disclaimer and click “Continue to Search” at the bottom. If you are not in California, Google your local medical board for a link.
Posted August 28, 2016 in Breast Augmentation, Breast Implant Revision Surgery, Home
Two and one half years ago, I posted about Jean-Claude Mas and his substandard PIP Breast Implants. Poly Implant Protheses, PIP for short, had their Breast Implants banned in 2010, after it was revealed that industrial grade silicone was being used, rather than the medical grade silicone that has passed safety tests for use in the human body.
PIP’s Jean-Claude Mas Goes To Jail
PIP founder, Jean Claude Mas, loses appeal in French court, and goes to jail.
Photo credit: Guillaume Horcajuelo
In 2013, Jean-Claude Mas was convicted of fraud. His sentence included: four years in prison, a75,000 euros ($86,000) fine and that he be banned for life from working in medical services or running a company. This year, a French appeals court upheld the decision.
Plastic Surgeons Blew The Whistle First
Plastic Surgeons were aware there was a problem years before the government took action, because PIP Breast Implants leaked about ten times as often as FDA approved breast implants. In fact, the US FDA refused PIP’s application for Silicone Breast Implant sales in the US.
Unfortunately, the Pre-filled Saline version of PIP Breast Implants was sold here for a short time. They also leaked at much higher rates than those seen with the other FDA approved Saline Breast Implant manufacturers at the time: Allergan and Mentor.
PIP – Cheaper Is Not Better
You have likely heard the expressions, “You get what you pay for,” and that, If something is too good to be true, it is false.” Well both these expressions apply to Plastic Surgery. It is not an area that you want to get the cheapest price.
PIP’s appeal was that they were cheap. While they claimed to be equivalent to other manufacturers, they were not. They cost less, because they were made cheaply. Industrial silicone is not the same grade or cost as medical silicone, and the company substituted industrial grade silicone for medical grade silicone for years without regulators catching on.
Jean-Claude Mas posing at his manufacturing facility. Only a few knew what was really going on with PIP’s breast implant quality control.
Plastic Surgeons complained for years that something was wrong with PIP Breast Implants, but the final straw was when the company supplying the large quantities of industrial grade silicone raised their suspicions also. Even the people selling the industrial grade silicone knew there was nothing good about these Cheap Breast Implants.
PIP Knew The End Was Coming
PIP Breast Implants manufacturing was headquartered in La Seyne-sur-Mer, France. Since they were not FDA approved, they were not subject to FDA rules, like surprise inspections. Incredulously, European inspectors had to give 10-days notice prior to an inspection. During this grace period, PIP would remove drums of industrial silicone from their manufacturing facility and quickly order the medical grade silicone they should have been using all along. After the inspection, the industrial silicone was brought out again and cheap manufacturing resumed.
When it was clear that the end was near, PIP slashed its prices further. Knowing that their inventory was going to be confiscated, they sold in bulk, and they sold quickly. PIP flooded the market with cheap “European Approved” breast implants throughout Europe and South America. In the end, between 300,000 and 400,000 women in 65 countries are believed to have received PIP implants. Europe was a major market, but more than half went to South America. Fortunately, they were not sold in the United States.
Medical Tourism – Buyer Beware
Poly Implant Protheses was founded in 1991 and shut down in 2010. It is thought that the manufacture of the Bogus Breast Implants, those made with industrial grade silicone, began in 2001.
It Is Recommended That All PIP Silicone Breast Implants Be Removed
PIP Silicone Breast Implants were never sold in the US; however, if you took advantage of cheap overseas breast augmentation early this millennium, you need to check if you have PIP Silicone Breast Implants.
Breast Implant Removal Before And After Photos: One option is to have the breast implants removed and not replaced. Another is to replace your PIP breast implants with FDA approved breast implants, the later options will also preserve the size of your breast. Be certain to ask your Board Certified Plastic Surgeon about your options for treatment.
PIP Silicone Breast Implants have a higher risk of leaking than approved models, as well as being implicated in several deaths due to systemic toxicity and several cases of induced breast cancer. If you have these breast implants, the current world-wide recommendation is to have them removed, and if you desire, replaced with approved Medical Grade Silicone Breast Implants.
Breast Implant Revision Surgery Consultations
The UK’s National Health Service (NHS) recommendations include seeking immediate care if you have any of the following signs:
- Lumpiness or swelling in and around the breast
- A change in the shape of the breast
- Pain and tenderness
- A burning sensation
- Enlarged lymph nodes in the armpit
If you have PIP Silicone Breast Implant’s, find an Experienced Board Certified Plastic Surgeon in your area and get the information about the benefits, and risks, of having them removed. I have removed several. The Ruptured Saline Breast Implants are easy to remove. The saline is absorbed by the body, and all that remains is the solid shell. Ruptured Silicone Breast Implants, especially those filled with the less cohesive gel, are a much bigger problem.
When Breast Implants are ruptured, the gel that fills them can migrate. Most the PIP silicone Breast Implants I have removed were ruptured. The longer the Leaking Breast Implants remain in your body, the less likely it is that all the industrial silicone gel can be removed. Like most problems, the sooner it is addressed the better the outcome. Breast Augmentation Revision is a better option. If you are in the San Francisco Bay Area, call (925) 943-6353 today.
Posted May 29, 2016 in Home, Patient Safety, Uncategorized
Many suffer from Migraines. Thanks to Allergan, we know that Botox can help, but there may be something safer and cheaper the can help, too.
A lot of my San Francisco Bay Area Plastic Surgery patients suffer from Migraine Headaches, so I looked into the incidence of Migraines and found that according to the Migraine Research Foundation, it is the third most prevalent and the eight most disabling illness in the world. In the U.S., 18% of women, 6% of men and 10% of children suffer from migraines, and I have found this to be true within my own patient population.
Migraines Run In Families
About 80% of Migraine sufferers have a positive family history. It runs in my family. I had a few myself, but I seem to have outgrown them. Thankfully, mine were few and far between, and they seemed to be associated with sleep deprivation. So diet, exercise and regular sleep were enough to keep them to a minimum, but others are not so lucky. Every 10 seconds, someone in the U.S. goes to the emergency room complaining of head pain. While most sufferers experience attacks once or twice a month, more than 4 million people have chronic daily migraine, with at least 15 migraine days per month.
Sleep and Migraines
My observation of an association between Migraines and sleep is not unique. One of the most commonly cited triggering agents happens to be changes in sleep habits. Insufficient sleep, greater than normal sleep, disturbed sleep or alterations to daily bedtime or waking all have been strongly correlated with initiating migraine attacks. Recent research suggests that some migraineurs might be deficient in melatonin production.
A nap can cure a Migraine, but sleep may also be preventative.
According to a well referenced online article by Dr. Mathew Long, Melatonin (a derivative of serotonin) is manufactured in the pineal gland at night, and it functions to regulate the sleep-wake cycle. Furthermore, it has been implicated in migraine pathophysiology due to its anti-inflammatory effects, ability to scavenge free-radicals, inhibition of dopamine and stimulation of nitric oxide synthase. Melatonin also has a role in membrane stabilization. With sleep-related factors featuring so prominently in migraineur’s lives, it makes sense that we examine the relationship between poor sleep hygiene, melatonin synthesis and the tendency to migraine. Research has linked low levels of melatonin in plasma and urine and altered peak time in melatonin levels to a variety of headache types, including migraines.
Sleep and Melatonin
Melatonin has been available as a supplement in the United States since the 1990s and is often used to aid sleep and attenuate jet lag. A study in published in Neurology in 2004 showed promising results in migraine prevention when 3 mg of melatonin was taken 1 hour prior to bedtime. This was confirmed 10 years later when Melatonin was compared head-to-head-to-head with amitriptyline and placebo.
As reported on Medscape, results from a multi-center, randomized, double-blind, placebo-controlled trial showed that 3 mg of melatonin was more effective than placebo and had efficacy similar to that of 25 mg of amitriptyline. Furthermore, it was better tolerated than amitriptyline, with lower rates of daytime sleepiness and no weight gain.
More Migraine Research Results
The principal investigator, Mario Peres, MD, PhD, published the Randomized clinical trial comparing melatonin 3 mg, amitriptyline 25 mg and placebo for migraine prevention in the Journal of Neurology, Neurosurgery & Psychiatry. He also presented his results at the 65th Annual Meeting of the American Academy of Neurology.
To test the efficacy and tolerability of melatonin and amitriptyline vs placebo for migraine prevention, the investigators recruited 178 men and women who met International Headache Society diagnostic criteria for migraine with and without aura and who had 2 to 8 migraine attacks per month. All patients underwent a 4-week baseline phase during which each participant kept a diary of migraine frequency.Participants were then randomly assigned to receive 3 mg melatonin (n = 60), 25 mg amitriptyline (n = 59), or placebo (n = 59) for 3 months. Medication was taken between 10 and 11 pm daily.
The study’s primary outcome was a reduction in the number of headache days per month. Secondary endpoints included migraine intensity and duration and analgesic use. Tolerability was also measured in all 3 study groups. The mean reduction in headache frequency was 2.7 in the melatonin group, 2.18 in the amitriptyline group, and 1.18 in the placebo group.
Proportion of responders (patients with a higher than 50% improvement in headache frequency, number of migraine headache days) comparing baseline vs last month of treatment.
Although migraine frequency did not differ between the 2 active treatment groups, the proportion of responders was greatest in the melatonin group: 54% vs 39.1% for amitriptyline and 20.4% for placebo. Melatonin was also “very tolerable” and had significantly fewer adverse effects compared with amitriptyline. Daytime sleepiness was the most frequent symptom in all 3 groups but was most pronounced in the amitriptyline group (n = 24). Although patients gained weight in both the amitriptyline (n = 3) and placebo (n = 1) groups, melatonin was associated with weight loss.
Timing of administration and formulation is also important. Ideally, melatonin should be taken between 10 pm and 11 pm to mimic the physiologic peak. In addition, a fast-acting rather than a slow-release formula should be used.
Overall, said Dr. Peres, the study’s findings are promising and warrant further research.
If you suffer from Migraines, Melatonin, a relatively inexpensive and safe over-the-counter supplement may help. I am not recommending you base your treatment on the blog post of a San Francisco Bay Area Plastic Surgeon. You should see a real headache doctor and have the appropriate testing and examinations performed prior to initiating treatment. However, when you see your doctor, if they do not bring up Melatonin, be certain to ask.
Posted February 06, 2016 in Accreditation, Home, Patient Safety
Surgery Center Accreditation – Another Way to Protect Plastic Surgery Patients
The majority of Plastic Surgery is performed in the outpatient setting, and in the San Francisco Bay Area, the majority of the these procedures are performed in Outpatient Surgery Centers. These facilities offer many advantages to patients and plastic surgeons, but are they safe? How can you be certain the ambulatory facility your cosmetic surgeon is using is up to the high standards required for surgery?
Accredited Ambulatory Surgery Centers
As a Board Certified Plastic Surgeon and an active member of both the American Society for Aesthetic Plastic Surgery and the American Society (ASAPS) of Plastic Surgeons (ASPS), I only operate in Fully Accredited Operating Rooms.
Professional societies are not all created equally. The ASAPS and ASPS are two of the most stringent when it comes to member requirements. Not only is proper training, ethical standards and board certification required, but every member is required to operate exclusively in Accredited Ambulatory Surgery Centers when anything other than local anesthesia is required. The reason — Patient Safety.
Plastic Surgery Patient Safety
Accreditation is performed by a limited number of regulatory bodies to assure the public that a Surgery Center is up to standards for both physical and administrative operations.
Physical Characteristics: include building codes like width of halls and doorways, construction materials, fire exits, power backup, oxygen safety and delivery and environmental heating, cooling and ventilation. Also included are the types of equipment kept on site for anesthesia, life support, sterilization and fire suppression.
Administrative Operations: include how patients and their private medical information are handled, as well as staff selection and peer review, drug tracking and data tracking of procedures and complications.
The Cost of Patient Safety
Don’t be fooled by doctors promoting the safety of surgery done under local anesthesia. They may be masking an unaccredited facility and the inability to offer general anesthesia. Often, they will offer lower prices, because accreditation may not be the only corner they are cutting.
Unfortunately, it is not cheap to maintain accreditation. Regulations change frequently. Often, consultants are hired before inspections to be certain the latest rules are being followed. The cost of the inspection is borne by the facility, and this is in addition to meeting additional building requirements and having the proper well maintained equipment. Often, multiple types of accreditation is required, and inspections may be required every three years or more, depending on the agency and the findings during inspection.
How To Check Accreditation
Below is a list of the current nationally recognized accrediting bodies. Ask your surgeon, or better the surgery center directly, which they are accredited by. You can also use the links below to learn more about the accrediting organizations.
Patient Safety First
Using only Accredited Surgery Centers is just one more way that your Plastic Surgeon can demonstrate that they care about your safety. If your surgeon is using accredited surgery centers, they will not be offended if you ask them. The hospitals and surgery centers I use are accredited by the state, federal (medicare) and at least one other of the above agencies.
The Accreditation Association for Ambulatory Health Care (AAAHC) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are two of the national recognized accreditation bodies in the United States.
John Muir Hospital Walnut Creek, John Muir Hospital Concord and San Ramon Regional Medical Center are all JCAHO Accredited, while Premier Surgery Center, Diablo Valley Surgery Center, Aspen Surgery Center and Sequoia Surgical Center are all AAAHC Accredited. This accreditation gives me peace of mind that every facility is regularly checked by an independent organization dedicated to the safety of my patients. It also means I can spend more of my time taking care of you.
Outpatient Surgery Centers Provide Convenience Too
Most surgical procedures are outpatient, meaning you can go home the same day. This is true for all surgery performed in the United States, not just Plastic Surgery. The vast majority of these procedures are performed in an ambulatory surgery center. In fact, there are not enough hospital operating rooms to accommodate the volume of surgery performed in ambulatory surgery centers. Without them, we could not provide appropriate patient care in a timely manner.
The main difference between a surgery center and a hospital is the amount of time you can spend there. Legally, an ambulatory center can keep you for 24-hours. After this time, either you should be safely on your way back home or transferred to a hospital if additional care is necessary.
There are other differences which may not be as obvious. Hospitals are for sick people, so that is where you find them, along with the diseases they are suffering from. Some of these diseases are contagious, and if you do not require the higher level of care that a hospital provides, staying away from the inpatient setting also means staying away from sick people. On the other hand, if you have multiple medical problems, or require a complicated surgical procedure, the higher risk of the hospital setting is more than balanced by the additional care that they provide.
Convenience is another factor that the ambulatory surgery center can provide. While Safety is number one, Predictability is a close second. Since Surgery Centers deal with healthier patients and less complicated procedures, they are more likely to run on time. Unlike a hospital with emergency rooms and trauma centers, there are few emergencies to “bump” the operating schedule and cause understandable, medically necessary but inconvenient delays.
This is the operating room for cardiovascular surgery at Gemelli Hospital in Rome, Italy. This hospital operating room is specialized, provides a higher level of care making it very expensive, and excessive, for Face Lifts or Breast Augmentation.
Cost is another factor. Ambulatory Surgery Centers do not need to be staffed 24-hours a day, and do not need all the additional equipment needed for the most complicated surgical procedures. Because of this, the hourly rate for an operating room located in an outpatient center averages significantly less then the hourly rate for an operating room located in a hospital.
Cosmetic Plastic Surgery
If you are considering Cosmetic Plastic Surgery in the San Francisco Bay Area, give me a call at (925) 943-6353. By using only accredited facilities, my goal is to provide you with the safest and most predictable results possible.