Vaping, Plastic Surgery and Life

Posted September 16, 2019 in Home, Patient Safety, Smoking and Plastic Surgery

I’ve written about smoking and plastic surgery and even vaping and plastic surgery previously. However, as the use of electronic cigarettes becomes more widespread, we are learning more about the negative consequences associated with vaping.

Vaping Done Properly is Toxic

We are only just beginning to learn the problems that vaping causes.

Last night’s news links six deaths to vaping. Hundreds of people have been sickened, and sadly, most have been previously healthy teens and young adults. Public health officials are trying to pinpoint the chemistry and mechanisms causing vaping-associated pulmonary illness.

Cheaper Is Not Better

Just like Plastic Surgery, when is comes to vaping, cheaper is not better. This applies to cheaper vapes whose batteries explode and bootleg vape cartridges containing toxic pesticides. Counterfeit THC oil is especially toxic as it has been demonstrated to release deadly hydrogen cyanide.

Vaping And Surgery

Since smoking has been around longer than vaping, much more is known about the health problems associated with smoking. When it comes to smoking and surgery, the combination is not good. Higher risks of infection and wound healing problems are associated with smoking. For example, smokers are six times more likely to have wound problems after a facelift.

Benefits of smoking cessation

How long does it take for your body to recover from smoking? The above timeline gives just a few examples and includes the average time it takes for each health benefits to be seen.

At first, it was hoped that vaping would have fewer detrimental effects than smoking. We know that smoking causes contraction and injury of the blood vessels in the skin which decreases the perfusion and oxygen delivery needed for wound healing. New evidence shows that vaping also has undesirable consequences. We won’t know what vaping is doing to our bodies for another 40 years, but the chart above may be a good indicator of the future findings.

Vaping and Nicotine

Nicotine, derived from tobacco, is the main addictive ingredient in vaping cartridges. Previous studies have shown that nicotinized electronic cigarettes cause cell damage and inflammation. A recent paper from the University of Pennsylvania School of Medicine explored the effect of the aerosol alone on endothelial function, and the results are frightening.

E-cigarettes Damage Your Blood Vessels

The article showed that a single e-cigarette can be harmful to your blood vessels. The article’s title is a mouthful: Acute Effects of Electronic Cigarette Aerosol Inhalation on Vascular Function Detected at Quantitative MRI. The results were published in the August 20, 2019, issue of the journal Radiology.

Long Term Effects of Vaping

The investigators at Penn concluded that, “Inhaling nicotine-free electronic cigarette aerosol transiently impacted endothelial function in healthy nonsmokers. Further studies are needed to address the potentially adverse long-term effects on vascular health.” Unfortunately, long term effects take a long time to discover. It has taken decades to demonstrate the enormous number of ill effects of smoking tobacco, and yet there are still deniers.

Both smoking and vaping are highly addictive, and both industries target youth to maximize the person-hours of smoking they can capture. Why else would a company offer sour gummy flavored vape juice? Since young people tend to be healthier and have more reserve, the ill effects are harder to detect in this population.

Ironically, the recent industry pivot to offer vaping as a method to stop smoking may attract an older, weaker population, so the problems associated with vaping may become apparent more quickly. However, the fact that so many young people have had dramatic, life-threatening health problems should be a clue that the use of e-cigarettes is hazardous.

Protecting Children From Candy-Coated Vaping

Last year, San Francisco voters upheld a ban on flavored vaping products. Michigan, not California, is the first state to ban flavored e-cigarettes. Last week, Governor Andrew Cuomo banned the sale of flavored electronic cigarettes in New York through an emergency executive action. Even President Trump is proposing a ban on vape flavors. While good intentioned, it will likely have little effect on teen vaping as they can already flavor their own cartridges with readily available dessert tastes.

Banning Vaping Altogether

This summer, San Francisco took the battle a step further when Mayor London Breed signed an ordinance effectively banning e-cigarette sales within the city, despite the fact that Juul is headquartered in SF. Unfortunately, since last year, the number of vapers has more than doubled. Again, the intentions are good; however, people have to want to quit. If we remember prohibition, many people died from unregulated bootleg liquor, and we have already seen deaths from bootleg vape cartridges despite both vaping and marijuana being legal currently.

Plastic Surgery And Vaping

Smoking and Aging - Twin Study

Can you tell which twin smokes? If you guessed the twin on the right, you are correct. Compared to her non-smoking sister in blue, the twin in red has advanced signs of aging including: marked loss of mid and lower face fullness, deeper nasolabial folds and smoker’s lines around the lips.

Like most plastic surgeons, I recommend halting all smoking and vaping for four weeks prior to any surgery involving skin flaps like Facelifts, Tummy Tucks and Breast Reductions. Multiple studies have demonstrated that stopping prior to surgery significantly decreases the preoperative risks; moreover, stopping also eliminates a bad habit that accelerates aging. For this reason, many patients remain non-smokers after surgery. Kicking the habit is not easy, but it is definitely worth it.

Whether you are a current smoker, former smoker or non-smoker and are considering plastic surgery, be sure to consult with a Board Certified Plastic Surgeon near you. In the San Francisco Bay Area, call (925) 943-6353 to schedule your private appointment in our Walnut Creek Plastic Surgery Center.

UPDATE 09/17/19 – Seventh vaping related death happened in California today.

UPDATE 09/18/19 – Michigan bans all flavored vaping products.

UPDATE 09/19/19 – Eighth vaping related death happened in Missouri today.

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Plastic Surgery After Massive Weight Loss

Posted September 09, 2019 in Arm Lift (Brachioplasty), Breast Lift (Mastopexy), Butt Lifts, Facelift (Rhytidectomy), Home, Lower Body Lift (Belt Lipectomy), Neck Lift (Rhytidectomy), Post-Bariatric Surgery (After Weight Loss), Thigh Lifts (Thighplasty), Tummy Tuck (Abdominoplasty)

Excessive weight can cause diabetes, high blood pressure, increased serum cholesterol and other health problems. For mild cases, diet and exercise are often effective treatment. For more severe cases weight loss surgery, Bariatric Surgery, may be recommended.

Bariatric Surgery has been proven successful for weight reduction, although proper diet and exercise are still required. Patients can lose tens to hundreds of pounds. Despite the fat is loss, excess skin often remains. Since it is uncommon for the skin to shrink sufficiently to the new body contours, patients often still feel uncomfortable with their appearance. Often, Post-Bariatric Plastic Surgery is requested to remove the excess skin.

Post-Bariatric Plastic Surgery Before And Afters

Extended Tummy Tuck Before and After Pictures Post-Bariatric Plastic Surgery

Post-Bariatric Plastic Surgery specializes in skin reduction after massive weight loss. Above, Extended Tummy Tuck Before and After Pictures show tightening of the abdominal wall and removal of the excess skin and fat from the abdominal wall and flanks.

Tummy Tuck Before and Afters

This post has several examples of Post-Bariatric Plastic Surgery. The Post-Bariatric Plastic Surgery Before And After Pictures above show what an extended Tummy Tuck can do. Tummy Tucks after massive weight loss are similar to abdominoplasty after pregnancy, but often need to be extended. The ultimate extended tummy tuck goes all the way around the trunk and is called a lower body lift

Arm Lift Before and Afters

Arm Lift Before and After Pictures - Post-Bariatric Plastic Surgery

An Arm Lift, also called a Brachioplasty, removes the excess skin that remains after weight loss.

Arm Lifts are another common Post-Bariatric Plastic Surgery. It is especially helpful in cases with redundant upper arm skin that makes it uncomfortable or impossible to wear normal sleeves.

Breast Augmentation with Breast Lift Before and Afters

Breast Augmentation with Breast Lift Before and After Pictures

After massive weight loss, the breasts often sag and appear deflated. Breast Augmentation with a Breast Lift can help restore the breasts to a more youthful and attractive state.

Breast Augmentation and Breast Lift (Mastopexy) surgery can help restore the breasts after childbirth and weight loss. The combination is particularly helpful after massive weight loss. A Breast Implant can restore volume, while a breast lift corrects sagging. When combined, the procedure is called Mastopexy Augmentation.

Breast Reduction for Men

Breast reduction for Men, also known as Gynecomastia Reduction usually involves removing fat and glandular tissue from behind the nipple. After massive weight loss, however, excess chest skin is very common and leads to sagging of the breasts. In the Breast Reduction Before and After Pictures below, simply removing the excess tissue from the breasts would leave the chest skin empty and saggy.

Gynecomastia Reduction Before and After Pictures

Male Breast Reduction after massive weight loss - post-bariatric plastic surgery  before and after pictures

The Post-Bariatric Plastic Surgery before and after pictures above show male breast reduction with removal of excess skin via an incision along the bottom of the breasts.

Skin removal for Breast Reduction is almost always needed for women, but rarely required for men. When it is necessary, it is almost always in association with massive weight loss like that seen after Bariatric Surgery. In the case above, the excess skin was removed via incisions placed in the fold under the breasts. If the nipples are below the fold, repositioning the nipples higher onto the chest is recommended for optimal results.

Post-Bariatric Plastic Surgery Consultations

If you have had Bariatric Surgery or have lost a lot of weight and are bothered by the excess skin that remains, consider a consultation for Post-Bariatric Plastic Surgery. In the San Francisco Bay Area call (925) 943-6353 to schedule a private consultation appointment. As a member of the American Society of Post Bariatric Plastic Surgeons, it is an area of Plastic Surgery in which I have experience and interest.

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Breast Augmentation Revision Surgery – SF Bay Area

Posted September 02, 2019 in Breast Asymmetry, Breast Augmentation, Breast Augmentation Lift, Breast Implant Removal, Breast Implant Revision Surgery, Breast Lift (Mastopexy), Capsular Contracture, Home

Breast Implant Revision Surgery is performed when there is a problem with the breast implants. Some problems are subjective, for example when the implants are judged to be too small or too large. Other problems are objective, such as issues with the breasts’ shape, firmness, symmetry or position. These are commonly associated with Capsular Contracture and breast implant malposition. A third group of breast implant problems require urgent attention, like infections or exposure of the breast implants.

Today’s post reviews Breast Revision Surgery and the treatment for some of the more common Breast Augmentation Problems.

Capsular Contracture Correction

Capsular Contracture occurs when the normal pocket that holds the breast implant in place becomes tight. It can be tight all around the implant causing firmness and a reduction in the apparent size of the implant(s), or it can be along one side, pushing the implant out of position, usually upward.

Breast Implant Revision for Capsular Contracture Before and After Pictures - Front View

These breast augmentation revision before and after pictures show grade III/IV capsular contracture of the right breast preoperatively, and the result of removing the tight capsule (capsulectomy) thus lowering the breast mound to match the left side. (Click image for uncensored view.)

In the Breast Implant Revision Before and After Pictures above, the right breast mound is significantly higher, and harder, than the normal appearing left breast mound (Grade III Capsular Contracture). This is a problem for the patient both in and out of clothing, and with time, the right breast has become tender (Grade IV Capsular Contracture).

This Breast Implant Malposition was treated with a complete capsulectomy, removal of the tight scar. The result is a softer breast, that is lowered back to its normal and symmetrical position. The areolae are also more symmetrical postoperatively. To see the nipple position, click or touch the picture above and the censoring will be removed. Tap again to replace it.

Symmastia Correction for Uniboob

Symmastia is a specific type of Breast Implant Malposition where the implant(s) move toward the midline. It is more common in women with tighter skin and larger, high profile breast implants. Just like raising the towers on the Golden Gate Bridge would raise the bridge’s cables across the mouth of the San Francisco Bay, the high profile breast implants have raised the skin across the sternum causing a Uniboob Deformity or “Bread Loafing”. In addition, this patient has “bottoming-out” of her breast implants, greater on her right side.

Breast Implant Revision for Symastia or Uniboob Before and After Pictures - Front View

These breast augmentation revision before and after pictures show symmastia of the breasts and bottoming out (right greater than left) preoperatively. The after photo shows the result of symmastia repair and breast implant replacement with smaller breast implants and raising of the inframammary folds (IMFs) thus getting rid of the uniboob bread-loafing of the implants in the midline. (Click image for uncensored view.)

The Symmastia Deformity was corrected by both repairing the damage and addressing the original problem to prevent recurrence. The damage was repaired by closing the original capsule medially, forming a pseudoneopocket in the correct anatomical position and reinforcing the repair. Since the original cause was breast implants too large for the chest, they were replaced with smaller implants. The after picture shows that the breasts have been elevated and separated into two separate breast mounds. Breast symmetry is improved and the reduction in breast implant size should help to maintain the superior cosmetic result.

Stage 1 – Breast Implant Removal for Impending Exposure

Breast Implant Exposure and Breast Implant Infections are emergencies, and require prompt surgical intervention. In the picture below, the square area at the base of her left breast is the lower edge of the breast implant which is about to erode through the breast skin. Once exposed, infection is inevitable, so the implant was removed promptly to prevent this eventuality.

Breast Implant Removal for impending breast implant exposure Before and After Pictures - Front View

These breast augmentation revision before and after pictures show stage one of treatment for breast implant exposure. Once an implant is exposed, it requires removal to prevent infection and sepsis. The after photo reveals that the left breast was smaller before breast augmentation, confirmed by the removal of a larger breast implant during surgery. (Click image for uncensored view.)

An inframammary incision was used to remove the breast implant, and the damaged skin at the base of the breast was also removed to allow for a secure closure. Her left breast implant was larger than the right, because her left breast was smaller than her right breast before Breast Augmentation. The size discrepancy is apparent in the after picture

Stage 2 – Breast Implant Replacement after Exposure

After breast implant infection or exposure, a minimum of three months is allowed to pass before replacing the breast implant. This is to reduce the risk of another infection. After three months, the patient returned to the operating room for delayed Breast Implant Replacement.

Breast Implant Replacement after breast implant exposure Before and After Pictures - Front View

These breast augmentation revision before and after pictures show stage two of treatment for breast implant exposure. After the breast implant is removed, and the site heals for several months, the breast implant can be replaced. The after photo shows the restoration of symmetrical breast mounds after Asymmetrical Breast Augmentation. (Click image for uncensored view.)

The before and after pictures above show the results of the second stage of reconstruction. The breast implants were replaced without complications, and the patient was happy to have her figure back.

Breast Augmentation Revision Consultations

If you are considering Breast Augmentation Revision be certain to consult with an experienced and Board Certified Plastic Surgeon in your area.

If you are in the San Francisco Bay Area, call (925) 943-6353, to schedule a private consultation appointment in my Walnut Creek, CA, plastic surgery office.

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Breast Implant Removal in the San Francisco Bay Area

Posted August 26, 2019 in Breast Implant Removal, Breast Implant Revision Surgery, Home

Breast Implant Removal is performed for about 1% of all Breast Augmentation patients. It is not a common procedure. Often it is elective, but sometimes it is as necessary as it is unwanted.

Breast Implant Removal Before and After Pictures - Side View

These breast implant removal before and after pictures show the result of removing moderate sized breast implants from a woman with young, elastic skin. No lift was needed. (Click image for uncensored view.)

Why Breast Implants Are Removed

Breast Implant Removal is chosen for many reasons ranging from completely elective to emergency situations. Elective reasons include the desire to have smaller breast, anticipating pregnancy and breast feeding and even a desire to exchange the current breast implants for larger ones. Urgent situations include exposure and infection of the implants.

How Are Breast Implants Removed?

Breast Implant Removal With Breast Lift Before and After Pictures - Side View

These breast implant removal before and after pictures show the result of removing ptotic, “bottomed-out” breast implants with a Breast Lift performed at the same time. (Click image for uncensored view.)

Breast Implants are often removed during a relatively short outpatient procedure through the same incisions originally used to place them.

For Saline Breast Implants, after a small incision is made the implants are deflated and then removed. The empty shell allows removal through a smaller incision.

Silicone Breast Implants are not deflated prior to removal to avoid leaving silicone inside the breasts. If silicone breast implants are already ruptured, the capsule is often removed to contain the extravasated silicone and to prevent gel migration.

Breast Implant Removal Recovery

Breast Implant Removal Before and After Pictures - Side View

These breast implant removal before and after pictures show the result of removing large breast implants from breasts with less elastic skin. No lift was performed, so the skin sags after the loss of support previously provided by the breast implants. (Click image for uncensored view.)

Recovery after Elective Breast Implant Removal is normally just a few days. If a capsulectomy is performed, a drain is often placed, and it may take longer for the swelling to subside. Aesthetically, the appearance of the breasts continues to improve for several months as the skin recoils postoperatively.

BioCell® Textured Breast Implants

Since the recall of BioCell® Textured Breast Implants a few weeks ago, I have received several phone inquiries regarding breast implant removal. This textured surface is associated with a small risk of developing BIA-ALCL; however, the FDA’s current recommendation is to leave the implants in place and follow them clinically for signs and symptoms including enlargement due to fluid collections around the implants and swelling.

Despite the FDA’s current recommendations, some patients feel more comfortable having their BioCell® textured breast implants removed or replaced. Allergan® will provide smooth replacement implants at not charge (until July 24, 2021). Since the FDA does not recommend removal, there is no financial support available for the elective surgical removal of BioCell® textured breast implants.

Breast Implant Removal Consultations

If you are considering elective Breast Implant Removal, be certain to consult with an experienced and Board Certified Plastic Surgeon. In cases with larger implants and skin laxity, a Breast Lift may be recommended, either at the time of breast implant removal or staged after recovery.

An experienced plastic surgeon can discuss these and other options with you and offer personalized guidance during an in-person consultation appointment. To schedule a private consultation in our Walnut Creek plastic surgery office call (925) 943-6353.

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Breast Reduction for Men (Gynecomastia Reduction) SF Bay Area

Posted August 19, 2019 in Breast Reduction, Breast Reduction (Men), Home

The medical term for Man Boobs is Gynecomastia. Since most men prefer to have a flat, masculine chest, Gynecomastia is usually problematic and a source of embarrassment. There are several methods of Gynecomastia Reduction, because gynecomastia presents in different ways.

What Is Gynecomastia?

Chest Reduction Before and After Pictures (Men)

Gynecomastia Reduction provides a more masculine contour both in and out of tight shirts.

Gynecomastia is the development of excessive, but normal breast tissue on the male chest. It is benign, firm and almost rubbery to the touch. It can be sensitive or painless, and it is located behind the nipple areolar complex. Development is usually bilateral and often asymmetrical.

Although rare, men account for 1% of all breast cancer patients, so hard, unilateral breast lumps need to be removed and sent to pathology for diagnosis.

How Is Gynecomastia Treated?

Male Breast Reduction Before and After Photos

For this adolescent male, gynecomastia reduction was a life changer. Male breast reduction surgery provided him with the mascline chest he desired.

Since Gynecomastia is benign, it does not have to be treated, but elective treatment is common, and the result is very satisfying. The typical reasons for treatment include discomfort and embarrassment due to obvious breast fullness both in and out of clothing.

Gynecomastia Treatment is surgical. Wearing compression shirts can help disguise male breast fullness in clothing, but they are hot, uncomfortable and minimally effective. There are no medications to shrink breast tissue, although some medications can cause male breast enlargement.

Gynecomastia Reduction Surgical Options

Gynecomastia Reduction for Puffy Nipples Before and After Pictures

Sometimes, gynecomastia reduction is all about the nipples. In this case, his puffy nipples are prominent and very noticeable even in clothing. Gynecomastia surgery allows the skin to tuck up against the muscle, relieving a source of embarrassment that had been present for this patient since puberty.

There are two main surgical options for reducing the male chest: Liposuction and Glandular Excision.

Liposuction is best for soft, global breast enlargement caused primarily by fatty tissue. The advantage of liposuction is small discrete scars that can be placed off the breasts. Excision, however, is required in the majority of Gynecomastia Cases.

Glandular Excision is performed to remove the firm, glandular tissue located beneath the nipples. Incisions are made along the lower aspect of the areolae for direct access to the surgical site.

Gynecomastia Reduction Consultations

Gynecomastia Reduction is one of the most common procedures I perform. If you are concerned with the appearance of your chest and would like to learn more about your options, call (925) 943-6353 today, to schedule a private and informative consultation appointment in my San Francisco Bay Area Plastic Surgery office.

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Allergan Updates Recalled BioCell Textured Implant Warranty

Posted August 12, 2019 in Breast Augmentation, Breast Implant Removal, Breast Implant Revision Surgery, Home, Patient Safety

Allergan Logo

On July 24, 2019, Allergan withdrew all BioCell textured breast implants from the market.

Last month, Allergan® recalled every textured breast implant they sold in the US. Read my previous post for details about the BioCell® Textured Breast Implants Recall.

This month, Allergan® has updated their warranty for the affected BioCell® Textured Breast Implants. The following information comes directly from Allergan®, and is correct at the time of publication. As with any warranty, be sure to check with Allergan® directly if you have questions about their products.

What Implants Are Covered?

The BioCell® Replacement Warranty covers all BioCell® textured implants that were manufactured under the brands McGhan®, Inamed®, Allergan® or Natrelle®. Both saline and silicone gel-filled textured implants are covered. This coverage will be available through July 24, 2021. Please note that Natrelle® smooth breast implants are not subject to this withdrawal.

What Are The Replacement Options?

FDA Logo

The FDA web site has up-to-date breast implant and BIA-ALCL information.

The FDA recommends not to remove devices if you do not have symptoms. However, if you and your plastic surgeon decide that replacing your device(s) is in your best interest, you can choose any Allergan® smooth breast implant(s) as a replacement on or before July 24, 2021.

You should bring your current patient ID card or any other information available about your implants with you to your appointment. You and your plastic surgeon will decide on the best size and style as a replacement option for you. Your plastic surgeon will request your replacement implants from Allergan® on your behalf.

Are Surgery Fees Covered?

No. As part of this program, Allergan® will not provide surgical fee assistance. This decision is aligned with the FDA’s recommendation not to remove textured implants or other types of breast implants in patients who have no symptoms of BIA-ALCL.

What If I DO NOT Explant My Textured Implants?

If you choose not to explant your BioCell® textured devices, you will continue to be covered under the Natrelle® ConfidencePlus® Warranty, which includes comprehensive coverage including rupture, capsular contracture and late seroma. More information about the Natrelle® ConfidencePlus® Warranty can be found at Allergan.com.

How Do I Know If My Implants Are Textured?

Allergan Smooth and Textured Breast Implants

Allergan Smooth and Textured Breast Implants

Most breast implants used world-wide are Smooth Breast Implants. All teardrop shaped implants are textured, so if you have teardrop shaped breast implants, you have textured implants. For Allergan®, these are called style-410. Some round implants are textured. You will need the catalogue number for your breast implants to know if they are textured.

Please visit Allergan.com to understand how to read your product ID card. If you don’t have a card, or would like to speak to someone at Allergan, please contact Allergan Medical Information at 1-800-678-1605, option #2, or email IR-Medcom@allergan.com.

How Do I Learn More About BIA-ALCL?

I am constantly updating my blog with new information about BIA-ALCL and other Plastic Surgery News. So keep tuned to the San Francisco Plastic Surgery Blog for more information. Additional reading is available on the FDA Website.

Textured Implant Removal or Exchange Consultations

If you are concerned about your breast implants and are considering changing size or style, be sure to consult with a Board Certified Plastic Surgeon near you. In the San Francisco Bay Area, call our Walnut Creek Plastic Surgery Center at (925) 943-6353 to schedule your appointment.

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Ear Pinning (Otoplasty) For Prominent Ears

Posted August 05, 2019 in Ear Pinning, Ear Shaping (Otoplasty), Home

Otoplasty means ear changing, and it is a cosmetic plastic surgery procedure used to enhance the ears, most commonly to pin back ears that stick out. It can also apply to the correction of Spock ears, Stahl’s ears, cupped ears, lop ears and even cauliflower ears. Today’s post discusses Otoplasty and and how ear aesthetics can be improved.

Otoplasty For Children

Ear Pinning For Children 5 or older - before and after pictures

Ear pinning is performed for children five and older when the ears stick out too far.

Otoplasty is performed for children when they reach age five. The reason for waiting is that by age five, the ear has reached 85% of its adult size, so a safe and predictable result is possible. Fortunately, teasing is less common before age five also.

For children, ear pinning is performed in an outpatient surgery center. The head remains wrapped for a week to protect the repair. Oral pain medication is available for postoperative discomfort which normally lasts a few days. Keeping the head elevated helps minimize swelling and speeds recovery

Doing surgery for a minor requires consent of the guardian, but since the surgery is on the child, the child has to agree that the ears are a problem. If the child is okay with their ears, surgery is not recommended, no matter how far they stick out. If the prominence of their ears becomes bothersome in the future, Otoplasty can always be performed.

Otoplasty For Adults

Otoplasty for Prominent Ears - Before and After Photos

Otoplasty is frequently performed for young adults, although the appearance of their ears has usually bothered them since their youth.

A second, and larger peak age for Ear Pinning is during young adulthood. The appearance of their ears has often been problematic since they were children, but cosmetic surgery may not have been in the family budget.

It is common for young adults to disguise the prominence of their ears with long hair. However, sometimes long hair is not an option, for example, when entering the workforce. Fortunately, with a relatively short procedure, Otoplasty can dramatically improve the appearance of prominent ears and eliminate the need to hide the ears.

Adult Otoplasty is similar to that for children, but since adults can be more cooperative during the procedure, local anesthesia with sedation is an adult option. Local anesthesia decreases postoperative nausea and drowsiness. The downside is that you are awake. You have to tolerate the administering of the local anesthesia and you will hear what I am doing during surgery. For many patients; however, these are not issues or concerns.

Other Ear Changing Procedures

Ear pinning is performed for prominent ears. Other Otoplasty procedures are performed for ears which are malformed. Some of the more common reasons are:

    Traumatic Ear Injuries –

    • Stretched out or Torn Earlobes
    • Piercing Injuries
    • Cauliflower Ears

    Birth Defects –

    • Prominent Ears
    • Stahl’s Ears (Spock Ears)
    • Cup Ears (Lop Ears)

Plastic Surgery for torn earlobes - before and after pictures

Earlobe repair is another type of otoplasty. In this case, her earrings have pulled through the skin leaving a split earlobe.

The most common traumatic injury to the ear is a torn ear lobe. It can happen during a fight, while removing a sweater or even as the result of the long term wearing of earrings or gauges that stretch the earlobe to its breaking point.

For repair, the skin lining the split needs to be removed. Any excess skin is excised, and then the repair is made to create a normal appearing earlobe. There is always a resultant scar, but often it is a good scar, and preferable to a split earlobe.

Ear repair after ear piercing gone bad - before and after pictures

The lump is the upper ear is from a piercing. It was repaired by removing the skin track of the piercing and trimming the deformed cartilage.

Plastic surgeons are not fans of cartilage piercing because when things go badly, we have to fix them. The before and after pictures above are for a relatively minor piercing injury where the cartilage has grown (hypertrophied) in response to the chronic irritation of the bar placed through the ear. Just like in cases with the more extensive Cauliflower Ear Deformity, the excess cartilage is removed and the skin repaired within the fold of the edge of the ear (the helix).

Otoplasty Consultations

Otoplasties are something we do regularly in my Walnut Creek Plastic Surgery center. In over 20 years of practice, I have fixed hundreds of ears for many happy patients. If you are considering cosmetic ear surgery, be certain to consult an experienced and board certified plastic surgeon. In the San Francisco Bay Area call (925) 943-6353 to schedule a private consultation appointment to learn if Otoplasty is right for you.

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Breast Implant Options – What Are Your choices?

Posted July 29, 2019 in Breast Augmentation, Breast Implant Options, Home

Today, Breast Implants come in different shapes, sizes and materials. For experienced board certified plastic surgeons, these are exciting options that provide us with the opportunity to customize your look and maximize your results. However, for patients, too many options can sometimes lead to overload and confusion. Today’s post will help navigate through the alternatives available for breast augmentation. There is no substitute for an in-person consultation appointment with a Board Certified Plastic Surgeon. Until then, the following is a brief introduction to the currently available breast implant options to get you started on your way.

Breast Implant Fillers – Silicone Vs. Saline

Breast Augmentation Before and After - Front View

These breast augmentation before and after pictures show results using silicone gel breast implants. (Click image for uncensored view.)

All breast implants have silicone shells and are classified as either silicone gel or saline depending on the filler. The current Silicone Gel Breast Implants are more popular than saline because today’s Silicone Gel is highly cohesive. This extra high strength gel is safer and more predictable because it does not flow. It supports the shape of the breast implant shell while remaining soft to the touch. Consequently, silicone gel filled breast implants have a lower incidence of rippling when compared with saline. They are also available in a greater variety of sizes, shapes and profiles. Moreover, my patients who have had both silicone and saline filled breast implants, prefer the look and feel of silicone implants.

Saline Breast Implants are also excellent devices. Saline is water with 0.9% salt (NaCl) added to make the solution as salty as we are. It is the same fluid we administer intravenously for hydration during emergencies and as a delivery medium for medications during surgery. Saline breast implants also come in a variety of shapes, sizes and profiles, but they tend to be more palpable and have a higher incidence of rippling (visible wrinkling). An advantage of saline is that it is much simpler to tell when a saline breast implant deflates. If a hole develops in the implant’s shell, the saline empties quickly and completely. Conversely, highly cohesive gel, with is found inside silicone breast implants (gummy bear implants), maintains its shape and fullness, even when there is a hole in the shell.

Breast Implant Shape – Round Vs. Teardrop

The final shape of the augmented breast is determined to a greater extent by the shape of the natural breast than by the shape of the breast implant. Most women already have most of their breast tissue in the lower pole of their breasts. Thanks to gravity, the majority of the breast implants’s volume also fills the lower half of the breast, so round implants do not necessarily mean round breasts.

Unlike shaped implants, round implants are axially symmetrical. That means round breast implants can spin without affecting the shape of the breast. For shaped breast implants, rotation is a significant problem. To help prevent rotation, shaped implants have a textured surface. The rough surface attaches to the inside of the capsule like Velcro®, hopefully preventing rotation. Unfortunately, texturing may also increase the risk of rippling and double capsules.

Shaped implants may be beneficial after a mastectomy and in congenital cases when the breast does not fully develop. Any likely benefit needs to be evaluated against the risks on an individual basis. Texturing is discussed later in this article.

Breast Implant Profile – Low, Medium, High Vs. Extra High

Breast Augmentation before and after pictures - front view African-American woman

The above breast augmentation before and after pictures show breast augmentation with high profile silicone gel breast implants. (Click image for uncensored view.)

The greatest innovation in implant shape has been the introduction of multiple breast implant profiles. Selecting the best profile often causes confusion, but hopefully this will help simplify the selection process. High profiles have greater projection for a fixed diameter. That means for a fixed width, high profiles are rounder and fuller. This means they are larger and project out from the chest more. My patients all want rounder, fuller breasts, but unless they are looking for maximum size, not everyone is a good candidate for high profile breast implants.

It’s easier to consider profile in terms of the diameter of the implant rather than how round it is because the base diameter of your breasts are fixed. They can’t be changed. The base diameter is an objective dimension that is easily determined during your consultation appointment. All it takes is a tape measure. From this measurement, the optimal diameter of your breast implant is determined. If the implant is too wide, it sticks out too far under the armpits. If the implant is too narrow, the cleavage gap between the breast implants is increased. The breast implant diameter is very important, objective and easy to determine.

To determine the best profile, we need two pieces of information. One is the measured breast diameter. The other is your goal size – i.e. the size you would like to be after breast augmentation because this determines the volume required for you breast implants. The volume of your natural breast tissue plus the volume of the breast implant determines the final size of the breasts. In other words, the goal size minus your current breast size equals the volume of the required breast implant.

Since the goal size is subjective, it is worth doing some homework. A good way to try on different sizes is to fill Zip-Lock® bags with rice and place them inside the bra you would like to wear after augmentation. Often, patients bring their optimal rice bags with them to the office to convey their desired result. It can be very helpful. Once we have determined your goal size and the base diameter of the breast is measured, we can choose the profile that fits the bill. All measurements and profiles should be confirmed with in-person guidance from an experienced board certified plastic surgeon.

Breast Implant Size – Too Small, Too Large Vs. Just Right

Breast Augmentation Before and After - Front View

These breast augmentation before and after pictures show the front view for breast augmentation using saline breast implants. (Click image for uncensored view.)

Choosing the correct breast implant volume is the most difficult aspect of breast implant selection. Everyone wants to be big enough, but not too big. I’ve had it described in many ways from noticeable, but guys should still make eye contact, to celebrity but not porn star. It all very subjective. Your “ideal” may not be mine, or your friends, so you need to be honest with yourself. If you give your board certified plastic surgeon a good idea of your goal size is, you have a much better chance of being satisfied with your final result. Wearing padded bras, using rice bags, sizers or bringing pictures to your consultation appointment all aid in size determination. Once I know what size a patient wants, the rest is measuring and math, and I like math.

Breast Implant Texture – Smooth Vs. Textured

I have always been a fan of smooth breast implants, primarily because of the excellent results they provide for my patients. They are simple, predictable and reliable, and for most patients they feel softer yet still give a teardrop shaped result. For cases of recurrent capsular contracture or when shaped implants are indicated, then texturing may provide an advantage, but recently texturing has been associated with an additional risk.

Textured Breast Implants have been in the news a lot lately, and in the future, some texturing may no longer be an option. Just this week, Allergan® voluntarily recalled its Biocell® textured breast implants from the world market. Biocell® was the most aggressive texturing and has an increased association with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Of the 573 cases of BIA-ALCL, 481 are reported to have Allergan® textured breast implants at the time of diagnosis.

This may seem like a lot of BIA-ALCL cases; however, there are millions of breast implant patients. If you have textured breast implants, your risk of developing BIA-ALCL is 1 in 20,000 or 0.005%. If you have Biocell® textured breast implants, your risk of developing BIA-ALCL is 1 in 3345 or 0.02%. By comparison, the risk of developing breast cancer is one in eight or 12.5%. Biocell® textured implants manufactured by Allergan®, represent less than 5% of breast implants sold in the U.S. In fact, textured implants account for only 10% of all breast implants sold in the US.

It is important to note that Allergan smooth and Microcell® breast implants are not impacted by the recent recall. If you do have Allergan® Biocell® textured breast implants and have no symptoms, the FDA does not recommend the removal of these or other types of breast implants due to the low risk of developing BIA-ALCL. If you have any questions, talk to your health care provider. If you have breast swelling, especially if it is one sided, or any other symptoms of BIA-ALCL, it is important to seek prompt medical follow-up with a board certified plastic surgeon for further testing. Like most medical problems, early diagnosis is associated with increased cure rates.

Breast Implant Makers/Warranties – Allergan®, Mentor® Vs. Sientra®

Sientra®, Allergan®, Mentor® and Ideal® are the four FDA approved breast implant manufacturers in the United States. Sientra® manufactures their implants in the US and only makes silicone gel filled breast implants. Allergan® and Mentor® make both Silicone and Saline filled breast implants, and Ideal® makes only saline filled breast implants. These are the only FDA approved breast implant companies in the US.

All US manufacturers of Breast Implants have breast implant warranties. The details vary between companies. I try to keep the latest information on my website’s Breast Implant Warranties Page, but for the most accurate and up-to-date information, please check with your implant’s manufacturer.

Breast Augmentation Consultations

To schedule a personalized Breast Implant Consultation, call (925) 943-6353 today. An in-person consultation with a Board Certified Plastic Surgeon can help you focus on the options specific to your needs and can save you a lot of time when considering Breast Augmentation.

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Allergan® Voluntarily Removes All BioCell® Textured Breast Implants from World Markets

Posted July 24, 2019 in Breast Augmentation, Breast Cancer Awareness, Home

Today, Allergan® voluntarily withdrew all BioCell® Textured Breast Implants and Tissue Expanders from the world markets due to an association with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Allergan Biocell textured breast implants

Allergan® Biocell® textured breast implants have the highest association of BIA-ALCL.

Textured Breast Implants and BIA-ALCL

I have been posting about an association of BIA-ALCL and textured breast implants for some time here on the San Francisco Plastic Surgery Blog. While many types of textured breast implants exist, a higher association of BIA-ALCL has been found with more aggressively textured breast implants. Allegan® has the most aggressively textured breast implants and thus the highest association with BIA-ALCL.

BioCell® Textured Breast Implants and BIA-ALCL

BioCell® textured surface (shell) is a unique surface used only by Allergan®. A detailed list of the specific BioCell® textured devices marketed in the U.S. that are recalled can be found at the end of this post.

The FDA’s analysis was attributed to a new worldwide reported total of 573 unique BIA-ALCL cases including 33 patient deaths. Of the 573 cases of BIA-ALCL, 481 are reported to have Allergan® textured breast implants at the time of diagnosis. In addition, 12 of 13 deaths occurring in patients with BIA-ALCL where the manufacturer was known occurred in patients implanted with an Allergan® textured breast implant at the time of their BIA-ALCL diagnosis. The manufacturer and/or texture is unknown for the remaining 20 reported deaths from BIA-ALCL.

The risk of BIA-ALCL with Allergan® BioCell® textured implants is approximately 6 times the risk of BIA-ALCL with textured implants from other U.S. manufacturers.

BIA-ALCL Is Not Breast Cancer

Early treatment is the key to the cure for BIA-ALCL as it is for any medical illness. When in doubt; check it out.

Early treatment is the key to the cure for BIA-ALCL as it is for any medical illness. When in doubt; check it out.

BIA-ALCL is a type of non-Hodgkin’s lymphoma (cancer of the immune system). In most cases, BIA-ALCL is found in the scar tissue and fluid near the implant, but in some cases, it can spread throughout the body. At this time, the overall incidence of developing BIA-ALCL is considered to be low; however, a BIA-ALCL diagnosis is serious and can lead to death, especially if not diagnosed early or promptly treated. In most patients, BIA-ALCL is treated successfully with surgery to remove the implant and the scar tissue surrounding the implant; however, some patients may require treatment with chemotherapy and/or radiation therapy.

BIA-ALCL Is Rare

It is important to understand how rare the occurrence is and put the numbers into perspective. Literature indicates the current lifetime risk is about 1 in 20,000 patients with textured implants. BioCell® has a 7x to 8x greater incidence of BIA-ALCL compared to all other manufacturers’ textures, including Sientra® Texture and Mentor® Siltex. Geographic regions also reported variable risks including: Australia 1 in 3,345 for BioCell® and 1 in 86,029 for Siltex. In 2018, over 400,000 women underwent breast augmentation and reconstruction with implants in the U.S. Here are some comparative rates from the Sientra website:

  • The average woman’s risk of developing breast cancer in her lifetime is 12.5%. This means that 1 out of 8 women may develop breast cancer in her lifetime.
  • The risk of developing recurrent breast cancer after mastectomy is 5-8%. This means that 5 to 8 out of 100 women may develop recurrent breast cancer after mastectomy.
  • The risk of capsular contracture through 10-years is ~14%. This means that 14 out of 100 patients may experience capsular contracture within 10 years after receiving implants.
  • The risk of breast implant rupture through 10-years is ~8%. This means that 8 out of 100 patients may experience implant rupture within 10 years after receiving implants.
  • The risk of developing BIA-ALCL from a textured breast implant is ~0.005%. This means that 1 out of 20,000 women with textured implants may develop BIA-ALCL.

FDA Is Not Recommending Removal Of Textured Implants

FDA Logo

To date, the FDA has not recommended removal of textured breast implants, including those with Allergan®‘s BioCell® texturing.

From the FDA website:

  • If you have no symptoms, we [the FDA] are not recommending the removal of these or other types of breast implants due to the low risk of developing BIA-ALCL.
  • Know the symptoms of BIA-ALCL – primarily persistent swelling or pain near the breast implant – and monitor the area around your breast implants for any changes.
  • Evaluation for BIA-ALCL typically involves a physical exam, imaging, and/or assessment of the fluid or tissue around the breast implant. It is important to undergo an evaluation to diagnose BIA-ALCL since a confirmed BIA-ALCL diagnosis may change the type of operation that should be performed.
  • Based on discussions with your healthcare provider, patients with confirmed BIA-ALCL should undergo implant removal and removal of the surrounding scar capsule, which is a more extensive operation than implant removal alone.
  • As with any implanted device, it is good to keep a record of the device manufacturer, unique device identifier, and implant model name. You may have received this information on a patient device card from your surgeon. If you would like to obtain any of this information, consider asking your surgeon or obtaining the record of your surgery (operative notes) from the facility where it was performed.
  • Understand that most cases of BIA-ALCL occur many years after breast implant placement
  • If you have any questions, talk to your healthcare provider.
  • The FDA understands that today’s action may cause concern to patients who have breast implants, especially those who know they have one of the listed Allergan® BioCell® model implants or may not know the implant’s manufacturer or model. The FDA continues to monitor and evaluate reports of adverse events in databases, including external patient registries, and in scientific literature for the incidence of BIA-ALCL across all breast implants and other devices intended for use in the breast. The FDA further notes that the macro-textured implants, like the BioCell® textured implants manufactured by Allergan®, represent less than 5% of breast implants sold here in the U.S. In fact, textured implants account for only 10% of all breast implants sold in the U.S. To fully understand your risk of developing BIA-ALCL, the FDA recommends that patients and healthcare providers follow the FDA’s recommendations stated above. More information about BIA-ALCL can be found on the Breast Implants webpage. Additionally, the FDA will continue to update the public about developments in this area.

List of Affected BioCell® Products

Allergan® Natrelle Textured Saline-Filled Breast Implants (formerly McGhan RTV Saline-Filled Mammary Implant) approved under P990074. The following are the textured styles:

  • Style 163 – BioCell® Textured Shaped Full Height, Full Projection Saline Breast Implants
  • Style 168 – BioCell® Textured Round Moderate Profile Saline Breast Implants, also referred to as 168MP (168 Moderate Profile)
  • Style 363 – BioCell® Textured Shaped Moderate Height, Full Projection Saline Breast Implants, Allergan® catalog includes 363LF, or 363 Low Height Full Projection
  • Style 468 – BioCell® Textured Shaped Full Height Moderate Projection Saline Breast Implants

Allergan® Natrelle Silicone-Filled Textured Breast Implants (formerly Inamed Silicone-Filled Breast Implants) approved under P020056. All the new Natrelle Inspira BioCell® textured breast implant style numbers start with “T”. If your Allergan® Natrelle Inspira breast implant style starts with “S”, they are smooth, and are not part of this withdrawal. The following are the textured styles:

  • Style 110 – BioCell® Textured Round Moderate Projection Gel Filled Breast Implants
  • Style 115 – BioCell® Textured Round Midrange Projection Gel Filled Breast Implants
  • Style 120 – BioCell® Textured Round High Projection Gel Filled Breast Implants
  • Style TRL – Natrelle Inspira BioCell® Textured Responsive Silicone-Filled Breast Implants
  • Style TRLP – Natrelle Inspira BioCell® Textured Responsive Silicone-Filled Breast Implants
  • Style TRM – Natrelle Inspira BioCell® Textured Responsive Silicone-Filled Breast Implants
  • Style TRF – Natrelle Inspira BioCell® Textured Responsive Silicone-Filled Breast Implants
  • Style TRX – Natrelle Inspira BioCell® Textured Responsive Silicone-Filled Breast Implants
  • Style TCL – Natrelle Inspira BioCell® Textured Cohesive Silicone-Filled Breast Implants
  • Style TCLP – Natrelle Inspira BioCell® Textured Cohesive Silicone-Filled Breast Implants
  • Style TCM – Natrelle Inspira BioCell® Textured Cohesive Silicone-Filled Breast Implants
  • Style TCF – Natrelle Inspira BioCell® Textured Cohesive Silicone-Filled Breast Implants
  • Style TCX – Natrelle Inspira BioCell® Textured Cohesive Silicone-Filled Breast Implants
  • Style TSL – Natrelle BioCell® Textured Soft Touch Silicone-Filled Breast Implants
  • Style TSLP – Natrelle BioCell® Textured Soft Touch Silicone-Filled Breast Implants
  • Style TSM – Natrelle BioCell® Textured Soft Touch Silicone-Filled Breast Implants
  • Style TSF – Natrelle BioCell® Textured Soft Touch Silicone-Filled Breast Implants
  • Style TSX – Natrelle BioCell® Textured Soft Touch Silicone-Filled Breast Implants

Natrelle 410 Highly Cohesive Anatomically Shaped Silicone Filled Breast Implants approved under P040046. All style 410 implants are BioCell® textured. The following are the textured styles:

  • Style 410FM
  • Style 410FF
  • Style 410MM
  • Style 410 MF
  • Style 410 FL
  • Style 410 ML
  • Style 410 LL
  • Style 410 LM
  • Style 410 LF
  • Style 410 FX
  • Style 410 MX
  • Style 410 LX

Allergan® tissue expanders for the breast that have BIOCELL texturing originally cleared as:

  • Natrelle 133 Plus Tissue Expander (K143354)
  • Natrelle 133 Tissue Expander with Suture Tabs (K102806)

What To Do?

If you don’t know what breast implants you have, find out. All my patients are given a card with their implant information to keep in a safe place. If your surgeon did not give you this information, or you can’t find it there are options. You can

  • call you surgeon’s office
  • contact the surgery center or hospital where you had surgery
  • contact the breast implant manufacturer

90% of the breast implants used in the U.S. are smooth and are not affected by this action. In my office, we have always preferred the results obtained with smooth breast implants. Less than 1% of the implants I have placed are textured, and not all of them are Allergan®. In fact, in my over 20 years of practice, I have removed more textured breast implants than I have placed. If you had your breast augmentation with me, and are wondering which implants you have, your breast implant card should state whether your implants are smooth or textures. If you don’t have your card, just give us a call and we will look it up.

If you have Allergan® BioCell® textured breast implants, don’t panic. Your risk of developing BIA-ALCL is still very low. If you are asymptomatic, the current recommendation is to leave them alone, and monitor for changes. If you have changes, do not delay in getting evaluated by your doctor. The most common presentation is an increase in size of one breast years after breast augmentation, usually due to a collection of fluid around the breast implant (seroma). While, most seromas are not due to BIA-ALCL, all should be investigated. If you have any concerns, contact your plastic surgeon for more detailed information.

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Liposuction of the Trunk Before and After Pictures – San Francisco Bay Area

Posted July 15, 2019 in Breast Reduction (Men), Home, Liposuction

Liposuction of the Trunk, in order of popularity includes liposculpture of the:

  • abdomen
  • flanks (sides)
  • back
  • chest

If you have disproportionate collections of fat in these areas that are bothersome, Liposuction may offer a solution.

Liposuction of the Abdomen

Liposuction of the Abdomen removes disproportionate fat from the belly. Fat is removed from between the skin and the abdominal muscles. This is usually stored in the lower abdomen, and may run around to the sides. Less commonly, fat is also deposited on the upper abdomen and along the ribs. Results are best with localized collections of fat, as opposed to globally deposited fat. Tight, thin skin helps reveal the results, while fat inside the abdomen, behind the abdominal muscles, cannot be removed with Liposuction. Internal abdominal fat requires weight loss for removal.

Liposuction of the Abdomen

Liposuction of the abdomen can help flatten the belly.

The woman above is close to her ideal body weight, yet continues to have disproportionate fat of the abdomen, especially within the lower abdominal wall. Tumescent Liposuction was performed to remove fat from the upper and lower abdomen and smooth her belly. Her clothes fit better, and she is much happier after her tummy nipping procedure.

Liposuction of the Flanks and Back

Back fat is annoying for everyone. It impacts the way clothes fit, and sometimes bulges over the top of jeans causing a Muffin Top or the hated Love Handles. It can be stubborn and persistent, even with exercise and after weight loss.

Liposuction of the Back (Love Handles)

Liposuction of the Love Handles or Muffin Top is one of the most popular areas for Liposculpting with a high degree of patient satisfaction.

The gentleman above is in great shape before his Liposculpture; however his physique is hidden under stubborn, localized fat surrounding his flanks and back. Liposuction was performed through small incisions located discretely below the belt line. The excess fat was removed on a Friday, and by Monday he was feeling fine.

Vigorous activities after Liposuction are limited for a week or so to prevent complications and reduce the duration of post-operative swelling. Additionally, an abdominal binder is worn postoperatively for a few weeks to help the skin stay smooth.

Liposuction of the Chest and Abdomen

Liposuction is best for fine tuning fat removal and improving body contours. It is not for weight loss. In fact, the maximum amount of fat that should be removed in one operation is five liters, or about eleven pounds. The more fat that is removed, the more likely the skin will fold, as support provided by the fat is lost. Much like the stuffing in a pillow case, the fat not only makes the skin bigger, but also holds it up. If skin laxity is present before liposuction, removing the fat will shrink the treated area, but it might also make the skin look worse.

Liposuction of the Chest and Abdomen in a Man

Liposuction of the chest can reduce mild gynecomastia. Liposuction of the back and abdomen can give a leaner look.

The patient above is in great shape, but complained of fullness in his chest and abdomen. He had disproportionate fat of the chest (pseudogynecomastia) and abdominal wall. He was a good candidate for Liposuction, because he had little intra-abdominal fat and no skin laxity. Liposuction was performed to remove the bothersome fat. His elastic skin shrunk, revealing better muscle definition and the physique he desired.

Liposuction Consultations

Before and after pictures are a good way to see what Liposuction can do. More Liposuction Before and After Photos with descriptions are available on DrMele.com on our new Liposuction Before and After Page. However, there is no substitute for an in person consultation with an experienced, Board Certified Plastic Surgeon.

To schedule a Liposuction Consultation in our Walnut Creek Plastic Surgery Clinic, call (925) 943-6353 today.

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