Over the years, I have posted more than 500 articles about a wide variety of Plastic Surgery Procedures. They are easily accessible and categorized in the side column under the “Search By Category” menu. Each post provides specific information about the procedure; however, this post is dedicated to the recovery process.
Generic Plastic Surgery Recovery
Before getting into the generic recovery rules, I provide the following disclaimer: Every procedure has specific post-operative instructions, and your plastic surgeon will provide you with post-operative instructions paired to the specific methods that they employ during your surgery. We plastic surgeons shape how we do each procedure to each patient based on our experience. I will try to provide some general guidelines. It goes without saying, but I’m going to say it: If you choose an Experienced Board Certified Plastic Surgeon because you trust them and you like the results they achieve, the best course of action is to do things their way.
Surgery is a form of injury and the common acronym for treating injuries is RICE. RICE stands for:
All of these can help ease discomfort and speed your recovery, when used appropriately.
The R in RICE stands for Rest.
Rest: Avoiding vigorous activity, heavy lifting and sudden movement helps prevent increased swelling and further injury. Immediately after surgery, rest prevents elevated blood pressure and post-operative bleeding. In the weeks after surgery, movement is good, but rest allows you to heal with increased comfort and a more predictable outcome.
The I in RICE stands for Ice.
Ice: Ice therapy is effective, especially for the first few postoperative days, and it can be continued if it feels good. I recommend using it for 15 minutes and then leaving it off for 45 minutes. Always keep a thin cloth between you and the ice to prevent frostbite. I had a patient fall asleep with ice directly on the skin and it froze causing blisters. He recovered fully, but prevention is the best medicine.
The C in RICE stands for Compression.
Compression: Compression garments are very important to control swelling and keep the skin smooth for many procedures. After procedures like Liposuction, the skin loses support as well as stuffing, so the garment is important for keeping the skin flat and smooth. It should be worn 24/7 for the first two weeks.
The E in RICE stands for Elevation.
Elevation: Elevation helps the surgical site drain. During the day this is easy, as our face and body are elevated. At night, laying flat will cause some increased swelling; however, sleep is very important. If you can sleep with the operated body part elevated for a few days, it helps.
Common Sense Recovery Advice
RICE therapy is based upon common sense, and it is a proven treatment. While it provides a grounded framework for comparing treatments, before starting any new therapy, it should be approved by your surgeon. Your surgeon has the most information and the greatest experience with your procedure. It is a good idea to discuss recovery during your initial consultation appointment, because while the surgery may be elective, once the procedure is performed, the recovery becomes mandatory.
If you are in the San Francisco Bay Area and want to learn more about a cosmetic plastic surgery procedure, feel free to use the contact form on this page, check out my main website: DrMele.com or call my office directly at (925) 943-6353, to schedule a personalized consultation appointment today.
Special Announcement Regarding Textured Breast Implants From The ISAPS
As of tomorrow, the use of Textured Breast Implants will be restricted in France.
From the ISAPS:
We have been informed today that the French health regulatory authorities (ANSM) have announced the following regulations regarding breast implants, and have summarized the most important information for you. You can read the full text of their announcement here.
As a precautionary step, ANSM decided on April 4, 2019, to withdraw macrotextured breast implants and polyurethane-coated breast implants from the market, as certain macrotextured implants and implants with polyurethane-coated surfaces may be a risk factor for the development of BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma). Given the rarity of the risk to exposure to BIA-ALCL, ANSM does not recommend preventive explantation for women with these implants, due to the very rare risk of serious disease. This decision will go into action on April 5, 2019. The purpose of this precautionary approach is to prohibit the sale, distribution, use, and withdrawal of this type of breast implant in the French market.
The ANSM reiterates its recommendation to use smooth breast implants as the preferred method of cosmetic or reconstructive surgery.
Since 2011, 59 cases of BIA-ALCL have been reported in France, with approximately 400,000 implants implanted annually in the country.
In addition, ANSM would like to reiterate the importance of proper information for women who wish to receive breast implants of all types. The patient and the surgeon should jointly discuss the advantages and disadvantages of the various implants available and alternative techniques in cosmetic surgery or post-breast cancer reconstruction.
An informed consent form containing the identification of the implant surface (smooth, microtextured, etc.), its limited life span, and the possible resulting need for re-intervention and medical care, must be submitted to all women prior to the placement of breast implants.
In the case of functional or physical symptoms in a woman with breast implants (such as abundant periprosthetic effusion, increased volume, pain, inflammation, mass, ulcers, or changes in general condition), particularly in the time since the postoperative phase, the diagnosis BIA-ALCL must be taken into account and ruled out by an analysis of the periprosthetic fluid (CD-30 testing, culture, cytology, and flow cytometry).
For women with breast implants and without clinical signs on the breast, the expert group recommends an annual follow-up examination of the breasts.
The International Society for Aesthetic Plastic Surgery
While ISAPS respects the decision reached by ANSM, we would like to point out that this disease BIA-ALCL is rare and, above all, easily treatable with total capsulectomy in early stages or Brentuximab in more advanced cases. Fortunately, compared to the high number of breast implants that are performed on a global scale, there are only few deaths worldwide. We are concerned about the recommendation to only use smooth implants, as we know from evidence-based data that the complication and reoperation rates are higher for smooth implants. Through this decision by ANSM, we plastic surgeons are effectively taken back to the time when there were no anatomical implants. This will affect breast reconstruction outcomes.
We believe that this is the wrong approach and less satisfactory for our patients. It is more important to inform our colleagues, family doctors and gynecologists about the early symptoms of the BIA-ALCL and how to evaluate patients. Patients must also be informed about the possible risks and symptoms of BIA-ALCL at the time of implantation. The information here should be cautious and always show the relation of an extremely rare disease.
We hope that the decision in France will remain on a case-by-case basis and that treatment options using macrotextured implants will not be taken away from our patients and us, as this would be a huge step backwards. Current opinion indicates that macrotextured implants can be safely used when appropriate precautions are taken to mitigate surface biofilm contamination, according to published data.
Dirk Richter, MD,
The response from the European Association of Societies of Aesthetic Plastic Surgery (EASAPS)
ANSM (agence national de sécurité du medicament et des produits de santé) stated April 3th, 2019 that macrotextured and surface-coated polyurethane implants from different labels are prohibited in France.
EASAPS opinion is that this is an regrettable decision that is not based on scientific data.
We need evidenced-based and statistically convincing studies for proper patient information on adverse events and the rare disease of ALCL.
What we know about Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is evolving. We learn more as each new case is identified. Right now, there are just too few cases to know many of the specifics; however, today I will go over the data currently available.
ASPS and ASAPS summary of BIA-ALCL in 2019
Much of this information comes from the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS). Thanks to its members voluntarily reporting and collecting information on BIA-ALCL, these US based national plastic surgery organizations have the best database on BIA-ALCL in the world.
What is BIA-ALCL?
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon and treatable type of T-cell lymphoma that can develop around breast implants. BIA-ALCL is not a cancer of the breast tissue itself. It is not breast cancer, but it is found in the breast, around the capsule which surrounds breast implants.
When Does It Present?
The time between breast implant insertion and diagnosis of BIA-ALCL varies greatly. It ranges from 9 months to 27 years, with an average delay in presentation of 9.2 years.
Who Gets BIA-ALCL?
Cases seem to be concentrated in patients who have, or who have had textured breast implants. It seems to be related to the aggressiveness of the texturing and has occurred in patients with both silicone and saline filled breast implants.
When in doubt; check it out. Early diagnosis and treatment are key to curing BIA-ALCL.
After reviewing all available case series, case reports, and registries, BIA-ALCL is more common with textured implants. Textured implants are used less frequently than smooth implants. Textured implants are also used more often for breast reconstruction after breast cancer, because shaped implants are more desirable in this population and texturing is used to reduce breast implant rotation for shaped implants.
To date, no cases of BIA-ALCL have been verified in patients who have had exclusively smooth breast implants. However, it is not possible to exclude the appearance of BIA-ALCL in association with smooth implants at this time. The FDA reports that they are aware of smooth breast implant only cases; however, they warn that this information is “unverified” and potentially “inaccurate.”
The association of BIA‐ALCL and textured implants may be related to the increased surface area of the texturing; however, this has not yet been definitively proven. The variation in surface texturing among breast implant manufacturers may mean there are variable risks for the development of BIA-ALCL.
How Does BIA-ALCL Present?
The majority of patients present years after their initial surgery with one breast gradually increasing in size. The increased size is from fluid, serum, collecting around the breast implant. This collection of fluid is called a seroma. Seromas are normal right after surgery; however these seromas appears later and are thus called a delayed seromas. A few patients have presented with different symptoms such as a mass, skin rash, fever and night sweats, and lymphadenopathy.
How Is The Diagnosis of BIA-ALCL Made?
BIA-ALCL usually presents as increased breast size due to fluid collecting around a textured breast implant.
Diagnosis is based on analysis of the fluid in the seroma. Most commonly, ultrasound‐guided fine needle aspiration of the peri-implant fluid is assessed with immunohistochemistry for CD30-positive large anaplastic T-cell lymphocytes.
How Is BIA-ALCL Worked Up?
PET‐CT is performed following a positive diagnosis. Mammograms are not helpful for evaluating lymphoma, but are important for the evaluation of breast cancer. Often, a multidisciplinary team approach including, when required, an oncological breast surgeon and an oncologist specializing in lymphoma.
How Is BIA-ALCL Treated?
The treatment of BIA-ALCL is evolving. In most cases, cure is obtained by removal of the breast implant and the capsule surrounding it. Incomplete capsular resection has been associated with both recurrence and significantly lower survival. Rarely, patients may present with a mass and have an increased risk of requiring radiotherapy and chemotherapy. Treatment approach should follow international guidelines established by the National Comprehensive Cancer Network (NCCN) for BIA-ALCL, available at nccn.org.
Current treatment recommendation is for bilateral complete capsulectomy and implant removal, as a small number of women have had contralateral disease found incidentally; however, it cannot be stressed enough that the treatment is still evolving, and each patient must be individually evaluated. If you suspect you have BIA-ALCL, do not delay, and contact your plastic surgeon or primary medical doctor immediately.
Summary Statement On BIA-ALCL From The ASPS
I have included below a statement released by the American Society of Plastic Surgeons (ASPS) this week. It summarizes well what we currently know about BIA-ALCL. The ASPS has also published an 2019 online BIA-ALCL summary.
“Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon type of lymphoma that can develop in the scar capsule near saline or silicone breast implants. This disease is currently being investigated as to its relationship with breast implants. The family of ALCL is a rare cancer of the immune system, which can occur anywhere in the body. Based on adverse event reports, the United States Food and Drug Administration (FDA) estimates the total number of cases of BIA-ALCL to be over 450 cases.”
“It has been noted that the majority of BIA-ALCL patients have a history of a textured-surface device. An exact single-number estimate of the risk for both textured and non-textured implants is not possible with the currently available data. Lifetime risk of BIA-ALCL has been estimated at 1:1,000 to 1: 30,000 for women with textured breast implants, and BIA-ALCL risk is currently under investigation. BIA-ALCL usually involves swelling of the breast at an average of 3 to 14 years after the initial breast implant operation. Most cases were cured by removal of the implant and the capsule surrounding the implant; however, rare cases have required chemotherapy and/or radiation therapy for treatment.”
“Patients with breast implants should be followed by a surgeon over time and seek professional care for implant-related symptoms such as pain, lumps, swelling, or asymmetry. Patients should monitor their breast implants with routine breast self-exams and follow standard medical recommendations for imaging (e.g. Mammography, Ultrasound, MRI). Abnormal screening results or implant-related symptoms may result in additional expenses for tests and/or procedures to properly diagnose and treat your condition. Tests and procedures could include but may not be limited to: obtaining breast fluid or tissue for pathology and laboratory evaluation, surgery to remove the scar capsule around the breast implant, implant removal, or implant replacement.”
The above Breast Reduction Before and After Side View Photos show improvement in breast shape, size and nipple position after Reduction Mammoplasty Surgery.
Today, I am posting the latest episode of KRON 4’s Body Beautiful. This video segment continues where the last post left off, discussing Breast Reduction for Women. This new Breast Reduction Video Presentation contains:
Recovery information and tips for after Reduction Mammoplasty
Narration of specific examples of Breast Reduction
Breast Reduction Video Presentation
You Are Not Alone
The above Breast Reduction Video is intended to provide general information about the procedure. However, there is no substitute for an in-person consultation with and experienced Board Certified Plastic Surgeon. Years of learning, practice and experience have shaped how I perform Breast Reduction. Many thousands of women have breast reduction surgery annually, but each case is different. Your plastic surgeon is here to guide you through each option and help you achieve the best possible results.
The Best Breast Reduction for You
There are several methods of Breast Reduction which may or may not apply to your specific needs. I tailor my approach to each individual patient, by choosing the option that will achieve the best result in the safest and most predictable manner.
These Breast Reduction before and after pictures demonstrate the amount of reduction and enormous lift possible with the inverted T-technique. You will notice that the breast hangs well below the level of the mole visible anterior to the crook of her elbow in the before photo, while in the after photo, the base of the breast is well above it.
Breast Reduction Consultation Appointments
For your Breast Reduction, you will want an experienced and well qualified Board Certified Plastic Surgeon. Members of the ASAPS (the American Society for Aesthetic Plastic Surgery) are particularly well suited for breast reduction surgery, as they are Board Certified Plastic Surgeons who specialize in Cosmetic Plastic Surgery, including all aspects of Breast Enhancement.
If you are in the greater San Francisco Bay Area and would like to schedule a personalized consultation appointment, call (925) 943-6363 today. Learn what is possible in a safe and private plastic surgery office that specializes in Cosmetic Plastic Surgery.
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.
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.
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.
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.