Posted March 08, 2018 in Home, Patient Safety
Now that you have selected your Plastic Surgeon, and you know which is the best procedure for your needs, you need to know about the recovery period.
In case you forgot, The five questions to ask before having plastic surgery are:
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.
Posted February 19, 2018 in About Dr. Mele, Home, Patient Safety
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 five questions are:
How Is The Procedure 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.
Posted February 04, 2018 in About Dr. Mele, Home, Patient Safety
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?
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.
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.